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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 Librarian UCI Science Library Desiree Lie, MD, MSEd UCI CAM Taskforce, Chair UCI Dept. of Family Medicine 5/25/2017 Funded by AMSA 1 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. 5/25/2017 Funded by AMSA 2 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 5/25/2017 Funded by AMSA 3 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 5/25/2017 Funded by AMSA 4 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? 5/25/2017 Funded by AMSA 5 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 5/25/2017 Funded by AMSA 6 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. 5/25/2017 Funded by AMSA 7 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 5/25/2017 Funded by AMSA 8 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. 5/25/2017 Funded by AMSA 9 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. 5/25/2017 Funded by AMSA 10 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. 5/25/2017 Funded by AMSA 11 Formulating Questions Background questions Foreground questions PICO Select appropriate database/sources Search Strategy 5/25/2017 Funded by AMSA 12 Background Questions General clinical questions for background knowledge. Can be answered by using “background” resources, e.g., current textbooks, and narrative reviews. Foreground Questions Specific questions (Diagnosis, Etiology, Prognosis, Therapy) about your patient: Need latest resources Answered by primary (original research) and secondary (systematic reviews and practice guidelines) sources 5/25/2017 Funded by AMSA 13 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) 5/25/2017 Funded by AMSA 14 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? 5/25/2017 Funded by AMSA 15 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 5/25/2017 Funded by AMSA 16 Search Results 5/25/2017 Funded by AMSA 17 • 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/> 5/25/2017 Funded by AMSA 18 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 5/25/2017<http://www.nlm.nih.gov/medlineplus/acupuncture.html> Funded by AMSA 19 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? 5/25/2017 Funded by AMSA 20 Formulating Patient Centered Questions P = Patient/Population/Problem I = Intervention/exposure or prognostic factor C = Comparison/Control O = Outcome/s 5/25/2017 Funded by AMSA 21 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? Primary vs. Secondary Sources 5/25/2017 Funded by AMSA 23 Primary Source: Original Research, RCTS - CAM on PubMED 5/25/2017 Funded by AMSA 24 PubMed Search Results 5/25/2017 Funded by AMSA 25 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 5/25/2017 Funded by AMSA 26 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-totreat analyses? Did the treatment and control groups remain the same with respect to important prognostic factors? 5/25/2017 Funded by AMSA 27 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? 5/25/2017 Funded by AMSA 28 Secondary Sources Example 1: PubMed Clinical Queries – Systematic Reviews 5/25/2017 Funded by AMSA 29 Secondary Sources Example 2: The Cochrane Library Systematic Reviews 5/25/2017 Funded by AMSA 30 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. 5/25/2017 Funded by AMSA 31 Tertiary evidence Bandolier Complementary and Alternative Therapies • Include acupuncture, homeopathy, massage, herbal medicine, supplements, and safety concerns. • Provides abstracts of systematic reviews, metaanalyses 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> 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> 5/25/2017 Funded by AMSA 33 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 5/25/2017 Funded by AMSA 34 Thank you! Questions? 5/25/2017 Funded by AMSA 35