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An Interview with Distinguished University Professor Gordon Guyatt, OC, FRSC (Part Four)


Author(s): Scott Douglas Jacobsen

Publication (Outlet/Website): In-Sight: Independent Interview-Based Journal

Publication Date (yyyy/mm/dd): 2017/05/22


An Interview with Distinguished University Professor Gordon Guyatt, OC, FRSC. He discusses: academic scientific organizations, research groups, and laboratories and their importance to the health of a society; observed impacts of evidence-based medicine in Canada; skepticism and importance of increasing academic and public awareness of critical thinking; hypothetical worst case scenario; hypothetical best case scenario; uncomfortable truths in the Canadian medical research community; uncomfortable truths in the international medical research community; concerns about Canadian culture and general medical knowledge; most correct ethical philosophy; most appealing political philosophy; most appealing social philosophy; clarification on social philosophy; most appealing economic philosophy; principles interrelating the philosophies; and principles that interrelate the philosophies.

Keywords:  biostatistics, epidemiology, evidence-based medicine, Gordon Guyatt, McMaster University, research.

An Interview with Distinguished University Professor Gordon Guyatt, OC, FRSC (Part Four)[1],[2],[3],[4]

*Footnotes in & after the interview, & citation style listing after the interview.*

*This interview has been edited for clarity and readability.*

1. Scott Douglas Jacobsen: What makes academic scientific organizations, research groups, and laboratories important to the health of a society with substantial technological sophistication such as Canada?

Professor Gordon Guyatt: Aside from the economic drivers, they lead to useful things for the economy. Ideally, they are treatments or management, or sometimes tests, leading to better patient outcomes, meaning people live longer or live better. Medicine has not been the number one contributor for living longer and living better

2. Jacobsen: What have been the observed impacts of evidence-based medicine in Canada?

Guyatt: That is a bit of a challenge. One that is unequivocal is that every educational program, undergraduate or post-graduate says, “We have to teach people to use the literature.” As you know, when the Royal College comes along and looks at residency programs, people who license universities to teach doctors. They say, “Are you teaching this EBM stuff?” Students are learning it. Indeed, it is standard for institutions to teach it. Guidelines have become more evidence-based.

The stories I told, you won’t see treatment where the evidence is in and the recommendations are ten years behind the times. You won’t see a new treatment where the randomized trials suggest the thing is useless, or even harmful to people. You do not see that anymore. We have a way to go in terms of dissemination now, but care is much more evidence-based than before. Values and preferences are still neglected! Ironically enough. However, people are doing things much, much more on the basis of the evidence than was previously the case.

3. Jacobsen: You mentioned a value in the home at the very outset of the conversation to do with skepticism. Something important to develop early in life, seems to me at least, comes from a natural philosophic or scientific bent, and logic and general doubt. Canadian, American, British, and Scottish cultural heroes state this in one way or another including David Suzuki, Carl Sagan, Bertrand Russell, the aforementioned David Hume, and others. What seems like the important of their – dead or alive, I know many of them are, 3 out of 4 – role for the increasing of academic and public awareness of critical thinking and evidence-based decision making?

Guyatt: Now, you’re asking me to be a social scientist, which I am not, I have a general notion: we’re always building on what is there before. EBM is skepticism-oriented. I don’t think we’re conscious a lot of the time about what has created the culture. So if you asked me who were the most prominent in intellectual history in Western culture, and in creating an atmosphere of skepticism, you listed a bunch. If you asked me before you listed them, I would have been in big trouble in terms of listing them myself.

You’re right. They created the milieu. When I went into it, and my mentors went into it, they had a natural skepticism. I am not a social scientist. I don’t know how this happened or how these things infiltrate the culture, but they do.

4. Jacobsen: Hypothetical worst case scenario: if Canadian citizens do not have accurate science information when making decisions about medicine, science, and public policy, how would this affect their everyday lives?

Guyatt: It depends on the particular decision. I will take one public policy item, which is the safe needle programs. The Harper government tried to shut down the Vancouver site. The safe needle program saves lives. This was interesting. It went to the Supreme Court. The Supreme Court said, “You can’t do this because of the evidence.” My political background and ideas lean Left. So it will not surprise that I was not fond of the Harper government, but their anti-science, suppressing the science in areas of the environment, in the areas of health, were extremely problematic.

One public policy issue where it was very problematic was the safe needle programs. The Supreme Court said, “Okay, you can’t ignore the science.” The science saved us.

5. Jacobsen: Hypothetical best case scenario: if Canadian citizens do have accurate science information when making decisions about medicine, science, and public policy, how will this affect their everyday lives?

Guyatt: That [Laughing] goes beyond medicine. To me, the swings in education are striking. Now, we should be structured. Everybody taking examinations and licensing. Ten years later, it is all wrong. We are restricting people. Nobody is being imaginative, and so on. Just do the rigorous experiments, and we would be able to find out what really is optimal.

The same thing happens in health care organization issues.  At one point you see the provincial government saying, “Oh, let’s centralize all healthcare decision-making in the province.”

Then a few years later, “Oh, it’s all going wrong.. No, no, let’s give more power to local decision-makers”  Then, a few years later. “No, no, that doesn’t work, let’s take the power back.” There are these swings. Why? Because nobody bothers to test it properly. Let’s get together, Canada is big enough. Let’s randomize jurisdictions to have decisions centralized, or take the responsibility and have the money going with it to local decision-makers. There are different ways of organizing decision-making. Let’s test it out!

As opposed to saying, or having people doing it out of conviction, “It sounds like a good idea. It kind of makes sense.” In medicine, we have recognized that’s not a good idea. People once thought bloodletting made sense as a treatment of pneumonia. Most supported bloodletting for all sorts of illnesses. It doesn’t make sense anymore, but it made sense to people before. As opposed to doing things because they made sense, the “what makes sense” is extremely fallible.

We have been conducting experiments and finding drugs thought to be beneficial, which end up killing people. Unfortunately, it happens from time-to-time. To do that within the wider realms of all kinds of public policy would be really nice.

6. Jacobsen: What seem like some uncomfortable truths in the medical research community at the moment in Canada?

Guyatt: I am having trouble, but one we may be swinging another way. We’re undertreating pain with narcotics. A lot of people suffer, unnecessarily. That was what was being told to everybody 10 years ago. Now, we have the epidemic of narcotic deaths. People were not prescribing properly. So there would be one example. Another one is everybody should be taking large doses of vitamin d for anything that ails you.

Now, fortunately, vitamin d is pretty innocuous. So we’re probably not hurting anyone, but the evidence in support of vitamin d helping anything is limited even in an optimistic analysis. It seems to have caught on as a rage. Like I say, the narcotics examples have terrible consequences. People might take too much of an unnecessary vitamin. Fortunately, it is not having – aside from the pocket book – minimal adverse effects.

7. Jacobsen: I could see a reason for that. 200,000 to 70,000 years ago, when we were roaming around from Lebanon’s Beqaa Valley to Mozambique, in the Great Rift Valley along with our other Great Primate ancestors, you’re in the sun all day. So you’re going to create a lot of vitamin d. I could see a reason for evolutionary mechanisms selected for that would buffer against or that would make it innocuous.

Guyatt: Yes, you’ve given a good example of physiological reasoning, which sometimes leads us in the right direction and occasionally in the wrong direction.

8. Jacobsen: What about in an international context, outside of Canada in other words?

There are unscrupulous people selling stem cell therapy for anything. In low and middle income countries, where things are not regulated as much, there are whole buildings and clinics built to take advantage of vulnerable people. Another thing would be cancer treatments. Another good example is multiple sclerosis. There is an Italian surgeon who came up with something about the blood vessels. It became a big rage. Everybody went off to different places all over to get his treatment.  Now, it has been recognized as completely without foundation.

There are drugs not in use in Canada, but are in use in India – where things are not regulated as well. These are useless. They are different than vitamin d. They have side effects. In low and middle income countries, where the dollar is much more crucial, there are all sort of unfortunate things happening.

9. Jacobsen: What about Canadian culture and general medical knowledge concerns you? Because that seems to me like the root of both to you of the things you’ve described.

Guyatt: One of my favorite mentees and a good friend is – he’s about my age – late in his career, and his current enthusiasm is about treating critical health thinking to grade school children. When I started in EBM, I realized this isn’t about healthcare, but this is about everything. I have given the education example, but people are talking evidence-based this, that, and the other thing now. I am delighted to hear it.

We need skepticism. The appropriate standards of what to believe and not to believe in every area. To an extent, my colleague succeeds in getting it into the grade schools and developing critical thinking is, or would be, a very good thing.

10. Jacobsen: What ethical philosophy seems the most correct to you?

Guyatt: “Correct” is an interesting word. How about substituting “appealing” for “correct”? Which tells you what I think about ethics, I told the story of the ethical standards with the 95-year-old demented person, which was radically different in North America, Peru, and Saudi Arabia. When people believed different things, the ethical decisions would differ. None of them is right. Healthcare, one of the big issues is equity. So we talked about equity versus choice. In the US, choice is a big value. I should be able to pay for better healthcare. A different ethical stance is equity is important. The fundamental thing, in politics and healthcare, my belief is equity is a much more important ethical principle than choice.

11. Jacobsen: What political philosophy seems the most appealing to you?

Guyatt: I am an old time socialist. [Laughing] I believe in governments. I believe in strong governments. We have seen plenty of evidence. When you don’t have governments regulating banks, and businesses, you have catastrophic results. I believe in income redistribution. Those responsible for the public wellbeing do things to ensure the public wellbeing.

12. Jacobsen: What social philosophy seems the most appealing to you?

Guyatt: Social philosophy, I am really ignorant. Quickly, educate me what is meant by “social philosophy.”

13. Jacobsen: By “social philosophy,” I mean the ways in which we should more efficiently, or better, arrange our social structures as a group or as individuals.

Guyatt: We are rich by interacting with each other. It is important to respect one another and to respect different ways of doing things.

14. Jacobsen: What economic philosophy seems the most appealing to you?

Guyatt: I do not like liberalism in the sense of economic liberalism and letting free markets do their thing. We have lots of examples. Obviously, there seems to me a big overlap between political and economic philosophies. I mentioned looking at the catastrophes of letting free markets operate in an unconstrained way.

15. Jacobsen: What principles interrelate these philosophies?

Guyatt: Equity would be one. Equity would be something that cuts across political and social philosophies. In contrasting between what’s more important, individual freedom or the wellbeing of the group, the individual freedoms, lower individual freedoms, and more emphasis on the wellbeing of the group. Those would be two.

16. Jacobsen: Any feelings or thoughts in conclusion?

Guyatt: The feeling and thought, and conclusion, is having the opportunity to hold forth in this way. I have really enjoyed it. Some of what I’ve achieved in education on some things. It has been a lot of fun. Thank you for thinking of me.

Jacobsen: Thank you for your time, Professor Guyatt.


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