Benjamin Djulbegovic Explained

Benjamin Djulbegovic
Birth Place:Sarajevo, Bosnia and Herzegovina, Yugoslavia
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Known For:methods to address uncertainty in scientific and medical evidence and clinical decision-making
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Benjamin Djulbegovic is an American physician-scientist whose academic and research focus revolves around optimizing clinical research and the practice of medicine by comprehending the nature of medical evidence and decision-making. In his work, he has integrated concepts from evidence-based medicine (EBM), predictive analytics, health outcomes research, and the decision sciences.

Biography

Djulbegovic was born in Sarajevo, Bosnia and Herzegovina, Yugoslavia. He was trained both in basic sciences and clinical medicine. In 1983, Djulbegovic earned his medical degree and PhD in biomedical sciences from the University of Sarajevo. He earned an M.S. degree in biophysics from the University of Zagreb (1983-1985) and was trained in internal medicine and hematology at the University of Sarajevo, Belgrade, and Christie Hospital, Manchester, England. Subsequently he completed his residency in internal medicine and a fellowship in hematology and medical oncology at the University of Louisville School of Medicine in the United States (1988-1991).[1] Djulbegovic then joined the University of Louisville as an assistant (and later, associate) professor (1996-1998). In 1998 he moved to the H. Lee Moffitt Cancer Center and the University of South Florida (USF), where he became a full professor.

During his tenure with the H. Lee Moffitt Cancer Center and the University of South Florida, where he was appointed as a Distinguished Professor of the university (2010-2017),[2] he founded the Center for Evidence-Based Medicine and the Health Outcomes Research Center[3] as a foundation for later development of core in research methods and biostatistics at USF. At USF he also served as the associate dean for clinical research (2012-2013).[4]

From 2017 to 2023, he served as a professor at the City of Hope National Medical Center, Beckman Research Institute, CA. Since 2023, Djulbegovic has served as the director of the Hematology Stewardship Program at the Medical University of South Carolina in Charleston, SC[5] and as an affiliate member of the Meta-Research Innovation Center at Stanford University.[6], his body of work had received over 52k citations with an h-index of 78. He has authored over 400 papers in peer-reviewed journals, four books, over 200 abstracts, book chapters, and editorials.[7]

Linking evidence-based medicine with decision-making

Djulbegovic's work includes the coherent linkage of evidence-based medicine (EBM) to formal systems in decision sciences. His collaboration with colleague Iztok Hozo summarized their previous work in the book "Threshold Models For Decision-Making in Clinical Medicine," published in 2023.[8] This work illustrates the connection between EBM and structured frameworks in the decision sciences in accordance with cited peer-reviewed work.

Djulbegovic has argued that underuse and overuse observed in clinical practice is a consequence of a relationship between scientific evidence (that exists on a continuum of credibility) and decision-making (that is, categorical, yes/no exercises, as decisions, have to be made) that creates the Sorites paradox. At which point is the probability of disease or outcomes sufficiently high or low enough for us to act?[9]

He and Hozo proposed threshold models as a rational (and pragmatic) way to address the Sorites paradox. Djulbegovic et al have also posited that the appropriateness of care, whether underuse or overuse, depends on the choice of a decision-theoretical framework.[10]

He contributed to understanding of the processes of evidence-based clinical practice guidelines.[11] [12] Medical Guidelines are widely considered as essential vehicles[13] for improving persistently suboptimal healthcare.[14] [15] However, because guidelines have their problems, Djulbegovic has also argued that further improvement of guidelines processes is only possible within a decision-analytical framework.[16] [17] In particular, he has argued that clinical practice guidelines can be improved if they are translated into clinical pathways and fast-and-frugal trees within the framework of threshold decision models to develop more individualized patient care.[18] [19] [20] [21]

These principles were translated into the systematic application of the science of EBM and decision analysis in the fields of hematology[22] and oncology,[23] The work was reviewed in hematology[24] and oncology[25] by the Journal of the National Cancer Institute.

Law of therapeutic discoveries

Through the analysis of the role of uncertainty in medicine and the clinical equipoise principle, Djulbegovic introduced the concept of "the law of therapeutic discovery."[26] [27] This theory predicts a 50-70% success rate in discovering new treatments in randomized clinical trials (RCT) based on the foundational ethical and scientific justification for conducting trials in humans.[28]

This principle - which links key precepts of moral philosophy with theories of rational decision-making is further explained and demonstrated in a BMJ manuscript that asks and then answers "Are experimental treatments for cancer in children superior to established treatments?"[29] Furthermore, Djulbegovic communicates how uncertainty and a loss of equipoise can fuel misinformation in patient populations.[30]

Rational clinical decision-making and development of "acceptable regret" theory

Together with Hozo, Djulbegovic developed the decision-theoretical concept of "acceptable regret." This concept allows clinicians, scientists, and policymakers to determine when they can accept findings, even if proven wrong later. "Acceptable regret" has been used to explain both underuse and overuse in the delivery of health services, offering insights into the decision-making process of satisficing in clinical practice.[31] The concept is held to shed light on why most people, whether patients or relatives caring for patients at the end-of-life require almost absolute certainty of imminent death before accepting referrals to hospice.[32]

Dramatic works

Djulbegovic translated his scientific writings on uncertainty[33] [34] [35] [36] [37] into a play titled "An Impossible Decision: The Life Interrupted by Uncertainty." Using the Socratic dialogue and playwright format, he illustrates the applicability of theoretical concepts of the science of uncertainty to real-life decision-making and how they matter to all of us individually and collectively.

Awards and honors

In his early career, he was awarded the Thomas C. Chalmers Award for empirical verification of the uncertainty (equipoise) principle (1999). His group's work was also recognized with a second Chalmers award in 2012.[38] [39]

In 2017 he received an award for Excellence In Person Centered Healthcare at the Fourth Annual Conference of the European Society for Person Centered Healthcare (ESPCH4), Westminster Cathedral Hall, London.

Selected publications

Notes and References

  1. Djulbegovic, B. Board Certifications: Hematology and Internal Medicine, https://www.abim.org/verify-physician?type=name&ln=Djulbegovic&fn=Benjamin
  2. 2010 Distinguished USF Health Professors, Morsani College of Medicine, Ben Djulbegovic, MD, ScD https://health.usf.edu/facultyaffairs/DistinguishedProf
  3. Thomas Chalmers Award in Evidence-Based Medicine Goes To USF Health.https://hscweb3.hsc.usf.edu/awardsblog/2012/03/04/thomas-chalmers-award-in-evidence-based-medicine-goes-to-usf-health
  4. Clinical Trials: About Half of New Treatments Perform Better Than Existing Ones - USF Health News https://hscweb3.hsc.usf.edu/blog/2012/10/17/clinical-trials-about-half-of-new-treatments-perform-better-than-existing-ones/
  5. Web site: Djulbegovic - Faculty Directory . Medical University of South Carolina.
  6. Web site: Benjamin Djulbegovic Meta Research Innovation Center at Stanford University . . en.
  7. Web site: Benjamin Djulbegovic . Google Scholar.
  8. Book: 10.1007/978-3-031-37993-2 . Threshold Decision-making in Clinical Medicine . Cancer Treatment and Research . 2023 . 189 . 978-3-031-37992-5 . Benjamin . Djulbegovic . Iztok . Hozo .
  9. Djulbegovic . Benjamin . Hozo . Iztok . Mandrola . John . Sorites paradox and persistence in overuse and underuse in healthcare delivery services . Journal of Evaluation in Clinical Practice . September 2023 . 29 . 6 . 877–879 . 10.1111/jep.13851 . 37165480 . free .
  10. Djulbegovic . Benjamin . Elqayam . Shira . Dale . William . Rational decision making in medicine: Implications for overuse and underuse . Journal of Evaluation in Clinical Practice . June 2018 . 24 . 3 . 655–665 . 10.1111/jep.12851 . 29194876 . 6001794 .
  11. Djulbegovic . Benjamin . Hozo . Iztok . Li . Shelly-Anne . Razavi . Marianne . Cuker . Adam . Guyatt . Gordon . Certainty of evidence and intervention's benefits and harms are key determinants of guidelines' recommendations . Journal of Clinical Epidemiology . August 2021 . 136 . 1–9 . 10.1016/j.jclinepi.2021.02.025 . 33662511 . free .
  12. Li . Shelly-Anne . Yousefi-Nooraie . Reza . Guyatt . Gordon . Talwar . Gaurav . Wang . Qi . Zhu . Ying . Hozo . Iztok . Djulbegovic . Benjamin . A few panel members dominated guideline development meeting discussions: Social network analysis . Journal of Clinical Epidemiology . January 2022 . 141 . 1–10 . 10.1016/j.jclinepi.2021.09.023 . 34555427 . 8934303 .
  13. Djulbegovic . Benjamin . Reljic . Tea . Elqayam . Shira . Cuker . Adam . Hozo . Iztok . Zhou . Qi . Li . Shelly-Anne . Alexander . Paul . Nieuwlaat . Robby . Wiercioch . Wojtek . Schünemann . Holger . Guyatt . Gordon . Structured decision-making drives guidelines panels' recommendations 'for' but not 'against' health interventions . Journal of Clinical Epidemiology . June 2019 . 110 . 23–33 . 10.1016/j.jclinepi.2019.02.009 . 30779950 . 7268742 .
  14. Yao . Liang . Ahmed . Muhammad Muneeb . Guyatt . Gordon H . Yan . Peijing . Hui . Xu . Wang . Qi . Yang . Kehu . Tian . Jinhui . Djulbegovic . Benjamin . Discordant and inappropriate discordant recommendations in consensus and evidence based guidelines: empirical analysis . BMJ . 25 November 2021 . 375 . e066045 . 10.1136/bmj-2021-066045 . 34824101 . 8613613 .
  15. Yao . Liang . Guyatt . Gordon H . Djulbegovic . Benjamin . Can we trust strong recommendations based on low quality evidence? . BMJ . 25 November 2021 . 375 . n2833 . 10.1136/bmj.n2833 . 34824089 . 8769229 .
  16. Djulbegovic . Benjamin . Guyatt . Gordon . Evidence vs Consensus in Clinical Practice Guidelines . JAMA . 27 August 2019 . 322 . 8 . 725–726 . 10.1001/jama.2019.9751 . 31322650 . 7275374 .
  17. Djulbegovic . Benjamin . Guyatt . Gordon H . Progress in evidence-based medicine: a quarter century on . The Lancet . July 2017 . 390 . 10092 . 415–423 . 10.1016/S0140-6736(16)31592-6 . 28215660 .
  18. Djulbegovic . Benjamin . Hozo . Iztok . Cuker . Adam . Guyatt . Gordon . Improving methods of clinical practice guidelines: From guidelines to pathways to fast-and-frugal trees and decision analysis to develop individualised patient care . Journal of Evaluation in Clinical Practice . April 2024 . 30 . 3 . 393–402 . 10.1111/jep.13953 . 38073027 . free .
  19. Djulbegovic . Benjamin . Hozo . Iztok . Dale . William . Transforming clinical practice guidelines and clinical pathways into fast-and-frugal decision trees to improve clinical care strategies . Journal of Evaluation in Clinical Practice . October 2018 . 24 . 5 . 1247–1254 . 10.1111/jep.12895 . 29484787 .
  20. Hozo . Iztok . Djulbegovic . Benjamin . Generalised decision curve analysis for explicit comparison of treatment effects . Journal of Evaluation in Clinical Practice . December 2023 . 29 . 8 . 1271–1278 . 10.1111/jep.13915 . 37622200 . free .
  21. Hozo . Iztok . Djulbegovic . Benjamin . Luan . Shenghua . Tsalatsanis . Athanasios . Gigerenzer . Gerd . Towards theory integration: Threshold model as a link between signal detection theory, fast-and-frugal trees and evidence accumulation theory . Journal of Evaluation in Clinical Practice . February 2017 . 23 . 1 . 49–65 . 10.1111/jep.12490 . 26683386 . 11858/00-001M-0000-002D-19E7-7 . free .
  22. Djulbegovic B and Beganovic S, Reasoning and Decision Making in Hematology, 1st ed. 1992, Churchill Livingstone,
  23. Djulbegovic B and Sullivan M,Decision Making in Oncology: Evidence-Based Management, 1st ed. 1997, Churchill Livingstone,
  24. Seifter . E. J. . BOOK REVIEWS . JNCI . 19 May 1993 . 85 . 10 . 829–830 . 10.1093/jnci/85.10.829 .
  25. Seifter . Eric J. . Decision Making in Oncology: Evidence-Based Management Benjamin Djulbegovic, Daniel M. Sullivan, eds. New York: Churchill Livingstone, 1997, 543 pp., $79.00. ISBN 0-443-08989-2 . JNCI . 15 April 1998 . 90 . 8 . 627 . 10.1093/jnci/90.8.627 .
  26. Djulbegovic . Benjamin . The Paradox of Equipoise: The Principle That Drives and Limits Therapeutic Discoveries in Clinical Research . Cancer Control . October 2009 . 16 . 4 . 342–347 . 10.1177/107327480901600409 . 19910921 . 2782889 .
  27. Djulbegovic . Benjamin . Kumar . Ambuj . Glasziou . Paul . Miladinovic . Branko . Chalmers . Iain . Trial unpredictability yields predictable therapy gains . Nature . August 2013 . 500 . 7463 . 395–396 . 10.1038/500395a . 23969443 . 3819120 .
  28. Djulbegovic . Benjamin . Kumar . Ambuj . Glasziou . Paul P . Perera . Rafael . Reljic . Tea . Dent . Louise . Raftery . James . Johansen . Marit . Di Tanna . Gian Luca . Miladinovic . Branko . Soares . Heloisa P . Vist . Gunn E . Chalmers . Iain . New treatments compared to established treatments in randomized trials . Cochrane Database of Systematic Reviews . 17 October 2012 . 2012 . 10 . MR000024 . 10.1002/14651858.MR000024.pub3 . 23076962 . 3490226 .
  29. Kumar . Ambuj . Soares . Heloisa . Wells . Robert . Clarke . Mike . Hozo . Iztok . Bleyer . Archie . Reaman . Gregory . Chalmers . Iain . Djulbegovic . Benjamin . Are experimental treatments for cancer in children superior to established treatments? Observational study of randomised controlled trials by the Children's Oncology Group . BMJ . 3 December 2005 . 331 . 7528 . 1295 . 10.1136/bmj.38628.561123.7C . 16299015 . 1298846 .
  30. Djulbegovic . Benjamin . Ethics of uncertainty . Patient Education and Counseling . November 2021 . 104 . 11 . 2628–2634 . 10.1016/j.pec.2021.07.025 . 34312034 .
  31. Djulbegovic . B. . Hozo . I. . Schwartz . A. . McMasters . K.M. . Acceptable regret in medical decision making . Medical Hypotheses . September 1999 . 53 . 3 . 253–259 . 10.1054/mehy.1998.0020 . 10580533 .
  32. Tsalatsanis . Athanasios . Hozo . Iztok . Djulbegovic . Benjamin . Acceptable regret model in the end-of-life setting: Patients require high level of certainty before forgoing management recommendations . European Journal of Cancer . April 2017 . 75 . 159–166 . 10.1016/j.ejca.2016.12.025 . 28235727 .
  33. Godlee . Fiona . In praise of uncertainty . BMJ . 3 December 2005 . 331 . 7528 . . 10.1136/bmj.331.7528.0-f . 1298834 .
  34. Djulbegovic . B . Well informed uncertainties about the effects of treatment . BMJ . 24 April 2004 . 328 . 7446 . 1018.2 . 10.1136/bmj.328.7446.1018-a . 15105342 . 404547 .
  35. Djulbegovic . Benjamin . Uncertainty and Equipoise: At Interplay Between Epistemology, Decision Making and Ethics . The American Journal of the Medical Sciences . October 2011 . 342 . 4 . 282–289 . 10.1097/MAJ.0b013e318227e0b8 . 21817885 . 3183244 .
  36. Book: 10.1016/B978-0-444-51787-6.50011-8 . Uncertainty in Clinical Medicine . Philosophy of Medicine . 2011 . Djulbegovic . Benjamin . Hozo . Iztok . Greenland . Sander . 299–356 . 978-0-444-51787-6 .
  37. Djulbegovic . Benjamin . Paul . Ash . From Efficacy to Effectiveness in the Face of Uncertainty: Indication Creep and Prevention Creep . JAMA . 18 May 2011 . 305 . 19 . 2005–2006 . 10.1001/jama.2011.650 . 21586716 .
  38. Djulbegovic B, Lacevic M, Lyman GH. Empirical verification of the uncertainty principle in conducting randomized trials. Proceedings of the 7th Cochrane Colloquium, 1999 https://community.cochrane.org/news/prizes-and-awards/thomas-c-chalmers-award
  39. Web site: Thomas Chalmers Award In Evidence-Based Medicine Goes To USF Health . University of South Florida College of Medicine.

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