2. Lets shake & Break Ice
• STEP – 1, Introductions & Opinions
• Those FOR EBM
• Those AGAINST EBM
• No NEUTRALS Allowed

3. Program Today
Time Slot Activity
10:30 – 11:00 Introductions, Ice-Breaking, Review of
Objectives & Expectations, Code of
Conduct, Basic Definitions Review
11:00 – 12:00 Role Play Activity – EBM or NOT
12:00 – 12:30 The New Hierarchy of Medical Education &
Profession
12:30 – 2:00 Break for Jumm’a Prayer
2:00 – 3:00 Real Life EBM in Abbottabad
3:00 – 4:00 EBM or NOT – Future Implications

5. Best teachers do not make new
knowledge
They let you realize what you already
know and do not know

6. OBJECTIVES
Participants will achieve:
• A midlevel understanding about their own
beliefs in applying EBM in medical education
• Graduate level confidence when discussing
EBM in national international medical circles
• Faculty level competence when teaching pros
and cons of EBM to their students
• An appreciation for the “Method of EBM”
already existing in their practices

9. EBM - ORIGINS
• In 1996 David Sackett wrote that "Evidence-
based medicine is the conscientious, explicit
and judicious use of current best evidence in
making decisions about the care of individual
patients”
• Adopted by major organizations, including
the Cochrane Collaboration and the Centre for
Evidence Based Medicine

10. EBM - BASICS
• Trisha Greenhalgh and Anna Donald define it
more specifically as
• “The use of mathematical estimates of the risk
of benefit and harm, derived from high-quality
research on population samples, to inform
clinical decision-making in the diagnosis,
investigation or management of individual
patients."

11. References
• Sackett DL, Rosenberg WM, Gray JA, Haynes RB,
Richardson WS (January 1996). "Evidence based
medicine: what it is and what it isn't". BMJ 312 (7023):
71–2.PMC2349778. PMID 8555924.
• Timmermans S, Mauck A (2005). "The promises and
pitfalls of evidence-based medicine". Health Aff
(Millwood)24 (1): 18-28. doi:
10.1377/hlthaff.24.1.18.PMID15647212.
• Greenhalgh, Trisha. How To Read a Paper: The Basics of
Evidence-Based Medicine. Wiley-Blackwell, fourth
edition, 2010, p. 1

12. First, Do No Harm!
• EBM seeks to assess the strength of the
evidence of risks and benefits
of treatments (including lack of treatment)
and diagnostic tests. This helps clinicians
predict whether a treatment will do more
good than harm
• Elstein AS (2004). "On the origins and development of evidence-based
medicine and medical decision making". Inflamm. Res. 53 (Suppl 2):
S184–9. doi:10.1007/s00011-004-0357-2. PMID 15338074.
• Atkins D, Best D, Briss PA, et al. (2004). "Grading quality of evidence
and strength of recommendations". BMJ 328(7454): 1490

13. QUALITY OF EVIDENCE
• Evidence quality can be assessed based on the
source type
• From meta-analyses and systematic reviews of
triple-blind randomized clinical trials with
concealment of allocation and no attrition at
the top end, down to conventional wisdom at
the bottom

14. QUALITY OF EVIDENCE
• Statistical validity, clinical relevance, currency,
and peer-review acceptance
• EBM recognizes that many aspects of health
care depend on individual factors such
as quality- and value-of-life judgments, which
are only partially subject to quantitative
scientific methods.

16. CASE - 1
• You are seeing an 18 year old female patient
in your private clinic. She is recently diagnosed
with acute cholecystitis. This is the third time
she has had this problem.
• How will you proceed with her investigations?
• What relevant screenings will you perform at
this point?
• What is the best treatment option?

17. CASE-2
• You are seeing a 28 year old female patient in
your private clinic. She is recently diagnosed
with acute cholecystitis. This is the third time
she has had this problem.
• During the history she tells you that her
mother, maternal grand mother and a
maternal aunt died of breast cancer.
• She mentions her fear of developing this
disease as well

18. CASE – 2 (cont.)
• How will you proceed with her investigations?
• What other screenings will you perform at this
point?
• What is the best treatment option?
• Self breast exam teaching
• Annual mammography after age 40 years
• BRCA GENE STATUS

19. CASE - 3
• You are seeing a 38 year old female patient in
your private clinic. She is recently diagnosed
with acute cholecystitis. This is the third time
she has had this problem.
• During the history she tells you that her
mother, maternal grand mother and a
maternal aunt died of breast cancer.
• She has recently had a breast lump biopsied.
She is very anxious about her future.

20. CASE – 3, (cont.)
• How will you proceed with her investigations?
• What other screenings will you perform at this
point?
• What is the best treatment option?
• Self breast exam teaching
• Annual mammography after age 40 years
• BRCA GENE STATUS
• ER/PR Status of Breast biopsy

22. FIVE STEPS OF EBM
1. Translation of uncertainty to an answerable question and includes
critical questioning, study design and levels of evidence
2. Systematic retrieval of best evidence available
3. Critical appraisal of evidence for internal validity that can be broken
down into aspects regarding:
 Systematic errors as a result of selection bias, information bias and
confounding
 Quantitative aspects of diagnosis and treatment effect
 Size and aspects regarding its precision
 Clinical importance of results
 External validity or generalizability
4. Application of results in practice
5. Evaluation of performance

23. COCHRANE COLLABORATION
• The systematic review of published research studies is
a major method used for evaluating particular
treatments. The XXX is one of the best-known,
respected examples of systematic reviews. Like other
collections of systematic reviews, it requires authors to
provide a detailed and repeatable plan of their
literature search and evaluations of the evidence.
• Once all the best evidence is assessed, treatment is
categorized as "likely to be beneficial", "likely to be
harmful", or "evidence did not support either benefit
or harm".

24. REFERENCES
• Cook DJ, Jaeschke R, Guyatt GH (1992). "Critical appraisal of therapeutic
interventions in the intensive care unit: human monoclonal antibody treatment in
sepsis. Journal Club of the Hamilton Regional Critical Care Group".J Intensive Care
Med 7 (6): 275–82. PMID 10147956
• Dawes M, Summerskill W, Glasziou P, et al. (January 2005). "Sicily statement on
evidence-based practice".BMC Med Educ 5 (1): 1. doi:10.1186/1472-6920-5-
1.PMC 544887. PMID 15634359. Archivedfrom the original on 2011-02-17.
• Richardson WS, Wilson MC, Nishikawa J, Hayward RS (1995). "The well-built clinical
question: a key to evidence-based decisions". ACP J. Club 123 (3): A12–3.PMID
7582737
• Rosenberg WM, Deeks J, Lusher A, Snowball R, Dooley G, Sackett D (1998).
"Improving searching skills and evidence retrieval". J R Coll Physicians Lond 32 (6):
557–63.PMID9881313
• Parkes J, Hyde C, Deeks J, Milne R (2001). "Teaching critical appraisal skills in health
care settings". Cochrane Database Syst Rev (3):
CD001270.doi:10.1002/14651858.CD001270 PMID 11686986.
• Epling J, Smucny J, Patil A, Tudiver F (October 2002). "Teaching evidence-based
medicine skills through a residency-developed guideline". Fam Med 34 (9): 646–
8.PMID 12455246
• Jamtvedt G, Young JM, Kristoffersen DT, Thomson O'Brien MA, Oxman AD (2003).
"Audit and feedback: effects on professional practice and health care
outcomes". Cochrane Database Syst Rev (3): CD000259

25. “Levels of Evidence” CEBM
• Level A: Consistent Randomised Controlled Clinical
Trial, cohort study, all or none, clinical decision rule
validated in different populations.
• Level B: Consistent Retrospective Cohort, Exploratory
Cohort, Ecological Study, Outcomes Research, case-
control study; or extrapolations from level A studies.
• Level C: Case-series study or extrapolations from level
B studies.
• Level D: Expert opinion without explicit critical
appraisal, or based on physiology, bench research or
first principles

26. U.S. Preventive Services Task Force (August
1989). Guide to clinical preventive services: report of
the U.S. Preventive Services Task Force
• Level I: Evidence obtained from at least one properly
designed randomized controlled trial.
• Level II-1: Evidence obtained from well-designed controlled
trials without randomization.
• Level II-2: Evidence obtained from well-
designed cohort or case-control analytic studies, preferably
from more than one center or research group.
• Level II-3: Evidence obtained from multiple time series with or
without the intervention. Dramatic results in uncontrolled
trials might also be regarded as this type of evidence.
• Level III: Opinions of respected authorities, based on clinical
experience, descriptive studies, or reports of expert
committees

27. Balshem H, Helfand M, Schünemann HJ, et al. (April
2011). "GRADE guidelines: 3. Rating the quality of
evidence". J Clin Epidemiol 64 (4): 401–6.
• The GRADE working group defines 'quality of
evidence' and 'strength of recommendations'
based on the quality as two different concepts
which are commonly confused with each
other.

28. Risk of bias
• Is a judgement made on the basis of the
chance that bias in included studies have
influenced the estimate of effect.

29. Imprecision
• Is a judgement made on the basis of the
chance that the observed estimate of effect
could change completely.

30. Indirectness
• : Is a judgement made on the basis of the
differences in characteristics of how the study
was conducted and how the results are
actually going to be applied.

31. Inconsistency:
• Is a judgement made on the basis of the
variability of results across the included
studies.

32. Publication bias
• Is a judgement made on the basis of the
question whether all the research evidence
has been taken to account

33. Schünemann H, Brożek J, Oxman A,, ed. (2009). [Available
from http://www.cc-ims.net/gradepro GRADE handbook for grading quality
of evidence and strength of recommendation] (Version 3.2 ed.)
• Large effect: This is when methodologically strong
studies show that the observed effect is so large that
the probability of it changing completely is less likely.
• Plausible confounding would change the effect: This is
when despite the presence of a possible confounding
factor which is expected to reduce the observed effect,
the effect estimate still shows significant effect.
• Dose response gradient: This is when the intervention
used becomes more effective with increasing dose.
This suggests that a further increase will likely bring
about more effect.

34. Quality of evidence as per GRADE
• High Quality Evidence: The authors are very confident
that the estimate that is presented lies very close to
the true value. One could interpret it as: there is very
low probability of further research completely
changing the presented conclusions.
• Moderate Quality Evidence: The authors are confident
that the presented estimate lies close to the true value,
but it is also possible that it may be substantially
different. One could also interpret it as: further
research may completely change the conclusions.

35. Quality of evidence as per GRADE
• Low Quality Evidence: The authors are not
confident in the effect estimate and the true
value may be substantially different. One could
interpret it as: further research is likely to change
the presented conclusions completely.
• Very low quality Evidence: The authors do not
have any confidence in the estimate and it is
likely that the true value is substantially different
from it. One could interpret it as: New research
will most probably change the presented
conclusions completely.

36. GRADE USERS
• http://www.gradeworkinggroup.org/society/i
ndex.htm

40. Your distance from light does not
matter in the process of your
enlightenment. You do!