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Trans-formative Journal Club Experience as a Basis for a Longitudinal EBM curriculum

Trans-formative Journal Club Experience as a Basis for a Longitudinal EBM curriculum. Renee Crichlow MD, FAAFP Dept . Family and Community Medicine North Memorial Residency Program. “Abstract Attack ". Why?.

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Trans-formative Journal Club Experience as a Basis for a Longitudinal EBM curriculum

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  1. Trans-formative Journal Club Experience as a Basis for a Longitudinal EBM curriculum Renee Crichlow MD, FAAFP Dept. Family and Community Medicine North Memorial Residency Program

  2. “Abstract Attack "

  3. Why?

  4. Requirementsforaccreditation…residents must participate actively in such scholarly activities… The Accreditation Council for Graduate Medical Education (ACGME)

  5. “Develops and demonstrates skills in locating sources of scientific data pertinent to the care of patients…”

  6. “…Analyzing the appropriateness of research design and statistical methods…”

  7. “…Obtaining information about diagnostic and therapeutic effectiveness,”

  8. “…Applying evidence from pertinent clinical studies to patient care.”

  9. The Primary Goals "Abstract Attack", a method to provide uniform acquisition of skills and knowledge, Sufficient for a practicing clinician to confidently, participate in efficient and effective Evidence Based critique of the medical literature at the point of care.

  10. Secondary Goal “Eschew Obfuscation”

  11. Eschew Obfuscation

  12. Santiago, BMC Medical Informatics and Decision Making 2008 8:61 Up to 53% of Pharmaceutical ads are not supported by the cited data

  13. The Four Areas of Promotional Claims • Effectiveness • Safety • Convenience • Costs

  14. The Five Deceptions • False Statement • Exaggeration • Unjustified Generalization • Absence of Relation • Transfer to Humans

  15. “Abstract Attack "

  16. What?

  17. AA-Rapid Critical Appraisal Pathway • Title • Conclusion • Background • Methods • Results • Figure 1 • Tables

  18. What is interesting about this? What is concerning about this? What do I need to know more about? The “3 Questions” that must be asked at each step

  19. Studies have shown • “…Journal clubs may improve knowledge of clinical epidemiology and biostatistics, reading habits,and the use of medical literature in practice…”

  20. Boring

  21. Engaged and Active

  22. Chapters of Curriculum • Teaching the Strategy of Abstract Attack • Developing a Clinical Query--PICO • Search for the Evidence • P-value and Confidence Intervals • Patient Oriented Outcomes vs. Disease Oriented Outcomes • The RCT, Randomized Controlled Trial • Absolute Risk Reduction vs. Relative Risk Reduction • NNT, Number Needed to Treat  • Odds Ratio and CI revisited • Sppin and Snnout • Meta-Analysis vs. Systematic Review • Determining the Level of Evidence and Strength of Recommendations • Appendix  • Formative review, post-test templates • Summative evaluation year-end review

  23. For every unit of the AA curriculum we use the AA method to critically appraise articles that illuminate the teaching point of that unit e.g. P-Value, Wakefield 1998

  24. “Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children.” Wakefield AJ1998 • “INTERPRETATION: We identified associated gastrointestinal disease and developmental regression in a group of previously normal children, which was generally associated in time with possible environmental triggers.”   • N=13 patients • “Abnormal laboratory results were significantly raised urinary methylmalonic acid compared with age-matched controls(p=0.003),low haemoglobin in four children, and a low serum IgA in four children.”

  25. P-value comparison • The Wakefield study which found only significant P-value was raised urinary methylmalonic acid in a study of 13 non random cases and concluded “associated gastrointestinal disease and developmental regression”, aka MMR causes autism theory • Vs Danish Study >500,000 patients Compared vaccinated and unvaccinated children. FoundNO significant p-value, thus NO difference in rates of autism secondary to exposure

  26. Teach the Unit…

  27. Patient Oriented Outcome vs Disease Oriented Outcome or “POO” is better than “DOO”.

  28. What does it mean to be a Patient oriented outcome? What does it mean to be a Disease oriented outcome?

  29. POO produces POE “Patient-oriented evidence (POE) refers to outcomes of studies that measure things a patient would care about, such as improvement in symptoms, morbidity, quality of life, cost, length of stay, or mortality. Essentially, POE indicates whether use of the treatment or test in question helped a patient live a longer or better life...” (Terms Used in Evidence-Based Medicine--AAFP)

  30. DOO produces DOE “Disease-oriented evidence (DOE) refers to the outcomes of studies that measure physiologic or surrogate markers of health, e.g. such as blood pressure, serum creatinine, HgBA1c,… or peak flow. Improvements in these outcomes do not always lead to improvements in patient-oriented outcomes such as symptoms, morbidity, quality of life, or mortality.” (Terms Used in Evidence-Based Medicine--AAFP)

  31. KEY POINTS Patient Oriented Outcomes and Disease Oriented Outcomes: POO indicates “whether use of the treatment or test in question helped a patient live a longer or better life...” DOO may lead to POO in another study OR may be the only data currently available Pharmaceutical Industry may make claims framed as POO based on a study of DOO DOO may be significant but have no bearing on POO

  32. Prepare for the Attack…

  33. Prepare for the Attack • The learner presenting the case should receive the article at least a week in advance • We choose for junior learners and senior learner get to select their own article pending approval of faculty • They receive a “Teaching Strategies for AA” document AND supplemental materials for critically appraising their article http://tinyurl.com/kfflq6d • Critical Appraisal information is available on line we use CEBM, Centre for Evidence Based Medicine, at http://www.cebm.net/index.aspx?o=1157 • The presenter must know the article very well in ordered to facilitate the conversation/discussion, • This advanced preparation increases the overall knowledge of EBM within the Residency and makes subsequent learner participation more robust

  34. An Example Critical Appraisal Sheet

  35. Lead the Attack…

  36. AA-Rapid Critical AppraisalPathway Title Conclusion Background Methods Results Figure 1 Tables What is interesting about this? What is concerning about this? What do I need to know more about?

  37. Questions for discussion STRUCTURE • What kind of study is this? • What’s the PICO? • Were all patients accounted for in Fig 1 CONTENT • Why did they do THIS study? • Is this POO or DOO? PRACTICE IMPACT • What more information do you need? • Do you think this study might influence your practice, why or why not?

  38. What’s Different about participating in an Abstract Attack vs. Traditional JC? • Biggest noted difference is number of people able to participate in a journal club having NEVER seen the article, 20% vs. 85-100% • Engaged participants are more likely to address primary literature, for patient care purposes

  39. Questions For information on Abstract Attack curriculum crichlow.umn@gmail.com UMN North Memorial Family Medicine “Where Excellence Meets Caring”

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