Evidence Based Medicine

[PA-SGuy]

Hello all,

I'm on my clinical rotations right now and just wanted to know how everyone practices EBM. What resources/sites/books do you use for EBM? Is there some magical website that has a lot of the guidelines in easy to read format (other than UTD). I have been using UpToDate a lot, especially in between patients when I don't know something. This worries me because it takes a few minutes and I can't do this for every patient in the real world. I am familiar with the USPTF recommendations on different things, however, sometimes i see patients who aren't treated with those guidelines like who gets aspirin etc. How do you deal with this? Obviously, as I learn more I will remember more guidelines but even then, guidelines differ between differ societies like mammogram screening guidelines are different between USPTF and american cancer society.

 

Thanks,

Anxious PA student

[Cideous]

Just remember one thing.  What is evidence based "fact" today, is old news tomorrow.  The evidence is always shifting.  Just ask any women who has inquired, "should I take hormone replacement pills?"    lol

[jlumsden]

Yes and no.  UptoDate is pretty good, although it throws the occasional editorial comment in (i.e. We like to put white pepper in our gravy to give it that extra zing).  Dynamed is actually faster at updating their clinical information, but my institution doesn't use it.

When you get to the job search, realize you are also interviewing them.  Ask what the place does to keep its providers current.  Mine has journal club, and a standard work committee that creates and revises evidence based templates based on common conditions.  Especially in the beginning, it's important to work at a place that incorporates this into their culture.

Finally, be consistent.  I use the USPSTF calculator for every physical.  I use UptoDate when I am in doubt (and it happens often, as a second year PA).  I review UptoDate's Practice Changing Updates monthly.  If an appointment feels muddled clinically, I make a point to work on improving my content knowledge in that area.

[sas5814]

You will find many patients who are not treated for different thing using evidence based medicine. The most current issue many of us are dealing with right now are antibiotics for colds. Man many many provider will give antibiotics and steroids for every drippy nose, throat tickle and cough. This has nothing to do with good medicine but patient satisfaction, Press-Gainey scores, and good old fashion filthy lucre. I have had UCs that wouldn't let me PRN for them anymore because I wouldn't do these things. Patient satisfaction has become a driving force in medical decision making sadly. It isn't confined to colds by any means but that is a very common example.

Talk to your peers a lot! Nobody can keep current on everything but between a large group of you someone has always read or heard something new or interesting.

No you can't look up everything every time but you can look up a lot of things often enough. I do it every day and I have been at this for 30 years. Today's truth is tomorrow's outdated medicine.

I use UptoDate a lot because it is built into my EHR. I also use the Sanford Guide to Antibiotics frequently. On rare occasion I can't find a good answer to something and I'll shoot a friendly email to someone in one of our specialty departments or clinics. I always get polite and very helpful answers.

never stop reading.

[PA-SGuy]

thanks for the replies everyone, eager to see if others chime in

[LT_Oneal_PAC]

Listen to primary care rap and EM rap. Follow preventive guidelines from USPSTF. Use a lot of UTD, but I don’t slave myself to it. You’ll end up doing a lot of unnecessary work ups if you do. When someone is outside the guidelines, I try to see why. Often I see it after closer look they had good reason. If they don’t and they were being outdated or lazy, then I fix it. I don’t make a big deal over it or say anyone is wrong (very bad idea) just state that the recommmendations have updated. If it’s just a preference thing and they aren’t my patient, I leave it.

[GetMeOuttaThisMess]

<$200/annually will buy you a subscription to Primary Care or Emergency Medical Abstracts.  Initially back in the 90's they were EM only and reviewed 30 abstracts per month and really opened my eyes to questioning things (I won't bring up my pet peeve again).  Over time they morphed into PC (though still discuss EM topics under such a heading) and have added a monthly paper of their own on multi topics.  They are now Cat. I CME and up to 10 hours per month as I recall.  This is how I stay current with what the Jones are doing next door.

The two initial docs have cut back dramatically (Hoffman and Bukata, who are EM boarded docs out of S. Cal.) but their younger guys who fill the void from across the country do a good job.  Think of these guys as the modern day medical "X-Files" investigators.  They want you to question, not just "believe".

[lkth487]

So interns and med students ask me this question a lot.  First step is to look at official guidelines from various societies (AAP, ACOG, etc) as well as uptodate or medscape or some other resource.  I think those are good places to start.  But while you should know the official recommendations, eventually you need to read the original studies and go through their methodologies.  That is super helpful because you will build up a knowledge base that will let you see flaws in the recommendations and when you could and should deviate from them.  There are a lot of "evidenced based" guidelines that aren't worth the paper they're printed on.

For my interns, I expect them to read and learn the guidelines. For my second year residents, I expect that they've looked at the studies behind those guidelines and have some understanding of their strengths and weakness.  At this point, towards the end of my residency, I am getting to the point where I can knowingly deviate from guidelines and have solid scientific reasons for doing so.  And it also gives me insight into what studies need to be done in the future that perhaps I can look into doing or getting involved instead  (publish or perish :p).  

For example, look at the mammogram example you mentioned.  Why do the recommendations differ?  It has to do with the number needed to treat vs number needed to harm, probably the two most important statistical items to consider.  Look at the study - for a 37 year old woman with no risk factors, what is the risk and benefit ratio of a mammogram? What about for a 52 year old woman with no risk factors? 42 year old woman with a strong family history of beast cancer?  If you look through the data, you will find very different answers to those questions, which will affect your choice in what to do - and you can make a decision on which guidelines to follow, or maybe why you shouldn't follow any of them.

Remember, this field we chose - it's lifelong learning, and that involves lifelong questioning.

[GetMeOuttaThisMess]

Let me once again play devil's advocate for a moment.  While it is nice to know the latest and greatest it is also important to have an understanding of the local standard of care for a problem.  I'm in that situation right now with treating influenza cases that meet the CDC recommendation for same without getting a rapid flu test (for any one of a number of reasons specific to my practice location).  Regardless of whether YOU are current and THEY aren't, THEY become the standard of care for your community and thus it could possibly present issues for you down the round as crazy as that might sound.  Case in point, USPSTF doesn't recommend automatic PSA screening but rather informed decision making between parties. A urologist on the east coast followed this protocol with patient's agreement, took a watch/wait approach for an average risk male, and next year he was found to have prostate CA.  Lawsuit led to decision for plaintiff due to the specialist for the "standard of care" in the community since all the other outdated folks were all still doing mindless PSA screens.

[lkth487]

That's hard, for sure.  By that logic, you end up always doing the most conservative thing possible in every situation.  Which I understand why people do - I am not an attending yet and I understand it's not my ass on the line, which changes the equation and it's much easier for me to be cavalier about that stuff.  I don't have an answer, nor do I have the hubris to promise that I will only practice EBM and not defensive medicine when I'm an attending.  The medicine you practice and the medicine you would like to practice in an ideal world are not always the same thing, and that's a sad fact of life.  

[LT_Oneal_PAC]

11 hours ago, GetMeOuttaThisMess said:

Let me once again play devil's advocate for a moment.  While it is nice to know the latest and greatest it is also important to have an understanding of the local standard of care for a problem.  I'm in that situation right now with treating influenza cases that meet the CDC recommendation for same without getting a rapid flu test (for any one of a number of reasons specific to my practice location).  Regardless of whether YOU are current and THEY aren't, THEY become the standard of care for your community and thus it could possibly present issues for you down the round as crazy as that might sound.  Case in point, USPSTF doesn't recommend automatic PSA screening but rather informed decision making between parties. A urologist on the east coast followed this protocol with patient's agreement, took a watch/wait approach for an average risk male, and next year he was found to have prostate CA.  Lawsuit led to decision for plaintiff due to the specialist for the "standard of care" in the community since all the other outdated folks were all still doing mindless PSA screens.

Well, that’s not even necessarily boiling down to locality. His own association agrees to yearly PSA. Other societies support different approaches, so it’s muddy water. I’d also have to wonder if he documented well about the risk/benefit discussion with the patient.

Personally, I only do things by locality if the evidence is weak or non existent, or justified by following a local antibiogram. 

I typically follow my own specialty guidelines.

But if I have solid evidence to back me up, then I’ll do that. Practicing good medicine is a hill I’m willing to die on.