Evidence-Based MedicineIntroduction

Department of Medicine - Residency Training ProgramTuesdays, 9:30 a.m. - 12:00 p.m. - UW Health Sciences

Library

Director:Matt Hollon MD MPH, Assistant Professor, UWMC General

Internal Medicine, e-mail: mfhollon@u.washington.eduInstructors:Erin Fouch MD, Outpatient Chief Resident, July-December, e-

mail: emsfouch@u.washington.eduTravis Baggett MD, Outpatient Chief Resident, January-June, e-

mail: baggettt@u.washington.eduLibrarians:Sherry Dodson MLS, Clinical Medical Librarian, UW Health

Sciences Library, e-mail: sdodson@u.washington.edu

Faculty

Course Web Sitehttp://courses.washington.edu/ebmed/EBM/index.shtml

You can link to this site from the Medicine Residency web page, the Roosevelt GIMC

Residents’ web page, or HSL Evidence Based Practice web page.

Evidence-based medicine is the integration of the best available research evidence with clinical expertise and patient

values.

Why Teach and Practice EBM?

• It is required to be taught by ABIM.• Outcomes research has documented

that patients who do receive evidence-based therapies have better outcomes than those who don’t.

• It may be a more efficient means of remaining current than traditional methods (e.g. journal subscriptions).

• A host of developments make EBM more possible than ever.

Developments• Efficient strategies for tracking and

appraising evidence.• Availability of evidence-based

journals.• Creation of systematic reviews and

concise summaries.• Information systems allowing

access to resources in seconds.

Objectives• Hands-on, real-time learning of skills

necessary to incorporate EBM into your daily practice of medicine.

• Provide the opportunity to apply these skills to actual clinical encounters.

• Have fun learning and teaching others.• Minimize work outside of day to day

clinical responsibilities.

Responsibilities• Attend all the sessions.• Each week during your clinical

encounters generate at least one question about patient care you would like to try and answer in EBM. We will tackle these questions thematically (therapy, prognosis, diagnosis).

• Apply and teach what you learn.

Steps in Practicing EBM1. Convert the need for information into

an answerable question.2. Track down the best evidence with

which to answer that question.3. Critically appraise the evidence for its

validity, impact, and applicability.4. Integrate the evidence with our clinical

expertise and our patient’s characteristics and values.

Limitations*

• Time.• Shortage of coherent and

consistent scientific evidence (therapeutic nihilism).

• Challenges of applying evidence to care of individual patients.

• General barriers to the practice of quality medicine (e.g. costs, patient expectations, etc.).

Putting Skills into Practice• Find evidence supporting one clinical

decision made on each of your inpatients.

• Find evidence supporting one clinical decision made on one patient per clinic day.

• Encourage the students and colleagues you work with to follow your lead.

• Work as a team to find evidence-based answers.

Course Structure - 8 week cycleWeek 1

• Introduction• Asking a clinical question• Critical appraisal of therapy articles• Therapy questions• Searching

Week 2• Critically appraise therapy

articles• Write CAT• New question and real-time

practice session

Week 3• Review asking a clinical question• Critical appraisal of prognosis

articles• Prognosis questions• Searching

Week 4• Critically appraise prognosis

articles• Write CAT• New question and real-time

practice session

Week 5• Introduction• Asking a clinical question• Critical appraisal of diagnosis

articles• Diagnosis questions• Searching

Week 6• Critically appraise diagnosis

articles• Write CAT• New question and real-time practice

session

Week 7• Review asking a clinical question• Critical appraisal of articles about

harm• Searching

Week 8• Critically appraise harm

articles• Write CAT• New question and real-time

practice session

Think of Therapy ?’

s

Think of Prognosis

?’s

Think of Diagnosis

?’s

Think of Harm ?’s

The Answerable Question

Steps in Practicing EBM1. Convert the need for information into

an answerable question.2. Track down the best evidence with

which to answer that question.3. Critically appraise the evidence for its

validity, impact, and applicability.4. Integrate the evidence with our clinical

expertise and our patient’s characteristics and values.

Good questions are the backbone of practicing

EBM. It takes practice to ask the well-formulated

question.

The nature of the question asked is critically

experience dependent.

GENERAL KNOWLEDGE

SPECIFIC KNOWLEDGETYPE OF

QUESTION

CLINICAL EXPERIENCE

Differences in Type of ?’s

• “Background” question composed of question modifier and condition.

• Cover the full range of biologic, psychologic, or sociologic aspect of human illness

• Can be answered by reference works.*

• Can be used as a trampoline for generating specific questions to be answered by EBM.

• “Foreground” question composed of patient and/or problem, intervention (therapy, diagnostic test, etc.), comparison and outcome.

• Often requires more comprehensive and intensive search strategies (not necessarily more time consuming).

• Suitable to answering using the techniques of EBM.

General Specific

Well-Built Clinical ?’s• Directly relevant to the care of the

patient and our knowledge deficit.• Contains the following elements:

– the patient or problem being addressed

– the intervention or exposure being considered

– the comparison intervention or exposure, when relevant

– the clinical outcomes of interest.

Well Formulated ?’s• Focus scarce learning time on evidence

directly relevant to patient’s needs and our particular knowledge needs.

• Suggest high-yield search strategies.• Suggest forms that useful answers might take.• Help us to model life-long learning techniques

for our colleagues and students.• Are answerable and, thus, reinforce the

satisfaction of finding evidence that makes us better, faster clinicians.

Q: How do you find current best evidence?

A: Ask your librarian!Sherry Dodson - Clinical Medical Librarian

Q: What is best evidence?OR

Q: What kind of evidence is least likely to be wrong?

Steps in Practicing EBM1. Convert the need for information into

an answerable question.2. Track down the best evidence with

which to answer that question.3. Critically appraise the evidence for its

validity, impact, and applicability.4. Integrate the evidence with our clinical

expertise and our patient’s characteristics and values.

The Evidence Pyramid

Validity/S

trength of Inference

Tim

e Spent in C

ritical Appraisal

Levels of Evidence

ResourcesMETA-SEARCH ENGINESPrimeAnswers TRIP+ SUMSearch

SYSTEMATIC REVIEWS/META-ANALYSESCochrane Library PubMed Clinical Queries using Research Methodology Filters

EVIDENCE GUIDELINES/SUMMARIESAHRQ Evidence Reports Clinical Evidence AHRQ Preventive Services

CLINICAL RESEARCH CRITIQUESACP Journal Club 1996- Bandolier 1994- BestBETs

CASE REPORTS/SERIES, PRACTICE GUIDELINES, ETCNational Guideline ClearinghousePubMed

Steps in Practicing EBM1. Convert the need for information into

an answerable question.2. Track down the best evidence with

which to answer that question.3. Critically appraise the evidence for its

validity, impact, and applicability.4. Integrate the evidence with our clinical

expertise and our patient’s characteristics and values.