Asking the Question and Finding the Answer The first steps in bringing evidence to the bedside

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Asking the Question and Finding the AnswerThe
first steps in bringing evidence to the bedside
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EBM Approach

• It is a cycle
• It ALWAYS starts with the patient and a question

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Just in case vs. Just in time

• Just in case Reading to keep up and hoping
  to remember the info when you need it Vs.
• Just in time Accessing information when you
  need it

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A New Years Resolution overheard on W44 I
will keep up with the medical literature this
year

• Annually
• 20,000 journals
• 17,000 new books
• MEDLINE
• 4,000 journals
• 6 Million references
• 400,000 new entries yearly

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Famous New Years Resolutions, cont
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More bad news about the just in case approach

• 85 of the NIH database turns over every 5 years
• Medical information doubles every 5 years
• 90 of learned info is obsolete in 15 years

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Solution Shift Gears

• From Memory Repositories (Just in case)
• To Information Managers (Just in time)
• From I will read as much as I can to keep up
  with new developments in Medicine so I can take
  the best care of my patients
• To How do I find answers when I need them to
  provide the best care to my patients?
• (Still need to find a system for answering this
  question What developments in Medicinedo I
  need to keep up with and how?)

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Just in Case vs. Just in Time

• Evidence-based medicine "converts the abstract
  exercise of reading and appraising the literature
  into the pragmatic process of using the
  literature to benefit individual patients while
  simultaneously expanding the clinician's
  knowledge base." (Bordley DR, American Journal of
  Medicine. 102(5)427-32, 1997) 

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Just in time?

• Most of our questions are NEVER answered
• Not enough time
• Cant find what were looking for (see 1 above)
• Patient gets discharged (see 1 above)
• Forget the question
• When answered, the information is likely to be
  neither the best nor up-to-date

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Getting better at answering questions just in time

• Ask a searchable question
• Know where and how to search
• Maximize retrieval of useful information
• Minimize work

Adapted from Slawson et al, J Fam Pract 1994
38505-513
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What Kind of Question?

• Background
• Asks for general information about a disorder
  (Who What Where When Why How)
• Foreground
• Asks for specific information about managing
  patients with a disorder

Foreground
Background
Experience with condition
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Finding the EvidenceBackground Questions

• Textbooks
• Up-to-Date
• MDConsult
• Review articles (Clinics of North America)

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A Hierarchy of Evidence Foreground Questions
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Finding the EvidenceForeground Questions

• Look for Systematic Reviews first
• Then turn to databases of high-quality
  pre-digested evidence
• Searching for individual journal articles
  increases work

http//www.healthsystem.virginia.edu/internet/libr
ary/collections/ebm/pyramid.cfm
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The Patient

• You have just admitted an 75 year old woman with
  inoperable pancreatic cancer and severe abdominal
  pain. The family wants to avoid narcotics. Can
  she be treated effectively with other modalities?
  You decide to go to the literature to see what
  you can find on this foreground question

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PubMed

• Separate search capability for
• individual clinical citations
• Meta-analyses, clinical guidelines, systematic
  reviews

http//www.healthsystem.virginia.edu/internet/libr
ary/collections/ebm/pyramid.cfm
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Even PubMed Can Be Easier!
Clinical Queries function
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SUMSearch sumsearch.uthscsa.edu

• Free Meta-search engine with contingency search
  strategy
• Systematic reviews listed first

http//www.healthsystem.virginia.edu/internet/libr
ary/collections/ebm/pyramid.cfm
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Take home messages

• You dont have to know or read EVERYTHING
• Ask a searchable question
• Use electronic resources to acquire useful
  information minimize work
• Appraise the evidence you find
• Apply what youve learned
• Assess its effects in your patient