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03/07/2012
Dr.Ilham Youssry, MD-JMHPE-CT 1
Student assignment
EBM process
Dr. Ilham Youssry, MD-IBCT-JMHPEprofessor of pediatrics, Pediatric Hematology
Member of EBM unit, MEDC, Cairo University
Master degree Health Profession Education, JMHPE
Certified trainer, IBCT
2012
What are your expectations
about Evidence-based
medicine (EBM)?
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Goal
To enable the 5th grade student to use
evidence based medicine in their medical
profession.
Objectives
• By the end of this meeting you will be able
to:
– Conclude why should we follow EBM
– Know what is EBM
– Understand how to practice EBM
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Why
EBM?
To get the
best available
answer to his
medical
problem
Medical
problem i.e.
questions
need answer
•Collect data
•Analyse &
interpret data
•Decision making
•Support his
decision by
evidence
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How could the doctor
support his decision
by evidence ?
Traditional process for medical
practice
...identify
the need
and try to meet this need
within available resources
Apply results
to our
patients
Accumulated
knowledge
Clinical Experience
(practice)
Reading
Expert And Peer
Opinion
Logic
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• Expansion of knowledge
• Increase the speed of knowledge change
• Appearance of the quality control laws
Limitations of the traditional
process for medical practice
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Knowledge
• Knowledge of best care decreases
by time (Shin etal, 1993)
0
20
40
60
80
100
120
0 10 20 30
Years since graduation
Know
ledge
Y values
Slippery slop
Reading
Traditional Text
books are always
outdated
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Reading
20 000 biomedical journals
5000 articles / day
Experience
• A New drug ! • A New
Technique !
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Expert & peer opinion
Take X
drugTake Z
drug
• Accumulated knowledge
• Clinical experience & practice
• Reading ---- books and/or periodicals
• Expert & peer opinion
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Limitations of the traditional
process for medical practice
We should use the
current best evidence in making
decisions about the care of individual
patients
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Medical practice
Traditional
process
EBM process
Why?
Objectives
• By the end of this meeting you will be able
to:
– Conclude why should we follow EBM
– Know what is EBM
– Understand how to practice EBM
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How?
What?
Steps of EBM
practice
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Assess the patient
Ask clinical question
Search for best
evidenceApplyevidence to
patient care
!
How could we practise
EBM?
So we followed the Evidence
based approach
Stop!!!!!
Before applying
the answer to our
patient, we should
make………….
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Evidence is never enough
Evidence should be integrated
Clinical
Expertise
Research Evidence
Patient Preferences
EBM
-- Sackett, et al Sackett, et al 20012001
Moving from
evidence
To action
• By the integration of the best research
evidence with clinical
experience and patients values
What is EBM?
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Objectives
• By the end of this meeting you will be able
to:
– Conclude why should we follow EBM
– Know what is EBM
– Understand how to practice EBM
–Formulate a clinical question
–Search EBM resources to answer these
questions
How could we practise
EBM?
ClinicalExpertise
Best Research Evidence
Patient Preferences
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Formulating Clinical Question AND
Searching The Medical Literature
Clinical scenario
• Your patient is a three years old male, presented to the ER with Purpura, mild gum bleeding
• The patient is clinically stable, and his physical examination is otherwise normal
• Complete blood count is totally normal apart from severe thrombocytopenia ( platelet count<10000/mm).
• You decided to admit the child and start treatment with intravenous immunoglobulin.
• One student asked you if treatment with pulsed high dose methyl-prednisolone would result in similar improvement at much lower cost for the hospital?
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Types of questions raised
• What causes idiopathic thrombocytopenic
purpura?
• What is the symptoms of ITP?
• How can we diagnose ITP?
• What are the treatment options for ITP?
Back ground questions
• When you need to know more information
about the disease
To fill your knowledge gap
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Types of questions raised
• In child suffering from ITP does treatment
with steroids, compared to IVIG results in
rapid cure
• In children suffering from ITP is complete
blood picture as accurate as bone marrow
aspirate in diagnosis.
Foreground questions
• When you need to know information that you
will:
– Tell your patient about
– Usually related to
–Diagnosis
–Therapy
–Prognosis
–harm
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Patient/
PopulationOutcome
Intervention/
ExposureComparison
IVIG SteroidsRapid cure
Child withacute ITP
Your Therapy Question
The PICO
Patient/Population
OutcomeIntervention/
ExposureComparison
Blood
pictureBone
marrow
Accurate
diagnosisChild withAcute ITP
Your Diagnosis PICO Question
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Patient/
PopulationOutcome
Intervention/
ExposureComparison
Risk ofbeing chronic
ITP
Child withAcute ITP
Your Prognosis PICO Question
Patient/
PopulationOutcome
Intervention/
ExposureComparison
IVIGHypersensitivity
reactions
Child with
Acute ITP
Your Harm PICO Question
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Clinical Question
Background Q Foreground Q
Types of clinical questions
Experience with condition
ForegroundBackground
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How could we move from clinical
question to search for the answer ?
• Extract the search terms
• Choose the sites that you will visit
searching for the answer
Basic Search Terms
• Pick up important elements in your question
– ITP
– IVIG
– Steroids
– child
Start your search
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Group Exercise on question
formulation from clinical scenarios
Scenario 1 (harm, therapy)
• 8 weeks old boy is brought for his first set
immunization - DPT+ oral Polio - His
mother is concerned that her baby may be at
greater risk of convulsion after his
immunization. She also asked is the
acellular pertussis vaccine better for her
son?
BackgroundQ Foreground Q
Searching key words
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Online Resources
• Cochrane abstracts
• Best practice
• Guidelines websites
• Trip database
• Pub Med
www.cochrane.orgwww.cochrane.org
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www.cochrane.org
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Ask PICO therapy• In 6 month child with bronchiolitis does
addition of antibiotic therapy compared to regular care alone result in rapid cure
• Pick up basic search terms
one word is enough Bronchiolitis
Search for evidence
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Thrombocytopenic purpura
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Searching through the best
practice web site
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www.tripdatabase.com
www.tripdatabase.com
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Boolean operators
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Measles image
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http://www.guideline.gov
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WWW.guideline.gov
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Searching The Medical
Literature
www.pubmed.com
WWW.pubmed.com
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Main search BoxThrombocytopenic purpura
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Search limits
• Search by phrase
• Use AND, OR, NOT
• Use Pubmed limits
Boolean operators
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Search limits
• Search by phrase
• Use Pubmed limits
• Use AND, OR, NOT
Boolean operators
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Search limits
• Search by phrase
• Use Pubmed limits
• Use AND, OR, NOT
Boolean operators
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Questions
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Sum up
In this meeting we answered 3Qs
– Why should we follow EBM?
– What is EBM?
– How could we practice EBM?
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–Formulate a clinical question
–Search EBM resources to answer these
questions
How could we practise
EBM?
http://www.hsl.unc.edu
/services/tutorials/ebm/
welcome.htm
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Questions
