Teaching EBM in a Clinical Setting Andrew P.J. Olson, MD, FAAP Assistant Professor Medicine and Pediatrics

You are on rounds and want to talk about the evidence… How might appraisal of the evidence differ between these learners? Third year medical student Intern Third year resident -Ensure learners look up evidence for specific patients by generating a good clinical question.  This makes the use of EBM seem much more than an exercise. -Make an attempt to give learners the evidence you are using in a specific situation and celebrate when they bring up evidence we aren't familiar with.  For example, when a third year student wants to transfuse to a hgb of 9, present an article showing this not to superior in studies to a threshold of 7. -Acknowledge when the evidence stops and when experience and n of 1 studies may play a role.

Developing knowledge Review articles or point-of-care resources Evaluate for bias Expert opinion Key or landmark studies Identify major gaps in the literature Diuretics must improve mortality in CHF, right?

Developing a good clinical question Start with a real patient and a real question Time spent developing the question will make this more productive for the learner. Model building a question for your team -Ensure learners look up evidence for specific patients by generating a good clinical question.  This makes the use of EBM seem much more than an exercise. -Make an attempt to give learners the evidence you are using in a specific situation and celebrate when they bring up evidence we aren't familiar with.  For example, when a third year student wants to transfuse to a hgb of 9, present an article showing this not to superior in studies to a threshold of 7. -Acknowledge when the evidence stops and when experience and n of 1 studies may play a role.

Let’s treat pneumonia What causes pneumonia in three year olds? What antibiotics should we use for this patient with pneumonia? Is ampicillin as effective as cephalosporins for pneumonia? Is ampicillin as effective as cephalosporins for community acquired pneumonia in three year olds? Is a two week course of antibiotics more effective than one week for community acquired pneumonia in three year olds?

Making sure we’re asking the same question… PICOTS Population Intervention Comparison Outcome Timing Setting

Educational Prescription There are many clinical questions that come up each day and we often think, “I really should look that up!” Making this a deliberate practice for all members of the team is helpful. Using an educational prescription (include yourself) is an effective method of ensuring follow through.

Ensure prescriptions get filled

Teachable Moments When something should work, but doesn’t, and you know why, this is an EBM moment: Most students will want to transfuse patients with upper gastrointestinal bleeding before their hemoglobin gets below 7 In fact, this makes sense, doesn’t it?

Celebrate learners as teachers

Much (most?) of what you do is not evidence based! Acknowledge when there isn’t evidence Be explicit when your patient wouldn’t be in the study Most trials of pneumonia treatment don’t include patients on dialysis with end-stage liver disease What is the role of experience? Be careful to stay alert to your practice becoming out of date

Make it practical There is little time, patience, or energy for powerpoint presentations on the ward. Take moments out of rounds to talk about the evidence but don’t make it onerous Take the onus on you if the team is busy

Thank you!