Sunday, August 05, 2007

How PICO proficient are you?

With all the recent discussion of UpToDate and how it compares with other resources let’s not forget Pub Med. It’s the ultimate site for evidence based medicine. After all, it’s precise and gets you to the primary sources.

A comment to a recent blog post said UpToDate is not as evidence based as Dynamed. It’s even been claimed that only about 10% of UpToDate’s content is evidence based. I don’t know what that means or how it was derived. UpToDate bases some recommendations on expert opinion but when it does, usually because no higher level of evidence exists, it clearly points that out. Other potential downsides are relatively infrequent revisions of content (every 3 months or so) and imprecise searching (partially made up for by ease of navigation and extensive linking).

Other popular EBM “filtered” resources such as Bandolier, Dare and Trip are useful but suffer from limited depth of content and imprecise searching. That brings me back to Pub Med. But Pub Med has a major hurdle. It requires skill which comes only with training and practice. That’s where PICO comes in. The first step in using Pub Med for evidence based searching is to formulate a focused clinical question which can be converted into Pub Med search terms. PICO is an acronym that lists the essential components of a focused clinical question: Patient population, Intervention in question, Comparison group or treatment and Outcome of interest. And that’s only the first step.

Medical schools are supposed to be teaching the skills of Pub Med searching, but given the widespread dependence of students and house staff on UpToDate trainees may not be getting the necessary practice. In fact, easy resources such as UpToDate and Google may have produced a dumbing down of formal searching skills, as I said here:

The medical Internet has grown and information retrieval is much better now, but there may be a downside. As is true in clinical practice, the ease and convenience that comes with new technology can lead to a decline in basic skills. Though the formal discipline of Boolean searching is as necessary now as it was 20 years ago for precise and comprehensive searching, today’s new and more user friendly resources don’t require the skill and many don’t even support it.

That brings me to this interesting study involving medical house staff at Duke, (via BMC Medical Informatics and Decision Making) which looked at residents’ Pub Med skills and the effectiveness of a software tool to enhance searching. The tool was a user friendly PICO template which served as a Pub Med interface installed on a hand held device. The findings, though inconclusive, (it was a pilot study with small numbers) suggested that residents’ skills were lacking, as evidenced by the number of ineffective searches, and improvement with the use of the template. The article is worth the read as much for its excellent general discussion of Pub Med searching as it is for the study results.

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