Dr. Faisal Al Haddad
Consultant of Family Medicine
& Occupational Health
Outline of Talk
Definition of EBM
History of EBM
Obstacles of EBM
How to practice EBM ( The Five A’s )
What is EBM?
Evidence-based medicine is the conscientious, explicit
and judicious use of current best evidence in making
decisions about the care of individual patients while
considering patient values.
The practice of evidence-based medicine means
integrating individual clinical expertise with the best
available external clinical evidence from systematic
How did it start?
Late 1970’s clinical epidemiologists at McMaster
University wrote a series of articles on how to read
clinical journals called critical appraisal that were
published in 1981 in Canadian Medical Association
This team started teaching the practice at the University
and the term changed to EBM in a document for
resident applicants in 1990.
In 1991 the term EBM appeared in ACP JC.
Daily need for valid information.
Inadequacy of traditional textbooks – out of date,
Disparity between our diagnostic skills and clinical
judgment – and up to date knowledge and clinical
The EBM process aims to make it easier to apply current
quality evidence from research in clinical and healthcare
Obstacles to EBM
Shortage of coherent consistent scientific evidence.
Difficulty applying to my patient population.
Developing skills for searching and appraising.
Limited number of studies that show “EBM” works.
EBM - How to practice:
The 5 A’s
Ask – formulated clinical question
Acquire – best evidence to answer a question
Appraise – evidence for validity, impact and applicability
Apply – to our patient
Assess – effectiveness
Formulate the Question :
A clinical question related to the diagnosis, treatment,
prognosis, or etiology of a patient’s illness.
Include the patient’s problem or diagnosis; the
intervention of interest, as well as any comparison
intervention; and the outcome of interest.
Needs to be focused and searchable.
Patient population and problem of interest
Intervention of interest or exposure
Comparison of interest
Outcome of interest
A 55-year old Type II diabetic woman came to your
clinic for regular follow up and result inquiring. You
notice that she has microalbuminuria.
You decide to start her on ACEI to prevent progression
to nephropathy. Sit-in intern asks you if ACEI is more
effective than ARB in term of prevention of
Patients: Type II diabetic patients with
Outcomes: Diabetic nephropathy
Aisha, a former nurse, brings her 18 months-old boy in
for a minor problem which is easily sorted out.
However, you noted that her child didn't have the
MMR vaccine till now.
When you ask Aisha 'why not' she says that she does not
want to give her son the MMR because it is probably
not safe and many boys have developed autism after
being immunized with the MMR. How would you
formulate clinical question?
Search for Answers
Having formulated the question, the next step is to
try to find an answer.
This step involves both an assessment of the type of
evidence that would be most appropriate to answer
the question, as well as the actual search for the
Best study design
Cross-sectional analytical study
Cohort, population based-case control
Double blind RCT or systematic review
Internet Database of Evidence-Based Abstracts and Articles
MEDLINE via PubMed
Up To Date
Appraise the Evidence
Once an article is located, it is necessary to appraise
its validity and importance before applying the
The specific analysis of the paper, regarding validity
and importance etc, depend on the type of study
design and the nature of the question.
Apply the Results to Your Patient
Is the evidence valid, important, applicable to your patient,
and feasible in your setting?
Would your patient fit inclusion and not exclusion criteria?
Were all clinically important outcomes considered?
Are costs and risks acceptable?
Are patients values/expectations considered?
Assess the Outcome
The final step includes an evaluation of your
performance in searching the literature, as well as an
assessment of the patient’s response.
Perform self evaluations to improve your skills in
Are my questions well formulated?
Am I effectively/efficiently searching?
How am I doing with critical appraisal?
Am I integrating what I have learned into clinical
Are patients benefiting?
The use of current best available evidence in
making decisions about patient care while
considering patient values.
Requires skills for critical appraisal as well as
skills for applying evidence appropriately to
Lifelong process of learning enhanced by selfevaluation.