EBM

(Evidence-based Medicine) Asking Answerable Clinical Questions

What is EBM?

Evidence-based medicine (EBM) requires the integration of the best research evidence with our clinical expertise and our patients unique values and circumstances

Best research evidence means valid and clinically relevant research Clinical expertise means ability to use our clinical skills and past experience to rapidly identify each patients unique health state and diagnosis Patient values means the unique preferences, concerns and expectations each patiens brigs to a clinical encounter and which must be integrated into clinical decisions if they are to serve the patient Patient's circumstances means their individual clinical state and clinical setting

How do we actually practice EBM?

Step-1: converting the need of information (about prevention, diagnosis, prognosis, therapy, causation, etc.) into an answerable questions Step-2: tracking down the best evidence with which to answer that question Step-3: critically appraising that evidence for its validity, impact and applicability

How do we actually practice EBM?...

Step-4: integrating the critical appraisal with our clinical expertise and with our patients unique biology, values, and circumstances Step-5: evaluating our effectiveness and efficiency in executing steps 1-4 and seeking ways to improve them both for next time

Evidence-Based Medicine

See a patient

Ask a question

Seek the best evidence

Monitor the change

Apply the evidence

Appraise that evidence

Scenario

A pediatrician was called to the hospital to attend the delivery of a new born. The mother, a 28 year old primigravida, had experienced elevated blood pressure during an otherwise uncomplicated pregnancy. The labor was induced because the pregnancy had continued 2 weeks past the expected date of delivery. During labor, evidence of fetal distress occurred. When the membranes ruptured, the obstetrician noted thick greenish containing meconium.

At the time of delivery the male newborn was limp and cyanotic, and had no spontaneous respiratory effort and a heart rate only 50 beats/ min. When meconium was suctioned from his mouth and nose, the baby did not grimace, cough, or sneeze. Vigorous effort at resuscitation were initiated, including bag-and-mask ventilation with 100% oxygen and chest compressions, but the Apgar Score at 1 min. of life was 1. Despite continuing resuscitation, the 5 min. Apgar score improved only to 2, with a heart rate of 110 beats/ min.

The 10 min. Apgar score remained depressed at 3, and the neonate was transferred to the Newborn Intensive Care Unit. With aggressive medical management, the 3100 gram neonate continued to improve without evidence of acute neurologic complications. He was discharged from the hospital on the twelfth day of life.

Apgar Score for Evaluation of Neonatal Asphyxia

Score
Sign
Heart Rate (x/ min) Respiration Muscle Tone Color 0 (-) (-) Limp Blue, pale 1 < 100 Slow, irregular Slow flexion Body pink, extremities blue Grimace 2 >100 Regular, crying Active motor Completely pink Cough, sneeze

Reflex response to None catheter in nostril

Questions

What are the complications of Low APGAR SCORE? How does the Low APGAR SCORE lead to neurological complications? What did the patient mean by if my baby can not cry immediately, will he be fine?

Questions

Among patients presenting Low APGAR SCORE, how often would develop neurological complications? In babies with Low APGAR SCORE, would joining an integrated self care parents management program reduce morbidity from abnormal mental capacity over 5-7 years?

Background and Foreground Questions

Background questions Ask for general knowledge about a condition or thing Have two essential components: 1. A question root (who, what, where, when, how, why) and a verb 2. A disorder, test, treatment or other aspect of health care

Background and Foreground Questions

Foreground questions Ask for specific knowledge to inform clinical decisions or actions Have four essential components: 1. Patient and/ or problem 2. Intervention or exposure 3. Comparison, if relevant 4. Clinical outcomes including time if relevant

(P) (I ) (C) (O)

Learn to Ask a Focused Clinical Question Foreground

Patient Problem / Population
Intervention
Be specific!
Description of the group to which your patient belongs, (age, gender, race, ethnicity, and stage of disease). The description should be specific enough to be helpful, but not overly specific. description of the test or treatment that you are considering

what you plan to do for that patient

the alternative. Not all questions need a comparison, the main alternative you are considering something that not only matters to you, but matters to the patient. Be specific! what is the main concern?

Comparison
Outcome
Be specific!

The components: P

Think about who / what you wish to apply this evidence to e.g.

People with a particular disorder?

e.g chronic recurrent cystitis

People in a particular care setting?

e.g. community
e.g. sexually active young women? the elderly? children?

Particular groups of people

How would you describe your clients / setting?

The components: I
The

intervention / topic of interest (e.g. cause, change in practice etc.) e.g.

Use of guava juice (as a drink) Might want to specify how much / how often For complex interventions may need to give specific detail / consideration to the description

What

exactly am I considering?

The components: C

The

comparison or alternative applicable to all questions) e.g.

Anti-biotic therapy? Nothing? Fluids alone?

(not

What

alternatives actions might I try?

The components: O

The outcome e.g.

Cure Duration of disease Prevention Death Side effects Pain (reduced) Wellbeing

What am I hoping to accomplish (what outcomes might reasonably be affected...)?

Foreground

Background

Experience with Condition

A = limited experience with the condition B = as we grow in clinical experience and responsibility C = further experience with the conditions Diagonal line shows were never too green to learn foreground knowledge or too experience to outlive the need for background knowledge

Our reactions to knowing and to not knowing

Clinical practice demands that we use large amounts of both background and foreground knowledge, whether or not were aware of its use. Combinations of practice demands and our awareness: 1st our patients predicament may call for knowledge that we already possess, so we will experience the reinforcing mental and emotional responses termed Cognitive Resonance

Our reactions to knowing and to not knowing

2nd we may realize that our patients illness calls for knowledge that we dont possess, and this awareness brings mental and emotional responses termed Cognitive Dissonance need to know 3rd - our patients predicament might call upon knowledge that we dont have, yet these gaps may escape our attention, so we dont know what we dont know and we carry on undisturbed ignorance.

Unfortunately if handled less well, our cognitive dissonance might lead us to less adaptive behaviors such as trying to hide our deficits, or by reacting with anger, fear, or shame

By developing awareness of our knowing and thinking, we can recognized our cognitive dissonance when it occurs, recognized when the knowledge we need would come from clinical care research, and articulate background and foreground questions we can use to find the answers.

Central issues in clinical work where clinical questions often arise

Clinical findings how to properly gather and

interpret findings from the history and physical examination

Etiology how to identify causes or risk factors

(including iatrogenic harms)

Clinical manifestation of disease knowing

how often and when a disease causes its clinical manifestations and how to use this knowledge in classifying our patient's illnesses

Central issues in clinical work where clinical questions often arise

Differential diagnosis Diagnostic tests Prognosis Therapy Prevention Experience and meaning Improvement how to keep up-to-date