https://www.columbiameded.com/penntalk/ Drinking From the Firehose How to keep up with the medical literature while working 80 hours a week. William Fuller, MD Instructor in Medicine Columbia University Medical Center

Some frequently asked questions… Q: Don’t you have other people to bother now? A: Ohhhh they’re getting it. Q: Is Hari really this desperate to avoid putting together another case conference? A: Yes. Yes he is. Q: But seriously, why are you here to talk about EBM? You may know me from my moderately respected blog… Also a member of the SGIM EBM Group Creator of the SGIM Bottom Line Podcast NOT an epidemiologist or statistician. Some frequently asked questions…

What is Evidence Based Medicine? EBM is not: Dropping names of articles to sound smart on rounds Bullying colleagues with citations Telling your patient she needs a statin because your risk calculator says so Telling doctors how they must practice medicine EBM is: Understanding why we think we know what we know Understanding the limitations of our knowledge and how we approach those limitations Talking to patients about why we recommend what we do “Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” What is Evidence Based Medicine? Sackett David L, Rosenberg William M C, Gray J A Muir, Haynes R Brian, Richardson W Scott. Evidence based medicine: what it is and what it isn't BMJ 1996; 312 :71

“You’re doing well. Read more.” -Literally Every Attending Problems More material published than a human could ever read In 1996, a general internist would have had to read 19 articles daily (ibid) Much of the literature has methodologic or analytic flaws Papers are really, really boring Like, aggressively boring “You’re doing well. Read more.” -Literally Every Attending

Explore strategies for learning the evidence that underlies medical decision making and methods of keeping track of what we’ve read Practice an analytic approach to a randomized clinical trial Review how to apply evidence to, and discuss said application with, patients Learning Objectives

What to read? Can’t someone do this for me? ACP Journal Club/Internist Weekly NEJM JournalWatch SGIM Bottom Line Summaries Subspecialty Journals Blogs/Podcasts More esoteric specialties are more limited No guarantee that they are selecting the articles most relevant to you If you’re going to stake patient outcomes on trial data, you should probably have read the trial Consider table of contents from major journals What to read?

How to read? Multiple levels of intensity Think of a patient General interest Abstract, discussion/conclusion, editorial/letters Practice-changing Above, plus PICO analysis Generating expertise Above, plus exploration of statistical methods, exploration of background studies, metanalyses, conflicting trials Think of a patient Write as you go How to read? Pain E, How to (seriously) read a scientific paper. Science Magazine, 03/2017, https://www.sciencemag.org/careers/2016/03/how-seriously-read-scientific-paper.

Bookmarking

Put 30 Minutes on the Clock Krebs EE et al., Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial. JAMA. 2018;319(9):872-882. doi:10.1001/jama.2018.0899 Go to https://www.columbiameded.com/penntalk/ for a PDF.

Patients Are the inclusion and exclusion criteria reasonable? Does the population studied represent the patients you care for? Are there unmeasured confounders? Is the NNT artificially low due to a very sick population? Patients

Interventions Is this a fair representation of clinical practice? Does this require me to stop other therapies? Interventions

Are the patients in the trial on the therapies you would already have prescribed them? Is the comparison group receiving the current standard of care? Is there a well-conceived method of blinding/placebo? Comparator

Outcomes Do patients care about the outcome in question? Is the outcome in the placebo group consistent with prior trials? What is the number needed to treat/absolute risk reduction? Are adverse events counted fairly? Do the authors seek to minimize their importance? P < 0.05 only means P < 0.05 Outcomes Ioannidis JPA. The Proposal to Lower P Value Thresholds to .005. JAMA. 2018;319(14):1429–1430. doi:10.1001/jama.2018.1536

Next steps Look at articles cited, especially in the discussion Read medical news/lay press writeups Ask your colleagues what they think Read the supplementary appendix Next steps

How can I talk about evidence with my patients? 9/10 patients want to be presented with options and have both risks and benefits discussed; fewer than 50% report such communication. “When you and your doctor sit down to talk about what tests or treatments to do, the conversation should involve the best medical evidence. But the research is constantly changing as we learn more, so the recommendations may change over time, too. As new treatments are developed, they are compared to the ones that exist today to determine if they’re really better. This is all part of the process of continuously improving our health care choices.” Reasonable people may decline an indicated therapy. How can I talk about evidence with my patients? Alston C et al., Communicating with Patients on Healthcare Evidence. IOM Roundtable on Value & Science-Driven Health Care, 09/2012. https://nam.edu/wp-content/uploads/2015/06/VSRT-Evidence.pdf

Explore strategies for learning the evidence that underlies medical decision making and methods of keeping track of what we’ve read Practice an analytic approach to a randomized clinical trial Review how to apply evidence to, and discuss said application with, patients Learning Objectives