Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Internal Medicine Residency Evidence-Based Practice Intro & Curriculum Integrating Evidence-Based Medicine Into Clinical Practice "The extent to which beliefs are based on evidence is very much less than believers suppose.“ Sceptical Essays, Bertrand Russell, 1928 Background • The ACGME and AAMC have called for intro of clinical epidemiology, biostatistics, critical appraisal, and medical informatics in medical school and GME curricula • Traditional method: Journal Club •95% of programs reporting an active Journal Club1 • Emerging Method: dedicated EBM curriculum •Includes Journal Club •only 37% of programs report having such courses2 1Sidorov, 2Green, J. Archives of Internal Medicine, 1995; 155:1193-7. M. Journal of General Internal Medicine, 2000; 15:129-33 Evidence-Based Practice Curriculum • Goals and Objectives – Improve residents’ ability to integrate clinical evidence into medical practice. – Improve EBM skills • Ask well-built clinical questions • Perform effective (efficient) literature searches • • • Utilize the NLM, other databases Use “best-evidence” resources, primary literature Learn basic critical appraisal skills • Apply to patients Evidence-Based Practice Curriculum • Goals and Objectives – Reduce barriers to accessing primary literature – Foster a sense of independence • Improved EBM self-efficacy • Enhance pattern of lifelong learning – Promote self-efficacy in and professional ethic of practice-based learning and systems-based practice improvement Evidence-Based Practice: Curriculum Elements I - Content EBM Core Topics for Conferences/Rounds • • • • • • • • • Intro to EBP, Asking clinical questions Finding the Evidence Articles about Therapy Articles about Diagnosis Articles about Harm/Etiology Articles about Prognosis Overviews/Meta-analysis Basic Biostatistics & Epidemiology Likelihood Ratios, Medical decision making Evidence-Based Practice: Curriculum Elements II - Avenues – – – – – Monthly Journal Club M & M/ quality improvement conference Ward Evidence-based Medicine Rounds Annual Intern Project (more later) Resident Practice Improvement Modules (PIM’s) through ABIM (more later) – Morning Report, Attending Rounds, Preclinical conferences Evidence-Based Practice Curriculum • EBP Attending Rounds – Goals: • Consolidate K/S/A taught in the core curriculum • Expand our knowledge base – Monthly structure • 4th Week Tue, Wed, Thu @ 0815-0845 • Teams prepare discussion • Present/discuss with facilitator, staff, and chief • Brief summary placed on web and in each intern/resident’s training portfolios – due by Thursday COB that week Evidence-Based Practice Rounds Each team prepares the following presentation: • • • • • A brief H&P and clinical question – Medical student – 2 min Search process – Intern – 3 min Presentation of the best evidence – Intern – 5 min Critical Appraisal using McMaster criteria – Resident - 10 minutes Group discussion: How can the information be applied? Evidence-Based Practice Basics: Asking the Right Questions “The most important thing is to never stop questioning” -Albert Einstein What is EBM? “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research." -Sackett D, 1996 What is EBM? • Medical decisions based on: – best research evidence – clinical expertise – patient values • Useful framework: – good patient care – effective medical education What EBM is not. • Rigid format that removes clinical judgment What does it mean to “Practice EBM”? (Recognize the 4 A’s) 1) Recognize: need for information 2) Ask: answerable clinical question 3) Acquire: search for “best evidence” 4) Assess: critical appraisal (validity, impact) 5) Apply: integrate with your patient Own clinical expertise Patient’s unique biology, values, and circumstances Case – Obscure GI Bleed Your patient: 64 yo man admitted to your service after presenting to the ED with weakness. In the ED: heme (+) stools and microcytic anemia Further eval: -verified Fe deficiency, but colo/EGD (-) -no signs of hemolysis or heme pathology You transfuse and discharge him, but he returns one month later, with the same thing. What kind of information can help you with the management of this patient? Step 1: Recognize need for info • Learning entry point is curiosity… need to know • Doctors under-estimate our need for info – Up to 5 times per inpatient encounter – 2 out of 3 outpatient visits Work of getting information + Limited Time Information needs not met Getting knowledge into practice… Acquisition versus Application • Replicative – Read/remember – Implicitly accept/follow • Appraisal-based – Involves all five steps of EBM – Time consuming…easier with practice! – Use for: problems dealt with most often • E.g. Morning report, Journal Club, EBM rounds Getting knowledge into practice… Acquisition versus Application • EBM Review-based – Skips lengthy critical appraisal step – Only search pre-appraised resources • Explicit criteria for evidence selection • Rigorous evaluation for validity – Examples: Cochrane Database, ACP Journal Club, Clinical Evidence, UpToDate? – Use for: day-to-day questions in busy practice/ward Step 2: Convert Info Need into… Answerable Clinical Question • Good Clinical Questions: – Begin with patient issue – Clarify particular informational needs – Make knowledge acquisition timely …It’s unlikely that management conference this week will coincidentally be about your patient – Suggest high-yield search strategies – Entry point for evidence-based learning Different Types of Questions Case: 47 year old woman with systemic lupus on prednisone presents with two days of nausea and abdominal discomfort and one day of vomiting, occasionally with coffee ground emesis. Supine BP 120/65, pulse 65; Standing BP 112/55, pulse is 71. Labs: Hct 32, creatinine 2.3 (1.2 last March), urine sediment has some red cells and granular casts. What questions would you ask about this patient? Different Types of Questions Background Questions – Ask for general knowledge about disorder – 2 essential components 1. A question root (5 W’s) with a verb 2. A disorder or aspect of a disorder – Examples: • How do you work up a GI bleeder? • What is relationship between H. Pylori and steroids? • What are the renal manifestations of lupus? • Why are interns so tired? Different Types of Questions Foreground Questions – Asks for specific knowledge – Usually refer to patients – Three (or four) components • Patient (or problem) of interest • Intervention of interest– “an exposure” • Comparison intervention (if relevant) • Outcome of clinical interest Different Types of Questions Foreground Question Examples: – For patients on chronic steroids with acute GI bleed due to PUD, does H. Pylori Rx reduce rebleeding? – For patients with lupus and suspected acute lupus nephritis, what is the prognostic value of renal biopsy? Types of Questions • • • • Clinical Findings: how to gather & interpret findings from the H&P Etiology: how to identify causes for disease DDx: what are they, ranked by likelihood, seriousness, and treatability Diagnostic Tests: confirm/exclude a dx: look at test characteristics (sensitivity, specificity, accuracy, PPV/NPV, safety, expense, etc.) • Prognosis: estimate likely clinical course and anticipate likely complications of disease. • Therapy: select treatments that do more good than harm and worth the effort and cost of using them • Prevention: reduce chance of disease by identifying and modifying risk factors and how to screen for disease Practice Asking Questions… • 47 y/o man with sarcoidosis has recently been diagnosed with HIV • “Doctor, how will my HIV affect my sarcoidosis?” What’s the Purpose? • In patients with sarcoidosis, does HIV lessen or • worsen their disease severity? A question of… A) B) C) D) E) Diagnosis Prognosis Etiology Therapy Prevention What’s the Purpose? • In patients with sarcoidosis, does HIV lessen or • worsen their disease severity? A question of… A) Diagnosis B) Prognosis C) Etiology D) Therapy E) Prevention The Elements P - The patient/population OR problem being addressed I - The “intervention” or question C - A comparison (when relevant) O - The outcome or outcomes of interest The Elements P - The patient/population OR problem being addressed Sarcoidosis I - The “intervention” or question C - A comparison (when relevant) O - The outcome or outcomes of interest The Elements P - The patient/population OR problem being addressed Sarcoidosis I - The “intervention” or question HIV/AIDS C - A comparison (when relevant) O - The outcome or outcomes of interest The Elements P - The patient/population OR problem being addressed Sarcoidosis I - The “intervention” or question HIV/AIDS C - A comparison (when relevant) no HIV/AIDS O - The outcome or outcomes of interest The Elements P - The patient/population OR problem being addressed Sarcoidosis I - The “intervention” or question HIV/AIDS C - A comparison (when relevant) no HIV/AIDS O - The outcome or outcomes of interest Severity Type of Question? Background or Foreground? The Search 1. exp SARCOIDOSIS, PULMONARY/ or exp SARCOIDOSIS/ or sarcoidosis.mp. 15526 2. (HIV or human immunodeficiency virus).mp. mp=title, original title, abstract, name of substance, mesh subject heading] 3. (AIDS or autoimmune deficiency syndrome).mp. [mp=title, original title, abstract, name of substance, mesh subject heading] 4. (prognosis or symptoms or survival or mortality or quality of life or outcome).mp. [mp=title, original title, abstract, name of substance, mesh subject heading] 5. 2 or 3 171810 6. 1 and 5 7. 4 and 6 10. from 7 keep 1-2, 4, 14-15, 17 126887 78196 911606 140 22 6 The Results 1. Pulmonary symptoms and lymphadenopathy in a human immunodeficiency virus-infected woman. [Case Reports. Journal Article] Archives of Pathology & Laboratory Medicine. 127(1):111-2, 2003 Jan. Hill KA. Till M. Laskin WB. Pathologic quiz case: UI: 12562277 2. Newly diagnosed pulmonary sarcoidosis in HIV-infected patients. [Journal Article] Radiology. 218(1):242-6, 2001 Jan. Haramati LB. Lee G. Singh A. Molina PL. White CS. UI: 11152809 3. Coexistent sarcoidosis and HIV infection. A comparison of bronchoalveolar and peripheral blood lymphocytes.[see comment]. [Case Reports. Journal Article] Chest. 102(6):1899-901, 1992 Dec. Newman TG. Minkowitz S. Hanna A. Sikand R. Fuleihan F. UI: 1446516 4. Sarcoidosis complicated by HIV infection: three case reports and a review of the literature. [Review] [25 refs] [Case Reports. Journal Article. Review. Review of Reported Cases] American Review of Respiratory Disease. Lowery WS. Whitlock WL. Dietrich RA. Fine JM. 142(4):887-9, 1990 Oct. UI: 2221596 5. Gowda KS. Mayers I. Shafran SD. Concomitant sarcoidosis and HIV infection. [Case Reports. Journal Article] CMAJ Canadian Medical Association Journal. 142(2):136-7, 1990 Jan 15. 6. UI: 2295031 Foulon G. Wislez M. Naccache JM. Blanc FX. Rabbat A. Israel-Biet D. Valeyre D. Mayaud C. Cadranel J. Sarcoidosis in HIV-infected patients in the era of highly active antiretroviral therapy. [Journal Article] Clinical Infectious Diseases. 38(3):418-25, 2004 Feb 1. UI: 14727215 The Results 1. Pulmonary symptoms and lymphadenopathy in a human immunodeficiency virus-infected woman. [Case Reports. Journal Article] Archives of Pathology & Laboratory Medicine. 127(1):111-2, 2003 Jan. Hill KA. Till M. Laskin WB. Pathologic quiz case: UI: 12562277 2. Newly diagnosed pulmonary sarcoidosis in HIV-infected patients. [Journal Article] Radiology. 218(1):242-6, 2001 Jan. Haramati LB. Lee G. Singh A. Molina PL. White CS. UI: 11152809 3. Coexistent sarcoidosis and HIV infection. A comparison of bronchoalveolar and peripheral blood lymphocytes.[see comment]. [Case Reports. Journal Article] Chest. 102(6):1899-901, 1992 Dec. Newman TG. Minkowitz S. Hanna A. Sikand R. Fuleihan F. UI: 1446516 4. Sarcoidosis complicated by HIV infection: three case reports and a review of the literature. [Review] [25 refs] [Case Reports. Journal Article. Review. Review of Reported Cases] American Review of Respiratory Disease. Lowery WS. Whitlock WL. Dietrich RA. Fine JM. 142(4):887-9, 1990 Oct. UI: 2221596 5. Gowda KS. Mayers I. Shafran SD. Concomitant sarcoidosis and HIV infection. [Case Reports. Journal Article] CMAJ Canadian Medical Association Journal. 142(2):136-7, 1990 Jan 15. 6. UI: 2295031 Foulon G. Wislez M. Naccache JM. Blanc FX. Rabbat A. Israel-Biet D. Valeyre D. Mayaud C. Cadranel J. Sarcoidosis in HIV-infected patients in the era of highly active antiretroviral therapy. [Journal Article] Clinical Infectious Diseases. 38(3):418-25, 2004 Feb 1. UI: 14727215 Remember “P-I-C-O” P – Patient I – Intervention C – Comparison O – Outcome EBM is not an end in itself… “Whoever undertakes to set himself up as judge in the field of truth and knowledge is shipwrecked by the laughter of the Gods.” -Albert Einstein