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How to practice EBM


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How to practice EBM

  1. 1. 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
  2. 2. Intro <ul><li>Why EBM? </li></ul><ul><li>What is EBM? </li></ul><ul><li>How to practice EBM </li></ul>
  3. 3. What is EBM? <ul><li>What are the essential elements of EBP? </li></ul><ul><ul><li>Write down (2 minutes) </li></ul></ul><ul><li>Compare with you neighbour </li></ul><ul><li>What did you </li></ul><ul><ul><li>Agree on </li></ul></ul><ul><ul><li>Disagree on </li></ul></ul>
  4. 4. What is Evidence-Based Medicine? <ul><li>“ Evidence-based medicine is the integration of best research evidence with clinical expertise and patient values ” - Sackett & Straus </li></ul>
  5. 5. 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
  6. 6. Skills for each of the 4 steps* <ul><li>Formulate an answerable question </li></ul><ul><li>Track down the best evidence </li></ul><ul><li>Critically appraise the evidence </li></ul><ul><li>Individualise, based clinical expertise and patient concerns </li></ul><ul><li>Evaluate our effectiveness and efficiency </li></ul><ul><ul><li>keep a record; improve the process </li></ul></ul>*Sicily statement on evidence-based practice. BMC Med Educ. 2005 Jan 5;5(1):1.
  7. 7. Six factors influence the uptake of innovations <ul><li>Relative benefit – what’s in it for me? </li></ul><ul><li>(non)-Complexity – is it easy to learn? </li></ul><ul><li>Trialability – can I try it out easily? </li></ul><ul><li>Observability – can I see others do it? </li></ul><ul><li>Compatability – fit with ideas and work </li></ul><ul><li>Reinvention – can I adapt it to me? </li></ul>Rogers, Diffusion of Innovations
  8. 8. 1. Relative Benefit – what’s in it for me? <ul><li>Evidence-Based Medicine can: </li></ul><ul><ul><li>Reduce reading by quality filters </li></ul></ul><ul><ul><li>Better management of patients </li></ul></ul><ul><ul><li>Relieve anxiety about uncertainty </li></ul></ul>
  9. 9. Keeping up to Date by “Just in Time” Education <ul><ul><ul><li>Shift focus to your current problems </li></ul></ul></ul><ul><ul><ul><ul><li>Relevant to YOUR practice </li></ul></ul></ul></ul><ul><ul><ul><ul><li>More m emorable (and practice changed) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Up to date </li></ul></ul></ul></ul><ul><ul><ul><li>But Four Barriers </li></ul></ul></ul><ul><ul><ul><ul><li>Admitting we don’t know </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Skills in obtaining current best evidence </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Evidence Resources at the point of care </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Time </li></ul></ul></ul></ul>
  10. 10. 2. Non-complexity – is it easy to use? <ul><li>How can we simplify EBM? </li></ul>
  11. 11. 3. Trialability – can I try it out? <ul><li>How can we make EBM easy to try? </li></ul>
  12. 12. Trialability: do 1 step and get help with others <ul><li>Formulate an answerable question </li></ul><ul><li>Track down the best evidence </li></ul><ul><li>Critically appraise the evidence </li></ul><ul><li>Individualise, based clinical expertise and patient concerns </li></ul><ul><li>Evaluate our effectiveness and efficiency </li></ul><ul><ul><li>keep a record; improve the process </li></ul></ul>*Sicily statement on evidence-based practice. BMC Med Educ. 2005 Jan 5;5(1):1.
  13. 13. 3. Trialability – provide easy steps <ul><li>Keep a paper question log </li></ul><ul><li>Answer a few important questions / week </li></ul><ul><li>Get help with searches </li></ul><ul><li>Simplify appraisal OR use pre-appraised topics </li></ul><ul><li>Focus on interpretation </li></ul>
  14. 14. We’ll peer into … <ul><li>Asking answerable questions for EBM </li></ul><ul><li>Barriers to learning with our questions </li></ul><ul><li>How to teach EBM with questions </li></ul><ul><li>Have some fun! </li></ul>
  15. 15. Group Task <ul><li>Groups of 2 – 3 </li></ul><ul><li>Discuss > 1 question from recent work </li></ul><ul><li>Write it down </li></ul><ul><li>Be ready to report to group </li></ul><ul><li>Return in 2 minutes </li></ul>
  16. 16. Questions <ul><li>… </li></ul><ul><li>… </li></ul><ul><li>… </li></ul>
  17. 17. 10 Common Questions <ul><li>Clinical findings </li></ul><ul><li>Harm/etiology </li></ul><ul><li>Differential diagnosis </li></ul><ul><li>Manifestations </li></ul><ul><li>Diagnostic tests </li></ul><ul><li>Prognosis </li></ul><ul><li>Therapy </li></ul><ul><li>Prevention </li></ul><ul><li>Experience, Meaning </li></ul><ul><li>Learning </li></ul><ul><li>(Not exhaustive or mutually exclusive) </li></ul>
  18. 18. ‘ Background’ Questions <ul><li>About the disorder, test, treatment, etc. </li></ul><ul><li>2 components : </li></ul><ul><li>a. Root * + Verb: “What causes …” </li></ul><ul><li>b. Condition: “Rheumatoid arthritis” </li></ul><ul><ul><ul><li>* Who, What, Where, When, Why, How </li></ul></ul></ul>
  19. 19. ‘ Foreground’ Questions <ul><li>About patient care decisions and actions </li></ul><ul><li>4 (or 3) components: </li></ul><ul><li>a. patient, problem, or population </li></ul><ul><li>b. intervention, exposure, or maneuver </li></ul><ul><li>c. comparison (if relevant) </li></ul><ul><li>d. clinical outcomes (including time horizon) </li></ul>
  20. 20. Background & Foreground
  21. 21. What Pushes Us … <ul><li>Toward </li></ul><ul><li>curiosity </li></ul><ul><li>Prove colleagues wrong </li></ul><ul><li>Keeps coming up </li></ul><ul><li>Risk of patient harm </li></ul><ul><li>Want to do better </li></ul><ul><li>Anxiety </li></ul><ul><li>Avoid litigation </li></ul><ul><li>Internet informed patient </li></ul><ul><li>Away </li></ul><ul><li>Time </li></ul><ul><li>We already know the answer </li></ul><ul><li>Fatigue </li></ul><ul><li>Access </li></ul><ul><li>Inferiority complex-anxiety-afraid of admitting knowledge gaps </li></ul><ul><li>Cynical </li></ul><ul><li>Laziness </li></ul><ul><li>Lack of support </li></ul><ul><li>Previous failure at searching </li></ul><ul><li>Lack of resources </li></ul><ul><li>Noone else does it </li></ul><ul><li>Fear of change </li></ul>
  22. 22. How does it feel … ? <ul><li>To know an answer? </li></ul><ul><li>To NOT know an answer? </li></ul>
  23. 23. 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 …
  24. 24. Emotions in Knowing <ul><li>Satisfaction : Self image of “knower” meets reality of “knew this” </li></ul><ul><li>Curiosity : the wind in the sails </li></ul><ul><li>Joy : knowing and/or learning brings benefits to others </li></ul><ul><li>“ Zero gravity” or “flow” : when learning engages the mind fully without self consciousness </li></ul>
  25. 25. The Real ‘Three R’s’ of Learning <ul><li>R esilient </li></ul><ul><li>R eflective </li></ul><ul><li>R esourceful </li></ul>
  26. 26. Group Task <ul><li>Groups of 2 – 3 </li></ul><ul><li>Discuss >1 question you recognized </li></ul><ul><li>Write it down </li></ul><ul><li>Be ready to report to the group </li></ul><ul><li>Return in 3 minutes </li></ul>
  27. 27. Questions <ul><li>a </li></ul><ul><li>b </li></ul><ul><li>c </li></ul><ul><li>d </li></ul><ul><li>e </li></ul>
  28. 28. Teaching with Questions <ul><li>Recognize: your learners’ questions </li></ul><ul><li>Select: which questions to pursue </li></ul><ul><li>Guide: how to ask and answer </li></ul><ul><li>Assess: how well & what to improve </li></ul>
  29. 29. Selecting Questions <ul><li>Consider: </li></ul><ul><li>What is illness? </li></ul><ul><li>What is role? </li></ul><ul><li>What are learning needs? </li></ul><ul><li>What are available resources? </li></ul><ul><li>Of these, select: </li></ul><ul><li>Most urgent </li></ul><ul><li>Most interesting </li></ul><ul><li>Most feasible to answer </li></ul><ul><li>Most likely to recur </li></ul>
  30. 31. FAQ: Why Bother? 1 <ul><li>Relevant to clinical needs </li></ul><ul><li>Relevant to learning needs </li></ul><ul><li>Plan searches </li></ul><ul><li>Recognize answers </li></ul><ul><li>Awaken curiosity </li></ul><ul><li>In teaching, improve comprehension </li></ul><ul><li>In referral, improve communication </li></ul><ul><li>Have some fun! </li></ul><ul><li>Any evidence? </li></ul>
  31. 32. FAQ: How Long … ? <ul><li>Proficient? Quickly </li></ul><ul><li>Mastery? Lifetime </li></ul><ul><li>Human expertise takes >10,000 hours, >10 years </li></ul><ul><li>-> Deliberate practice </li></ul>
  32. 33. Questions: Take ‘Em Home <ul><li>Believe Q’s rule </li></ul><ul><li>Q are chances to learn and to use evidence </li></ul><ul><li>Recognize Q’s </li></ul><ul><ul><li>Background </li></ul></ul><ul><ul><li>Foreground </li></ul></ul><ul><li>Select Q wisely </li></ul><ul><li>Match to Resources </li></ul>
  33. 34. Acknowledgements <ul><li>“ There is nothing new under the sun” </li></ul><ul><li>These slides have been partially adapted from: </li></ul><ul><li>How do we nurture Evidence-Based Practice? </li></ul><ul><li>Paul Glasziou, Centre for Evidence Based Medicine, University of Oxford </li></ul><ul><li>Teaching EBM With Learners’ Questions </li></ul><ul><li>W. Scott Richardson, M.D. </li></ul>