1. Learning And Teaching Evidence Based Medicine: Asking And Answering a Clinical Question Christopher Bunt, MD, FAAFP Kimberly Jarzynka, MD, FAAFP

2. Disclosures: Nothing to disclose. DoD Disclaimer: The views expressed in this presentation are those of the authors and do not necessarily reflect the official policy or position of the Air Force at-large, the Department of Defense or the U.S. Government.

3. Objectives Foreground vs. Background questions PICO framework EBM Resources Practice as a group

4. What is EBM? Primary research literature sources –Randomized Controlled Trials (RCTs) –Meta-analyses –Systematic Reviews (Cochrane Reviews) –Clinical Practice Guidelines (CPGs)

5. What is NOT EBM? Most Secondary Resources –UpToDate © –General review articles –Textbooks Other stuff –Wikipedia –Google

6. Background vs. Foreground Background Questions –General knowledge –Who, what, how? Foreground Questions –PICO Model

7. ASK the Question: PICO Model Patient/Problem –Can be individual or a group Intervention –Can be new or old therapy Control –Can be watchful waiting (doing nothing) Outcome –Want to focus on patient oriented outcomes

8. Patient vs. Disease-Oriented Outcomes Patient –Morbidity –Mortality –Cost –Symptoms Disease –Blood pressure –Lab test results –Radiologic findings

9. Why do we care? The #1 way to answer your clinical question is to create an answerable question. Creating a foreground question using the PICO format will guarantee that you will have the best chance to answer your question.

10. Background vs. Foreground What are the diagnostic tests for Lyme disease? BACKGROUND In a patient with suspected Lyme disease, is the immediate clinical treatment or test-and- then-treat approach better for morbidity? FOREGROUND

11. Background vs. Foreground Who can get an IUD? BACKGROUND Is immediate IUD insertion after childbirth effective and safe? FOREGROUND

12. Background vs. Foreground Every clinical question can be both a background and a foreground question Both can be useful in clinical practice Foreground questions will allow you to complete a successful critical appraisal

13. Answering your PICO Where can I start?

14. Point of care resource –synthesized, valid, reliable, LOE, concise, bottom line Daily POEMs Alerts, weekly podcasts Mobile optimized CME available $88 per year for individual subscription 30 day free trial http:// www.essentialevidenceplus.com

15. Point of care resource –synthesized, valid, reliable, LOE, bulleted text Updated daily DynaMed EBM Focus newsletters weekly Mobile app (Skyscape medical) CME available $395 per year (less for residents, students) 30 day free trial https://dynamed.ebscohost.com/

16. Point of care resource –primary literature Uses PICO format to search MEDLINE/PubMed Narrow by publication type Link to full-text article (save or email) Mobile app Free http://pubmedhh.nlm.nih.gov/

17. Practice with the PICO Model Review synopsis Patient/Problem Intervention Control Outcome

18. Practice with PICO Please download PubMed4HH app or access website: http://pubmedhh.nlm.nih.gov/nlmd/pico/pic onew.php http://pubmedhh.nlm.nih.gov/nlmd/pico/pic onew.php Search and see what you can find!

19. Objectives Foreground vs. Background questions PICO framework EBM Resources Practice as a group

20. Questions? Christopher.bunt@usuhs.edu Visit the Family Medicine Clerkship Curriculum for more info on how to teach the PICO model. http://www.stfm.org/cci/index.cfm