Evidence at the Point of Care
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Am Fam Physician. 2002 Jan 1;65(1):27-28.
We are delighted to launch a new series1 in American Family Physician, brought to our readers via a unique collaboration with the BMJ Publishing Group. AFP will feature selected excerpts from Clinical Evidence, a regularly updated collection of evidence-based systematic reviews on common and important clinical topics that appears in print every six months. AFP will publish edited versions of the original text highlighting key recommendations on treatment. The AFP Web site (www.aafp.org/afp) will feature the full-text versions, also available at www.clinicalevidence.org.
As pointed out in a recent editorial in Clinical Evidence, the mere distribution of evidence-based guidelines does not change practice for the better.2 However, we believe that in the hands of our readers, this practical resource, combined with other sources of information, will provide a basis for better clinical decision-making.
The Problem: Questions, Questions, Questions
Questions arise during most consultations with patients in the family practice office.3 Most of these questions are about treatment, diagnostics, or prognosis, and answers to these questions affect the care that patients receive. Physicians often sidestep these questions or turn to colleagues for advice but still may not find a viable solution.
Experience, Textbooks, and Guidelines
Experience is a key to growth as a physician, but it can generate more questions than it answers. On reflection, it is hard to know how much of what happens to our patients is influenced by our actions, and how much is related to other factors. Decisions based only on reflection are likely to be unreliable.4 Textbooks can help, but they are often out of date when they are published, contain a variable mixture of fact and opinion, and rarely address problems specific to subgroups of patients. Guidelines seek to provide practical advice for physicians, and they often incorporate available evidence. However, the authors of guidelines attempt to make recommendations relying on a mixture of evidence, consensus, and assumption to reach their conclusions. This can create confusion regarding reasonable management options.
Evidence About What Works and What Does Not Work
In focus groups, physicians and patients have asked for clear and simple information about what works and does not work. When little evidence is available, they ask for the simplest description of what is known.
Rarely do we find clear evidence that a treatment is beneficial in all patients or harmful in all patients. The relative importance of these benefits and harms varies from patient to patient; for example, benefits of treatment are likely to be more significant for people with more severe illness. To help our patients make informed decisions, we need to know the evidence behind management recommendations.
Thorough Searches, Regularly Updated
Clinical Evidence identifies commonly asked questions about treatments and other interventions. It then performs extensive and detailed searches of the world's scientific literature to find the best evidence, based on systematic reviews and recent studies, to create simple bottom-line statements about what works and what does not. It states where a gap exists, but it does not try to fill that gap. Summaries are presented immediately after each question and can be read without delving into detail. For those who want to delve further, the evidence is reviewed and links to original studies are provided. Whenever possible, the variation of benefits and harms among subgroups is described. Updated evidence is posted on the Web site as soon as it is available, and a snapshot of the Web site is printed biannually.
A Step in the Right Direction
Providing the best available abstracts of the evidence is a good start, but to be truly useful, this information must be accessible and easy to use at the point of care. Electronic patient records and knowledge databases that provide information tailored to the individual may help in the future, but for most, they remain a dream for now. One practical advance has been the release of a version of Clinical Evidence for handheld computers, which can be freely downloaded for a limited time from www.clinicalevidence.org.
Evidence-Based Medical Education, Practice, and Systems
This series from Clinical Evidence is one of several ways in which AFP is strengthening its approach to evidence-based continuing medical education. Clinical Evidence joins and links to our ongoing “Cochrane for Clinicians” series that features selected excerpts from the Cochrane Collaboration (www.cochrane.org). Of all the questions asked by Clinical Evidence, 40 percent were the subject of a systematic review, and 35 percent of these systematic reviews were Cochrane reviews. AFP's new “Information for Authors” recommends rating levels of evidence for key clinical recommendations.5 AFP's Web site contains links to a host of resources in evidence-based medicine, including articles on reading and writing evidence-based clinical reviews.6,7 AFP will also be serializing executive summaries of new reports from the U.S. Preventive Services Task Force, as well as a series of evidence-based quizzes derived from them, labeled “Putting Prevention into Practice.” Future issues of AFP will continue to offer new avenues for evidence-based medicine.
Jay Siwek, M.D., is professor and chair of the Department of Family Medicine at Georgetown University School of Medicine, Washington, D.C. He is also the editor of American Family Physician.
Stuart Barton, M.D., is publishing director of BMJ Knowledge and editor-in-chief of Clinical Evidence. He trained in physiology in Oxford before working in biophysics at Woods Hole, Mass., and Stony Brook, N.Y. He worked in family medicine for 12 years, with a special interest in medical education.
Address correspondence to Jay Siwek, M.D., Department of Family Medicine, 212 Kober-Cogan Hall, Georgetown University Medical Center, 3800 Reservoir Rd. NW, Washington, D.C. 20007 (e-mail: firstname.lastname@example.org).
1. McKelvie RS. Heart failure. Am Fam Physician. 2002;65:99–102.
2. Barton S. Using clinical evidence. Having the evidence in your hand is just a start—but a good one. BMJ. 2001;322:503–4.
3. Ely JW, Osheroff JA, Ebell MH, Bergus GR, Levy BT, Chambliss ML, et al. Analysis of questions asked by family doctors regarding patient care. BMJ. 1999;319:358–61.
4. Skinner BF. ‘Superstition’ in the pigeon. Journal of Experimental Psychology 1948;38:168–72. Retrieved December 2001, from: http://www.wabash.edu/depart/psych/Courses/Psych97A/STUDENT%20PROJECTS/Skinner/hammondk/abstracts.html.
5. Information for authors. Am Fam Physician 2001; 64:519–22. Retrieved December 2001, from: http://www.aafp.org/afp/authors.
6. Shaughnessy AF, Slawson DC. Getting the most from review articles: a guide for readers and writers. Am Fam Physician. 1997;55:2155–60.
7. Siwek J, Gourlay M, Slawson DC, Shaughnessy AF. How to write an evidence-based clinical review article. Am Fam Physician 2002. In press.
Copyright © 2002 by the American Academy of Family Physicians.
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