Last week, in the shadow of the lonely mountain (Etna), the good hobbits of the EBM shire held council on the shores of the Ionian sea at Tauromenion.
Well, to be less dramatic perhaps, those invested in the world of Evidence Based Medicine, met for the 8th International Conference for Evidence-Based Healthcare Teacher and Developers in Taormina, Sicily (25th to 28th October, 2017). What an awesome 4 days! Engaging, dynamic, and inspiring: involving 148 delegates from 24 countries. The theme of the conference was ‘The ecosystem of evidence: connecting generation, synthesis and translation’. It was an impossible task to note here all that was learnt – but here Becca reflects on some of the main lessons that she came away with. Interspersed amongst the lessons are some personal reflections.
Reflection #1 When in Sicily– do go for a swim at sunrise: therapy for heart and mind.
And before we start – what is the evidence ecosystem you might ask ? This was answered by Nino Cartabellotta. It has three major interacting components: the ‘players’, the ‘environment’ and the ‘evidence’. Running across the 5 take home lessons was the recognition for the need of transparency in all that we do, and the need for investment in training to help the players in the ‘living part’ of the evidence ecosystem be better at what they do.
#Lesson 1 We still need to be better at asking the right question
From the pre-conference workshop from Trish Groves, to the plenaries of John Ioannidis and Paul Glazsiou, it seems we are still failing at getting this simple action right, both in what we research and how we ask the question. We need greater involvement of stakeholders and end-users when setting our research priorities. We also need to ensure that any new research builds on the existing evidence base otherwise we are simply adding to the pile of avoidable #researchwaste. Unfortunately we continue to fall short of this. For those unfamiliar with this area, look no further than the Lancet Series or the REWARD alliance website. It was reassuring to note that our PenCLAHRC prioritisation (which Becca presented on) is right on point with this.
#Lesson 2 We still need to be better at doing and reporting research
Doug Altman in his 1994 editorial said ‘We need less research, better research, and research done for the right reasons’ and it seems in many ways we have not really moved on. John Ioannides pointed out that we have an extreme case of MMM (medical misinformation mess, see Ioannides et al 2017). There was much discussion about the issues of doing research for research sake, with incentives and rewards to publish from institutes partly to blame. Doing research for the greater good, rather than for self-promotion, was a strong echo from many of the plenary speakers. We heard about the manifesto for reproducible science – Improving the transparency, reproducibility and efficiency of scientific research. Having more meaningful interpretation of patient reported outcomes was discussed by Gordon Guyatt, and the shortly to be released new handbook on ‘MIDs’ (minimally important differences), will be an important resource for all to refer to. Another new resource is the Handbook of Non-Drug Interventions (HaNDI) which aims to make prescribing non-drug interventions as easy as writing prescriptions, and should assist in the reporting of interventions. Indeed, having asked the right question and chosen the right design, it is then essential that you report it well. Authors should ‘keep it simple’ (said Doug Altman), and journals (and their editors) have a key role in acting as gate-keepers for both well conducted and well reported research, and for ensuring that conflict of interests are reported. Howard Bauchner showcased how JAMA attempt to do this in their extensive peer-review process for submitted manuscripts. And of course, don’t forget EQUATOR. The EQUATOR network is a fantastic resource of reporting guidelines – love it and use it – was the comment!
Reflection #2 – When in Sicily you should try a Cannoli or two!
#Lesson 3 We need to be better at thinking about certainty of evidence
GRADE continues to gain traction as the tool to turn to for assessing the certainty and strength of evidence on which to base recommendations and guidelines. An excellent workshop from Nancy Santesso, and engaging discussions from Gordon Guyatt and many others, documented the latest updates in GRADE. It is still not without issues – there was discussion of the subjectivity that can occur in the downgrading and upgrading of evidence, but it is the best we tool we have to date, and the one that is most widely used. Being transparent in your decisions when using GRADE is essential.
#Lesson 4 We need to listen more and talk more
Guidelines and protocols are all very well, but we must consider the patient narrative. Trish Greenhalgh talked about her concerns of #rubbishEBM: when patient history and preference are given little say or consideration in favour of the static rules of the guideline world. For realEBM, clinicians need to use their expertise, know the guidelines AND listen to the patient. Shared decision making is important, but we must remember that some patients don’t want to be involved in the process – if we listen, we will know this.
We also heard about the need for greater listening and talking between politicians and researchers. Walter Ricciardi entertained us with his forecast of ‘the perfect storm’ brewing in healthcare and the challenges this poses to the ecosystem. He illustrated the disconnect between policy makers and researchers in a series of Italian paintings entitled ‘politicians are from Mars, researchers are from Venus’. It’s very difficult, he said, for discourse when the two have such disparate vocabularies: 7000 words for the politician compared to 140,000 for the academic! Was this an evidence-based based fact? We don’t know – but the sentiment is true: we need to get better at talking a common language with each other. Read the man in the balloon story and replace the man in the balloon with ‘politician’ and the engineer with ‘researcher’ – and you’ll get the message. The future of a healthy ecosystem is dependent on us building bridges, not simply admiring the view from our respective silos.
We heard from David Tovey about the crisis of realism in ‘EBM’: we want answers more quickly, we want real world data, the evidence is more complex and there is a movement toward personalised medicine. Are we facing an evolution, a revolution or a bit of both? The Cochrane answer is their very own Cochrane Review Ecosystem.
Reflection #3 – When in Sicily do try pizza e vino!
#Lesson 5 We need to embrace the digital world of EBM
The digital age of EBM is well and truly here. Point of care medicine is at our fingertips. Per Olav Vandvik talked us through the magic of the MAGICapp and how it can be used for the production of guidelines and evidence summaries. MAGIC have been working the BMJ to produce rapid recommendations – which aim to accelerate evidence into practice to answer the questions that matter quickly and transparently through trustworthy recommendations. Douglas Badenoch led us through new developments in CARL (critical appraisal resource library) on the testingtreatmentsinteractive website: a one stop place for EBM teaching tools. Dynamed (EBSCOHealth) were on hand to showcase DynamedPlus: a clinical reference tool which provides fast, easy access to the latest evidence-based information. Lastly, Amanda Burls showcased ‘should I believe it?’ : an app designed to help users understand (or teach) statistical concepts, in particular the p-value.
Reflection #4 – It’s good to go to a conference by yourself: you connect with more people. And with Sicilian hospitality you never feel alone….especially not at EBHC2017!