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Starting EBM Life-Long Journey – a reflection of teaching experience for more than 15 years in different residency programs (Afify Principles)

Dr Ayman Afify

By Dr Ayman Afify

Consultant & Senior Trainer of Family Medicine& Med Educ, PSMMC, Riyadh, KSA. working in the field of Family Medicine Practice & Training both in Egypt & Saudi Family Medicine residency programs since 2003, has a special interest in LifeStyle Medicine, Clinical Prevention, EBM, research field & Medical education.

Background:

Since Prof. David Sackett & his colleagues founded the famous 5 steps for the Evidence-Based Medicine (EBM) process, people used to look to the first 3 fundamental steps as being very tough steps and sometimes perceived academic. I hope this reflective effort from my personal teaching & learning experience will blow more practicality to these steps and making them less challenging. I recommend for the trainers to orient the trainees with these principles from the very beginning to catch the essence of these steps. This effort (which is a yield of hundreds of workshops that I shared in either attending, conducting or coordinating since 2004 & a summary of many medical schools that I communicated within this field) is targeting both the Trainees & the Trainers.

First EBM Step (PICO)

The Problem;

  1. Learning while being indulged in a busy practice

The Concept;

  1.  Life is the main source of learning.
  2. any process in our lives to be completed perfectly, should start by a sharply clear and focused ‘Objective’.

The Value;

  1. Feel good when you don’t know – questioning is the spark of light toward gaining knowledge.
  2. Writing is the 1st step toward organized thinking.

Why Questioning?

  1. As we all know, a child learns via a built-in system of inquiry (we can call it ‘Why system’). As we get older, we lose this why capability. Our golden chance to learn is to face a problem that we have no solution for it. Our clinics are the fields where we face clinical problems. We do believe that the best way of learning –from the perspective of a busy clinician- is to learn while in a situation of inquiry while practicing. This is of course ‘opportunistic learning or just in time way of learning’ will make the solution of any problem very up to date, relevant to your current patients & unforgettable as it solves a painful issue to the practioner.
  2. It is recommended to transfer this unsolved scenario or problem, into a question, as question format – by default- will focus your inquiry. This question will turn to be the objective of your search journey toward an answer.

Why PI/ECO?

PICO is the standard format that will make your question focused, and it will highlight the key terms for this question while you are looking for an answer.

“Good questions lead to good answers, while fuzzy questions lead to fuzzy answers”

N.B; It is highly advisable – at least initially – to write the question as this written statement will alert you with what you are specifically looking for, and it will also keep reminding you to search for an answer as soon as you can (Figure 1).

Example of (EBM Prescription) for writing PICO

Figure 1. An example of (EBM Prescription) for writing PICO including patient identification & date to be answered, help to be memorable & a very good tool for self-improvement & adopting LLL attitude, “from Oxford Centre of EBM, 2019”.

The second step (Search)

The Problem; we as clinicians are always thirsting for knowledge, drowning in information (this is the era of “Plethora” of information & “Oligemia” of our Time).

The Concept; Regardless of the search tool used, the key factors in any online search are your specific search strategy & technique.

The Value; of Clever Information Seeker.

Suggested search strategy;

– Give Time for PICO

  1. Constructing the proper PICO Question (for your current patient).
  2. Write it down.
  3. Determine the Question Type (therapy/ Prognosis. Etc.) which will guide you toward the type of the study (RCT, Cohort, etc.) and which electronic database to look for.
  4. Identify exactly the Key Terms.

– It is highly recommended to

  1. Access medical Information mostly in a problem-solving mode (Hunting Mode) rather than browsing Mode.
  2. Start looking for your answer 1st in 2ry resources; e.g.; EB guidelines, high valid SR (Systematic Review), Or Evidence Summaries, … e.g. Cochrane Collaboration/ NICE guideline/ Best Practice/ Trip database… etc.
  3. If you don’t find the answer in the previous step, go to the primary resources.
  4. Don’t use Generic search engines, like Google, Yahoo…etc. for decision-making.
  5. Concentrate as much as you can on Patient-Oriented (POEM) literature.

– Create your own online resource lists that you trust & master their tips

  1. Use their free trials & read their online help.
  2. Start by at least 2 different databases besides the PubMed & then go on…
  3. Store your search results & subscribe, or sign in.

N.B;  Most of the 2ry resources are pre-appraised.

3rd Step (Appraisal) – Especially With Primary Resources

The Problem; “Not all that Glitters is Gold”.

The concept; where your job here is typical like the reviewer of any narration or a movie, or a sport game; so the researchers – in our situation- are like the actors, the writer, or the player & you are the expert critique, each one of you has his/ her important, but different roles; they are like inventors showing their talents and creativity, and the critiques are applying the scientific principles to assess these efforts looking forward to a better future creation, so, you are not supposed to be a researcher or a statistician, keep this in your mind, you are just asked to be a research-minded & good fast data interpreter.

The Value:Take it as a game & the essence of the game is not to be fooled by the author or the statistician.

– 2 hands, 2 eyes:

Your worksheet (there are many worksheets for the appraisal purpose, from many medical & EBM schools) in one hand & the article for appraisal in another hand & go question by question, one eye on the questions & the guide to answer it, and the other eye on the part of the document where you can find if it is met or no.

– ONLY METHOD & RESULT:

We are appraising 2 major parts:
a. Validity……. mainly through reading the Methodology section.
b. Result………mainly through reading the Result.
So, it is recommended that the appraiser – especially busy practioners & those new in the EBM journey- only read the Methodology & the Result section from the article, plus – for sure- the abstract (to get oriented with the main objective of the trial (PICO) which will reflect Relevance).

– Validity comes 1st. & the importance of the 1st two Questions:

After getting the relevant (to your current patient problem {PICO}) article, validity is more important than other parts so if you mark the article as valid, even if 6 out of 10, you can continue its reading & accepting its results and the Vice Versa. The most important questions to assess validity are usually the 1st 2 questions (The concept of the primary Guide) so very rapidly if both of them take frank NO, don’t continue with this article (except for training purpose or you don’t have other evidence in that topic) & if they took Frank Yes, mostly you will accept it & the other probabilities going as per the appraiser’ considerations.

– DON’T ASSUME:

i.e.; we are only trusting what is written & no room to assume that the authors did or didn’t do this work… “What is not documented, not done” at the same time, we are not suspicious about the written words as far as they are transparently written. That’s why, I consider (Can’t tell) or (Yes But), is an option sometimes when we face limitation or concealment in reporting.

– AN INDIVIDUAL EFFORT:

Critical Appraisal at the end of the day is an individual effort. so, the result may vary according to the medical background of the appraiser, experience with the EBM concept and with the process of the critical appraisal. So, one may answer one question as (Yes) while another one may say (Y, but…) or (can’t tell). This is accepted & may even be considered healthier when justified. That’s why in this process, we mostly need more than one appraiser. BUT mostly whenever the appraisers have minimal skills and depending upon the previous principle, we will not find one rate (Y) & another rate (No) for the same question except in a very rare instance. And like any skill, it will be sharpened over time& via more practice, “Practice makes perfect”.

– Diagrams:

Whenever available, go to the tables & figures. They will summarize the result section & offer it in an easier way for reading & interpretation. Also, it is highly advisable that after you read the abstract to draw a diagram for the design of the study & label each arm with the numbers & the main outcomes. This will help a lot; especially in therapy, Prognosis & Diagnosis papers.

N.B, most of the well-written articles are presenting these diagrams. Ex; look at the attached figures as examples of scratch drawings 2&3.

– Interpretation only:

In the result section, you are concerned only with interpretation & the meaning of all the numbers & values. You are not concerned at all with the equations or calculations. Ex of interpretation is the width of CI (Confidence Interval) rather than its calculation & the value of LR (Likelihood Ratio) in a diagnostic paper (either positive or negative) rather than to load your mind with its formula, and so on for any article type.

N.B; you may optimize the use of EBM Calculator software for all the calculations that you need after proper construction of the relevant 2*2 table.

A simple diagram that represent an RCT design

Figure 2. A simple diagram that represents an RCT design that could be used by the trainee while reading the article for appraisal to simplify the methodology & result section.

Simple example of a diagram for diagnostic study design (From the User’s Guide to medical Literature, 3rd edition)

Figure 3. A simple example of a diagram for diagnostic study design (From the User’s Guide to Medical Literature, the 3rd edition).

Conclusions

This is an introduction for teaching EBM foundation steps – especially to the beginners in the journey – that may help to foster the Lifelong Learner spirit within the Trainees.

To sum up, this article is a trial to:

1- Conceptualize the 3 fundamental EBM steps within a major principles that may help adult learner to understand & to mentally digest them within a context, so it may augment their active participation within the learning process as it should be always within any adult training activity, and so we hope learners can fish every day whenever they want, and going faster by time.

2- Trying to facilitate the practice of the 1st 3 EBM steps via practical simple tips that may help the busy physician, enhancing the self-directed learning capabilities, ultimately, hopefully improving health care.

Always remember: ‘if you give someone a fish, he will eat today, if you teach him, how to fish, he will eat everyday…’

 

Practice Points

E.B.M.

* What do we know?

Definition; Evidence-based medicine (EBM) is the conscientious, explicit, judicious and reasonable use of modern, best evidence in making decisions about the care of individual patients.

– 2 Principles; The practice of EBM rests into 2 principles. The first postulates the hierarchy of evidence & the second principle is that evidence itself is not enough for making clinical decisions.

3 Components;

* Best Available Evidence/* Physician Experience/*Patient’ preferences

4 Levels; Studies/ SR (Synthesis)/ Synopsis (Summaries)/ Systems

5 steps;

* Ask/*Acquire/*Appraise/ Apply/*Assess.

* What does this paper add to you?

As adults learn best when they see the value in what they learn and can comprehend the big picture; I hope this guide may help when employed to make the job of the EBM’ trainers easier & the EBM’ journey of the new trainees more focused, through linking the 1st 3 fundamental steps of EBM to the logic behind & the major principle that may govern them, from my point of view, and also, linking it to the practical problem from the perspectives of our end-user (busy clinician).

 

Acknowledgments;

  • My wife, Eman Elbaz& My sons; Ahmed& Belal, for being very patient with me, understanding my work condition & tolerating me a lot, they are my 1st
  • The entire EBM Jeddah group, with whom I shared learning, teaching & Facilitating different EBM courses since 2004
  • Prof Gordon Guyatte; I benefited a lot from his lectures and sharing multiple symposia with him in Saudi Arabia since 2005 & I was honored to share an email with him about my article & got his written feedback & comments to me.
  • Prof Samir Mossa; for being always my Educator’ Model
  • NGCEBM (National& Gulf Center for EBM); I shared teaching & attending with them different courses & exchanged experiences since 2006
  • Dr. Hesham Omar; giving few English rephrasing comments for a very long time& have a very good trust in mine.
  • Prof Samar Abdelazeem, a highly supportive, inspiring coach & helped me to transfer these difficult concepts through attractive short videos.
  • Prof Mostafa Kofi guided me for the structure & importance of the article and believing in my capabilities.
  • Prof Tarek Al-Saied; for being keen to read my article & giving his personal feedback from his rich experience in the EMB field & also in English language rephrasing.

References

1- David Sackett, et al. 1991. Clinical epidemiology: a basic science for clinical medicine, 2nd ed, BMJ.
2- Course Material for Post Graduate Medical Education. 2004. UK: Dundee University.
3- David LS, Sharon ES, Scott R, William R, Brian H. 2000. Evidence-based medicine: how to practice and teach EBM. 2nd ed. Edinburgh: Churchill Livingstone.
4- Gordon G, Drummond R, Maureen OM, Deborah JC. 2015. User’s guide to the medical literature. 3rd ed. USA: McGraw-Hill Education.
5- Oxford Centre EBM. 2006-2019; https://www.cebm.net/
6- Shaughnessy AF, Slawson DC, Bennett JH. Becoming an Information Master: A Guidebook to the Medical Information Jungle. The Journal of Family Practice 1994;39(5):489-99.
7- The User

Guides to Evidence-Based Medicine. JAMA series on step-by-step critical appraisal, JAMA, 1993 and 1994.