Interview with Trish Greenhalgh
Trish Greenhalgh is Professor of Primary Care Health Sciences at Oxford University. As Co-Director of the Interdisciplinary Research In Health Sciences (IRIHS) unit, her applied research regularly pushes the boundaries of evidence-based policy and practice. We caught up with her to find out her views on Brexit, the impact agenda and what continues to motivate her ongoing work. Her answers show why she has become such an inspirational figure to many researchers.
1) “You have dedicated your career to improving medicine by understanding how to get evidence into practice. What is your core motivation for working at the research-practice interface, and how do you motivate your colleagues to make their research count?”
“I was a young doctor and had just been appointed to my first academic post when evidence-based medicine (EBM) appeared on the horizon (around 1992). I had qualified in 1983 so the first few years of my career had introduced me to the long tradition of ‘priestly authority’ and ‘eminence based medicine’ in my profession. A group of us seized upon EBM as an approach that promised to revolutionise the investigation and treatment of patients. No longer would we be working by guesswork.
But very soon after immersing myself in the (epidemiological) science behind EBM, I realised that the existence of high-quality evidence (from research trials) did not automatically lead to the systematic and rational care of patients, for three reasons. First, a lot of research evidence is inaccessible (and in particular, it’s not to hand for point-of-care decisions). Second, even the most ‘factual’ research evidence is still open to multiple
interpretations (take the current arguments on statins for example). And third, there is no simple solution to the question of how to dovetail research evidence with more traditional forms of knowledge such as the wisdom of experience or the hunch of intuition. So, in summary, I got into the ‘research-practice interface’ because that was where the interesting research questions lay.
How do I motivate my colleagues to make their research count? I wouldn’t put it quite like that. What I would say is that nobody is going to care about your research unless they have a direct personal stake in the findings. In my experience, the best way to get anyone to care about your research is to make sure they’re involved in setting the research questions, designing the study, doing the research and helping disseminate the findings. I know there’s a lot of attention currently on getting patients involved in research, but the same principle applies to policymakers and clinicians. And early involvement of these stakeholders is not just to give you an opportunity to TELL them your ideas, it’s a series of opportunities for you to LISTEN and NEGOTIATE so that the research you undertake gradually gets shaped into something that matters to your non-academic stakeholders.”
2. “How did your experience as a practicing GP shape your practice as an academic?”
“Actually, the best story here is from before I became a GP. I was training in diabetes, and I remember a patient—an elderly lady originally from the Caribbean—who I saw for the first time in a busy diabetic clinic. As she came in I started to ask her “did you bring your book of blood glucose readings?”, but in parallel with me asking that question, she said—very quickly so it sounded like a foreign language at first: “DocIgotyousomebananabutIleftemintheson carwhenhegivemethedropo .” I asked her to repeat this greeting more slowly so I could follow it. “Doctor, I went and got you some bananas (as a present). But I left them in my son’s car when he dropped me off”. The lady had not brought her blood glucose book, but (unlike me) she was not troubled by this. What troubled her was turning up to see her doctor without a gift. She respected everything I told her, and (as I got to know her over the next few months) turned up faithfully to her appointments, always with some fruit or vegetables for me. But we never made much progress with her diabetes control. This patient had a profound e ect on my academic career. She made me realise that unless we understand where patients are coming from culturally (what is the significance of the gift relationship between patient and doctor in her society?), we might as well put our evidence-based guidelines through the shredder.
I’ve deliberately given a very specific example—partly because this particular lady gave consent for me to ‘teach’ on her case, but mainly to illustrate that in medicine, it is usually by reflecting on surprises or incongruities at the fine-grained level of individual patient care that some of the best research ideas are born. This particular case inspired me to write my very first research grant, which led to a Wellcome Trust-funded study of diabetes narratives in different cultural groups, undertaken in collaboration with two anthropologists, which was (I believe) the first ever cross-cultural study of patients’ illness narratives to be published in the British Medical Journal (1998; 316: 978-83).”
3. “You tweeted recently that “evidence-based medicine saved my life”. How has this experience shaped how you view research?”
“In June 2015, I was diagnosed with a rare and aggressive form of breast cancer. Fortunately, it was caught early. Even more fortunately, the tumour cells were covered in a protein called HER-2 (human epidermal growth factor receptor 2). One of the biggest success stories in modern medicine is the drug trastuzumab (Hercpetin), a bioengineered monoclonal anti- body that binds tightly to the HER-2 protein (and in doing so, kills the cancer cell). I had surgery and conventional chemo- therapy but those treatments alone would have been unlikely to have saved me because of the very high grade and growth rate of my tumour. But a year of Herceptin injections has reduced the possibility of any recurrence to less than 1 percent. By coincidence,
I was on the NICE appraisals committee that originally approved Herceptin for use on the NHS because the evidence of its efficacy in HER-2 breast cancer was overwhelming. At the time, I never thought I would one day be on the receiving end of this ‘designer drug’.
So how has that experience changed me as a researcher? Firstly, when I look at the results of clinical research studies, I now tend to imagine real people with real illnesses—some of them life-threatening—on the receiving end of the drugs or procedures. Small impacts on population samples may mask big impacts on individuals (and perhaps negative effects on some). Secondly, I’m nowhere near as sceptical about ‘personalised medicine’. It’s true that in the 20 years since Herceptin was marketed, only a handful of anti-cancer drugs with comparable dramatic effects at the molecular level have appeared on the market. Cancer is a fickle and changeable beast—there are many thousands of cancer types, each with a different target protein(s), and hundreds of research groups testing candidate molecules (my university alone has just built an enormous building called the ‘Target Drug Institute’ to house some of those groups). The attempt to match every cancer type to a new magic bullet sometimes seems overwhelmingly ambitious and prohibitively expensive. But now that I owe my own life to one of those magic bullets, I feel committed to support the endeavour.
4. You are vocal online about the potential negative impacts of Brexit. What do you see as the key threats to evidence-informed policy and practice in healthcare and beyond?
Brexit is, in my view, a disastrous mistake. It will have both immediate and far-reaching effects on the science base of our country for numerous reasons. First, there will be a drain of talent away from the UK at every level, from professors right down to MSc and PhD students. Second, international collaborations will be harder to initiate and maintain. Third, the economic effects of Brexit will mean severe cutbacks in research budgets even notwithstanding the potential loss of access to EU funding. But as important as any of these effects is the cultural impact of a profoundly regressive policy decision. Since Britain joined the EU in the early 1970s, we have enjoyed progressively greater tolerance and cross-cultural interaction. It is no coincidence that women, as well as religious and sexual minorities, have seen improvements in their human rights and that all this has gone hand-in-hand with progression in intellectual thought and academic freedom. We are beginning to see signs that all these freedoms—including the freedoms we academics hold most dear—are being called into question. To be honest, this scares me deeply and I do not know whether I will be prepared to continue to live in the UK post-Brexit.
5. If you could give one piece of advice to a researcher who is interested in generating impacts from their work, but can’t find time, what would you say?
I’d invite them to look on their job description. If the upstream activity that will one day lead to impact (e.g. building relationships with policymakers, engaging with industry or clinicians, speaking to the lay public) is not on their job description, and if they’re not being performance-managed against those kinds of activities, then it’s probably not the researcher’s fault they’re doing little or no impact work. It’s a system issue. I would encourage that researcher’s head of institute to work on the human resources policies, ensuring that researchers at every level are incentivised and rewarded for impact-related activities and that they are trained appropriately. Apparently at the leading US universities, 20% of all research-active time is designated to impact-related activity. In the UK, too many worthwhile impact initiatives are described by seniors as “wasting time”. So let’s look at the models of good practice and change the system.
Trish Greenhalgh’s new book, How to Implement Evidence-Based Healthcare, is published by Wiley Blackwell. Find out more about her work on Twitter @trishgreenhalgh or at: https://ww- w.phc.ox.ac.uk/team/trish-greenhalgh