Well, well, welcome. Welcome to the Martin School. And this is one of my favourite buildings at Oxford.
I love the elephant in the spotlight at night.
If you haven't seen it before, you will see the elephant lit from the bottom when you go out because of the history of Indian Institute.
Well, there aren't many superstars in decision making, but one of them is here tonight.
Get bigger answer. And I just looked at my bookshelf and so I just think a little bit of work bounded rationality.
This idea, that rationale that we're all rational human beings, well, to a degree, their degree is spoken,
bounded rationality and the concept of adaptive thinking and then for the public risk, risk savvy.
How do people make decisions? And this has been it is which we restarted evidence based medicine.
I think I've heard of getting cigarettes are a great pity.
But over the years we've seen how the idea of logic and teaching people things called facts and using things called numbers only go so far.
Because rationality only goes so far as scared to describe it.
And I once said to Dave Sackett how you judge a library, how you evaluate a library.
He said it's the number of books being stolen. And the only this is a book, get an eye.
Everything called better doctors, better patients, better decisions.
And I've only got a German edition left and really get has helped us think dramatically differently about the way decisions are made.
When we launched this book,
I looked around and they are sitting about there was the governor of the Bank of England because he'd read been influenced by Gipped.
Because for and I wonder why the hell is he here? Because we have AIDS in doctors making decisions and patients making decisions.
But of course, Gurnard sure that supposing you were a young, bright young hedge fund manager, what sort of decision maker were you?
You'd be a gambler. All right. How do you use your rustics? Well, no one ever thought of that before.
So the Bank of England and people who the big money people also recognised what Kurt had to offer,
and that's what led to the centre in Cambridge with David Spiegelhalter and Gert's own work,
which has spanned a number of countries, including Chicago. And he's now based back in Berlin.
But we're very privileged to have you here. We've learnt a great deal from you.
You're working full blast. I know. And the job not done yet.
I'm very. That you're still working. So are leading. Gentlemen get gieger into.
Thank you, Mira, for giving us the insight in your private library, portable private library.
In the 19th century, the health of the public increased substantially by clean water,
better hygiene and healthy food and enough of it that what is called the first revolution in health care in the 20th century.
We had the professionalisation of medicine and great scientific breakthroughs on the clinics.
It was the centre of the clinics and the doctors. What did 20th Century has not had in its vision is patients.
That would understand. And could make informed decisions.
Today in the 21st century,
we are waiting for the third revolution in health care after the 20th century revolution that Miller and I called the century of the patient.
That medicine makes a turn to Boland's having as its primary goal, the patient, not all the other things.
And yet in modern high tech health care, patients appear to be the stumbling block.
An uninformed, anxious, noncompliant folk with unhealthy lifestyles would demand treatments advertised by celebrities
who insist on unnecessary but expensive imaging and may eventually turn into plaintiff's.
The one solution proposed is new paternalism.
Namely, nudge to patients where you want that they end up.
I don't think we need more paternalism in the 21st century.
We had enough in the past. There is a different vision, namely patients who are risk literate, who know where to find information that's reliable.
And you can make informed decisions based on your own values.
Grey and I got together in two thousand and nine on a workshop where we collected 40 people from medicine,
psychology, computer science and statistics in order to discuss the possibility for such a third revolution.
The outcome of that meeting is a book with the title Better Doctors, Better Patients, Better Decisions Envisioning Health 2020.
Now, that's now looking back, we might have written better envisioning Healthcare 21 20.
But Roger and I are a little bit on the optimistic side and impatient and wants to get things done.
And we also believed that then 2009, the financial crisis would actually help to get this project done,
because if there is less money, then the medical profession has time to think about the true.
Virtue and the true goal, the patient now in this workshop,
we analysed seven problems in health care that we believe need to be solved in
order to get towards the centre of the patient and that are the seven problems.
It's a simple calculation. You add them up and you get misinformed patients.
You don't even need all of them. And what I'm going to do today is to go quickly to some of them and spend most of the time on the last one.
And to give you the key essence is the good news is that our book is as timely and relevant as a decade ago.
That's also the bad news. There is one thing I should add that we hadn't envisioned so 10 years ago.
That is the impact of digital technology on health and the push of I.T. companies into health.
We had somehow naively believed that digitalisation would help our cause.
It would provide access for everyone to all the information relevant.
Yet that hasn't happened. Just to illustrate on digital health records are a great idea.
But. They will not be able to unfold their potential in current health systems.
They are not falling on fertile ground. So one example in the US in 2005.
The calculations by the rain corporations were that by having electronic health records, one could save eighty one billion every year.
So, for instance, avoiding duplicate tests and having the information available and all the errors that come in.
In 2013, they reviewed the situation and found that cost had not decreased.
They had steeply increased. What had happened? The industry, the software industry had gained.
The electronic health records that were made in the first place for billing, not for serving the patient.
For instance, recommender systems were built in. That would recommend to doctor.
Maybe you should do that. That test. Maybe a C.T.
Maybe something else. And doctors sometime surrendered to that.
Just to be on the safe side. And that was how the entire system was gamed.
Or. There is another example is much funding has been invested OSes, something we did not foresee into big data analytics in health.
You may remember I beams IBM's Watson into acting as Bob Dylan, Serena Williams and other celebrities.
Lots of marketing. But does all of that help patients?
A systematic review last year of 58 articles on big data applications in genomics,
drug discovery, personalised healthcare, precision medicine, mental health, oncology and so on.
Concluded that there is no evidence of its practical benefits in health care.
My personal conclusions on that no topic is the benefits of digitalisation can be read only if the existing problems, the seven sins.
All resolved first, otherwise digital health will become a band aid solution.
So how does our list fare today? So I will now go through some of these points.
And as I've said, spent most of the time to the last one.
Every one of these points in the book has a number of recommendations.
I will cannot report all of that. I can't go into anything.
I cannot present a systematic review of every these points.
You can do that. You can write seven systematic reviews on each of these points, how it is now.
But I will start with an example that is on the first point and illustrates the key problem.
I use a very common example, namely breast cancer screening with mammography.
So in many countries, health institutions and doctors ask, how can we get more women into screening?
Many countries set a certain goal like 80 percent in the UK.
No deal. How would you do that? There are basically a number of options.
One is strong paternalism. The president of Uruguay.
Has installed mandatory breast cancer screening for all women who are in public service.
That's a simple solution. It is not.
One that makes people are risk literate or invest in countries.
We have many attempts to nudge people into behaviour.
So the nudge women into it by sending them a letter is a certain date or by giving them misleading information.
That's also it. This is not our vision. Why not?
Do something and inform women about the benefits and the harms.
Of breast cancer screenings so that every women can make her own decision.
That can be easily done. Here is a fact box.
The fact box is from the Harding Centre for Risk Literacy, which I direct.
It is called Harding Centre because it has been funded since twelve years by a London investment banker, David Harding.
Things to his. He read one of my books called Reckoning with Risk.
And as a investment banker, he knew that most other investment bankers and financial experts don't understand numbers.
But he wasn't a beer. The doctors also are innumerate and churches and lawyers to.
So he thought, oh, that's a case where I've spent my money. And by the way, in Cambridge, you're parked on your university.
There is the Winton Centre for Risk Leaders and Evidence Communication, which is our sister institute.
We are the only ones. And so a fact box takes all the available evidence in that case about randomised studies with about five hundred thousand women.
But reports everything in simple, understandable numbers, no alterations.
No relative risk or other misleading statistics. So how do you read that?
So think about 1000 women who participate in screening, 1000 women who don't.
They're all over 50. The question is, what happens 10 years later?
And benefits. Breast cancer mortality. Five out of thousand died from breast cancer.
And in this screening group, it's four.
Then total cancer mortality is even more important because you don't know always from which cancer a person died.
If she had multiple cancers and it's twenty one in each group that tells you there's no life saved from mammography screening.
But one women. Less dies in the screening group.
But one woman more dies in the screening for another cancer. And then there are harms.
So women who do not have cancer, they are false positive.
The test isn't good. And an estimated 50 to 200 are harmed.
You will see here the harm numbers are all intervals.
What's the reason? The focus of most medical research is on the benefits.
Harms are not so taken so seriously. So we have no very precise estimates.
And the second harm is for women who do have cancer.
But the candidates non progressive that this they wouldn't even notice of that thing that happened to their cells in their lifetimes.
And it shouldn't be called cancer, but it's detected and they get unnecessary lumpectomy, mastectomy or other kinds of treatments.
So that's a fact box. That's the way one could transparently do it.
And you can see many fat boxes under our website. And so you have an easy way to look into what evidence based medicine knows today.
And they are being updated. So now let's go back to the question.
How can we get women into. And we get more women into screening.
This is not the proper question from my point of view.
The proper question is how can be informed women and the men, that's the way to do it.
So if you would push women into a screening, what would you do?
You would not report about total cancer mortality. And that's.
Find me a single healths brought to you where this fact is being reported.
And how would you report the one in thousand difference in breast cancer mortality?
So you might not say it's zero point one percent. But you might say there is a 20 percent.
Reduction. Because it it's a relative risk.
It sounds better, isn't it? And 20 percent reduction is often rounded up to 30 percent or more.
Here. Developed NHS leaflet Breast Cancer Screening says breast screening has been
shown to reduce the risk of dying from breast cancer by around 35 percent.
No absolute numbers. Given. That's a reduction from five to four.
Rounded up. Or New Zealand comes up with 33 percent.
The changes here to the NHS leaflet for England, so no longer a relative risk.
But now it's absolute risk. How it should be. But look at the number.
It's not one out of thousands of 200 in Germany.
We had the same situation. So first.
Long ago, women were just told what to do. Then one gave the number, but misleading numbers like 35 percent.
Then we protest. Protests over years. And then finally, absolute numbers were given, but also one out of 200, not one thousand.
I know the situation in Germany very well, and it's probably similar here.
There was one fraction who wanted to increase participation rates and they were against reporting absolute numbers.
And there was another fraction that we can't go on in the 21st century.
And misleading women. We should be honest.
And the agreement was, yes, we report absolute numbers, but higher numbers.
In Germany, we have now gone beyond this phase.
And the proper numbers, like one to two in in in Thousand Oaks or in the brochures are just an example.
So what is the consequence of the misleading brochures on the thinking of women?
What's the benefits of. Breast cancer screening does mammograms.
We have done the first European wide study with a thousand British women and asked them so exactly the questions.
So if a thousand women go, Feltham, don't go. What happens 10 years later?
How many if you die from breast cancer and the proper?
The best answer is one out of a thousand. And these are CHURMAN women here.
What do you see? And less than one percent is aware of that.
Most are always debated highly or have no idea.
Are British women better informed? What do you think?
Yes, it's more than hundred percent more in reality.
You have a huge peak here in the UK and that's 20 percent.
We had nine countries. Here's a question on your intuition about health systems, how they influenced their citizens.
There was one country out of nine who stood up in the sense that they were much more people, many more people who had an estimate in the correct area.
Which country is that? I'll give you two countries. So it's not Germany.
You can't be worse. It's not the UK. The other countries will only be countries in in Europe.
France, Italy, Spain, the Netherlands, the Austria, Poland and the European part of Russia.
There's one country. Were good.
Definitely more correct. Angel standing all of the OSes.
What do you think the Netherlands is everyone's guess who is informed about the health system because they have a very good health system.
But no, in terms of screening, the population is equally misled.
Do you have another case? Russia right here, you see the and it holds both for women and for men.
So the realistic estimates, everything unrealistic is an order, an order of magnitude or two orders of magnitude too high.
The reason is not that Russians get more information about screening than.
All the rest of Europe. The reason is probably they get less information and less mis leading information.
On this issue about the biased reporting health pamphlets, there is a positive news in Germany.
We have succeeded to have in the National Cancer Plan a clear statement that and Germany is moving now away from.
I read the goal of informed participatory decision making is now ranked higher than the goal of a maximum participation rate in cancer screening.
That's a very clear and honest statement which says before we were not our primary goal was not to inform women.
Now it is. That's a brave statement. And it's still difficult to push it through against all the interests and also.
Against the emotions of many patients. Who feel that some, particularly the US many women, feel a cancer screening is a moral obligation.
If you don't do it, your friends will not loan or talk to you.
They are brainwashed. And it takes all the courage to take over responsibility about your own health yourself.
But medical science gives you a good key to make correct decisions.
And sometimes if you understand the health system.
Then you understand you need to think yourself.
Because you are in health systems that are more or less depending on the country.
Profit Liftin. And not in your interest. So let's go on.
I'll go quickly biased reporting in the media compared to the first point, in my opinion.
Not much has changed.
And we have a new problem, the social media, which increases the variance totally of reports, biased reporting in medical journals.
I did a cheque for this talk. And here is here are two of the recommendations that you and I gave.
So every of these points has a number of recommendations. The first one was Trudel.
Editors should clearly announce that evidence framed in relative risk because our baselines mismatch framing five year survival rates was cleaning.
And as a non-transparent, transparent formats will no longer be published.
I will explain this format in a minute.
And also, institutions that subscribe to mitigate journals should give journals publishers two years to implement the previous action.
And if publishers do not comply, cancel their subscription.
We thought it's a brilliant idea. But not much has his head.
And I'll show you here just an example before better doctors.
There was an article. That had analysed 119 systematic reviews in the BMJ, the British Medical Journal in JAMA, in The Lancet between 2004 and 2006.
Absolute risks. That are easy to understand.
Well reported in only 50 percent of the reviews.
Or similar numbers like number needed to treat mismatch framing.
Is the idea that you report numbers for benefits and harms.
But your report, absolute risk for the one and relatives for the other one case.
How how would you do that? How would you report the benefits in the relative when absolute numbers in the relative because they're a big item.
And how do you report in the same article as the harms in absolute numbers?
Because there's also that was the case in 30 percent of the articles.
That means misleading statistics starts, not risk lists.
It starts already in the top medical journals and of course, in press releases.
Has that changed after better doctors? I found two large studies.
One was about two hundred and two systematic reviews, including about half of the Cochrane reviews.
The best evidence bases. We have absolute risk reporting that only 30 thinks of these reviews for the most relevant patient outcome.
So. There's no improvement here.
And and this is so they looked at 55 guideline recommendations, an absolute risk for benefits and harms reported in 31 percent.
I can't not detect. Hear that anything has improved.
And it's very clear why it's being done.
Because in these days, journals and journal editors think about how they're represented in the media, including the social media.
And if you have a news that you have a drug that reduces heart attack by 50 percent, that has a chance to go and fly.
But if you say, oh, it reduces mortality from heart attack from two hundred to one in hundred, that means one percentage point doesn't fly.
And people are still innumerate to fall into this trap.
The Enlightenment is far away. So back.
Biased funding of research.
Is the problem that research being funded, that's in the interest of the industry, but not in the interests of the patient?
Typical example, meat, two trucks. The drug already exists, but the company wants to have another one to sell it to.
That's of little help to patients. One of our recommendations was that research should be funded.
That helps to understand the causes of lack of risk literacy amongst doctors, health care providers and patients.
That has also not happened. A great example is, do you know health news reviews, dot org, health news reviews, dot org, garish bitzer,
a Web site that exists since more than 10 years, which has 10 criteria on which media reports about health are rated.
For instance, today mentioned the funding source.
Do they report about harms and not only about benefits?
Do they report in the same currency and so on? That's a great institution.
They are struggling with getting funding.
There have been partially closed down for these important things that make people smart in a smart role.
There's almost no funding. The the the my personal story is hiding something similar.
Now, the funding by David Harding is running out and we are struggling to find.
Any source, if he would produce a drug that already exists and just market it, that would be great.
And but funding to that helps doctors and patients understand the evidence is still not running, commercial conflicts of interest is very clear.
We are suffering lots amongst them. On the defensive medicine means that doctors do not advise you the best.
They believe it's for you. But something second or third base that protects them from you as a potential plaintiff being sued.
That's the way the American system is most supportive for defensive medicine.
And in every study where doctors ask whether they perform defensive medicine, more than 90 percent of the doctors say yes and have no chance.
I can't do the best medicine for our patients. So what they do then?
Unnecessary city's unnecessary. A Martys and anything he's done or India biotics.
That's the problem, which is also not lost. No, I'm spending the rest on the last issue.
Doctors lack of understanding health statistics. That's probably the least known problem.
You may rightly think that your doctor is trained to understand evidence.
Mm hmm. Have you ever checked it? Ask your doctor.
So I will talk about collective risk literacy.
The term means that patients, doctors, journalists, politicians and many Aussies.
Have never learnt to understand evidence and can be easily tricked, like was the relative risk that he saw before.
I'm going now to another famous concept, its five year survival rates.
Let's start with Rudy Giuliani. When he was running for president of the United States, Giuliani said, I had prostate cancer five, six years ago.
My chances of surviving prostate cancer and thank God I was cured of it in the US, 82 percent.
My chances of surviving prostate cancer in England, only 44 percent under socialised medicine.
That's what you got. And he proved here that American commercialised his impro.
Profit is just better. It's free market. England, wake up.
Give up your NHS. You might not like that, but eighty two is more than 44, isn't it?
Rudy Giuliani misled the public and probably himself.
The fact is that differences in survival rates, say, between the US and the UK.
Don't correlate at all with differences, mortality rates.
And at that time, the mortality from prostate cancer was about the same in England as in the US.
How can it be that mortality is basically the same? But five year survival rates are so different.
Because five year survival rates don't tell you anything about mortality.
That's the nice thing. And why is this? It's easy to understand the first reasons lead time bias.
So think about a group of men that has terminal prostate cancer or go or invasive prostate cancer.
They all die at age 70. Half of this group doesn't go screening.
The other half goes screening. So those who do not go screening, then prostate cancer is detected late, say age 67.
They die at age 70. What is the five year survival rate? Zero.
Clear. The other group, gun screening.
Prostate cancer is detected the age 60, they die at age 70.
What is the five year survival rate? I know percent got it.
The trick, second reason, overdiagnosis. Again, two groups go screening, don't go screaming.
So we the people, the who do not go screening.
So was Prokosch. If prostate cancer five years later. Forty four.
Forty four percent of them are alive. The others died.
So the five year survival rate is 44 percent. Now those who go screening.
So it's not only that progressive cancers are detected, but many more non progressive cancers.
So there's this is, again, a cancer that you will never bother you in your life, you will die with the cancer, not from it.
If your name. And lucky to live into old age, it's almost certain that you have prostate cancer.
It's a good news because that's. Desired effect.
You good old. There are estimates that amongst 80 year olds, 80 percent have prostate cancer, but only three percent die.
So. So here's the calculation.
Men with screening. Now, these two thousand in this example was non progressive prostate cancer.
They, by definition, don't die, but they enter the numerator and the denominator and outcomes.
Rudy Giuliani's number. See the trick?
So the key to understand is that five year survival rates are measured from the beginning of the diagnosis and in screening, the diagnosis is only.
That's what the game was or not. You live longer.
And now the question is, do physicians understand?
Or would they fall prey to Rudy Giuliani's argument?
We have tested. We've done the first study was German physicians.
So sixty five physicians have given them the the actual data from one of the big randomised trials, but not mentioned prostate cancer, just cancer.
So they have no prejudice. And then giving them is a differences in survival rates like Rudy Giuliani did.
And then. Ninety seven percent. No.
Seventy nine percent. Church screening is effective, although they don't tell you anything.
The difference is here. And if there were and mortality rates only five percent.
That means we can. Direct the opinion of doctors of seventy five or three quarters of doctors in any direction about screening,
depending on how we frame the success, is survival or mortality rates.
When we are asking about lead time bias, only two of sixty five. Understood.
You all very bitter and overdiagnosis.
Are American doctors better? We did the first study with no representative sample of four hundred twelve primary care
physicians and basically the same result when the information was provided in survival rates.
Just like Rudy Giuliani, then 83 percent judged the mortality benefit as large, although they should say it doesn't tell me anything.
And when he was present, the mortality rates than. Many, many, more or less.
It's higher than the Trumans because the Americans tend to do something. And also, more on the pressure of defensive fighters in the.
We also asked with a screen to take the Kansas if a bitter five year survival was visit there, proves that cancer screening tests saves lives.
And the same number three quarter thought. Yes. And mortality rates.
The correct answer is 80. About the same. Eighty one percent thought.
Yes. And there are almost 20 percent who don't even know that.
What surprised us most was the answers to the number two question, which proves that a cancer screening test saves lives.
More cancers are detected in screening population. That doesn't prove anything.
But almost half of the doctor things and other studies since then have just replicated.
If you just detect something, then you save life. So.
The situation as I see them is that in this respect, not much has changed.
Doctors are equally uninformed about understanding health statistics as 10 years ago.
And they will later come. The reason of that, let me first.
As soon as a question, do politicians understand health statistics and we already hit Rudy Giuliani, is he the only one?
How about the U.K.? Here's another case.
The UK Office of National Statistics noted that five year survival rates for colon cancer was 60 percent in the US,
compared to only thirty five percent in Britain. Experts called this finding disgraceful and asked for a doubling of government spending.
Now, in response, Tony Blair set the target to increase survival rates by 20 percent over the next 10 years, saying we don't match other countries.
It's that colon cancer prevention, diagnosis and treatment. He has been misled in the same way.
And the target to increase survival rates by 20 percent is through screening.
You get it automatically without any benefit to patients.
There is a May 20 years later announced her cancer strategy and again, foot fell prey to the survival rate story.
She said survival rates are increasing, but we are lagging behind other countries.
Same thing like the US. The US pushes everyone to screenings where they get the big survival rates but not pay the mortality rates.
And then the five year survival rates for bowel cancer, all over 90 percent of caught early, but less than 10 percent if diagnosed late.
And so either by twenty twenty eight, fifty five thousand more people will be alive five years after they're diagnosed.
That's her goal here. You just screened them. You get it automatically. What you need is better politicians.
So now let's go into digital technology and the big data analysis that I mentioned before,
that I'm not aware that there are many applications of big data analysis that actually help patients.
But there are many stories and much of funding goes goes in it, which we could use elsewhere.
So you may remember that Microsoft engineers wanted to predict pancreas cancer.
So imagine you are on. So on being on Microsoft's Web site and you are working on a brilliant text and suddenly a window pops up but says attention.
You may have pancreatic cancer visit immediately, your doctor.
How do you feel? Can you ignore that?
No. You go to your doctor. No, that's.
I've written about that in the BMJ. How did they argue?
They argued it could increase five year survival rates.
Of course, it will increase for survival rate, but they build it up because we have no cure for pancreas cancer.
It's another distraction to real problems. And there were a number of other misleading screening.
The New York Times, by the way, reported that evely that quote,
The study suggested early screening can increase the five year survival rate of patients
with pancreatic cancer from five to seven to five to seven from just three percent.
That also didn't get it. Journalists still have no training in understanding health statistics.
And that's not the only case. So many other I.T. companies tried to prove their relevance by moving into the health care.
So Googling flu has also used search terms to predict the flu.
It all fall that we have shown that by Googling flu had 50 million search terms and and the complex Ikarus was a
hundred sixty selected search terms and they tested hundreds of millions of models and and predicting the flu.
So here's the short answer. A, I works in a stable world, and here's where the successes are.
Chess go jeopardy. But it has huge difficulties to deal with an unstable world that's dynamic where things change.
The flu changes all the time. People are unpredictable. What they do in this in this world is, well, complexity doesn't work.
We have shown that if you use a single data point.
You can predict the flu better than this big data, but that's another story.
I'm not talking about my research on heuristics here. So those questions, do medical students learn to understand health statistics?
And I will now show you one of the reasons for all of this mess is that thinking is not taught in medical school, with very few exceptions.
And we have developed a test that tests 10 elementary concepts, just concepts.
A test makes two errors. As you can overlook something and the rate is a miss rate or sensitivity, it's called.
Or it can. The so the sensitivity is now one minus, miss.
And or it can create a false alarm.
And that's measured by the false alarm rate. What is specificity is one minus.
False alarm rate not be difficult. All of the cons of what is a relative is absolute.
It's 10 questions like that. Actually, a few of that.
These are the first six. A test sensitivity is a central criterion for its quality as a diagnostic tool.
The sensitivity is now for alternatives and the student need just to find the right one.
So these stars are not there in the test. Therefore, you add a sensitivity proportion of people with a positive test result.
Amongst those who are sick and it's not a proportion of people, it is a negative test results amongst those sick.
Every medical student and doctor should know that as well.
You cannot read any report about a new test, even digital test.
The test specifically, same questions, same possible answers.
And so it goes on. Quite simple things to do.
I show, you know, the results of the final year medical students at the charity in Berlin.
The charity is one of Europe's light houses and medicine.
And every student should get a hundred percent on this test because these are so elementary questions.
It's not about an interval. It's not about auto ratio or anything like that.
You what body get the red line is what you get expect by chance.
On average, the students get 50 percent correct.
And you get already 25 percent. By closing your eyes and just pointing.
So what's the specificity? 20 percent don't know that.
What's the story? The sensitivity. What's the specificity? 30 percent don't know that at the end of the studies.
What's the positive predictive value? 40 percent don't know that.
What's the negative politically for almost 50 percent? Those noted.
And so it goes on. What we have talked before are the relative risk versus upper low risk.
So then it's only 20 percent who don't know even that.
And the mortality rate was the survival rate. That's even below chains and lead-time buyers and over Gopinath.
Right now, these students are not prepared.
To read and critically evaluate or even understand an article in their own field, almost all of medicine is about statistics.
And if that's exactly what's not being taught, then we are failing.
And then we are not. Don't have to be surprised. Why do doctors don't notice?
Now, here is now two hypotheses as why this happens.
One hypothesis is that students, after many years of medical training, they have unlearnt thinking.
The other one is. In this many years of medical training, they've never learnt, never been taught that.
So we did two tests that a short 90 minute test after these the same students.
That included concepts and techniques to be developmental, to make this easier.
And here's the result. Now they're on a level of 90 percent.
So it's not that some of these Miss Riot. It's just simply that nobody teaches them.
And here this is a US study I've done with professors of medicine.
They should have more than a hundred percent, right? There are only up 75 percent on the road.
And finally, how can we help? And I'll be brief here.
Fat boxes. And here's a fact box about with a influenza vaccination helps.
Here's a fact. Books about ovarian cancer screening. It is fact boxes are available on tablets, on smartphones with the AOC.
That's the largest German health insurer. And at the end, here is where we want to be.
These are the seven points we need to solve. And I hope that someone of you at some point can the report we are there.
So I was talking today about risk literacy. Many doctors, students, politicians and journalists and patients still don't understand health statistics.
We need to do something about that. And we also need clean information, fact boxes, not misleading statistics.
And at the end, the benefits of digitalisation can not be reaped if we don't solve the existing problems.
Thank you for your attention. The evidence is that better the speaker, the more your mind is engaged.
So I let you know to turn to your neighbour for two minutes and pick out some important things for you and for medicine and health care.
There will be some question comments. OK. Talk to your neighbour. Introduce yourself who you have met before and said.
That's. If I stop talking right questions and they were our suggestions for action.
Yes, this they say, what what are you, a medical student or a doctor or statistician?
Hi. Before we start, I'm going to use the microphone and just say just to let you all know that you're being filmed live webcast.
So please bear that in mind when answering your question. And please wait for the microphone.
Yes. Thanks very much for the talk. I'm a mathematical modeller up at the hitting thing medical campus.
I was curious about this, the understanding of five year survival rates amongst doctors and was curious if you've
looked at a control group of UK or US statisticians and seen what the understanding is.
And there is a as a suitable comparison. I haven't studied the UK statisticians.
You can do that.
I worked very closely with David Spiegelhalter and he surely understands that, say more statisticians who like to be hands up a greater statistician.
We make up to you. There we go. Yes, hi. I'm actually a medical science communicator.
So why spend my time talking about these? I'm actually curious about something.
Why do you think mortality rate is something that is so misunderstood?
Because it's not exactly very different. Very difficult. If you keep having very low rates of spending.
Please keep the graph, Sordi. One reason is that mortality rates are in these examples I cited not being reported.
Only survival rates. And the reason is because there is typically almost no difference in mortality rates.
But then you're always going to report a difference in survival rates.
And if you have the Microsoft application, you target survival rates because you will win.
That's one of the reasons.
The other reasons, of course, that the medical schools I know they're not teaching these health statistics, and that's the most surprising thing.
I have had conversations with heads of medical schools, including the last three CEOs of the charity.
And showed him always what's happening on the own universities.
If you think anything. Would have happened?
No. Two students at the charity have now found in a work group on risk literacy.
They want to learn it. Their professors. Mostly this interested.
People want to land pipetting. I think that the key thing in medical schools are focus on laboratories.
Hi. I am a medical doctor and I was wondering if you have data on the accuracy of clinicians for identifying the how close the patients there are.
They are about to prescribe an intervention to is similar to the piece of evidence where that prescription come from.
To put an example. We know that Trumbull's is for people who have an acute stroke.
The more you deviate from the inclusion criteria of this study that prove a benefit, the more harm you do and the less benefits you get.
And in the 10 concepts in the test you showed, I think it would be very interesting and very relevant to see how accurate doctors are to identify.
Is these patients like the ones in the study that prove the benefit I am trying to transmit.
You have to you. Have you ever looked into that?
You make an important point, namely that doctors have to evaluate whether even if they know the evidence base,
was it the patient fits to that population being studied?
Yes. The problem is that I pointed out that most doctors cannot even understand the evidence base.
And that's the next question that would come.
I don't have conducted and don't know specific studies to this process of innovation, but it's an important point.
It shows the evidence based medicine, as I understand it, can not be just knowing randomised trials.
But you need a judgement whether this trial actually fits with the patients that you have.
There are always something a bit big, give your base what you know.
But you still need clinical lots of experience, even gut feelings.
I'm also hoping somebody will be saying a little about what they're doing to tackle these problems with the economy or others.
But, you know, anyone in the audience doing things, they tried to make the world less bad.
I'm always cautious about trying to make things better, but to make things less bad. Yep.
Yeah. Oh, sorry. You are. Yes. I get these guys. Hello.
I'm for the purposes of this, a patient in the U.K., there's a strong push towards patient participation in decisions.
And I have seen quite a bit of conflict where the doctor is struggling to get their point across based on their knowledge versus,
say, the patient's been influenced by Dr Google to a certain extent.
I mean, how do you find the fact boxes help the doctors and the patients with those conversations?
My experience that, in fact, boxes help both sides to get the evidence.
The problem is that the ideal of informed consent cannot happen if patients and many doctors don't understand the evidence.
It's a total illusion.
Also Mirrors Wonderful programme of Value-Based requires that someone understands what the evidence is as it was not getting for Andy and on.
Today, in the many, many patients, probably most look for information in the Internet about health and what you find if you cheque on a certain issue.
Take a screening study is just a wonderful place for misleading information.
I have. I gave her in California.
I talk to a large medical department and looked before what I did on the Internet about, say, mammography screening on the first page.
This is where most people start and end on the first page, the baby with 10 or doesn't articles.
All of them were misleading. Was one exception. There was to be Expedia in three in English and and we had edited it all.
Others were driven by other interests in getting women into screening, making money,
defensive decision making, all things that do not help you as patient factually as I did leading it right.
It did well course coming down the tracks in lung cancer screening,
which is a major issue, which being in a year's time, we'll be revisiting that link up.
Yes. Hello. I'm a general practitioner and I'm currently working on a project to develop a Web site to
give general practitioners better information on the benefits and harms of treatments.
And in researching how to do that, I've been talking to Tepees and most of them have forgotten even very simple statistical terms,
even if they had been taught in medical school.
And where it looks like it's heading is that the way to communicate information to them will be in very, very plain language.
As a layperson level and using simple graphic I arrays to illustrate to one hundred people and five in 100 people,
it seems to be the three way that is appealing. Most people, even the doctors.
Is the de facto boxes that you can find on our Web site and other places, they those were showed mostly in numbers.
But he came to them with those numbers. In my experience, most doctors prefer lockboxes, boxes without numbers and patients anyhow.
So if you'd set up a Web site, go to our Web site and steal the fact boxes from ours.
Just give a reference or steal them and disseminate them.
I think that's one of the most powerful tools that people can see the evidence and make their own judgement.
What do you still need to convey on the Web site? Is is the message.
Have courage to take all the responsibility for your own life and the life or the health of your children and talk restocks doctors, of course.
Yeah, but keep in mind. If you're in the U.S., most doctors, Keano, device you the best thing because it's defensive medicine or almost everyone.
Most doctors don't even know the evidence or they'll conflicts of interest.
So you need to take over the responsibility for your life.
Convey that on your Web site just to repeat it again and again and again and again.
You are a doctor and nothing is certain in this world.
And if you take over the responsibility, at least you can blame yourself.
Sorry. She'll be able to take over responsibility.
That's what I have tried to do, but it's not easy.
It's not easy to find the right evidence and to to compare the relative risk with the absolute risks.
And I would like to be able to rely on my doctor. So if from what you've seen tonight, I have felt that I haven't been able to rely on that.
And now I feel even more than I probably can't.
But I'm not sure whether I understand what I'm looking for and maybe the fact boxes I've not come across.
But, you know, you struggle as an individual to take that control right away.
Let me just make a comment that they get.
And then I'd like to ask Carol Hennigan, because when Carol and I is the director of surgery, everything is medicine.
But the people we talk about most are the ones you're seeing in the weekend who reach 90 to stop.
It's not that they been multi or ability be multi speciality problems.
And so they're maybe dealing with three specialities, all of them prescribing different things.
And then you people try to look up the evidence. I mean, we we haven't done this.
It is quite hard to be the first editorial in the BMJ and to 20/20.
Was about multi morbidity and saying we have to think in a different way with an ageing population,
car related comment and the evidence for this really different group.
You see when you're on call. There we go. Yeah, thanks me. Although it's a real privilege to listen to.
Good to follow this work for 20 years. We've had 25 years of evidence based medicine at Oxford.
Most people won't know in the room that the reason for that was that Muir made it happen when he brought Tasaki here.
It worked.
And so we've been wrestling with lots of the issues and some of the people you've had, like the Steve Wallace shins up there in the Leifur shorts.
It's amazing work. And I think there are three points, really.
I think the first is to say you made it in the sort of funding the people who do this work for people like yourself.
David Spiegelhalter, amazing what they do. But there's actually so few people who do this work.
It is quite amazing in research institutes. And you all said the pipetting.
There's lots of that going on,
but there's very few people working in a world to say how do we apply evidence and communicate evidence at the coalface, if you like.
And that's interesting. And that's a real problem. And that's a probably a distortion of the incentives in research institutes.
That's one, too, is I think it's very difficult.
And and, ah, integration with clinical practise is really interesting. There are issues about the medical statistics.
But if you look at the number of patients seen on a daily basis in the NHS, you know,
we're talking about a million patients seen in summary in a week in outpatients.
The actual number of estimates are quite small.
So there are really interesting things going on within the consultation of when should you use the information?
And when can you read? You said it. When can you rely on experience, expertise, other things like pattern recognition, recognition?
So there's some really interesting issues in decision making.
But I think your your mama referred and sorry I could stand there all day, but the lung cancer screening is a great example right now.
We wrote about it last year with spending 70 million in the UK doing case finding as an experiment.
Lung cancer Nelson trial came out a week ago and it actually was incredibly similar to the breast cancer screening.
In fact, there was a 24 percent reduction in lung cancer specific mortality that translated into a 24 percent reduction in mortality.
But actually, the overall mortality has increased in Nelson.
And it's really interesting.
Call if you said you underwent screening and you would have a 10 percent increase in risk from death from other causes, you would go, oh, my gosh.
So we had one thing here. I'm sorry to leave, but the point is, it comes down to a value judgement, doesn't it?
The decision to do screening is a decision about whether you think it's a good thing or a bad thing.
Our issue is and what you're trying to do, which is incredibly interesting, is touched the surface of how do we better inform the public,
but particularly policy makers is a big issue right now because before we know it's going to lung
cancer screening is to be rolled out and it's going to cost us about a billion pound for no benefit.
And that's where the problem lies. So with the let let me start by the previous person who asked how can I take over responsibility?
I think it's an essential thing. We all need to learn that we all still are in a paternalists world.
And it's not the US or the Big Daddy, it's us who want to be the child.
And we need to learn in many other areas like financial investment, take over responsibility and have a minimum information about these things.
And the tools are there like fact boxes. And if you don't find a fact box, there's the Cochrane reviews.
There are more difficult. But you in the UK have access to the primary news, your privilege.
Chairman Donald, we've been fighting for a long time.
The Americans also have no access. Yeah.
So the. And on the. So just think.
But I can't really give you advice. But look, in in my position I think I only live once.
And when the day is where I die and I look back and said, you didn't dare.
That would be the worst thing for me. Failing is good. On the question.
On the. That so few people do this work.
Correct. And the one reason is also lack of funding.
Steve Woloshin, Elizabeth Schwartz was struggling all the time.
They had positions that were full professors, but they had to find their own money for their salary.
And the I mentioned Gary Schmitz's health news review, a beautiful bedside.
It's still up. But they're struggling on survival.
And the same thing I'm looking for since year for another David Harding, who was someone who spun, says the Harding Centre.
It is almost impossible. People give money to all cases, but not really ever.
To make people risk literate and the lung cancer screening story is a typical story, I would go.
So you never know everything, but a good guess is the following.
We have no evidence that any kind of cancer screening saves lives.
There are about five or six who reduce the Kienzle specific mortality, like in mammography screening.
And typically one out of a thousand, but one person dies from another course.
So that's not saving lives. And I would say, given that we shouldn't invest more, what was it?
Billion of pounds in finding a tiny, significant difference.
That's irrelevant. But we should stop. Funding and investing the money.
Well, we can expect that it will save lives from cancer and the.
And this story is very simple. Here's the argument. About 50 percent of cancers are at the end due to behaviour.
And it's everyone knows it's smoking. It's everything that contributes to obesity.
Maybe too many. I'll call this second. These behaviours, like eating the wrong things, are for early in life.
In childhood, mostly before puberty. Third, what follows invest in making young people risk literate.
So did I understand what's being done? Once we see them, when they enter puberty, how they're being misled.
From industry to eat the wrong things, to get drunk.
And how they also depend on their peers. Get them the. If we only reach 20 percent in a programme in schools that does stato in a playful way,
not notching, not forbidding does make the little kids competent.
Tell them things. That's how you will be manipulated. Then get them emotionally.
If you only get 20 percent, we will save more lives from cancer.
As the entire cancer screening programmes, including probably the successes in medication, why don't we invest in that?
I can tell you an entire story where I spent three years with the Dutch Cancer Society
and we had all planned and the cancers that I was willing to had to to invest money.
At the end, he gave the money to big data analytics.
And they're still searching for the cause of cancer. Who ever got it?
IBM or Siemens, as always. They make the business. That's the problem.
We need to turn around and invest. Well, we actually can do something good for patients and save lives.
Well, they may have to take a different approach. But Dave, second came, I told them two things.
I didn't want him waiting his time inside the outer ring road. Apart from seeing patients.
Because he was come to do something else. And secondly, I said Martin Luther should be his his role model and to to to preach.
For conversion, and maybe we do need to think of a different approach.
If we think of, I mean, the brain power of Karl-Henrik and others in this room.
But this is much more emotional. And I'm just wondering whether we shouldn't rebrand what we're doing.
And one thing that's emerged, I think it's been I mean, the word patient, by the way, set up a campaign for death to the patient.
Let's get rid of the word patient. And a legal point of view, the person we call the patient is the principle and the clinician is the agent.
So the word patient may be part of the problem we've got.
I think we need to be thinking now about a different approach and with a good practise in a city like Berlin and Luther and Oxford,
where we're very good at religion and talking about things, I think we were where we're not succeeding in our rational approach.
Now, Karl's very good at getting on television shows that the academics perhaps would not approve of.
But we have to think think of a new way we are that we need a new movement.
And that movement is about the citizen, the principal, the person.
And it is much more. This is the most complex business, earth.
And what we've heard tonight has been someone making the most complex decisions that you ever
face in your life about whether to have this treatment or that treatment or no treatment.
Clearly. And we just need to think how we spread that word, get you be an inspiration to us.
And I'm glad you're working full blast. And I told you gathered in addition to do me with the word retirement.
I've done a B with a word, the word patient. We've done away with the word retirement. So Gibson is Renee Souls.
And they I think we need to think now about how we take this forward.
Get you're an inspiration to us. Thank you very much.