Welcome Training Residents in the Evidence Based Practice

Welcome… Training Residents in the Evidence. Based Practice of Surgery Presented by: Lori J. Toedter, Ph. D, Department of Research Co-Developers: Lora L. Thompson, MSLIS, AHIP, Medical Library Director Chand Rohatgi, MD, FACS, Department of Surgery

Purpose of this Workshop • Familiarize participants with EBP/S concepts • Describe skill sets for collaborating instructors [Overview: See pp. 2 -3] • Provide details on how to start and run a program like ours [Quick overview: See p. 1] • Demonstrate the ways in which our evidencebased approach assists in fulfilling ACGME competencies

Workshop Organization • PART 1: Overview of the Evidence-Based Practice of Surgery & Related Concepts • PART 2: The “How To’s” of Starting a Program

PART 1 The Roots of the Evidence-Based Practice of Surgery: EBM [p. 2] “the conscientious, explicit, and judicious use of the current best evidence in making decisions about the care of individual patients. ” -SACKETT DL, ROSENBERG WMC, HAYNES RB, et al. EVIDENCEBASED MEDICINE: WHAT IT IS AND WHAT IT ISN’T. BMJ 1996; 312: 71 -2.

Defining EBM: From the Surgeon’s Perspective “EBM is about integrating individual clinical expertise and the best external evidence derived from research. ” -BLACK N. EVIDENCE-BASED SURGERY: A PASSING FAD? WORLD J SURG 1999; 23: 789 -793.

The Controversy [See Appendix, pp. 21 -22] The pros and cons of evidence-based surgery Evidence-based science: A worthwhile mode of surgical inquiry? Surgical practice is evidence based Evidence-based surgical practice: What is it and do we need it? Evidence-based surgery: A passing fad?

Role of the ACS • Formation of the Office of Evidence-Based Surgery (2003) (Appendix: p. 24) – Accessible sources of best evidence – Reliable outcome studies & clinical trials • Name Change: Office of Continuous Quality Improvement – Initiation of evidence-based reviews in surgery (2005) (Appendix: p. 22)

What the Training Programs Need to Do • Recognize the difficulties of conducting randomized controlled trials in surgery • Acknowledge that there will never be enough Cochrane reviews to cover all the questions surgeons have • Commit to training residents in the “how to” of answering clinical questions with the best evidence available

Evidence-Based Practice of Surgery in Resident Training • Literature is over-focused on critical appraisal skills (World J Surg May, 2005) • Databases lead the user to be overconfident • Many practicing surgeons lack access to medical library services • Forming searchable patient care questions is a teachable skill

4 Steps in the Evidence-Based Practice of Surgery [p. 2] 1. Formulate a question based on clinical situation encountered in daily practice. 2. Do a focused search of the relevant literature. 3. Critically appraise the literature obtained to find the best evidence. 4. Integrate information (both internal and external) and act in accordance with the best available evidence.

Formulating the Clinical Question • Not all questions are created equal !! • Where do the questions come from? – One’s own experience in patient care – One’s attending/mentor – The patient

Formulating the Question From a breast cancer patient: “ Should I be taking arimidex? I read about it in the newspaper. ”

What the EBP/S Novice Does • Uses your MEDLINE search engine to enter the logical words (see p. 8): – Breast Cancer/tamoxifen/arimidex • Gets 6950 ‘hits’ and looks at the first abstract (p. 9) • Sees no relevance to patient care & walks away annoyed or angry!

What the EBP Trained Resident Does: The PICO Model [p. 4] Well-framed clinical questions contain the following components: P – The Patient or Problem addressed I – The Intervention (or Exposure) being considered C – A Comparison intervention or exposure O – The clinical Outcome of interest

Reframing the Question Using PICO P – Women with advanced breast cancer taking tamoxifen I – Adding arimidex to tamoxifen C – Tamoxifen alone O – Increased length of disease-free survival

Question in PICO Format “Will adding arimidex to tamoxifen in the adjuvant treatment of advanced breast cancer increase the patient’s disease-free survival? ”

The PICO-Guided Search • Search an inexperienced searcher can perform after initial training (See pp. 5 -7) • Searcher is now using: medical subject headings, text words and limiters (See p. 10) • RESULTS: 31 hits with first abstract a best evidence article (See p. 11) • Note to surgical trainees: EBP saves time and gets better results!!

PART 2 The “How To” Starting a Training Program in the Evidence-Based Practice of Surgery

Your Key Personnel (See p. 12 for detail on skill sets ) • Attending Surgeon • Medical Librarian • Research Coordinator/Clinical Research Specialist PLUS!! The good will and support of the Program Director and Residency Coordinator

What the Attending Surgeon Contributes • Professional expertise in the subject matter • Enthusiasm as a role model and mentor • An inquiring mind!

What Your Medical Librarian Contributes · Information literacy education (One-on-one and group instruction) · Expert help with multiple databases · Interlibrary loan for accessing articles not available in the library

What Your Research Coordinator (or Clinical Research Specialist) Contributes • Training in critical analysis of the literature • Liaison with attending surgeon and librarian • Assistance in the selection of best evidence

Overview of the Evidence-Based Practice in Surgery (EBP/S) Curriculum [pp. 1&12] Session 1 Introduction to EBS, the EBS Controversy & the Focused Clinical Question Attending, Librarian & Research Coordinator Session 2 Introduction to the Literature Search Librarian Session 3 Critical Analysis of the Results of a Literature Search Attending & Research Coordinator Sessions 4+ The Evidence-Based Practice in Surgery Journal Club Attending, Librarian & Research Coordinator

Session 1 (Orientation Week) • Introduction to the Evidence-Based Practice of Surgery (Appendix, pp. 21 -22) • Discussion of the Controversy (Appendix, pp. 21 -22) • PICO Practice • Journal Club Overview (pp. 16 -17) & Schedule (p. 18) Approx. 1 hour in length (see p. 1)

Session 2 (Early Summer) • Introduction to Literature Searching – Librarian-led search on topic of interest from previous year’s clubs – Review of Search Help Sheets (pp. 5 -7) – Practice Search Assignment distributed Approx. 1 hour in length (see p. 1)

Session 3 (Late Summer) • Critical Analysis of the Literature – Tips for Selecting Best Evidence (Using abstracts obtained in practice search) – Levels of Evidence & Users’ Guides – Assign Critical Analysis exercise Approx. 1 hour in length (see p. 1)

Tips for Selecting Best Evidence [p. 12] • • • Directly answers PICO question Well-respected journal Highest quality of evidence Larger sample size More recent Not sponsored by those with vested interest

Oxford Centre for Evidence-based Medicine Levels of Evidence Level 1 a: Systematic Review (i. e. Meta-analysis) with homogeneous RCTs Level 1 b: Individual RCT with narrow confidence intervals for primary outcomes Level 2 a: Systematic Review with homogeneous cohort studies Level 2 b: Individual Cohort Study (including low quality RCTe. g. <80% follow-up)

Oxford Centre for Evidence-based Medicine Levels of Evidence Level 3 a: Systematic Review with homogeneous case-control studies Level 3 b: Individual Case-control study Level 4: Case Series (and poor quality cohort & case-control studies) Level 5: Expert opinion

Users’ Guides to the Surgical Literature Three Main Questions: (See Annotated Bibliography, pp. 24 -25) 1. Are the results of the study valid? 2. What were the results? 3. Will the results help me in caring for my patients?

Session 4 (Early Fall) • Literature Search II: Tailored to Individual Resident Needs – 1 -on-1 and small group sessions with medical librarian and/or research coordinator – First assignment given (due in 2 weeks) Approx. 1 hour in length (see p. 1)

Resident Search Assignment Advantages of Using Assignments: · · Gives the attending surgeon, medical librarian and research coordinator objective data upon which to base their evaluation of residents Provides assessment of learning needs of residents to facilitate program planning Training streamlines future searches for residents Involves a hands-on strategy oriented to professional adult learners

Sample Assignment (See bottom, p. 13) The Question: In diabetic patients with foot ulcers or gangrene, does hyperbaric oxygen therapy quicken wound healing?

The Assignment 1. Perform a literature search using Medline in EBSCO. 2. Print your search results and your search history (see librarian if not sure how to do this). 3. Review the abstracts; indicate which articles represent the best evidence in answer to the question posed. 4. Drop your materials off in the Medical Library no later than Friday, April 15.

Evaluating Assignments • Master search is completed by librarian (See p. 14 top) • Summary of best evidence completed by attending & research coordinator (See p. 14 bottom) • EELSEF Form completed (See p. 15): Copy for resident & copy for files)

The Evidence-Based Practice of Surgery Journal Club: Purpose [pp. 16 -17] • Assist residents in learning library search skills to obtain the most relevant articles in answer to a well-framed clinical question • Train residents in the critical appraisal of the literature • Assist residents in refining their professional presentation skills • Update attendees on contemporary clinical issues relevant to patient care • Allow discussion & debate of newly emerging issues in the surgical literature

The EBP of Surgery Journal Club • Run quarterly (can cover 2 topics in 1 hour) • Dates scheduled at beginning of academic year (See sample schedule, p. 18 & sample club announcement, p. 19) • Due dates on sample schedule appear on monthly calendar prepared by Residency Coordinator

Journal Club Process • Residents must comply with dates for getting question to attending, consulting on literature search & critical analysis, getting articles to attendees • Brief presentation of best evidence articles and approach to their selection (5 -10 minutes) • Discussion focuses on whether the answer to the question will change clinical practice (15 -20 minutes)

Good EBS/P topics are ones that. . . Question the “traditional wisdom” Example: The need for nasogastric tube or decompression after GI surgery.

Good EBP/S topics are ones that. . . Are part of a paradigm shift due to changing technology Example: The need for exploration of all 4 parathyroid glands in contemporary hyperparathyroid surgery with evolution of (1) the hand held gamma probe; (2) the quick PTH assay

Good EBS topics are ones that. . . Have a potential for impact on practice/patient care Example: Use of ultrasound in breast/surgical procedure Example: Use of lymphatic mapping in breast and other solid cancers

Good EBS topics are ones that. . . Have potential for generating resident research projects Example: Use of ultrasound in diagnosing acute cholecystitis in the university vs. community hospital setting

EBP/S in Helping to Meet the ACGME Competencies · Patient Care · Medical Knowledge · Practice Based Learning and Improvement

The EBP/S Journal Club and the ACGME Competencies PATIENT CARE · · Make informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment. Use information technology to support patient care decisions and patient education.

The EBP/S Journal Club and the ACGME Competencies MEDICAL KNOWLEDGE · Demonstrate an investigatory and analytical thinking approach to clinical situations.

The EBP/S Journal Club and the ACGME Competencies PRACTICE-BASED LEARNING AND IMPROVEMENT · · · Locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems. Apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness. Facilitate the learning of students and other health care professionals.

The EBP/S Program: Documenting Performance in Resident Evaluation • Assignments/Continuous Improvement • Journal Club Discussion and preparation • See p. 20: Items 5, 6, 7 completed every 6 months by surgical attending, librarian & research coordinator

Thank You! We welcome feedback so that we can continue to improve our program.