Evidence-based Medicine Domain Research Articles

Association between self-reported evidence-based medicine competencies and prescribing of drugs without scientific evidence against mild COVID-19 among recently graduated physicians in Peru

ObjectiveTo evaluate the association between self-rated evidence-based medicine (EBM) competencies and the prescription of drugs without scientific evidence against mild COVID-19 (present with any of the signs and symptoms of COVID-19 but who do not have shortness of breath, dyspnea, or abnormal chest imaging) among recently graduated physicians in Peru. MethodsWe conducted an analytical cross-sectional study where we evaluated a non-probability sample of recently graduated physicians during June and July 2021 (end of second wave of COVID-19 in Peru). Self-rated EBM competencies were assessed by four domains (formulation of a clinical question, search, analysis, and application) using a Likert scale with scores from zero to four (“Very inadequate” = 0, to “Very Adequate” = 4), it was considered as “Adequate” if the score was three or four. In addition, the variable “General competence on EBM” was rated as “Adequate” if in all domains evaluated it presented an adequate self-rating. For the outcome, drug prescription, we considered the use of ivermectin, azithromycin, other antibiotics, hydroxychloroquine, dexamethasone, and anticoagulants (drugs with no efficacy demonstrated for patients with mild COVID-19). To assess the association, we used Poisson regression models with robust variances and obtaining crude (cPR) and adjusted (aPR) prevalence ratios with their 95% confidence intervals (95%CI). ResultsOf a total of 239 physicians included 70.7% prescribed at least one drug without scientific evidence. A total of 51.1% reported adequate ratings in all evaluated domains of EBM. Self-rating the “Clinical Question Formulation” competency as adequate was associated with a lower frequency of prescribing medications for mild COVID-19 (aPR: 0.93; 95% CI: 0.91–0.95). While self-rating as adequate the competency of “Identify possible implications of investigations” was associated with an increase in the prescription of such drugs (aPR: 1.14; 95% CI: 1.09–1.20). Additionally, self-rating all domains as adequate were associated with less prescription (aPR: 0.93; 95% CI: 0.90–0.96). ConclusionSeven out of ten recently graduated physicians prescribed some type of medication without scientific evidence to treat patients with mild COVID-19. Having adequate self-perceived EBM competencies was associated with a lower frequency of prescribing medications without scientific evidence to manage patients with mild COVID-19.

The Effectiveness of a Journal Club for Improving Evidence-Based Medicine Skills and Confidence in Pre-clerkship Medical Students.

Evidence-based medicine (EBM) refers to medical practice that uses current best evidence to inform decision-making. This requires several skills including (1) creating an answerable question, (2) searching literature, (3) critically appraising evidence, and (4) applying results. Journal clubs are known to be effective in improving searching and critical appraisal skills in graduate medical education. In pre-clerkship medical education, journal clubs are used less often, and students often do not have the opportunity to engage in all of the steps above. We developed a journal club for pre-clerkship students and measured its effectiveness using a pre-test, post-test design. Students attended 5 journal club sessions run by rotating student leaders and facilitated by faculty. Student groups developed searchable questions from clinical cases, searched the literature, located and critically appraised an article, and applied results to the case. We measured EBM skills and confidence using two validated questionnaires. Twenty-nine students (MS-1 and MS-2) completed the study. EBM confidence significantly improved at post-test with greatest improvements in the MS-1 student cohort. Confidence in developing a searchable question from a patient case significantly improved in both cohorts. There were no changes measured on the Test of EBM Knowledge and Skills. Participation in a faculty-mentored, student-led journal club improved confidence across all domains of EBM, primarily in MS-1 students. Journal clubs are positively received by pre-clerkship medical students and provide effective mechanisms to teach and promote all steps of EBM in pre-clerkship curricula. The online version contains supplementary material available at 10.1007/s40670-023-01779-y.

Geriatric emergency medicine-a model for frailty friendly healthcare.

As the world's population continues to age over the decades ahead, medical educators and researchers in every adult medical and surgical specialty will need to 'geriatricise' their clinical science. Many have already engaged with geriatrics. Here we describe the progress that has been made and the opportunities ahead in the field of Geriatric Emergency Medicine (GEM), a field that has taken large steps in integrating holistic care. Future opportunities exist in the three domains of evidence-based medicine: including patient preferences and needs, generating scientific evidence, and improving physician knowledge and expertise. Implementation requires new innovations also in the organisation of care. Similar strategies may be useful in other fields of medicine, in making holistic care the standard for older people.

From precision of the evidence to the evidence for precision: An intriguing odyssey!

Dear Editor, Evidence-based medicine (EBM), described as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients” is the expected modus operandi of delivering health care in the 21st century.[1] However, the original connotation has been probably lost in transition with the increasing incorporation of perioperative guidelines and protocols, promoting pertinent concerns on the impact on physician autonomy, individualized clinical judgement, and the implications of practice variability which are being increasingly debated by the fraternity.[2-4] Interestingly, while a number of factors such as physician awareness of and compliance to the ever-increasing research volume are often cited as reasons precluding the EBM practice, the precision of the evidence continues to be an important contemplation. The spectrum consists of controversies over highly cited randomized controlled trials, medical reversal phenomenon, and the inherent biases involved.[2] Nevertheless, the wise words of Prof Ioannidis: “EBM has been hijacked and has been transformed into guidelines-based medicine” highlight the underlying inexorable transition process in the EBM domain.[3] This is heralded by the fact that the guidelines are often only EBM in concept, prone to biases emanating from institutional support, conflicts of interest, etc. Moreover, they are peculiarly “rigid”, designed for an average subset, demonstrating an inherent lack of sensitivity for the clinical and individual context.[4] The discussion is further accentuated by the various practitioners emphasizing the need for befitting evidence as per the context-appropriateness considering the elucidation of the detrimental effect of various clinical pathways in particular scenarios.[567] Alongside the continuing deliberation on the precision of the evidence that is worth practice changing, the concept of precision medicine has dawned almost inevitably. The precision medicine slogan: “One-size-does-not-fit-all” embraces the commonplace heterogeneity observed in the treatment effects, perioperative complications and associated outcomes.[89] The proponents of the notion opine that EBM by nature regards treatment at a population level with minimal individualistic considerations and highlight the importance of personalizing clinical medicine. Nevertheless, the overarching premise to make precision medicine evidence-based is substantially challenging given a patient is much more than a set of covariates and incurs multipronged difficulties in the terms of investigation, knowledge-acquisition, education, interpretation, and dissemination of multilevel data, from cellular level to environment and lifestyle, for the ever-diversifying patient population. To conclude, much or most of the practice variability in clinical medicine stems from the subtle differences among the patients.[789] Therefore, personalized management is appreciated well even in the era of EBM aimed at improving patient outcomes as it does not annihilate intuition, clinical expertise, and reasoning physiology as the ground for decision-making while accounting for the systematic evaluation of the evidence. In fact, distant from the dogma of EBM and precision medicine being dichotomous, an intuitive “open-mind” can complement both to practice evidence-based precision medicine in a unified pluralistic health care model, particularly relevant in the perioperative management of high-risk surgical cohort. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Clinical Decision Science emphasizes unique social context in a way that Evidence-Based Medicine does not

INTRODUCTION: The ideal of evidence-based medicine includes the integration of clinical experience and patient values with research evidence. We introduce clinical decision science, a new framework that includes patient social context to demonstrate this integration, which has been absent from evidence-based medicine sources. METHODS: This is an observational study comparing published articles within the domains of clinical decision science and evidence-based medicine. In a standardized manner, investigators identified and counted instances of social interaction within the publications. RESULTS: Publications of Clinical Decision Science had a higher number of markers of social interaction per paper and greater proportion of papers that included any markers of social interaction compared to publications in the Evidence-based medicine domain. DISCUSSION: We identified a framework that allows exploration of a new scientific domain that includes both research evidence and individual patient social context.

Extractive summarization of medical documents using domain knowledge and corpus statistics

Evidence Based Medicine (EBM) practice requires practitioners to extract evidence from published medical research when answering clinical queries. Due to the time- consuming nature of this practice, there is a strong motivation for systems that can automatically summarise medical documents and help practitioners find relevant information. The aim of this work is to propose an automatic query- focused, extractive summarisation approach that selects informative sentences from medical documents. We use a corpus that is specifically designed for summarisation in the EBM domain. We use approximately half the corpus for deriving important statistics associated with the best possible extractive summaries. We take into account factors such as sentence position, length, sentence content, and the type of the query posed. Using the statistics from the first set, we evaluate our approach on a separate set. Evaluation of the qualities of the generated summaries is performed automatically using ROUGE, which is a popular tool for evaluating automatic summaries. Our summarisation approach outperforms all baselines (best baseline score: 0.1594; our score 0.1653). Further improvements are achieved when query types are taken into account. The quality of extractive summarisation in the medical domain can be significantly improved by incorporating domain knowledge and statistics derived from a specialised corpus. Such techniques can therefore be applied for content selection in end-to-end summarisation systems.

The marriage of evidence and narrative: scientific nurturance within clinical practice

Published elaborations of evidence-based medicine (EBM) have failed to materially integrate the domains of interpersonal sensibility and relationship with tools intended to facilitate attention to biomedical research and knowledge within clinical practice. Furthermore, the elaboration of EBM skills has been confined to a narrow range of clinical research. As a result, crucial tools required to connect much clinically relevant research and practice remain hidden, and explorations of the deeper challenges faced by practitioners in their struggle to integrate sound science and shared clinical action remain elusive. We developed a model for scientifically informed, individualized, medical practice and learning that embraces the goals, resources and skills of EBM within a larger framework of practice defined by narrative process: 'attention', 'representation' and 'affiliation'. We drew from published elaborations of EBM, narrative medicine (NM) and the results of a project to develop tools for assessment of the cognitive skills embedded within a practice based EBM domain. Within the resulting model, a tool of representation, whose components are Problem delineation, Actions, Choices and Targets, enables the clinical problem to be delineated and the patient and practitioner perspectives to be concretely defined with reference to four classes of clinical interaction: 'therapy', 'diagnosis', 'prognosis' and 'harm'. As a result, the 'information literacy' skills required to access, evaluate and apply clinical research using electronic resources are well defined but subordinated to shared appreciation of patient need. The model acknowledges the relevance of the full range and scope of scientifically derived medical knowledge. A model based on integration of NM and EBM can lead to instructional tools that integrate clinical epidemiological knowledge with enforced consideration of differing patient and practitioner perspectives. It also may inform avenues for qualitative research into the processes through which such differing perspectives can be productively identified and shared.

Where is the wisdom? I – A conceptual history of evidence‐based medicine

Rationale Evidence-based medicine (EBM) has been acclaimed as a major advance in medical science, but criticized as a proposed alternative model for the practice and teaching of medicine. Ambiguity regarding the proper role of the contributions of EBM within the fabric of medicine and health care has contributed to this discrepancy. Aims and objectives We undertook a critical review of the history of the EBM movement, beginning with its origins in the 1970s and continuing through this century. We drew upon the results of an independent project that rationalized the EBM domain from the perspective of educational evaluation and assessment. We considered the content of EBM in relationship to the propositions and promises embodied in advocacy publications. Results EBM emerged in the context of the explosion of biomedical information in the decade preceding public access to the Internet in the mid-1990s and drew upon the independently derived 'information literacy' formula developed by information scientists during the 1980s. The critically important content and achievements of EBM are fully explained within the confines of the information literacy model. The thesis that EBM offers an alternative paradigm for individualized health care, asserted in the advocacy literature, is not supported by published models of evidence-based clinical practice. Conclusion A critical historical review of the origins, content and development of the EBM movement proposes that full integration of the fruits of the movement into routine clinical care remains a conceptual and practical challenge.

Impact of an evidence-based medicine curriculum based on adult learning theory.

To develop and implement an evidence-based medicine (EBM) curriculum and determine its effectiveness in improving residents' EBM behaviors and skills. Description of the curriculum and a multifaceted evaluation, including a pretest-posttest controlled trial. University-based primary care internal medicine residency program. Second- and third-year internal medicine residents (N = 34). A 7-week EBM curriculum in which residents work through the steps of evidence-based decisions for their own patients. Based on adult learning theory, the educational strategy included a resident-directed tutorial format, use of real clinical encounters, and specific EBM facilitating techniques for faculty. Behaviors and self-assessed competencies in EBM were measured with questionnaires. Evidence-based medicine skills were assessed with a 17-point test, which required free text responses to questions based on a clinical vignette and a test article. After the intervention, residents participating in the curriculum (case subjects) increased their use of original studies to answer clinical questions, their examination of methods and results sections of articles, and their self-assessed EBM competence in three of five domains of EBM, while the control subjects did not. The case subjects significantly improved their scores on the EBM skills test (8.5 to 11.0, p = .001), while the control subjects did not (8.5 to 7.1, p = .09). The difference in the posttest scores of the two groups was 3.9 points (p = .001, 95% confidence interval 1.9, 5.9). An EBM curriculum based on adult learning theory improves residents' EBM skills and certain EBM behaviors. The description and multifaceted evaluation can guide medical educators involved in EBM training.