1
萬里之行.始於足下
實證醫學.起於提問
2008 Mar 13
基隆長庚.實證中心
http://ebm.twbbs.org/
楊宗翰醫師
http://dr3939.twbbs.org/
2
5 Steps
• 問
• 查
• 讀
• 用
• 審
• Ask
• Acquire
• Appraise
• Apply
• Audit
3
EBM is like …
• We need a President…
• Ask: Taiwan (P) / 馬 (I) / 謝 (C) / … (O)
• Acquire: Searching
• Appraise: Collect/...
4
Contents
• 介紹臨床問題
• 如何建構臨床問題
– 問題的類型: background or foreground
– PICO or PICOT
– 臨床問題的類型:治療、診斷、病因、預後、其他…
– 練習
• 醫學文獻
• 臨...
臨床問題…
• 臨床上我們每天都會遇到一些問題:
– 診斷: accuracy of diagnostic tests
– 預後: the power of prognostic markers
– 治療: the efficacy & saf...
6
問什麼?
• 精確( specific )的問題
– 可以被回答 (answerable)
– 可以被搜尋 (searchable)
7
Which one is answerable by a
single research?
• What is the meaning of life?
• What is the risk of autism following a
me...
8
Contents
• 介紹臨床問題
• 如何建構臨床問題
1. 問題的類型: background or foreground
2. PICO or PICOT
3. 臨床問題的類型:治療、診斷、病因、預後、其他…
– 練習:醫學文獻 & ...
9
Ask – Step 1 – Back/Foreground
• Background - 5W & 1H
– who, when, where, what, why & how
– Question about a disorder, t...
10
11
Ask a foreground question
• The specific, answerable,
searchable clinical question.
12
Ask – Step 2 - PICO
• Patients
• Intervention / Index test / Indicator
(Exposure)
• Comparator
• Outcomes
13
Ask – Step 3 - Type of Questions
• Intervention, or Prevention
• Etiology (Risks / Causes / Harm)
• Diagnosis – DDx or ...
14
Current Best Evidence
15
The process of building a
question
1. Background or Foreground question
2. PICO
3. Type of clinical question
16
Examples 1
• 有哪些中草藥能預防或治療禽流感?
– Background or Foreground ?
– What Category ?
• 六十歲男性,一年前經診斷有大腸腺性瘜
肉 (adenomatous polyp)...
17
Examples 2
• 53 year-old man with chronic tophaceous gout.
He is allergic to allopurinol and his creatinine is 2
mg/dL....
18
Exercise
• 醫學文獻 • 臨床情境
19
Type Background Foreground
Intervention What to do?
How to treat?
I vs C
Etiology What is the cause? I vs C
Diagnosis D...
20
Contents
• 介紹臨床問題
• 如何建構臨床問題
1. 問題的類型: background or foreground
2. PICO or PICOT
3. 臨床問題的類型:治療、診斷、病因、預後、其他…
– 練習:醫學文獻 &...
臨床醫學的問題…
• 臨床上我們每天都會遇到一些問題:
– 診斷: accuracy of diagnostic tests
– 預後: the power of prognostic markers
– 治療: the efficacy & ...
22
Solutions!
• 承認不知道
• 隨手記下
• 有空就查
23
24
25
Search Strategy
• 精確( specific )的問題
– 可以被回答 (answerable)
– 可以被搜尋 (searchable)
26
Ask …
• Selecting, Scheduling, Saving
– Immediate
– In PICO format (papers, desktop/PDA
computers, cards)
27
Important, Relevant, Time,
Interesting, Recur
• Examples 2
– 53 year-old man with chronic tophaceous gout. He is
allerg...
28
Ask & then …
• 記下 key question
• 想一下
– 這類的問題最佳的解決方案(研究方法)為
何?
– 那個資料庫能快速的幫我們找到最佳實證
29
Contents
• 介紹臨床問題
• 如何建構臨床問題
– 問題的類型: background or foreground
– PICO or PICOT
– 臨床問題的類型:治療、診斷、病因、預後、其他…
– 練習
• 醫學文獻
• ...
30
Which one do you think is/are
answerable by a single research?
• What is the meaning of life?
• What is the risk of aut...
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The First Step of EBP.

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  • http://www.vghks.gov.tw/erli/Index/clinicaltrainingcenter/ebm/index.htm
    http://www.vghks.gov.tw/lib
    http://www2.edah.org.tw/edh/EBM/
  • <number>
    Residents’ medical information needs in clinic: are they being met? Am J Med. 2000 Aug 15;109(3):218-23. PMID:10974185
  • EBP workbook 2007, 2/e.
  • <number>
  • <number>
  • Ask an Answerable Question

    1. 1. 1 萬里之行.始於足下 實證醫學.起於提問 2008 Mar 13 基隆長庚.實證中心 http://ebm.twbbs.org/ 楊宗翰醫師 http://dr3939.twbbs.org/
    2. 2. 2 5 Steps • 問 • 查 • 讀 • 用 • 審 • Ask • Acquire • Appraise • Apply • Audit
    3. 3. 3 EBM is like … • We need a President… • Ask: Taiwan (P) / 馬 (I) / 謝 (C) / … (O) • Acquire: Searching • Appraise: Collect/Compare information • Apply: Making decision. • Audit: Enjoy our new P, U vote him again?
    4. 4. 4 Contents • 介紹臨床問題 • 如何建構臨床問題 – 問題的類型: background or foreground – PICO or PICOT – 臨床問題的類型:治療、診斷、病因、預後、其他… – 練習 • 醫學文獻 • 臨床情境 • 如何處理提出的臨床問題
    5. 5. 臨床問題… • 臨床上我們每天都會遇到一些問題: – 診斷: accuracy of diagnostic tests – 預後: the power of prognostic markers – 治療: the efficacy & safety of Rx – 平均 • 每 3 個門診病人有 2 個問題 • 每 1 個住院病人有 5 個問題 • 有多少我們去找答案? < 1/3
    6. 6. 6 問什麼? • 精確( specific )的問題 – 可以被回答 (answerable) – 可以被搜尋 (searchable)
    7. 7. 7 Which one is answerable by a single research? • What is the meaning of life? • What is the risk of autism following a measles vaccine? • What is the best treatment for osteoarthritis? • Why don’t patients take their prescribed medications? EBP workbook 2007, 2/e.
    8. 8. 8 Contents • 介紹臨床問題 • 如何建構臨床問題 1. 問題的類型: background or foreground 2. PICO or PICOT 3. 臨床問題的類型:治療、診斷、病因、預後、其他… – 練習:醫學文獻 & 臨床情境 • 如何處理提出的臨床問題
    9. 9. 9 Ask – Step 1 – Back/Foreground • Background - 5W & 1H – who, when, where, what, why & how – Question about a disorder, test, treatment … • Foreground - PICO – Specific knowledge to inform clinical decision or action – A & B diagnostic test or treatment for a disorder
    10. 10. 10
    11. 11. 11 Ask a foreground question • The specific, answerable, searchable clinical question.
    12. 12. 12 Ask – Step 2 - PICO • Patients • Intervention / Index test / Indicator (Exposure) • Comparator • Outcomes
    13. 13. 13 Ask – Step 3 - Type of Questions • Intervention, or Prevention • Etiology (Risks / Causes / Harm) • Diagnosis – DDx or tests • Prognosis - Prediction • Frequency and rate – Clinical manifestations of dx • Disease prevalence, incidence, … – Clinical findings (Hx/PE …) • Experience & meaning, Improvement
    14. 14. 14 Current Best Evidence
    15. 15. 15 The process of building a question 1. Background or Foreground question 2. PICO 3. Type of clinical question
    16. 16. 16 Examples 1 • 有哪些中草藥能預防或治療禽流感? – Background or Foreground ? – What Category ? • 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?
    17. 17. 17 Examples 2 • 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). – What is the etiology of gout? – What is the risk factor for gout attack? – Will he require dialysis in the long run? – Is vitamin C supplement decrease serum UA or gout attack?
    18. 18. 18 Exercise • 醫學文獻 • 臨床情境
    19. 19. 19 Type Background Foreground Intervention What to do? How to treat? I vs C Etiology What is the cause? I vs C Diagnosis Does the patient have …? I vs C Prognosis Who will have …? Frequency & Rate How common …?
    20. 20. 20 Contents • 介紹臨床問題 • 如何建構臨床問題 1. 問題的類型: background or foreground 2. PICO or PICOT 3. 臨床問題的類型:治療、診斷、病因、預後、其他… – 練習:醫學文獻 & 臨床情境 • 如何處理提出的臨床問題
    21. 21. 臨床醫學的問題… • 臨床上我們每天都會遇到一些問題: – 診斷: accuracy of diagnostic tests – 預後: the power of prognostic markers – 治療: the efficacy & safety of Rx – 平均 • 每 3 個門診病人有 2 個問題 • 每 1 個住院病人有 5 個問題 • 有多少我們去找答案? < 1/3 – Why? time, memory – Sources? Books (31%), articles (21%), consultants (17%)
    22. 22. 22 Solutions! • 承認不知道 • 隨手記下 • 有空就查
    23. 23. 23
    24. 24. 24
    25. 25. 25 Search Strategy • 精確( specific )的問題 – 可以被回答 (answerable) – 可以被搜尋 (searchable)
    26. 26. 26 Ask … • Selecting, Scheduling, Saving – Immediate – In PICO format (papers, desktop/PDA computers, cards)
    27. 27. 27 Important, Relevant, Time, Interesting, Recur • Examples 2 – 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). • Recognize potential questions! • Decide which one is the most important Q!
    28. 28. 28 Ask & then … • 記下 key question • 想一下 – 這類的問題最佳的解決方案(研究方法)為 何? – 那個資料庫能快速的幫我們找到最佳實證
    29. 29. 29 Contents • 介紹臨床問題 • 如何建構臨床問題 – 問題的類型: background or foreground – PICO or PICOT – 臨床問題的類型:治療、診斷、病因、預後、其他… – 練習 • 醫學文獻 • 臨床情境 • 如何處理提出的臨床問題
    30. 30. 30 Which one do you think is/are answerable by a single research? • What is the meaning of life? • What is the risk of autism following a measles vaccine? • What is the best treatment for osteoarthritis? • Why don’t patients take their prescribed medications? EBP workbook 2007, 2/e.

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