Introduction to Evidence-Based

Medicine
Yunisa Astiarani
Department of Public Health and
Nutrition
But first, a test…
WHAT IS THE BASIS OF YOUR
MEDICAL PRACTICE?
(Check all that apply)

A. Training, clinical experience and consultation

with other professionals

B. Convincing evidence (non-experimental) from

articles, case reports, product literature, etc.

C. Preferences of the patient

D. Active search of Randomized Controlled Trials,

Systematic Reviews, Meta-Analysis Reports
WHAT IS THE BASIS OF YOUR
MEDICAL PRACTICE?
EXCELLLENT!
A. Training, clinical experience and consultation
with other professionals

B. Convincing evidence (non-experimental) from

articles, case reports, product literature, etc.

C. Preferences of the patient

D. Active search of Randomized Controlled Trials,

Systematic Reviews, Meta-Analysis Reports
 BUT… Past knowledge and
practice might be outdated or
inadequate

Graduate Medical School Practiced Physician

WHAT IS THE BASIS OF YOUR
MEDICAL PRACTICE?
FANTASTIC!
A. Training, clinical experience and consultation with
other professionals

B. Convincing evidence (non-experimental) from articles,

case reports, product literature, etc.

C. Preferences of the patient

D. Active search of Randomized Controlled Trials,

Systematic Reviews, Meta-Analysis reports
 BUT… This evidence may be biased,
outdated, incorrect, or not applicable to
your patient

JOURNALS (1987 to present)

ARTICLES ADVERTISEMENTS
WHAT IS THE BASIS OF YOUR
MEDICAL PRACTICE?
WONDERFUL!
A. Training, clinical experience and consultation with other
professionals

B. Convincing evidence (non-experimental) from articles,

case reports, product literature, etc.Mutual Respect +
Shared Goals =
Better Cooperation and
C. Preferences of the patient Compliance

D. Active search of Randomized Controlled Trials,

Systematic Reviews, Meta-Analysis reports
 The patient should be involved in
all important decisions
But this is NOT always an easy task!

And conflicts WILL occur!

 No salt? I WON’T take that medicine…
Lose weight? The side effects are But doctor, I DO want
Forget it! INTOLERABLE! to have children!
Just give me a pill!

And conflicts WILL occur!

 No salt? I WON’T take that medicine…
Lose weight? The side effects are But doctor, I DO want
Forget it! INTOLERABLE! to have children!
Just give me a pill!

Education about current alternatives and risks is often needed…

for both the Patient and the Doctor!
 Wow… Yes, I’d like to try that I’ll discuss those risks
I never knew that high new medication! with my husband.
blood pressure could be so
dangerous at my age!

Education about current alternatives and risks is often needed…

for both the Patient and the Doctor!
An important rule in Evidence Based Medicine…
It STARTS with the patient and ENDS with the
patient.
The patient’s preferences MUST be
considered!
WHAT IS THE BASIS OF YOUR
MEDICAL PRACTICE?
WOW!!! SUPERB!!!
A. Training, clinical experience and consultation with other
professionals

B. Convincing evidence (non-experimental) from articles,

case reports, product literature, etc.

C. Preferences of the patient

D. Active search of Randomized Controlled Trials,

Systematic Reviews, Meta-Analysis reports
 In the practice of Evidence Based
Medicine, it is the physician’s duty to
find the best and most current
information and apply it judiciously
for the benefit of the patient.
But… A practice based exclusively on science
and math is effective only if your patients are
robots or clones!

Don’t forget to allow for individual

human differences
and personal preferences!
WHAT IS THE BASIS OF YOUR
MEDICAL PRACTICE?
If you checked all 4 items…
A. Training, clinical experience and consultation with other
professionals

B. Convincing evidence (non-experimental) from articles,

case reports, product literature, etc.

C. Preferences of the patient

D. Active search of Randomized Controlled Trials,

Systematic Reviews, Meta-Analysis reports
 CONGRATULATIONS!
You are practicing EVIDENCE
BASED MEDICINE!
A. Training, clinical experience and consultation with other
professionals

B. Convincing evidence (non-experimental) from articles, case

reports, product literature, etc.

C. Preferences of the patient

D. Active search of Randomized Controlled Trials, Systematic

Reviews, Meta-Analysis reports
 Definition
A BRIEF HISTORY
1980’s: McMasters University in Ontario, Canada
Dr. David Sackett and colleagues proposed Evidence Based
Medicine (EBM) as a new way of teaching, learning and
practicing medicine.
Dr. Sackett defines EBM as:
“…The conscientious, explicit, and judicious use of current
best evidence in making decisions about the care of
individual patients.”
Things to note….
• EBM integrates clinical experience and patient values with
the best available research information.
• EBM requires new skills of the clinician, including efficient
literature-searching, and the application of formal rules of
evidence in evaluating the clinical literature.
• The practice of evidence-based medicine is a process of
lifelong, self-directed, problem-based learning in which
caring for one’s own patients creates the need for clinically
important information about diagnosis, prognosis, therapy
and other clinical and health care issues.
• It is not “cookbook” with recipes, but its good application
brings cost-effective and better health care.
THREE MAJOR
COMPONENTS PATIENT
of EBM

Question
or
Problem
PHYSICIAN
INFORMATION
THE FIVE BASIC STEPS OF EBM

• Clinical Question
• Patient-focused, problem-oriented
• Find Best Evidence
• Literary Search
• Critical Appraisal
• Evaluate evidence for quality and usefulness
• Apply the Evidence
• Implement useful findings in clinical practice
• Evaluate
• The information, intervention, and EBM
 BACKGROUND and FOREGROUND QUESTIONS (all part of
EBM)

FOREGROUND QUESTIONS
NEW POSSIBILITIES
INDEFINITE ANSWERS
“Where do we want to go,
and how else might
we get there?”
“Where are we now?
And which way are we headed?”
BASIC & CONCRETE
BACKGROUND QUESTIONS

STUDENT GRAD EXPERT

 BACKGROUND QUESTIONS
BASIC & CONCRETE

1. QUESTION
• Who, What, Where, When, Why, How

2. VERB
• is, causes, does, treats, reduces, cures, prevents, affects

3. GENERAL KNOWLEDGE ABOUT DISORDER

clinical manifestations of disease, patient findings, differential
diagnosis, etiology, patient experience, comorbid condition,
screening and diagnostic tests, prognosis, therapy, risk factors,
STUDENT GRAD
etc.
 FOREGROUND QUESTIONS
NEW POSSIBILITIES
INDEFINITE ANSWERS

PT AND/OR PROBLEM Differential dx, Unusual presentation, uncertain

etiology, pt’s prior experience, comorbid conditions

INTERVENTION Exposure, test. Prognostic factor,

treatment, pt perception, etc.

COMPARISON INTERVENTION

OUTCOMES

EXPERT
FRAMING THE QUESTION (Example: PICO)

ELEMENT PROMPTS THE QUESTION:

Patient How would I describe a group of patients similar to mine?

Intervention What main action am I considering?
Comparison What is/are the other options?
Outcome What do I (or the patient) want to happen (or not happen)?

Example:

P: In kids under age 12 with poorly controlled asthma on metered dose inhaled
steroids…
I: would the addition of salmetrol to the current therapy
C: compared to increasing the dose of current steroid
O: lead to better control of symptoms without increasing side effects?
 Case
• A man, 45 y.o, came to the health facility with disturbing
cough which last for 3 weeks. He also feels tired easily,
malaise, sweating at night and significant weight loss. The
physician found that the patient has crackle sounds in his
upper chest and asked him to do the molecular test for TB.
• The test result showed that the patient has positive
M.Tuberculosis in his sputum. The doctor informed him and
his wife that he is currently a TB patient.
• The patient and his wife asked if the disease could affect his
work (as a Security), and could spread to his family (they
have 2 toddlers). Currently, they lived in a small rent house
(20 m2) and has no access in direct sunlight.
 Find the Best Evidence
“The Literary Search”

The BEST EVIDENCE is:

External - from outside resources (researchers, experts)

Current – not out of date, most recent

High Quality - accurate, precise, effective, safe

Patient focused - applicable and appropriate for your individual patient

Thank You