Yeah. Thanks very much. Yeah. You wouldn't want me talking about Metro analysis because I'm not.
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.
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.
Evidence lies, and it's based on a little encounter I had with the concrete on my bike.
But it, it, I've used it to illustrate actually a paper that I've just finished.
I just sent it off to the Journal of Evaluation in Clinical Practice this week about guidelines,
evidence based guidelines and why we need to think about them.
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.
So I started off oh, you mean about 2013 having this argument with Carl Hennigan on Twitter who do follows me on Twitter.
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
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,
but they're not. They're being stupid. And that's what I called hashtag Rubber Sheba.
So I then got invited to speak at Evidence live about the difference between
really rubbishing Beam and what was really Beam and what was rubbish beam.
And it was like, they've distorted what I meant.
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?
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.
Is it an appropriate that is real or inappropriate?
That is rubbish application of the principles of IPM because you know, these people get pretty pompous.
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.
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.
So you come from better in the how this is. You know, you're really,
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.
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.
And, you know, that individual in front of you represents the average because mostly they don't.
So Mark Tonelli, who actually met recently back in 1999 and nearly 20 years ago,
he was talking about the individuality of patients being devalued in the practice of IBM.
The focus of clinical practice, if we're not careful, is shifted away from the care of individuals and towards the care of populations.
In other words, everyone gets the average. The complex nature of sound clinical judgement is not fully appreciated.
Who's a clinician here? Oh, great. Lots of you.
Okay, so you know what I'm talking about? This is this would be dead easy that.
So in my view, I think there have been three phases in abm's epistemological claims.
In other words, its own claims about what it's about. The first phase was epidemiological evidence.
In other words, epidemiological evidence kind of trumped intuition and clinical.
John How to get away from intuition, get away from clinical judgement.
Just have this pure, wonderful, beautiful epidemiological truth that is that didn't last long.
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.
In fact Eben is both of these and the patient perspective,
but it didn't really get into how you're going to integrate Texas epidemiologist you didn't know about all
the other stuff and then now you've got certainty in Oxford at the moment is this precision medicine,
this individualisation of epidemiology via this sort of stratification perspective, defining of subgroups.
And the more you look at the last one, the more you realise they haven't got there yet.
So I think we're still mostly.
In Phase two, where what we've got is somehow the need to combine epidemiological evidence, clinical judgement and the patient perspective.
So you'll talk about that. That's what you did. That's the mantra.
But what happens? You're right.
Well, epidemiological evidence you've got you got your trials, you've got your observational data, all that kind of thing.
Then you've got what's clinical judgement? Well, you could say it's a combination of tacit knowledge.
That sort of embodied knowledge that we pick up over the years,
know the stuff that my son is only just qualified as a doctor, hasn't yet got tacit knowledge,
practical wisdom and what John Gabbay called mind lines,
the sort of shared assumptions and approaches and perspectives that you get in what they call the community of practice.
A whole lot of you sit around and share stories, and through those stories you're really exchanging practical wisdom.
So the mind line I study mine was a love mind line, actually.
And then, yeah, right. If we're going to do it properly, we've got to incorporate the patient's perspective and the,
you know, the social psychologists to do that through active listening and shared decision making.
And there's lots and lots in the literature on all of that. Well, that sounds great, and that sounds pretty great.
Now, let's go back to Dave Sackett, one of the founding fathers of IPM.
This is what he said in Oxford when on that very first CBM course I went on in 1995, he said,
Look, when you're looking at the results of a trial, same results of a systematic review.
Were the patients in this trial sufficiently similar to the patient in front of me,
this individual, in whatever key respects, that I can safely apply the findings in this case.
And he added, If not [INAUDIBLE] on it, you know, that was that was sick.
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,
I know you've found the randomised controlled trial but that is not going to apply to my mother.
And then you think, no, no, it's not so much that you've read the trial in detail,
but you know the mother in law and data is just not going to apply for whatever reason.
So old fashioned clinical method because I'm old enough to practice medicine before IBM was invented,
all these before came over to this side of the of the ocean.
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,
her history findings from the examination, the test results, how this patient reacted the last time she took the drug.
Family circumstances. Given all that, what evidence do I now need?
This is patient based evidence. It's not just patient preferences.
It's not just, you know, the little tick boxes in the shared decision making form.
It's the totality of what's going on with this patient.
And if that the patient's unconscious, you can gather an awful lot of data about that patient.
I don't think we use this enough.
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.
These are just to the process of interpretation in, in clinical method.
I these are not things that you get given as a, as a student of EPM.
I think you should hear some more narrative the hold over this must be 20 years ago that was
published narrative based medicine and then evidence based what is in the British Medical Journal?
How do we combine the rich narrative of what the patient is experiencing with the
evidence that we get from critically appraise doctors and systematic reviews?
Okay, so this is a fine Engebretsen philosophical paper published quite recently and based on the philosopher called Lonergan,
who I've never heard of before, I read this paper. So he asks the question, Well, what do we mean by knowing?
What do we mean by that in a clinical knowing?
So he says, the first thing we need to do is collect sensations and observations,
taking the patient's pulse, whatever it might be, something that calls for explanation.
First thing you do, you know, take a history, examine the patient data.
We then go into a phase of interpreting those data, asking the question, what could this be?
And you've all been there almost. You've been there as clinicians and patient comes in the symptoms.
You take a look and you said, well, it could be this, it could be this, it could be this.
Once you've interpreted those, you've reached some level of understanding.
The next phase is weighing up those competing acts.
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.
And that means you're now making a judgement. But then the interesting the most interesting phase here is choosing how to act,
what's the right thing to do, the morally right thing, because actually medicine is not a science.
This is not an art. Medicine is a moral practice, case based reasoning.
Aristotle. Every patient that we see,
we are making a moral choice about what is the best thing to do with this lady or this gentleman in these particular circumstances.
The example is use of that as a member woman came to me once, very late on a Friday night,
and she was in the right of states and she was, you know, all sort of flustered and understood it.
And she wanted me to fit her within it. She tried contraceptive device and she got it from the chemist and she brought
it along and she'd got the three kids sitting in the waiting room and she said,
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.
She'll haven't got time for that. You know, I've got to pick up my fourth child from something,
and we went through this and in the end I said, Look, I'm sorry, I'm not going to fit that right now.
I want I want you to come back and I'll make a special appointment on Monday or whatever.
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,
with the woman in state she was in, having not engaged with the pros and cons,
I thought it was not morally right to agree to fit this device because of the risks and all that kind of thing.
In other words, it's not just a science.
It's it's a judge, a contextual judgement. You get the idea really, really important.
Okay. That wasn't what was going to tell you about I don't tell you about falling off my bike.
So those of you been following me on Twitter for a while will know.
A few years ago, actually, as nearly four years ago, that was what I tweeted.
Bad bike smash in the hospital.
Two broken arms on today's trauma list thanks to kind bystanders and NHS sorry will be out of action until further notice.
Yeah, it was horrible, really horrible. Bike Smash. And what happened was I was cycling along on the canal actually in London.
It was a bright, sunny day and I was going along on a concrete and something got caught in my wheel.
I used to be a good cyclist, you know, I was going on with was was with wisdom.
I like chrome clipped into the pedals and the whole bike suddenly flipped up in the air and came smashing down on the concrete.
Like I came down with arms up my head, smack, smack, you know, compound fractures, all the rest of it.
One very nice, very well, that kind of thing.
Plenty of that. There I am with both arms in temporary slings.
And then a week later there I am playing with the putty, and a month later I'm feeling quite a lot better.
So that was a whizz through what had apparently happened when I came off my bike.
So look, here's the patient narrative.
I was riding a bike on the towpath, going about 20 miles an hour, something in the way of bike somersaulted, blah blah.
I was very dazed, wasn't knocked out, both arms deformed and useless.
Really bad, nasty. Fingers were numb. All my fingers immediately numb.
Couldn't see them properly and my helmet was split.
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.
Welcome return in the nose was a 55 year old female fell off a bike.
Now actually on the day I came off the bike, I was only 54.
But by the time the wardrobe did come round the next day, I was in the denominator population for false prevention.
So a nice lady in a white coat with a clipboard.
It was a false prevention coordinator. Came along to my hospital bed and the first question she asked was, Can you hear me?
So actually, that's how you start when you're doing false prevention in the over 50 fives.
Now, can you see these?
Let me see if I can read them. I can't read them. Maybe I can read one here.
Do you take four or more prescription medicines?
Do you ever feel dizzy? You do. Deafness?
They asked about. Has it been more than two years since you had an eye exam?
Blah, blah, blah. Okay, so you can see the narrative here.
The rich patient narrative is not mapping onto the fool's free plan.
Right. This. Let's just keep going. Now, with the objective summary of what happened to me.
Well, over the next four months, I had seven operations on my arms, veins back in to put metal in,
take metal out, take out a chunk of one bone because they reckon the reason why my fingers are still numb.
Oh, you must have a distorted ulnar or whatever. Still going in.
The numb fingers will look. You broke your arms. What do you expect?
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.
So at an MRI scan and three crushed fractures and severe disc prolapse.
So I went along to a different orthopaedic surgeon that was very good at replacing
bits and bobs in your neck and gave me two titanium discs went very well.
Now, here we go.
Here's a nice guideline on selection of adults for imaging of the cervical spine, adults presenting who have sustained the head injury.
Well, I definitely sustained a helmet injury. Let's go to split helmets.
But the obvious injuries were elsewhere. Interesting guideline here.
I want you to look at this, but you are not really complaining about the doctors who did this.
That's not the point. The point is, this is a mistake that we could all make.
The guideline isn't going to personalise your management.
So you can say, well, dangerous mechanism of injury fall from greater than one metre was a foot is a kind of
slip from great because I went up in the air and down ejection from a motor vehicle.
It wasn't motorised but it was pretty a do you see it takes a bit of judgement to think well it is.
Does this guideline actually apply to the letter of the guideline apply bicycle collision?
Well, the bicycle didn't collide with anything. It just went up in the air when I collided with the ground.
So technically it doesn't quite fit. But of course if you look at that and you think, oh yeah,
that's that's kind of that's it's it's a bit better than the falls prevention guideline, doesn't it?
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.
But when I was writing it up this week, I thought there must be another a deeper reason why nobody thought to use this,
because I was a pretty serious trauma case. I'm covered in bruises.
It wasn't it was clear that this was, you know, whatever.
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.
Achilles fracture, in other words, fractured the radius and everything impacted so that this arm was much shorter.
And I kind of pull it out under general anaesthetic.
And I called it Achilles Fracture until last weekend and then I realised it wasn't actually Achilles fracture because
Achilles fracture is the fault hand or fracture with the dorsal displacement of the distal part of the radius.
That's clever, isn't it. Boned up on both pedals.
Now, if you break this part of your radius but you haven't got dorsal displacement, it's not technically Callie's fracture.
And I didn't have the dorsal displacement displaced in another direction.
The Collins fracture is the fracture you get when you've got low bone density.
And it's a fragility fracture. And the epidemiology is postmenopausal women with not very much trauma.
And it goes with broken hips and the fracture and the, you know, all that kind of thing.
There's no such thing. I had I had orthopaedic cleat,
the same kind of fracture that you get in younger male athletes aged between 20 and
50 who are doing high impact sports or coming off a horse or something like that.
So that's a the epidemiological patterning of that kind of fractured radius goes with people who are doing crazy things to their bodies,
like doing high impact sports. The name Collins Fracture shapes your mindset to think this was a fragility fracture,
especially since this person is now in the over 50 fives and isn't male.
And I actually think that it was the label called these fracture that flipped them into picking a falls prevention guideline.
There's a book by Jeff Barker. And Susan, these starts a fascinating book is called Sorting Things Out Classification and Its Consequences.
And it actually uses the ICD ten, the international classification of diseases as a work example of what happens here.
We create these schemes and then once we've created the schemes, they become totally enshrined in guidelines and protocols,
and then they ossify our assumptions, they reproduce our assumptions, and then those assumptions appear to be scientific.
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,
and she was saying things like Crohn's disease and colitis, we've classified patients into Crohn's and you see,
but actually at a molecular level,
we ought to be classifying people completely differently in terms of the underlying biochemistry and the underlying genetics of that condition.
And what we should be doing is getting rid of these Crohn's.
And you see similarly for asthma and COPD, you talk to people up the hill, we say the same thing.
We should be classifying people into eosinophilic wheeze, a non-issue,
an emphatic and then that will determine much better which one's response is such such.
But you try getting the DPS, for example, to stop using the term asthma.
They don't like that at all. It's because of this is because these classification schemes have become very enshrined.
Similarly, colleagues fracture. Okay, let's go on to a different bit of my management because I was tweeting saying, hey, guess what guys,
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.
So an awful lot of people, including two professors in my own department, says you don't need the cervical disc replacement operation.
Randomised trials have shown that in cervical disk lesions the surgical groups didn't do any better than the ones who
are conservative managed who's heard that statement and we heard that statement about about cervical disk replacement.
We do too many of them. Okay. A couple of people nodding, but they said that without understanding what had happened,
they just said, your patient is going off to have this cervical disk operation.
We don't need to do that. You know, you're obviously being over managed, what do they call it?
Overdiagnosis, overtreatment. They hadn't looked at the MRI.
They hadn't, etc. All right. That's rubbish.
Even that's what I mean by rubbish. Should be a. Okay.
It's evidence based, but it's not.
The evidence doesn't apply to this patient.
Look, here's our city, which showed that surgery with physiotherapy resulted in more rapid improvement in the first post-operative year,
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.
But look at the exclusion criteria.
The first one is obvious myopathy, which I had even slight intermittent signs of, but allopathy and the history of neck distortion.
So those patients were not in the trial.
So don't tell someone who's, you know, met the exclusion criteria that he's the evidence base that applies to you.
It doesn't. Also, those patients hadn't previously tried physiotherapy.
Come on, I've been doing it for months. John Grimley Evans written this fantastic paper many years or 20 years old.
Now, who says this is to use evidence in the manner of the fabled drunkard who
searched under the streetlamp for is dorky because that's where the light was,
even though he dropped the case somewhere else.
And in fact, the paper that I've written based on this case is called of Lamp Posts, Keys and Drunkards.
A Tale of Four Guidelines. Anyway, all right.
Here's the last guideline on non guideline.
I want to tell you about, because I've been telling you about three different ones. Like I was advised by somebody,
someone not very senior in my do not take nonsteroidal anti-inflammatory drugs for a month after my cervical disk replacement,
because I was told there's some evidence of delayed healing of of bone repairs and that the risk of bleeding was higher.
So don't take any ibuprofen, naproxen or whatever.
So here's my narrative. Should I take non-steroidal?
I don't want to bleed. I don't want delayed healing.
But I don't want to be in pain. And I hate opiates. So here we go.
I put it out on Twitter. Nice open ended question.
So the first person who said, well, look,
if you're not worried about the evidence of disc replacement in the first place and why you worried about the steroids,
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,
opioid sparing, get you up and about quickly and not referring to evidence at all.
If you think his clinical judgement is unthinkable. Should I? Should I believe this Abbey?
Should I believe that, you know, the practitioner and then this guy saying, well, you know, for the lumbar discs.
Oh yeah, that's fine. But cervical discs, you know, they could bleed around your airway so, so quick I could actually die.
So I'm concerned. So I started looking up the evidence.
So the one that comes out, the one that's been cited most, this inhibition of fracture healing turns out to be 12 rats.
12 rats who they've deliberately smashed so, you know, broken the legs of.
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
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.
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.
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.
Know that triangle with the evidence hierarchies is pretty low down.
Is this the best evidence? So there must be a systematic review.
So I found to actually I love this.
It's an animal and in-vitro studies present.
So it's such conflicting data that even studies with identical parameters have opposing results.
So the evidence base is an absolute quagmire.
So why are these people confidently putting it out on Twitter? So that is another one.
So the research is required? Yeah, there is. There is actually no good evidence one way or the other.
Okay. So what do we do?
This is a really common situation in clinical practice where you've really tried to help the patient by looking up the evidence.
And what you've got is as it is, it just is. You can't hang your hat on.
So I think what the evidence show. Non-steroidal.
They inhibit the same kind of prostaglandins that are involved in both.
Here is a plausible metabolic explanation. Animals show slower healing, but they're not.
You know, the studies are pretty crap.
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.
Okay. Well of course of course anybody who takes a non steroids don't have a higher incidence of bleeding.
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.
I used to a lot of sport. Sued you quite a lot.
I've had two years of non-steroidal. You take them all the time when you're training because then you can train harder.
No adverse effects whatsoever is to knock back ibuprofen like smarties had a number of stress fractures treated with non-steroidal.
Not only did they heal perfectly fine, but if you look in the book, this fracture is supposed to take six weeks.
I'd be back running on it after months. I mean, I was always having them non-steroidal.
Didn't didn't delay healing in me.
Okay. I've had adverse reaction to opioids. The surgeon said, look, this is really difficult.
I came around this time. It took us 6 hours to sort your neck out.
So that was that's tough. And he described all the stuff he'd been doing, sought me out, and I was in pain.
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.
Okay. So now we've got a huge amount of evidence here.
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,
the clinical picture, the equivocal nature of the evidence, the benefit home balance is massively in favour of non-steroidal.
So we know this patient isn't allergic to them, doesn't react badly to them, especially after the first 24 hours.
So I agreed I wouldn't take them in the first 24 hours and then take them.
Okay. So this is a fairly uncontroversial conclusion, I think, is that when we're practising medicine, nursing,
whatever in the is the management of this patients in these circumstances an appropriate that is real or an inappropriate that is rubbish application
of the principles of IBN and the IBN experts should avoid pulling rank on experienced clinicians by citing irrelevant acts out of context,
because I actually think I've got an attitude, some of them.
Here's a more controversial question and I think rather more interesting if we practice patient focussed individualisation of the evidence,
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.
We already know it's pretty flaky and probably will still be flaky.
Perhaps the uncertainty in science is inherent.
Perhaps it'll never get resolved with more RC tes, more mature analyses, etc.
So I probably wasted your money on coming on this course. No, maybe not.
And perhaps we need to return to old fashioned clinical methods and use EPM a little bit less comprehensively.
Let's go back and get patient based evidence. All right, go.
That's the end of that. I'd love to hear your comments.