Pediatric Residents: EBM Review and Practice

Provides specialty based search examples for practicing the EBM steps related to asking clinical questions and acquiring evidence.

EBM Definition

3 parts of EBM

EBM integrates:

  • the best available research evidence;
  • the clinician's expertise;
  • and the patient's values & preferences.

EBM in Pediatrics

“Pediatricians must be able to use the EBM process to identify, access, apply and integrate new knowledge into their practice to provide high-quality care for their patients. They need to obtain knowledge and skills in EBM and become familiar with the different types of evidence available to them. Pediatricians should be able to assume the roles of Replicator, Doer and User within their practice. The highlighted EBM resources will help pediatricians make clinical decisions about patient care that are based on the best, most current, valid, and relevant evidence available.

“EBM should appeal to trainees and practitioners of pediatrics especially. We must protect our patients, with their higher degree of vulnerability, from the dangers of available technology.18 Even if a useless treatment was absolutely harmless, given the disparities in funding pediatric care, we must avoid any waste in time, cost, and effort. Also, given the relative rarity of pediatric subspecialty disease, our subspecialties are for the most part limited to academic centers and thus by necessity (and fortunately) remain scholarly fields for all of the practitioners. We are therefore more naturally attracted to seeking a scientific basis for our practice. Still, one does not learn EBM through the research experience but through clinical training and experience. We clearly need to improve the effectiveness of our teaching EBM and the use of EBM in practice.4 and 5 We should extend that academic focus of our specialty and subspecialties to include empirical evidence of diagnostic and therapeutic field-effectiveness whenever possible. That the evidence will often be limited or nonexistent is no reason to abandon the technique. In fact, those revelations should drive our quest for investigation and clarifying the role that critical thinking must have in medical decision-making when dealing with uncertainty.”

Background Information

Some clinical questions, particularly in the early years of building clincial expertise during residency, can be answered or informed by using textbooks and other synthesized resources. These resources provide a quick way to determine what is known about a topic at a specific point in time. As pointed out in the quotes above, standard practices can change over time in response to new research so it is very important to stay current with the research in your field and to search journal databases for topics that are undergoing re-evaluation.

Sources for background information:

Lifecycle of Asking Clinical Questions

The 5 steps of EBM: Assess, Ask, Acquire, Appraise, and Apply

 

Assess Ask Acquire Appraise Apply

 

PICOTT: Ask Clear Complete Clinical Questions

PICO is a tool that clarifies and focuses questions that arise during a patient assessment. It identifies and organizes the key aspects of a complex patient presentation: P=Patient or Population; I=Intervention or Indicator; C=Comparison or Control (not part of all questions; O=Outcome.

Adding Type of Question and Type of Study to the PICO framework to create PICOTT reminds you that different types of study designs are used to answer different types of questions.

Parts of PICOTT

Levels of Evidence

Systematic Reviews of RCTs, RCTS, SRs of Cohort Studies, Cohort

Evidence hierarchies provide a short-cut to help you filter your searches to the most likely best evidence for the kind of question you are asking.

For prevention and treatment questions, start by searching for evidence at the top of the list, systematic reviews of randomized trials. Consider the publication date in the selection process. If the systematic review you find was published a number of years ago and found inconclusive evidence, then look for newer randomized trials as your next step. If no evidence is found at the top levels, move down the list looking for systematic reviews and then single studies of first cohort studies and then case-series or case-control studies.

Remember that all evidence must be critically appraised. A poorly conducted or reported randomized trial does not provide stronger evidence than the results of a well conducted cohort study.

Critical Appraisal

The next step in the EBM process, Appraise, is beyond the scope of this module. Here are some tools that will help you with that step.

Support Research, Teaching, & Learning - Give to the HSL