Lifelong Learning and Evidence-Based Medicine for Primary Care
From WiserWiki
[edit] Lifelong Learning and Evidence-Based Medicine for Primary Care
W. Scott Richardson
Cynthia D. Mulrow
Excellent primary care physicians are handmade. They fashion themselves, with the help of teachers, colleagues and patients, by building skills, attitudes, and knowledge of many kinds. They sharpen and resharpen their abilities throughout their careers, carrying out their own programs of lifelong learning.[1][2] Indeed, the commitment to lifelong study is a central value for a career in the health professions.[3] This textbook aims to help primary care physicians keep that commitment to their profession, their patients, and themselves.
Throughout their careers, excellent primary care physicians learn and use many kinds of knowledge, some of which are depicted in Fig. 1-1. For instance, in caring for a patient with advancing heart failure, a physician might draw on: clinical experience to quickly recognize the progression of symptoms despite treatment; human pathophysiology to identify possible causes of the worsening; research evidence to estimate the patient's prognosis; clinical ethics and the patient's perspective to plan advance directives; and the context of care, to know what palliative services are available in the community. Each form of knowledge may have strengths and limitations, and no single form can supply all that physicians need for every decision. Thus wise physicians become comfortable learning several forms of knowledge and use clinical judgment to select, weigh, and integrate these forms for the care of individual persons.[4]
These forms of knowledge all change over time, but three in particular change rapidly: the context of care, human biology, and clinical care research. The yearly volume of new knowledge in any one of these areas is overwhelming, and together they outstrip human mental capacity. No one person can read it all and know it all. Thus we need methods to select the relatively small proportion of new knowledge in each field that warrants our attention. This chapter concerns such methods for selecting knowledge from clinical care research.
In addition to confronting the sheer volume of research publications, primary care physicians attempting to understand and use evidence from clinical care research face other challenges. When this research is examined critically, only about 2% of it represents evidence that is sufficiently valid and clinically applicable to warrant a change in practice.[5] Without some help, physicians are more likely to encounter information that should not change their practice than information that should. Even in the face of this “plenty,” many clinical questions arise during patient care that go unanswered,[6] and with time the cumulative effect of not learning is obsolescence.[7][8] Unfortunately, traditional continuing education based on passive learning methods, such as didactic lectures, does little to stop the inexorable decline in our clinical knowledge or actual performance.[9]
Evidence-based medicine (EBM) is a relatively new approach to lifelong learning and clinical practice that holds much promise for primary care. EBM is “the conscientious and judicious use of current best evidence from clinical care research in the management of individual patients,” and practicing it means integrating current best evidence along with clinical expertise, patients' perspectives, and other knowledge.[10] EBM provides clinicians with tools for finding, understanding, and using evidence from research that is scientifically valid and clinically useful. Thus evidence-based practicing and learning can help primary care physicians carry out their programs of lifelong learning.
After finishing formal postgraduate training, primary care physicians find themselves in two situations in which evidence from clinical care research can be learned and integrated: when trying to keep current and when solving patient problems. Although there is much overlap, these two situations have some differences in emphasis and require that we plan our learning differently. This chapter summarizes the skills and resources of EBM for lifelong learning in primary care and intersperses tips on how to use them for keeping current and for solving problems.
[edit] 
EVIDENCE-BASED MEDICINE STEPS AND SKILLS (Box 1-1
[edit] Recognizing Information Needs
)The first step in using research evidence is to recognize when it is needed. Several kinds of knowledge for primary care are needed, and much of the time, we already possess and can readily use this knowledge. The sense of satisfaction that goes with knowing what we need to know has been called cognitive resonance.[11] At times, caring for patients brings unfamiliar clinical circumstances or challenging information, and at some level we become aware that our knowledge stores do not have the necessary information. The disturbing feelings such situations provoke have been called cognitive dissonance, and these sensations can motivate us to learn.[11] Being alert to our own cognitive dissonance can help us recognize when we need new knowledge.
| Box 1-1 - Evidence-Based Medicine Steps and Skills |
|
Since knowledge of several kinds is used for primary care, not every information need will be a gap of evidence from the medical literature. Sometimes cognitive dissonance is a signal that we lack information about our patient's preferences or that we lack sufficient experience with a disorder. Often, however, cognitive dissonance is a signal that new knowledge from clinical care research is needed in order to make sensible clinical decisions. These moments are opportunities for evidence-based learning, and with practice we can recognize them in our everyday work.
[edit] Asking Answerable Clinical Questions
Having found a gap in knowledge, we convert the information need into a clinical question, the answer to which should fill the gap. Clinical questions about knowledge come in infinite variety, but most can be loosely classified as either background or foreground questions (Fig. 1-2). Background questions ask about the disorder itself, such as “What is essential hypertension?” or “When do the complications of hypertension occur?” Note that background questions usually have two components: a question root (who, what, where, when, how, and why) with a verb, and the disorder (or an aspect of it) under study. Questions about background knowledge are especially useful when we have little familiarity with the disorder under study.
In contrast, foreground questions ask about caring for patients with the disorder, such as “In elderly patients with isolated systolic hypertension, does antihypertensive drug therapy reduce stroke, cardiovascular disease, and total mortality enough to be worth its adverse effects?” Note that foreground questions usually have three or four components: the patient and/or problem (in this example, elderly patients with isolated systolic hypertension); the intervention, test, or exposure (antihypertensive drug therapy); comparison interventions, when relevant (implied comparison to no drug); and the clinical outcomes of interest (stroke, cardiovascular disease, mortality, adverse effects). Questions about foreground knowledge are useful when we are already familiar with the background knowledge about the disorder.
Asking questions in this manner takes practice, but with time it can become second nature. Good questions can pay off by helping us focus our scarce reading time for learning that is directly relevant to our patients' illnesses and our learning needs; suggesting the forms that good answers will take; leading directly to efficient search strategies; and improving communication with other clinicians in consultation and when learning.[12][13][14] Expert physicians recognize innumerable questions that could be asked about patients and their problems. Rather than trying to answer every one, we should focus on those questions that seem most urgent for a particular patient's care, most appropriate to personal knowledge needs, or most feasible to answer in the available time.
[edit] Finding Answers to Questions
Having chosen a question and phrased it clearly, we can begin finding answers. Because time is short, it makes sense to start the search with resources that have the highest chance of yielding the needed answers. Since questions will vary, so should resource use. For background questions, the best sources are up-to-date summaries about the disease in question, as might be found in a recent text chapter or narrative review. For foreground questions, the most useful sources are up-to-date summaries of the best evidence informing the management of patients with the disease, as would be found in recent systematic review or evidence-based practice guideline. Good searching skills, although beyond the scope of this chapter, can be developed with practice and coaching and are essential for sustaining an evidence-based learning program.
[edit] Appraising Research Evidence
Having found information that may yield the necessary answer, we have to decide whether or not to use it. To do this, we make judgments about whether this information is sufficiently credible, important, and applicable to the clinical situation to warrant its use. Making these judgments has been termed critical appraisal, and involves applying some rules of evidence along with common sense, within a framework that balances open-mindedness with healthy skepticism.[15]Box 1-2 lists critical appraisal issues for several common forms of evidence in the form of checklists of questions to ask.[16] We can use these checklists when appraising the evidence ourselves or when reviewing the appraisal portions of evidence summarized by others.
| Box 1-2 - Critical Appraisal of Selected Types of Evidence |
Individual Trials of Therapy
|
When applying the evidence-based clinical routines and practice policies that others develop, we cannot and should not expect to repeat this critical appraisal step ourselves; those who summarized the evidence and built the practice policies are expected to have performed this critical appraisal carefully, making explicit how the evidence was found, how the evidence was appraised, and how the strength of the evidence was considered when making clinical recommendations.
[edit] Understanding Research Evidence
We can apply evidence-based clinical routines and practice policies without an intimate knowledge of the raw results of the underlying research. Often, though, when estimating the expected benefits and possible harms of applying the recommended test or treatment, we need to understand what the research results are and what they mean. Such results may be reported in quantitative terms, including some that may not be familiar. Some definitions, explanations, and tips for understanding these numerical results of evidence about diagnosis and therapy are presented in Boxes 1-3[17] and 1-4.[18] More complete discussions of these topics are available; some of them are listed at the end of the chapter.
| Box 1-3 - Understanding Evidence About Diagnostic Tests✢ | ||||||||||||||||||||||||
| ||||||||||||||||||||||||
[edit] Applying Research Evidence to Individual Patients
Having decided that the evidence warrants use, we now apply the intervention to our patients. Each patient is an individual person, with a unique blend of biologic, psychologic, and sociologic factors that may influence the outcomes of illness and the responsiveness to our interventions. We can never foretell with absolute certainty whether our patient will respond in the same way as the patients in whom the intervention was studied. Even so, we can extrapolate evidence from studies to our patients, if we do it carefully and sensibly. To help decide whether extrapolation is wise, we might ask the following questions[19]:
Is my patient so different from those in the study that results cannot be applied?
Is the treatment feasible in my setting?
What are the likely benefits and harms from the treatment?
How will my patient's values influence the decision?
Most of the time variations in human risk and responsiveness are matters of degree, in that we differ quantitatively in amount of risk or chances of responding. Seldom do we differ in absolute terms in risk or responsiveness, such that interventions produce opposite effects. Thus we can usually apply the evidence to our patients, after considering how their unique biology, psychology, and sociology adjust our estimates of their risk and responsiveness. We can then add consideration of the balance of benefits and harms and incorporate our patients' preferences into patient-centered decisions informed by evidence.
[edit] Putting Evidence into Practice in Lifelong Learning
When building a plan for lifelong learning in primary care, physicians face two main learning situations: keeping current and solving patient problems. Research evidence can be understood and used for both learning situations, and the strategies and tactics of EBM can help you do this. We have gathered our own and others' tips for keeping current and solving patient problems into Fig. 1-3.[20][21][22][23][16]
One of the great challenges in trying to keep current is finding the time to devote to it. The pace of practice, the urgency of clinical problems, and other competing demands all seem to get in the way of this important, yet less urgent activity. Whether you get an hour per month, per week, or per day to spend on keeping current, your time is still finite. Learning and practicing EBM will not add a single minute to your hour, but it can help you use your limited learning time wisely and efficiently. Thus we emphasize managing time well, learning some evidence-based learning skills, and managing the evidence literature well.
| Box 1-4 - Understanding Evidence About Therapy✢ | ||||||||||||||||||||||||
| ||||||||||||||||||||||||
Time is even more critical when solving patient problems. Not only is there little time to carry out learning, but occasionally the clinical situations impose short deadlines by which decisions must be made. Often, however, the pace of outpatient illness is such that learning to solve patient problems can be accomplished between visits, rather than all at once. Our advice emphasizes preparing by developing skills and resources, carrying out evidence-based learning when (not if) the situations arise, and using the evidence in patient care. The accumulated learning from many such interactions is great, and being patient-based, it may be easier for us to remember. According to an old proverb, “long journeys begin with a single step,” to which we would add “and they continue in the same manner, one step at a time.”
Together, keeping up-to-date and solving patient problems compose most of our individual work for lifelong learning. If we choose them carefully, formal continuing medical education (CME) activities can be useful supplements for our overall learning program. As we mentioned earlier, CME programs based on passive methods such as lectures simply do not work. Continuing education can be effective, however, if it relies on methods shown in trials to be effective, including individualized audit and feedback on actual practice; individualized advice on practice from a respected, evidence-based teacher; academic detailing using evidence-based recommendations; and mini-sabbaticals to clinical sites that practice up-to-date, evidence-based care.[9] Moreover, we suggest selecting CME that allows us to target our specific learning needs; allows us to integrate new knowledge with prior experience; allows us to plan and practice our behavior changes; provides coaching and constructive feedback; and encourages us to plan follow-up on our learning at a later time.[1][11]
[edit] LEARNING MORE ABOUT EVIDENCE-BASED MEDICINE
As with most clinical skills, evidence-based learning takes practice. This chapter provides only an introduction, and we suggest you learn more about the concepts and skills of EBM by using the resources listed in Box 1-5 and in the References and Additional Readings. As with any other clinical field, keep watch for new developments in EBM that make it easier and faster to stay excellent as primary care physicians.
| Box 1-5 - Surfing the Net |
|
[edit] SUMMARY
EBM represents a way of practicing in which we can integrate valid and important new research findings with our other knowledge to solve patient problems and keep up-to-date. Practicing EBM builds on, rather than replaces, our clinical expertise and enhances our abilities to decide with our patients which management plans best fit their preferences. Using EBM skills for lifelong learning can help us provide primary care that is clinically expert, evidence-based, and person-centered.
[edit] REFERENCES
- ↑ 1.0 1.1 PC Candy: Self-direction for lifelong learning: a comprehensive guide to theory and practice. San Francisco: Jossey-Bass; 1991:
- ↑ DA Davis RD Fox The physician as learner: linking research to practice. Chicago: AMA; 1994:
- ↑ RJ Napodano: Values in medical practice. New York: Human Sciences; 1986:
- ↑ EJ Cassell: Doctoring: the nature of primary care medicine. New York: Oxford University; 1997:
- ↑ RB Haynes: Where's the meat in clinical journals? [Editorial]. ACP J Club 1993; 119:A22 - A23.
- ↑ R Smith: What clinical information do doctors need?. Br Med J 1996; 313:1062 - 1068.
- ↑ CE Evans, RB Haynes, NJ Birkett,et al.: Does a mailed continuing education program improve clinician performance? Results of a randomized trial in antihypertensive care. JAMA 1986; 255:501 - 504.
- ↑ PG Ramsey, JD Carline, TS Inui,et al.: Changes over time in the knowledge base of practicing internists. JAMA 1991; 266:1103 - 1107.
- ↑ 9.0 9.1 DA Davis, MA Thompson, AD Oxman,et al.: Changing physician performance: a systematic review of the effect of continuing medical education strategies. JAMA 1995; 274:700 - 705.
- ↑ RB Haynes, DL Sackett, JAM Gray,et al.: Transferring evidence from research into practice: 1. The role of clinical care research evidence in clinical decisions [Editorial]. ACP J Club 1996; 125:A14 - A16.
- ↑ 11.0 11.1 11.2 R Neighbour: The inner apprentice. Newbury, UK: Petroc; 1996:
- ↑ AD Oxman, DL Sackett, GH Guyatt, Evidence-Based Medicine Working Group: Users' guides to the medical literature: I. How to get started. JAMA 1993; 270:2093 - 2095.
- ↑ WS Richardson: Ask, and ye shall retrieve [EBM Note]. Evidence-Based Medicine 1998; 3:100 - 101.
- ↑ WS Richardson, MC Wilson, J Nishikawa,et al.: The well-built clinical question: a key to evidence-based decisions [Editorial]. ACP J Club 1995; 123:A12 - A13.
- ↑ DL Sackett RB Haynes GH Guyattet al.: Clinical epidemiology: a basic science for clinical medicine. ed 2. Boston: Little, Brown; 1991:
- ↑ 16.0 16.1 DL Sackett WS Richardson WMC Rosenberget al.: Evidence-based medicine: how to practice and teach EBM. New York: Churchill-Livingstone; 1997:
- ↑ GH Guyatt, AD Oxman, M Ali,et al.: Laboratory diagnosis of iron-deficiency anemia: an overview. J Gen Intern Med 1992; 7:145 - 153.
- ↑ NASCET Collaborators: Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade stenosis. N Engl J Med 1991; 325:445 - 453.
- ↑ P Glasziou, GH Guyatt, AL Dans,et al.: Applying the results of trials and systematic reviews to individual patients [Editorial]. ACP J Club 1998; 129 (3):A15 - A16.
- ↑ DJ Cook, MO Meade, MP Fink, Evidence-Based Medicine in Critical Care Group: How to keep up with the critical care literature and avoid being buried alive. Crit Care Med 1996; 24:1757 - 1768.
- ↑ FM Davidoff: Continuing medical education resources. J Gen Intern Med 1997; 12 (Suppl. 2):S15 - S19.
- ↑ RH Fletcher, SW Fletcher: Evidence-based approach to the medical literature. J Gen Intern Med 1997; 12 (Suppl. 2):S5 - S14.
- ↑ EB Larson: How can clinicians incorporate research advances into practice?. J Gen Intern Med 1997; 12 (Suppl. 2):S20 - S24.
[edit] ADDITIONAL READINGS
- D Friedland, AS Go, JB Davoren,et al.: Evidence-based medicine: a framework for clinical practice Stamford, Conn: Appleton Lange; 1998:
- T Greenhalgh: How to read a paper London: BMJ Books; 1997:
- Silagy C Haines A Evidence-based practice in primary care. London: BMJ Books; 1998:
- SE Straus, D Badenoch, WS Richardson,et al.: Practising evidencebased medicine: learner's manual ed 3. Oxford, UK: Radcliffe Medical; 1998:
