1. EBM In Residency
Training
Dr. Imad Salah Ahmed Hassan MD (UK) FACP FRCPI MSc MBBS
Chairman, Knowledge Translation Committee
Department of Medicine, KAMC,KSA
3. Objectives
Why do we need to include EBM in
Residents Education Curricula
Prerequisites for a successful program
Practical Examples
Assessment
4. Information Gap
We need evidence (about the accuracy of
diagnostic tests, the power of prognostic
markers, and the comparative efficacy and
safety of interventions, etc.) about 5 times
for every in-patient and twice for every 3
outpatients. – David Sackett, M.D.
IT HAPPENS FOR EVERYONE !!!!!!!!
4
5. Green ML. Evidence-based medicine training in internal medicine residency programs a
national survey. J Gen Intern Med. 2000 Feb;15(2):129-33. Free PMC Article
6. Why Evidence-based Practice?
Improves the quality of patient care
Standardizes the delivery of healthcare
Reduces the expense of healthcare
Incorporates patient values into healthcare
decisions
Bridging the Gaps
Knowledge
Practice
Resources
Expenditure
6
7. Why Evidence-based Practice?
Essential component of Outcome-based,
Competency-focused Training
OUTCOME-BASED
MEDICAL TRAINING:
HAVING THE END PRODUCT
IN MIND
7
8. How is the world making better doctors?
‘Scottish Doctor’
‘Tomorrow’s Doctor’
‘Good Medical Practice’
CanMEDS 2000
World Federation for Medical Education
Accreditation Council for Graduate Medical Education
WHO/EMRO
Gulf Cooperation Council
Institute for International Medical Education
Association of American Medical Colleges
10. What is Competency?
Is a standardized requirement for an
individual to properly perform a specific job.
It encompasses a combination of knowledge,
skills and attitude (behavior) utilized to
improve performance.
More generally, competency is the state or
quality of being adequately or well qualified,
having the ability to perform a specific role.
16. Barriers to the Practice of EBM
(Physicians in Training)
Access to electronic information resources
Skills in searching information resources
Clinical question tracking
Time
Clinical question priority
Personal initiative
Team dynamics
Green ML and Ruff TR
Acad Med 2005: 80(2);
Institutional culture
176.
16
17. Health Care Model: Donabedian
Model
Anatomy
Care
Process
Structure
Process
•Staff
•Departments
•Equipment
•Supplies
•Environment
Outcome
•Pathways
•Protocols
•Physician
orders
•Nursing Care
•Housekeeping
•Transport
Six Ds:
Death
Disease
Disability
Discomfort
Dissatisfaction
Destitution
(cost)
18. Health Care Model: Donabedian
Model
Anatomy
Care
Process
Structure
Process
•EBM Skilled
Faculty
•Access to
Medical
Information
•Medical
Education
Department
•EBM Rotation
•Regular Educational
Prescriptions Activity
•PICO Exercises
•5As in Journal Club,
Morning Meetings and
Ward Rounds
•Computer Lab
Training Sessions
•Developing Evidencebased Policies,
Pathways and
Guidelines
Outcome
Six Ds:
Death
Disease
Disability
Discomfort
Dissatisfaction
Destitution
(cost)
19. Health Care Model: Donabedian
Model
Anatomy
Care
Process
Structure
Process
•EBM Skilled
Faculty
•Access to
Medical
Information
•Medical
Education
Department
•EBM Rotation
•Regular Educational
Prescriptions Activity
•PICO Exercises
•5As in Journal Club,
Morning Meetings and
Ward Rounds
•Computer Lab
Training Sessions
•Developing Evidencebased Policies,
Pathways and
Guidelines
Outcome
EBM
Competency
20. Necessary Structures
•
•
EBM Skilled Faculty
Access to Medical Information
•
Telephone Hotline, Intranet and Internet access, Wellstocked Medical Library, Personal Digital Assistant/
Pocket PCs etc.
Educational materials: Memos, letters, electronic
reminders (emails, discussion groups, internet
sites/links).
Education Department
Both Junior and Senior staff training
Educationalists members
21. Necessary Processes: Knowledge
& Skills
EBM Education (Knowledge)
EBM Rotation
Regular Educational Prescriptions Activity
PICO Exercises
5As in Journal Club, Morning Meetings, M&M meetings
and Ward Rounds
Training in using Point-of-Care Resources
Computer Lab Training Sessions
Training in Developing Evidence-based Policies,
Pathways, Protocols, Order-sets and Guidelines
22. Necessary Processes
EBM Education (Knowledge)
EBM Rotation
Description and evaluation of an EBM curriculum using a block rotation.
Thom DH, Haugen J, Sommers PS, Lovett P. BMC Med Educ. 2004 Oct 11;4:19.
Free PMC Article
Integrating an evidence-based medicine rotation into an internal medicine
residency program.
Akl EA, Izuchukwu IS, El-Dika S, Fritsche L, Kunz R, Schünemann HJ.
Acad Med. 2004 Sep;79(9):897-904.
23. Description and evaluation of an EBM curriculum using a block rotation.
Thom DH, Haugen J, Sommers PS, Lovett P. BMC Med Educ. 2004 Oct 11;4:19.
24. Necessary Processes
•
Regular Educational Prescriptions
Activity
What is an educational prescription?
It specifies the clinical problem that generated the question.
It states the PICO question, in all of its key elements.
It specifies who is responsible for answering it.
It reminds everyone of the deadline for answering it (taking
into account the urgency of the clinical problem that
generated it).
Finally, it reminds everyone of the steps of searching,
critically appraising and relating the answer back to the
patient.
25. Educational Prescription
Patient’s Name
Learner:
3-part Clinical Question
Problem/Target Disorder:
Intervention (+/- comparison):
Outcome:
Date and place to be filled:
Presentations will cover:
search strategy;
search results;
the validity of this evidence;
the importance of this valid evidence;
can this valid, important evidence be applied to your patient;
your evaluation of this process.
27. Necessary Processes
•
5As in Journal Club, Morning Meetings,
M&M meetings and Ward Rounds
Mixing it up: integrating evidence-based medicine and patient care.
Korenstein D, Dunn A, McGinn T. Acad Med. 2002;77(7):741-2.
28. Clinical Query: EBM Approach
Ask clinical
Acquire the
questions
best evidence
Assess
effectiveness,
efficiency of
EBM process
5A’s !!
Appraise
the evidence
Apply
evidence to
Your patient
30. EBM in the Ward Round
What is EB ward rounds?
Why is it important?
How is it different form our usual way of
doing ward rounds?
How is it done?
What do you need to do it?
31. What is an Evidence-based Ward
Rounds?
All diagnostic, therapeutic and prognostic
decisions are evidence-based.
Clinically relevant questions that arise while
seeing patients are being answered after a
quick literature search whenever possible.
The number of questions may go up to few
questions per patients, or none.
It should also take into account patient’s values
and preferences.
32. What is an Evidence-based Ward
Rounds?
Asking questions
Acquiring literature
Appraising evidence
Applying findings
All EBM steps
Evidence-based Medicine
33. What is an Evidence-based Ward
Rounds?
Clinical problem
Traditional
ward round
Expertise,
Experience &
Pathophysiology
Decision making
about diagnosis
& treatment
34. What is an Evidence-based Ward
Rounds?
Clinical problem
Traditional
ward round
Decision making
about diagnosis
& treatment
Expertise,
Experience &
Pathophysiology
Ask answerable
questions
EB ward round
Acquire relevant
articles
Appraisal of
evidence
35. Exercises in the Ward Round
(Also possible in the Morning Meeting)
Use of point of care resources:
Literature Searching
Decision Support tools: Calculators (physiological, risk, severity
etc), Online Clinical Pathways/Flow charts etc
Shared Decision Making/Patient Education Tools
Use of educational prescriptions
Exercises on critical appraisal
Evidence–based clinical examination (using resources
such as The Rational Clinical Examination textbook)
Evidence-based appropriate tests and therapeutic
interventions are then demonstrated.
36. Exercises in the Ward Round
(Also possible in the Morning Meeting)
Relevant concepts in EBM like SpPin, SnNout,
Likelihood Ratios, NNT, NNH etc are explained pertinent
to the case.
Appraisal home works
Process Change Skills training/Quality Improvements
Having a librarian is extremely useful.
37. EBM in the Ward Round
Bed-side Literature Searching:
Clinical Knowledge Summaries (CKS) :National
Library for Health: http://cks.library.nhs.uk/
DynaMed: http://www.dynamicmedical.com/
Essential Evidence Plus (formerly InfoRetriever)
http://www.essentialevidenceplus.com/
First Consult: http://www.firstconsult.com/
UpToDate: http://www.uptodate.com/
Clinical Evidence
http://clinicalevidence.bmj.com/ceweb/index.jsp
ACP PIERS pier. http://pier.acponline.org/index.html
38. Educational Prescription
Patient’s Name
Learner:
3-part Clinical Question
Problem/Target Disorder:
Intervention (+/- comparison):
Outcome:
Date and place to be filled:
Presentations will cover:
search strategy;
search results;
the validity of this evidence;
the importance of this valid evidence;
can this valid, important evidence be applied to your patient;
your evaluation of this process.
44. EBM in the Ward Round
Handheld ultrasound, B-natriuretic peptide for screening stage B heart
failure. Hebert K, Horswell R, Heidenreich P, Miranda J, Arcement L.
South Med J; 2010 Jul ; 103(7):616-22. PubMed ID: 20531053
[TBL] [Abstract] [Full Text] [Related]
45. EBM in the Ward Round
Decision Support Systems
Evidence-based Scoring Systems:
Stroke: CHADS2, NIH Stroke Score
Pulmonary Embolism: Well’s
Cardiac Events
Statin Indications
Pneumonia Severity
Fracture Risk
46. EBM in the Ward Round
Decision Support Systems
Uptodate
Calculator: Ranson criteria for pancreatitis prognosis
Calculator: Blatchford score for gastrointestinal bleeding
Calculator: Rockall score for upper gastrointestinal
bleeding
Calculator: Crohn's disease activity index (CDAI)
Calculator: Mayo score for assessing ulcerative colitis
activity
47. EBM in the Ward Round
Decision Support Systems
Uptodate
Calculator: Bedside index of severity in acute
pancreatitis (BISAP) score
Calculator: Harvey-Bradshaw index of Crohn's disease
activity
Calculator: Glasgow alcoholic hepatitis score
Calculator: Hepatitis discriminant function for
corticosteroid rx in alcoholic hepatitis
Calculator: Child Pugh classification for severity of liver
disease (SI units)
48. EBM in the Ward Round
Decision Support Systems
Isabel http://www.isabelhealthcare.com/home/default
Open Clinical http://www.openclinical.org/dss.html
DXplain http://dxplain.org/dxp/dxp.pl
Medical Calculators
http://easycalculation.com/medical/medical.php
Skyscape: http://www.skyscape.com/archimedesonline/archimede
sindex.aspx
Emergency Medicine on the Web: http://www.ncemi.org/
MedicineWorld.Org: http://medicineworld.org/online-medicalcalculators.html
Clinical Decision Making
Calculators: ttp://www.fammed.ouhsc.edu/robhamm/cdmcalc.htm
50. Structure of JC
Clinical Query: Foreground Question
PICO
Article Selection: Searching for Evidence/Literature Search
Appraising the Evidence: Critical Appraisal
Presentation
Critique and summary
Recommendations:
New research
Change or audit of current practice
Writing a letter to the editor
Publishing your appraisal in a CAT journal or website
(own or in the WWW)
51. Computer Lab Training Sessions
Literature searching skills
Scope of Resources
Point of Care Clinical Resources
Up-Dates & New Evidence
Critical Appraisal Tools
Evidence-Based Quality Improvement
Evidence-Based Guidelines, Policies and Protocols
Decision Support Systems
EBM Audiovisual Training
Portals to All
52. EBM Training Assessment
Green ML. Evidence-based medicine training in internal medicine residency programs a national
survey. J Gen Intern Med. 2000 Feb;15(2):129-33. Free PMC Article
54. EBM is here to stay. It has become
an essential way of teaching and
practicing in the uncertain world of
medicine. The challenge is to engage
the whole healthcare team in learning
about it and making it part of the
routine of clinical practice.
Editorial. BMJ 2004;329:989-990
54
Notas del editor
SmartArt custom animation effects: pictures peek-in(Basic)To reproduce the SmartArt effects on this page, do the following:On the Home tab, in the Slides group, click Layout, and then click Blank. On the Insert tab, in the Illustrations group, click SmartArt.In the Choose a SmartArt Graphic dialog box, in the left pane, click Matrix. In the Matrix pane, double-click Titled Matrix (second option from the left) to insert the graphic into the slide. Select the graphic. Under SmartArt Tools, on the Format tab, click Size, and then do the following:In the Height box, enter 5.67”.In the Width box, enter 8.5”.Under SmartArt Tools, on the Format tab, click Arrange, click Align, and then do the following:Click Align to Slide.Click Align Middle. Click Align Center. Select the graphic, and then click one of the arrows on the left border. In the Type your text here dialog box, enter text in the top-level bullet only (text for the rounded rectangle at the center of the graphic). To remove the [Text] placeholder in the second-level bullets, select each bullet and press SPACE.On the slide, select the graphic. Under SmartArtTools, on the Design tab, in the SmartArtStyles group, click More, and then under Best Match for Document click Moderate Effect.Select the rounded rectangle at the center of the graphic. On the Home tab, in the Font group, select 28 from the Font Size list, click the arrow next to Font Color, and then click White, Background 1 (first row, first option from the left).With the rounded rectangle selected, under SmartArtTools, on the Format tab, in the bottom right corner of the ShapeStyles group, click the FormatShape dialog box launcher. In the FormatShape dialog box, click Fill in the left pane, select Gradient fill in the Fill pane, and then do the following:In the Type list, select Linear.In the Direction list, select LinearUp (second row, second option from the left).Under Gradient stops, click Add or Remove until three stops appear in the drop-down list.Also under Gradient stops, customize the gradient stops as follows:Select Stop 1 from the list, and then do the following:In the Stop position box, enter 0%.Click the button next to Color, and then under Theme Colors click White, Background 1, Darker 35% (fifth row, first option from the left).Select Stop 2 from the list, and then do the following: In the Stop position box, enter 80%.Click the button next to Color, and then under Theme Colors click White, Background 1, Darker 35% (fifth row, first option from the left).Select Stop 3 from the list, and then do the following: In the Stop position box, enter 100%.Click the button next to Color, and then under Theme Colors click White, Background 1, Darker 15% (third row, first option from the left).Right-click the top left shape in the graphic, and then click Format Shape. In the Format Shape dialog box, in the left pane, click Fill. In the Fill pane, click Picture or texture fill,and then under Insert from, click File.In the Insert Picture dialog box, select a picture and then click Insert. Right-click the top right shape in the graphic, and then click Format Shape. In the Format Shape dialog box, in the left pane, click Fill. In the Fill pane, click Picture or texture fill,and then under Insert from, click File.In the Insert Picture dialog box, select a picture and then click Insert. Right-click the bottom left shape in the graphic, and then click Format Shape. In the Format Shape dialog box, in the left pane, click Fill. In the Fill pane, click Picture or texture fill,and then under Insert from, click File.In the Insert Picture dialog box, select a picture and then click Insert. Right-click the bottom right shape in the graphic, and then click Format Shape. In the Format Shape dialog box, in the left pane, click Fill. In the Fill pane, click Picture or texture fill,and then under Insert from, click File.In the Insert Picture dialog box, select a picture and then click Insert. To reproduce the animation effects on this slide, do the following:On the Animations tab, in the Animations group, click CustomAnimation.On the slide, select the graphic, and then do the following in the CustomAnimation task pane: Click Add Effect, point to Entrance, and then click MoreEffects. In the Add Entrance Effect dialog box, under Subtle, click Expand. Under Modify: Expand, in the Speed list, select Fast.Under Modify: Expand, in the Start list, select After Previous.Also in the Custom Animation task pane, click the arrow to the right of theanimation effect, and then click EffectOptions. In the Expand dialog box, on the SmartArt Animation tab, in the Group Graphic list, select One by one.Also in the Custom Animation taskpane, click the double-arrow below the animation effect to expand the list of effects, and then do the following:Press and hold CTRL, and then select all five animation effects in the Custom Animation task pane. Under Modify: Expand, in the Start list, select With Previous.Press and hold CTRL, select the second, third, fourth, and fifth animation effects (expand effects for the picture-filled rectangles), and then do the following:Click Change, point to Entrance, and then click MoreEffects. In the Change Entrance Effect dialog box, under Basic, click Peek In. Under Modify: Peek In, in the Speed list, select Fast.Select the second animation effect. Under Modify: Peek In, in the Start list, select After Previous.Select the third animation effect. Under Modify: Peek In, in the Direction list, select From Left.Select the fourth animation effect. Under Modify: Peek In, in the Direction list, select From Right.Select the fifth animation effect. Under Modify: Peek In, in the Direction list, select From Top.To reproduce the background effects on this slide, do the following:Right-click the slide background area, and then click Format Background. In the Format Background dialog box, click Fill in the left pane, select Gradient fill in the Fill pane, and then do the following:In the Type list, select Radial.Click the button next to Direction, and then click From Corner (fifth option from the left).Under Gradient stops, click Add or Remove until two stops appear in the drop-down list.Also under Gradient stops, customize the gradient stops as follows:Select Stop 1 from the list, and then do the following:In the Stop position box, enter 0%.Click the button next to Color, and then under Theme Colors click White, Background 1 (first row, first option from the left).Select Stop 2 from the list, and then do the following: In the Stop position box, enter 71%.Click the button next to Color, and then under Theme Colors click White, Background 1, Darker 15% (third row, first option from the left).