The fool wonders, the wise (women) ask... about tropical diseases in their practice
http://www.100md.com
《英国医生杂志》
1 Department of Internal Medicine, Yale University School of Medicine, New Haven, CT 06520, USA
Correspondence to: M Green, Yale Primary Care Residency Program, Waterbury Hospital, 64 Robbins Street, Waterbury, CT 06721, USA michael.green@yale.edu
Lockwood and colleagues have shared their seven year experience of integrating evidence based medicine into their practice at the Hospital for Tropical Diseases in London.1 Consultants, assigned as "chairs" in rotation, identify emerging clinical questions, search the literature for clinical research studies, assign articles to participants, and distribute materials in advance of a bimonthly "EBM meeting." During these two hour meetings, the group appraises the evidence and strives to reach a consensus about its implications for their practice.
Reviewing their experience, the group classified the outcome of each meeting, citing examples that resulted in a change in practice, confirmed or clarified existing practice, or identified a need for more evidence. The latter outcome often provided the impetus for a new research project. In addition to these concrete changes in practice, Lockwood and colleagues qualitatively observed a cultural shift in their institution. Physicians, in this new atmosphere of inquiry, aimed to base their decision making on "evidence rather than tradition." Importantly, the authors turned inwards and evaluated the process of their particular model of evidence based practice. And they kindly offer these lessons learnt, mid-course corrections, and general guidelines to readers inspired to adopt it.
This theme issue of BMJ asks the question: Does EBM "work?"... does it really change anything? For obvious methodological limitations, we cannot draw a straight line of causality from these EBM meetings, representing a discreet intervention, to changes in practice and then to improved outcomes in patients. None the less, we can say that the authors, clearly a reflective bunch, embraced EBM and witnessed substantial changes in their practice, both in their management of specific conditions and their general approach to decision making. Furthermore, they committed not only to a style of practice but to a style of lifelong learning that is in keeping with an international movement towards practice based, self directed approaches and away from traditional continuing medical education. I suspect that their electronic "portfolio" of clinical questions would be more useful than sitting through conferences on parasitic diseases.
In deciding how to integrate EBM into their practice, Lockwood and colleagues did their homework. The format of their meetings bears a striking resemblance to the EBM curriculums offered by many internal medicine residency programmes. In several studies, participants in these curriculums improved their EBM knowledge, skills, and certain behaviours.2 3 At Yale, our residents, with faculty guidance, have brought their clinical questions to weekly EBM seminars since 1995.4 However, we enjoy the luxury of protected time in a training programme. The longevity of the EBM meeting at the Hospital for Tropical Diseases (seven years and still going strong) demonstrates its feasibility for busy clinicians in "routine practice."
Finally, the authors' experience adds tropical medicine to the growing number of settings in which sufficient evidence exists to guide many clinical decisions. It would be interesting for them to determine more precisely, as did Ellis and colleagues, the exact proportion of therapeutic manoeuvres in their practice that were supported by systematic reviews of randomised controlled trials, individual randomised controlled trials, or "convincing non-experimental evidence."5
Funding: None.
Competing interests: None declared.
Ethical approval: Not required.
References
Lockwood DNJ, Armstrong M, Grant AD. Integrating evidence based medicine into routine clinical practice: seven years' experience at one hospital. BMJ 2004;329: 1020-3.
Smith CA, Ganschow PS, Reilly BM, vans AT, McNutt RA, Osei A, et al. Teaching residents evidence-based medicine skills: a controlled trial of effectiveness and assessment of durability. J Gen Intern Med 2000;15: 710-5.
Ross R, Verdieck A. Introducing an evidence-based medicine curriculum into a family practice residency—is it effective? Acad Med 2003;78: 412-7.
Green ML, Ellis PJ. Impact of an evidence-based medicine curriculum based on adult learning theory. J Gen Intern Med 1997;12: 742-50.
Ellis J, Mulligan I, Rowe J, Sackett DL. Inpatient general medicine is evidence based. A-Team, Nuffield Department of Clinical Medicine . Lancet 1995;346: 407-10.
((Michael L Green, associat)
Correspondence to: M Green, Yale Primary Care Residency Program, Waterbury Hospital, 64 Robbins Street, Waterbury, CT 06721, USA michael.green@yale.edu
Lockwood and colleagues have shared their seven year experience of integrating evidence based medicine into their practice at the Hospital for Tropical Diseases in London.1 Consultants, assigned as "chairs" in rotation, identify emerging clinical questions, search the literature for clinical research studies, assign articles to participants, and distribute materials in advance of a bimonthly "EBM meeting." During these two hour meetings, the group appraises the evidence and strives to reach a consensus about its implications for their practice.
Reviewing their experience, the group classified the outcome of each meeting, citing examples that resulted in a change in practice, confirmed or clarified existing practice, or identified a need for more evidence. The latter outcome often provided the impetus for a new research project. In addition to these concrete changes in practice, Lockwood and colleagues qualitatively observed a cultural shift in their institution. Physicians, in this new atmosphere of inquiry, aimed to base their decision making on "evidence rather than tradition." Importantly, the authors turned inwards and evaluated the process of their particular model of evidence based practice. And they kindly offer these lessons learnt, mid-course corrections, and general guidelines to readers inspired to adopt it.
This theme issue of BMJ asks the question: Does EBM "work?"... does it really change anything? For obvious methodological limitations, we cannot draw a straight line of causality from these EBM meetings, representing a discreet intervention, to changes in practice and then to improved outcomes in patients. None the less, we can say that the authors, clearly a reflective bunch, embraced EBM and witnessed substantial changes in their practice, both in their management of specific conditions and their general approach to decision making. Furthermore, they committed not only to a style of practice but to a style of lifelong learning that is in keeping with an international movement towards practice based, self directed approaches and away from traditional continuing medical education. I suspect that their electronic "portfolio" of clinical questions would be more useful than sitting through conferences on parasitic diseases.
In deciding how to integrate EBM into their practice, Lockwood and colleagues did their homework. The format of their meetings bears a striking resemblance to the EBM curriculums offered by many internal medicine residency programmes. In several studies, participants in these curriculums improved their EBM knowledge, skills, and certain behaviours.2 3 At Yale, our residents, with faculty guidance, have brought their clinical questions to weekly EBM seminars since 1995.4 However, we enjoy the luxury of protected time in a training programme. The longevity of the EBM meeting at the Hospital for Tropical Diseases (seven years and still going strong) demonstrates its feasibility for busy clinicians in "routine practice."
Finally, the authors' experience adds tropical medicine to the growing number of settings in which sufficient evidence exists to guide many clinical decisions. It would be interesting for them to determine more precisely, as did Ellis and colleagues, the exact proportion of therapeutic manoeuvres in their practice that were supported by systematic reviews of randomised controlled trials, individual randomised controlled trials, or "convincing non-experimental evidence."5
Funding: None.
Competing interests: None declared.
Ethical approval: Not required.
References
Lockwood DNJ, Armstrong M, Grant AD. Integrating evidence based medicine into routine clinical practice: seven years' experience at one hospital. BMJ 2004;329: 1020-3.
Smith CA, Ganschow PS, Reilly BM, vans AT, McNutt RA, Osei A, et al. Teaching residents evidence-based medicine skills: a controlled trial of effectiveness and assessment of durability. J Gen Intern Med 2000;15: 710-5.
Ross R, Verdieck A. Introducing an evidence-based medicine curriculum into a family practice residency—is it effective? Acad Med 2003;78: 412-7.
Green ML, Ellis PJ. Impact of an evidence-based medicine curriculum based on adult learning theory. J Gen Intern Med 1997;12: 742-50.
Ellis J, Mulligan I, Rowe J, Sackett DL. Inpatient general medicine is evidence based. A-Team, Nuffield Department of Clinical Medicine . Lancet 1995;346: 407-10.
((Michael L Green, associat)