Evidence-based medicine

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Evidence-based medicine is "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.".[1] Alternative definitions are "the process of systematically finding, appraising, and using contemporaneous research findings as the basis for clinical decisions"[2] or "evidence-based medicine (EBM) requires the integration of the best research evidence with our clinical expertise and our patient's unique values and circumstances."[3] Better known as EBM, evidence based medicine emerged in the early 1990s.

Evidenced-based practice is not restricted to medicine among the health sciences, dentistry, nursing and other allied health science are adopting "evidence-based medicine" as well.Evidence-Based Health Care or evidence-based practice extends the concept of EBM to all health professions, including purchasing and management [1].

Why do we need evidence-based medicine?

Why should such an approach to clinical medicine merit its own name, let alone another acronym in the medical literature? Don't physicians always use scientific evidence conscientiously and judiciously in treating patients? Isn't that simply routine medical care?

In fact, most of the specific practices of physicians and surgeons are based on traditional techniques learned from their seniors in the care of patients during training, that are modified with personal clinical experience and information gleaned from the medical literature and continuing education courses. Although these practices almost always have a rational basis in biology, the actual efficacy of treatments is rarely explicitly proven by experimental trials in people. Further, even when the results of experimental trials or other evidence have been reported, there is a lag time between accepting changes in procedures, treatments and tests in medical care at centers where such research is carried out or reviewed, and establishing them as routine practice in clinical care.

Evidence-based medicine seeks to promote practices that have been shown, through the scientific method to have validity by empiric proof. As such, it currently encompasses only a few of the actual practices in clinical medicine and surgery. More often, recommendations are made on the basis of best evidence that are reasonable, but not proven. Evidence-based medicine is also a philosophy, however, that seeks to validate practices by finding proof.

Steps in evidence-based medicine

Ask

"Ask" - Formulate a well-structured clinical questions.

Acquire

The ability to "acquire" evidence in a timely manner may improve healthcare.[4] Unfortunately, doctors may be led astray when acquiring information as often as they find correct answers.[5]

A proposed structure of the evidence search is the 5S search strategy,[6] which starts with the search of "summaries" (textbooks). A randomized controlled trial supports the efficiency of this approach.[7]

Appraise

To "Appraise" the quality of the answer found is very important as one third of the results of even the most visible medical research is eventually either attenuated or refuted.[8] There are many reasons for this[9]; two of the most important reasons are publication bias[10] and conflict of interest[11].

These two problems interact, as conflict of interest often leads to publication bias.[12][10]

Publication bias

Publication bias is the tendency for negative studies not to be published; the most common reason may be due to authors choosing not to publish studies that are thought to be uninteresting.[10][13] Publication bias may be more prevalent in industry sponsored research.[14]

In performing a meta-analyses, a file drawer[15] or a funnel plot analysis[16][17] may help detect underlying publication bias among the studies in the meta-analysis.

Conflict of interest

Regarding the design of randomized controlled trials, industry-sponsored studies may be more likely to select an inappropriate comparator group that would favor finding benefit in the experimental group.[14]

Regarding the reporting of data in randomized controlled trials, industry-sponsored studies may be more likely to omit intention-to-treat analyses.[12]

Regarding the conclusions reached in randomized controlled trials, one study did not find evidence of overstatement[18]; however, a later study[19] found that industry sponsored studies are more likely to recommend the experimental drug as treatment of choice even after adjusting for the treatment effect. Similarly, industry sponsored studies may be more likely to conclude that drugs are safe, even when they have increased adverse effects.[20]

Unfortunately, the presence of authors with conflict of interests is not reliably indicated in journal articles.[21] In addition, when studied in the late 1990s, approximately 10% of some types of articles used 'ghost writers'.[22] Ghost writers mean that the credited author in the byline may not have been the real author and the real author may have a conflict of interest.

Other issues

Other issues in appraising evidence include statistical issues such as adequacy of sample size.[23]

Apply

It is important to "apply" correctly the answers found. Common problems in applying evidence are 1) difficulties with numeracy and 2) recognition of the correct population that evidence applies to.

Difficulties with health numeracy

Both patients and healthcare professionals have difficulties with health numeracy and probabilistic reasoning.[24]

Difficulties in applying evidence to the correct patient population

Studies document that extrapolating study results to the wrong patient populations (over-generalization)[25][26][27] and not applying study results to the correct population (under-utilization)[28] can both increase adverse outcomes.

Over-generalization
The problem in over-generalization of study results may be more common among specialist physicians.[29] Two studies found specialists were more likely to adopt COX-2 drugs before the drugs were recalled by the FDA [30][31]. One of the studies went on to state "using COX-2s as a model for physician adoption of new therapeutic agents, specialists were more likely to use these new medications for patients likely to benefit but were also significantly more likely to use them for patients without a clear indication".[31] Similarly, orthopedists may provide more intensive care for back pain, but without benefit from the increased care.[32] Specialists may be less discriminating in their choice of journal reading. [33]

Under-utilization
The problem of under-utilizing study results may be more common when physicians are practicing outside of their expertise. For example, specialist physicians are less likely to under-utilize specialty care[34][35], while primary care physicians are less likely to under-utilize preventive care[36][37].

Assess

"Assess". Evaluate one's performance

Classification

Two types of evidence-based medicine have been proposed.[38]

Evidence-based guidelines

Evidence-based guidelines (EBG) is the practice of evidence-based medicine at the organizational or institutional level. This includes the production of guidelines, policy, and regulations.

Evidence-based individual decision making

Evidence-based individual decision (EBID) making is evidence-based medicine as practiced by the individual health care provider and an individual patient. There is concern that current evidence-based medicine focuses excessively on EBID.[38]

Evidence-based individual decision making can be further divided into three modes, "doer", "user", "replicator" by the intensity of the work by the individual.[39]

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%).[40] This categorization for doctors is supported by a preliminary empirical study of Green et al. that grouped doctors into Seekers, Receptives, Traditionalists, and Pragmatists.[41] The study of Green et al. has not been externally validated.

The same doctors may vary which group they resemble depending on how much time is available to seek evidence during clinical care.[42] Medicine residents early in training tend to prefer being taught the practitioner model, whereas residents later in training tended to prefer the user model.[43]

Doer

The "doer"[39] or "practitioner"[44] of evidence-based medicine does at least the first four steps (above) of evidence-based medicine and are performed for "self-acquired"[42] knowledge.

If the Doers are the same as the "Seekers" in the study of Green, then this group may be 3% of physicians.[41]

This group may also be the similarly small group of doctors who use formal Bayesian calculations[45] or MEDLINE searches[46].

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"[39]. More recently, the 5S search strategy,[6] which starts with the search of "summaries" (evidence-based textbooks) is a quicker approach.[7]

If the Users are the same as the "Receptives" in the study of Green, then this group may be 57% of physicians.[41]

Replicator

For the "replicator", "decisions of respected opinion leaders are followed"[39]. This has been called "'borrowed' expertise".[42]

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.[41] 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", may be at increased risk of disciplinary action by medical boards.[47]

Metrics used in evidence-based medicine

Diagnosis

  • Sensitivity and specificity
  • Likelihood ratios

Interventions

Relative measures

  • Relative risk ratio
  • Relative risk reduction

Absolute measures

  • Absolute risk reduction
  • Number needed to treat
  • Number needed to screen
  • Number needed to harm

Health policy

  • Cost per year of life saved[48]
  • Years (or months or days) of life saved. "A gain in life expectancy of a month from a preventive intervention targeted at populations at average risk and a gain of a year from a preventive intervention targeted at populations at elevated risk can both be considered large."[49]

Statistical significance

The p-value expresses the likelihood that a null hypothesis is true.[50] However, the p-value should be interpreted in light of how plausible is the hypothesis based on prior research and physiologic knowledge.[51][50][52]

Experimental trials: producing the evidence

For more information, see: Randomized controlled trial.


Evidence synthesis: summarizing the evidence

Systematic review

For more information, see: Systematic review.


Meta-analysis

Systematic reviews that quantitatively pool results from research studies are called meta-analyses.

Clinical practice guidelines

For more information, see: Clinical practice guideline.


Incorporating evidence into clinical care

Practicing clinicians usually cite the lack of time for reading newer textbooks or journals. However, the emergence of new types of evidence can change the way doctors treat patients. Unfortunately the recent scientific evidence gathered through well controlled clinical trials usually do not reach the busy clinicians in real time. Another potential problem lies in the fact that there may be numerous trials on similar interventions and outcomes but they are not systematically reviewed or meta-analyzed.

Medical informatics

Medical informatics (MI)is an essential adjunct to the practice of EBM and focuses on creating tools to access and apply the best evidence for making decisions about patient care.[3]

Before practicing EBM, informaticians (or informationists) must be familiar with medical journals, literature databases, medical textbooks, practice guidelines, and the growing number of other dedicated evidence-based resources, like the Cochrane Database of Systematic Reviews and Clinical Evidence.[53]

Similarly, for practicing medical informatics properly, it is essential to have an understanding of EBM, including the ability to phrase an answerable question, locate and retrieve the best evidence, and critically appraise and apply it.[54][55]

Studies of the effectiveness of teaching evidence-based medicine

A systematic review of the effectiveness of teaching EBM concluded "standalone teaching improved knowledge but not skills, attitudes or behaviour. Clinically integrated teaching improved knowledge, skills, attitudes and behaviour."[56] A second review concluded improvements in unvalidated measures of "knowledge, skills, attitudes or behavior."[57] Neither review examined improvements in clinical care.

Two systematic reviews of EBM provide the framework below for measuring outcomes.[58][59]

Information retrieval

Increasing use of information

A randomized controlled trial of volunteer senior medical students found that access to information portal on a handheld computer increased self-reported use of information.[60] The information portal contained multiple pre-appraised resources, including a textbook and drug resource, and would best resemble the "user" mode. The study was not able to isolate which resources in the portal had increased use. It is possible that the benefit was solely due to the textbook or drug resource.

A randomized controlled trial of teaching and encouraging use of MEDLINE by medical resident physicians showed increased searching for evidence during 6-8 weeks of observation.[61] Based on the median number of searches and hours spent searching, each search averaged 22 minutes, which may not be sustainable over the long term.

Improving clinical care

Teaching "user" mode only using syntheses and synopses, without summaries, has not shown benefit in two studies. A controlled trial of teaching the "user" mode (see above) was negative.[62] However, this study encouraged the use of syntheses and synopses and did not encourage the more practical "summaries" (evidence-based textbooks) of the "5S" search strategy.[6] A quasi-randomized, controlled investigation of teaching medical students the use of studies, syntheses, and synopses using an automated search engine was negative.[63]

Information awareness

Increasing use of information

A cluster randomized trial of McMaster Premium LiteratUre Service (PLUS) led to " increased the utilization of evidence-based information from a digital library by practicing physicians."[64]

Improving clinical care

No controlled studies have addressed improving clinical care by use of information awareness strategies.

Clinical reasoning

Improving clinical care

A controlled trial of teaching Bayesian principles (probabilistic reasoning) "improves the efficiency of test ordering."[65]

Studies on how to teach evidence-based medicine

This sections includes implications based on the preceding discussion on studies of effectiveness. In addition, this section includes other studies or reports of teaching methods, even though these methods have not been subjected to study of effect on clinical outcomes.

Ask

Acquire

A search strategy similar to the 5S strategy should be taught for use when the searcher has limited time available during clinical care. This is based on one positive study of its use[7] and two negative studies[62][63] of teaching the use using secondary and primary publications. In addition, indirect evidence on the time needed to search also supports the emphasis on using tertiary publications. Doctors may have two minutes available to search[46], whereas using MEDLINE may take 20 minutes or more.[66][61]

Teaching MEDLINE searching would be appropriate for Doers who might be willing to invest time in searching MEDLINE when not hurried by clinical care. Based on studies of common errors in searching MEDLINE, learners should be taught Medical Subject Headings (MeSH) terms and their explosion, appropriate limits, and best evidence to search for.[67] The mnemonic PEARL may guide how to each.[68] PEARL stands for:

  1. "Choose a 'Preplanned search intervention'"
  2. "Allow learners to 'Execute the search,' thus committing themselves"
  3. "'Allow learners to teach other learners' about their search process
  4. "'Review the quality of evidence' for the information found"
  5. "Discuss 'Lessons of the search.'"

Appraise

Apply

Clinical reasoning

There are various methods of clinical reasoning include probabilistic (Bayesian), causal (physiologic), and deterministic (rule-based).[69] In addition, medical experts rely more on pattern recognition which is faster and less prone to error[70]; however, clinical experts seem flexible and may use whichever method of reasoning most easily represents and solves a given problem.[71] Scales to measure clinical reasoning have been proposed.[72] Explicit Bayesian thinking with precise numbers is rarely done.[73][45] Basic science knowledge is probably "encapsulated" into clinical knowledge.[74]

Competing-hypotheses heuristic[75]
Finding Disease A Disease B
Fever 66% cell B
Rash cell C cell D
The most important missing information is cell B

Possible strategies to improve clinical reasoning have been reviewed[76][77] and using problem-based learning[77], include teaching appropriate problem representation creating a one-sentence summary of a case[76], standardized patients[78], teaching hypothetico-deductive reasoning[79][80], cognitive forcing strategies[81][82] to avoid premature closure[83], teaching the competing-hypotheses heuristic[75], and using fuzzy-trace theory[84].

Studies are inconclusive on using cognitive feedback[85] and teaching logic[86][87].

Assess

Criticisms of evidence-based medicine

Evidence-based medicine has been criticized as an attempt to define knowledge in medicine in the same way that was done unsuccessfully by the logical positivists in epistemology, "trying to establish a secure foundation for scientific knowledge based only on observed facts".[88]

Complexity theory

Complexity theory is proposed as further explaining the nature of medical knowledge.[89][90]

References

  1. ↑ Sackett DL et al. (1996). "Evidence based medicine: what it is and what it isn't". BMJ 312: 71–2. PMID 8555924. [e]
  2. ↑ Evidence-Based Medicine Working Group (1992). "Evidence-based medicine. A new approach to teaching the practice of medicine. Evidence-Based Medicine Working Group". JAMA 268: 2420–5. PMID 1404801. [e]
  3. ↑ 3.0 3.1 Glasziou, Paul; Strauss, Sharon Y. (2005). Evidence-based medicine: how to practice and teach EBM. Elsevier/Churchill Livingstone. ISBN 0-443-07444-5. 
  4. ↑ Banks DE et al (2007). "Decreased hospital length of stay associated with presentation of cases at morning report with librarian support". Journal of the Medical Library Association : JMLA 95: 381–7. DOI:10.3163/1536-5050.95.4.381. PMID 17971885. Research Blogging.
  5. ↑ McKibbon KA, Fridsma DB (2006). "Effectiveness of clinician-selected electronic information resources for answering primary care physicians' information needs". Journal of the American Medical Informatics Association : JAMIA 13: 653–9. DOI:10.1197/jamia.M2087. PMID 16929042. Research Blogging.
  6. ↑ 6.0 6.1 6.2 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]
  7. ↑ 7.0 7.1 7.2 Patel MR et al. (2006). "Randomized trial for answers to clinical questions: evaluating a pre-appraised versus a MEDLINE search protocol". JMLA 94: 382–7. PMID 17082828. [e] Cite error: Invalid <ref> tag; name "pmid17082828" defined multiple times with different content
  8. ↑ Ioannidis JP (2005). "Contradicted and initially stronger effects in highly cited clinical research". JAMA 294: 218–28. DOI:10.1001/jama.294.2.218. PMID 16014596. Research Blogging.
  9. ↑ Ioannidis JP et al. (1998). "Issues in comparisons between meta-analyses and large trials". JAMA 279: 1089–93. PMID 9546568. [e]
  10. ↑ 10.0 10.1 10.2 Dickersin K, Min YI, Meinert CL (1992). "Factors influencing publication of research results. Follow-up of applications submitted to two institutional review boards". JAMA 267: 374–8. PMID 1727960. [e] Cite error: Invalid <ref> tag; name "pmid1727960" defined multiple times with different content Cite error: Invalid <ref> tag; name "pmid1727960" defined multiple times with different content
  11. ↑ Smith R (2005). "Medical journals are an extension of the marketing arm of pharmaceutical companies". PLoS Med 2: e138. DOI:10.1371/journal.pmed.0020138. PMID 15916457. Research Blogging.
  12. ↑ 12.0 12.1 Melander H et al. (2003). "Evidence b(i)ased medicine--selective reporting from studies sponsored by pharmaceutical industry: review of studies in new drug applications". BMJ 326: 1171–3. DOI:10.1136/bmj.326.7400.1171. PMID 12775615. Research Blogging.
  13. ↑ Krzyzanowska MK et al. (2003). "Factors associated with failure to publish large randomized trials presented at an oncology meeting". JAMA 290: 495–501. DOI:10.1001/jama.290.4.495. PMID 12876092. Research Blogging.
  14. ↑ 14.0 14.1 Lexchin J et al. (2003). "Pharmaceutical industry sponsorship and research outcome and quality: systematic review". BMJ 326: 1167–70. DOI:10.1136/bmj.326.7400.1167. PMID 12775614. Research Blogging. Cite error: Invalid <ref> tag; name "pmid12775614" defined multiple times with different content
  15. ↑ Pham B et al. (2001). "Is there a "best" way to detect and minimize publication bias? An empirical evaluation". Evaluation & the Health Professions 24 (2): 109–25. PMID 11523382. [e]
  16. ↑ Egger M et al. (1997). "Bias in meta-analysis detected by a simple, graphical test". BMJ 315: 629–34. PMID 9310563. [e]
  17. ↑ Terrin N et al. (2005). "In an empirical evaluation of the funnel plot, researchers could not visually identify publication bias". J Clinical Epidemiol 58: 894–901. DOI:10.1016/j.jclinepi.2005.01.006. PMID 16085192. Research Blogging.
  18. ↑ Friedberg M et al. (1999). "Evaluation of conflict of interest in economic analyses of new drugs used in oncology". JAMA 282: 1453–7. PMID 10535436. [e]
  19. ↑ Als-Nielsen B et al. (2003). "Association of funding and conclusions in randomized drug trials: a reflection of treatment effect or adverse events?". JAMA 290: 921–8. DOI:10.1001/jama.290.7.921. PMID 12928469. Research Blogging.
  20. ↑ Nieto A et al. (2007). "Adverse effects of inhaled corticosteroids in funded and nonfunded studies". Arch Intern Med 167: 2047–53. DOI:10.1001/archinte.167.19.2047. PMID 17954797. Research Blogging.
  21. ↑ Papanikolaou GN et al. (2001). "Reporting of conflicts of interest in guidelines of preventive and therapeutic interventions". BMC medical research methodology 1: 3. PMID 11405896. [e]
  22. ↑ Laine C, Mulrow CD (2005). "Exorcising ghosts and unwelcome guests". Ann Intern. Med 143: 611–2. PMID 16230729. [e]
  23. ↑ Glasziou P, Doll H (2007). "Was the study big enough? Two "café" rules (Editorial)". ACP J Club 147: A08. PMID 17975858. [e]
  24. ↑ Ancker JS, Kaufman D (2007). "Rethinking Health Numeracy: A Multidisciplinary Literature Review". DOI:10.1197/jamia.M2464. PMID 17712082. Research Blogging.
  25. ↑ Gross CP et al. (2000). "Relation between prepublication release of clinical trial results and the practice of carotid endarterectomy". JAMA 284: 2886–93. PMID 11147985. [e]
  26. ↑ Juurlink DN, Mamdani MM, Lee DS, et al (2004). "Rates of hyperkalemia after publication of the Randomized Aldactone Evaluation Study". N Engl J Med 351: 543–51. DOI:10.1056/NEJMoa040135. PMID 15295047. Research Blogging.
  27. ↑ Beohar N et al. (2007). "Outcomes and complications associated with off-label and untested use of drug-eluting stents". JAMA 297: 1992–2000. DOI:10.1001/jama.297.18.1992. PMID 17488964. Research Blogging.
  28. ↑ Soumerai SB et al. (1997). "Adverse outcomes of underuse of beta-blockers in elderly survivors of acute myocardial infarction". JAMA 277: 115–21. PMID 8990335. [e]
  29. ↑ Turner BJ, Laine C (2001). "Differences between generalists and specialists: knowledge, realism, or primum non nocere?". J Gen Intern Med 16: 422-4. DOI:10.1046/j.1525-1497.2001.016006422.x. PMID 11422641. Research Blogging. PubMed Central
  30. ↑ Rawson N et al. (2005). "Factors associated with celecoxib and rofecoxib utilization". Ann Pharmacother 39: 597-602. PMID 15755796.
  31. ↑ 31.0 31.1 De Smet BD et al. (2006). "Over and under-utilization of cyclooxygenase-2 selective inhibitors by primary care physicians and specialists: the tortoise and the hare revisited". J Gen Intern Med 21: 694-7. DOI:10.1111/j.1525-1497.2006.00463.x. PMID 16808768. Research Blogging.
  32. ↑ Carey T et al. (1995). "The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors, and orthopedic surgeons. The North Carolina Back Pain Project". N Engl J Med 333: 913-7. PMID 7666878.
  33. ↑ McKibbon KA et al. (2007). "Which journals do primary care physicians and specialists access from an online service?". JMLA 95: 246-54. DOI:10.3163/1536-5050.95.3.246. PMID 17641754. Research Blogging.
  34. ↑ Majumdar S et al. (2001). "Influence of physician specialty on adoption and relinquishment of calcium channel blockers and other treatments for myocardial infarction". J Gen Intern Med 16: 351-9. PMID 11422631.
  35. ↑ Fendrick A, Hirth R, Chernew M (1996). "Differences between generalist and specialist physicians regarding Helicobacter pylori and peptic ulcer disease". Am J Gastroenterol 91: 1544-8. PMID 8759658.
  36. ↑ Lewis C et al. (1991). "The counseling practices of internists". Ann Intern Med 114: 54-8. PMID 1983933.
  37. ↑ Turner B et al.. "Breast cancer screening: effect of physician specialty, practice setting, year of medical school graduation, and sex". Am J Prev Med 8: 78-85. PMID 1599724.
  38. ↑ 38.0 38.1 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.
  39. ↑ 39.0 39.1 39.2 39.3 Straus SE, McAlister FA (2000). "Evidence-based medicine: a commentary on common criticisms". CMAJ : Canadian Medical Association Journal 163: 837–41. PMID 11033714. [e]
  40. ↑ Berwick DM (2003). "Disseminating innovations in health care". JAMA 289: 1969–75. DOI:10.1001/jama.289.15.1969. PMID 12697800. Research Blogging.
  41. ↑ 41.0 41.1 41.2 41.3 Green LA, Gorenflo DW, Wyszewianski L (2002). "Validating an instrument for selecting interventions to change physician practice patterns: a Michigan Consortium for Family Practice Research study". Journal of Family Practice 51: 938–42. PMID 12485547. [e]
  42. ↑ 42.0 42.1 42.2 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]
  43. ↑ 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.
  44. ↑ Guyatt GH et al. (2000). "Practitioners of evidence based care. Not all clinicians need to appraise evidence from scratch, but all need some skills". BMJ 320: 954–5. PMID 10753130. [e]
  45. ↑ 45.0 45.1 Reid MC et al. (1998). "Academic calculations versus clinical judgments: practicing physicians' use of quantitative measures of test accuracy". Am J Med 104: 374–80. PMID 9576412. [e] Cite error: Invalid <ref> tag; name "pmid9576412" defined multiple times with different content
  46. ↑ 46.0 46.1 Ely JW et al. (1999). "Analysis of questions asked by family doctors regarding patient care". BMJ 319: 358–61. PMID 10435959. [e] PubMed Central Cite error: Invalid <ref> tag; name "pmid10435959" defined multiple times with different content
  47. ↑ 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.
  48. ↑ Tengs TO et al (1995). "Five-hundred life-saving interventions and their cost-effectiveness". Risk Anal 15: 369–90. PMID 7604170. [e]
  49. ↑ Wright JC, Weinstein MC (1998). "Gains in life expectancy from medical interventions--standardizing data on outcomes". N Engl J Med 339: 380–6. PMID 9691106. [e]
  50. ↑ 50.0 50.1 Goodman SN (1999). "Toward evidence-based medical statistics. 1: The P value fallacy". Ann. Intern. Med. 130 (12): 995–1004. PMID 10383371. [e]
  51. ↑ Browner WS, Newman TB (1987). "Are all significant P values created equal? The analogy between diagnostic tests and clinical research". JAMA 257 (18): 2459–63. PMID 3573245. [e]
  52. ↑ Goodman SN (1999). "Toward evidence-based medical statistics. 2: The Bayes factor". Ann. Intern. Med. 130 (12): 1005–13. PMID 10383350. [e]
  53. ↑ Mendelson D, Carino TV (2005). "Evidence-based medicine in the United States--de rigueur or dream deferred?". Health Affairs (Project Hope) 24: 133–6. DOI:10.1377/hlthaff.24.1.133. PMID 15647224. Research Blogging.
  54. ↑ Hersh W (2002). "Medical informatics education: an alternative pathway for training informationists". JMLA 90: 76–9. PMID 11838463. [e]
  55. ↑ Shearer BS et al. (2002). "Bringing the best of medical librarianship to the patient team". JMLA 90: 22–31. PMID 11838456. [e]
  56. ↑ Coomarasamy A, Khan KS (2004). "What is the evidence that postgraduate teaching in evidence based medicine changes anything? A systematic review". BMJ 329: 1017. DOI:10.1136/bmj.329.7473.1017. PMID 15514348. Research Blogging.
  57. ↑ Flores-Mateo G, Argimon JM (2007). "Evidence based practice in postgraduate healthcare education: a systematic review". BMC Health Services Research 7: 119. DOI:10.1186/1472-6963-7-119. PMID 17655743. Research Blogging.
  58. ↑ Shaneyfelt T et al (2006). "Instruments for evaluating education in evidence-based practice: a systematic review". JAMA 296: 1116–27. DOI:10.1001/jama.296.9.1116. PMID 16954491. Research Blogging.
  59. ↑ Straus SE et al (2004). "Evaluating the teaching of evidence based medicine: conceptual framework". BMJ 329: 1029–32. DOI:10.1136/bmj.329.7473.1029. PMID 15514352. Research Blogging.
  60. ↑ Leung GM et al. (2003). "Randomised controlled trial of clinical decision support tools to improve learning of evidence based medicine in medical students". BMJ 327: 1090. DOI:10.1136/bmj.327.7423.1090. PMID 14604933. Research Blogging.
  61. ↑ 61.0 61.1 Cabell CH et al. (2001). "Resident utilization of information technology". J Gen Intern Med 16: 838–44. PMID 11903763. [e] Cite error: Invalid <ref> tag; name "pmid11903763" defined multiple times with different content
  62. ↑ 62.0 62.1 Shuval K et al. (2007). "Evaluating the impact of an evidence-based medicine educational intervention on primary care doctors' attitudes, knowledge and clinical behaviour: a controlled trial and before and after study". Journal of Evaluation in Clinical Practice 13: 581–98. DOI:10.1111/j.1365-2753.2007.00859.x. PMID 17683300. Research Blogging.
  63. ↑ 63.0 63.1 Badgett RG et al. (2001). "Teaching clinical informatics to third-year medical students: negative results from two controlled trials". BMC Medical Education 1: 3. PMID 11532204. [e] PubMed Central
  64. ↑ Haynes RB et al. (2006). "McMaster PLUS: a cluster randomized clinical trial of an intervention to accelerate clinical use of evidence-based information from digital libraries". Journal of the American Medical Informatics Association : JAMIA 13: 593–600. DOI:10.1197/jamia.M2158. PMID 16929034. Research Blogging.
  65. ↑ Davidoff F et al. (1989). "Changing test ordering behavior. A randomized controlled trial comparing probabilistic reasoning with cost-containment education". Medical care 27: 45–58. PMID 2492066. [e]
  66. ↑ Chambliss ML, Conley J (1996). "Answering clinical questions". The Journal of Family Practice 43: 140–4. PMID 8708623. [e]
  67. ↑ Gruppen LD et al. (2005). "A controlled comparison study of the efficacy of training medical students in evidence-based medicine literature searching skills". Academic medicine 80: 940–4. PMID 16186614. [e]
  68. ↑ Silk H et al. (2006). "A new way to integrate clinically relevant technology into small-group teaching". Academic Medicine 81: 239–44. PMID 16501264. [e]
  69. ↑ Kassirer JP (1989). "Diagnostic reasoning". Ann Intern Med 110: 893–900. PMID 2655522. [e]
  70. ↑ Leape LL (1994). "Error in medicine". JAMA 272: 1851–7. PMID 7503827. [e]
  71. ↑ Norman G (2006). "Building on experience--the development of clinical reasoning". N Engl J Med 355: 2251–2. DOI:10.1056/NEJMe068134. PMID 17124025. Research Blogging.
  72. ↑ Boshuizen HP et al. (1997). "Measuring knowledge and clinical reasoning skills in a problem-based curriculum". Medical education 31: 115–21. PMID 9231115. [e]
  73. ↑ Moskowitz AJ et al. (1988). "Dealing with uncertainty, risks, and tradeoffs in clinical decisions. A cognitive science approach". Ann. Intern. Med. 108: 435–49. PMID 3277516. [e]
  74. ↑ de Bruin AB et al. (2005). "The role of basic science knowledge and clinical knowledge in diagnostic reasoning: a structural equation modeling approach". Academic Medicine 80: 765–73. PMID 16043534. [e]
  75. ↑ 75.0 75.1 Wolf FM et al. (1988). "Use of the competing-hypotheses heuristic to reduce 'pseudodiagnosticity'". J Med Educ 63: 548–54. PMID 3385753. [e]
  76. ↑ 76.0 76.1 Bowen JL (2006). "Educational strategies to promote clinical diagnostic reasoning". N Engl J Med 355: 2217–25. DOI:10.1056/NEJMra054782. PMID 17124019. Research Blogging.
  77. ↑ 77.0 77.1 Graber M et al. (2002). "Reducing diagnostic errors in medicine: what's the goal?". Academic Medicine 77: 981–92. PMID 12377672. [e]
  78. ↑ Windish DM et al. (2005). "Teaching medical students the important connection between communication and clinical reasoning". J Gen Intern Med 20: 1108–13. DOI:10.1111/j.1525-1497.2005.0244.x. PMID 16423099. Research Blogging.
  79. ↑ Wiese J et al. (2002). "Improving oral presentation skills with a clinical reasoning curriculum: a prospective controlled study". Am J Med 112: 212–8. PMID 11893348. [e]
  80. ↑ Eddy DM, Clanton CH (1982). "The art of diagnosis: solving the clinicopathological exercise". N Engl J Med 306: 1263–8. PMID 7070446. [e]
  81. ↑ Croskerry P (2000). "The cognitive imperative: thinking about how we think". Academic Emergency Medicine 7: 1223–31. PMID 11073470. [e]
  82. ↑ Croskerry P (2002). "Achieving quality in clinical decision making: cognitive strategies and detection of bias". Academic Emergency Medicine 9: 1184–204. PMID 12414468. [e]
  83. ↑ Dubeau CE et al. (1986). "Premature conclusions in the diagnosis of iron-deficiency anemia: cause and effect". Medical Decision Making 6: 169–73. PMID 3736379. [e]
  84. ↑ Lloyd FJ, Reyna VF (2001). "A web exercise in evidence-based medicine using cognitive theory". J Gen Intern Med 16: 94–9. PMID 11251760. [e] PubMed Central
  85. ↑ Poses RM et al. (1995). "You can lead a horse to water--improving physicians' knowledge of probabilities may not affect their decisions". Medical Decision Making 15: 65–75. PMID 7898300. [e]
  86. ↑ Cheng PW et al. (1986). "Pragmatic versus syntactic approaches to training deductive reasoning". Cognitive Psychology 18: 293–328. DOI:10.1016/0010-0285(86)90002-2. PMID 3742999. Research Blogging.
  87. ↑ Jenicek M (2006). "The hard art of soft science: Evidence-Based Medicine, Reasoned Medicine or both?". Journal of Evaluation in Clinical Practice 12: 410–9. DOI:10.1111/j.1365-2753.2006.00718.x. PMID 16907682. Research Blogging.
  88. ↑ Goodman SN (2002). "The mammography dilemma: a crisis for evidence-based medicine?". Ann Intern Med 137: 363–5. PMID 12204023. [e]
  89. ↑ Sweeney, Kieran (2006). Complexity in Primary Care: Understanding Its Value. Abingdon: Radcliffe Medical Press. ISBN 1-85775-724-6. Review
  90. ↑ Holt, Tim A (2004). Complexity for Clinicians. Abingdon: Radcliffe Medical Press. ISBN 1-85775-855-2.  Review, ACP Journal Club Review
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