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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 ... – PowerPoint PPT presentation

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Title:


1
  • Where is the wisdom we have lost in knowledge,
  • and where is the knowledge we have lost in
    information.
  • T S Eliot

2
Evidence-Based MedicineShould We Stop the
Madness?
  • Mark C. Wilson, M.D., M.P.H.
  • Wake Forest University School of Medicine

3
Reason for Healthy Skepticism
4
Whats Irritating AboutEvidence-Based
Medicine?
5
Why EBM Chafes
  • Arrogant Posture
  • to publish the gold that intellectually intense
    processes will mine from the ore of 100 of the
    worlds top journals
  • Elitism
  • how dare you insinuate Im a bad doc
  • Unfamiliar Trendy Terminology
  • Threatens the Art of Medicine
  • Best Evidence Frequently Incomplete/Contradictory

6
Initial Evidence-Based Resources
  • Secondary Publications
  • ACPJC EBM

7
Explosion of Evidence-Based Stuff
  • Secondary Publications
  • ACPJC EBM
  • Evidence-Based Cardiovascular Medicine
  • Evidence-Based Nursing
  • Evidence-Based Mental Health
  • Evidence-Based Health Policy and Management

8
Isnt This Getting Out of Control???
  • Secondary Publications
  • ACPJC EBM
  • Evidence-Based Cardiovascular Medicine
  • Evidence-Based Nursing
  • Evidence-Based Mental Health
  • Evidence-Based Health Policy and Management
  • New Series
  • Evidence-Based Critical Care
  • Evidence-Based Emergency Medicine

9
Evidence-Based is EVERYWHERE
  • Evidence-Based Patient Information
  • Evidence-Based Patient Choice
  • Evidence-Based Sports Medicine
  • Evidence-Based Outpatient Dermatology
  • Evidence-Based Dental Care
  • Evidence-Based Chiropractic Care
  • Evidence-Based Alternative Medicine
  • Evidence-Based Veterinarian Practice

10
Todays Road Map
  • Evolution of EBM
  • Patients Clarify EBMs Place
  • EBM An Imperfect Label
  • Where to From Here?

11
Its a Paradigm Shift
  • When defects in an existing paradigm accumulate
    to the extent that the paradigm is no longer
    tenable, the paradigm is challenged and replaced
    by a new way of looking at the world
  • A new paradigm for medical practice is emerging
  • Evidence-based medicine requires new skills of
    the physician
  • JAMA 1992 2682420-5

12
Evidence Based Medicine
  • Clinical intuition, unsystematic experience,
    pathophysiologic rationale

Evidence from clinical research
13
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?

14
Other Emerging EBM Descriptors
  • Evangelism
  • By
  • Messiah

15
Routine Concerns about EBM
  • Old Hat
  • Ivory Tower Exercise
  • Wont Vanquish Uncertainty Thus Paralyzing
  • Fixed Cookbook Approach
  • A Tool for Cost Cutters
  • Just about RCTs Statistics

16
EBM A Hierarchy of Evidence
  • N-of-1 Trials
  • Meta-Analysis of Homogeneous RCTs
  • Single RCT
  • Cohort Study
  • Case-Control Study
  • Case Series
  • Individual Clinical Experience

17
Remember ...
  • Whenever You Get Confused,
  • Start Back with the Patient

18
Patients with New Proximal DVTs
  • What Are Your Current Practice Patterns?

19
Where Would You Turn for Quick High Quality
Evidence?
  • MKSAP
  • SAM-CD
  • Up to Date
  • Best Evidence

20
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

21
How Would You Treat These Patients With Newly
Diagnosed 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

22
So we discovered that ...
  • Evidence Alone
  • Never
  • Makes Clinical Decisions

23
Determinants of Decision-Making
  • Evidence
  • clinical evidence from patient
  • best available external evidence
  • systematic research
  • pathophysiology
  • local experts
  • Values
  • your patients
  • your own

24
Lots of Decisions Are Lacedwith Uncertainty ...
25
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

26
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

27
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

28
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

29
Problems in the Evidence of EBM
  • Major Constraints in Best Available Evidence to
    Help Care for Individual Patients
  • Implying that a Specific Collection of Evidence
    is the Best Available Sets Stage for Abuses by
    Guideline Makers and Health Systems
  • EBM Places Excess Emphasis on Gathering RCTs and
    Doing Meta-analyses
  • EBM Advocates De-emphasize Soft Data
  • Am J Med 1997 103529-35

30
Is Life Too Short For EBM?
  • YES!
  • Excessively Emphasizes Biomedical Model of
    Decision-Making
  • Insufficient to Explain All that Occurs in a
    Doctor-Patient Relationship
  • Editorial, Internal Medicine News, 10/98

31
Is Life Too Short For EBM?
  • NO!
  • Its Empowering
  • Its a Challenging Form of Self-Directed Learning
  • Its Fun
  • Editorial, Internal Medicine News 10/98

32
Perhaps EBM is a Concept/Paradigm with an
Imperfect Label
  • Consider the Perspectives of the 3 Blind Men
    Encountering the Elephant of Individualized
    Clinical Decision Making
  • Theres No Better Name at Present
  • So lets just get on with our work of seeking
    to integrate external evidence with our other
    professional tools

33
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
34
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

35
Much Work Still to Do
  • EBM is Still in its Infancy
  • EBM is Not a Panacea

36
Much Work Still to Do
  • EBM is Still in its Infancy
  • EBM is Not a Panacea
  • But the process of EBM is quite appealing on
    multiple levels

37
So Where to Now?
38
So Where to Now?
  • Cultivate Curiosity

39
So Where to Now?
  • Cultivate Curiosity
  • Carefully Select When to Pursue Best Evidence

40
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

41
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

42
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
  • Have FUN!!!

43
Where Our Road Took Us
  • Evolution of EBM
  • Patients Clarify EBMs Place
  • EBM An Imperfect Label
  • Where to From Here?

44
  • Where is the wisdom we have lost in knowledge,
    and where is the knowledge we have lost in
    information.
  • T S Eliot

45
EBM Will It Really Ever Matter?
46
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47
Cochrane Collaboration
  • International, volunteer initiative to evaluate
    healthcare interventions.
  • Collaboration works to prepare, disseminate, and
    continuously update systematic reviews of
    controlled trials for specific patient problems.
  • Concerns include
  • meta-analysis -philia
  • quality control nightmare
  • poised for abuse by labeling best evidence
  • diverts clinical researchers from original
    research

48
(No Transcript)
49
Reason for Healthy Skepticism
50
Evidence-Based Medicine
  • Essential EBM Skills
  • 1) Focus Clinical Questions
  • 2) Efficient Information Retrieval
  • 3) Appraise Information
  • 4) Apply to Patient

51
The Practice of EBM Requires
  • Life-long, self-directed learning skills when
    caring for patients that creates the need for
    specific types of information about clinical
    issues.

52
Evidence-Based MedicineAn Imperfect Label
  • Mark C. Wilson, M.D., M.P.H.
  • Wake Forest University School of Medicine
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