1. Evidence Based Medicine Module 1: Introduction to EBM Module 2: Applying EBM--Diagnosis Module 3: Applying EBM--Treatment Prepared by: Jennifer Kleinbart, MD, Asst. Professor of Medicine, Director, EBM Curriculum Emory University School of Medicine Mark V. Williams, MD, Associate Professor of Medicine, Director, Hospital Medicine Unit Emory University School of Medicine Lawrence Blond, MD, Associate Director Graduate Medical Education, Alton Ochsner Medical Foundation

2. Evidence Based Medicine An evidence-based approach to answering clinical questions

4. Bloodletting The cure for hot, moist diseases

5. Pierre Louis (1787-1872) Inventor of the “numeric method” and the “method of observation” Found that, on average, patients who were bled did worse than those who were not.

6. Overall Results (n=77) “ Experimental” Group “ Control” Group Absolute Risk Reduction - 19% 25% 44% Mortality Difference Bled Late Bled Early

7. William Osler (1849 -1919) First “attending physician” at Johns Hopkins Hugely influential textbook author, believed that most drugs in his day were useless, but still advocated blood-letting in some cases.

8. But…. We practice EBM today

12. EBM Misconceptions EBM is useless when there is no good evidence EBM means appropriately using the best available evidence to care for patients EBM is algorithms that ignore clinical judgment/expertise Clinical judgment must be used in deciding how to apply the evidence EBM is just numbers and statistics EBM is not numbers in a vacuum – the evidence must be individualized to each patient FACT FALLACY

13. EBM - What is it? Clinical Expertise Research Evidence Patient Preferences

18. So, how does it work? EBM Method

19. EBM Method A cquire the best evidence A ppraise the evidence A pply evidence to patient care A ssess your patient A sk clinical questions

21. Ask Clinical Questions Components of Clinical Questions Patient/ Population Outcome Intervention/ Exposure Comparison In patients with acute MI In post- menopausal women In women with suspected coronary disease does early treat- ment with a statin what is the accuracy of exercise ECHO does hormone replacement therapy compared to placebo compared to exercise ECG compared to no HRT decrease cardio- vascular mortality? for diagnosing significant CAD? increase the risk of breast cancer?