Obstetrics and Gynecology 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 Obstetrics and Gynecology

  1. "Conclusion: In obstetrics, as well as in many other medical fields, consideration should be given to a different hierarchy of evidence, including reality-based medicine as one of the highest levels of evidence. Such evidence would reflect what actually happens in real life, as opposed to what happened in a confined number of patients in a RCT. Reality-based medicine from the patient’s perspective makes sense even more. For instance, Kypros Nicolaides’ group, as well as many other experienced groups of investigators from Europe and United States, have repeatedly published in many peer-reviewed journals extremely high detection rates of Down syndrome (more than 85%) from first-trimester nuchal translucency screening when it is done under rigorous quality monitoring. However, this does not mean that in real life all practitioners have such high detection rates of Down syndrome. A recent reality-based publication by Wax et al 10 showed that in real practice nuchal translucency images are of poor quality, failing “two-thirds” of the quality criteria. Thus, it would be unreasonable for anyone to expect detection rates of over 85% in real life, when the nuchal translucency images are of such poor quality.”
    Vintzileos AM. Evidence-based compared with reality-based medicine in obstetrics. Obstet Gynecol. 2009 Jun;113(6):1335-40. 
  2. “EBM is a lifelong learning process and not something that can be acquired over the short term. It is important to remember that individual clinical expertise acquired through years of experience and practice is invaluable. But the same skills and expertise then need to be utilised in applying the best evidence in patient care. EBM is not a substitute for clinical skills/expertise. It is only an effort toward giving up out-dated medical tests/therapies and making the most effective use of medical knowledge for the best outcomes in terms of patients’ benefit and safety. We all should aspire to practice EBM. As new knowledge is added to our specialty and new evidence arises, we have to incorporate the relevant changes into our practice to stay up-to-date with the latest techniques.”
    Talaulikar V, Nagarsekar U. Evidence-Based Medicine: An Obstetrician and Gynaecologist's Perspective. J Obstet Gynaecol India. 2012 Apr;62(2):146-53.
  3. “The benefits of an e-learning approach to teaching should be considered as a viable way in meeting these challenges, as it can support a wide range of learning activities, which are readily accessible and can be tailor-made to meet specific learning objectives. As our trial implies, e-learning teaching provides knowledge gains equivalent to that of standard classroom-based teaching. Particularly, the benefits should be considered when planning EBM curricula as it allows standardization of teaching materials and is a potential cost-effective alternative to standard lecture-based sessions.”
    Hadley J, Kulier R, Zamora J, Coppus SF, Weinbrenner S, Meyerrose B, Decsi T, Horvath AR, Nagy E, Emparanza JI, Arvanitis TN, Burls A, Cabello JB, Kaczor M, Zanrei G, Pierer K, Kunz R, Wilkie V, Wall D, Mol BW, Khan KS.  Effectiveness of an e-learning course in evidence-based medicine for foundation (internship) training. J R Soc Med. 2010  103(7):288-94. Epub 2010 Jun 3.PMID: 20522698

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.

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