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E-B Pain ReliefE-B Pain Relief
• E-B Pain ReliefE-B Pain Relief• Distribute the promotion of EBM Distribute the promotion of EBM
passwordpassword
Life long learning Life long learning with with EBMEBM
• Prof Eiad Al-Faris Prof Eiad Al-Faris MD, MSc, MMEd, MD, MSc, MMEd, MRCGP MRCGP
• Consultant Family MedicineConsultant Family Medicine• Prof. King Saud UniversityProf. King Saud University• Supervisor -King Saud University Supervisor -King Saud University
chair for medical educationchair for medical education
OutlineOutline
• IntroductionIntroduction• Definition of EBMDefinition of EBM• Steps of EBMSteps of EBM• Practical searchPractical search• Conclusion Conclusion • ClosureClosure
1900 1990 2000
10,000
100,000
?250,000INFORMATION EXPLOSION
MEDICAL JOURNALS
4
Rule 31 – Review the World Literature Rule 31 – Review the World Literature Fortnightly*Fortnightly*
0
500000
1000000
1500000
2000000
2500000
Trials MEDLINE BioMedical
Med
ical
Art
icle
s p
er Y
ear
5,000?per day
1,260 per day55 per
day
Clinical ScenarioClinical Scenario
• Ibrahim is a 60 years old teacher, Ibrahim is a 60 years old teacher, he is known case of hypertension. he is known case of hypertension. He presented to the ED with severe He presented to the ED with severe chest pain for the last two hours. chest pain for the last two hours.
• In addition to hitory/ exam and ECG, In addition to hitory/ exam and ECG, you wonder should you request for you wonder should you request for the timely diagnosos: troponin or the timely diagnosos: troponin or creatine kinase- MB or both?creatine kinase- MB or both?
When confronted with a When confronted with a clinical question, whom clinical question, whom
usually you consult?usually you consult?
Colleagues- experts Colleagues- experts
• A great source of information. A great source of information. • Quick, affordable and Quick, affordable and
accessible.accessible.• But potentially very biased:But potentially very biased:
VariabilityVariability
Not updated Not updated
TextbooksTextbooks
• Rapidly out-of-date (2-4y). Rapidly out-of-date (2-4y). • They are a good source of They are a good source of
background information background information (pathophysiology), (pathophysiology),
• but a poor source of information for but a poor source of information for most foreground questions (clinical). most foreground questions (clinical).
Burn your traditional textbooksBurn your traditional textbooks
The integration of the The integration of the current best current best evidence (from research)evidence (from research) with our with our clinical expertiseclinical expertise and patient’s and patient’s values.values.
EBM isEBM isEBM isEBM is
Three (Three (EsEs)- EBM Components)- EBM Components
ClinicalClinicalPracticePractice
The “Evidence Transfer Gap”
Controlled trials
Rules of EvidenceRules of Evidence
• All evidence is All evidence is notnot created equal. created equal.
• Values Values alwaysalways influence influence decisions. decisions.
• Evidence alone Evidence alone nevernever makes makesclinical decisions.clinical decisions.
Hierarchy of EvidenceHierarchy of EvidenceMeta-analysis of RCTs
Multi-centric large RCTsMulti-centric large RCTs
Single Centre RCT
Observational studiespatient-important outcomespatient-important outcomes
Clinical experience
Basic researchtest tube, animal, human physiologytest tube, animal, human physiology 16
Ask
Acquire
Appraise
Apply
Act & Assess
Patient dilemma
Principles of evidence-based
practice
Evidence alone does not decide – combine with otherknowledge and values
Hierarchy of evidence
Process of EBP
5 5 AAs to practice EBMs to practice EBM5 5 AAs to practice EBMs to practice EBM
Ask focused Question(s)
Acquire the Evidence(s)
Appraise the Evidence(s)
Apply the best Evidence
Assess your Performance
Acquire the Evidence(s)
Appraise the evidence(s)
Apply The best evidence
to patient
Assess your patient
Ask clinical questions
6 6 AAs to practice EBMs to practice EBM
Assess Yourself
Assess Your PatientAssess Your Patient
• HistoryHistory• Physical examinationPhysical examination• Objective data – labs, x-raysObjective data – labs, x-rays
• Formulate differential diagnosis• Pretest probability of disease
Acquire the Evidence(s)
Appraise the evidence(s)
Apply The best evidence
to patient
Assess your patient
Ask clinical questions
6 6 AAs to practice EBMs to practice EBM
Assess Yourself
To answer a clinical question To answer a clinical question effectively, First, turn your effectively, First, turn your scenarios into scenarios into 'well-built' 'well-built' clinical clinical Q.Q.
Four domains:Four domains: PICOPICO
1) the 1) the ppatient (atient (pproblem)roblem)
2) the 2) the iintervention or ntervention or exposure exposure
3) the 3) the ccomparison omparison (intervention)(intervention)
4) the clinical 4) the clinical ooutcomesutcomes
For healthy adults For healthy adults is it is it worthwhile to worthwhile to give aspirin as give aspirin as prophylaxis to reduce prophylaxis to reduce MI and or stroke ?MI and or stroke ?
Aspirin and Primary Aspirin and Primary PreventionPrevention
1. 1. PPatient atient population.population.
2. 2. IIntervention.ntervention.
3. 3. CComparison omparison intervention.intervention.
4. 4. OOutcomes. utcomes.
Asymptomatic adults Asymptomatic adults with no risk factors with no risk factors
Aspirin Aspirin
PlaceboPlacebo
Incidence of CV eventsIncidence of CV events
““In asymptomatic adults no risk factors, would the In asymptomatic adults no risk factors, would the use of aspirin reduce the incidence of cardiovascular use of aspirin reduce the incidence of cardiovascular events?events?
Ask Clinical Questions (PICO)Ask Clinical Questions (PICO)
Patient/Population Outcome
Intervention/Exposure
Comparison
Components of Clinical Questions (PICO)
In patients withacute MI
In post-menopausal
women
In women withsuspected
coronary disease
does early treat-ment with a statin
what is the accuracy of
exercise ECHO
does hormonereplacement
therapy
compared to placebo
compared to exercise
ECG
compared to noHRT
decrease cardio-vascular mortality?
for diagnosingsignificant
CAD?
increase therisk of
breast cancer?
Presentations will cover: 1. search strategy; 2. search results; 3. the validity of this evidence; 4. the importance of this valid evidence; 5. can this valid, important evidence be applied to your patient; 6. your evaluation of this process.
3-part Clinical Question
Patient’s Name Learner:
Target Disorder:
Date and place to be filled:
Intervention (+/- comparison):
Outcome:
Types of clinical questionsTypes of clinical questions
• Therapy and harmTherapy and harm:: how to select how to select treatments to offer patients that do more treatments to offer patients that do more good than harm good than harm
• Diagnostic testsDiagnostic tests:: how to select and interpret how to select and interpret diagnostic tests, in order to confirm or diagnostic tests, in order to confirm or exclude a diagnosisexclude a diagnosis
• PrognosisPrognosis:: how to estimate the patient's how to estimate the patient's likely clinical course over timelikely clinical course over time
Acquire the Best EvidenceAcquire the Best Evidence• Prefiltered Sources:Prefiltered Sources:Secondary sourcesSecondary sources
– ACP Journal Club ACP Journal Club (www.acpjc.org) (www.acpjc.org)
– Cochrane Library (www.update-Cochrane Library (www.update-software.com/cochrane) software.com/cochrane)
– Up-to-Date Up-to-Date (www.uptodate.com) (www.uptodate.com)
– Clinical Evidence Clinical Evidence (www.evidence.org) (www.evidence.org)
– InfoRetriever InfoRetriever (www.infopoems.com) (www.infopoems.com)
– Ovid (www.ovid.com)Ovid (www.ovid.com)– MD Consult MD Consult
(www.mdconsult.com)(www.mdconsult.com)– Medscape Medscape
(www.medscape.com) (www.medscape.com) – Dynamed (Dynamed (www.dynamed.comwww.dynamed.com))
• Unfiltered SourcesUnfiltered Sources
– MEDLINE MEDLINE (www.pubmed.gov) (www.pubmed.gov) – Google Google (www.google.com(www.google.com
We need to focus and familiarize yourself with few of them
EBM journal / ACP j. clubClinical Practice Guidelines
Cochrane Library / Systematic Reviews
Computer DecisionSupport System (CDSS)eg. Dynamed“Point of care”
Single RCT in Journal
Developments (4 s) that facilitate EBM PracticeDevelopments (4 s) that facilitate EBM Practice
Pre-filtered Sources:Pre-filtered Sources:–Cochrane Library Cochrane Library http://www.thecochranelibrary.chttp://www.thecochranelibrary.comom
–Up-to-Date www.uptodate.comUp-to-Date www.uptodate.com
–Clinical Evidence Clinical Evidence
www.clinicalevidence.orgwww.clinicalevidence.org
– Ovid www.ovid.comOvid www.ovid.com
30
–ACP Journal Clubwww.acpjc.orgACP Journal Clubwww.acpjc.org
– InfoRetriever InfoRetriever
www.infopoems.com www.infopoems.com
–MD Consult www.mdconsult.comMD Consult www.mdconsult.com
–Medscape www.medscape.comMedscape www.medscape.com
–Dynamed Dynamed www.dynamed.comwww.dynamed.com
31
Best Evidence 5.lnk
PROCESSPROCESS• 120+ journals scanned120+ journals scanned
– 50,000 articles50,000 articles
• Is it Is it validvalid? (<5%)? (<5%)– Intervention: RCTIntervention: RCT– Prognosis: inception cohortPrognosis: inception cohort– EtcEtc
• Is it Is it relevant?relevant?– 6-12 GPs & specialists 6-12 GPs & specialists
asked:asked:Relevant? Newsworthy?Relevant? Newsworthy?
• < 0.5% selected< 0.5% selected
www.evidence-basedmedicine.com
EBM can reduce reading needHow much is valid AND relevant?
Number Needed to Readis 20+
Number Needed to Readis 200+
Deals with barriersDeals with barriers
Involves seniors and juniorsInvolves seniors and juniors
EBM EnvironmentEBM Environment
New EBM teaching modelsNew EBM teaching models
The Challenge – Bridging the gap!The Challenge – Bridging the gap!
Appraise the EvidenceAppraise the Evidence
• Relevance: Relevance: It focuses on medical problems common to It focuses on medical problems common to our practice. patient-oriented evidenceour practice. patient-oriented evidence
• Validity: Validity: Correctness (Correctness (likely to be true) true)
• Results: Results: Clinically important
• Can we apply the results to our Can we apply the results to our patient? patient? Applicable in and useful for my patients
RelevanceRelevance
Consider three questions to Consider three questions to determinedetermine
Relevance Relevance – Common to practiceCommon to practice– Require change of practice Require change of practice – Patient-oriented outcomePatient-oriented outcome
POEM Vs. DOEPOEM Vs. DOEPOEM Vs. DOEPOEM Vs. DOE
POEMPOEM: Patient-oriented evidence : Patient-oriented evidence that matterthat mattermortality, morbidity, quality of lifemortality, morbidity, quality of life
DOEDOE: Disease-oriented evidence: Disease-oriented evidencepathophysiology, pharmacology, pathophysiology, pharmacology,
etiologyetiology
Comparing DOE and POEMComparing DOE and POEM
DOEDOE POEMPOEM
AntihypertenAntihypertens therapys therapy
Lowers Blood Lowers Blood PressurePressure
MortalityMortality
MIMI
CVACVA
Screening for Screening for prostate CAprostate CA
PSA screening PSA screening detects detects
Prostate CA at Prostate CA at an early stagean early stage
Unknown whether Unknown whether PSA screening PSA screening
reduces Mortalityreduces Mortality
Clofibrate Clofibrate decreases decreases
cholesterol cholesterol
Clofibrate decreases CV Clofibrate decreases CV mortality/mortality/
MorbidityMorbidity
It Increases overall It Increases overall mortalitymortality
ββ ––blockers are blockers are contraindicated for contraindicated for heart failure patientsheart failure patients
ββ ––blockers are blockers are indicated for heart indicated for heart failure patientsfailure patients
Antiarrhythmic A Antiarrhythmic A decreases PVCsdecreases PVCs
Antiarrhythmic A Antiarrhythmic A decreases symptomsdecreases symptoms
Antiarrhythmic A Antiarrhythmic A increases mortalityincreases mortality
40DOE POEM
The cardiac arrhythmia suppression trial. N Engl J Med 1991.
44
Clofibrate Clofibrate decreases decreases
cholesterol cholesterol
Clofibrate decreases CV Clofibrate decreases CV mortality/mortality/
MorbidityMorbidity
It Increases overall It Increases overall mortalitymortality
ββ ––blockers are blockers are contraindicated for contraindicated for heart failure patientsheart failure patients
ββ ––blockers are blockers are indicated for heart indicated for heart failure patientsfailure patients
Antiarrhythmic A Antiarrhythmic A decreases PVCsdecreases PVCs
Antiarrhythmic A Antiarrhythmic A decreases symptomsdecreases symptoms
Antiarrhythmic A Antiarrhythmic A increases mortalityincreases mortality
DOE POEM
The cardiac arrhythmia suppression trial. N Engl J Med 1991.
45
Clofibrate Clofibrate decreases decreases
cholesterol cholesterol
Clofibrate decreases CV Clofibrate decreases CV mortality/mortality/
MorbidityMorbidity
It Increases overall It Increases overall mortalitymortality
ββ ––blockers are blockers are contraindicated for contraindicated for heart failure patientsheart failure patients
ββ ––blockers are blockers are indicated for heart indicated for heart failure patientsfailure patients
Antiarrhythmic A Antiarrhythmic A decreases PVCsdecreases PVCs
Antiarrhythmic A Antiarrhythmic A decreases symptomsdecreases symptoms
Antiarrhythmic A Antiarrhythmic A increases mortalityincreases mortality
DOE POEM
The cardiac arrhythmia suppression trial. N Engl J Med 1991.
46
5 journals with highest 5 journals with highest concentration of POEMSconcentration of POEMS
• JAMA-17%JAMA-17%• Annals of Internal Medicine-17%Annals of Internal Medicine-17%• NEJM-16%NEJM-16%• Journal of the American Board of Family Journal of the American Board of Family
Practice-16%Practice-16%• Journal of Family Practice-15%Journal of Family Practice-15%
Ebell MH et al. J Fam Pract 1999 48: 350-Ebell MH et al. J Fam Pract 1999 48: 350-
355355
ValidityValidity
In RCT:In RCT:
• RandomizationRandomization• BlindnessBlindness• Drop-outDrop-out• ITTITT
ResultsResults
Results clinical importance Results clinical importance can be assessed by its:can be assessed by its:
1.1. MagnitudeMagnitude
2.2. PrecisionPrecision
50
Results of a hypothetical Results of a hypothetical randomized trialrandomized trial
TreatmentTreatment No. who No. who improvedimproved
No. who No. who did not did not improveimprove
Total N. Total N. of Ptsof Pts
IbuprofenIbuprofen 2222 1818 4040
PlaceboPlacebo 77 3333 4040
51
Calculations made from Calculations made from these resultsthese results
• Experimental event rateExperimental event rate
• Control event rateControl event rate
• Experimental event Experimental event oddsodds
• Control event oddsControl event odds
• Odds ratioOdds ratio
• RelativeRelative riskrisk
• Relative risk Relative risk increaseincrease
• Absolute Absolute risk increase risk increase or reductionor reduction
• NNTNNT
52
Results of a hypothetical Results of a hypothetical randomized trialrandomized trial
TreatmentTreatment No. who No. who improvedimproved
No. who No. who did not did not improveimprove
Total N. Total N. of Ptsof Pts
IbuprofenIbuprofen 2222 1818 4040
PlaceboPlacebo 77 3333 4040
53
Relative RiskRelative Risk
A relative risk is the risk in A relative risk is the risk in the treatment group the treatment group compared to the risk in compared to the risk in the control group.the control group.
A relative risk of (1) means A relative risk of (1) means there is no difference there is no difference between the groups between the groups
54
Results of a hypothetical Results of a hypothetical randomized trialrandomized trial
TreatmentTreatment No. who No. who improvedimproved
No. who No. who did not did not improveimprove
Total N. Total N. of Ptsof Pts
IbuprofenIbuprofen 2222 1818 4040
PlaceboPlacebo 77 3333 4040
55
Results of a hypothetical Results of a hypothetical randomized trialrandomized trial
TreatmentTreatment No. who No. who improvedimproved
No. who No. who did not did not improveimprove
Total N. Total N. of Ptsof Pts
IbuprofenIbuprofen 2222 1818 4040
PlaceboPlacebo 77 3333 4040
• Experimental event rat: Experimental event rat: • 22/4022/40 =55%=55%
• Control event rate: Control event rate: • 7/40 = 18%7/40 = 18%
• RelativeRelative risk: risk: =0.55/ 0.18= 3.1 =0.55/ 0.18= 3.1
• Relative risk increase: Relative risk increase: =0.55- 0.18/=0.55- 0.18/ 0.18 0.18 = = 2.06 2.06
• Absolute risk increase or reductionAbsolute risk increase or reduction== 0.55- 0.18 = 0.370.55- 0.18 = 0.37
• NNT = NNT = 1/ 0.37 = 2.71/ 0.37 = 2.7
58
OddsOdds
The odds of an event are the The odds of an event are the probability of it occurring probability of it occurring
compared to the probability compared to the probability of it not occurringof it not occurring
59
Results of a hypothetical Results of a hypothetical randomized trialrandomized trial
TreatmentTreatment No. who No. who improvedimproved
No. who No. who did not did not improveimprove
Total N. Total N. of Ptsof Pts
IbuprofenIbuprofen 2222 1818 4040
PlaceboPlacebo 77 3333 4040
60
What was the ratio of What was the ratio of odds?odds?
•The odds of an event in The odds of an event in the treatment (or the treatment (or exposed) group compared exposed) group compared to the odds in the control to the odds in the control (or unexposed) group(or unexposed) group
•OR=(A/B)/(C/D)OR=(A/B)/(C/D)
61
An odds ratioAn odds ratiois the odds of an event in a is the odds of an event in a
patient in the experimental patient in the experimental group relative to that of a group relative to that of a patient in the control group. patient in the control group.
Relative risk is the risk of an Relative risk is the risk of an event in a patient in the event in a patient in the experimental group relative to experimental group relative to that of a patient in the control that of a patient in the control group.group.
62
Results of a hypothetical Results of a hypothetical randomized trialrandomized trial
TreatmentTreatment No. who No. who improvedimproved
No. who No. who did not did not improveimprove
Total N. Total N. of Ptsof Pts
IbuprofenIbuprofen 2222 1818 4040
PlaceboPlacebo 77 3333 4040
• Experimental event odds:Experimental event odds:
22/18= 1.222/18= 1.2
• Control event oddsControl event odds::
7/ 337/ 33 = =0.210.21
• Odds ratio: Odds ratio:
1.2/ 0.21= 5.71.2/ 0.21= 5.7
ApplicabilityApplicability
3 arms for the applicability criteria 3 arms for the applicability criteria toto
be looked at be looked at (IPP) (IPP)
• IIntervention ntervention • PPatient populationatient population• PPatient preferences.atient preferences.
To answer a clinical question To answer a clinical question effectively, First, turn your effectively, First, turn your scenarios into scenarios into 'well-built' 'well-built' clinical clinical Q.Q.
Four domains:Four domains: PICOPICO
1) the 1) the ppatient (atient (pproblem)roblem)
2) the 2) the iintervention or ntervention or exposure exposure
3) the 3) the ccomparison omparison (intervention)(intervention)
4) the clinical 4) the clinical ooutcomesutcomes
Clinical ScenarioClinical Scenario
• Ibrahim is a 60 years old teacher, Ibrahim is a 60 years old teacher, he is known case of hypertension. he is known case of hypertension. He presented to the ED with He presented to the ED with severe chest pain for the last two severe chest pain for the last two hours. hours.
• You wonder should you request You wonder should you request troponin or creatine kinase- MB or troponin or creatine kinase- MB or both?both?
Treponine or creatine Treponine or creatine kinase-MBkinase-MB
1. 1. PPatient atient population.population.
2. 2. IIntervention.ntervention.
3. 3. CComparison omparison intervention.intervention.
4. 4. OOutcomes. utcomes.
Patients attending the Patients attending the ED with chest painED with chest pain
Troponine
creatine kinase-MB
Accuracy of diagnosis of IHD Accuracy of diagnosis of IHD
““In In Patients attending the ED with chest pain, , is troponine as compared to creatine kinase-MB more valid for the diagnosis of ischemic heart disease?
Information management Information management PrinciplesPrinciples
OBJECTIVE: The aim of this study was to evaluate the diagnostic OBJECTIVE: The aim of this study was to evaluate the diagnostic efficacy of multiple tests-heart-type fatty acid-binding protein efficacy of multiple tests-heart-type fatty acid-binding protein (H-FABP), cardiac troponin I (cTnI), creatine kinase-MB, and (H-FABP), cardiac troponin I (cTnI), creatine kinase-MB, and myoglobin-for the early detection of acute myocardial myoglobin-for the early detection of acute myocardial infarction among patients who present to the emergency infarction among patients who present to the emergency department with chest pain.department with chest pain.
• METHODS: A total of 1128 patients provided a total of 2924 METHODS: A total of 1128 patients provided a total of 2924 venous blood samples. Patients with chest pain were venous blood samples. Patients with chest pain were nonselected and treated according to hospital guidelines. nonselected and treated according to hospital guidelines. Additional cardiac biomarkers were assayed simultaneously at Additional cardiac biomarkers were assayed simultaneously at serial time points using the Cardiac Array (Randox Laboratories serial time points using the Cardiac Array (Randox Laboratories Ltd, Crumlin, United Kingdom).Ltd, Crumlin, United Kingdom).
• RESULTS: Heart-type fatty acid-binding protein had the RESULTS: Heart-type fatty acid-binding protein had the greatest sensitivity at 0 to 3 hours (64.3%) and 3 to 6 hours greatest sensitivity at 0 to 3 hours (64.3%) and 3 to 6 hours (85.3%) after chest pain onset. The combination of cTnI (85.3%) after chest pain onset. The combination of cTnI measurement with H-FABP increased sensitivity to 71.4% at 3 measurement with H-FABP increased sensitivity to 71.4% at 3 to 6 hours and 88.2% at 3 to 6 hours..to 6 hours and 88.2% at 3 to 6 hours..
Receiver operating characteristic curves demonstrated that H-FABP had the greatest diagnostic ability with area under the curve at 0 to 3 hours of 0.841 and 3 to 6 hours of 0.894. The specificity was also high for the combination of H-FABP with cTnI at these time points. Heart-type fatty acid-binding protein had the highest negative predictive values of all the individual markers: 0 to 3 hours (93%) and 3 to 6 hours (97%). Again, the combined measurement of cTnI with H-FABP increased the negative predictive values to 94% at 0 to 3 hours, 98% at 3 to 6 hours, and 99% at 6 to 12 hours.CONCLUSION: Testing both H-FABP and cTnI using the Cardiac Array proved to be both a reliable diagnostic tool for the early diagnosis of myocardial infarction/acute coronary syndrome and also a valuable rule-out test for patients presenting at 3 to 6 hours after chest pain onset
Applying ResearchApplying ResearchOne size doesn’t fit allOne size doesn’t fit all
Physicians searching skills Physicians searching skills are poorare poor
• 23 Physicians answered multiple-choice questions 23 Physicians answered multiple-choice questions and chose 2 to obtain further information using and chose 2 to obtain further information using their own information resources. their own information resources.
• For each questionFor each question– a mean of 13 minutes searching a mean of 13 minutes searching – an average of 1.8 resourcesan average of 1.8 resources
• Before searching Before searching – 18 (39%) of the 46 answers were correct 18 (39%) of the 46 answers were correct
• After searchingAfter searching– 19 (42%) of the 46 answers were correct. 19 (42%) of the 46 answers were correct.
• 6 answers went from incorrect to correct;6 answers went from incorrect to correct;5 went from correct to incorrect5 went from correct to incorrect
McKibbon KA, Fridsma DB. J Am Med Inform Assoc. 2006; 13(6):653-9.
Learning about “Just in Time” Learning about “Just in Time” learninglearning
• Keep a logbook of questionsKeep a logbook of questions• Answer a few important questionsAnswer a few important questions• Search and appraise yourself, thenSearch and appraise yourself, then• Discuss with colleagues / mentorDiscuss with colleagues / mentor
“Journal” Clubs
Learning about learning in teams
(Post graduate “problem-based” learning)
List our important current issues
Vote on importance
Search for evidence for next session
Example Questions
1. Does ‘bibliotherapy’ help depression?
2. Should all diabetics take aspirin?
3. Are antidepressants safe in adolescents?
4. Is atenolol OK for hypertension?
5. What is the impact of Tamiflu on flu?
6. Is diabetic self-monitoring helpful?
Questions? Questions?
The Prognosis of Ignorance is The Prognosis of Ignorance is PoorPoor
Implications for practiceInteractive workshops can improve
professional practice. Lectures alone are unlikely to change professional practice
Treatment of Ignorance
Prevention & TreatmentPrevention & Treatment
If EBM looks impossible then If EBM looks impossible then resign it!resign it!
117
JASPA*JASPA*(Journal associated score of personal angst)(Journal associated score of personal angst)
J: J: Are you ambivalent about renewing your Are you ambivalent about renewing your JOURNALJOURNAL subscriptions?subscriptions?
A: A: Do you feel Do you feel ANGERANGER towards prolific authors? towards prolific authors?
S: S: Do you ever use journals to help you Do you ever use journals to help you SLEEPSLEEP??
P: P: Are you surrounded by Are you surrounded by PILESPILES of PERIODICALSof PERIODICALS??
A: A: Do you feel Do you feel ANXIOUSANXIOUS when journals arrive? when journals arrive?
* Modified from: BMJ 1995;311:1666-1668
0 (?liar) 1-3 (normal range) >3 (sick; at risk for polythenia gravis and related conditions)
Evidence alone is not Evidence alone is not enoughenough
Patients’ values Patients’ values
Would you treat with antibiotics: Would you treat with antibiotics:
a 75 YO patient who is, Demented, a 75 YO patient who is, Demented, bedridden, contracted, debilitated, not bedridden, contracted, debilitated, not oriented, who developed pneumonia ? oriented, who developed pneumonia ?
120