internal medicine residency evidence-based practice intro & curriculum integrating...

Internal Medicine Residency Internal Medicine Residency Evidence-Based Practice IntroEvidence-Based Practice Intro

& Curriculum& Curriculum

Integrating Evidence-Based Integrating Evidence-Based Medicine Into Clinical Practice Medicine Into Clinical Practice

"The extent to which beliefs are based on evidence is very much less than believers suppose.“

Sceptical Essays, Bertrand Russell, 1928

BackgroundBackground• The ACGME and AAMC have called for intro of The ACGME and AAMC have called for intro of clinical epidemiology, biostatistics, critical clinical epidemiology, biostatistics, critical appraisal, and medical informatics in medical appraisal, and medical informatics in medical school and GME curriculaschool and GME curricula

• Traditional method: Traditional method: Journal ClubJournal Club

•95% of programs reporting an active Journal 95% of programs reporting an active Journal ClubClub11

• Emerging Method: Emerging Method: dedicated EBM curriculumdedicated EBM curriculum

•Includes Journal ClubIncludes Journal Club

•only 37% of programs report having such only 37% of programs report having such coursescourses22

1Sidorov, J. Archives of Internal Medicine, 1995; 155:1193-7.

2Green, M. Journal of General Internal Medicine, 2000; 15:129-33

Evidence-Based Practice Evidence-Based Practice CurriculumCurriculum

• Goals and ObjectivesGoals and Objectives – Improve residents’ ability to integrate Improve residents’ ability to integrate

clinical evidence into medical practice. clinical evidence into medical practice. – Improve EBM skillsImprove EBM skills

• Ask well-built clinical questions Ask well-built clinical questions

• Perform effective Perform effective (efficient)(efficient) literature literature searches searches • Utilize the NLM, other databasesUtilize the NLM, other databases• Use “best-evidence” resources, primary literatureUse “best-evidence” resources, primary literature• Learn basic critical appraisal skills Learn basic critical appraisal skills

• Apply to patientsApply to patients


• Goals and ObjectivesGoals and Objectives – Reduce barriers to accessing primary Reduce barriers to accessing primary

literatureliterature– Foster a sense of independenceFoster a sense of independence

• Improved EBM self-efficacyImproved EBM self-efficacy

• Enhance pattern of Enhance pattern of lifelong learninglifelong learning

– Promote self-efficacy in and professional Promote self-efficacy in and professional ethic of practice-based learning and ethic of practice-based learning and systems-based practice improvementsystems-based practice improvement

Evidence-Based Practice:Evidence-Based Practice:Curriculum Elements I - ContentCurriculum Elements I - Content

EBM Core Topics for EBM Core Topics for Conferences/RoundsConferences/Rounds

• Intro to EBP, Asking clinical questionsIntro to EBP, Asking clinical questions• Finding the Evidence Finding the Evidence • Articles about TherapyArticles about Therapy• Articles about DiagnosisArticles about Diagnosis• Articles about Harm/EtiologyArticles about Harm/Etiology• Articles about PrognosisArticles about Prognosis• Overviews/Meta-analysisOverviews/Meta-analysis• Basic Biostatistics & EpidemiologyBasic Biostatistics & Epidemiology• Likelihood Ratios, Medical decision makingLikelihood Ratios, Medical decision making

– Monthly Journal ClubMonthly Journal Club– M & M/ quality improvement conferenceM & M/ quality improvement conference– Ward Evidence-based Medicine RoundsWard Evidence-based Medicine Rounds– Annual Intern Project (more later)Annual Intern Project (more later)– Resident Practice Improvement Modules Resident Practice Improvement Modules

(PIM’s) through ABIM (more later)(PIM’s) through ABIM (more later)– Morning Report, Attending Rounds, Morning Report, Attending Rounds,

Preclinical conferencesPreclinical conferences

Evidence-BasedEvidence-Based PracticePractice::Curriculum Elements II - AvenuesCurriculum Elements II - Avenues


• EBP Attending RoundsEBP Attending Rounds– Goals:Goals:

• Consolidate K/S/A taught in the core Consolidate K/S/A taught in the core curriculumcurriculum

• Expand our knowledge baseExpand our knowledge base

– Monthly structureMonthly structure• 44thth Week Week Tue, Wed, Thu @ 0815-0845 Tue, Wed, Thu @ 0815-0845• Teams prepare discussionTeams prepare discussion• Present/discuss with facilitator, staff, and Present/discuss with facilitator, staff, and

chiefchief• Brief summary placed on web and in each Brief summary placed on web and in each

intern/resident’s training portfolios – due by intern/resident’s training portfolios – due by Thursday COB that weekThursday COB that week

Evidence-Based Practice Evidence-Based Practice RoundsRounds

Each team prepares the following Each team prepares the following presentation:presentation:

• A brief H&P and clinical questionA brief H&P and clinical question– Medical student – 2 minMedical student – 2 min

• Search processSearch process– Intern – 3 minIntern – 3 min

• Presentation of the best evidencePresentation of the best evidence– Intern – 5 minIntern – 5 min

• Critical Appraisal using McMaster criteria Critical Appraisal using McMaster criteria – Resident - 10 minutesResident - 10 minutes

• Group discussion: How can the information Group discussion: How can the information be applied?be applied?

Evidence-Based Practice Evidence-Based Practice Basics:Basics:

Asking the Right QuestionsAsking the Right Questions

““The most important thing is to The most important thing is to never stop questioning”never stop questioning”

-Albert Einstein

What is EBM?What is EBM?

““the conscientious, explicit and the conscientious, explicit and judicious use of current best judicious use of current best evidence in making decisions about evidence in making decisions about the care of the individual patient. It the care of the individual patient. It means integrating individual clinical means integrating individual clinical expertise with the best available expertise with the best available external clinical evidence from external clinical evidence from systematic research." systematic research."

-Sackett D, 1996-Sackett D, 1996

What is EBM?What is EBM?

• Medical decisions based on: Medical decisions based on: – best research evidencebest research evidence– clinical expertiseclinical expertise– patient valuespatient values

• Useful framework:Useful framework:– good patient caregood patient care– effective medical educationeffective medical education

What EBM is not.What EBM is not.

• Rigid format that removes clinical Rigid format that removes clinical judgmentjudgment

What does it mean to “Practice What does it mean to “Practice EBM”? EBM”? ((RRecognize the 4 ecognize the 4 AA’s)’s)

1)1) RRecognize: ecognize: need for informationneed for information

2)2) AAsk: sk: answerable clinical questionanswerable clinical question

3)3) AAcquire: cquire: searchsearch for “best evidence” for “best evidence”

4)4) AAssess: ssess: critical appraisal critical appraisal (validity, (validity, impact)impact)

5)5) AApply:pply: integrate integrate with with youryour patient patient Own clinical expertiseOwn clinical expertise Patient’s unique biology, Patient’s unique biology,

values, and circumstancesvalues, and circumstances

Case – Obscure GI BleedCase – Obscure GI Bleed

Your patient: 64 yo man admitted to your service after presenting to the ED with weakness.

In the ED: heme (+) stools and microcytic anemia

Further eval:

-verified Fe deficiency, but colo/EGD (-) -no signs of hemolysis or heme pathology

You transfuse and discharge him, but he returns one month later, with the same thing.

What kind of information can help you with the management of this patient?

Step 1: Step 1: Recognize need for infoRecognize need for info

• Learning entry point is curiosity…Learning entry point is curiosity…need to knowneed to know

• Doctors under-estimate our need for infoDoctors under-estimate our need for info– Up to 5 times per inpatient encounterUp to 5 times per inpatient encounter– 2 out of 3 outpatient visits2 out of 3 outpatient visits

Work of getting informationWork of getting information

++

Limited TimeLimited Time

Information Information needs not needs not

metmet

Getting knowledge into Getting knowledge into practice… practice… AcquisitionAcquisition versus versus

ApplicationApplication• ReplicativeReplicative

– Read/rememberRead/remember– Implicitly accept/followImplicitly accept/follow

• Appraisal-basedAppraisal-based– Involves all five steps of EBMInvolves all five steps of EBM– Time consuming…Time consuming…easier with practice!easier with practice!– Use for: Use for: problems dealt with most oftenproblems dealt with most often

•E.g. Morning report, Journal Club, EBM E.g. Morning report, Journal Club, EBM rounds rounds

Getting knowledge into Getting knowledge into practice… practice… AcquisitionAcquisition versus versus

ApplicationApplication• EBM Review-basedEBM Review-based

– Skips lengthy critical appraisal stepSkips lengthy critical appraisal step– Only search Only search pre-appraisedpre-appraised resources resources

•Explicit criteria for evidence selectionExplicit criteria for evidence selection

•Rigorous evaluation for validityRigorous evaluation for validity

– Examples: Examples: Cochrane Database, ACP Cochrane Database, ACP Journal Club, Clinical Evidence, UpToDate?Journal Club, Clinical Evidence, UpToDate?

– Use for: day-to-day questions in busy Use for: day-to-day questions in busy practice/wardpractice/ward

Step 2: Convert Info Need into… Step 2: Convert Info Need into… Answerable Clinical QuestionAnswerable Clinical Question

• Good Clinical Questions:Good Clinical Questions:– Begin with Begin with patient issuepatient issue

– ClarifyClarify particular informational needs particular informational needs

– Make knowledge acquisition Make knowledge acquisition timelytimely……It’s unlikely that management conference this It’s unlikely that management conference this week will coincidentally be about your patientweek will coincidentally be about your patient

– Suggest Suggest high-yield searchhigh-yield search strategies strategies

– Entry point for evidence-based Entry point for evidence-based learninglearning

Different Types of Different Types of QuestionsQuestions

Case: 47 year old woman with systemic lupus on prednisone presents with two days of nausea and abdominal discomfort and one day of vomiting, occasionally with coffee ground emesis.

Supine BP 120/65, pulse 65; Standing BP 112/55, pulse is 71.

Labs: Hct 32, creatinine 2.3 (1.2 last March), urine sediment has some red cells and granular casts.

What questions would you ask about this patient?

Different Types of Different Types of QuestionsQuestions

Background QuestionsBackground Questions– Ask for general knowledge about disorderAsk for general knowledge about disorder– 2 essential components2 essential components

1.1.A question root (5 W’s) with a verbA question root (5 W’s) with a verb2.2.A disorder or aspect of a disorderA disorder or aspect of a disorder

– Examples:Examples:• How do you work up a GI bleeder?How do you work up a GI bleeder?• What is relationship between H. Pylori and What is relationship between H. Pylori and

steroids?steroids?• What are the renal manifestations of lupus?What are the renal manifestations of lupus?• Why are interns so tired?Why are interns so tired?

Different Types of Different Types of QuestionsQuestionsForeground QuestionsForeground Questions

– Asks for specific knowledgeAsks for specific knowledge– Usually refer to patientsUsually refer to patients– Three (or four) componentsThree (or four) components

• PPatient (or problem) of interestatient (or problem) of interest• IIntervention of interest– “an ntervention of interest– “an

exposure”exposure”• CComparison intervention (if relevant)omparison intervention (if relevant)• OOutcome of clinical interestutcome of clinical interest

Different Types of Different Types of QuestionsQuestionsForeground QuestionForeground Question Examples:Examples:

– For patients on chronic steroids with acute GI For patients on chronic steroids with acute GI bleed due to PUD, does H. Pylori Rx reduce bleed due to PUD, does H. Pylori Rx reduce rebleeding?rebleeding?

– For patients with lupus and suspected acute For patients with lupus and suspected acute lupus nephritis, what is the prognostic value lupus nephritis, what is the prognostic value of renal biopsy?of renal biopsy?

Types of QuestionsTypes of Questions

• Clinical FindingsClinical Findings: how to gather & interpret findings from the : how to gather & interpret findings from the H&PH&P

• EtiologyEtiology: how to identify causes for disease: how to identify causes for disease

• DDxDDx: what are they, ranked by likelihood, seriousness, and : what are they, ranked by likelihood, seriousness, and treatabilitytreatability

• Diagnostic TestsDiagnostic Tests: confirm/exclude a dx: look at : confirm/exclude a dx: look at test test characteristics characteristics (sensitivity, specificity, accuracy, PPV/NPV, safety, (sensitivity, specificity, accuracy, PPV/NPV, safety, expense, etc.)expense, etc.)

• PrognosisPrognosis: estimate likely clinical course and anticipate likely : estimate likely clinical course and anticipate likely complications of disease.complications of disease.

• TherapyTherapy: select treatments that do more good than harm and : select treatments that do more good than harm and worth the effort and cost of using themworth the effort and cost of using them

• PreventionPrevention: reduce chance of disease by identifying and : reduce chance of disease by identifying and modifying risk factors and how to screen for diseasemodifying risk factors and how to screen for disease

Practice Asking Questions…Practice Asking Questions…

• 47 y/o man with sarcoidosis has 47 y/o man with sarcoidosis has recently been diagnosed with HIVrecently been diagnosed with HIV

• ““Doctor, how will my HIV affect my Doctor, how will my HIV affect my sarcoidosis?”sarcoidosis?”

WhatWhat’’s the Purpose?s the Purpose?

• In patients with sarcoidosis, does HIV In patients with sarcoidosis, does HIV lessen or worsen their disease severity?lessen or worsen their disease severity?

• A question of…A question of…A)A) DiagnosisDiagnosis

B)B) PrognosisPrognosis

C)C) EtiologyEtiology

D)D) TherapyTherapy

E)E) PreventionPrevention

The ElementsThe ElementsP - The patient/population OR problem P - The patient/population OR problem

being addressedbeing addressed

I - The “intervention” or questionI - The “intervention” or question

C - A comparison (when relevant)C - A comparison (when relevant)

O - The outcome or outcomes of interestO - The outcome or outcomes of interest


being addressedbeing addressed SarcoidosisSarcoidosis

I - The “intervention” or questionI - The “intervention” or question





I - The “intervention” or questionI - The “intervention” or questionHIV/AIDSHIV/AIDS






C - A comparison (when relevant)C - A comparison (when relevant) no HIV/AIDSno HIV/AIDS





C - A comparison (when relevant)C - A comparison (when relevant) no HIV/AIDSno HIV/AIDS

O - The outcome or outcomes of interestO - The outcome or outcomes of interest SeveritySeverity

Type of Question?Type of Question?

Background or Foreground?Background or Foreground?

The SearchThe Search

1. exp SARCOIDOSIS, PULMONARY/ 1. exp SARCOIDOSIS, PULMONARY/

or exp SARCOIDOSIS/ or sarcoidosis.mp.or exp SARCOIDOSIS/ or sarcoidosis.mp. 15526 15526

2. (HIV or human immunodeficiency virus).mp. 2. (HIV or human immunodeficiency virus).mp.

mp=title, original title, abstract, name mp=title, original title, abstract, name

of substance, mesh subject heading]of substance, mesh subject heading] 126887 126887

3. (AIDS or autoimmune deficiency syndrome).mp. 3. (AIDS or autoimmune deficiency syndrome).mp.

[mp=title, original title, abstract, name of [mp=title, original title, abstract, name of

substance, mesh subject heading]substance, mesh subject heading] 78196 78196

4. (prognosis or symptoms or survival or mortality4. (prognosis or symptoms or survival or mortality

or quality of life or outcome).mp. [mp=title, original title,or quality of life or outcome).mp. [mp=title, original title,

abstract, name of substance, mesh subject heading]abstract, name of substance, mesh subject heading] 911606 911606

5. 2 or 35. 2 or 3 171810 171810

6. 1 and 56. 1 and 5 140140

7. 4 and 67. 4 and 6 2222

10. from 7 keep 1-2, 4, 14-15, 1710. from 7 keep 1-2, 4, 14-15, 17 66

The ResultsThe Results1.1. Hill KA. Till M. Laskin WB. Pathologic quiz case: Hill KA. Till M. Laskin WB. Pathologic quiz case: PulmonaryPulmonary symptomssymptoms and lymphadenopathy and lymphadenopathy

in a in a humanhuman immunodeficiencyimmunodeficiency virusvirus-infected woman. [Case Reports. Journal -infected woman. [Case Reports. Journal Article]Article] ArcArchivhives of Pathology & Laboratory Medicine. 127(1):111-2, 2003 Jan.es of Pathology & Laboratory Medicine. 127(1):111-2, 2003 Jan. UIUI: 12562277 : 12562277

2.2. Haramati LB. Lee G. Singh A. Molina PL. White CS. Haramati LB. Lee G. Singh A. Molina PL. White CS. Newly diagnosed Newly diagnosed pulmonarypulmonary sarcoidosissarcoidosis in in HIVHIV-infected patients. [Journal Article]-infected patients. [Journal Article] Radiology. 218(1):242-6, 2001 Jan.Radiology. 218(1):242-6, 2001 Jan. UIUI: 11152809 : 11152809

3.3. Newman TG. Minkowitz S. Hanna A. Sikand R. Fuleihan F. Newman TG. Minkowitz S. Hanna A. Sikand R. Fuleihan F. Coexistent Coexistent sarcoidosissarcoidosis and and HIVHIV infection. A comparison of bronchoalveolar and peripheral blood lymphocytes.[see infection. A comparison of bronchoalveolar and peripheral blood lymphocytes.[see comment]. [Case Reports. Journal Articlecomment]. [Case Reports. Journal Article] ] Chest. 102(6):1899-901, 1992 Dec.Chest. 102(6):1899-901, 1992 Dec. UIUI: 1446516 : 1446516

4.4. Lowery WS. Whitlock WL. Dietrich RA. Fine JM. Lowery WS. Whitlock WL. Dietrich RA. Fine JM. SarcoidosisSarcoidosis complicated by complicated by HIVHIV infection: infection: three case reports and a review of the literature. [Review] [25 refs] [Case Reports. three case reports and a review of the literature. [Review] [25 refs] [Case Reports. Journal Article. Review. Review of Reported CasesJournal Article. Review. Review of Reported Cases] ] American Review of Respiratory Disease. American Review of Respiratory Disease. 142(4):887-9, 1990 Oct.142(4):887-9, 1990 Oct. UIUI: 2221596 : 2221596

5.5. Gowda KS. Mayers I. Shafran SD. Gowda KS. Mayers I. Shafran SD. Concomitant Concomitant sarcoidosissarcoidosis and and HIVHIV infection. [Case infection. [Case ReportsReports. Journal Article] . Journal Article] CMAJ Canadian Medical Association Journal. 142(2):136-7, 1990 Jan 15.CMAJ Canadian Medical Association Journal. 142(2):136-7, 1990 Jan 15. UIUI: 2295031 : 2295031

6.6. Foulon G. Wislez M. Naccache JM. Blanc FX. Rabbat A. Israel-Biet D. Valeyre D. Mayaud C. Cadranel J. Foulon G. Wislez M. Naccache JM. Blanc FX. Rabbat A. Israel-Biet D. Valeyre D. Mayaud C. Cadranel J.

SarcoidosisSarcoidosis in in HIVHIV-infected patients in the era of highly active antiretroviral -infected patients in the era of highly active antiretroviral therapytherapy. [Journal Article] . [Journal Article] Clinical Infectious Diseases. 38(3):418-25, 2004 Feb 1.Clinical Infectious Diseases. 38(3):418-25, 2004 Feb 1. UIUI: 14727215 : 14727215

Remember “P-I-C-Remember “P-I-C-O”O”

P – Patient

I – Intervention

C – Comparison

O – Outcome

EBM is not an end in itself…EBM is not an end in itself…

““Whoever undertakes to set Whoever undertakes to set himself up as judge in the field himself up as judge in the field of truth and knowledge is of truth and knowledge is shipwrecked by the laughter of shipwrecked by the laughter of the Gods.”the Gods.”

-Albert Einstein-Albert Einstein

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