Hi everyone,

Thanks to all for the excellent discussion on this list. 

With respect to Sandra, I don't think the definition of high quality research evidence should be different in non-medical professions.  I think that in all professions we need to use the most appropriate study design to the question at hand. If we are testing the effects of interventions we really do need an RCT to be sure that effects seen really are as a result of the intervention given (or even better a high quality systematic review). If we have a question about prognosis and factors which influence outcome we need a cohort study. If we are seeking to understand patients' experiences we need qualitative studies. Physiotherapists have written about this approach in the book "Practical Evidence-based Physiotherapy", Herbert et al 2005 http://www.elsevier.com/wps/find/bookdescription.cws_home/705265/description#description
 
Within physiotherapy we have created PEDro http://www.pedro.org.au/ which aims to cut down searching and appraisal time by giving access bibliographic details of quality-rated trials, reviews and evidence-based guidelines of relevance to physiotherapy (we now have 15,000 records!). Similar resources are now available for occupational therapists http://www.otseeker.com/ , speech pathologists http://www.speechbite.com/ and psychologists working with people with brain injury http://www.psycbite.com/  

Of course these databases do not solve all the challenges others have identified in the real world daily application of evidence. Clinicians still need to interpret the results of research studies and use these to assist in decision making in conjunction with individual patients. 

I am awaiting the updated Sicily statement with interest. 

Best wishes,
Cathie



Cathie Sherrington
Senior Research Fellow
Musculoskeletal Division
The George Institute for International Health
and Sydney Medical School, The University of Sydney
Phone:  +61 2 9657 0300 (reception), 9657 0386 (direct), 0418 225 929 (mobile)
Fax:      +61 2 9657 0301
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-----Original Message-----
From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Sandra Kaplan
Sent: Friday, 23 October 2009 3:05 AM
To: [log in to unmask]
Subject: Re: The EBM curriculum - revising the Sicily statement

Hi all, Thank you for this running discussion.  As a non-physician, I  
would like to remind all that other disciplines have adopted the  
approach of EBM, but have broadened it conceptually to be evidence  
based practice. That said, I agree with point 3, but often that is  
interpreted to mean that RCTs have it over cohort studies. In the area  
of ongoing therapies, such as physical, occupational, speech, or  
behavioral health, RCTs may not always reflect  the best evidence for  
the real clinical world, where patient mix is messy, and many  
confounding variables are known to affect therapy outcomes. If a list  
of principles are to be developed, it should be inclusive of the ways  
EBP is used by all health professions.  In fact, it does not sound as  
though we need a list of principles as much as a decision tree process  
or flow chart that accounts for all of the steps and inputs to the  
clinical decision making process.  And quite possibly, those flow  
charts may look different for different stages of care, and for  
different types of health services (emergency vs acute vs chronic  
management). In all cases, the starting point will be the patient's  
problem that generates the question, and the end point will be  
assessment of the impact on the patient for achieving the desired  
outcome.
I am really looking forward to a real time discussion of these ideas  
next week.

Sandra L. Kaplan PT,PhD
Director, Post Professional DPT Program
Assoc. Dir, DPT Program
Stuart D. Cook MD Master Educator Guild
[log in to unmask]
973-972-2459


On Oct 22, 2009, at 11:43 AM, Paul Glasziou wrote:

> Hi Fred
> That's a nice idea.  We might develop a list of principles that  
> spell out the philosophy of EBM first, and then move to the skills.
> I'd definitely include being patient-centred among these. Something  
> like (stealing from Dr Armstrong):
> 1. Since the aim of EBM is to benefit patients, its practice should  
> be patient-centred.
> 2. EBM require comfort in saying we don't know and embracing this as  
> a positive phenomenon.
> 3. Though knowledge comes from a variety of sources, EBM favours  
> high quality research evidence over case experience or theories of  
> mechanism.
> 4. Others ....
> Thanks all,
> Paul Glasziou
>
>
>
> Tudiver, Fraser G. wrote:
>> I also wish to thank Paul for opening this dialogue. Rakesh made an  
>> important point with regard to the "challenge" to keeping it  
>> patient centered. Even though the concept of patient focus is in  
>> the very definition of EBM, I along with others find that it is  
>> often absent, in particular in the teaching of EBM skills. I  
>> suggest that patient-centered focus not be yet another EBM step,  
>> but instead be seen as a concept/construct that permeates across  
>> all the EBM steps.
>> Regards,
>>  Fred Tudiver  Director for Primary Care Research  Director,  
>> International Center for Evidence-Based Medicine  Dept Family  
>> Medicine  James H Quillen College of Medicine  East Tennessee State  
>> University  Box 70621  Johnson City, TN, 37614  Voice: 423-439-6738
>> ________________________________
>>
>> From: Evidence based health (EBH) on behalf of Rakesh Biswas
>> Sent: Thu 10/22/2009 7:47 AM
>> To: [log in to unmask]
>> Subject: Re: The EBM curriculum - revising the Sicily statement
>>
>>
>> Very important point Nina.
>> I have quoted from Dr Armstrong's work before on this list and  
>> somehow feel like revising it from time to time when we approach  
>> these areas:
>> Not knowing, the chaos of real life clinical questions, a healthy  
>> skepticism, appreciation of the rapid turnover of information and  
>> the realization that active and interactive learners learn, are the  
>> energies that fuel problem based learning in EBM. (Armstrong  
>> 2004).  This variety of bottom up learning in medicine has spurred  
>> caregivers and care seekers (in effect most humans) into moving  
>> from routinely accepting media dominated content to questioning the  
>> vested interests that may control them.  The biggest challenge for  
>> EBM facilitators has been keeping it patient-centered. It has been  
>> noted that residents and medical students often struggle with a  
>> format where the primary focus is the patient and is question  
>> driven and where the emphasis is in large part on process and skill  
>> acquisition rather than finding "the right answer". This takes them  
>> out of their cultural comfort zone of didactic and content focused  
>> education where not knowing is traditionally frowned upon. It  
>> requires that they become comfortable saying they don't know and  
>> embrace this as a positive phenomenon, which will over time, drive  
>> their desire to know and keep up to date in a world of medicine  
>> where the only constant is change.(Armstrong 2004).  Thanks Paul  
>> for initiating such a good discussion.
>> regards,
>> rakesh
>>
>>
>> On Thu, Oct 22, 2009 at 4:35 PM, Nina Rydland Olsen <[log in to unmask] 
>> > wrote:
>>
>>
>> 	Hello,
>> 	
>> 	I agree that we need another step before "step 1: Translation of  
>> uncertainty to an answerable question".
>> 	
>> 	In Norway, we teach our students that step 1 is to identify your  
>> information need; asking them to reflect on "What do you need more  
>> information about?", What information do you already have about  
>> this clinical issue?", "What is usual practice (today) concerning  
>> this issue?". I guess this is equivalent to "step 0" that you  
>> already mention in the Sicily Statement:
>> 	
>> 	"Indeed, the most difficult step (sometimes dubbed
>> 	"step 0") is to get students and colleagues to recognise and
>> 	admit uncertainties."
>> 	
>> 	Perhaps this step should be step 1?
>> 	
>> 	Best wishes
>> 	
>> 	Nina Rydland Olsen
>> 	PhD student
>> 	Centre of Evidence-Based Practice
>> 	Bergen University College, Norway
>> 	
>> 	
>> 	-----Opprinnelig melding-----
>> 	Fra: Evidence based health (EBH) [mailto:[log in to unmask] 
>> ] På vegne av Piersante Sestini
>> 	Sendt: 22. oktober 2009 12:30
>> 	Til: [log in to unmask]
>> 	Emne: Re: The EBM curriculum - revising the Sicily statement
>> 	
>>
>> 	Paul Glasziou wrote:
>> 	> Do you have suggestions about the curriculum for EBM? The  
>> forthcoming
>> 	> Sicily EBHC conference (28-31 Nov) will include afternoon  
>> discussions of
>> 	> the EBM curriculum. The Sicily Statement on the Curriculum for
>> 	> evidence-based practice arose out of the first Sicily meetings.
>> 	
>> 	I have two suggestions, both relative to the starting steps:
>> 	
>> 	1) Add a step on "setting a goal" at the beginning. Without a goal  
>> is
>> 	impossible to ask a question (in particular, to select an outcome)
>> 	Note that this would require to move the exploration of patient's  
>> values
>> 	 at this stage, since obviously the patient should participate in  
>> the
>> 	choice of the goal (and hence in framing the question).
>> 	
>> 	2)Integrate the proposal of Franz Portzolt of explicitly consider
>> 	current knowledge and expertise (and look for more expertise if  
>> needed
>> 	using background questions) while framing the problem.
>> 	
>> 	Porzsolt F, Ohletz A, Thim A, Gardner D, Ruatti H, Meier H,
>> 	Schlotz-Gorton N, Schrott L. Evidence-based decision making--the 6- 
>> step
>> 	approach. ACP J Club. 2003 Nov-Dec;139(3):A11-2
>> 	
>> 	
>> 	
>> 	regards,
>> 	Piersante Sestini
>> 	
>>
>>
>
> -- 
> Paul Glasziou
> Director, Centre for Evidence-Based Medicine,
> Department of Primary Health Care,
> University of Oxford www.cebm.net
> ph - +44-1865-289298 fax +44-1865-289287