David Sackett, MD, the reputed father of evidence-based medicine (EBM), died Wednesday, May 13, at age 80, but lived long enough to see physicians using smartphones to look up practice guidelines at a patient's bedside. It was an inevitable outcome of the movement he spawned.
EBM married Dr Sackett's statistic-laden field of epidemiology, normally focused on public health, with clinical practice. In his words, it is "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients." Dr Sackett and others in the EBM movement saw it as a corrective to the all-too-common practice of medicine based on personal experience, anecdote, intuition, and slapdash forays into the medical literature.
"What a giant he was," said Donald Berwick, MD, a former administrator of the Centers for Medicare & Medicaid Services and former head of the Institute for Healthcare Improvement, in an interview with Medscape Medical News. "David Sackett was a key force in taking the concept of basing care on best evidence from theory to practice.
"In that sense, David was one of the creators of the modern movement toward healthcare quality improvement."
Many honorifics accrued to him over the years, but one thing he did not want to be called was an expert. He once famously wrote that experts needed to retire, lest their reputations and biases eclipse new ideas.
"Because I was an expert," he said once about a symposium he attended, "my opinion had an added weight it didn't deserve. And it cut off conversation."
True to his convictions, Dr Sackett announced his retirement as an EBM expert in 2000, giving no more lectures on the subject, just as he had officially retired as an expert on patient adherence to therapeutic regimens almost 20 years earlier. His former colleagues describe him as a man who did not need to be the alpha dog or the center of attention. More than anything, Dr Sackett was more concerned about the next generation of physicians — and his students in particular — making a future for themselves.
"He felt that experts should get out of the way so the people they were mentoring could carry on and take over," said former student R. Brian Haynes, MD, PhD, a professor of clinical epidemiology and biostatistics at McMaster University in Hamilton, Ontario, Canada, where Dr Sackett taught for many years.
In addition to the role he played in the EBM movement, Dr Sackett helped shape the daily medication regimen of millions of people around the world, extending their lives in the process. He was one of 13 authors of a paper published in the New England Journal of Medicine in 1985 that demonstrated that patients with unstable angina who take aspirin subsequently have lower rates of cardiac death and nonfatal heart attacks. This and other studies established low-dose aspirin as a routine prescription to prevent heart attacks and strokes.
Publication of that article came at the same time Dr Sackett voluntarily was repeating his internal medicine residency 2 decades after his first round of training. Long before the current-day furor over maintenance of board certification, he was pushing himself to remain clinically up to date.
Dr Sackett also was one of the original members of Medscape's editorial board.
Rounding With the Evidence Cart
Born in Chicago, Illinois, Dr Sackett earned his medical degree at the University of Illinois, trained as an internist and nephrologist, and then received a master's degree in epidemiology from Harvard University in Boston, Massachusetts. He joined the faculty of McMaster University's brand new medical school in Hamilton, Ontario, Canada, in 1967, where he established the world's first department of clinical epidemiology. There, he created a training program in health research methods to teach clinicians and anyone else who was interested how to do studies to generate sound, unbiased evidence about the cause, diagnosis, course, prevention, and management of health problems, said Dr Haynes. Together with Dr Haynes and others, Dr Sackett wrote a now-standard textbook on clinical epidemiology.
Dr Sackett and colleagues then set out to help clinicians apply the evidence from research. They wrote articles and developed courses on "critical appraisal" for systematically evaluating a given research article. These articles and courses taught users of evidence to ask whether the study addresses a clearly focused question, uses valid methods to address the question, and reports results that are important as well as valid, and whether those results apply to the patient at hand. Part and parcel of this analysis is locating a study on the hierarchy of evidence, starting at the bottom with case reports and series and eventually topping out with individual randomized clinical trials, and then meta-analysis and systematic reviews, ideally of randomized clinical trials.
EBM took critical appraisal one step further by combining it with a physician's clinical skills and an individual patient's needs and preferences. This approach came into full flower in the 1990s, when Dr Sacket accepted an invitation to launch and direct the Centre for Evidence-Based Medicine at the University of Oxford in the United Kingdom. During this time, he also was instrumental in creating the Cochrane Collaboration, an international enterprise that gathers and summarizes the best research to help physicians treat their patients.
The EBM movement initially encountered stiff criticism. Some physicians "feared cookbook medicine and guarded their prerogatives to rely on their individual impressions and judgement, even when the scientific evidence was firm and consistent," said Dr Berwick. "I do not believe Dave ever meant to remove judgement from the equation, but he was also aware of the enormous variability in practice patterns — variation that defied common sense.
"It took courage — and he had plenty — to step out and declare the importance of evidence in practice."
Some of the strongest opponents of EBM tended to be midcareer clinicians "who were used to making pronouncements at the bedside," Dr Sackett said in an oral history of EBM published by JAMA in 2014. Elder clinicians secure about their status tended to be more supportive. The most enthusiastic adherents of EBM, Dr Sackett said, were young physicians who felt empowered to ask their elders why they were doing such and such in light of a new journal article that "showed that the old guy was dead wrong."
Instead of merely arguing his case, Dr Sackett won over physicians one by one as he showed them EBM in action on rounds at John Radcliffe Hospital in Oxford. It helped that he was a gifted teacher.
"He was a very charming and persuasive and enthusiastic person, who could explain things very well," Dr Haynes told Medscape Medical News.
Dr Sackett created a rolling "evidence cart" to help physicians in training tap into research at the point of care. The cart featured a computer, compact discs of MEDLINE and the Cochrane Database of Systematic Reviews and meta-analyses, textbooks, an in-house compilation of evidence-based guidelines, and a projector. Today physicians can access such resources on their smartphones without all the pushing.
Dr Sackett eventually returned to Canada and, leaving the EBM field for others, devoted himself to researching and writing about randomized clinical trials in a wooden cabin on Irish Lake in Ontario. There he canoed and snowshoed with family and friends.
"What a Gift He Gave Everyone"
Although Dr Sackett is called the father of EBM, "he didn't do it all by himself," said Dr Haynes. Instead, he was academic medicine's version of Tom Sawyer, Mark Twain's fictional character who convinced his friends to take over his job of whitewashing a fence because it was so much fun.
Dr Sackett's fence painters were students such as Dr Haynes, whom he mentored. Bringing along new physicians mattered to Dr Sackett so much that he coauthored a book with Sharon Straus, MD, titled, Mentorship in Academic Medicine. During his later years, he invited fellows at McMaster University to come to his cabin on Irish Lake to study.
Kay Dickersin, PhD, the director of the Center for Clinical Trials at Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland, recalls a scene from Dr Sackett's life as a mentor: Dr Dickersin and members of her research group were attending a meeting of the Society for Clinical Trials in Denver, Colorado, in 2001. Dr Sackett was there as well, and he asked Dr Dickersin if he could join her group for dinner.
"They were bowled over that this luminary would like to go out with them," said Dr Dickersin, a director of the US branch of the Cochrane Collaboration, in an interview with Medscape Medical News.
Dr Sackett sat at the head of the table, but did not hold court. He asked each person there to share their favorite memory from third grade.
"The conversation wasn't about work or fame or the future, but who we were as people and how we got that way," said Dr Dickersin. "Everybody talked. Everybody was important to him.
"I thought, what a gift he gave everyone at the table."
Dr Sackett died of cholangiocarcinoma. He is survived by his wife Barbara and their four sons.
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Cite this: David Sackett, 'Father of Evidence-Based Medicine,' Dies at 80 - Medscape - May 18, 2015.