How to practice EBM

How to Establish and Encourage an Evidence-Informed Massage Therapy Practice Learn to overcome key obstacles: lack of time, support, knowledge, and confidence. West Coast College of Massage Therapy July 13, 2008 Presented by: Bodhi Haraldsson, RMT MTABC research department chair

Intro
Why EBM?
What is EBM?
How to practice EBM

What is EBM?
What are the essential elements of EBP?
Write down (2 minutes)
Compare with you neighbour
What did you
Agree on
Disagree on

What is Evidence-Based Medicine?
“ Evidence-based medicine is the integration of best research evidence with clinical expertise and patient values ” - Sackett & Straus

Ask Acquire Appraise Apply Act & Assess Patient dilemma Principles of evidence-based practice Evidence alone does not decide – combine with other knowledge and values Hierarchy of evidence Process of EBP

Skills for each of the 4 steps*
Formulate an answerable question
Track down the best evidence
Critically appraise the evidence
Individualise, based clinical expertise and patient concerns
Evaluate our effectiveness and efficiency
keep a record; improve the process
*Sicily statement on evidence-based practice. BMC Med Educ. 2005 Jan 5;5(1):1.

Six factors influence the uptake of innovations
Relative benefit – what’s in it for me?
(non)-Complexity – is it easy to learn?
Trialability – can I try it out easily?
Observability – can I see others do it?
Compatability – fit with ideas and work
Reinvention – can I adapt it to me?
Rogers, Diffusion of Innovations

1. Relative Benefit – what’s in it for me?
Evidence-Based Medicine can:
Reduce reading by quality filters
Better management of patients
Relieve anxiety about uncertainty

Keeping up to Date by “Just in Time” Education
Shift focus to your current problems
Relevant to YOUR practice
More m emorable (and practice changed)
Up to date
But Four Barriers
Admitting we don’t know
Skills in obtaining current best evidence
Evidence Resources at the point of care
Time

2. Non-complexity – is it easy to use?
How can we simplify EBM?

3. Trialability – can I try it out?
How can we make EBM easy to try?

Trialability: do 1 step and get help with others
Formulate an answerable question
Track down the best evidence
Critically appraise the evidence
Individualise, based clinical expertise and patient concerns
Evaluate our effectiveness and efficiency
keep a record; improve the process
*Sicily statement on evidence-based practice. BMC Med Educ. 2005 Jan 5;5(1):1.

3. Trialability – provide easy steps
Keep a paper question log
Answer a few important questions / week
Get help with searches
Simplify appraisal OR use pre-appraised topics
Focus on interpretation

We’ll peer into …
Asking answerable questions for EBM
Barriers to learning with our questions
How to teach EBM with questions
Have some fun!

Group Task
Groups of 2 – 3
Discuss > 1 question from recent work
Write it down
Be ready to report to group
Return in 2 minutes

Questions
…
…
…

10 Common Questions
Clinical findings
Harm/etiology
Differential diagnosis
Manifestations
Diagnostic tests
Prognosis
Therapy
Prevention
Experience, Meaning
Learning
(Not exhaustive or mutually exclusive)

‘ Background’ Questions
About the disorder, test, treatment, etc.
2 components :
a. Root * + Verb: “What causes …”
b. Condition: “Rheumatoid arthritis”
* Who, What, Where, When, Why, How

‘ Foreground’ Questions
About patient care decisions and actions
4 (or 3) components:
a. patient, problem, or population
b. intervention, exposure, or maneuver
c. comparison (if relevant)
d. clinical outcomes (including time horizon)

Background & Foreground

What Pushes Us …
Toward
curiosity
Prove colleagues wrong
Keeps coming up
Risk of patient harm
Want to do better
Anxiety
Avoid litigation
Internet informed patient
Away
Time
We already know the answer
Fatigue
Access
Inferiority complex-anxiety-afraid of admitting knowledge gaps
Cynical
Laziness
Lack of support
Previous failure at searching
Lack of resources
Noone else does it
Fear of change

How does it feel … ?
To know an answer?
To NOT know an answer?

Emotions in Not Knowing Inattention Detachment Sadness Withdraw Stop trying Body stress Distress Cry for help Disrupt Undermine Anger Fight Leave Invisible Fear Flee Behaviors Feeling Ready to …

Emotions in Knowing
Satisfaction : Self image of “knower” meets reality of “knew this”
Curiosity : the wind in the sails
Joy : knowing and/or learning brings benefits to others
“ Zero gravity” or “flow” : when learning engages the mind fully without self consciousness

The Real ‘Three R’s’ of Learning
R esilient
R eflective
R esourceful

Group Task
Groups of 2 – 3
Discuss >1 question you recognized
Write it down
Be ready to report to the group
Return in 3 minutes

Questions
a
b
c
d
e

Teaching with Questions
Recognize: your learners’ questions
Select: which questions to pursue
Guide: how to ask and answer
Assess: how well & what to improve

Selecting Questions
Consider:
What is illness?
What is role?
What are learning needs?
What are available resources?
Of these, select:
Most urgent
Most interesting
Most feasible to answer
Most likely to recur

FAQ: Why Bother? 1
Relevant to clinical needs
Relevant to learning needs
Plan searches
Recognize answers
Awaken curiosity
In teaching, improve comprehension
In referral, improve communication
Have some fun!
Any evidence?

FAQ: How Long … ?
Proficient? Quickly
Mastery? Lifetime
Human expertise takes >10,000 hours, >10 years
-> Deliberate practice

Questions: Take ‘Em Home
Believe Q’s rule
Q are chances to learn and to use evidence
Recognize Q’s
Background
Foreground
Select Q wisely
Match to Resources

Acknowledgements
“ There is nothing new under the sun”
These slides have been partially adapted from:
How do we nurture Evidence-Based Practice?
Paul Glasziou, Centre for Evidence Based Medicine, University of Oxford
Teaching EBM With Learners’ Questions
W. Scott Richardson, M.D.

How to practice EBM

by Bodhi Haraldsson on Jul 13, 2008

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