On the subject of doctors who write

"So why do these doctors write so well, and so much better (to my mind, at least) than other non-writers? Perhaps there are elements of doctoring that lie in harmony with writing: peeling back the layers to get to the core of an issue; confronting the obvious but being willing to look beyond it; learning where to 'cut in,' of course; and, more than anything, recognizing that this object before you – in one case a human body, in the other a manuscript – is on a certain level a miraculous object with the power to astound, and on another level is a complex, dynamic system which can (and must be) reduced to a schematic, laid out on paper or x-ray film."

Stephen J. Dubner

http://anesthesioboist.blogspot.com/2007/09/doctors-who-write.html

Flaws in medical publishing

https://www.thestar.com/news/investigations/2018/12/21/inside-the-flawed-world-of-medical-publishing-that-allowed-a-lie-in-a-paper-coauthored-by-dr-gideon-koren-to-pollute-the-scientific-record.html

Inside the flawed world of medical publishing that allowed a lie in a paper coauthored by Dr. Gideon Koren to pollute the scientific record

By RACHEL MENDLESONInvestigative Reporter
MICHELE HENRYStaff Reporter
ANDREW BAILEYData Analysis

Fri., Dec. 21, 2018

In January 2000, a paper was published in a respected academic journal that trumpeted the successes of a Canadian lab in a burgeoning area of drug testing.

The researchers who wrote the paper claimed they had analyzed strands of hair to trace long-term exposure to illicit drugs, such as cocaine, and used gold-standard testing to verify its results.

Dr. Gideon Koren is one of Canada’s most prolific scientific authors. The Star’s review of more than 1,400 papers co-written by Koren over 30 years reveals the inability — and unwillingness — of journals and research institutions to preserve the integrity of the scientific record.  (TORONTO STAR)

What everyone failed to notice — from the medical institution where the lab was housed to the federal agency that funded the study to the journal that published the article — was that the gold-standard claim was a lie.

In fact, Dr. Gideon Koren’s Motherisk lab at The Hospital for Sick Children rarely confirmed its results with gold-standard testing before 2010.

That lie was exposed in 2015, amid a scandal that tore apart vulnerable families and prompted two government-commissioned inquiries, which found Motherisk made millions selling its hair tests for use in criminal and child-protection cases despite the fact that it often failed to verify its preliminary results. This was contrary to international forensic standards for evidence presented in court.

Three years later, the article that was published in Forensic Science International still stands, uncorrected, polluting the scientific literature.

The paper has been cited 54 times, as recently as May 2017. The journal told the Star this week that it will be “looking into these issues.”

Citations — when other researchers cite the study as a reference in their published work — are an indication of its influence.

A researcher’s publication record is the currency of modern-day science. It is the pre-requisite to securing competitive tenure-track positions at prestigious universities, the key to unlocking funding and the measure by which research institutions are assessed.

But it is a moment of reckoning for medical publishing. Last week, Sick Kids, which housed the Motherisk lab, announced it will undertake a wholesale review of Koren’s vast body of published work, after the Star presented the hospital with findings from this investigation that identified what appear to be problems in more than 400 of Koren’s papers, including the Jan. 2000 hair-testing article, collectively cited more than 6,000 times.

These papers appeared problematic because they have been inadequately peer-reviewed, failed to declare, and perhaps even obscure, conflicts of interest, and, in a handful of cases, contain lies about the methodology used to test hair for drugs.

We identified just 18 instances in the 400 studies flagged by the Star where it appears journals have taken action, in the form of a correction or clarification.

The Hospital for Sick Children announced last week it will undertake a wholesale review of Gideon Koren's vast body of published work.  (RICHARD LAUTENS / TORONTO STAR FILE)

Sick Kids’ announcement follows similar cases in the U.S. There, a research misconduct scandal recently prompted the resignation of Dr. Jose Baselga, the former chief medical officer of Memorial Sloan Kettering Cancer Centre in New York City, after a New York Times-ProPublica investigation found he failed to disclose payments from healthcare companies. Elsewhere, Ohio State University cancer scientist Ching-Shih Chen resigned after he was found to have falsified data.

The Star’s review of more than 1,400 papers co-written over 30 years by Koren, one of Canada’s most prolific scientific authors, reveals the inability — and unwillingness — of journals and research institutions to preserve the integrity of the scientific record.

Several concerns about Koren’s research were identified in 2015 by a Sick Kids internal review. The hospital posted a summary of its findings on its website, and told the Star it sent a copy to the province’s medical watchdog, which is investigating Koren.

The Star’s investigation has found the system of medical publishing is one with little accountability, where the onus is on authors to voluntarily disclose conflicts of interest. Journals don’t vet these claims (or the authors who make them). Institutions have discretion to investigate allegations of misconduct as they see fit.

Corrections, if they happen at all, routinely take years to be published.

The Star’s findings are consistent with the systemic problems that have been identified by Retraction Watch, a pioneering organization with an online database of retractions and corrections.

Founded in 2010, the organization began collecting retractions, by searching journals online and in print, and, by the time the database went live in October 2018, it had amassed more than 18,000 retractions. This made it the most extensive catalogue of such notices available, says the site’s co-founder, Ivan Oransky, a doctor, journalist and professor at New York University.

Despite the commonly held belief in the power of peer-review and the ability of academic publishing to root out cases of misconduct and fraud, Oransky describes “the vaunted self-correction mechanism of science” as one that is “held together by spit and bubble gum.”

From the institutions who rely on researchers to bring in grant money to the journals and authors whose reputations and careers are at stake, “at every stage the incentives are against doing the right thing,” he said.

“I don’t know if the barrel is totally rotten, but there are a lot more rotten apples in the barrel than people would like us to admit.”

Koren, who retired from Sick Kids in June 2015, has continued to publish since his departure. Neither he nor his lawyers responded to emails and phone calls seeking comment for this story.

Koren, who now lives in Israel, had been working as a senior researcher for Maccabi Health, a healthcare provider. In late October, Physicians for Human Rights Israel, a medical ethics’ watchdog, wrote to Maccabi Health with concerns that Maccabi may not know about Koren’s role in two Sick Kids controversies, including the Motherisk scandal. On Dec. 5, Maccabi, in a letter obtained by the Star, wrote back saying it had appointed a committee to “examine the role of Professor Koren in these incidents.”

Israel Hayom, a national newspaper, reported on Dec. 18, that Maccabi Health said Koren will be on leave until the end of the investigation. Haaretz, another Israeli newspaper reported that day that Koren defended the Motherisk lab by saying it was clinical, not forensic, and “won praise.” He said, according to the newspaper, that claims of biased or misleading research were outright libel.

Sick Kids said last week that it is “regrettable” that an audit of Koren’s work had not been conducted sooner and that there should have been “closer oversight of his disclosure and publication practices.”

In the 30 years he spent at the helm of Motherisk, Koren’s staggering publication record helped make the program the foremost source of advice for generations of pregnant women and their doctors. He held editorial positions at more than 15 academic journals, attracted more than $29 million in grants from public and private sources, won prestigious awards and supervised up to a dozen graduate students per year, the Star found.

The institutions and journals that benefited now face possible problems in hundreds of papers in a case that reveals problems ailing the system of academic publishing, and provides a prescription for much-needed improvement.

***

The Star’s findings were in many ways foretold 15 years ago, when the University of Toronto’s dean of medicine tried — and failed — to get a journal to retract one of Koren’s papers.

In April 2002, at a faculty council meeting, Dr. David Naylor, who is now interim CEO at Sick Kids, recorded a finding of research misconduct against Koren related to a 1999 study published in the journal Therapeutic Drug Monitoring.

The public chastisement was intended as a coda to Koren’s dispute with Dr. Nancy Olivieri, a blood diseases specialist at Sick Kids who, like Koren, held cross-appointments at U of T. Tensions boiled over while the pair was running a clinical trial with partial funding from the Canadian generic drug-maker Apotex. Olivieri voiced concerns about the efficacy of the drug, which Koren did not share.

Dr. Nancy Olivieri, a blood diseases specialist at SickKids who also held cross-appointments at U of T, was the subject of disparaging "poison pen letters" that DNA testing eventually proved were written by Koren.  (CARLOS OSORIO / TORONTO STAR FILE)

In 2000, the heads of Sick Kids and U of T suspended and fined Koren, who was also stripped of an endowed chair for “repeatedly lying” and sending anonymous “poison pen letters” to doctors and the media disparaging Olivieri and her supporters. He denied writing the letters until DNA evidence provided irrefutable proof.

A committee formed by the U of T Faculty of Medicine found that Koren had published the 1999 paper without consulting the other researchers, failed to disclose Apotex’s support for the trial, and had not discussed the safety concerns about the drug.

“I sincerely hope that resolution of this … brings the entire episode to an end,” Naylor told the faculty council in 2002, according to the meeting minutes.

Naylor said that he insisted Koren write to the journal to acknowledge his error and request the article be deleted from the scientific record. “He has done so, and also sent appropriate personal letters of apology,” Naylor said, according to the minutes of the faculty council meeting. “I consider the matter closed.”

The article was never withdrawn.

An erratum was published in April 2004, stating that “the specific industry sponsor, Apotex Inc., of Weston, Ontario, was not mentioned.”

Koren’s failure to consult with his co-researchers and discuss the safety concerns, were not addressed in this correction.

In response to questions from the Star for this story, Naylor said Koren contacted the editor, Dr. Steven Soldin, within weeks of being notified of Naylor’s decision.

Naylor said Soldin was made aware of the “inappropriate use of shared data” and the “non-disclosure issue,” but that Soldin declined to retract the article.

Soldin, who is now a senior scientist at the National Institutes of Health Research in Maryland, told the Star he doesn’t recall a conversation with Koren about the paper after it was published and said he was never contacted by any official from U of T.

“If the Toronto academic faculty felt strongly about something, they should definitely have spoken with me,” he said. “It’s got to be a serious conversation, or it’s not going to be taken seriously.”

The matter was still outstanding when, in early 2004, Koren became North American editor of Therapeutic Drug Monitoring, based in part on the recommendation of his predecessor, Soldin.

In February 2004, Naylor wrote to Olivieri with an update. In that correspondence, obtained by the Star, Naylor said he wrote a letter urging retraction of the 1999 article, and, “as agreed,” Koren passed it to the publisher. In a recent email to the Star, Naylor said that he reached out to the publisher who rejected his request.

The current journal editor, Dr. Uwe Christians, said he “cannot comment further on the matter,” but, in general, “the journal editor and editorial board have full editorial independence; the publisher is not involved in editorial decisions.”

Arthur Schafer, founding director of the University of Manitoba’s Centre for Professional and Applied Ethics, said Koren should have been fired for his conduct in the Olivieri affair. That U of T and Sick Kids allowed him to continue publishing after his proven research misconduct, apparently without adequate oversight and supervision, is “astonishing,” he said.

Naylor, speaking in his capacity as U of T’s former dean of medicine, said he rejects the suggestion that the university’s “handling of this case somehow accounted for Koren’s ongoing failures to disclose industry funding sources and personal payments.”

“(Third) parties gave critical and wide public airing of Dr. Koren’s disclosure misconduct during and after these proceedings,” he said, referring to U of T’s investigation into the research misconduct allegations. “(His) aberrant conduct apparently continued regardless …. He was evidently impervious to discipline or criticism.”

A spokesperson for Sick Kids said that the issue surrounding the 1999 paper, “was addressed many years ago by the University of Toronto and the Hospital has no further comment.”

***

In his recent book, Doctors in Denial: Why Big Pharma and the Canadian Medical Profession are Too Close for Comfort, Dr. Joel Lexchin, a health policy expert at York University, writes that since the ’90s, pharma money has increasingly flowed to scientists who are regarded as having a favourable view of a company’s products and could be a willing, positive ambassador at conferences and dinners with colleagues.

Doctors who receive money from pharmaceutical companies “are almost uniformly resolute that they are promoting the product because they believe in its effectiveness and that they are independent and able to say what they believe,” Lexchin writes. He adds that “they sometimes indulge in self-censorship to avoid the risk of losing funding for research and attendance at conferences.”

In the U.S., federal law requires drug companies to disclose payments to doctors.

No such law exists in Canada.

Legislation, passed by Ontario’s former Liberal government last year to make these disclosures mandatory, has yet to be proclaimed by the new Tory government.

Dr. Andrew Boozary, an assistant professor at U of T and the co-founder of Open Pharma, a leading advocate for pharmaceutical payment transparency, said that there is no universal standard for disclosing conflicts of interest, ties to industry or anything else that could be seen to bias academic publishing.

When submitting a manuscript, authors are often asked to complete an online form that asks a simple “yes” or “no” question: “Are there any relevant conflicts of interest?”

Journal editors told the Star they rely on authors to be honest.

Koren has acknowledged in published papers and on one version of his C.V. that about 10 drug companies, including Pfizer, Duchesnay and Apotex, have provided him with money.

The Star found nearly 300 papers that contain concerns related to undisclosed, or possibly obscured, conflicts of interest. That includes roughly 30 papers that discuss morning sickness or Diclectin, the only medication approved by Health Canada to treat this condition, and do not acknowledge Koren’s long-term support from Duchesnay, the Quebec-based maker of the drug. Duchesnay provided funding to Koren beginning in 1994, according to his C.V.

Of the nearly 300 papers, about 270 cite “The Research Leadership for Better Pharmacotherapy During Pregnancy and Lactation.” Sick Kids, following its internal probe of Motherisk in 2015, said Koren created this name to refer to funds donated “by a variety of individuals and organizations.” In the years leading up to the Motherisk scandal, the primary donor was Duchesnay, the hospital said, and, in some cases where Koren used the “Research Leadership” name, he did not acknowledge funding from that drug company.

The Star requested a complete list of donors and the amount of money provided, but Sick Kids said this is “not possible,” because this was “not an actual fund set up at the hospital.”

In a statement, a spokesperson for Duchesnay confirmed the company “terminated its partnership with/and funding of” Sick Kids and Motherisk in 2015, but said “it is not our policy to announce the specific amounts it pays or has paid to Canadian health professionals for various consultations, speaker and research services.”

None of the other drug companies provided to the Star the amount or details of the funding to Koren or Motherisk.

Thomas Knudsen is editor-in-chief of the journal Reproductive Toxicology, which has published 13 papers co-written by Koren that the Star deemed problematic, because they relate to hair-testing, cite the Research Leadership name or discuss morning sickness or Diclectin without acknowledging support from Duchesnay.

Knudsen said that his editorial staff does not generally investigate conflict-of-interest disclosures. Peer reviewers are “not going to do a Google search” of the author, Knudsen said; their job is to review the science. Without a whistleblower or a note from a researcher’s institution, he asked, how was he supposed to know who or what to look into?

“We are not police officers,” he said.

“That’s up to the university.”

The journal published two more of Koren’s articles this year. A third was stopped by reviewers with concerns about the study design and conclusions. Knudsen recently rejected this study. He said that information provided by the Star about the findings of the news organization’s investigation into Koren’s papers, and the problems at Motherisk “made it easier” to render the “unfavourable” decision.

***

Sick Kids vowed to communicate the results of its recently announced review to “all involved journals.” This could prove a monumental task. The more than 400 papers identified by the Star as containing possible problems were published in roughly 75 journals and co-authored by more than 450 doctors, nurses and academics.

In these cases, publications can be slow to act, if they do at all, said Oransky of Retraction Watch.

Retractions, the most severe form of punishment a journal takes, are rare.

Corrections, known as “errata” or “corrigenda,” are more common.

But they can take years to materialize, are difficult to find and tend to be opaque.

In a search of three online scientific article databases, the Star found corrections related to 18 of the more than 400 articles we flagged.

Most are not appended to the online versions of the original articles.

The problems in the system were evident in our search for corrections related to five hair-testing papers that retired judge Susan Lang identified in her 2015 report on Motherisk as containing lies about using the gold-standard testing to confirm results.

Justice Susan Lang, the retired Ontario judge who conducted the independent review of the Motherisk lab, identified five hair-testing papers in her 2015 report as containing lies about using the gold-standard testing to confirm results.  (BERNARD WEIL / TORONTO STAR FILE)

In her report, Lang said that Koren told her that he had sent erratum letters to the affected journals explaining the inaccuracies in these articles.

Sick Kids reiterated Koren’s claim in the press release last week.

Three years later, the Star’s online search found corrections related to two of those articles: an erratum related to a 2007 article published in Therapeutic Drug Monitoring, and a corrigendum related to a 2009 article published in Forensic Science International.

When asked why Forensic Science International did not publish a correction related to the 2000 paper discussed at the beginning of this story, the editor, Dr. Christian Jackowski said “no further corrigendum/erratum was published or provided by the author.”

The editor of a third journal, on request, sent the Star the corrigendum that was published in relation to a 2007 article.

None of these notices mentioned that the Motherisk lab has been discredited.

They claim that, despite the fact that results were not confirmed with gold-standard testing, this did not affect results.

Dr. Ronald Cohn, Sick Kids pediatrician-in-chief, took issue with Koren’s assertion that the gold-standard lie “had no impact on the results” of the study.

That prompted Therapeutic Drug Monitoring, one of the journals, to also issue an “expression of concern,” a stronger statement, about one of the articles.

Jackowski, the editor of Forensic Science International, said he told a Sick Kids official that he would additionally publish a letter to the editor stating the hospital’s position. But it was never submitted, he told the Star. Sick Kids told the Star it did send the letter, but would reach out to the journal again to clear up any misunderstanding.

Meanwhile, Dr. Togas Tulandi, the editor of Elsevier’s Journal of Obstetrics and Gynaecology Canada, which published an opinion piece by Koren in 2017, said that he was unaware of Koren’s research misconduct until he was contacted by the Star. He said his associate is “looking into it” and the journal may “withdraw (Koren’s) article.”

Therapeutic Drug Monitoring, which Koren edited until 2015, has recently taken the most aggressive approach of any journal towards Koren’s articles; Christians said the current president of the society that runs the journal asked Koren to step down as editor after he learned of the Motherisk scandal. Koren “accepted the termination without question,” he said.

In 2017, the journal reviewed all of the roughly 90 articles Koren co-authored, and sent 19 to independent reviewers for additional scrutiny. In seven, the reviewers recommended action, such as requesting proof of confirmation testing and ethics-board approval from the authors.

Christians said that the follow-up on these actions was delayed by the transition to a new editor, but that it “is now being prioritized.”

Following the Star’s inquiries, Christians said he is now considering retracting the 1999 paper that resulted in the research misconduct finding against Koren.

***

Naylor said Koren’s case is an “ugly and outsized” example of the systemic problems with conflicts of interest and protecting the scientific record.

The “only way to move forward,” he said, is for institutions to keep better tabs on researchers’ financial relationships, ensure the penalties for not disclosing are clear and collaborate with journal editors to “work out a more explicit system” to share information and “oversight of the processes for correcting the scientific record.”

Naylor said it would be “a huge help if all industry payments made directly to physicians were simply disclosed publicly by the payers.”

Koren continues to submit manuscripts to journals to be considered for publication.

He published a study in August about a severe form of morning sickness. The paper acknowledges he is “a consultant for Duchesnay.”

In September, Koren was singled out among the world’s “hyperprofilic” authors in an article in Nature. These were researchers who wrote more than 72 papers in any year from 2000 to 2016 — roughly one paper every five days — which, the study authors noted, “many would consider implausibly prolific.”

Lead author, Stanford University professor John Ioannidis, said the study is an attempt to understand hyper-prolific authorship, for better or worse.

Koren responded to a request from the study authors to comment on his output. He credited teamwork, 16-hour work days, and two “very supportive work environments.”

“I perceive myself as an individual who is highly committed to scientific discovery,” he said. “I do not feel I have to apologize for my high productivity.”

With files from Tania Pereira, May Warren, Stefanie Marotta, Jason Miller and Brendan Kennedy.

Ryerson note: The Star’s investigation into Koren’s publications was conducted in partnership with Ryerson University School of Journalism students Stefanie Phillips, Emerald Bensadoun, Kate Skelly and Alanna Rizza.

Rachel Mendleson is a Toronto-based investigative reporter. Follow her on Twitter: @rachelmendleson

Michele Henry is a Toronto-based investigative reporter. Follow her on Twitter: @michelehenry

When 'average' isn't representative

https://www.thestar.com/news/insight/2016/01/16/when-us-air-force-discovered-the-flaw-of-averages.html

When U.S. air force discovered the flaw of averages

By TODD ROSE

Sat., Jan. 16, 2016

In the late 1940s, the United States air force had a serious problem: its pilots could not keep control of their planes. Although this was the dawn of jet-powered aviation and the planes were faster and more complicated to fly, the problems were so frequent and involved so many different aircraft that the air force had an alarming, life-or-death mystery on its hands. “It was a difficult time to be flying,” one retired airman told me. “You never knew if you were going to end up in the dirt.” At its worst point, 17 pilots crashed in a single day.

The two government designations for these noncombat mishaps were incidents and accidents, and they ranged from unintended dives and bungled landings to aircraft-obliterating fatalities. At first, the military brass pinned the blame on the men in the cockpits, citing “pilot error” as the most common reason in crash reports. This judgment certainly seemed reasonable, since the planes themselves seldom malfunctioned. Engineers confirmed this time and again, testing the mechanics and electronics of the planes and finding no defects. Pilots, too, were baffled. The only thing they knew for sure was that their piloting skills were not the cause of the problem. If it wasn’t human or mechanical error, what was it?

In the early 1950s, the U.S. air force measured more than 4,000 pilots on 140 dimensions of size, in order to tailor cockpit design to the "average" pilot. But it turned out the average airman didn't exist.  (U.S. NATIONAL ARCHIVES /THE ASSOCIATED PRESS FILE PHOTO)

After multiple inquiries ended with no answers, officials turned their attention to the design of the cockpit itself. Back in 1926, when the army was designing its first-ever cockpit, engineers had measured the physical dimensions of hundreds of male pilots (the possibility of female pilots was never a serious consideration), and used this data to standardize the dimensions of the cockpit. For the next three decades, the size and shape of the seat, the distance to the pedals and stick, the height of the windshield, even the shape of the flight helmets were all built to conform to the average dimensions of a 1926 pilot.

Now military engineers began to wonder if the pilots had gotten bigger since 1926. To obtain an updated assessment of pilot dimensions, the air force authorized the largest study of pilots that had ever been undertaken. In 1950, researchers at Wright Air Force Base in Ohio measured more than 4,000 pilots on 140 dimensions of size, including thumb length, crotch height, and the distance from a pilot’s eye to his ear, and then calculated the average for each of these dimensions. Everyone believed this improved calculation of the average pilot would lead to a better-fitting cockpit and reduce the number of crashes — or almost everyone. One newly hired 23-year-old scientist had doubts.

Lt. Gilbert S. Daniels was not the kind of person you would normally associate with the testosterone-drenched culture of aerial combat. He was slender and wore glasses. He liked flowers and landscaping and in high school was president of the Botanical Garden Club. When he joined the Aero Medical Laboratory at Wright Air Force Base straight out of college, he had never even been in a plane before. But it didn’t matter. As a junior researcher, his job was to measure pilots’ limbs with a tape measure.

It was not the first time Daniels had measured the human body. The Aero Medical Laboratory hired Daniels because he had majored in physical anthropology, a field that specialized in the anatomy of humans, as an undergraduate at Harvard. During the first half of the 20th century, this field focused heavily on trying to classify the personalities of groups of people according to their average body shapes — a practice known as “typing.” For example, many physical anthropologists believed a short and heavy body was indicative of a merry and fun-loving personality, while receding hairlines and fleshy lips reflected a “criminal type.”

Daniels was not interested in typing, however. Instead, his undergraduate thesis consisted of a rather plodding comparison of the shape of 250 male Harvard students’ hands. The students Daniels examined were from very similar ethnic and socio-cultural backgrounds (namely, white and wealthy), but, unexpectedly, their hands were not similar at all. Even more surprising, when Daniels averaged all his data, the average hand did not resemble any individual’s measurements. There was no such thing as an average hand size. “When I left Harvard, it was clear to me that if you wanted to design something for an individual human being, the average was completely useless,” Daniels told me.

So when the air force put him to work measuring pilots, Daniels harboured a private conviction about averages that rejected almost a century of military design philosophy. As he sat in the Aero Medical Laboratory measuring hands, legs, waists and foreheads, he kept asking himself the same question in his head: How many pilots really were average?

He decided to find out. Using the size data he had gathered from 4,063 pilots, Daniels calculated the average of the 10 physical dimensions believed to be most relevant for design, including height, chest circumference and sleeve length. These formed the dimensions of the “average pilot,” which Daniels generously defined as someone whose measurements were within the middle 30 per cent of the range of values for each dimension. So, for example, even though the precise average height from the data was five foot nine, he defined the height of the “average pilot” as ranging from five-seven to five-11. Next, Daniels compared each individual pilot, one by one, to the average pilot.

Before he crunched his numbers, the consensus among his fellow air force researchers was that the vast majority of pilots would be within the average range on most dimensions. After all, these pilots had already been pre-selected because they appeared to be average sized. (If you were, say, six foot seven, you would never have been recruited in the first place.) The scientists also expected that a sizable number of pilots would be within the average range on all 10 dimensions. But even Daniels was stunned when he tabulated the actual number.

Zero.

Out of 4,063 pilots, not a single airman fit within the average range on all 10 dimensions. One pilot might have a longer-than-average arm length, but a shorter-than-average leg length. Another pilot might have a big chest but small hips. Even more astonishing, Daniels discovered that if you picked out just three of the ten dimensions of size — say, neck circumference, thigh circumference and wrist circumference — less than 3.5 per cent of pilots would be average sized on all three dimensions. Daniels’s findings were clear and incontrovertible. There was no such thing as an average pilot. If you’ve designed a cockpit to fit the average pilot, you’ve actually designed it to fit no one.

Daniels’ revelation was the kind of big idea that could have ended one era of basic assumptions about individuality and launched a new one. But even the biggest of ideas requires the correct interpretation. We like to believe that facts speak for themselves, but they most assuredly do not. After all, Gilbert Daniels was not the first person to discover there was no such thing as an average person.

Norma was designed to represent the "ideal" female form, based on measurements collected from 15,000 young adult women. The statue on display at the Cleveland Health Museum was the creation of a gynecologist, Dr. Robert L. Dickinson, and his collaborator Abram Belskie.

A misguided ideal

Seven years earlier, the Cleveland Plain Dealer announced on its front page a contest co-sponsored with the Cleveland Health Museum and in association with the Academy of Medicine of Cleveland, the School of Medicine and the Cleveland Board of Education. Winners of the contest would get $100, $50, and $25 war bonds, and 10 additional lucky women would get $10 worth of war stamps. The contest? To submit body dimensions that most closely matched the typical woman, “Norma,” as represented by a statue on display at the Cleveland Health Museum.

Norma was the creation of a well-known gynecologist, Dr. Robert L. Dickinson, and his collaborator Abram Belskie, who sculpted the figure based on size data collected from 15,000 young adult women. Dr. Dickinson was an influential figure in his day: chief of obstetrics and gynecology at the Brooklyn Hospital, president of the American Gynecological Society and chairman of obstetrics at the American Medical Association. He was also an artist — the “Rodin of obstetrics,” as one colleague put it — and throughout his career he used his talents to draw sketches of women, their various sizes and shapes, to study correlations of body types and behaviour.

Like many scientists of his day, Dickinson believed the truth of something could be determined by collecting and averaging a massive amount of data. “Norma” represented such a truth. For Dickinson, the thousands of data points he had averaged revealed insight into a typical woman’s physique — someone normal.

In addition to displaying the sculpture, the Cleveland Health Museum began selling miniature reproductions of Norma, promoting her as the “Ideal Girl,” launching a Norma craze. A notable physical anthropologist argued that Norma’s physique was “a kind of perfection of bodily form,” artists proclaimed her beauty an “excellent standard” and physical education instructors used her as a model for how young women should look, suggesting exercise based on a student’s deviation from the ideal. A preacher even gave a sermon on her presumably normal religious beliefs. By the time the craze had peaked, Norma was featured in Time magazine, in newspaper cartoons, and on an episode of a CBS documentary series, This American Look, where her dimensions were read aloud so the audience could find out if they, too, had a normal body.

On Nov. 23, 1945, the Plain Dealer announced its winner, a slim brunette theatre cashier named Martha Skidmore. The newspaper reported that Skidmore liked to dance, swim, and bowl — in other words, that her tastes were as pleasingly normal as her figure, which was held up as the paragon of the female form.

Before the competition, the judges assumed most entrants’ measurements would be pretty close to the average, and that the contest would come down to a question of millimetres. The reality turned out to be nothing of the sort. Less than 40 of the 3,864 contestants were average size on just five of the nine dimensions and none of the contestants — not even Martha Skidmore — came close on all nine dimensions. Just as Daniels’ study revealed there was no such thing as an average-size pilot, the Norma Look-Alike contest demonstrated that average-size women did not exist either.

But while Daniels and the contest organizers ran up against the same revelation, they came to a markedly different conclusion about its meaning. Most doctors and scientists of the era did not interpret the contest results as evidence that Norma was a misguided ideal. Just the opposite: many concluded that American women, on the whole, were unhealthy and out of shape. One of those critics was the physician Bruno Gebhard, head of the Cleveland Health Museum, who lamented that postwar women were largely unfit to serve in the military, chiding them by insisting “the unfit are both bad producers and bad consumers.” His solution was a greater emphasis on physical fitness.

Daniels’ interpretation was the exact opposite. “The tendency to think in terms of the ‘average man’ is a pitfall into which many persons blunder,” Daniels wrote in 1952. “It is virtually impossible to find an average airman not because of any unique traits in this group but because of the great variability of bodily dimensions which is characteristic of all men.”

Rather than suggesting that people should strive harder to conform to an artificial ideal of normality, Daniels’ analysis led him to a counterintuitive conclusion that serves as the cornerstone of this book: any system designed around the average person is doomed to fail.

Daniels published his findings in a 1952 Air Force Technical Note entitled The “Average Man”? In it, he contended that if the military wanted to improve the performance of its soldiers, including its pilots, it needed to change the design of any environments in which those soldiers were expected to perform. The recommended change was radical: the environments needed to fit the individual rather than the average.

Amazingly — and to their credit — the air force embraced Daniels’ arguments. “The old air force designs were all based on finding pilots who were similar to the average pilot,” Daniels explained to me. “But once we showed them the average pilot was a useless concept, they were able to focus on fitting the cockpit to the individual pilot. That’s when things started getting better.”

By discarding the average as their reference standard, the air force initiated a quantum leap in its design philosophy, centred on a new guiding principle: individual fit. Rather than fitting the individual to the system, the military began fitting the system to the individual. In short order, the air force demanded that all cockpits needed to fit pilots whose measurements fell within the 5-per-cent to 95-per-cent range on each dimension.

When airplane manufacturers first heard this new mandate, they balked, insisting it would be too expensive and take years to solve the relevant engineering problems. But the military refused to budge, and then — to everyone’s surprise — aeronautical engineers rather quickly came up with solutions that were both cheap and easy to implement. They designed adjustable seats, technology now standard in all automobiles. They created adjustable foot pedals. They developed adjustable helmet straps and flight suits.

Once these and other design solutions were put into place, pilot performance soared, and the U.S. air force became the most dominant air force on the planet. Soon, every branch of the American military published guides decreeing that equipment should fit a wide range of body sizes, instead of standardized around the average.

Why was the military willing to make such a radical change so quickly? Because changing the system was not an intellectual exercise — it was a practical solution to an urgent problem. When pilots flying faster than the speed of sound were required to perform tough manoeuvres using a complex array of controls, they couldn’t afford to have a gauge just out of view or a switch barely out of reach. In a setting where split-second decisions meant the difference between life and death, pilots were forced to perform in an environment that was already stacked against them.

Excerpted from The End of Average by L. Todd Rose © 2016. Published by HarperCollins Publishers Ltd. All rights reserved. Illustration used by permission of the Cleveland Museum of Natural History.