What's up from Texas.
I'm thrilled to hear the students from UAE have asked such an astute
question, which might be paraphrased as "do I have to do this entire process
for every question on every patient?" Or, "are there such things as
evidence-based shortcuts, when my time and my patients' illnesses make it
impossible for me to do the whole process?"
Dave Sackett tells me that he and his colleagues like Vic Neufeld, Peter
Tugwell, Brian Haynes have wondered these same things for two or more
decades. Somewhere in our travels together, I learned from Dave his/their
notion of 3 levels of personal involvement with the evidence that a
clinician may have:
1) 'Applying': Where the clinician applies the recommendations, clinical
routines and practice policies that others formulate, after these 'others'
find/appraise/synthesize the evidence. Here, the emphasis is on
individualizing care to fit the patient's particular circumstances (biologic
factors, psychologic state, social situation, etc).
2) 'Using': Where the clinician finds up-to-date summaries of evidence, that
others have searched/appraised/synthesized, and uses these summaries to
build clinical routines and practice policies themselves. The clinician then
applies these policies to the patient's predicament.
3) 'Appraising': Where the clinician searches for original and integrative
research evidence, appraises it, synthesizes it in some fashion, and then
uses it to build clinical policies, which then get applied to the clinical
situation. [This is the 'whole process' the UAE students referred to.]
These are arranged in order of increasing degree of personal involvement
with the evidence, and of increasing resource use (mainly of time, but
others too) and skills required. For years, I had guessed that most of the
time, practitioners using evidence in practice did a lot of applying, some
of using, and a little of appraising, and that these proportions varied
depending on such factors as time available, skill mix, competing demands,
etc. But I've been hankering for some empirical evidence, so ... .
Just finished a month on hospital wards, where one of the bright young
physicians asked the same question, so we have undertaken an audit of the
month's admissions. We're still analyzing the data and writing them up, so
it'd be premature to tell you all the results. I can tell you this: we did a
lot of 'applying' clinical routines/practice policies of others. There are
several reasons why (clinical, educational and accidental), including some
we didn't anticipate.
I would very much like to hear of others who have completed similar audits
of their own clinical practices [please reply directly to me, and I'll
summarize for list]. If you've published such an audit, please send me the
citation as well [I'm afraid I hadn't found your work, if you have]. To make
EBHC a reality, we have to be realistic.
Take care and cheers!
WSR
W. Scott Richardson, M.D.
Audie L. Murphy Memorial Veterans Hospital *******************
7400 Merton Minter Blvd. Harsh sound
San Antonio, TX 78284 hail spattering
T: (210) 567-4808 my traveler's hat
F: (210) 617-5234 Basho
Email: [log in to unmask] *******************
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