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The Origin of Evidence-Based Medicine and the Users' Guides to the Medical Literature: Gordon Guyatt, MD, MSc, explains the origin of the term "evidence-based medicine" and describes the Users' Guides to the Medical Literature and the benefits of applying the medical literature to clinical practice.
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The Origin of Evidence-Based Medicine and the Users' Guides to the Medical Literature: Gordon Guyatt, MD, MSc, explains the origin of the term "evidence-based medicine" and describes the Users' Guides to the Medical Literature and the benefits of applying the medical literature to clinical practice.
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Segment:0 .
>> I'm Joan Stevenson, editor of JAMA's Medical News and Perspectives section. Today I have the pleasure of speaking with Dr. Gordon Guyatt. Dr. Guyatt, why don't you introduce yourself to our listeners? >> I'm Gordon Guyatt. I'm a professor of medicine and of clinical epidemiology and bio-statistics at McMaster University, in Hamilton, Canada. And I'm one of the editors of the user's guides to the medical literature. >> Dr. Guyatt, I understand that you can coined the term evidence-based medicine. Can you describe how and why you did this?
>> Well, in 1990, I took over as director of the internal medicine residency program at McMaster University. At the time I took it over, for a number of years, we will be developing what started as critical appraisal, and eventually become the concepts of evidence-based medicine. We really felt it was a new way of practicing medicine, that it changed what you did in the ward, and how you looked after your patients. And my mission, when I took over as director of the residency program, was to teach this new paradigm, this new way of practicing medicine, to the residents who came into my program.
I wanted to attract people who would be interested in the approach, and I wanted to advertise it widely. And we needed to say what exactly were we teaching here? We needed a name for it. My first attempt to give it a name was scientific medicine. The department that I was in, internal medicine at McMaster, was not too pleased to think that they had been practicing unscientific medicine. The second attempt to give a label to what we were teaching at McMaster, evidence-based medicine, proved very catchy.
>> The user's guides to medicine literature series began running in JAMA in 1993. How did this series get started? >> Well, in the early 1980s, Dave Sackett and his colleagues at McMaster University produced a series of articles that were entitled Critical Appraisal of the Literature. And they were the first set of articles that provided a practical approach for clinicians to use the medicine literature, to appraise it, to understand it well enough to apply to their patients.
However, by the late 80s and early 90s, we perceived the limitations of this approach. And for the particular limitation is that, or one of the limitations, was that the focus was more on the validity of the article, and simply appraising from that point of views, rather than applying it to patient care. And we thought that although the first series was excellent, that we could do an even better job, and make a whole number of innovations, that would make it more relevant for applying the results to clinical practice.
Dave Sackett and I got together with Drummond Rennie, one of the editors at JAMA, who proved to be the champion of this series. Who was, thought we had a good idea and was ready to sell that idea to his colleagues at JAMA. And that's how it got started. And it proved, we were very happy with what we produced, and other people, fortunately, were happy as well. It proved an extremely popular series for JAMA.
>> The first JAMA article about evidence-based medicine was published in 1992. What was the medical community's reaction to this article about the role of evidence-based medicine in medical education? >> Well, the reaction was varied. The uptake of the term and to some extent the concepts was really quite remarkable. So I remember being very surprised. It came out in 1992. In 1993, I received some, late in 93, I received some advertising from the American College of Physicians that started out, in this era of evidence-based medicine.
So although I coined the term in 1990, and it appeared in the literature in 1991, the first highly-public article was 1992 in JAMA. And within a year, we were in an era of evidence-based medicine. So in one, to some extent, there was a remarkably rapid positive uptake. At the same time, that there were people who, in my perception, were threatened, were unhappy at the implication.
Their unhappiness is somewhat understandable. That the way they'd been doing medicine all their lives had some important limitations that evidence-based medicine could address. And so I think it was some of the, what I perceive as threatened reactions, were somewhat understandable. And they continue to some extent to this day, although once again, overall the uptake in terms of its integration in residency programs and undergraduate medical education worldwide, over a relatively short period of time, has been quite extraordinary.
>> The Internet has transformed the way in which we look for information. Before the development of the internet, what were the processes for finding and retrieving articles? >> Well, it was, I guess many people, I think, reflecting, going back 20 years. Certainly people involved in medicine, in academic medicine. The way we did things, really, in over a relatively short period of time, looking back on them, seem quite primitive. So one would be going to the library, one would be using the paper-bound index medicus.
And the electronic resources were just beginning. So it was, so at the start of this, it was a much less efficient process than it was now. And, to be quite honest, we were pushing the boundaries of what was feasible. There was no question that what we, that the electronic resources and the internet in particular, have made what we, the real practice of evidence-based medicine, highly feasible.
It was a stretch at the beginning. Because of the technical limitations. >> What advantages and other resources do clinicians have today that they didn't, pre-internet? >> Well, it's really quite extraordinary, what has changed. So that the number of, of ways of searching the literature and getting at specific articles has expanded enormously. There are many effective search engines.
And of course, the Pub Med itself has gotten more and more sophisticated. There's a feature in Pub Med called clinical queries that make searching much more, much easier. So that the ways of searching and getting at articles efficiently has been transformed. And there are many other electronic databases. In addition to that, there has been a big move in the last decade which I think is very important for evidence-based practice, which is pre-appraised articles.
So you have journals that do pre-appraisal, secondary journals, ACP journal club is one that scans, oh, I don't know, 150 or 200 journals, picks out the articles that are most relevant and of highest methodologic quality, presents structured abstracts and commentaries. And it just becomes a much more efficient way of keeping up, than the pile of journals that used to accumulate in the corner of many physicians' offices. In addition, there are textbooks, electronic textbooks that are now very different from our old vision of textbooks, and adhere much more to evidence-based principles.
Things like BMJ clinical evidence and Up to Date are two that come to mind. And in addition, there are resources like these. There's the User's Guide to the Medical Literature, and an electronic guide to the User's Guide to the Medical Literature that people can take advantage of to understand what they are reading more, and gain the skills to use the literature optimally in improving their clinical care. >> What resources on the JAMAevidence website do you think will be most helpful for learners?
>> Well, there are a whole number that I think are really important and valuable. So for one thing, the full text of the Complete User's Guide to the Medical Literature is fully searchable on that website. There are a host of interactive calculators, work sheets, what we call question wizards, that will be fun to use and informative. We have a, quite a comprehensive glossary to the User's Guides, and there are links throughout the electronic text to the definitions in the glossary.
The User's Guide is also linked on that website to the full text of the Rational Clinical Examination, where concepts described in the User's Guides are shown how to help with making clinical diagnoses based on physical examination. So the concept of likelihood ratios, which we introduced for diagnostic tests, are equally applicable to aspects of physical examination and are part of nearly every chapter in the Rational Clinical Examination.
In addition, for people who are teaching evidence-based medicine, the web site has a downloadable PowerPoint slides presentation for major sections of the User's Guide and for the Rational Clinical Examination, that educators can use. And this would be for people teaching evidence-based medicine, people teaching physical exam classes, workshop, curricula, making the teaching much more efficient, and giving them ideas about how to present the concepts most effectively.
Finally, paper textbooks are not that easy to update. On the other hand, electronic textbooks are very easy to update. And new articles that will have to wait for the third paper edition will appear in the JAMAevidence. So, for instance, we've just had accepted a three-part series, a new User's Guide on genetic association studies, and that, that User's Guide will quickly be integrated into JAMAevidence.
>> Dr. Guyatt, in a recent article in JAMA, you and Victor Montori wrote that evidence alone is not sufficient to make clinical decisions. And that whatever the evidence, value and preference judgements are implicit in every clinical decision. What do you mean by this? >> Well, I'll give you two examples that illustrate that. One is one that I use when I lecture, go to various places in the world, and I ask people, do you believe that antibiotics are effective in treating pneumococcal pneumonia?
And everybody says yes, of course they are. And then I present them with a 95-year-old demented individual, contractures, incontinent of bowel and bladder, who moans from morning to evening in apparent distress, and nobody has visited the individual in five years. And then I ask, should this patient getting pneumonia be treated with antibiotics? In North American audiences, about 95% say yes.
Say no, excuse me. But 5% say yes. So even within these, in North American audiences, there's a difference. When I go to South America, in what has been explained to me as a function of a more Catholic culture, two-thirds say yes and one-third say no. And when I go to Saudi Arabia, everybody says yes, the patient should be treated. What is the difference in the reactions both within and across cultures has nothing to do with the evidence or our perceptions of the evidence.
Everybody agrees that the drug is effective. What does it have to do with? Something that we have labeled values and preferences that are used to interpret situations and that are necessary for clinical decisions. I'll give one more example. Which is patients with atrial fibrillation. Patients with atrial fibrillation are at increased risk of stroke, and Warfarin is better than aspirin and better than nothing, substantially better in reducing strokes.
However, it has a great deal of inconvenience associated with it. And an increased risk of bleeding, particularly serious gastrointestinal bleeding. Well, the same patient who is very stroke-averse will choose to take Warfarin despite its inconvenience and bleeding risk. And another patient, otherwise identical and at similar risk, might well choose not to take Warfarin because they are less stroke-averse, but find the inconvenience and limitations associated with Warfarin and the bleeding risk would make the stroke reduction not worth it.
In these examples, the evidence that the people see is identical. The evidence in both of these cases would be high quality evidence, and yet the decisions differ within individuals, within cultures, across individuals, and across cultures. And in fact, when you look carefully, all our clinical decisions, any time there's tradeoffs, and there's virtually always important tradeoffs, upsides and downsides, desirable and undesirable aspects about any of the alternatives we see.
And it is the values and preferences that determine the choices of our patients in trading off the desirable and undesirable consequences of alternative courses of action. >> In the same JAMA article, you used a rather colorful analogy, comparing evidence-based medicine and nuclear fission. Could you elaborate? >> Well, the idea was something extremely powerful, that can be used for good or can be used for what people might call evil, but certainly things that are not so good.
So, many clinicians are concerned that evidence-based approaches can be used by administrators who at least, in their vision, have an interest not in necessarily delivering the best medical care, but controlling cost. So if you believe that, I suppose there are some administrators who would, who would meet that description. And certainly the administrators might have different values and preferences than the clinicians.
And in the worst instance, individuals who are not optimally concerned with the best medical care, but rather with controlling cost, could be using the tool of evidence-based medicine for their particular ends. Even more of a problem from my point of view is the pharmaceutical industry. So the pharmaceutical industry has the interest in selling their product. And they can use the tools of evidence-based medicine, in my view, to distort things.
In my view, making sophisticated but misleading presentations that would lead their medications, they're just doing their job, but lead their medications to be more attractive than they really are. And in my view, we see many, many, many examples of this misuse of evidence-based medicine. And of course, it can be used in the right way, as a powerful tool to make sure we are helping patients understand the tradeoffs and make the decisions that are best for them and ensure optimal clinical care.
So here's a powerful tool that, like nuclear fission, can be used very well to make for the benefit of humankind, or it can be used badly in ways that will not advance people's well-being. >> And what do you see as the future of evidence-based medicine? >> Well, it's very exciting. We've come a long way in the, getting close to 20 years. And the, the future is very exciting as well.
So I talked earlier in this interview about pre-appraised resources. And those pre-appraised resources are going to get better and better. We're going to be learning to use the Internet more effectively. We're going to be using to learn, we're going to be learning to use electronic resources to make learning evidence-based concepts more and more fun, and more and more efficient. The User's Guide to the Literature, the paper version of the User's Guide to the Literature, represents advances where I think we've got better and better at explaining the concepts.
And those improvements will continue. The JAMAevidence represents the electronic use of, of what's in the User's Guide to enhance learning. The-- I referred to secondary journals that summarize the literature. I think these are going to become more and more widespread, and move into subspecialties of medicine. And into allied health professionals, and resources that I also mention effect evidence-based textbooks, like the BMJ's Clinical Evidence and Up-to-Date will get more and more effective and more and more evidence-based.
Finally, there is the frontier of values and preferences. We have identified, as I explained, I think very clearly, that evidence itself never tells you what to do. It's always evidence in the context of values and preferences. But we aren't that good yet. We don't have the optimal tools, the optimal approaches, for ensuring that it is the individual patient's values and preferences that get optimally understood and optimally incorporated, so that the decisions are not only consistent with the best evidence, but are also consistent with each patient's values and preferences.
And one of the key frontiers for evidence-based medicine is learning how better to elicit patients' values and preferences to, in an efficient way, to ensure that the decisions are best for that individual patient. >> It should be fascinating to see how all of this unfolds. Thank you, Dr. Guyatt. >> My pleasure.
Segment:0 .
>> I'm Joan Stevenson, editor of JAMA's Medical News and Perspectives section. Today I have the pleasure of speaking with Dr. Gordon Guyatt. Dr. Guyatt, why don't you introduce yourself to our listeners? >> I'm Gordon Guyatt. I'm a professor of medicine and of clinical epidemiology and bio-statistics at McMaster University, in Hamilton, Canada. And I'm one of the editors of the user's guides to the medical literature. >> Dr. Guyatt, I understand that you can coined the term evidence-based medicine. Can you describe how and why you did this?
>> Well, in 1990, I took over as director of the internal medicine residency program at McMaster University. At the time I took it over, for a number of years, we will be developing what started as critical appraisal, and eventually become the concepts of evidence-based medicine. We really felt it was a new way of practicing medicine, that it changed what you did in the ward, and how you looked after your patients. And my mission, when I took over as director of the residency program, was to teach this new paradigm, this new way of practicing medicine, to the residents who came into my program.
I wanted to attract people who would be interested in the approach, and I wanted to advertise it widely. And we needed to say what exactly were we teaching here? We needed a name for it. My first attempt to give it a name was scientific medicine. The department that I was in, internal medicine at McMaster, was not too pleased to think that they had been practicing unscientific medicine. The second attempt to give a label to what we were teaching at McMaster, evidence-based medicine, proved very catchy.
>> The user's guides to medicine literature series began running in JAMA in 1993. How did this series get started? >> Well, in the early 1980s, Dave Sackett and his colleagues at McMaster University produced a series of articles that were entitled Critical Appraisal of the Literature. And they were the first set of articles that provided a practical approach for clinicians to use the medicine literature, to appraise it, to understand it well enough to apply to their patients.
However, by the late 80s and early 90s, we perceived the limitations of this approach. And for the particular limitation is that, or one of the limitations, was that the focus was more on the validity of the article, and simply appraising from that point of views, rather than applying it to patient care. And we thought that although the first series was excellent, that we could do an even better job, and make a whole number of innovations, that would make it more relevant for applying the results to clinical practice.
Dave Sackett and I got together with Drummond Rennie, one of the editors at JAMA, who proved to be the champion of this series. Who was, thought we had a good idea and was ready to sell that idea to his colleagues at JAMA. And that's how it got started. And it proved, we were very happy with what we produced, and other people, fortunately, were happy as well. It proved an extremely popular series for JAMA.
>> The first JAMA article about evidence-based medicine was published in 1992. What was the medical community's reaction to this article about the role of evidence-based medicine in medical education? >> Well, the reaction was varied. The uptake of the term and to some extent the concepts was really quite remarkable. So I remember being very surprised. It came out in 1992. In 1993, I received some, late in 93, I received some advertising from the American College of Physicians that started out, in this era of evidence-based medicine.
So although I coined the term in 1990, and it appeared in the literature in 1991, the first highly-public article was 1992 in JAMA. And within a year, we were in an era of evidence-based medicine. So in one, to some extent, there was a remarkably rapid positive uptake. At the same time, that there were people who, in my perception, were threatened, were unhappy at the implication.
Their unhappiness is somewhat understandable. That the way they'd been doing medicine all their lives had some important limitations that evidence-based medicine could address. And so I think it was some of the, what I perceive as threatened reactions, were somewhat understandable. And they continue to some extent to this day, although once again, overall the uptake in terms of its integration in residency programs and undergraduate medical education worldwide, over a relatively short period of time, has been quite extraordinary.
>> The Internet has transformed the way in which we look for information. Before the development of the internet, what were the processes for finding and retrieving articles? >> Well, it was, I guess many people, I think, reflecting, going back 20 years. Certainly people involved in medicine, in academic medicine. The way we did things, really, in over a relatively short period of time, looking back on them, seem quite primitive. So one would be going to the library, one would be using the paper-bound index medicus.
And the electronic resources were just beginning. So it was, so at the start of this, it was a much less efficient process than it was now. And, to be quite honest, we were pushing the boundaries of what was feasible. There was no question that what we, that the electronic resources and the internet in particular, have made what we, the real practice of evidence-based medicine, highly feasible.
It was a stretch at the beginning. Because of the technical limitations. >> What advantages and other resources do clinicians have today that they didn't, pre-internet? >> Well, it's really quite extraordinary, what has changed. So that the number of, of ways of searching the literature and getting at specific articles has expanded enormously. There are many effective search engines.
And of course, the Pub Med itself has gotten more and more sophisticated. There's a feature in Pub Med called clinical queries that make searching much more, much easier. So that the ways of searching and getting at articles efficiently has been transformed. And there are many other electronic databases. In addition to that, there has been a big move in the last decade which I think is very important for evidence-based practice, which is pre-appraised articles.
So you have journals that do pre-appraisal, secondary journals, ACP journal club is one that scans, oh, I don't know, 150 or 200 journals, picks out the articles that are most relevant and of highest methodologic quality, presents structured abstracts and commentaries. And it just becomes a much more efficient way of keeping up, than the pile of journals that used to accumulate in the corner of many physicians' offices. In addition, there are textbooks, electronic textbooks that are now very different from our old vision of textbooks, and adhere much more to evidence-based principles.
Things like BMJ clinical evidence and Up to Date are two that come to mind. And in addition, there are resources like these. There's the User's Guide to the Medical Literature, and an electronic guide to the User's Guide to the Medical Literature that people can take advantage of to understand what they are reading more, and gain the skills to use the literature optimally in improving their clinical care. >> What resources on the JAMAevidence website do you think will be most helpful for learners?
>> Well, there are a whole number that I think are really important and valuable. So for one thing, the full text of the Complete User's Guide to the Medical Literature is fully searchable on that website. There are a host of interactive calculators, work sheets, what we call question wizards, that will be fun to use and informative. We have a, quite a comprehensive glossary to the User's Guides, and there are links throughout the electronic text to the definitions in the glossary.
The User's Guide is also linked on that website to the full text of the Rational Clinical Examination, where concepts described in the User's Guides are shown how to help with making clinical diagnoses based on physical examination. So the concept of likelihood ratios, which we introduced for diagnostic tests, are equally applicable to aspects of physical examination and are part of nearly every chapter in the Rational Clinical Examination.
In addition, for people who are teaching evidence-based medicine, the web site has a downloadable PowerPoint slides presentation for major sections of the User's Guide and for the Rational Clinical Examination, that educators can use. And this would be for people teaching evidence-based medicine, people teaching physical exam classes, workshop, curricula, making the teaching much more efficient, and giving them ideas about how to present the concepts most effectively.
Finally, paper textbooks are not that easy to update. On the other hand, electronic textbooks are very easy to update. And new articles that will have to wait for the third paper edition will appear in the JAMAevidence. So, for instance, we've just had accepted a three-part series, a new User's Guide on genetic association studies, and that, that User's Guide will quickly be integrated into JAMAevidence.
>> Dr. Guyatt, in a recent article in JAMA, you and Victor Montori wrote that evidence alone is not sufficient to make clinical decisions. And that whatever the evidence, value and preference judgements are implicit in every clinical decision. What do you mean by this? >> Well, I'll give you two examples that illustrate that. One is one that I use when I lecture, go to various places in the world, and I ask people, do you believe that antibiotics are effective in treating pneumococcal pneumonia?
And everybody says yes, of course they are. And then I present them with a 95-year-old demented individual, contractures, incontinent of bowel and bladder, who moans from morning to evening in apparent distress, and nobody has visited the individual in five years. And then I ask, should this patient getting pneumonia be treated with antibiotics? In North American audiences, about 95% say yes.
Say no, excuse me. But 5% say yes. So even within these, in North American audiences, there's a difference. When I go to South America, in what has been explained to me as a function of a more Catholic culture, two-thirds say yes and one-third say no. And when I go to Saudi Arabia, everybody says yes, the patient should be treated. What is the difference in the reactions both within and across cultures has nothing to do with the evidence or our perceptions of the evidence.
Everybody agrees that the drug is effective. What does it have to do with? Something that we have labeled values and preferences that are used to interpret situations and that are necessary for clinical decisions. I'll give one more example. Which is patients with atrial fibrillation. Patients with atrial fibrillation are at increased risk of stroke, and Warfarin is better than aspirin and better than nothing, substantially better in reducing strokes.
However, it has a great deal of inconvenience associated with it. And an increased risk of bleeding, particularly serious gastrointestinal bleeding. Well, the same patient who is very stroke-averse will choose to take Warfarin despite its inconvenience and bleeding risk. And another patient, otherwise identical and at similar risk, might well choose not to take Warfarin because they are less stroke-averse, but find the inconvenience and limitations associated with Warfarin and the bleeding risk would make the stroke reduction not worth it.
In these examples, the evidence that the people see is identical. The evidence in both of these cases would be high quality evidence, and yet the decisions differ within individuals, within cultures, across individuals, and across cultures. And in fact, when you look carefully, all our clinical decisions, any time there's tradeoffs, and there's virtually always important tradeoffs, upsides and downsides, desirable and undesirable aspects about any of the alternatives we see.
And it is the values and preferences that determine the choices of our patients in trading off the desirable and undesirable consequences of alternative courses of action. >> In the same JAMA article, you used a rather colorful analogy, comparing evidence-based medicine and nuclear fission. Could you elaborate? >> Well, the idea was something extremely powerful, that can be used for good or can be used for what people might call evil, but certainly things that are not so good.
So, many clinicians are concerned that evidence-based approaches can be used by administrators who at least, in their vision, have an interest not in necessarily delivering the best medical care, but controlling cost. So if you believe that, I suppose there are some administrators who would, who would meet that description. And certainly the administrators might have different values and preferences than the clinicians.
And in the worst instance, individuals who are not optimally concerned with the best medical care, but rather with controlling cost, could be using the tool of evidence-based medicine for their particular ends. Even more of a problem from my point of view is the pharmaceutical industry. So the pharmaceutical industry has the interest in selling their product. And they can use the tools of evidence-based medicine, in my view, to distort things.
In my view, making sophisticated but misleading presentations that would lead their medications, they're just doing their job, but lead their medications to be more attractive than they really are. And in my view, we see many, many, many examples of this misuse of evidence-based medicine. And of course, it can be used in the right way, as a powerful tool to make sure we are helping patients understand the tradeoffs and make the decisions that are best for them and ensure optimal clinical care.
So here's a powerful tool that, like nuclear fission, can be used very well to make for the benefit of humankind, or it can be used badly in ways that will not advance people's well-being. >> And what do you see as the future of evidence-based medicine? >> Well, it's very exciting. We've come a long way in the, getting close to 20 years. And the, the future is very exciting as well.
So I talked earlier in this interview about pre-appraised resources. And those pre-appraised resources are going to get better and better. We're going to be learning to use the Internet more effectively. We're going to be using to learn, we're going to be learning to use electronic resources to make learning evidence-based concepts more and more fun, and more and more efficient. The User's Guide to the Literature, the paper version of the User's Guide to the Literature, represents advances where I think we've got better and better at explaining the concepts.
And those improvements will continue. The JAMAevidence represents the electronic use of, of what's in the User's Guide to enhance learning. The-- I referred to secondary journals that summarize the literature. I think these are going to become more and more widespread, and move into subspecialties of medicine. And into allied health professionals, and resources that I also mention effect evidence-based textbooks, like the BMJ's Clinical Evidence and Up-to-Date will get more and more effective and more and more evidence-based.
Finally, there is the frontier of values and preferences. We have identified, as I explained, I think very clearly, that evidence itself never tells you what to do. It's always evidence in the context of values and preferences. But we aren't that good yet. We don't have the optimal tools, the optimal approaches, for ensuring that it is the individual patient's values and preferences that get optimally understood and optimally incorporated, so that the decisions are not only consistent with the best evidence, but are also consistent with each patient's values and preferences.
And one of the key frontiers for evidence-based medicine is learning how better to elicit patients' values and preferences to, in an efficient way, to ensure that the decisions are best for that individual patient. >> It should be fascinating to see how all of this unfolds. Thank you, Dr. Guyatt. >> My pleasure.
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Space bar will play and pause the media.
You can press A to open the Accessibility Dialog.
This describes many other keyboard shortcuts for media controls.
Exit Clip Mode
The video is currently set-up to show just a clip from 0:00 to video end. You have requested to see a portion of the media outside of the clip.
Click OK to switch to the full media or click if you would like to stay inside the clip. You can always go back to the clip with Tools and Clip Mode