Dr. Gordon Guyatt
Gordon Henry Guyatt is a physician and professor of clinical epidemiology and biostatistics at McMaster University in Hamilton, Ontario. He is internationally recognized for his work on evidence-based medicine. In addition to his journal articles, Dr. Guyatt has written and been quoted extensively on health care policy in the mainstream press; he also co-founded an organization that supports universal health care in Canada. In 2004 and 2006, Guyatt was a New Democratic Party (NDP) candidate for Canadian parliament and he plans to run again.
It has made life far easier with respect to laboratory reports and X-rays, switching paper and hard copy to electronic images and electronic information. It still, however, is hugely underutilized. It is a terrible shame that we don't have a national electronic system that links patient records collected everywhere. They have done it with Veteran's Administration (V.A.) data in the U.S. Fifteen years ago, the V.A. was seen as the poor antiquated part of American medicine. Now the agency is in a leadership position. If you live in Chicago, you go to Florida for vacation and you get sick and go to the V.A. there, your records are there immediately. It prevents repetition of testing, it eases interpretation and it just makes for better patient care. So, it's great what's been happening up to now, but we have a long way to go.
Evidence-based medicine advocates practice based on the best current research evidence, acknowledging that evidence itself never is sufficient for decision-making: patient values and preferences play a role in all but technical decisions. Optimal practice of evidence-based medicine requires rapid access to the highest quality current evidence. Before the era of electronic access this was extremely challenging. High-quality electronic data sources have made a huge difference, and are continuing to make the practice of evidence-based medicine more and more feasible.
The story of hormone replacement therapy (HRT) provides insight into the role of evidence-based medicine. For a decade, experts recommended HRT for post-menopausal women on the basis of a putative reduction in heart attacks and cardiac death. Eventually, randomized trials demonstrated that HRT does not reduce risks of heart attack, and may even increase the risk. Furthermore, the study found that HRT increases breast cancer risk. If the experts making the recommendations had understood the principles of evidence-based medicine, women would never have been mislead in the way they were. If physicians had been taught how to understand original research articles and if they had better access to them, the story might have been a far happier one.
Again, huge benefit. Now, as I tell people: I'm extremely paper allergic. All the files are electronic. It makes it much easier to access and work. The second thing is huge facilitation of international collaboration. As one colleague put it, we can interact with someone on another continent sometimes more easily than the person in the next room. The huge efficiency and capability of international collaboration has been enormously beneficial.
The problems are how do publishers who are used to making money one way now make money in an electronic world. That is unquestionably an obstacle. I'm not sure I'd describe it as a debate. There is some degree of angst and uncertainty and people still are struggling to find ways of making what used to be easily commercially viable to remain commercially viable and ultimately serve the scientific public. However, overall there are many more online free access journals, which is a positive improvement.
Open access clearly serves the interest of science, which is maximum rapid dissemination of knowledge. From a selfish point of view, publishing in open access journals ensures that readers can access investigators' work without obstacles.
In Canada we have a universal access system for physicians and hospital services, though it is constantly under attack. However, we have generally done quite well in maintaining support for it. Perhaps one aspect that facilitates this is that even if conventional media tend to be conservative and emphasize the limitations of universal health care, people now have access to a potentially more balanced perspective through the increased flow of digital information.
It's a huge benefit now. There are still problems. Many of the resources are still costly, particularly if you want to get full text. Wherever I go, I tell the people: You have to get all universities in the country together and then go to the expensive, really useful resources and say: 'We have a united goal among all universities in Pakistan. Here we are putting up a substantial amount of money. Can you make this available for all of us?' But, so far I don't know if anyone has done that. So, there still remains potential to enhance it. In rich places like Saudi Arabia, they have the best and a lot of them are right up there with the North Americans in terms of electronic resources and it's made a huge difference. You can go to these places and it's not a dream world to talk about really practicing evidence-based medicine because they can access many of the resources to get the best, current data. Whereas without electronic information, you are there telling them to practice according to the best evidence available. They are simply not able to access the complete resources.
Within scholarship, I can see wider dissemination and a shift toward the real establishment of the online journals. I can see them getting more established and perhaps even more will move toward open access. Maybe somebody will suggest a solution to maintain the commercial viability while still taking some advantage of online dissemination.