Subscribe to this channel for more inspiring content.
Join the Unstress Health Community: https://unstresshealth.com
Follow Dr Ron Ehrlich:
Website: https://drronehrlich.com
Instagram: https://instagram.com/drronehrlich
Facebook: https://facebook.com/drronehrlich
Twitter: https://twitter.com/drronehrlich
LinkedIn: https://linkedin.com/in/drronehrlich
Chapters:
00:00 Understanding Evidence-Based Medicine
11:41 Biases in Research and Their Impact
19:41 Evaluating Research Quality
28:19 Reproducibility and Its Challenges
28:47 Evidence-Based Marketing: Relative vs Absolute Risk
32:16 New Chapter
42:02 Towards a Patient-Centred Model
44:54 The Nuances of Bias in Medicine
45:30 Relative Vs Absolute Risk and the ‘Number-Needed-to-Treat’
46:38 Taking Control of Your Health
Takeaways:
Evidence-based medicine is often misinterpreted and oversimplified.
Understanding the difference between relative and absolute risk is crucial for making informed decisions.
Biases in research can significantly affect outcomes and interpretations.
Industry funding plays a significant role in shaping medical research.
Not all published studies are of high quality or rigor.
Patients should take an active role in their health decisions.
The importance of critical thinking in evaluating medical literature.
Many biases can influence research results.
A double-blind randomised controlled trial is considered the gold standard.
Patient-centred care is essential for better health outcomes.
Navigating Evidence-Based Medicine: Myths and Realities
________________________________
Dr Ron Ehrlich (00:02.222)
Hello and welcome to Unstressed Health. My name is Dr Ron Ehrlich. Well, today’s subject is evidence-based medicine. And that term is one that you will often hear prefacing any health advice that you get. Yes, this advice is evidence-based. And your doctor will say to you, yes, this treatment is evidence-based. And the public health officials will say, this evidence is, this treatment, a policy is evidence-based.
And to the uninitiated, that would seem very reassuring, but to anybody that’s taken a slightly deeper dive into that term, you will know that it is not quite as straightforward as it sounds. Another aspect to it is when doctors, when you ask your medical practitioner for X, Y or Z, and they say, there’s no evidence to support that, which implies that they have read all the evidence that there is.
And anybody who has taken a deeper dive into that will know that that is just simply not possible. It would be better for that practitioner to simply be honest and say, I’m not aware of any evidence to support that. And that would be an honest answer. But evidence-based medicine is an issue. And one of the most cited medical health practitioners in the world, Professor John Ioannidis from Stanford University, has alerted us to the fact that there is difficulty in distinguishing between evidence-based medicine and evidence-based marketing.
And that is very much the topic of today. What is evidence-based medicine? What are some of the challenges, some of the biases, some of the pitfalls, and what can we do about it? How can we approach it? But in order to solve a problem, it always helps to know whether there is a problem, what that problem is.
And this is a story, particularly for a busy health practitioner that is very easy to miss, but once you hear it, very difficult to ignore.
My guest today is Dr. Lewis Ehrlich. Now, Lewis is the principal of the Sydney Holistic Dental Centre, a practice that I founded over 40 years ago with my brother, Dr. Joshua Ehrlich. He is co-principal there with Dr. Yin Yin Teoh and Dr. Craig Wilson.
And it is a patient-centered practice and it has dealt with the issues of evidence-based for our entire professional life. And we’ve kept a very open mind about it.
Now, this is actually a two-part podcast because in this first part, I talked to Lewis about evidence-based medicine. The reason I do is not only because he is a dentist in a holistic practice.
But some four or five years ago or three or four years ago when the pandemic arose and there was a whole deal of great deal of controversy about what evidence was, Lewis decided to do a degree at Oxford University, the home of evidence-based medicine. This is where the fathers, if you like, of the Cochrane collaboration, which was put together to give some weight, to give some meat behind what evidence-based really was about.
The heads of the Department of Evidence-based Medicine at Oxford were his teachers and I was so impressed with him undertaking such a study that I wanted to get him on to share his insights and all that he has learnt along the way.
I hope you enjoy this conversation I had with Dr. Lewis Ehrlich
Dr Ron Ehrlich (03:03.16)
Welcome back to the show, Lewis.
Dr Lewis Ehrlich (03:05.233)
Thanks, Uncle Ron. Good to be back on.
Dr Ron Ehrlich (03:07.502)
You can just call me Ron for this podcast. Listen, you know, we have we’re talking today about evidence based medicine and it’s a word that or an expression that many doctors use and it gives them peace of mind, I guess, and many patients listen to and feel reassured by. But I think we both know that it’s not everything that it’s cracked up to be.
We’re going to cover some of those challenges. wondered if we might just start with what exactly is evidence-based medicine? How was it originally conceived?
Dr Lewis Ehrlich (03:41.766)
Yeah, evidence-based medicine is basically giving a framework for making clinical decisions. you know, making them based on evidence that’s there or not there, and that’s an important distinction. The purpose of evidence-based medicine is to actually make sure that you’re doing decisions in your practice that are actually based on evidence. And it’s important to realize that it’s flung about as a term, but a lot of people don’t actually know what that means.
And I can speak from personal experience because in dental school and in my bachelor of science degree, and I’ve studied for now 21 years, I still, even after all those years, I still didn’t really know how to analyze scientific literature. And I think a lot of people speaking to people at Oxford, they actually don’t know too much about it. Medical doctors that I was there with, was there with neurosurgeons, oncologists, psychologists, psychiatrists, you name it, everyone was in the classroom.
And we all asked the question to each other, how much work did you do in medicine or in dentistry or in any other field that they were involved in on analyzing rigorously the data that was presented? And it wasn’t very much at all, you know? So then the term evidence-based medicine or there’s no evidence to support that or there is evidence to support that is…
Dr Lewis Ehrlich (05:37.704)
is flung about a lot with health practitioners. And I think there’s a bit of a issue throwing terms out like that because it’s one thing to say that, but it’s another thing to actually understand how to critique studies, which a lot of people aren’t armed with and I was one of those people. So that’s why I went and did it.
Dr Ron Ehrlich (06:03.598)
Yes, well, we’re going to dive into a bit more of the detail and answer some of those challenges because it is a word that’s bandied around. It’s almost like a doctor. Once the doctor says, this is evidence based, they feel justified to continue. another common term is, well, there’s no evidence to support. And that would suggest that they have read all the evidence that there is there. And I think we both know that it takes around 600 hours a wee to keep up with all of the evidence. So that’s not a real statement in and of itself. But you chose and you’ve acknowledged the fact that you’ve been in practice, you’ve been studying now for over 20 years and you weren’t well placed to understand what it actually meant. Before we dive into it, tell us a bit about what you did and why you did it.
Dr Lewis Ehrlich (06:57.148)
Yeah, so I recognize that a lot of scientific research studies that you would read, I actually didn’t have any skillset specifically to go and read it and go, is this good data? Is this accurate data? Are the findings relevant? Can you throw them out? Is the statistics solid? Is it just basically good research?
at the end of the day, it’s like, if somebody brings you a dental product, for example, and they say this is the latest and greatest and you should adopt it because you know, x, y, z, you actually have to know whether or not that’s true. And it doesn’t matter if you’re a cardiologist, a dentist. If you don’t have the skill set, you can’t, you can’t analyze it and you can’t pass that on to your patients. So I feel more confident in my practice now that having gained these skills that I can actually question what I do, you know, to a level that I would assume is higher than most. And therefore I can get better health outcomes based on knowing what to analyze.
So I think that it’s a good thing for practitioners to do. But even within that, there’s still huge flaws within the evidence-based system as well. And I thought that Oxford, one of the reasons why I chose Oxford was that that was the birthplace of evidence-based medicine. And the theme through all my professors was that they weren’t afraid to rip studies to shreds and say, you know, this is this is not great evidence. This is this is good evidence. And even if it meant that it didn’t hold the university in necessarily good stead, you know, so they were willing to critique themselves to a really high standard. And they kind of knew what they were there for. They knew that they trying to advance science as opposed to. You know.
Dr Lewis Ehrlich (09:17.828)
allowing industry influence or, you the reputation of the university to be maintained at a really high level. I thought that they were really thorough, as unbiased as possible. And it was just a really brilliant experience on that front. And speaking of bias, I’ll give you an example of what I’m talking about. There’s a catalog of bias that the University of Oxford have established as about, it’s an ongoing document and they’ve got about 48 different types of biases that can be found within scientific research. So at the University of Oxford, they’ve found 48 biases that can sway data and sway the evidence and the results of evidence. So for example,
One is all’s well bias, all’s well bias. So that’s where positive outcomes are more likely to be published as opposed to negative outcomes. So if it’s positive, they’ll bias it towards being published and more data comes out on that particular topic because people love to read positive….positive results as opposed to negative results.
We know in research that negative results are less likely to be published. So there’s one such bias. And then there’s another one called hot stuff bias, which is where the latest and greatest fad is always sort of published in positive terms. And there’s just almost this raft of research on the newest, coolest thing. It might be
microbiome testing, it might be some sort of new, new, amazing tests that establishes whether you can pick up a disease early or not, you know, this is like hot stuff in the media. So they’re more likely to get, get a lot of airtime and almost sway data in the studies to make sure that that’s pumped out and in accordance with what’s come before it.
Dr Lewis Ehrlich (11:37.96)
So there’s 48 different types of biases that they’ve established. And I think that that shows that they’re ahead of the game where you can read a paper, use the catalog of bias, that they’ve got examples. And when I’m reading a paper, I would actually just go through and go, that’s bias in that sense, that’s bias in that sense, that’s bias in that sense. And therefore I’m less likely to…
to really trust that evidence if a lot of those biases were found in those papers.
Dr Ron Ehrlich (12:13.678)
I mean, another bias must be who’s paying for the research. That’s a big bias. In terms of health care, medicine, what percentage of research is funded by the pharmaceutical industry?
Dr Lewis Ehrlich (12:29.986)
in well the TGA for example that’s the Australian equivalent of the FDA
Dr Ron Ehrlich (12:36.152)
That’s the Therapeutic Goods Association as opposed to the Food and Drug Administration in America. Yeah.
Dr Lewis Ehrlich (12:42.512)
Yeah, 96 % of funding comes from industry. So that’s a huge, huge number. But, I think that would surprise people, but I think to play devil’s advocate to that, there’s two things to mention. Obviously it’s not good that the tentacles of, you know, private enterprise have entered science.
Dr Ron Ehrlich (12:51.778)
Yes.
Dr Lewis Ehrlich (13:10.108)
Right. So that’s a huge problem. But on the flip side, you have to realize that performing studies is extremely expensive and a lot of universities don’t have the backing to constantly pump out the amount of research that’s necessary to keep up the pace with medical science and all its advances. So there, there are industry sponsored studies that we’ve read that are quite solid, you know, but they’ve we’ve needed a private enterprise to actually provide the resources to conduct studies. So what I’m saying is you can’t throw the baby out with the bathwater in the sense that yes, there’s huge influence, which is a problem that you need to recognize.
But on the flip side to that, you sometimes need industry money in order to conduct the studies to…get the information out there and get advancements out there. So for example, for a study to make its way into recommendations, that can take up to 17 years. So you can read medical guidelines on how to eat a healthy diet or what to do for heart health.
Now we can, that’s a minefield in and of itself because we can analyze diets and what’s heart healthy and all these sorts of things. The cows come home. But the point I’m trying to make is that it takes 17 years for that to become recommendations. So in order to speed up the pace at which recommendations are actually delivered to patients with the latest and greatest, you actually need to be conducting a lot of studies. So to play a
Dr Lewis Ehrlich (15:12.104)
a sort of balanced argument here. It’s a problem that 96 % of industry funding of the TGA is there. But equally, you need some sort of pumping in of financial resources to get studies out that can speed up science and advancement. So there’s studies that I’ve read where I’m like, okay, that industry influence, you can see it, clear as day and it’s a problem and it’s bias and you can tell that they’re trying to get out positive information so that they make money for their shareholders. But equally I’ve read studies that have been sponsored by industry that have said, actually this doesn’t work. This isn’t good. So what I would say to people is that there’s nuance and not to say, okay, because there’s industry sponsor of this study, we need to just throw it out.
Okay, because you still have to analyze what’s within the paper and you can tear it to shreds and find that actually it’s a solid paper that can be used. So I think there’s nuance that people need to understand because we’re very black and white in today’s society. We’re very polarized. And so I would exercise caution with that because there are some reasons why they’re involved, which can be positive.
Dr Ron Ehrlich (16:27.298)
Yes.
Dr Ron Ehrlich (16:37.422)
Yeah. Well, I admire your, you know, that nuance and clearly having done the course and being exposed to the reality to hear you speak in such nuanced terms is very reassuring. However, I would just add that if somebody, a pharmaceutical industry is funding a university to do studies and one of the 48 biases or two of the 48 biases are…all’s well. If they funded 20 of those studies and 15 of them were negative but five were positive, it’s very likely that the 15 that were negative may not find their way into the literature as much as quickly as the five that were positive, particularly if they added another bias, hot stuff to that, then you’ve got a double bias there, is an incentive. And the university would know, hey, look, we got, we got a positive result here and we’re to get more funding. So we’re really on a little bit of a something here. Let’s, let’s continue this relationship. And even better if the regulatory body is funded by the industry, that’s a really neat way of speeding approvals up. Isn’t it?
Dr Lewis Ehrlich (17:59.1)
Yeah, 100%. So you’re correct. The data does show that positive studies are far more likely to be published, like I said earlier. And it is a little bit of a concern when you’ve got the people that are meant to be looking out for, you know, these drug companies that they’re doing the right thing, they’re pumping in so much money into the people that are meant to be guiding that. That’s a massive
Dr Ron Ehrlich (18:08.27)
Hmm.
Dr Lewis Ehrlich (18:29.138)
That’s a massive conflict of interest. But also that’s another reason why I was really happy with Oxford is that they’re one of the leading universities that are getting actually out a conflict of interest database where, know, back in the day, it was very easy to kind of hide your, conflicts of interest, but they’re, really trying to aim for as much transparency as possible. And they’ve created a database where you can actually analyze the extent to which there is conflict of interest in studies. So you have to actually put it into a database now. So that’s driven in a large part due to Oxford.
Dr Ron Ehrlich (19:12.162)
What another thing that I think is worth mentioning because you mentioned, you know, 21 years of studying, you weren’t really well equipped to do it. You were in a cohort of students at Oxford that recovered almost every medical specialty, cardiologists, psychiatrists, doctors, dentists, whatever. I think it’s fair to say that doctors who who look at the literature will typically tick two boxes. Number one, if it’s published, in a referee journal, that to them is good enough and that constitutes evidence-based as far as they’re concerned. Or if they want to be really thorough, they’ll read the abstract. And that would account for probably 95 % of practitioners’ approach to evidence-based medicine. But an article in a referee journal involves much more than that. Can you just run us through, you know, a typical article in a research? What are they published? What’s wrong with just looking at an abstract or knowing that it’s published in a journal? Do I need to know any more than that?
Dr Lewis Ehrlich (20:25.66)
Yeah. So I think the, the, the first point you raised there on is that you, there’s a difference between reference based medicine and evidence based medicine. a lot of look practice. have to, I have to again show nuance here. So as a health practitioner, we all know how under the pump we are. Okay. And there’s an absolute mountain of evidence. Right. So people need to spend time with their family. They need to see you know, all these different, all these different patients have to treat all these, you know, people day to day.
And so then to go and trawl through the research without a skillset to do so, like I mentioned, it’s really difficult. So are many people going to put in that effort? And the answer is likely no. So that’s, that’s obviously a problem for patient outcomes, but understandable, we’ve all been there. It’s not like I’m you know, 24 seven either. So you have to give people a little bit of a pass on that front, you know? so the, the difference between reference based medicine and evidence based medicine is that if I have, this also speaks to bias. If I have an idea of what I want to say or do or promote,
Dr Ron Ehrlich (21:34.627)
sure.
Dr Lewis Ehrlich (21:52.668)
then I’m going to troll the evidence and I’m going to find a reference that supports my point of view. That is not the way to do science and practice your particular health profession. What it should be is here’s the question I want answered. I’m going to go through the research, analyze the research to a really high standard with the skillset that I’ve acquired, and I will then make an informed decision, an evidenced informed decision rather than, and you see it all over social media, what I’m talking about. This is my point of view. I’ve found a way of thinking I am going to find a reference, a result in an abstract, not in a paper, not gonna go to the lengths of reading the actual paper.
I’m going to find an abstract that supports my argument. I’m going to put up a social media post. I’m going to tell all my patients, I’m going to tell all my family, I’m going to, that’s the way a lot of people operate. And I think it’s problematic because it creates this immense division in society and it gets rid of the nuance within it. So, you know, like I’ve been to many doctors that say there’s no evidence to support that or that’s not right or
The science is clear on that. And then the flip side to that is that people don’t even look at evidence. The other side of the fence is just like, this is what I believe. This is what I know. And you get headstrong patients that come in and go, I don’t care how much study you’ve done. I don’t care how much experience you have. This is what I believe. And each to their own, no problem but they’re two sides to the spectrum. And so I suppose to answer the next part of your question is yes, there’s different journals that have what we call a higher impact factor. know, Cochrane Review, British Medical Journal, these are the New England Journal of Medicine. These ones are a higher impact. There’s more rigor.
Dr Lewis Ehrlich (24:17.936)
more peer reviewing, et cetera. Now that’s not to say that there’s not issues with them. You know, just because it’s published in the New England Journal of Medicine doesn’t mean a paper hasn’t ever been retracted. know, so, you know, there’s, there’s several, there’s several examples of those that we discussed in our course where, you know, the New England Journal of Medicine was heavily criticized in, certain aspects, on certain topics, on certain science that we’d read.in class and tear it apart. So just because it’s a high impact journal doesn’t necessarily mean that it’s without flaws. But it means that it’s been more rigorously looked at by people that are hopefully as unbiased as possible as possible. But this notion that you can just read a paper and say, it’s in this high impact journal.
therefore I’m going to read the abstract and tell everybody as if it’s gospel is not necessarily the smart thing to do because even those papers need to be rigorously studied. Study design and the amount of people that have been in it. What were the results? What are the statistical analyses? Have people
Dr Ron Ehrlich (25:31.694)
But
Dr Lewis Ehrlich (25:45.434)
manipulated the statistics within it. How many studies were compiled in a systematic review? What were the quality of those studies? What were the conflicts of interest within those studies? There’s a million different things you can look at within a paper. And so this is why it’s frustrating when I hear there’s no evidence to support that. That’s a classic one.
Dr Ron Ehrlich (26:12.866)
Yes.
Dr Lewis Ehrlich (26:14.556)
you know, that you’ll hear from a practitioner. Because it’s impossible to troll through all the research and to even within the ones that are published, there are still many ways in which you can critique that and say that it’s not necessarily accurate. But there are some times where we actually need to use what’s available to guide our clinical decisions as well.
So again, nuance, know, sometimes things aren’t studied as, as, as rigorously or as I suppose the amount of papers on a particular topic aren’t there for certain topics. You know, everything that’s ever been discovered once was not discovered. And so there’s a point at which, you know, there’s not a lot of data on things. And so you have to build on evidence over time, which is why you’ll hear at the end of it, more studies are needed, which is good.
Dr Ron Ehrlich (27:14.424)
Hmm. I mean, often within a paper and the, course, the reason people go through and just read the abstract is it’s usually one or two paragraphs and it’s quick and easy and easy to read because an article is typically starts with a hypothesis or a discussion about what they’re trying to do in this study. Then it goes through the methodology of, know, we used a thousand patients, we randomized control, we did this, we did that.
Dr Lewis Ehrlich (27:27.581)
Yeah.
Dr Ron Ehrlich (27:43.266)
And then the next one is about statistics, what we found, the results and how we analyzed them. And here is the conclusion. And the conclusion often informs the abstract. That’s a typical study, but even within a study, the results, the statistics could say one thing and it’s not unusual for a conclusion to draw a different conclusion than what their own results showed. That happens too, doesn’t it?
Dr Lewis Ehrlich (27:48.285)
Yep.
Dr Lewis Ehrlich (28:13.702)
Yeah, it does. And it’s a minefield with statistics as well, because statistics are basically an analysis on whether or something is more likely to be true or not. Like, like almost like something didn’t happen by chance, you know, that that brings sort of rigor and strength to it to a paper. But even within that, there are really brilliant people out there that can bend statistics to find a result that they want to there’s
Dr Ron Ehrlich (28:45.548)
Hmm. So sort of deliver an all-wells, all-well result so they can keep getting funding to keep the machine of research going.
Dr Lewis Ehrlich (28:57.458)
correct or the flip side to that is that the statistics is poor due to mistakes and then somebody who’s really good at analyzing statistics actually goes, that’s really incorrect statistical analysis and he’s the true result. So it can be deliberate or it can be mistakes or it can be completely accurate. That’s also true.
Dr Lewis Ehrlich (29:27.25)
But it’s interesting, one of the really fascinating parts of reading a bit of research is does the abstract actually match the actual paper? Because there’s sometimes where the title of the paper will say, this is what we’re looking for. The abstract will say something different to what’s in the paper as well.
So, you know, there’s this whole thing called a Pico, which is population intervention, a comparator, and then an outcome. So they have to match, the abstract has to match what’s in the paper in that Pico, right? So oftentimes we had ones in class where those didn’t match up at all. You would read the title, the abstract, and then in the first paragraph, they started talking about something completely different.
Dr Ron Ehrlich (30:13.343)
No.
Dr Lewis Ehrlich (30:25.98)
So then you throw that paper away, you don’t even bother, right? So that everything has to match. So yeah, I mean, it’s a real, I think it’s one of those topics that you could study for your whole life and you would never like truly master it. It’s extremely complex and nuanced, but.people love simplicity. And I think that that buts heads because people want to know for sure that something is true or not. And the reality is that there’s a huge amount of gray area within science, which is kind of a good thing because it keeps people curious to find out answers, if their heart’s in the right place, which is good.
Dr Ron Ehrlich (31:13.998)
Reproducibility is another important part of research, isn’t it? And there is a little bit of a problem with reproducibility in the healthcare industry, isn’t there?
Dr Lewis Ehrlich (31:24.808)
Yeah, so nature, speaking of high impact journals, nature is a high impact journal, very well respected. They came up with a paper that showed so reproducibility is essentially, you know, the ability to reproduce results. So therefore you build confidence to know that those results are actually more likely to be true than not. And so nature, nature does study and show that 70 % of scientists couldn’t reproduce the study results of other scientists in their analysis and 50 % of scientists couldn’t reproduce the results of their own research when done again.
Dr Ron Ehrlich (32:12.92)
Jesus. Okay, yeah, yeah, yeah. Well, you know, this comes back to, I mean, it’s great. I know there is a guy, a professor at Stanford University, John Ioannidis, who I’d love to get on as a guest. I’m gonna, that’s my next thing after you, Lew. Well, just to put this in perspective for our listener, when you write an article in a scientific journal and it gets referenced, that’s called a citation.
Dr Lewis Ehrlich (32:25.81)
Yeah.
Dr Lewis Ehrlich (32:31.334)
I’d love to listen to that.
Dr Ron Ehrlich (32:42.158)
And if you get a couple of hundred or even a couple of thousand citations, you are doing very well. 10,000 citations is amazing. John A. and Edie’s has been cited over 200,000 times and he alerted us many, the medical health community many years ago to the fact that there is a very difficult to tell the difference between evidence-based medicine and evidence-based marketing. What are your thoughts on that?
Dr Lewis Ehrlich (33:11.964)
Yeah, I think it comes back to a little bit of the tentacles of industry getting into science and then swaying results. I think that if you want to promote a new medical product, a new pharmaceutical, a new supplement even, you know, because let’s not forget the nutraceutical industry is not immune to bias as well, even though it’s considered more quote unquote natural.
Dr Lewis Ehrlich (33:43.0)
so there’s, yeah, again, it’s, it’s one of those things where there’s huge amounts of biases, positive results and more likely to be published than negative ones. But like I also said, there are some good studies, you know, on industry as well. So, I mean, look, I think that you could definitely find huge amounts of papers that are evidence-based marketing.
Dr Ron Ehrlich (33:57.826)
Right.
Dr Ron Ehrlich (34:09.048)
Yeah, I think I know we’ve been talking about this within our family and Annie, my wife, who works at University of Technology Sydney, and she prefers the term evidence informed, which is, I think, alludes more to your nuanced approach. There are some, what do, I mean, a lot of practitioners are not gonna go off and do a one year program at Oxford.
that you’ve done or 18 month program at Oxford that you’ve done on evidence based medicine. What are some red flags that practitioners and patients should look out for when evaluating these kind of things? What would you suggest? Knowing what you know now and knowing that a lot of practitioners aren’t going to do what you’ve done.
Dr Lewis Ehrlich (34:54.524)
Yeah, so I think that the first thing to say is that there’s a there’s a huge amount of resources out there that don’t necessarily mean you have to go off and study, you know, for multiple years doing this this sort of course. So I mean, just there’s so many podcasts, for example, at the moment where they’re actually doing really great interviews that are showing you how to. analyze data. So I know, like, for example, Peter, it’s here is a, you know, has a big podcast called the drive. He’s got he’s had one back in 2023, where he sits down with somebody and they actually go through how to analyze research at a high level. So you could, you know, that’s an that’s an hour and a half or two hour podcasts, it can give you an idea. There’s so many sub stack people to follow. I
Dr Ron Ehrlich (35:49.79)
Who are you following?
Dr Lewis Ehrlich (35:51.784)
I follow Dr. Vinay Prasad. He’s an American oncologist that really understands how to dig into the data and simplify it for people. Very statistically sound as well. The head of Oxford Evidence-Based Medicine is a guy called Carl Hennegan and he has a
Dr Ron Ehrlich (35:55.426)
Mm-hmm.
Dr Ron Ehrlich (36:05.762)
Mm-hmm.
Dr Lewis Ehrlich (36:20.314)
subset called trust the evidence and they just go through examples of you know studies or topics that say one thing and they might say something different and they show you how to actually get to that point so that can give you a more sort of nuanced balanced approach as opposed to taking something as gospel so there are a few
But yeah, just in terms of paper analysis itself, you know, you’re obviously looking at sample size, you’re looking at study design, you’re looking at whether or not the statistics are sound, that’s another topic. You know, the quality of research put into a systematic review, like even within a study, you still have to go and look at the studies within the studies that they’ve quoted. So that can be a bit of a minefield as well. How much bias is in it? You know, like all that catalog of bias that I talked about earlier, you can go and see if there’s signs of those things popping up in a paper, a whole range of things. But I think that those…resources that I mentioned are actually a really good thing for health practitioners to go and listen to and subscribe to and just show an interest in because you’ll get better health outcomes and provide better advice.
Dr Ron Ehrlich (37:47.374)
We’ll have links to those in our show notes. Just coming back to the quality of a research, because this is another issue within evidence-based medicine that we’ve come to the point where a double-blind randomized control trial is seen as the gold standard for medical research. I mean, it might be worth reminding our listener of what a double-blind randomized control trial is, firstly.
Dr Lewis Ehrlich (38:07.666)
Mm-hmm.
Dr Lewis Ehrlich (38:14.557)
Mm.
Dr Ron Ehrlich (38:15.118)
But in fact, let’s do that. What is, I mean, is that true? What are the levels of standards of research from randomized control to observational longitude? And I don’t even know what some of those mean. Can you just give us a little bit of a short 101?
Dr Lewis Ehrlich (38:31.504)
Yeah. So like a, there’s just a pyramid of a hierarchy of evidence, essentially. So, you know, systematic review meta analysis is a compilation of whole range of studies. And then they’re the really rigorous ones are placed into the studies themselves, the study itself, and only the ones that are really rigorous get included. And then they do a full statistical analysis.
that’s what a meta meta analysis is. It’s the statistical side of things, but a systematic review is a compilation of the, the really rigorous papers that have made it into that to form a totality of evidence that suggests that a result is true or not. So that’s like the gold standard. Obviously a randomized control trial is a single study. So a systematic review is a compilation of, of all those studies.
Then the next level is obviously randomized control, double blinds. So you’ve got two groups compared to each other. One’s blinded, they don’t know that they’re getting an intervention versus another group that get a placebo, for example. And then the results are analyzed and…and recommendations based off that and then you get into observational studies, you know, where you…
Dr Ron Ehrlich (39:57.452)
And the double blind, is referencing the fact that not only is the patient blinded to what they’re receiving, but so is the practitioner. Is that right? Is blind as well. So that’s the double.
Dr Lewis Ehrlich (40:07.046)
Yeah, the researcher is blinded as well. So there’s no bias and influence that could be, you know, they might not, if the researcher’s not blinded, they could, you know, potentially change things to guide people, guide the results to what they want. So it’s obviously far better if both the person and the researcher is blinded, because it’s more likely to minimize bias.
Dr Ron Ehrlich (40:36.428)
And just to remind our listener too about placebo, placebo typically would be something totally inert that wouldn’t elicit any kind of reaction at all. So you can’t get it. It’s not like you give the same, a different drug as the placebo, like you’re doing antidepressants, you’re giving the new antidepressant to one patient and an old antidepressant to another patient. That’s not a placebo. A placebo would be a sugar pill.
Dr Lewis Ehrlich (40:44.125)
Yeah.
Dr Lewis Ehrlich (41:04.326)
A sugar pill. Yeah.
Dr Ron Ehrlich (41:05.806)
or something that’s not going to have any effect at all.
Dr Lewis Ehrlich (41:08.614)
Yeah, like say you want to, like just off the top of my head, say you wanted to treat PTSD on military veterans and you give someone, you know, medical grade MDMA and you give somebody else a sugar pill. And that’s obviously going to build a lot of rigor into the data because you’re not comparing, you know, like for like.
Dr Ron Ehrlich (41:33.514)
Yeah, and the same would be true, say, I know this is a contentious issue, but vaccinations too. If you were trying to show that a vaccine was effective and safe, you would compare that vaccine to a sugar pill or a salt injection that had no effect at all. That would be a gold standard to establish the safety of a vaccine. that be that’d be right? Yeah, yeah, we could spend a whole hour talking about.
Dr Lewis Ehrlich (41:56.144)
Yeah, correct.
Dr Ron Ehrlich (00:01.944)
Now, Lew I know there’s another aspect that is often used in the world of evidence-based marketing, and that is the difference between a relative and absolute risk. Like, I know that, for example, statins reduce the risk of heart attack or heart disease by 36%. And that’s really impressive. Who wouldn’t do something like that?
And we need to understand the difference between relative and absolute risk. Can you just explain that one to us?
Dr Lewis Ehrlich (00:36.9)
Yeah, so really important because a lot of the the articles in the media will often use relative risk and people go, wow, that’s an amazing result. So for example, if you took a a new Alzheimer’s drug, and it reduced the risk of Alzheimer’s by 50%, you would read that in an article and go, wow, 50%. That’s huge. What a reduction. But if you use absolute risk, and you found that the actual risk went from one and a thousand, you know, got to two and a thousand, the difference is 50%. So the absolute risk is tiny, you know, one and a thousand to two and a thousand.
But the relative risk of that is 50%. You’d go, my God, this is incredible. But the reality is that it barely moves the needle, right? And we know that even you know, Alzheimer’s drugs, cancer drugs, COVID vaccines, often what’s reported in the media is actually relative risk, which often inflates their efficacy.
Dr Ron Ehrlich (01:50.956)
Yeah, yeah, yeah. And that that is so often used in the in selling of a drug because to a busy practitioner, you know, if you can reduce the risk of dementia by 50 percent, who wouldn’t do that?
Dr Lewis Ehrlich (02:06.753)
Yeah, credit to Oxford as well on that because in class we went through about 10 newspaper articles in class together with all the health practitioners in the one classroom and we analysed what the newspaper article said. We pulled up the paper that it was based on and what we found is almost exclusively that it was never nearly as effective as what was written.
in the media. So that’s just something for people to keep in mind.
Dr Ron Ehrlich (02:39.554)
The other one that I have heard now Ross Walker has talked about on this program before as well is number needed to treat. What tell her can you explain that one to us?
Dr Lewis Ehrlich (02:50.945)
Number needed to treat, yeah, so basically, how would I put this in real simple terms? So basically the amount of people you need to treat to get the result that you need. So, you know, if you give somebody a…a drug, one person a drug and you get a great result, that’s obviously a good number needed to treat.
But if you have to give people 100,000, you have to give 100,000 people this particular drug and then you get a result, the number needed to treat is obviously huge and therefore the drug isn’t that effective. So that’s how.
you would explain that. So the number needed to treat, if I gave you Ron a drug and said, this will reduce your risk of heart disease significantly. And it did do that after one, but if I gave it to a hundred thousand people and none of them worked until the hundred thousandth person, then obviously you need to treat a lot of people to get the result. So not as effective.
Dr Ron Ehrlich (42:00.832)
What about, look, I mean, there’s a lot of issues here. And I love the fact that you having studied as much as you have, have taken this very nuanced approach. You know, I’m very proud of you, Lew. It’s not the way I would approach things. then, you know, you’re more mature about this than I am, clearly. Look, I also know that the practice that we are part of, you are part of, you’re now the principal of,
talks about a patient-centered approach. If the current model of evidence-based medicine is compromised, and I think you can be as nuanced as you like, it is compromised. What does a more trustworthy patient-centered model look like? How do we get there? What do you think?
Dr Lewis Ehrlich (42:50.95)
Yeah, I’ve been asked this a few times. It’s a really tricky one. I think one thing is to definitely educate as many people to a deeper level that are health practitioners. I think it has to be more deeply taught in their degree because
you have to be able to analyze things at a deeper level because the waters are getting so murky, you know, in terms of influence, buyers, study design, et cetera. Particularly, I suppose, you know, with AI coming as well, it’s going to just be, the research will just be coming out left, right and center. I think that we need to reduce the amount of industry influence in.research and try and build more philanthropic.
Dr Lewis Ehrlich (43:52.392)
resource availability. There’s a lot of hugely wealthy people that could do some really amazing things by just letting universities conduct their own studies and try and minimize the amount of bias that’s within it. I think I’d love to see more negative results come out on things.
But I think that at the moment, like 96 % of TGA funding coming from industry, like 4 % is not, it’s not 50-50, it’s hugely skewed. So like I said, there are advantages of having industry, but we just need to get more neutral, unbiased funding as opposed to the funding being given by people that need to.get a result so that they can keep shareholders happy. think, you know, non-for-profit is idealistic, but also helps science a lot, you know.
Dr Ron Ehrlich (45:02.552)
Yeah. Lew I want to thank you for joining us today, sharing your knowledge and wisdom. I know we’re going to get you back very soon. In fact, in next week’s episode, we’re going to talk about a very contentious and controversial issue in dentistry on root canal treatments. And I think this was a good introduction to that next episode. I’ll have links to a lot of the resources you’ve suggested, but thank you so much for joining us today.
Dr Lewis Ehrlich (45:32.562)
Thanks, Ron. Appreciate it.
Dr Ron Ehrlich (04:00.654)
Well, it’s complicated, isn’t it? It’s nuanced. I love the fact that Lewis, having studied all of that, has kept a very open mind and realizes and explains how nuanced it is. There are over 48, there are 48 different categories of bias that can influence a work, how it’s funded. Is it all all’s well? Is it a, does it have…
Is it hot stuff that will make the news? Will it continue the funding to be channeled into research, et cetera, et cetera? And look at the end of the day, this is a story that I’ve been following since my very early days in dentistry when I was parroting what I had been taught. And in that particular case at university, what I’d been taught was that…
Mercury is locked into a silver amalgam filling. 50 % of it is mercury, but don’t worry, it’s locked in. And that’s what I was taught. But actually that is not true. And fluoride, water fluoridation is a great thing. And we could talk about that. I’ve done other topics on that. And if you’ve read my book, you’ll know my position on that, but it’s nuanced. The same goes for a whole range of things. So I’ve been following this story for a long time. Now it’s interesting that
Lewis mentioned some of the referee journals and the Cochrane collaboration because one of those referee journals that he mentioned, the New England Journal of Medicine, some 20 odd years ago, the editors started to write editorials which were somewhat critical of big pharma’s influence on health care. And she was dismissed from that journal and then went on to write a book called The Truth About Drug Companies and How They Deceive Us.
the head of the founder, one of the founders of the Cochrane Collaboration, Danish physician, Professor Peter Gotzsche he’s a physician, an epidemiologist, a researcher. He was one of the founders of the Cochrane Collaboration and 10 years ago published a book called Deadly Medicines and Organized Crime, How Big Pharma Has Corrupted Healthcare.
And if you’re following the food story about how public health policies set about the food pyramids and about the low-fat diet and the demonization of animal products. One needs to know look no further than big food for the influence there and the influence they have on all levels of health care. So this is a very very big story and I think it’s important to understand the nuances and the challenges involved and where does that leave us as a listener, as a member of the public?
Well you have to take control of your own health, and stick to some very basic things. I believe that as the world we live in becomes increasingly more complicated, so many of the solutions are remarkably simple, they’re cheap, they’re accessible, they’re sustainable, and what’s more, they are effective. That’s for the vast majority. Now, if you are then diagnosed with a condition, well, you need to take a step back and take stock and do some exploring that yourself and go to trusted sources.
And that’s what I hope this podcast is about. That’s what I hope. That’s what I know. Unstressed health is about. And I invite you to join that community until next time. And we will be getting Dr. Lewis back next week to talk about another very contentious issue. Root canal treatments. Now, if you have had any, you will may or may not be familiar with it, but it is a contentious issue.
Again, it’s nuanced and I’ll invite you to join me for that until next time.
This is Dr. Ron Ehrlich. Be well.
Transform your health with the Unstress Health Membership
