The Collaborative Role of Medical Librarians in Facilitating the EBCAM Faculty Development Workshop

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The Collaborative Role of Medical Librarians in
Facilitating the EBCAM Faculty Development
Workshop
Presented at the NCNMLG ? MLGSCA ? PNC/MLA Joint
Meeting ? Sacramento, Jan 28-31, 2004

• Linda S. Murphy, MLIS
• Health Sciences LibrarianUCI Science Library
• Desiree Lie, MD, MSEd
• UCI CAM Taskforce, Chair
• UCI Dept. of Family Medicine

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Background

• New CAM Center (Susan Samueli Center for CAM)
  established in 2001
• New CAM curriculum to be introduced starting 2002
• CAM Task Force Multidisciplinary membership
• AMSA Grant (2003)
• Provided faculty with skills to integrate CAM
  instruction into a variety of teaching programs
  and clinical settings.

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Workshop Development Implementation

• A small working group (2 MD faculty, a PhD and a
  librarian).
• Workshop planning
• Established goals and objectives
• Discussed presentation methods
• Pre-designed 3 patient cases.
• Identified literature, speakers, pre- and post
  workshop assessment tools to evaluate learners
  EBCAM skills and knowledge

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Program Contents

• Welcome, Current state of CAM Education
• Small Group Discussions
• Group 1 Discussed EBM search and critical
  appraisal.
• Group 2 Divided into 3 smaller groups to discuss
  and use model patient cases for future CAM
  instruction.
• Lunch Break
• Evaluating CAM instruction and competencies
• Wrap up and suggestions for next years program

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Clinical Scenario 1 Back pain

• Pt a 25-yr male restaurant manager, 6-months
  of neck and LBP
• Px localized pain in neck/shoulder persistent
  ache in L2-4 occasional headaches
• Dx x-ray of the neck and lumbar spine was
  normal
• Tx given NSAIDs, exercise and PT without
  resolution
• PtQ will chiropractic manipulation or
  acupuncture Rx improve pain and function and
  what risks might be involved?

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Clinical Scenario 2Womens health and Menopause

• Pt a 50-yr female teacher with menopausal
  symptoms, started HRT a yr ago working with her
  physician to discontinue
• Hx breast cancer and heart disease
• Dx re-experiencing symptoms of hot flushes,
  mood swings, and night sweats.
• Tx was treated with HRT.
• PtQ Black Cohosh, Red Clover, and Estroven
  relieve menopausal symptoms risk of breast
  cancer and heart disease

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Clinical Scenario 3Congestive Heart Failure and
Herbals

• Pt Mr. Mitchell, a 73 year old retired bus
  driver
• Dx hypertension and atrial fibrillation
  insomnia gastrointestinal discomfort
• Tx Digoxin (control heart rate) and Coumadin
  (prevent thrombotic emboli) hydrochlorothiazide
  (for hypertension)
• Self Med St. Johns Wart, Valerian (help with
  sleep) Ginger (for GI Discomfort) Vitamin E
  (for memory problems)
• Probls Digoxin and coumadin levels are unstable.
  

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Why Keep Up With the Literature?

• Decide what diagnostic test to use
• What treatment to choose
• What expected outcome might be
• Keeping up with the latest news in health care
• Stay abreast of what patients bring in from the
  media, from the Internet, from friends

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What is EBCAM?

• Integrates the best research evidence with
  clinical expertise and patient values.
• Seeks to inform, leaving the final decision to
  the clinician and patient.
• Effective means to bridge the gap between
  information and practice.
• Facilitates interaction between conventional and
  CAM practitioners.

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Why is EBCAM needed?

• Growing national interest in CAM
• A billion dollar industry, need evidence for
  efficacy of CAM modalities.
• Recent movement to integrate CAM content into
  allopathic curricula.
• Increased funding for CAM education.
• Faculty need updated knowledge for CAM to be
  comfortable teaching students and residents.

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The EBCAM Process

• Ask a well-structured clinical question
• Conduct a high-quality literature search.
• Identify evidence most relevant to addressing the
  clinical question
• Appraise the quality of this evidence
• Apply the evidence to the care of the patient.

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Formulating Questions

• Background questions
• Foreground questions
• PICO
• Select appropriate database/sources
• Search Strategy

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• Background Questions
• General clinical questions for background
  knowledge.
• Can be answered by using background resources,
  e.g., current textbooks, and narrative reviews.
• Foreground Questions
• Specific questions (Diagnosis, Etiology,
  Prognosis, Therapy) about your patient
• Need latest resources
• Answered by primary (original research) and
  secondary (systematic reviews and practice
  guidelines) sources

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Internet Searching

• Google search
• back pain" acupuncture (120,000 hits)
• low back pain acupuncture (27,900)
• chronic low back pan acupuncture (5,020)
• red clover Hot Flushes (3,760 hits)
• red clover "menopausal symptoms (5,570)
• St. Johns Wort Coumadin (9,090 hits)

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Researching Background Questions

• What are the standard treatment for back injury?
• What is acupuncture?
• What are Black Cohosh, Red Clover, and Estroven
  used for today?
• What is atrial fibrillation?
• What are St. Johns Wart, and Valerian used for?

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Background CAM Resources

• The Natural Medicines Comprehensive Database
• Provides evidence-based clinical data on dietary
  supplements and natural products.
• Designed for medical professions and updated
  daily.
• Products can be searched by scientific names,
  common names, or brand names or by ingredients.
• Search Black Cohosh

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Search Results
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• 1998, a division of NIH.
• Exploring CAM and alternative healing practices
  in the context of rigorous science.
• Educating and training CAM researchers,
  disseminating authoritative info. to the public
  and professions lthttp//www.nccam.nih.gov/gt

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MEDLINEplus

• Access to info about specific diseases and
  conditions.
• Links to self-help groups, consumer health info,
  clearinghouses, list of CAM practitioners. in
  Spanish and other languages, and clinical trials.
  
• Alternative Medicine lthttp//www.nlm.nih.gov/medli
  neplus/alternativemedicine.htmlgt
• Back pain lthttp//www.nlm.nih.gov/medlineplus/back
  pain.htmlgt
• Interactive Tutorial lthttp//www.nlm.nih.gov/medli
  neplus/tutorials/backpain.htmlgt
• Chiropractic lthttp//www.nlm.nih.gov/medlineplus/c
  hiropractic.htmlgt
• Acupuncture
• lthttp//www.nlm.nih.gov/medlineplus/acupuncture.ht
  mlgt

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Researching Foreground Questions

• How effective is spinal manipulation or
  acupuncture compared with NSAID in reducing back
  pain in your patient?
• What are the risks of HRT use, particularly with
  respect to CHD events, compared with no HRT?
• What are the efficacy of black cohosh, red clover
  and estroven in reducing menopausal symptoms?
• What is the efficacy of St. John Wart in treating
  a hypertensive patient with depression and atrial
  fibrillation?

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Formulating Patient Centered Questions

• P Patient/Population/Problem
• I Intervention/exposure or prognostic
  factor
• C Comparison/Control
• O Outcome/s

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Framing PICO

• Case 1 Back pain
• Given a 25-yr male restaurant manager with
  chronic neck/back pain (P), does acupuncture or
  chiropractic Rx (I) compared with ibuprofen
  and/or naprosyn (C) reduce symptoms of neck and
  back pain (O)?
• Case 2 Womens Health and Menopause
• In female with menopausal symptoms, do natural
  hormones (estroven, black cohosh, and red clover)
  compared to HRT or no Rx, relieve menopausal
  symptoms and reduce the risk of heart disease?
• Case 3 Congestive Heart Failure and Herbals
• In elderly men with hypertension and atrial
  fibrillation, do multiple supplements, herbs and
  vitamins interact with heart and blood thinner
  medications, compared to medications only produce
  poor control of Digoxin and unstable Coumadin
  levels?

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Primary vs. Secondary Sources
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Primary Source Original Research, RCTS - CAM on
PubMED
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PubMed Search Results
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Critical Appraisal

• Protocols for validating quality of research
  articles
• Therapy RCT
• Diagnosis Sensitivity/Specificity, Predictive
  Value of Tests
• Etiology Cohort, Case-Controlled Studies
• Prognosis Cohort, Follow-up Studies, Mortality
• Screening/Prevention
• Systematic Review
• Practice Guidelines
• Economic Analyses

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Critical Appraisal - Therapy

• Are the Rx and control groups similar?
• Were patients randomized?
• Were the benefits of randomization preserved
  through use of concealment and intention-to-treat
  analyses?
• Did the treatment and control groups remain the
  same with respect to important prognostic factors?

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Application to Patient

• What were the results?
• What is the estimate of the effect?
• How precise is this estimate of the effect?
• Can the results be applied to your patient?
• Is your patient similar to the patients in the
  study?
• Were all important outcomes examined?

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Secondary Sources

• Example 1 PubMed Clinical Queries Systematic
  Reviews

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Secondary Sources

• Example 2 The Cochrane Library Systematic
  Reviews

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Secondary Sources

• Example 3 ACP Journal Club
• A publication of the American College of
  Physicians, and BMJ Evidence.
• Screen and identify studies, then provide
  abstracts with commentary.

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Tertiary evidence

• Bandolier Complementary and Alternative Therapies
  
• Include acupuncture, homeopathy, massage, herbal
  medicine, supplements, and safety concerns.
• Provides abstracts of systematic reviews,
  meta-analyses on CAM studies.
• Extracts info from secondary reviews of primary
  trials.
• Contains over 100 summaries on the effectiveness
  of CAM, e.g., Arthritis, bones and joints
  lthttp//www.jr2.ox.ac.uk/bandolier/booth/booths/bo
  nes.htmlgt

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Workshop Summary

• Review EBCAM Process
• The EBM Guidebook http//www.ucihs.uci.edu/com/med
  ed/pd/PDPFD/EBM20Guidebook1.pdf
• The Critical Appraisal Worksheets
  http//www.cebm.utoronto.ca/teach/materials/cawork
  sheets.htm
• Links UCI Libraries CAM Resources
  lthttp//www.lib.uci.edu/online/subject/clinical/cl
  inalt.htmlgt
• Evaluated learners EBCAM knowledge and skills
  the interactive EBCAM case exam
  lthttp//meded.lib.uci.edu/database/ebcam/camexam.p
  hpgt

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Challenges

• Lack of clinical knowledge, e.g., Identify valid
  questions that are patient-based
• Finding the appropriate literature for a CAM case
  study
• Keeping up with the literature.
• Self learning and motivation
• Time
• Teaching different levels of learners
• Getting support from library administration

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Thank you!

• Questions?