Chapter 003. Decision-Making in Clinical Medicine (Part 9)

Evidence-Based Medicine The "art of medicine" is traditionally defined as a practice combining medical knowledge (including scientific evidence), intuition, and judgment in the care of patients (Chap. 1). Evidence-based medicine (EBM) updates this construct by placing a much-greater emphasis on the processes by which the clinician gains knowledge of the most up-to-date and relevant clinical research. The key processes of EBM can be summarized in four steps:1.Formulating the management question to be answered2. research dataSearching the literature and on-line databases for applicable3. and relevanceAppraising the evidence gathered with regard to its validity4.Integrating this appraisal with knowledge about the uniqueaspects...
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Chapter 003. Decision-Making in Clinical Medicine (Part 9) Chapter 003. Decision-Making in Clinical Medicine (Part 9) Evidence-Based Medicine The art of medicine is traditionally defined as a practice combiningmedical knowledge (including scientific evidence), intuition, and judgment in thecare of patients (Chap. 1). Evidence-based medicine (EBM) updates this constructby placing a much-greater emphasis on the processes by which the clinician gainsknowledge of the most up-to-date and relevant clinical research. The keyprocesses of EBM can be summarized in four steps: 1. Formulating the management question to be answered 2. Searching the literature and on-line databases for applicable research data 3. Appraising the evidence gathered with regard to its validity and relevance 4. Integrating this appraisal with knowledge about the unique aspects of the patient (including preferences) Steps 2 and 3 are the heart of EBM as it is currently used in practice. Theprocess of searching the worlds research literature and appraising the quality andrelevance of studies thus identified can be quite time-consuming and requiresskills and training that most clinicians do not possess. Thus, the best starting pointfor most EBM searches is the identification of recent systematic overviews of theproblem in question (Table 3-3). Table 3-3 Selected Tools for Finding the Evidence in Evidence-BasedMedicine Name Descriptio Web Address Availab n ility Eviden Comprehe http://www.ovid.com Subscripce-Based nsive electronic tion required;Medicine database that availableReviews combines and through integrates: medical center libraries and 1. The other Cochrane institutions Database of Systematic Reviews 2. ACP Journal Club 3. The Database of Abstracts of Reviews of Effectiveness Cochra Collection http://www.cochrane.org Subscripne Library of EBM databases tion required; including The abstracts of Cochrane systematic Database of reviews Systematic available free Reviews—full online; some text articles countries have reviewing funding to specific health provide free care topics access to all residents ACP Collection http://www.acpjc.org SubscripJournal Club of summaries of tion required original studies and systematic reviews; published bimonthly; all data since 1991 available on Web site, updated yearly Clinica Monthly http://www.clinicaleviden Subscripl Evidence updated directory ce.com tion required; of concise free access for overviews of UK and for common clinical developing interventions countries MEDL National http://www.nlm.nih.gov Free viaINE Library of Internet Medicine database with citations back to 1966 Note: ACP, American College of Physicians; EBM, evidence-basedmedicine. Generally, the EBM tools listed in Table 3-3 provide access to researchinformation in one of two forms. The first, primary research reports, is the originalpeer-reviewed research work that is published in medical journals. Initial access tothis information in an EBM search may be gained through MEDLINE, whichprovides access to a huge amount of data in abstract form. However, it is oftendifficult, using MEDLINE, to locate reports that are on point in a sea of irrelevantor unhelpful information and being reasonably certain that important reports havenot been overlooked. The second form, systematic reviews, comprehensivelysummarizes the available evidence on a particular topic up to a certain date andprovides the interpretation of the reviewer. Explicit criteria are used to find all therelevant scientific research and grade its qu ...