When Will I Know It All?
MS3: Dr Epling, I just saw Ms Henderson. She’s 48 years old, and she’s here to follow up on her hypertension, her irregular periods, and her anxiety. She also wants to know about whether she should get a colonoscopy. She—well—I—(falls silent with a pained expression on her face).
Dr E: Wow, you seem a little overwhelmed.
MS3: Dr Epling, I don’t get how you’re supposed to keep all this stuff in your head—there’s internal medicine stuff, GYN stuff, psych stuff, and prevention. To make it worse, every attending seems to say a different thing—some like calcium channel blockers for hypertension, some like HCTZ. I really like the idea of family medicine, but it scares me that I won’t be able to know what I need to, and I’d hate to feel like I’m not doing the best job I can for the patient.
Dr E: I’d hate for you to feel that way, too. Being a patient’s family doctor is a really important job, and we need the smartest students in the country going into family medicine, so it really worries me that you’re this nervous. I know you did pretty well in the first 2 years.
MS3: I think that’s why it’s so frustrating! I had a defined set of things to know, and I knew them. Now it seems like the knowledge is a moving target; it changes and everyone seems to have a different way of doing things.
Dr E: I think it might be useful to talk for just a second about how physicians can learn and keep up to date.
MS3: OK, but I know you’re like a big EBM guy, and I just really don’t get all those statistics, and I don’t think I ever will.
Dr E: OK, now relax. This is not a quiz on likelihood ratios. I’ll bet you know more than you think you do about this. In our office, what ways have you seen the physicians learn new things?
MS3: Well, they look at the textbooks on the shelves or at the Web site “Very-Current-Medicine” Some of you talk to consultants about patients, and some of you look at the library’s EBM sites—they have Cochrane, FPIN [Family Physicians Inquiries Network], Dynamed, Essential Evidence. Some of you even go on MEDLINE and track down articles and look at them. That’s what I mean, everyone does different things.
Dr E: Indeed. And what’s worse is that each physician will look in a different place each time they have a question. Confusing, eh?
Dr E: Well, not if you think about why they’re going to each source. Do you remember the difference between foreground and background questions?
MS3: Foreground questions are more specific, background are more general.
Dr E: Good. Textbooks and Very-Current-Medicine might be good places to go for background questions—to review a topic that you don’t know well—but textbooks aren’t updated frequently enough, and sites like Very-Current-Medicine don’t always give you a real good idea of the quality of the research evidence behind the answers. So they’re not very useful for foreground questions, where you need the best, most current research evidence to answer the question well. If you don’t have time to go hunting for that evidence yourself, then those aren’t real helpful.
MS3: Yeah, I saw some textbooks on the shelf in the doctors’ area from 1980!
Dr E: Yes, well anyway, foreground questions are harder because we have lots of them every day, and it’s important to get them answered well. Dr Sharon Straus wrote an article1 a few years ago…
MS3: Dr Epling, no stats!
Dr E: I promise, no stats. Just bear with me for a second. She said that physicians might “do EBM” in different ways—there will be those that can do a detailed critical appraisal and statistical review of an article, those that prefer to use high-quality summaries of articles to keep current, and those who model their practice after someone who is very evidence based.
MS3: You mean copy someone else’s practice?
Dr E: Sort of. We do it all the time; we just don’t acknowledge it very often. The key is to look at any information source with a critical eye. So if you have a consultant that you prefer, you might get a sense from her how she makes her recommendations. I’m reminded of a cardiology consultant I know that constantly works details of recent studies and trials into our conversations and is frank about telling me where the evidence ends and where his opinion starts.
Dr E: So I’ve modeled lots of my practice on my attendings, colleagues, and consultants who I think are the most evidence based. But on a regular basis, I realize I need to update my knowledge, so I use the article summary sites that you mentioned before and do a quick search through those. I concentrate on evidence from systematic reviews first, then look for single studies that might answer the question. The different sites do all this differently. Cochrane has systematic reviews of relatively focused topics, concentrating on therapy questions but now branching into diagnostic questions. Dynamed provides well-referenced and annotated summaries of a wide array of clinical topics. FPIN produces evidence-based answers to important clinical questions from family doctors and grades the evidence and their recommendations clearly. Essential evidence has a library of article reviews, clinical calculators, and guidelines that help you practice evidence-based medicine. I use most of these sites when I’m looking for an answer quickly. I also use Clinical Evidence, which US physicians can get for free from one of the insurance companies, as another evidence-based topic summary.
MS3: Do you ever do a MEDLINE search?
Dr E: I try not to.
MS3: I heard that!
Dr E: Now wait, what I mean is that I try not to do a MEDLINE search too often, because it takes a decent amount of work. So that’s my last option. If I can’t find the answer in the summary sites, I go to PubMed and use the “Clinical Queries” filter or the “Systematic Review” filter to help me find the best information. Then I use those criteria we talked about in EBM to figure out if the article is well done and how to interpret those findings.
MS3: I think I have those worksheets around somewhere.
Dr E: Good. You can also find different worksheets on the Web—there are several different sites. But I don’t expect you to be an expert in detailed critical appraisal. When you’re in practice, know where to go and whom to ask for help with critical appraisal.
MS3: So, it sounds like you’re saying you don’t have to know everything, just know where to find it.
Dr E: And that your relationship with medical knowledge is just like your relationship with your patients in family medicine—it gets richer, deeper, and more refined as you work on it. I personally would rather have a doctor that knows how to keep up and find the right answers over a doctor that thinks he/she knows it all already.
MS3: OK, so, I have to tell you about Ms Henderson.
Dr E: Right. Let’s see how much we need to find out about her.
John W. Epling Jr, MD, MSEd, Author
- Straus SE, Green ML, Bell DS, et al. Evaluating the teaching of evidence-based medicine: conceptual framework. BMJ 2004;329:1029-32.
- Cochrane Database of Systematic Reviews: www.cochrane.org
- Family Physicians Inquiries Network: www.fpin.org
- Dynamed: www.ebscohost.com/dynamed/
- Essential Evidence Plus: www.essentialevidenceplus.com/
- Clinical Evidence: www.clinicalevidence.com
- PubMed: www.ncbi.nlm.nih.gov/pubmed
Editor’s Note: Dr Epling has declared several potential conflicts of interest. He has done work for FPIN and InfoPOEMS (now called Essential Evidence) in the past. He is currently writing a Cochrane systematic review and is an ongoing contributor to Clinical Evidence. Some of the ideas presented here are taken from material created by the Evidence-based Medicine Working Group and the Information Mastery Working Group.
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