1. What information I would want as a patient (and what I’d get in Britain) Richard Smith Editor, BMJ www.bmj.com/talks

2. The basics A doctor who listens and doesn’t try to fit me into “one-size-fits-all healthcare” A doctor who is not captured by the drug industry, the government, my employer, or other “corporate groups” A doctor who “tells it how it is” but who recognises that sometimes I may want something softer A doctor who functions well as part of a team and a system

3. The basics A health care system that is built around patients not the producers (perhaps not available anywhere) Health care free at the point of delivery (“I grew up in a country where health care was a right and carrying a gun was a privilege. Now I live in a country where it’s the opposite way round.” Ian Morrison) No anxiety that I will be bankrupted A recognition that I am not just an individual but also part of a family, a community, a nation-- that is, others matter as well, not just me My own access to high quality, evidence based information

4. Evidence based information What is evidence based information? A question is asked: Do antibiotics hasten the resolution of sore throats? All relevant research is located (hard) Quality criteria are set and low quality evidence is discarded (most of it) The rest of the evidence is brought together, perhaps numerically

5. Tales of evidence based medicine

6. Sir Arbuthnot Lane removed the colons from London’s rich at the turn of the century with a 10% mortality Satirised in Bernard Shaw’s Doctors Dilemma as Sir Patrick Ridgeon, who removed the nuciform sac from everybody-- except himself

7. Tales of evidence based medicine How many of you have tonsils? In Britain most people over 45 don’t; most under 45 do Son born in 1982: wife had an enema, public hair shaved, and fetal intrapartum monitoring; all gone when my daughter was born in 1991 Still happens in Spain, Taiwan, and ?

8. Sources of evidence based information (in Britain) I am the chief executive of the BMJ Publishing Group which produced some of the sources of information I’m about to mention But--probably amazingly to you--I’m paid a fixed salary and so will not benefit financially from increased sales But I may get fired if everything crashes

9. Sources of evidence based information (in Britain) Cochrane Library Clinical Evidence Bandolier Centre for Reviews and Dissemination NICE (National Centre for Clinical Excellence) Evidence based journals Best Treatments (may soon be available in Britain) Many “half evidence based” resources (But is it possible to be “half evidence based” ?

10. But…. Most of the sources are concerned with treatment--and all are patchy In 50% of cases where people have searched for evidence on effectiveness of treatments they can find no good evidence On prognosis, diagnosis, harms of treatment there is virtually nothing-- so we have only part of the picture On evidence that relates to me as opposed to a population there is (almost) nothing

11. And for and from patients…. There is little (?nothing) for patients On evidence from patients--as opposed to evidence from research-- there is just one systematic source that I know of--DIPEX (Personal experiences of health and illness) www.Dipex.org www.Dipex.org They use “purposive sampling” to gather all experiences from patients

12. So if there is no evidence? Look for a trial from the meta- register of trials: www.controlled- trials.comwww.controlled- trials.com Being in a trial means better outcomes than not being in a trial, even if you are in the control arm Collect my evidence in a high quality prospective database of all patients

13. When there is no evidence Trials need to be randomised (to avoid bias) big (to detect small effects) and simple ( to maximise recruitment)--most aren’t But we can’t do trials to answer every question So we need large, high quality, prospective databases--why not everybody?

14. When there is no trial and no evidence Collect all clinical questions that can’t be answered (at least two in the average meeting between a doctor and a patient) Start trials to answer the questions (We still don’t know the best treatment for acute stroke, but if we had entered every patient in the world who had a stroke into the trial we would have had enough patients in 18 hours)

15. And what would I get in Britain? Possibly a doctor who couldn’t be bothered with the evidence (probably not) Little good evidence based information for patients Some evidence based information for doctors--but slow and incomplete: National Electronic Library for Health The emergency room at night-- ”knowledge poverty”

16. And what would I get in Britain? Unlikely to get information on trials or an invitation to join one--unless I insist Should I have “Please enter me into a trial” tattooed onto my chest? Some databases--but few; no national one No systematic collection of questions Few (er) trials designed to answer questions from patients as opposed to questions from drug companies

17. And in the United States? You tell me. That’s why I’m here.