An Interview with Distinguished University Professor Gordon Guyatt, OC, FRSC on EBM and Too Much Medicine (Part Three)

Author(s): Scott Douglas Jacobsen

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

Publication Date (yyyy/mm/dd): 2019/10/08

Abstract 

Dr. Gordon Guyatt, OC, FRSC is a Distinguished University Professor is the Department of Health Research Methods, Evidence, and Impact at McMaster University. He discusses: Cochrane Collaboration and EBM; Too Much Medicine; and the start of the Too Much Medicine movement.

Keywords: Canada, evidence-based medicine, Gordon Guyatt, medicine.

An Interview with Distinguished University Professor Gordon Guyatt, OC, FRSC on EBM and Too Much Medicine: Distinguished Professor, Health Research Methods, Evidence, and Impact, McMaster University; Co-Founder, Evidence-Based Medicine (Part Three)^{[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: Before the last calls over the last several months; we have talked about how to do effective speeches, for instance. We have talked about some of the talks that you have given on EBM. Some of the other things we could probably talk about would be the areas in which the Canadian public is known not to have a savvy attitude about science, as close to as desired as possible.

It hasn’t been talked about before, but it is something that they need to know. So, strongly, a bit of apart from this conversation on supplements and Chinese medicine compared to the methodology of EBM, in terms of getting some good information out.

Distinguished Professor Gordan Guyatt: So, in fact, I do not have much to say. That is not an area of my particular investigation now. There is attention being given to getting the information to the doctors and the other health professionals. There is work going on; they’re getting it out to patients,

Is there is much less being done and being studied in terms of how to get an opt out to patients? People are hoping that if you get it out to the health providers; the health providers will effectively communicate it to the patients.

Now, that may or may not be the case.

Jacobsen: [Laughing].

Guyatt: That is the hope. So, what do I do about this? The Cochrane Collaboration, which puts together systematic reviews, as plain language summaries for patients up to date, this electronic textbook now has hired somebody to try and get the material in a way that it can be communicated well to patients. So, you have a few initiatives like this, but nobody is doing an up to date for patients exclusively. Nobody is, I do not think that nobody is taking it seriously.

Having them helping patients to dealing with the incredible profusion of sometimes valuable, sometimes misleading, information on the internet, for instance. So long way, long way to go, in terms of there as well, so, one of my colleagues now has a focus on this. You said earlier on the skeptics about science.

Jacobsen: [Laughing].

Guyatt: So, the skeptics about science: their problem may be that they do not understand that there are ways of getting accurate, reliable, trustworthy inferences, in ways that aren’t useful. Their skepticism may be from not being able to make that distinction, or thinking it is impossible to make that distinction.

So, this colleague of mine by the name of Andy Oxman, he is about my age. So, he is in the latter part of his career. For the last few years, he has been focusing on getting – his goal is people – getting people to be able to assess health claims, to have the wherewithal. He has decided, looking at the world, that the only way to do this is to get them while they’re in school. When they’re out, subsequent to that, it is pretty difficult. Maybe not hopeless, but pretty difficult.

Although his research states, so I’ll show you. I’ll tell you about one of those results that suggests it is not complete.

Jacobsen: [Laughing].

Guyatt: He remarkably asked: where if you wanted to do this, where would you start?

He said, “Let’s start in grade schools in Uganda.” So, he goes; he teaches grade school kids in Uganda on how to assess health claims. He creates material that is appropriate for assessing health claims. Among again, school children.

And the he did a big randomized trial, where they went to their regular schools. They went to the schools where the teachers were provided with the materials to teach children how to assess health claims: big effects, big positive effects on children being assessed and able to assess health claims. Where the other interesting finding, the kids got to take their material home to the parents, show their parents the material, then there was some little extra material that they could give to the parents. Against all odds, the parents’ ability to assess health claims improved as well, having been taught by their children.

Jacobsen: Statistically, scientifically.

Guyatt: Interesting. So, he is now saying, “Now that we have done the easy part with Uganda, let’s take it to the Western world.” Now, we have done the easy part with the great school kids, let’s take it to the kids in high school. That is where he is doing ongoing work at the moment.

Jacobsen: That is interesting.

Guyatt: Yes.

2. Jacobsen: That is interesting. I recall some research, it was around that type of math, and then the age of the person in terms of their future interest in sciences, the STEM fields. So, if someone – it was Algebra, and it was age 12, I think, one is starting to learn some of these slightly more advanced math concepts relative to their age.

If they learn that, and they get the principles down, it is something about early, abstract manipulation of variables. That becomes a strong predictor for interest in Science. So, I’d be curious to know what the end result of all this research is, in terms of knowing; maybe, there is a general curve of possibility and then the decline.

Because you are noting after school, you are getting older, then more established cognitively. So, they’re more fixed in terms of their, unfortunately, sometimes non-critical thinking about what we were talking before alternative epistemologies.

Guyatt: Non-predictable, or sets of rules, they’re very critical but misguided.

Jacobsen: That is a good way to put it. What are some extra topics? We could cover the pressure research out all these new aspects, especially NMAs and, and then alternative medicine, big data, “Chinese medicine for 6,000 years,” outreach in Uganda.

Guyatt: Something else occurs to me. So, there is now a movement called Too Much Medicine.

Jacobsen: You are kidding.

Guyatt: No, no, no, a big movement, Too Much Medicine.

3. Jacobsen: Where did it start?

Guyatt: It started in the Clin-Epi (Clinical Epidemiology) in the EBM Clin-Epi world, or I would say this is the source of it. There is a campaign called Choosing Wisely. That is a related thing. Then it comes from an awareness that we are doing too many tests where are the benefits are questionable and we are giving up treatments where the benefits are questionable.

So, there is now a whole movement to say, “Wait a minute, we have gone too far. We need to scale back.” So, I’ll tell you about three of our relevant BMJ rapid recommendations. So, it used to be that when you hurt your knee, torn meniscus, as they say, the cartilage.

So, before the surgeons would operate, they had to be sure. It was hard to be sure, because the X rays can only show the bones; they cannot show the soft tissues. If you had an operation, it was a big deal. It took weeks to recover from your surgery. So, two things happened there. One was, we had MRI that could show the soft tissue. So, you can say, “Aha, that cartilage looks torn.”

We can fix that, arthroscopic surgery. We do not have to open anymore. We can stick the little thing. We can operate arthroscopically. A gigantic expansion in the surgeries, hundreds of thousands of them all the time, taking tens of millions of dollars. The patients go to the surgeon and they said, “Oh, thank you, doctor, I am better.”

Jacobsen: [Laughing].

Guyatt: They get going, and so a randomized trial. People are doing randomized trials of mock surgery, or placebo surgery.

Jacobsen: [Laughing].

Guyatt: What they do is they, for instance, whether you are getting real surgery or not, they will put up a screen between you and your knee.

Either they will do the real thing, or they will splash around some water to simulate this though, they will give you a little plat. Now, you need a little anesthesia to do this thing. Move your knee around, in the end, the patient does not know whether they got the surgery or not. As it turns out, the first one of these trials shows no benefit from the surgery. Surgeons do not want to hear this. They have all sorts of reasons.

All sorts of reasons not believe it. But then, there is a second trial, showing no difference. The third and the fourth and the fifth, and the surgeons won’t still believe it. So, now, we have about 10 trials.

Jacobsen: Wow.

Guyatt: By 10 of them, we can do a meta-analysis. So, now, we are able to pick up small effects. There is a small transient benefit. So, three months, people with the surgery do a little better, the effect seems to disappear by six months, but it is trivial. Our guideline panel, our rapid recommendations guideline panel, thought so clearly trivial that they were making a strong recommendation against this search.

Worldwide, there are probably, literally, millions of these surgeries happening every year that they are doing and having marginal, trivial benefit. So, this is an example of too much medicine. Then another one, when you break your bone, this putting a particular type of ultrasound is supposed to help heal and, maybe, radiologically it does. We did the biggest trial so far of this ultrasound machine. We failed to show any difference on radiologic healing, but clearly absolutely no difference in terms of function.

We did the meta-analysis and randomized trials, no difference in function, again, millions of dollars being spent on this stuff that isn’t doing anybody any good. I made a strong recommendation against this. Our latest one is shoulder. So, it is the same story as the knee. It used to be that you had to operate the shoulder, big deal. Surgeons were quite hesitant to do this.

We didn’t have the radiologic tools to investigate it. Then we got the MRI to show exactly what’s going on with shoulder. We can now do arthroscopic. So, so this takes off., bunch of randomized trials show a small benefit, then people do two of these blinded placebo surgery trials – no benefit.

Jacobsen: [Laughing].

Guyatt: So, and what we are finding out is surgery has substantial placebo effects. Right? Yes, people do feel better. But it isn’t the surgery. It isn’t. It isn’t that somebody with something biological happened. It is that surgery has big placebo effect. So, anyway, all these shoulders, so the latest it is not out yet being not quite out yet, it will be soon.

But our latest BMJ rapid recommendation is a strong recommendation against doing this surgery. So, our rapid recommendations have three examples, so far, of too much medicine.

4. Jacobsen: When did this movement start with Too much Medicine?

Guyatt: Five years ago.

Jacobsen: Who was the founder?

Guyatt: Oh, there is no one individual. If there is, I do not think there is one individually. There are a lot of people who contributed. I was at this too much medicine conference. So, there is now a regular too much medicine conference. People come together. They share stories of too much medicine. So, here is another, here is a good one that I heard of. So, a drug company starts to think that, “Well, first, there are these stories of how the companies, the first thing they do is they do a campaign to create a disease that was not there before.”

This disease that was not there before, is dry, itchy, uncomfortable eyes. Then they say, “There is an epidemic of this dry, itchy, uncomfortable eyes.” Then they have a drug, “This is what you need for your dry, itchy, uncomfortable eyes.” Again, randomized trials are in our margins, no benefits. But nevertheless, they have been able to create a big industry. Now, the funny part of this, so they were telling the story and it is probably problematic.

So, again, millions of people using this, huge amounts of money spent on this stuff. It is a drug that you use for chemotherapy that they’re putting in people’s eyes, believe it or not. Then thousands of people are doing that. Now, the funniest part is as we are talking about this, my eyes start to feel quite uncomfortable.

Anyway, I was talking to one of my various seniors. He said the same thing. I started on the power of suggestion, “Isn’t it?” So you have these advertising campaigns? “Oh, I feel my eyes like this. It is a little uncomfortable.” It is funny. I mean, I do not know.

Every time I talk about it, I get the same sensation in my eyes, not when I am not talking about what I am talking about it.  So, here is another example, here is another example of too much medicine. So there are lots of these, there are real problems with too much medicine.

Jacobsen: Fair enough. When we talk of the grade, the NMA, the EBM, of either acronyms or initialisms coming into the medical fields, now, when a lot of this almost a medical yawn effect. So, maybe if someone’s reading this, they can come up with a YAWN acronym for this effect of someone yawning, it is contagious. Contagious, but not innocuous.

Guyatt: Good point. It is contagious the way the audience is contagious.

Jacobsen: That is stunning.

Guyatt: There was one, this conference and one story after another of these things.

Jacobsen: That I would like to explore next, if possible.

Guyatt: All right.

5. Jacobsen: Excellent. Thank you much for your time. Appreciate that.

Guyatt: Pleasure. Take care. Bye for now.

Appendix I: Footnotes

[1] Distinguished Professor, Health Research Methods, Evidence, and Impact, McMaster University; Co-Founder, Evidence-Based Medicine

[2] Individual Publication Date: October 8, 2019, at http://www.in-sightjournal.com/guyatt-three; Full Issue Publication Date: January 1, 2020, at https://in-sightjournal.com/insight-issues/.

[3] B.Sc., University of Toronto; M.D., General Internist, McMaster University Medical School; M.Sc., Design, Management, and Evaluation, McMaster University.

[4] Credit: McMaster University.

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