Julio A. Ramirez, MD, FACP Professor of Medicine Chief, Infectious Diseases Division, University of Louisville Chief, Infectious Diseases Section, Veterans Affairs Medical Center Louisville, Kentucky, USA The Role of “Research Training” in the Specialist Curriculum

Teaching the Specialist Role of Research Training Role of Research Training Clinical Reasoning & Medical-Decision Making Clinical Reasoning & Medical-Decision Making 2. Clinical Expertise (based on personal experience) 2. Clinical Expertise (based on personal experience) 1. Clinical Judgment (based on medical literature) 1. Clinical Judgment (based on medical literature) 1980’s 1980’s

Teaching the Specialist Role of Research Training Role of Research Training Clinical Reasoning & Medical-Decision Making Clinical Reasoning & Medical-Decision Making 2. Clinical Expertise (based on personal experience) 2. Clinical Expertise (based on personal experience) 1. Clinical Judgment (based on medical literature) 1. Clinical Judgment (based on medical literature) 1980’s 1980’s Our clinical reasoning and medical-decision making should be consistent with and supported by good clinical research Our clinical reasoning and medical-decision making should be consistent with and supported by good clinical research Evidence-Based Medicine

Role of Research Training Role of Research Training EBM: making a conscientious effort to base clinical decisions on good quality research EBM: evaluation of the quality of clinical research by critically assessing techniques reported by researchers in their publications. EBM: Assessing the quality of evidence Evidence-Based Medicine

Role of Research Training Role of Research Training Evidence-Based Medicine Laboratory research Animal Research Editorials / Opinions Case Reports Case Series Case Control Studies Cohort Studies RTC Meta- analysis The hierarchy of clinical evidence

Role of Research Training Role of Research Training Evidence-Based Medicine Laboratory research Animal Research Editorials / Opinions Case Reports Case Series Case Control Studies Cohort Studies RTC Meta- analysis The hierarchy of clinical evidence D. Very Low Evidence C. Low Evidence B. Moderate Evidence A. High Evidence Quality of Evidence: A, B, C, D

Answer Research Question Database Study Results Role of Research Training Role of Research Training Evidence-Based Medicine

Answer Patients in the universe the universe Patients in the sample the sample Answer Role of Research Training Role of Research Training Evidence-Based Medicine Research Question Database Study Results

AnswerRight Answer?Wrong Answer? Patients in the universe the universe Patients in the sample the sample Answer Role of Research Training Role of Research Training Evidence-Based Medicine Research Question Database Study Results

AnswerRight Answer?Wrong Answer? Patients in the universe the universe Patients in the sample the sample Answer Is the association causal? (cause-effect) Role of Research Training Role of Research Training Evidence-Based Medicine Research Question Database Study Results

Patients in the universe the universe Patients in the sample the sample Answer Right AnswerWrong Answer? Is the association causal? (cause-effect) Truth Role of Research Training Role of Research Training Evidence-Based Medicine Research Question Database Study Results

Patients in the universe the universe Patients in the sample the sample Answer Right Answer?Wrong Answer Confounding Bias Chance Is the association causal? (cause-effect) Role of Research Training Role of Research Training Evidence-Based Medicine Research Question Database Study Results

Patients in the universe the universe AnswerRight Answer?Wrong Answer? Patients in the sample the sample Answer The association is False The association is Real (Cause-Effect) Bias Chance Truth Confounding Role of Research Training Role of Research Training Evidence-Based Medicine Research Question Database Study Results

Role of Research Training Role of Research Training Evidence-Based Medicine Laboratory research Animal Research Editorials / Opinions Case Reports Case Series Case Control Studies Cohort Studies RTC Meta- analysis The hierarchy of clinical evidence D. Very Low Evidence C. Low Evidence B. Moderate Evidence A. High Evidence Quality of Evidence: A, B, C, D

Role of Research Training Role of Research Training Evidence-Based Medicine Laboratory research Animal Research Editorials / Opinions Case Reports Case Series Case Control Studies Cohort Studies RTC Meta- analysis Future change in the “state of the art” “state of the art” D. Very Low Evidence C. Low Evidence B. Moderate Evidence A. High Evidence Quality of Evidence: A, B, C, D

Role of Research Training Role of Research Training Evidence-Based Medicine Laboratory research Animal Research Editorials / Opinions Case Reports Case Series Case Control Studies Cohort Studies RTC Meta- analysis Future change in the “state of the art” “state of the art” D. Very Low Evidence C. Low Evidence B. Moderate Evidence A. High Evidence Quality of Evidence: A, B, C, D D. Most likely C. Very Likely B. Likely A. Unlikely

Role of Research Training Role of Research Training Evidence-Based Medicine Laboratory research Animal Research Editorials / Opinions Case Reports Case Series Case Control Studies Cohort Studies RTC Meta- analysis Future change in the “state of the art” “state of the art” D. Very Low Evidence C. Low Evidence B. Moderate Evidence A. High Evidence Quality of Evidence: A, B, C, D D. Most likely C. Very Likely B. Likely A. Unlikely What quantity of “good evidence” is necessary before developing a “guideline”

Evidence-Based Medicine Role of Research Training Role of Research Training EBM applied EBM applied to populations: “EB Guidelines” EBM applied EBM applied to individuals: “EB Patient Care” Two branches of Evidence-Based Medicine

Evidence-Based Medicine Role of Research Training Role of Research Training EBM applied EBM applied to populations: “EB Guidelines” EBM applied EBM applied to individuals: “EB Patient Care” EBM applied EBM applied to populations: “EB Guidelines” EBM applied EBM applied to individuals: “EB Patient Care” Two branches of Evidence-Based Medicine

Teaching the Specialist Role of Research Training Role of Research Training Clinical Reasoning & Medical-Decision Making Clinical Reasoning & Medical-Decision Making An effective specialist will use all of the above strategies to define the best management of the individual patient An effective specialist will use all of the above strategies to define the best management of the individual patient 2. Clinical Expertise 2. Clinical Expertise 1. Clinical Judgment 1. Clinical Judgment 4. EB Patient Care 4. EB Patient Care 3. EB Guidelines 3. EB Guidelines