Linda S. Murphy, MLIS Health Sciences Librarian UCI Science Library Desiree Lie, MD, MSEd

1. The Collaborative Role of Medical Librarians in Facilitating the EBCAM Faculty Development Workshop Presented at the NCNMLG MLGSCA PNC/MLA Joint Meeting Sacramento, Jan 28-31, 2004 Linda S. Murphy, MLIS Health Sciences LibrarianUCI Science Library Desiree Lie, MD, MSEd UCI CAM Taskforce, Chair UCI Dept. of Family Medicine Funded by AMSA

2. Background • New CAM Center (Susan Samueli Center for CAM) established in 2001 • New CAM curriculum to be introduced starting 2002 • CAM Task Force: Multidisciplinary membership • AMSA Grant (2003) • Provided faculty with skills to integrate CAM instruction into a variety of teaching programs and clinical settings. Funded by AMSA

3. Workshop Development & Implementation • A small working group (2 MD faculty, a PhD and a librarian). • Workshop planning • Established goals and objectives • Discussed presentation methods • Pre-designed 3 patient cases. • Identified literature, speakers, pre- and post workshop assessment tools to evaluate learners’ EBCAM skills and knowledge Funded by AMSA

4. Program Contents • Welcome, Current state of CAM Education • Small Group Discussions • Group 1: Discussed EBM search and critical appraisal. • Group 2: Divided into 3 smaller groups to discuss and use model patient cases for future CAM instruction. • Lunch Break • Evaluating CAM instruction and competencies • Wrap up and suggestions for next year’s program Funded by AMSA

5. Clinical Scenario 1:Back pain • Pt: a 25-yr male restaurant manager, 6-months of neck and LBP • Px: localized pain in neck/shoulder; persistent ache in L2-4; occasional headaches • Dx: x-ray of the neck and lumbar spine was normal • Tx: given NSAIDs, exercise and PT without resolution • PtQ: will chiropractic manipulation or acupuncture Rx improve pain and function and what risks might be involved? Funded by AMSA

6. Clinical Scenario 2:Women’s health and Menopause Pt: a 50-yr female teacher with menopausal symptoms, started HRT a yr ago working with her physician to discontinue Hx: breast cancer and heart disease Dx: re-experiencing symptoms of hot flushes, mood swings, and night sweats. Tx: was treated with HRT. PtQ: Black Cohosh, Red Clover, and Estroven relieve menopausal symptoms; risk of breast cancer and heart disease Funded by AMSA

7. Clinical Scenario 3:Congestive Heart Failure and Herbals Pt: Mr. Mitchell, a 73 year old retired bus driver Dx: hypertension and atrial fibrillation; insomnia; gastrointestinal discomfort; Tx: Digoxin (control heart rate) and Coumadin (prevent thrombotic emboli); hydrochlorothiazide (for hypertension) Self Med: St. Johns Wart, Valerian (help with sleep); Ginger (for GI Discomfort); Vitamin E (for memory problems) Probls: Digoxin and coumadin levels are unstable. Funded by AMSA

8. Why Keep Up With the Literature? • Decide what diagnostic test to use • What treatment to choose • What expected outcome might be • Keeping up with the latest news in health care • Stay abreast of what patients bring in from the media, from the Internet, from friends Funded by AMSA

9. What is EBCAM? • Integrates the best research evidence with clinical expertise and patient values. • Seeks to inform, leaving the final decision to the clinician and patient. • Effective means to bridge the gap between information and practice. • Facilitates interaction between conventional and CAM practitioners. Funded by AMSA

10. Why is EBCAM needed? • Growing national interest in CAM • A billion dollar industry, need evidence for efficacy of CAM modalities. • Recent movement to integrate CAM content into allopathic curricula. • Increased funding for CAM education. • Faculty need updated knowledge for CAM to be comfortable teaching students and residents. Funded by AMSA

11. The EBCAM Process • Ask a well-structured clinical question; • Conduct a high-quality literature search. • Identify evidence most relevant to addressing the clinical question; • Appraise the quality of this evidence; • Apply the evidence to the care of the patient. Funded by AMSA

12. Formulating Questions • Background questions • Foreground questions • PICO • Select appropriate database/sources • Search Strategy Funded by AMSA

13. Background Questions • General clinical questions for background knowledge. • Can be answered by using “background” resources, e.g., current textbooks, and narrative reviews. Foreground Questions • Specificquestions (Diagnosis, Etiology, Prognosis, Therapy) about your patient: • Need latest resources • Answered by primary (original research) and secondary (systematic reviews and practice guidelines) sources Funded by AMSA

14. Internet Searching Google search • “back pain" +acupuncture (120,000 hits) • “low back pain” +acupuncture (27,900) • “chronic low back pan” +acupuncture (5,020) • “red clover” + “Hot Flushes” (3,760 hits) • “red clover” +"menopausal symptoms” (5,570) • St. Johns Wort +Coumadin (9,090 hits) Funded by AMSA

15. Researching Background Questions • What are the standard treatment for back injury? • What is acupuncture? • What are Black Cohosh, Red Clover, and Estroven used for today? • What is atrial fibrillation? • What are St. Johns Wart, and Valerian used for? Funded by AMSA

16. Background CAM Resources The Natural Medicines Comprehensive Database • Provides evidence-based clinical data on dietary supplements and natural products. • Designed for medical professions and updated daily. • Products can be searched by scientific names, common names, or brand names or by ingredients. • Search: Black Cohosh Funded by AMSA

17. Search Results Funded by AMSA

18. 1998, a division of NIH. • Exploring CAM and alternative healing practices in the context of rigorous science. • Educating and training CAM researchers, disseminating authoritative info. to the public and professions <http://www.nccam.nih.gov/> Funded by AMSA

19. MEDLINEplus • Access to info about specific diseases and conditions. • Links to self-help groups, consumer health info, clearinghouses, list of CAM practitioners. in Spanish and other languages, and clinical trials. • Alternative Medicine <http://www.nlm.nih.gov/medlineplus/alternativemedicine.html> • Back pain <http://www.nlm.nih.gov/medlineplus/backpain.html> • Interactive Tutorial <http://www.nlm.nih.gov/medlineplus/tutorials/backpain.html> • Chiropractic <http://www.nlm.nih.gov/medlineplus/chiropractic.html> • Acupuncture <http://www.nlm.nih.gov/medlineplus/acupuncture.html> Funded by AMSA

20. Researching Foreground Questions • How effective is spinal manipulation or acupuncture compared with NSAID in reducing back pain in your patient? • What are the risks of HRT use, particularly with respect to CHD events, compared with no HRT? • What are the efficacy of black cohosh, red clover and estroven in reducing menopausal symptoms? • What is the efficacy of St. John Wart in treating a hypertensive patient with depression and atrial fibrillation? Funded by AMSA

21. Formulating Patient Centered Questions • P= Patient/Population/Problem • I= Intervention/exposure or prognostic factor • C= Comparison/Control • O= Outcome/s Funded by AMSA

22. Framing PICO Case #1: Back pain • Given a 25-yr male restaurant manager with chronic neck/back pain (P), does acupuncture or chiropractic Rx (I) compared with ibuprofen and/or naprosyn (C) reduce symptoms of neck and back pain (O)? Case #2: Women’s Health and Menopause • In female with menopausal symptoms, do natural hormones (estroven, black cohosh, and red clover) compared to HRT or no Rx, relieve menopausal symptoms and reduce the risk of heart disease? Case #3: Congestive Heart Failure and Herbals • In elderly men with hypertension and atrial fibrillation, do multiple supplements, herbs and vitamins interact with heart and blood thinner medications, compared to medications only produce poor control of Digoxin and unstable Coumadin levels?

23. Primary vs. Secondary Sources Funded by AMSA

24. Primary Source: Original Research, RCTS - CAM on PubMED Funded by AMSA

25. PubMed Search Results Funded by AMSA

26. Critical Appraisal Protocols for validating quality of research articles • Therapy = RCT • Diagnosis = Sensitivity/Specificity, Predictive Value of Tests • Etiology = Cohort, Case-Controlled Studies • Prognosis = Cohort, Follow-up Studies, Mortality • Screening/Prevention • Systematic Review • Practice Guidelines • Economic Analyses Funded by AMSA

27. Critical Appraisal - Therapy Are the Rx and control groups similar? • Were patients randomized? • Were the benefits of randomization preserved through use of concealment and intention-to-treat analyses? Did the treatment and control groups remain the same with respect to important prognostic factors? Funded by AMSA

28. Application to Patient What were the results? • What is the estimate of the effect? • How precise is this estimate of the effect? Can the results be applied to your patient? • Is your patient similar to the patients in the study? • Were all important outcomes examined? Funded by AMSA

29. Secondary Sources Example 1: PubMed Clinical Queries – Systematic Reviews Funded by AMSA

30. Secondary Sources Example 2: The Cochrane Library Systematic Reviews Funded by AMSA

31. Secondary Sources Example 3: ACP Journal Club • A publication of the American College of Physicians, and BMJ Evidence. • Screen and identify studies, then provide abstracts with commentary. Funded by AMSA

32. Tertiary evidence Bandolier Complementary and Alternative Therapies • Include acupuncture, homeopathy, massage, herbal medicine, supplements, and safety concerns. • Provides abstracts of systematic reviews, meta-analyses on CAM studies. • Extracts info from secondary reviews of primary trials. • Contains over 100 summaries on the effectiveness of CAM, e.g., Arthritis, bones and joints <http://www.jr2.ox.ac.uk/bandolier/booth/booths/bones.html>

33. Workshop Summary • Review EBCAM Process • The EBM Guidebook http://www.ucihs.uci.edu/com/meded/pd/PDPFD/EBM%20Guidebook1.pdf • The Critical Appraisal Worksheets http://www.cebm.utoronto.ca/teach/materials/caworksheets.htm • Links UCI Libraries CAM Resources<http://www.lib.uci.edu/online/subject/clinical/clinalt.html> • Evaluated learners EBCAM knowledge and skills : the interactive EBCAM case exam: <http://meded.lib.uci.edu/database/ebcam/camexam.php> Funded by AMSA

34. Challenges • Lack of clinical knowledge, e.g., Identify valid questions that are patient-based • Finding the appropriate literature for a CAM case study • Keeping up with the literature. • Self learning and motivation • Time • Teaching different levels of learners • Getting support from library administration Funded by AMSA

35. Thank you! Questions? Funded by AMSA