SGEM Xtra: Carl Heneghan – Legend of Evidence-Based Medicine

[Music] Welcome to the Skeptics Guide to Emergency Medicine. Meet him, greet him, treat him and treat him. Today's date is March 4, 2026, and I'm your Skeptical Host, Ken Mill. The title of today's podcast is, "What would you say if they be calling you a radical Professor Carl Hennegan?" [Music] Legend of Evidence-Based Medicine. Today, we are launching a brand new SGM series, Legends of Evidence-Based Medicine. Now, in the past, I've interviewed legends of emergency medicine, people like Dr. Diane Bernbommer, Dr. Ian Steele, Dr. Jerome Hoffman, Dr. Rick Buchata, and Dr. Judy Tintnelli. Yes, she wrote the book on emergency medicine. But today, we pivot to the people who shaped how we think about evidence itself. And our very first guest is Professor Carl Hennegan. Carl is a general practitioner, Professor of Evidence-Based Medicine at the University of Oxford, and current director of the Center for Evidence-Based Medicine. I first met Carl back in 2012 when I took the Teaching Evidence-Based Practice Course at Oxford. That experience directly inspired the skeptics guide to emergency medicine, a knowledge translation project. So in many ways, Carl, this is all your fault. Welcome to the SGM. Well, look, I apologize. And I apologize to all your listeners for the. No, I'm not called for the misery over those years. Blaming you for like 600 plus episodes. You know, I give my age away. When I was at school, I thought you had gone for pink Floyd and know the brick in the wall. Oh, another brick in the wall. You would have picked that one, would you? That classic. Classic. Before we start the formal part of the podcast, we should acknowledge that we are recording this on location at the University of Oxford. The place where cobblestone streets, spires, Latin inscriptions, and the occasional person wearing an academic robe, basically it's Hogwarts. So, Carl, how does it feel working in a place that's been around since I think what? 1096? 1096? Yeah, yeah. There's been a university here for a thousand years. I mean, interesting the building we're in. This is the center for evidence-based medicine, but it's actually the Department of Primary Care. But going back about 20 years ago, 25 years ago, this is the old racked lip-in firmly site. There's been a hospital on here for over 250 years. And the building we're in used to be the emergency department, so it's full circle. Oh, I love it. Now, I love it. And actually, this is a site of one of the first emergency departments in the world. And on the front is a blue plaque, which actually if you go out the front, you should take a picture. I did already this morning. I took a picture of the site on the 1770 forward. But on the front building is a blue plaque. This is the site of the first administration of an antibiotic in the world, penicillin. Unbelievable. Just after the war, this is the place. And you think about the revolution, that's cool. So there's lots of full circles here in the emergency world. But you're right. Every time a cycle through here, I've just come through what's called the Radcliffe Square, where you've got the bodily and all the old buildings, and even the pubs here are 450-year-olds. So I think there's some residents, one of the things I say if you're a student here, go and sit in the old libraries, because you can sort of feel the presence of people who've been scholarly here for hundreds of years. I think there's some interest in about Oxford. It's not that people are any smarter here. It's just the density of people. About one in every three people is either connected to the university or healthcare in some way. So you're bound to be that to next to somebody who's really smart. And the quality of the conversation, just me and it all, you get better and more thoughtful. And I've had an amazing run with some amazing people who have helped me sharpen my tools and my epidemiological thinking. Well, that's a great segue into my other question. Is do you ever just walk around this place and the buildings and think, somebody debated Aristotle here? And now I'm arguing about confidence intervals and what does a p-value really mean? Yeah, yeah. No, I went to Padua to do a talk in Padua. And I was on the lecture fair to where Galileo stood. Wow. So you just think, and I sat there and I thought, Jesus, that's wrong here. I'm the imposter in the place. So I think there's always that, you know, we talk a lot about imposter syndrome and what does it mean? But actually, I think the key in academia, and I think this is in healthcare, is if you have a passion for learning and knowledge, there's just always so much to know and try and understand and interpret. And so it makes you humble when you realize that there are many areas you're going to that there are uncertainties. And this is a basic principle of evidence, based medicine. What is the job of evidence is to reduce uncertainty and it's reduced those uncertainties for decision-making so you can make better decisions for healthcare. One of the key principles that we come again, is all the time, is people who come with certainty. People like certainty, really down side there, creates confidence, but you sit there and go, well, what's the evidence for this? How does it inform the decision you're about to make? There's huge uncertainties in practice, and I think that's what makes it so interesting. And the more you can embrace them, the more likely you are to come to an evidence-based approach to try and help you go through this, my or of complexity and emergency medicine as a great area where you see, there are some things you know, well actually the evidence is really strong. We can do this, but there are many areas you practice, and that's where you go into more of, here's my experience I bring to the table. Absolutely, I think that's why, you know, emergency medicine as a group really leans into evidence and evidence-based medicine, because they're more comfortable I think with uncertainty, because they see people quickly, because of necessity, they get limited information, and sometimes those decisions that they make are life and death, and they don't have the full picture, but a decision needs to be made and they can't be paralyzed within decision. And so they're always searching for the better evidence to inform their practice so they can give great care, and I think that's how I, you know, I'm approaching 60, how did I end up at Oxford as a student, because I have that lifelong learning mentality. Well, it's interesting. Most people, when you talk about evidence, thought or think about treatment effects. But actually the treatment effect evidence is pretty easy to deal with, you know, you're looking for randomized trials, you're looking for systematic reviews, and you're trying to interpret bias. But actually there's a whole world of evidence in diagnostics, in prognosis is really, why is it if we do nothing with this patient? So there's all that going on. All my friend Chris Carpenter is going to love that comment about diagnosed against uncertainty. Yeah, that part. And I was really captured early on, so just to say my job is sort of in the interface. I work in urgent care general practice. And I do lots of home visits. I'm at the interface between who we admit, who we don't, who we can manage in their own setting. But actually one of the early things that really captured me was the Jammah, the rational clinical exam series. And I've still got the book, it's at home, I took it home, it was within this office a few weeks ago. But I, is what an amazing series, you know, and I still quote that does this patient have pneumonia? Community Acquired Neumoni, it's a brilliant example when I'm teaching, and I've got people out going to the status quo, you're doing this and I'm trying to listen to this. And I go, what features really make a difference in this exam? And actually it's temperature pulse and respiratory rate. You've got all three of them have normal temperature above 30, a pulse at 100, respiratory rate above 25 or 30, whatever it. That gives you about 50% chance. The absence is less than five. So immediately you can really clean up your practice if you understand the evidence. As opposed to the use of a steppesco which is like load ratios are always around about one and precondition by what somebody tells you you're looking for. It's really helpful. Now what's interesting is in the molecular biotech era, we've sort of lost face in or we just don't prioritize the sort of the routine sort of clinical research we used to do in sort of symptoms and signs and history taking. Somewhere around the corner we're going to have a new test, the other there. But I still think if I was to say start with an evidence based approach as a clinician, go and revisit some of the rational clinical exam theories. And it's a great place to teach about when you're looking at particular features like I look at the heart failure, does this patient have heart failure? And it talks about things like when I was at med school, the headings like purely be lines and all the top which I'm like what is that supposed to be. And then all of a sudden you go, well, this has a specificity greater than 10. This is what you're looking for. And this rule that in versus this is what rules it out. And you can have a much better understanding, clinical. And I always remember in the early days, it was the old needle in the haystack that when I see people who are not evidence based and they don't understand the interaction of diagnostics and some of the evidence, you can see them, they go around in circles. we're going to get to the early years. I have a question coming up about the early years, but just a couple of more questions about Oxford itself. Do you have a favorite spot that you'd like to go and think? There are many favorite spots for me. I'm going to start with the golden triangle. Okay, the golden triangle. Yeah, and that is free pubs in Oxford. Oh, you see that's leading into my next question. It says the two thousand, the King's and the White Horse, and if you look at them, they form a perfect triangle within about 100 yards of each of them. The very first podcast that I did in Oxford, back in 2012, was at the King's Arms. And the next question I had was, where do the big EBM ideas are, where are they born? And I had, is it over T, is it in a pub, or in a college quad? You've answered the question. It is in the golden triangle. Yeah, I think, you know, these are the sort of particularly learning, and you know, this is why people go to conferences, this is why it's, it's those in the corridor moment. It's why Zoom can't replace them. Yeah, these, these meetings that are online, we're just out of like dinosaurs here, but you know, like you said, meeting in the court or having a car, or a tea with somebody going out for a drink or a meal and breaking bread with them. This is where all the actual juices have. You never, so that, the pub, the one place, but the university parks is amazing. Down by the river is amazing. I started my life at New College, which is 13th century. It was new in the 13th century. It's not new anymore. Let's hold you off there because the five questions I have for you go back to your origin story. So let's talk about the five questions I have. Oh, yeah. Question number one, it's always a superhero origin story. So in the beginning, what got you interested in evidence-based medicine, and was there a moment that you thought, hang on, we should probably see if there's any data on this. So I came here as a medical student in 1994. The following year, Dave Sackett arrived from Canada to head up the Center for evidence-based medicine at the first director of the Center for evidence-based medicine, which I now direct. And in the second year of medicine at Oxford, they have this, it's a very, it's not like a crash course. Turns here are very short in the undergraduate. They're eight weeks. So that incredibly intense. But then what happens is after five terms, you do an intercalacy degree in physiological sciences. And coming it to the end of the second VM, you do a dissertation project. And much of the stuff here is basic science. That's where the Q-doth is, the real money, that's where the Nobel Prize is. Are you going to discover the latest vaccine? Are you going to discover some pathway of oxygen? Okay. And I'm like, I'm just not interested in that. And at the time, there was a bit of an emphasis in evidence-based medicine, thinking about people like Richard Dole who'd been here and some great professor here like Peter Ruffwell who's done all the work on stroke to you. But actually, he'd arrived. And I just had this, somebody said to me, a wacky idea, well, why don't you talk today and see if you can do a project with Dave. With Dave Sackett. Yeah. And I turned up with Dave. And we had a chat. And I always remember the first ever concert he introduced me to was the number-needed retreat. The NNT, yes. And this was in five minutes of meeting the guy. And at the time, the aspirin tri-less collaboration system, I think, would you that come out, IPD, going back to 1994-195. But this is a systematic review. Looking at the number needed to treat for aspirin in a stemmy or an STL-abated, right? Yeah. 42 is the answer, by the way. Yeah, so I was going to say at the time, you said, look, the number needed to treat is for every 40 people, you said, you treat with that, then you say, one life, but Dave, yeah, no. So there you go. You've got 42. I've got 40 in my life. Well, the two is the answer. Now we know what the question was. Yeah, so he introduced me to that concert. And then the second question is he said, look, we're building a website. What do you know about websites? And I guess I've always been the sort of person who leans to get involved and have a job. I don't know quite much, but I'm quite happy to have a go. Give it try, yeah. And we, I decided to just say, well, look, let's build it. Let's put some concept, write some pages like what's an NNT. That page still exists the day on the website. It's like 30 years old. And Dave was here for a five years. And his mission really was to spread the world about what evidence-based medicine is, what the approach is and how it should be adopted. There was a lot of resistance at the time. Well, actually, that, you know, I was wondering in the early years, was there a real tension between Eminence Space Medicine, I told you to do it this way. I said so I was taught how to do it this way versus evidence space medicine. So, was there, you know, if we go back to 1990s, "Do-do-do-do-do-do!" that's time traveled, by the way. Was there this tension between Eminence versus Evinance Space Medicine in Oxford in those early years? Yeah, there definitely was in the work conditions who really riled their feathers. Dave had a thought style that could rile feathers because he'd walk in a room and start asking questions and showing how basically he might as well flip a coin for the answer given the variation in the room. That's what a style with a bit North American, it broke at the time. I mean, it was actually worth it. Earlier, later, we used to it by now. And the Lamsit Road editorial, you know, saying again to this, but actually you can see within about five years by 2000 the landscape of dramatic change. I mean, by then we had nice and emerged within by the end of that century. Nice being. National Institute at Clinic Lakes, I was producing technology appraisals, guidelines. The idea that you produce evidence for the drugs you would adopt was actually quite a revolution of change that all emerged within a three or four-year process. So I think and there was one thing Dave was particularly good with was with students. And it was almost like he sort of said, "Well, all of these people at the back end, they're lost causes. You're too entrenched and you've used." Let's filter down here and try and see. There's some famous line about, "Give me your child or give me your son for seven years or something and I'll produce something or other with regards to a religious concept." Well, I think I have to get them young. Yeah, I better way. I know also I remember in saying once he said, "When people walk in this room and I use this one all the time, they walk in with their dreams and my job is to make sure they leave them in tact." And I see too many people in medicine, particularly in academia, we think their job is to rip headlifters in a bar, destroy the student and they walk out the room in bits and somehow they'll put it all together. But actually, it's fascinating. Young people and students and I work with a huge variation whether it's under graduates. I run the EBM course in the medical school, we run the graduate school. Is everybody has good ideas? It's about getting the skills and the tools to be able to turn them into someone that can become an evidence-based approach. And that's part of the parcel. And I actually think that everybody in medicine should be involved in some aspect of improving the service. And they're the people who are actually the most happiest in medicine. So that means it's part of our training. We just started now a special study feed module in year four of the medical school. And so the first bit is we created a proposal. How to look at a paper. How do you think of it in the context of a clinical question? All that passive. We flip it on the head, the following term and go right, you're all going to do a systematic review. Come on in. Everybody does a systematic review. Well, there's about 25. Okay. But what we do is we get them to bring their own questions. We give them an online learning. They have a two-week course where we have from the question right through to the protocol development. But we get them to then team up and prioritize which is the best one to do. And then they collaborate on the portfolio. And they fall out to be learning. Yeah. So out of about 25, we end up with about eight systematic reviews of which more than half go on to publication. That's great. And it's been amazing. And actually I'm overwhelmed at the moment with students contacting me going, well, we're just doing this without our excursion. Can we ask you this? And so I have this flexible approach where I call it match effort. If you do nothing, I'll do nothing. But if you want to take some approved to publication, I'll match that effort. And so I'm very flexible in my approach which is coming through from I think the EBM approach is, you know, if you're doing a system I think you'll be able to load a little bit where you go, well, not quite sure what to do here. The first time you do them is a little boring, isn't it? And as you do it more and more, you get more skilled and you see the patterns and a bit like clinical practice, you know where you go. And the enthusiasm that they bring is contagious. Just like you said, if they're enthusiastic, you're enthusiastic. They're not enthusiastic. That's what they're going to get. Yeah. The lack of enthusiasm. And the thing is they come with questions. I'm like, this is a great question. And I call, that's the thing about, you know, and I guess the thing about which is a problem if you get in the world of evidence based medicine and use skill yourself to support people to do things like systematic reviews or that. This is what's a light bulb moment come up where people come in with a question and go, oh, that's really interesting. You know, I had one recently, it's in a systematic review on brief psychological interventions in the mental health in refugee population. Some are not so really just in question. Does it work? Does it? We don't know. Let's find out. And I think that's the key to healthcare. Understanding what works and what doesn't is still a major issue for us in healthcare. And it's going to come to a head because we're running out of money and resources to keep doing healthcare as we currently are. And somehow we've got to reorientate. So I, although we go back in 90s, the thing about the 90s here is Sensor of Urban Space Medicine started. The Cochran Library started at the same time. And the Center for Statistics in Medicine led by Doug Altman. If you don't know, Doug Altman, I'll call it Blan than Altman. Yeah, Blan Altman plus. One of the top 10 cited academics of all time. So there was a huge excitement for about the Halcyon days. And a lot of that, but loss, I think, in a sort of, oh, we're just going to produce the evidence and everything's going to be all right. Well, we'll get things some of that. The second question that I had for you was, you know, you started 32 years ago, 1994. So here we are in 2026. And you're looking back. You have this perspective to look over the horizon over three decades. When you look back at your career, what do you think you've contributed to the evolution of evidence based medicine? That's a difficult question, I think. I didn't want to bring you easy questions. I think that's it. I, you know, the substantial interest in publications that I've done and put out there and work with people. I think the biggest contribution I've made is all the people I've touched in the world of mentoring, supervising, teaching, comes back to the people, doesn't it? You know, you said you started with you came on the 2012 course. Yes. I went on the 1995 course. That was my first one and we've got a 3D run in them days. There's not a thought it is now. So I've been 30 years on teaching evidence based medicine. And then you became the director? Yeah. A director. So that's an excessive of thousand teachers we produced. But you also did all trials as well. You've evolved in starting that in the transparency. You know, the real push to make sure that we have transparency in public. Yeah. And I guess the old trials came out of what probably one of the most influential pieces of research we ever did, which were the tummy-flung trials, which was the cockle review, which we published in the B&J, which basically came from the basic principle that over two thirds of the day to have never published any form. And that was on Ulcer Tamavir. Yeah. Because I like to use the generic names, but Ulcer Tamavir. And I have to say that is the longest systematic review I've ever read. It was over 500 pages. And we covered it on the SGM actually. Yeah. Yeah. Huge, huge work. Well, this is the realization that what's published in a journal. So if you go to New England journal, you might get four or five pages. And one of the largest ever treatment trials done for, I'm going to call it, Tammy Flesher. I go, is, well, as M76001, that's the name it gets before it becomes a drug and that's the criminal. It was published as an abstract. 300 word abstract. That's what you're supposed to go up. The CSR, the clinical study report, was in excess of 9,000 pages. It took us four years to get the data out of Roche. Yeah. And a GSK. Oh, GSK. Sorry. Yeah. No, no. GSK was the name of it. Roche with Ulcer Tamavir. Okay. Okay. So there was a couple of coughed up in the end when we had the BMJ. We had channel form, media, real pressure to get the data released. One for God it released. We went, oh gosh, we've got a problem. We've got 90,000 pages of documents here. We've got to go through. I wish I had AI to be able to help us, but then days yet to do it by hand. And that took us four and a half years. But what it showed me is, and we still believe this and it's still the way, for the important public health interventions, the drug, the vaccine, that actually you should be using the clinical study reports to do the systematic reviews. Have an individual patient data lesson, they have all the, all the data, all the data. I actually remember I was, I had a GP. I was, I trained in family medicine and I had a family medicine practice. And this is in the late 1990s. Ish. And I remember getting sent a huge box of all satan of year because the government bought it all up for a flu pandemic that was coming through. And then the Cochrane review was published after that showing, well, so we published the review, it shared what it did. I went to a public account, committed a UK government committee meeting here. I went in, I explained all the issues about problems with observation, evidence, I thought it did a great job. I explained every minute full and a week later we spent another 50 million pounds stockpiling the drug. And so you have to have a level of humility that when it comes to politics, evidence goes down the, down the sort of levels of decision making. And fortunately, at political level, their argument was we need to be seen to be doing something. The intervention bias right there. We got to be, we got to, we got to, we got to, we're doing something whether it won't, if it's the secondary. Well, one of the things I've always admired about you is that you don't just use the evidence, you question it, whether the evidence itself is trustworthy. And this is something you challenged in your substack. You have this substack and podcast called Trust the Evidence TTE, which you describe as a couple old geezers writing about the evidence you, you could have called it, hey, you kids, get off my lawn. Do you think that skepticism is something that is missing in modern EBM? So I think, I think what I've real, I mean, the reason we've gone down this approach is through the pandemic, actually. We realize in the pandemic who do we want to start talking to. And actually, if you go through the journal route, it's slow, laborious, it gets delayed, edit it, sometimes don't like what you're writing. And so you don't actually get to communicate with anybody and you don't communicate. So number one is to do a lot in the media, right in, I wrote a piece in the telegraph last week about the demise of the NHS. But actually in the substack with Tom Jefferson, who we go back 20 years and he was Tammy Flew and Tom's an amazing guy because he's very forensic in his approach. And when you work with people, I say this, you can, you can, you know, people who, if you're interested in academia or collaboration, just try and work with one person and make them stick. And if you do that one a year, in 10 years, you'll be so busy, you won't need anybody to collaborate ever again with. So work with people, stick, find the good guys, find the people who compliment your own thinking, but look at the world differently. So he's very forensic in his approach and I learnt that from him. In the trusty evidence, it's amazing because we get to talk, we get hundreds of comments on each article. Oh, I, we've got them. Yeah, it's an interaction. I've just put a piece out today, but the other thing is it makes me take my thoughts and put them down on paper and I'm learning so much more. That was on puberty block. Yeah, I read it this morning. Yeah. Now, interestingly, the NHS patient safety commissioner here has asked my, my view on this issue. So instead of rushing in and going, oh, here's my view. I just wrote a back and said, well, we're right in a series of articles. When I get to the end of them, you can read them, then we can have a discussion. But I actually realized there are, it's so easy to go, I have a view and take a side as opposed to going back and seeing what in in forums. Yeah, and it, when both people are looking at it, what are the issues at hand? So it's actually, I'm just less this morning, sent the four posts to Tom. So actually, it's going to take six posts to get through my views on where I get to. And then I'll have a good understanding. So a discipline of taking your thoughts and putting them in a medium and writing them down and putting them out. The process is incredibly helpful for your own thinking. I sent your post this morning to a good friend of mine in the United States who was very interested in this area and asked her for her views and said, hey, I'm not an expert in this area. You're an expert in this area. What do you think of this guy's geyser? Yeah, yeah. And wait until you get to about points for post three. If you send a post to him three, she'll start to go, oh, this is logical. We're following the, we're setting up a pattern of how you think from both sides. Right. And then what are the issues? And, and actually, it's a very interesting question because engendered discovery of what's happened is we'll set the argument up. Is that actually people have jumped forward to treatment? Mm-hmm. They never asked the question is what about the diagnosis and the prognosis? And the long-term outcome was the, you're talking about about, but also, one of the important things about diagnosis is it needs to be stable. And the purpose of a diagnosis is to identify people with a worse prognosis that allows you to intervene. That's the whole purpose. And if the prognosis, if the diagnosis is not stable, then how can you create a group to intervene on? And if you don't understand the prognosis, what are you trying to do with the treatment? I think you're going to get lots of feedback in this area because Gord Guyette recently, I don't know, about six months ago, got involved in this gender affirming sort of, come. - Yeah, a low-traverse event as some kind of statement. - Yeah, so we've already, we were at the forefront of this because 2017 Tom and I wrote a review on, we worked with BBC Panorama. They said, could you do the review of the evidence and then for it? And we put down the evidence was, yeah, actually it's low quality, exactly like the cast review, the derf of evidence and actually what people are doing in its participating in the experiment. - There is a derf we've got for lots of areas. - Yeah, and particularly in childhood and adolescent. - Idiotrically. - Idiotrically. - You use a lot of off-label treatments. But purpose of medicine is to ensure that people we use regulatory approaches that evidence appropriately. But it's a very good area. But what, and we got pilleted in 2017, so I'm well aware of it. - You're prepared? - Okay. - So I'm well prepared. If you look at what we're doing now, it's not saying something's good or bad. Article three will say, if you look what's happened here now, is the cast review couldn't look, 9,000 people went through the gender eye that these four of your services in the UK. They've got information, they've got a cohort, but they didn't let them look at it. So we've had to pass it. - They didn't do a comeback. - They've record linkage and outcome. We actually have a new act of parliament to allow the record linkage to go ahead. That's how to call three. - Well, don't give away everything. You've got to tease the audience, but don't give it all away. - But actually, it's a fascinating evidence-based moment, 'cause you then go, well, what study would you do? How would you do it? How would you account for confounders? Well, and so we set out a basic principle. So that's some of the thinking and that's, they're really interested in. What I call is the clinical epidemiological of evidence-based medicine. You're interested in the questions. How do you answer them? How do you get to where you wanna be? As opposed to your opinion, everybody will have an opinion. - Oh, yeah. - And that's fine. We can all have opinions. Every start, the conversation is, how does their evidence reduce the interest? - Well, as Christopher Hitchens says, that can be asserted without evidence, can be dismissed without evidence. The problem in the modern era, and this is probably, is I came from an era in the '90s where you ask questions. You were critical. People would be critical back and you tried to sharpen your thinking and bring it up to the fore. I think the modern era with the way social media works in X-Z is making people afraid of speaking out or. - It certainly has caused some polarization and made it more difficult to have those respectful conversations because I think that you can disagree without being disagreeable, but social media fuels that disagreeable part. - So there are two things that are really interested about evidence based on when you do speak out or go into the media is. The first is, it will always be controversial. You mean, so if I speak to people of the public say, what do you do on professor of evidence based and then they'll turn the EBM round the other way and they'll go, well, isn't all medicine based on evidence and the EBM. You see, and they just go, well, sure, it's all based on evidence. And you go, well, here we go. Now, and you're going to areas where people will have fixed ideology, competing, interesting and they revel in the uncertainty and you go, well, there's the evidence. So first, you have to be aware that's really controversial. Actually, things are a little bit more uncertain. You can see that. - I don't think people realize how much of what we do in medicine and I've done a show on what we do in emergency medicine and only 3% had high quality evidence to inform our care. And it doesn't mean 97% doesn't work. It just, we haven't investigated it well enough with good enough methodology to confirm that it does work and that's an important distinction. - So I'll come back to that. Let's come back to the aspect and it's a good example of that. But the second thing is, when you're in the media or in the other day, well, what would you do in this situation? - Oh, yeah. And I, my standard answer is, well, I'm going to look at the evidence and I'll look at the benefits in the heart and then doing that, I don't know. But what would you argue? Well, you should go and look at the evidence of vandicoidation and it can explain it to you. And that gets you out of all the problems 'cause soon as you go into your own opinion, you're in trouble. But yet the high quality evidence, so the interesting thing about how we, if you go back into the 80s and 90s, you had an issue like aspirin and mi, you as a clinician at a low cost, you could do a randomized control trial in your clinical setting, come on to your patients. - Yep. - The problem is, over the last 20, 30 years, people are gone out with a lot of problems with that, if they're internal validity and x. So we need bigger trial, better done, and the cost is fortune. But you go back to aspirin, over 200 trials. And it's replicated, so replication is important. When you do the IPD, you get a modulant effect, high quality. - Just so people understand that's individual patient. - Yeah. - And so when you go to clinical practice, you go, well, actually, everybody gets aspirin and mi, unless they're allergic or conjugate, if you go, well, we don't need an audit. We just, clinicians respond to high quality evidence. The problem is now, it's a real problem for us to develop clinical evidence in practice. And now, as remember, Ian Charmers, saying this once, Ian Charmers was here to teach out the UK Cochran Center and the Cochran Library, theory and charmers, another legend of EBM. He basically said, "When I go into hospital, I'd like to participate in a randomized control trial if there's uncertainty." Because at least that way, I've got 50% chance of having the correct achievement. (laughing) And so I thought that was because that's what a hospital should do, shouldn't they? Should say, on the way in here, in areas of uncertainty, by the way, you'll be participating in RCT. And it's a sort of, it's a condition of using this facility. And there are loads of areas. I mean, emergency medicine, fractures is weight bearing. - Absolutely, there's things of uncertainty and questions that have been resolved. - Can you use an anti-inflammatory, if you'd like? You might want to be like, "No, you can't. I go, well, it's evidence in rats." - Yeah, but you've prepared to give a little old lady to ogie and fall over. - And break another it. - So there are loads of areas where you go, yes, you're randomized to the group of, I know you've fractured, you've fibula, what we're gonna randomize you to is a boot and early weight bearing. As soon as you feel it's okay, start weight bearing. Let's see what happens. But as opposed to standard advice, which is come back in sick tweet. - And don't weight bear. - And I just think these things are, if you think you can shorten the duration of weight bearing in society by three weeks with no early time, that's a massive socio-economic benefit, doesn't it? - And talk about deconditioning and all these other things that come up. - Yeah, yeah. Well, I'm gonna get the question three now. And this question is specifically tailored to a good friend of mine. Her name is Suci, and she's a huge Taylor Swift fan. So this is my T-Swift question. Ready for this? Hey, there's gonna hate. And EBM hasn't been without controversy and critics. And some of the criticisms have involved being too much, like a cookbook. Like, so you're practicing cookbook medicine. Having too much pharma influence or being hijacked by pharma are being overly reductionist. And using this artificial hierarchy and this EBM evidence pyramid while dismissing mechanistic evidence and being too focused on just RCTs and being dismissive of clinical expertise and ignoring patients' values and preferences, saying, oh, it has to be about the evidence or the literature. What is your response to some of the criticism that has evolved over the last two decades? I think, you know, some of the criticism and the legitimate about the use of evidence, how it's developed and how it's reported. But the first thing is to say, when people come at it, you say, well, what's the alternative? And then you have to think about some of the seminal points of where our structure of the evidence developed. So go back to the 1950s, it's Phalydamite. When RF candidate, JFK Kennedy said, we're gonna have clinical trials at the point of regulation. Oh, it was a Canadian who turned it down. A Canadian who was working for the FDA as a woman. - Trump, please, Kelsey. - Came from London, Ontario. I remember when they, in our newspaper, the London Free Press had a big article about, I think she was in her 90s when she passed away and she stood her ground against the pharma for the FDA. She was working in the FDA. So first off, you've got to think, okay, so actually, evidence based medicine led to the realization you've got to have clinical trials for the proof of the drugs. In the absence of that, you get Phalydamite. - Mm-hmm. - So that's a good idea. The second one that is we move forward to the 80s and 90s, the cardiac arrhythmia suppression trials. They're more Americans than the whole of Vietnam war. And because people said, this makes sense pathophysiologically. You have an arrhythmia post-MI. We can give you a drug that starts here. - Well, suppress that. Yeah, and it makes sense. Shouldn't that be a benefit? This is the pathophysiology explanation. - And the ECG returns to normal. Superb. However, when you trial it in a randomized trial, you realize you kill excess number of people. - Yeah, the number of people at the end of the trial that are in the act of treatment weren't around. Not the goal. - And then you've got the sorts of call coronavirus, which is bring the systematic reviews to the fourth or you don't cherry pick evidence. So within the evidence there are lots of problems within how evidence is produced, how it's disseminated, how it's reported, totally you get that. And it's almost like because the reason is there's so much money to be made in healthcare. I mean I went to a talk which was an American here in Oxford and he said look in the US it's 20% GDP is healthcare. The good news is there's another 80% to go after. I never heard that. So you think about it. It makes you spend all your money. You've got to produce all sorts of treatments and interventions. And I actually do think if I sit here now the production of evidence, what's published, what's reported is worth now than it's ever been. So that means see that again. It's worth now that. Yeah. Now than it's ever been. Yeah. Well I've spent with the medical students and I talked to them about I said a lot there's about 1.8 million articles indexed on PubMed a year. So in four years a clinical medicine you've got 5.4 million you come in before to be sat in this lecture what you do and you need to go and read all the 4,000 articles a day. Yeah. I think so. And the problem is a lot of them now you see in the big day to the sort of cohort of the vaginal study real world data. So we're trying to use it around the mask control trial. So you have to have a nose now to be able to detect bias. That is something else in terms of your skill base because just around the corner is always a new treatment, new tests, new this. I think this is really important. So there are legitimate concerns about the evidence we use to inform practice. That doesn't mean we shouldn't be using an evidence based approach and those that are critics always want to do things that say well look randomised control trials have all of these problems. Why can't we use a real world data to inform practice and you're just going to let all of these biases and morphs look back in. So the point is if you're not going to have an ebium what are you going to do and that I've never had a reasonable answer to and there are times when you remember it's not it's not those that are high skilled in evidence based world do not come along and say all of practice has to be informed by randomised control trial. Because number one it doesn't help you with diagnosis and prognosis. There are many areas like rare adverse events or often diseases where you may use lower quality evidence. I did a recent piece of work on Saudi involvement in pregnancy and its impact on congenital malformations and that's a classic example of our failure to take approach of the evidence. 1982 was when it first emerged as a real problem in observational cohort. By about 1992 the signal was clear doubling of congenital malformations statistically significant. It took till 2014 in Europe for people to have an action at the regulatory level and that didn't work so it was 2018 before we got to a black box you can't prescribe this unless you're in a specialist neuro to tend to. This is a drug that dramatically increases your risk of autism and ADHD and so there are these exposures which we've been using for 24 years where we shouldn't have been because people fail to adhere to the evidence. With a non-evidence based approach pregnant we would still be getting that drug today and we'd be asking why those huge numbers of kids here with autism and ADHD and congenital malformations being women with epilepsy. Now anybody giving me a rational approach to how you answer that without evidence. I'm quite happy to listen to. What you find is the difficult thing about evidence is it's not easy. It's not simple. You don't can't read a headline and have an opinion. You've got to go and look at the study. You can't just read the abstract. That's the movie trailer and it could ruin the movie for you. You actually have to go to the method section which is my favorite section to say have they even designed this to answer the question they're asking. The thing that I wanted to bring up there is my mentor and legend of emergency medicine Dr. Jerome Oppman talked about the limitations of the EBM and like rare, rare outcomes. You need observational data to capture that. You don't need to randomize control trial to say should I look both ways before I cross the street. The parachute issue, all sorts of things have been brought up. When I agree with him but there's a guy that grew up at a castle down the road here. What's the name of the castle? The big castle here that Winston Churchill came from? Oh, Blanem Palace. Blanem Palace. He famously said about democracy that it was the worst form except all the others that had been tried. What I'm hearing from you is sure evidence based medicine is and as it's flaws it's had its limitations and things like that but it's the best system we've found so far. What do you suggest to replace it? Yeah, so I think the the number one thing that I think is that we do and I talk a lot about is that we're about to have another meeting to revise it. One of the things we did early on with the Oxford Centre for evidence based medicine levels of evidence. You've been cited huge. Cross the different questions whether it's diagnosis, prognosis, screening or treatment, there are different evidence that you would use as a heuristic. To answer those questions. Yeah. Yeah. So is he fine to be looking at a cohort study? Yes, he chits. That's evident. What it's not fine to be doing is making a decision if the systematic review of randomized controlled trials exist on the same question and you're looking at lower quality. Well, yeah. Now one of the people I work with in here in the centre is Jeff Anderson who's a clinical pharmacologist and we have these discussions all the time. So for instance if you have a drug and you have Stephen Johnson syndrome a single case report is enough to tell you that that drug can give you Stephen Johnson's. You don't need to run randomized controlled trial. But the interesting issue is then you get into all these things of the effects is independent of prognosis and the reason we use a randomized controlled trial is because we think people have different prognoses and so. And that's the way we can identify which ones will and which ones most like. Yeah. And what we're trying to do is say the effect is free of these confounders. Now often people say randomized trials are causative and I go no no no it just means the effect you have observed is free of confounding. It's not necessarily causative. So if you because if you go into any trial you go well everybody in the placebo does better and some people are always harmed. Now this is a very difficult thing to understand. The major principle that we're all interested in is bias. Yes. Minimizing it. Everybody thinks that statistics is the hard bit. That's not the issue. The real issue is trying to understand whether this the result is true or not. Trying to get to the quote unquote truth. Yeah. And that's where one of the things we did when Dave's acut died just not long ago but about seven or eight years ago. He did this paper back in the seventies which I've always been fascinated and your supervisor Dave Nune has fascinated it's called analytical biasing research and he listed about fifty biases and at the end of it he said anybody interested in the cataloging these bias are be interested to hear from them and we should start a catalog of bias and then it went to sleep and then we decided we've got this online now catalog of bias on the website. On the website. Yes. Millions of hits. I use it all the time and we go away went away in December for a day and half and we sit there and people just write about bias. Imagine going to meet for a day and half and what you talked about bias and if you know just bias and so we're meeting again next week and we just keep it updated. Not about two hundred and sixty but the real interesting academic issue is bias but there are there's no speciality of bias is a biasologist or whatever. Biodedemiology there are that you know medical statisticians are all these areas but nobody's really interested in understanding when faced with this bits of evidence and an effect size how do I understand if it's true or not. Yeah and that really is an incredibly interesting journey but a bit nerdy. Yeah I like being nerdy. One of the things that you know the criticism about evidence based medicine that I find is that it's how the tool is used because sometimes the tool is misused and so evidence based medicine has been misused by pharma by other individuals and so the one of the not hacks and I just come in there. Sure. It depends on the outcome. Oh of how the tool is used. No no if you're in district and your outcome is profit. Oh yeah and somebody says you have to adhere to these standards what they do is go will adhere to them standards and I think you have to and be mindful they go our responsibilities to our shareholders. Oh that's their responsibility yes. The problem is I actually don't have a problem with the industry and how they operate. I think the problem is is in the middle ground of all those people who become key opinion leaders and conflicted and our regulatory processes should be fit for purpose and then not. - Well, my beef is when guidelines are interpreted as guidelines. The implementation of these things are thou shalt do this when I think they miss the whole idea of this is the best evidence we have. We put it together. Here is some kind of grade of recommendation that we have, but most of the recommendations aren't thou shalt. They are. - So I think the problem is that sort of simplistic approach like grade has become reductionist. Like, I have a very simple way of having where we fixed guidelines. How's that? Well, you have recommendations of the green light. These are the ones, the aspirin and my high quality evidence. Everybody can see it. Everybody can agree. Then there are the red lights. This is harmful. Don't do it. The evidence is quite true. And then everything in the middle is amber. And it's uncertain. And we need you to be involved in developing better research to bring it out of the green or red light. So we're not going to give you a recommendation apart from what you should be doing in the context of research. And it gets rid of all that opinion, lower ed. - It's nice to say we don't know. - We don't know enough to make a recommendation one way or the other way. - Well, then also the guidelines and clinicians will be setting the agenda for the research field for which there are huge numbers of areas where there just nothing has been addressed. And I'll give Tom and I a right and series at the moment. We've just had a pandemic, dominated by viruses, respiratory virus, acute respiratory infections. There are two areas where there are huge, had a huge impact of respiratory viruses. One is the hospital-acquired infections and then it goes, there is nursing homes. And you go there and you go, there's no research agenda. We've asked the UKHSA. We've sent our FIs. We're trying to find out who's funding anything. There is nothing. Despite the fact, it accounted for about 80% of the mortality in the pandemic. You go in, yeah, we're not doing anything about it. And each year we have a winter crisis. You have a man in Canada. Nobody's doing anything about it. We fixed the MRSA. It's almost like we said, oh, MRSA is quite easy to fix. But then they come every winter and go into this panic mode. Oh, he's hugely complex. It needs people who understand epidemiology, clinical epidemiology and evidence-based approach to say, we are going to investigate this and try and work out what's going on, what works, what doesn't. And if we do that, we may be able to say it to the public, hey, you know each winter, we're not going to cry to it. We've got some way of managing this. And you think, well, that surely is a really important agenda for us, but you go, there's no business there. Every winter it comes back again. Oh, my goodness, we're shocked. Yeah, yeah, they're shocked. We have a influenza circulating. We called it super flu this year. And about three weeks into it, everybody sort of had to disappear down a big hole because it wasn't the super flu. It was just a normal influenza that was circulating along with you of the pathogen. Well, we need to get to the fourth question. And we've covered your superhero origin story in EBM. What you feel you've contributed to EBM. We've talked about critics. Now I'd like to go to the future. And this question is about looking forward 30 years, 'cause you have 30 years of experience here. Let's look forward to 2056. So in 2056, what do you think evidence-based medicine looks like? Yeah, I think this is, I mean, one of the, before I look at evidence-based medicine, I think about what will healthcare look like. And when I do a lot of talks for bigger organizations, the health systems, there's a lining for his company running. And the guy says to him, "Is there something like?" How will you know when you get there, if you don't know where you go in? And so I use that with organizations to say, "Where are you going? What's the outcomes of interest? What do we want to achieve in healthcare?" And I think, I wrote a recent piece that we've gone very much bureaucratic and technocratic around metrics. So it might be four hour wait times or X. So we're very much about that, as opposed to going things like, well, what's happening to the population health, healthy life expectancy? So I'm not as flatlined here and you go to all the works like in Canada, but it's not. We have lots of metrics, specifically in emergency medicine, looking at left without being seen, timed first position contact, length of stay, all of these kind of metrics and scorecards. Well, so the issue here is that, if you look at here, a life expectancy if a woman here is about 8 to 1, 82 years, men is about 79, 80, slightly different. But if you look at healthy life expectancy and so, it's just, it's about 61, but men and women. So women have 20 years of unhealthy life expectancy in men about 90. - I don't think that's the goal. - Yeah, that isn't. And so we're running into this huge problem of multi-morbideter with chronic diseases in an aging population and there isn't enough money. So when the money runs out, at some point, and this is starting to happen a little bit in the US, if you look at, you know, you might have a lot of problems at the US and X, but they have appointed some smart people like J. Butterchari, Vinnie Prasad, who are evidence based in their approach. Who are starting to say, "Hmm, there's lots of things we're doing here that are making people a lot of money, but not improving the healthy life expectancy of the population." Once we start thinking about that, we will switch all of our research agenda and start focusing on how do we improve that healthy life expectancy component. And that is to most people. It's not about quantity, it's a quality. - Quality, yeah. You want both? - You want both. - You want both. - You don't like to live forever, but you've gone. But you also don't want to live forever in firm, you know. - I was a member of Rod Jackson, one of his questions, "What's a death rate?" It's 100% that's one of his Judith questions. - Yeah. - Great, you go, "Whoa, what is that?" We all come up with the majority. - The majority of the mortality rate is 100%. - Yeah, as we all go. - But this, so once that happens, there's gonna have to be a shift of focus into trying to understand particularly a value based approach. With the results, you've got available. How are you best, and are important, and to deliver more healthy life expectancy gained? That's really interesting. And we haven't even got there, but we have to stop doing a lot of things. But this doesn't come until the money runs out. When there's lots of money sloshing about, you can carry on with a low value, low quality. - It incentivizes, those are the controls systems that incentivizes certain research as opposed to, well, there's no money to do this. So that's not incentivizing good questions about what happens every winter, respiratory system. - And most of what I thought, when I got involved in an evidence-based world, it would be about understanding, interpreting interventions that would deliver benefits. Actually, the reality is, I spend most of my time trying to stop harm that interventions that are delivering harm. And one of the biggest ones was the metal hits I got involved in that very early on. It wasn't difficult statistic where is the failure rate was about 3% at 10 years, and I looked at the data and said the failure rate's 10% at three years. You don't need a rocket science at work now. Now, the problem is that had been sold on a short-term outcome. You can get back to work, you could cycle the hell quicker, some it's more durable, stronger, but actually about for a year that you start to have lots of problems. And this is a problem of the failure of the evidence-based devices. So no medium to long-term evidence in full-mail use, until it was too late. And now you've got people with programming and co-vert leaving and leaking into the air to disaster. So with the technological advances, that everybody says around the corner we'll be doing this. There'll be a lot of work for people like me going to here's another harm emerging. And it's because we are intolerant to waiting for the evidence to be available. People want to get on with it now. And you've got the Elon Musk saying, "Yeah, I will be doing all this tomorrow." Oh, that's my personal question in this whole episode. Because I'm here in Oxford doing a D-Fill in how AI, so artificial intelligence can be used ethically and responsibly to improve evidence-based medicine. So I'm wondering, what are your thoughts on AI and will it strengthen evidence-based medicine or is it going to be undermined? Yeah, no. The university is adopted, chat GPT version, latest version. 5.2. 5.2. We've got a university license that processing power of it is amazing. So for someone like me and yourself, and it's fantastic, even if you want to do statistical analyses or apps, you can put in some data, it'll do the analysis, it can do forest plots. I did a system of reviewing their test in it out in a day, which had took me weeks. Yeah, I was wondering if systematic reviews will become obsolete or will it just become real time that you can just check it every day? Yeah, the thing is, when you do use it a lot, it is mindful is, it is, by is it wrong or what? Yes. And it just goes, it's just going into the world and blocking out what it thinks is the most prominent or important messaging and pulling it back into your interface. So as a tool to interact with is phenomenally interesting, you have to be mindful it can be incorrect. But what I find is when I'm developing ideas, I just go back and forward asking further questions, back and forward, testing it out saying, "Well, you know you said this, but what about and they all go, "Oh, that's a good question." We'll go over here. So it isn't thinking, it is just pulling information in relation to your interactions. People have tried to create diagnostic algorithms and computers for 40, 50 years, something, it's not new. What the problem is, is the assumption that diagnostics is a simple linear process where you're either unwell or not well. And a classic example, most emergency department, is the unwell child turning up. It's not about the diagnosis, it's about the prognosis, isn't it? - Yeah, you can tell, it's a good question. - Yeah, yeah, so the interaction is, the secondary question is, "Well, what might be causing the sickness?" Because you're like, you know, open it, - And did we think to change the prognosis? - This child's gone on par with literature, checked in, in fact, in '98, I was 100 descending home with good information and how to come back. There's two kids there, are you going, "Hmm, there's someone not right here." - Yeah, yeah, and in doing so, you're this evil, "Oh, let's just leave him in the corner for four hours and monitor them, I'll be back in four hours." And I'm just a bit worried about them. - Isn't time a great day, again, yeah? - Yeah, in a tour. - Well, that comes back to actually one of the most interesting pieces of work I did, was when I was first started academic journey, was on diagnostic reasoning. And it's in the BMJ. And I did this process where I used to go to check classes in the BM about how to teach, and used to do, know the grounds, and two about two tables, and I'm like, "Gee, that's amazing." - That's a diversity, likely, and I was, and I went away and said, "Well, I'm going to start experimenting on myself, and I did this process where I worked out what was happening, a reasoning book in practice, in urgent care and GP, and then I got five or six GP's to try it out as well, and they all confirmed it. And this was a whole smog as bored of, it's a really interesting paper, but it really can help you think about. So, at the initiation, you will go on single piece of the word like fever and a child. That's enough to set off. You add in another piece of information like rash, you get a pattern recognition, don't you? So there are certain things, and it's only once you get beyond that initiation, do you get into what I call the revignment, and you, on occasion, might be use some probability, but not all the time. Most of what we do in a pattern recognition. That gets into the heuristics of thinking fast and slow. Yeah, and there was a chap here, Kim John Balla, who was from Australia, who was a really interested in neurologist, spent years with us, and we did the system one system to reasoning wrote papers about that. What we could never work out, so, in that reason, in fast and slow thinking is you've got this, you've thought, got this intuitive reasoning. Somebody, oh, that's what allows us, I can recognize you when I walk in the room, not seeing you before. So I might show pictures of Oxford, and if you've been here, you go, oh, that's a record camera, that's a king's number. You've never been here, you can't recognize it. And then you've got your analytical reasoning. Well, that's where your evidence comes in. So your experience is in the intuitive, and your analytical reasoning, your slower reasoning, it's going, oh, no, no, no, no, no, no, I need to test for it. What you're to check for? And in effect, what you do is, you go round a loop where you go, that analytical reasoning will either lead you to some action, where you go, oh, I think this person's got a respiratory tract infection as well, and then give them some of my biostatum home end of the loop. Or sometimes you go back round the loop because you don't have no idea what's going on. Let's just revisit the history. Tell me again, haas, and that's why people why is the doctor asking me again? Well, this is, what, does he not know what is doing? What we could never work out in all that is the decisions for adults for action. That is a really interesting area, which AI could thought people who really smart trying to look up wonder and the speed at which people do it, whether experience and how they bring it, but you, the real experience ones, you see them when you go, oh, it's not right, they go much more analytical and slow down. So they go, and then suddenly they're like, oh, that's going to a lot more questions there. Well, you don't understand that when you're in experience and you're a student. But actually, that's the sort of thing we should be teaching much earlier on. And I think if we could understand how to do that better, we'd end up better clinicians. Much more efficient, but also much better able to navigate what I call the fog on certain day in emergency care. Well, we've covered the future of evidence-based medicine now. My last question, my fifth and final question is about future EBM leaders. You and I are getting a little long in the tooth. As they say, the no hairs and gray hairs. So who do you think are the future leaders of evidence-based medicine? Can you give a shout out to one or two that you really are thinking, wow, these people are going somewhere? I'm going to give a sort of much bigger-- I'm going to say the public. OK. Because I think the pandemic gave the public a huge appetite for an evidence-based approach. They were fed political messages and people started to question what's going on on the issue that-- and I think the number one, the public, are going to start mobilizing. I see that already. They're much more proactive and active in terms of an evidence-based approach. So I think that's going to be huge. I don't. I think the next wave is going to emerge because I think not to be downhearted or correct. I think the last 15 years or so has created a wave of academics and clinicians who've been more interested in towing the path to life. And sort of being part of the establishment, do this, get trial, do this publication, you'll get your job. And that has been OK for a wave of people. But what we need now is much more maverick so return to the '80s and '90s, where people are prepared to speak out more. But in doing so, you have to learn the craft and skills of communication. I'm with you, Ken. You've been doing it for years. You know, sometimes you've got to temper your reviews. You have them. You've got to know sometimes to hold it back because you might-- my dad used to say, five years to build a good reposition, five minutes to ruin it. And so you've got to craft your ability. But I'm looking for people who can start to mobilize their thoughts and communicate them to a wider audience. And if they do that, they'll be the future leaders. And in doing so, it's a lot of fun. It's a bit of hard work. It's a lot of fun. And the work doesn't seem that hard when you're enjoying it. Yeah, I get up to hours earlier in the day now. And I sit there. I speak to Tom on the phone. Then I start writing. And then I start my day's work. And go for the day's work. And when I get back home, I'll be speaking to him again. So I think, you know, but it's fun. It's interesting. So that's where the future is. And I look forward to reading those people who are mobilized into action. I found that the pandemic was both character revealing because there were physicians that I highly regarded who really did some very strange things in my opinion. And so it was character revealing. But it was also character building. Some people stepped up. And we really got to focus on, what do we count as evidence? What do we consider evidence? And what evidence is informing our public messaging and mandates that are coming out and all around vaccines and masking and all of that side of stuff. It was really character revealing and also character building in my opinion. Yeah, I think you see the thing is, again, the pandemic is very controversial from an evidence-based approach. Things come out like we had rules of six social distancing two meters rule. And you just go, where did that come from? Where's the evidence? Where does-- Now, people will go, oh, you can't have that rhetoric. And they go, well, what if it's incorrect and it's harmful? People have an assumption. And why not just be honest with people and say, we don't know yet? I think one of the biggest things to learn and I talk a lot about is equipoise. That means that principle will be equally harmful as beneficial. And once you understand that, when you go into the world and intervene, if you don't have evidence to lie, you're going to harm some people. And on average, if interventions make no effect, 2.5% of them are going to be harmful, and 2.5% of them will be beneficial even statistically. So you've got to account for that. So we had huge numbers of interventions that in the light of day, people can look back. But what I think happens is people are starting to understand why we need an evidence-based approach. But particularly the public is demanding it. They're demanding it of the politicians and their understanding of going, you just can't tell us what to do anymore. And I think that's where it's unmanageable now because on the social media out in the world, people can write and put out their views and say, well, we don't understand this. Yeah, there's no-- [INAUDIBLE] Keep a filter preventing you from doing it because you can start a podcast, you can start a sub-sac, you can do a blog, you can put out a TikTok video, and stuff like that, and reach millions of people potentially. But one of the things I'd say about practice in EBM, it's not just about the doing, it's not just about using it for decision making. My revised sort of thoughts about it is that you should be involved in developing the evidence. Because We've got too many conditions and too much uncertainty and so more people have been involved in the game of delivering high quality evidence with the skills Means we get nearer to some of the sort of issues and be able to answer them much quicker. I Just love your final answer about you know the future of evidence-based medicine being involving the public and getting more mavericks I clearly picked the right song super trap, you know You know with the lyric what would you think if they were calling you a radical? You're still a radical 32 years later. Yeah, I guess mine still is I'm trying to put another brick in the wall You know in a bit of a crumbling and falling about and I'll just come and feel like the the spade work the hard work That's required but I'd say a lot The two groups of people I I See in clinical practice who you know towards the retirement are still having a lot of fun and passionate. They're either involved in research or teaching The people in research are a bit more lonely Get more rewards the people in teaching are more happier get less rewards But actually have a great time and so one of the things I think which we really should be thinking about in medicine is I Do you think this is that an Oxford has a great tradition the medical school here to amazing because it has this sort of wheelie Mosler in the background He was the archetypal clinician physician teacher Mm-hmm. And so here the people who teach here are really all over it and it's the medical school has had this Philosopher so I do combine teaching and Research in clinical epidemiology that makes it really busy but a lot fun and I just say to people getting Evolved in one of those two aspects and if you're really a bit mad try and do both So Carl thank you very much for being our inaugural Legends of evidence-based medicine. I would like to leave you with an open-ended Comment about anything else you'd like to say about evidence-based medicine before we go Well, I go back to this doesn't it goes back to what for the definition with day growing 95 in the BMJ The integration of the best available research evidence with clinical experience and patient values People often forget that actually the idea of the patient being the focus of what we do in our experiences so usually important in evidence-based approach and It's not the evidence it the best available evidence you're looking for at any point in time And if you remember that you understand then why it helps you when you practice in Of the clinician. I'm so glad we got to record this in Oxford I mean it it's a beautiful sunny day. It is a blue sky out there. You rode your bike in for this interview I just have one final request before you go and that is can you read the SGM tagline? I can try my best Remember to be skeptical of anything you wrote even if you've heard it on the sketchy sky to emergency medicine. Talk to everyone next week You