Dr Nik Makretsov, Canada.
Looking back, less than one year after completing MSc EBHC
A retrospective view from Dr Nik Makretsov, Vancouver, Canada.
What prompted you to study for an MSc in evidence-based health care?
As an anatomical pathologist, a lot of our work is still largely based on expert opinions and biased assumptions of benefit. I was inspired to learn about evidence-based health care to develop sustainable health care for REAL benefits for our patients. I think it will be a long term struggle.
How has the MSc impacted your professional life?
During my dissertation, I prospectively collected and analysed 5-year longitudinal data provided by about 80 Canadian pathology laboratories on diagnostic accuracy of Estrogen and Progesterone tests in breast cancer. The ER and PR tests are critical decision making points for medical oncologists, as they are used to predict benefit from hormonal therapy in breast cancer, which has been convincingly shown to reduce long-term mortality. As with any cancer drugs, they have significant side effects and therefore a personalized approach is necessary, and this requires accurate test results. To make testing reliable and comparable, good quality control procedures are necessary. My goal was to develop a practical methodology for quality control, to account for the inevitable test errors (due to the sensitivity and specificity of the reagents) and to use statistical modelling techniques to reliably identify the outliers and drifters while avoiding false alarms.
Under the guidance of Dr. Sue Mallett and with help of Dr. Teresa Peres, a visiting statistician from Madrid, we developed this methodology from learning about diagnostic accuracy. We were able to visualize a large amount of test data in forest plots of test sensitivity and specificity. Their 95% confidence intervals showed the range of uncertainty in quality control assessments. We also explored several methods of modelling to compare the diagnostic accuracy between different laboratories. We observed unique patterns of statistical distribution in the data, and interpreted this for quality control in pathology. This is the first time that this has been done, in my knowledge. I am very pleased that this methodology is under consideration for implementation by Canadian Immunohistochemistry Quality control. I expect that statistically robust and evidence-based quality control will have profound effect on oncology practice. Although it is indirect, patients will benefit in different regions of Canada and around the world, as reliable and reproducible laboratory breast cancer testing will have potential to maximize the treatment benefit while avoiding unnecessary exposure to cancer therapy in a more personalized and targeted way.
Having Oxford credentials has been a powerful addition to my academic achievements. I have been asked to be a co-ordinator of the business meeting of the European Society of Pathology in London this coming September. The organizing committee has agreed to include an evidence-based agenda for the first time in the history of this society. I am proud to be among the invited speakers at this meeting. Also, Royal College of Physicians and Surgeons of Canada has supported my application for further professional development in EBM. I am excited that I will me able to take an additional module “Teaching Evidence-based practice” in Oxford this fall and re-join EBM learning community!
How have you shared your learning from the MSc with other colleagues?
I initiated a transformation of our departmental journal club into critical appraisal sessions, and the feedback has been overwhelmingly positive. I have submitted several abstracts for European and Canadian Pathology meetings based on the results of my research. I am also preparing my dissertation for submission to publication in a format of a small book.
What is your next challenge?
My immediate challenge is implementation of evidence-based practice into pathology and laboratory medicine. One of the common misconceptions about EBM is that it is all about medical interventions and clinical trials and is not applicable to laboratory diagnostic testing. My goal is to clear this misconception and spread the word about modern EBM in pathology community through critical appraisal and teaching of evidence-based practice (and perhaps future participation in biomarker-driven genomics clinical trials) as hugely applicable to the area of modern diagnostic testing.
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