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Evidence based medicine

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  • 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. This definition of what EBM is and isn’t has gained wide acceptance and made it easier for us to get our points across.
  • Weatherall DJ: The inhumanity of medicine. BMJ 1994;308:1671-2.

Transcript

  • 1. Evidence based medicine Learning and Teaching
  • 2. What evidence-based medicine is:
    • Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. Its philosophical base dates back to the sceptics of post-revolutionary Paris (Bichat, Louis, Magendie).
  • 3. What evidence-based medicine is:
    • The practice of EBM requires the integration of
    • individual clinical expertise
      • with the
    • best available external clinical evidence from systematic research.
  • 4. What evidence-based medicine is:
    • Individual clinical expertise : the increasing proficiency and judgement that individual clinicians acquire through clinical experience and clinical practice.
      • reflected especially in more effective and efficient diagnosis, and
      • in the more thoughtful identification and compassionate utilisation of individual patient’s predicaments, rights, and preferences in making clinical decisions about their care.
  • 5. What evidence-based medicine is:
    • Best available external clinical evidence :
      • clinically relevant research, often from the basic sciences of medicine, but especially from patient-centred research into the accuracy and precision of diagnostic tests (including the clinical examination), the power of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative, and preventive regimens.
  • 6. What evidence-based medicine is:
    • External clinical evidence has a short doubling-time, and both invalidates previously accepted diagnostic tests and treatments and replaces them with new ones that are more powerful, more accurate, more efficacious, and safer
  • 7. What evidence-based medicine is:
    • Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough.
      • Without the former, practice risks becoming evidence-tyrannised, for even excellent external evidence may be inapplicable or inappropriate for an individual patient.
      • Without the latter, practice risks becoming rapidly out of date, to the detriment of patients and patient-care.
  • 8. What evidence-based medicine is:
    • this definition also helps us identify and understand what evidence-based medicine is not .
  • 9. EBM is neither old-hat nor impossible to practice:
    • The former argument falls before the evidence:
      • of striking variations in the integration of patient values into our clinical behaviour
      • of striking variations in the rates with which clinicians provide interventions of established benefit and uselessness to their patients.
      • in the inability of clinicians to keep abreast of important medical advances reported in primary journals
  • 10. Why do we need EBM?
    • Daily need for valid information about diagnosis, prognosis, therapy and prevention
    • approx twice for every three out patients or may effect around eight decisions a day
  • 11. Why do we need EBM?
    • Traditional sources are usually inadequate because
      • out of date (textbooks)
      • frequently wrong (experts)
      • ineffective (didactic CME)
      • too overwhelming in volume and variable in validity (medical journals)
  • 12. Why do we need EBM? 3
    • Disparity between our diagnostic skills and clinical judgement which increase with experience and our up to date knowledge which declines
  • 13. How do we practice EBM?
    • STEP 1
      • Converting the need for information (about prevention, diagnosis, pregnosis, therapy, causation etc) into an answerable clinical question
  • 14. How do we practice EBM?
    • STEP 2
      • track down the best evidence with which to answer that question
    • STEP 3
      • critically appraise the evidence for its validity (closeness to the truth), impact (size of effect), and applicability (usefulness in our clinical practice)
  • 15. How do we practice EBM?
    • STEP 4
      • integrate the critical appraisal with our patient’s unique biology , values and circumstances
    • STEP 5
      • evaluate our effectiveness and efficiency in executing steps 1-4 and seek ways to improve them for next time
  • 16. Can we do this?
    • “Promoting and improving access to summaries of evidence, rather than teaching all GPs literature searching and critical appraisal, would be the more appropriate method of encouraging evidence based general practice”
    • Conclusion of survey into GPs attitudes to EBM and there related educational needs (BMJ 1996)
  • 17. Can we do this?
    • In other words miss out the appraising (step 3) and just do the searching using reliable sources or preappraised evidence eg
      • Cochrane
      • Best Evidence
      • Bandolier
      • York Centre
      • etc
  • 18. Teaching EBM - opportunities
    • Almost every patient!
    • Problem and Random cases
    • Topic tutorials
    • Project
    • Consultation skills (patients individual circumstances ideas etc, giving information, informed choice)