EBM In Residency
Training
Dr. Imad Salah Ahmed Hassan MD (UK) FACP FRCPI MSc MBBSChairman, Knowledge Translation Committee
Department of Medicine, KAMC,KSA
Incorporating EBM in Residency Training: Time for a Map
Objectives Why do we need to include EBM in
Residents Education Curricula Prerequisites for a successful program Practical Examples Assessment
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Information Gap
IT HAPPENS FOR EVERYONE !!!!!!!!
We need evidence (about the accuracy ofdiagnostic tests, the power of prognosticmarkers, and the comparative efficacy and safety of interventions, etc.) about 5 times for every in-patient and twice for every 3 outpatients. – David Sackett, M.D.
Green ML. Evidence-based medicine training in internal medicine residency programs a national survey. J Gen Intern Med. 2000 Feb;15(2):129-33. Free PMC Article
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Why Evidence-based Practice? Improves the quality of patient care Standardizes the delivery of healthcare Reduces the expense of healthcare Incorporates patient values into healthcare
decisions
Bridging the Gaps
Knowledge Practice
Resources Expenditure
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Why Evidence-based Practice? Essential component of Outcome-based,
Competency-focused Training
OUTCOME-BASEDMEDICAL TRAINING:
HAVING THE END PRODUCTIN MIND
How is the world making better doctors?
‘Scottish Doctor’
‘Tomorrow’s Doctor’
CanMEDS 2000
World Federation for Medical Education
‘Good Medical Practice’
Accreditation Council for Graduate Medical Education
WHO/EMRO
Gulf Cooperation Council
Association of American Medical Colleges
Institute for International Medical Education
Building your Curriculum………..
What is Competency?
Is a standardized requirement for an individual to properly perform a specific job.
It encompasses a combination of knowledge, skills and attitude (behavior) utilized to improve performance.
More generally, competency is the state or quality of being adequately or well qualified, having the ability to perform a specific role.
Holistic Quality
• Quality Clinical CareClinical Skills
• Holistic Continuous Quality CareNon-Clinical
Skills
Process Diagram
Process
Input
Output
Importance of a Holistic Professional development not only Clinical Skill-building.
What are CanMeds competencies?
CanMEDS Scholar Competency
Continuous Professional Development
EBM Skills
Teaching Skills
Research Skills
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Barriers to the Practice of EBM(Physicians in Training) Access to electronic information resources Skills in searching information resources Clinical question tracking Time Clinical question priority Personal initiative Team dynamics Institutional culture
Green ML and Ruff TRAcad Med 2005: 80(2);176.
Health Care Model: Donabedian Model
Process
Structure
OutcomeSix Ds:
DeathDiseaseDisabilityDiscomfortDissatisfactionDestitution (cost)
Care Process
Anatomy
•Pathways•Protocols•Physician orders•Nursing Care•Housekeeping•Transport
•Staff•Departments•Equipment•Supplies•Environment
Health Care Model: Donabedian Model
Process
Structure
OutcomeSix Ds:
DeathDiseaseDisabilityDiscomfortDissatisfactionDestitution (cost)
Care Process
Anatomy
•EBM Rotation•Regular Educational Prescriptions Activity•PICO Exercises•5As in Journal Club, Morning Meetings and Ward Rounds •Computer Lab Training Sessions•Developing Evidence-based Policies, Pathways and Guidelines
•EBM Skilled Faculty•Access to Medical Information•Medical Education Department
Health Care Model: Donabedian Model
Process
Structure
Outcome
EBM Competency
Care Process
Anatomy
•EBM Rotation•Regular Educational Prescriptions Activity•PICO Exercises•5As in Journal Club, Morning Meetings and Ward Rounds •Computer Lab Training Sessions•Developing Evidence-based Policies, Pathways and Guidelines
•EBM Skilled Faculty•Access to Medical Information•Medical Education Department
Necessary Structures• EBM Skilled Faculty• Access to Medical Information
Telephone Hotline, Intranet and Internet access, Well-stocked Medical Library, Personal Digital Assistant/ Pocket PCs etc.
Educational materials: Memos, letters, electronic reminders (emails, discussion groups, internet sites/links).
• Education Department Both Junior and Senior staff training Educationalists members
Necessary Processes: Knowledge & Skills EBM Education (Knowledge) EBM Rotation Regular Educational Prescriptions Activity PICO Exercises 5As in Journal Club, Morning Meetings, M&M meetings
and Ward Rounds Training in using Point-of-Care Resources Computer Lab Training Sessions Training in Developing Evidence-based Policies,
Pathways, Protocols, Order-sets and Guidelines
Necessary Processes EBM Education (Knowledge) EBM Rotation
Description and evaluation of an EBM curriculum using a block rotation.Thom DH, Haugen J, Sommers PS, Lovett P. BMC Med Educ. 2004 Oct 11;4:19.
Free PMC Article
Integrating an evidence-based medicine rotation into an internal medicine residency program.Akl EA, Izuchukwu IS, El-Dika S, Fritsche L, Kunz R, Schünemann HJ.
Acad Med. 2004 Sep;79(9):897-904.
Description and evaluation of an EBM curriculum using a block rotation.Thom DH, Haugen J, Sommers PS, Lovett P. BMC Med Educ. 2004 Oct 11;4:19.
Necessary Processes• Regular Educational Prescriptions
Activity What is an educational prescription? It specifies the clinical problem that generated the question. It states the PICO question, in all of its key elements. It specifies who is responsible for answering it. It reminds everyone of the deadline for answering it (taking
into account the urgency of the clinical problem that generated it).
Finally, it reminds everyone of the steps of searching, critically appraising and relating the answer back to the patient.
Presentations will cover:
search strategy;search results;
the validity of this evidence;the importance of this valid evidence;
can this valid, important evidence be applied to your patient;your evaluation of this process.
3-part Clinical Question
Patient’s Name Learner:
Problem/Target Disorder:
Date and place to be filled:
Intervention (+/- comparison):
Outcome:
Educational Prescription
Necessary Processes• PICO Exercises
Patient/problem
Intervention
Comparison
Outcome
Necessary Processes• 5As in Journal Club, Morning Meetings,
M&M meetings and Ward Rounds
Mixing it up: integrating evidence-based medicine and patient care.Korenstein D, Dunn A, McGinn T. Acad Med. 2002;77(7):741-2.
Clinical Query: EBM Approach
Ask clinical questions
Acquire the best evidence
Appraise the evidence
Applyevidence to Your patient
5A’s !!Assess
effectiveness, efficiency of
EBM process
Why is it Important?
EBM in the Ward Round
What is EB ward rounds? Why is it important? How is it different form our usual way of
doing ward rounds? How is it done? What do you need to do it?
What is an Evidence-based Ward Rounds? All diagnostic, therapeutic and prognostic
decisions are evidence-based. Clinically relevant questions that arise while
seeing patients are being answered after a quick literature search whenever possible.
The number of questions may go up to few questions per patients, or none.
It should also take into account patient’s values and preferences.
Asking questions
Acquiring literature
Appraising evidence
Applying findings
All EBM steps Evidence-based Medicine
What is an Evidence-based Ward Rounds?
Traditionalward round
Decision making about diagnosis
& treatment
Expertise,Experience &
Pathophysiology
Clinical problem
What is an Evidence-based Ward Rounds?
EB ward round
Appraisal of evidence
Ask answerable questions
Traditionalward round
Decision making about diagnosis
& treatment
Expertise,Experience &
Pathophysiology
Clinical problem
Acquire relevant articles
What is an Evidence-based Ward Rounds?
Exercises in the Ward Round(Also possible in the Morning Meeting) Use of point of care resources:
Literature Searching Decision Support tools: Calculators (physiological, risk, severity
etc), Online Clinical Pathways/Flow charts etc Shared Decision Making/Patient Education Tools
Use of educational prescriptions Exercises on critical appraisal Evidence–based clinical examination (using resources
such as The Rational Clinical Examination textbook) Evidence-based appropriate tests and therapeutic
interventions are then demonstrated.
Exercises in the Ward Round(Also possible in the Morning Meeting) Relevant concepts in EBM like SpPin, SnNout,
Likelihood Ratios, NNT, NNH etc are explained pertinent to the case.
Appraisal home works Process Change Skills training/Quality Improvements Having a librarian is extremely useful.
EBM in the Ward Round Bed-side Literature Searching:
Clinical Knowledge Summaries (CKS) :National Library for Health: http://cks.library.nhs.uk/
DynaMed: http://www.dynamicmedical.com/ Essential Evidence Plus (formerly InfoRetriever)
http://www.essentialevidenceplus.com/ First Consult: http://www.firstconsult.com/ UpToDate: http://www.uptodate.com/ Clinical Evidence
http://clinicalevidence.bmj.com/ceweb/index.jsp ACP PIERS pier. http://pier.acponline.org/index.html
Presentations will cover:
search strategy;search results;
the validity of this evidence;the importance of this valid evidence;
can this valid, important evidence be applied to your patient;your evaluation of this process.
3-part Clinical Question
Patient’s Name Learner:
Problem/Target Disorder:
Date and place to be filled:
Intervention (+/- comparison):
Outcome:
Educational Prescription
Does this Patient have CCF?
Diagnosing LVF in a dyspnoeic patient?
EBM in the Ward Round
Handheld ultrasound, B-natriuretic peptide for screening stage B heart failure. Hebert K, Horswell R, Heidenreich P, Miranda J, Arcement L.South Med J; 2010 Jul ; 103(7):616-22. PubMed ID: 20531053[TBL] [Abstract] [Full Text] [Related]
EBM in the Ward Round
Decision Support Systems
Evidence-based Scoring Systems: Stroke: CHADS2, NIH Stroke Score Pulmonary Embolism: Well’s Cardiac Events Statin Indications Pneumonia Severity Fracture Risk
EBM in the Ward Round
Decision Support Systems
Uptodate Calculator: Ranson criteria for pancreatitis prognosis Calculator: Blatchford score for gastrointestinal bleeding Calculator: Rockall
score for upper gastrointestinal bleeding Calculator: Crohn's disease activity index (CDAI) Calculator: Mayo score for assessing ulcerative colitis ac
tivity
EBM in the Ward Round
Decision Support Systems
Uptodate Calculator: Bedside index of severity in acute pancreatiti
s (BISAP) score Calculator: Harvey-Bradshaw index of Crohn's
disease activity Calculator: Glasgow alcoholic hepatitis score Calculator: Hepatitis discriminant
function for corticosteroid rx in alcoholic hepatitis Calculator: Child Pugh classification for severity of liver d
isease (SI units)
EBM in the Ward Round Decision Support Systems Isabel http://www.isabelhealthcare.com/home/default Open Clinical http://www.openclinical.org/dss.html DXplain http://dxplain.org/dxp/dxp.pl Medical Calculators
http://easycalculation.com/medical/medical.php Skyscape:
http://www.skyscape.com/archimedesonline/archimedesindex.aspx Emergency Medicine on the Web: http://www.ncemi.org/ MedicineWorld.Org:
http://medicineworld.org/online-medical-calculators.html Clinical Decision Making Calculators:
ttp://www.fammed.ouhsc.edu/robhamm/cdmcalc.htm
What is an Evidence-based Journal Club?
Structure of JC
Clinical Query: Foreground Question PICO Article Selection: Searching for Evidence/Literature Search Appraising the Evidence: Critical Appraisal Presentation Critique and summary Recommendations:
New research Change or audit of current practice Writing a letter to the editor Publishing your appraisal in a CAT journal or website
(own or in the WWW)
Computer Lab Training Sessions Literature searching skills Scope of Resources
Point of Care Clinical Resources Up-Dates & New Evidence Critical Appraisal Tools Evidence-Based Quality Improvement Evidence-Based Guidelines, Policies and Protocols Decision Support Systems EBM Audiovisual Training Portals to All
EBM Training Assessment
Green ML. Evidence-based medicine training in internal medicine residency programs a national survey. J Gen Intern Med. 2000 Feb;15(2):129-33. Free PMC Article
EBM Training Assessment
Multi-source Feedback Short Answer Questions MCQ Objective structured assessment of technical
skills (OSATS) OSCE
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EBM is here to stay. It has become an essential way of teaching and practicing in the uncertain world of medicine. The challenge is to engage the whole healthcare team in learning about it and making it part of the routine of clinical practice.
Editorial. BMJ 2004;329:989-990