Better evidence, improved care

BMJ 2006; 333 doi: (Published 21 December 2006) Cite this as: BMJ 2006;333:1320
  1. Lee Goldman, executive vice president for health and biomedical sciences
  1. 1Columbia University Medical Center, Columbia University, New York, NY 10032, USA
  1. lgoldman{at}

    As is hopefully true for all doctors, I am inspired by the opportunity to spend my professional lifetime trying to improve the health and welfare of humanity. How to achieve that goal is intensely personal, however. In deciding to be a clinical investigator, teacher, and, more recently, a medical administrator rather than a full time clinician, my inspiration goes beyond the desire to help individual patients in a series of one-on-one encounters. I believe that individual doctors can become an even more powerful force when they are informed, educated, stimulated, and even moulded to benefit from collective knowledge and to raise their standards of performance. Nevertheless, my decision to maintain an active clinical practice underscores the recognition that these other activities have little merit unless they can be transformed by practitioners into improvements in patient care.

    While in medical school I made the unusual decision simultaneously to pursue a masters degree in public health. My peers on each side were equally perplexed. The medical students and medical faculty saw public health, at least in the United States, as largely outside the realm of real patient care. My public health colleagues saw doctors as unable to recognise the big picture of what truly influences the course of human health. I vacillated between being hopelessly discouraged that the two sides would never meet and hoping that a potentially powerful alliance could be forged if these professional neighbours could come together.

    During my subsequent clinical training, I was privileged to train at several top US medical institutions. At each, I was struck by the influence of local experts, veritable gurus whose powers of deductive reasoning established them as the local wise ones. Their opinions were followed loyally and sometimes even blindly by trainees, especially in their areas of expertise, but often also beyond those areas. Expertise was attributed to wisdom, which was based on experience and cumulative observations over time as well as the logic and persuasiveness of the thought processes. Unfortunately, there was little or no recognition that these expert opinions depended on all the biases inherent in uncontrolled observations. What I found most striking was that their experiential wisdom became dogma in their local environment, yet that same opinion could be heresy at an equally prestigious institution where the deductive powers of another experienced local leader led to different conclusions.

    Despite my degree in public health, I always believed that no higher calling existed than to help individual patients. However, such a goal was not possible if the wisest experts could not agree on the most fundamental issues. This knowledge gap inspired me to pursue a career that would focus on developing better evidence so that expertise in medicine would be based on true science rather than pseudoscientific deduction. The best doctors would understand the evidence and create systems in which decisions incorporated that wisdom, always adapted to the individual characteristics of the patient at hand. My aspiration became to perform research that would meet this standard.

    During my training as a cardiologist, both my inspiration and my aspiration were reinforced by an offhand comment that influenced me greatly. As a group of leading American cardiologists were recommending the addition of quinidine to digoxin for a patient with heart failure and atrial fibrillation, a foreign trainee, who had come to the US to learn our advanced technology and take it back to his home country, blurted out, “Everybody knows that the combination of quinidine and digoxin kills people.” Suddenly it became clear to me that the disparity between what is classified as dogma in one institution but heresy in another did not occur in the US alone, but was an international phenomenon. Years later, data confirmed that adding quinidine to digoxin kills people, that neither drug is particularly efficacious, and that each has substantial side effects. For heart failure, drugs such as digoxin that increase the performance of individual cardiac myocytes are of surprisingly little value and often are deleterious. For arrhythmias, drugs such as quinidine that suppress aberrant beats make the electrocardiogram look better but often worsen prognosis. In theory, everything I was taught as a cardiology fellow about the treatment of heart failure complicated by atrial fibrillation seemed logical: get the myocytes to work better and suppress the arrhythmia. In truth, however, all of it was wrong. The inspiration was that deductive reasoning may be dangerous. The aspiration was reinforced: help physicians to gather, interpret, and use evidence more appropriately.

    As my career progressed, that aspiration—to spread the word about the difference between deductive reasoning and medical evidence—became inspiring as well. I had the privilege personally to supervise dozens of trainees who have gone on to distinguished careers gathering and interpreting medical knowledge and, as a result, improving the health care of populations and of individual patients in one-on-one care. I have also organised training programmes that have educated more than 1000 young doctors from all over the world. I am inspired every day by what they have accomplished collectively and by the multiplicative effect as they themselves become leaders and teachers of others. These professional descendants and many others like them have helped medical care advance, with epidemiology guiding basic science, basic science breakthroughs generating new treatments, new treatments being evaluated by randomised trials, and data from randomised trials influencing systems of care.

    Now, this manifest impact on medical knowledge and practice has generated for me a new series of aspirations guided by the same inspiration. I am inspired by the hope that medical education can be changed, the delivery of medical care can be improved, and my one-on-one encounters with my own patients will result in better outcomes. In this way, the seemingly divergent skills and perspectives that I learnt as both a medical student and as a student of public health will converge in improvements in the health and welfare of populations and of individuals.


    Lee Goldman is the Harold and Margaret Hatch professor and executive vice president for health and biomedical sciences at Columbia University, where he also serves as dean of the Faculties of Health Sciences and Medicine at Columbia University Medical Center. Before joining Columbia, he was chair of the Department of Medicine at the University of California, San Francisco and a professor at Harvard.

    His research has focused on the effectiveness and costs of diagnostic and therapeutic strategies, with special emphasis on how the delivery of medical care can be improved by the results of high quality clinical investigation. His work at the interface between “public health school methods” and clinical medicine is exemplified by the “Goldman index” to predict the cardiac risk of non-cardiac surgery.

    Lee Goldman is a past editor of The American Journal of Medicine, and he is currently the lead editor of the Cecil Textbook of Medicine and co-editor of Hospital Medicine and Primary Cardiology.

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