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Thanks Arin, I like that synthesis very much. It also accommodates Vinod's important point that how one practices EBM can often be situational, depending on the extent to which one is familiar with the particular therapeutic area. One's practice might be more like one level in some therapeutic contexts, and more like a higher or lower level in others. In terms of encouraging the adoption of EBM both personally and organisationally, I can also see parallels with adoptions models such as that of Fraser and Plsek, and Hall and Hord (see Greenahlgh et al's superb SR) - in particular the latter. Hall and Hord's Concerns Based Adoption Model doesn't seem to be so widely discussed, so forgive me for running over it briefly. At what they call the preadoption stage (Arin's agnostics and contemplators, below) adopters must have sufficient information about the change in practice (in this case it might be eg adopting a hunting and foraging approach), what it does, how to use it and how it would affect them personally. But successful adoption of the change is more likely to occur if in the early stages (EBH initiators, below) adopters have continuing access to information about the change and support to put it into practice, and if in the later stages of adoption they have feedback on their practice (EBH actives) and also the opportunity and autonomy to adapt and refine the change to tailor it to their particular needs and circumstances (EBH actives and Jedis). Change is precarious and needs reinforcement if it is to be maintained. So those of us seeking to encourage the adoption of EBM need to provide personal support and advice to address problems and concerns which arise, especially at the early stages (what Fraser and Plsek call the phases of evaluation and conviction, and action to change; analogous to abstract conceptualization and active experimentation in Kolb's learning cycle) Thank you very much for your comments Kind regards Andy Fraser SW and Plsek P. Translating evidence into practice: a process of externally driven spread or personal adoption? Education for Primary Care; 2003: 14: 129-138 Greenhalgh T, Robert G, MacFarlane F, Bate P and Kyriakidou O. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Quarterly 2004; 82: 581-629 Andy Hutchinson email: [log in to unmask] tel: 07824 604962 web: www.npc.co.uk or www.npci.org.uk -----Original Message----- From: Arin Basu [mailto:[log in to unmask]] Sent: 02 April 2008 23:19 To: Hutchinson Andy Cc: [log in to unmask] Subject: Re: how can I show I am an evidence based practitioner Hi All, Andy's and Bruce's approach were very interesting. If I may bring attention to a corollary of the "Stages of Change Theory by Prochaska and DiClemente (1) here, one may think of synthesizing the two classifications and bring up something like: Stage I: EBH-Agnostics (Precontemplators) -- Physicians who are naively unaware or minimally aware of the need of EBH or actively resist. Stage II: EBH-Aware (Contemplators) -- Physicians who are aware of the basic principles of EBM (they can frame a question, search the literature, are aware of the principles of critical appraisal, and of the shared decision making) but have never applied them in their practice settings Stage III: EBH-initiators (Preparation) -- Physicians who have started taking action to use EBH in their day to day practice (as outlined in the stages 1 and 2 by Andy) but have not yet reached the stage where they can actively forage and hunt for information Stage IV: EBH-Actives (Action) -- Physicians who regularly use principles of EBH in their day to day lives, and meet all the criteria outlined by Bruce. These physicians belong to the group identified by Level 3 and to some extent level 4 of Andy's classification (some extent because they may not have reached a stage yet where they can help "others" to reach their stage) Stage V: EBH-Jedi (Maintenance) -- Physicians who are committed to ebh, and fulfil the crieria for level 5 by Andy (Master Level). This is still a half-baked idea, but it came to mind reading Andy's mail. Phys8cians can be operative in various stages of their practice (?levels), and can probably even shift from one stage to the other, although it's understood that once they reach stage 4 or stage 5, there's little chance that they'll revert to stage 1. Etc, Cheers, Arin Basu Reference (1) DiClemente, C.C., Prochaska, J.O. (1982), "Self-change and therapy change of smoking behavior: a comparison of processes of change in cessation and maintenance", Addictive Behavior, Vol. 7 pp.133-42. On Thu, Apr 3, 2008 at 7:08 AM, Hutchinson Andy <[log in to unmask]> wrote: > >> But it might be better to think of this as a spectrum. For example, some > folk distinguish EBM "users" from "practioners" based on whether they > are appraising themselves or trusting others to do the appraisals > > I would agree with that whole-heartedly. > > So may I suggest we have at least five different levels, with the following ideas of demonstrable competencies: > > 1 - entry level - eg can describe the 5S approach to finding answers to clinical questions (or similar); can describe the hierarchy of evidence and why it is as it is; understands the difference between absolute and relative risk and how baseline risk affects absolute benefits; can explain in simple terms the common terms use in EBM (eg RR, RRR, ARR, NNT, NNH, P, 95%CI) > > 2 - developing practitioner - eg as 1 but also: shows evidence of using the 5S approach (or similar) much of the time in his/her practice with a foraging approach to keeping up to date with relevant, valid information (Slawson and Shaunesey); developing ability to communicate the evidence base to patients in ways meaningful to them > > 3 - higher level practitioner - as 1 and 2, but also: practice is characterized by a hunting and foraging technique; audits own (or team's if appropriate) practice against best available evidence; well developed ability to communicate the evidence base to patients in ways meaningful to them; encourages and supports others to develop as EBM practitioners; developing critical appraisal skills > > 4 - Advanced practitioner - as 1,2,3 but also: well developed critical appraisal skills used locally to help develop local practice guidelines and/or interpret evidence for other practitioners; mentor to level 1,2 and 3 practitioners; researches improved ways of communicating evidence to patients (eg patient decision aids, etc) > > 5 - Master level - as 1,2,3,4 but also: expertise is recognised at national/international level; leads or contributes to major pieces of EBM work of wider significance (eg published systematic reviews and meta-analyses); researches across the EBM spectrum > > > OK, I'm sure this could be improved a great deal, and the competencies here could be moved around, added to and deleted. > > But I do strongly feel that a stepped approach is important. The danger otherwise is that people think they need to be at level 4 or 5 to be an EBM practitioner, and move there straight away - and feel disheartened and give up. It may be that level 3 or 4 is right for them, but as Paul says below, it's a gradual shift in clinical practice over years - and if we could get most people to level 2 (or even level 1!) we'd do a lot for modern patient care. > > I'd be most interested in and grateful for any comments people have > > Andy > > > Andy Hutchinson > email: [log in to unmask] > tel: 07824 604962 > web: www.npc.co.uk or www.npci.org.uk > > -----Original Message----- > From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Paul Glasziou > Sent: 02 April 2008 18:18 > To: [log in to unmask] > > Subject: Re: how can I show I am an evidence based practitioner > > Dear Bruce > An excellent question! I think your list is a good start, but I'd add > appraising primary research, reading a secondary abstract journal, and > running a team "journal" club to the list. > But it might be better to think of this as a spectrum. For example, some > folk distinguish EBM "users" from "practioners" based on whether they > are appraising themselves or trusing others to do the appraisals (see: > Akl EA, Maroun N, Neagoe G, Guyatt G, Schünemann HJ. EBM user and > practitioner models for graduate medical education: what do residents > prefer? Med Teach. 2006 Mar;28(2):192-4. ) > I also tell folk that the difference is not an instant change, but being > EBM-aware leads to a gradual shift in clinical practice over years, as > we adopt or drop different treatments, tests, etc. > Cheers > Paul Glasziou > > > > Bruce Arroll wrote: > > Dear all > > > > > > I would like your thoughts on this question? > > I have recently run seminars with nurses and GPs on EBH. I start with > > the question "how would you know I am an evidence based practitioner". I > > am aware that there is interest in this from the research point of view > > but I am keen to build up a list of "activities" that would show I > > practice in an explicitly evidenced based manner. > > > > > > You would almost certainly have to see me in my clinical setting and > > interview me about my practice > > > > 1. Have ready access to evidence based guidelines from say NICE, SIGN, > > New Zealand guidelines group > > -when a new guideline is published I would look at the algorithm > > and see if my practice was concordant and if not I would investigate the > > references further and change my behaviour > > > > 2. I would conduct audits on my practice and alter practice accordingly > > > > 3. I would use evidence based knowledge refineries eg Cochrane pearls > > from www.cochraneprimarycare.org, perhaps medscape, BMJplus > > > > 4. Know the hierarchy of evidence and acknowledge that in my discussions > > with patients (eg where there was rct evidence I would say there is good > > trial evidence about this or where there is only case series I would > > couch the evidence in terms of there is not a lot of good evidence about > > this. i.e I would explicitly use the language of EBH > > > > 5. I would use explicit evidence based clinical textbooks such as > > dynamic medical.com or some of the others but hunt for evidence eg in > > uptodate in their abstracts > > > > Regards > > > > Bruce > > > > Bruce Arroll MBChB, PhD, FRNZCGP, FAFPHM > > Professor and Head of Department > > Dept of General Practice and Primary Health Care > > University of Auckland > > Private Bag 92019 > > Auckland > > ph 649-3737599 ext 86978 > > fax 649-3737624 > > > > Physical address room 378 building 730 > > School of Population Health > > Corner of Morrins and Merton Rds > > Glen Innes > > Auckland > > -----Original Message----- > > >