Hi Dan:
First of all, thank you for a fantastic overview resolving the "user"
versus the "doer" dilemma that Kumara raised. I'd like to add here that
even when one reads/evaluates a piece of secondary evidence, the
"secondary" evidence does contain enough pointers to the original source
articles/reviews, which the reader then is free to access and review.
That, in my humble opinion, is the EBM part (rather than accepting the
face value of everything the secondary evidence suggests).
My all time favorite tool of appraisal is of course, Prof Rod Jackson's
GATE framework. It's an amazing tool!
/Arin
Dan Mayer wrote:
> Hi Kumara and the rest of the list serve,
>
> I think that we ought to be thinking about this a bit differently and
> see that the USER mode is not exclusive to searching only. We can look
> at the practices of most physicians and see the modes that they are
> practicing in during routine medical practice.
>
> The user mode is how EBM would be used practically for patient care "AT
> THE POINT OF CARE". However, USERS will still be reading journals on a
> regular basis and some of the articles in them are not particularly
> valid. This requires some critical appraisal skills, but not the full
> EBM process. The EBM process is a paradigm that can support all levels
> of EBM practice.
>
> Asking: Determining the educational need in patient care or for life
> long learning also known as "reflective practice"
>
> Acquiring: Use of informatics to find the best evidence using the Haynes
> 5S pyramid, which can be preappraised sources or primary research
> literature.
>
> Appraising: For studies in journals read on a regular basis to be a
> lifelong learner. Also, for studies that are being appraised to become
> CATs or Evidence Based Journal entries or as part of meta-analyses, etc.
> for the DOERS.
>
> Applying: Using clinical expertise to determine the applicability of
> evidence (obtained from studies either as a USER or DOER) to an
> individual patient. Also as part of the Knowledge Translation process
> to apply the best evidence to routine care of patient populations.
>
> Assessment: Determining if the evidence is being used in a particular
> clinical setting (departmental or organizational QI directors) or
> determining ways to improve uptake of best evidence as part of the
> Knowledge Transfer process.
>
> I suppose the REPLICATORS are the only ones who dont need any of these
> skills, putting them in the category of older physicians who were in
> practice before EBM skills became commonly taught in medical training.
>
> A recent study of resident wishes by Akl et al (Medical Teacher, 28:
> 192, 2006) came to the conclusion that residents (at the University of
> Buffalo) preferred to be taught the full EBM process to use for future
> EBM practice.
>
> It seems that we can create a theoretical framework to justify teaching
> all parts of the EBM process from undergraduate to graduate to
> professional medical education.
>
> As far as a tool to measure ability to find evidence, I think that the
> 5S pyramid ought to be able to be turned into such an instrument and I
> would be glad to help any other members of the list serve create and
> test such an instrument.
>
> Hope this all helps,
>
> Best wishes,
>
> Dan
>
> ****************************************************************************
> Dan Mayer, MD
> Professor of Emergency Medicine
> Albany Medical College
> 47 New Scotland Ave.
> Albany, NY, 12208
> Ph; 518-262-6180
> FAX; 518-262-5029
> E-mail; [log in to unmask]
> ****************************************************************************
>
>>>> K Mendis <[log in to unmask]> 07/08/07 5:08 PM >>>
>>>>
> Dear all,
>
>
> EBM is a multistep process and not all doctors want or need to learn how
> to
> practice all five steps of EBM - (1) asking, (2) acquiring, (3)
> appraising,
> (4) applying, (5) assessing (BMJ 2004;329:1029-1032).
>
>
>
> 'Clinicians can incorporate evidence into their practices in 3 ways.
> First
> is the "doing" mode, in which at least the first 4 steps are carried out
> before an intervention is offered. Second is the "using" mode, in which
> searches are restricted to evidence sources that have already undergone
> critical appraisal by others, such as evidence-based guidelines or
> evidence
> summaries (thus skipping step 3). Third is the "replicating" mode, in
> which
> the decisions of respected opinion leaders are followed (abandoning at
> least
> steps 2 and 3). Of course, even clinicians trained to the "doing" level
> move
> back and forth between these modes, typically depending on whether they
> are
> dealing with clinical problems they encounter frequently or only
> rarely'.(CMAJ 2000; 163 (7))
>
>
>
> My questions are:
>
> a) If doctors practice in the "USER" mode - is that sufficient to agree
> that
> they practice EBM?
>
> b) Are there validated instruments that can be used to evaluate EBM in
> USER
> mode?
>
> Especially web-based tools?
>
> (I am aware of two validated questionnaires - Fresno and Berlin that
> encompass the five steps.)
>
>
> Thanks in advance
>
> Kumara
> -------------------------------------------------------------------
> Dr. Kumara Mendis
> MBBS, MSc (Medical Informatics), MD (Family Medicine)
> Senior Lecturer
> School of Rural Health
> University of Sydney
> Tel: +61 02 6885 7996
> Mob:+61 0408 975 784
> ----------------------------------------------------------------------------
> ----------------
>
>
>
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