Rabia KAHVECİ, Filiz ÖZYİĞİT

Kanıta dayalı tıp beceri edindirme yöntemleri

Kanıta Dayalı Tıp (KDT) hasta bakımı ile ilgili alınan kararlarda mevcut en iyi kanıtların dikkatli, şeffaf ve akılcı kullanımıdır. Tıbbi müdahalelerin yalnızca %15’inin kanıta dayalı olduğu tespit edilmiştir. Artan talep, yeni teknolojik gelişmeler, malpraktis yasaları, bilgi ve bilgi kaynaklarının hızla artışı hekimleri KDT’ye yönlendirmiş, ancak beraberinde hekimlere KDT uygulamaları için beceri edinme yükünü de yüklemiştir. Klinik deneyler ve gözlemsel çalışmaların artması ile klinik manevralara da daha çok ihtiyaç duyulmuştur. Ancak, hasta bakımında ön saflardaki hekimlerin birçoğu bu artan kanıtları uygulamamaktadır. Hekimlere kanıtları rahat kullanmalarını sağlayacak becerileri edindirmeye yönelik farklı eğitimler verilmiştir. KDT becerileri edindirmeye yönelik birçok eğitim yöntemi vardır ve bu eğitimler tıp fakültesinde, takiben uzmanlık eğitimi döneminde veya sahadaki hekime sürekli tıp eğitimi şeklinde verilebilir. Ülkemizde de bu farklı yöntemleri tartışmak ve etkili ve uygulanabilir yöntemlerin yaygınlaşması için gerekli çalışmaları teşvik etmek gerekmektedir.

Training methods to improve evidence-based medicine skills

Evidence based medicine (EBM) is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. It is estimated that only 15% of medical interventions is evidence-based. Increasing demand, new technological developments, malpractice legislations, a very speed increase in knowledge and knowledge sources push the physicians forward for EBM, but at the same time increase load of physicians by giving them the responsibility to improve their skills. Clinical maneuvers are needed more, as the number of clinical trials and observational studies increase. However, many of the physicians, who are in front row of patient care do not use this increasing evidence. There are several examples related to different training methods in order to improve skills of physicians for evidence based practice. There are many training methods to improve EBM skills and these trainings might be given during medical school, during residency or as continuous trainings to the actual practitioners in the field. It is important to discuss these different training methods in our country as well and encourage dissemination of feasible and effective methods.

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1. Sackett DL, Rosenberg W, Gray JA, Haynes RB, WS Richardson. Evidence based medicine: what it is and what it isn’t. BMJ. 1996; 312: 71-2.
2. K. Ann McKibbon, Nancy Wilczynski, Robert S. Hayward, Cynthia J. Walker-Dilks, R. Brian Haynes. The medical literature as a resource for evidence-based care. Working Paper from the Health Information Resources Unit, McMaster University, Ontario, Canada. Journal of the American Society for Information Science. 1999; 46(10): 737-742
3. Gambrill E. Evidence-based clinical practice, (corrected) evidence-based medicine and the Cochrane collaboration. J Behav Ther Exp Psychiatry. 1999; 30(1): 1-14.
4. Kitchener H. Evidence-based medicine applied to cervical cancer. Virus Res. 2002; 89(2): 175- 81.
5. Grimshaw JM, Santesso N, Cumpston M, Mayhew A, Mc Gowan J. Knowledge for knowledge translation: the role of the Cochrane Collaboration. J Contin Educ Health Prof. 2006; 26(1): 55-62.
6. K. Ann McKibbon, Nancy Wilczynski, Robert S. Hayward, Cynthia J. Walker-Dilks, R. Brian Haynes. The medical literature as a resource for evidence-based care. Working Paper from the Health Information Resources Unit, McMaster University, Ontario, Canada. Journal of the American Society for Information Science. 1999; 46(10): 737-742
7. Gambrill E. Evidence-based clinical practice, (corrected) evidence-based medicine and the Cochrane collaboration. J Behav Ther Exp Psychiatry. 1999; 30(1): 1-14.
8. Green ML, Ellis PJ. Impact of an evidence-based medicine curriculum based on adult learning theory. J Gen Intern Med. 1997; 12 (12): 742-50.
9. Ghali WA, Saitz R, Eskew AH, Gupta M, Quan H, Hershman WY. Teaching evidence based medicine to medical students. Med Teach. 2003; 25(2): 202-4.
10. Rosenberg WM, Deeks J, Lusher A, Snowball R, Dooley G, Sackett D. Improving searching skills and evidence retrieval. JR Coll Physicians Lond. 1998; 32(6): 557-63.
11. Holloway R, Nesbit K, Bordley D, Noyes K. Teaching and evaluating first and second year medical students’ practice of evidence based medicine. Med Educ. 2004; 38(8): 868-78.
12. Srinivasan M, Weiner M, Breitfeld PP, Brahmi F, Dickerson KL, Weiner G. Early introduction of an evidence based medicine course to preclinical medical students. J Gen Intern Med. 2002; 17(1): 58-65.
13. Ghali WA, Saitz R, Eskew AH, Gupta M, Quan H, Hershman WY. Successful teaching in evidence based medicine. Med Educ. 2000; 34(1): 18-22.
14. Dorsch JL, Frasca MA, Wilson ML, Tomsic ML. A multidisciplinary approach to information and critical appraisal instruction. Bull Med Libr Assoc. 1990; 78(1): 38-44.
15. Hunt DP, Haidet P, Coverdale JH, Richards B. The effect of using team learning in an evidence based medicine course for medical students. Teach Learn Med. 2003; 15(2): 131-9.
16. Dorsch JL, Aiyer MK, Meyer LE. Impact of an evidence based medicine curriculum on medical students’ attitudes and skills. J Med Libr Assoc. 2004; 92(4): 397-406.
17. Smith CA, Ganschow PS, Reilly BM, Evans AT, McNutt RA, Osei A, et al. Teaching residents evidence based medicine skills: a controlled trial of effectiveness and assessment of durability. J Gen Intern Med. 2000;15(10): 710-5.
18. Akl EA, Izuchukwu IS, El-Dika S, Fritsche L, Kunz R, Schünemann HJ. Integrating an evidence based medicine rotation into an internal medicine residency program. Acad Med. 2004; 79(9): 897-904.
19. Nicholson LJ, Shieh LY. Teaching evidence based medicine on a busy hospitalist service: residents rate a pilot curriculum. Acad Med. 2005; 80(6): 607-9.
20. Schilling K, Wiecha J, Polineni D, Khalil S. An interactive web-based curriculum on evidence based medicine: design and effectiveness. Fam Med. 2006; 38(2): 126-32.
21. O'Brien MA, Rogers S, Jamtvedt G, Oxman AD, Odgaard-Jensen J, Kristoffersen DT, et al. Educational outreach visits: effects on Professional practice and health care outcomes (Cochrane review). The Cochrane Library Issue 4. Oxford. Update Software, 2000.
22. Markey P, Schattner P. Promoting evidence based medicine in general practice- the impact of academic detailing. Fam Pract. 2001; 18(4): 364- 6.
23. Korenstein D, Dunn A, McGinn T. Mixing it up: integrating evidence based medicine and patient care. Acad Med. 2002; 77(7): 741-2.
24. Dinkevich E, Markinson A, Ahsan S, Lawrence B. Effect of a brief intervention on evidence based medicine skills of pediatric residents. BMC Med Educ. 2006; 6: 1.
25. Grimes DA, Bachicha JA, Learman LA. Teaching critical appraisal to medical students in obstetrics and gynecology. Obstet Gynecol. 1998; 92(5): 877-82.
26. Landry FJ, Pangaro L, Kroenke K, Lucey C, Herbers J. A controlled trial of a seminar to improve medical student attitudes toward, knowledge about, and use of the medical literature. J Gen Intern Med. 1994; 9(8): 436-9.
27. Cayley WE Jr. Evidence based medicine for medical students: introducing EBM in a primary care rotation. WMJ. 2005; 104(3): 34-7.
28. Grad R, Macaulay AC, Warner M. Teaching evidence based medical care: description and evaluation. Fam Med. 2001; 33(8): 602-6.
29. Gruppen LD, Rana GK, Arndt TS. A controlled comparison study of the efficacy of training medical students in evidence based medicine literature searching skills. Acad med. 2005; 80(10): 940-4.
30. Ross R, Verdieck A. Introducing an evidence based medicine curriculum into a family practice residency—is it effective? Acad Med. 2003; 78(4): 412-7.
31. Taylor RS, Reeves BC, Ewings PE, Taylor RJ. Critical appraisal skills training for health care professionals: a randomized controlled trial. BMC Med Educ. 2004; 4(1): 30.
32. Edwards R, White M, Gray J, Fischbacher. Use of a journal club and letter-writing exercise to teach critical appraisal to medical undergraduates. Med Educ. 2001; 35(7): 691-4.
33. Seelig CB. Affecting residents’ literature reading attitudes, behaviors, and knowledge through a journal club intervention. J Gen Intern Med. 1991; 6(4): 330-4.
34. Bazarian JJ, Davis CO, Spillane LL, Blumstein H, Schneider SM. Teaching emergency medicine residents evidence based critical appraisal skills: a controlled trial. Ann Emerg Med. 1999; 34(2): 148-54.
35. Macrae HM, Regeher G, Mc Kenzle M, Henteleff H, Taylor M, Barkun J, et al. Teaching practicing surgeons critical appraisal skills with an internet-based journal club: a randomized controlled trial. Surgery. 2004; 136(3): 641-6.
36._http://www.medicine.ankara.edu.tr/basic_medica l/basicmed/kdtindex.htm [Erişim Tarihi: 10 Mart 2008].
37. http://www.tip.deu.edu.tr/index.php?id=487 [Erişim tarihi: 10 Mart 2008].
38. McCluskey A, Lovarini M. Providing education on evidence-based practice improved knowledge but did not change behaviour: a before and after study. BMC Med Educ. 2005; 5: 40.
39. Straus SE, Ball C, Balcombe N, Sheldon J, McAlister FA. Teaching evidence based medicine skills can change practice in a community hospital. J Gen Intern Med. 2005; 20(4): 340-3.
40. Norman GR, Shannon SI. Effectiveness of instruction in critical appraisal (evidence based medicine) skills: a critical appraisal. CMAJ. 1998; 158(2): 177-81.
41. Taylor R, Reeves B, Ewings P, Binns J. A systematic review of the effectiveness of critical appraisal skills training for clinicians. Med Educ. 2000; 34(2): 120-5.
42. Parkes J, Hyde C, Deeks J, Milne R. Teaching critical appraisal skills in health care settings. Cochrane Database Syst Rev. 2001; (3): CD001270.
43. Watkins C, Timm A, Gooberman-Hill R, Harvey I, Haines A, Donovan J. Factors affecting feasibility and acceptability of a practice-based educational intervention to support evidence based prescribing: a qualitative study. Fam Pract. 2004; 21(6): 661-9.
44. Nazareth I, Freemantle N, Duggan C, Mason J, Haines A. Evaluation of a complex intervention for changing Professional behaviour: the Evidence Based Out Reach (EBOR) Trial. J Health Serv Res Policy. 2002; 7(4): 230-8.
45. Fretheim A, Oxman AD, Havelsrud K, Treweek S, Bjorndal A. Rational Prescribing in primary care (RaPP-trial). A randomized trial of a tailored intervention to improve prescribing of antihypertensive and cholesterol-lowering drugs in general practice. BMC Health Serv Res. 2003; 3: 5.
46. Fretheim A, Oxman AD, Havelsrud K. Rational Prescribing in Primary Care (RaPP): A cluster randomized trial of a tailored intervention. PLoS Med. 2006; 3(6): 134-139.
47. Habraken H, Janssens I, Soenen K, Driel Van M. Pilot study on the feasibility and acceptability of academic detailing in general practice. Eur J Clin Pharmacol. 2003; 59(3): 253-60.
48. Ilett KF, Johnson S, Greenhill G, Mullen L, Brockis J, Golledge CL, et al. Modification of general practitioner prescribing of antibiotics by use of a therapeutics adviser (academic detailer). Br J Clin Pharmacol. 2000; 49(2): 168-73.
49. Bernal-Delgado E, Galeote-Mayor M, Pradas- Arnal F, Peiró-Moreno S. Bernal-Delgado E, Galeote-Mayor M, et al. Evidence based educational outreach visits: effects on prescriptions of non-steroidal anti-inflammatory drugs. J Epidemiol Community Health. 2002; 56(9): 653-8.
50. Simon SR, Smith DH, Feldstein AC, Perrin N, Yang X, Zhou Y, et al. Computerized prescribing alerts and group academic detailing to reduce the use of potentially inappropriate medications in older people. J Am Geriatr Soc. 2006; 54(6): 963-8.
51. Monane M, Matthias DM, Nagle BA, Kelly MA. Improving prescribing patterns for the elderly through an online drug utilization review intervention: a system linking the physician, pharmacist and computer. JAMA. 1998; 280(14): 1249-52.
52. Alper BS, Hand JA, Elliott S. How much effort is needed to keep up with the literature relevant for primary care? J Med Libr Assoc. 2004; 92(4): 429-37.
53. Coomarasamy A, Ola B, Gee H. Medical journals and effective dissemination of health research. Health Info Libr J. 2001; 18(4): 183-91.
54. Derose SF, Dudl JR, Benson VM, Contreras R. Point of Service reminders for prescribing cardiovascular medications. Am J Manag Care. 2005; 11(5): 298-304.
55. Dubey V, Mathew R, Ilgar K, Moineddin R. Improving preventive service delivery at adult complete health check-ups: the preventive health evidence based recommendation form (PERFORM) cluster randomized controlled trial. BMC Fam Pract. 2006; 7: 44.
56. Dubey V, Glazier R. Preventive care checklist form. Evidence-based tool to improve preventive health care during complete health assessment of adults. Can Fam Physician. 2006; 52: 48-55.
57. Milone SD, Milone SL. Evidence based periodic health examination of adults. Memory aid for primary care physicians. Can Fam Physician. 2006; 52: 40-7.
58. Sackett DL, Straus SE. Finding and applying evidence during clinical rounds: the ‘evidence cart’. JAMA. 1998; 280(15): 1336-8.
59. Lobach DF. Electronically distributed, computergenerated, individualized feedback enhances the use of a computerized practice guideline. Proc AMIA Annu Fall Symp. 1996; 493-7
60. Filippi A, Sabatini A, Badioli L, Samani G. Effects of an automated electronic reminder in changing the antiplatelet drug-prescribing behaviour among Italian general practitioners in diabetic patients: an intervention trial. Diabetes Care. 2003; 26(5): 1497-500.
61. Gandhi TK, Sequist TD, Poon EG, Karson AS, Andrew S, Harvey M, et al. Primary care clinician attitudes towards electonic clinical reminders and clinical practice guidelines. AMIA Annu Symp Proc. 2003; 848.
62. Sequist TD, Gandhi TK, Karson AS, Fiskio JM, Bugbee D, Sperling M, et al. A randomized trial of electronic clinical reminders to improve quality of care for diabetes and coronary artery disease. J Am Med Inform Assoc. 2005; 12(4): 431-7.
63. Patterson ES, Nguyen AD, Halloran JP, Asch SM. Human factors barriers to the effective use of ten HIV clinical reminders. J Am Med Inform Assoc. 2004; 11(1): 50-9.
64. Saleem JJ, Patterson ES, Militello L, Render ML, Orshansky G, Asch SM. Exploring barriers and facilitators to the use of computerized clinical reminders. J Am Med Inform Assoc. 2005; 12(4): 438-47.
65. Wiecha J, Barrie N. Collaborative online learning: a new approach to distance CME. Acad Med. 2002; 77(9): 928-9.
66. Vollmar HC, Maly-Schürer CC, Frahne J, Lelgemann M, Butzlaff M. An e-learning platform for guideline implementation- evidence and case-based knowledge translation via the internet. Methods Inf Med. 2006; 45(4): 389-96.
67. Lobach DF, Hammond WE. Computerized decision support based on a clinical practice guideline improves compliance with care standards. Am J Med. 1997; 102(1): 89-98.
68. Magrabi F, Coiera EW, Westbrook JI, Gosling AS, Vicland V.General practitioners’ use of online evidence during consultations. Int J Med Inform. 2005; 74(1): 1-12.
69. Magrabi F, Westbrook JI, Coiera EW. What factors are associated with the integration of evidence retrieval technology into routine general practice settings? Int J Med Inform. 2007; 76(10): 701-9.
70. Westbrook JI, Gosling AS, Coiera E. Do clinicians use online evidence to support patient care? A study of 55,000 clinicians. J Am Med Inform Assoc. 2004; 11(2): 113-20.
71. Westbrook JI, Gosling AS, Westbrook MT. Use of point-of-care online clinical evidence by junior and senior doctors in New South Wales public hospitals. Intern Med J. 2005; 35(7): 399- 404.
72._Evidence_based_Medicine._http://www.cebm.ut oronto.ca [Erişim Tarihi: 12.03.2008].
73._Evidence_based_Health_Care._http://www.ebmn y.org [Erişim Tarihi: 12.03.2008].
74. Uptodate Inc. http://www.uptodateinc.com [Erişim Tarihi: 12.03.2008].