EVIDENCE-BASED MEDICINE CAN WE PRACTICE EFFECTIVELY WITHOUT IT ? Readings Hassan Ba’aqeel Hassan Ba’aqeel MBBS, FRCSC, FRCOG Chairman Depart. of Obs&Gyn, King Khalid National Guards Hosp., Jeddah – Saudi Arabia.
As a researcher, knowing the importance of translating research results into practice and the fact that over the last 2 decades an ever increasing number of Randomized Controlled Trials evaluating traditional concepts being published and the evolution of formal system of evaluation of evidence, I became interested in Evidence-Based Medicine (EBM). Having been chairman of obstetrics and gynecology departments at various institutions, I'm excited about EBM that provided me with a scientific tool that helped me to induce positive changes in clinical practice.
THE HISTORIC PARADIGM Authoritarian education and practice Experts Textbooks Consensus statements The assumption : “Professional authorities represent infallible and comprehensive knowledge”
A number of prestigious authority figures. Sometimes the advice lacked scientific proof. THE HISTORIC PARADIGM (Cont’d) Delayed true progress in optimizing maternal fetal outcome.
Prominent examples of “The advice” Bloodletting for eclamptic fits. Diuretics for preeclampsia. Routine episiotomy. “Once a section always a section”. Ventrosuspension for infertility. Removal of epsilateral ovary in EP. THE HISTORIC PARADIGM (Cont’d)
THE EVIDENCE-BASED PARADIGM Recognition of the need to encourage patterns of care that do more good than harm. Taking greater account of systematically collated EVIDENCE. Responding to the teaching of Archie Cochrane (1972)! “RCT” as the gold standard. Drug Vs None drug type of interventions
ASSUMPTIONS OF AUTHORITARIAN PARADIGM Individual clinical experience is the foundation. Pathophysiology provide the foundation. Personal/collective experience used to evaluate new tests. Mastery of the subject areas dictate practice guidelines.
ASSUMPTIONS OF EVIDENCE BASED PARADIGM Systematic, reproducible attempts to record outcome (RCT). Knowledge of pathophysiology alone is insufficient. Formal rules of evidence are prerequisites to understanding the literature.
EBM - WHY BOTHER ? (1) New types of evidence are being generated Pathophysiology Vs “RCT” Metaanalysis Major changes in patient care
EBM - WHY BOTHER ? (2) In spite of clear need for the evidence WE FAIL TO GET IT
STAGE OF CAREER RANGE OF MEDIAN READING TIME (mins) % No READING LAST WEEK Medical Student60 –1200 % Intern0 – 20UP TO 75 % Resident10 –30UP TO 15 % Registrar10 – 90UP TO 40 % Senior Registrar10 – 45UP TO 15 % Consultant <15 yrs15 – 60UP TO 30 % Consultant >15 yrs UP TO 40 %
EBM - WHY BOTHER ? (3) Because 1&2, up to date knowledge and clinical performance DETERIORATE WITH TIME
Years since graduation, Range (3-42)
TRADITIONAL CME HAS BEEN SHOWN THROUGH RCT’s NOT TO IMPROVE OUR CLINICAL PERFORMANCE ! EBM - WHY BOTHER ? (4)
EBM - WHY BOTHER ? (5) A different approach to clinical learning utilizing “EBM” approach has been shown to keep its practitioner up to date
Years in practice Mean total score HYPERTENSION – KEEPING UP TO DATE USING EBM
PRACTICING EBM, THE NEEDS Evidence-based approach to patient care create the NEED for Clinically Important Information about
PRACTICING EBM, THE STEPS Transform information needs into answerable questions. Track down the best evidence to answer them. Critically appraise the Validity and usefulness of the evidence. Apply result of appraisal to clinical practice. Evaluate your performance.
Printed reviews CD ROMDiskettes Internet version OUTPUTOUTPUT Databases of abstracts of reviews of effectiveness INPUT FROM CC The Cochrane Database of Systematic Reviews The Cochrane Controlled Trials Register The Cochrane Review Methodology Database Collaborative Review Groups Methods Working Groups The Cochrane Centers / Cochrane Fields THE COCHRANE LIBRARY
“ IT AIN’T SO MUCH WHAT WE DON’T KNOW THAT GETS US INTO TROUBLE AS WHAT WE DO KNOW THAT AIN’T SO “ Will Rogers “An American cowboy philosopher”