To the Editor:
We read “Making Evidence-Based Medicine Doable in Everyday Practice” [February 2004, page 51] with great interest. For more than five years, we have taught such a model to residents and colleagues and have presented data on our work in regional and national forums. We are proponents of the use of secondary resources of publication as a tool for physicians to do “just-in-time” knowledge management in daily practice. We are disappointed to see American Family Physician (AFP) listed as such a resource.
Although AFP is the premier publication of the AAFP, it fails the standard of a resource of secondary publication. Articles do not consistently cite levels of evidence or provide such critical data as number needed to treat, odds ratios or likelihood ratios. At times, the content of articles may conflict with the best available evidence. In addition to the uneven consistency of AFP from an evidentiary point of view, its online search engine lacks the sophistication and efficiency to permit efficient searches while seeing patients.
Recent examples of the above are a patient handout in the Feb. 1, 2004, issue, which supported routine self-exam to screen for testicular cancer. This recommendation runs counter to the U.S. Preventive Services Task Force (USPSTF) finding that there is no evidence to support routine screening for testicular cancer by physicians or self-examination by patients. The Dec. 15, 2003, issue had a feature article on strategies for primary prevention of stroke. The article included a table on the effectiveness of various stroke prevention strategies that cited relative risk reductions (RRR), rather than the much more clinically meaningful absolute risk reductions (ARR) or numbers needed to treat (NNT) for the respective interventions.
While AFP remains an important review journal and CME resource for family physicians, it does not yet possess the rigor and utility of an adequate resource of secondary publication for using evidence at the point of care. It is our hope that one day AFP will achieve that status. At that time we will wholeheartedly incorporate it into our teaching and presentations.
It’s true that AFP is not a purely evidence-based, just-in-time resource. It was included in the article because of its evidence-based components, which anyone can access free of charge at https://www.aafp.org/afp, and because of its efforts to include evidence-grading scales for key clinical recommendations and offer more evidence-based clinical review articles. For more information about these efforts, read “AFP: Doing More to Help You Get the Best Evidence” in the Feb. 1, 2004, issue of AFP.
Given the nature of the comments by Dr. Armstrong and Dr. Stello, we asked the editors of AFP to respond as well.
At AFP, we are strongly committed to the transition from an authority-based review journal to an evidence-based review journal. This commitment is exemplified by the following:
Development of new evidence-based features, such as Clinical Evidence Concise, Cochrane for Clinicians, POEMs (Patient-Oriented Evidence That Matters), Point-of-Care Guides, and Recommendations and Rationale from the USPSTF;
Leadership in the development of the Strength of Recommendations Taxonomy (SORT) for rating evidence;
Consistent use of the SORT in all upcoming review articles;
Naming a Deputy Editor for Evidence-Based Medicine and new medical editors such as Allen Shaughnessy, PharmD, and Henry Barry, MD, MS, who have national reputations as experts in evidence-based medicine.
Obviously, any effort to change the editorial direction of a journal that publishes more than 2,000 pages per year takes time. We appreciate the patience and support of our readers as we make this transition. And we would welcome good, succinct, practical, evidence-based reviews from physicians such as Drs. Armstrong and Stello.