Incorporating EBM in Residency Training
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Ideas for Incorporating EBM Competency Training in Medical Residency Programs
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Incorporating EBM in Residency Training
- 1. EBM In Residency Training Dr. Imad Salah Ahmed Hassan MD (UK) FACP FRCPI MSc MBBS Chairman, Knowledge Translation Committee Department of Medicine, KAMC,KSA
- 2. Incorporating EBM in Residency Training: Time for a Map
- 3. Objectives Why do we need to include EBM in Residents Education Curricula Prerequisites for a successful program Practical Examples Assessment
- 4. Information Gap We need evidence (about the accuracy of diagnostic tests, the power of prognostic markers, and the comparative efficacy and safety of interventions, etc.) about 5 times for every in-patient and twice for every 3 outpatients. – David Sackett, M.D. IT HAPPENS FOR EVERYONE !!!!!!!! 4
- 5. Green ML. Evidence-based medicine training in internal medicine residency programs a national survey. J Gen Intern Med. 2000 Feb;15(2):129-33. Free PMC Article
- 6. Why Evidence-based Practice? Improves the quality of patient care Standardizes the delivery of healthcare Reduces the expense of healthcare Incorporates patient values into healthcare decisions Bridging the Gaps Knowledge Practice Resources Expenditure 6
- 7. Why Evidence-based Practice? Essential component of Outcome-based, Competency-focused Training OUTCOME-BASED MEDICAL TRAINING: HAVING THE END PRODUCT IN MIND 7
- 8. How is the world making better doctors? ‘Scottish Doctor’ ‘Tomorrow’s Doctor’ ‘Good Medical Practice’ CanMEDS 2000 World Federation for Medical Education Accreditation Council for Graduate Medical Education WHO/EMRO Gulf Cooperation Council Institute for International Medical Education Association of American Medical Colleges
- 10. What is Competency? Is a standardized requirement for an individual to properly perform a specific job. It encompasses a combination of knowledge, skills and attitude (behavior) utilized to improve performance. More generally, competency is the state or quality of being adequately or well qualified, having the ability to perform a specific role.
- 11. Holistic Quality Clinical Skills NonClinical Skills • Quality Clinical Care • Holistic Continuous Quality Care
- 13. Importance of a Holistic Professional development not only Clinical Skill-building.
- 14. What are CanMeds competencies?
- 15. CanMEDS Scholar Competency Continuous Professional Development EBM Skills Teaching Skills Research Skills
- 16. Barriers to the Practice of EBM (Physicians in Training) Access to electronic information resources Skills in searching information resources Clinical question tracking Time Clinical question priority Personal initiative Team dynamics Green ML and Ruff TR Acad Med 2005: 80(2); Institutional culture 176. 16
- 17. Health Care Model: Donabedian Model Anatomy Care Process Structure Process •Staff •Departments •Equipment •Supplies •Environment Outcome •Pathways •Protocols •Physician orders •Nursing Care •Housekeeping •Transport Six Ds: Death Disease Disability Discomfort Dissatisfaction Destitution (cost)
- 18. Health Care Model: Donabedian Model Anatomy Care Process Structure Process •EBM Skilled Faculty •Access to Medical Information •Medical Education Department •EBM Rotation •Regular Educational Prescriptions Activity •PICO Exercises •5As in Journal Club, Morning Meetings and Ward Rounds •Computer Lab Training Sessions •Developing Evidencebased Policies, Pathways and Guidelines Outcome Six Ds: Death Disease Disability Discomfort Dissatisfaction Destitution (cost)
- 19. Health Care Model: Donabedian Model Anatomy Care Process Structure Process •EBM Skilled Faculty •Access to Medical Information •Medical Education Department •EBM Rotation •Regular Educational Prescriptions Activity •PICO Exercises •5As in Journal Club, Morning Meetings and Ward Rounds •Computer Lab Training Sessions •Developing Evidencebased Policies, Pathways and Guidelines Outcome EBM Competency
- 20. Necessary Structures • • EBM Skilled Faculty Access to Medical Information • Telephone Hotline, Intranet and Internet access, Wellstocked Medical Library, Personal Digital Assistant/ Pocket PCs etc. Educational materials: Memos, letters, electronic reminders (emails, discussion groups, internet sites/links). Education Department Both Junior and Senior staff training Educationalists members
- 21. Necessary Processes: Knowledge & Skills EBM Education (Knowledge) EBM Rotation Regular Educational Prescriptions Activity PICO Exercises 5As in Journal Club, Morning Meetings, M&M meetings and Ward Rounds Training in using Point-of-Care Resources Computer Lab Training Sessions Training in Developing Evidence-based Policies, Pathways, Protocols, Order-sets and Guidelines
- 22. Necessary Processes EBM Education (Knowledge) EBM Rotation Description and evaluation of an EBM curriculum using a block rotation. Thom DH, Haugen J, Sommers PS, Lovett P. BMC Med Educ. 2004 Oct 11;4:19. Free PMC Article Integrating an evidence-based medicine rotation into an internal medicine residency program. Akl EA, Izuchukwu IS, El-Dika S, Fritsche L, Kunz R, Schünemann HJ. Acad Med. 2004 Sep;79(9):897-904.
- 23. Description and evaluation of an EBM curriculum using a block rotation. Thom DH, Haugen J, Sommers PS, Lovett P. BMC Med Educ. 2004 Oct 11;4:19.
- 24. Necessary Processes • Regular Educational Prescriptions Activity What is an educational prescription? It specifies the clinical problem that generated the question. It states the PICO question, in all of its key elements. It specifies who is responsible for answering it. It reminds everyone of the deadline for answering it (taking into account the urgency of the clinical problem that generated it). Finally, it reminds everyone of the steps of searching, critically appraising and relating the answer back to the patient.
- 25. Educational Prescription Patient’s Name Learner: 3-part Clinical Question Problem/Target Disorder: Intervention (+/- comparison): Outcome: Date and place to be filled: Presentations will cover: search strategy; search results; the validity of this evidence; the importance of this valid evidence; can this valid, important evidence be applied to your patient; your evaluation of this process.
- 27. Necessary Processes • 5As in Journal Club, Morning Meetings, M&M meetings and Ward Rounds Mixing it up: integrating evidence-based medicine and patient care. Korenstein D, Dunn A, McGinn T. Acad Med. 2002;77(7):741-2.
- 28. Clinical Query: EBM Approach Ask clinical Acquire the questions best evidence Assess effectiveness, efficiency of EBM process 5A’s !! Appraise the evidence Apply evidence to Your patient
- 29. Why is it Important?
- 30. EBM in the Ward Round What is EB ward rounds? Why is it important? How is it different form our usual way of doing ward rounds? How is it done? What do you need to do it?
- 31. What is an Evidence-based Ward Rounds? All diagnostic, therapeutic and prognostic decisions are evidence-based. Clinically relevant questions that arise while seeing patients are being answered after a quick literature search whenever possible. The number of questions may go up to few questions per patients, or none. It should also take into account patient’s values and preferences.
- 32. What is an Evidence-based Ward Rounds? Asking questions Acquiring literature Appraising evidence Applying findings All EBM steps Evidence-based Medicine
- 33. What is an Evidence-based Ward Rounds? Clinical problem Traditional ward round Expertise, Experience & Pathophysiology Decision making about diagnosis & treatment
- 34. What is an Evidence-based Ward Rounds? Clinical problem Traditional ward round Decision making about diagnosis & treatment Expertise, Experience & Pathophysiology Ask answerable questions EB ward round Acquire relevant articles Appraisal of evidence
- 35. Exercises in the Ward Round (Also possible in the Morning Meeting) Use of point of care resources: Literature Searching Decision Support tools: Calculators (physiological, risk, severity etc), Online Clinical Pathways/Flow charts etc Shared Decision Making/Patient Education Tools Use of educational prescriptions Exercises on critical appraisal Evidence–based clinical examination (using resources such as The Rational Clinical Examination textbook) Evidence-based appropriate tests and therapeutic interventions are then demonstrated.
- 36. Exercises in the Ward Round (Also possible in the Morning Meeting) Relevant concepts in EBM like SpPin, SnNout, Likelihood Ratios, NNT, NNH etc are explained pertinent to the case. Appraisal home works Process Change Skills training/Quality Improvements Having a librarian is extremely useful.
- 37. EBM in the Ward Round Bed-side Literature Searching: Clinical Knowledge Summaries (CKS) :National Library for Health: http://cks.library.nhs.uk/ DynaMed: http://www.dynamicmedical.com/ Essential Evidence Plus (formerly InfoRetriever) http://www.essentialevidenceplus.com/ First Consult: http://www.firstconsult.com/ UpToDate: http://www.uptodate.com/ Clinical Evidence http://clinicalevidence.bmj.com/ceweb/index.jsp ACP PIERS pier. http://pier.acponline.org/index.html
- 38. Educational Prescription Patient’s Name Learner: 3-part Clinical Question Problem/Target Disorder: Intervention (+/- comparison): Outcome: Date and place to be filled: Presentations will cover: search strategy; search results; the validity of this evidence; the importance of this valid evidence; can this valid, important evidence be applied to your patient; your evaluation of this process.
- 40. Does this Patient have CCF?
- 41. Diagnosing LVF in a dyspnoeic patient?
- 44. EBM in the Ward Round Handheld ultrasound, B-natriuretic peptide for screening stage B heart failure. Hebert K, Horswell R, Heidenreich P, Miranda J, Arcement L. South Med J; 2010 Jul ; 103(7):616-22. PubMed ID: 20531053 [TBL] [Abstract] [Full Text] [Related]
- 45. EBM in the Ward Round Decision Support Systems Evidence-based Scoring Systems: Stroke: CHADS2, NIH Stroke Score Pulmonary Embolism: Well’s Cardiac Events Statin Indications Pneumonia Severity Fracture Risk
- 46. EBM in the Ward Round Decision Support Systems Uptodate Calculator: Ranson criteria for pancreatitis prognosis Calculator: Blatchford score for gastrointestinal bleeding Calculator: Rockall score for upper gastrointestinal bleeding Calculator: Crohn's disease activity index (CDAI) Calculator: Mayo score for assessing ulcerative colitis activity
- 47. EBM in the Ward Round Decision Support Systems Uptodate Calculator: Bedside index of severity in acute pancreatitis (BISAP) score Calculator: Harvey-Bradshaw index of Crohn's disease activity Calculator: Glasgow alcoholic hepatitis score Calculator: Hepatitis discriminant function for corticosteroid rx in alcoholic hepatitis Calculator: Child Pugh classification for severity of liver disease (SI units)
- 48. EBM in the Ward Round Decision Support Systems Isabel http://www.isabelhealthcare.com/home/default Open Clinical http://www.openclinical.org/dss.html DXplain http://dxplain.org/dxp/dxp.pl Medical Calculators http://easycalculation.com/medical/medical.php Skyscape: http://www.skyscape.com/archimedesonline/archimede sindex.aspx Emergency Medicine on the Web: http://www.ncemi.org/ MedicineWorld.Org: http://medicineworld.org/online-medicalcalculators.html Clinical Decision Making Calculators: ttp://www.fammed.ouhsc.edu/robhamm/cdmcalc.htm
- 49. What is an Evidence-based Journal Club?
- 50. Structure of JC Clinical Query: Foreground Question PICO Article Selection: Searching for Evidence/Literature Search Appraising the Evidence: Critical Appraisal Presentation Critique and summary Recommendations: New research Change or audit of current practice Writing a letter to the editor Publishing your appraisal in a CAT journal or website (own or in the WWW)
- 51. Computer Lab Training Sessions Literature searching skills Scope of Resources Point of Care Clinical Resources Up-Dates & New Evidence Critical Appraisal Tools Evidence-Based Quality Improvement Evidence-Based Guidelines, Policies and Protocols Decision Support Systems EBM Audiovisual Training Portals to All
- 52. EBM Training Assessment Green ML. Evidence-based medicine training in internal medicine residency programs a national survey. J Gen Intern Med. 2000 Feb;15(2):129-33. Free PMC Article
- 53. EBM Training Assessment Multi-source Feedback Short Answer Questions MCQ Objective structured assessment of technical skills (OSATS) OSCE
- 54. EBM is here to stay. It has become an essential way of teaching and practicing in the uncertain world of medicine. The challenge is to engage the whole healthcare team in learning about it and making it part of the routine of clinical practice. Editorial. BMJ 2004;329:989-990 54
Notas do Editor
- SmartArt custom animation effects: pictures peek-in(Basic)To reproduce the SmartArt effects on this page, do the following:On the Home tab, in the Slides group, click Layout, and then click Blank. On the Insert tab, in the Illustrations group, click SmartArt.In the Choose a SmartArt Graphic dialog box, in the left pane, click Matrix. In the Matrix pane, double-click Titled Matrix (second option from the left) to insert the graphic into the slide. Select the graphic. Under SmartArt Tools, on the Format tab, click Size, and then do the following:In the Height box, enter 5.67”.In the Width box, enter 8.5”.Under SmartArt Tools, on the Format tab, click Arrange, click Align, and then do the following:Click Align to Slide.Click Align Middle. Click Align Center. Select the graphic, and then click one of the arrows on the left border. In the Type your text here dialog box, enter text in the top-level bullet only (text for the rounded rectangle at the center of the graphic). To remove the [Text] placeholder in the second-level bullets, select each bullet and press SPACE.On the slide, select the graphic. Under SmartArtTools, on the Design tab, in the SmartArtStyles group, click More, and then under Best Match for Document click Moderate Effect.Select the rounded rectangle at the center of the graphic. On the Home tab, in the Font group, select 28 from the Font Size list, click the arrow next to Font Color, and then click White, Background 1 (first row, first option from the left).With the rounded rectangle selected, under SmartArtTools, on the Format tab, in the bottom right corner of the ShapeStyles group, click the FormatShape dialog box launcher. In the FormatShape dialog box, click Fill in the left pane, select Gradient fill in the Fill pane, and then do the following:In the Type list, select Linear.In the Direction list, select LinearUp (second row, second option from the left).Under Gradient stops, click Add or Remove until three stops appear in the drop-down list.Also under Gradient stops, customize the gradient stops as follows:Select Stop 1 from the list, and then do the following:In the Stop position box, enter 0%.Click the button next to Color, and then under Theme Colors click White, Background 1, Darker 35% (fifth row, first option from the left).Select Stop 2 from the list, and then do the following: In the Stop position box, enter 80%.Click the button next to Color, and then under Theme Colors click White, Background 1, Darker 35% (fifth row, first option from the left).Select Stop 3 from the list, and then do the following: In the Stop position box, enter 100%.Click the button next to Color, and then under Theme Colors click White, Background 1, Darker 15% (third row, first option from the left).Right-click the top left shape in the graphic, and then click Format Shape. In the Format Shape dialog box, in the left pane, click Fill. In the Fill pane, click Picture or texture fill,and then under Insert from, click File.In the Insert Picture dialog box, select a picture and then click Insert. Right-click the top right shape in the graphic, and then click Format Shape. In the Format Shape dialog box, in the left pane, click Fill. In the Fill pane, click Picture or texture fill,and then under Insert from, click File.In the Insert Picture dialog box, select a picture and then click Insert. Right-click the bottom left shape in the graphic, and then click Format Shape. In the Format Shape dialog box, in the left pane, click Fill. In the Fill pane, click Picture or texture fill,and then under Insert from, click File.In the Insert Picture dialog box, select a picture and then click Insert. Right-click the bottom right shape in the graphic, and then click Format Shape. In the Format Shape dialog box, in the left pane, click Fill. In the Fill pane, click Picture or texture fill,and then under Insert from, click File.In the Insert Picture dialog box, select a picture and then click Insert. To reproduce the animation effects on this slide, do the following:On the Animations tab, in the Animations group, click CustomAnimation.On the slide, select the graphic, and then do the following in the CustomAnimation task pane: Click Add Effect, point to Entrance, and then click MoreEffects. In the Add Entrance Effect dialog box, under Subtle, click Expand. Under Modify: Expand, in the Speed list, select Fast.Under Modify: Expand, in the Start list, select After Previous.Also in the Custom Animation task pane, click the arrow to the right of theanimation effect, and then click EffectOptions. In the Expand dialog box, on the SmartArt Animation tab, in the Group Graphic list, select One by one.Also in the Custom Animation taskpane, click the double-arrow below the animation effect to expand the list of effects, and then do the following:Press and hold CTRL, and then select all five animation effects in the Custom Animation task pane. Under Modify: Expand, in the Start list, select With Previous.Press and hold CTRL, select the second, third, fourth, and fifth animation effects (expand effects for the picture-filled rectangles), and then do the following:Click Change, point to Entrance, and then click MoreEffects. In the Change Entrance Effect dialog box, under Basic, click Peek In. Under Modify: Peek In, in the Speed list, select Fast.Select the second animation effect. Under Modify: Peek In, in the Start list, select After Previous.Select the third animation effect. Under Modify: Peek In, in the Direction list, select From Left.Select the fourth animation effect. Under Modify: Peek In, in the Direction list, select From Right.Select the fifth animation effect. Under Modify: Peek In, in the Direction list, select From Top.To reproduce the background effects on this slide, do the following:Right-click the slide background area, and then click Format Background. In the Format Background dialog box, click Fill in the left pane, select Gradient fill in the Fill pane, and then do the following:In the Type list, select Radial.Click the button next to Direction, and then click From Corner (fifth option from the left).Under Gradient stops, click Add or Remove until two stops appear in the drop-down list.Also under Gradient stops, customize the gradient stops as follows:Select Stop 1 from the list, and then do the following:In the Stop position box, enter 0%.Click the button next to Color, and then under Theme Colors click White, Background 1 (first row, first option from the left).Select Stop 2 from the list, and then do the following: In the Stop position box, enter 71%.Click the button next to Color, and then under Theme Colors click White, Background 1, Darker 15% (third row, first option from the left).