Join the conversation! Our Twitter hashtag is MSE12 Coffee Talks: Bridging Clinical Reasoning with Evidence Based Medicine/Information Mastery STFM Long Beach February 2012 Drs. Todd Felix, Sam Faber, Dave Richard

Objectives 1.Define Clinical Reasoning and how it’s incorporated into teaching conference 2.Electronic Tools; What’s best 3.Highlight Information Mastery via PICO exercise 4.Evaluation Tools; What’s that 5.Putting it all together; Coffee Talks a novel approach at Penn State

Case conference in 3 rd year Family Medicine Clerkship Local students (10 per month) work through cases with Faculty led discussion, highlighting CR skills Clinical questions are searched in small working groups using Evidence-based resources Coffee Talks: Bridging Clinical Reasoning with Information Mastery

Small Group setting with ‘real’ cases yields high buy-in for students Ability to learn a variety of approaches in reasoning and information searching Highlights clinical experiences, collaboration with colleagues, literature review and professionalism in patient care Coffee Talks

Definition; Clinical Reasoning is the application of critical thinking to the formulation of a differential diagnosis, diagnostic evaluation and treatment plan of clinical problems Why do we choose a certain clinical path – what changed as we learned more? Clinical Reasoning

How do we think through the case? 50 yo female with acute onset shortness of breath…… With pleuritic chest pain…. Recent cold symptoms…. Heavy menses… What is important to know? History of asthma, Family history of Factor 5, smoker Clinical Reasoning, Continued

What determines what we ask, examine, order, and/or prescribe for the patient? Pulse ox … Labs normal… What if d dimer positive? CXR interstitial markings bilaterally? At each step, how does this change our differential diagnosis and WHY?? Clinical Reasoning, continued

Information Mastery and Evidence Based Medicine are the tools that access and evaluate the best available external clinical evidence from systematic research in order that it may appropriately inform and guide Clinical Reasoning. Information Mastery/Evidence Based Care

Usefulness=Relevance x Validity/Work Dynamed, Clinical Evidence Essential Evidence ACP Pier, TRIP UP to Date Clinical consult Textbook/ PubMED Adapted from THCI Information Mastery course, Boston, Nov 2010

Topic RangeScore Background 1.Establishes a clear clinical question (+1 point) 2.Properly translates clinical question into PICO format (+1 point) 3.Provides useful background information (+1 point) 0-3 Search Process 1.Discusses search process using appropriate, evidence based resources (+2 points, using at least 2 EBM resources) 2.Reviews strength of recommendation for sources used (+1 point) 0-3 Summary and Recommendations 1.Summarizes findings from evidence reviewed (+1 point) 2.Discusses shortfalls of current available evidence (+1 point) 3.Gives recommendations for clinical practice (+1 point) 0-3 Organization/Deductions 1.Presents information clearly and concisely (+1 point) 2.Late to session (-1point) 3.Powerpoint slides not submitted on time (-1 point) 1 Total Score 10 Adapted THCI Boston Evaluation Tools

The Clinical Question It all starts with a clinical encounter Understanding background and foreground questions. Converting into a PICO format allows for a more specific search, and higher yield answer Students are tackling some of the big questions in medicine……

+ Does mammography screening actually decrease overall mortality in women? Hannah Nam Class of 2012 Penn State College of Medicine

+ Case 50 yo F patient presenting for routine health maintenance visit. She is apprehensive about receiving a mammogram, and wonders how much mammography screening will actually help her to live longer.

+ Current Recommendations US Preventive Services Task Force USPSTF Screening mammograms should be done every two years beginning at age 50 American Cancer Society ACS Screening mammograms should be done every year beginning at age 40

+ PICO Population: Women eligible for screening mammography (>40 yo) Intervention: Mammography Comparison or Gold Standard: Women who have not received a mammography Outcome: Difference in long term morbidity/mortality

+ Cochrane Review 2011 Mammography screening may not decrease overall mortality but is associated with reduced breast cancer mortality (level 2 evidence). No significant difference in overall mortality after 13 years. Relative risk 0.99 (95% CI 0.95 – 1.03). Decreased risk for breast cancer mortality after 13 years. RR 0.81 (95% CI 0.74 – 0.87) Increased risk of lumpectomy / mastectomy in screening group. RR 1.31 (95% CI 1.22 – 1.42)

+ Cochrane Review 2011 Cochrane authors estimated benefit of invitation to regular screening for 10 years to be 0.05% absolute risk reduction for breast cancer mortality (or 1 in 2,000 women), based on expected breast cancer mortality 0.22% over 7 years 15% relative risk reduction (estimate between results of overall meta-analysis and higher quality meta-analysis)

+ Cochrane Review 2011 In other words… For every 2000 women invited for screening throughout 10 years, 1 will have her life prolonged 10 healthy women, who would not have been diagnosed without screening, will be treated unnecessarily More than 200 women will have false positive findings, that lead to psychological distress

+ So in practice… Unclear whether screening mammogram does more benefit then harm. Significant awareness and public education already out there Emotionally charged subject Try to unconvince someone that they need a mammogram? Open discussion with patients needed regarding mammograms Discussion on how this should be implemented?

Thanks for your Attention!!