Transcript Having been chairman of obstetrics and gynecology departments at

EVIDENCE-BASED MEDICINE
CAN WE PRACTICE EFFECTIVELY
WITHOUT IT
?
Hassan Ba’aqeel MBBS, FRCSC, FRCOG
Chairman Depart. of Obs&Gyn,
King Khalid National Guards Hosp.,
Jeddah – Saudi Arabia.
Readings
As a researcher, knowing the importance of
translating research results into practice and the
fact that over the last 2 decades an ever
increasing number of Randomized Controlled
Trials evaluating traditional concepts being
published and the evolution of formal system of
evaluation of evidence, I became interested in
Evidence-Based Medicine (EBM). Having been
chairman of obstetrics and gynecology
departments at various institutions, I'm excited
about EBM that provided me with a scientific
tool that helped me to induce positive changes in
clinical practice.
THE HISTORIC PARADIGM
 Authoritarian education and practice
Experts
Textbooks
Consensus statements
 The assumption :
“Professional authorities represent
infallible and comprehensive knowledge”
THE HISTORIC PARADIGM
(Cont’d)
 A number of prestigious authority figures.
 Sometimes the advice lacked scientific proof.
Delayed true progress in optimizing
maternal fetal outcome.
THE HISTORIC PARADIGM
(Cont’d)
 Prominent examples of “The advice”
 Bloodletting for eclamptic fits.
 Diuretics for preeclampsia.
 Routine episiotomy.
 “Once a section always a section”.
 Ventrosuspension for infertility.
 Removal of epsilateral ovary in EP.
THE EVIDENCE-BASED PARADIGM
 Recognition of the need to encourage
patterns of care that do more good
than harm.
 Taking greater account of
systematically collated EVIDENCE.
 Responding to the teaching of Archie
Cochrane (1972)!
 “RCT” as the gold standard.
Drug Vs None drug type of interventions
ASSUMPTIONS OF
AUTHORITARIAN PARADIGM
 Individual clinical experience is the
foundation.
 Pathophysiology provide the
foundation.
 Personal/collective experience used
to evaluate new tests.
 Mastery of the subject areas dictate
practice guidelines.
ASSUMPTIONS OF
EVIDENCE BASED PARADIGM
 Systematic, reproducible attempts to
record outcome (RCT).
 Knowledge of pathophysiology alone
is insufficient.
 Formal rules of evidence are
prerequisites to understanding the
literature.
EBM - WHY BOTHER ? (1)
New types of
evidence are
being
generated
 Pathophysiology
Vs “RCT”
 Metaanalysis
Major changes in patient care
EBM - WHY BOTHER ? (2)
In spite of clear need for the evidence
WE FAIL TO GET IT
STAGE OF
CAREER
RANGE OF
MEDIAN
READING
TIME (mins)
Medical Student
60 –120
Intern
0 – 20
Resident
10 –30
Registrar
10 – 90
Senior Registrar
10 – 45
Consultant <15 yrs
15 – 60
Consultant >15 yrs
10 - 45
% No
READING
LAST
WEEK
0%
UP TO 75 %
UP TO 15 %
UP TO 40 %
UP TO 15 %
UP TO 30 %
UP TO 40 %
EBM - WHY BOTHER ? (3)
Because 1&2, up to date knowledge
and clinical performance
DETERIORATE WITH TIME
MCQ scores
BASIC KNOWLEDGE OF HT OVER TIME
10
20
30
40
Years since graduation
Years since graduation, Range (3-42)
(Range - )
50
EBM - WHY BOTHER ? (4)
 TRADITIONAL CME HAS
BEEN SHOWN THROUGH
RCT’s NOT TO IMPROVE OUR
CLINICAL PERFORMANCE !
EBM - WHY BOTHER ? (5)
 A different approach to clinical
learning utilizing “EBM” approach
has been shown to keep its
practitioner up to date
HYPERTENSION- KEEPING UP TO DATE USING
HYPERTENSION – KEEPING UP TO DATE USING EBM
EBM
80
Mean
Meantotal
totalscore
score
70
60
50
40
30
20
10
0
McMaster ----Toronto
-----
0
5
10
Years in
in practice
practice
Years
15
20
PRACTICING EBM, THE NEEDS
Evidence-based
approach to patient
care create the
NEED for Clinically
Important
Information about
PRACTICING EBM, THE STEPS
 Transform information needs into
answerable questions.
Track down the best evidence to
answer them.
Critically appraise the Validity and
usefulness of the evidence.
 Apply result of appraisal to clinical practice.
 Evaluate your performance.
Printed
reviews
CD ROM
Diskettes
THE
COCHRANE
LIBRARY
INPUT FROM CC
The Cochrane
Database of
Systematic Reviews
The Cochrane
Controlled Trials
Register
Collaborative
Review Groups
Internet
version
Databases of
abstracts of
reviews of
effectiveness
The Cochrane Review
Methodology
Database
Methods Working
Groups
The Cochrane Centers / Cochrane Fields
“ IT AIN’T SO MUCH WHAT
WE DON’T KNOW THAT
GETS US INTO TROUBLE
AS WHAT WE DO KNOW
THAT AIN’T SO “
•Will Rogers
•“An American cowboy philosopher”