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