تصميم‌سازی بالينی الگوهای طبابت دکتر پيام کبيری پزشک، اپيدميولوژيست بالينی رئيس مرکز توسعه و هماهنگی اطلاعات و انتشارات علمی معاونت تحقيقات و فن‌آوری وزارت بهداشت، درمان و آموزش پزشکی

منابع اطلاعاتی دانش پايه (Basic Knowledge) کتاب‌ها (Books) دانش روزآمد (Updated Knowledge) مجلات و نشريات ادواری (Periodicals)

انواع مقالات در علوم پزشکی Original Article Review Article Case Reports Editorial Short Communication (short papers) Letter to Editor مقاله پژوهشی اصيل مقاله مروری مقاله گزارش مورد سرمقاله (سخن سردبير) مقاله کوتاه نامه به سردبير

تصميم‌سازی بالينی، الگوهای طبابت Traditional Medicine Evidence-Based Medicine مدل سنتی مدل مبتنی بر شواهد

EBM تاريخچه G. Guyatt from McMaster University in 90s Sackett in 1995 defined EBM “Our clinical decesion malking should be based on the best scientific avaiabe evidence”

What is Evidence? Evidence is anything used to determine or demonstrate the truth of an assertion. Scientific evidence is evidence which serves to either support or counter a scientific theory or hypothesis. In scientific research evidence is accumulated through observations of phenomena occur in the natural world, or created as experiments in a laboratory

What is ‘level of evidence’? The extent to which one can be confident that an estimate of effect or association is correct (unbiased).

Levels of Evidence Level of Evidence Type of Study 1a 1b 2a 2b 3a 3b 4 Systematic reviews of randomized clinical trials (RCTs) 1b Individual RCTs 2a Systematic reviews of cohort studies 2b Individual cohort studies and low-quality RCTs 3a Systematic reviews of case-controlled studies 3b Individual case-controlled studies 4 Case series and poor-quality cohort and case-control studies 5 Expert opinion based on clinical experience Levels of Evidence To help clinicians critically review the external evidence they locate, Sackett et al. developed a hierarchical model to categorize most studies. It is important to note that these levels of evidence are not a rigid set of rules, but serve only as a set of guidelines for the critical appraisal of the literature. According to Sackett (BMJ 1996;312:71-2), the randomized trial (especially the systematic review of randomized trials) has become the “gold standard” for judging whether or not a particular treatment is beneficial. The practice of evidence-based medicine is not restricted to randomized trials. Studies from other levels may be better meet you needs for information or may be better in terms of quality. For example, although the cohort study design ranked lower than that of the randomized controlled trial, it may be the highest level of evidence (excluding systematic reviews) for other aspects of patient care (e.g., validity of diagnostic tests, assessing prognosis) or when randomized controlled clinical trials cannot be performed due to ethical concerns (e.g., study of harmful interventions or exposures). Adapted from: Sackett DL et al. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. Churchill Livingstone; 2000.

What is Evidence-Based Medicine? “Evidence-based medicine is the integration of best research evidence with clinical expertise and patient values” - Sackett & Straus Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS: Evidence based medicine: what it is and what it isn’t. BMJ 1996;312:71-2. This definition of what EBM is and isn’t has gained wide acceptance and made it easier for us to get our points across.

EBM - What is it? Clinical Expertise Research Patient Preferences Evidence Patient Preferences “Explicit, judicious, and conscientious use of current best evidence from medical care research to make decisions about the medical care of individuals” Clinical expertise IS important! Why? Experience with patients: improves efficiency of diagnosis and treatment Improves ability to determine applicability of research data to your patients Allows consideration of patient preferences EBM is the process of systematically finding the most recent applicable research, appraising its validity, and using it as the basis for clinical decisions. Clinical Expertise improves efficiency of Dx and Rx considers patient preferences Overestimates usefulness of therapy -placebo effect - loss to follow-up “Have not all concerned physicians been doing this (EBM) for ages... ? The steps and recommendations of the EBM acolytes reek of obfuscations and platitudes.” WKC Morgan, London, Ontario Lancet, October 28, 1995

Traditional medicine Experiences Pathophysiology, references,… Patient value

By best research evidence clinically relevant research Unbiased research Reproducible research often from the basic sciences of medicine especially from patient centered clinical research

By clinical expertise We mean the ability to use our clinical skills and past experience to rapidly identify each patient’s unique health state and diagnosis, their individual risks and benefits of potential interventions, and their personal values and expectations.

By patient values We mean the unique preferences, concerns and expectations each patient brings to a clinical encounter and which must be integrated into clinical decisions if they are to serve the patient.

When these three elements are integrated, clinicians and patients form a diagnostic and therapeutic alliance which optimizes clinical outcomes and quality of life

جايگزين‌های طبابت مبتنی برشواهد Eminence based medicineعلووبزرگی Vehemence based medicine غیظ و غضب Eloquence based medicine فصاحت Providence based medicine مشیت الهی Nervousness based medicine عصبانیت Diffidence based medicine عدم اعتماد به نفس Confidence based medicine اعتماد به نفس

Was it clear enough !

بزنید ! Email اگر میل داشتید kabiri@research.ac.ir