Transcript Physical Medicine & Rehabilitation Evidence

The Collaborative Role of Medical
Librarians in Facilitating the EBCAM
Faculty Development Workshop
Presented at the NCNMLG  MLGSCA  PNC/MLA
Joint Meeting  Sacramento, Jan 28-31, 2004
Linda S. Murphy, MLIS
Health Sciences Librarian
UCI Science Library
Desiree Lie, MD, MSEd
UCI CAM Taskforce, Chair
UCI Dept. of Family Medicine
7/17/2015
Funded by AMSA
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Background
 New CAM Center (Susan Samueli
Center for CAM) established in 2001
 New CAM curriculum to be introduced
starting 2002
• CAM Task Force: Multidisciplinary
membership
 AMSA Grant (2003)
 Provided faculty with skills to integrate CAM
instruction into a variety of teaching programs
and clinical settings.
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Workshop Development &
Implementation
 A small working group (2 MD faculty, a PhD
and a librarian).
 Workshop planning
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Established goals and objectives
Discussed presentation methods
Pre-designed 3 patient cases.
Identified literature, speakers, pre- and post
workshop assessment tools to evaluate learners’
EBCAM skills and knowledge
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Program Contents
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Welcome, Current state of CAM Education
Small Group Discussions
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Group 1: Discussed EBM search and critical
appraisal.
Group 2: Divided into 3 smaller groups to discuss
and use model patient cases for future CAM
instruction.
Lunch Break
Evaluating CAM instruction and competencies
Wrap up and suggestions for next year’s
program
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Clinical Scenario 1:
Back pain
 Pt: a 25-yr male restaurant manager, 6-months
of neck and LBP
 Px: localized pain in neck/shoulder; persistent
ache in L2-4; occasional headaches
 Dx: x-ray of the neck and lumbar spine was
normal
 Tx: given NSAIDs, exercise and PT without
resolution
 PtQ: will chiropractic manipulation or acupuncture
Rx improve pain and function and what risks
might be involved?
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Clinical Scenario 2:
Women’s health and Menopause
Pt:
a 50-yr female teacher with menopausal
symptoms, started HRT a yr ago working
with her physician to discontinue
Hx: breast cancer and heart disease
Dx: re-experiencing symptoms of hot flushes,
mood swings, and night sweats.
Tx: was treated with HRT.
PtQ: Black Cohosh, Red Clover, and Estroven
relieve menopausal symptoms; risk of
breast cancer and heart disease
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Clinical Scenario 3:
Congestive Heart Failure and Herbals
Pt: Mr. Mitchell, a 73 year old retired bus driver
Dx: hypertension and atrial fibrillation; insomnia;
gastrointestinal discomfort;
Tx: Digoxin (control heart rate) and Coumadin
(prevent thrombotic emboli);
hydrochlorothiazide (for hypertension)
Self Med: St. Johns Wart, Valerian (help with
sleep); Ginger (for GI Discomfort); Vitamin E
(for memory problems)
Probls: Digoxin and coumadin levels are unstable.
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Why Keep Up With the
Literature?
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Decide what diagnostic test to use
What treatment to choose
What expected outcome might be
Keeping up with the latest news in health
care
 Stay abreast of what patients bring in from
the media, from the Internet, from friends
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What is EBCAM?
 Integrates the best research evidence with
clinical expertise and patient values.
 Seeks to inform, leaving the final decision
to the clinician and patient.
 Effective means to bridge the gap between
information and practice.
 Facilitates interaction between
conventional and CAM practitioners.
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Why is EBCAM needed?
 Growing national interest in CAM
 A billion dollar industry, need evidence for
efficacy of CAM modalities.
 Recent movement to integrate CAM
content into allopathic curricula.
 Increased funding for CAM education.
 Faculty need updated knowledge for CAM
to be comfortable teaching students and
residents.
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The EBCAM Process
 Ask a well-structured clinical question;
 Conduct a high-quality literature search.
 Identify evidence most relevant to
addressing the clinical question;
 Appraise the quality of this evidence;
 Apply the evidence to the care of the
patient.
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Formulating Questions
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Background questions
Foreground questions
PICO
Select appropriate database/sources
Search Strategy
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Background Questions
 General clinical questions for background
knowledge.
 Can be answered by using “background”
resources, e.g., current textbooks, and narrative
reviews.
Foreground Questions
 Specific questions (Diagnosis, Etiology,
Prognosis, Therapy) about your patient:
 Need latest resources
 Answered by primary (original research) and
secondary (systematic reviews and practice
guidelines) sources
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Internet Searching
Google search
 “back pain" +acupuncture (120,000 hits)
 “low back pain” +acupuncture (27,900)
 “chronic low back pan” +acupuncture (5,020)
 “red clover” + “Hot Flushes” (3,760 hits)
 “red clover” +"menopausal symptoms”
(5,570)
 St. Johns Wort +Coumadin (9,090 hits)
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Researching Background
Questions
 What are the standard treatment for
back injury?
 What is acupuncture?
 What are Black Cohosh, Red Clover,
and Estroven used for today?
 What is atrial fibrillation?
 What are St. Johns Wart, and Valerian
used for?
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Background CAM Resources
The Natural Medicines Comprehensive
Database
 Provides evidence-based clinical data on
dietary supplements and natural products.
 Designed for medical professions and updated
daily.
 Products can be searched by scientific names,
common names, or brand names or by
ingredients.
 Search: Black Cohosh
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Search Results
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• 1998, a division of NIH.
• Exploring CAM and alternative healing
practices in the context of rigorous science.
• Educating and training CAM researchers,
disseminating authoritative info. to the public
and professions <http://www.nccam.nih.gov/>
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MEDLINEplus
• Access to info about specific diseases and
conditions.
• Links to self-help groups, consumer health info,
clearinghouses, list of CAM practitioners. in
Spanish and other languages, and clinical trials.
• Alternative Medicine
<http://www.nlm.nih.gov/medlineplus/alternativemedicine.html>
• Back pain <http://www.nlm.nih.gov/medlineplus/backpain.html>
• Interactive Tutorial
<http://www.nlm.nih.gov/medlineplus/tutorials/backpain.html>
• Chiropractic
<http://www.nlm.nih.gov/medlineplus/chiropractic.html>
• Acupuncture
7/17/2015<http://www.nlm.nih.gov/medlineplus/acupuncture.html>
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Researching Foreground
Questions
• How effective is spinal manipulation or
acupuncture compared with NSAID in reducing
back pain in your patient?
• What are the risks of HRT use, particularly with
respect to CHD events, compared with no HRT?
• What are the efficacy of black cohosh, red
clover and estroven in reducing menopausal
symptoms?
• What is the efficacy of St. John Wart in treating
a hypertensive patient with depression and atrial
fibrillation?
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Formulating Patient
Centered Questions
 P = Patient/Population/Problem
 I = Intervention/exposure or
prognostic factor
 C = Comparison/Control
 O = Outcome/s
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Framing PICO
Case #1: Back pain
• Given a 25-yr male restaurant manager with chronic neck/back
pain (P), does acupuncture or chiropractic Rx (I) compared with
ibuprofen and/or naprosyn (C) reduce symptoms of neck and
back pain (O)?
Case #2: Women’s Health and Menopause
• In female with menopausal symptoms, do natural hormones
(estroven, black cohosh, and red clover) compared to HRT or no
Rx, relieve menopausal symptoms and reduce the risk of heart
disease?
Case #3: Congestive Heart Failure and Herbals
• In elderly men with hypertension and atrial fibrillation, do multiple
supplements, herbs and vitamins interact with heart and blood
thinner medications, compared to medications only produce
poor control of Digoxin and unstable Coumadin levels?
Primary
vs.
Secondary Sources
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Primary Source:
Original Research, RCTS - CAM on PubMED
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PubMed Search Results
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Critical Appraisal
Protocols for validating quality of research articles
• Therapy = RCT
• Diagnosis = Sensitivity/Specificity, Predictive Value
of Tests
• Etiology = Cohort, Case-Controlled Studies
• Prognosis = Cohort, Follow-up Studies, Mortality
• Screening/Prevention
• Systematic Review
• Practice Guidelines
• Economic Analyses
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Critical Appraisal - Therapy
Are the Rx and control groups similar?
• Were patients randomized?
• Were the benefits of randomization preserved
through use of concealment and intention-totreat analyses?
Did the treatment and control groups remain
the same with respect to important
prognostic factors?
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Application to Patient
What were the results?
• What is the estimate of the effect?
• How precise is this estimate of the effect?
Can the results be applied to your patient?
• Is your patient similar to the patients in the
study?
• Were all important outcomes examined?
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Secondary Sources
Example 1: PubMed Clinical Queries – Systematic
Reviews
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Secondary Sources
Example 2: The Cochrane Library Systematic
Reviews
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Secondary Sources
Example 3: ACP Journal Club
• A publication of the American College of
Physicians, and BMJ Evidence.
• Screen and identify studies, then provide
abstracts with commentary.
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Tertiary evidence
Bandolier Complementary and Alternative
Therapies
• Include acupuncture, homeopathy, massage,
herbal medicine, supplements, and safety
concerns.
• Provides abstracts of systematic reviews, metaanalyses on CAM studies.
• Extracts info from secondary reviews of primary
trials.
• Contains over 100 summaries on the
effectiveness of CAM, e.g., Arthritis, bones and
joints <http://www.jr2.ox.ac.uk/bandolier/booth/booths/bones.html>
Workshop Summary
• Review EBCAM Process
• The EBM Guidebook
http://www.ucihs.uci.edu/com/meded/pd/PDPFD/EBM%20Guidebook1.pdf
• The Critical Appraisal Worksheets
http://www.cebm.utoronto.ca/teach/materials/caworksheets.htm
• Links UCI Libraries CAM Resources
<http://www.lib.uci.edu/online/subject/clinical/clinalt.html>
• Evaluated learners EBCAM knowledge and
skills : the interactive EBCAM case exam:
<http://meded.lib.uci.edu/database/ebcam/camexam.php>
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Challenges
• Lack of clinical knowledge, e.g., Identify
valid questions that are patient-based
• Finding the appropriate literature for a CAM
case study
• Keeping up with the literature.
• Self learning and motivation
• Time
• Teaching different levels of learners
• Getting support from library administration
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Thank you!
Questions?
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