Family Doctor, Clinical Epidemiologist, Researcher, Teacher, Therapist, Life coach.
Bruce Arroll graduated in New Zealand, trained in Family Medicine at McMaster University in Hamilton, Ontario, and completed a Masters in Clinical Epidemiology in Vancouver, before returning to NewZealand.
At McMaster, he was so impressed with clinical epidemiology, which later became an evidence-based practice, that he began a PhD in Epidemiology when he returned to NZ late in 1987, conducting a randomised controlled trial of sodium restriction and exercise in treated hypertensives. In 1991, he joined the Department of General Practice and Primary Health Care, where he has remained. His research changed to rational prescribing of antibiotics in primary care, and he later got interested in rapid assessment and treatment of mental health conditions. In 2015, he started training in FACT (focussed acceptance and commitment therapy). He now works at the Calder Clinic at the Auckland City Mission with a highly disadvantaged group of citizens, most of whom have been homeless but are now housed, and many of whom have substance issues and where the average age of death is 51. Bruce has trained in written exposure therapy and is planning on conducting a randomised controlled trial in the Calder Clinic. He is also director of the Goodfellow Unit (www.goodfellowunit.org), which educates primary care clinicians.
Watch the video of the interview below or on Youtube and listen to the podcast on Spotify and all the major platforms
“…a friend of mine was thinking of going to medical school. I had thought that it was too late to switch, but I decided to switch and after two years of engineering, I joined the class that I graduated in. I felt a bit old for the first three months but after that I adapted and a lot of my best friends are classmates from that time.”
Today I’m talking to Bruce Arroll in New Zealand. Bruce, you’ve had the most wonderful, exciting, and interesting career, but I want to take you back to the very beginning because you very nearly didn’t do medicine. You started off in engineering.
Bruce Arroll: My father was a pharmacist, and he wanted me to be a doctor, but I was quite good at maths at school and my headmaster was a mathematician and he tried to encourage me to do something with mathematics. So, I went into engineering for a couple of years and I think realized that you really have to be a genius in mathematics. And I was no genius. I was just pretty good at it. I can calculate but I wasn’t one of these people who could imagine four dimensional things like some of the really bright scientists. So, I did a couple of years and then a friend of mine was thinking of going to medical school. I had thought that it was too late to switch, but I decided to switch and after two years of engineering, I joined the class that I graduated in. I felt a bit old for the first three months but after that I adapted and a lot of my best friends are classmates from that time.
DMacA: Even at that stage you had an international perspective because you went on an elective to Nepal.
BA: I knew the daughter of the Himalayan Trust doctor who was a good friend of Ed (Edmund) Hillary and, although I didn’t meet Hillary at that point, I met Hillary later in life as part of the Fred Hollows Foundation, which is charity. (https://nzhistory.govt.nz/edmund-hillary-and-tensing-norgay-reach-summit-of-everest)
I went there for three months and that was amazing. Visually its a most amazing country, and culturally extraordinary. And, the medicine was pretty amazing. I got very good at diagnosing and treating tuberculosis with old fashioned drugs like streptomycin, which is what we were using at the time there.
I got as far as Tengboche Monastery but I didn’t get quite to Everest ‘base camp’ because it snowed when I got up there. I didn’t have the best footwear and I was a bit afraid of frostbite. I got up to about 12,000ft, and was able to see Mount Everest. I took about ten film reels of photographs. In those days you didn’t have a digital image so I had to bring the film back to New Zealand to get developed before I knew if I’d even succeeded in getting one. In New Zealand we have a bit of a love affair with Mount Everest because of Edmund Hillary, the first person to climb it, and it looms large now in our history
DMacA: Nepal has stayed with you throughout your life and you’re still involved.
BA: I’m on the Himalayan Trust now with Ed Hillary’s son Peter. He’s climbed Everest twice. And his grandson Alexander, who’s the CEO. It’s one of my roles on the Himalayan Trust is to select students from New Zealand to go to Nepal for their elective. We sent three up last year and we’ve another student going up in a couple of weeks. One has since become a Rhodes Scholar, which is pretty good. We try to send the best of students up there so they don’t ruffle feathers and they have a good experience. It’s a wonderful place to do an elective.
“And the other amazing thing about McMaster was that your educational needs trumped your service needs. It was like a smorgasbord of learning and I signed up for everything. “
DMacA: After you’re qualified, you spent some time in Canada, and you went to that cathedral of evidence-based medicine, Mc Master.
BA: Absolutely, I lucked out there big time. I wrote to a bunch of places looking to do a Master’s in general practice, and McMaster wrote a beautiful letter the back saying- we don’t think you’re ready for a Master’s, but would you like to come and be a family practice resident? It was like a job offer and off I went. I didn’t realize that clinical epidemiology and evidence-based medicine were just starting then. And I got taught how to read a medical journal with Brian Hutchinson, who just passed away about six months ago, who was one of my teachers at McMaster with Jacqui Wakefield. And that was so enlightening because, in that era, the senior consultant was always right, and the medical student was wrong. But, if you can read the latest paper, you can be right and the boss may be wrong, so that was very liberating. And the other amazing thing about McMaster was that your educational needs trumped your service needs. It was like a smorgasbord of learning and I signed up for everything. Because I’d done a bit of general practice in New Zealand I went into the second year and I was with Jacqui Wakefield who was one of the top guns. They put me with her because I’d done a bit of general practice, they thought she could probably contain me, which she did, and that was wonderful. They had so many talented people at McMaster and it was amazing. I didn’t meet Dave Sackett that year because he was on sabbatical but I got to meet him later and was his minder when he came to New Zealand and, after he retired, we kept in touch by email. I was very sad when he passed away but what a wonderful man and what a wonderful contribution to health care. And I liked the Gordon Guyatt’s quotation, when he said, clinical epidemiology is the basic science in evidence-based practice, because in recent years I started to quietly call myself a clinical epidemiologist because I’ve been quite interested in the science behind our decision making and effective treatments, in which I think all GPs should be interested.
DMacA: You clearly enjoyed Canada because you stayed on and spent some time at the University of British Columbia, in Vancouver.
BA: I went to rural BC because I had to go to a place where no Canadian would work, and at the first place I went to my two colleagues were suing each other in court so I got out after ten months and went to Lillooet and that was lovely. There were two doctors there, a British doctor and a Canadian who had both done their surgical training, so they did operations. Indeed, we did a tracheotomy on a patient one night. I had a lovely time and I’ve still got a lot of friends there when I get back. And then I went to Vancouver, where I did six months in psychiatric emergency care, worked in general practice, and then did a Master’s in Clinical Epidemiology. It was part of public health training and I was the first one to do the clinical epidemiology option with Martin Schecter, who had graduated from McMaster, and Sam Sheps, and Clyde Hertzman who passed away quite a few years ago, they’re all McMaster acolytes. It was as if McMaster had moved to the West Coast. I reconnected with Gordon Guyatt when I was there and I later invited him to New Zealand to a couple of a couple of times so we’ve kept in touch.
“There was a GP there who said- the trouble with you academics is you don’t talk medical shop anymore, you talk about your research. I always remember that …Gordon Guyatt still does clinical work as well as his research work. And, you know, David Sackett actually went back and retrained as a physician.”
DMacA: Inspired, you came back to New Zealand, and did a PhD in clinical epidemiology.
BA:. Yes. I and that was with Robert Beaglehole a well known epidemiologist cardiovascular and worked with Rod Jackson, who’s become quite prominent over the years. He developed the cardiovascular risk assessment. He got one of those little Framingham calculators and we put that into a table. He then published cardiovascular risk tables which have now become international. Then we started combining risk factors rather than treating single risk factors. You have Q risk in Europe and we still do five year risk here. Robert Beaglehole went on to work with the W.H.O.. and was the director of non-communicable diseases for a while. It was very handy having him as a boss as we got a few big publications, because of his name I think, not because of mine as nobody knew me.
DMacA: You have mentioned some intriguing names and you’ve met some fascinating people? Tell us about some of the people you’ve met.
BA: Carol Herbert was there at the time and my friend David Kuhl is still in Vancouver. There was a GP there who said- the trouble with you academics is you don’t talk medical shop anymore, you talk about your research. I always remember that and I always make sure that when I’m with my clinical buddies, we talk shop. And I’m very pleased to see that Gordon Guyatt still does clinical work as well as his research work. And, you know, David Sackett actually went back and retrained as a physician. At age 55 he went back and did residency again to get back his clinical skills. When I came back to New Zealand, I got invited to the Cochrane set up in Australia. I found Iain Chalmers particularly inspirational. I’d not heard of him although, interestingly, there was a link through the paper I’d done on episiotomy which got me into research, because he was on the West Berkshire trial. So, I’d actually came across his name research wise, but I didn’t know who he was or where he was, but I think he is a really values driven human being. And so that got me in the Cochrane Collaboration. The whole Cochrane thing was amazing because it lead to a number of BMJ systematic reviews. The Cochrane software just made that so easy to do. The whole science of systematic reviews and the ability to do a meta-analysis without having all sorts of software was pretty amazing. Meeting Iain Chalmers was quite inspirational at that point in my life.
And then meeting people like Chris Del Mar, who just passed away after a surfing accident a few years ago. They were great people to meet. And they really made you want to work with them, basically.
DMacA: Taking you back a little because I believe you did your house jobs with another remarkable and unusual person…
BA: Richard Smith, of all people. I was the trainee intern and he was the house surgeon. And a chap called John Kolbe was the registrar. And, Richard was just Richard. He just made us laugh. He’s such a funny, clever man. He can have you rolling around the floor. We did think it was rather odd that he was going off to be a deputy editor of the BMJ. I’d never heard of the BMJ before that, and I remember thinking it was a bit of a waste, a bit of a dead end, only to see him explode the quality of the BMJ, which is actually one of my favourite journals. One of my particular favourites is the Christmas BMJ. I’ve had two articles in the Christmas BMJ, which were a lot of fun. So I’m still trying to get my third one, I want to get the trifecta. I’ve got one more idea.
“…you think you’re going to be doctors but, actually, you’re going to become behaviour change specialists. For example, in getting somebody to follow your advice after an operation you need to change people’s behaviour; to get people to take their medication, it’s all about behaviour change.”
DMacA: We’ve talked about your research and your interest in clinical epidemiology, but you have a great interest in education as well. Tell us where your interest in education came from.
BA: Well, when I was a medical student, I can remember subtly assessing my lecturers for the quality of their lectures. And, it went from the truly great to the truly awful.
I remember one guy, who was a lovely, lovely man, but he did the anatomy of the respiratory tract. And instead of starting from the nose and going to the alveoli, he jumped around all over the place. And I kept thinking that, if I were giving the lecture, I’d start at one end and go to the other so you can see how the cells changed. And I always thought, I would like to be a really good teacher. I really enjoy teaching and throughout my career that’s one of the things I’ve loved. When I retire from the university, I will have a major grief experience at not having a class of medical students. I’ve always looked at ways of making teaching exciting and getting feedback. And, I have a website called www.BruceArroll.com which has a link to “How to give a good talk”, if anybody’s interested. I love doing lectures. I love trying to make things simple for people. If you go to a lecture and you come out feeling like you know less afterwards, that’s a bad experience.
More recently, in the last ten years, I’ve been Director of the Goodfellow Unit at the University of Auckland, which some people actually think is the department because it’s fairly prominent. It was set up by a generous family in New Zealand, the Goodfellow family, about 40 years ago. And we got into podcasts and webinars and a lot of digital stuff fairly early. I’m quite amazed at how podcasts are exploding. When we started ten years ago, we were one of the first kids on the block for medical podcasts. And, that’s been very satisfying, because I feel like as a researcher, I generate all this new knowledge but does anybody take any notice of it? Probably not. So, the idea is to try and get clean information, as Muir Gray, would say. We want to get clean clear information to the troops just as we try to get clear clean water to the population in the 19th century. And, of course, with the modern disinformation that has its own challenges. But, its a lot of fun. We have a group of about six of us and we produce a webinar every two weeks, a podcast every two weeks, online stuff all the time, and so we do about 200 products a year. This digital world is amazing.
DMacA: Now, let me ask you about something else. You have such a wide range of interests and now you’re not a life coach…
BA: I heard a woman called Sharee Johnson who does coaching for doctors in Australia, on Sam Mangar’s podcast, The GP Show. and I thought, wow! I contacted her and she said, well, if you want to work for me, you have to do this course through ICEL in Sydney, one of the best coaching organizations. So, for the last two years I’ve been doing my coaching training with them. And I have to say there’s quite an overlap with clinical medicine. As I say to my students, you think you’re going to be doctors but, actually, you’re going to become behaviour change specialists. For example, in getting somebody to follow your advice after an operation you need to change people’s behaviour; to get people to take their medication, it’s all about behaviour change. And I think that coaches do it better than the doctors and they have a whole lot of checklists to make sure people are going to do it. I’m offering free coaching to final year a medical students at the moment. That’s been pretty interesting, just hearing about their concerns, and it seems that imposter syndrome is one of the big things that seems to be bothering a lot of them as they’re about to go out in the real world and become doctors. As you can imagine, that interface is a bit stressful for some students.
DMacA: Allied to that, you also are involved in something called Focused Acceptance and Commitment Therapy (FACT)
BA: A colleague of mine called Peter Bowden, who was a community GP, came to the department one day with a stack of books, and he started talking about a bunch of things, including acceptance and commitment therapy. In 2015, I had a sabbatical in Vancouver, and I went down to Yakima, which is, three hours drive east of and over the mountains from Seattle to spend a week with Dr Kirk Strosahl who was one of the founders of Acceptance and Commitment Therapy. He and his wife figured out that if you want to provide psychological help to primary care, you’ve got to be embedded in the clinic and see patients as they turn up. His partner, Patti Robinson, was doing it for the US Air Force and the New Zealand government were looking for this. So, we now have hundreds of health improvement practitioners in New Zealand trained by Patti Robinson. I’ve been going more to ACT conferences in recent years than primary care ones, because I’ve got more interested in mental health and I find there is just not enough mental health at the primary care conferences. My research focus now, and for the last probably 25 years has been increasingly on rapid diagnosis and rapid interventions. And I discovered just a few years ago through Pim Cuijpers in Amsterdam, a meta-analyst, who I got to know, that behavioural activation is the most effective treatment for depression, not drugs. Drugs really only work in very severe depression. But the effect size is still small. That’s where evidence-based practice has been quite good because I’m always running around looking for effect sizes, looking for big ones and the big ones aren’t with the drugs in the mental health context, they are with behavioural activation. That’s been quite a fun journey in itself. And now I’ve got a single question for depression- emotional quality of life. We validated it and I audited my practice and it’s quite a popular paper in the British Journal of General Practice Open.
“…I’m really enjoying the place. The characters are amazing, the medicine is amazing, and the staff are amazing. So I have probably another ten years and then that’s it for me. I leave the university in a couple of years and that will be a very sad moment. But, it’s been a good run.”
Annual New Zealand Primary Healthcare Awards | He Tohu Mauri Ora 2021. New Zealand Doctor Rata Aotearoa
DMacA: We’ve ranged across your entire career with all these academic and various other commitments. But finally, I’d like to bring it back to real general practice, because that’s where you are at the moment. You’re working in a mission environment.
BA: I worked in South Auckland for 32 years and, about a year ago, because the driving was getting too hard, I did a locum for my colleague Prof Ngaire Kerse. And I really liked the staff. The staff are extraordinary because they have to be, the average age of death is 51 years old in this clinic. The people are medically very sick. When I got there, I discovered that pretty well everyone had a diagnosis of PTSD because that goes with substance use and homelessness and all that sort of stuff. Now I’m interested in an intervention called Written Exposure Therapy, on which I’m about to do, my last randomized trial. I haven’t got the energy to do any more randomized trials, but we’re doing a little randomized trial in the mission. It’s very effective. About 95% of people get a pretty good response. It’s about writing about your trauma on five occasions. Based on the work of James Pennebaker from Texas, this is expressive writing, and that’s pretty exciting. Its only because I had an honours student that I went to all this trouble. I’ve really run out of energy for ethics committee, and clinical trials registry, and all the circus that goes with just even starting a randomized trial that takes a year’s work. But I’m really enjoying the place. The characters are amazing, the medicine is amazing, and the staff are amazing. So I have probably another ten years and then that’s it for me. I leave the university in a couple of years and that will be a very sad moment. But, it’s been a good run.
DMacA: When I hear you say it’s been good run, I’m thinking about title of the movie of your life. And I think you’ve already given us the title. It will be “My last randomized controlled trial” Bruce, it’s been an absolute pleasure talking to you. Thank you very much for sharing so much of your life and your career and your interests. It’s just been wonderful. Thank you.
Some key papers
- Arroll B, Roskvist R, Moir F, Harwood M, Eggleton E, Dowrick C, Cuijpers P. Antidepressants in primary care: limited value at the first visit. World Psychiatry 2023;22:2:340
- Arroll B, Allan GM, Elley R, Kenealy T, McCormack J, Hudson B, Hoare K.Diagnosis in primary care: probabilistic reasoning. J Prim Health care.2012;4(2):166–173.
- Arroll B, Chin W, Moir F et al. An Evidence-Based First Consultation for depression Br J GP 2018;68(669)200-1
- Dahle N, Matthew C, Roskvist R, Moir F,Arroll B. Emoqol-100: Development and validation of a single question for low mood in primary care. A retrospective audit. Br J GP Open 2023 July DOI:10.3399/BJGPO.2023.0011
