Some comments have touched on a few of these points but I’ll try to bring them together. So first, yes the headline is a joke (BMJ Xmas has satirical content),

Some comments have touched on a few of these points but I’ll try to bring them together. So first, yes the headline is a joke (BMJ Xmas has satirical content), but it also has a history beyond the immediate point of the paper—that sometimes RCTs can’t accrue properly to a control arm to fairly evaluate an intervention. Quick points: - There’s a history to this analogy and paper within biomedicine and this journal (BMJ) from a 2003 article, which I’ll get to. - Parachutes are a dangerous metaphor in medicine, where almost nothing has an absolute risk reduction of >99% (note: not 100% because, yes, a handful of people have survived falling from altitude without a parachute), especially over the time-frame of a matter of hours. - This should not be a call to stop attempting RCTs (which is the conclusion some commenters have made), but an exhortation to find ways to create better ones when conditions are challenging. Frequently, objections to doing an RCT because “how could we withhold X from the control arm!”, are not as obvious once the data are in. Some background: beyond Retraction Watch looking for outright fraud, there’s a movement toward opening trial data for analysis because abuses in RCT design/analysis/reporting have gotten more criticism and attention lately. This is happening at the same time as the FDA has been moving toward lower/faster evidentiary standards for approval (see Sarepta controversy and general guidance in 21st Century Cures Act to allow drugs to market with earlier phase evidence and based on “surrogates” like was the tumor 2in vs 3in bigger vs hard endpoints like “did this person die later than the control”), so it couldn’t come at a better time. The broader point is that the 2003 “parachute” article in the same journal (BMJ), was frequently incorrectly understood / used. While “parachutes” makes an easily understandable headline, it is almost totally unrelated to the field of medicine where we rarely have a shot at doing something as obviously lifesaving as making someone hit the ground at 10 mph vs 120 mph. The problem is that people have cited the 2003 paper mentioned in the thread to justify a number of interventions that ended up not being better than prior care. The interventions were started in good faith because was “obvious” to their creators that doing X would be helpful (spoiler: it usually wasn’t or wasn’t that beneficial). A lot of this is cribbed from Vinay Prasad, who has a twitter thread about this: https://twitter.com/VPplenarysesh/status/1073298754298556416 https://twitter.com/VPplenarysesh/status/1073298754298556416 He is a controversial figure, but I think he does a good job of hammering home some important skepticism about a great deal of medical literature and practice to a broad audience. I’d appreciate hearing objections to the above, btw.