News Review
6 DECEMBER 2024 ausdoc . com . au
Evidence for real-world medicine ?
Mohana Basu Australian Doctor reporter .
Professor Paul Glasziou has enjoyed a stellar career ensuring the evidence is medicine-based .
WHEN Professor Paul Glasziou first went through medical training in the late ’ 70s , doctors were taught based on understanding the disease process with what seemed like a good idea for a treatment coupled with doctors ’ own experiences .
It did not mean treatments were bad , he says , but factors such as the placebo effect were uncontrolled .
Nearly 50 years on , Professor Glasziou is about to retire as Professor of Evidence-Based Medicine at the Gold Coast ’ s Bond University , having authored over 250 peer-reviewed journal articles and seven books . For most of his stellar career , he has been thinking about how evidence can be translated into clinical care to improve treatment and outcomes in the real world .
The Epley manoeuvre
Of all the examples about the struggles to apply the evidence , the one that springs to his mind is the Epley manoeuvre .
There had been numerous good randomised controlled trials done showing that the manoeuvre worked to treat benign positional vertigo , he says .
“ Yet most people were unaware of it . And the few people who had heard about it did not know how to do it .”
In a journal club he set up during his time during the late ’ 80s as a professor at the University of Oxford , Professor Glasziou spent a month letting GPs try the manoeuvre on him to boost their confidence and encourage its adoption .
“ There was no resistance from the GPs . They thought , ‘ If this helps my patients , I ’ m going to do it .’
“ The resistance isn ’ t that doctors don ’ t believe the evidence , it ’ s more their concern that they don ’ t know how to apply it to their own patients .”
For him this was part of a deeper issue : doctors were flooded with information .
“ A lot of learning was not through formal programs , such as reading journals or going to CPD .”
Sometimes , it was from newspapers , he says . Often , it was being passed on by colleagues .
“ Most doctors learn through a chaotic process ,” he says , meaning that doctors turn to experts for advice , in turn breeding an industry of key opinion leaders who validate medical practice .
“ Some key opinion leaders are great , but the thing is that the drug companies seek them out ,” says Professor Glasziou , a champion of non-drug interventions .
Early career
As a young doctor , he started out doing GP locum work both in rural and metro practices .
But his interest in the evidence question had burned for some time .
While working as an academic at the University of Sydney , he met Professor David Sackett , the Canadian epidemiologist widely credited for having formalised the evidence-based medicine movement .
In 1969 , Professor Sackett had written a paper laying out his vision of a doctor caring for patients through the application of “ epidemiological and biometric methods to the study of the diagnostic and therapeutic process to effect a health improvement ”.
Fortunately , by the ’ 80s , one of his students had coined the phrase ‘ evidence-based medicine ’. It helped popularise the movement .
Professor Glasziou is quick to stress the history .
“ It was not as if trials were not being done before then ,” he says .
He refers to the 1948 randomised trial of streptomycin for TB as the first clinical trial , which was followed by “ lots of big trials in the 1950s — the biggest being the polio vaccine trial ”.
The big turning point , however , came when the US Food and Drug Administration began demanding evidence of effectiveness , not just safety , in drug approvals in 1962 .
One thing worth stressing about
‘ I was not completely closed-minded about homeopathy .’
Professor Sackett was his decision to repeat his medical internship 20 years after his original training because , in his own words , he “ wasn ’ t a good enough doctor ”, despite being a medical school professor . This also influenced Professor Glasziou . He decided to return to clinical practice part-time , working Friday nights at the Royal Prince Alfred Hospital in Sydney .
But while his work in ED was interesting , he realised he missed a deeper connection with patients .
“ In particular , I realised that I liked seeing the same people over and over .”
So , he moved to Queensland and retrained as a GP while lecturing at the University of Queensland .
“ It took me a long time to go through college training because I was part-time . I was a professor by the time I sat my exam .”
Homeopathy
Perhaps of all the systematic reviews that Professor Glasziou has led , the one that made the biggest headlines was his 2016 NHMRC review on the efficacy of homeopathy .
It looked at 57 systematic reviews , covering 176 individual studies and 68 different conditions and found that homeopathy could not treat any of them . Did Professor Glasziou expect any other conclusion ? “ Look , I was not completely closedminded ,” he says .
“ I had the tiniest sliver of a crack because you never want to close it off completely . But boy , you would need some pretty persuasive evidence now to convince me that homeopathy works for anything .” But was it not a waste of his time ? “ No . If it ’ d been a waste of time , the homeopathic community wouldn ’ t have fought it so hard and tried to discredit it ,” he says .
“ There were lots of ways of attempting [ to discredit it ] but it was interesting that they didn ’ t say , ‘ We should do some more trials ’ or ‘ You misinterpreted it ’. “ They started pursuing legal avenues .” This is a reference to the formal complaint lodged with the Commonwealth Ombudsman by the Australian Homeopathic Association accusing the NHMRC of “ bias , misconduct and misleading the public ”.
It took seven years before the complaint was thrown out .
“ That review not only influenced Australia in terms of the credibility of homeopathy ,” Professor Glasziou says .
“ The impact on the rest of the world was probably much bigger . Yes , reviews had been done , but not at that level .”
Beyond retirement
He has no plan to stay idle once he retires this month .
He wants to work on disease definitions as a means of tackling overdiagnosis .
“ I have been concerned about overdiagnosis for a long time . The biggest problem that is unsolved is the way that diseases are defined .”
For example , the definition of gestational diabetes was changed about 10 years ago , meaning twice as many women were diagnosed .
However , trials suggest that these women had minimal or zero benefits from being treated , he says .
The next generation
His greatest career satisfaction is knowing that GPs now regularly ask the question : “ What does the evidence show ?”
And his message for the next generation of GPs ?
“ Get engaged in research . It is fun . And when you are engaged in it , it makes the research even more useful in the real world .”