BMD 1107: Professional Development

Evidence Based Medicine (EBM):

Introduction & Principles
Batch 6 MBBS (Sept 2016 intake)
15th March 2017

Prof. Subhada Prasad Pani, MBBS, MD, PhD, FISCD

 Learning Outcomes

At the end of this session students will be able to:

• Explain the term Evidence Based Medicine (EBM)

• Discuss the relevance & need for EBM form
individual patient care also from the community
health care points of view
• List & describe the dimensions (elements) of
EBM practice
• Classify and list the grades (levels) of evidence
in EBM
• List the steps of practice of EBM
 General Learning Outcomes of
MBBS Programme
• Apply the basic scientific knowledge of various
branches of medicine to understand the disease
process
• Apply clinical skills to recognise and manage
common health problems
• Provide effective first contact care in emergency
situations according to agreed protocols and
established quality standards
 General Learning Outcomes of
MBBS Programme
• Identify the behavioural, social and
environmental risk factors for diseases and apply
them in the provision of health care including
health education with regard to its preventive
and promotive aspects.
• Demonstrate caring attitude, good communication
skills and excellent bedside manners
 General Learning Outcomes of
MBBS Programme
• Carry out administrative and medico-legal functions
appropriate to a primary health care provider and
explain the economic aspects of health and
disease
• Recognise his/her limitations as a primary care
provider and be willing to refer patients for further
consultation at the appropriate time to the
appropriate specialty healthcare
 General Learning Outcomes of
MBBS Programme
• Adopt a critical and evidence-based approach
to solving patients’ problems and continue
improving personally and professionally as a
lifelong learner
• Practice medical ethics as enunciated by the
Malaysian Medical Council.
 What is EBM?
Definition of EBM

• “The conscientious, explicit, and

judicious use of current best
evidence in making decisions about
the care of individual patients.“
(includes drugs / diagnostics)

• Recently also being used in the

public health intervention context,
such as vaccines / screening tests
The slippery slope
The Need for Info !

Benefit versus Harm dilemma

Source of Medical Information

• Colleagues
• Conferences
• Drug Reps (Pharma
representative)
• Textbooks
• Journals
• Internet / Patients
 The Need for Info
• We need evidence - about the
accuracy of diagnostic tests,
the power of prognostic
markers, the comparative
efficacy and safety of
interventions (drugs) etc.
• We get less than a third of it
The three dimensions of EBM
The practice of EBM is the
integration of
1. Individual clinical expertise with

2. The best available external

clinical evidence and
3. Patient’s values and expectations
Clinical Expertise
 I. Individual Clinical Expertise

 Clinical skills and clinical

judgement to recognise a clinical
problem
 Vital for determining whether the
evidence (or guideline) applies to
the individual patient at all and, if
so, how?
 II. Best External Evidence

 From real clinical research among

patients.
 Has a short doubling-time (10 years
or even less).
 Replaces currently accepted
diagnostic tests and treatments with
new ones that are more powerful,
more accurate, more efficacious, and
safer.
 III. Patients’ Values &
Expectations
 Have always played a central role
in determining whether and which
interventions take place
 We’re getting better at
understanding, quantifying and
integrating these
 Dimensions (elements) of
clinical decision making

Clinical skills &

Judgement

Patients’ Values &

Best External Expectations
Evidence
 5 steps to Practice EBM

When patient care creates the need for

information:
Convert it into an answerable question
(patient/intervention/outcome).
 Efficient track-down of the best evidence
 secondary (pre-appraised) sources e.g.,
Cochrane; E-B Journals
 primary literature
 EBM – 5 steps to Practice
 Critical appraisal of the evidence for
its validity and clinical applicability è
generation of a brief summary
Integration of that critical appraisal
with clinical expertise and the patient’s
unique biology and beliefs è action
 Performance & Outcome evaluation
 5 steps to Practice EBM

When patient care creates the

need for information:
Convert it into an answerable
question
(patient/intervention/outcome).
 1. The Question

 Background
 Anatomy and Physiology
 Pathophysiology
 Pharmacology and Toxicology
 Differential diagnosis
 Diagnostic testing
 Treatment
 Textbooks, reviews, lectures, experts
Formulating clinical questions
 5 steps to Practice EBM

When patient care creates the need for

information:
Convert it into an answerable question
(patient/intervention/outcome).
 Efficient track-down of the best evidence
 secondary (pre-appraised) sources e.g.,
Cochrane; E-B Journals
 primary literature
 Sources of Information

1. Has someone done the review already?

(secondary sources)
• Cochrane database: www.cochrane.org
• Bandolier: www.jr2.ox.ac.uk/Bandolier/
• Clinical Evidence: www.clinicalevidence.com
• Evidence-Based On Call: www.eboncall.org

2. If not, find literature (primary sources):

• PubMed/ other medical search engine
 EBM and E-B Guidelines

 The best evidence comes from

systematic reviews (such as
Cochrane) with meta-analysis:
 Much more likely (than personal
search and critical appraisal) to be
true
 Saves the clinician’s precious
(scarce!) time
 Avoids error and duplication of effort
Grading of Quality of Available Evidence

 Ia- meta-analysis of randomized controlled

trials
 Ib- at least one randomized controlled trial
 IIa- at least one controlled study without
randomization
 IIb- at least one other type of quasi
experimental study
 III- non-experimental, descriptive studies,
such as case studies
 IV- expert committee reports or the opinions
or clinical experience of respected
authorities, or both
 Strength of
recommendation
 Grade A (levels Ia and Ib)- at least one RCT as
part of the body of literature of overall good
quality and consistency addressing specific
recommendations
 Grade B (levels IIa, IIb, and III)- availability of
well conducted clinical studies, but no RCT on
the topic of recommendation
 Grade C (level IV)- expert committee reports or
the opinions or clinical experience of
respected authorities, or both, in the absence
of directly applicable clinical studies of good
quality
5 steps to Practice EBM

When patient care creates the need for

information:
Convert it into an answerable question
(patient/intervention/outcome).
 Efficient track-down of the best evidence
 secondary (pre-appraised) sources
e.g., Cochrane; E-B Journals
 primary literature
 EBM – 5 steps to Practice

 Critical appraisal of the evidence for its

validity and clinical applicability è
generation of a brief summary
 Integration of that critical appraisal with
clinical expertise and the patient’s unique
biology and beliefs è action
 Performance & Outcome Evaluation
Patients “want to see & make
up their own minds”
 Reactions From Patients to
EBM

 All are grateful that their values/opinions

are being sought
 »1/3 want to see the calculations and make
up their own minds. (“Google patients”)

 »1/3 adopt the Risk/Benefit as presented

 »1/3 say “Whatever you tell me, doctor !”

 Benefits of Adopting EBM
1. When you raise 2. Evidence Based practice
clinical questions that are is
not adequately answered
– “safe practice” – legal
by available evidence, defence will be easier and
– It may motivate you to robust
conducting a meaningful
– Quality of care is at par
research
with the best available
– Review, Meta-analysis or
options
Original research
– You then go on from 3. Search for evidence
being ‘just a user to a keeps you well informed in
doer’ of research the areas of medicine that
relevant to your patients are relevant to your
practice
– “Self directed CME”
– Life long learning
 What EBM is NOT

 EBM is not cook-book medicine

 evidence needs extrapolation to the patient’s
unique biology and values
 EBM does not over-rule patient’s wishes
 Data helps them decide their best option
 EBM is not cost-cutting medicine
 When efficacy for a patient is paramount,
costs may rise, not fall
 Conclusion

 An understanding of EBM is essential for

doctors of today
 Good evidence has become increasingly
accessible to all
 Practice EBM by following the steps:
1. Translate a clinical problem into answerable question
2. Track down the best evidence to answer it
3. Appraise that evidence for its validity and applicability
4. Integrate that evidence with your clinical expertise,
patient preferences and apply it in practice
5. Evaluate your performance and continue to improve
 Learning Outcomes

At the end of this session students will be able to:

 Explain the term Evidence Based Medicine (EBM)

 Discuss the relevance need for EBM form patient
care also community health care points of view
 Discuss the dimensions (elements) of EBM
practice
 Classify and list the grades (levels) of evidence in
EBM
 List the steps of practice of EBM
http://www.cebm.net/index.aspx?
o=1083
THANK YOU