Friday, May 08, 2009

American Family Physician series on putting evidence into practice

In issue 1 of 2009 the journal American Family Physician launched a series on the application of evidence based medicine: how to put best evidence into practice. (I don’t know why I bothered to link to the issue. In a reversal of today’s trend towards open access publication AFP has recently gone from open access to controlled access. Worse yet, you can’t even view the table of contents on line, let alone the abstracts. You can access the content if you are a member of AAFP, you have your own subscription, you or your hospital library has access to the MD Consult Core Collection or you get your own “throw away” copy in the mail).

Traditional teaching on EBM held that doctors should do PubMed searches to find answers to clinical questions. Because PubMed is cumbersome and time consuming for unskilled users, recent trends favor filtered resources or, as the writer of the introductory editorial calls them, secondary literature:

There is a rich body of literature advising physicians on how to ask and answer questions. Too often, though, it has encouraged physicians to focus on PubMed searches and the original research literature, a time–consuming and sometimes frustrating process. This is not unlike trying to encourage people to use e–mail and the Internet by teaching them how to write Javascript code, or encouraging people to bake bread but forcing them to grow their own wheat. Hardly a recipe for success!

Family physicians are busier than ever and have limited time to keep current with the literature. Reading lengthy and detailed original research studies is hardly the best use of that time. Practicing physicians, and even most academic physicians, do not have the training or time to critically appraise all of the articles needed to answer clinical questions or stay current.

I propose a different skill set that prioritizes making the practicing family physician an informed consumer of the secondary literature (e.g., evidence–based guidelines, systematic reviews, critical appraisals, validated decision–support tools).

I only partially agree. While secondary sources are indispensable, there are situations where there’s no substitute for the primary source. And while some secondary sources like UptoDate have the advantage of greater speed, PubMed can be used very efficiently with a little training and practice.

While this series is directed toward family physicians the information should be useful to general internists and hospitalists as well. If time constraints and lack of computer searching skills are barriers to the application of EBM this series should help. I’ll be commenting on various installments in future posts.

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