Origins of Evidence Based Medicine

There was an interesting editorial by Richard Smith and Drummond Rennie in the BMJ recently. The editorial is based on two interviews of pioneers in this field by Richard Smith, the former editor of the BMJ. In the first oral history he interviews Iain Chalmers, Muir Gray and David Sackett. They said that authors from a previous generation were inspirational, namely Thomas C Chalmers, Alvan Feinstein and Archibald Cochrane. David Sackett tells us that he read Chalmers’ 1955 report of a randomised factorial trial of bed rest and diet for hepatitis and said:

“Reading this paper not only changed my treatment plan for my patient, it forever changed my attitude towards conventional wisdom, uncovered by latent iconoclasm and inaugurated my career and what I later labelled clinical epidemiology”

Iain Chalmers, cofounder of the Cochrane Collaboration, tells us that he was working in Gaza as a GP and realised he did not have the evidence to help him treat his patients and that is what stimulated him to go down the path that he eventually did. David Sackett, perhaps regarded by many as the father of evidence based medicine, came to Oxford from McMaster as Director of the newly established Centre for Evidence in Medicine, having been recruited by Iain Chalmers and Muir Gray. He had a rough time in Oxford at the start, particularly when he criticised data in the Oxford Textbook of Medicine for being wildly out of date for not citing relevant randomised trials. However gradually he converted everyone to the concept of practicing medicine on as good evidence as one could obtain. He did not coin the phrase evidence based medicine, but says that Gordon Guyatt, Professor of Epidemiology, Biostatistics and Medicine at McMaster University, after he took over as Director of the Internal Medicine Residency Programme in 1999 , at first suggested  Scientific medicine as the appropriate term for this new discipline but this also created antagonism and he changed it to evidence based medicine.

There is a second interview by Richard smith, hosted by JAMA in which he interviews Gordon Guyatt, Drummond Rennie, Brian Haynes, Paul Glasziou and Kay Dickersin, all pioneers in the development of evidence based medicine. This is quite a long interview, the best part of 50 minutes but well worth the time. Some interesting points struck me, namely that Brian Haynes felt that everyone should try to provide the best evidence, but Kay Dickersin commented that because of the push from “the academic reward system” there was a lot of junk published and this makes it so much more difficult to obtain relevant evidence. She also made the point that observational studies and their appraisal needs more attention and there is a need for much more attention on safety of interventions. Doug Rennie was adamant that money had to be taken out of the system and he enlarges on that in the interview. Paul Glasziou in looking to the future made two points, firstly that systematic reviews are done too slowly, taking at least two years to complete in the Cochrane organisation for example, and one needed a system that could produce a systematic review within two weeks. The second point he made was that the bulk of the work was directed at pharmacointerventions and there needs to be much more study of nonpharmacological interventions.  Guyatt felt that there has to be much more of pre-processed information available and I must say that the Transplant Library fits in exactly to what he would like to see develop in the future.

The editorial gives you the main thrust of the interviews but for people who are generally interested in the origins of evidence based medicine and where it might go in the future these videos are required watching. Richard Smith in summary feels that there is still a long way to go. I would recommend watching these splendid interviews.