Evidence-based individual decision making

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Evidence-based individual decision making is evidence-based medicine (EBM) as practiced by the individual health care provider and an individual patient. This is in contrast to Evidence-based guidelines which is EBM at the organizational or institutional level, and involves producing guidelines, policy, and regulations. There is concern that current evidence-based medicine focuses excessively on EBID.[1]

Classification

Evidence-based individual decision making can be divided into three modes: "doer", "user", "replicator" by the intensity of the work by the individual.[2]This categorization somewhat parallels the theory of Diffusion of innovations, but without pejorative terms, in which adopters of innovation are categorized as innovators (2.5%), early adopters (13%), early majority (33%), late majority (33%), and laggards (16%).[3] This categorization for doctors is supported by a preliminary empirical study of Green et al. that grouped doctors into Seekers, Receptives, Traditionalists, and Pragmatists.[4] (The study of Green et al. has not been externally validated.) The same doctors may operate in different modes depending on how much time is available to seek evidence during clinical care.[5] Medicine residents early in training tend to prefer being taught the practitioner model, whereas residents later in training tended to prefer the user model.[6]

Doer

The "doer"[2] or "practitioner"[7] of evidence-based medicine does at least the first four steps (above) of evidence-based medicine and are performed for "self-acquired"[5] knowledge. If the Doers are the same as the "Seekers" in the study of Green, then this group may be 3% of physicians.[4] This group may also be the similarly small group of doctors who use formal Bayesian calculations[8] or MEDLINE searches[9].

User

For the "user" of evidence-based medicine, [literature] searches are restricted to evidence sources that have already undergone critical appraisal by others, such as evidence-based guidelines or evidence summaries"[2]. More recently, the 5S search strategy,[10] which starts with the search of "summaries" (evidence-based textbooks) is a quicker approach.[11] If the Users are the same as the "Receptives" in the study of Green, then this group may be 57% of physicians.[4] Teaching this group management of information resources may be especially important.[12]

Replicator

For the "replicator", "decisions of respected opinion leaders are followed"[2]. This has been called "'borrowed' expertise".[5] If the Replicators are the same as the "Traditionalists" and "Pragmatists" combined in the study of Green, then this group may be 40% of physicians.[4] This is a very broad group of doctors. Possibly the lowest end of this group may be equivalent to the laggards of Rogers. This much smaller group of doctors, ones who have "severely diminished capacity for self-improvement", are cautious about change[13], and may be at increased risk of disciplinary action by medical boards.[14]

Teaching evidence-based individual decision making

For more information, see: Teaching evidence-based medicine.


References

  1. Eddy DM (2005). "Evidence-based medicine: a unified approach". Health affairs (Project Hope) 24: 9–17. DOI:10.1377/hlthaff.24.1.9. PMID 15647211. Research Blogging.
  2. 2.0 2.1 2.2 2.3 Straus SE, McAlister FA (2000). "Evidence-based medicine: a commentary on common criticisms.". CMAJ 163 (7): 837-41. PMID 11033714. PMC PMC80509.
  3. Berwick DM (2003). "Disseminating innovations in health care". JAMA 289: 1969–75. DOI:10.1001/jama.289.15.1969. PMID 12697800. Research Blogging.
  4. 4.0 4.1 4.2 4.3 Green LA et al. (2002). "Validating an instrument for selecting interventions to change physician practice patterns: a Michigan Consortium for Family Practice Research study". J Fam Practice 51: 938–42. PMID 12485547. [e] Cite error: Invalid <ref> tag; name "pmid12485547" defined multiple times with different content Cite error: Invalid <ref> tag; name "pmid12485547" defined multiple times with different content
  5. 5.0 5.1 5.2 Montori VM et al. (2002). "A qualitative assessment of 1st-year internal medicine residents' perceptions of evidence-based clinical decision making". Teaching and Learning in Medicine 14: 114–8. PMID 12058546. [e] Cite error: Invalid <ref> tag; name "pmid12058546" defined multiple times with different content
  6. Akl EA et al. (2006). "EBM user and practitioner models for graduate medical education: what do residents prefer?". Medical Teacher 28: 192–4. DOI:10.1080/01421590500314207. PMID 16707306. Research Blogging.
  7. Guyatt GH, Meade MO, Jaeschke RZ, Cook DJ, Haynes RB (2000). "Practitioners of evidence based care. Not all clinicians need to appraise evidence from scratch but all need some skills.". BMJ 320 (7240): 954-5. PMID 10753130. PMC PMC1117895.
  8. Reid MC, Lane DA, Feinstein AR (1998). "Academic calculations versus clinical judgments: practicing physicians' use of quantitative measures of test accuracy.". Am J Med 104 (4): 374-80. PMID 9576412.
  9. Ely JW, Osheroff JA, Ebell MH, Bergus GR, Levy BT, Chambliss ML et al. (1999). "Analysis of questions asked by family doctors regarding patient care.". BMJ 319 (7206): 358-61. PMID 10435959. PMC PMC28191.
  10. Haynes RB (2006). "Of studies, syntheses, synopses, summaries, and systems: the "5S" evolution of information services for evidence-based health care decisions". ACP J Club 145: A8. PMID 17080967. [e]
  11. Patel MR et al. (2006). "Randomized trial for answers to clinical questions: evaluating a pre-appraised versus a MEDLINE search protocol". J Medical Library Ass : JMLA 94: 382–7. PMID 17082828. [e]
  12. McCord G et al (2007). "Answering questions at the point of care: do residents practice EBM or manage information sources?". Acad Med 82: 298–303. DOI:10.1097/ACM.0b013e3180307fed. PMID 17327723. Research Blogging.
  13. Salisbury C, Bosanquet N, Wilkinson E, Bosanquet A, Hasler J (December 1998). "The implementation of evidence-based medicine in general practice prescribing". Br J Gen Pract 48 (437): 1849–52. PMID 10198506. PMC 1313292[e]
  14. Papadakis MA et al. (2005). "Disciplinary action by medical boards and prior behavior in medical school". N Engl J Med 353: 2673–82. DOI:10.1056/NEJMsa052596. PMID 16371633. Research Blogging.