1 00:00:00,180 --> 00:00:05,940 It's fair to say, to introduce and actually publicly congratulate Trish, 2 00:00:06,780 --> 00:00:13,710 who recently joined the Department of Primary Care Health Sciences as a professor in Primary Care from Queen Mary University in January. 3 00:00:14,310 --> 00:00:22,260 So having read just recently in the BMJ, you've actually convinced me on the on the campaign trail. 4 00:00:22,260 --> 00:00:27,180 Even when I asked her to join the campaign, she said that there's actually no charge in the team, so there is no team. 5 00:00:27,450 --> 00:00:35,580 So, of course, it's got I'm hoping tonight that she will convince you to become part of the team and join the campaign to really be a thank you. 6 00:00:36,270 --> 00:00:46,080 It's amazing, actually, because in 1985 I came to Oxford for the very first IPM workshop. 7 00:00:46,710 --> 00:00:50,820 Maybe it was No, no, 85 women will know something, or it's when one of my kids was born. 8 00:00:50,820 --> 00:00:54,920 When would it have been? 90. It's no 90. 9 00:00:55,780 --> 00:00:58,959 Five, 95, 1995. Yeah, they were small, I remember. 10 00:00:58,960 --> 00:01:04,960 They were small. They weren't. They'd been born. So now that's like 20 years. 11 00:01:05,800 --> 00:01:10,810 That's, that's, it's a whole generation. It's quite amazing. 12 00:01:11,710 --> 00:01:14,260 An Oxford in Oxford, an evidence based medicine. 13 00:01:14,620 --> 00:01:22,720 I've got a bit of a history, but, you know, 20 years, it's like one of those marriages, you know, isn't a done 20 years of marriage. 14 00:01:23,200 --> 00:01:30,750 I mean, I've done nearly 30 years. You know, after 20 years, you think, oh, god, I cannot be like this, right? 15 00:01:31,090 --> 00:01:40,540 But it's fine. It's fine. But seriously, ABM'S been going quite a long time and I think maybe not now, tonight, 16 00:01:40,540 --> 00:01:46,750 but about now in the history of CBM, it's time to really take a hard think. 17 00:01:48,070 --> 00:01:53,650 You know, it has it got into a rut. It has it really it's it's got to move on. 18 00:01:53,770 --> 00:01:56,800 I think it's got to move on. But that's my view. 19 00:01:56,920 --> 00:01:59,469 Do you who agrees with that? Some of you. 20 00:01:59,470 --> 00:02:04,120 I mean, you are a completely self-selecting sample because if you didn't think that, you probably wouldn't be here. 21 00:02:04,120 --> 00:02:10,179 You've already gone home. All right, all right. Right. So firstly, yeah, look, thanks for inviting me. 22 00:02:10,180 --> 00:02:19,540 But also people associate. Well, you know, I that paper in the in the BMJ presents Tricia's paper that's 15 authors Jeremy put and say hello Jeremy 23 00:02:19,810 --> 00:02:25,210 yeah Jeremy is a co-author on that and there is anyone else but it was a co-author that is here. 24 00:02:25,390 --> 00:02:29,640 No, it's really important. This this isn't me. 25 00:02:29,650 --> 00:02:36,550 This I think Dave Sackett is kind of master of the cliche is to say I'm a symptom, not a cause. 26 00:02:36,940 --> 00:02:47,710 I'm not evidence based medicine. You know, IPM was going to happen in, you know, sometime between sort of mid 1980 and late 1990s. 27 00:02:48,520 --> 00:02:49,599 It was going to happen. 28 00:02:49,600 --> 00:02:55,660 And Sackett always say, Look, I'm a symptom, I'm somebody who's in the right place at the right time, the right book and all the rest of it. 29 00:02:56,440 --> 00:03:04,330 And in a way, I suppose the the campaign for really been is much isn't just me, the paper wasn't just me. 30 00:03:04,510 --> 00:03:06,160 This was stuff that was happening. 31 00:03:06,340 --> 00:03:18,070 And so genuinely, you know, the stuff that I'm going to talk about today is I'm the mouthpiece of stuff that's been going on all over the place. 32 00:03:18,790 --> 00:03:22,420 All right, look, you've had enough of me, real case. 33 00:03:22,600 --> 00:03:27,310 You've done four days out, five on your basically because you even want to one. 34 00:03:27,460 --> 00:03:36,790 This should be dead easy. Talk to your neighbour and give me some questions that you might then go and such that she felt so. 35 00:03:36,790 --> 00:03:43,750 What have you got? What questions have you got that would impress Carl Hennigan don't you don't care about 36 00:03:43,810 --> 00:03:49,299 impressing cop did you say oh right we don't know what impress him or you don't know what. 37 00:03:49,300 --> 00:03:55,600 Go on tell us. We think that they that we should ask the patient what's important to her. 38 00:03:55,750 --> 00:04:04,540 Right? Like prioritise her symptoms. And we should also look at some of the interactions in those drugs that she's been prescribed to me. 39 00:04:04,540 --> 00:04:07,659 She's on to me. That's okay. Okay. 40 00:04:07,660 --> 00:04:15,550 So, so what what is this patient you want to start off and say with the patient's priorities and also, whoa, that's a big long list. 41 00:04:15,940 --> 00:04:20,530 How many of you clinicians, you know, doctors, nurses, pharmacists? Yeah. Most of, you know, two thirds. 42 00:04:21,010 --> 00:04:24,370 Okay. Other questions? Yeah. 43 00:04:24,850 --> 00:04:28,480 So what's the evidence you can make? You ask her at the same time? 44 00:04:28,960 --> 00:04:35,470 Okay, what's the evidence? So zoom in on one of those medications and say, hang on a minute, she needs to be on both of these. 45 00:04:35,470 --> 00:04:39,250 Who invented that combination drug? Might she be better off on just one of those? 46 00:04:39,520 --> 00:04:44,410 What's the added benefit for putting two of them in together? Yeah, I'd ask her. 47 00:04:44,770 --> 00:04:48,549 How does she feel? I'm this thing. So how does she feel? 48 00:04:48,550 --> 00:04:49,240 Unwell. Yeah. 49 00:04:50,080 --> 00:04:58,239 You want more detail, you want more clinical detail on just you feel I'm well you know so she says, look, I'm, I've got ringing in my ears. 50 00:04:58,240 --> 00:05:06,260 You might be able to identify which of the drugs is giving or whatever. Yep, yep. Or exercise or weight reduction. 51 00:05:07,270 --> 00:05:14,349 Okay. So now you're thinking, wait a minute. Okay, so she's on, she's got diabetes and you've been given the drug list, 52 00:05:14,350 --> 00:05:18,370 but you're going off pace and you're going to say, we're going to do lifestyle measures. 53 00:05:18,370 --> 00:05:25,480 We're not just going to look at the drug list. Yep. So can you give me a question about exercise or diet? 54 00:05:26,050 --> 00:05:28,480 Can you frame it in that, you know, 55 00:05:28,690 --> 00:05:37,840 ask a focussed question way that I'm sure you've been taught in patients with type two diabetes comma, go on, which is more effective or. 56 00:05:38,440 --> 00:05:49,240 Yeah, okay. Okay. So what is the benefits versus the harms of regular exercise versus metformin in controlling diabetes, that kind of thing? 57 00:05:49,360 --> 00:05:55,210 Okay. So how many potentially how many questions are going to come out of this? 58 00:05:55,610 --> 00:06:00,799 An infinite amount, but certainly hundreds. Yeah. I mean, I came up with those. 59 00:06:00,800 --> 00:06:08,630 I mean, you're no better or worse than the ones that are probably better than these, but these are the ones that I started to try and unpack. 60 00:06:09,380 --> 00:06:15,230 I mean, interestingly, I didn't come up with the one of I've rather zoomed in on the drugs. 61 00:06:15,560 --> 00:06:19,390 And actually, I totally agree. We need another thing here about non-drug treatments. 62 00:06:19,730 --> 00:06:28,100 And I'm not giving you this example as a kind of perfectly well worked up example of of EB and done brilliantly by clever professor at all. 63 00:06:28,100 --> 00:06:33,080 This is just kind of me. So that patient one's in clinic and you know, used it as an example. 64 00:06:33,530 --> 00:06:39,589 The point I'm trying to make here is this kind of patient is absolutely standard. 65 00:06:39,590 --> 00:06:49,280 I did a morning surgery this morning and I must have seen three people with an equivalent package to Mrs. Patel, one of whom had also been beaten up. 66 00:06:49,710 --> 00:06:58,370 You know, that's just this morning. I didn't see very many people, for example, who had got a pure post-stroke. 67 00:06:59,210 --> 00:07:02,900 Can you talk about my blood pressure treatment, doctor, or my blood thinning treatment? 68 00:07:02,900 --> 00:07:06,950 I didn't see any of those. I saw people with carrier bags full of medication and that kind of thing. 69 00:07:07,400 --> 00:07:15,080 And this is something that EPM wasn't primarily designed to address. 70 00:07:15,080 --> 00:07:18,290 Why not? Can you help me give the lecture? 71 00:07:18,440 --> 00:07:21,910 It'd be much more interesting. Got to get. 72 00:07:24,220 --> 00:07:28,049 Too many. Compounding that, both are the women behind. 73 00:07:28,050 --> 00:07:33,150 You've got their hands up. What was it, simpler 20 years ago? 74 00:07:33,540 --> 00:07:44,910 Was life simpler 20 years ago? This is just one polypharmacy that more maybe so there was still polypharmacy then maybe there's a bit more of it now. 75 00:07:45,810 --> 00:07:50,760 Certainly. I'm getting some slides. I'm going to show you what it suggests that certain people think there's more polypharmacy now. 76 00:07:51,390 --> 00:07:56,130 So come on, let's think about the scenario of a done the drug trial, 77 00:07:56,490 --> 00:08:01,390 because that's a very focussed questions and this kind of pleasant faces multiple diseases. 78 00:08:03,060 --> 00:08:10,290 Yes. Okay. So EPA was designed for focussed questions and MULTIMORBIDITY doesn't lend itself to. 79 00:08:10,440 --> 00:08:14,790 I love that. That's really cool too on the podcast, haven't we? So we can kind of caught it. 80 00:08:14,890 --> 00:08:21,660 That's where I get, I should say, as elicited from the audience by Professor Greenhouse, this clever comment or something that's is really good. 81 00:08:21,660 --> 00:08:29,070 But you're right, I think that's. But I think my colleague here is right as well that multimorbidity isn't a new thing. 82 00:08:31,080 --> 00:08:36,180 Maybe it's got worse going. I can say that multiple is. 83 00:08:37,250 --> 00:08:40,640 We realised that she probably wouldn't qualify. Right. 84 00:08:41,150 --> 00:08:45,380 Come on. Let's, let's. Yeah, let's explore a bit more. 85 00:08:45,500 --> 00:08:49,940 Put your hand in here if you've ever been involved in a drug trial. 86 00:08:50,210 --> 00:08:55,700 As someone who either writes the grant application or enters people into the trial, 87 00:08:55,700 --> 00:09:00,370 or does any of that research type stuff, whether you've been an administrator or Jeremy's been. 88 00:09:00,590 --> 00:09:04,159 Come on in. Who else? All my mates from my department. What about people who know? 89 00:09:04,160 --> 00:09:07,460 Not. Yeah. Gone. What was your experience of a drug trial? 90 00:09:07,850 --> 00:09:11,030 I'm a clinical trial. Perfect. Come on, tell us how it's done. 91 00:09:11,660 --> 00:09:15,740 Well, it's very strict. Mm hmm. 92 00:09:18,530 --> 00:09:22,520 Anything like that? And so what? 93 00:09:22,650 --> 00:09:28,960 Did you get your money from a major HCA anywhere? 94 00:09:29,160 --> 00:09:37,620 Okay. Okay, now, look, I'm doing a bit of work with the people at the moment, the sort of some of the top brass at the HCA. 95 00:09:37,620 --> 00:09:42,790 We're doing a little fun piece of work is, but we spent a long time kind of hanging out on trains together. 96 00:09:42,790 --> 00:09:47,790 And you learn overhearing overhearing how this works. 97 00:09:48,360 --> 00:09:52,440 Guess what the state does for every bit of government money that they are? 98 00:09:52,710 --> 00:09:59,020 Department of Health money. What do they do, first of all? The very first thing they have to do is keep Sally Davis happy or whatever. 99 00:09:59,040 --> 00:10:02,159 And she Sally's a goodie, really a very good thing. 100 00:10:02,160 --> 00:10:06,209 But, you know, they ask a focussed question, all of them, you know, 101 00:10:06,210 --> 00:10:12,240 M.S. When did you last apply for M.S. money and be successful when you didn't have a focussed question? 102 00:10:12,840 --> 00:10:22,500 Something fundamentally flawed about the whole research machinery isn't there, but IBM is predicated on focussed questions. 103 00:10:23,370 --> 00:10:30,600 Somebody said to me once that research is the art of finding precise answers to simple questions. 104 00:10:30,990 --> 00:10:34,410 It's it's just deeply problematic, isn't it, guys? 105 00:10:34,680 --> 00:10:40,170 Because actually, you know, it's not helping the very people look. 106 00:10:40,420 --> 00:10:45,740 Have another look at Ms. Patel again. You know, if we can't help people like this lady, we've got problems, haven't we? 107 00:10:45,750 --> 00:10:50,700 I mean, you know, these are people who are very needy, very vulnerable, etc. 108 00:10:50,700 --> 00:10:54,480 All right. You know, you've all been given that paper. Have you been given that paper? 109 00:10:55,380 --> 00:10:58,590 Look, it's free. I mean, I paid £3,000 to make this open, access it. 110 00:10:59,190 --> 00:11:02,700 So get on, get onto the BMJ website. 111 00:11:04,090 --> 00:11:09,389 You must then tweet about it because it's already the most tweeted about paper that was 112 00:11:09,390 --> 00:11:15,540 published in the BMJ in the whole of 2014 is that we did we did good stuff on social media. 113 00:11:16,590 --> 00:11:20,250 All right. Now I'm going to give given the who, who's read it, be honest. 114 00:11:20,940 --> 00:11:23,580 Okay. So the rest of this lecture is all about persuading you to go read it. 115 00:11:25,800 --> 00:11:31,110 I'm not going to work up to telling you how we how we came to write that paper 116 00:11:31,380 --> 00:11:34,860 and how many times the BMJ rejected it before they agreed to publish it. 117 00:11:35,460 --> 00:11:39,600 So who has seen that sentence before? 118 00:11:39,900 --> 00:11:42,330 We hadn't seen that sentence before. Okay. 119 00:11:42,330 --> 00:11:49,049 So about half of you, maybe I am, is the conscientious, judicious and explicit use of cannabis making decisions about care of individual patient. 120 00:11:49,050 --> 00:11:55,140 Was it rather was that rubbish was a complete and utter rubbish apart from the picture of motherhood and apple pie on the bottom, 121 00:11:55,140 --> 00:11:59,120 which really tells you. I mean, it's flannel, isn't it? 122 00:11:59,520 --> 00:12:03,600 They think disagree with me. Come on over. 123 00:12:03,750 --> 00:12:06,959 Individual patients, is it. I think it's based on this. 124 00:12:06,960 --> 00:12:12,150 Based on principle. Oh. Oh, I hadn't thought of that. 125 00:12:12,150 --> 00:12:14,969 But yeah, you're right. Now is the other bit. 126 00:12:14,970 --> 00:12:21,360 I was kind of from the other half of the sentence I was taking issue with the yeah, the whole of the sentence is actually pretty flawed. 127 00:12:24,600 --> 00:12:28,830 I think as bright as I am, I can't possibly know everything. Okay. 128 00:12:30,390 --> 00:12:35,970 But no. Oh, okay. 129 00:12:35,980 --> 00:12:41,520 So it's a council of perfection. So it's like Winnicott, who said, look good. 130 00:12:41,550 --> 00:12:48,300 Don't read all these good parenting books. He wrote this book about good enough mothering, but if today you would have good enough fathering as well, 131 00:12:48,690 --> 00:12:52,240 that actually you don't need to be a perfect parent, you just need to be good enough parent. 132 00:12:52,260 --> 00:12:55,460 And the rest of it is up to the child, isn't it? I see. 133 00:12:57,750 --> 00:13:01,070 But. Well, I think it's rubbish. 134 00:13:01,080 --> 00:13:06,900 It doesn't say anything because it's not telling us what it is at all, 135 00:13:08,040 --> 00:13:15,180 or it doesn't define term best evidences and all this kind of rhetoric, conscientious, judicious. 136 00:13:15,190 --> 00:13:19,350 Explain all that saying is you doing, you know, you trying hard, you try your best. 137 00:13:20,220 --> 00:13:32,400 But what is doing rhetorically is associating a very particular methodology and approach with words that you couldn't possibly disagree with, 138 00:13:32,910 --> 00:13:42,350 because it's saying if you don't buy into this dirty, great hierarchy here, actually you're not being conscientious, judicious or anything. 139 00:13:42,510 --> 00:13:47,729 All these lovely things that we all want to be because we wouldn't want to be non conscientious and judicious all the rest of it. 140 00:13:47,730 --> 00:13:54,600 So this is a very clever piece of rhetoric and it is the most highly cited sentence that's ever been published in the BMJ. 141 00:13:55,560 --> 00:14:01,230 So what is PM then, if it's not that? Well, I think it's about an Anna Donaldson. 142 00:14:01,230 --> 00:14:04,530 I wrote another book. Or was it a book chapter or something? 143 00:14:04,530 --> 00:14:10,890 We said, we can't use that definition, we got to improve on it. And we said, Eben, then a few years ago, 144 00:14:11,370 --> 00:14:24,269 is the the use of mathematical estimates of the probability of benefit and the probability of harm derived 145 00:14:24,270 --> 00:14:34,170 from population samples to inform decision making when discussing decisions with individual patients. 146 00:14:35,100 --> 00:14:41,159 Now, Mike Kelly would say, yeah, but it's also about decisions about populations because you have evidence based public health 147 00:14:41,160 --> 00:14:44,410 and say things like should we have minimum alcohol pricing and use CBM for that as well. 148 00:14:44,670 --> 00:14:47,990 So the about individual patients, you could argue that all date, 149 00:14:48,000 --> 00:14:56,280 but the bit I think is wrong with that is it doesn't say it doesn't make explicit that this is about epidemiology. 150 00:14:57,630 --> 00:15:07,230 Now that I think is highly problematic because everything about APM has been driven by the paradigm of epidemiology. 151 00:15:07,230 --> 00:15:15,030 It is about sampling. So you have a population, you take a statistical sample, you then do an experiment on it, 152 00:15:15,030 --> 00:15:19,230 or perhaps you just observe it on whether a cohort or or trial or whatever, 153 00:15:19,470 --> 00:15:24,630 and you then get some numbers out and you then put a confidence in it around those numbers. 154 00:15:24,870 --> 00:15:28,380 You then program it into a decision support tool possibly, or put it into a book. 155 00:15:29,490 --> 00:15:33,660 And then when when you ask these questions, I go back. 156 00:15:33,870 --> 00:15:40,470 So I'm going to go back and forth. For example, in Asian women over 80 with Condition X, what is the benefit of drug war and what are the harms? 157 00:15:41,040 --> 00:15:44,190 You want numbers? Don't. You don't just want war. It's quite good. 158 00:15:44,970 --> 00:15:50,430 Do you see what I mean? So what we're talking about is the hierarchy of evidence. 159 00:15:50,430 --> 00:15:54,280 You know what this is? Don't you have? Is that okay? 160 00:15:54,280 --> 00:16:03,160 Now, do they do the Cochrane Collaboration still use this logo because I think it hasn't been revamped something I have using that that's still. 161 00:16:03,600 --> 00:16:09,770 You see that picture. Yeah. Okay so you know this is your you know, this is individual try one, two, three, four, five, six. 162 00:16:09,870 --> 00:16:13,139 Remember what it was about and then that's your grand me. 163 00:16:13,140 --> 00:16:18,810 Then the idea is yeah, you know, if increase in significance is all about big numbers and small confidence intervals 164 00:16:19,530 --> 00:16:28,360 and it's also about a methodological hierarchy method drives the quality assessment. 165 00:16:28,710 --> 00:16:33,030 Okay, so this method is higher quality than that method is not about theory. 166 00:16:33,870 --> 00:16:38,489 I have people from outside epidemiology. This is completely different now of course. 167 00:16:38,490 --> 00:16:45,240 Then what they did was they said, Oh yeah, but we also want to find out the patient's values and preferences. 168 00:16:45,240 --> 00:16:51,070 And actually the first comment that came from you people, splendid when I ask the question, 169 00:16:51,100 --> 00:16:55,890 is going to ask about Mr. Savage, what are her preferences, what are her desires, what in what way is she sick, etc.? 170 00:16:56,070 --> 00:16:59,160 Brilliant. Great. Because you're your contemporary people. 171 00:16:59,160 --> 00:17:00,690 You're not from 20 years ago. 172 00:17:00,930 --> 00:17:11,460 So ABM has now incorporated the idea that the patient's values preferences priorities should influence the way you apply epidemiology, 173 00:17:11,970 --> 00:17:15,090 but they're still pretty fixated on this. 174 00:17:15,090 --> 00:17:21,899 Now, that's not because I mean, I don't believe that a Nonrandomized trial is better than the randomised trial. 175 00:17:21,900 --> 00:17:26,340 I absolutely accept that within epidemiology. Yeah, that's okay. 176 00:17:27,300 --> 00:17:33,310 But. What I'm saying is outside epidemiology, there's all sorts of other things that we haven't yet taken account of. 177 00:17:34,030 --> 00:17:39,609 Okay. So and that's probably because I've been trained in social science, so I'm not really a doctor. 178 00:17:39,610 --> 00:17:47,740 I mean, I'm a doctor, but in my in my head, the paradigm I go for is much more around organisational sociology or, 179 00:17:48,370 --> 00:17:52,870 you know, something that actually isn't sitting in epidemiology. 180 00:17:53,230 --> 00:18:03,910 So I was getting into an argument with Carl. So this is way back in 2013, we deleted some of these, but I challenged this all happened on Twitter. 181 00:18:03,910 --> 00:18:07,960 Who's on Twitter? Who on Twitter? Oh, come on, the rest of me. 182 00:18:08,260 --> 00:18:11,470 Look, it's great. It's really great. 183 00:18:12,040 --> 00:18:17,680 I've got two PhD students, probably two of the best page theses I've ever had that came to me via Twitter. 184 00:18:19,330 --> 00:18:22,300 I've got two grants that came to me via Twitter. 185 00:18:22,600 --> 00:18:31,870 I had breakfast the other day with the master of an Oxford College with a research program that we started growing on Twitter. 186 00:18:32,020 --> 00:18:37,120 Don't tell me it's about exchanging pictures of kittens. This is this is you want to get into academia, get into Twitter. 187 00:18:38,950 --> 00:18:44,120 So I chucked out a few comments to call saying I didn't say be careful. 188 00:18:44,350 --> 00:18:47,350 I didn't say eBay is rubbish. Right? 189 00:18:47,350 --> 00:18:53,229 I didn't say that. And that some of the people have reframed that. What I said was there are two ways of applying EPM. 190 00:18:53,230 --> 00:18:56,230 One is really beam and one is rubbish. 191 00:18:56,350 --> 00:19:00,459 Beam Okay, really. Beam Really. 192 00:19:00,460 --> 00:19:06,190 Beam is what we want because actually it is a good idea to have robust randomised trial evidence blah blah blah. 193 00:19:06,640 --> 00:19:09,880 Look up in hill. He told you I was ill. He told you I've been ill. Yeah. 194 00:19:09,910 --> 00:19:16,570 No, no, no radio. I had to slip discs and I had to make a decision about spinal surgery. 195 00:19:16,960 --> 00:19:23,740 You know, Tiger can't go in there past your carotid artery and all that kind of thing and kind of fiddle on his spinal cord type stuff. 196 00:19:23,950 --> 00:19:31,000 I had to decide whether or not to have major, major drilling around that area or whether to leave it. 197 00:19:31,570 --> 00:19:35,300 I want to have randomised trials so I'm not opposed to randomised trials. 198 00:19:35,410 --> 00:19:41,200 Know I was desperate with those randomised trials and actually when I when you come to evidence live, 199 00:19:41,200 --> 00:19:46,620 I'm going to be talking about those kind of personal decisions. So I wasn't, I'm not opposed to them. 200 00:19:46,630 --> 00:19:57,580 But what I was saying was sometimes when you apply epidemiology in decision making with and about individual patients, 201 00:19:57,580 --> 00:20:00,850 it becomes rubbish, it becomes absurd, it becomes completely crazy. 202 00:20:02,110 --> 00:20:10,210 Now I wanted to do is talk to each other and think about an example of rubbish. 203 00:20:10,220 --> 00:20:17,130 EPA When is APM rubbish? Anyone got a good example? 204 00:20:19,590 --> 00:20:22,830 Anyone heard a good example from the person sitting next to you? On what time? 205 00:20:23,250 --> 00:20:30,840 Give me. Give us a good example of rubbish. EPA politics generally go on. 206 00:20:31,920 --> 00:20:35,180 Policies. Policies. Oh. 207 00:20:35,220 --> 00:20:45,000 Policies. I can say. I can see Nick getting very interested in policy making or ex policy is not the right. 208 00:20:45,210 --> 00:20:49,800 Come on. One example of a policy that is rubbish. 209 00:20:49,800 --> 00:20:53,490 CBM great, great example, great general example. 210 00:20:53,490 --> 00:20:59,520 And I want a specific example of a policy that is rubbish, even though if you don't know because Nicola, help us here. 211 00:20:59,640 --> 00:21:03,090 He's got armloads of the health checks. 212 00:21:03,600 --> 00:21:10,499 Come on for those. Because there may be some people from outside the UK who don't know that examples are just just in 140 characters. 213 00:21:10,500 --> 00:21:14,880 What are they? I don't Queen, but I wish you did. 214 00:21:15,210 --> 00:21:20,160 Look at the old becoming a 40 year old guy that loves it. 215 00:21:20,670 --> 00:21:26,360 Hmm. I was one of the Facebook. Okay. 216 00:21:26,990 --> 00:21:32,870 So just for the podcast, I'm going to repeat that. So it's for two year olds from me. 217 00:21:33,080 --> 00:21:36,620 So is it Jessie's 40 with Jessie? You're going to get one? 218 00:21:36,950 --> 00:21:41,089 Yes, Jessie. Sorry, I have that one, though, because you had a cake with 40 on it. 219 00:21:41,090 --> 00:21:46,669 It's not a secret, is it? Okay. So you get this very thing and get that letter from your GP. 220 00:21:46,670 --> 00:21:53,840 Anyone up to the age of 70. Apparently after 70 you because you you to check your health anyway. 221 00:21:54,170 --> 00:22:02,720 But before between 40 and 70. And it's invitation to go along to your GP and have a health check which is going to involve 222 00:22:03,230 --> 00:22:08,570 assessing your risk score for various things and said if you're too fat and you smoke, 223 00:22:10,640 --> 00:22:15,560 you'll have what's your cholesterol, whatever it might be. And then they're going to say, right, you better sort your life out. 224 00:22:15,560 --> 00:22:17,630 You know, give up the cancer, see all that kind of thing. 225 00:22:18,560 --> 00:22:28,190 So what that is presented as evidence based and yet there have been no randomised controlled trials of that. 226 00:22:29,660 --> 00:22:34,820 There have been no serious regional pilots of it. 227 00:22:35,390 --> 00:22:39,590 So in what way is it evidence based and why has it come up in this lecture? 228 00:22:40,010 --> 00:22:48,020 I agree with you. I think it is an example of rubbish. CBM But why are we saying that's EPM at all when when it's, you know, 229 00:22:48,830 --> 00:22:55,280 are individual aspects of that that have to based on it and so you catch it on this note. 230 00:22:55,670 --> 00:23:04,250 Okay. So some components of the intervention, a speculative intervention that might follow from the health check. 231 00:23:04,730 --> 00:23:07,620 So you might say, well, look, if we've, you know, 232 00:23:07,700 --> 00:23:12,049 put overweight people on diets and they successfully lose weight, let's get diabetes, something like that. 233 00:23:12,050 --> 00:23:15,680 We give an intensive support. So. So, of course, the first thing we have to do is catch them. 234 00:23:16,250 --> 00:23:20,360 You know, you go, you've got to bring them in. But it's a kind of leap, isn't it? 235 00:23:20,570 --> 00:23:29,960 It's a leap. But the reason why it's a brilliant example is that it is being touted by politicians as being based on evidence. 236 00:23:30,620 --> 00:23:37,279 And the definition of evidence by a politician is what support, you know, whatever written thing, 237 00:23:37,280 --> 00:23:42,110 read a written text supports what they're going to do or indeed spoken word. 238 00:23:42,470 --> 00:23:46,210 I was once observed by someone with evidence. 239 00:23:46,290 --> 00:23:54,290 I went into a big committee meeting and a board meeting of a health authority, and I have various different types of evidence. 240 00:23:54,290 --> 00:23:58,429 And I had, you know, some reason I had Cochrane reviews. 241 00:23:58,430 --> 00:24:03,410 I wanted to see which of the evidence that the board was interested in, and that was the whole point of the research. 242 00:24:03,740 --> 00:24:09,290 And then at the end of it, I asked the person who was had been watching me, which which evidence do you think they were most interested in? 243 00:24:09,290 --> 00:24:13,390 And she said, You were the evidence. You are the evidence. 244 00:24:13,400 --> 00:24:17,580 You are the expert. That's why they invited you. They didn't even look at what you put on the table. 245 00:24:17,990 --> 00:24:27,200 So actually, the evidence that supports health choice was probably some expert that came and got lunch, had breakfast with the Camerons or whatever. 246 00:24:27,530 --> 00:24:30,580 Okay, so another example of rubbish. 247 00:24:30,830 --> 00:24:40,040 So evidence that a policy that is not based on epidemiological evidence but which the politicians say it is evidence based, 248 00:24:40,040 --> 00:24:49,279 that's a very good example of rubbish. CBM And it's what we called appropriation of the evidence based kite mark by government for I think I 249 00:24:49,280 --> 00:24:52,939 initially called it bastardisation but I thought been the use that works mind set people but you know 250 00:24:52,940 --> 00:24:59,149 what I mean it's I think I'll it's quite good because they anyway another example different type of 251 00:24:59,150 --> 00:25:05,870 example different class of example of rubbish eben GP checks for Alzheimer's the incentives okay, 252 00:25:05,870 --> 00:25:13,849 same kind of thing, good GP checks with dementia, but I'd say it's absolutely brain example, but it's the same class of examples. 253 00:25:13,850 --> 00:25:18,690 I want a totally different example. Has anyone ever experienced what they believe to be rubbish? 254 00:25:18,690 --> 00:25:24,590 GBM Sorry, I didn't see the stats and ization of everyone over 50. 255 00:25:24,790 --> 00:25:28,280 What was the most that you know where that come from? 256 00:25:28,430 --> 00:25:32,510 It's rubbish because although it's based on allegedly good evidence that is. 257 00:25:32,840 --> 00:25:36,100 Yeah. Then the number to treat is very, very high. 258 00:25:36,110 --> 00:25:39,260 Oh yes. Okay. 259 00:25:40,220 --> 00:25:42,200 Yes you will. A few will benefit. 260 00:25:42,200 --> 00:25:49,820 And in addition to that, because no one understands the probability of patients that don't know that and so they did know. 261 00:25:50,150 --> 00:25:56,570 Yeah. So do you all know this example, the idea that everybody over 50 should be on a statin? 262 00:25:57,140 --> 00:26:00,469 Okay, now, this actually doesn't come from politicians. 263 00:26:00,470 --> 00:26:08,570 This comes from academics. It's shocking, but particularly epidemiologists and in fact, gets worse because I'm Nick Wald, 264 00:26:08,570 --> 00:26:15,800 who I used to work with, who's an extremely accomplished epidemiologist. 265 00:26:15,950 --> 00:26:19,130 I mean, he's got a knighthood for being a very good epidemiologist. 266 00:26:19,340 --> 00:26:22,910 And he did all that down screening and he saved lots of lives, all the rest of it. 267 00:26:23,300 --> 00:26:25,190 He's come up with this. Called the polypill, 268 00:26:25,580 --> 00:26:31,440 which contains a statin and a bit of antihypertensive and a bit of something else probably easier for you because I can't remember. 269 00:26:31,440 --> 00:26:40,130 It is a combination of all these drugs. And he has written many editorials saying everyone over 50 should take the polypill 270 00:26:40,790 --> 00:26:44,269 six dose combination of all these different things is a little bit you know, 271 00:26:44,270 --> 00:26:47,570 it's a bit more than homeopathy. And why does he say that? 272 00:26:48,140 --> 00:26:53,510 Because if the population over 50 took that drug, the population would live longer. 273 00:26:54,530 --> 00:27:01,229 And I've sons had it out with Nick Wold saying, no, I as an individual would not benefit from this. 274 00:27:01,230 --> 00:27:07,400 So the chances of me benefitting are vastly less than the chances of me being harmed. 275 00:27:08,150 --> 00:27:14,930 And he says Yes, but if the population took the polypill, the population would live longer. 276 00:27:14,930 --> 00:27:20,090 Therefore, everyone should take the polypill. So it's so it's reasoning from the population to the individual. 277 00:27:20,210 --> 00:27:23,390 And that's I mean, epidemiologists never see patients when they should. 278 00:27:23,390 --> 00:27:26,540 I said, Jim, come sit in my clinic and I'll show you individualised decision making. 279 00:27:27,230 --> 00:27:31,370 But why else? Actually, the polypill example is another very good example. 280 00:27:31,670 --> 00:27:35,510 Guess who's got shares in the polypill? Oh, no world. 281 00:27:35,630 --> 00:27:38,960 Yeah, yeah, yeah. Really? 282 00:27:39,080 --> 00:27:46,010 All right, look, when we all got together so much so I don't know how many of us were at 20. 283 00:27:47,060 --> 00:27:51,620 We all got together when the Oxford College is, as you do, you know, for this sort of thing. 284 00:27:51,980 --> 00:27:53,330 And we went around the table, 285 00:27:53,330 --> 00:28:04,480 this is the first evening of a workshop that we held to talk about this really versus rubbish should and the first say we I mean look at this bottom 286 00:28:04,490 --> 00:28:13,040 line first of all our own Janice Identity's none of us were anti bee I mean some people were had published articles saying IBM's gone a bit far. 287 00:28:13,040 --> 00:28:17,629 It's got a bit above itself. And others of us had published articles saying, look, we need more. 288 00:28:17,630 --> 00:28:19,880 IBM is this is what's going to save the world. 289 00:28:19,880 --> 00:28:28,700 But really we were all convinced of IBM's benefits and in its place, but we were very wary of its potential harms. 290 00:28:30,950 --> 00:28:40,009 And actually that first evening, I mean, said it was quite moving because the first story that people told that one of 291 00:28:40,010 --> 00:28:43,969 the people around that table is a leading professor of evidence based medicine, 292 00:28:43,970 --> 00:28:49,280 started off the story about how his sister had just died of lung cancer despite never having been a smoker, 293 00:28:49,670 --> 00:28:52,670 despite the best evidence based care and all that kind of thing. 294 00:28:53,540 --> 00:29:01,729 The second class of what we subsequently labelled as rubbish should be in the paper. 295 00:29:01,730 --> 00:29:06,560 What was this generation of doctors who engage very defensively rather than critically 296 00:29:06,830 --> 00:29:12,320 with evidence based guidelines who seem that this found themselves doing it? 297 00:29:13,130 --> 00:29:16,700 I mean, I've done it before thinking, Yeah, that's what guidelines says, you better do it. 298 00:29:16,700 --> 00:29:20,630 Don't want to get sued, don't get till the balls, don't you know, whatever. 299 00:29:21,710 --> 00:29:24,710 And I think we all know that guidelines are there to be broken. 300 00:29:24,710 --> 00:29:29,300 And Dave Sackett would be the first person to say these are guidelines, they're not protocols. 301 00:29:29,300 --> 00:29:37,340 You know, they're not you know, you shouldn't be driven by them. Nevertheless, we are becoming, we manage to rules ourselves. 302 00:29:39,380 --> 00:29:43,310 Rubbish. EPA Have you ever looked up a Cochrane review in the middle of a clinic? 303 00:29:44,330 --> 00:29:52,370 I mean, you know, I tried to do it this morning, just gets a great reams and reams of ifs and buts and you want a decision for the patient. 304 00:29:52,580 --> 00:29:57,469 Suddenly the evidence mountain is getting higher. It's getting worse and worse. 305 00:29:57,470 --> 00:30:00,620 It's getting harder and harder to get the bit of evidence you need. 306 00:30:02,840 --> 00:30:07,850 Cochrane reviews. Oh day last. Last year at the Cochrane Review, the Cochrane Collaboration, I gave a keynote. 307 00:30:07,850 --> 00:30:15,889 It was entitled Why Cochrane Review said boring and and Martin Buxton Buxton Burton Burton. 308 00:30:15,890 --> 00:30:19,280 Martin Burton is worried about that too. That's why he asked me to give the lecture. 309 00:30:19,640 --> 00:30:26,960 You know, there's something about that process of lining everything up and doing research is making everything, 310 00:30:27,080 --> 00:30:32,150 you know, getting down, stripping all the way to that focussed question, suddenly taking the whole meaning out of it. 311 00:30:33,110 --> 00:30:37,880 You really have to take in the texture, everything that I know. 312 00:30:38,150 --> 00:30:41,510 That's why it's so much nicer to read an editorial than it is to read Cochrane Review. 313 00:30:41,630 --> 00:30:49,160 We're going to be doing something about this search. I'm going to Vienna is some nice place in October to get people talking about this because I 314 00:30:49,160 --> 00:30:53,150 don't know what the answer is because the Cochrane Review is the pinnacle of epidemiology. 315 00:30:54,410 --> 00:30:58,549 And then we talked about appropriation, commercialisation, the brand. 316 00:30:58,550 --> 00:31:04,760 This is evidence based and it's not evidence based. It's all shared decision making. 317 00:31:04,850 --> 00:31:09,290 You know, again, you all were very keen on that. We've got to make sure we get the patients priorities. 318 00:31:09,590 --> 00:31:13,850 But hang on, we've been talking about shared decision making for 20 years. We still don't do it. 319 00:31:13,850 --> 00:31:18,500 I don't think I did it once this morning in saying, oh, no, I kind of tried to, 320 00:31:19,100 --> 00:31:22,910 but if you'd videoed me and really said, Come on, is that decision really shared? 321 00:31:23,670 --> 00:31:28,020 It wasn't really it was sort of me being kind of paternalistic and trying to work 322 00:31:28,020 --> 00:31:33,320 out what the patient would have wanted if at that time to ask them sort of thing. And I get good takes in those. 323 00:31:33,330 --> 00:31:36,980 This is a nice doctor question is, you know, I'm not I'm not horrible or anything. 324 00:31:38,550 --> 00:31:43,950 Government interference in professional practice. You got that. But then all this stuff, this bottom one, this was Diane. 325 00:31:43,960 --> 00:31:47,040 He brought this up and she writes beautifully about it. 326 00:31:47,040 --> 00:31:51,070 Hang on a minute. We we supposed to be prolonging life at all costs. Is that what the deal is? 327 00:31:51,780 --> 00:31:57,839 Is that what the deal is? Now, I'll give you a lecture on Saturday at University College of the Legacy of John 328 00:31:57,840 --> 00:32:02,220 Ratcliffe about some of the research I'm doing in elderly people with Multimorbidity. 329 00:32:02,760 --> 00:32:08,190 And we studied people who were, you know, in the old days, they would have died of their stroke ages ago. 330 00:32:08,190 --> 00:32:13,950 But now they haven't. They still strung out. And, you know, we've managed to stop people dying, but they're leading miserable lives. 331 00:32:14,850 --> 00:32:18,780 And I've already said, you know, to my kids and my husband, when I get to that stage, 332 00:32:18,780 --> 00:32:22,200 you know, just throw away my feet and chuck me one of those beautiful lakes in the lake. 333 00:32:22,200 --> 00:32:25,950 Just something like that. Don't don't kind of I don't want to live forever. 334 00:32:25,950 --> 00:32:35,609 I don't I really don't. Once I, you know, get to about 80 and I'll be fine in 90 and then this this lack of use. 335 00:32:35,610 --> 00:32:44,190 But so that was all the stuff about when we, we had an initial brainstorm about rubbish and what is it. 336 00:32:45,900 --> 00:32:53,640 So when they finally published a paper after we had rejected it three times for being not of interest to anybody, 337 00:32:55,530 --> 00:32:59,250 they did this poll about is EPA broken? 338 00:32:59,550 --> 00:33:07,920 And it was, you know, the tightest decision because, you know, they put a poll up and it's either, you know, 80% one way or 20% the other way. 339 00:33:08,850 --> 00:33:14,490 But this people were evenly split and I don't know which way I voted and it's only recently I've realised that's the wrong question. 340 00:33:15,030 --> 00:33:24,479 We were never saying the ABM was broken, we were saying it in certain specific decisions even can be used well or badly, 341 00:33:24,480 --> 00:33:33,870 appropriately or inappropriately, rhetorically, instrumentally, or to underpin an appropriate decision, etc. etc. etc. 342 00:33:34,380 --> 00:33:37,580 Okay. You go get lemon. 343 00:33:37,580 --> 00:33:42,350 Is Lemon talking on this? Of course, because he ought to be. You have Richard Lemon talking on this one. 344 00:33:42,680 --> 00:33:50,390 Oh, it does is really great talk. But since I've with his full consent and Becky, I nicked his slides because he gave this brilliant talk. 345 00:33:50,990 --> 00:33:56,660 This is Mrs. Patel, if you like. He's got a really nice argument about heart failure. 346 00:33:56,660 --> 00:33:58,340 It doesn't matter what it is because you can pick anything. 347 00:33:58,340 --> 00:34:06,140 But he's got this nicely worked up and he's got this, I'll tell you, because I've got I think I've got the slides sort of packed out here. 348 00:34:07,100 --> 00:34:12,050 Someone's already said this in real life, patients with heart failure, really old. 349 00:34:12,380 --> 00:34:19,880 I had the case this morning. There was a bloke who's 91 who was being referred for an echo to look at how his heart failure was getting on. 350 00:34:21,020 --> 00:34:25,000 Men and women equal. Half have got preserved. Left ventricular ejection fraction. 351 00:34:25,890 --> 00:34:29,750 You know, heart isn't that bad. And they almost all have co-morbidity. 352 00:34:29,990 --> 00:34:38,420 Almost all of them spoke this morning. Did. But because his landmark trial has picked men who are not very old, who've been recruits, 353 00:34:38,660 --> 00:34:42,080 the inclusion criteria and this is our clinical trials manager you've got to have 354 00:34:42,080 --> 00:34:47,000 reduced left ventricular ejection fraction and you can't have co-morbidity as a result. 355 00:34:47,000 --> 00:34:51,920 All the evidence that we're using to treat heart failure actually doesn't apply to the patient in front of you. 356 00:34:51,920 --> 00:34:57,889 This is a big problem, but also the end points in heart failure trials. 357 00:34:57,890 --> 00:35:02,580 I'm going to read you out the patient's priorities. 358 00:35:02,580 --> 00:35:06,200 You know, you came up with this. What are Mrs. Patel's priorities? 359 00:35:06,410 --> 00:35:14,210 In what way does she feel ill? Actually, most people with heart failure would be prepared to trade better function for shorter life. 360 00:35:14,450 --> 00:35:22,579 End stage renal failure evaluated the renal quality improvement program once and we had people with end stage renal failure. 361 00:35:22,580 --> 00:35:29,060 And one of the things that the doctors wanted was to they said that sometimes people on dialysis just stop coming. 362 00:35:29,510 --> 00:35:32,959 How can we how can we stop them doing that? 363 00:35:32,960 --> 00:35:36,620 How can we make them keep coming for the dialysis? And they called it engagement. 364 00:35:36,830 --> 00:35:41,690 We went looking to see the patient. So we're absolutely clear this this is being this is worse than being dead. 365 00:35:41,690 --> 00:35:47,480 I would rather just chuck it in. I know that I've got a few months in in stage renal failure. 366 00:35:47,690 --> 00:35:54,380 Please, could I have some palliative care? You know, but the consultant felt that they were failing the patients. 367 00:35:55,070 --> 00:36:03,440 So, you know, just think about that. And then this is why this is why a lot of patients become polyphonic. 368 00:36:04,040 --> 00:36:06,739 And I've had correspondence with my mother's GP. 369 00:36:06,740 --> 00:36:17,510 If you realise she's now on 18 different medications, she would like to stop the following because the trials, 370 00:36:17,570 --> 00:36:21,820 the trials are there to, you know, get a statistically significant difference. 371 00:36:21,820 --> 00:36:25,910 So huge numbers of patients entered into the trial because the more patients you entered into, 372 00:36:26,330 --> 00:36:30,830 the more likely you are to have something statistically significant. I don't mean clinically significant, of course it doesn't. 373 00:36:32,570 --> 00:36:35,270 And so you get this up titration of dosage and you've all done it. 374 00:36:35,270 --> 00:36:39,620 If you if your doctor and patient comes in, then you say, Oh, look, let's give you a little bit more of that, 375 00:36:39,650 --> 00:36:45,020 a little bit more of that, and then you get the Mrs. Patel scenario. 376 00:36:45,950 --> 00:36:51,080 So what Richard was saying was that this is a great example of maximally disruptive medicine. 377 00:36:51,830 --> 00:37:02,479 And again, you can see how trials that were done to the best level of methodological robustness with strict inclusion had it all that 378 00:37:02,480 --> 00:37:10,400 kind of thing have somehow led to a situation that none of us would want to be in or want our grandmother in or whatever. 379 00:37:11,540 --> 00:37:14,929 And that's what I mean. Doesn't mean the ABM is rubbish. 380 00:37:14,930 --> 00:37:16,879 Do you see what I mean? It doesn't mean not at all. 381 00:37:16,880 --> 00:37:25,160 But it does mean we have to think a bit harder about the design of clinical trials, the application of evidence, etc. 382 00:37:25,490 --> 00:37:32,059 All right. So really. PM Well, no, I was going to tell you, I was going to ask you, did you read that? 383 00:37:32,060 --> 00:37:39,620 You shouldn't have read it. Come on, talk to each other about what really is then, because there's about seven or eight points that we made. 384 00:37:40,310 --> 00:37:51,440 Well, how can you how can we make CBM real? Okay now because I already showed you that this should be pretty straightforward. 385 00:37:51,800 --> 00:37:53,980 This nobody disputes the top one. Hey, 386 00:37:55,160 --> 00:38:07,220 but actually that word ethical is really important because and this is where somebody who's only ever worked in epidemiology may not quite get it. 387 00:38:07,490 --> 00:38:12,530 Okay? Because, you know, for them, ethics is about the ethics of consenting to trials and all that kind of thing. 388 00:38:12,770 --> 00:38:18,709 But what I mean by ethical care medicine and I speak now as a GP, 389 00:38:18,710 --> 00:38:23,960 I speak now as someone who sees patients, you have a patient in front of you and the question you ask is, 390 00:38:23,960 --> 00:38:31,400 what is the right thing to do for this patient in front of me right now with these conditions in this situation, 391 00:38:32,510 --> 00:38:35,540 philosophers among us will recognise that that. 392 00:38:35,590 --> 00:38:44,020 It's an example of ethical, case based reasoning, informed by science, informed by a lot of other things as well. 393 00:38:44,620 --> 00:38:47,620 But it is not science doesn't tell you what to do. 394 00:38:47,860 --> 00:38:51,400 It's about making an ethical judgement about what? 395 00:38:51,580 --> 00:38:57,190 What is the best course of action. And that is one of the fundamental flawed assumptions. 396 00:38:57,190 --> 00:39:00,820 That's why this whole business of APM is a conscientious, judicious, explicit, used company. 397 00:39:01,300 --> 00:39:07,340 Well, now, wait a minute. Let's. Let's start that. Let's start with. Clinical practice is about case based reasoning. 398 00:39:07,360 --> 00:39:13,850 To what extent can epidemiological evidence help that case based reasoning, individualised evidence? 399 00:39:13,870 --> 00:39:21,610 That's pretty obvious. Because the example of me and Nick Ward arguing about whether I should take a poly pill. 400 00:39:22,240 --> 00:39:27,340 I'm not interested in his argument that if everybody took a poly on average, we'd live longer. 401 00:39:27,370 --> 00:39:33,429 I'm interested in what's the benefit for me and the potential harm for me in taking 402 00:39:33,430 --> 00:39:39,540 all these things and aspirin as well as can you tell us by expert judgement. 403 00:39:39,550 --> 00:39:44,800 And there's a whole science around mainly from from the educationists actually. 404 00:39:46,390 --> 00:39:48,640 What is it to make an expert judgement. 405 00:39:48,670 --> 00:39:58,600 Now if you look at the evidence on how experts make judgements, the first thing we do when you're learning something new, 406 00:39:58,810 --> 00:40:02,380 just doing a course myself on something I know nothing about finance. 407 00:40:03,250 --> 00:40:06,760 You plod along and you follow the rules absolutely mechanically. 408 00:40:07,270 --> 00:40:13,930 And then you get quite good at following the rules. And as you get become more of an expert, you know when to break the rules. 409 00:40:14,200 --> 00:40:19,360 You know the situations when it's appropriate, when it's actually better to break the rules. 410 00:40:20,200 --> 00:40:26,200 That's when, for example, I sent a patient to an expert in brain surgery. 411 00:40:26,530 --> 00:40:36,160 They know when I think this person's a bit unusual, I think I will have to do a scan even though the guideline says don't just type thing. 412 00:40:36,760 --> 00:40:44,649 So the problem with an evidence based guideline is it only takes you to the advanced novice stage of expertise. 413 00:40:44,650 --> 00:40:50,380 It doesn't take you into that whole field of rule breaking as part of expert judgement. 414 00:40:52,090 --> 00:40:57,430 Sharing decisions with patients has to happen through meaningful conversations with the emphasis on meaningful, 415 00:40:57,430 --> 00:41:01,780 not just, you know, conversation I had with my mother. 416 00:41:01,780 --> 00:41:05,589 Would you like to carry on taking the warfarin? Would you like to go on to Dabigatran? 417 00:41:05,590 --> 00:41:08,919 Would you like to take aspirin? Would you like to take nothing but another thing too? 418 00:41:08,920 --> 00:41:20,110 I'm might. But when you say, you know Mrs. So-and-so from church, she has to go twice a month to that clinic. 419 00:41:20,110 --> 00:41:25,600 We have to get two buses to have a blood test to check whether or not the blood's being thinned at the right amount. 420 00:41:25,840 --> 00:41:33,900 Oh, no, I don't want to do that now. It's meaningful. That's what being a wolf remains, etc., and applied so mechanically. 421 00:41:34,060 --> 00:41:39,820 All right. That really. Yeah. These decision making tools, are you doing them in your course? 422 00:41:40,600 --> 00:41:45,910 Do you do these sorts of things? So converting numbers needed to treat to the sort of smiley face things. 423 00:41:46,150 --> 00:41:55,510 Chris Case Good guy, but nobody uses them. And then these option grids that Glyn Elwyn has, who's seen these before. 424 00:41:56,860 --> 00:42:04,179 Yeah. So actually a tiny minority of you, the idea is that you need to have a meaningful conversation. 425 00:42:04,180 --> 00:42:10,200 This is this is unstable angina. And then you have the two alternatives that the patient might, you know, 426 00:42:10,240 --> 00:42:16,360 do you want to go and have a stent fitted or you and carry on taking the tablets and then the questions that the patients might ask? 427 00:42:16,360 --> 00:42:24,399 Well, hang on a minute. Tell me more about the treatment. Tell me about the side effects, etc. and they are beginning to get a set of these. 428 00:42:24,400 --> 00:42:27,520 And I have used them in clinical practice as one for sciatica. 429 00:42:27,520 --> 00:42:36,520 That's quite a good one to look at but it's just WWL your option great dog these we're beginning to get these decisions but we're still 430 00:42:36,760 --> 00:42:43,330 it's in its infancy it's really in its infancy parliament because everyone would dispute everything that you put in those boxes. 431 00:42:43,870 --> 00:42:52,779 All right. How do we get real IPM now? This is the hardest part of the paper to write, because it's all in the future. 432 00:42:52,780 --> 00:43:00,970 It's all rather speculative. But it seems to me that this campaign has got to be patient driven and we're all patients. 433 00:43:01,060 --> 00:43:06,280 You know, I spent most of the last year being a patients of one kind or another. 434 00:43:06,610 --> 00:43:14,560 And when your patients tell you, I feel completely different. But also I firmly believe if you look at the big changes, I mean, 435 00:43:15,040 --> 00:43:21,610 why did the Cochrane Database Company came from e c p c that was driven by women 436 00:43:21,820 --> 00:43:25,150 who were a bit fed up with being told they needed to your tummy in childbirth. 437 00:43:25,480 --> 00:43:35,110 And so the patient driven campaign supported by in Chalmers led to ECP which then became which then morphed into you know. 438 00:43:36,550 --> 00:43:43,340 Big changes, big changes in the way HIV is managed were led by the HIV positive community. 439 00:43:43,360 --> 00:43:50,559 Breast cancer and actually the conditions where we're still practising rubbish PBMs at the time are often 440 00:43:50,560 --> 00:43:54,310 the ones where the patients are so disempowered they haven't organised and they haven't been able. 441 00:43:54,460 --> 00:44:02,080 So I actually believe that we need to bring patients on board and actually follow where patients are already leading. 442 00:44:02,080 --> 00:44:04,070 Mental health is another brilliant example. 443 00:44:04,540 --> 00:44:10,930 The survivor movement, they call it patients who fought against it, but they also they've also fought against all sorts of things. 444 00:44:11,410 --> 00:44:15,670 And we should actually be saying, you know, how can we help you? Clinical training. 445 00:44:16,450 --> 00:44:24,040 Don't get me started on our skills with training our youngsters to be automatons. 446 00:44:24,470 --> 00:44:31,870 At my son's medical centre just drives me nuts to see the way they're trying to kill the spark. 447 00:44:32,890 --> 00:44:38,770 The producers of evidence need to take account much more of the audience. 448 00:44:39,410 --> 00:44:42,820 It's not just on Let me write my paper. Let me write out my trial. 449 00:44:43,090 --> 00:44:46,570 Who who's going to be reading this paper? Is this what they need to know? 450 00:44:48,650 --> 00:44:52,930 Publishers This is something I think we really need. You've got now methodological standards. 451 00:44:52,930 --> 00:44:59,559 You can fill out your consult statement if you want to get a paper published, which is did take I did design the study. 452 00:44:59,560 --> 00:45:07,060 Right. My randomisation was anonymous. It was do they call it concealment of allocation, all those tick, tick, tick. 453 00:45:07,270 --> 00:45:11,410 And if you've done that methodologically, you pay. Your study was okay, so we'll publish it. 454 00:45:11,710 --> 00:45:15,190 I finish up another readability checklist. 455 00:45:15,730 --> 00:45:18,760 Could I show it to my Auntie Maude and my Auntie Maude? 456 00:45:18,760 --> 00:45:28,450 Know what you did? Or could I show it to a reasonable GP on the Clapham omnibus and for him or her to say, Yeah, I get that. 457 00:45:29,410 --> 00:45:34,330 Well, not many packs will pass that. We could introduce those standards fairly easily. 458 00:45:35,830 --> 00:45:41,350 But look at this. Well, Nick, take me up on this. We've got to be policy. 459 00:45:41,370 --> 00:45:46,149 There's got to be a bit more aware of the way evidence is being manipulated, for example, 460 00:45:46,150 --> 00:45:55,540 by drug companies who now offer us free starting nurses to kind of parachute into general practices in order to get more patients on statins. 461 00:45:55,540 --> 00:45:59,529 Oh yeah, we are lucky in this country. 462 00:45:59,530 --> 00:46:09,579 I gave this talk, this old life. I gave a similar talk to this in Florence a few weeks ago, and they got this number six independent funders. 463 00:46:09,580 --> 00:46:12,900 You know, we've got the premier of the nationalist excellence with them. I'll see. 464 00:46:13,180 --> 00:46:17,920 You know, most at your trial manager didn't mention the private sector. 465 00:46:18,130 --> 00:46:26,260 Well, in Italy, almost all trials are funded by drug companies because they haven't got that sort of government allocation, 466 00:46:26,440 --> 00:46:30,730 and that's been ringfenced actually in citation. So we're doing well here. 467 00:46:32,140 --> 00:46:37,150 But some countries aren't as lucky. But this is what I'm interested in. 468 00:46:37,390 --> 00:46:39,880 I would would not because really I'm a social scientist. 469 00:46:40,210 --> 00:46:47,830 The research agenda has got to move beyond epidemiology because some of the questions are not about epidemiology. 470 00:46:47,830 --> 00:46:49,210 You can't answer that with epidemiology. 471 00:46:49,480 --> 00:46:57,940 Maybe you answer them with philosophy or qualitative research, policy analysis, cognitive psychology, etc., etc. 472 00:46:59,950 --> 00:47:12,040 And we're doing I've been commissioned invited by Biomed Central to edit a series of papers on how EPA might be extended extending. 473 00:47:12,040 --> 00:47:15,550 Even so, those papers at the moment are being submitted. 474 00:47:15,880 --> 00:47:19,380 But we've got one on values based medicine that you to know. 475 00:47:19,820 --> 00:47:24,910 Michael Michael's leading it. We're writing for another one. So yeah, we're doing all the other one. 476 00:47:25,000 --> 00:47:31,030 But all the people from your unit are on it on broader, qualitative, 477 00:47:31,030 --> 00:47:34,780 and not just interviewing patients to find out what they feel about this particular illness. 478 00:47:34,780 --> 00:47:40,870 But why do the patients with the worst things wrong with them in the most things wrong with them never come to the doctor at all. 479 00:47:40,870 --> 00:47:46,449 So all that stuff about access, social determinants, what else are we looking at anyway? 480 00:47:46,450 --> 00:47:52,089 Loads of things and we've got another one on randomised trials. 481 00:47:52,090 --> 00:47:59,150 When is the randomised trial, not the MRI? For some things it is, but when is the randomised controlled trial actually a flawed design? 482 00:47:59,380 --> 00:48:03,370 Warren Peirce is doing nice, beautiful paper. I've seen it anyway. 483 00:48:03,490 --> 00:48:09,730 Lots of stuff that say Look at Britain's epidemiology, I wasn't great, but we need more. 484 00:48:10,480 --> 00:48:15,840 All right, so there it was. This is a summary really that's out metrics. 485 00:48:16,030 --> 00:48:19,389 It's gone up since then. So did you know about these out metrics? 486 00:48:19,390 --> 00:48:23,530 If you publish a paper, you can actually out metric. 487 00:48:23,860 --> 00:48:28,270 It's a normally if you get above about 30 or 40, you're doing really well. 488 00:48:28,840 --> 00:48:32,229 So like this is like colossal success is just amazing. 489 00:48:32,230 --> 00:48:35,410 We can believe it. Even though the BMJ initially said this is nothing new. 490 00:48:37,400 --> 00:48:47,050 And I think it was because what we were doing was capturing the mood of both the ABM movement and the, if you like, the anti ABM movement. 491 00:48:47,060 --> 00:48:50,629 You know, they sort of coalesced. It's not perfect. 492 00:48:50,630 --> 00:48:55,520 Okay. Okay, we're going to debate this, but evidence, evidence, life. 493 00:48:56,180 --> 00:48:59,360 I can't remember what the motion is, but it's something who's coming to evidence live? 494 00:48:59,780 --> 00:49:05,480 So three things from the talk I think we could all make sure that we do is the Richardson paper. 495 00:49:05,990 --> 00:49:09,440 We need to make sure that we don't watch and tweet about it. We don't do it. 496 00:49:09,440 --> 00:49:12,560 And how can it really be out there? Thank you very much, Chris. 497 00:49:12,860 --> 00:49:13,160 Thank.