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Applying Evidence-Based Practice: Robert Hayward, MD, explains how clinicians can apply evidence-based medicine to their practices.
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Applying Evidence-Based Practice: Robert Hayward, MD, explains how clinicians can apply evidence-based medicine to their practices.
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Language: EN.
Segment:0 .
>> I'm Joan Stephenson, Editor of JAMA's Medical News and Perspective section. Today, I have the pleasure speaking with Dr. Rob Hayward. Dr. Hayward why don't you introduce yourself to our listeners? >> Well, hi Joan. It's a distinct pleasure to chatting with you today. I do wear lots of different hats as it concerns evidence-based practice, but I am a contributing editor for the User's Guides of JAMAevidence and on the Advisory Board at my home institution at the University of Alberta. I serve as Assistant Dean of Health Informatics and I direct the center for health-evidence, which has had a long and very happy and productive affiliation with the User's Guides Initiative.
>> Well, I'm thinking in how clinicians can apply this information to their work. What is evidence-based practice and how can a busy clinician use evidence to make clinical decisions? >> Well, there's lots of evidence-based words out there; evidence-based medicine, practice, nursing, decision-making, policy, whatever and there's a lot of, in my view, misconceptions about what the whole evidence-based movement is all about. If it gets a bad rap it's usually that it asks us to pay attention only to the results at the highest quality of randomized double-blinded control trials, whereas, those who work in the field, I think, are more convinced that it's about the practice side of things and not so much the evidence side.
An evidence-based practitioner is committed to being as aware as is possible of the type and the strength of the evidence that links what we do and why we do it. So, it's really about the connection between evidence and action and that enforces upon us a kind of pragmatism. There just aren't trials out there that address all the questions that we have to ask, but we do need to have good taste in what knowledge is stronger or weaker for the questions that we're asking.
So, it tends to boil down to having skills in asking answerable questions, asking questions that can be addressed by the kinds of knowledge sources that are available to us, and being very sensible and pragmatic in how we apply that to patient care. But if I was to sum it down to just three things that I tell all of the learners that I work with, it doesn't matter whether you are thinking about evidence that comes from a colleague, some evidence in a consultant's letter, or something that you read in a high-quality journal, at the tip of your tongue must always be questions of validity, importance, and applicability.
In other words, can I believe what I'm hearing even if it's believable? Does it promise me impact that my patients would care about and even if it is of high-impact, is the kind of knowledge that I can use given my circumstances and my patients' circumstances and values? And so, it boils down to the three pillars of validity, importance, and applicability. >> Health care decision-makers must consider various sources of evidence to arrive at optimal decisions, and that includes external and internal evidence.
What are some of the examples of these? >> Well, the distinction between external evidence and internal evidence is something that we hear about and we're reading more and more in the literature. It's very simple, and in fact, it's a marker of some of the real excitement in the evidence-based movement today. That excitement is the realization of the thinking tools that have been developed to help us decide whether we believe, care about, and can use the results of experiments that are done, clinical experiments, control trials, qualitative inquiry, whatever.
Well, that inquiry has been conducted usually on patients other than our own, and in that sense, it's clearly external to our own patient populations that we're trying to help. And so, two major sources of external evidence would be the results of clinical investigation, control trials, and other forms of investigation, but then also, in a very large and increasing body of health services research that concerns itself with the costs, the staffing, the processes of how to actually implement knowledge in a way that is efficient, effective, and affordable.
But within our health care systems, as a byproduct of a digital revolution we were talking about earlier, we have some pretty impressive administrative data systems, electronic medical records, outcomes databases that give us access to higher fidelity information about what's going on in our own population, and the real trick to making good use of the results of research is to see when to apply it in your circumstance and when maybe you shouldn't.
That depends upon knowing your circumstance very well. So, there's two major sources of internal evidence that we're getting better at gathering, organizing, and understanding; one source is what comes from our various clinical systems labs, radiology systems, medical records; and another is increasing access to things like well, Google Health, consumer-centered information systems that improve the tracking of our patients' experiences and symptoms.
The real excitement for evidence-based practice is that those core thinking tools that we've been honing over the years on how for different types of questions you can decide whether you believe the research. We're finding that those map very nicely to the kinds of thinking tools you need to use when making sense of internal evidence. And so, that's probably more an answer than you were looking for, but there's a lot of excitement in applying the thinking of EPM to the medical records, administrative datasets, claims datasets, that we find within our own internal health care organizations.
So, I would emphasize some of the extra things that are part of the online resource that you simply can't get in the book, interactive calculators, worksheets that help you take a paper you're reading, answer some basic questions and have more of a sense of its believability and things like the information cycles attached to many of the chapters. >> Is there anything else you would like JAMA evidence users to know about evidence-based medicine? >> Well, that it's finally coming into its own and it's going to have a huge impact on the way in which we manage and experience the information flow at the point of care.
Impact not only because we finally are seeing the emergence of more and more high-quality evidence-based systems that make it clear for clinicians how to guide their practice with the evidence that they are reading in a highly distilled and summarized format, but also because the very medical records and so on that we are using are starting to change in ways that are more sympathetic to the needs of an evidence-based decision-maker. So, yes, I'd emphasize that the stuff that appears in JAMAevidence, and particularly the goal that is found in the Rational Clinical Exam Series, that's very much of its time.
We urgently need it. And for those of you coming up for any kind of assessments, examinations, or certifications, it's the kind of thinking that examiners are looking for these days. But if I was to answer that question from the point-of-view of JAMAevidence itself, the one final thing I would want folks to know is that this is a dynamic resource. It's not static. There's new stuff being added fairly regularly and the new stuff reflects not just what the author's think, but what the folks using the Users Guides think and give feedback about additional questions, or issues in applying that they would like to have explored.
>> Thank you very much Dr. Hayward. >> Thank you.
