EBM introduction and Asking Question

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2007 Jan 19 @ 長庚紀念醫院.桃園分院.中醫部

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EBM introduction and Asking Question

  1. 1. 萬里之行.始於足下 實證醫學.起於提問 2007 Jan 19 楊宗翰
  2. 2. Contents - Ask <ul><li>Introduction </li></ul><ul><li>Teach by example </li></ul><ul><li>The process of building a question </li></ul><ul><li>Recognize potential questions </li></ul><ul><li>Use educational prescriptions </li></ul>
  3. 3. EBM 是一種主義 <ul><li>甚麼是主義呢?主義就是一種 思想 、一種 信仰 和一種 力量 。大凡人類對於一件事,研究當中的道理,最先發生思想。思想貫通以後,便起信仰。有了信仰,就生出力量。所以主義是先由 思想再到信仰 ,次 由信仰生出力量 ,然後完全成立。 </li></ul><ul><li>思想 > 信仰 > 力量 </li></ul><ul><li>服務 > 教學 > 研究 </li></ul>
  4. 4. <ul><li>問題 導向 </li></ul><ul><li>病人 中心 </li></ul><ul><li>學以致 用 </li></ul>
  5. 5. <ul><li>The application of the best available evidence to patient care. </li></ul>
  6. 6. Dr. Sackett <ul><li>EBM is the integration of best research evidence with clinical expertise and patient values . </li></ul>
  7. 7. What – 4 E of EBM EASY <ul><li>Communication </li></ul><ul><li>Hx/PE, Reasoning </li></ul><ul><li>patient value </li></ul><ul><li>preference </li></ul>Evidence Expectation Expertise
  8. 8. 5 Steps for EBM approach <ul><li>問 Ask </li></ul><ul><li>查 Acquire </li></ul><ul><li>讀 Appraise </li></ul><ul><li>用 Apply </li></ul><ul><li>審 Audit/Access </li></ul>
  9. 9. Contents - Ask <ul><li>Introduction </li></ul><ul><li>Teach by example </li></ul><ul><li>The process of building a question </li></ul><ul><li>Recognize potential questions </li></ul><ul><li>Use educational prescriptions </li></ul>
  10. 10. EBM is like … <ul><li>I need a notebook … </li></ul><ul><li>A sk: P 30 y/o M / I PC / C MAC / O </li></ul><ul><li>A cquire: Searching </li></ul><ul><li>A ppraise: Collect/Compare information </li></ul><ul><li>A pply: Making decision. </li></ul><ul><li>A udit: Use your notebook. </li></ul>
  11. 11. Time? 30 hr 30 min 10 min Total Audit 5 min 1 min Apply 15 min 5 min Appraise 10 min 3 min Acquire 1 min 1 min Ask Maximum Average Minimum
  12. 12. Mode of Action I/C F/R VS For 非常少見 V V Replicating 較少見 每日見 Condition V Audit V V Apply V Appraise V V Acquire V V Ask Using Doing
  13. 13. Contents - Ask <ul><li>Introduction </li></ul><ul><li>Teach by example </li></ul><ul><li>The process of building a question </li></ul><ul><li>Recognize potential questions </li></ul><ul><li>Use educational prescriptions </li></ul>
  14. 14. Ask - <ul><li>Background - 5W & 1H </li></ul><ul><ul><li>who, when, where, what, why & how </li></ul></ul><ul><ul><li>Question about a disorder, test, treatment … </li></ul></ul><ul><li>Foreground - PICO </li></ul><ul><ul><li>Specific knowledge to inform clinical decision or action </li></ul></ul><ul><ul><li>A & B diagnostic test or treatment for a disorder </li></ul></ul>
  15. 16. Ask a foreground question <ul><li>The specific , answerable , searchable clinical question. </li></ul><ul><ul><li>Clinical findings (Hx/PE) </li></ul></ul><ul><ul><li>Etiology / DDx </li></ul></ul><ul><ul><li>Dx / Prognosis / Rx / Prevention </li></ul></ul><ul><li>P atients </li></ul><ul><li>I ntervention </li></ul><ul><li>C omparison </li></ul><ul><li>O utcomes </li></ul>
  16. 17. Type of Questions <ul><li>Clinical findings (Hx/PE …) </li></ul><ul><li>Etiology (Risks / Causes / Harm) </li></ul><ul><li>Clinical manifestations of dx </li></ul><ul><ul><li>Disease prevalence, incidence, … </li></ul></ul><ul><li>Diagnosis – DDx or tests </li></ul><ul><li>Prognosis </li></ul><ul><li>Intervention , or Prevention </li></ul><ul><li>Experience & meaning, Improvement </li></ul>
  17. 18. Contents - Ask <ul><li>Introduction </li></ul><ul><li>Teach by example </li></ul><ul><li>The process of building a question </li></ul><ul><ul><li>Question that a paper addressed </li></ul></ul><ul><ul><li>Question about caring our patients </li></ul></ul><ul><li>Recognize potential questions </li></ul><ul><li>Use educational prescriptions </li></ul>
  18. 19. Papers <ul><li>Type of articles </li></ul><ul><ul><li>Original or Review (narrative or systematic) </li></ul></ul><ul><li>Type to study </li></ul><ul><ul><li>Clinical or bench work </li></ul></ul><ul><li>Methodology </li></ul><ul><ul><li>RCT, Cohort, cross-sectional, case-control, case series, case report. </li></ul></ul>
  19. 21. Contents - Ask <ul><li>Introduction </li></ul><ul><li>Teach by example </li></ul><ul><li>The process of building a question </li></ul><ul><ul><li>Question that a paper addressed </li></ul></ul><ul><ul><li>Question about caring our patients </li></ul></ul><ul><li>Recognize potential questions </li></ul><ul><li>Use educational prescriptions </li></ul>
  20. 22. What is the Question? <ul><li>有哪些 中草藥 能 預防 或 治療 禽流感 ? </li></ul><ul><ul><li>Background or Foreground ? </li></ul></ul><ul><ul><li>What Category ? </li></ul></ul><ul><li>六十歲男性,一年前經診斷有 大腸腺性瘜肉 (adenomatous polyp) ,他需要接受 檢查或治療 嗎?有哪些 藥物治療 適合他? </li></ul>
  21. 23. What is the Question? <ul><li>53 year-old man with chronic tophaceous gout. He is allergic to allopurinol and his creatinine is 2 mg/dL. He suffered from frequent attack of arthritis (once every one to two week). </li></ul><ul><ul><li>What is the etiology of gout? </li></ul></ul><ul><ul><li>What is the risk factor for gout attack? </li></ul></ul><ul><ul><li>Will he require dialysis in the long run? </li></ul></ul><ul><ul><li>Is vitamin C supplement decrease serum UA or gout attack? </li></ul></ul>
  22. 24. Contents - Ask <ul><li>Introduction </li></ul><ul><li>Teach by example </li></ul><ul><li>The process of building a question </li></ul><ul><li>Recognize potential questions </li></ul><ul><li>Use educational prescriptions </li></ul>
  23. 25. The case … <ul><li>The 76-year-old retired farmer was consulted for progressive digital gangrene for 1 month . He is a chain smoker for a long time. A left supraclavicular lymphadenopathy was noted one month ago. His left third distal finger became cyanotic, and then gangrenous in the same time. His fingers and toes were cool and painful intermittently. He didn't have a typical triphasic nor biphasic changes of Raynaud's phenomonon. </li></ul><ul><li>Right upper lobe lung cancer is diagnosed by chest radiography without pathology. Bone scan showed multiple bony metastases. His echocardiography and electrocardiogram exclued the possiblity of cardiac thromboembolism. </li></ul><ul><li>He did not have arthritis, myalgia, dry eye, dry mouth, and dysphagia. No history of hepatitis. </li></ul>
  24. 26. The questions … <ul><li>What is the pathophysiology of Raynaud’s phenemenon (RP)? </li></ul><ul><li>What is the differential diagnosis? </li></ul><ul><li>How to treat the patient? </li></ul><ul><li>Is the patient has ‘primary’ or ‘secondary’ RP, what is the probability? </li></ul><ul><li>How good is ANA to differentiate the causes? </li></ul><ul><li>Dose the patient require anti-coagulants or aspirin? </li></ul><ul><li>Is CCB better than ACEi in treating RP? </li></ul>
  25. 27. Contents - Ask <ul><li>Introduction </li></ul><ul><li>Teach by example </li></ul><ul><li>The process of building a question </li></ul><ul><li>Recognize potential questions </li></ul><ul><li>Use educational prescriptions </li></ul>
  26. 28. 臨床醫學的問題… <ul><li>臨床上我們每天都會遇到一些問題: </li></ul><ul><ul><li>診斷: accuracy of diagnostic tests </li></ul></ul><ul><ul><li>預後: the power of prognostic markers </li></ul></ul><ul><ul><li>治療: the efficacy & safety of Rx </li></ul></ul><ul><ul><li>平均 </li></ul></ul><ul><ul><ul><li>每 3 個門診病人有 2 個問題 </li></ul></ul></ul><ul><ul><ul><li>每 1 個住院病人有 5 個問題 </li></ul></ul></ul><ul><li>有多少我們去找答案? < 1/3 </li></ul>
  27. 31. Ask … <ul><li>Selecting, Scheduling, Saving </li></ul><ul><ul><li>Important, Relevant, Time, Interesting, Recur </li></ul></ul><ul><ul><li>Immediate </li></ul></ul><ul><ul><li>In PICO format (papers, desktop/PDA computers, cards) </li></ul></ul>
  28. 32. Ask & then … <ul><li>The key question: </li></ul><ul><li>The best answer to the clinical problem in your mind/brain: </li></ul><ul><li>The initial evidence resources: </li></ul>
  29. 33. Summary <ul><li>Use “Current Best Evidence” to care our patients. </li></ul><ul><li>The Integration of Evidence, Expertise, Expectation. </li></ul><ul><li>5 steps ( 問,查,讀,用,審 ) </li></ul><ul><ul><li>Ask, Acquire, Appraise, Apply, Audit </li></ul></ul><ul><li>Ask – foreground or background questions </li></ul><ul><ul><li>PICO, & type of questions </li></ul></ul>

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