Evidence-Based Medicine: Overview
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Evidence-Based Medicine: Overview
- 1. IMPLEMENTING E.B.M. IN THE E.D. NATHAN CLEVELAND, MD, MS UNIVERSITY MEDICAL CENTER 18 JULY 2012
- 2. IMPLEMENTING E.B.M. IN THE E.D. TITLE WHAT IS EBM THE QUESTION HISTORY GOALS 1 PURPOSE EBM DEFINED ASSUMPTIONS
- 3. IMPLEMENTING E.B.M. IN THE E.D. EVIDENCE TITLE WHAT IS EBM THE QUESTION HISTORY GOALS 1 PURPOSE EBM DEFINED ASSUMPTIONS
- 4. IMPLEMENTING E.B.M. IN THE E.D. EVIDENCE TITLE WHAT IS EBM THE QUESTION HISTORY GOALS 1 PURPOSE EBM DEFINED ASSUMPTIONS Esoterica [esâ˘oâ˘terâ˘iâ˘ca] pl. n. Greek esášterikÓ; see esoteric 1. Things that are impractical or specialized.
- 5. IMPLEMENTING E.B.M. IN THE E.D. 1. History of medicine 2. What is EBM? 3. Why practice EBM? 4. Why not practice EBM? 5. How to practice EBM (theory)? 6. How to practice EBM (reality)? THE EXPERT EVIDENCE WHAT IS EBM THE QUESTION HISTORY GOALS 1 PURPOSE EBM DEFINED ASSUMPTIONS
- 6. IMPLEMENTING E.B.M. IN THE E.D. WHY EBM? THE EXPERT EVIDENCE WHAT IS EBM HISTORY GOALS 1 PURPOSE EBM DEFINED ASSUMPTIONS
- 7. IMPLEMENTING E.B.M. IN THE E.D. WHY EBM? THE EXPERT EVIDENCE WHAT IS EBM HISTORY GOALS 1 PURPOSE EBM DEFINED ASSUMPTIONS
- 8. IMPLEMENTING E.B.M. IN THE E.D. WHY EBM? THE EXPERT EVIDENCE WHAT IS EBM HISTORY GOALS 1 PURPOSE EBM DEFINED ASSUMPTIONS
- 9. IMPLEMENTING E.B.M. IN THE E.D. 1. DOGMA WHY EBM? THE EXPERT EVIDENCE WHAT IS EBM HISTORY GOALS 1 EBM DEFINED ASSUMPTIONS
- 10. IMPLEMENTING E.B.M. IN THE E.D. 1. DOGMA WHY EBM? THE EXPERT EVIDENCE WHAT IS EBM HISTORY GOALS 1 EBM DEFINED ASSUMPTIONS
- 11. IMPLEMENTING E.B.M. IN THE E.D. PHILOSOPHY METHOD 1. DOGMA WHY EBM? THE EXPERT EVIDENCE WHAT IS EBM HISTORY GOALS 1 EBM DEFINED ASSUMPTIONS
- 12. IMPLEMENTING E.B.M. IN THE E.D. 2. GESTALT âThe conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient.â Sackett DL, et al. BMJ 1996; 312(7023):71-2 1. DOGMA WHY EBM? THE EXPERT EVIDENCE WHAT IS EBM HISTORY EBM DEFINED ASSUMPTIONS
- 13. IMPLEMENTING E.B.M. IN THE E.D. BEST EXTERNAL EVIDENCE PATIENT VALUES CLINICAL EXPERTISE Sackett DL, et al. Evidence-based medicine: how to practice and teach EBM. 2000 EBM 2. GESTALT 1. DOGMA WHY EBM? THE EXPERT EVIDENCE WHAT IS EBM HISTORY EBM DEFINED ASSUMPTIONS
- 14. IMPLEMENTING E.B.M. IN THE E.D. BEST EXTERNAL EVIDENCE PATIENT VALUES / ACTIONS CLINICAL STATE Haynes, Devereaux, Guyatt. Clinical expertise in the era of evidence-based medicine and patient choice. Evid Based Med 2002;7:36-38. CLINICAL EXPERTISE 2. GESTALT 1. DOGMA WHY EBM? THE EXPERT EVIDENCE HISTORY EBM DEFINED ASSUMPTIONS WHAT IS EBM
- 15. IMPLEMENTING E.B.M. IN THE E.D. 3. THE TARGET Norman GR. Examining the assumptions of evidence-based medicine. J Eval Clin Pract 1999; 5(2):139-47 1. Generalizable truth exists 2. Methodology matters 3. Research begets practice 4. Clinicians can learn EBM 5. EBM leads to better care 6. Widespread use of EBM 2. GESTALT 1. DOGMA WHY EBM? THE EXPERT EVIDENCE EBM DEFINED ASSUMPTIONS WHAT IS EBM
- 16. IMPLEMENTING E.B.M. IN THE E.D. ⢠No physician preference circle ⢠We contribute the evidence 4. QUALITY BEST EXTERNAL EVIDENCE PATIENT VALUES / ACTIONS CLINICAL STATE 3. THE TARGET 2. GESTALT 1. DOGMA WHY EBM? THE EXPERT EVIDENCE EBM DEFINED ASSUMPTIONS
- 17. IMPLEMENTING E.B.M. IN THE E.D. Sackett DL, et al. Evidence-based medicine: how to practice and teach EBM. 2000 4. QUALITY 3. THE TARGET 2. GESTALT 1. DOGMA WHY EBM? THE EXPERT EVIDENCE EBM DEFINED ASSUMPTIONS
- 18. IMPLEMENTING E.B.M. IN THE E.D. 5. COST 4. QUALITY 3. THE TARGET 2. GESTALT 1. DOGMA WHY EBM? THE EXPERT EVIDENCE ASSUMPTIONS
- 19. IMPLEMENTING E.B.M. IN THE E.D. WHY NOT EBM? 5. COST 4. QUALITY 3. THE TARGET 2. GESTALT 1. DOGMA WHY EBM? THE EXPERT EVIDENCE
- 20. IMPLEMENTING E.B.M. IN THE E.D. 1. Dogma sucks:1. NO EVIDENCE WHY NOT EBM? 5. COST 4. QUALITY 3. THE TARGET 2. GESTALT 1. DOGMA WHY EBM? THE EXPERT
- 21. IMPLEMENTING E.B.M. IN THE E.D. 2. You (we) are not good enough:2. EBM LIMITS 1. NO EVIDENCE WHY NOT EBM? 5. COST 4. QUALITY 3. THE TARGET 2. GESTALT 1. DOGMA WHY EBM?
- 22. IMPLEMENTING E.B.M. IN THE E.D. 2. You (we) are not good enough: http://www.healthpartners.com accessed 7/3/2012 2. EBM LIMITS 1. NO EVIDENCE WHY NOT EBM? 5. COST 4. QUALITY 3. THE TARGET 2. GESTALT 1. DOGMA WHY EBM?
- 23. IMPLEMENTING E.B.M. IN THE E.D. 3. The target is moving:3. EBM FAILS âClinical knowledge doubles every 18 months.â -Nick van Terheyden 2. EBM LIMITS 1. NO EVIDENCE WHY NOT EBM? 5. COST 4. QUALITY 3. THE TARGET 2. GESTALT 1. DOGMA
- 24. IMPLEMENTING E.B.M. IN THE E.D. 4. Quality: 4. DISTRACTION BMJ Qual Saf 2011;20(Suppl 1):i13ei17 3. EBM FAILS 2. EBM LIMITS 1. NO EVIDENCE WHY NOT EBM? 5. COST 4. QUALITY 3. THE TARGET 2. GESTALT
- 25. IMPLEMENTING E.B.M. IN THE E.D. 5. Cost:5. THE PATIENT 4. DISTRACTION 3. EBM FAILS 2. EBM LIMITS 1. NO EVIDENCE WHY NOT EBM? 5. COST 4. QUALITY 3. THE TARGET
- 26. IMPLEMENTING E.B.M. IN THE E.D. HOW EBM? 5. THE PATIENT 4. DISTRACTION 3. EBM FAILS 2. EBM LIMITS 1. NO EVIDENCE WHY NOT EBM? 5. COST 4. QUALITY
- 27. IMPLEMENTING E.B.M. IN THE E.D. 1. There is no evidence that evidence-based medicine works. P.I.C.O. HOW EBM? 5. THE PATIENT 4. DISTRACTION 3. EBM FAILS 2. EBM LIMITS 1. NO EVIDENCE WHY NOT EBM? 5. COST
- 28. IMPLEMENTING E.B.M. IN THE E.D. 2. EBM sucks (sometimes):2. SEARCH BMJ 2003;327:20â27 1. P.I.C.O. HOW EBM? 5. THE PATIENT 4. DISTRACTION 3. EBM FAILS 2. EBM LIMITS 1. NO EVIDENCE WHY NOT EBM?
- 29. IMPLEMENTING E.B.M. IN THE E.D. 3. EBM fails:3. APPRAISE Cochrane Database of Systematic Reviews 2012;6:CD002766.pub2 2. SEARCH 1. P.I.C.O. HOW EBM? 5. THE PATIENT 4. DISTRACTION 3. EBM FAILS 2. EBM LIMITS 1. NO EVIDENCE
- 30. IMPLEMENTING E.B.M. IN THE E.D. 4. Too many regulations and competing interests. 4. APPLY 3. APPRAISE 2. SEARCH 1. P.I.C.O. HOW EBM? 5. THE PATIENT 4. DISTRACTION 3. EBM FAILS 2. EBM LIMITS
- 31. IMPLEMENTING E.B.M. IN THE E.D. 5. EBM ignores the patient.HOW EBM? 4. APPLY 3. APPRAISE 2. SEARCH 1. P.I.C.O. HOW EBM? 5. THE PATIENT 4. DISTRACTION 3. EBM FAILS
- 32. IMPLEMENTING E.B.M. IN THE E.D. REAL EBM HOW EBM? 4. APPLY 3. APPRAISE 2. SEARCH 1. P.I.C.O. HOW EBM? 5. THE PATIENT 4. DISTRACTION
- 33. IMPLEMENTING E.B.M. IN THE E.D. Step 1: Formulate a question P â Patient / population I â Intervention / indicator C â Comparison / control O â Outcome SUMMARY REAL EBM HOW EBM? 4. APPLY 3. APPRAISE 2. SEARCH 1. P.I.C.O. HOW EBM? 5. THE PATIENT
- 34. IMPLEMENTING E.B.M. IN THE E.D. Step 1: Formulate a question Step 2: Search the literature BREAK SUMMARY REAL EBM HOW EBM? 4. APPLY 3. APPRAISE 2. SEARCH 1. P.I.C.O. HOW EBM?
- 35. IMPLEMENTING E.B.M. IN THE E.D. Step 1: Formulate a question Step 2: Search the literature Step 3: Critically appraise literature GOALS 2 BREAK SUMMARY REAL EBM HOW EBM? 4. APPLY 3. APPRAISE 2. SEARCH 1. P.I.C.O.
- 36. IMPLEMENTING E.B.M. IN THE E.D. Step 1: Formulate a question Step 2: Search the literature Step 3: Critically appraise literature Step 4: Apply to patient THE DATA GOALS 2 BREAK SUMMARY REAL EBM HOW EBM? 4. APPLY 3. APPRAISE 2. SEARCH
- 37. IMPLEMENTING E.B.M. IN THE E.D. RESOURCES Step 1: Formulate a question Step 2: Search the literature Step 3: Critically appraise lit Step 4: Apply to patient THE DATA GOALS 2 BREAK SUMMARY REAL EBM HOW EBM? 4. APPLY 3. APPRAISE
- 38. IMPLEMENTING E.B.M. IN THE E.D. RESOURCES THE DATA GOALS 2 BREAK SUMMARY REAL EBM HOW EBM? 4. APPLY 3. APPRAISE
- 39. IMPLEMENTING E.B.M. IN THE E.D. 1. Personal commitment ⢠Know your resources ⢠Commit to staying up to date ⢠Start with EB clinical guidelines ⢠Common / important PICOs ⢠Use it in your dictation ⢠Donât forget the patient PROMPT RESOURCES THE DATA GOALS 2 BREAK SUMMARY REAL EBM HOW EBM? 4. APPLY
- 40. IMPLEMENTING E.B.M. IN THE E.D. 2. Group Culture ⢠Evidence above eminence PROMPT RESOURCES THE DATA GOALS 2 BREAK SUMMARY REAL EBM HOW EBM? 4. APPLY
- 41. IMPLEMENTING E.B.M. IN THE E.D. 2. Group Culture ⢠Evidence above eminence ⢠Geek it out PROMPT RESOURCES THE DATA GOALS 2 BREAK SUMMARY REAL EBM HOW EBM? 4. APPLY
- 42. IMPLEMENTING E.B.M. IN THE E.D. 2. Group Culture ⢠Evidence above eminence ⢠Geek it out ⢠Pass it on PROMPT RESOURCES THE DATA GOALS 2 BREAK SUMMARY REAL EBM HOW EBM? 4. APPLY
- 43. IMPLEMENTING E.B.M. IN THE E.D. PULL 1. History of medicine 2. What is EBM? 3. Why practice EBM? 4. Why not practice EBM? 5. How to practice EBM (theory)? 6. How to practice EBM (reality)? PROMPT RESOURCES THE DATA GOALS 2 BREAK SUMMARY REAL EBM HOW EBM?
- 44. IMPLEMENTING E.B.M. IN THE E.D. PUSH PULL PROMPT RESOURCES THE DATA GOALS 2 BREAK SUMMARY REAL EBM
- 45. IMPLEMENTING E.B.M. IN THE E.D. NATHAN CLEVELAND, MD, MS UNIVERSITY MEDICAL CENTER 18 JULY 2012
- 46. IMPLEMENTING E.B.M. IN THE E.D. TEXTBOOKS PUSH PULL PROMPT RESOURCES THE DATA GOALS 2 BREAK SUMMARY 1. Define problem-based learning 2. Review hierarchy of evidence 3. Introduce prompt / push / pull 4. Provide specific resources to help you implement EBM 5. EBM caveats
- 47. IMPLEMENTING E.B.M. IN THE E.D. âHalf of what you are taught as medical students will in 10 years have been shown to be wrong. And the trouble is, none of your teachers know which half.â Sydney Burwell, MD, Dean of Harvard Medical School RESOURCES TEXTBOOKS PUSH PULL PROMPT RESOURCES THE DATA GOALS 2 BREAK
- 48. IMPLEMENTING E.B.M. IN THE E.D. The solution: Problem-based learning RESOURCES TEXTBOOKS PUSH PULL PROMPT RESOURCES THE DATA GOALS 2 BREAK
- 49. IMPLEMENTING E.B.M. IN THE E.D. Sackett DL, et al. Evidence-based medicine: how to practice and teach EBM. 2000 RESOURCES TEXTBOOKS PUSH PULL PROMPT RESOURCES THE DATA GOALS 2 BREAK
- 50. IMPLEMENTING E.B.M. IN THE E.D. DiCenso A, et al. Accessing pre-appraised evidence: fine-tuning the 5S model into a 6S model. Evid Based Nurs 2009;12(4):99-101. RESOURCES TEXTBOOKS PUSH PULL PROMPT RESOURCES THE DATA GOALS 2 BREAK
- 51. IMPLEMENTING E.B.M. IN THE E.D. 1. Prompt resources 2. Pull resources 3. Push resources PULL DATA RESOURCES TEXTBOOKS PUSH PULL PROMPT RESOURCES THE DATA GOALS 2
- 52. IMPLEMENTING E.B.M. IN THE E.D. PUSH DATA PULL DATA RESOURCES TEXTBOOKS PUSH PULL PROMPT RESOURCES THE DATA
- 53. IMPLEMENTING E.B.M. IN THE E.D. RESOURCES PUSH DATA PULL DATA RESOURCES TEXTBOOKS PUSH PULL PROMPT RESOURCES
- 54. IMPLEMENTING E.B.M. IN THE E.D. PULL - DEMO RESOURCES PUSH DATA PULL DATA RESOURCES TEXTBOOKS PUSH PULL PROMPT
- 55. IMPLEMENTING E.B.M. IN THE E.D. ⢠Background info ⢠Lots of expert opinion ⢠Out of date ⢠Not for making clinical decisions PUSH - DEMO PULL - DEMO RESOURCES PUSH DATA PULL DATA RESOURCES TEXTBOOKS PUSH PULL
- 56. IMPLEMENTING E.B.M. IN THE E.D. Which resources should I be using?PUBMED TEACHERATTENDING SR RESIDENT/ FELLOW JR RESIDENTINTERN MED STUDENT TEXTS REVIEWS / SUMMARIES META-ANALYSES / LARGE STUDIES SYSTEMATIC REVIEWS RANDOMIZED CONTROLLED TRIALS BASIC SCIENCE RESEARCH PUSH - DEMO PULL - DEMO RESOURCES PUSH DATA PULL DATA RESOURCES TEXTBOOKS PUSH
- 57. IMPLEMENTING E.B.M. IN THE E.D. ANNALS EM PUBMED PUSH - DEMO PULL - DEMO RESOURCES PUSH DATA PULL DATA RESOURCES TEXTBOOKS
- 58. IMPLEMENTING E.B.M. IN THE E.D. ⢠Online texts with variable degree of critical appraisal: ANNALS EM PUBMED PUSH - DEMO PULL - DEMO RESOURCES PUSH DATA PULL DATA RESOURCES TEXTBOOKS
- 59. IMPLEMENTING E.B.M. IN THE E.D. ⢠EBM Search engines:ANNALS EM PUBMED PUSH - DEMO PULL - DEMO RESOURCES PUSH DATA PULL DATA RESOURCES TEXTBOOKS
- 60. IMPLEMENTING E.B.M. IN THE E.D. ⢠EBM Synopses:ANNALS EM PUBMED PUSH - DEMO PULL - DEMO RESOURCES PUSH DATA PULL DATA RESOURCES TEXTBOOKS
- 61. IMPLEMENTING E.B.M. IN THE E.D. EBM CAVEATS ⢠Relevant EBM literature sent to you as it occurs:ANNALS EM PUBMED PUSH - DEMO PULL - DEMO RESOURCES PUSH DATA PULL DATA RESOURCES
- 62. IMPLEMENTING E.B.M. IN THE E.D. SUMMARY EBM CAVEATS ANNALS EM PUBMED PUSH - DEMO PULL - DEMO RESOURCES PUSH DATA PULL DATA
- 63. IMPLEMENTING E.B.M. IN THE E.D. Donât like it? Donât know it? Wonât use it. SUMMARY EBM CAVEATS ANNALS EM PUBMED PUSH - DEMO PULL - DEMO RESOURCES PUSH DATA PULL DATA
- 64. IMPLEMENTING E.B.M. IN THE E.D. END SUMMARY EBM CAVEATS ANNALS EM PUBMED PUSH - DEMO PULL - DEMO RESOURCES PUSH DATA
- 65. IMPLEMENTING E.B.M. IN THE E.D. SUMMARY EBM CAVEATS ANNALS EM PUBMED PUSH - DEMO PULL - DEMO RESOURCES END
- 66. IMPLEMENTING E.B.M. IN THE E.D. SUMMARY EBM CAVEATS ANNALS EM PUBMED PUSH - DEMO PULL - DEMO END
- 67. IMPLEMENTING E.B.M. IN THE E.D. SUMMARY EBM CAVEATS ANNALS EM PUBMED PUSH - DEMO END
- 68. IMPLEMENTING E.B.M. IN THE E.D. 1. EBM is not litigation-based medicine 2. EBM is not efficiency-based medicine 3. EBM is not a panacea SUMMARY EBM CAVEATS ANNALS EM PUBMED END
- 69. IMPLEMENTING E.B.M. IN THE E.D. 1. EBM is the dominant philosophy 2. EBM will provide the safest, most efficient, best care for patients 3. We should adopt EBM personally and as a group SUMMARY EBM CAVEATS ANNALS EM END
- 70. IMPLEMENTING E.B.M. IN THE E.D. 4. Clinical questions should be answered with âbest availableâ 5. Be proficient in accessing data ⢠Prompt ⢠Pull ⢠Push SUMMARY EBM CAVEATS ANNALS EM END
- 71. IMPLEMENTING E.B.M. IN THE E.D. NATHAN CLEVELAND, MD, MS UNIVERSITY MEDICAL CENTER 18 JULY 2012
Hinweis der Redaktion
- OK, letâs start with a question. Who believes we should be practicing evidence-based medicine? Why?
- When it comes to this topic, I will readily admit that I am a bit of an evangelist. The purpose of this lecture is two fold: First, I hope to make you a convert. I want to convince you of the rightness of EBM and then inspire you to change the way you approach emergency medicine. Second, I want to provide the 50,000 foot overview of the landscape of evidence-based emergency medicine. This is a huge topic. There are entire curricula in med schools designed to teach EBM. You can even do a fellowship in EBM. Iâm not trying to teach you EBM in 2 hours â but although this is a broad overview lecture, Iâll also provide some very specific ways that you can incorporate EBM into your practice.
- The third purpose of this talk is to provide you with some tools to identify the best available evidence and teach others how to practice EBM. Now, I have to warn you that this talk is a bit of esoterica. I think you will get some practical application out of it, but there is some true nerdiness in this talk.
- In ancient times, a physicianâs expertise came from only two places: apprenticeship and personal experience with patients and disease. Expertise depended entirely on experience. In this model, a physician was essentially a tradesman.
- The Renaissance led to two important changes: the printing press allowed documentation of medical knowledge so that a physician could learn from more than one master; there was still training via apprenticeship (and later residency); and there was an increased focus on basic science knowledge. Expertise still depended on personal experience but with a foundation of basic science and medical education. From the Renaissance to the 1970s the physician was expected to be both a tradesman and a scientist.
- Beginning in the 1970s there was an increase in medical journals and the advent of, first the computer, then the internet allowed more widespread dissemination of medical knowledge and the concept of the physician as a tradesman not only faded, it became passe. Education was no longer a one-time event but an ongoing requirement. Expertise depended on knowledge of EVERYONEâs experience. Evidence and data were elevated to the most exalted position in medicine. And that brings us to the current topic⌠Evidence-Based Medicine.
- I have no idea what this means, I just thought it was the dumbest explanation of EBM that I have ever seen, and wanted to share it with you.
- The term first got widespread use in the mid-1990s. Although the concept had been evolving since the 70s, it was the work of Canadian physician David Sackett that really defined EBM. The term is used interchangeably to mean two different things: first, EBM is a philosophy about the way in which we think about the practice of medicine. Second, EBM refers to a method by which to enact that philosophy about medicine.
- Dr. Sackett is uniformly regarded as the father of modern evidence-based medicine and in 1996 wrote a landmark editorial called EvidenceBased Medicine Whatitis and whatitisn´t. In thatarticle he defines EBM thisway⌠Thisterm âcurrentbestevidenceâ or âbestavailableevidenceâ is a termthatyou are goingtoseeover and over in thislecture and itis a term I wantyoutogetusedtousing.
- Early models of EBM looked like this. In an ideal world, there is a nice intersection between clinical expertise, patient values and the best available evidence. EBM lives at that intersection. Now, in this diagram, all three of these components are equal in size and weight. I will admit that I believe one of these components should actually dominate the equation â weâll see if you can guess which component by the end of this hour.
- More recently this diagram has been modified to include the Clinical State and Circumstances â meaning that factors unique to your patient, population and clinical environment - impact this equation. For example, if you donât have a cath lab, all the data in the world regarding PCI is useless to you. Patient values became patient values and actions â because these matter too right? If you invented a medicine that cures cancer, and you have it available in your practice, but the side effects are so unbearable that no one will take it, that matters. And then clinical expertise comes in being able to integrate the other three components.
- 1. For the most part, we believe that there is a âright wayâ to practice and that it can be applied to a population. We all believe that vaccines save lives â so we donât have to ask whether we should administer to each individual pt. 2. We believe that truth can be revealed by methodologically sound clinical trials. 3. There is a direct link between the results of research and clinical practice. 4. For EBM to be useful, it has to be useable. 5. Physicians who practice based on the best available evidence, will provide better and more efficient care. 6. EBM is so compelling that its adoption should be rapid and widespread.
- If we go back to our model of EBM, we see that there is no component related to physician preference. Now, do I believe it should be a completely austere environment where there is no room for personal style? Of course not. But your personal tendencies should not matter. Now, there are people who work on changing patient actions and people who work on improving our clinical state, but the only component that we are all responsible for, is our knowledge of the best available evidence.
- Now is a good time to at least introduce you to the EBM Pyramid. Weâll revisit this a few times in the next hour but this shows us the hierarchy of quality of evidence. Just take a second to look at the levels. This is a revolutionary concept. In 40 years, âthe expertsâ went from the pinnacle of medical knowledge, to the bottom â ranking below case reports. Itâs scary to think about, but my beliefs and opinions (and therefore yours) donât even appear on the diagram. Actually, itâs pretty funny, I found a journal called Expert Opinion on Medical Diagnostics. Talk about irony. But maybe Iâm exaggerating by saying that expert opinion is irrelevantâŚ
- What we really need to do is just change the expert paradigm. Itâs no longer this doctor on the left who is the expert. Itâs this guy who has an ability to access the evidence he needs and then adapt his practice in light of that best available evidence.
- OK, so now we have some idea of WHAT evidence-based medicine is, but WHY do we need to practice EBM? I mean, western medicine was pretty good prior to the 1990s right? Whatâs the big deal that we needed to change everything? Iâll give you 5 reasons that we need to adopt EBM.
- As I like to say, donât let your dogma poop on my data. Who thinks we should not give abdominal pain pts narcotics until surgery has evaluated them? What about the importance of early beta-blocker in ACS? Youâre gonna love this one. All women with abdominal pain in the ED require a pelvic exam right? But what about things we KNOW are true? Prenatal care improves birth outcomes right? Who thinks we should be stretching before and after exercise? Medical history is littered with wrong medical dogma. Some of the dogma you learn from me and other attendings will ultimately be proven wrong some dayâŚ
- Forget all the possible errors that are inherent in practicing medicine (procedural errors, documentations errors, dosing errors, etc., etc.) weâre not even very good at clinical reasoning. Weâre prone to things like âclinical inertiaâ where, for instance, we do things âjust because we always do it that wayâ regardless of whether it fits with the current situation. We fail even at diagnosing common diseases â how are we ever going to catch the more rare ones? Abdominal pain is one of the most common complaints in the pediatric ED, appendicitis is the most common surgical cause of abdominal pain, yet it is missed 28-57% of the time on first presentation. In some conditions, gestalt performs almost (but not quite) as well as clinical prediction rules, yet without the rule, agreement of gestalt between physicians is terrible. The likelihood of being diagnosed depends heavily on which doctor is working when you present.
- Howâs this for sobering: 2pts/hr x 140hrs/mo x 10mo/yr x 20-30decisions/pt x 30 years of practice = 2.5 million decisions in your career. You take 136 million steps in your lifetime. Who has tripped in the last month? It is really easy to make mistakes even at things we do all the time. Donât get me wrong, EBM wonât eliminate mistakes but I, for one, would rather not rely on my own gestalt if I donât have to.
- We live in the age of medical informatics. Even if you have a very narrow specialty â say youâre a pediatric corneal oncologist â you cannot possibly keep up with all of the new information by âlearning itâ in the classic sense. Here is a screenshot of PubMed with a search for âEvidence-Based Medicine.â Look at this graph, the upslope begins in about 1995 and that is an enormous volume of literature just focusing on the practice of EBM. Here is a screenshot of search term âemergency medicineâ â scary huh? A British medical informatics guru estimated that clinical knowledge doubles every 18 months. It used to be that our âtargetâ for appendicitis was getting the patient to the OR as soon as possible. New data suggests sometimes those pts donât even need to OR â it is a constantly moving target and we have to constantly re-evaluate the evidence over time.
- I believe that there are really only two major ways to improve healthcare delivery: improved knowledge (thatâs where evidence based medicine comes in) and improved processes (thatâs really where QI programs come in). This is a great article on the interplay between these two. And I love this sentence out of the article. They try to diagram this interplay with the following figure: There are two separate knowledge bases. One is clinical knowledge and the other is process knowledge. Clinical knowledge affects our clinical decisions (doing the right thing) process knowledge improves our processes (doing things right) and so if we implement our clinical decisions via good processes we have a better chance of doing the right things right and affecting patient care and therefore outcomes. And if improved outcomes are not sufficient motivation in and of themselves, how about this: In the very near future, your pay may be tied to whether you practice according to the best available evidence. CMS is gradually trying to change the way physicians are paid. Currently we have the Physicians Quality Reporting Initiative (PQRI) which provides small financial carrots for reporting performance on quality metrics. This is a âpay-for-performanceâ program. CMS has already begun trials of âpay-for-efficiencyâ programs as well and the only way we can safely become more efficient in our test ordering, treatments and admissions is to adhere to the best available evidence. And frankly, Iâm OK with the concept of being paid for doing the right thing.
- Certainly there are times when adherence to EBM will actually increase cost. But one of the big assumptions of EBM is that overall, reliance on sound evidence will lead to more efficient care â more bang for your buck. This recent study out of Archives of Internal Medicine suggests that fully 1/3 of CTPE studies are unnecessary if the physician adheres to the current best evidence on diagnosing PE with risk stratification tools and d-dimer when appropriate. Youâll often hear, âbut I heard about a guy with a saddle embolus whoâs Wells Score was low or d-dimer negative.â Well, that sounds like the exception that proves the rule â remember the EBM pyramid, case reports are pretty low quality of evidence. Or how about this study where they implemented the best available evidence regarding PO versus IV vitamin supplementation in alcoholics and showed a dramatic reduction in the more expensive and usually unnecessary âbanana bag?â
- There are plenty of people who believe that we should not be focusing on evidence based medicine. Letâs look at why:
- Perhaps the most compelling and clever argument against EBM is that there is currently NOT any evidence that it can accomplish all of the things its proponents claim â at least on a large scale. Those assumptions we went through are just that⌠assumptions.
- There are many questions that will never be answered by strong clinical trials. If you remember our EBM pyramid, observational studies and case reports are near the bottom. In this classic out of BMJ, the others perform a systematic review of parachute use and find that there is insufficient evidence to conclude that parachutes have any mortality benefit.
- Here you go, straight out of The Cochrane Collaboration, arguably the pinnacle of the EBM pyramid â ž studies looking at healing touch for acute wounds found some benefit. These are studies that are considered robust enough to be included in the Cochrane Database!! Many people have commented on studies like this that find a positive benefit of therapies that donât even have a plausible physiologic explanation according to our current understanding of the basic science. And it is a hard argument to argue with.
- In other words, thereâs just too much red tape for EBM to be practical. When weâre concerned about door-to-doctor time, patient satisfaction, trying to accommodate consultants, liability, etc., etc. then there is just too much red tape hindering our ability to practice according to the best available evidence. Certainly there does have to be some balance. Does it always make since to stand your ground on the patient with an ankle sprain that doesnât meet Ottawa Ankle Rules criteria for an xray, if it means that person will storm out of your ED unhappy with their visit? Probably not.
- The classic teaching is that EBM is a simple 4 step process. Step 1 is to formulate a question. I really think this can be the hardest part. Most people use the PICO model for clinical questions. First define your patient. Then determine the treatment, or diagnostic test you want to look at. Decide what you want to compare to â this can be the current accepted treatment / another medication / a gold-standard test. Then look at the outcome you are interested in. The more specific your question, the more applicable the results. An example: in emergency department patients with spinal cord injury, does steroid administration, as compared with no steroid administration, reduce long term neurologic deficits.
- There are dozens of places to look for the right literature and dozens of ways to perform the search within each database.
- Right now, this is what you should be saying to me. WTF. I work in a place like this, where chaos reigns, Iâm supposed to see at least 2pts/hr, keep the LOS short, keep the pts happy, and you want me to formulate a question for my patient, search the literature, critically appraise that literature and then apply it to my pt??? There is no way!
- So what we really should be talking about is how WE practice EBM, because we work in a very unique environment. In the last part of this hour, weâre going to talk about some very specific ways that we can implement EBM into OUR daily practice.
- One of the biggest barriers to practicing EBM is lack of knowledge about how to find the data you need. Weâll talk about how to access the right information from available resources in the next hour. Since we work in a specialty where we donât have time to look up a lot of things while we work, you have to commit to being up to date on the literature before you need it. A great place to start is to know some evidence based clinical guidelines. Then begin to ask PICO questions about conditions that are common and important. Letâs face it, we basically see the same types of pts daily. A very specific thing you can do is force yourself to reference the EBM that guides your decision making in your dictation. This may help protect you medicolegally and you get paid for it. Finally, donât forget that the main reason to use EBM is for your pt. Discuss your reasoning with the pt and give them (at least the illusion) of autonomy in their care.
- We donât want to practice eminence-based medicine. We need to elevate evidence above eminence. Yes, you should respect and learn from those in positions of authority in the hospital but in addition to their greater experience, it should be their grasp of the best available evidence that makes them worthy of that position.
- Next, we are all really nerds at heart. Embrace that. I love the debate of whether we should be using a d-dimer to help evaluate for PE (we should). Or whether all sutured wounds require wound check in 2 days (they donât). Or if we should be ordering serum ethanol levels and drug screens in the ED (almost never). We should be routinely having these discussions.
- Finally, pass it on. Share your knowledge of the best available evidence with your attendings, with interns and med students, with off-service residents, with consultants. Just donât be an ass about it. If we do all of these things we can change the collective culture of our department in a way that will make it easier for us to practice EBM.
- We reviewed the hx of medicine and how we have moved from being tradesman to being accessors of data. We defined EBM as the conscientous and explicit use of the best available evidence to make decisions about pt care. We talked about the myriad of reasons I believe we should be practicing EBM. Dogma sucks. Weâre not perfect. The target is moving. Improved quality. Reduced cost. We talked a little about the arguments against medicine. And we began to explain how to practice EBM. First by changing your personal approach to medicine. And second by changing our group culture regarding what constitutes good medicine.
- Sydney Burwell, Dean of the Harvard Medical School said⌠And get this, guess what year he said it in?? Imagine how much more true that statement is today! If we rely on our formal education for our medical knowledge we have about a 2 year window of practice before we are dangerous. We have to have a system for accessing the best available evidence on an ongoing basis.
- The solution is problem-based learning. You could try to learn how to solve three-dimensional color-coded puzzles. Or you could do the more efficient thing and define your problem, then find the resources to solve that problem. Now obviously this does not mean we should skip medical school and go straight to practice. There has to be some background of basic science, pathophysiology, etc. etc.
- Letâs go back to the EBM pyramid. Any of these levels of evidence MIGHT be the best available evidence. The classic example of a field that relies on lower-levels of evidence would be toxicology. For the most part, IRBs will not let you perform RCTs where you poison human subjects. For the most common / important conditions we are really interested in having evidence that lands in these top tiers.
- Another way to think about the quality of evidence hierarchy is like this:
- OK, I want to introduce you to three categories of EBM resources. Prompt resources are resources that are built into our systems of practice and reflect the best available evidence. Pull resources allow you to go and get (pull) the information you need to you. Push resources send the relevant data to you as it becomes available.
- So here are our two pyramids representing the hierarchy of quality of evidence. It is my view that the quality of the evidence affects the way in which we access that data. Evidence that is at the top of the pyramid is so overwhelming that we cannot afford to miss it â we need prompts built into our systems to make sure we apply this evidence to our patients. This really requires technology â which we are way behind on at UMC. Wouldnât it be awesome if your EMR recognized SIRS criteria even when you didnât then prompted you to consider antibiotics when those criteria were met, since we have an abundance of high-quality research that tells us that early antibiotics improve mortality from sepsis. Weâre not really going to talk about prompt resources here. This is a systems level issue and unfortunately not something that we individually control.
- Pull resources are pre-appraised sources that provide overviews of the best available evidence on a topic. These are meta-analyses and review articles.
- Push resources are services that sort through the giant mass of new literature and pick out articles that are relevant to you. This is information that can be delivered to you by email, RSS feeds, twitter, etc. to provide an ongoing stream of high quality original literature to you. Although there are some journals that do this, these resources are generally not JAMA, Annals of EM, NEJM. These are services that take info from multiple journals.
- Just a quick note about textbooks â you should burn all of your texts. Just kidding. Textbooks are essential for providing background info. They give broad overviews of topics and included review of pathophysiology and treatment of diseases. Textbooks are best for reminding yourself about diseases and conditions which we might not see often. There are some evidence-based texts out there but keep in mind that textbooks include lots of expert opinion which may or may not be true and can quickly become out of date.
- But first, a lot of people ask which resources they should be focusing on. Well, the short answer is that at any given level of training, you should be able to use all of these resources. But this diagram attempts to show the relative contribution that I think any type of literature should have in your education at various levels of training.
- Pull resources are collections of organized, pre-appraised articles to reference. Some pull resources are actually publishing their own articles to summarize the best available evidence out there (Cochrane, BestBETs,) while others are merely databases or search engines to access articles that are published in another place (Trip Database).
- Online, âevidence basedâ texts are more up to date than paper texts, tend to be based on best available evidence but can (sometimes) be influenced by the authors opinions more than some other pull resources. These should be used for the same thing as textbook â background information and overviews of topics.
- These are search engines where the articles that are included in the search have already been appraised and deemed to represent the best available evidence or engines that can be manipulated to only show critically appraised articles.
- These sites provide summary articles (or guidelines) of the best available evidence out there.
- Iâm not a huge fan of push resources always. I find it hard to keep up. For me it is usually better to go and get the info that I am looking for and because Iâm getting it and immediately applying it to my pt, I am better able to remember the information. In my opinion, though, the best push resources out there are Journal Watch and a good working knowledge of F.O.A.M. (which is another lecture entirely â and perhaps will be even more important to your ongoing education than any of these resources).
- So your head must be spinning at this point. I just presented 30 possible resources to find the best available evidence and told you there are 30 more out there. So again youâre saying, âWTF?â Practicing EBM is somehow supposed to be better than the traditional style of medical practice and this just makes it seem much worse. So what do I do? When someone gave this talk to me in residency, they just went through every one of these resources and explained them all. What I am going to do today is simplify it. Iâll start with 3 resources that I think are essential to us
- So hereâs the thing about resources. If it is not something you like and know well, you just wonât use it.
- Cochrane database are high-level systematic reviews. Inclusion criteria for studies are stringent and therefore, the conclusions are often sometimes weak. But IN GENERAL if a diagnostic test or treatment is recommended by Cochrane, you can assume it is the best available evidence out there. BestBETSare brief, well-constructed reviews of the best available evidence for very specific questions in the ED. Biggest limitation is the number of BETs currently available. Guideline.gov is a repository of medical guidelines. For the most part, it publishes the official guidelines or clinical policies of various medical organizations such as ACEP, AHA, ACOG, European Society of Cardiology. The biggest limitation with this site is that you should be aware that not all guidelines are evidence-based.
- You canât possibly subscribe to and review all of the journals where new and important studies would be published. So you should have one reliable push resource to scan the literature for you and deliver only those things that are important. I use Journal Watch. It does cost money - $99/yr but I think a resource like this is a must.
- You should also have some skill in searching the medical literature yourself. This is really not something that you have time to do at work but is more for after work when you want to answer a question regarding a clinical scenario. Weâre not going to talk about how to use these types of search engines right now but come find me if you want help on doing this.
- Whether you are an AAEM fan or an ACEP fan, I think it is hard to argue with the fact that Annals of EM is our specialtyâs flagship publication. It has the highest impact-factor score and is becoming a better and better journal every year. I am not a fan of having dozens of journals delivered to you each month because I think the majority of us fail when it comes to sifting through them and picking out the relevant and high-quality articles. That being said, I think this is a journal that we should all be getting and reading each month.
- OK, just a couple quick caveats about EBM before we wrap this section up.