1 / 34

Integrating Evidence-Base Medicine into the Clerkship

Integrating Evidence-Base Medicine into the Clerkship. Alex Krist MD Fairfax Family Practice Residency 3/13/2004. Exercise #1.

solada
Download Presentation

Integrating Evidence-Base Medicine into the Clerkship

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Integrating Evidence-Base Medicine into the Clerkship Alex Krist MD Fairfax Family Practice Residency 3/13/2004

  2. Exercise #1 • You are seeing a 55 year old male for a health maintenance examination. You either order (or decide not to order) a PSA test to screen for prostate cancer. The medical student says, “On the last rotation I was on I was told to always [do the opposite of what you did].” • How do you explain your decision

  3. Overview • Basic EBM concepts • Family practice and EBM • Key EBM resources • How to integrate EBM with teaching

  4. What do you think of when you hear the term Evidence-Based Medicine?

  5. Definition of EBM • An approach to practicing medicine in which the clinician is aware of the evidence in support of clinical practice, and the strength of that evidence • A methodology for evaluating the validity of research in clinical medicine and applying the results to the care of individual patients • The conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients • The integration of best research evidence with clinical expertise and patient values

  6. Uses of EBM • Answer a clinical question • Guide for personal training • Prioritize time (reading) • Anyone can be an expert • Resolves conflict • Teaching tool

  7. Production Research/ Experience Consumer Education • Evidence-Based Medicine • Information Mastery Refinement Information Systematic Mastery Reviews Distribution Informatics Slawson

  8. Frequency of Questions in Practice? • Outpatient setting • By recall – 1 question per day – Chambliss 1996 • By observation • 2 questions per 3 patients – Covell 1985 • 5.7 questions per 10 patients – Gorman 1995 • 3.2 questions per 10 patients – Ely 1999

  9. Where do Clinicians go for Answers? • Colleague • Physicians Desk Reference • Textbook

  10. “Men stumble over the truth from time to time, but most pick themselves up and hurry off as if nothing had happened…” -W Churchill

  11. Ways of Reaching the Truth Faith – “The seductive approach” • “Trust me” • “In my experience” • Length of coat defines who is right • The bandwagon

  12. Ways of Reaching the Truth It makes sense – “The inductive approach” • Based on pathophysiology and DOE • Examples of inductive failures: • Antiarrhythmics • External fetal monitoring • Right heart catheterization • Clofibrate for hypercholesterolemia • Hormone replacement therapy

  13. Ways of Reaching the Truth Evidence-Based Medicine – “The deductive approach” • Based on outcomes research • “Putting it all back together” • Demonstration that it works

  14. EBM Framework for Screening Treat: radiation, prostatectomy Screen: PSA, DRE Reduced prostate cancer morbidity, mortality Early Prostate Cancer Asymptomatic Men Adverse effects of screening: false pos, false neg, inconvenience, labeling Adverse effects of Rx: Impotence, incontinence, death, overtreatment

  15. Patient Oriented (deductive) Mortality Morbidity Quality of life Effects clinical events Disease Oriented (inductive) Pathophysiology Pharmacology Etiology Epidemiology Outcomes

  16. POE Example UK Prospective Diabetes Study Group Comparing “tight” to “standard” BP control • Decreased microvascular disease 9% vs 14%, NNT=21 • Decreased diabetes related death 11% vs 16%, NNT=20 • Decreased diabetes related endpoints more then BS control 24% vs 12% BMJ 1998; 317: 703-13

  17. DOE Debunked “Don’t use beta-blockers in patients with diabetes because it may blunt hypoglycemic symptoms and it is not as effective.” UK Prospective Diabetes Study Group • Captopril and atenolol equally efficacious in controlling BP and preventing diabetes related complications • No difference in hypoglycemic episodes BMJ 1998; 317: 713-20

  18. Proven DM Surrogates Blood pressure Cholesterol HgbA1c Be careful because even proven surrogates have limited value. Examples include HgbA1c in UKPDS trial, chlofibrate for cholesterol, CCBs for hypertension. Questionable DM Surrogates C-Peptide Insulin levels Surrogate Markers

  19. Hard to Unlearn Practice Study showing that compliance with JNC VI guidelines for treating hypertension (i.e. – using betablockers and diuretics as first line) is inversely proportional to year graduated from medical school

  20. Patient Oriented Evidence that Matters (POEM) • A POEM is an article on an issue that: • Studies patient oriented outcomes • Is seen in your practice at least every 6 months • If true, would change the way you practice

  21. POEM and (Time Management)

  22. Paradigm Shift? From Authority to Evidence From Anecdote to Outcomes i.e. – learning how to interpret evidence for yourself

  23. Teachers and Specialists • YODA – Your Own Data Analyzer • YUCK – Your Unsubstantiated Clinical Know-it-all

  24. Family Physician as a Specialist • Common medical conditions • Preventative medicine • Recognizing uncommon conditions and getting patients appropriate care • EBM

  25. EBM Resources • http://www.cebm.net/learning_ebm.asp • http://www.med.ualberta.ca/ebm/ebm.htm • Slawson, Information Mastery, http://www.healthsystem.virginia.edu/internet/familymed/docs/info_mastery.cfm • Sackett, Clinical Epidemiology: a Basic Science for Clinical Medicine • Gordis, Epidemiology

  26. Exercise #2 • Put together a list of Evidence-Based resources

  27. And this mess is so big And so deep and so tall, We can not pick it up. There is no way at all -Dr Seuss

  28. … And the Rest of the Literature? • PubMed search for “hypertension” yields 10,411 articles • Searching for “hypertension” on www.guideline.gov yields 244 related guidelines

  29. Strength of Design • RCT / Meta-Analysis • Cohort study • Case-control study • Case series • Expert opinion

  30. External Validity • Or do the findings in this study apply to my patient? • Initial findings of studies that set the standard of care evaluating coumadin for stroke prevention in A-fib were only generalizable to about 5% of the population

  31. Key Resources • Clinical Evidence http://www.unitedhealthfoundation.org/registration.cfm • USPSTF http://www.ahrq.gov/clinic/uspstfix.htm • National Guideline Clearinghouse http://www.guidelines.gov/index.asp • Cochrane Abstracts http://www.cochrane.org/reviews/index.htm

  32. Exercise #3 • Brainstorm on methods to integrate EBM into practice and teaching when working with a medical student

  33. EBM and the Preceptor • Evidence-based medicine (EBM) is the integration of best research evidence with clinical expertise and patient values

  34. EBM and the Preceptor • Gives Family Medicine authority • FP as an expert • Makes students knowledge generalizable • Can explain logic behind clinical choices • Gives students a framework for future studies • Can repeat the process in other situations

More Related