Weaving EBM into Your Clinical Teaching

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Weaving EBM into Your Clinical Teaching

• Mark C. Wilson, MD, MPH
• March 27, 2001

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Mornin
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We Have Lots to Cover and I Hope to Avoid . . .

• The Dopeler Effect
• The Tendency of Stupid Ideas to Seem Smarter
  When They Come at You Rapidly

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Successful Strategies
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Evidence-Based Is EVERYWHERE

• Evidence-Based Patient Information
• Evidence-Based Patient Choice

• Evidence-Based Sports Medicine

• Evidence-Based Orthodontics
• Evidence-Based Midwifery
• Evidence-Based Chiropractic Care
• Evidence-Based Alternative Medicine
• Evidence-Based Veterinarian Practice

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Back at the Home Office

• What Do Your Colleagues Think EBM Is???

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Common Beliefs about EBM

• Old Hat
• Ivory Tower Exercise
• Limiting Paralyzing
• Fixed Cookbook Approach
• A Tool for Cost Cutters
• Just about RCTs Statistics

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Others Find EBM Liberating

• It helps deal with volume overload
• Its an approach to keeping up-to-date
• It stimulates life-long, self-directed learning
• Caring for patients necessitates that we track
  down clinically important information

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Evolution of Evidence-Based Medicine
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Its a Paradigm Shift

• When defects in an existing paradigm accumulate
  to the extent that the paradigm is no longer
  tenable, the paradigm is challenged and replaced
  by a new way of looking at the world
• A new paradigm for medical practice is emerging
• Evidence-based medicine requires new skills of
  the physician
• JAMA 1992 2682420-5

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Evidence Based Medicine

• Clinical intuition, unsystematic experience,
  pathophysiologic rationale

Evidence from clinical research
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Users Guides Series in JAMA(Evidence-Based
Medicine Working Group)

• Are the Results Valid?
• Are the Results Important?
• Will the Results Help Me Care for My Patients?

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Other Emerging EBM Descriptors

• Evangelism
• By
• Messiah

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EBM A Hierarchy of Evidence

• N-of-1 Trials
• Meta-Analysis of Homogeneous RCTs
• Single RCT
• Cohort Study
• Case-Control Study
• Case Series
• Individual Clinical Experience

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A Wise Clinician Once Told Me

• Whenever You Get Confused,
• Start Back with the Patient

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Patients with New Proximal DVTs

• What Are Your Current Practice Patterns?

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Ahh Some Best Evidence

• RCT at 15 Centers in Canada
• 500 patients with acute proximal DVT
• Enoxaparin 1mg/kg SQ bid versus Standard
  continuous heparin infusion
• Equal rates of recurrent VTE (5-6) and major
  bleeding rare (1-2)
• 50 of LMWH group never hospitalized
• Levine, et al. NEJM 1996 334677-81

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How Would You Treat These Patients With Newly
Diagnosed DVT?

• 43 y/o truck driver whose husband is a nurse
• 68 y/o man 3 weeks s/p TKR who was participating
  in rehab program 3X/week
• 75 y/o woman with metastatic ovarian cancer who
  is non-communicative after CVA 2 yrs ago and has
  no advance directives

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Determinants of Decision-Making

• Evidence
• clinical evidence from patient
• best available external evidence
• systematic research
• pathophysiology
• local experts
• Values
• your patients
• your own

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So We Discovered . . .

• Evidence Alone
• NEVER
• Makes Clinical Decisions

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So We Discovered . . .

• Values
• ALWAYS
• Influence Decisions

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And We Discovered . . .

• Evidence
• NEVER
• Eliminates Uncertainty

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Regardless of How Much Evidence We Gather . . .
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EBM What it is

• Evidence-Based Medicine is the conscientious,
  explicit, and judicious use of current best
  evidence in making decisions about the care of
  individual patients.
• Practice of evidence-based medicine means
  integrating individual clinical expertise with
  the best available external clinical evidence
  from systematic research.
• EBM What it is and what it isnt. Br Med J
  1996 31271-72

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EBM What it is

• Evidence-Based Medicine is the conscientious,
  explicit, and judicious use of current best
  evidence in making decisions about the care of
  individual patients.
• Practice of evidence-based medicine means
  integrating individual clinical expertise with
  the best available external clinical evidence
  from systematic research.
• EBM What it is and what it isnt. Br Med J
  1996 31271-72

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EBM What it is

• Evidence-Based Medicine is the conscientious,
  explicit, and judicious use of current best
  evidence in making decisions about the care of
  individual patients.
• Practice of evidence-based medicine means
  integrating individual clinical expertise with
  the best available external clinical evidence
  from systematic research.
• EBM What it is and what it isnt. Br Med J
  1996 31271-72

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EBM What it is

• Evidence-Based Medicine is the conscientious,
  explicit, and judicious use of current best
  evidence in making decisions about the care of
  individual patients.
• Practice of evidence-based medicine means
  integrating individual clinical expertise with
  the best available external clinical evidence
  from systematic research.
• EBM What it is and what it isnt. Br Med J
  1996 31271-72

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EBM What it is

• EBM is the Integration of Best Research Evidence
  with Clinical Expertise and Patient Values.
• How to Practice and Teach EBM, 2nd Edition, 2000
• So, EBM is a Process for Self-Directed Learning
  that Begins with Individual Patient Care Problems

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Clinical Decision Making
Patient Circumstances
Evidence from research
Preferences, values and rights
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Evidence-Based Clinical Practice
Best External Evidence
Patient Preferences
Flexible Management Strategies
Establishing Effective Physician-Patient Communica
tion
Patients Clinical Problems
Co-Morbidities
Social Support
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A Precepting Moment
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Be Observant
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The Obvious

• Listen
• Diagnose the Learners Needs
• Assess the Learners EBM Readiness
• Exploit the Opportunity . . . Not the Learner

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So Where to Now?

• Hone Your Own Basic EBM Skills to Question,
  Search, Appraise, and Make Judgements
• Explicitly Wrestle with Components of Clinical
  Decision-making Think Out Loud
• Integrate External Evidence with Your Other
  Professional Tools
• Role-Model EBM as a Fun Process for Self-
  Directed Learning
• Cultivate Curiosity
• Be Fearless . . . And Wise

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Equip Yourself
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The Basics of EBM

• ASK a Clinically Relevant Question
• ACCESS the Best Available Evidence
• APPRAISE its Quality Importance
• APPLY the Evidence in Patient Care

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