Einstein Foundation Award winner Gordon Guyatt improved the quality of clinical research and helped bring evidence to medicine. His next mission is bringing patients into the discussion. In the 1970s, patients who were hospitalized after heart attacks were routinely given the same treatment: An infusion of the drug lidocaine, which doctors thought would ward off lethal arrhythmias in the wake of a cardiac event.
As a young doctor on a rotation through a cardiac care center in Toronto, Canada, Gordon Guyatt followed the conventional wisdom. “When I was in training in the mid-80s, I did an intravenous infusion of lidocaine on every patient who came through the door,” he says.
Between 1970 and 1988, 15 different randomized trials — involving nearly 9,000 patients — turned his thinking around. None of them showed that lidocaine was any better at preventing arrhythmia after a heart attack than a placebo. In fact, the cumulative evidence suggested doctors were doing more harm than good.
Forty-five years later, Guyatt often begins lectures with the lidocaine example to prove a point: The history of medicine is full of treatments that were based mostly on guess-work and intuition rather than solid evidence. From hormone-replacement therapy to anti-oxidant vitamins, “a lot of what was taught as fact was based on low or very low-quality evidence you couldn’t substantiate,” he says. “It became evident, as people started doing more high-quality studies, that we had been messing up a lot, and we’d better try to generate higher-quality evidence.”
Now a Professor of Health Research Methods, Evidence, and Impact at McMaster University in Hamilton, Ontario, Guyatt has devoted his career to that cause. His work pushed fellow doctors to base treatments on stronger evidence — particularly randomized control trials, the gold standard of research design. His contributions to evidence-based medicine and clinical epidemiology — including improving the methods of randomized trials, measuring how patients are feeling, systematic reviews, and clinical practice guidelines — have been cited over 300,000 times, making him one of the most-cited living scientists in the world.
It might come as a surprise that medicine has ever been practiced any other way. But until fairly recently, doctors-in-training learned only through an apprenticeship model in which their mentors relied on intuition, tradition, and authority. Those mentors had received little or no training in recognizing trustworthy from untrustworthy evidence — for instance, they were often unprepared to distinguish between observational studies and randomized trials.
“When I got interested in clinical epidemiology, it became vividly evident we were on sand. There was no foundation for most of what we were doing.”
Oxford University Professor of Stroke Medicine Alastair Buchan, who is part of the Einstein Foundation Award jury, calls it “ego-based medicine”. Guyatt is even less generous, describing the way doctors sitting on prestigious panels made official guideline recommendations as GOBSAT, short for “Good Old Boys Sitting Around a Table”. “When I got interested in clinical epidemiology, it became vividly evident we were on sand,” Guyatt recalls. “There was no foundation for most of what we were doing.”
In the 1980s, Guyatt was named head of the internal medicine residency program at McMaster’s medical school, in charge of designing the curriculum for doctors-to-be. He was determined to raise the standards of clinical evidence.
“I thought clinicians should know how to read the literature and distinguish between when there was good evidence for what we do and when there’s little or no evidence,” he says. When Guyatt and other doctors at Canada’s McMaster University decided to incorporate the concept into their teaching in the 1980s, they realized there was no simple term for what was at the time a revolutionary approach. “When we took it to wards and clinics, people realized it was a different way of practicing medicine than we had all been taught,” Guyatt says.
In 1991, Guyatt coined the term “evidence-based medicine”, a term that stuck. The concept, too, has proved powerful. His work, together with that of other scientists and doctors, has transformed the medical field in the last 30 years. The shift to evidence-based medicine has changed everything, from the way large-scale clinical trials are designed and conducted to the way patients and doctors interact. “He’s had a huge impact on the way medicine is practiced,” Buchan says.
In a pivotal 1992 paper published in the Journal of the American Medical Association entitled “Evidence-based medicine: A new approach to teaching the practice of medicine”, Guyatt and his colleagues laid out the new approach: Residents in internal medicine at McMaster were taught to de-emphasize intuition and unsystematic clinical experience in favor of high-quality evidence like randomized control trials, a model Guyatt hoped others would adopt. “Rather than accept opinion being handed down, the Hamilton group said they wanted to see the evidence,” Buchan says. “That’s had a huge impact on the way medicine was practiced."
The initial response to the idea was “rage”, Guyatt recalls. “We were essentially telling colleagues, ’Sorry, guys, you weren’t trained to be a good doctor.’ It wasn’t a very popular position.”
“The word has got out. Evidence-based health policy and education have spread all over the world.”
But evidence-based medicine quickly caught on. Thirty years later, it is standard practice, improving the quality of medicine by bringing the best science to bear on patient problems. “The word has got out,” Guyatt says. “Evidence-based health policy and education have spread all over the world."
After years of teaching evidence-based medicine to residents, Guyatt recognized that doctors could use some help — most don’t have time to keep up with the scientific literature, even if they have been trained to evaluate its quality. That was part of the reason he helped develop the GRADE approach (Grading of Recommendations Assessment, Development, and Evaluation), a transparent framework for weighing scientific evidence and translating the tradeoffs of any given treatment for patients. Guyatt calls it “a science of how to do systematic reviews”. “Clinicians need to understand what the benefits and harms are,” he says.
By systematically evaluating the quality of clinical trials, the approach had an impact on the quality of the studies themselves. “It defined the way in which things should be evaluated and used this to drive home what was good medicine,” Buchan says.
The next frontier? Finding and testing good ways to bring patients into the conversation. Of course, Guyatt is gathering evidence along the way — work that has him branching out into psychology and social science. “We can still do randomized control trials of one approach versus another,” he says, “and we should.”