Dr Amy Price

The Gift of Evidence

The greatest gift Evidence-Based Health Care bestows is the power to critically appraise Health Science. I learned from Oxford that the most powerful teaching is that which we can put into daily practice and help others to do the same.

Sharing evidence requires building relationship and developing trust. We are taking others to a new place. They may be blind to knowledge and a little afraid. When we deliver the branch of knowledge we can share it like a lifeline or use it for a stick. When we beat with the stick of superiority, authority and argument the experience of evidence is avoided. Yet when we share evidence as discovery and answers, people everywhere seek it.

We are fortunate to live in the age where technology, communication and knowledge is accessible.

Evidence lives when it is delivered in bite-sized pieces where we are shown the recipe, the ingredients are made available and the learning we need is targeted and just in time. It helps when we say just enough. A great example is the single statement in the BMJ which asks, “Were patients or the Public involved in this research?” Prospective authors know that this is something they need to consider and it is up to them to find ways to do this. This one statement is more powerful than many warnings. The BMJ has also recently implemented patient reviewers to work side by side with traditional reviewers. You can join here.

The Culture of Health is the task of a lifetime. Evidence learned and applied can heal that which has broken. This is the future we own and shape.

In sharing about research knowledge we can stir the pot just by asking, “What evidence brought your thinking to this place? If it is good, we can encourage and multiply what is found and if it is faulty we can suggest alternatives and be ready to answer the whys.

For Life or Disaster: Two Evidence Communicators

The National Elf Service

It is evidently impossible for health and social care professionals in most fields to keep up to date with the torrent of high quality evidence now being published. The sheer volume of quality research is, of course, something very much to be celebrated, but if practitioners cannot absorb all of the important new knowledge, then patients do not benefit. Nor is it reasonable to demand that practitioners demonstrate continuous professional development without some way of navigating this sheer volume of research. [André Tomlin 2015]

The National Elf Service article, Mental health research: let us reason together #RCTdebate The elves and I co-authored acted as a vehicle to open doors of opportunity and understanding between academic researchers, clinical trial advocates. mental health service users and the public. There is still ongoing discussion and collaboration even five months later. The Elves were recently recognized by The Lancet for their work in the mental health community. You can attend the National Elf Service and BMJ pre-workshop to learn the best ways to communicate science and critically appraise a research paper.

Making Evidence Live: Introduction to Social Media and Blogging

0900-1700 Tuesday 21^st June, Oxford

This fun hands-on workshop will equip you with the skills you need to:

1. Critically appraise an important piece of new research
2. Blog about the evidence in an accessible way
3. Discuss the evidence on Twitter and other social media

Blogs and social media are an essential part of science communication and evidence-based practice in the 21^st century. Find the best ways to use these tools to keep up to date with the latest reliable research and how to maximize your online impact.

Evidence Aid

Evidence Aid is at Evidence Live 2016 and was formed in 2004 to enable the reception of humanitarian aid in the most timely, effective and appropriate fashion and to inspire and enable those guiding the humanitarian sector to apply an evidence-based approach in their activities and decisions.

You can’t know when you will be faced with a disaster but now you know where to find practical [p]help.  Evidence Aid offers lay friendly and professional level evidence for humanitarian disasters. During Hurricane Andrew, I worked with the Red Cross to bring relief. This was the most destructive hurricane to hit in the history of the USA. We were ill equipped. Untrained volunteers were left to improvise about what to do with armed gang members in shelters, domestic violence, supply shortages, and emergency medical care.

With an increasing demand for ‘value for money’, proof of impact, and effectiveness in the provision of humanitarian aid, it is essential to ensure that decisions and activities are evidence-based. This requires an agile organisation with a scientific approach to operate from a robust and responsive network.  Evidence Aid  collaborates to ensure an evidence centered application and they welcome volunteers, collaborators and end users.

“The job of the human being [in the digital age] is to become skilled at locating relevant valid data for their needs. In the sphere of medicine, the required skill is to be able to relate the knowledge generated by the study of groups of patients or populations to that lonely and anxious individual who has come to seek help” (Sir Muir Gray, 2001)

These organizations have bridged gaps to meet evidence needs for populations and individuals. They build the digital bridge while others still speak of the digital divide.

Cite as Price A (2016): Tools to Communicate Evidence so Others Can Own It CEBMJ /tools-to-communicate-evidence-so-others-can-own-it/ DOI: 10.13140/RG.2.1.4796.9688

When I tell people about my research group’s systematic review of systematic reviews, also known as an ‘overview’, my colleagues often reply “why not do a ‘regular’ review‘?”

In 1979 Archie Cochrane gives us the answer when he scolded the medical community for not having a system in place to produce a ‘critical summary, by speciality or subspeciality, adapted periodically, of all relevant randomised controlled trials’.¹ At that time, the rate of trial publication was increasing nearly exponentially. The same pattern has emerged for published systematic reviews² and it is a problem. For researchers trying to understand the state of the literature in an area, the volume of published reviews can be difficult to manage. For clinicians and policy-makers trying to use reviews to inform their decisions, it is impossible.

Overviews can be used to manage the multitude of reviews. Broadly speaking, they serve the same purpose as ‘traditional’ reviews: to map the evidence base and to compare, contrast, and synthesise findings from multiple studies. The only difference is that the included articles are systematic reviews instead of primary studies. However, overviews can also be used to answer novel questions that can’t feasibly be answered using traditional reviews.

The Cochrane Collaboration has identified five types of overviews, classified based on their objective.³ One type in particular holds huge potential to support the success of health systems: outcomes-based overviews.

An outcomes-based overview compares the effectiveness of different interventions to achieve a single outcome, and is well-suited to answer questions of relevance to health systems. For example, what are the most effective, evidence-based interventions to reduce unscheduled hospital admissions? Decision-makers want to know the answer to this broad and ambitious question.  It usually wouldn’t be feasible to conduct a traditional review as the number of randomized trials may run into the thousands. Furthermore, if we were to conduct a review of RCTs , meta-analysing ‘like with like’ would result in hundreds of sub-groups and ultimately mirror the results of the individual systematic reviews anyway.

By comparing and contrasting existing reviews we can utilize the meta-analysed results of thousands of trials to prioritize interventions that may be targets for implementation in-practice.

“Our overview⁴”, I tell my colleagues, “has utilised thousands of trials via hundreds of systematic reviews to find evidence-based approaches to reduce hospital admissions. In the end, we will have a list of interventions ranked by absolute reduction in admissions and the quality of evidence that researchers, clinicians, and decision-makers can use to guide pilot projects and resource allocation.”

“So what’s at the top of the list?” they ask.

“It’ll have to wait until Evidence Live where I am presenting the results.”

Niklas Bobrovitz

Niklas Bobrovitz is a PhD candidate in the Nuffield Department of Primary Health Care Sciences at Oxford University, a Clarendon Scholar, a member of the Centre for Evidence-Based Medicine, and a member of the Evidence Live 2016 steering committee which this year includes a theme on translating Evidence into Better-Quality Health Services.

You can follow him on twitter at @nikbobrovitz

Evidence Live June 22 – 24, 2016, University of Oxford

Competing interests: I have read and understood BMJ policy on competing interests. I have no other competing interests to declare.

Disclaimer: The views expressed are those of the author and not necessarily of any of the institutions or organisations mentioned in the article.

References

1. Cochrane AL (1979) 1931–1971: a critical review, with particular reference to the medical profession. In: Medicines for the Year 2000. London: Office of Health Economics. pp 1–11
2. Bastian H, Glasziou P, Chalmers I.PLoS Med. Seventy-five trials and eleven systematic reviews a day: how will we ever keep up?2010 Sep 21;7(9):e1000326. doi: 10.1371/journal.pmed.1000326.
3. Becker LA, Oxman AD. Chapter 22: Overviews of reviews. In: Higgins JPT, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0. The Cochrane Collaboration; 2011. http://handbook.cochrane.org/chapter_22/22_overviews_of_reviews.htm.
4. Bobrovitz N, Onakpoya I, Roberts N, Heneghan C, Mahtani KR. Protocol for an overview of systematic reviews of interventions to reduce unscheduled hospital admissions among adults. BMJ Open. 2015 Aug 21;5(8):e008269. doi: 10.1136/bmjopen-2015-008269.

Cite as Bobrovtiz N (2016): Are Outcomes-Based Overviews the Best Kept Secret in Health Research? CEBMJ /are-outcomes-based-overviews-the-best-kept-secret-in-health-research/ DOI: 10.13140/RG.2.1.3027.4966

Dr Amy Price

Medicine needs to fit and not just multiply

We face the challenge of the century, knowledge about medicine and healthcare is growing faster than the systems that support it. Clinicians and academics struggle to keep

up. The argument that too much medicine provides too little care and at great cost is significant. The counter argument is that a person has value as an individual and if a few persons in a thousand are spared we need to save them. This quote by Margaret McCartney sums things up:

“Too much testing of well people and not enough care for the sick worsens health inequalities and drains professionalism, harming both those who need treatment and those who don’t.”

McCartney eloquently states the broad problem. Health care money is limited and when it is spent on a focus that is not sustainable, patients will suffer and die.

Mapping the route to a solution requires more. Sir Muir Gray proposes we attend to allocative, technical and individual values during structural change to preserve engagement. Decision-making is not only about patients or doctors; it is integrated throughout our society and we need to consider how these values will surface and influence the process.

Abraham Verghese reminds us that in medicine, “We are all fixing what is broken and it is the task of a lifetime”.

Information is not enough when it lives alone

Health researchers might look to solutions like data mining and new systems to manage literature and yet neglect the greatest resource we have in health science which is the public we serve. Nurturing these relationships will propel last century tradition beyond useless debate into evidence based practice. As E-Patient Dave says, “Let Patients Help.”

In 2010, it was estimated that 75 RCTs and 11 systematic reviews are produced daily.

Donald Lindberg at the National Library of Medicine reports “If I read and memorized two medical journal articles every night, by the end of a year I’d be 400 years behind. The challenge is that medicine changes rapidly and the rules that fit yesterday may be out of context today.

Getting to grips with growing pains

The sheer volume and complexity of possibilities makes taking a road that is new and untested both exciting and overwhelming. Proactive change in the health sciences is inevitable. From passengers to Co-pilots, patients’ roles expand according to Anderson et al.  Encouragement to proceed can be gleaned from the history of Mother Teresa who changed the future for lepers in Calcutta by starting out to help just one. Google became the largest search engine in the world with the simple concept of having the public type in questions to a blank page and through this they used public interest and priorities by adding search terms to a database to build powerful algorithms.

Thinking through solutions

Don Berwick in this JAMA article challenges us all with nine points to consider to usher in the next era in medicine. They are listed verbatim. To find out why read the paper, it is free:

1. Reduce Mandatory Measurement
2. Stop Complex Individual Incentives
3. Shift the Business Strategy from Revenue to Quality
4. Give Up Professional Prerogative When It Hurts the Whole
5. Use Improvement Science
6. Ensure Complete Transparency
7. Protect Civility
8. Hear the Voices of the People Served
9. Reject Greed

The other points become viable with this quote shared by Berwick:

“Everything possible begins in civility” (Robert Waller, MD, former president and CEO of Mayo Clinic, written communication, January 31, 2016)

At Evidence Live you can learn to build a protocol, teach about evidence, engage patient reviewers like they do at BMJ,launch rapid reviews, master the nuts and bolts of how guidelines work and get your academic papers accepted. You might attend and be an answer others have waited for.

Information alone is worthless until it is shared. Conversational insight and powerful research about research quality, communication, informed shared decision making and ways to practice patient and public participation are in the works at Evidence Live 2016, June 22-24. Come and get involved through workshops, discussions, and conversations. Health care is changing, you can build it, we can help.

References

1       Glasziou P, Moynihan R, Richards T. Too much medicine ; too little care. Br Med J 2013;347:1–2. doi:10.1136/bmj.f4247

2       Gigerenzer G, Muir Gray JA. Better doctors, better patients, better decisions; Envisioning health care 2020. The Ernst Strüngmann Forum 2009. MIT Press 2011.

3       Purkayastha S, Price A, Biswas R, et al. From Dyadic Ties to Information Infrastructures: Care-Coordination between Patients, Providers, Students and Researchers. Contribution of the     Health Informatics Education Working Group.Yearb Med Inform 2015;10:68–74. doi:10.15265/iy-2015-008

4       Verghese A. Cutting for stone : a novel. New York: : Alfred A. Knopf 2009.

5       DeBronkart D. Let Patients Help ! 2013.

6       Bastian H, Glasziou P, Chalmers I. Seventy-five trials and eleven systematic reviews a day: how will we ever keep up? PLoS Med 2010;7:e1000326. doi:10.1371/journal.pmed.1000326

7       Anderson M, Mccleary KK. From passengers to co-pilots : Patient roles expand. Sci Transl Med 2015;7:1–3.

8       Berwick DM. Era 3 for Medicine and Health Care. JAMA 2016;315:1329–30. doi:10.1001/jama.2016.1509

This blog was originally posted on http://www.cebm.net/much-much-medicine-matter/.

Cite as Price A (2016): How Much Does Too Much Medicine Matter? CEBMJ http://www.cebm.net/much-much-medicine-matter/ DOI: 10.13140/RG.2.1.3562.5367

Leading up to Evidence Live 2016, we will be publishing a series of blog posts highlighting projects, initiatives and innovative ideas from future leaders in evidence based medicine.
Please read on for the second in the series from Sophie Roberts of Oxford AHSN.
If you are interested in submitting a blog post, please contact alice.rollinson@phc.ox.ac.uk. Stay tuned! 

The world loves a nutrition news story but there is a danger to this unrelenting flow of contradictory stories.  This week’s superfood is black pudding, hot on the heels of chia seeds and kale.  People reading contradictory media stories report being the most confused about what to eat and understandably believe that “scientists keep changing their minds” [1].  Journalistic quality is a contributing factor, with only 6% of a sample of newspaper health stories being based on high quality, authoritative research evidence such as randomized controlled trials or systematic reviews [2].  The academic community also plays a part in this with institutions often overhyping the impact of individual studies to increase press coverage and journal editors and funders doing little to raise the quality of nutrition research [3].

As a profession dietitians are trained and regulated to ‘engage in evidence-based practice’ [4], but with fewer than 7000 of us in the UK the real challenge is to find a way to communicate the big picture behind these stories to the entire country.  To answer this we created the BDA Media Centre [5]. After only six years we are now in a position where our team of media spokespeople is a trusted resource for journalists across the major TV, radio and paper news outlets and many magazines and high profile websites. We’re invited to comment on stories from celebrity diets and health scares to public health policy.

Everyone on the team has training in interpreting research evidence and communication skills and many spokespeople are leaders in their subject areas or experienced researchers. We are known for regularly meet hectic journalistic schedules and typically match requests with a willing spokesperson within the hour.  Our success is down to strength in numbers with over 90 volunteer dietitians on the team.  For speedy turnaround the team also has an online secret weapon called the Practice-based Evidence in Nutrition Database [6].

Look out for us when there is nutrition in the news and I bet you’ll be surprised how often we are there.

References

1. Nagler, Rebekah H. “Adverse Outcomes Associated with Media Exposure to Contradictory Nutrition Messages.” Journal of health communication1 (2014): 24–40. PMC. Web. 26 Feb. 2016.
2. Robinson, A., et al. “Analysis of health stories in daily newspapers in the UK.” Public Health1 (2013): 39-45.
3. Ladher, Navjoyt. “Nutrition science in the media: you are what you read.” BMJ 353 (2016)
4. Health and Care Professions Council (2016). Standards of conduct, performance and ethics. London, Health and Care Professions Council.
5. British Dietetic Association. (2016) BDA Media Centre. Retrieved 26 February 2016 from https://www.bda.uk.com/media/home
6. Dietitians of Canada. (2016) Practice-based Evidence in Nutrition [PEN]. Retrieved 26 February 2016 from http://www.pennutrition.com.

Leading up to Evidence Live 2016, we will be publishing a series of blog posts highlighting projects, initiatives and innovative ideas from future leaders in evidence based medicine.
Please read on for the second in the series from Charles Badu-Boateng of King’s College London.
If you are interested in submitting a blog post, please contact alice.rollinson@phc.ox.ac.uk. Stay tuned! 

A recent evaluation by the Lambeth Long Term Conditions Delivery Programme in 2012-13 highlighted a number of key barriers to optimising blood pressure control including poor-adherence and untimely titration of medication¹. Evidence from Public Health England suggests that better control of current hypertensive patients can save £120 million of NHS and social care spending over 10 years².

Southwark Clinical Commissioning Group (CCG) Medicines Optimisation Team is currently running a hypertension audit, examining the effectiveness in using virtual clinics to aid primary care clinicians in managing patients with systolic blood pressure over 160 mmHg and/or diastolic blood pressure over 100 mmHg. The Hypertension Virtual Clinic is a clinical session where hypertension specialists and primary care clinicians discuss difficult patient cases. As a final year medical student on my general practice rotation, I had the opportunity to get involved in this scheme. My role involved using a pre-defined search query on the Egton Medical Information System (EMIS) to identify eligible patients registered with our general practice surgery, and present them for discussions at the virtual clinic.

A Pre-clinic individual hypertension action plan was developed for all the identified patients (36 in total), using both local (South East London Area Prescribing Committee) and national (NICE) guidance. This approach allows clinicians to focus on key areas affecting the patient, whilst at the same time ensuring a holistic evidence-based and patient-centred care. It also identified areas of improvement in patient care without the need to involve specialist clinicians. A post-clinic hypertension action plan (following specialist input) was then prepared, coupled with an immediate discussion with the patient to discuss outcomes of the clinic session.

The hypertension virtual clinic offers an efficient and effective alternative to the traditional hospital based outpatient service, helping to break down any real or perceived boundaries between primary and secondary management of hypertension. It reduces the number of inappropriate referrals to secondary care, which improves patient services, as well as saving clinical time with unnecessary referrals and treatments.

References

1. Southwark CCG, 2015. Hypertension Virtual Clinics 2015-16: Guide for Primary Care Practices. Available online: [file:///C:/Users/k0936408/Downloads/Lambeth%20%20Southwark%20Hypertension%20virtual%20clinic%20guide%20June%202015.pdf]. Accessed 03-02-2016
2. Public Health England (2014). Tackling high blood pressure: From evidence into action. Available online: [https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/404881/Tackling_high_blood_pressure_-_FINAL.pdf]. Accessed 30-01-2016

Leading up to Evidence Live 2016, we will be publishing a series of blog posts highlighting projects, initiatives and innovative ideas from future leaders in evidence based medicine.
Please read on for the second in the series from Kristin Danko at the University of Ottawa.
If you are interested in submitting a blog post, please contact alice.rollinson@phc.ox.ac.uk. Stay tuned! 

“[Paradigms function] by telling the scientist about the entities that nature does and does not contain and about the ways in which those entities behave. That information provides a map whose details are elucidated by mature scientific research. And since nature is too complex and varied to be explore at random, that map is as essential as observation and experiment to science’s continuing development” – T. Kuhn, pg. 109 (1)

Translating evidence into practice, and in turn developing the science of translation is complex, challenging work. Several interrelated disciplines have arisen to address this challenge (e.g., implementation science, knowledge translation, quality improvement, among others) to determine the methods that most effectively get evidence into practice to improve health services and care. While the global objective of these disciplines is essentially the same, their methods, terminology and underlying epistemological frameworks are diverse (although not wholly indistinguishable) (2). Nilsen for example, identified over 40 theories, models and frameworks guiding the design, evaluation and interpretation of implementation studies (3). Lokker and colleagues noted 51 diverse classification schemes for characterizing the content of implementation interventions (4).

With so many options to choose from, is it any wonder that syntheses of implementation studies observe such diverse permutations of interventions with correspondingly high variation of effect (to say nothing of studies produced by researchers still choosing to remain agnostic to theories, models, and shared terminologies…). While such diversity of approaches speaks to the multidimensional nature of the phenomena being studied, it may limit the efficiency and effectiveness with which we are able to develop a cumulative science and may contribute to research waste (5).

How then, as a scientific community do we push this field forward to actualize the benefits of translating knowledge into practice and improve patient care? How do we become more scientific?

In considering such normative questions, I considered implementation science (broadly defined) through the lens of Thomas Kuhn’s classic, The Structure of Revolutions (1).  If a paradigm is the map guiding research –that is, the force defining the realm of acceptable questions, methods, terminologies and solutions – then implementation science is currently operating under the direction of multiple competing and overlapping paradigms. Indeed, Kuhn’s articulation of a period of ‘extraordinary research’ (“The proliferation of competing articulations, the willingness to try anything, the expression of explicit discontent, the recourse to philosophy and to debate over fundamentals”, Kuhn, pg. 91 (1)) seems particularly apt in describing the current state of implementation science. Yet extraordinary research does not produce cumulative knowledge. Rather, one paradigm (or perhaps several complementing, but not incompatible paradigms) must emerge in order for productive science to be executed and global understanding advanced.

If this thought exercise is true, then what next? While it is difficult to know how to best achieve a more efficient and effective scientific state, researchers interested in translating evidence into practice could consider the following in their future studies with respect to implementation science paradigms:

1. Become aware of the plethora of existing paradigms and their elements; build studies to empirically evaluate and extend existing paradigm elements (e.g., compare the effectiveness of two implementation models) instead of creating new ones.
2. Transparently report the choice of paradigm(s) over others, and comprehensively report paradigm elements using pre-existing terminologies and guidelines.
3. Engage in cross-paradigm collaboratives to promote shared agreement of terminologies and methods, and systematic and synergistic evaluation of interventions.

Perhaps with these objectives in mind, we may shape future paradigms to better support our scientific understandings, rather then obfuscate them.

Kristin Danko is a second year doctoral student in the Department of Epidemiology at the University of Ottawa, and a research coordinator the Ottawa Hospital Research Institute.  She is interested in improving synthesis methods for implementation science/knowledge translation interventions as well as knowledge translation methods for improving the conduct of primary studies themselves.

1. Kuhn TS. The Structure of Scientific Revolutions. 4th editio. London: The University of Chicago Press; 1962.
2. Walshe K. Pseudoinnovation: the development and spread of healthcare quality improvement methodologies. Int J Qual Health Care [Internet]. 2009 Jun [cited 2016 Feb 26];21(3):153–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19383716
3. Nilsen P. Making sense of implementation theories, models and frameworks. Implement Sci [Internet]. BioMed Central; 2015 Jan 21 [cited 2016 Jan 3];10(1):53. Available from: http://implementationscience.biomedcentral.com/articles/10.1186/s13012-015-0242-0
4. Lokker C, McKibbon KA, Colquhoun H, Hempel S. A scoping review of classification schemes of interventions to promote and integrate evidence into practice in healthcare. Implement Sci [Internet]. 2015 Dec [cited 2015 Mar 26];10(1):220. Available from: http://www.implementationscience.com/content/10/1/27
5. Ivers NM, Grimshaw JM, Jamtvedt G, Flottorp S, O’Brien MA, French SD, et al. Growing literature, stagnant science? Systematic review, meta-regression and cumulative analysis of audit and feedback interventions in health care. J Gen Intern Med [Internet]. Springer; 2014 Nov 1 [cited 2015 Jan 3];29(11):1534–41. Available from: /pmc/articles/PMC4238192/?report=abstract

By Peter J Gill 

As a junior doctor, the idea of changing the healthcare system seems daunting, even impossible. The delivery of healthcare is not only complex but also frozen with the inertia of a large organization. I felt similarly during my doctoral thesis, one person trying to tackle an ambitious research agenda in a narrow sphere of science.

Archie Cochrane, the late Scottish physician whom the Cochrane Collaboration is named after, probably felt similar doubts as a young doctor. Yet, as a prisoner of war during World War II, he managed to conduct a simple non-randomized controlled trial showing that supplementing prisoner’s diet with yeast prevented the development of severe edema. Cochrane’s first foray into trials ignited a life-long pursuit interrogating the effectiveness and efficacy of routine therapies.

Cochrane’s journey reminds us that important changes start with an idea, often a simple one. Yet, simple ideas can be revolutionary. The most innovative and creative ideas often come from students, trainees and early career researchers. By nature of their status, these individuals are often on the ‘front-line’, seeing the way healthcare is delivered and research is conducted.

Compare Trials is one example of a student-led initiative that is making waves. Many published clinical trials report outcomes that are different from those pre-specified during trial registration. According to the CONSORT Statement, guidelines which outline the minimum reporting standards for clinical trials, outcomes must be pre-specified (i.e. decided before the trial begins recruitment), and trial reporting in peer reviewed journals should be consistent with the protocol.

Unfortunately, this often does not happen. Outcomes that were pre-specified in the protocol are not reported, or new outcomes are reported that were not pre-specified. One might expect this to happen in little known journals, but it happens in prestigious general medical journals like the Lancet, BMJ and NEJM. Research is messy, and unforeseen circumstances frequently arise, but the final paper should clearly flag and explain why outcomes were changed. Ultimately, outcome switching distorts data for front-line clinicians.

Compare Trials, spearheaded by graduate medical students at the University of Oxford and supported by CEBM wants to bring attention to the problem of outcome switching. They are identifying all clinical trials published in major general medical journals (e.g. NEJM, Lancet, BMJ, Annals of Internal Medicine and JAMA) and are looking for discrepancies between the published paper and the trial protocol.

While similar projects have been conducted in the past, Compare Trials is unique for several reasons. First, they are systematically writing to all journals highlighting the issues they identify, requesting responses and tracking progress. Second, they are posting responses from journals and highlighting misunderstandings (which seem to be pervasive in the editorial community). Third, everything is open and transparent including the data extraction table, the letter sent to the editor and the responses received. Compare Trials intends the conversation about outcome switching with medical journals to be a public one.

There are several other examples of successful student led initiatives such as Students 4 Best Evidence and Hacking Health. However, many other ideas stall at the implementation phase. Barriers are erected as new ideas often clash with the conventional mantra. The medical students involved in Compare Trials had help and support from CEBM but such support may not always exist.

At CEBM and Evidence Live, we recognize this dilemma, and we want to help. The Future Leaders in Evidence-Based Medicine stream at Evidence Live targets students, junior doctors and early career researchers. We want to hear about projects, initiatives and new ideas and are offering 5 free places for the top 5 submissions and have 50 discounted places for future leaders.

We also want to create a network of future leaders, identify the challenges that trainees face and come up with creative solutions. Students, junior trainees and early career researchers are vital to the future of healthcare.

But to do this, we need future leaders to attend. Submit your project or idea, and Register for Evidence Live 2016. Remember, it only takes a simple idea to transform healthcare.

—

This blog was written by Peter Gill, member of the Evidence Live 2016 Steering Committee, paediatric resident at the [Hospital for Sick Children at the University of Toronto and an Honorary Fellow at the Centre for Evidence-Based Medicine.