It's fair to say, to introduce and actually publicly congratulate Trish,
who recently joined the Department of Primary Care Health Sciences as a professor in Primary Care from Queen Mary University in January.
So having read just recently in the BMJ, you've actually convinced me on the on the campaign trail.
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.
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.
It's amazing, actually, because in 1985 I came to Oxford for the very first IPM workshop.
Maybe it was No, no, 85 women will know something, or it's when one of my kids was born.
When would it have been? 90. It's no 90.
Five, 95, 1995. Yeah, they were small, I remember.
They were small. They weren't. They'd been born. So now that's like 20 years.
That's, that's, it's a whole generation. It's quite amazing.
An Oxford in Oxford, an evidence based medicine.
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.
I mean, I've done nearly 30 years. You know, after 20 years, you think, oh, god, I cannot be like this, right?
But it's fine. It's fine. But seriously, ABM'S been going quite a long time and I think maybe not now, tonight,
but about now in the history of CBM, it's time to really take a hard think.
You know, it has it got into a rut. It has it really it's it's got to move on.
I think it's got to move on. But that's my view.
Do you who agrees with that? Some of you.
I mean, you are a completely self-selecting sample because if you didn't think that, you probably wouldn't be here.
You've already gone home. All right, all right. Right. So firstly, yeah, look, thanks for inviting me.
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
yeah Jeremy is a co-author on that and there is anyone else but it was a co-author that is here.
No, it's really important. This this isn't me.
This I think Dave Sackett is kind of master of the cliche is to say I'm a symptom, not a cause.
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.
It was going to happen.
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.
And in a way, I suppose the the campaign for really been is much isn't just me, the paper wasn't just me.
This was stuff that was happening.
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.
All right, look, you've had enough of me, real case.
You've done four days out, five on your basically because you even want to one.
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.
What have you got? What questions have you got that would impress Carl Hennigan don't you don't care about
impressing cop did you say oh right we don't know what impress him or you don't know what.
Go on tell us. We think that they that we should ask the patient what's important to her.
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.
She's on to me. That's okay. Okay.
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.
How many of you clinicians, you know, doctors, nurses, pharmacists? Yeah. Most of, you know, two thirds.
Okay. Other questions? Yeah.
So what's the evidence you can make? You ask her at the same time?
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.
Who invented that combination drug? Might she be better off on just one of those?
What's the added benefit for putting two of them in together? Yeah, I'd ask her.
How does she feel? I'm this thing. So how does she feel?
Unwell. Yeah.
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.
You might be able to identify which of the drugs is giving or whatever. Yep, yep. Or exercise or weight reduction.
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,
but you're going off pace and you're going to say, we're going to do lifestyle measures.
We're not just going to look at the drug list. Yep. So can you give me a question about exercise or diet?
Can you frame it in that, you know,
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.
Yeah, okay. Okay. So what is the benefits versus the harms of regular exercise versus metformin in controlling diabetes, that kind of thing?
Okay. So how many potentially how many questions are going to come out of this?
An infinite amount, but certainly hundreds. Yeah. I mean, I came up with those.
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.
I mean, interestingly, I didn't come up with the one of I've rather zoomed in on the drugs.
And actually, I totally agree. We need another thing here about non-drug treatments.
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.
This is just kind of me. So that patient one's in clinic and you know, used it as an example.
The point I'm trying to make here is this kind of patient is absolutely standard.
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.
You know, that's just this morning. I didn't see very many people, for example, who had got a pure post-stroke.
Can you talk about my blood pressure treatment, doctor, or my blood thinning treatment?
I didn't see any of those. I saw people with carrier bags full of medication and that kind of thing.
And this is something that EPM wasn't primarily designed to address.
Why not? Can you help me give the lecture?
It'd be much more interesting. Got to get.
Too many. Compounding that, both are the women behind.
You've got their hands up. What was it, simpler 20 years ago?
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.
Certainly. I'm getting some slides. I'm going to show you what it suggests that certain people think there's more polypharmacy now.
So come on, let's think about the scenario of a done the drug trial,
because that's a very focussed questions and this kind of pleasant faces multiple diseases.
Yes. Okay. So EPA was designed for focussed questions and MULTIMORBIDITY doesn't lend itself to.
I love that. That's really cool too on the podcast, haven't we? So we can kind of caught it.
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.
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.
Maybe it's got worse going. I can say that multiple is.
We realised that she probably wouldn't qualify. Right.
Come on. Let's, let's. Yeah, let's explore a bit more.
Put your hand in here if you've ever been involved in a drug trial.
As someone who either writes the grant application or enters people into the trial,
or does any of that research type stuff, whether you've been an administrator or Jeremy's been.
Come on in. Who else? All my mates from my department. What about people who know?
Not. Yeah. Gone. What was your experience of a drug trial?
I'm a clinical trial. Perfect. Come on, tell us how it's done.
Well, it's very strict. Mm hmm.
Anything like that? And so what?
Did you get your money from a major HCA anywhere?
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.
We're doing a little fun piece of work is, but we spent a long time kind of hanging out on trains together.
And you learn overhearing overhearing how this works.
Guess what the state does for every bit of government money that they are?
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.
And she Sally's a goodie, really a very good thing.
But, you know, they ask a focussed question, all of them, you know,
M.S. When did you last apply for M.S. money and be successful when you didn't have a focussed question?
Something fundamentally flawed about the whole research machinery isn't there, but IBM is predicated on focussed questions.
Somebody said to me once that research is the art of finding precise answers to simple questions.
It's it's just deeply problematic, isn't it, guys?
Because actually, you know, it's not helping the very people look.
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?
I mean, you know, these are people who are very needy, very vulnerable, etc.
All right. You know, you've all been given that paper. Have you been given that paper?
Look, it's free. I mean, I paid £3,000 to make this open, access it.
So get on, get onto the BMJ website.
You must then tweet about it because it's already the most tweeted about paper that was
published in the BMJ in the whole of 2014 is that we did we did good stuff on social media.
All right. Now I'm going to give given the who, who's read it, be honest.
Okay. So the rest of this lecture is all about persuading you to go read it.
I'm not going to work up to telling you how we how we came to write that paper
and how many times the BMJ rejected it before they agreed to publish it.
So who has seen that sentence before?
We hadn't seen that sentence before. Okay.
So about half of you, maybe I am, is the conscientious, judicious and explicit use of cannabis making decisions about care of individual patient.
Was it rather was that rubbish was a complete and utter rubbish apart from the picture of motherhood and apple pie on the bottom,
which really tells you. I mean, it's flannel, isn't it?
They think disagree with me. Come on over.
Individual patients, is it. I think it's based on this.
Based on principle. Oh. Oh, I hadn't thought of that.
But yeah, you're right. Now is the other bit.
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.
I think as bright as I am, I can't possibly know everything. Okay.
But no. Oh, okay.
So it's a council of perfection. So it's like Winnicott, who said, look good.
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,
that actually you don't need to be a perfect parent, you just need to be good enough parent.
And the rest of it is up to the child, isn't it? I see.
But. Well, I think it's rubbish.
It doesn't say anything because it's not telling us what it is at all,
or it doesn't define term best evidences and all this kind of rhetoric, conscientious, judicious.
Explain all that saying is you doing, you know, you trying hard, you try your best.
But what is doing rhetorically is associating a very particular methodology and approach with words that you couldn't possibly disagree with,
because it's saying if you don't buy into this dirty, great hierarchy here, actually you're not being conscientious, judicious or anything.
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.
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.
So what is PM then, if it's not that? Well, I think it's about an Anna Donaldson.
I wrote another book. Or was it a book chapter or something?
We said, we can't use that definition, we got to improve on it. And we said, Eben, then a few years ago,
is the the use of mathematical estimates of the probability of benefit and the probability of harm derived
from population samples to inform decision making when discussing decisions with individual patients.
Now, Mike Kelly would say, yeah, but it's also about decisions about populations because you have evidence based public health
and say things like should we have minimum alcohol pricing and use CBM for that as well.
So the about individual patients, you could argue that all date,
but the bit I think is wrong with that is it doesn't say it doesn't make explicit that this is about epidemiology.
Now that I think is highly problematic because everything about APM has been driven by the paradigm of epidemiology.
It is about sampling. So you have a population, you take a statistical sample, you then do an experiment on it,
or perhaps you just observe it on whether a cohort or or trial or whatever,
and you then get some numbers out and you then put a confidence in it around those numbers.
You then program it into a decision support tool possibly, or put it into a book.
And then when when you ask these questions, I go back.
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?
You want numbers? Don't. You don't just want war. It's quite good.
Do you see what I mean? So what we're talking about is the hierarchy of evidence.
You know what this is? Don't you have? Is that okay?
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.
You see that picture. Yeah. Okay so you know this is your you know, this is individual try one, two, three, four, five, six.
Remember what it was about and then that's your grand me.
Then the idea is yeah, you know, if increase in significance is all about big numbers and small confidence intervals
and it's also about a methodological hierarchy method drives the quality assessment.
Okay, so this method is higher quality than that method is not about theory.
I have people from outside epidemiology. This is completely different now of course.
Then what they did was they said, Oh yeah, but we also want to find out the patient's values and preferences.
And actually the first comment that came from you people, splendid when I ask the question,
is going to ask about Mr. Savage, what are her preferences, what are her desires, what in what way is she sick, etc.?
Brilliant. Great. Because you're your contemporary people.
You're not from 20 years ago.
So ABM has now incorporated the idea that the patient's values preferences priorities should influence the way you apply epidemiology,
but they're still pretty fixated on this.
Now, that's not because I mean, I don't believe that a Nonrandomized trial is better than the randomised trial.
I absolutely accept that within epidemiology. Yeah, that's okay.
But. What I'm saying is outside epidemiology, there's all sorts of other things that we haven't yet taken account of.
Okay. So and that's probably because I've been trained in social science, so I'm not really a doctor.
I mean, I'm a doctor, but in my in my head, the paradigm I go for is much more around organisational sociology or,
you know, something that actually isn't sitting in epidemiology.
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.
Who's on Twitter? Who on Twitter? Oh, come on, the rest of me.
Look, it's great. It's really great.
I've got two PhD students, probably two of the best page theses I've ever had that came to me via Twitter.
I've got two grants that came to me via Twitter.
I had breakfast the other day with the master of an Oxford College with a research program that we started growing on Twitter.
Don't tell me it's about exchanging pictures of kittens. This is this is you want to get into academia, get into Twitter.
So I chucked out a few comments to call saying I didn't say be careful.
I didn't say eBay is rubbish. Right?
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.
One is really beam and one is rubbish.
Beam Okay, really. Beam Really.
Beam is what we want because actually it is a good idea to have robust randomised trial evidence blah blah blah.
Look up in hill. He told you I was ill. He told you I've been ill. Yeah.
No, no, no radio. I had to slip discs and I had to make a decision about spinal surgery.
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.
I had to decide whether or not to have major, major drilling around that area or whether to leave it.
I want to have randomised trials so I'm not opposed to randomised trials.
Know I was desperate with those randomised trials and actually when I when you come to evidence live,
I'm going to be talking about those kind of personal decisions. So I wasn't, I'm not opposed to them.
But what I was saying was sometimes when you apply epidemiology in decision making with and about individual patients,
it becomes rubbish, it becomes absurd, it becomes completely crazy.
Now I wanted to do is talk to each other and think about an example of rubbish.
EPA When is APM rubbish? Anyone got a good example?
Anyone heard a good example from the person sitting next to you? On what time?
Give me. Give us a good example of rubbish. EPA politics generally go on.
Policies. Policies. Oh.
Policies. I can say. I can see Nick getting very interested in policy making or ex policy is not the right.
Come on. One example of a policy that is rubbish.
CBM great, great example, great general example.
And I want a specific example of a policy that is rubbish, even though if you don't know because Nicola, help us here.
He's got armloads of the health checks.
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.
What are they? I don't Queen, but I wish you did.
Look at the old becoming a 40 year old guy that loves it.
Hmm. I was one of the Facebook. Okay.
So just for the podcast, I'm going to repeat that. So it's for two year olds from me.
So is it Jessie's 40 with Jessie? You're going to get one?
Yes, Jessie. Sorry, I have that one, though, because you had a cake with 40 on it.
It's not a secret, is it? Okay. So you get this very thing and get that letter from your GP.
Anyone up to the age of 70. Apparently after 70 you because you you to check your health anyway.
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
assessing your risk score for various things and said if you're too fat and you smoke,
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.
You know, give up the cancer, see all that kind of thing.
So what that is presented as evidence based and yet there have been no randomised controlled trials of that.
There have been no serious regional pilots of it.
So in what way is it evidence based and why has it come up in this lecture?
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,
are individual aspects of that that have to based on it and so you catch it on this note.
Okay. So some components of the intervention, a speculative intervention that might follow from the health check.
So you might say, well, look, if we've, you know,
put overweight people on diets and they successfully lose weight, let's get diabetes, something like that.
We give an intensive support. So. So, of course, the first thing we have to do is catch them.
You know, you go, you've got to bring them in. But it's a kind of leap, isn't it?
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.
And the definition of evidence by a politician is what support, you know, whatever written thing,
read a written text supports what they're going to do or indeed spoken word.
I was once observed by someone with evidence.
I went into a big committee meeting and a board meeting of a health authority, and I have various different types of evidence.
And I had, you know, some reason I had Cochrane reviews.
I wanted to see which of the evidence that the board was interested in, and that was the whole point of the research.
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?
And she said, You were the evidence. You are the evidence.
You are the expert. That's why they invited you. They didn't even look at what you put on the table.
So actually, the evidence that supports health choice was probably some expert that came and got lunch, had breakfast with the Camerons or whatever.
Okay, so another example of rubbish.
So evidence that a policy that is not based on epidemiological evidence but which the politicians say it is evidence based,
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
initially called it bastardisation but I thought been the use that works mind set people but you know
what I mean it's I think I'll it's quite good because they anyway another example different type of
example different class of example of rubbish eben GP checks for Alzheimer's the incentives okay,
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.
I want a totally different example. Has anyone ever experienced what they believe to be rubbish?
GBM Sorry, I didn't see the stats and ization of everyone over 50.
What was the most that you know where that come from?
It's rubbish because although it's based on allegedly good evidence that is.
Yeah. Then the number to treat is very, very high.
Oh yes. Okay.
Yes you will. A few will benefit.
And in addition to that, because no one understands the probability of patients that don't know that and so they did know.
Yeah. So do you all know this example, the idea that everybody over 50 should be on a statin?
Okay, now, this actually doesn't come from politicians.
This comes from academics. It's shocking, but particularly epidemiologists and in fact, gets worse because I'm Nick Wald,
who I used to work with, who's an extremely accomplished epidemiologist.
I mean, he's got a knighthood for being a very good epidemiologist.
And he did all that down screening and he saved lots of lives, all the rest of it.
He's come up with this. Called the polypill,
which contains a statin and a bit of antihypertensive and a bit of something else probably easier for you because I can't remember.
It is a combination of all these drugs. And he has written many editorials saying everyone over 50 should take the polypill
six dose combination of all these different things is a little bit you know,
it's a bit more than homeopathy. And why does he say that?
Because if the population over 50 took that drug, the population would live longer.
And I've sons had it out with Nick Wold saying, no, I as an individual would not benefit from this.
So the chances of me benefitting are vastly less than the chances of me being harmed.
And he says Yes, but if the population took the polypill, the population would live longer.
Therefore, everyone should take the polypill. So it's so it's reasoning from the population to the individual.
And that's I mean, epidemiologists never see patients when they should.
I said, Jim, come sit in my clinic and I'll show you individualised decision making.
But why else? Actually, the polypill example is another very good example.
Guess who's got shares in the polypill? Oh, no world.
Yeah, yeah, yeah. Really?
All right, look, when we all got together so much so I don't know how many of us were at 20.
We all got together when the Oxford College is, as you do, you know, for this sort of thing.
And we went around the table,
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
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.
It's got a bit above itself. And others of us had published articles saying, look, we need more.
IBM is this is what's going to save the world.
But really we were all convinced of IBM's benefits and in its place, but we were very wary of its potential harms.
And actually that first evening, I mean, said it was quite moving because the first story that people told that one of
the people around that table is a leading professor of evidence based medicine,
started off the story about how his sister had just died of lung cancer despite never having been a smoker,
despite the best evidence based care and all that kind of thing.
The second class of what we subsequently labelled as rubbish should be in the paper.
What was this generation of doctors who engage very defensively rather than critically
with evidence based guidelines who seem that this found themselves doing it?
I mean, I've done it before thinking, Yeah, that's what guidelines says, you better do it.
Don't want to get sued, don't get till the balls, don't you know, whatever.
And I think we all know that guidelines are there to be broken.
And Dave Sackett would be the first person to say these are guidelines, they're not protocols.
You know, they're not you know, you shouldn't be driven by them. Nevertheless, we are becoming, we manage to rules ourselves.
Rubbish. EPA Have you ever looked up a Cochrane review in the middle of a clinic?
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.
Suddenly the evidence mountain is getting higher. It's getting worse and worse.
It's getting harder and harder to get the bit of evidence you need.
Cochrane reviews. Oh day last. Last year at the Cochrane Review, the Cochrane Collaboration, I gave a keynote.
It was entitled Why Cochrane Review said boring and and Martin Buxton Buxton Burton Burton.
Martin Burton is worried about that too. That's why he asked me to give the lecture.
You know, there's something about that process of lining everything up and doing research is making everything,
you know, getting down, stripping all the way to that focussed question, suddenly taking the whole meaning out of it.
You really have to take in the texture, everything that I know.
That's why it's so much nicer to read an editorial than it is to read Cochrane Review.
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
don't know what the answer is because the Cochrane Review is the pinnacle of epidemiology.
And then we talked about appropriation, commercialisation, the brand.
This is evidence based and it's not evidence based. It's all shared decision making.
You know, again, you all were very keen on that. We've got to make sure we get the patients priorities.
But hang on, we've been talking about shared decision making for 20 years. We still don't do it.
I don't think I did it once this morning in saying, oh, no, I kind of tried to,
but if you'd videoed me and really said, Come on, is that decision really shared?
It wasn't really it was sort of me being kind of paternalistic and trying to work
out what the patient would have wanted if at that time to ask them sort of thing. And I get good takes in those.
This is a nice doctor question is, you know, I'm not I'm not horrible or anything.
Government interference in professional practice. You got that. But then all this stuff, this bottom one, this was Diane.
He brought this up and she writes beautifully about it.
Hang on a minute. We we supposed to be prolonging life at all costs. Is that what the deal is?
Is that what the deal is? Now, I'll give you a lecture on Saturday at University College of the Legacy of John
Ratcliffe about some of the research I'm doing in elderly people with Multimorbidity.
And we studied people who were, you know, in the old days, they would have died of their stroke ages ago.
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.
And I've already said, you know, to my kids and my husband, when I get to that stage,
you know, just throw away my feet and chuck me one of those beautiful lakes in the lake.
Just something like that. Don't don't kind of I don't want to live forever.
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.
But so that was all the stuff about when we, we had an initial brainstorm about rubbish and what is it.
So when they finally published a paper after we had rejected it three times for being not of interest to anybody,
they did this poll about is EPA broken?
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.
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.
We were never saying the ABM was broken, we were saying it in certain specific decisions even can be used well or badly,
appropriately or inappropriately, rhetorically, instrumentally, or to underpin an appropriate decision, etc. etc. etc.
Okay. You go get lemon.
Is Lemon talking on this? Of course, because he ought to be. You have Richard Lemon talking on this one.
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.
This is Mrs. Patel, if you like. He's got a really nice argument about heart failure.
It doesn't matter what it is because you can pick anything.
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.
Someone's already said this in real life, patients with heart failure, really old.
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.
Men and women equal. Half have got preserved. Left ventricular ejection fraction.
You know, heart isn't that bad. And they almost all have co-morbidity.
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,
the inclusion criteria and this is our clinical trials manager you've got to have
reduced left ventricular ejection fraction and you can't have co-morbidity as a result.
All the evidence that we're using to treat heart failure actually doesn't apply to the patient in front of you.
This is a big problem, but also the end points in heart failure trials.
I'm going to read you out the patient's priorities.
You know, you came up with this. What are Mrs. Patel's priorities?
In what way does she feel ill? Actually, most people with heart failure would be prepared to trade better function for shorter life.
End stage renal failure evaluated the renal quality improvement program once and we had people with end stage renal failure.
And one of the things that the doctors wanted was to they said that sometimes people on dialysis just stop coming.
How can we how can we stop them doing that?
How can we make them keep coming for the dialysis? And they called it engagement.
We went looking to see the patient. So we're absolutely clear this this is being this is worse than being dead.
I would rather just chuck it in. I know that I've got a few months in in stage renal failure.
Please, could I have some palliative care? You know, but the consultant felt that they were failing the patients.
So, you know, just think about that. And then this is why this is why a lot of patients become polyphonic.
And I've had correspondence with my mother's GP.
If you realise she's now on 18 different medications, she would like to stop the following because the trials,
the trials are there to, you know, get a statistically significant difference.
So huge numbers of patients entered into the trial because the more patients you entered into,
the more likely you are to have something statistically significant. I don't mean clinically significant, of course it doesn't.
And so you get this up titration of dosage and you've all done it.
If you if your doctor and patient comes in, then you say, Oh, look, let's give you a little bit more of that,
a little bit more of that, and then you get the Mrs. Patel scenario.
So what Richard was saying was that this is a great example of maximally disruptive medicine.
And again, you can see how trials that were done to the best level of methodological robustness with strict inclusion had it all that
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.
And that's what I mean. Doesn't mean the ABM is rubbish.
Do you see what I mean? It doesn't mean not at all.
But it does mean we have to think a bit harder about the design of clinical trials, the application of evidence, etc.
All right. So really. PM Well, no, I was going to tell you, I was going to ask you, did you read that?
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.
Well, how can you how can we make CBM real? Okay now because I already showed you that this should be pretty straightforward.
This nobody disputes the top one. Hey,
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.
Okay? Because, you know, for them, ethics is about the ethics of consenting to trials and all that kind of thing.
But what I mean by ethical care medicine and I speak now as a GP,
I speak now as someone who sees patients, you have a patient in front of you and the question you ask is,
what is the right thing to do for this patient in front of me right now with these conditions in this situation,
philosophers among us will recognise that that.
It's an example of ethical, case based reasoning, informed by science, informed by a lot of other things as well.
But it is not science doesn't tell you what to do.
It's about making an ethical judgement about what?
What is the best course of action. And that is one of the fundamental flawed assumptions.
That's why this whole business of APM is a conscientious, judicious, explicit, used company.
Well, now, wait a minute. Let's. Let's start that. Let's start with. Clinical practice is about case based reasoning.
To what extent can epidemiological evidence help that case based reasoning, individualised evidence?
That's pretty obvious. Because the example of me and Nick Ward arguing about whether I should take a poly pill.
I'm not interested in his argument that if everybody took a poly on average, we'd live longer.
I'm interested in what's the benefit for me and the potential harm for me in taking
all these things and aspirin as well as can you tell us by expert judgement.
And there's a whole science around mainly from from the educationists actually.
What is it to make an expert judgement.
Now if you look at the evidence on how experts make judgements, the first thing we do when you're learning something new,
just doing a course myself on something I know nothing about finance.
You plod along and you follow the rules absolutely mechanically.
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.
You know the situations when it's appropriate, when it's actually better to break the rules.
That's when, for example, I sent a patient to an expert in brain surgery.
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.
So the problem with an evidence based guideline is it only takes you to the advanced novice stage of expertise.
It doesn't take you into that whole field of rule breaking as part of expert judgement.
Sharing decisions with patients has to happen through meaningful conversations with the emphasis on meaningful,
not just, you know, conversation I had with my mother.
Would you like to carry on taking the warfarin? Would you like to go on to Dabigatran?
Would you like to take aspirin? Would you like to take nothing but another thing too?
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.
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.
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.
All right. That really. Yeah. These decision making tools, are you doing them in your course?
Do you do these sorts of things? So converting numbers needed to treat to the sort of smiley face things.
Chris Case Good guy, but nobody uses them. And then these option grids that Glyn Elwyn has, who's seen these before.
Yeah. So actually a tiny minority of you, the idea is that you need to have a meaningful conversation.
This is this is unstable angina. And then you have the two alternatives that the patient might, you know,
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?
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.
And I have used them in clinical practice as one for sciatica.
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
it's in its infancy it's really in its infancy parliament because everyone would dispute everything that you put in those boxes.
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.
It's all rather speculative. But it seems to me that this campaign has got to be patient driven and we're all patients.
You know, I spent most of the last year being a patients of one kind or another.
And when your patients tell you, I feel completely different. But also I firmly believe if you look at the big changes, I mean,
why did the Cochrane Database Company came from e c p c that was driven by women
who were a bit fed up with being told they needed to your tummy in childbirth.
And so the patient driven campaign supported by in Chalmers led to ECP which then became which then morphed into you know.
Big changes, big changes in the way HIV is managed were led by the HIV positive community.
Breast cancer and actually the conditions where we're still practising rubbish PBMs at the time are often
the ones where the patients are so disempowered they haven't organised and they haven't been able.
So I actually believe that we need to bring patients on board and actually follow where patients are already leading.
Mental health is another brilliant example.
The survivor movement, they call it patients who fought against it, but they also they've also fought against all sorts of things.
And we should actually be saying, you know, how can we help you? Clinical training.
Don't get me started on our skills with training our youngsters to be automatons.
At my son's medical centre just drives me nuts to see the way they're trying to kill the spark.
The producers of evidence need to take account much more of the audience.
It's not just on Let me write my paper. Let me write out my trial.
Who who's going to be reading this paper? Is this what they need to know?
Publishers This is something I think we really need. You've got now methodological standards.
You can fill out your consult statement if you want to get a paper published, which is did take I did design the study.
Right. My randomisation was anonymous. It was do they call it concealment of allocation, all those tick, tick, tick.
And if you've done that methodologically, you pay. Your study was okay, so we'll publish it.
I finish up another readability checklist.
Could I show it to my Auntie Maude and my Auntie Maude?
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.
Well, not many packs will pass that. We could introduce those standards fairly easily.
But look at this. Well, Nick, take me up on this. We've got to be policy.
There's got to be a bit more aware of the way evidence is being manipulated, for example,
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.
Oh yeah, we are lucky in this country.
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.
You know, we've got the premier of the nationalist excellence with them. I'll see.
You know, most at your trial manager didn't mention the private sector.
Well, in Italy, almost all trials are funded by drug companies because they haven't got that sort of government allocation,
and that's been ringfenced actually in citation. So we're doing well here.
But some countries aren't as lucky. But this is what I'm interested in.
I would would not because really I'm a social scientist.
The research agenda has got to move beyond epidemiology because some of the questions are not about epidemiology.
You can't answer that with epidemiology.
Maybe you answer them with philosophy or qualitative research, policy analysis, cognitive psychology, etc., etc.
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.
Even so, those papers at the moment are being submitted.
But we've got one on values based medicine that you to know.
Michael Michael's leading it. We're writing for another one. So yeah, we're doing all the other one.
But all the people from your unit are on it on broader, qualitative,
and not just interviewing patients to find out what they feel about this particular illness.
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.
So all that stuff about access, social determinants, what else are we looking at anyway?
Loads of things and we've got another one on randomised trials.
When is the randomised trial, not the MRI? For some things it is, but when is the randomised controlled trial actually a flawed design?
Warren Peirce is doing nice, beautiful paper. I've seen it anyway.
Lots of stuff that say Look at Britain's epidemiology, I wasn't great, but we need more.
All right, so there it was. This is a summary really that's out metrics.
It's gone up since then. So did you know about these out metrics?
If you publish a paper, you can actually out metric.
It's a normally if you get above about 30 or 40, you're doing really well.
So like this is like colossal success is just amazing.
We can believe it. Even though the BMJ initially said this is nothing new.
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.
You know, they sort of coalesced. It's not perfect.
Okay. Okay, we're going to debate this, but evidence, evidence, life.
I can't remember what the motion is, but it's something who's coming to evidence live?
So three things from the talk I think we could all make sure that we do is the Richardson paper.
We need to make sure that we don't watch and tweet about it. We don't do it.
And how can it really be out there? Thank you very much, Chris.
Thank.