Download Teaching Your Team (Finding Good Answers Quickly)

Finding the Best Answers to
Clinical Questions – Quickly and
Effectively
Karen Odato
Educ. Coordinator, Biomedical Libraries
David Nierenberg
SBM Program Director
Objectives
• Select appropriate resources to
answer specific clinical questions.
• Identify quality information on which
to base patient care.
You are a third-year clerk doing your inpatient
medicine rotation on the M2 service at MHMH. You
admitted a patient the previous evening who is a 79year-old man who is widowed (about four months
ago), and trying to care for himself at home. He says
he does a pretty good job, but sometimes gets
confused about which medications he has taken, and
when he should be taking them. He has limited
driving to local neighborhoods, because he sometimes
gets stressed or lost driving in unfamiliar areas.
He was admitted through the emergency room after
he accidentally started a stove fire at his house (he
forgot he was heating up some spaghetti sauce, and
the pot caught fire), ran for a fire extinguisher, fell,
bumped his head on the table, and was shaken and
confused. You suspect from his history and physical
exam and admission lab data, that he has Alzheimer’s
Disease. His CT scan done last night (because of the
head trauma) shows moderate atrophy and is
consistent with that Dx.
Several issues come up on walk rounds with the
attending the next day. Many of the questions will be
“referred” to the DMS 3 student. Where would you
go to quickly find the “best (evidence-based)
answers” in the most efficient manner?
There are a number of issues that come up - and not
much time to look for the answers.
Issue 1
• There is disagreement among the team as
to whether the patient has normal aging
and forgetfulness, or “mild cognitive
impairment”, or Alzheimer’s Disease.
Issue 1
• There is disagreement among the team as
to whether the patient has normal aging
and forgetfulness, or “mild cognitive
impairment”, or Alzheimer’s Disease.
• How are these conditions different? We
need some background information on all
three…
Issue 1
• There is disagreement among the team as
to whether the patient has normal aging
and forgetfulness, or “mild cognitive
impairment”, or Alzheimer’s Disease.
• How are these conditions different? We
need some background information on all
three…
• Try looking in textbooks (print or online) or
a synthesis resource (e.g., UpToDate or
eMedicine).
Issue 2
• The team finally agrees that the patient has
Alzheimer’s Disease, but isn’t sure what the
currently recommended workup should be to “make
sure” they aren’t missing some other treatable
process. They disagree about whether the CT was
needed, and about whether an LP should be done.
Issue 2
• The team finally agrees that the patient has
Alzheimer’s Disease, but isn’t sure what the
currently recommended workup should be to “make
sure” they aren’t missing some other treatable
process. They disagree about whether the CT was
needed, and about whether an LP should be done.
• What are current consensus guidelines for a
thorough but cost effective workup for a patient
with clinically suspected Alzheimer’s Disease?
Issue 2
• The team finally agrees that the patient has
Alzheimer’s Disease, but isn’t sure what the
currently recommended workup should be to “make
sure” they aren’t missing some other treatable
process. They disagree about whether the CT was
needed, and about whether an LP should be done.
• What are current consensus guidelines for a
thorough but cost effective workup for a patient
with clinically suspected Alzheimer’s Disease?
• Try looking in the National Guideline
Clearinghouse, Cochrane Database, eMedicine, or
MEDLINE (limit to Publication type “Practice
Guideline).
Issue 3
• The team now agrees that with a mini-mental
status exam of 24/30, the patient has “early”
Alzheimer’s Disease. However, they can’t agree on
what FDA-approved prescription drug should be
given at this point.
Issue 3
• The team now agrees that with a mini-mental
status exam of 24/30, the patient has “early”
Alzheimer’s Disease. However, they can’t agree on
what FDA-approved prescription drug should be
given at this point.
• What drugs have been approved by the FDA
specifically for the treatment of AD?
Issue 3
• The team now agrees that with a mini-mental
status exam of 24/30, the patient has “early”
Alzheimer’s Disease. However, they can’t agree on
what FDA-approved prescription drug should be
given at this point.
• What drugs have been approved by the FDA
specifically for the treatment of AD?
• Try a search by indication in Clinical Pharmacology
Online. CPOnHand and Epocrates Rx are similar
resources for the PDA.
#1
#2
Issue 4
• The team decides to start the patient on
Aricept@ (donepezil). However, the intern has
heard that Vit E might be useful and the resident
recently heard about statins being used for
treating AD.
Issue 4
• The team decides to start the patient on
Aricept@ (donepezil). However, the intern has
heard that Vit E might be useful and the resident
recently heard about statins being used for
treating AD.
• Is there any research indicating that vitamin E or
statins might be useful in this situation? Is there
an ongoing clinical trial in which the patient can
participate?
Issue 4
• The team decides to start the patient on
Aricept@ (donepezil). However, the intern
has heard that Vit E might be useful and
the resident recently heard about statins
being used for treating AD.
• Is there any research indicating that
vitamin E or statins might be useful in this
situation? Is there an ongoing clinical trial
in which the patient can participate?
• Try CPO, Cochrane, or MEDLINE;
Clinicaltrials.gov for ongoing trials.
Issue 5
• After several days of working with your patient,
you become convinced that the patient is
depressed as well - partly about the new diagnosis,
but also about the loss of his wife a few months
earlier.
Issue 5
• After several days of working with your patient,
you become convinced that the patient is
depressed as well - partly about the new diagnosis,
but also about the loss of his wife a few months
earlier.
• Is depression a common complication of AD? What
antidepressant drugs are indicated and
contraindicated in this situation? What kind of
psychotherapy works best with these patients?
Issue 5
• After several days of working with your patient,
you become convinced that the patient is
depressed as well - partly about the new diagnosis,
but also about the loss of his wife a few months
earlier.
• Is depression a common complication of AD? What
antidepressant drugs are indicated and
contraindicated in this situation? What kind of
psychotherapy works best with these patients?
• Try looking in Cochrane, MEDLINE (Clinical
Queries section), or PsycINFO.
Issue 6
• The patient’s daughter shows up the next day.
She heard about the use of fish oil and ginkgo
biloba in Alzheimer patients and asks about other
possible alternative treatments.
Issue 6
• The patient’s daughter shows up the next day.
She heard about the use of fish oil and ginkgo
biloba in Alzheimer patients and asks about other
possible alternative treatments.
• Are there any safe, effective complementary
treatment options?
Issue 6
• The patient’s daughter shows up the next day.
She heard about the use of fish oil and ginkgo
biloba in Alzheimer patients and asks about other
possible alternative treatments.
• Are there any safe, effective complementary
treatment options?
• Try looking for studies in PubMed (limit to the
Complementary Medicine subset) and HerbMed
(see the Libraries’ Alternative Med subject guide.)
In summary:
• Identify appropriate resources for
your clinical questions
• Use handouts and the EBM subject
guide
• Use librarians: Library Advisors and
the reference desk