(First Annual)
Learning to Practice and Teach
Evidence-based Health Care
An Intensive Workshop
Introductions
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Robert Wild & Dave Thompson
Susan Hollingsworth
Speakers
Facilitators
Participants
A true story
• A randomized trial of treating high blood
pressure on the jobsite (a steel mill) vs.
referral for treatment to primary care
doctor
• Primary outcome: treatment compliance
• No difference in compliance between the
groups
• Some patients who were referred with
documented hypertension did not get
treated
Determinants of the clinical decision to
treat some, but not other, high blood
pressure patients:
1 The level of diastolic blood pressure.
2 The patient’s age.
3_
4 The amount of target-organ damage.
Determinants of the clinical decision to treat
some, but not other, hypertensive patients:
1 The level of diastolic blood pressure.
2 The patient’s age.
3 The physician’s year of graduation from
medical school.
4 The amount of target-organ damage.
How we “know”
• observations in the world
• clinical experience
– open to bias
• specious causal connections
• vividness and immediacy
• small samples
• laboratory and physiological research
– systematic but generalization dangerous
• observational studies
– non-comparable groups
What we (did) know that ain’t so:
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HRT to decrease cardiovascular risk
– observational studies consistently suggest
decreased risk
– RCTs show increased risk
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High flow oxygen for RDS
– My 6th grade pen-pal was in the “gifted
children” class at the Ohio state school for
the blind
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Anti-arrythmics post-MI
Contrasting Reasoning
• Patho-physiologic
reasoning
– Depends on logic and
knowledge of
pathophysiology
– This leads to a
decision to prescribe
flecainide to patients
after heart attack
• Evidence from
systematic studies in
human subjects:
– Randomized trial of
flecainide after MI:
• 7.7% dead on
flecainide
• 3.0% dead on placebo
– Leads to a decision
NOT to prescribe
flecainide after MI
Hierarchy of Evidence
Meta-analysis of RCTs
systematic review of RCTs
Individual RCT
Observational studies
patient-important outcomes
Basic research
test tube, animal, human physiology
Clinical experience
Why don’t we practice EBM?
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Exploding information supply
Textbooks are out of date
No time to read
Traditional CME doesn’t work
Asking questions
• Practice identifying information needs:
– Routinely question decisions
– Question routine decisions
• Identify the specific issue at hand
• Do you need background or foreground
information?
Identify the type of information
that is needed
• Background information: What IS
myelomonocytic leukemia?? Best source of
information for background questions is recent
textbooks or recent general review articles.
• Foreground information: Should patients with
myelomonocytic leukemia be treated with
methotrexate? The best information for
foreground questions comes from original
research in human subjects.
Asking Questions
• Design a focused clinical question that
addresses the information need
– Patient/population
– Intervention
– Comparison if relevant
– Outcome
• The “PICO question”
• PCOS
Why bother with EBM?
• without EBM we are helpless in the face of
– misguided experts
– overenthusiastic experts
– drug company hype
• without EBM our ability is limited
– to understand difficult tradeoffs
– to help our patients make difficult decisions
• with EBM comes
– understanding and power
– greater effectiveness in helping our patients
Seven Alternatives to Evidence
Based Medicine
• Eminence Based Medicine (marked by radiance
of white hair)
• Vehemence Based Medicine
• Eloquence Based Medicine
• Providence Based Medicine
• Diffidence Based Medicine
• Nervousness Based Medicine
• Confidence Based Medicine
– (Isaacs and Fitzgerald, BMJ 1999;319:1618)
Structure of the Workshop
• Breakfast at 8:00am both days
• First plenary at 9:15 am on Friday and 9:00am Saturday
• Small group sessions
– 10:15-11:40 am Friday, 1:30-3:30 pm Friday
– Saturday 10:15-11:30 adjourn Sat 11:30 am
• Box Lunches Friday and Saturday
• Lunchtime registrants hands - on searching session
today
– Sign up at registration table, limited space • facilitators go to room 251 Provost Conference PM
• Reception this afternoon after last plenary 4:45PM
• Please turn in your evaluations. CME can be obtained
for an additional $25 , slide presentations, and the library
resource guide with links to many, many helpful websites
will be posted on URL
http://moon.ouhsc.edu/dthompso/cdm/ebhc1/ … in your
packet
Goals of the workshop
• To learn and practice skills of critical
appraisal of the research literature
• To learn techniques for teaching EBM
Your own goals
• You will have come with your own
objectives for the workshop
– Please share them with your group
Ground Rules
• Facilitators are there to facilitate and
demonstrate
• Please arrive on time and prepared for
each session
• Have a good time!