CEBM and BMJ logo

Time for a Second Tipping Point in Evidence-Based Medicine


I am currently reading The Tipping Point: How Little Things Can Make a Big Difference, a book published in 2000 by the journalist and writer Malcolm Gladwell. In medicine, we seldom think laterally and seek ideas from other disciplines; I hoped Gladwell could inspire some radical ideas in anticipation of Evidence Live 2015.

The Tipping Point outlines why certain trends, ideas or behaviour’s suddenly ‘take off’, using examples such as teenage smoking and the AIDS epidemic. In describing why certain trends reach their ‘tipping point’, Gladwell proposes three key concepts: ‘The Law of a Few’, the ‘Stickiness Factor’ and the ‘Power of Context’. In particular, the ‘Law of a Few’ suggests that certain people play an integral role in epidemics: connectors, mavens and salesmen. I will describe how these individuals relate to the initial tipping point in evidence-based medicine.

  1. Connectors: bringing people together

Connectors are people with “a special gift for bringing the world together.” They are people who seem to know everyone, and who bring seemingly diverse groups of people together. Gladwell describes that while most people have ‘six degrees of separation’, some only have three or four degrees; they are the connectors, and they play a powerful role transmitting messages and igniting epidemics.

Who are the connectors that tipped the scales for evidence-based medicine? The first person that comes to mind is Sir Iain Chalmers, co-founder of the Cochrane Collaboration. When I first met Chalmers at his office in 2010, before sitting down, he asked me to sign his guestbook. I somewhat embarrassingly did, unclear why a young student warranted space in his book. Yet the guestbook is an illustration of Chalmers meticulously attention to people, and I witnessed countless examples of him ‘connecting’ people. Undoubtedly, his diverse social circles and innate ability to connect people, combined with his captivating speaking skills helped lay the foundation for the Cochrane Collaboration in 1992. I would argue this achievement was a key tipping point in evidence-based medicine.

  1. Mavens: the devils in the details

Mavens are individuals who accumulate knowledge. In the economic literature, they are referred to as “price vigilantes” because they meticulously monitor prices, looking for discrepancies and tell others when they find them, not for personal gain but simply because they want to help.

The equivalent ‘evidence vigilantes’ in medicine are the Cochrane Collaboration, an international organisation of people who methodically seek to compile all clinical information to ensure clinicians and patients can make informed decisions. For example, one author group has spent the past decade trying to find all clinical information about drugs used to treat influenza called neuraminidase inhibitors, otherwise known as Tamiflu and Relenza. These mavens discovered that many trials funded by pharmaceutical companies were not published and more concerning, that limited data were presented to drug regulators.

Early work by these evidence mavens made public the serious limitations in how clinical studies were designed, conducted and reported. Such findings led to a number of important changes such as Trial Registration and the CONSORT Statement. Mavens can be markedly persuasive simply because they have nothing to gain from sharing the information.

  1. Salesmen: communicating the message effectively and persuasively

Lastly, salesmen are people who persuade. They are the charming, charismatic and influential individuals who seem trustworthy, sincere and convincing. The pharmaceutical industry has mastered this role, for example by hiring young, good-looking sales representatives who arrive at doctor’s offices with a free lunch, free drug samples and a well designed sales pitch for why the new therapy is better than the competitor. But the employee may not provide information about other drugs, may only highlight benefits without discussing harms, and fundamentally has a conflict of interest.

An excellent example of a salesmen in evidence-based medicine is Ben Goldacre, journalist and author of the best-selling books Bad Science and Bad Pharma. Both books were in response to widespread misuse of science by the media, the public and the pharmaceutical industry. For example, Goldacre challenges the (absent) link between autism and the MMR vaccine, and details the unethical tactics used by drug companies.

Goldacre is a popular and well-liked individual because he is charming, easy-going and affable. He does not come across as abrasive or aggressive, but rather as enthusiastic and funny. Goldacre is remarkably likeable which makes him a good salesman.

Is it time for another tipping point in evidence-based medicine?

Applying Gladwell’s theories of the role of key individuals in epidemics, I have provided examples of how they apply to evidence-based medicine. But why do some say that Evidence-Based Medicine is a movement in crisis? I suggest that over the past decade the scales have shifted: the connectors, mavens and salesmen have disproportionately distorted the use of evidence-based medicine away from its’ core values.

But, we must find fault in ourselves. For too long, we have relied on traditional academia to demonstrate the self-evident benefits of evidence-based medicine. I would argue, such an approach is complacent, passively assuming for example, that the conclusions of a high quality Cochrane systematic review will change practice. By applying Gladwell’s principles, the latter approach relies on connectors and mavens.

The evidence-based medicine movement must now more actively embrace the role of salesmen to tip the scales and re-align the agenda back to the core principles: integrating the best available evidence with clinical judgement and patient values. New initiatives such as Choosing Wisely and AllTrials are examples of taking the message to the public with persuasive messages.

Evidence-based medicine has already had one tipping point but it is time for another. It starts by bringing together the connectors, mavens and salesmen; all of whom will be at Evidence Live 2015. On April 13th and 14th in Oxford, let’s start another epidemic in evidence-based medicine.


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

2017 Highlights