EBM QUESTIONS ANYONE ?

1. EBMQUESTIONS ANYONE ? Todd D. Tillmanns, MD, FACOG Assistant Professor Division of Gynecologic Oncology West Clinic & University of Tennessee Health Science Center

2. What is Evidence Based Medicine (EBM) • Evidence-based medicine is the care of patients using the best available evidence from the results of research to guide clinical decision making [1-3] • Sackett, DL, Straus, SE, Richardson, WS, et al. Evidence-based medicine. How to practice and teach EBM, 2nd edition, Churchill Livingstone, Edinburgh 2000. • 2. Sackett, DL, Rosenberg, WM, Gray, JA, et al. Evidence-based medicine. What it is and what it isn't. BMJ 1996; 312:71. • 3. Geyman, JP, Deyo, RA, Ramsey, SD. Evidence-Based Clinical Practice, Butterworth-Heinemann, Woburn, MA 1999.

3. What EBM is not! • Eminence • Vehemence • Eloquence • Confidence of the source • Practicing defensive medicine • The way we do it, you could….. Isaacs, D, Fitzgerald, D. Seven alternatives to evidence based medicine. BMJ 1999; 319:1618.

4. Don’t put the cart before the horse • The question must be defined before the answer to the question can be elucidated through a careful search

5. Good Evidence Based Questions • Is the finding abnormal? • What is the diagnosis? • How often does it occur? • What are the risk factors for the disease? • What is the pathogenesis? • What is the natural history? • How effective (harmful) is the treatment? • How effective or (harmful) are preventative interventions?

6. Putting EBM into practice • What is the incidence and prevalence? • What are the signs and symptoms? • What are the best diagnostic tests with the best clinical findings that confirm the suspected diagnosis? • What is the best treatment of the disease process? • Once treated what is the best way to maintain health for discharge from your care? • How would you prevent the disease process?

7. Where do you find the answers? • You must invest your time to become proficient searching these sites and others • full text journals (OVID, Medline, Pubmed) • Cochran Data Base • Organizations • American College of Physicians • American Society of Internal Medicine • APGO, ACOG • Infectious Disease Society of America • governmental organizations: • National Institutes of Health • Centers for Disease Control and Prevention • National Guideline Clearinghouse: www.guideline.gov

8. Summary of Good Sources for Quick EBM Review • UpToDate editors and authors revise the program continually. New information is highlighted in each new edition of the CD-ROM and internet versions, and the date when the topic was last updated is noted at the beginning of each topic review. Other textbooks are finding ways to update regularly, but readers should be aware of how often each part of the information base is updated and when the last update of each section they are depending on was done. • ACP Journal Club is published every two months by the American College of Physicians/American Society of Internal Medicine. It reviews the world's English-language medical journals in internal medicine, selects scientifically strong articles by explicit criteria, and summarizes those meeting these criteria as structured abstracts with commentary by an expert, one article per page. (ACP Journal Club, ACP-ASIM, 190 North Independence Mall West, Philadelphia, PA 19106-1572, USA; 800-523-1546) • The Medical Letter, a four-page, biweekly, evidence-based review of drugs, including effectiveness, mechanism of action, side effects and interactions, and cost – for new drugs in relation to older alternatives. (The Medical Letter, Inc., 1000 Main Street, New Rochelle, NY 10801; 800-211-2769). • Evidence-Based Medicine is similar to ACP Journal Club but with a wider scope, including articles of interest to family medicine, pediatrics, obstetrics and gynecology, surgery, and psychiatry. (Evidence-Based Medicine, ACP-ASIM, 190 N. Independence Mall West, Philadelphia, PA 19106-1572; 800-523-1546) • The Family Practice Newsletter is a four-page, "biweekly update and commentary on new and practical clinical information for the primary care practitioner," written by a family physician with public health and law degrees. (Primary Care Press, 5423 Monocracy Drive, Bethlehem, PA 18017; 888-399-7442; fax 631-474-5390; cpkerr@nni.com). • Evidence-Based Practice, "patient-oriented evidence that matters," from the publishers of The Journal of Family Practice. (Dowden Health Media, 110 Summitt Ave., Montvale, NJ 07645-9894; 800-707-7040; ebp@dowdenhealth.com) • Journal Watch is a monthly publication of the Massachusetts Medical Society that summarizes recent articles with commentary. (Massachusetts Medical Society. 860 Winter St. Waltham, MA 02451.1411. 781-893-4610).

9. Credibility of Resources • Internal validity: Are the results of clinical research correct for the patients in the study? (threatened by two processes: bias and chance) • Generalizability: Do the results of the study apply to my patients • Classification of levels of evidence and recommendations

11. Guidelines for practicing EBM • Worksheet for EBM presentations by residents • Clinical question • Reference research articles by level of evidence • Identify the incidence and prevalence of disease or disorder • Give background • Signs and symptoms ( M/C symptom most reliable) • Laboratory, studies, findings that confirm diagnosis (and exclude others) • Treatment (Best, most economical and options for second line) • Discharge measures and follow up evaluation • Preventative measures • EBM Guidelines • Guidelines for proposing good EBM questions (Sackett)

12. THANK YOU!QUESTIONS? Even my family has stopped listening to me! Love is unconditional with Nora