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Yeah. Thanks very much. Yeah. You wouldn't want me talking about Metro analysis because I'm not.

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It's not one of my strong points, but, you know, hey, this is the pre-dinner talk, so it's not supposed to be cool.

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And it certainly won't come up in your assignments or anything like that. This is talk I gave a couple of years ago, actually.

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Evidence lies, and it's based on a little encounter I had with the concrete on my bike.

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But it, it, I've used it to illustrate actually a paper that I've just finished.

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I just sent it off to the Journal of Evaluation in Clinical Practice this week about guidelines,

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evidence based guidelines and why we need to think about them.

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And I'm a great fan of PBM. In fact, many alive because of IBN, but that is a different a completely different talk anyway.

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So I started off oh, you mean about 2013 having this argument with Carl Hennigan on Twitter who do follows me on Twitter.

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Yeah. So Mike and I decided we needed a campaign to really beam and I put together this hashtag really be it hashtag really be I mean

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hashtag rubbish EPM Because there are an awful lot of people on a lot of people on Twitter who think they're applying a beam,

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but they're not. They're being stupid. And that's what I called hashtag Rubber Sheba.

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So I then got invited to speak at Evidence live about the difference between

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really rubbishing Beam and what was really Beam and what was rubbish beam.

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And it was like, they've distorted what I meant.

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So what I was trying to say was that the key question isn't easy beam real or is a beam rubbish, which is the way they framed it?

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Are you for or against CBM? That's not the thing. It's when you got a particular patient in front of you is the management that you're offering them.

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Is it an appropriate that is real or inappropriate?

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That is rubbish application of the principles of IPM because you know, these people get pretty pompous.

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So I'm giving you a oh, I had to repeat that, you know you're giving me rubbish CBM so that's what the talks about.

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Alright. Okay. So the big issue in this I think and I'm not alone in this is the lack of individualisation or, or inadequate individualisation.

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So you come from better in the how this is. You know, you're really,

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really good at crunching the numbers and producing the little black diamond in the bottom right hand corner and saying this is the population average.

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But actually the person in front of you is one data point in a meta analysis that might have 103,000 individual participants in it.

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And, you know, that individual in front of you represents the average because mostly they don't.

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So Mark Tonelli, who actually met recently back in 1999 and nearly 20 years ago,

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he was talking about the individuality of patients being devalued in the practice of IBM.

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The focus of clinical practice, if we're not careful, is shifted away from the care of individuals and towards the care of populations.

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In other words, everyone gets the average. The complex nature of sound clinical judgement is not fully appreciated.

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Who's a clinician here? Oh, great. Lots of you.

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Okay, so you know what I'm talking about? This is this would be dead easy that.

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So in my view, I think there have been three phases in abm's epistemological claims.

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In other words, its own claims about what it's about. The first phase was epidemiological evidence.

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In other words, epidemiological evidence kind of trumped intuition and clinical.

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John How to get away from intuition, get away from clinical judgement.

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Just have this pure, wonderful, beautiful epidemiological truth that is that didn't last long.

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We then had Dave Sackett coming back and saying then you need clinical judgement, you need to into we've you EPM and you clinical judgement.

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In fact Eben is both of these and the patient perspective,

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but it didn't really get into how you're going to integrate Texas epidemiologist you didn't know about all

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the other stuff and then now you've got certainty in Oxford at the moment is this precision medicine,

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this individualisation of epidemiology via this sort of stratification perspective, defining of subgroups.

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And the more you look at the last one, the more you realise they haven't got there yet.

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So I think we're still mostly.

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In Phase two, where what we've got is somehow the need to combine epidemiological evidence, clinical judgement and the patient perspective.

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So you'll talk about that. That's what you did. That's the mantra.

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But what happens? You're right.

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Well, epidemiological evidence you've got you got your trials, you've got your observational data, all that kind of thing.

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Then you've got what's clinical judgement? Well, you could say it's a combination of tacit knowledge.

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That sort of embodied knowledge that we pick up over the years,

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know the stuff that my son is only just qualified as a doctor, hasn't yet got tacit knowledge,

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practical wisdom and what John Gabbay called mind lines,

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the sort of shared assumptions and approaches and perspectives that you get in what they call the community of practice.

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A whole lot of you sit around and share stories, and through those stories you're really exchanging practical wisdom.

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So the mind line I study mine was a love mind line, actually.

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And then, yeah, right. If we're going to do it properly, we've got to incorporate the patient's perspective and the,

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you know, the social psychologists to do that through active listening and shared decision making.

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And there's lots and lots in the literature on all of that. Well, that sounds great, and that sounds pretty great.

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Now, let's go back to Dave Sackett, one of the founding fathers of IPM.

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This is what he said in Oxford when on that very first CBM course I went on in 1995, he said,

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Look, when you're looking at the results of a trial, same results of a systematic review.

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Were the patients in this trial sufficiently similar to the patient in front of me,

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this individual, in whatever key respects, that I can safely apply the findings in this case.

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And he added, If not [INAUDIBLE] on it, you know, that was that was sick.

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It's words. It's, it's a very subjective judgement really, isn't it, because you think, okay, well you know as my husband said,

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I know you've found the randomised controlled trial but that is not going to apply to my mother.

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And then you think, no, no, it's not so much that you've read the trial in detail,

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but you know the mother in law and data is just not going to apply for whatever reason.

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So old fashioned clinical method because I'm old enough to practice medicine before IBM was invented,

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all these before came over to this side of the of the ocean.

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The question we need to ask and I'll come back to this question, what do I know about this patient, the patient in front of me,

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her history findings from the examination, the test results, how this patient reacted the last time she took the drug.

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Family circumstances. Given all that, what evidence do I now need?

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This is patient based evidence. It's not just patient preferences.

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It's not just, you know, the little tick boxes in the shared decision making form.

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It's the totality of what's going on with this patient.

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And if that the patient's unconscious, you can gather an awful lot of data about that patient.

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I don't think we use this enough.

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So there's lots of background to this in terms of the evidence base on clinical judgement and there's a couple of papers that I really like.

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These are just to the process of interpretation in, in clinical method.

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I these are not things that you get given as a, as a student of EPM.

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I think you should hear some more narrative the hold over this must be 20 years ago that was

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published narrative based medicine and then evidence based what is in the British Medical Journal?

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How do we combine the rich narrative of what the patient is experiencing with the

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evidence that we get from critically appraise doctors and systematic reviews?

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Okay, so this is a fine Engebretsen philosophical paper published quite recently and based on the philosopher called Lonergan,

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who I've never heard of before, I read this paper. So he asks the question, Well, what do we mean by knowing?

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What do we mean by that in a clinical knowing?

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So he says, the first thing we need to do is collect sensations and observations,

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taking the patient's pulse, whatever it might be, something that calls for explanation.

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First thing you do, you know, take a history, examine the patient data.

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We then go into a phase of interpreting those data, asking the question, what could this be?

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And you've all been there almost. You've been there as clinicians and patient comes in the symptoms.

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You take a look and you said, well, it could be this, it could be this, it could be this.

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Once you've interpreted those, you've reached some level of understanding.

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The next phase is weighing up those competing acts.

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Well, it's it's actually less likely to mean that because she's this kind of patient, it's more likely to be that because of what I found.

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And that means you're now making a judgement. But then the interesting the most interesting phase here is choosing how to act,

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what's the right thing to do, the morally right thing, because actually medicine is not a science.

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This is not an art. Medicine is a moral practice, case based reasoning.

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Aristotle. Every patient that we see,

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we are making a moral choice about what is the best thing to do with this lady or this gentleman in these particular circumstances.

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The example is use of that as a member woman came to me once, very late on a Friday night,

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and she was in the right of states and she was, you know, all sort of flustered and understood it.

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And she wanted me to fit her within it. She tried contraceptive device and she got it from the chemist and she brought

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it along and she'd got the three kids sitting in the waiting room and she said,

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Well, can you fit this right now? So I said, Well, we've got to go through all the pros and cons and all that kind of thing.

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She'll haven't got time for that. You know, I've got to pick up my fourth child from something,

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and we went through this and in the end I said, Look, I'm sorry, I'm not going to fit that right now.

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I want I want you to come back and I'll make a special appointment on Monday or whatever.

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Now, the reason why I'm giving you that example is actually I didn't think that that in that rush with the kids outside,

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with the woman in state she was in, having not engaged with the pros and cons,

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I thought it was not morally right to agree to fit this device because of the risks and all that kind of thing.

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In other words, it's not just a science.

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It's it's a judge, a contextual judgement. You get the idea really, really important.

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Okay. That wasn't what was going to tell you about I don't tell you about falling off my bike.

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So those of you been following me on Twitter for a while will know.

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A few years ago, actually, as nearly four years ago, that was what I tweeted.

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Bad bike smash in the hospital.

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Two broken arms on today's trauma list thanks to kind bystanders and NHS sorry will be out of action until further notice.

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Yeah, it was horrible, really horrible. Bike Smash. And what happened was I was cycling along on the canal actually in London.

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It was a bright, sunny day and I was going along on a concrete and something got caught in my wheel.

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I used to be a good cyclist, you know, I was going on with was was with wisdom.

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I like chrome clipped into the pedals and the whole bike suddenly flipped up in the air and came smashing down on the concrete.

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Like I came down with arms up my head, smack, smack, you know, compound fractures, all the rest of it.

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One very nice, very well, that kind of thing.

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Plenty of that. There I am with both arms in temporary slings.

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And then a week later there I am playing with the putty, and a month later I'm feeling quite a lot better.

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So that was a whizz through what had apparently happened when I came off my bike.

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So look, here's the patient narrative.

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I was riding a bike on the towpath, going about 20 miles an hour, something in the way of bike somersaulted, blah blah.

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I was very dazed, wasn't knocked out, both arms deformed and useless.

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Really bad, nasty. Fingers were numb. All my fingers immediately numb.

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Couldn't see them properly and my helmet was split.

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It's funny, isn't it? You come down in your arms how that split my helmet because I bounced that on the head on the second bounce.

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Welcome return in the nose was a 55 year old female fell off a bike.

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Now actually on the day I came off the bike, I was only 54.

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But by the time the wardrobe did come round the next day, I was in the denominator population for false prevention.

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So a nice lady in a white coat with a clipboard.

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It was a false prevention coordinator. Came along to my hospital bed and the first question she asked was, Can you hear me?

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So actually, that's how you start when you're doing false prevention in the over 50 fives.

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Now, can you see these?

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Let me see if I can read them. I can't read them. Maybe I can read one here.

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Do you take four or more prescription medicines?

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Do you ever feel dizzy? You do. Deafness?

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They asked about. Has it been more than two years since you had an eye exam?

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Blah, blah, blah. Okay, so you can see the narrative here.

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The rich patient narrative is not mapping onto the fool's free plan.

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Right. This. Let's just keep going. Now, with the objective summary of what happened to me.

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Well, over the next four months, I had seven operations on my arms, veins back in to put metal in,

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take metal out, take out a chunk of one bone because they reckon the reason why my fingers are still numb.

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Oh, you must have a distorted ulnar or whatever. Still going in.

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The numb fingers will look. You broke your arms. What do you expect?

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Six months and I've got quite marked wasting having this clumsiness in my hands and long track signs in my legs mean something squashed.

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So at an MRI scan and three crushed fractures and severe disc prolapse.

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So I went along to a different orthopaedic surgeon that was very good at replacing

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bits and bobs in your neck and gave me two titanium discs went very well.

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Now, here we go.

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Here's a nice guideline on selection of adults for imaging of the cervical spine, adults presenting who have sustained the head injury.

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Well, I definitely sustained a helmet injury. Let's go to split helmets.

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But the obvious injuries were elsewhere. Interesting guideline here.

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I want you to look at this, but you are not really complaining about the doctors who did this.

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That's not the point. The point is, this is a mistake that we could all make.

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The guideline isn't going to personalise your management.

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So you can say, well, dangerous mechanism of injury fall from greater than one metre was a foot is a kind of

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slip from great because I went up in the air and down ejection from a motor vehicle.

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It wasn't motorised but it was pretty a do you see it takes a bit of judgement to think well it is.

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Does this guideline actually apply to the letter of the guideline apply bicycle collision?

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Well, the bicycle didn't collide with anything. It just went up in the air when I collided with the ground.

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So technically it doesn't quite fit. But of course if you look at that and you think, oh yeah,

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that's that's kind of that's it's it's a bit better than the falls prevention guideline, doesn't it?

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Which is the one that was applied to me. But nobody thought this. So the learning point is pretty obvious, and I'm labouring it slightly.

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But when I was writing it up this week, I thought there must be another a deeper reason why nobody thought to use this,

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because I was a pretty serious trauma case. I'm covered in bruises.

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It wasn't it was clear that this was, you know, whatever.

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So it looked I found looking up the right arm, I'd had what I called at the time and everybody called at the time.

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Achilles fracture, in other words, fractured the radius and everything impacted so that this arm was much shorter.

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And I kind of pull it out under general anaesthetic.

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And I called it Achilles Fracture until last weekend and then I realised it wasn't actually Achilles fracture because

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Achilles fracture is the fault hand or fracture with the dorsal displacement of the distal part of the radius.

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That's clever, isn't it. Boned up on both pedals.

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Now, if you break this part of your radius but you haven't got dorsal displacement, it's not technically Callie's fracture.

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And I didn't have the dorsal displacement displaced in another direction.

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The Collins fracture is the fracture you get when you've got low bone density.

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And it's a fragility fracture. And the epidemiology is postmenopausal women with not very much trauma.

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And it goes with broken hips and the fracture and the, you know, all that kind of thing.

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There's no such thing. I had I had orthopaedic cleat,

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the same kind of fracture that you get in younger male athletes aged between 20 and

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50 who are doing high impact sports or coming off a horse or something like that.

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So that's a the epidemiological patterning of that kind of fractured radius goes with people who are doing crazy things to their bodies,

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like doing high impact sports. The name Collins Fracture shapes your mindset to think this was a fragility fracture,

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especially since this person is now in the over 50 fives and isn't male.

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And I actually think that it was the label called these fracture that flipped them into picking a falls prevention guideline.

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There's a book by Jeff Barker. And Susan, these starts a fascinating book is called Sorting Things Out Classification and Its Consequences.

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And it actually uses the ICD ten, the international classification of diseases as a work example of what happens here.

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We create these schemes and then once we've created the schemes, they become totally enshrined in guidelines and protocols,

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and then they ossify our assumptions, they reproduce our assumptions, and then those assumptions appear to be scientific.

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And that's if you go back to personalised medicine. I was interviewing Fiona Parry the other day, who's a professor of gastroenterology here,

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and she was saying things like Crohn's disease and colitis, we've classified patients into Crohn's and you see,

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but actually at a molecular level,

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we ought to be classifying people completely differently in terms of the underlying biochemistry and the underlying genetics of that condition.

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And what we should be doing is getting rid of these Crohn's.

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And you see similarly for asthma and COPD, you talk to people up the hill, we say the same thing.

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We should be classifying people into eosinophilic wheeze, a non-issue,

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an emphatic and then that will determine much better which one's response is such such.

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But you try getting the DPS, for example, to stop using the term asthma.

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They don't like that at all. It's because of this is because these classification schemes have become very enshrined.

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Similarly, colleagues fracture. Okay, let's go on to a different bit of my management because I was tweeting saying, hey, guess what guys,

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I've found that they've been found to have these whatever I'm going to I'm going off to have a cervical disk replacement.

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So an awful lot of people, including two professors in my own department, says you don't need the cervical disc replacement operation.

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Randomised trials have shown that in cervical disk lesions the surgical groups didn't do any better than the ones who

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are conservative managed who's heard that statement and we heard that statement about about cervical disk replacement.

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We do too many of them. Okay. A couple of people nodding, but they said that without understanding what had happened,

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they just said, your patient is going off to have this cervical disk operation.

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We don't need to do that. You know, you're obviously being over managed, what do they call it?

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Overdiagnosis, overtreatment. They hadn't looked at the MRI.

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They hadn't, etc. All right. That's rubbish.

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Even that's what I mean by rubbish. Should be a. Okay.

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It's evidence based, but it's not.

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The evidence doesn't apply to this patient.

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Look, here's our city, which showed that surgery with physiotherapy resulted in more rapid improvement in the first post-operative year,

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but by two years they were both the same. So this is the kind of stuff that is influencing people to say, stop operating on people's cervical discs.

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But look at the exclusion criteria.

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The first one is obvious myopathy, which I had even slight intermittent signs of, but allopathy and the history of neck distortion.

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So those patients were not in the trial.

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So don't tell someone who's, you know, met the exclusion criteria that he's the evidence base that applies to you.

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It doesn't. Also, those patients hadn't previously tried physiotherapy.

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Come on, I've been doing it for months. John Grimley Evans written this fantastic paper many years or 20 years old.

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Now, who says this is to use evidence in the manner of the fabled drunkard who

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searched under the streetlamp for is dorky because that's where the light was,

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even though he dropped the case somewhere else.

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And in fact, the paper that I've written based on this case is called of Lamp Posts, Keys and Drunkards.

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A Tale of Four Guidelines. Anyway, all right.

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Here's the last guideline on non guideline.

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I want to tell you about, because I've been telling you about three different ones. Like I was advised by somebody,

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someone not very senior in my do not take nonsteroidal anti-inflammatory drugs for a month after my cervical disk replacement,

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because I was told there's some evidence of delayed healing of of bone repairs and that the risk of bleeding was higher.

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So don't take any ibuprofen, naproxen or whatever.

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So here's my narrative. Should I take non-steroidal?

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I don't want to bleed. I don't want delayed healing.

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But I don't want to be in pain. And I hate opiates. So here we go.

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I put it out on Twitter. Nice open ended question.

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So the first person who said, well, look,

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if you're not worried about the evidence of disc replacement in the first place and why you worried about the steroids,

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so they're still giving me a hard time about having the operation. But then this clinician says, why routinely prescribe them really good painkillers,

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opioid sparing, get you up and about quickly and not referring to evidence at all.

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If you think his clinical judgement is unthinkable. Should I? Should I believe this Abbey?

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Should I believe that, you know, the practitioner and then this guy saying, well, you know, for the lumbar discs.

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Oh yeah, that's fine. But cervical discs, you know, they could bleed around your airway so, so quick I could actually die.

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So I'm concerned. So I started looking up the evidence.

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So the one that comes out, the one that's been cited most, this inhibition of fracture healing turns out to be 12 rats.

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12 rats who they've deliberately smashed so, you know, broken the legs of.

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And then they've they've given them no stretch thinking on what we saw in our we been 12 rats and then there was something in humans

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so you know you go through the pub med g tick the human box and half the evidence disappears or actually two thirds of it disappears.

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So what they had here was 32 patients who had non-union of a broken leg, and then they matched them, you know, in sort of case control thing.

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And they found that the ones who got the non-union were more likely to take a non-steroidal just give them a minute quote with the evidence.

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Know that triangle with the evidence hierarchies is pretty low down.

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Is this the best evidence? So there must be a systematic review.

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So I found to actually I love this.

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It's an animal and in-vitro studies present.

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So it's such conflicting data that even studies with identical parameters have opposing results.

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So the evidence base is an absolute quagmire.

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So why are these people confidently putting it out on Twitter? So that is another one.

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So the research is required? Yeah, there is. There is actually no good evidence one way or the other.

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Okay. So what do we do?

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This is a really common situation in clinical practice where you've really tried to help the patient by looking up the evidence.

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And what you've got is as it is, it just is. You can't hang your hat on.

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So I think what the evidence show. Non-steroidal.

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They inhibit the same kind of prostaglandins that are involved in both.

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Here is a plausible metabolic explanation. Animals show slower healing, but they're not.

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You know, the studies are pretty crap.

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People with delayed healing were more likely to have have taken them and in randomised trials post surgical patch such high incidence of GI bleeding.

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Okay. Well of course of course anybody who takes a non steroids don't have a higher incidence of bleeding.

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All right. Now, individualised evidence, this isn't evidence in the textbooks, isn't evidence you can get from reading my file or taking history.

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I used to a lot of sport. Sued you quite a lot.

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I've had two years of non-steroidal. You take them all the time when you're training because then you can train harder.

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No adverse effects whatsoever is to knock back ibuprofen like smarties had a number of stress fractures treated with non-steroidal.

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Not only did they heal perfectly fine, but if you look in the book, this fracture is supposed to take six weeks.

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I'd be back running on it after months. I mean, I was always having them non-steroidal.

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Didn't didn't delay healing in me.

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Okay. I've had adverse reaction to opioids. The surgeon said, look, this is really difficult.

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I came around this time. It took us 6 hours to sort your neck out.

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So that was that's tough. And he described all the stuff he'd been doing, sought me out, and I was in pain.

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And I promise forgot that I was going to write an editorial for the BMJ that we so had a really good reason for not being knocked off by opiates.

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Okay. So now we've got a huge amount of evidence here.

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Now, despite the fact that the evidence in the literature is weak and confusing, you don't know which way to go in this patient given her history,

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the clinical picture, the equivocal nature of the evidence, the benefit home balance is massively in favour of non-steroidal.

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So we know this patient isn't allergic to them, doesn't react badly to them, especially after the first 24 hours.

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So I agreed I wouldn't take them in the first 24 hours and then take them.

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Okay. So this is a fairly uncontroversial conclusion, I think, is that when we're practising medicine, nursing,

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whatever in the is the management of this patients in these circumstances an appropriate that is real or an inappropriate that is rubbish application

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of the principles of IBN and the IBN experts should avoid pulling rank on experienced clinicians by citing irrelevant acts out of context,

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because I actually think I've got an attitude, some of them.

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Here's a more controversial question and I think rather more interesting if we practice patient focussed individualisation of the evidence,

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i.e. if we practice really, and we also find that more research isn't needed, we don't need to do any more research.

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We already know it's pretty flaky and probably will still be flaky.

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Perhaps the uncertainty in science is inherent.

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Perhaps it'll never get resolved with more RC tes, more mature analyses, etc.

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So I probably wasted your money on coming on this course. No, maybe not.

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And perhaps we need to return to old fashioned clinical methods and use EPM a little bit less comprehensively.

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Let's go back and get patient based evidence. All right, go.

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That's the end of that. I'd love to hear your comments.