In evidence we trust: how do doctors decide which treatments to recommend to their patients?
[[{“value”:”
In evidence we trust: how do doctors decide which treatments to recommend to their patients?
Our bodies are incredibly complex, and so are the diseases and disorders that make us sick. In order to make us better, doctors and healthcare professionals prescribe medicines and recommend therapies. But how do they know which treatments are best? Dr Romina Brignardello from McMaster University in Canada uses systematic reviews to summarise and evaluate the trustworthiness of medical evidence. During the COVID-19 pandemic, Romina’s research was used by the World Health Organization (WHO) to inform their guidance on different treatments for the virus.
Talk like a health research methodologist
Evidence-based medicine (EBM) — an approach that systematically uncovers and evaluates scientific knowledge to support clinicians and their patients when making healthcare choices
GRADE — a system for presenting evidence summaries and grading the quality of evidence when making healthcare recommendations
Network meta-analysis — a statistical method used to compare results from multiple independent studies, allowing for the comparison of different interventions
Randomised clinical trial — a medical research study in which participants are randomly allocated to different treatments for comparison
Systematic review — a structured approach to combining research evidence for a particular treatment by identifying, assessing and summarising different trials to produce an overview of evidence. A ‘living’ systematic review incorporates new research studies as they are published, enabling doctors to make decisions based on the most up-to-date evidence
In today’s modern society, we often take our healthcare for granted. If we feel unwell, our doctors are usually able to successfully diagnose our illness and prescribe the best treatments. But this hasn’t always been the case. For example, if you needed a blood transfusion in the late 19th Century, there’s a good chance that your veins would have been pumped full of cow’s milk!1
Thankfully, things have improved since then, largely because modern medicine is based on evidence. Now, when your doctor recommends you a treatment, you can be confident that it is backed up by the latest evidence-based guidelines. Dr Romina Brignardello and her team from McMaster University use systematic reviews to evaluate medical research and ensure that doctors have access to the best available evidence.
This forms the basis of evidence-based medicine, an approach that encourages doctors to: 1) use the most up-to-date evidence available 2) assess the trustworthiness of this evidence and 3) consider patient values and preferences when making healthcare decisions.
Studying new treatments
To study potential new treatments, medical researchers conduct randomised clinical trials. “Researchers take a group of people who are candidates for the treatment and divide them into two groups at random,” explains Romina. “One group receives the new treatment, and the other receives a ‘comparator’. This can be the best existing treatment at that time, or an inactive treatment, called a placebo.”
“The two groups are treated exactly the same throughout the trial, except for the intervention they receive (either the new medicine or the comparator),” continues Romina. “As a result, any differences in health outcomes, such as mortality, hospitalisations or symptoms, can be attributed to the new medicine and nothing else.”
Assessing the evidence
When doctors want to know whether a new treatment is better than the existing one, they need to consider all the trials that compared the two treatments. When considered collectively, these trials are known as the ‘body of evidence’.
In order to evaluate a body of evidence, Romina uses the GRADE system. “GRADE is a system that allows us to assess how trustworthy the body of evidence is in a reproducible manner,” she explains. “It gives us a framework in which we have to consider all the potential limitations that the body of evidence can have.”
GRADE helps Romina to classify the trustworthiness, or certainty, of evidence. “This follows the first two principles of evidence-based decision-making: to base medical advice on the best available evidence, and to know how trustworthy this evidence is,” says Romina. “Ideally, clinicians would rely on high certainty evidence; however, evidence often has low or very low certainty. Clinicians still need to consider this evidence when making decisions and giving advice – the key is to understand the implications of this uncertainty and act accordingly.”
This process of evaluating and drawing conclusions from the body of evidence is called a systematic review. “When doing a systematic review, we can answer questions about whether a single treatment is better than another, or about how multiple options compare, like we did in our COVID-19 project,” says Romina.
Creating COVID-19 guidelines
During the COVID-19 pandemic, the world was in limbo. Researchers raced to develop and test vaccines and treatments, driven by the shared goal of finding the best solutions to protect and save lives across the globe. “The magnitude of the pandemic led researchers to mobilise at a scale never seen before,” says Romina. “Over eight months, researchers started roughly 1,000 randomised trials, with findings being published weekly. Decision-makers needed to make sense of all this information, but they could not keep up with every single publication.” To review and assess the ballooning body of evidence for COVID-19 treatments, Romina and her team carried out a living network meta-analysis.
“To start, we conducted a systematic review of all randomised clinical trials that compared treatments for COVID-19,” says Romina. “We put all the data about health outcomes in a network meta-analysis, which allowed us to compare all the treatments against all the other treatments at the same time and learn which of them resulted in more benefits or more harms than others. Then, we used GRADE to assess how trustworthy the evidence was, and drew conclusions about which treatments were the most effective.”
Due to the urgency and scale of the pandemic, and the rate at which new evidence was being produced, Romina and her colleagues had to continuously update their project, making it a ‘living’ network meta-analysis. “Living evidence synthesis is crucial in areas where evidence emerges constantly, so that healthcare professionals can continue to make evidence-based decisions,” explains Romina.
Global solutions
The World Health Organization (WHO) coordinated global efforts to respond to the COVID-19 pandemic. “Our work was the main source of information that the WHO used to make their recommendations for the treatment of COVID-19, followed by healthcare professionals across the world,” says Romina. “The WHO put a panel of experts together and used the evidence summaries we gave them to learn about the effects of interventions on health outcomes like risk of death, risk of hospitalisation and duration of symptoms. Considering these effects, they decided whether or not to recommend the treatments.”
Reference
https://doi.org/10.33424/FUTURUM636
Responding to the scale and pace of research during the pandemic was challenging, but Romina believes it was worth it. “We believe that our work was useful to many clinicians who wanted to keep updated about the most effective treatments for people with COVID-19,” she says.
Romina has been inspired by the success of her work, and is now looking to improve and use her methods elsewhere. “We are conducting tests to increase the efficiency of our methods without decreasing the trustworthiness,” she says. “We are also moving onto other research projects that focus on different topics such as antimicrobial resistance.”
1 onlinelibrary.wiley.com/doi/abs/10.1111/j.1537-2995.1969.tb04920.x
Dr Romina Brignardello
Associate Professor, Department of Health Research Methods, Evidence and Impact, McMaster University, Canada
Fields of research: Health research methodology, evidence-based decision-making
Research project: Summarising the evidence around the treatment of patients with COVID-19 to inform living practice guidelines
Funders: Canadian Institutes for Health Research (CIHR)
Funding reference numbers: VR4-172738, MM1-174897
About health research methodology
Working in health research methodology involves contributing to clinical research studies and ensuring that evidence-based decision-making is implemented effectively to maximise the positive impact on people’s health. The work can involve helping other researchers to refine the questions that need to be answered, designing and implementing research studies and trials, collecting and analysing data, and reviewing and assessing studies carried out by others.
“It is exciting because your days are never exactly the same,” says Romina. “You get to work with different groups of people, such as different types of healthcare workers or decision-makers, in different kinds of projects, and you are constantly learning about new healthcare areas and where there is room for contributing to improve people’s health outcomes. The main reward is that your work as a methodologist makes researchers’ work more trustworthy and useful for different audiences that use evidence-based decision-making.” This work helps to improve the confidence of clinicians across the world who give diagnoses and treatment recommendations. In turn, this has a positive impact on patients who receive trustworthy and tailored advice and support.
Integrating artificial intelligence (AI) into the field is becoming increasingly important. “It will be our job to find the best ways to interact with AI as if it were another colleague, to understand the ways in which it can make our work easier, and to recognise when it may not be trustworthy,” explains Romina. “This creates opportunities for research into the strengths and limitations of AI as a tool for health research methodologists. In addition, as AI makes its way into people’s healthcare journeys, it is likely that more of the clinical questions that we answer through research studies will be addressing the impact of AI on health outcomes and how we should use it.”
Pathway from school to health research methodology
Subjects such as biology, chemistry and mathematics provide a solid foundation for any career in healthcare. “Any subject that stimulates critical thinking and teaches you how to apply a concept to several situations will be valuable,” says Romina. Studying subjects such as statistics and health education will give you an added advantage.
Generally, health research methodology is taught as a post-graduate degree. Romina says, “People who pursue a degree in health research methodology have often completed an undergraduate degree in health sciences or life sciences, or medical training to become healthcare professionals such as nurses, doctors or dentists.”
Seeking out work experience or internships in health research can help you figure out what you enjoy, and gaining experience of working with patients will also be an advantage.
Explore careers in health research methodology
Learn more about the work of Romina and her colleagues at McMaster University and the different areas of research within health research methodology.
Learn more about the health research methodology programme at McMaster University.
Visit the CLARITY website to learn more about evidence-based medicine:
Studying health research methodology could lead to jobs in hospitals, laboratories, universities or private companies, such as pharmaceutical companies that conduct research.
Meet Romina
I am originally from Chile, where exploring activities outside of high school was not a common thing. As such, I was focused on getting good grades to get into university. I knew I was leaning towards a health profession, and I ended up landing in dentistry and becoming a dentist by the age of 23. My background and experience as a dentist piqued my interest in clinical research and evidence-based decision-making, which is what led me to my current career path.
I am proud of being a faculty member at the birthplace of evidence-based decision-making, even though I started at a disadvantaged position. The educational system in Chile is very different to the system in North America; for example, there is no encouragement to do extracurricular activities, to get engaged in research activities, or to apply to education or research awards. As a result, the CV of someone trained in Canada is very different from that of an international student. I am proud to have caught up with my peers and become a successful independent researcher.
I believe that my natural ability for logical thinking is what helps me the most. I am good at connecting ideas, extrapolating and noticing when something seems out of place. Being self-aware and open to continuous learning, and not having a problem acknowledging when I am wrong (not only when it comes to my research and teaching, but also at a personal level) have also served me well. I think that every research and teaching experience has given me the opportunity to exercise these traits and to expand them by applying them from a different angle.
My two most influential role models are my supervisors and mentors, Dr Gordon Guyatt and Dr George Tomlinson. From an academic standpoint, I admire how they are able to communicate and put even the most complex concepts into words that anybody can understand. From a personal standpoint, I admire how respectful, supportive and generous they are with their students.
To unwind from work, I enjoy watching a familiar TV show, reading a book or going for a long walk with my dogs when the weather is nice.
Romina’s top tip
The most important thing is to remember that short-term paths can lead to many different long-term paths. Life is unpredictable.
“I love teaching and interacting with students,” says Romina. “Two of my students, Sara Ibrahim and María José Oliveros, played key roles in our COVID-19 living network meta-analysis project.” Below, Sara and María José tell us about their research interests, their experiences of studying health research methodology and their hopes for the future.
Meet Sara
Position: Health Research Methodology second year PhD Student and Research Assistant
Fields of research: Evidence synthesis, guideline development, antimicrobial resistance
During my undergraduate degree in health sciences, I knew I wanted to do something related to health care, but I wasn’t quite sure what. It wasn’t until the COVID-19 pandemic that I became aware of the role that evidence synthesis (bringing together all of the evidence on a topic) plays in evidence-based decision-making and in navigating an abundance of information and misinformation. During that time, I had the opportunity to be involved in several evidence synthesis and meta-analysis projects for COVID-19. It was these experiences that showed me the importance and impact of research, which inspired me to pursue graduate education in health research methodology.
My research is focused on evidence synthesis methodology and guideline development, both of which can be applied to a variety of fields. Evidence synthesis methodology encompasses a variety of research methods, such as systematic reviews. Guideline development takes this a step further and uses the results of evidence syntheses (among other things) to consult with experts and formulate recommendations for clinical practice. In my PhD, I am both using and critically appraising these methods in the field of antimicrobial resistance.
I love how collaborative and interdisciplinary the field of health research is. Research methods can be applied to any discipline, which means I can work on projects in a wide range of fields – from oral health to COVID-19 – at the same time. Working on a wide range of topics always keeps me on my toes as I get to learn new things and work with a range of experts. Many of our projects are conducted in large teams, so it’s always a great opportunity to learn from others.
Throughout my PhD, I’ve had the opportunity to mentor students through their undergraduate thesis and also work as a teaching assistant – these are some of my favourite and most rewarding experiences. I hope that in the future I will be able to continue working with students in a teaching or mentorship capacity. I also hope to be more involved in guideline development in the future, as this is the step that really bridges research to clinical practice and makes research findings directly applicable to the real world.
I have been fortunate to have worked with encouraging mentors who always push me to step out of my comfort zone. During my undergraduate degree, Dr Romina Brignardello generously offered me a spot on her team, knowing I had no experience in this field. Over the course of several years and numerous projects, I have continued to work with and learn from her. It’s a privilege to have had someone take a chance on me and continue to invest in teaching me. Romina has been a great resource thanks to her expertise in these research methods, and she has shown me how to be a better teacher and mentor to students. Her continuous support for her students and their growth is inspiring.
I’m an avid music lover who is always looking to learn how to play a new instrument! For as long as I can remember, I have been involved in something related to music in some way – whether that be singing in the school choir and playing in the school band, or volunteering as a music teacher for children while I was at university. So far, I have had experiences with the piano, wind instruments and string instruments – next on my list to learn is the guitar.
Sara’s top tips
1. Don’t be afraid to try new things! I never would have imagined myself to be where I am today if it weren’t for those research experiences during my undergraduate degree. At the time, it was nerve-wracking to try something new and be one of the youngest on the team, but I’m so glad I had those opportunities to expand my knowledge and meet new people who have become great mentors and friends.
2. Don’t assume that everyone else around you has it figured out. To this day, I am still navigating my journey as a student – it took me a while to realise that several of my peers are in the same boat. Have an open mind and treat everything as a learning experience to help guide you as you decide what path you wish to take beyond high school.
Meet María José
Position: Health Research Methodology fourth year PhD student and Research Assistant
Fields of research: Evidence synthesis, rehabilitation
As a child, I wanted to be a researcher — although my idea of research at the time was someone looking at cells through a microscope. When I started my degree in physical therapy, I was introduced to evidence-based practice, and it immediately made sense to me. It showed me that improving health outcomes requires generating knowledge that focuses on the right populations, relevant health issues and meaningful outcomes for patients. Pursuing a PhD in health research methodology felt like the natural step forward, allowing me to contribute to better healthcare decision-making in a rigorous and meaningful way — especially at an institution recognised as the birthplace of evidence-based medicine.
My research is rooted in clinical rehabilitation and exercise, combined with a focus on evidence synthesis for health decision-making. I am interested in how we gather, summarise, assess and present evidence so that it can be effectively used by clinicians when treating patients or by policymakers when shaping health policies. This methodological focus has allowed me to extend my scope far beyond my clinical discipline — in other words, what I have learned and developed not only enhances rehabilitation research but also contributes to improving decision-making across various areas of healthcare.
As a physical therapist, at heart and by vocation, I always consider how my work can contribute to advancing rehabilitation research. One of my projects aims to identify and analyse the outcomes being reported in systematic reviews of rehabilitation. This can help us understand what is currently being researched and assess whether these outcomes truly align with what matters most to patients. Ultimately, the goal is to optimise the research process to ensure that what we study and publish genuinely informs healthcare needs.
I love working alongside academics and students who are deeply passionate about evidence-based medicine. It is inspiring to work with people who advocate for rigorous, impactful research. Health research has advanced significantly in recent years, but there is still so much to explore. The way we conduct and interpret research directly influences healthcare practices and policies, which ultimately impacts people’s lives. If you are motivated by seeing how knowledge can address real health challenges and make a tangible difference, then this field is incredibly fulfilling.
As an international student, I plan to return to my home country, Chile, and use what I’ve learned to support health research and decision-making there. I want to contribute to improving how we generate and use evidence to address public health challenges in my community. At the same time, I hope to continue collaborating with the international network of researchers I’ve built during my PhD.
Throughout my journey, I have been fortunate to have incredible mentors who have shaped my approach to research and healthcare. Early in my career as a clinician, a colleague taught me that rehabilitation goes far beyond technical skills — it is about truly centring the person in their own recovery process. During my PhD, Romina, my supervisor, has been a source of continuous inspiration. She has challenged me to refine my skills, uphold the highest standards and sharpen my critical thinking — all while providing unwavering support and guidance. Her expertise in evidence synthesis and commitment to methodological rigour have significantly shaped my approach to research. Working with her has allowed me to see firsthand how, through our contributions in methodology, we can transcend disciplines and impact decision-making across different areas of healthcare.
I love nature, exploring new places, and spending time with family and friends. When it comes to physical activity, I enjoy any kind of sport — even if I’m not particularly good at them! I’ll give anything a try!
María José’s top tips
1. Most young people don’t have everything figured out when they finish high school, and that’s completely normal. What’s important is to stay curious, explore different interests and pay attention to what excites you. Recognise your strengths and be open to new opportunities.
2. After high school, a world of possibilities will open up, and different paths will present themselves — some you may have never even considered. The better you understand what drives and fulfils you, the more confident you’ll be in choosing a direction that aligns with your goals and values. Your path doesn’t have to be linear; what matters is that it feels meaningful to you.
Do you have a question for Romina?
Write it in the comments box below and Romina will get back to you. (Remember, researchers are very busy people, so you may have to wait a few days.)
Learn more about how doctors are trying to alleviate the emotional burden of cancer care:
The post In evidence we trust: how do doctors decide which treatments to recommend to their patients? appeared first on Futurum.
“}]]