Reflection: Evidence Based Medicine

This was definitely a jam-packed week of statistics and critical appraisal. It was very valuable to have the opportunities to not only learn about the different critical appraisal tools, but also apply and use it for patient cases. Even with the time allotted for us to use the tools, I was not able to finish going over the entire checklist and was able to truly appreciate how long a full and comprehensive critical appraisal can take. The big thing that most of our presenters emphasized was the need to practice, practice practice before you can expect to be efficient in this skill. As residency progresses, I aim to refine this skill as I prepare for my future journal clubs, project and literature searches.

 

Some points that I took away were:

  • Make evidence synopses! Always question the evidence of what you are recommending or counselling (e.g. no alcohol while taking antibiotics — this belief actually came about because people were dying from STIs and they were still infective while taking ab treatment, and alcohol increased the likelihood they would have more intercourse)
    • Cochrane reviews: as unbiased as you can get, but still have bias
    • Search: drug name meta-analysis systematic review, RCTs
  • Even if it is a small study where SS cannot be achieved (e.g. pilot studies), statistics can still be used to tell you about variance, mean, population size
  • Talking to patients about evidence
    1. Set the stage (WOW Intro: Who you are, Occupation, Why you are here)
    2. Use Framing language
    3. Understand the Patient’s Experience and Expectations
    4. Build partnerships
    5. Explain disease
    *Why they were at risk
    *Disease and symptoms
    *Impact of having that disease and complications
    6. Explain medications
    7. Provide Evidence on Benefit and Risk
    (Benefits, Risks, Characteristics)
    8. Elicit patient’s benefits, values and preferences
    9. Discuss a shared recommendation
    10. Check for understanding and agreement
    11. Talk about follow-up

Helpful Resources:

 

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EBM Day #2: Library Research

Library Session:

Despite all the library sessions we had throughout undergraduate, I still find myself struggling with navigating all the available resources when doing a literature search. After this session, I feel more comfortable with finding what resources would be most appropriate for the clinical question given. As I am not tech-savvy at all, I will aim to become familiar with one database for my primary literature searches (e.g. MedLine).

Systematic approach:

  • Obtain demographics of requestor
  • Obtain background information for the situation
  • Determine and categorize the ultimate question
  • Develop strategy, conduct search
  • Critically evaluate information
  • Formulate and provide response
  • Follow-up, document.

Some pearls and guidelines to searching:

  • Start general and then go more specific
    (e.g. tertiary → primary)
  • Purpose of MeSH terms:  ↑ specificity and relevancy of results
  • In order to find hallmark trial (e.g. finding all the analysis of it but can’t find original trial), sorting by date can help
  • Guidelines for Systematic Reviews:
    http://guides.library.ubc.ca/SystematicReviews
  • What characterizes a good drug information response:
    timely, current, accurate, complete, concise, well-referenced, clear, logical, unbiased, etc. “Tell me what you are going to say…Tell me what you said”
  • Tips for writing response:
    Keep it simple, use sub-headings, chronological, strength of evidence, compare/contrast, use tables to succinctly present data, don’t feel you need to include everything you want (e.g. exclude weaker evidence if stronger evidence exists = i.e. be selective)
  • Tips for verbal communication:
    check if requestor has time, dialogue, tailor level of information to requestor, etc.

General:

Specific:

  • Databases available: Medline, PubMed, Embase
    • Medline and Embase are available on Ovid (as Ovid needs to sign for the articles, it is slower than Pubmed) → PubMed is the fastest to update
    • For Medline:
      • Look at scope note (i under scope) and tree (by clicking the subject heading)
      • “Map term to subject headings”: Looks for search word as the key words (very literal)
        • By unclicking it, it will search “mp”: checking search word in multiple places (e.g. abstract, etc)
      • Explode: compile all the narrower headings into the search (depends on how the articles are organized)
        • e.g. useful for antidepressive agents → explode and search for all the names “under” antidepressive agents
      • Focus: finds MeSH term/sub-headings and tries to focus on articles where it is the main thing (i.e. what they think the article is actually about)
      • Able to explode and focus in the same search
      • Able to choose “Limits”
      • Can export up to 2000 at a time to RefWorks
      • Better than PubMed for finding good MeSH terms (PubMed is very literal — e.g. just putting an “s” at the end produces different results)
    • For Embase:
      • Good for Pharmacy Trade Magazines
      • 60% overlap with Medline
        • Available function to exclude Medline journals (exclusion not good for systematic reviews)
      • In Ovid, can change database from Medline to Embase
      • Medline and Embase can export citations
        • Export as RIS (recognized by Mendeley, etc)
      • As with Medline, check the tree (looks different – e.g. narrower words = what it will “explode” into)
      • Zotero and Mendeley don’t always import correctly form Embase
      • Updated weekly
    • For PubMed:
      • Automatically tries to match your search terms with MeSH terms
        • Able to see the MeSH terms in search details box
        • Change dropdown menu in the search bar from PubMed to MeSH to explore what MeSH terms, sub-headings are available
      • Automatically explodes
      • Medline from PubMed and Medline from Ovid = takes same time to get updated articles (updated daily)
    • Tutorials for Ovid: http://guides.library.ubc.ca/Ovid
  • Other Database:
    • CINAHL: http://resources.library.ubc.ca/92/
      • can be useful for qualitative studies
      • Embase and CINAHL has conference notes
    • Web of Science: more multi-disciplinary database (e.g. also has humanities, social science studies, good for doing systematic reviews; can also see who has cited the article since it was published)
    • GoogleScholar: lacking in advanced search terms
  • Citation management: Mendeley, Citeworks
    • merges results from different search databases

Other Resources:

  • Medicines Complete:
    • AHFS Drug Information (Monthly updates)
    • Martindale (Quarterly updates)
    • Stockley’s Drug Interactions (Quarterly updates)
  • Natural Medicines (updated daily)
  • Minor Side Effect of Drugs (print) — from head to toe
    • Available at DPIC or Woodward
  • British Columbia – guidelines from MOH and BCMA
    (can download all or access via compute or mobile device)
    http://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/bc-guidelines

    • May not be the most up to date, but can see what family physicians/GPs are referring to as standard of care
  • CPG Infobase: Clinical Practice Guidelines Database:
  • National Guidelines Clearing House
    • www.guideline.gov
    • US based but includes international clinical pharmacy guidelines, provides summary and links to full guideline, search by keyword, many filters in advanced search, FDA warnings mentioned, may be useful when local or national guidelines are not available
    • Good advanced search
  • NICE Guidance (National Institute for Health and Clinical Excellance) – from UK
  • TRIP Database (Turning Evidence into Practice):
    • https://www.tripdatabase.com/
    • Clinical search engine to find high-quality research evidence to support practice
    • Meta database – combs through all guidelines
    • Guidelines from around the world
    • PICO search
    • Also yields systematic reviews, evidence-based synopses and primary literature, blogs and eBooks
  • In order to find a book on a topic, can use UBC summons and limit to e-books and books under content type, and limit library location (e.g. to online)
  • Document delivery: click on title of book –> online catalogue –> blue box (order document delivery) –> can deliver to VGH library (e.g. from Okanagan or Woodward, etc)
  • Point of Care Tools: BMJ Best Practice, Dynamed, UptoDate
    • BMJ Best Practice: http://resources.library.ubc.ca/page.php?id=2279
      • over 1000 articles
      • incorporates BMJ’s clinical evidence reviews, guidelines and expert opinion
      • articles are signed and dated
      • easy to read; useful step by step treatment algorithms
      • App available
      • Drug info from martindale
    • Dynamed: considered to be one of the most current databases (can be difficult to read)
  • Evaluation of a Self-Paced Learning Module in Drug Literature Evaluation
    (available in Print)