Welcome…
Training Residents in the EvidenceBased Practice of Surgery
Presented by: Lori J. Toedter, PhD, Department of Research
Co-Developers: Lora L. Thompson, MSLIS, AHIP, Medical Library Director
Chand Rohatgi, MD, FACS, Department of Surgery
Purpose of this Workshop
• Familiarize participants with EBP/S concepts
• Describe skill sets for collaborating instructors
[Overview: See pp. 2-3]
• Provide details on how to start and run a program
like ours [Quick overview: See p. 1]
• Demonstrate the ways in which our evidencebased approach assists in fulfilling ACGME
competencies
Workshop Organization
• PART 1: Overview of the Evidence-Based
Practice of Surgery & Related Concepts
• PART 2: The “How To’s” of Starting a
Program
PART 1
The Roots of the Evidence-Based
Practice of Surgery: EBM [p. 2]
“the conscientious, explicit, and judicious use of the current
best evidence in making decisions about the care of
individual patients.”
-SACKETT DL, ROSENBERG WMC, HAYNES RB, et al. EVIDENCEBASED MEDICINE: WHAT IT IS AND WHAT IT ISN’T. BMJ 1996;
312: 71-2.
Defining EBM: From the
Surgeon’s Perspective
“EBM is about integrating individual clinical expertise
and the best external evidence derived from research.”
-BLACK N. EVIDENCE-BASED SURGERY: A PASSING FAD?
WORLD J SURG 1999; 23: 789-793.
The Controversy
[See Appendix, pp. 21-22]
The pros and cons of evidence-based surgery
Evidence-based science: A worthwhile mode of surgical inquiry?
Surgical practice is evidence based
Evidence-based surgical practice: What is it and do we need it?
Evidence-based surgery: A passing fad?
Role of the ACS
• Formation of the Office of Evidence-Based
Surgery (2003) (Appendix: p. 24)
– Accessible sources of best evidence
– Reliable outcome studies & clinical trials
• Name Change: Office of Continuous
Quality Improvement
– Initiation of evidence-based reviews in surgery
(2005) (Appendix: p. 22)
What the Training Programs
Need to Do
• Recognize the difficulties of conducting
randomized controlled trials in surgery
• Acknowledge that there will never be
enough Cochrane reviews to cover all the
questions surgeons have
• Commit to training residents in the “how
to” of answering clinical questions with the
best evidence available
Evidence-Based Practice of
Surgery in Resident Training
• Literature is over-focused on critical
appraisal skills (World J Surg May, 2005)
• Databases lead the user to be overconfident
• Many practicing surgeons lack access to
medical library services
• Forming searchable patient care questions is
a teachable skill
4 Steps in the
Evidence-Based Practice of Surgery [p. 2]
1. Formulate a question based on clinical situation
encountered in daily practice.
2. Do a focused search of the relevant literature.
3. Critically appraise the literature obtained to
find the best evidence.
4. Integrate information (both internal and
external) and act in accordance with the best
available evidence.
Formulating the Clinical
Question
• Not all questions are created equal !!
• Where do the questions come from?
– One’s own experience in patient care
– One’s attending/mentor
– The patient
Formulating the Question
From a breast cancer patient:
“ Should I be taking arimidex? I read about it
in the newspaper.”
What the EBP/S Novice Does
• Uses your MEDLINE search engine to enter
the logical words (see p. 8):
– Breast Cancer/tamoxifen/arimidex
• Gets 6950 ‘hits’ and looks at the first
abstract (p. 9)
• Sees no relevance to patient care & walks
away annoyed or angry!
What the EBP Trained Resident Does:
The PICO Model [p. 4]
Well-framed clinical questions contain the following components:
P – The Patient or Problem addressed
I – The Intervention (or Exposure) being considered
C – A Comparison intervention or exposure
O – The clinical Outcome of interest
Reframing the Question Using PICO
P – Women with advanced breast cancer taking tamoxifen
I – Adding arimidex to tamoxifen
C – Tamoxifen alone
O – Increased length of disease-free survival
Question in PICO Format
“Will adding arimidex to tamoxifen in the
adjuvant treatment of advanced breast
cancer increase the patient’s disease-free
survival?”
The PICO-Guided Search
• Search an inexperienced searcher can perform
after initial training (See pp. 5-7)
• Searcher is now using: medical subject headings,
text words and limiters (See p. 10)
• RESULTS: 31 hits with first abstract a best
evidence article (See p. 11)
• Note to surgical trainees: EBP saves time and
gets better results!!
PART 2
The “How To”
Starting a Training Program
in the
Evidence-Based Practice of Surgery
Your Key Personnel
(See p. 12 for detail on skill sets )
• Attending Surgeon
• Medical Librarian
• Research Coordinator/Clinical Research
Specialist
PLUS!! The good will and support of the Program
Director and Residency Coordinator
What the Attending Surgeon
Contributes
• Professional expertise in the subject matter
• Enthusiasm as a role model and mentor
• An inquiring mind!
What Your Medical Librarian Contributes
 Information literacy education (One-on-one and
group instruction)
 Expert help with multiple databases
 Interlibrary loan for accessing articles not
available in the library
What Your Research
Coordinator (or Clinical Research
Specialist) Contributes
• Training in critical analysis of the literature
• Liaison with attending surgeon and librarian
• Assistance in the selection of best evidence
Overview of the Evidence-Based Practice in
Surgery (EBP/S) Curriculum [pp. 1&12]
Session 1
Introduction to EBS, the EBS Controversy &
the Focused Clinical Question
Attending, Librarian & Research Coordinator
Session 2
Introduction to the Literature Search
Librarian
Session 3
Critical Analysis of the Results of a
Literature Search
Attending & Research Coordinator
Sessions 4+ The Evidence-Based Practice in Surgery
Journal Club
Attending, Librarian & Research Coordinator
Session 1 (Orientation Week)
• Introduction to the Evidence-Based Practice of
Surgery (Appendix, pp. 21-22)
• Discussion of the Controversy
(Appendix, pp. 21-22)
• PICO Practice
• Journal Club Overview (pp. 16-17) &
Schedule (p.18)
Approx. 1 hour in length (see p.1)
Session 2 (Early Summer)
• Introduction to Literature Searching
– Librarian-led search on topic of interest from
previous year’s clubs
– Review of Search Help Sheets (pp. 5-7)
– Practice Search Assignment distributed
Approx. 1 hour in length (see p.1)
Session 3 (Late Summer)
• Critical Analysis of the Literature
– Tips for Selecting Best Evidence (Using
abstracts obtained in practice search)
– Levels of Evidence & Users’ Guides
– Assign Critical Analysis exercise
Approx. 1 hour in length (see p.1)
Tips for Selecting Best Evidence
[p.12]
•
•
•
•
•
•
Directly answers PICO question
Well-respected journal
Highest quality of evidence
Larger sample size
More recent
Not sponsored by those with vested interest
Oxford Centre for Evidence-based Medicine Levels of Evidence
Level 1a:
Systematic Review (i.e. Meta-analysis) with
homogeneous RCTs
Level 1b:
Individual RCT with narrow confidence intervals for
primary outcomes
Level 2a:
Systematic Review with homogeneous cohort studies
Level 2b:
Individual Cohort Study (including low quality RCTe.g.<80% follow-up)
Oxford Centre for Evidence-based Medicine Levels of Evidence
Level 3a:
Systematic Review with homogeneous case-control
studies
Level 3b:
Individual Case-control study
Level 4:
Case Series (and poor quality cohort & case-control
studies)
Level 5:
Expert opinion
Users’ Guides to the
Surgical Literature
Three Main Questions:
(See Annotated Bibliography, pp. 24-25)
1. Are the results of the study valid?
2. What were the results?
3. Will the results help me in caring for my
patients?
Session 4 (Early Fall)
• Literature Search II: Tailored to Individual
Resident Needs
– 1-on-1 and small group sessions with medical
librarian and/or research coordinator
– First assignment given (due in 2 weeks)
Approx. 1 hour in length (see p.1)
Resident Search Assignment
Advantages of Using Assignments:
Gives the attending surgeon, medical librarian and
research coordinator objective data upon which to
base their evaluation of residents

Provides assessment of learning needs of
residents to facilitate program planning

Training streamlines future searches for
residents

Involves a hands-on strategy oriented to
professional adult learners
Sample Assignment
(See bottom, p. 13)
The Question: In diabetic patients with foot
ulcers or gangrene, does hyperbaric oxygen
therapy quicken wound healing?
The Assignment
1. Perform a literature search using Medline in
EBSCO.
2. Print your search results and your search
history (see librarian if not sure how to do this).
3. Review the abstracts; indicate which articles
represent the best evidence in answer to the
question posed.
4. Drop your materials off in the Medical Library
no later than Friday, April 15.
Evaluating Assignments
• Master search is completed by librarian
(See p. 14 top)
• Summary of best evidence completed by
attending & research coordinator (See p. 14
bottom)
• EELSEF Form completed (See p. 15): Copy
for resident & copy for files)
The Evidence-Based Practice of Surgery
Journal Club: Purpose [pp. 16-17]
• Assist residents in learning library search skills to
obtain the most relevant articles in answer to a
well-framed clinical question
• Train residents in the critical appraisal of the
literature
• Assist residents in refining their professional
presentation skills
• Update attendees on contemporary clinical issues
relevant to patient care
• Allow discussion & debate of newly emerging
issues in the surgical literature
The EBP of Surgery Journal Club
• Run quarterly (can cover 2 topics in 1 hour)
• Dates scheduled at beginning of academic
year (See sample schedule, p. 18 & sample
club announcement, p. 19)
• Due dates on sample schedule appear on
monthly calendar prepared by Residency
Coordinator
Journal Club Process
• Residents must comply with dates for getting
question to attending, consulting on literature
search & critical analysis, getting articles to
attendees
• Brief presentation of best evidence articles and
approach to their selection (5-10 minutes)
• Discussion focuses on whether the answer to the
question will change clinical practice (15-20
minutes)
Good EBS/P topics are
ones that. . .
Question the “traditional wisdom”
Example: The need for nasogastric tube or
decompression after GI surgery.
Good EBP/S topics are
ones that. . .
Are part of a paradigm shift due to
changing technology
Example: The need for exploration of all 4 parathyroid
glands in contemporary hyperparathyroid
surgery with evolution of (1) the hand held
gamma probe; (2) the quick PTH assay
Good EBS topics are
ones that. . .
Have a potential for impact on
practice/patient care
Example: Use of ultrasound in breast/surgical procedure
Example: Use of lymphatic mapping in breast and other
solid cancers
Good EBS topics are
ones that. . .
Have potential for generating resident
research projects
Example: Use of ultrasound in diagnosing acute
cholecystitis in the university vs. community
hospital setting
EBP/S in Helping to Meet
the ACGME Competencies
 Patient Care
 Medical Knowledge
 Practice Based Learning and
Improvement
The EBP/S Journal Club and
the ACGME Competencies
PATIENT CARE


Make informed decisions about diagnostic and
therapeutic interventions based on patient
information and preferences, up-to-date scientific
evidence, and clinical judgment.
Use information technology to support patient
care decisions and patient education.
The EBP/S Journal Club and
the ACGME Competencies
MEDICAL KNOWLEDGE

Demonstrate an investigatory and analytical
thinking approach to clinical situations.
The EBP/S Journal Club and
the ACGME Competencies
PRACTICE-BASED LEARNING AND IMPROVEMENT



Locate, appraise, and assimilate evidence from
scientific studies related to their patients’ health
problems.
Apply knowledge of study designs and statistical
methods to the appraisal of clinical studies and
other information on diagnostic and therapeutic
effectiveness.
Facilitate the learning of students and other health
care professionals.
The EBP/S Program: Documenting
Performance in Resident Evaluation
• Assignments/Continuous Improvement
• Journal Club Discussion and preparation
• See p. 20: Items 5, 6, 7 completed every 6
months by surgical attending, librarian &
research coordinator
Thank You!
We welcome feedback so that we
can continue to
improve our program.