Richard Smith: Six memos on the future of healthcare

Richard SmithHow many of us can expect a year after we die to have some 500 people attend a meeting to celebrate our life, discuss our work, and think about the future agenda that flows from our work? “Almost none of us” is the answer, but it happened for Alessandro Liberati in Bologna in December. Most of us in the audience knew Alessandro personally, and we were celebrating not only his work but his great personal warmth. He was fun to be with, and his warmth and ideas have been captured in a video filmed over two days at Forte Dei Marmi when shortly before he died he sat with his friends and talked. The video will be available online soon.

Alessandro founded the Italian Cochrane Centre and promoted evidence based healthcare and policy in Italy. He was passionate that research should be relevant to patients’ problems and easily available to them, and these passions were strengthened by the poor quality of research and the unavailability of evidence on the myeloma that eventually killed him. Several speakers during the day quoted the letter he published in the Lancet shortly before his death in which he wrote: “How far can we tolerate,” he wrote, “the butterfly behaviour of researchers, moving onto the next flower well before the previous one has been fully exploited.”

The friends of Alessandro who organised the meeting had the interesting idea of constructing the day around Italo Calvino’s  Six Memos for the Next Millennium. Calvino is one of the most original and unusual writers there has been, and his book comprises five of the six lectures he was due to give at Harvard in 1985-6. He died before he could give the lectures, but he had written five and thought about the sixth. They all have one word titles—lightness, quickness, exactitude, visibility, multiplicity, and the unwritten consistency—and they are all built around books. The past millennium, write Calvino, was “the millennium of the book. In that it [saw] the object we call a book take on the form now familiar to us.” He thought about the future of the book confident in the future of literature because of “the knowledge that there are things that only literature can give us, by means specific to it.”

Some mental gymnastics were needed to relate medical knowledge and Alessandro’s ideas to these themes, but the two dozen or so speakers rose to the challenge, some sticking close to Calvino, others concentrating on Alessandro, and some doing their own thing.

Lightness was characterised as “removing weight” and avoiding dogmatism. Alessandro was strongly opposed to dogmatism, which has been a failing of some zealots for evidence based medicine. He believed as well in a light style of writing, often using the first person and aiming for the opposite of what Micheal O’Donnell famously called “decorated municipal gothic,” the favoured style of the pompous, a large group within medicine. Medicine too should be light, concentrating on what can bring benefit to patients, and avoiding the overdiagnosis and overtreatment that are now weighing it down.

Quickness or rapidity can be a problem for those who believe medicine and health policy should pay close attention to systematic reviews because such reviews take a long time. Policymakers often want evidence quickly, and systematic reviewers must balance providing the evidence they need with producing reliable reviews. Researchers might be able to do better by thinking harder about the opportunity costs of not supplying evidence and the risks of getting advice wrong.

Exactitude is difficult for clinicians because healthcare is characterised by uncertainty. There is more that we don’t know than we do know.  It is important not only to be clear about what we don’t know, healthcare’s uncertainties, but also to develop mechanisms to help doctors and patients prioritise the uncertainties that should be addressed through research. The James Lind Alliance has helped people do this, and Testing Treatments Interactive is an inspiring and sometimes amusing website that helps people understand how treatments can be tested. This understanding is worth having because an important systematic review recently published in the Cochrane Library showed that new treatments are hardly any better than existing ones.  Progress is slow and possibly an illusion.

Systematic reviews could be said, however, to aim at some kind of exactness, and Alessandro weighed in on their behalf in some fierce intellectual battles. Alvan Feinstein, one of America’s leading epidemiologists, argued in the Journal of Clinical Epidemiology in 1995 that systematic reviews were just the modern equivalent of alchemy, trying through dubious methods to create intellectual gold from rubbish. Alessandro argued against him in the same journal and gave as good as he got, and history has come down on his side. (This debate was played out again in a less intellectual, but more gladiatorial and show business form between me and one of the editors of the New England Journal of Medicine, which took Feinstein’s view, at the Cochrane Colloqium in Rome organised by Alessandro.)

Impossible to intimidate, Alessandro also debated with Hans-Georg Gadamer, a leading German philosopher, who argued that the relationship between a patient and a doctor was more important than the discipline of medicine or the evidence. Alessandro retorted that this was a false dichotomy.

In his essay on visibility Calvino discusses the question of the priority of the visual image or verbal expression. He leans towards the visual image, and when asked to think of health systems people, I suspect, see doctors in white coats, surgeons operating, and large, sparkling hospitals.  Some four fifths of people in all countries also think of medicine as an exact or almost exact science. These images were destroyed in a session that showed how health systems are actually characterised by complexity, uncertainty, opacity, poor measurement, variability in decision making, asymmetry of information, conflict of interest, and corruption. I’ve already blogged on this session, and as of today (29 December) the short blog has been Tweeted some 200 times, suggesting it struck a chord.

I spoke on multiplicity and the core of my argument, which I must confess was far from coherent, was that everything is connected to everything else and that most of the time the many will do better than the few. I plan a separate blog on this.

Calvino never wrote his essay on consistency, but we were taken back at the meeting to an earlier lecturer in the same Harvard series—Leonard Bernstein, the great American conductor and composer. Bernstein talked about the crisis in music in the first decade of the 20th century when Wagner and Liszt had pushed traditional musical systems to their limits. Then came atonality with the fear that music would collapse into anarchy, noise. In fact new and beautiful music emerged, showing how there can be at least two forms of consistency.

Consistency matters in public health as well as music, and Austin Bradford Hill described consistency as one of the features that suggests not simply association but causality.  But we were reminded that results that might seem inconsistent might actually be consistent on deeper analysis.

This very special day, which Alessandro’s widow and two daughters attended, ended with the federal minister of health paying tribute to Alessandro. He had driven across the Apennines from Rome specifically for the meeting. The whole day was captured on video, and you can learn and see more on the Facebook site.

Competing interest: RS spoke at the meeting and had his expenses paid by the health department of Emilia-Romagna.  He was a friend of Alessandro Liberati, and when RS was editor of the BMJ and chief executive of the BMJ Publishing Group there were both intellectual and business collaborations between the group and enterprises involving Alessandro.

Bologna on La Sanità tra Ragione e passione (Health through reason and passion). The meeting was held to celebrate the life and work of Alessandro Liberati, the founder of the Italian Cochrane Centre, who died last year.

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.