April 3, 2014
“It is astonishing with how little reading a doctor can practice medicine, but it is not astonishing how badly he may do it.” Sir William Osler 1849-1920
Why should you bother searching for the evidence, why is it difficult to keep up to date? These questions keep arising and the major problem is the sheer volume of published material; 20,000 trials each year, 50 new randomized trials per day.
You might consider one of the following:
- Reading an evidence-based abstraction journal,
- Keeping a log book of your own clinical questions, or
- Running a case based discussion journal club around questions you have recorded and selected.
One of the key components of evidence based practice is reflecting on how you learn and how you keep up to date and in addition, how much time you spend on each process. Activities usually identified by clinicians include: attending lecture and conferences, reading journals, tutorials, textbooks and guidelines, clinical practice, small group learning, study groups, electronic resources, and speaking to colleagues and specialists. There is no right or wrong way to learn, but it is impossible to keep up to date with all the latest advances.
Some of the things you may want to consider
The first thing is to recognize the questions out there:
- How many do you and answer, if so How?
- Do you keep a record of your questions?
- How many foreground questions are you answering (link to questions section).
One of the things we’ve found useful is to keep a record of our questions in a logbook (link to EBM logbook). We often give these out on workshops to folk.
Are you using the components of a well built clinical question: a) the patient, problem, or population, b) Intervention, exposure, or maneuver, c) comparison (if relevant), d) clinical outcomes (including time horizon).
To achieve the right balance it can be helpful to think of learning as a ‘push’ and ‘pull’ activity.
The ‘push’ method
Information can be gathered from a variety of sources across a wide spectrum of topics. This could be lectures, seminars, reading journals or just listening. We have no control over the content, it is often helpful, but often does not match the questions arising each day in practice. To aid the ‘push’ technique you may consider reading some pre-appraised source material. An example is the Evidence-Based Medicine Journal or Clinical Evidence. For example, the EBM journal scans 120 plus journals per year, for some 50,000 articles, rating them for validity and clinical relevance, and selects approximately 0.5% of these articles. This cuts down the number needed to read to find a clinically relevant article likely to change practice to about 20.
The ‘pull’ Method
Whereby you keep a record of questions formulated using the PICO principle outlined and then ‘pull’ information as you need it.
Resources to use include BMJ updates; Clinical Evidence and the use of a formal literature search can be useful.
What might you consider as your first steps in developing evidence-based practice?
Firstly, read an evidence-based abstraction journal. Secondly, keep a log book of your own clinical questions and thirdly consider running a case based discussion journal club around questions you have recorded and selected. These journal clubs aim to advance the quality of care and knowledge in a group setting. The common themes in effective journal clubs seem to be that they are question-driven and appraisal-focused and seek to generate a written record (often as a critically appraised topic, or sometimes a Best Evidence Topic. (See www.bestbets.org)
Evidence based medicine: increasing, not dictating, choice
BMJ 2007; 334 Suppl 1:s10
Dickersin K, Straus SE, Bero LA
The well-built clinical question: a key to evidence-based decisions
ACP J Club 1995; 123(3):A12-A13
Richardson WS, Wilson MC, Nishikawa J, Hayward RS
What makes evidence-based journal clubs succeed?
ACP J Club 2004; 140(3):A11-A12
Phillips RS, Glasziou P