EVIDENCE-BASED MEDICINE & CRITICAL APPRAISAL

Madeleine Grace M. Sosa, MD, FPPS, FPNA, FCNSP, MScE

March 14, 2014; 8:00-10:00 AM
Family and Community Medicine II
OBJECTIVES
Part I Evidence-based Medicine
Part II Appraising an Article on Diagnosis
Part III Appraising an Article on Treatment

PART I WHAT IS EVIDENCE-BASED MEDICINE?

Evidence-based medicine is the integration of

best evidence with clinical expertise and patient

values (Dave Sackett, 2001)

Critical Appraisal is part of Evidence-Based Medicine.

Patients Name

Target Disorder:

Learner:

3-part Clinical
Question

Intervention (+/- comparison):

Outcome:

*Research evidence outweighs clinical expertise, regardless of

how long a drug or treatment modality has been used.
Date and place to be filled:

De-emphasizes physiological rationale and

individual experience
Determines the best evidence relevant to a

clinical problem and uses that evidence to

resolve the issue.

Presentations will cover:

1. search strategy;
2. search results;
3. the validity of this evidence;
4. the importance of this valid evidence;
5. can this valid, important evidence be applied to your patient;
6. your evaluation of this process.

*In EBM, we have something called an educational

prescription which consists of the patients name, the target
disease, and the intervention, outcome, and date when this will
be filed. The learner will try to look for answer to questions and
they will put it in this prescription. They will do perform search
strategies yielding search results, look for validity of the
evidence, and eventually apply it to the patient.

*New definition of EBM, which inculcates patient preferences

AREAS OF EXPERTISE IN EBM: OUTLINE

1. Assessing Research Evidence (Why How)
2. Assessing Patient Values (Why How)
3. Assessing Clinical Circumstances (Why How)

ACCURACY VS. PRECISION

Accuracy
How the results are close to the true value
Precision
How repeated tests will yield the same
results

CRITICAL APPRAISAL
TYPE OF CLAIM
Claims of Effectiveness
Claims of Accuracy
Claims on Causation
Claims on Prognosis

o
o
o
o

TESTS FOR:
Drug treatment
Diagnostic tests
Cause-and-effect
Results

Transcriber/s: Marie Mae Pantolla, Craig Angelo Reyes

Formatting: Craig Angelo Reyes
Editor/s: John Henry Amper

*A precise, inaccurate (occurs in systematic errors); B

accurate, precise (ideal, especially for diagnostic tests); C low
accuracy, imprecise (poor)

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FOUR STEPS IN EBM

1. Formulate answerable question
2. Track down the best evidence
3. Critically appraise the evidence
4. Individualize results, based clinical expertise, and
patient concerns
For example, a parent comes to the physician and says, I
heard that stem cells are effective. I want my autistic son to
be treated with stem cell therapy for autism. As a
practitioner already treating patients with autism, the
physician should respond that we have to do further testing
and look for more evidence, and we cannot do it to your child
right away because there is no yet evidence of effectiveness.
Take note of this example, as this was used throughout
the lecture

1. FORMULATE ANSWERABLE QUESTION

TYPES OF QUESTIONS (DOMAINS)

TYPE OF QUESTION
(DOMAIN)

STUDY DESIGN

o Cohort
o Case-control
Therapy
o RCT
Prognosis
o Cohort
o Cohort
Harm
o Case-control
o Cross-sectional
Diagnosis
o case-control
Economic
o Cost-effectiveness analysis, etc.
*These domains are usually addressed by different study designs.
REMEMBER THIS. ~Dra. Sosa
*RCTs cannot be done is rare diseases (i.e. SSPE), in cancer, or
when proven treatments already exist
Etiology

FORMULATION OF A DIAGNOSIS QUESTION

Will stem cell therapy benefit a child with autism?

ARCHITECTURE OF A FOCUSED QUESTION

Determines if the question is good upon
appraisal
A 4-Part Review Question (PICO + STUDY
DESIGN)
P Who is the Patient or what Problem is
being addressed?
Disease or condition
Stage, Severity
Demographic characteristics (age,
gender, etc.)
I What is the Intervention or exposure?
Type of intervention or exposure
Dose, duration, timing, route, etc.
C What is the Comparison group?
Absence of risk or treatment
Placebo or alternative therapy
O What is the Outcome or endpoint?
Risk or protective
Dichotomous or continuous
Type: mortality, morbidity, quality of
life, etc.
And the STUDY DESIGN
Randomized controlled trials (RCTs)
Cohort
Case-control
Cross-sectional
All
How are these questions different? Which is better?
1. Does aspirin improve survival after acute myocardial
infarction?
2. In patients with acute myocardial infarction, does
daily, low-dose, oral aspirin lead to higher survival
rates as compared to placebo?
The 2nd question is clearly better
P Patients with acute myocardial infarction
I Daily, low-dose, oral aspirin
C Placebo
O Higher survival rates

Transcriber/s: Marie Mae Pantolla, Craig Angelo Reyes

Formatting: Craig Angelo Reyes
Editor/s: John Henry Amper

*The 2nd question here is better than the 1st question because of
its compliance with the PICO + Study design architecture.

HOW A FOCUSED QUESTION HELPS IN SEARCHING

FOR STUDIES

*It is important to establish a focused question in order for

searching articles for studies will be easier and much more
comprehensive via search engines. Thus, all items from the
PICO architecture, with the addition of the study design, should
be included in the search.

2. TRACK DOWN THE BEST EVIDENCE

Use the PICO + Study Design method and certain
MeSH words (Medical Subject Headings words)
for subjects that would include similar terms (i.e. if
one types pediatrics, the search engine should
also show child, infant, 0-10 years old).
This ensures a thorough search
3. CRITICALLY APPRAISE THE EVIDENCE
CRITICAL APPRAISAL is a method of assessing
and interpreting the evidence by systematically
considering its validity, results, and relevance to
the area of work considered

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***
These are an
example of a
Critically
Appraised Topic
(CAT) for
Diagnosis and an
Appraisal Form for
Diagnosis used in
EBM are forms
needed to be filled
up.
By using these
forms, a researcher
will already know if
the article is worth
reading and
utilizing for his or
her study, even by
just looking at the
validity criteria
alone.
***

Transcriber/s: Marie Mae Pantolla, Craig Angelo Reyes

Formatting: Craig Angelo Reyes
Editor/s: John Henry Amper

D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 3 of 14

***
These are an example of a
Critically Appraised Topic (CAT)
for Treatment/Therapy and an
Appraisal Form for
Treatment/Therapy, also forms
needed to be filled up.
***

Transcriber/s: Marie Mae Pantolla, Craig Angelo Reyes

Formatting: Craig Angelo Reyes
Editor/s: John Henry Amper

D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 4 of 14

4. INDIVIDUALIZE RESULTS, BASED CLINICAL

EXPERTISE, AND PATIENT CONCERNS
Applying to the individual
What do the results mean on average?
What do they mean for this individual?
REQUIREMENTS FOR THE PRACTICE OF EVIDENCEBASED MEDICINE (4 As)
a. Asking (Formulating a good question)
b. Acquiring (Searching the literature)
c. Appraising (Critical appraisal)
d. Applying (Implementing to patient)
e. Assessing (Evaluating applicability to patient,
considering patient values)

*No matter the circumstance, the physician must ensure

that the intervention will do no harm to the patient.

PART II APPRAISING AN ARTICLE ON DIAGNOSIS

Diagnostic Accuracy of NS1 ELISA and Lateral Flow Rapid Tests for Dengue Sensitivity,
Specificity and Relationship to Viraemia and Antibody Responses

APPRAISING DIAGNOSTIC TESTS: 3 EASY STEPS

1. Are the results valid?

2. What are the results?

3. Will they help me look after my patients?

Appropriate spectrum of patients?
Does everyone get the gold standard?
Is there an independent, blind or objective

comparison with the gold standard?

ASKING
Collaborative answer of Aubrey Medina & Aibhen
Naguna: Tell your uncle that GeneXpert is a relatively new
test is not standard for MDR-TB diagnosis, so we will have to
search first for the evidence for its usefulness.
Focused question: Among 40- to 50-year old patients with
tuberculosis (P), is GeneXpert (molecular test) a more
sensitive and specific test (I) for the diagnosis of MDR-TB
(O) as compared to the gold standard, sputum
examination (C)?
Study design: Cross-sectional study

PRACTICE EBM: CLINICAL SCENARIO

Your uncle called up asking help regarding their
househelp. They brought their 45-year old househelp to
the clinic because of prolonged cough of 2 weeks
duration, associated with low-grade fever and body
weakness. They also noticed that she is losing weight.
She has been with them for one year already. On
history, she took INH and Rifampicin 1 years ago
because of the same symptoms for 6 months. The
doctor who examined the woman claimed that she has
pulmonary tuberculosis and that this recurrence might
suggest MDR-TB. They requested for a GeneXpert test
for TB. Your uncle wants to know if it is worthwhile to
do the test, because it costs around P6,000. What will
be your response to your uncle?

Transcriber/s: Marie Mae Pantolla, Craig Angelo Reyes

Formatting: Craig Angelo Reyes
Editor/s: John Henry Amper

D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 5 of 14

Diagnosis of Mycobacterium tuberculosis using molecular biology

*An example of an article needed to answer the clinical question

I. EVALUATING DIRECTNESS
Does the study provide a direct enough answer
to your clinical question in terms of:
P = patient population with a certain
disease;
I = the intervention( or treatment) to be
administered;
C = the comparison;
O = the outcome( or condition ) that the
treatment are intended to prevent or
promote; and
M = Methodology?
COMPARE THE CLINICAL QUESTION WITH

THE RESEARCH QUESTION

When will there be a mismatch in population
(P)?
What will happen if there is a mismatch in
interventions (I)?
When will there be a discrepancy in the
outcome (O)?
*The PICOM of the Clinical Question will be compared to
the Research Question in the article; if they match, it means
the article has directness, and can be used as a reference in
the researchers study.

Clinical Question
(Researcher)

Research Question
(Article appraised)

P
I
C
O
M
*I purposely left this table for you to fill out

II. ARE THE RESULTS OF THE STUDY VALID?

Was the reference standard (gold standard) an
acceptable one?
Was a reference standard interpreted
independently from the test in question?
Follow-up questions:
How the authors assembled their
patients
How the test was applied
An appropriate reference or gold
standard

*This shows what the reference stand is and how the samples were obtained.
Transcriber/s: Marie Mae Pantolla, Craig Angelo Reyes
Formatting: Craig Angelo Reyes
Editor/s: John Henry Amper

D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 6 of 14

III. INTERPRETING RESULTS?

What likelihood ratios were associated with the range of possible results?
Measures of accuracy
Sensitivity
Specificity
Positive predictive value
Negative predictive value
Estimate the likelihood ratios for each of the possible results
Estimate the pre-test and post-test probability
CATmaker
Can be downloaded online
A calculator for 2x2 tables
But for our purpose, we have to know how to calculate them manually. ~Dra. Sosa

TEST
RESULT
Disease
present
Disease
absent
TOTAL

REFERENCE STANDARD
Disease
Disease
Present
Absent
True
False
Positive
Positive
(A)
(B)
False
True
Negative
Negative
(C)
(D)
A+C

B+D

TOTAL
A+B

C+D
A+B+C+D

*Your trusty 2x2 tables. ~Dr. Michael Van Haute.

These things are forever ingrained in research lore.

Transcriber/s: Marie Mae Pantolla, Craig Angelo Reyes

Formatting: Craig Angelo Reyes
Editor/s: John Henry Amper

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UTILITY

FORMULA

Sensitivity (Se)

Specificity (Sp)

Positive Predictive
Value (PPV)

Negative
Predictive Value
(NPV)

DEFINITION

There is a 64.28%
probability of the
presence of
pulmonary
tuberculosis in
positive sputum
tests

Probability of disease in a
patient with a positive test
result

There is a 93.75%
probability of the
absence of
pulmonary
tuberculosis in
negative sputum
tests

Probability of not having

the disease in a patient
with a negative test result

( + )

( + )
-or-

( + )

( + )
-or-

Likelihood ratio
for negative result
(LR-)

75% of people
without pulmonary
tuberculosis will
have a negative
sputum test

Proportion of people
without the disease who
have a negative test for the
disease

+ =

90% of people with

the pulmonary
tuberculosis will
have a positive
sputum test

Proportion of people with

the disease who have a
positive test for the disease

Likelihood ratio
for positive test
result (LR+)

EXAMPLE AND INTERPRETATION

How much more likely is a

positive test to be found in
a person with the disease
than in a person without it

See image on the next page for

interpretation

How much more likely is a

negative test to be found in
a person without the
condition than in a person
with it

See image on the next page for

interpretation

*Adapted and edited from the previous transcription Dra. Carnates Data Collection lecture
+ =

REFERENCE STANDARD
TEST
RESULT
Disease
present
Disease
absent
TOTAL

Disease Present

Disease Absent

TOTAL

Sensitivity

100-Specificity

A+B

100-Sensitivity

Specificity

C+D

A+C

B+D

A+B+C+D

*NOTE: These are not formulas; these simply show the principle that sensitivity and specificity decrease when the results become inaccurate.

*Although specificities, sensitivities, PPVs, and NPVs are already given, these are not enough. An optimal appraisal would involve
calculations of likelihood ratios (LRs), since the element of comparison is present.
Transcriber/s: Marie Mae Pantolla, Craig Angelo Reyes
Formatting: Craig Angelo Reyes
Editor/s: John Henry Amper

D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 8 of 14

WHAT DO LIKELIHOOD RATIOS MEAN?

IV. ASSESSING APPLICABILITY

Are there biologic issues that may affect
accuracy of the test?
Is there a sex predilection?
Is there a race predilection?
Is there an age predilection?
Are there socio-economic issues that may affect
accuracy of the test?
Is it available in the locality?
Is it affordable and acceptable to the
patient?

Pretest Odds

Piece of the pie divided by the remainder

For example, for 2 removed from a value of 10
= 2 is to 8
Obtained with via this formula: x/1-x =
Probability/100 x probability

V. INDIVIDUALIZING RESULTS
How will the results affect the probability of
disease in your patients?
WILL THE RESULTS HELP ME IN CARING FOR MY
PATIENT?
Will the reproducibility of the test result and its
interpretation be satisfactory in my setting?
Are the results applicable to my patient?
Will the results change my management?
Will patients be better off as a result of the test?
INDIVIDUALIZING RESULTS
Step 1: Estimate the pre-test probability (depends
upon the researcher)
Step 2: Convert pretest probability to odds
Step 3: Multiply pretest odds by the LR of test
result to get the post-test odds
Step 4: Convert post-test odds to post-test
probability in percent
PRETEST PROBABILITY AND ODDS
Pretest Probability
Piece of the pie divided by the whole pie
Expressed in percentage
For example, for a value of 60 out of 100 =
60% ( 60/100)

Transcriber/s: Marie Mae Pantolla, Craig Angelo Reyes

Formatting: Craig Angelo Reyes
Editor/s: John Henry Amper

*Probability = piece of the pie / the whole pie (25/100)

*Odds = piece of the pie / the remainder (25 to 75)

POST-TEST ODDS AND PROBABILITY

Obtained with via these formulas:
Post-test odds = LR x pretest odds
Post-test probability = x/1+x = odds/1 +
odds x 100
Post-test Odds = 72 x 1.5 = 108
Post-test Probability = 108/1+ 108 =
99%
WILL THE RESULT CHANGE MANAGEMENT?

*Probability of disease
*Since the post-test probability has increased to 99% from the
pre-test probability of 60%, action to treat can now be taken with
more conviction and commitment.

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NORMOGRAM
For easier post-test probability determination
without calculations, a researcher may just opt to
use a normogram
This requires the presence of the likelihood ratio
A ruler is placed on the given pre-test probability
and continued onto the likelihood ratio, and the
value to which the ruler lands on at the end will be
the post-test probability value

WILL THE REPRODUCIBILITY OF THE TEST RESULT

AND ITS INTERPRETATION BE SATISFACTORY IN
MY SETTING?
One important characteristic of a research is
reproducibility
The value of the test depends on its ability to
yield the same results when re-applied to stable
patients
Poor reproducibility can results from problems
with the test itself or in cases where the test will
require interpretation
An about the diagnostic test will tell readers
how reproducible the test results can be expected
to be
ARE THE RESULTS APPLICABLE TO MY PATIENT?
Similar setting
Patient meets all the study inclusion criteria
Patient does not violate any of the exclusion
criteria
SUMMARY

PART III APPRAISING AN ARTICLE ON THERAPY

The same appraisal tips, including evaluating directness, creating a focused question, appraising validity, and assessing
validity apply, apply here with a few subtle differences.
FORMULATION OF A THERAPY QUESTION

Were all patients analyzed under the groups to

which they were originally randomized?

Was follow-up rate adequate?
BLINDING
Issues in the assessment of outcome status
Use the same methods of ascertainment for
treatment and control groups

*The 2nd question is a better question than the 1st, as it satisfies

directness. Since we will talk about therapeutics, we will use
RCTs.

APPRAISING VALIDITY
Were patients randomly assigned to treatment
groups? (Randomization)
Was allocation concealed? (Allocation
concealment)
Were baseline characteristics similar at the start
of the trial? (Matching)
Were patients, caregivers, and/or study personnel
blinded to the treatment assignment? (Blinding)
Transcriber/s: Marie Mae Pantolla, Craig Angelo Reyes
Formatting: Craig Angelo Reyes
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D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 10 of 14

METHODS

*The study clearly states the methodology

and here as well. If none is indicated, then it considered that no methodology exists.

Continuous variable
e.g. change in weight, change in
quality of life scale, change in BP
Values that are numerical

INTERPRETING RESULTS
How large was the effect of the treatment?
How precise was the estimate of the treatment
effect?
HOW LARGE IS THE EFFECT OF TREATMENT?
Compare the outcomes in the treatment and
control groups
Outcomes:
Dichotomous variable
e.g. dead or alive, hospitalized or not
Values that are nominal

MEASUREMENT OF ESTIMATES
Dichotomous variable
Relative Risk (RR)
Relative Risk Reduction (RRR)
Absolute Risk Reduction (ARR)
Continuous variable
Mean difference

Example: Express your change in weight, if it went down from 80kg (WC) to 60kg (WT)
VARIABLE

FORMULA

Absolute weight reduction (ARR):

Weight change = 20kg

Relative Risk (RR):

New weight/original weight = 60/80 = 0.75

Relative weight reduction (RRR):

Weight loss/original weight = 20/80= 25%

VARIABLE

DESCRIPTION

Absolute Risk
Reduction

= Risk change
Usually in percent (%)

Relative risk

= New risk/original risk

Usually in decimal (0.00)

Relative Risk
Reduction

= Risk change/original risk

Usually in percent (%)

FORMULA

OUTCOME
I lost 20kg (2% of my
risk)
My risk is now 0.75 (I now
weigh 75% of what I used to
weigh)
I lost 25% of my risk( I lost
25% of my weight)

INTERPRETATION
> 0% = Treatment is beneficial
= 0% = Treatment has no effect
< 0% = Treatment is harmful
< 1.0 = Treatment is beneficial
= 1.0 = Treatment has no effect
> 1.0 = Treatment is harmful
> 0% = Treatment is beneficial
= 0% = Treatment has no effect
< 0% = Treatment is harmful

*Rc = risk in the control; Rt = risk in the treatment

Transcriber/s: Marie Mae Pantolla, Craig Angelo Reyes

Formatting: Craig Angelo Reyes
Editor/s: John Henry Amper

D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 11 of 14

EXAMPLE

Old drug: Ethoxusimide

Treated = 53%
Failure = 47% = (Rc)
New drug: Lamotrigine
Treated = 29%
Failure = 71% = (Rt)
VARIABLE

SOLUTION

INTERPRETATION

ARR

ARR = 0.47 0.71 = -0.24

RR

< 0% = Treatment is harmful

> 1.0 = Treatment is harmful

RR = 0.71/.47= 1.5

RRR

< 0% = Treatment is harmful

RRR = -0.24/0.47 = -0.51 = -51%

FREEDOM-FROM-FAILURE: TREATED
Now changing the new drug
Old drug: Ethoxusimide

Treated = 53%
Failure = 47% (Rc)
New Drug: Valproic Acid
Treated = 58%
Failure = 42% (Rt)
VARIABLE
ARR

RR

SOLUTION

=
ARR = 0.47 0.42 = 0.05

INTERPRETATION

OUTCOME

> 0% = Treatment is beneficial

Risk change (5% of my risk)

< 1.0 = Treatment is beneficial

My risk is now 0.89 (The risk is now 89%

of the previous risk)

> 0% = Treatment is beneficial

I lost 10.6% of my risk

RR = 0.42/.47= 0.89
RRR

RRR = 0.05/0.47 = -0.106 = 10.6%

*THE PRIMARY OUTCOME WAS FREEDOM-FROM-TREATMENT-FAILURE AFTER 16 WEEKS OF THERAPY

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Formatting: Craig Angelo Reyes
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D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 12 of 14

HOW PRECISE WAS THE ESTIMATE OF THE TREATMENT EFFECT?

Interval estimates
Estimated at 95% CI 95% sure that the true effect of the treatment lies within this range
E.g. RRR = 75% (95%CI: 52%, 90%)
RULE OF THUMB: WE AIM FOR A SMALLER CONFIDENCE INTERVAL! SMALLER MARGIN OF ERROR
CI: CONFIDENCE INTERVAL (Given)
When both ends of the CI are on the side of the benefit,
The treatment is definitely beneficial
When both ends of the CI are on the side of the harm,
The treatment is definitely harmful
When one end reflects important benefit and the other end reflects harm, then
The study is inconclusive
When one end reflects a small unimportant benefit and the other end reflects a small unimportant harm, then
for all intents and purposes the
Two treatments being compared are equal

AT CONFIDENCE INTERVAL = 95%

A
B
C

*RR= 0.89; A. CI= 0.07-1.0; B. CI = 0.05-1.23; C. CI = 0.05-0.91

----------------------------------------------------------------------------------------------------------------------------- -------------------------A. May be beneficial, but still inconclusive; B. Inconclusive; C. Definitely beneficial
----------------------------------------------------------------------------------------------------------------------------------------- -------------WHICH IS THE BEST CI?

D
C
B

*A. RR = 2.3 (95%CI: 1.5, 3.1); B. RR = 0.63 (95% CI: 0.53, 0.73);
C. RR = 0.98 (95%CI: 0.50, 1.50); D. RR = 0.98 (95% CI: 0.95, 1.02)
----------------------------------------------------------------------------------------------------------------------------- -------------------------A. Definitely Harmful, but with a wide CI; B. Definitely beneficial, and with a short CI
C. Equal; D. May be beneficial, but still inconclusive
----------------------------------------------------------------------------------------------------------------------------- -------------------------Since we aim for a shorter confidence interval, B has the best confidence interval. Risk reduction as reflected by failure rates is
much more important than success rates
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Formatting: Craig Angelo Reyes
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D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 13 of 14

 NNT = 100/ARR
ARR = 0.05
NNT = 100/0.05 = 2000
Interpretation: You need to treat 2000
patients with seizures to treat 1
absence epilepsy
NNT x cost of treatment

ASSESSING APPLICABILITY
Are there biologic issues that may affect
applicability of treatment?
Are there socio-economic issues affecting
applicability of treatment?
INDIVIDUALIZING THE RESULTS
Are the likely treatment benefits worth the
potential harm and costs?
Compute for NNT (Number Needed to Treat)

*Even if a treatment is beneficial, it may have adverse effects

or it may be too expensive. Estimate NNT x cost of treatment
(and duration, if relevant) to calculate the overall cost to
prevent the event.

SUMMARY: EBM
Clinical
problem

Experience
and expertise

Authoritative
practice

Decision
making

Clinical
problem

Ask answerable
questions

Ward rounds,
Clinics

Apply evidence
in decision
making

Acquire
(and appraise)
evidence

CLINICAL TOOLS TO TEACH VARIOUS STEPS OF

EBM IN DIFFERENT CLINICAL SETTINGS

Journal club

Managing
bringing change
in practice

Appraise
evidence

LIFE-LONG LEARNING

Morbidity/mortality
meeting
Audit

The hardest conviction to get into the mind of a

beginner is that the education upon which he is
engaged is not a medical course, but a life course, for
which the work of a few years under teachers is but a
preparation.

Integrate
evidence
into practice

REFERENCES

~Sir William Osler (1849-1919), from: The Student

of Medicine

Richardson et al. The well-built clinical question: a key to

evidence-based decisions. ACP Journal Club 1995;A-12

Counsell C. Formulating questions and locating primary

studies for inclusion in systematic reviews. Ann Intern Med
1997;127:380-7.

-END-

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REMARKS

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Of all 18 COMMED topics, this will go on as big boss of them all. Toxic. Dangerous. Nasty. Anyhow, its done, its made, and its ready
for use in kicking Evaluation 6s ass. This is the last transcription for FCM 2, and thanks for the support and patronage. Thanks also for
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