1. Evidence-based medicine:
a hands-on workshop
Presented by
Chris Maloney, MD
Director, Medical Student Education in Pediatrics
Venus Wilke, MD
Assistant Clerkship Director for Pediatrics
University of Utah
Salt Lake City, Utah
Here we can introduce ourselves and make a statement of how we became interested in EBM, how we were “taught” EBM practices and how we have integrated EBM into our practice of medicine and our teaching.

2. Objectives and Priorities
Pediatrics Topics Session 1 and 2
Formulate a clinical question relative to a patient’s problem. Conduct an effective search of the medical literature. Critically read the pediatric literature and apply the information in developing a differential diagnosis, diagnostic plan, or management plan.

3. Clinical judgment
and experience
Best research
evidence
EBM
Patient values

4. Evidence-based medicine
Defined
David L. Sacket
Evidence-based Medicine
How to practice and teach EBM
The integration of best research evidence
with clinical expertise and patient values

5. EBM: Defined
Best research evidence – clinically relevant research into
the accuracy and precision of diagnostic tests, the power
of prognostic markers, and the efficacy and safety of
therapeutic, rehabilitative and preventive regimens.
Clinical expertise – the ability to use clinical skills and past
experience to rapidly identify each patient’s health state
and diagnosis, their individual risks and benefits of
potential interventions.
Patient’s values – 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.

6. barriers between research and practice
slide 4.2
barriers between research and practice
30 kg of guidelines per family doctor per year
25000 biomedical journals in print
8000 articles published per day
95% of studies cannot reliably guide clinical decisions
2001 Bazian Ltd

7. The steps toward the practice of EBM
Step 1: Converting the need for information to an answerable question.
Step 2: Tracking down the best evidence with which to answer the question.
Step 3: Critically appraising that evidence for its validity (closeness to the truth),
impact (size of the effect), and applicability (usefulness in our
clinical practice).
Step 4: Integrating the critical appraisal with our clinical expertise and with
our patients unique biology, values and circumstances.
Step 5: Evaluating our effectiveness and efficiency at achieving steps 1-4
and seeking new ways to improve them both for next time.

8. How evidence changed clinical practice
32. Failure of extracranial-intracranial arterial bypass to reduce the risk of Ischemic stroke. Results of an international randomized trial. The EC/IC Bypass Study Group. New England Journal of Medicine 1985; 313: 1191 – 1200.
31. Extracranial to intracranial vascular anastomosis for occlusive Cerebrovascular disease: experience in 110 patients. Surgery 1977; 82:

9. systematic review of RCTs
slide 7.1
hierarchy of major study designs
systematic review of RCTs
interventional
RCT
observational
cohort
case control
validity
2001 Bazian Ltd

10. Formulating a Question
Foreground
Background A B C
Novice
Experience with the condition
Expert

11. Formulating a Question: “Background Information”
Ask for general knowledge about a disorder
This question has 2 essential components
A question root with a verb
(who, what, where, when, how or why)
A disorder or an aspect of a disorder

12. Formulating a Question: “Foreground Information”
Ask for specific information about managing a
patient with a specific disorder
This question has 3 or 4 essential components
P – Patient/Population/Problem
I – Intervention/Exposure
C – Control/Comparison (if relevant)
O – Outcome

13. Evidence-based Resources
ACP Journal Club --
articles report original studies and systematic reviews that warrant immediate attention by physicians attempting to keep pace with important advances in internal medicine
Clinical Evidence --
from the BMJ Publishing Group; an international source of the best available evidence for effective health care
Guidelines --
a public resource for evidence-based clinical practice guidelines
Evidence-based Reviews
Contains ACP Evidence-based Medicine reviews and Cochrane Library databases
Centre for EBM --
this website helps develop, disseminate, and evaluate resources that can be used to practice and teach EBM

14. Major Electronic Resources (available from Eccles Library)
Access Medicine
home.aspx
A collection of textbooks, hot topics and self-assessment tools: Harrison’s, Goodman and Gilman, etc.
Cochrane Library
A database of systematic reviews and more
DynaMed
1,800 clinical topic summaries; designed for use at point of care, providing best available evidence; updated daily

15. Major Electronic Resources (available from Eccles Library)
PubMed/MEDLINE with LinkOut
Buttons indicate if material is available in print or electronic formats
STAT!Ref – ACP’s PIER
Physicians' Information and Education Resource
Plus 23 other textbooks for background information
UpToDate
Author evaluated review of the best evidence
FreeMedicalJournals
Promoting free access to medical journals

16. Searching PubMed URL – http://pubmed.gov
With LinkOut (indicates if library has print or
electronic copies)

17. Searching PubMed MESH Database Ease of use Mapping of many terms
Explode capability
Hierarchical arrangement of terms
Ability to limit to the major focus area
Can use to broaden a search
Can limit to age

18. Searching PubMed
MESH Database

19. Searching PubMed
MESH Database

20. Searching PubMed Clinical Queries Limits to clinical trials Therapy
Diagnosis
Prevention
Prognosis
Systematic Reviews

21. Searching PubMed

22. Searching PubMed Limits article type age of subjects entrez date
publication date
language
human or animal subjects
subsets
gender

23. Searching PubMed

24. Searching PubMed
External Linking

25. Searching PubMed Use of quotes vs. no quotes 'brca 1' vs brca 1
Use of wildcards
chemotherap*
y, ies, eutic
with synonyms
eradicat* OR cur* OR eliminat*
(Note: Use of quotes and wildcard turns off automatic mapping)
Use of AND OR NOT
e.g. Bronchiolitis AND RSV NOT Influenza [MESH]

26. Levels of Evidence

28. Levels of Evidence

29. General areas covered today
Therapy
Harm/Etiology
Diagnosis
Prognosis

30. One approach to critically selecting an article
1. What is the Authors reputation?
2. What is the Institutions reputation?
3. What is the Type of study? i.e RCT, review
4. What is the Population and how do they compare with my situation?
5. Regardless of the outcome will it change my practice?
6. What are the Methods?
7. What are the Results?

31. Some Statistical Information

32. design features that increase validity
slide 8.1
design features that increase validity
2001 Bazian Ltd

33. Event Rate and Number Needed to Treat

34. Likelihood Ratios

35. Confidence Intervals

36. Group Exercise 1. Working in groups of 2 - 4 2. Identify a question
preferably a foreground question
3. Determine a search strategy
4. Perform the search and obtain an article
5. Critically review the article(s) using the worksheets
6. Share your question, strategy and results

37. References How to practice and teach EBM. Sackett DL, Straus SE,
Richardson WS, Rosenberg W, and Haynes RB.
Churchill Livingstone. Second Ed
Users guide to the medical literature. A manual for evidence-
Based clinical practice. Guyatt G and Rennie D.
AMA Press

38. Worksheets