Active Learning,
Evidence, and the
Clinical Classroom
Michelle Barber, MSW, DC
Assistant Professor
Palmer College of Chiropractic
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Fish is Fish
Leo Leonni
The 5 A’s of EBCP
1. ASK = Develop a clinically relevant question
2. ACQUIRE = Search the literature to find the best
available evidence to answer your question
3. APPRAISE = Evaluate the evidence for validity
and applicability to the clinical circumstances
4. APPLY = Use the relevant evidence in the clinical
situation
5. ASSESS = Evaluate your effectiveness in carrying
out steps 1 through 4 and revise if necessary
Ask
Patient
dilemma
Acquire
Evidence Cycle
Assess the results
of the action with
patient
Appraise
Apply
PICO
A format for developing clinical questions
P:
I:
C:
O:
Patient, population
Intervention or therapy
Comparison, control
Outcome
Patient Scenario
• You have an 8 year old
female patient diagnosed
with ADHD brought in by
her mother, as she would
prefer to treat her child
with more natural, holistic
methods
• At a recent visit, Mom tells
you that she saw something
in a pamphlet that
suggested a diet restricting
dairy and sugar would help
her daughter’s symptoms
• She asks you if you think this
is something she should do
or if you can make any other
diet/supplement
recommendations
PICO: Focused Clinical Question
Consider
Your Question
P
Patient or
problem
Describes patient
(age, gender, race,
condition/symptom, etc)
• 8 year old/pediatric
• Female
• ADHD
I
Intervention
What treatment, diagnostic test,
intervention is being considered?
• Diet restricting dairy and
sugar
C
Comparison
Compared to what?
Another intervention, Gold
Standard, Nothing
• Other dietary changes
• Supplementation
O
Outcomes
What is the desired effect of the
intervention?
(decreased symptoms, improved
function, etc)
• Reduction of symptoms
• Reduced need for
medication
Ask
Patient
dilemma
Acquire
Evidence Cycle
Assess the results
of the action with
patient
Appraise
Apply
Acquire
• Quick database search
– Some of my favorites
• Index to Chiropractic
Literature
• PubMed
• Natural Standard
Database
• Dynamed
• Rehabilitation
Reference Center
Hierarchy of Evidence
Randomized
Controlled
Double Blind
Studies
Systematic
Reviews and
Meta-analyses
Review…
Strong…
More recent
publication…
Let’s look at this
one
Ask
Patient
dilemma
Acquire
Evidence Cycle
Assess the results
of the action with
patient
Appraise
Apply
JTASS
Journal
Title
Author
Site
Summary
Adapted from: Department of Clinical Epidemiology & Biostatistics, McMaster University Health Sciences Center. How
to read clinical journals: I. Why to read them and how to start reading them critically. CMAJ 1981;124:555-8.
Journal
Expert
Review of
Neurotherapeutics
Title
Relevant to
our question
Looks
interesting
Peer
reviewed,
indexed in
PubMed
Authors
Rucklidge,
Julia J
Primary
author, 25
articles
Keywords:
• Supplementation
• Treatment
of ADHD
18 of 25 re:
ADHD
Site
Review, so
multiple
sites
Summary
Most evidence is
sparse and
conflicting
Best evidence:
Zinc (2 RCTs)
Mixed evidence:
carnitine,
pycnogenol, EFAs
Population
similarity,
able to
reproduce
intervention
if valid
Inconclusive:
vitamins, Mg, Fe,
Sam-e, tryptophan,
Ginko biloba
w/Ginseng
No support: St
John’s Wort,
tyrosine,
phenylalinine
Ask
Patient
dilemma
Acquire
Evidence Cycle
Assess the results
of the action with
patient
Appraise
Apply
APPLY
• Consider the best available evidence, combine
Best
this with your clinical experience, and
Evidence
incorporate the patient’s preferences
into the final recommendations
• present the pros and cons of the different options to
patients in a way they can understand, and let them
choose how they would like to proceed
Clinical
Expertise
Patient
Values
APPLY
• Shared with Mom that there is little evidence to support
dietary restriction
• Recommended supplementation with Zinc to help decrease
symptoms of ADHD and perhaps reduce need for stimulant
medication
– Evidence suggests approx. 15 mg of Zinc/day
• Mom excited to receive the information, going to try Zinc
on a trial basis
– Good use of EBCP, incorporating patient values
Student Assessment
• Students were then given 4
clinical scenarios to choose
from
• Had to go through process
(“Ask, Acquire, Appraise, Apply”)
• Completed worksheets for
each step of process
• Turned in worksheets along
with chosen article
Additional Samples of
Clicker Questions…
The hormone that most directly
influences Na+ balance in the body is
Vasopressin
Angiotensin
Rennin
Aldosterone
Atrial natriuretic
peptide
25% 25%
22%
17%
e
tid
tic
iu
re
at
r
ia
ln
At
r
pe
p
os
te
r
on
e
n
Al
d
nn
i
Re
n
ns
i
te
An
gi
o
re
s
sin
12%
Va
so
p
1.
2.
3.
4.
5.
A 65-year-old man has difficulty rising from a seated
position and straightening his trunk, but he has no difficulty
flexing his leg. Which of the following muscles is most likely
to have been injured?
1. Gluteus maximus
20%
2. Gluteus minimus
18%
3. Hamstrings
23%
4. Iliopsoas
17%
5. Obturator internus
22%
What is the most likely Dx?
1. Lytic metastasis
17%
2. Osteoporosis
15%
3. Multiple myeloma
20%
4. Paget’s Disease
14%
5. lymphoma
34%
Both pleural effusion and lobar pneumonia are
characterized by _____ heard on percussion.
34%
Tympany
Dullness
Resonance
Hyperresonance
28%
22%
Hy
pe
rre
so
na
nc
e
ce
Re
so
na
n
es
s
Du
lln
ny
17%
Ty
m
pa
1.
2.
3.
4.