Dear Ben,
I sympathise with your view of the difficulties, but am not so pessimistic.
Can I make a couple of suggestions?
1. Change the way you keep up to date. Most folk spend several hours per
week in some continuing medical education activity - lectures, journals,
textbooks, seminars, etc (average among family docs I teach is 3 hrs). Dave
Davis's review suggests much of this is unhelpful. So, stop this and shift
to (a) current patient problems, and (b) selective reading, e.g, ACP
journal club or the EBM journal which screens out the weak evidence and
irrelevant articles.
2. Share the work. Focus journal clubs on current patient problems and use
(best) evidence for this - as there is more time, this is an easier place
to start EBM activities, and shares the learning (and allows both the
research and clinical expertise a place). Other ways to share the load are
to ask residents or students to look things up with educational
prescriptions, etc.
3. If a change is important, then consider implementation and monitoring.
Even if we've learnt from the research evidence, we can be unable or forget
to do the appropriate thing, so consider ways for the team to make sure it
happens (quality improvement methods are helpful here).
These do not give a "100% solution", but are better than the near 0%
solutions we currently work with. We've used all three methods in our group
practice for several years, and have substantial changed our own education
and medical care in that time.
I'd be very interested to hear of other folks real-time experience
(failures and successes),
Best wishes,
Paul Glasziou
Department of Primary Health Care &
Director, Centre for Evidence-Based Practice, Oxford
www.cebm.net
At 9/5/2003, Djulbegovic, Benjamin wrote:
>I think we should not be so quick to dismiss the criticism about the value
>of EBM that the recent e-mail raised. After teaching various courses on
>EBM (since 1997) and the attempts to integrate it in my own practice, I am
>not so sure how FEASIBLE is to teach EBM at bedside. Medicine is primary
>problem-solving and decision-making exercise. While we have all argued
>over the years that understanding the nature and quality of evidence etc
>is a key to practice of medicine, the original EBM paradigm
>(ask-search-appraise-decide) is simply very difficult to apply in
>practice. The primary reason, of course, is time-constraint. When my team
>has 20-25 of acutely ill patients on the ward and admit and discharge
>every day 3-7 patients, it is impossible to approach decision-making and
>problem-solving in EBM structured way. So, in practice, instead of serving
>as a facilitator, I end up spoon-feeding that necessary knowledge, which
>students, residents, fellows are supposed to discover on their own. When I
>don't know the answer, then we call consultants to help us with our
>questions. We simply don't have time to go through EBM process (despite
>the fact that I work in high-tech surroundings with computers at every
>corner, linked to any database you can think of...of course, we have
>journal clubs, teaching conferences, educational objectives, assignments
>and all that...we even do decision models, meta-analyses, understand the
>differences between normative vs. descriptive vs. prescriptive decision
>making etc). However, at the end of the day, it is CONTENT (i.e.
>content-specific expertise) that wins the day and not the process, or
>method-oriented approach which EBM paradigm promised. That is, the
>consultants (from the various disciplines who may or may not be of EBM
>kind) are the one whose advice you will follow (99% of time) regardless if
>that advice is EBM formulated or not. Several years ago I have been
>dreaming (and still do) that we will be able to identify all high-quality
>evidence (in my field, hematology and oncology), which we will then
>pre-processed and have at finger-tips at the bedside. Other folks have
>done the same in other areas of medicine. While I am still hoping that
>"thrill is not gone", EBM (and related initiatives including
>decision-analysis) has to face the key aspect of clinical medicine:
>LIMITED TIME FRAME FOR DECISION-MAKING UNDER CIRCUMSTANCES OF UNCERTAINTY.
>
>I am hopeful that this e-mail, which I wanted to send for some time, but
>did not have time, will help stimulate some constructive debate.
>
>Benjamin Djulbegovic, MD,PhD
>Professor of Oncology and Medicine
>H. Lee Moffitt Cancer Center & Research Institute
>at the University of South Florida
>Department of Interdisciplinary Oncology
>SRB #4, Floor 4, Rm #24031 (Rm# West 31)
>12902 Magnolia Drive
>Tampa, FL 33612
>
>Editor: Cancer Treatment Reviews (Evidence-based Oncology Section)
>http://www.harcourt-international.com/journals/ctrv/
>
>
>e-mail:[log in to unmask]
>http://www.hsc.usf.edu/~bdjulbeg/
>phone:(813)979-7202
>fax:(813)979-3071
>
>
>
>-----Original Message-----
>From: badri badrinath [mailto:[log in to unmask]]
>Sent: Friday, September 05, 2003 8:57 AM
>To: [log in to unmask]
>Subject: Evidence based teaching
>
>
>Dear Andrew,
>
>Greetings from sunny Southend on the English coast.
>
>You wondered "why teaching does not seem to have picked up on EBP"
>
>There are some initiatives in this direction. Here are a few examples.
>
>http://www.bemecollaboration.org/
>Some of the topic reviews look very interesting.
>http://www.bemecollaboration.org/topics.htm
>
>http://education.ntu.ac.uk/research/ebt/ Evidence based teaching in primary
>school.
>
>http://nursing.jbpub.com/catalog/0763709379/ A text on Evidence based
>teaching in the area of nursing.
>
>Cheers & regards and have a wonderful weekend.
>
>Badri
>
>Dr.P.Badrinath M.D.,B.S.,M.Phil(Epid).,PhD(Cantab).,MPH., MFPHMI
>Specialist Registrar in Public Health Medicine,
>Southend PCT, Harcourt House,
>Harcourt Avenue, Southend-on-Sea,
>Essex SS2 6HE, UK
>http://myprofile.cos.com/badrishanthi
>
>_________________________________________________________________
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