Evidence is everything for this researcher, even when — especially when — the results are disappointing
By Jan Greene
A chance encounter in a medical library launched Kaiser Permanente Division of Research (DOR) investigator Andy Avins, MD, MPH, into a career as a researcher. He learned of a new discipline called evidence-based medicine and became committed to “finding the truth” about what really works in patient care.
Avins, also an internist with The Permanente Medical Group (TPMG), carries out research at DOR and cares for patients a day each week in the urgent care clinic of Kaiser Permanente Oakland Medical Center. He spent parts of his 30-year career researching and teaching at the University of California, San Francisco, San Francisco General Hospital, and the Veterans Affairs Medical Center.
In this interview, Avins reflects on his search for medical truth and where it took him.
How did you become a researcher and choose what to study?
When I started my medical training in the early 1980s, I had no interest at all in research; I wanted to be a primary care doc and was headed on that path. That changed one night at 2 or 3 in the morning in the medical library when I was an intern in medicine at Kaiser Permanente San Francisco. I just stumbled on a bunch of readings in these things called “clinical epidemiology” and “evidence-based medicine,” which were new concepts at the time. And it changed things for me almost instantly.
Until then, there was experience-based medicine and belief-based medicine. There was always the peer-reviewed literature, of course, but there never seemed to be an organized skepticism that called on us to question everything that we do in the pursuit of truth.
Clinical epidemiology seemed like a particularly ridiculous combination of words – clinical medicine happens in the clinic and epidemiology is what nerds do with computers. Putting those two together really made no sense until I began to understand that melding these ideas was the foundation of honesty and objectivity in the pursuit of optimal patient care.
What were your main topics of interest in research?
I did a lot of work for many years in preventive medicine, particularly in preventive cardiology, and the rational application of evidence in the clinical encounter. Then I, like many of my colleagues, realized how medicine’s mistaken acceptance of the safety of opioids had contributed to the horrible problem of opioid misuse. So I became interested in testing integrative, non-pharmacologic therapies for chronic pain.
In our chronic pain work, we’ve done studies in acupuncture, which has shown itself to be modestly but consistently effective. With some wonderful colleagues in Kaiser Permanente Northern California, we also conducted an NIH-funded clinical trial of oral steroids for patients with acute sciatica due to a herniated intervertebral disc. Oral steroids were widely used for sciatica but nobody had ever done a rigorous study of them. And we found that, in fact, oral steroids provided almost no benefit over placebo, despite their common use.
I and a colleague at UCSF published the first NIH-funded clinical trial of a widely used herbal supplement called saw palmetto for men with enlarged prostates. Despite the results of many industry-funded studies, we found absolutely no benefit at all of saw palmetto for any subgroup or for any outcome. Our work was replicated in another larger NIH-funded international multicenter trial (in which we also participated), which was validating and vindicating. But it was frustrating that we actually did not wind up finding an additional therapeutic option for these men.
Disappointing findings are an essential part of evidence-based medicine. If things don’t work, we should know they don’t work. Thinking we’re better than we are invites complacency; an honest appraisal of our current clinical capabilities should motivate us to try that much harder to identify approaches and opportunities that really do work for our patients. Fortunately, it’s not all discouraging: I’ve also had the pleasure of seeing some very meaningful progress result from some recent collaborations with my TPMG colleagues.
How do you balance clinical work with research both at DOR and in academic settings?
I don’t think I ever will stop clinical work. Being able to see patients is a welcome change from my day-to-day research. And the care of patients really provides a relevance and an immediacy to my research work.
The academic world and DOR are very different. DOR is part of a select group of large health care organizations that are very academically oriented, which is quite unusual. And that’s a huge gift to public health and clinical medicine, because this is the real world, where medical care is delivered. In many ways, we have the best of both worlds.
Mentorship is also important. A lot of my work right now is promoting and supporting our clinician researchers through the Rapid Analytics Unit and Physician Researcher Program of TPMG’s Delivery Science & Applied Research program. It supports a lot of very bright, very passionate clinicians who simply may not have the time or support or expertise to make their research goals a reality on their own. We can step in and provide that.
What advice would you have for new researchers entering the field?
Establish great collaborations with people in your field, who can help open up doors, who can introduce you to others in the field, and who really take a genuine interest in your success as a scientist. Given our incredible data and our huge and diverse patient population, young investigators at DOR have an extremely valuable card they can play when they go out into the world and try to develop these kinds of collaborations.
While the coin of the realm in this business is still the peer-reviewed, published paper, also consider quality improvement and implementation work. It can be very fulfilling to help an organization we really believe in, like Kaiser Permanente, help achieve its goals; this kind of work can often be aligned to support your own personal research agenda.
What do you like to do in your free time?
We live in Marin and so I do a fair amount of mountain biking and I’m hoping to get out and start kayaking again. I do my best to keep up playing a lot of music during the shelter in place, trying to get my guitar and rudimentary banjo skills back to where they were. And hopefully one of these days I can start traveling with my family again. I remain ever hopeful.