Curating Evidence for the Primary Care Clinician
Mark Ebell recently retired as Professor from the College of Public Health at the University of Georgia and is currently Professor of Family Medicine at Michigan State University.
Dr. Mark H. Ebell is a graduate of the University of Michigan’s Medical School, Family Medicine Residency, and School of Public Health. He is Editor-in-Chief of Essential Evidence Plus and Deputy Editor of the journal American Family Physician. He is author of over 600 peer-reviewed articles and is author or editor of eight books, with a focus on evidence-based practice, screening, respiratory infections, and clinical decision-making. Dr. Ebell served on the US Preventive Services Task Force from 2012 to 2015, and in 2019 was a Fulbright Scholar at the Royal College of Surgeons in Dublin, Ireland. In 2024 he won the STFM Curtis Hames Award for lifetime achievement in primary care research.
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“… that started out when I was the only doctor in this rural practice, I was really struck by- how do I find the answers to questions I might have. I used to be able to just tap someone on the shoulder and ask them a question. So, how do you keep up with new information? How do you make better decisions?”
Today I’m talking to Mark Ebell a well known primary care epidemiologist. First lets talk about your backstory. You’ve described yourself as a quite unusual American. Tell us a little bit about that.
Mark Ebell: Well, I was raised by German parents. I was born in Montreal and I grew up speaking German before I spoke English. As a result of having all of my family in Germany, we travelled to Europe quite a bit and my wife and I still enjoy going to Europe. I’ve spent the last month or so in Europe, in Wales, in Copenhagen, in Croatia, and in Italy. And I love it. My wife actually had a Fulbright Scholarship which she did in Padua, Italy. She’s also an academic but in a totally different field. We fell in love with that old university town in the north of Italy and we bought a small apartment there. We go there several times a year and absolutely love it. We’re trying to learn Italian, which is horribly hard for an old brain, but we’re working at it.
DMacA: Let’s bring you back to medical school. Tell us about that trajectory because your first degree was in biology.
ME: Yes, that’s pretty typical in the US. We do four years, usually of a science discipline, and I did biology at Kalamazoo College. And I’m not going to say which year, but I think it’s our 41st reunion at Kalamazoo College that’s coming up this weekend! It’s a small school and I loved the experience there. There were only 1200 students and I was really able to participate and get to know my professors. And then I went to the University of Michigan for medical school and also did my family medicine residency there. A few years later I also did a degree in clinical research design and statistical analysis and that was a really important part of my research trajectory because, instead of just faking it and not really knowing what a p-value was, I learned some basic statistics, epidemiology, and I was able to apply that. I still do all of my own analyses when I do my research.
DMacA: Tell us about the transition from family medicine to epidemiology.
ME: That was really an accident as, like so many things it was not planned. I was an associate professor with tenure at Michigan State University. My wife got an offer of a faculty position at the University of Georgia, which was a great offer for her, and we decided we would take that. I left my position and basically went to work for myself. I was in a private practice. I was starting a software company that eventually developed the POEMs and Essential Evidence and I was working on that. And then the University of Georgia decided to start a medical school so they hired me to help plan this new medical campus, which was a lot of fun. I love building new things and creating new things, and it was a great experience. But when that was done, there wasn’t a research position at that new medical campus as it was purely educationally focused. So, I went to the College of Public Health, where the best fit was in epidemiology because they studied things like respiratory infections. And I thought, I study respiratory infections and cancer screening, that’ll work. And, so I’m not really an epidemiologist. I’m a family physician and my identity is as a primary care researcher.
DMacA: You mentioned POEMS and you mentioned your software company. And that’s developed into something that’s really terrific. Just take us through, step by step, the evolution of this idea.
ME: In 1990 I was the only doctor in Madison County, Georgia, my first position out of medical training. I went from this really busy medical centre to being the only doctor. There were three treatment rooms, a nurse and me, and that was it in rural Georgia. Culturally I’m from the north of the US and the south is can be quite different. I still had in the back of my mind this idea of doing academic medicine and I signed up as a peer reviewer. Paul Fisher, who was the editor of the Journal of Family Practice which at the time was a research journal, sent me an article to review. It was an essay about a new idea called Information Mastery. Dave Slawson and Allen Shaughnessy had come up with this idea, a framework for how family physicians can keep current with new information and improve their practice. Information Mastery
Paul had initially rejected it. Dave and Allen asked him to please send it out for review. I thought it was absolutely brilliant, I loved it. It ended up getting published, fortunately. And then at the next Society of Teachers of Family Medicine meeting, I met Dave and Allen, and we schemed ways to get these POEMs into print and to do it on a more sustainable basis.
We’ve been writing them for over 25 years. We write about 250 per year and it’s a wonderful effort. It’s been a lot of fun. I enjoy doing it. It keeps me current and, hopefully, its helpful to the folks who get it every day in their email.
DMacA: So how does that work? How do you get that penetration of the community?
ME: Initially what we were doing, and what we still do to some extent, is to publish a selection of the POEMs in medical journals. American Family Physician, for example, has four POEMs per month so people learn about it that way. We also publish four per month in an Italian journal, A lot of faculty learn about it through meetings that we go to, presentations we give, and social media obviously and POEMs and Information Mastery have won several national awards. Dave and Allen got an STFM award recently for their work on POEMs and, I guess, it’s just grown organically. People hear about it and, if they like it, they subscribe. I’m not much of a marketeer!
DMacA: When you when you say subscribe, what does subscribe mean?
ME: We started this company back in the mid 90s and in 2007, Wiley Blackwell, a publisher, purchased it and they now operate it as a subscription business- Essential Evidence Plus. For $90 or $100 a year, you get the POEMs every day. Plus you get Essential Evidence, which is an online reference aimed at family physicians. It’s mostly written by family physicians as well as specialists but the primary audience is primary care doctors.
DMacA: Perhaps you would tell us more about Essential Evidence Plus.
ME: Again, that started out when I was the only doctor in this rural practice, I was really struck by- how do I find the answers to questions I might have. I used to be able to just tap someone on the shoulder and ask them a question. So, how do you keep up with new information? How do you make better decisions? And this was in the really early days of the internet, with dial up modems. There were no online references and we still had books on a shelf. For example, I was in a clinic for people without insurance or with Medicaid, who had very few resources, and there were these brand new fancy drugs called calcium channel blockers and ace inhibitors. These were new at the time and much more expensive. My question was – were they any better than hydrochlorothiazide? I had a big jar of hydrochlorothiazide tablets that I could just give people. Was it better to put them on an ace inhibitor? I also noticed differences in what people were doing. For example, post MI in Michigan we used beta blockers and never used calcium channel blockers. At the hospital in Athens, Georgia, the cardiologists all use calcium channel blockers and no one used is beta blockers. They can’t both be right. They can’t be singing off the same page of the hymnal. That really made me wonder about evidence and the how we make decisions. And that shaped my career. So I started writing software while I was in solo practice, and I would send out disks, and I printed up a little handbook. It was very primitive. It was written up in MD Computing magazine and eventually that became a software that was more full featured called Info Retriever, with a little golden retriever on the logo (and I have two golden retrievers behind me here!). Eventually it became more professionalized when Wiley bought the company.
“When I was 15 I took a class at the local community college and it was punch cards on a mainframe computer. I taught myself various other computer languages, and I still write code. I write code for my research and also for Essential Evidence as part of my work. I enjoy that.”
DMacA: We’ve been talking about computers and programs, but you wrote a real book as well. Tell us about the book.
ME: I’ve written a few. The one you might be thinking of is ‘Handheld Computing” which I wrote with Scott Strayer, and this was in the early days when the Apple Newton had just come out. This is early 2000 and the Palm was a thing. I’ve been playing around with computers for a long time. When I was 15 I took a class at the local community college and it was punch cards on a mainframe computer. I taught myself various other computer languages, and I still write code. I write code for my research and also for Essential Evidence as part of my work. I enjoy that.
DMacA: And then, with your background in evidence based medicine, you wrote in 2017, that only 18% of clinical recommendations are based on high quality evidence. Do you still feel that’s the case?
ME: I think it’s getting better and this view is based on Essential Evidence. We have 800 chapters with each built around a different disease or different symptom such as chest pain, diabetes, hypertension and each chapter has a set of bottom line key recommendations graded by A, B or C using the taxonomy where A is consistent patient oriented evidence at the highest level. We just counted up the recommendations- how many A, how many B, how many C, that we’re basing our decisions on. And that was a way of trying see how strong the evidence is. I think it’s gradually getting better. Every year there are more and more randomized trials, more and more meta analyses published. It’s kind of nuts how many there are- there were like 40,000 meta analyses published in the last year! In many cases there are more meta analyses than there are original studies on a question. The ease of doing a meta analysis compared to the difficulty of doing a randomized controlled trial, relatively speaking, has led to, what I would say and I think some people would argue, too many meta-analyses. We’re drowning in them. And what we really need is more original research and clinical trial evidence.
DMacA: So, when you’re asked by a single handed family physician in a rural area, what’s my best way of keeping up to date? What your answer to him or her?
ME: Of course, I would recommend they subscribe to Essential Evidence! But, there are some things that I’ve learned in other countries. In Ireland, for example, where I did a Fulbright Fellowship in Dublin at RCSI with Tom Fahey, and met with folks at University College Dublin, and Susan Smith who is at Trinity now. When I was there I learned about these learning circles. Irish GP’s often get together in small groups on a regular basis and have a learning circle. I was recently in Copenhagen talking about using POEMs as a way to do continuing education and in Denmark they do the same thing. I’ve always thought that’s a really great idea because you have a group of peers, you feel comfortable, and you’re okay exposing your lack of knowledge on a topic as you get to know folks better and trust them. And that’s when you can learn, when you’re open to learning new things. I think that’s a really good example and I hope other countries can emulate that. We don’t do it here in the United States, not in any formal, national, or structural basis. But I think that’s something that would be good.
You really need two things. You need some way of being alerted to new information and that’s what the POEMs do. I was talking to a physician yesterday and she said, ‘I read a POEM about antibiotics for community acquired pneumonia. And I read another one about diltiazem with the direct oral anticoagulants increasing bleeding. And at the time I read those, I didn’t use them. I just filed it away. And then a month or two later, I had a patient with pneumonia, and I started thinking about that network meta-analysis. I had a patient who came in bleeding on diltiazem and Eliquis (apixaban)’ And she said, ‘I remembered those studies and I was able to go back and stop the medication because I now knew that that was probably part of this patient’s problem.’
First, you need a way to be alerted, and then you need to be able to find that information in those 2 or 3 minutes that you have at the point of care to access the information. You need both of those tools. That’s a framework that David and Allen came up with that they call Information Mastery. And there are other good sources of these alerting services.
There’s Journal Watch from the New England Journal of Medicine and I think they do a pretty good job. They’re more focused on adult medicine and don’t do as much in the way of Obstetrics, Gynaecology or Pediatrics like we do. There’s several out there, but the main thing is that they must be independent of pharma and industry which is, obviously, something we value a lot.
We do two free podcasts without advertising aimed at primary care physicians,” Primary Care Update” (30 minutes every 2 weeks) and “Primary Care POEM of the Week” (5-10 minutes per week). They can be found on various podcast hosts including Apple Podcasts and Spotify. The show profile pages are shown here:
Primary Care Update: https://podcasters.spotify.com/pod/show/primary-care-update
Primary Care POEM of the Week: https://podcasters.spotify.com/pod/show/mark-ebell
DMacA: What comes across is that you’re really still enthusiastic and keen to impart this information. So how do you keep academically fresh? You’ve mentioned the Fulbright Fellowship, which is one example. Tell us about the Fulbright Fellowship and other opportunities.
ME: The Fulbright is a wonderful Fellowship. It’s from the US State Department. My wife did one in 2018, in Padua. And, I thought, that’s great. I’ll do it in 2019 in Ireland. I had gotten to know Tom Fahey, and some other folks at the RCSI in Dublin from various meetings. There’s a meeting called the General Practice Research on Infections Network or GRIN and I’ve been going to the GRIN meetings for about ten years. I was usually the only American there. It is a small meeting of 80 or 90 people, folks like Paul Little, Theo Verheij, or Sam Coenen. It’s a really great group of researchers. It’s my happy place to go to the GRIN meeting each year and I was just in Wales last month at that meeting. I got to know Tom and we talked about some ideas for projects. We both have an interest in clinical prediction rules so we built several projects around that and meta analyses. I also did a study looking at aspirin for primary prevention because my office was next to a pharmacologist who was interested in that. It was a really wonderful, experience and, obviously, living in Dublin for a few months is a great thing. I was very fortunate. But I’ve also spent time as a visiting professor in Würzburgand in Zagreb, and other countries, and I’ve always enjoyed that experience.
Some representative studies from 2024
*The LOCH risk score for COVID-19 in outpatients: https://www.jabfm.org/content/jabfp/37/2/324.full.pdf
*An interactive calculator for the LOCH risk score: https://ebell-projects.shinyapps.io/LehighRiskScore/
*Best antibiotics for outpatients with community-acquired pneumonia, a network meta-analysis: https://pubmed.ncbi.nlm.nih.gov/38360961/
*Acute cough in outpatients: what causes it, how long does it last, and how severe is it for different viruses and bacteria? (from our EAST-PC study funded by AHRQ): https://pubmed.ncbi.nlm.nih.gov/38977076/
Link to paper in Annals of family Medicine
DMacA: Let me ask you now about another academic component, which is very topical at the moment, and that is your recent paper on Alzheimer’s.
ME: The new monoclonal antibodies, in particular, were being quite heavily promoted. And what first caught our attention was that the Food and Drug Administration, the FDA, convened an advisory panel and they had, I think, nine people on it. The advisory panel voted with eight against and one abstention and no one supported the approval of the drug.
And they said, ‘oh, thank you for your service’. And they approved the drug anyway. When the next drug in that category came up, they didn’t even bother to convene the advisory panel. And this just seemed very fishy to us. We started looking at the studies and our focus was on looking at what’s called the minimal clinically important difference, or MCID.
We have these scales, so you have an 80 point cognitive scale. How many points does someone have to improve before they notice it? Or their caregiver notices it? It turns out that it’s typically in the range of 8 to 10% so that maybe a 6 or 7 point difference on an 80 point scale might be noticeable. But these drugs were improving the rating on the scales by 1 or 2 points, far less than the MCID and far less than a patient or their caregiver would typically notice, even after two years of treatment, and they were causing some significant harms. People were dying because of these medications and the company knew it. And in many cases, people had seizures, they would have swelling or bleeding in the brain that was clinically causing symptoms. There was also the need for a regular MRI to monitor these things. In addition, the drugs are insanely expensive, perhaps $30 to $40,000 a year. So it’s the combination of very little benefit, significant harms, high cost, high inconvenience. What’s not to like! We decided to do a meta-analysis of all of the studies of all of the drugs, whether they were approved or not. And it was a very consistent story for each drug- very little benefit. None of them came close to exceeding that MCID and all of them had significant harms.
DMacA: That certainly is the academic controversy of the current moment, which almost brings us up to date in your academic career. But tell us a little bit about the Curtis Hames Award https://stfm.org/curtisghames
ME: That was a lovely surprise. Curtis Hames was a physician in Georgia who, back in the 1940s and 50s, was a general practitioner in rural Georgia who did cardiovascular prevention research on the patients in his practice. He took drew blood samples, he had a fridge in his basement where he kept them, and he did work on cardiovascular risk factors. He was really a model and he was probably the first general practice researcher in the United States. This award is for lifetime achievement in research and it’s given by the Society of Teachers of Family Medicine. And I was really honoured to receive it this spring in Los Angeles.
DMacA: Before people begin to think that you are just a one track academic, my final question is to ask about what you do for relaxation, because I think we’ve a shared interest in physical activity.
ME: Yes, I love to bike. I’ll be going for a bike ride later. The temperature is getting up to about 58 degrees, which is, about nine degrees Celsius, and I’m up in our home on Lake Michigan to enjoy the Fall colours. So I’m going to go for a nice long bike ride. My wife and I love to bike when we’re in Europe, and I’ll be going on a tour with some friends in the Netherlands in the spring, so I love doing that.
I also am very nerdy. I enjoy building airplanes and models, and so I’m sitting here working on a Hawker Hart biplane right now, and that’s something I picked up about 10 or 15 years ago after having abandoned it as a child. And, I still find it very relaxing.
DMacA: It’s been an absolute pleasure talking to you. Thank you very much for sharing your academic world, your leisure world, your background, and indeed your life. Thanks so much.
