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How to Establish and Encouragean Evidence-Informed Massage Therapy
Practice Learn to overcome key obstacles: lack of
time, support, knowledge, and confidence.
West Coast College of Massage Therapy
July 13, 2008
Presented by: Bodhi Haraldsson, RMT
MTABC research department chair
What is Evidence-Based Medicine?“Evidence-based medicine is the integration of best
research evidence with clinical expertise and patient values”
- Sackett & Straus
Ask
Acquire
Appraise
Apply
Act & Assess
Patient dilemma
Principles of evidence-based
practice
Evidence alone does not decide – combine with otherknowledge and values
Hierarchy of evidence
Process of EBP
Skills for each of the 4 steps*
Formulate an answerable questionTrack down the best evidence Critically appraise the evidenceIndividualise, based clinical expertise and
patient concerns
Evaluate our effectiveness and efficiency – keep a record; improve the process
*Sicily statement on evidence-based practice. BMC Med Educ. 2005 Jan 5;5(1):1.
Six factors influence the uptake of innovations
Relative benefit – what’s in it for me?
(non)-Complexity – is it easy to learn?
Trialability – can I try it out easily?
Observability – can I see others do it?
Compatability – fit with ideas and work
Reinvention – can I adapt it to me?
Rogers, Diffusion of Innovations
1. Relative Benefit – what’s in it for me?• Evidence-Based Medicine can:
– Reduce reading by quality filters– Better management of patients– Relieve anxiety about uncertainty
2. Non-complexity – is it easy to use?• How can we simplify EBM?
3. Trialability – can I try it out?
• How can we make EBM easy to try?
Trialability: do 1 step and get help with othersFormulate an answerable questionTrack down the best evidence Critically appraise the evidenceIndividualise, based clinical expertise and
patient concerns
Evaluate our effectiveness and efficiency – keep a record; improve the process
*Sicily statement on evidence-based practice. BMC Med Educ. 2005 Jan 5;5(1):1.
3. Trialability – provide easy steps
Keep a paper question log
Answer a few important questions / week
Get help with searches
Simplify appraisal OR use pre-appraised topics
Focus on interpretation
We’ll peer into … • Asking answerable
questions for EBM
• Barriers to learning with our questions
• How to teach EBM with questions
• Have some fun!
Group Task
• Groups of 2 – 3
• Discuss >1 question from recent work
• Write it down
• Be ready to report to group
• Return in 2 minutes
Questions• …
• …
• …
10 Common Questions• Clinical findings
• Harm/etiology
• Differential diagnosis
• Manifestations
• Diagnostic tests
• Prognosis
• Therapy
• Prevention
• Experience, Meaning
• Learning
(Not exhaustive or mutually exclusive)
‘Background’ Questions• About the disorder, test, treatment, etc.
2 components:
a. Root* + Verb: “What causes …”
b. Condition: “Rheumatoid arthritis”
• * Who, What, Where, When, Why, How
‘Foreground’ Questions• About patient care decisions and actions
4 (or 3) components:
a. patient, problem, or population
b. intervention, exposure, or maneuver
c. comparison (if relevant)
d. clinical outcomes (including time horizon)
Background & Foreground
What Pushes Us … Toward• curiosity• Prove colleagues wrong• Keeps coming up• Risk of patient harm • Want to do better• Anxiety• Avoid litigation• Internet informed patient
AwayTimeWe already know the answerFatigueAccessInferiority complex-anxiety-
afraid of admitting knowledge gaps
CynicalLazinessLack of supportPrevious failure at searchingLack of resourcesNoone else does itFear of change
How does it feel … ?
To know an answer?
To NOT know an answer?
Emotions in Not KnowingReady to … Feeling Behaviors
Flee Fear LeaveInvisible
Fight Anger DisruptUndermine
Cry for help Distress Stop tryingBody stress
Withdraw Sadness InattentionDetachment
Emotions in Knowing• Satisfaction: Self image of “knower”
meets reality of “knew this”
• Curiosity: the wind in the sails
• Joy: knowing and/or learning brings benefits to others
• “Zero gravity” or “flow”: when learning engages the mind fully without self consciousness
The Real ‘Three R’s’ of Learning
• Resilient
• Reflective
• Resourceful
Group Task• Groups of 2 – 3
• Discuss >1 question you recognized
• Write it down
• Be ready to report to the group
• Return in 3 minutes
Questions• a
• b
• c
• d
• e
Teaching with Questions
• Recognize: your learners’ questions
• Select: which questions to pursue
• Guide: how to ask and answer
• Assess: how well & what to improve
Selecting QuestionsConsider:• What is illness?• What is role?• What are learning
needs?• What are
available resources?
Of these, select:
• Most urgent
• Most interesting
• Most feasible to answer
• Most likely to recur
FAQ: Why Bother? 1• Relevant to clinical
needs
• Relevant to learning needs
• Plan searches
• Recognize answers
• Awaken curiosity
• In teaching, improve comprehension
• In referral, improve communication
• Have some fun!
• Any evidence?
FAQ: How Long … ?• Proficient? Quickly
• Mastery? Lifetime
• Human expertise takes >10,000 hours, >10 years
→Deliberate practice
Questions: Take ‘Em Home
• Believe Q’s rule
• Q are chances to learn and to use evidence
• Recognize Q’s– Background– Foreground
• Select Q wisely
• Match to Resources
Acknowledgements
“There is nothing new under the sun”
These slides have been partially adapted from:• How do we nurture Evidence-Based Practice?
Paul Glasziou, Centre for Evidence Based Medicine, University of Oxford
• Teaching EBM With Learners’ Questions
W. Scott Richardson, M.D.