David Sackett: The father of evidence-based medicine

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In his final year of medical school, David Sackett was entrusted with the care of a teenager being treated for what is now call hepatitis A. At the time, the late 1950s, the standard treatment was months of bed rest, the belief being that until the liver receded to its normal size, activity would surely result in death.

As the weeks dragged on, the teenager grew ever more restless; spurred by daily confrontations with a patient begging to roam, the medical student began to wonder what the evidence was for strict immobility.

In the days before the Internet and PubMed, the soon-to-be Dr. Sackett turned to the U.S. Armed Forces Medical Library. There, he discovered an elegantly simple study that took two groups of soldiers with hepatitis and randomly assigned them to bed rest or regular activity and found that they had precisely the same outcomes. There was no evidence that bed rest was useful; the "conventional wisdom" that guided medical practice was bunk.

On that day, he read his first randomized clinical trial and discovered the power of evidence, an epiphany that changed his life and, eventually, the practice of medicine in the Western world. He also apologized to his patient and told him to walk around as much as he liked.

Dr. Sackett, professor emeritus at McMaster University in Hamilton, died on May 13 at the age of 80 of metastatic cholangiocarcinoma (cancer of the bile ducts).

He is widely known as the father of evidence-based medicine, a movement The BMJ (formerly known as the British Medical Journal) described as one of the most important medical advances in the past 150 years, alongside the discovery of vaccines and antibiotics.

"He was a giant among giants," P.J. Devereaux, a professor of clinical epidemiology and biostatistics at McMaster, said in an interview. "He will be remembered as one of the greats, on a par with William Osler."

Dr. Devereaux said that what is amazing about Dr. Sackett is that he influenced medicine across a broad spectrum, from pediatrics to geriatrics, not just in one specialized area.

For the lay public, the notion that medicine should be evidence-based may seem self-evident. In fact, medical practice was long rooted in tradition and expert opinion.

Dr. Sackett challenged what he called the "we've always done it that way" mentality and pooh-poohed anecdote-driven practice. Instead of taking medical textbooks as gospel (in his day, the sacred text was Harrison's Principles of Internal Medicine), he insisted on knowing the evidence and, if there was none, developing clinical trials to find the answers.

His methods and philosophy, now standard practice, have helped determine everything from what surgery is best after a heart attack to what type of hospital administration provides the best bang for the buck. He personally led several landmark trials, notably one showing that Aspirin was effective in preventing recurrence of heart attacks and strokes.

David Lawrence Sackett – "Sack" to his friends – was born on Nov. 17, 1934, in Chicago, the son of an artist-designer father, DeForest, and homemaker-bibliophile mother, Margaret (née Ross). A self-described "prototypical geek," he was a tall, awkward child with poor eyesight and worse teeth (he wore braces before they were common), but was nevertheless happy-go-lucky. At 12, he suffered from polio and spent months in bed, becoming a voracious reader. As part of his recovery, he took up running and became a gregarious track star. He also developed a life-long love for music, barber shop-style singing in particular.

While he excelled academically, his high school record was most notable for its abundance of misconduct slips, a result of what he described as a "predilection for marching to a different drummer." He followed his two brothers to Lawrence College in Appleton, Wis., where he discovered an interest in physiology, and was pointed toward medicine. He chose the University of Illinois because, at $500 a year, it was the only medical school he could afford.

In his final year of med school, in 1959, he decided to become an internist and then specialize in nephrology. But he nurtured an interest in clinical trials, the result being that he often clashed with colleagues about whether their care was evidence-based.

In 1962, during the Cuban missile crisis, he was drafted, and assigned to the U.S. Public Health Service. There, he learned epidemiology and wondered how it could apply to clinical medicine. This application of public health methods to medicine would shape his career.

"David pioneered the approach of bringing public health methods to clinical care. He insisted that sound evidence guides practice for the sake of the patient," said Brian Haynes, a former student who is now a professor of clinical epidemiology and biostatistics at McMaster.

In 1967, Dr. Sackett was wooed to McMaster by the legendary John Evans. Together, they helped reshape medical education with hands-on, evidence-based approach to learning.

After founding McMaster's department of clinical epidemiology at 32, Dr. Sackett remained at the university for 26 years, producing a monumental body of research, including writing Clinical Epidemiology: A Basic Science For Clinical Medicine, often described as the bible of evidence-based medicine. He was also physician-in-chief at Chedoke Hospital in Hamilton.

Dr. Sackett called his method "critical appraisal." The term "evidence-based medicine" was coined in 1990 by one of his students, epidemiologist Gordon Guyatt.

Dr. Sackett founded the journal Evidence-Based Medicine, and became the first chair of the Cochrane Collaboration, a group that promotes evidence-based medicine around the world. He also became a much sought after medico-legal expert, heavily involved in monitoring the safety and efficacy of clinical trials.

In 1974, Dr. Sackett became a Canadian citizen. That year, during a sabbatical spent at the medical journal The Lancet, he discovered the writings of Kurt Vonnegut, an author who wrote wryly about the intersection of science and humanity.

A burly, jovial man, Dr. Sackett peppered his lectures with Vonnegutian wisdom and sneaked in the name Kilgore Trout (a character in Slaughterhouse-Five) as a co-author of some of his papers, as a way of poking fun at the establishment.

One of his most unusual decisions was to repeat his residency when he was 49; Dr. Sackett felt that practice had changed so much that he wasn't a good enough doctor any more.

In 1994, he moved to the University of Oxford in England to establish the International Centre for Evidence-Based Medicine. He retired five years later, at 65. He also gave his last lecture about evidence-based medicine; he firmly believed that "experts" were an impediment to progress and change, so no career should last more than 10 years. (In all, he had eight distinct careers.)

In retirement, he and his wife, Barbara (née Bennett), settled in tiny Markdale, Ont., and founded the Trout Research & Education Centre. There, on the shores of Irish Lake, he conducted workshops and seminars about clinical trials, and continued to mentor young scientists. He mentored more than 300 during his career, and published extensively about the importance of mentorship, saying that the role of scientific elders should be to "serve the young."

The Sacketts embraced small-town life, volunteering at the library, the United Church, and the Chapman's Ice Cream festival. They also continued their esoteric ways, at one point renting an RV and seeking places in the United States named "Sackett."

He leaves his wife, Barbara; sons David, Charlie, Andy and Bob; eight grandchildren; and brother Jim.

In his long career, Dr. Sackett won many awards, including the 2009 Gairdner Wightman Award (often called the Baby Nobel), and was inducted into the Canadian Medical Hall of Fame. But he was most proud of being named an officer of the Order of Canada, in 2001, because it recognized his contribution to the larger community, not just to medicine.

When word spread of his cancer diagnosis, Dr. Sackett was inundated with requests for interviews, which he rarely agreed to. Aware that there was great interest in his career, he invited questions and, with the help of his wife and his close friend Dr. Haynes, he essentially wrote an autobiography in question-and-answer format. He made his last contributions just days before he died. (The 103-page "interview" is available online.)

Dr. Sackett remained unpretentious to the end. Asked to explain his success, he again cited Kurt Vonnegut: "We are what we pretend to be."

One of the most common questions about his cancer diagnosis was whether, in his treatment, he received evidence-based care. Dr. Haynes relayed Dr. Sackett's cryptic answer – that someone who dedicated his life to evidence-based care "was bound to get a condition for which there is not much evidence."