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Benjamin Djulbegovic

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Benjamin Djulbegovic
File:BDjulbegovic-photo-.png

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.

Djulbegovic's received the USF Faculty Outstanding Research Achievement Award for "the development of two theories in clinical research and decision-making: the theory regarding treatment success in clinical trials and the acceptable regret theory"[1]

His works on uncertainty, industry bias and Phase 3 Cancer trials were recognized by James Lind Library (2005) [2][3][4]

In his early career, he was awarded the Thomas C. Chalmers Award, 2nd prize, for empirical verification of the uncertainty (equipoise) principle (1999).[5][6]

As of January 2024, he has 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]

Early Life and Education

He 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. From 1983 to 1985, he received a Master of Science degree in biophysics from the University of Zagreb and was trained in internal medicine and hematology at the University of Sarajevo, Belgrade, and Christie Hospital, Manchester, England. Subsequently, from 1988 to 1991, he completed his residency in internal medicine and a fellowship in Hematology and Medical Oncology at the University of Louisville School of Medicine.[8]

Career

Since 2024, Professor Djulbegovic has served as the director of the Hematology Stewardship Program in the Division of Hematology/Oncology at the Medical University of South Carolina in Charleston, SC.[9] and as an affiliate member of the Meta-Research Innovation Center at Stanford.[10]

From 2017 to 2023, he served as a professor at the City of Hope National Medical Center, Beckman Research Institute, CA.During his tenure with the H. Lee Moffitt Cancer Center and the University of South Florida (USF), in Tampa, Florida,where he served as Distinguished Professor (2010-2017)[11] he founded the Center for Evidence-Based Medicine and the Health Outcomes Research Center[12]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).[13]

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. [14]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? [15]

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.[16]

He contributed to understanding of the processes of evidence-based clinical practice guidelines [17][18] Medical Guidelines are widely considered as essential vehicles[19]for improving persistently suboptimal healthcare.[20][21]However, because guidelines have their problems, Djulbegovic has also argued that further improvement of guidelines processes is only possible within a decision-analytical framework.[22][23] 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.[24][25] [26][27]

These principles were translated into the systematic application of the science of EBM and decision analysis in the fields of hematology[28] and oncology[29], The work was reviewed in hematology[30]and oncology[31]by the Journal of the National Cancer Institute.

The 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."[32] [33] 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.[34][35] This principle - which links key precepts of moral philosophy with theories of rational decision-making is further explained and demonstrated in the classic BMJ manuscript that asks and then answers "Are experimental treatments for cancer in children superior to established treatments?"[36]Furthermore, Djulbegovic communicates how uncertainty and a loss of equipoise can fuel misinformation in patient populations.[37]

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.[38] Most importantly, acceptable regret sheds 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.[39]

The Art of Communicating Uncertainty

Djulbegovic translated his scientific writings on uncertainty [40][41][42][43][44] 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 do matter to all of us individually and collectively.The screenplay is open access and available to all.[45]

Selected publications

Linking evidence-based medicine with decision-making

  • Djulbegovic, Benjamin; Guyatt, Gordon H (July 2017). "Progress in evidence-based medicine: a quarter century on". The Lancet. 390 (10092): 415–423. doi:10.1016/S0140-6736(16)31592-6. PMID 28215660. S2CID 46762513.
  • Djulbegovic, Benjamin; Hozo, Iztok (2023). "Evidence and Decision-Making". Threshold Decision-making in Clinical Medicine. Cancer Treatment and Research. Vol. 189. pp. 1–24. doi:10.1007/978-3-031-37993-2_1. ISBN 978-3-031-37992-5. PMID 37789157.
  • Djulbegovic, Benjamin; Hozo, Iztok (2023). Threshold Decision-making in Clinical Medicine: With Practical Application to Hematology and Oncology. Cancer Treatment and Research. Vol. 189. doi:10.1007/978-3-031-37993-2. ISBN 978-3-031-37992-5. S2CID 263612558.

The law of therapeutic discoveries

Rational clinical decision-making and development of "Acceptable Regret" theory

References

  1. ^ Worth, Sarah. "USF Health faculty members honored for outstanding research". University of South Florida College of Medicine.
  2. ^ https://www.jameslindlibrary.org/djulbegovic-b-lacevic-m-cantor-a-fields-kk-bennett-cl-adams-jr-kuderer-nm-lyman-gh-2000/
  3. ^ https://www.jameslindlibrary.org/lexchin-j-bero-la-djulbegovic-b-clark-o-2003
  4. ^ https://www.jameslindlibrary.org/djulbegovic-b-kumar-a-soares-hp-hozo-i-bepler-g-clarke-m-bennett-cl-2008/
  5. ^ 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
  6. ^ "Thomas Chalmers Award In Evidence-Based Medicine Goes To USF Health". University of South Florida College of Medicine.
  7. ^ "Benjamin Djulbegovic". Google Scholar.
  8. ^ Djulbegovic, B. Board Certifications: Hematology and Internal Medicine, https://www.abim.org/verify-physician?type=name&ln=Djulbegovic&fn=Benjamin
  9. ^ "Djulbegovic - Faculty Directory". Medical University of South Carolina.
  10. ^ n"Benjamin Djulbegovic | Meta Research Innovation Center at Stanford". Meta-Research Innovation Center at Stanford.
  11. ^ 2010 Distinguished USF Health Professors, Morsani College of Medicine, Ben Djulbegovic, MD, ScD https://health.usf.edu/facultyaffairs/DistinguishedProf
  12. ^ 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
  13. ^ 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/
  14. ^ Threshold Decision-making in Clinical Medicine: With Practical Application to Hematology and Oncology Cancer Treatment and Research, Djulbegovic B and Hozo I Springer, 1st ed. 2023 edition, ISBN-13 978-3031379925
  15. ^ Djulbegovic B, Hozo I, Mandrola J. Sorites paradox and persistence in overuse and underuse in delivery of health services. J Eval Clin Pract 2023; Sep;29(6):877-879. doi: 10.1111/jep.13851.
  16. ^ Djulbegovic B, Elqayam S, Dale W. Rational decision-making in medicine: implications for overuse and underuse. J Eval Clin Practice 2018 Jun; 24(3): 655–665. [PMID: 29194876]
  17. ^ Djulbegovic B, Hozo I, Li S-A, Razavi M, Cuker A, Guyatt G. Certainty of evidence and intervention's benefits and harms are key determinants of guidelines’ recommendations. Journal of Clinical Epidemiology 2021;136:1-9. DOI:https://doi.org/10.1016/j.jclinepi.2021.02.025.
  18. ^ Li SA, Yousefi-Nooraie R, Guyatt G, Talwar G, Wang Q, Zhu Y, Hozo I, and Djulbegovic B. A few panel members dominated guideline development meeting discussions: Social network analysis. J Clin Epidemiol 2021;141:1-10. (In eng). DOI: 10.1016/j.jclinepi.2021.09.023.
  19. ^ Djulbegovic B, Reljic T, Elqayam S, et al. Structured decision-making drives guidelines panels' recommendations “for” but not “against” health interventions. Journal of Clinical Epidemiology 2019;110:23-33. DOI:https://doi.org/10.1016/j.jclinepi.2019.02.009
  20. ^ Yao L, Ahmed MM, Guyatt GH, Yan P, Hui X, Wang Q, Yand K, Tian J, and Djulbegovic B. Discordant and inappropriate discordant recommendations in consensus and evidence based guidelines: empirical analysis. BMJ 2021;375:e066045. DOI: 10.1136/bmj-2021-066045
  21. ^ Yao L, Guyatt GH, Djulbegovic B. Can we trust strong recommendations based on low quality evidence?BMJ 2021;375:n2833. DOI: 10.1136/bmj.n2833.
  22. ^ Djulbegovic B, Guyatt G. Evidence vs Consensus in Clinical Practice Guidelines JAMA 2019;322(8):725-726.DOI: 10.1001/jama.2019.9751.
  23. ^ Djulbegovic, Benjamin; Guyatt, Gordon H (July 2017).Progress in evidence-based medicine: a quarter century on". The Lancet. 390 (10092): 415–423. doi:10.1016/S0140-6736(16)31592-6. PMID 28215660. S2CID 46762513
  24. ^ Djulbegovic B, Hozo I, Cuker A, Guyatt G. Improving methods of clinical practice guidelines: From guidelines to pathways to fast-and-frugal trees and decision analysis to develop individualised patient care. J Eval Clin Pract. Dec 10 2023;doi:10.1111/jep.13953
  25. ^ Djulbegovic B, Hozo I, Dale W. Transforming clinical practice guidelines and clinical pathways into fast-and-frugal decision trees to improve clinical care strategies. J Eval Clin Pract. 2018; 24(5): 1247-1254. doi:10.1111/jep.12895
  26. ^ Hozo I, Djulbegovic B. Generalised decision curve analysis for explicit comparison of treatment effects. J Eval Clin Pract. 2023; 29: 1271-1278. doi:10.1111/jep.13915
  27. ^ Hozo I, Djulbegovic B, Luan S, Tsalatsanis A, Gigerenzer G. Towards theory integration: threshold model as a link between signal detection theory, fast-and-frugal trees and evidence accumulation theory. J Eval Clin Pract. 2017; 23(1): 49-65. doi:10.1111/jep.12490
  28. ^ Djulbegovic B and Beganovic S, Reasoning and Decision Making in Hematology, 1st ed. 1992, Churchill Livingstone, ISBN-13 978-0443088582
  29. ^ Djulbegovic B and Sullivan M,Decision Making in Oncology: Evidence-Based Management, 1st ed. 1997, Churchill Livingstone, ISBN-13978-0443089893
  30. ^ Seifter E.J M.D.JNCI: by the Journal of the National Cancer Institute, Volume 85, Issue 10, 19 May 1993, Pages 829–830, https://doi.org/10.1093/jnci/85.10.829
  31. ^ Seifter E.J.MD, JNCI: Journal of the National Cancer Institute, Volume 90, Issue 8, 15 April 1998, Page 627, https://doi.org/10.1093/jnci/90.8.627
  32. ^ Djulbegovic B. Paradox of equipoise: the principle that drives and limits discoveries in clinical research. Cancer Control 2009;16:342–347; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2782889/
  33. ^ Kumar A, Glasziou P, Miladinovic B, Chalmers I, Djulbegovic B. Trial unpredictability yields predictable therapy gains. Nature 2013;500:395–396;https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3819120/,
  34. ^ Djulbegovic B, Kumar A, Glasziou PP, et al. New treatments compared to established treatments. Cochrane Database Syst Rev 2012;10:MR000024.
  35. ^ (Research Support, N.I.H., ExtramuralResearch Support, Non-U.S. Gov't) (In eng). DOI: 10.1002/14651858.MR000024.pub3.
  36. ^ Kumar A, Soares H, Wells R, Clarke M, Hozo I, Bleyer A, Chalmers I, Djulbegovic B. Are experimental treatments for cancer in children superior to established treatments? Observational study of randomised controlled trials by the Children's Oncology Group BMJ 2005; 331 :1295 doi:10.1136/bmj.38628.561123.7C
  37. ^ Djulbegovic, B. (November 2021). "Ethics of uncertainty". Patient Education and Counseling. 104 (11): 2628–2634. doi:10.1016/j.pec.2021.07.025. PMID 34312034. S2CID 236451819.
  38. ^ Djulbegovic, B.; Hozo, I.; Schwartz, A.; McMasters, K. M. (September 1999). "Acceptable regret in medical decision making". Medical Hypotheses. 53 (3): 253–259. doi:10.1054/mehy.1998.0020. PMID 10580533.
  39. ^ Tsalatsanis A, Hozo I, and Djulbegovic B. Acceptable regret model in the end of life setting: Patients require high level of certainty before forgoing management recommendations. Eur J Cancer 2017; 75:159-166 [PMID: 28235727
  40. ^ Godlee F. In praise of uncertainty BMJ 2005;331:0fdoi:10.1136/bmj.331.7528.0-f
  41. ^ Djulbegovic B. Well informed uncertainties about the effects of treatment: Paradox exists in dealing with uncertainty. BMJ 2004;328(7446):1018-. (http://bmj.com)
  42. ^ Djulbegovic B. Uncertainty and Equipoise: At Interplay Between Epistemology, Decision Making and Ethics. Am J Med Sci 2011;342(4):282-9. (In Eng). DOI: 10.1097/MAJ.0b013e318227e0b8
  43. ^ Djulbegovic B, Hozo I, Greenland S. Uncertainty in Clinical Medicine. In: Gifford F, ed. Philosophy of Medicine (Handbook of the Philosophy of Science). London: Elsevier; 2011:299-356.
  44. ^ Djulbegovic B, Paul A. From Efficacy to Effectiveness in the Face of Uncertainty Indication Creep and Prevention Creep JAMA 2011;305(19):2005-2006.
  45. ^ Djulbegovic B, An Impossible Decision: The Life Interrupted by Uncertainty, Int J Biomed Healthc.:2022-1; 10-4-suppl.1: 274-302nPDF - FULL TEXT | DOI: 10.5455/ijbh.2022.10.274-302 https://www.ejmanager.com/mnstemps/220/220-1682836071.pdf?t=1707760409; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10498372/
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