Current issues of ACP Journal Club are published in Annals of Internal Medicine


Editorials

Evidence-based medicine on the wards: report from an evidence-based minion

ACP Journal Club. 1999 Jan-Feb;130:A15. doi:10.7326/ACPJC-1999-130-1-A15



I often hear people say, “Real doctors don't have time for evidence-based medicine.” In fact, practising evidence-based medicine while you work doesn't take much time at all—just motivation. I did it as a house officer (intern), and you don't get much busier than that. Once you get into the right frame of mind, it is hard not to work in an evidence-based way, and it is lots of fun.

How can you get started practising evidence-based medicine?

Evidence-based medicine uses information from high-quality clinical studies to answer questions about patients in your care. For newcomers, all this evidence mumbo-jumbo can seem intimidating and can cause you to lose sight of the goal—treating patients more effectively. Fortunately, there are plenty of ways to learn all the essential information relatively painlessly. First, excellent books and articles that can help are available (1-24) as well as some evidence-based textbooks (25-27).

Second, increasing numbers of courses are being offered by institutions worldwide that teach the process of asking answerable questions about patients, finding and appraising relevant articles quickly, and synthesising data into 1-page summaries called critically appraised topics (CATs). Courses are also available that are aimed specifically at medical students. Good examples are the Oxford and the Manchester Conferences on Critical Appraisal for Medical Students (http://cebm.jr2.ox.ac.uk/docs/cams.html). For information about other courses, see the Web sites at the U.K. Centre for Evidence-Based Medicine (http://cebm.jr2.ox.ac.uk) and McMaster University in Canada (http://hiru.mcmaster.ca/).

How can you carry out evidence-based medicine as a house officer or student?

In the beginning, don't be too ambitious. Practice evidence-based medicine only when you are in the mood. When you see a new patient, try to ask yourself 1 question about their treatment, diagnosis, or prognosis. Choose the problems you find most interesting and go searching.

First, search the databases that have articles already selected for quality, such as acpjc.org and the Cochrane Library. I can usually find a useful article in one of those sources in a couple of minutes. Subscriptions to these databases are cheap enough for you to put them on your home computer, allowing you to do searches when you want and not when the library is open. If you need to use MEDLINE, PubMed, which is produced by the U.S. National Library of Medicine, is available on the Internet for free (http://www.ncbi.nlm.nih.gov/PubMed/). PubMed includes a feature designed to tackle clinical problems and uses search filters developed at McMaster University to optimize retrieval of clinically applicable studies (28).

Photocopy the articles you find while you are digesting your lunch and read them during clinical meetings when everyone else is asleep. Don't forget to write a CAT and file it for easy reference. The U.K. Centre for Evidence-Based Medicine has produced a computer program called CATmaker that helps you create CATs and calculates such clinically useful statistics as relative risk reduction and numbers needed to treat. Try to write 1 or 2 CATs per week. It is better to have a few completed CATs than a dozen incomplete searches. Persevere: Your skills will increase quickly.

If you want to keep up-to-date with the journal literature, subscribe to “secondary review” journals like Evidence-Based Medicine or ACP Journal Club that have already screened for high-quality articles. These two journals are published bimonthly; therefore, you need only read six issues during your house-officer year to stay on top.

Once you have found the evidence, don't forget to apply it to your patient. Remember to incorporate your patient's ideas as well as advice from local experts into your decision. Doing what is best for your patient may not always match the best evidence.

How can you convince your superiors to practice evidence-based medicine?

When you are the most junior member in a team, it can be hard to get your bosses to listen to the great evidence you've found. My advice is to be subtle. Find articles that agree with your bosses' approach. Their response may be “Who needs evidence-based medicine to show that?” But you are bolstering their image as evidence-based clinicians, and you've learned something. Use mock uncertainty: “I'm not sure whether diclofenac is better than pethidine (meperidine) for ureteric colic. Can you help?” This will make your bosses feel needed and will allow you to chat about evidence-based medicine. All house officers have to make presentations: Use them as opportunities to present good studies you have found. As an added bonus, you will find talks easier to give, and your audience will be more interested. Photocopy your CATs and post them somewhere readily visible, or hand them out to your team as “an interesting article I found.” However, don't expect miracles or sudden conversions—just work at creating a cheerful, inquisitive environment that supports the practice of evidence-based medicine. Bosses are like supertankers: They take a little time to turn, but once they're heading in your direction, you can't stop them.

What happens if your boss disagrees with the evidence?

Remember that evidence-based medicine doesn't provide absolute answers; it simply gives some numbers to help doctors make decisions. A lot of other factors need to be taken into account. Medicine is an art, and evidence-based medicine is just one of the tools used to create the whole picture. Bosses have lots of experience in patient care: Hear what they have to say before you write them off as being from the Stone Age. After all, they are ultimately responsible for their patients, so the decision has to be theirs. Remember to keep things in perspective; there will be other opportunities.

So what is possible?

Since graduating 18 months ago, I have produced over 400 CATs, and I currently write about 1 CAT for every day I work. I'm not special either. There are several junior doctors and students who are practising evidence-based medicine in the United Kingdom. Bob Phillips and Nick Shenker are 2, and together our experiences have prompted us to write a radically new type of medical handbook titled Evidence-based On-Call. The book is aimed at junior doctors and will cover more than 70 medical and surgical topics. With the assistance of about 50 contributors from North America, Europe, and Australia, we propose to provide a synopsis of the best evidence available on each topic. We are currently looking for additional contributors and reviewers and would welcome any offers of help.

To be an evidence-based doctor doesn't require a superhuman effort. Whatever the amount of evidence-based medicine you practice, it is worth the trouble. It keeps you thinking, keeps you up-to-date, and keeps medicine fun.

Chris Ball, MA, BM, BCh
Hammersmith Hospital
London, England, UK


References

1. Sackett DL, Haynes RB, Guyatt GH, Tugwell P. Clinical Epidemiology: A Basic Science for Clinical Medicine. 2d ed. Boston: Little, Brown; 1991.

2. Sackett DL, Richardson WS, Rosenberg W, Haynes RB. Evidence-based Medicine: How to Practice and Teach EBM. Edinburgh: Churchill Livingstone; 1997.

3. Evidence-based Medicine Working Group. JAMA. 1992;268:2420-5.

4. Guyatt GH, Rennie D. JAMA. 1993; 270:2096-7.

5. Oxman AD, Sackett DL, Guyatt GH. JAMA. 1993;270:2093-5.

6. Guyatt GH, Sackett DL, Cook DJ. JAMA. 1993;270:2598-601.

7. Guyatt GH, Sackett DL, Cook DJ. JAMA. 1994;271:59-63.

8. Jaeschke R, Guyatt GH, Sackett DL. JAMA. 1994;271:389-91.

9. Jaeschke R, Guyatt GH, Sackett DL. JAMA. 1994;271:703-7.

10. Levine M, Walter S, Lee H, Haines T, et al. JAMA. 1994;271:1615-9.

11. Laupacis A, Wells G, Richardson WS, Tugwell P. JAMA. 1994;272:234-7.

12. Oxman AD, Cook DL, Guyatt GH. JAMA. 1994;272:1367-71.

13. Richardson WS, Detsky AS. JAMA. 1995;273:1292-5.

14. Richardson WS, Detsky AS. JAMA. 1995;273:1610-3.

15. Hayward RS, Wilson MC, Tunis SR, Bass EB, Guyatt G. JAMA. 1995;274:570-4.

16. Wilson MC, Hayward RS, Tunis SR, Bass EB, Guyatt GH. JAMA. 1995;274: 1630-2.

17. Guyatt GH, Sackett DL, Sinclair JC, et al. JAMA. 1995;274:1800-4.

18. Naylor CD, Guyatt GH. JAMA. 1996; 275:554-8.

19. Naylor CD, Guyatt GH. JAMA. 1996; 275:1435-9.

20. Guyatt GH, Naylor CD, Juniper E, Heyland DK, Jaeschke R, Cook DJ. JAMA. 1997;277:1232-7.

21. Drummond MF, Richardson WS, O'Brien BJ, Levine M, Heyland D. JAMA. 1997;277:1552-7.

22. O'Brien BJ, Heyland D, Richardson WS, Levine M, Drummond MF. JAMA. 1997;277:1802-6.

23. Dans AL, Dans LF, Guyatt GH, Richardson S. JAMA. 1998;279:545-9.

24. Greenhalgh T. How To Read a Paper: The Basics of Evidence Based Medicine. London: BMJ; 1997.

25. Lee BW, Hsu SI, Stasior DS. Quick Consult Manual of Evidence-based Medicine. Philadelphia: Lippincott-Raven; 1997.

26. Yusuf S, Cairns J, Camm AJ, Fallen EL, Gersh BJ, eds. Evidence Based Cardiology. London: BMJ; 1998.

27. Panzer RJ, Black ER, Griner PF. Diagnostic Strategies for Common Medical Problems. Philadelphia: American College of Physicians; 1991.

28. Haynes RB, Wilczynski N, McKibbon KA, Walker CJ, Sinclair JC. J Am Med Informatics Assoc. 1994;1:447-58.