Y-ECCO Interview Corner: Glen Doherty

 

Glen Doherty © ECCO

ECCO has recently adopted the GRADE process – can you explain what that is?

This adds a more formal appraisal of evidence that informs the statements that go into ECCO Guidelines. The concept of adopting GRADE was to improve the objectivity of the guidelines and reduce any potential for bias from various sources, because of either expert opinion or even commercial bias. The GRADE process involves selection of a series of “PICO” questions – these are focussed on a particular Population, a particular Intervention and Comparator and a particular Outcome or set of outcomes and allow us to make a very objective appraisal of evidence according to the framework.

What is the process like? In practice what difference does it make in comparison to the Oxford process?

The main difference is that in the Oxford process there was more heterogeneity in the way that the draft statements would be formulated, so it was more dependent on the individual work group members and work group leaders. Some work groups, when asked to review a topic, would come back with ten draft statements, while others would come back with, say, 50 draft statements, and so it was much harder to standardise the activity of each of the groups. The GRADE process is more work for each individual, but it does provide a standardised process for how each recommendation emerges.

What kind of non-medical support do you have within the GRADE process?

We now have assistance from a professional group of librarians to generate the literature search, because we wanted to be sure that everybody was performing literature searches that informed these questions in the same way. We also have assistance from methodologists who advise us how we implement the GRADE methodology in a sound way to make sure that we follow the correct process. The other important group now involved in the GRADE process is patients.

So, patients have recently joined the guideline process within ECCO. What difference has that made?

The role of the patients is that they help us to rank the importance of the outcomes for each question. What is interesting about having the patients participate is that the perspective of the patients and the perspective of the physicians differ more than I would have thought when I started off. Patients are very focussed on quality of life whereas they place much less value on factors which physicians value a lot, such as mucosal healing and objective markers. Physicians like those objective markers, but patients are much less worried about the numbers and more worried about their quality of life.

What makes a good guideline?

There are a couple of key things. First of all, it needs to be up to date, so that it contains an appraisal of all the most recent evidence. It should also be easy to navigate – so if you have a question in your clinical practice and want to see what the guidelines say about that particular topic, you can find the information quickly. This is important because most of us don’t sit down and read the guideline cover to cover – it is something one will dip into as questions come up as part of our clinical practice. We also have to be very careful about how the guidelines are written: we have to keep an emphasis on real clinical practice. We have to remember that although it is great to have very rigorous guidelines with good methodology, we also want guidelines to be of use to physicians in daily clinical practice, and we should never lose sight of that.

ECCO produces many guidelines, but then so do many of the individual countries within Europe. Should individual countries make their own guidelines?

That is a tricky question. There can sometimes be important differences in the healthcare delivery system between different countries and there may therefore be a role for individual countries to make their own guidelines. I come from Ireland; we’re a small country, we don’t really have the resources or the manpower to produce our own guidelines. I think it is important for smaller countries to not need to produce their own guidelines but to be able to fall back on the ECCO Guidelines, and we don’t feel we’re losing anything in doing that.

How do you manage the relationship between the guideline creators and industry?

I think there is more scrutiny now than there has ever been in regard to conflicts of interest and the potential for commercial bias. I think if you are acting as a coordinator on a guidelines project, you need to be checking at all points of the process to make sure there is no bias or perception of bias. Oftentimes it won’t emerge out of anything deliberate – one person will draft a statement about drug A and another person will draft a statement about drug B, then when the two statements are put side by side, perhaps because of the language one will sound stronger or more positive than the other. Sometimes you have to make a judgement as to whether in the interests of fairness the statements need to be adjusted. It is a really important role of the coordinator of any such project that they’re really mindful of that and that there is transparency around the conflicts of interest of anyone who takes part in the guideline process. I do think the GRADE process does help to minimise any potential for either commercial bias or expert opinion to distort recommendations. The recommendations are very much based on the evidence that is there. They should be entirely reproducible – if another person were to go through the same process, they should come up with the same recommendation.

Why should Y-ECCOs get involved in the guideline process?

First of all, we want the stakeholders within the guideline process to be as broad as possible. When we look at the group of people involved, we want physicians, nurses, dietitians and so on. We want as broad a panel of people as possible who represent the spectrum of professional background, geographical spread, gender and so on. In particular I think Y-ECCO Members bring a lot of energy and enthusiasm and that’s something that helps to keep the momentum of the guideline process. I also think it is a great education for a young gastroenterologist to see under the bonnet how guidelines are developed and put together. There is also an educational value as I think you learn a lot about guideline development as well as reviewing a section of the literature in detail. Hopefully that gives people an appetite for being involved in guideline development in the future, but also teaches you to critically appraise other guidelines and the literature from a more informed perspective.

What’s your background? How did you get into medicine and IBD?

I grew up in Northern Ireland, and I don’t think I knew what I wanted to do when I was younger, but I sort of had this interest in science, so I applied and was fortunate enough to get into medical school. I was a bit uncertain as to what field I wanted to go into – I think for a long time when I was a student I wanted to be a psychiatrist because I thought the theory of it was intellectually very interesting, but when it came to the clinical practice it was much more challenging. Then when I got into the medical rotation I came upon a group of very enthusiastic gastroenterologists. My observation as a resident was that the gastroenterologists seemed to enjoy their job much more than other people and I think my experience since then has continued to affirm that belief!

You have previously worked in colorectal cancer. Do you continue to pursue that interest?

In day-to-day clinical practice I do see a lot of IBD patients, but I still have a research interest in colorectal cancer. My other clinical interest is in high-risk screening and genetic or familial colorectal cancer. I did my PhD looking at colorectal cancer biology, which focusses a lot on immune markers, and this lent itself well to looking at the immunology of IBD. In the group where I work we try to maintain our interest in both areas in parallel and we try to understand how they interact. There is a lot of cross-fertilisation between the two areas.

So, with all the work in research and ECCO, do you still have time for clinical practice?

I do less clinical work, but it is still a big part of my work. In Ireland gastroenterologists do internal medicine, so I have just come off my 6 weeks on internal medicine. I don’t think I would want to give that up – I really think it helps to keep up my skills as a physician. Then I see a lot of IBD patients every week in clinic and on the wards. I maintain a very active clinical practice. One of the things I really like in IBD is the fact that, because it is a chronic illness, you do develop relationships with your patients. When I think back to how several of my patients were when I first met them maybe 10 years ago, it is very satisfying to see that your management has really made a difference for them.

What do you do when you’re not working?

I like reading and theatre and art. I also sing in tenor in a choir singing classical choral works like Mozart’s Requiem, Handel’s Messiah and so on. I have been singing in a choir like that since I was a medical student and I’ve found it a fantastic way to de-stress because when you’re singing you don’t think about anything else. I notice if I miss it for a while for whatever reason and then go back to it. I somehow feel I’m not in as good shape or something. It really is good for posture and breathing and so on. Singing tenor is great – because every choir is always short of tenors, they’re not too strict with you if you miss a few rehearsals! It’s a great way to interact with people as well. 

Do you have any career regrets? Any advice for Y-ECCOs?

Although it is a small thing, when I was doing my fellowship programme I had a choice on whether to move on from the centre I’d been working at for a couple of years or to stay on where I was. At the time I made the easy decision to stay where I was. If I could go back now, I would advise myself to put myself out there and take the chance – don’t play it safe. I mean I had a fine year staying where I was, but I don’t think I learned as much as I could have if I had put myself out there a little bit more. If I had moved, I would have worked with different gastroenterologists and had exposure to different practices. Even the fellows that work with me, I encourage them to go and work in other centres if possible. I think it does enrich your background and enrich your training. Because once you work in your own practice, you tend to stay working in the same place for years and years. So, I would advise people to work in as many different places as they can.

You grew up in Northern Ireland and now you live in Dublin, but you still have family in Northern Ireland. What are the implications of Brexit for you?

It is having a big impact on my family as they live right on the border between Northern Ireland and the Republic of Ireland and when I was growing up there was a definite hard border between the two. You had to queue up and go through security check points to cross the border. It has made such a difference to the people who live there that for the last 20 years people can just drive backwards and forwards over the border and you don’t even know it is there. So, the idea that something might happen that would bring back the hard border has made people very anxious about the future. Ireland is a small country at the periphery of Europe and where I grew up is at the periphery of that small island.  Because it’s always been rather marginal, it’s always been economically disadvantaged and things like this don’t help. It’s very hard to attract industry and it’s hard to keep people living there. Many people like me go off to Dublin or to the UK and a lot of us don’t go back, at least not to live.

And is there any impact for patients?

Potentially yes – there has been a big growth in the last 10 years in cross-border cooperation in how healthcare is delivered because Northern Ireland has a small population, perhaps 1 million, and then there are 4 or 5 million in the Republic of Ireland, and the border area is quite sparsely populated, so it makes a lot of sense to have cross-border services. For example, for coronary revascularisation, patients who have a myocardial infarction in the far North West of Ireland, say in County Donegal, will get brought to Northern Ireland for out of hours PCI and angiography. Also, for cancer services there is a lot more cross-border cooperation. There is a big fear that with Brexit that is going to be much more difficult to sustain and that it will isolate those populations who have enjoyed better access to more timely care and more accessible care in recent years.

How do you manage stress?

Well, it is something you have to manage actively. Small things matter – you need to make sure you get enough sleep and maybe a little bit of exercise. Don’t drink too much and maintain your interests outside work, even if that is just reading a book, going to a gallery or phoning a friend who isn’t a medic and remembering that there is life outside work. I think I manage to keep the balance most of the time. But there are always times when we all get a bit overwhelmed by stuff and it’s always important to keep it in perspective. Keep your channels with your friends and family open and remember there are more important things in life than work.

What’s next for you?

I’m not applying for any other ECCO Committees at the moment, partly because even when I step down from the Guidelines Committee there are a lot of projects that will continue for another year or two and I would like to bring them to an end and feel I have done my piece on the Guidelines Committee. I feel it would be a distraction if I applied for a new role and a new project. But I am always thinking about the future and there are other initiatives that I am interested in. My other big passion is that I helped to establish the national study group within Ireland, trying to increase collaboration within Ireland, trying to get more collaborative studies. One of the things we are trying to do is to use that network to train our fellows in good research skills. We are also supporting some of our IBD nurses, to get them engaged and involved in research because I think we need to improve the amount of nursing research that is done within IBD. In addition, we’re working to get the other disciplines, the dietitians, the colorectal surgeons and so on, involved in IBD research. I am also working with the patient organisation in Ireland, trying to identify what are the big priorities in research that matter to them. I believe that if we are doing investigator-led studies we need to think about the populations of patients that are underrepresented in other types of research – the proctitis patients, the stoma patients or patients with pouches who don’t tend to get recruited into clinical trials, with the consequence that there’s very little evidence to inform their treatment. I think research networks provide a great opportunity to prioritise under-studied or under-served groups of patients.

Charlotte Hedin, Y-ECCO Member

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