EVIDENCE-BASED MEDICINE

Zwasta Pribadi M

Discuss this question with your

A quick question to help you grow
neighbour

X is a sexually transmitted disease

With prevalence of 0.2%
Fatal in 1 in 8 people
Treatment prevents death
End
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Sensitivity of a test to detect X is 99%
Specificity of a test to detect X is 99%
1 in 25 people diagnosed with X commit suicide
Will screening prevent more deaths than it causes?

A dilemma

You are very ill

Which doctor do you want?

William Osler, 1900

Smart young doctor

Which doctor do you want?

Wise & experienced smart young doctor

What is evidence-based medicine?

Evidence-based medicine is the integration of

best research evidence with clinical expertise
and patient values
Patient
Concerns
EBM
Best research Clinical
Expertise
evidence

What is EBM ?

By best research evidence we mean clinically relevant

research, often from the basic sciences of medicine, but
especially from patient centered clinical research into
the accuracy and precision of diagnostic tests (including
the clinical examination), the power of prognostic
markers, and the efficacy and safety of therapeutic,
rehabilitative, and preventive regimens.
New evidence from clinical research both invalidates
previously accepted diagnostic tests and treatments
and replaces them with new ones that are more
powerful, more accurate, more efficacious, and safer

What is EBM ?

By clinical expertise we mean the ability to use our

clinical skills and past experience to rapidly identify
each patients unique health state and diagnosis,
their individual risks and benefits of potential
interventions, and their personal values and
expectations

What is EBM ?

by patient values we mean the unique preferences,

concerns and expectations each patient brings to a
clinical encounter and which must be integrated into
clinical decisions if they are to serve the patient

Why the sudden interest in EBM?

our daily need for valid information about diagnosis,

prognosis, therapy and prevention (up to 5 times per in-patient
and twice for every 3 out-patients).
the inadequacy of traditional sources for this information
because they are out-of-date (textbooks), frequently wrong
(experts), ineffective (didactic continuing medical education) or
too overwhelming in their volume and too variable in their
validity for practical clinical use (medical journals).
the disparity between our diagnostic skills and clinical
judgement, which increase with experience, and our up-to-date
knowledge and clinical performance, which decline.
our inability to afford more than a few seconds per patient for
finding and assimilating this evidence, or to set aside more
than half an hour per week for general reading and study

Rule 31 Review the World Literature Fortnightly*

*"Kill as Few Patients as Possible" - Oscar London

Articles
MedicalArticles
YearYear
Per per
Medical

2500000

5,000?
per day

2000000
1500000

1,500
per day

1000000

95 per
day

500000
0

Biomedical

MEDLINE

Trials

Diagnostic?

The Need for EBM

In the years after you graduate, two things will
happen:
1.
Your memory of what you learned in medical
school will lose its freshness.
2.
New treatment methods will be found that they
never taught you about in school because they
didn't exist.

The Need for EBM

If you are to remain a good doctor, or become a

better one, you need to stay on top of new
developments as they occur.
Evidence Based Medicine provides you with the
tools you need to find important new medical
research quickly and easily, and to work out its
implications for your practice.

Is keeping up to date Mission Impossible?

Bluegreenblog 2006

How do we actually practice EBM?

Step 1Converting the need for information (about prevention,

diagnosis, prognosis, therapy, causation, etc) into an
answerable question.
Step 2 Tracking down the best evidence with which to answer
that question.
Step 3 Critically appraising that evidence for its validity
(closeness to the truth), impact (size of the effect), and
applicability (usefulness in our clinical practice).
Step 4 Integrating the critical appraisal with our clinical
expertise and with our patient's unique biology, values and
circumstances.
Step 5 Evaluating our effectiveness and efficiency in executing
Steps 1-4 & seeking ways to improve them both for next time

EBM practice requires:

Asking
Acquiring
Appraising
Applying
Assessing

Patient
dilemma

Process of EBP

Act & Assess

Ask

Acquire

Principles of
evidence-based
practice

Appraise

Hierarchy
of evidence

Apply

Evidence alone does not

decide combine with other
knowledge and values

The five As of the Evidence Cycle

ASSESS: Clinical Evaluation
The clinician must ASSESS the patient and the
problem to determine the pertinent issues, which
may include a differential diagnosis, treatment
decisions, or prognosis

The five As of the Evidence Cycle

ASK: Clinical Question Development
The clinician must draw from this evaluation and
ASK a clear, answerable question to be pursued.

The five As of the Evidence Cycle

ACQUIRE: Searching for the Evidence
The next step is to efficiently ACQUIRE the evidence
from an appropriate source. Potential sources
include original research studies, systematic reviews,
evidence-based journal abstracts, textbooks and
computerized decision support systems

The five As of the Evidence Cycle

APPRAISE: Critical Appraisal of the Evidence
With a potential source in hand, the clinician must
APPRAISE the evidence to further examine its worth
and reliability

The five As of the Evidence Cycle

APPLY: Applying Evidence to the Patient
Finally, the process must conclude by returning to the
individual patient, as the clinician has to decide
whether it is appropriate to APPLY the evidence to
the particular patient and their unique values and
circumstances.

What are your clinical questions?

A 35 year old man says his

brother recently died of a
ruptured cerebral aneurysm.
He is worried about whether
he might have one and what
the chances are that it would
rupture.

-> PIC Table

Types of question: stroke

Frequency

Risk Factors
Cohort Study

Prognosis

Survey Inception Cohort Study

CT Scan
Treatments

Treatment Effect

Randomised Trial

Symptoms
Signs, Tests

Cause(s)

Cross Sectional Study

Past

current

future

Background/Foreground Questions

Where you look for information is determined by

what kind of question you are asking. One way
of classifying your question is to ask whether you
are seeking background information or foreground
information.

Background information

is sought when a learner has general clinical

questions regarding a topic such as what is the
disorder; what causes it; how does it present; what
are some treatment options.
These questions can be answered by using
"background" resources such as textbooks (both in
print and electronic) and narrative reviews in
journals which give a general overview of the
topic.

Foreground information

answers specific questions a clinician has regarding

a specific patient.
Foreground resources can be divided into primary
sources such as original research articles published
in journals; and secondary sources such
as systematic reviews of the topic, and synopses
and reviews of individual studies.

The Benefits of EBM

The total amount of knowledge out there is far greater

and often more reliable than the clinical experience of
one physician or even a group of experts.
You no longer need to read through masses of journals
in order to take advantage of it.
It is no longer your job to know everything, even in your
chosen specialty.
It IS your job to be able to find the information as and
when you and your patients need it.

The Benefits of EBM

A detailed and exact knowledge of the outcomes of

different interventions, derived from the research,
can often save lives.

Thank you for joining in

Questions
or comments ?
Send to
zwasta_pm@yahoo.com