Evidence-Based Medicine Tutorial
Definition of Evidence-Based
Medicine
Evidence
based medicine (EBM) was originally defined as the conscientious,
explicit, and judicious use of current best evidence in making
decisions about the care of individual patients. The practice of
evidence based medicine means integrating individual clinical
expertise with the best available external clinical evidence from
systematic research.
(Sackett
DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. Evidence
based medicine: what it is and what it isn't. BMJ 1996; 312:
71-2)
The revised
and improved definition of evidence-based medicine is a
systematic approach to clinical problem solving which
allows the integration of the best available research
evidence with clinical expertise and patient
values.
(Sackett
DL, Strauss SE, Richardson WS,et al. Evidence-based
medicine: how to practice and teach EBM. London:
Churchill-Livingstone,2000)
What EBM skills do all practicing clinicians really need?
While EBM is a
large step forward, these skills are necessary but not sufficient
for the practice of contemporary medicine. All clinicians should
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Find the best evidence for every day
practice (Information mastery)
-
Assess
relevance before rigor. Is the evidence patient oriented?
-
Evaluate
information about therapies, diagnostic tests, and clinical
decision rules. Is it true?
-
Understand
basic statistics.
-
Have at
fingertips “just in time’ information at the point of care using
web based and/or handheld computer based information and tools
for clinical decision making
-
Evaluate
expert-based information, including colleagues, CME,
presentations, reviews and guidelines.
-
Critically
evaluate information from pharmaceutical representatives.
No Free
Lunch.
Slawson DC,
Shaughnessy AF. Teaching
evidence-based medicine: should we be teaching information
management instead? Acad Med. 2005 Jul;80(7):685-9.
EBM as Lifelong Learning
The practice of evidence-based medicine is a process of
lifelong, self-directed, problem-based learning in which
caring for one's own patients creates the need for
clinically important information about diagnosis,
prognosis, therapy and other clinical and health care
issues.
Instead of routinely reviewing the contents of dozens of
journals for interesting articles, EBM suggests that you
target your reading to issues related to specific
patient problems. Developing clinical questions and then
searching current databases may be a more productive way
of keeping current with the literature.
Evidence-based medicine "converts the abstract exercise
of reading and appraising the literature into the
pragmatic process of using the literature to benefit
individual patients while simultaneously expanding the
clinician’s knowledge base."
(Bordley,
D.R. Fagan M, Theige D. Evidence-based
medicine: a powerful educational tool for clerkship
education.
Am J
Med. 1997 May;102(5):427-32.)
Five Steps Model of Evidence-Based
Medicine
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Convert information needs into answerable questions
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Track down with maximum efficiency the best evidence with
which to answer them
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Critically appraise that evidence for its validity and
usefulness
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Apply the results of this appraisal in your practice
-
Evaluate your performance
To convert your information needs
into a focused question, PICO format, see:
Levels
of Evidence
Major Evidence Based Medicine
Databases (EBM Foraging Tools)
A
high-quality foraging tool employs a transparent process that
-
systematically
surveys or reviews the literature
-
filters
out disease-oriented research and presents only patient-oriented
research outcomes,
-
demonstrates that a validity assessment has been performed using
appropriate criteria,
-
assigns
levels of evidence, based on appropriate validity criteria, to
individual studies,
-
provides
specific recommendations, when feasible, on how to apply the
information, placing it into clinical context,
-
comprehensively reviews the literature for a specific specialty
or discipline, and
-
coordinates with a high-quality hunting tool.
(Slawson, et
al)
EBM Hunting Tools:
These resources combine many of the above resources into one
tool that searches multiple resources, then organizes the
results by category representing the type of question you have.
Three of the
following are available on the web and PDA for all CoM faculty
and students. Step-by step-directions for using
each of these products on the web and PDA is available in this
PDF document:
Using EBM Resources
-
Clinical Evidence
Evidence-based evaluations of interventions for common clinical
conditions developed in collaboration with the American College
of Physicians, the American Society of Internal Medicine and
BMJ.
-
InfoRetriever
Collection of systematic review, calculators, and other evidence
based resources. Includes the Cochrane abstracts, InfoPOEM
reviews, guidelines, clinical prediction tools, 5 Minute
Clinical Consult and much more.
-
DynaMed
DynaMed contains
clinically organized summaries of nearly 1,800 topics and is
updated daily from review of the research literature. Includes
the Cochrane abstracts, ACP Journal Club, guidelines, USPSTF
recommendations, their own
reviews, as well as background materials.
-
ACP PIER
PIER (Physicians' Information and Education Resource) is a
Web-based decision-support tool designed for rapid point-of-care
delivery of up-to-date, evidence-based guidance for clinicians.
The Maguire library has a subscription at the ACP. It is also free to all members of the ACP and to all medical students
with an ACP membership at the same site.
-
NEW!
WebFeat Searching Tool Web only.
Search all Evidence Based Medicine resources subscribed to by
the Medical Library at one time. In development, so be
patient. Simplify searches if no answers found.
Link to
EBM Resources on the Medical Library Website
Last resort to track down
evidence.
Articles will need to be appraised before using.
Advanced EBM
Skills
Only a
small percentage of clinicians in each specialty need to be able
to do the following
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Critical Appraisal and Interpretation of Research on:
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Therapies
-
Diagnostic Tests
-
Prognosis
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Critical Evaluation and Interpretation of:
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Systematic Reviews, Including Meta-analysis
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Decision Analysis
-
Practice Guidelines
-
Pharmaceutical Advertising, Including Pharmaceutical
Representatives
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Assigning Levels of Evidence to Research Findings to:
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Teaching Level 1 Skills
-
Written Communication of Research Findings
To help critically appraise an
article or guideline, use the following guides:
To understand study design, statistics and
levels of evidence, consult the following sites:
To locate more information about
evidence-based medicine, see:
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