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EVIDENCE-BASED-HEALTH  October 1998

EVIDENCE-BASED-HEALTH October 1998

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Subject:

Re: the impact of what we've all been doing as reflected in the responses of trainees to sessions in ebm

From:

"Toby Lipman 7, Collingwood Terrace, Jesmond, Newcastle upon Tyne. Tel 0191-2811060 (home), 0191-2869178 (surgery)" <[log in to unmask]>

Reply-To:

Toby Lipman 7, Collingwood Terrace, Jesmond, Newcastle upon Tyne. Tel 0191-2811060 (home), 0191-2869178 (surgery)

Date:

Thu, 15 Oct 1998 20:19:02 +0100

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (96 lines)

Dear all

>there simply seems to have been a sea-change in the attitudes and
>enthusiasm of SHOs toward ebm.
>
>that's wonderful!  and we all share the credit for it.
>
>so good on us all!
>

That *is* great! But there are still lots of GPs and hospital clinicians
who aren't much interested - or never had the opportunity to experience
EBM or maybe they thought it was something else. 

I did a presentation on EBM to 24 GPs a couple of weeks ago. It was
mainly basic principles - why do we do it? where did it come from?
what's it involve? why is there so much argument about it? We did a role
play about diagnostic tests (and went on to sens/spec, PPV, LR etc) and
a run through of structured questions, the difference between RRR and
ARR, and NNTs. It was lively, very interactive (and a shame we only had
2 hours!) They responded very positively but several said they hadn't
realised until then what it was all about. And this was a bright bunch
of people.

Conversely 2 nurses from my practice attended a "workshop" on "EBP"
(inverted commas are deliberate!) run by a local (and in this company
nameless) trust. There were 2 workshops. I think about 12 attended the
first but only 4 the second. One of our nurses said she thought she knew
more about EBP from the sessions we do in the practice than the tutor,
who basically read out what was printed on a lot of acetates. This sort
of thing could give EBP a bad name (and it's interesting that none of my
local EBP enthusiast colleagues had ever heard of the tutor)

It's taken about 2 years from me attending the 3rd UK workshop to begin
to get EBP going properly in the practice. This is what happened to us
(abstract for this year's NoReN research day):

 Background: After returning from the 3rd UK Workshop on Teaching
Evidence-Based Medicine (July 1996) the author became enthusiastic about
using evidence-based learning methods within the primary health care
team. Other members of the team were sceptical, but agreed in early 1997
to introduce protected time for learning in small groups as part of a
Primary Care Act Pilot, without specifying evidence-based medicine as
the model.
Aims: This paper will describe one practice's experience of introducing
the methodology of evidence-based practice to general practitioners and
nurses. 
Methods: Contemporaneous reflective diary kept by the author from April
1997, and records of educational sessions in the practice including
participant feedback. 
Results: Several members of the team repeatedly expressed serious
reservations about evidence-based practice and the team as a whole was
not convinced of its relevance by the time that fortnightly small group
educational sessions commenced in May 1998. In effect a structure
(protected time, databases, overhead projector, flip chart), and a
process (facilitated small group learning) had been put into place in
the hope that useful outcomes (improved learning and clinical practice
based upon best current evidence) would follow. Several clinical topics
were addressed, including guidelines for hypertension, cardiovascular
risk assessment, review of oral contraceptive prescribing and the use of
pyridoxine in pre-menstrual syndrome. The group was introduced to
critical appraisal (using checklists), calculating NNTs, constructing
answerable clinical questions, searching databases (the Cochrane
Library, Best Evidence), the use of confidence intervals and the
interpretation of meta-analyses. GPs and practice nurses attended the
sessions (but district nurses and health visitors have yet to be
persuaded to come). Several individuals became frustrated because they
felt that some of the techniques used were too technical and they found
it hard to ask for explanations. Some (especially nurses) expressed the
view that the process of finding and interpreting evidence should be
delegated to an "expert", who would simply tell them what to do in the
form of practice protocols. Frustration was expressed at the slow pace
of implementation: "we've been doing this since May but don't seem to
have got anywhere." Feedback enabled some of these problems to be raised
and addressed. After six months members of the group were able to "self-
direct" their learning. They were able to ask clinical questions, search
for evidence in the Cochrane Library on CD-ROM, select promising papers
and obtain the full texts, and critically appraise them in a subsequent
session. The author facilitated and acted as a resource, but the group
itself was able to relate the evidence available to the clinical
question and identify further questions and means of pursuing them.
Conclusions: Evidence-based practice can be done in primary health care
teams, despite many barriers. A defined structure is necessary before
the process can begin and it may take many months for the process to be
established. It is important to seek feedback and address team members'
doubts and difficulties.

Cheers

Toby
-- 
Toby Lipman 7, Collingwood Terrace, Jesmond, Newcastle upon Tyne. Tel 
0191-2811060 (home), 0191-2437000 (surgery)


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