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Evidence based practice of pediatrics - right time to start
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     Department of Pediatrics, All India Institute of Medical Sciences, New Delhi-110029, India

    I recall my first year of post graduation, working through mountains of new information under the auspices of learning the basic of pediatrics. Although useful, these tasks often seemed far removed from the ultimate goal of quality patient care. During this I was introduced to the "Evidence based medicine (EBM)" through a talk, which changed my learning attitude.

    Evidence-based medicine, the "conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients," has become a keyword of modern medicine.[1],[2] The goal of EBM is to improve the health of people through decisions that will maximize their quality of life and prolong the life span.[2] EBM is a way to solve problems, to learn effectively, to remain up-to-date and to improve quality of health care. The practice of EBM demands a set of skills to help clinicians locate, interpret and apply current best evidence.[3] EBM skills are fundamental components of self directed learning and refining and applying these skills in clinical practice is essential. The right time to start learning this is during post graduate training, when we are taking decisions regarding patient care. It is best that we pick up good decision making skills right from the beginning.

    Most postgraduates place passing examination as their priority. I think the attitude that 'for passing the exams, it is not necessary to study journals and only studying textbooks are good enough' is the main barrier to EBM practice. Beside this there is limited applicability of evidence to an individual patient. Lack of consistent and coherent evidence, an unsupportive learning environment and limited availability of EBM resources are also barriers to inculcating practice of evidence-based medicine during residency. EBM practice and learning require time from postgraduate student. Postgraduate students are busy everywhere, more so in busy hospitals. This poses also important limitation in EBM practice.

    EBM education needs to be fully integrated into postgraduate clinical decision making and learning. If today's postgraduate students are to become effective evidence-based practitioners, focused educational interventions targeting each of these specific skills are necessary. While traditional curricula such as grand rounds and lectures provide passive learning, EBM requires active student involvement. While journal club sessions focus primarily on critical appraisal, EBM encompasses clinical question formulation, literature search, critical appraisal of the published literature and thereby application of evidence with approximately equal emphasis. The resident should receive a set of lectures on introduction of EBM and the basis of critical appraisal in early postgraduation course. The group discussions on EBM providing residents a foundation in formulating clinical questions, effective search strategies, and evaluating literature should be instituted. The difficult task of searching evidence of the clinical question is made easy by synthesized available evidence. Examples of such synthesized evidence include The Cochrane Library, Clinical Evidence (published by BMJ Publishing Group), and evidence-based practice guidelines from professional groups such as the American Academy of Pediatrics.[3],[4] These resources are also available on the Internet. Active student involvement is essential component. Faculty members should act as role models in practicing EBM. Strategies should be developed to introduce EBM based assessments that reflect and measure EBM learning.

    References

    1.Evidence-Based Medicine Working Group. Evidence-based medicine: a new approach to teaching the practice of medicine. JAMA 1992; 268 : 2420-2425. [PUBMED]

    2.Guyatt GH, Haynes RB, Jaeschke RZ et al. Users' guides to the medical literature: XXV. Evidence-based medicine: Principles for applying the users' guides to patient care. JAMA 2000; 284: 1290-1296.

    3.Heneghan C, Badenoch D. Evidence Based Medicine Toolkit . London; BMJ Publishing Group, 2002.

    4.Greenhalgh T. How to Read a Paper: The Basics of Evidence Based Medicine. 2nd edn. London; BMJ Publishing Group, 2001.(Sahu Jitendra K)