EBM (Evidence-based Medicine) Asking Answerable Clinical Questionsdr. Isti Ilmiati Fujiati, MSc.CM-FM, MPd.Ked.

What is EBM?Evidence-based medicine (EBM) requires the integration of the best research evidence with our clinical expertise and our patients unique values and circumstances

Best research evidence means valid and clinically relevant research Clinical expertise means ability to use our clinical skills and past experience to rapidly identify each patients unique health state and diagnosisPatient values means the unique preferences, concerns and expectations each patiens brigs to a clinical encounter and which must be integrated into clinical decisions if they are to serve the patientPatient's circumstances means their individual clinical state and clinical setting

How do we actually practice EBM?Step-1: converting the need of information (about prevention, diagnosis, prognosis, therapy, causation, etc.) into an answerable questionsStep-2: tracking down the best evidence with which to answer that questionStep-3: critically appraising that evidence for its validity, impact and applicability

Step-4: integrating the critical appraisal with our clinical expertise and with our patients unique biology, values, and circumstancesStep-5: evaluating our effectiveness and efficiency in executing steps 1-4 and seeking ways to improve them both for next time How do we actually practice EBM?...

ScenarioA pediatrician was called to the hospital to attend the delivery of a new born. The mother, a 28 year old primigravida, had experienced elevated blood pressure during an otherwise uncomplicated pregnancy. The labor was induced because the pregnancy had continued 2 weeks past the expected date of delivery. During labor, evidence of fetal distress occurred. When the membranes ruptured, the obstetrician noted thick greenish containing meconium.

At the time of deliverythe male newborn was limp and cyanotic, and had no spontaneous respiratory effort and a heart rate only 50 beats/ min. When meconium was suctioned from his mouth and nose, the baby did not grimace, cough, or sneeze.Vigorous effort at resuscitation were initiated, including bag-and-mask ventilation with 100% oxygen and chest compressions, but the Apgar Score at 1 min. of life was 1. Despite continuing resuscitation, the 5 min. Apgar score improved only to 2, with a heart rate of 110 beats/ min.

The 10 min. Apgar score remained depressed at 3, and the neonate was transferred to the Newborn Intensive Care Unit. With aggressive medical management, the 3100 gram neonate continued to improve without evidence of acute neurologic complications. He was discharged from the hospital on the twelfth day of life.

Apgar Score for Evaluation of Neonatal Asphyxia

ScoreSign012Heart Rate (x/ min)RespirationMuscle ToneColor

Reflex response to catheter in nostril(-)(-)LimpBlue, pale

None< 100Slow, irregularSlow flexionBody pink, extremities blueGrimace>100Regular, cryingActive motorCompletely pink

Cough, sneeze

Questions What are the complications of Low APGAR SCORE?How does the Low APGAR SCORE lead to neurological complications?What did the patient mean by if my baby can not cry immediately, will he be fine?

Among patients presenting Low APGAR SCORE, how often would develop neurological complications?In babies with Low APGAR SCORE, would joining an integrated self care parents management program reduce morbidity from abnormal mental capacity over 5-7 years?

Questions

Background and Foreground QuestionsBackground questionsAsk for general knowledge about a condition or thingHave two essential components:1. A question root (who, what, where, when, how, why) and a verb2. A disorder, test, treatment or other aspect of health care

Background and Foreground QuestionsForeground questionsAsk for specific knowledge to inform clinical decisions or actionsHave four essential components:1. Patient and/ or problem (P)2. Intervention or exposure (I)3. Comparison, if relevant (C)4. Clinical outcomes including time if relevant (O)

Learn to Ask a Focused Clinical Question - Foreground

Patient Problem / PopulationDescription of the group to which your patient belongs, (age, gender, race, ethnicity, and stage of disease). The description should be specific enough to be helpful, but not overly specific.Intervention Be specific!description of the test or treatment that you are consideringwhat you plan to do for that patient Comparisonthe alternative. Not all questions need a comparison, the main alternative you are consideringOutcome

Be specific!something that not only matters to you, but matters to the patient. Be specific!what is the main concern?

The components: PThink about who / what you wish to apply this evidence to e.g.People with a particular disorder?e.g chronic recurrent cystitisPeople in a particular care setting?e.g. communityParticular groups of peoplee.g. sexually active young women?the elderly?children?How would you describe your clients / setting?

The intervention / topic of interest (e.g. cause, change in practice etc.) e.g.Use of guava juice (as a drink)Might want to specify how much / how oftenFor complex interventions may need to give specific detail / consideration to the descriptionWhat exactly am I considering?

The components: I

The comparison or alternative (not applicable to all questions) e.g.Anti-biotic therapy?Nothing?Fluids alone?What alternatives actions might I try?The components: C

The outcome e.g.CureDuration of diseasePreventionDeathSide effectsPain (reduced)WellbeingWhat am I hoping to accomplish (what outcomes might reasonably be affected...)?The components: O

ABCBackgroundForegroundExperience with Condition

A = limited experience with the conditionB = as we grow in clinical experience and responsibility C = further experience with the conditionsDiagonal line shows were never too green to learn foreground knowledge or too experience to outlive the need for background knowledge

Our reactions to knowing and to not knowing Clinical practice demands that we use large amounts of both background and foreground knowledge, whether or not were aware of its use. Combinations of practice demands and our awareness:1st our patients predicament may call for knowledge that we already possess, so we will experience the reinforcing mental and emotional responses termed Cognitive Resonance

Our reactions to knowing and to not knowing2nd we may realize that our patients illness calls for knowledge that we dont possess, and this awareness brings mental and emotional responses termed Cognitive Dissonance need to know3rd - our patients predicament might call upon knowledge that we dont have, yet these gaps may escape our attention, so we dont know what we dont know and we carry on undisturbed ignorance.

Unfortunatelyif handled less well, our cognitive dissonance might lead us to less adaptive behaviors such as trying to hide our deficits, or by reacting with anger, fear, or shame

By developing awareness of our knowing and thinking, we can recognized our cognitive dissonance when it occurs,recognized when the knowledge we need would come from clinical care research, and articulate background and foreground questions we can use to find the answers.

Central issues in clinical work where clinical questions often ariseClinical findings how to properly gather and interpret findings from the history and physical examinationEtiology how to identify causes or risk factors (including iatrogenic harms)Clinical manifestation of disease knowing how often and when a disease causes its clinical manifestations and how to use this knowledge in classifying our patient's illnesses

Differential diagnosisDiagnostic testsPrognosisTherapyPrevention Experience and meaningImprovement how to keep up-to-date

Central issues in clinical work where clinical questions often arise

For you to have the skills in questioning Make an answerable clinical questions (background or foreground question)Use your knowledge in semester 1, 2, 3, and/ or 4 to make the question. You can choose the scenario from one of the triggers in Tutorial to help you formulate the questionsYou have 7 minutes to do this exercise

Well donekeeping practice!

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