AFP's Series on Finding Evidence and Putting It into Practice
Am Fam Physician. 2009 Jan 1;79(1):7-8.
If you are a typical family physician, you will see between 20 and 30 patients per day. Direct observation studies show that at least 20 clinical questions will arise as you see those patients,1 but that most go unanswered because of lack of time or resources, or a perception that a good answer does not exist.2,3 Other research has shown that the answers to those unanswered questions have the potential to change patient care, and we know from the adult learning literature that answering questions and solving problems in the context of our work is critical for learning and growth.
The answers to your questions— perhaps too many answers—are out there. In 2007, more than 750,000 articles were indexed in PubMed, including more than 70,000 review articles and more than 30,000 clinical trials. Physicians are bombarded with information from these studies, in addition to monographs, continuing medical education lectures, practice guidelines, pharmaceutical company representatives, local experts, and colleagues. Whereas an ophthalmologist or radiation oncologist can limit his or her reading to a few key journals, information critical to the practice of family medicine is published in a wide range of medical journals.
If family physicians don't keep asking and answering clinical questions, their knowledge base will grow increasingly out of step with current practice, and their patients will suffer. But it isn't enough to find just any answer; it should reflect the best patient-oriented evidence, have the potential to change practice for the better, and improve important clinical outcomes.4
Family physicians are busier than ever and have limited time to keep current with the literature. Reading lengthy and detailed original research studies is hardly the best use of that time. Practicing physicians, and even most academic physicians, do not have the training or time to critically appraise all of the articles needed to answer clinical questions or stay current.
I propose a different skill set that prioritizes making the practicing family physician an informed consumer of the secondary literature (e.g., evidence-based guidelines, systematic reviews, critical appraisals, validated decision-support tools [Table 1]).6–13 The physician must become an expert at assessing the quality of an information source. Does the information focus on patient-oriented outcomes? Is it truly evidence based, or does it merely have a lot of references? Is it free of industry or other special interest bias? Does it summarize information in a way that makes it easy to access and apply at the point of care?
Table 1. Examples of Secondary Medical Literature
Examples of Secondary Medical Literature
Evidence-based practice guideline
Guideline based on a systematic review of the literature that states the strength of evidence for key recommendations
National Guideline Clearinghouse (http://www.guidelines.gov)
National Institute for Health and Clinical Excellence (http://www.nice.org.uk)
U.S. Preventive Services Task Force (http://www.ahrq.gov/clinic/uspstfix.htm)
Study that addresses a focused clinical question by reviewing all of the literature and combining data from different studies, if appropriate
Cochrane Collaboration (http://www.cochrane.org/)
Database of Abstracts of Reviews of Effects (http://www.crd.york.ac.uk/crdweb/)
Meta-analyses and systematic reviews published in the original medical literature
Structured summary of a research study that describes findings and identifies any methodologic shortcomings
American College of Physicians Journal Club (http://www.acpjc.org/)
Essential Evidence Plus (http://www.essentialevidenceplus.com)
Validated decision-support tool
Decision-support tool that integrates findings from the history, physical examination, and laboratory tests to assist in diagnosis or prognosis
Strep score for diagnosis of group A beta-hemolytic streptococcal pharyngitis12
Wells scores for deep venous thrombosis13
Contemporary physicians must also have the ability to ask good, answerable clinical questions; they must be skilled computer users; and they must understand the language of evidence-based medicine. By identifying the best secondary information sources and using them to stay current and answer clinical questions, family physicians can become experts at managing medical information to benefit their patients.
In this issue of American Family Physician, Dr. Shaughnessy launches a six-part series on finding evidence and putting it into practice.14 These short articles, which will be published once a month, will teach you how to become a more informed physician, with a focus not on math and statistics, but on practical skills you can apply immediately in your practice.
1. Ebell M. Information at the point of care: answering clinical questions. J Am Board Fam Pract. 1999;12(3):225–235.
2. Gorman PN, Helfand M. Information seeking in primary care: how physicians choose which clinical questions to pursue and which to leave unanswered. Med Decis Making. 1995;15(2):113–119.
3. Ely JW, Osheroff JA, Ebell MH, et al. Obstacles to answering doctors' questions about patient care with evidence: qualitative study. BMJ. 2002;324(7339):710
4. Shaughnessy AF, Slawson DC, Bennett JH. Becoming an information master: a guidebook to the medical information jungle. J Fam Pract. 1994;39(5):489–499.
5. Sackett DL, Straus SE, Richardson WS, Rosenberg W, Haynes RB. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. New York, NY: Churchill Livingstone; 2000.
6. Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003;349(26):2510–2518.
7. Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet. 2001;357(9266):1391–1396.
8. Aujesky D, Auble TE, Yealy DM, et al. Prospective comparison of three validated prediction rules for prognosis in community-acquired pneumonia. Am J Med. 2005;118(4):384–392.
9. Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med. 1997;336(4):243–250.
10. Stiell IG, Greenberg GH, Wells GA, et al. Prospective validation of a decision rule for the use of radiography in acute knee injuries. JAMA. 1996;275(8):611–615.
11. Stiell IG, Greenberg GH, McKnight RD, et al. Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation. JAMA. 1993;269(9):1127–1132.
12. McIsaac WJ, Goel V, To T, Low DE. The validity of a sore throat score in family practice. CMAJ. 2000;163(7):811–815.
13. Wells PS, Anderson DR, Rodger M, et al. Evaluation of d-dimer in the diagnosis of suspected deep-vein thrombosis. N Engl J Med. 2003;349(13):1227–1235.
14. Shaughnessy AF. Keeping up with the medical literature: how to set up a system. Am Fam Physician. 2009;79(1):27–28.
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