Weaving EBM Into Your Clinical Practice

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Weaving EBM Into Your Clinical Practice

• Mark C. Wilson, M.D., M.P.H.
• Wake Forest University School of Medicine

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We Have Lots to Cover and I Hope to Avoid . . .

• The Dopeler Effect
• The Tendency of Stupid Ideas to Seem Smarter
  When They Come at You Rapidly

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The Obvious
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Common Pitfalls
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Successful Strategies
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Hmmm ...

• Reflect on Past Situations When Your Chief
  Resident / Attending Tried to Weave EBM into the
  Teaching Encounter

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Back at the Home Office

• What Do Your Residents Think EBM Is???

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A Wise Clinician Once Told Me

• Whenever You Get Confused,
• Start Back with the Patient

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Venous Thromboembolic Disease

• What Are Your Current Practice Patterns?

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Where Would You Turn for Quick High Quality
Evidence?

• Medical Letter
• MKSAP
• SAM-CD
• Up to Date
• Best Evidence
• Cochrane Reviews

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Ahh The Best Evidence

• RCT at 15 Centers in Canada
• 500 patients with acute proximal DVT
• Enoxaparin 1mg/kg SQ bid versus Standard
  continuous heparin infusion
• Equal rates of recurrent VTE (5-6) and major
  bleeding rare (1-2)
• 50 of LMWH group never hospitalized
• Levine, et al. NEJM 1996 334677-81

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How Would You Treat These Patients With New
Proximal DVT?

• 43 y/o truck driver whose husband is a nurse
• 68 y/o man 3 weeks s/p TKR who was participating
  in rehab program 3X/week
• 75 y/o woman with metastatic ovarian cancer who
  is non-communicative after CVA 2 yrs ago and has
  no advance directives

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Determinants of Decision-Making

• Evidence
• clinical evidence from patient
• best available external evidence
• systematic research
• pathophysiology
• local experts
• Values
• your patients
• your own

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So We Discovered . . .

• All Evidence
• IS NOT
• Created Equal

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So We Discovered . . .

• Evidence Alone
• NEVER
• Makes Clinical Decisions

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So We Discovered . . .

• Values
• ALWAYS
• Influence Decisions

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So We Discovered . . .

• Evidence
• NEVER
• Eliminates Uncertainty

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The Futile Search for Certainty
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And, We Discovered . . .

• We Should
• Make This Process
• EXPLICIT

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EBM What it is

• Evidence-Based Medicine is the conscientious,
  explicit, and judicious use of current best
  evidence in making decisions about the care of
  individual patients.
• Practice of evidence-based medicine means
  integrating individual clinical expertise with
  the best available external clinical evidence
  from systematic research.
• EBM What it is and what it isnt. Br Med J
  1996 31271-72

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EBM What it is

• Evidence-Based Medicine is the conscientious,
  explicit, and judicious use of current best
  evidence in making decisions about the care of
  individual patients.
• Practice of evidence-based medicine means
  integrating individual clinical expertise with
  the best available external clinical evidence
  from systematic research.
• EBM What it is and what it isnt. Br Med J
  1996 31271-72

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EBM What it is

• Evidence-Based Medicine is the conscientious,
  explicit, and judicious use of current best
  evidence in making decisions about the care of
  individual patients.
• Practice of evidence-based medicine means
  integrating individual clinical expertise with
  the best available external clinical evidence
  from systematic research.
• EBM What it is and what it isnt. Br Med J
  1996 31271-72

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EBM What it is

• Evidence-Based Medicine is the conscientious,
  explicit, and judicious use of current best
  evidence in making decisions about the care of
  individual patients.
• Practice of evidence-based medicine means
  integrating individual clinical expertise with
  the best available external clinical evidence
  from systematic research.
• EBM What it is and what it isnt. Br Med J
  1996 31271-72

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EBM What it is

• EBM is the Integration of Best Research Evidence
  with Clinical Expertise and Patient Values.
• How to Practice and Teach EBM, 2nd Edition, 2000
• So, EBM is a Process for Self-Directed Learning
  that Begins with Individual Patient Care Problems

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Evidence-Based Health Care
Best External Evidence
Patient Preferences
Flexible Management Strategies
Establishing Effective Physician-Patient Communica
tion
Patients Clinical Problems
Co-Morbidities
Social Support
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The Teaching Scenario
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EBM Attempts to

• Inspire Us to Conscientiously Pursue Best
  Available Evidence
• Help Us Explicitly Acknowledge the Strengths
  Limitations of Evidence that Influence Our
  Decisions
• Motivate Us to Tackle the Difficult Judgements
  for Individual Patients that We Must Make
• Empower Us to Keep Up-to-Date and Maintain Our
  Autonomy

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So Where to Now?

• Hone Your Own Basic EBM Skills to Question,
  Search, Appraise, and Make Judgements
• Explicitly Wrestle with Components of Clinical
  Decision-making Think Out Loud
• Integrate External Evidence with Your Other
  Professional Tools
• Role-Model EBM as a Fun Process for Self-
  Directed Learning
• Cultivate Curiosity
• Be Fearless . . . And Wise

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Be Observant
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Avoid Misadventures
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Equip Yourself
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Where Our Road Took Us

• Patient Care Clarifies EBM
• Strong Research Evidence Dogmatism
• Non-MedLine Resources Are Valuable

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The Obvious
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The Obvious

• Listen
• Diagnose the Learners Needs
• Assess the Learners EBM Readiness
• Exploit the Opportunity . . . Not the Learner

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Common Pitfalls
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Common Pitfalls

• Biting Off More Than You Can Chew

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Successful Strategies
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Users Guides Series in JAMA(Evidence-Based
Medicine Working Group)

• Are the Results Valid?
• Are the Results Important?
• Will the Results Help Me Care for My Patients?

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Evidence-Based Medicine

• Essential EBM Skills
• 1) Focus Clinical Questions
• 2) Efficient Information Retrieval
• 3) Appraise Information
• 4) Apply to Patient

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Todays Road Map

• Patient Care Clarifies the Practice of EBM
• Revisit Your Needs / Challenges
• Where to From Here?

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Where Our Road Took Us

• Patient Care Clarifies EBM
• Strong Research Evidence Dogmatism
• Where to From Here?

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So Where to Now?

• Cultivate Curiosity
• Carefully Select When to Pursue Best Evidence
• Hone Your Basic EBM Skills
• Focusing Clinical Questions
• Efficient Searching
• Critical Appraisal
• Make Judgements about Applicability
• Explicitly Wrestle with the Components of
  Clinical Decision-making Think Out Loud