Evidence Detectives

"Evidence based medicine is the conscientious, explicit and judicious use of current, best evidence in making decisions about the care of individual patients. This practice means integrating individual clinical experience with the best available external clinical evidence from systematic research" Sackett et al., BMJ 1996, 332, pp.72-3.

Evidence Detectives is a monthly exercise, the goal of which is to engage each resident in the learning the principles of evidence-based medicine, and confer upon them the tools necessary to employ this knowledge in everyday practice.

Goals

Identify practice-based questions about patient management in the clinical setting.

Learn how to articulate a question in a manner conducive to optimal searching.
Become facile with rapid, but comprehensive literature searches, using the most appropriate databases, in order to find the articles that most relevantly address the clinical question.
Critically appraise the literature, and become familiar with common sources for bias in the study design of each of the major question-types (therapy, diagnosis, prognosis, harm, systematic review, meta-analysis).
Become proficient with interpreting the results, as well as their implications with regard to the clinical bottom (line power calculations, relative risk, odds ratio, relative risk reduction, absolute risk reduction, number needed to treat, number needed to harm, sensitivity, specificity, pre-test probability, post-test probability, likelihood ratios, Fagan nomogram, testing threshold, treatment threshold, confidence intervals, surrogate outcomes, subgroup analysis).

In order to accomplish these goals, we have employed an interactive, team-based learning method, whereby each resident is a member of a larger "team", comprised of residents across all years of clinical experience. Each resident works first individually, then as a part of this group, in order to accomplish a set of challenges put forth at the beginning of each two-hour Evidence Detectives session. The "teams" then compete with one another in the justification of their responses to these challenges.

Curriculum Application

Each resident, with the assistance of a faculty Mentor and the Education/Research Chiefs, will facilitate a single Evidence Detectives (ED) session during his or her PGY-2 year.

Part A: Evidence Consult

The resident will complete the following 5 steps...

Select 3 clinical questions from the evidence consult database*, formulating a clinical case vignette and a PICO for each question.
Meet with a NYP librarian to perform a comprehensive literature search on the 3 chosen clinical questions. The goal of the literature search is to find the best evidence +/- pertinent counter-evidence to guide clinical practice, using the evidence pyramid as a template.
Meet with the Education & Research Chiefs for 1-2 sessions during the 4 weeks for guidance on article discernment and PICO/ Vignette formulation.

This work will be presented in ED as...

3 case vignettes with their defining clinical question and the derived PICOs, using small groups for questions and responses to the management/investigation dilemma.
A brief summary of the literature search for each PICO, presenting the current best evidence +/- counter-evidence for clinical practice

(Residents attending the conference will receive the presented articles in ED package. Those not attending will be able to view and download the articles as reponses to the evidence consult questions from the NYP EM Evidence-Based Practice and Research Homepage.)

*Evidence Consult

The evidenceconsult@gmail.com email account serves a forum where clinical questions from residents and faculty alike can be posted (eg: "are we giving Steroids to Migraines nowadays?"; "do platelets in ASA pts with hemorrhagic stroke really affect outcome?"). All clinical questions unanswered on shifts should be posted to evidence consult. The most clinically relevant questions will be addressed either on the NYP EM Evidence-Based Practice and Research Homepage Blog or selected to be used in the following months' Evidence Detectives.

PART B: Evidence Analysis:

The resident will complete the following 5 steps...

Select ONE of the articles used in Evidence Consult for the Evidence Analysis section. This article will be posted to residents via email 1 month in advance.
With their Faculty Mentors' guidance, design the curriculum for the session; specifically the "Application Oriented Activity," which is the vehicle through which the majority of teaching points and critical appraisal will be accomplished.
Critique methodology of article with particular respect to " is this study applicable to my patient population?" thus "can this guide my practice?"
Critique statistical analysis focusing on ONE of the statistical tools used in the article (OR, CI, NNT etc).
Guide the ED groups through results interpretation, with particular respect to "Can this/will this guide my practice?"

The resident will facilitate all discussion between "teams" in their work toward attaining the objectives articulated at the outset of their allotted time, and in their competition with one another

Format and Timeline:

Pre-conference: Read ED article distributed via email 1 month in advance of the lecture.

0:00-0:45: Evidence Consult. 3 case presentations, PICO formations, presentation of search strategies, summary of level of evidence found, brief presentation of best evidence +/- counter evidence to guide clinical practice.

0:45-1:00: Group Readiness Assurance Test.

1:00-1:15: Simultaneous Reporting of Responses to Readiness Assurance Test.

1:15-1:20: Brief repetition of case presentation, PICO formation.

1:20-1:35: Group Application Oriented Activity.

1:35-2:00: Simultaneous Reporting of Responses to Application Oriented Activity and Clinical Bottom Line.

Evidence Detectives Features:

Readiness Assurance Test (RAT)

This activity takes the form of a 5-question challenge, meant to assess background knowledge of the specific topic or teaching point being addressed in the current session. The RAT is first taken individually, then as a team, whereby the team as a whole must agree upon the answers to each part of the RAT before proceeding. Finally, each "team" simultaneously reports their groups' consensus, which inevitable results in an interactive discussion between teams, facilitated by the PGY-2 resident leading the session.

PICO Derivation and Presentation of Search Strategy:

The PICO exercise and effective literature searching are two of the emphases of each Evidence Detectives Session, which rests on the platform that the ability to articulate an accurate and searchable question, and arrive at the most relevant and methodologically superior article is paramount to any successful evidence based practice.

Application Oriented Activity (AOA):

This activity is the raison d’etre of the Evidence Detectives session. It is another 5-question challenge, designed by the PGY-2 resident facilitating the session, and is meant to stimulate higher-order thinking and secondary/tertiary application of critical appraisal concepts to the article that has been chosen as the focus of the activity. The AOA is first taken as a team. Then, once again, the teams are challenged to convince the others of the legitimacy of their answers in a highly interactive setting, facilitated by the PGY-2 resident, which is meant to promote further and deeper discussion of the article.

Next Steps: Effecting Change in the Clinical Setting:

When the evidence suggests a treatment or practice pattern is different from local standards of care, the resident-attending team is encouraged to create policy suggestions to advance through the nursing and physician practice committee. In fact, historically, several Evidence Detectives sessions have yielded high-quality resident scholarly projects, poster presentations, and publications in years past.

Faculty:

Peter Wyer, MD (Track Leader)
Aleksandr Tichter, MD (Defacto Track Leader)
Peter Greenwald, MD
Kiran Pandit, MD
Jeremy Simon, MD
Richard Lappin, MD