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Hi and welcome to another podcast from the sense of evidence based medicine, evidence based health care program.

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Today, David Noonan to myself are joined by Professor Paul Glacier.

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And we're going to spend some time today talking about Paul's experience of

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leadership and his work in capacity building through teaching and supervision.

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Paul, thank you so much for joining us today. Can I just ask you to introduce yourself and tell us a little about your work?

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Well, it's a pleasure to be here, Carol. And I'm currently on the Gold Coast at a place called Bond University because the surf's pretty good here.

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And I direct a thing called the Institute for Evidence based Health Care, which mostly focuses on research.

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But it comes out of the work I did at the Centre for Evidence based Medicine in Oxford.

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So the central interest still is very much on how do we get better evidence in the hands of practitioners at the coalface.

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Great. Thanks. And have you been surfing today? Yes.

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It wasn't great this morning, but still in lockstep with how we get here.

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So of course, we know you really well and we work with you as well.

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One of the reasons we wanted to talk to you and take some time out was to hear a bit more about your journey.

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And, you know, you've talked about your time in Oxford. Obviously your work now in Australia as well on the Gold Coast.

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Can you tell us a little bit more about about your journey as in, you know,

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from an earlier stage and your your development through that journey to where you are now?

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Sure. So if you don't mind, I might go back quite a long way.

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So when I was a young post Ph.D. researcher and I got very interested in how research got into practice or influence policy.

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And I had the good fortune to meet Dave Sackett, who's one of the fathers of evidence based medicine, when he was visiting Sydney.

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And then a couple of years later I visited him at McMaster and did a ward round.

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This is before the term evidence based medicine had been coined by Gordon Knight, so to speak, about 1990 and did a ward round with Deborah Cooke.

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The dive took me on.

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And one of the fascinating things was just the way that she managed the whole process of the war ground and introduced evidence into it.

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And a dramatic example of this was a patient who was anaemic and we were discussing whether it might be iron deficiency anaemia.

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And in the back of the paper chart was the meta analysis of the accuracy of ferritin for predicting iron deficiency anaemia.

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And apparently this was relatively routine and McMaster had been doing this for a while, which was to bring paper copies to the point of care.

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Now, of course, we've moved on then. This was the days before we had PubMed even, and you could have your handheld.

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But it was a dramatic example of trying to bring evidence to the point of care and the best evidence to the point of care.

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And I can tell you all about the rest of the ward ran,

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but it was a dramatic moment for me because I saw, yes, actually, you can connect these two worlds.

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So that got me very interested intellectually. Went back inspired by Dave and retrained in medicine, not been out of clinical practice for a while.

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Did emergency department work on Friday evenings for quite some time and then retrained as a

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general practitioner interested in how do you get evidence based medicine into primary care?

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And that's been a zig zag journey, I think, as all clinical and academic careers are.

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But the central question has always been how do we better use evidence at the point of care and experimenting with different ways of doing that,

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running journal clubs, getting people to use logbooks of questions, training people in evidence based medicine,

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giving them pre appraised materials, all sorts of different ways of doing it.

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And I think that experimentation is very important for us to progress in evidence based

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medicine because there's been a lot of change since the tort term was coined by Gordon Gott.

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But we still have a long way to go to. Yeah.

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And you mentioned being inspired by David and Deborah.

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And so what was it about them that that really grabbed you?

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What was it about? You know, what they did, what they said that inspired you?

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Hmm. Well, Dave Stack, it was just a lovely guy and just had very interesting ways of looking at the world and treated people differently.

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He was an excellent mentor. In fact, he and Sharon Strauss, Sharon was this registrar at the John Radcliffe for quite some time,

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and then she went back to Canada to continue evidence based medicine.

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He and she wrote a book on mentoring.

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And of course, they did a systematic review of all the literature on mentoring to look at what

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the best evidence for mentoring was in order to inform the writing of the book.

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And that was very typical of Dave, that he took something that was very important to people,

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a subject like mentoring, but then had this, well, let's try and get evidence to see what we could do to improve it.

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So he was very much into the scientific method, if you like, of experimenting,

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getting best evidence and using that to inform important human problems.

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And he inspired other people to take that open minded, sort of sceptical but not closed minded attitude towards everything,

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and thinking of constant experimentation with things, constant learning and trying to improve.

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For the benefit of patient care. Yeah.

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So I was just about to say so the underlying principle was to improve care, but it was also the way that he went about.

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That also inspired you? I mean, you mentioned first thing you said or one of the first thing he did was he was just a lovely person.

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And and I'm just I'm just curious. And and you also mentioned mentoring and and enjoying what he did to improve care.

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So what elements do you think of those or of other people that you've been inspired by?

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Have you taken on board yourself as a leader? Oh, well, I suppose I'm a mishmash of all sorts of excellent people that I've met throughout my career.

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I could go through a long list of them, but you learn things from the good people that you meet along the way and certainly Dave.

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Ian Chalmers I would name is another one as this being people who'd been very influential on the way that I go about both research,

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work, patient care and everyday life in fact. That's great.

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And Sharon, as you said, Sharon Strauss, as you mentioned.

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So along this journey, you know, you described it as a mishmash of, you know, you also changed track in your clinical you know,

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you said you went from emergency medicine to general practice as well and became more of a generalist with that specific focus,

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as you said, on using evidence to improve clinical care like Dave Sacco as well.

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But in your own practice. Along that journey.

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So after, you know, working with Dave, at what point did you feel as if, you know,

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I think I'm ready to now start doing things and perhaps inspiring others?

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Was it was it before you came to Oxford or what time what prime time point in your career did you start for?

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You know, I want to I want to make it my own thing of this. Mm.

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Yeah. So it was well before Oxford.

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So I think the first point at which I was really doing it was from I took up a position at the

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University of Queensland teaching the medical students clinical what was called clinical epidemiology.

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We can call it evidence based medicine because the term was it was about then

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it was being coined and the medical students actually helped with that too,

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because some of the stuff that I was teaching them I think was too technical.

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So they complained about that.

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And so I listened to their complaints, but there was stuff that they really appreciated as well, though not necessarily at the time.

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One of the interesting things has been just meeting people who have been my medical students more

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than a decade ago and saying how much they now appreciated having the clinical epidemiology,

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teaching and how useful it's been in their career.

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And they wish they'd listened more at the time because I didn't realise how important this was because they said far more

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important than many of the other things that they have been thinking were important in the sort of biological basis of medicine.

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So after that, I gradually refined what I was trying to teach, in fact,

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of being forever trying to refine what I teach to students based again on a deep second principle.

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One of the things that Dave used to say is that he wouldn't teach people stuff that he wasn't doing himself.

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Another words, unless he'd worked out how to make this thing practical in patient care, he wouldn't tell people how to do it.

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And that's why he stepped back when he stopped practising from from teaching bedside evidence based medicine.

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So that's what I actually gradually moved to was saying, Well,

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what is it that I do and what is it that I think might be helpful for others trying to use evidence in their own practices to learn about?

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And that's a question I'm still trying to answer. By the way, there's no end to this.

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Evidence based medicine is still evolving. We're still learning more about how to do this better.

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And it will keep changing and keep improving, I think.

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I mean, I think that's an important point. Well, I'm just going to pick up. You know,

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I recognise I was one of those medical students in London who wrote to you and David

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meant and that ended up my connection to the centre about maybe 20 years ago.

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But looking back, some of you said about it constantly being an opportunity to learn and and I just wanted to pick up on.

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I mean, you say you say, you know, you tell yourself this.

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And so there's obviously an element of reflection, self-reflection in your constant self, in your work.

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How important is that as a as a developing career scientist and then then a leader?

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I mean, do you how do you work that in terms of defining and helping you shape what you do next?

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Yeah. So I think it's, as I described, a process of constantly trying things yourself,

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first of all, or working with a small group of other people to try out something.

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And then once you think you've got something, then moving that into the teaching.

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I'm so an example of this that we'll come to a bit later on is what's the role of shared decision making and evidence based medicine?

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And I've been pondering that for years and often with tweeted at the end.

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So for example, when I was in Oxford, one of the things that we would do is at the end of a critical appraisal, get the students to role play.

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So okay let's let's now actually move this pretend you want to explain the results of

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this study to a patient or at least what the the impact of the treatment would be.

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Let's try that and then get them to reverse the roles, like give feedback to one another,

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the class would give feedback, etc. like Tammy Hoffmann has been suggesting, Well, why don't we start there?

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So reverse the steps of evidence based medicine and start with the process of teaching, shared decision making,

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and then ask where do these numbers come from as a way of motivating the process of evidence based medicine?

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Can I believe the numbers that I'm using in a shared decision making process?

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And we've done in one experimental workshop with that from about two years ago, which was very well received.

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But it's an area I think it's promising but needs more research.

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That's fascinating. I mean, one thing that's clearly coming through the discussion with you is that you you like to be innovative.

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You like to try things that are perhaps following your reflection, as you said,

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and then ideas and then putting them into practice, even just testing them in little pilots.

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How do you deal with with with moments when they don't work sometimes when the pilots and the ideas don't come off because, you know, it happens.

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You know, if you're going to leave things teaching, research, you know, teams as well, you're going to put ideas, but they don't always kind of.

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How do you manage that? Yeah, well, you you can't be an innovator unless you can accept failures.

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Because most, most things won't work, particularly when you first try them.

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You've got to be prepared to to try various different ways of doing it.

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But I would always try and do that in a safe environment.

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So I put it with a group of people that, you know, that you feel comfortable with once you think you've got a version of it that really does work.

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That's when I might go and do you know, larger experiments, large studies with it, or start teaching using that process?

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But yeah, you've got to make sure you've got a safe way of filing.

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Yeah. Now that's a great way. That's a great framing of that, that point.

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And I'm curious, too, because you mentioned, you know, the safe environment,

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working with small, intimate teams to begin with and then expanding out from there.

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What sort of what sort of characteristics do you think those team members would say that you have as a leader and an innovator?

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What sort of things do you think that they see in you that maybe others can learn from?

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Oh, that's probably for them to say. So just guessing some of the things, I think I would be seen as relatively creative.

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But that's just because I'm prepared to innovate. I don't think I'm particularly creative,

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but I'm always pondering on ways that you could improve things and being prepared as a side to fail to learn from others, to always look at will.

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Have other people tried this? So not to think that I can do every everything from scratch.

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It's always worth looking at what other people have done, including within other disciplines as well.

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So looking even outside medicine sometimes to find inspiration for looking for new ways of doing things.

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Some examples of that is one of my great inspirations,

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I think has been the Hull Quality Improvement area, which came out of industrial processing and Deming,

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some working Japanese back in the 1950s and sixties, and Deming's principles,

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which is really of continuous improvement, which is heavily influenced my approach to things.

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I mean, that's why I said you're right about the quality improvement.

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And again, it signals your radar an awareness of new techniques and new ideas emerging,

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as you said, even from other fields we can bring in to health care.

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And that fits with that innovation that you mentioned. And in terms of wider collaboration, just could you talk to us and, you know,

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we talked and you sent us some some thoughts and notes about collaboration.

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And I loved some of your frameworks about how do you choose how to collaborate with and who to collaborate with and what are you looking for?

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Maybe can you just talk us through that? I think it would be really interested in that.

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Yeah. Okay. So I think the first thing to say is that not everybody is a good collaborator.

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Some people see the synergy that occurs in a collaboration so that it's actually a win win.

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You get more than what you both put into. It comes out of the collaboration.

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But some people are what my wife calls zero sum thinkers.

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If you win, somebody else must lose.

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And I think that's always one of those tensions in working out who to collaborate with, who is a good collaborator, to be a good collaborator.

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They've got to be good to work with.

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That doesn't necessarily mean they're a pleasant and nice person,

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but that you can work with them and they're sort of intrinsically good hearted and that they do not think

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in a zero sum game fashion that they would be open and reasonably honest with you about the process.

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You can work out what your thinking styles are.

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So that there's an important thing is that there's an investment that goes into developing any collaboration.

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So in that regard, you want to work out early on whether this is a group or an individual that you want to collaborate with,

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that you think you're going to get something out of. It's like choosing friends really in a way,

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because you need to be prepared to invest that time in the people you think will work out as good collaborators.

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That's created by Paul. Final question from me and then I know David wants to talk to you about your teaching and capacity building.

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But listen, I mean, there's some amazing work.

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I mean, a collaboration, basically having a thick skin and not being afraid to try and be innovative and accept failure.

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That was a that was a great insight.

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I mean, a lot of a lot of people will be at different stages of their career to tell you who may be listening to this.

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Many will be inspired by your work, other works and other people's work in health care as in evidence based health care.

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What sort of final tips or thoughts might you offer them about developing their career

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and thinking about themselves as the next generation of leaders and evidence base?

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Any any final tips that we haven't covered from you that they can maybe take away?

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Oh. Okay. So here's one general one that I was seeing with one of my colleagues last week,

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which is I usually want to be working in a couple of different areas because you'll often find one area is working well and things are

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starting to bloom in that area and that sort of keeps you going while you get through the difficult ones of the other project areas.

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Now, having said that, you have to, I think,

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work in an area for probably at least two or three years before you're really getting sufficiently

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deep knowledge in that area to really start making some some important contributions in the area.

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So you have to be prepared to be in it for the long term. So that means if you're picking up a new area, you want to keep it.

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Let's say you work in three areas. You want to keep two standard areas whilst you develop that third area.

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You can't just start a new suite of things straightaway because you will need the collaborations,

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the knowledge, etc. in that new area in order to be able to develop it.

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But don't be afraid of doing that. But just keep something. Keep all the irons in the fire at the same time.

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Yeah. So diversify your collaborators and your areas as well.

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Paul That's been fantastic insights into your journey and your leadership journey and your application.

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I'm going to hand over to David now, who wants to talk a bit bit more about your teaching experience.

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That's okay. Sure. Thanks.

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Well, thanks. Bye. Bye. Carmel?

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Yeah. No, I'm starting to run out of Post-it notes with all that, with all the tips and the things.

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And I'm sure others are just writing down all the fantastic stuff that's been coming from that conversation.

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Generally leadership. But actually it's interesting.

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I'm taking notes, but a lot of my notes are actually around around teaching a lot of things you've talked around and the examples you've given,

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Paul, have been have been, you know, I would say mentoring and teaching type examples.

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I don't know if that's deliberate of that. If that's just with IBM and ABC, they go hand in hand.

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What I can certainly is inspirational because the reason I'm talking to you now and where I am, where I am,

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is because you gave me the first lecture I ever had on evidence based medicine when I arrived at the Centre for Space Medicine in 2010.

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You might not know this, but I attended I attended your one day intro workshop and and that was it that,

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that I use this story to tell people how my journey only came about.

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And I was lucky enough to have pulled as you show me the ropes and inspire me from the first from the first point.

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So I can certainly vouch for the fact that inspirational is definitely going to be one of the characteristics that comes out.

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I do want to get your general philosophy on teaching and education and having

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just sort of described how a lot of your examples come from looks like teaching.

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So just just what's your general philosophy towards the importance and relevance of teaching of EPM and EBC?

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So do I have a general philosophy? I'm not really sure.

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I think I was starting to cover it by saying, what is it about evidence that can help you with patient care?

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And that's the fundamental problem. And one thing I should have said earlier in the advice about the theory is to always focus on a specific problem.

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Some people get wrapped up in a particular process like shared decision making or evidence synthesis or whatever it is,

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and that's great, but you've always got to look to the end point that you're after.

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What's the end game of this? And that is to try and bring evidence to inform better decisions at the point of care.

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I want all things that, you know, in order to improve you use evidence better in patient care.

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So let's go back to the quadrant for a moment.

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And is that serum ferret and meta analysis that's in the back of the chart?

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Like you can't as a layperson or normal, most medical students just pull that out and start using it.

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So there are some fundamental things that you're going to need to know first in order to use it.

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You will need to know what a sensitivity and specificity is. For example, you need to know what a meta analysis is.

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You'd have to have some ideas of critical appraisal in order to pull out from that

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article the things that are going to be useful to the care of that specific patient.

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So and this is an ongoing question in evidence based medicine,

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I think is so one of the fundamental things that you do need to know in order to use evidence at the point of care.

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You can't go in as a blank slate. You have to have some fundamentals of clinical epidemiology,

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but you probably don't need to know how to calculate a nice square statistically or heterogeneity in a systematic review.

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You may need to want to know how to interpret, but not how to calculate.

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Okay, so there's a lot.

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The vast majority of stuff within sort of statistics, epidemiology, etc. you are not going to have to know for a medical student or as a clinician.

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But there are some fundamentals that you need to know before you can start interpreting.

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And then the other part of it is the practical aspects of the process of doing this.

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So what does it look like to be an evidence based practitioner?

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And there isn't one magic solution to that. Again, it will actually vary by speciality, and you'll probably have to need several processes.

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So we talk about the push pull, for example, that sometimes you'll need to get evidence that you don't currently have.

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To answer a specific patient question. Other times, the evidence will come to you.

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The latest issue of the BMJ might come to you or the Lancet, and you'll say, Can I believe this new thing?

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I had never thought about it before, but now they're suggesting such and such might work.

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This new surgical treatment or this new physiotherapy and being able to appraise that as well.

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So you'll need a bag of tricks. And it might be keeping a log book, knowing how to run a journal club,

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knowing which people to to ask for advice, and then asking them how they know that.

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What's the evidence on which you base that piece of advice?

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Thanks, Paul. And really, really,

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really key key tips that I think and I'm just sort of touching on some of the points you made about keeping an idea in mind of the original,

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if you like, task BBM was was. How do we how do we inform and inform best practice of of of of our of our practice via via

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evidence and and what skills that you therefore need in order to help you achieve that goal.

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You've that you're always keeping that top end goal in mind. I find it interesting we put out a call in the BMJ IBM Journal recently for.

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So what's the next paradigm shift in the teaching education of IBM?

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Because we've got to be thinking about it because it's, you know, the conditions under which IBM was launched are not the same now.

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So what's changing in the way that we educate, in the way we do this well?

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And and as part of the background for that, I read and you touched on it Gordon guy,

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it sounds like it's paper in 1992 where they introduced IBM and I hadn't it hadn't stood

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out to me enough before until I really dived into this paper that even in the title,

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it's called A New Approach to Teaching the Practice of Evidence Based Medicine.

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And then I did a bit of a sort of word analysis of how many words are related to teaching and education and how many words related to practice.

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And there are more words around and more and more teaching and education of this topic.

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I think that's what's come across in in your points there. You've touched across a couple of points that in some of my next questions,

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which was going to be one around in your 2000 article where you write and I still use it in my teaching as the example,

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a 21st century clinician who cannot critically read the study is as unprepared

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as one who cannot take a blood pressure exam in a cardiovascular system.

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And, you know, I use that as as a class, as an example all the time in my teaching.

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But I wonder if you still stand by that quote.

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And I only say that because we were both at the EBC conference in Sicily in 2009 Tipene and you were there via Zoom,

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if I recall, cause I remember watching you, but Gordon Guyot,

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who we all know and the ones we should focus on,

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and he was referring to he was referring to the fact that he wrote about this in in actually in the BMJ in 2000.

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But but he's taken 20 years of that time to try and get the message out that we need to be thinking about different types of ways of teaching,

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about what students need to know. And he's talking about pre pre appraise evidence, really.

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So how to how to identify trustworthy sources that you then rely on them to have done the sort of skills of the appraisal for you.

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And then you just have to work out how to then apply that and maybe know a little bit about the numbers.

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So you want to get your thoughts on is that where we should be going with the teaching now sort of really focusing down on the

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pre appraise stuff and and the skills to judge trustworthiness and where that might lead us and some of the pros and cons.

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Mm hmm. So I think Gordon makes an important point that that most people will probably not routinely be

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critically appraising evidence as their primary way of keeping up to date the way that Dave Sackett did.

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I still think that it's an important skill to teach and it reminds me a little bit of microbiology.

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You know, most microbiology is done for you. You just send the sample off to the laboratory and back comes this report.

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And you don't know how to. You don't have to know how to plate things out, etc. or do PCR.

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All you need to know is how to how to get the sample, when to get the sample, and how to interpret the result.

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But you still need to understand some microbiology. Well, it's not like you just hand the whole thing over to the laboratory and say, Well,

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you guys can take care of this and just give me the answer to I give you the patient antibiotics or not.

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How could that have been a false positive sample? But I take it in the right way.

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Should I repeat this to interpret the results of time? Back to you.

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And I think we're still struggling with how much people know,

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need to know about clinical epidemiology concepts in order to be able to use it in practice.

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So I think Gordon's right that we should focus on using the pre appraise topics.

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That's very important, but they'll still be holes in that because you'll have delays, for example,

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while somebody pre appraises that for you, it might take several months or it may never occur for a topic that's relevant to you.

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There may not be a pre appraised version of that ever.

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And it makes me think of an emergency journal club that I held several years ago

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when the Women's Health Initiative trial came out on hormone replacement therapy.

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So what happened was that the JAMA article came out, it hit the headlines, and we were getting inundated with phone calls.

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So we had a regular journal club, but we held an emergency journal club that lunchtime to go through the paper so that

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we could answer the questions that the women were bringing in signing up about.

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The pre surprise stuff. Well, there was a guidelines on this.

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It took the the the purveyors of the guideline about two months to take it down and I never replaced it.

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So that's about all you ever got in the terms in terms of the pre appraised evidence and experts,

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so-called experts were saying all sorts of contradictory things about the study.

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So we felt we needed to get down ourselves and be able to appraise that piece of evidence.

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And that's probably still true today, I think, in the pandemic, for example.

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And I didn't want to touch on this too much, but think of all of the therapies that have been suggested.

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And sure, there are some great groups producing those pre appraise materials now and trying to keep the guidelines up to date.

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But to even understand which group you should be listening to and what the basis for their evidence is,

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you still need some fundamental ABM concepts in clinical epidemiology,

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concepts about trials and systematic reviews and confidence intervals and interpreting the quantitative things as well,

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the relative risk reduction or absolute risk reduction.

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So I don't think we can abandon it completely,

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but we need to incorporate more of the pre apprised materials and good guidelines and being able to know what they are.

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And I'm very onside with Gordon John about the need for guidelines to do better,

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which is why he really introduced grade to make sure that first of all, there was a standard way of looking at evidence.

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And second, that guidelines were in general, in general evidence based,

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and you could trust that they were if they were using a reasonable grade process.

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Yeah, I know, cause you touched on, like, the point where you're talking about little,

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little nuggets that tell you whether something is is doing the thing the way you think it should be done.

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So doing the right kind of appraisal, doing the steps that you would expect.

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But I just want to say, Paula,

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on the back of your response to the question around what should we be teaching an IBM and should it be a focus on preparation?

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And you touched on a point of some really good sort of.

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Points is a little,

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little litmus tests of whether a resource is doing best practice in terms of providing you with the best available evidence and doing a good job

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of appraising it and and some some markers like are they using a system like grade or something similar to show you the certainty of evidence?

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And and I think that's really important because a good example of where I feel like

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if we don't have those skills and we just rely purely on pre appraised trust,

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trustworthy evidence, is that what happens when that trustworthiness is lost?

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And as you know, it takes years to build trustworthiness, but you can almost lose overnight.

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And a good example was watching on Twitter was the recent saga with the Cochrane Group.

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And you know some folk will be and you're you're probably familiar self Paul with the issue around some of the some of the decisions

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that Cochrane was making at the senior level and how that played out on Twitter over a particular Cochrane review around HPV vaccines.

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And and and you just saw you saw clinicians on there tweeting going I used to, you know, I trusted Cochrane.

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What do I do now?

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And that that for me, if I was to dive into that, that would be a great study just to ask these people, well, what do you normally do?

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How do you normally so maybe they haven't got those the skills to be able to to read that primary evidence that the Cochrane reading

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or something I don't know I thought that was just a really interesting test of this stress test of this idea of trustworthiness.

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Yeah. I think that really speaks to the idea that, you know,

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we would really like some authority that knew the truth about everything and we're never going to have that.

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So whatever, whatever trusted authority you have, it's always going to fail at some stage.

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You know, Cochran gave sidekick Jamal Karl the eventually they're going to say something wrong then.

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So you have to be the person that says, okay, what's the basis of that and how do I decide?

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And not put. So one of the worries,

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I think with moving to pre appraised and guidelines is being the way of doing things is it's a move back to authority based medicine.

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So I still think you need to be able to look at that evidence yourself, at least for the,

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you know, does this contain the right sort of things of thinking the right way about this?

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Yeah. Oh, fantastic. Okay. So for my last point, Paul, it's something that I've been meaning to talk to you for ages about.

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I just never actually got around to it. So I'm really glad that I've got the opportunity to talk to you about it today.

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But in 2015 you wrote a blog for the BMJ about six proposals for evidence based medicine's future, if you like.

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Who would have known five years later that IBM's future was really being tested right now?

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But, you know, they were all really great suggestions.

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And but one particularly particularly caught my eye with with regards to my teacher in

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education that's when I put that one on was was this idea of IBM practice laboratories.

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And it sounds like you've touched upon this idea of experimentation anyway throughout the throughout the conversation.

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And, and and you wrote you said, we need to better record, evaluate and teach the different ways of doing IBM in the clinical setting.

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And I'd really like to hear just how have you how have you taken that idea

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forward from 2015 and in particular around the teaching and education aspect?

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And I'm probably thinking around the sort of shared decision making stuff that you may have done or there may be others,

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but that's the stuff that I've seen. But what's what laboratory have you created and what things are you doing in terms of and how have you done it?

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I think our listeners were really interested to work out how have you gone about this IBM laboratory idea, particularly from a teaching perspective?

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Okay. So just the genesis of the idea.

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First of all, while I was still at the Centre for Evidence Base,

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that is one of the things that I did in the last couple of years was to interview a whole series of people,

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most of whom had been either teachers on the the the teaching evidence based medicine course or had attended that.

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And what I was interested in is what does evidence based medicine look like to an obstetrician

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or an oncologist or a neonatologist or a general practitioner or general physician,

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etc., etc. And so I interviewed a whole series of people.

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And boy, the really interesting thing was how different they were.

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To give you one flavour of this, Bob Phillips, who used to teach regularly on the course, have become a paediatric oncologist.

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And he said, actually,

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they didn't look up very evidence very much at all because so many of the kids were in the clinical trials that virtually every child,

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though a treatment, they were either in the lightest trial or they were using the protocol of the better arm from the recently completed trials.

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And that's the way kids oncology has worked.

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So it's not the published literature. They're actually at the edge of the research all the time, at least the good units.

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And so it's like 50% of kids under the age of six with childhood cancers are actually enrolled in clinical trials.

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It's just staggering, particularly for me as a GP.

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The idea that 50% of my patients would be in clinical trials is just unbelievable.

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So that's one extreme. And then there are other groups that I met that were using just the Cochrane Library,

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particularly for the the perinatal care area, where in fact Cochrane had pretty good coverage because of where it came from.

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They've grown out of Ian Chalmers Oxford database of prenatal John effective care of pregnancy and childbirth.

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And so that group's always kept most of their reviews up to date.

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And so you could rely on it for me as a general practitioner.

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No such Cochrane Field existed.

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So a lot of the things that would everyday problems for a general practitioner were not answered by Cochrane, so we needed a different approach.

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So the emphasis here is that, is that there isn't one particular way of doing it.

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I mean, it's different for different fields and even within a field people can approach that whole thing in different lines.

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So having said that, what have I been doing recently?

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When I arrived here in Australia, we started looking at getting journal clubs set up in general practice.

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And because they most people had had no prior clinical epidemiology training,

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we had to do it a bit differently to the way I had been doing it in Oxford.

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Running a journal club because it was a much less clinical epidemiology literate groups.

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And in fact our partner in Sydney, Lyndal Trevena, who's a GP there,

387
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was doing it mostly by presenting the the equivalent of a summary of findings title sort of again starting at the end point or in fact sometimes that

388
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start with decision aids as as the thing that they would look at in journal clubs and then they might work backwards from there because it'll say,

389
00:39:41,110 --> 00:39:42,640
Well, where did this come from?

390
00:39:43,090 --> 00:39:51,220
But it was starting with the endpoint was actually a way of doing it a little like we're talking about earlier teaching, shared decision making first.

391
00:39:52,760 --> 00:39:58,909
So that's been an interesting experiment and I've also been working with the local hospital group as well.

392
00:39:58,910 --> 00:40:06,180
And again, very different styles of of evidence based practice and doing things within different groups.

393
00:40:06,200 --> 00:40:17,690
The latest project is trying to get clinical decision rules socialised and normalised into the emergency department.

394
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And there is.

395
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Making things easier for people, but also making sure that appropriate education is occurring around the interpretation of the decision rules.

396
00:40:34,680 --> 00:40:41,210
Can I just jump from there to one other thing that's related to this, which was a question you'd suggested to me,

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which is what is what do we think ABM should now focus on what could have been missing from the evidence based medicine teaching agenda?

398
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And for me, it's actually one simple thing that I wished I'd focussed on much, much earlier.

399
00:40:56,150 --> 00:40:58,729
If I went back to the beginning of my teaching career,

400
00:40:58,730 --> 00:41:08,690
I would add that simply the idea of teaching about risk probability charts ideas because in a way that's fundamental to ABM.

401
00:41:09,900 --> 00:41:16,020
I actually see far too much use of Ebert so-called evidence based medicine that I

402
00:41:16,050 --> 00:41:20,430
call yes or no evidence based medicine or black and white evidence based medicine.

403
00:41:21,030 --> 00:41:25,910
Does the treatment work or not? Okay.

404
00:41:27,050 --> 00:41:33,560
Critical appraisal. It passes all the tests, it's blinded, it's randomised and the P-value is less than 0.05.

405
00:41:33,560 --> 00:41:34,970
It works. So we should give the treatment.

406
00:41:37,070 --> 00:41:45,080
And that is for me, it's not quite the antithesis, but it's a very wrongheaded way of trying to apply evidence based medicine,

407
00:41:45,530 --> 00:41:48,920
particularly if you think about that in terms of shared decision making,

408
00:41:49,340 --> 00:41:57,260
where what you want to do is explain to the patient what would happen if we just waited and see what's the watchful waiting approach.

409
00:41:57,590 --> 00:42:04,309
And here are the options. And here's what the probabilistic benefit or the timeframe benefit is.

410
00:42:04,310 --> 00:42:11,810
If we went to this treatment rather than this treatment and that quantification of both the risk

411
00:42:12,140 --> 00:42:18,320
and also how the probabilities change by using different treatments I think is so important.

412
00:42:18,680 --> 00:42:25,930
And it's a fundamental of evidence based medicine that we need to teach better to get people to think about risks,

413
00:42:25,940 --> 00:42:29,990
chance, etc., as a fundamental part of their thinking.

414
00:42:30,440 --> 00:42:35,480
And then think about how do you get those numbers? Wow.

415
00:42:35,530 --> 00:42:40,299
So sort of flipping it back to to what what do these numbers actually mean?

416
00:42:40,300 --> 00:42:45,820
And then how, you know, how much can we trust them? And that's where the critical appraisal skills come in to know how well you can trust them.

417
00:42:45,820 --> 00:42:53,830
But then you're absolutely right. Again, for me, you know, that whole situation now that we're in currently, if ever,

418
00:42:53,830 --> 00:43:00,819
is shown the need for that idea around probability and and understanding those the risk of things

419
00:43:00,820 --> 00:43:05,110
and the probability of things and this idea of yes or no is just not is just not good enough.

420
00:43:05,110 --> 00:43:07,870
Like you say, it takes us too far away from what we actually should be trying to achieve,

421
00:43:07,870 --> 00:43:11,370
which is letting people understand, but having ways of communicating that.

422
00:43:11,380 --> 00:43:13,800
I think the challenge for us as educators is to, well,

423
00:43:13,810 --> 00:43:19,030
how do we teach about the different kinds of ways that you can you can teach about these sorts of things, probability and risk.

424
00:43:19,030 --> 00:43:23,919
And do you use an actual frequencies or do you still rely on the percentages and do how do people understand those?

425
00:43:23,920 --> 00:43:29,409
And I think there's been a lot of work on that. It's just, like you say, making sure that's the forefront of our education and pushing that forward.

426
00:43:29,410 --> 00:43:34,810
So I mean, that's a really good point to end on in terms of where do we where should we as educators be focusing on?

427
00:43:35,440 --> 00:43:42,130
And I think seeing a lot of good work around that is certainly an area that I'm really interested in pushing forward for my teaching as well.

428
00:43:43,120 --> 00:43:48,849
So Paul, just like to say thank you so much for taking the time to talk to us today.

429
00:43:48,850 --> 00:43:54,850
It's been really fascinating. Great to hear your insights, your stories and and just sharing your experience as well.

430
00:43:54,850 --> 00:43:58,780
So so thank you again. I'm sure people listening will be taking away loads.

431
00:43:58,780 --> 00:44:01,570
I certainly am from the conversation. So, so thank you again.