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.
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    Weatherall DJ: The inhumanity of medicine. BMJ 1994;308:1671-2.
  • Evidence based medicine

    1. 1. Evidence based medicineEvidence based medicine Learning and TeachingLearning and Teaching
    2. 2. What evidence-based medicineWhat evidence-based medicine is:is: Evidence-based medicine is theEvidence-based medicine is the conscientious, explicit and judicious use ofconscientious, explicit and judicious use of current best evidence in making decisionscurrent best evidence in making decisions about the care of individual patients. Itsabout the care of individual patients. Its philosophical base dates back to thephilosophical base dates back to the sceptics of post-revolutionary Parissceptics of post-revolutionary Paris (Bichat, Louis, Magendie).(Bichat, Louis, Magendie).
    3. 3. What evidence-based medicineWhat evidence-based medicine is:is: The practice of EBM requires the integrationThe practice of EBM requires the integration ofof individual clinical expertiseindividual clinical expertise with thewith the best available external clinical evidencebest available external clinical evidence from systematic research.from systematic research.
    4. 4. What evidence-based medicineWhat evidence-based medicine is:is: Individual clinical expertiseIndividual clinical expertise : the increasing: the increasing proficiency and judgement that individualproficiency and judgement that individual clinicians acquire through clinicalclinicians acquire through clinical experience and clinical practice.experience and clinical practice. • reflected especially in more effective andreflected especially in more effective and efficient diagnosis, andefficient diagnosis, and • in the more thoughtful identification andin the more thoughtful identification and compassionate utilisation of individualcompassionate utilisation of individual patient’s predicaments, rights, andpatient’s predicaments, rights, and preferences in making clinical decisionspreferences in making clinical decisions about their care.about their care.
    5. 5. What evidence-based medicineWhat evidence-based medicine is:is: Best available external clinical evidenceBest available external clinical evidence :: • clinically relevant research, often from theclinically relevant research, often from the basic sciences of medicine, but especiallybasic sciences of medicine, but especially from patient-centred research into thefrom patient-centred research into the accuracy and precision of diagnostic testsaccuracy and precision of diagnostic tests (including the clinical examination), the power(including the clinical examination), the power of prognostic markers, and the efficacy andof prognostic markers, and the efficacy and safety of therapeutic, rehabilitative, andsafety of therapeutic, rehabilitative, and preventive regimens.preventive regimens.
    6. 6. What evidence-based medicineWhat evidence-based medicine is:is: External clinical evidence has a shortExternal clinical evidence has a short doubling-time, and both invalidatesdoubling-time, and both invalidates previously accepted diagnostic tests andpreviously accepted diagnostic tests and treatments and replaces them with newtreatments and replaces them with new ones that are more powerful, moreones that are more powerful, more accurate, more efficacious, and saferaccurate, more efficacious, and safer
    7. 7. What evidence-based medicineWhat evidence-based medicine is:is: Good doctors use both individual clinical expertiseGood doctors use both individual clinical expertise and the best available external evidence, and neitherand the best available external evidence, and neither alone is enough.alone is enough. • Without the former, practice risks becomingWithout the former, practice risks becoming evidence-tyrannised, for even excellent externalevidence-tyrannised, for even excellent external evidence may be inapplicable or inappropriate forevidence may be inapplicable or inappropriate for an individual patient.an individual patient. • Without the latter, practice risks becoming rapidlyWithout the latter, practice risks becoming rapidly out of date, to the detriment of patients andout of date, to the detriment of patients and patient-care.patient-care.
    8. 8. What evidence-based medicineWhat evidence-based medicine is:is: this definition also helps us identify andthis definition also helps us identify and understand what evidence-based medicineunderstand what evidence-based medicine isis notnot..
    9. 9. EBM is neither old-hat norEBM is neither old-hat nor impossible to practice:impossible to practice: The former argument falls before the evidence:The former argument falls before the evidence: • of striking variations in the integration of patientof striking variations in the integration of patient values into our clinical behaviourvalues into our clinical behaviour • of striking variations in the rates with whichof striking variations in the rates with which clinicians provide interventions of establishedclinicians provide interventions of established benefit and uselessness to their patients.benefit and uselessness to their patients. • in the inability of clinicians to keep abreast ofin the inability of clinicians to keep abreast of important medical advances reported in primaryimportant medical advances reported in primary journalsjournals
    10. 10. Why do we need EBM?Why do we need EBM? Daily need for valid information aboutDaily need for valid information about diagnosis, prognosis, therapy anddiagnosis, prognosis, therapy and preventionprevention approx twice for every three out patients orapprox twice for every three out patients or may effect around eight decisions a daymay effect around eight decisions a day
    11. 11. Why do we need EBM?Why do we need EBM? Traditional sources are usually inadequateTraditional sources are usually inadequate becausebecause • out of date (textbooks)out of date (textbooks) • frequently wrong (experts)frequently wrong (experts) • ineffective (didactic CME)ineffective (didactic CME) • too overwhelming in volume and variable intoo overwhelming in volume and variable in validity (medical journals)validity (medical journals)
    12. 12. Why do we need EBM? 3Why do we need EBM? 3 Disparity between our diagnostic skills andDisparity between our diagnostic skills and clinical judgement which increase withclinical judgement which increase with experience and our up to date knowledgeexperience and our up to date knowledge which declineswhich declines
    13. 13. How do we practice EBM?How do we practice EBM? STEP 1STEP 1 • Converting the need for information (aboutConverting the need for information (about prevention, diagnosis, pregnosis, therapy,prevention, diagnosis, pregnosis, therapy, causation etc) into an answerable clinicalcausation etc) into an answerable clinical questionquestion
    14. 14. How do we practice EBM?How do we practice EBM? STEP 2STEP 2 • track down the best evidence with which totrack down the best evidence with which to answer that questionanswer that question STEP 3STEP 3 • critically appraise the evidence for its validitycritically appraise the evidence for its validity (closeness to the truth), impact (size of effect),(closeness to the truth), impact (size of effect), and applicability (usefulness in our clinicaland applicability (usefulness in our clinical practice)practice)
    15. 15. How do we practice EBM?How do we practice EBM? STEP 4STEP 4 • integrate the critical appraisal with ourintegrate the critical appraisal with our patient’s unique biology , values andpatient’s unique biology , values and circumstancescircumstances STEP 5STEP 5 • evaluate our effectiveness and efficiency inevaluate our effectiveness and efficiency in executing steps 1-4 and seek ways to improveexecuting steps 1-4 and seek ways to improve them for next timethem for next time
    16. 16. Can we do this?Can we do this? ““Promoting and improving access toPromoting and improving access to summaries of evidence, rather thansummaries of evidence, rather than teaching all GPs literature searching andteaching all GPs literature searching and critical appraisal, would be the morecritical appraisal, would be the more appropriate method of encouragingappropriate method of encouraging evidence based general practice”evidence based general practice” Conclusion of survey into GPs attitudes toConclusion of survey into GPs attitudes to EBM and there related educational needsEBM and there related educational needs (BMJ 1996)(BMJ 1996)
    17. 17. Can we do this?Can we do this? In other words miss out the appraisingIn other words miss out the appraising (step 3) and just do the searching using(step 3) and just do the searching using reliable sources or preappraised evidencereliable sources or preappraised evidence egeg • CochraneCochrane • Best EvidenceBest Evidence • BandolierBandolier • York CentreYork Centre • etcetc
    18. 18. Teaching EBM - opportunitiesTeaching EBM - opportunities Almost every patient!Almost every patient! Problem and Random casesProblem and Random cases Topic tutorialsTopic tutorials ProjectProject Consultation skills (patients individualConsultation skills (patients individual circumstances ideas etc, givingcircumstances ideas etc, giving information, informed choice)information, informed choice)

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