Evidence-based Medicine Process Research Articles

The gender-affirming model of care is incompatible with competent, ethical medical practice.

To examine the compatibility of gender-affirming care with the principles and practices of psychiatry. The assumption that there is no pathology involved in the development of gender diversity is a necessary precondition for the unquestioning affirmation of self-reported gender identity. Cases where psychosis is the undeniable cause of gender diversity demonstrate this assumption is categorically false. To protect this false assumption, gender-affirming guidelines forbid the application of the core psychiatric competencies of phenomenology and psychopathology to the assessment of gender diversity. They substitute the political goal of expanding personal liberty for the evidence-based medicine processes of clinical reasoning, rendering them incompatible with competent, ethical medical practice.

Undergraduate courses of evidence-based medicine in Peruvian medical schools: Characteristics and addressed topics

BackgroundMedical schools are increasingly including evidence-based medicine (EBM) courses in their curricula. However, little is known about the characteristics of these courses in Peru. Therefore, the present study aimed to describe the characteristics and topics addressed by undergraduate courses on EBM in Peruvian medical schools, and to compare the content of these courses with predefined EBM competencies. MethodsWe conducted a cross-sectional study. We obtained the syllabi of undergraduate EBM courses from all medical schools for the latest year available. We extracted their characteristics and categorized the topics they included according to the five steps necessary to apply EBM, divided into 22 competencies. ResultsIn 2021, Peru had 47 universities with active undergraduate medical schools, of which 9 (19.1%) had EBM courses. These courses were not mandatory in three of the universities, and were typically offered between the 2nd and 5th year of the degree program. When analysing the topics covered in the syllabi, we found that they addressed 7 to 13 of the 22 core competencies evaluated. The least addressed topics belonged to steps 4 (apply) and 5 (evaluate) of the EBM process. ConclusionWe found that few Peruvian universities offer EBM courses, and that these courses have heterogeneous characteristics, with syllabi that do not include all essential topics for applying the five steps of EBM.

Evidence-Based Decision-Making 1: Critical Appraisal.

This chapter provides an introduction to the concept of Evidence-based Medicine (EBM) including its history, rooted in Canada and its important role in modern medicine. The chapter introduces EBM and explains the process of conducting EBM . The chapter starts with a description of the traditional hierarchy of evidence that exists in research with reference to the critical appraisal tools often used to assess the quality or credibility of individual studies. It includes a section on assessing risk of bias in randomized clinical trials and non-randomized studies and guidelines for reporting study findings now fully captured in the EQUATOR Network. In addition, a section on GRADE (Grades of Recommendation Assessment, Development and Evaluation) and the process used to determine the quality of evidence when guiding clinical decisions or developing clinical practice guidelines is included. In response to the substantial number of research syntheses being published, AMSTAR2, a tool used to critically appraise the quality and reporting of systematic reviews is described. The main focus of the chapter remains on how to critically appraise the medical literature, as one step in the EBM process. However, this process also includes an assessment of study bias and an understanding of reporting guidelines. At its basic level, critical appraisal requires an understanding of the strengths and weaknesses of study design and how these in turn impact the validity and applicability of research findings. Strong critical appraisal skills are critical to evidence-based decision-making .

Effectiveness of Modalities to Teach Evidence Based Medicine to Pediatric Clerkship Students: A Randomized Controlled Trial

ObjectiveTo evaluate the effectiveness of a traditional didactic session (TDS) as compared to a self-paced, interactive, multimedia module (SPM) on the application of evidence-based medicine (EBM) skills among medical students during their inpatient pediatric rotation.MethodsWe conducted a randomized controlled trial from June, 2017 to June, 2018 at a quaternary care children's hospital. Students were randomized to TDS or SPM during each 2-week block. All students completed a critical appraisal tool (CAT) of evidence related to a clinical question in a standardized appraisal form and self-reflected about the EBM process. The primary outcome was the numeric score of the CAT derived by using the validated Fresno tool. Secondary outcomes of knowledge, attitudes, confidence, and self-reported behaviors related to EBM were measured using validated surveys. Statistical analysis was performed using Student's t test for CAT scores and mixed-model procedure (PROC MIXED), with subject as random effect and time as repeated measure for the secondary outcomes.ResultsOne hundred twenty-seven clerkship students were included. Overall, there was no significant difference in mean CAT scores for TDS (n = 59) versus SPM (n = 66) groups (90.3 vs 92.0, P = .65). There were no significant differences between SPM and TDS groups for knowledge (P = .66), attitudes (P = .97), confidence (P = .55), and accessing evidence (P = .27). Both groups showed significant gains in knowledge, attitudes, confidence, and accessing evidence from baseline to postcourse. Improvements in knowledge and confidence were sustained at 3-months.ConclusionA SPM learning module is as effective as a TDS module for application of EBM concepts and knowledge to patient care.

Piloting a blended-learning concept for integrating evidence-based medicine into the general practice clerkship.

Objective: The present study investigates the feasibility of the application of evidence-based medicine (EBM) procedures by students as part of practical training in general medicine through a newly developed blended-learning teaching concept.Methodology: This study describes the development, piloting and evaluation of a blended-learning concept for implementing EBM education as part of general practice training. Our concept consists of an online tutorial introducing the theoretical background, two classroom seminars for consolidation and practical exercises based on case studies. Following this, students were to apply their knowledge to real-life cases during their training. To evaluate the learning outcome, we have developed an evaluation tool based on the Fresno Test (Bonn Test). At the end of the seminar, students were invited to evaluate the concept.Results: A total of 35 students took part in the feasibility study and 27 Bonn tests were evaluated. All students achieved more than the pass mark required in the Bonn Test in the preparation of clinical case studies. Because of the differentiated assessment of learning outcomes in all categories of the 5A EBM process, difficulties in the translation process can be revealed by the Bonn test. As a result, the concept can be refined and improved continuously. In the evaluation, 74% of the students rated the teaching concept "good" or "very good".Conclusion: Overall, this study confirmed the feasibility of our EBM concept while demonstrating that students are able to apply the theoretical knowledge acquired to real-life settings. Further research with our concept is needed, especially at an earlier stage in the curriculum.

Classifications in Brief: The Spinal Instability Neoplastic Score.

Classifications in Brief: The Spinal Instability Neoplastic Score.

Why do multicenter randomized controlled trials not confirm the positive findings of single center randomized controlled trials in acute care?

It is a common observation that many multicenter randomized controlled trials (mRCT) performed in critically ill patients do not achieve the positive findings often seen in single center studies (sRCT). This has, of course, relevant consequences for clinical practice, as mRCTs have higher scientific validity compared to sRCTs. The aim of this manuscript was to review and discuss the several potential causes of this phenomenon and to relate them to the future of mRCTs in critical care medicine. Overall, this seems to recall the old mythologic story of Achilles and the tortoise: although mRCTs (i.e. Achilles) are much more powerful, indeed, they always arrive later in time compared to the sRCTs (i.e. the tortoise) from which they were powered. However, sRCTs are more prone to several bias compared to mRCTs, such as local effect bias, selection and performance bias, detection and reporting bias, analysis and attrition bias, concomitant therapy bias, low fragility index and publication bias. In this sense, it is high time the critical care community should see the positive findings of sRTCs with a very high level of scientific caution, unless they are confirmed by mRCTs. MRCTs represent the final step of the process of evidence-based medicine and in the end (however slowly and painfully) such evidence catches up with sRCT and truly helps changes practice worldwide.

Practising evidence-based medicine (EBM): a descriptive analysis of medical students’ whole-task EBM assignments

Researchers have suggested whole-task learning activities to practice and teach evidence-based medicine (EBM); however, limited description exists of their use in EBM curricula. This article describes medical students' execution of...

74: HOW CLINICAL LIBRARIAN ACTS IN EVIDENCE-BASED MEDICINE? A SYSTEMATIC REVIEW

Background and aims:The rapid growth and specialization in Medical Sciences increase the volume of information and therefore make physician problems and difficulty to access reliable information. Physicians can`t decide only...

79: IMPACT OF INFORMATION TECHNOLOGY ON EFFICIENCY OF EVIDENCE-BASED MEDICINE: A SYSTEMATIC REVIEW

Background and aims:Evidence-based medicine (EBM) is a systematic process of searching, evaluating and using the best evidence available for clinical decision that this evidence obtained from clinical research consciously. Information...

An Integrated, Case-Based Approach to Teaching Medical Students How to Locate the Best Available Evidence for Clinical Care.

A major step of the evidence-based medicine (EBM) process is to locate the most current evidence in support of clinical care. This requires identifying and searching appropriate evidence-based resources. Medical library faculty at the Oakland University William Beaumont School of Medicine teach these skills as part of a dedicated EBM course at the end of the second year of the medical school curriculum. A 3-hour "Locating the Best Available Evidence" session is divided into two major components: an optional 50-minute didactic lecture followed by a mandatory 2-hour interactive lab. Students formulate a PICO (patient, intervention, comparison, outcome) question from a case, develop search strategies, and gather evidence. Formative feedback is provided to the students to help them prepare for a final case presentation. Session effectiveness is assessed using course evaluations and the case presentation grade. Course evaluations indicate that students find this session structure to be especially helpful in learning the breadth of available EBM resources, preparing for their course case presentations, and acquiring skills for clinical clerkships. Quality of the case presentations also indicates students have acquired the necessary skills to be successful in practicing EBM skills in clerkship rotations and residency. Whether institutions have a dedicated EBM course or integrate EBM skills into the medical school curriculum, this session could easily be adapted and implemented. It could also be tailored for graduate or continuing medical education environments in any specialty.

Self-perception and knowledge of evidence based medicine by physicians.

BackgroundThe influence, legitimacy and application of Evidence Based Medicine (EBM) in the world is growing as a tool that integrates, the best available evidence to decision making in patient care. Our goal was to identify the relationship between self-perception about the relevance of Evidence Based Medicine (EBM) and the degree of basic knowledge of this discipline in a group of physicians.MethodsA survey was carried out in a third level public hospital in Mexico City. Self-perception was measured by means of a structured scale, and the degree of knowledge through parameter or “rubrics” methodology.ResultsA total of 320 questionnaires were given to 55 medical students (17 %); 45 pre-graduate medical interns (14 %); 118 medical residents (37 %) and 102 appointed physicians of different specialties (32 %).Self-perception of EBM: The majority of those surveyed (n = 274, 86 %) declared that they were very or moderately familiar with EBM. The great majority (n = 270, 84 %) believe that EBM is very important in clinical practice and 197 physicians (61 %) said that they implement it always or usually. The global index of self-perception was 75 %.Knowledge of EBM: Definition of EBM; Seven of those surveyed (2 %) included 3 of the 4 characteristics of the definition, 82 (26 %) mentioned only two characteristics of the definition, 152 (48 %) mentioned only one characteristic and 79 (25 %) did not include any characteristic of EBM. Phases of the EBM process: The majority of those surveyed (n = 218, 68 %) did not include the steps that characterize the practice of EBM, of which 79 participants (25 %) mentioned elements not related to it. The global index of knowledge was 19 %.ConclusionsThe majority of the surveyed physicians have a high self-perception of the relevance of EBM. In spite of this, the majority of them did not know the characteristics that define the EBM and phases of the process for its practice. A major discrepancy was found between self-perception and the level of basic knowledge of EBM among the surveyed physicians.Electronic supplementary materialThe online version of this article (doi:10.1186/s12909-016-0681-6) contains supplementary material, which is available to authorized users.

Evidence-based decision-making 1: Critical appraisal.

This chapter provides an introduction to the concept of Evidence-based Medicine (EBM) including its history, rooted in Canada and its important role in modern medicine. The chapter both defines EBM and explains the process of conducting EBM. It includes a discussion of the hierarchy of evidence that exists with reference to common methods used to assess the levels of quality inherent in study designs. The focus of the chapter is on how to critically appraise the medical literature, as one step in the EBM process. Critical appraisal requires an understanding of the strengths and weaknesses of study design and how these in turn impact the validity and applicability of research findings. Strong critical appraisal skills are critical to evidence-based decision-making.

Evolution of evidence-based medicine to detect evidence mutations.

Frustrating to some and exhilarating to others, medical knowledge is in continual evolution. Medicine’s evidence base evolves in many ways, sometimes in ways that can be compared to random mutations (such as adverse effects of a drug leading to investigation of its use where the effect could be beneficial) and other times through selection pressure that allows substandard evidence to flourish in ecological niches (such as a research community accepting existing reports as an established and unquestioned foundation). We describe several ways in which pathways resembling aberrant evolutionary changes distort our evidence base (how has our evidence evolved?), and discuss areas where evidence-based medicine (EBM) processes can adapt (how does EBM need to evolve?).

Research in spinal surgery: Evaluation and practice of evidence-based medicine.

Evidence-based medicine (EBM) is a common concept among medical practitioners, yet unique challenges arise when EBM is applied to spinal surgery. Due to the relative rarity of certain spinal disorders, and a lack of management equipoise, randomized controlled trials may be difficult to execute. Despite this, responsibility rests with spinal surgeons to design high quality studies in order to justify certain treatment modalities. The authors therefore review the tenets of implementing evidence-based research, through the lens of spinal disorders. The process of EBM begins with asking the correct question. An appropriate study is then designed based on the research question. Understanding study designs allows the spinal surgeon to assess the level of evidence provided. Validated outcome measurements allow clinicians to communicate the success of treatment strategies, and will increase the quality of a given study design. Importantly, one must recognize that the randomized controlled trial is not always the optimal study design for a given research question. Rather, prospective observational cohort studies may be more appropriate in certain circumstances, and would provide superior generalizability. Despite the challenges involved with EBM, it is the future of medicine. These issues surrounding EBM are important for spinal surgeons, as well as health policy makers and editorial boards, to have familiarity.

Illicit drugs, policing and the evidence-based policy paradigm

The mantra of evidence-based policy (EBP) suggests that endeavours to implement evidencebased policing will produce better outcomes. However there is dissonance between the rhetoric of EBP and the actuality of policing policy. This disjuncture is critically analysed using the case study of illicit drugs policing. The dissonance may be ameliorated by taking into account the policing context, and lessons from the extant evidence-based medicine, research translation and policy processes literature. Furthermore a developmental pathway notion suggests that it is only once research is fully embedded within the policy culture that critical reflections on the role of evidence become possible.

Evidence-based healthcare practice in Qatar: A need to move forward

Evidence-based medicine (EBM) is considered the gold standard approach to therapeutic decisionmaking in modern medicine. It was first described in the 1990s as a way to improve patient outcomes by promoting rational therapeutic decision-making through translation of high quality clinical studies. It was originally defined as the conscientious, explicit, and judicious use of the best available evidence to make decisions regarding the care of individual patients. By translating results of high quality clinical trials into the therapeutic management of patients, better outcomes can be achieved. Additionally, it allows for standardized therapeutic management of disease and evaluation using audit and feedback. The practice of EBM goes hand on hand with individual clinical expertise and the use of available evidence. The five steps of evidence-based practice are summarized in Table 1. The initial step in the process involves the creation of a specific clinical question, commonly referred to as a PICO (Patient or Problem, Intervention, Comparator, Outcomes) question. Using the elements contained within the PICO question, a systematic search of available evidence would then occur (Step 2). Subsequently, critical appraisal of identified literature occurs with assessment for relevance, internal quality, interpretation of findings and applicability to the patient or problem defined by the original clinical question (Step 3). Finally, the practitioner makes an informed decision based on the evidence identified and appraised (Step 4). While these steps complete the EBM process for patient care, a final stage of evaluation and feedback may occur by auditing individual clinician’s practices to benchmark evidence-based practice among peers (Step 5). There is a traditional belief that high quality evidence refers to only randomized controlled trials, or systematic reviews with meta-analysis. When well conducted, these studies usually represent high internal validity but may lack external validity, or generalizability to real-life patients. Therefore, other types of evidence (epidemiological studies, population based studies, case-series and even case reports) cannot always be ignored. The type of evidence selected for appraisal and therapeutic decision-making is largely based on the patient of interest or the problem at hand. For instance, a public health authority searching for evidence regarding immunization programs for influenza may be better suited to appraise epidemiological and population-based studies, rather than randomized controlled trials of individual patients. Another example would be a question relating to management of a rare adverse drug reaction or diseases, for which only case reports are available. Although this type of evidence is not ideal due to high susceptibility to bias and confounding, it may be the only existing source available. Any chosen evidence must be appraised and assessed for quality and relevance, prior to incorporation into clinical decision-making. Sources of evidence range from online medical literature databases such as PubMed to international organizations offering evidence summaries and appraisals of published studies. The Cochrane Collaboration is a commonly cited source of high quality systematic reviews that are synthesized using objective, standardized methods. Additionally, organizations such as the Britain’s Centre for Reviews and Dissemination at the University of York strive to standardize reporting and dissemination of high quality evidence reviews. Publications from these organizations can greatly

An exploration of Traditional Chinese Medicine practitioners' perceptions of Evidence Based Medicine

ObjectivesTo explore understanding of Evidence Based Medicine (EBM) and use of evidence by Traditional Chinese Medicine (TCM) practitioners, practising in Scotland. DesignQualitative study incorporating semi-structured interviewing of 12 TCM practitioners practising TCM in Scotland. SettingTCM practitioners' premises in an urban area of Scotland, UK. ResultsFew participants were aware of the process of EBM but all reported importance of learning from a range of sources including patients and practice. Participants reported no involvement in the wider demands of the EBM process. ConclusionsTCM practice here was informed by a range of sources but many barriers to full engagement with the EBM process were evident and the small business model of service delivery seemed important here. Participants' prioritisation of classical books and practice as evidence sources poses some cause for concern at a time of rapid growth in well evidenced western biomedical and TCM knowledge and practice.

Clinical meta-analyses of targeted therapies in adenocarcinoma

Although the interpretation of the data reported in meta-analyses may hide several issues, it is undoubtable that this methodological approach may significantly contribute to implement the results of clinical trials, and represent a useful and practical tool for the evidence-based medicine process. Indeed, level-one recommendations should consider well-conducted meta-analyses as well as large and adequately powered randomized trials as the main contributors for the definition of guidelines for clinical practice. In addition, the role of meta-analyses for issues whereas conflicting data (and/or unpowered results) are provided, is well established. In the field of lung cancer, meta-analyses already participated to change the current standard, and are now facing the challenging issues of predictive biomarkers of prognosis and/or efficacy of targeted agents. With this aim, the meta-analytic approach helped in the recent years to implement the quantification of the magnitude of the benefit of targeted agents, and added new insights by interpreting the data coming from clinical trials by integrating them with biomarkers. The treatment-interaction analyses according to putative predictive factors of efficacy may clarify unknown issues and generate new hypotheses for future perspectives. The current review attempts to put in the context of the clinical data of targeted agents for lung cancer all the pros and cons of the meta-analytic process published to date, and critically analyze all the potential perspectives which this methodology may add for both current practice and forthcoming research.

The Limits of Evidence-Based Medicine and Its Application to Mental Health Evidence-Based Practice: Part One

The present article outlines the major limitations of evidence-based medicine (EBM) and through a close review demonstrates that the three component EBM process model is a pseudoscientific tool. Its “objective” component is the collection, systematic analysis, and listing of “effective” treatments applying a research hierarchy from most rigorous (systematic reviews of randomized controlled trials [RCTs]) to least rigorous (expert opinion). Its two subjective components are the clinical judgment of helping professionals about which “evidence-based” treatment to select and the specific and unique relevant personal preferences of the potential recipients regarding treatment. This procedural mishmash provides no more rigor in choosing “best practice” than has been provided by good clinical practitioners in the past because both turn out to be subjective and authority based. The article also discusses EBM’s further methodological dilution in the National Institute of Mental Health (NIMH) endorsed Evidence-Based Mental Health Practice (EBP) movement. In EBP, the allegedly rigorous EBM protocol is altered. Instead of systematic expert protocol-driven EBM reviews of RCTs, NIMH sanctioned expert consensus panels decide “evidence-based practices.” This further problematizes the development of best practices in mental health by converting it to a political process. The article concludes with some observations on these issues. In a second article (part two) forthcoming, assertive community treatment (ACT) is examined as an example of an EBP that fails as a scientifically effective treatment despite its EBP certification and general popularity among practitioners.