“I met this weird guy called David Sackett who was inventing the ideas that became evidence based medicine. And that led to the future….”
Jim Dickinson is a Family Physician and Professor at the Department of Family Medicine at the University of Calgary.
After medical training from Queensland University, Australia, he trained in Family Medicine at McMaster University, Canada, then a Kellogg Fellowship at McGill University in Canada. He returned to Australia and wrote his PhD on Preventive Activities in General Practice, while working in General Practice and as a Fellow at Newcastle University. Subsequently he was the first advisor in General Practice to the Australian Department of Health in Canberra, then held chairs in the University of Western Australia and Chinese University of Hong Kong. He returned to Canada in 2002, and been at the University of Calgary since then,
He has had a long-term interest in prevention and screening, and has contributed to provincial and national screening program committees, and was appointed to the Canadian Task Force on Preventive Health Care from 2009 to 2016. He runs the Alberta sentinel practice program for surveillance of respiratory virus disease in the Alberta community, the TARRANT program. He also researches antibiotic use in community practice and writes about health care policy.
Martina Kelly is a professor in the Department of Family Medicine at the University of Calgary. She qualified in Ireland, later completed her Master’s on reflective practice in clinical placement learning in 2007, earned an ASME travelling grant to the University of Alberta in 2010, and she moved to Calgary in 2012. Her PhD comprised a series of qualitative studies, using a phenomenological lens, on the meaning of touch in clinical practice. In 2022 she received the AFMC–Gold Humanism Award as a leading investigator in the nuances of human connection.
Walking to the Department of Family Medicine on a winter morning.
Photo, Martina Kelly
Hello, my name is Martina Kelly and welcome to MedicsVoices.com, where we talk to the key opinion leaders in health and medicine. Today I’m talking to Professor Jim Dickinson, who is Professor of Family Medicine in the University of Calgary. And I am lucky enough to call him a colleague. So thanks, Jim, for joining us. And I have a few questions for you.
I wanted to start by asking you about what it was like growing up in Australia, and what made you interested in becoming a doctor?
James Dickinson: I grew up in Brisbane and my father was a GP. I’m a third generation GP. All of his siblings were doctors. So, it was just part of the way the world was. He was a GP with his surgery in the house, and people would come to the door to be seen.
It was just part of life. And he always was on call. He had a colleague down the road and they swapped call so he took some time off but, you know, he was very much the old fashioned GP. He later moved into a government job working with the insurance agency. My brother and I, he’s a year older than me, we just did the usual things. We were sailors, that was a big sport. At school, I was interested in science, and in particular, had a wonderful bio/ zoology teacher that really got me excited about that. First I thought, yes, I’d love to do marine biology, because the Great Barrier Reef is there and I was fascinated by all of that.
But then I realized that there’s not many careers in that field and I transferred into medicine.
MK: You did your undergraduate studies in Australia but then you moved to Canada..
JD: As a medical student, I was interested in medical education, so I learned a bit about medical education and had read about McMaster University as being the center of new ideas in medical education. I did the usual rotating internship and did some time in rural areas and during the second year I was thinking of doing surgery, but then I had a chance to go to McMaster as a family medicine resident, so I took that. I thought I’d do it for a year, see how it goes. And everything went on from there because I met this weird guy called David Sackett who was inventing the ideas that became evidence based medicine. And, that led, to the future.
MK: I wanted to ask you about working with David Sackett, a name we all sort of venerate. How was that, working with him and learning with him?
JD: Well, it wasn’t that I was working with him. I was working with the family medicine teachers, who were influenced by him. All the people around were thinking hard about- what are we really doing? Why are we doing it? And that was what was most interesting.
I managed to do two courses in his department which was in addition to being a family medicine resident. It was just the way of looking at things in a different way. I remember one particular seminar that he introduced by saying that “criticism is an act of love. It shows that you care enough to help this person to move ahead, so that they’ll be better the next time.” And there were other educational principles that came through McMaster that I had not met before which were really interesting. That led to not just accepting the status quo. It’s about questioning and moving forward in a way that I had not met in my medical school education
MK: From working with you, I would say that you’ve continued to bring that ethos and ethic into your clinical practice and your education. Criticism as a form of love feels against some of the more general ways in which we think sometimes in family medicine. What has that experience been like for you over your career?
JD: With the particular sort of person I’m not fazed by criticism although I recognize that some people can’t cope with it very well. And that’s one of the problems that I’ve had over the years.
MK: I see you as somebody who’s always able to stand up for things you believe in. And in a way, I think you’ve also challenged the tide. Advocating for less would be something I would see as a hallmark of your work in, for example, the change in cervical screening policy here, not just routinely doing PSA screening…Would you be able to talk about your experiences of doing that.
JD: Maybe it all comes from childhood. One of my father’s mantras was- leave it alone, it’ll get better. One of the big things in family medicine is working out the threshold. What things are best just left alone. And which things do you actually need to treat. And that’s a constant battle that we have to work on. Given the body’s physiology and ability to heal and so on, we have to be really cautious about when we actually need to do things and when not. That’s one of the things that David Sackett pointed out as well. And, if something works, just because it’s a good thing doesn’t mean a whole lot more is a whole lot better. And that was certainly the issue in cervical screening. Yes, cervical screening was a good thing and has really helped to reduce cervical cancer enormously. But, doing it from a very young age and every year, which was the standard in North America, really doesn’t actually help. I do remember a case at McMaster, of a young girl of about 16 who wanted go on the pill and I was told I had to do a pap test on her, and that just didn’t make sense. That’s one of the things that led me to question what was going on. And as I read more into it, I realized that in Europe, they don’t start screening until aged 25 or 30, and it’s not as if women are dying on the street from cervical cancer. In fact, they had better outcomes. So yes, doing less, do the right thing, but don’t overdo it.
MK: And what has your experience been as a family doctor advocating in that space. I would see you as a leader in screening in Canada and I think that that’s not always been an easy space to be in.
JD: That’s right. A lot of what we’ve done has generated huge pushback, and that’s not surprising. Many specialists see disasters but they tend to generalize from what they see. And, of course, their job is to see the disasters. But that doesn’t mean that we should necessarily treat every patient that we see as if they’re going to become a disaster. Getting that balance right is the tricky bit. And that’s led to a lot of pushback when talking about screening. We say you do this much, but doing more isn’t going to add extra benefit. I remember when I was doing some palliative care, where we ran a palliative care program for the region in Newcastle, when I went to see people who were dying of cancer, I would come back into my practice and think, I’m really going to try and prevent this. But then I’d realize that, no, we can only do so much. Some things are just not preventable. And, rather than feverishly following recommendations to screen everybody, even those who are at very, very low risk, part of it is understanding this is a probability game, not perfection. There will be some people who will get breast cancer at the age of 18, and no screening program is going to be able to solve that. We can only do screening when the probability is high enough. That makes it worthwhile doing it against the potential hazard, harms, and costs of doing that screening. Getting that balance right is a really tricky thing, and there’s never going to be a perfect answer.
MK: Just reflecting on North America or Canada. that sort of goes against the mantra of trying to do everything with every piece of technology thrown at the patient, do you feel there’s an important role for academic family medicine in countering that narrative?
JD: Absolutely. There seems to be an idea which I think comes out of Central Europe, it also occurs in the central Europe, Germanic, Viennese culture of medicine, that somehow dying is optional. That, if you do everything, you won’t die. Well, sorry guys, there’s only two things that are certain in life. And you know, it’s only a matter of which thing we’re going to die of. There’s that concept that if we do a lot more we can hold back the tides of time. And unfortunately, we can’t. So, our job as doctors is to help people on their way through life. But the death rate will remain 100%.
MK: In later years, you have also been quite a strong public health advocate for things like vaccinations and public health water issues. And I’ve seen your writing in the academic literature, but also leveraging more public ways of disseminating knowledge. Would you be able to talk a little bit about your experience in doing that?
JD: The vaccine work really came out of taking over from my predecessor, Mike Tarrant, and his program of influenza surveillance in Alberta. I picked up on that, which wasn’t an area I had done a lot of work on. But then I got involved with the wonderful Dr. Danuta Skowronski at BC CDC, who used that surveillance data to actually assess vaccine effectiveness. The problem with influenza vaccines is that they’re only partly effective. It’s great to have vaccines like measles and tetanus where, if you apply the vaccine, the disease disappears. But of course, it’s much more nuanced when you have vaccines that are only partially effective. Trying to understand what their role is has been interesting. And then, yes, you have to speak about it so people understand what’s happening. That was the one thing.
And the other one was where I got invited to help on the campaign to restore water fluoridation here in Calgary after it had been removed by the council. That was where epidemiological skills came in, very helpfully, because the evidence about fluoridation is mixed. Again, it’s not a perfect solution to the problem and trying to understand some of the older evidence. Yes, it’s not good according to modern ways of producing evidence but it was still valuable evidence for today. Trying to put together all this partial evidence has helped me to reflect on scientific knowledge because the opponents of fluoridation use every trick of rhetoric and misleading science to make it sound obvious that fluoride is a poison and that it’s going to kill lots of people.
But, you know, there’s lots of people around the world who get fluoride and none of them are dying from it. The other argument is that it’s going to cause brain deficits but again, there is no evidence that the people of Singapore have terrible brain problems because they got 100% fluoride. There’s no signal.
So, how come people are picking up little bits of data and shouting from the rooftops that fluoride is bad. What are the logical bits? What is the actual evidence? What does it show? It’s been a real intellectual challenge, and working out what’s going on and then trying to communicate it. In a sense the fun thing is how to communicate good scientific evidence, particularly in areas where there is only partial evidence, a lot of smokescreens and misleading ideas. That’s fun. That’s intellectually challenging.
MK: One of the things I read in one of your biographies, and that you had written about, is engaging strategic authorship for knowledge dissemination. Could you give the rest of us some tips on how to go about that?
JD: Well, one of the classic fallacies is argument ad hominem. And so let’s take cervical screening, for example. If I, as a middle aged male, am trying to tell women what they should do, that doesn’t come across very well. So it’s really helpful if I enlist help from women who are personally involved. That helps the story to make sense to readers who are, not necessarily looking only at the science, but looking at everything around it. That’s one example…
“People who deal with selected populations really don’t have any idea of what we’re dealing with on the frontline, both in terms of the issue of probability, trying to work out who we should actually screen, who’s appropriate, but also in terms of seeing the harms. ”
MK: I’m going to shift gear a little to talk about medical education, which has also been a big interest of yours. Would you be able to comment on how you started with David Sackett and the emergence of evidence based medicine, which is now almost de rigueur. Do you have any reflections on your journey through evidence based medicine and how we teach it now?
JD: In a sense, when David Sackett was first starting, it was much simpler. The principles were there and there wasn’t a lot of extra. Since then, as it’s developed, things have become more complex. For example, the process for doing a systematic review is now very much more complex. The Cochrane handbook about how you do a systematic review is enormously thick. Ultimately, though, it still requires judgment. And unfortunately, we now see a lot of people doing systematic reviews who haven’t yet developed judgment. If you just apply it as a recipe, you can often get some very peculiar results. And the systematic reviews of fluoride are, perhaps, a good example, because the systematic review process was really set up to help put together evidence from randomized controlled trials, and the fluoride evidence doesn’t really fit into that format. Another example was perhaps the cervical screening work where people said- but there are no proper trials of cervical screening. And at the time it was introduced, there weren’t randomized trials. It was just introduced by enthusiasts. So all you could do was look at areas with and without screening so these were population cohort studies, which ranked lower on the scale of evidence. But nonetheless you can definitely see a large effect. So I had to persuade people that this was still good evidence, that you don’t have to insist on randomized controlled trials, but you have to interpret it all carefully.
And I think part of the problem with the fluoride reviews is they insist on applying the framework of randomized controlled trials to data that doesn’t really fit that framework. And their conclusion is that this is all uncertain- we don’t know whether it works or not. But, no, that’s the wrong way to look at it because its the equivalent of using a screwdriver on a bolt. It doesn’t work very well.
MK: The other thing for learners to think about is looking at the quality of data.
JD: Looking at the quality of the data is really important. And that’s part of the problem with the fluoride stuff where there’s a lot of poor quality data on selected populations that needs to be set in context. And if you set it in context, you see that, no, that really doesn’t apply. It looks good initially if you just do simplistic analyzes. So you have to really engage with the evidence to come out with what conclusions you can draw from it, and then you find out whether they’re right.
MK: Do you think your clinical experience as a generalist helps you take that broad overview, in being able to see the bigger picture when you’re thinking about different forms of evidence.
JD: Absolutely. It’s necessary to do that. Whenever we engage with specialists in any particular field, whether it’s in mammography or cervical screening or various other fields, they see the world from among the patients they see which, as I say, are a biased set. Being a generalist, you can see that that it’s a biased set. And therefore, unless you’re very careful, you can reach conclusions that may be quite correct based on what you see, but that actually don’t apply to the broader population. So the issue of, population relevance is really critical.
MK: So from your perspective, having generalists or family physicians on screening, guideline teams is a key component, in order to appraise the evidence appropriately?
JD: For screening guidelines its essential, particularly because it’s our population on whom you’re doing the screening. People who deal with selected populations really don’t have any idea of what we’re dealing with on the frontline, both in terms of the issue of probability, trying to work out who we should actually screen, who’s appropriate, but also in terms of seeing the harms. With mammography, for example, they don’t see the patients who say- I’m never going to do that again- after they’ve had a couple of bad experiences. When we get people coming back and saying- well, they took me in and they squeezed my breasts, and then they gave me this biopsy, and that was really painful. And yeah, I may have lumpy breast, but I’m just not going to ever go back to that place again- . Or, the ones who’ve had various treatments and suffered the side effects of it. We see everybody coming back so we get a better overall picture of what’s happening to people and also recognize that the number who are actually cured may only be a small fraction of those with the disease, and that the benefit is only perhaps very small for the total population.
“To have a health care system that works properly, we really need have to have good front line workers in the trenches, and that includes the whole team that we need around us. Medicine has got a whole lot more complex during my career. It’s much more difficult to do what we do and we need more support to do it.”
MK: I’m going to shift gears again because one of the things I’ve enjoyed about working with you is your sense of humor. So I’m going to share a bit of a secret that you dress up as the Easter Bunny every year and give out Easter eggs, and that you distribute “Lamingtons” (a famous Australian cake). So I wanted to ask you about having a sense of humor in in family medicine.
JD: With my patients, particularly those that I’ve been seeing for 20 years of so, it’s just fun interacting with people that you’ve got to know and you can deal with at a humorous level. You can get messages across in a different way. Actually, two of my academic papers of which I’m very proud, are teaching papers based on humor. One was the paper about the ‘The Elsewhere Bias’- how the doctors at the ‘Mount Olympus General Hospital’ are always complaining about the terrible referrals they get from the town of Elsewhere, and it’s because of the intrinsic bias. Doctors in the town of Elsewhere are fairly ordinary doctors, and they manage them and treat most of the patients that come to see them- and they go away happy. Some get worse no matter what you do, and some even get side effects from their treatment so they go to the Elsewhere hospital and the specialists them with the facilities they have available, and the vast majority get better and go on their way happy. But, some of them get worse, or they need special investigations that aren’t available. Or, sometimes, the specialists at Elsewhere hospital make mistakes. So that defines the set of patients that get referred to Mount Olympus. And so the Mount Olympus Hospital only sees the two levels of failure, the failures of the first primary care doctors, and of the specialists at Elsewhere hospital, and their judgement is us based on that subset of patients. But, what is Mount Olympus for? It’s role is actually to look after those really complex and difficult patients. So they can’t complain because that’s their job. That’s the whole point. So setting that up as a humorous article, had more value, I think than, just trying to say it directly. That was fun to do.
MK: You’ve just retired and I hope you’ve lots of cool things planned, but for the rest of us left in the trenches, do you have any advice you could offer your clinical or academic colleagues based on your long career?
JD: Well, one of my biggest regrets is that I haven’t done enough about the policy issues that affect family medicine. We really need to make the point that our job is to look after 95% of the people that come in to see us. And that means we need really well-educated family physicians, because if we can only manage 90% that means 10% get referred. If a little bit of extra education could get it up to 95%, that takes a whole lot of pressure off the specialist systems and things will work better. So, we really need to advocate for better education, and for family medicine that matters, especially in Canada, where we have the shortest family medicine education program. We really need to do better than that.
But, we need to pay for it because those extra things, extra skills, take time to acquire and then to maintain. So we need to have a payment model that pays family medicine better for what we do and pays for more continuing education so we can maintain and develop our skills. I got involved in this a little but health economics and all the things around that are not really my skill, so I haven’t done enough of that. I would wish to do more. And I think we’ve got to develop advocates who can keep taking the case to the politicians that fund family medicine. I think this is a case around the world. But, we’ve also got to inform other academics who really, especially as academics, really don’t get what the problem is.
And we need to continue taking that case to the Deans of Medicine and other places that are influential in the system. To have a health care system that works properly, we really need have to have good front line workers in the trenches, and that includes the whole team that we need around us. Medicine has got a whole lot more complex during my career. It’s much more difficult to do what we do and we need more support to do it.
MK: Thank you Jim. It’s been great chatting with you.
JD: Well, it’s a pleasure to talk to you and particularly about things that matter so much, that this is what I’ve been doing all my life.
Looking to the horizon at a recent ‘Rural Practice’ meeting in Alberta
Photo, Martina Kelly
