When grappling with difficult cases, clinicians often wonder, “What does the evidence say, and how can I find it?” Thanks to evidence-based medicine (EBM), study results are easier to track down and apply to patient care.
From our experience, we tell how to use EBM’s 5 steps and offer tips and shortcuts to help you quickly find the evidence you need.
SPEEDING RESEARCH TO PRACTICE
Health care is rich in evidence-based innovations, but successful innovations are often disseminated slowly—if at all—to practitioners.1 Studies that demonstrate effective treatments for mental disorders may take considerable time to find their way into clinical practice.2 Similar delays have been noted in other specialties, depriving patients of the most up-to-date medical treatments. Academic medical center surveys show that up to 40% of clinical decisions are not supported by the literature.3,4
Evidence-based psychiatry: Teaching tool makes leap to clinical practice
Faculty at McMaster University in Canada developed evidence-based medicine as a medical education model by which physicians would rely on the literature—rather than textbooks or tradition—to solve patient problems.7 EBM’s influence on psychiatry has been greatest in the United Kingdom through efforts of its National Health Service, the Centre for Evidence-Based Mental Health at the University of Oxford, and the journal, Evidence-Based Mental Health.5
The U.S. experience. Given managed care’s influence on American medicine, one might expect EBM to have had a similar effect in the United States. This has not been the case, however, perhaps because for-profit HMOs have focused more on controlling costs rather than improving quality.
The U.S. Agency for Healthcare Research and Quality has funded evidence-based practice centers that produce systematic reviews but has done relatively little to promote EBM teaching and practice. Instead, professional organizations such as the American College of Physicians and journals such as JAMA have taken the lead in teaching physicians about EBM.
Residents learning EBM. Most EBM instruction occurs in medical school primary care departments. This is changing, however, now that the Accreditation Council for Graduate Medical Education (ACGME) requires all residents to show competence in EBM methods.8 ACGME requires residency programs in all specialties—including psychiatry—to ensure that graduates achieve EBM core competencies, including being able to use the process described in this article.
Two problems that daunt psychiatrists and other physicians—information overload and uncritical acceptance of information—contribute to less-than-optimal care.5
Information overload. With thousands of medical journals and millions of articles being published, no clinician can keep up with all developments in his or her field. Furthermore, study results often appear contradictory.
Review articles summarize the literature, but most are “journalistic” or “narrative”—not systematic reviews—and thus are subject to author bias in the studies cited and methods used to summarize conflicting results.4 Textbook chapters have the added problem of being almost immediately out-of-date.6
Uncritical acceptance of information occurs when clinicians rely too heavily on personal experiences, noncritiqued study results, expert opinion, and pharmaceutical industry influence.4,6
Two approaches could narrow the gap between research and practice:
- clinical practice guidelines and pathways, a “top-down” approach favored by administrators
- evidence-based medicine, a “bottom-up” approach favored—and developed by—medical educators (Box 1).5,7,8
EBM and patient care. EBM has been described as “partly a philosophy, partly a skill, and partly…a set of tools.”9 David Sackett—often considered the father of EBM—has defined it as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.”10
Although some critics disagree, clinical expertise plays an important role in EBM, as the clinician must integrate research evidence, patient preferences, and the patient’s clinical condition when making decisions.11
EBM’S 5 ACTION STEPS
With EBM, evidence from the medical literature is applied to patient care through 5 action steps:
- Formulate the question.
- Search for answers.
- Appraise the evidence.
- Apply the evidence to the patient.
- Assess the outcome.5,6,12
Step 1: Formulate the question. EBM begins with a clinical question related to the diagnosis, treatment, prognosis, or cause of a patient’s illness. The question is formatted to include the patient’s problem or diagnosis, the intervention of interest and any comparison intervention, and the outcome of interest.
Take, for example, this question: “In patients with bipolar disorder, is lamotrigine as effective as lithium in preventing relapse?” In this format:
- bipolar disorder is the diagnosis
- lamotrigine is the intervention of interest
- lithium is the comparison intervention
- relapse is the outcome of interest.
Step 2: Search for answers. Because answering different types of questions requires different types of evidence, this step involves determining the most appropriate type of evidence and searching for it.13