Dave Sackett, a professor emeritus at McMaster University in Hamilton, has been awarded the prestigious Gairdner Wightman Award, which is given to a Canadian who has demonstrated outstanding leadership in medicine. He received his award last night at a gala event in Toronto.
Dr. Sackett is a pioneer in the field of clinical epidemiology and evidence-based medicine, which aim to teach health professionals how to separate good research from bad and apply it to the individual needs of their patients. He is also a world expert on the design and implementation of clinical trials.
In 1967, at age 32, he established the department of clinical epidemiology and biostatistics at the newly-created McMaster medical school, then went on to do hundreds of clinical trials, some of which had massive implications, such as the research that showed the benefits of Aspirin for preventing heart attacks and strokes.
At age 49, Dr. Sackett took up clinical practice, becoming physician-in-chief of Chedoke-McMaster Hospitals. In 1994, he turned to academia, as founding director of the Centre for Evidence-Based Medicine at Oxford University. Five years later, Dr. Sackett retired from clinical practice and founded the Trout Research & Education Centre in Markdale, Ont., where he reads, researches, writes and teaches about randomized clinical trials.
Dr. Sackett sat down with Globe and Mail reporter André Picard to discuss his contribution to medicine.
You are the dean of "clinical epidemiology." Does that concept, from many decades ago, still matter?
Well, it was the forerunner of evidence-based medicine in that it was from clinical epidemiology that we developed these quite straightforward tactics and methods for looking at an article and determining if it was likely to be true.
You are the dean of "clinical epidemiology." Does that concept, from many decades ago, still matter?
Well, it was the forerunner of evidence-based medicine in that it was from clinical epidemiology that we developed these quite straightforward tactics and methods for looking at an article and determining if it was likely to be true. It was the outgrowth of the Cuban missile crisis. I was a bench researcher in Chicago when [Soviet premier Nikita]Khrushchev put the missiles in Cuba. I was pulled from the lab and put into military service. It was the public-health service rather than the navy so I had to start learning epidemiology and biostatistics. In public health, you study epidemics, large populations and so on. I thought, wouldn't it be interesting, perhaps useful, if I took those methods from public health sciences and tried to apply them to individual patients? I needed to name it something so I called it clinical epidemiology and started a unit in Buffalo. The folks at McMaster University found out about it and asked me to come up and help start the medical school.
You are a pioneer in evidence-based medicine. This is a major issue for health professionals, but does it matter to the public?
I think it matters to the public because it represents bringing together for clinicians the three crucial elements that patients are going to benefit from in interacting with health professionals:
1) We have much better evidence of what works and what doesn't work, what is risky and what is beneficial, than we ever had before;
2) We're much better than we ever were before at getting that information into a form that can be accessed quickly by clinicians and the public and;
3) The essential piece in terms of the public perspective: We now have better ways of bringing patient desires, expectations and what they deserve into that equation.
So it's a combination of the evidence, the clinical expertise and the patient's views that come together. It was difficult to do it before so we decided to stick a new name on it - evidence-based medicine.
In the age of the Internet is it easier to get that information and, if so, are we making better use of the information?
I think the answer to both of those questions is "yes." Back in my days at Oxford [in the 1990s] we tried to put information together and bring it to the bedside during our rounds. In those days, we required a machine approximately the size of this table [a large four-seater in a restaurant] It had a big old computer on it, an overhead projector we could flash on the wall, it had a few books and it had a telephone line that we could hook into at the magical rate of 80 kilobytes per second. Even doing that, we found that we could get highly relevant evidence about every patient we were seeing and we could get 20 of them right on the ward in the same time it would take us to go to the library and get information on just one. Now, of course, the folks on rounds are looking up information on the PDAs, BlackBerrys or whatever and they get information instantly. So it makes a big difference.
But is there an information overload?
Yes, there's more good information around, but there's more baloney around. The essential element with regard to many fields of medicine is there has been a filtering put in by some really remarkable folks. We went back in the early days to the leading clinical journals - 20 of them - and pulled out all the articles about diagnosis, prognosis, therapy and side effects and toxicity. We looked at them in terms of their scientific standards - we pulled out the ones that were true - then asked clinicians which ones were clinically relevant today.
In doing so, we reduced the literature by 98 per cent. It's that remaining 2 per cent that's true and highly relevant that folks need at the bedside. That kind of sorting is being done by Brian Hayes and the British Medical Journal publishing group; they are putting together valuable information and making it rapidly available.
Is it getting more difficult or easier to sort out the good info from the baloney?
It's getting easier because the number of folks who are skilled at this sorting is increasing and because the resources required to carry this out are increasing. The initial sort, in terms of quality, is being done by an expanding number of highly qualified librarians. We trained these librarians in epidemiology and biostatistics and now they spend much of their time going through all the journals and reducing the material down to what is true.
Evidence-based medicine is not universally embraced. Do you still get a lot of push back?
Oh sure, that's been going on since we started. When we began, we were almost pariahs because, of course, all the old guys rejected it because it challenged them and all the young guys loved it because it gave them a way to challenge their seniors in a more polite way, instead of simply telling them they were out of date. In addition, people who are wed to certain policies, if they have already decided what the answer is for an individual or a community, the last thing they want to hear or see is evidence. So, they get quite upset.
Is there also a misinterpretation of what evidence-based medicine is? Some say it's about double-blind clinical trials for everything and that's not possible.
To a certain extent, it's a misinterpretation and to a certain extent it's about not understanding what EBM [evidence-based medicine]is really about. EBM is not just about randomized trials. EBM is saying: Here is a problem we have to solve and what is the best evidence we have right now? If it's a randomized trial or, even better, a systematic review, great. If not, what is the next best evidence? In many cases we can't wait to do the trial. People who are mad about EBM, to a large extent, don't understand what it is. Indeed, the evidence-based practitioner of medicine, nursing, physiotherapy, public health or whatever, would say: This is a problem I have to solve today, so what is the best evidence available to me? I'll take what I can get but at least I'm going to look for evidence, not just depend on the experts.
What's wrong with experts?
The experts killed George Washington. They bled him to death. The expert clinicians told us to treat people with heart attacks by keeping them in bed for five weeks and they died of pulmonary emboli. The experts said if patients had an unstable heart rhythm, we would give them certain drugs to suppress their heart rate, and this approach killed more people in the U.S. than the Viet Cong had killed. EBM is saying rather than just rely on tradition, expert opinion, wishful thinking, let's try and find the evidence and apply it.
When you read the popular media, do you see evidence-based medicine reflected in the health stories, or do you pull your hair out?
It varies enormously. There's some stuff that's really quite remarkable. There was a reporter named Betty Lou Lee who came to me and we started to write together about the latest scares: We put together some simple tests the public can use to see if they should be worried. Others just rely on the experts, not the evidence. Given the pressure on newspaper to sell papers, that hampers the ability of reporters to give the other side, or to say this is really the early days. You know, ideas don't always pan out. The randomized trials, when we actually get to that stage, only half of them will ever show a treatment is beneficial and the other half will show no benefit at all or actual harm. If we look at our big neurosurgical trials, the first one we did was the neurosurgical equivalent of heart bypass. They were taking the superficial temporal artery in front of your ear, sticking it through a burr hole and hooking it up to the cerebral as a way of preventing strokes. When we did that trial we found out it did more harm than good. The next trial we did of carotid endarterectomy showed it was extraordinarily beneficial. Looking for evidence can show you benefits and harms.
I have to ask you about the issue of the day: Should we be worried about H1N1, or swine flu, based on the evidence?
[Laughs.]In order to answer that question well, you need to know what the evidence says. Because of the Gairdner honour, I've given 15 talks in the past week and I haven't been keeping up. It's not enough to know the methodology, you have to know the evidence and, in the case of swine flu, I don't know it so I can't comment.
What does the Gairdner mean to you?
It's a very important honour. When I was a young buck, I was happy to accept any prize people would give me; as an old buck, I've had a lot more trouble and started turning them down. That's because I dislike being singled out for what was obviously a group accomplishment. I felt I was being honoured in front of people who were far more deserving and I don't like that at all. My colleagues convinced me to not say "No" to this prize. I see the Gairdner not as an individual award but as an award for clinical epidemiology and evidence-based medicine. It's an award for a delightful bunch of talented people and the credit goes to all of them, not to me. So I accept this on their behalf.