In God we trust (motto on US

banknotes) everything else needs

evidence
Paraphrasing Hui Lee, 2002

David L. Sackett

Evidence based medicine

Science and Art of Medicine

Clinical problem
Clinical
expertise

Scientific
evidence

Patients
preference

Clinical decision

Well-built clinical question

The first step in EBM

The steps in EBM

ASSESS
the patient

1. Start with the patient -- a clinical problem or question

arises from the care of the patient

ASK
2. Construct a well built clinical question derived from
the question the case
ACQUIRE
3. Select the appropriate resource(s) and conduct a
the evidence search
APPRAISE
4. Appraise that evidence for its validity (closeness to the
the evidence truth) and applicability (usefulness in clinical practice)
APPLY:
5. Return to the patient -- integrate that evidence with
talk with the clinical expertise, patient preferences and apply it to
patient
practice
Selfevaluation

6. Evaluate your performance with this patient

Anatomy of a good clinical

question
PICO

Types of questions

Study designs for questions

The evidence pyramid

Clinical question for our

patient

Case 1 : Tamiflu for seaonal

flu
ASSESS
1. Start with the patient -- a clinical problem or
the patient question arises out of the care of the patient

You just graduated from medical school and

are getting ready to start your internship.
Your brother calls you to ask for your advice.
He thinks he has the flu. Three of his coworkers are home with the flu and he is sure
he has it now.
Hes headed to the Urgent Care Clinic but
wants to hear from you before he sees the
doctor. Should he insist on a prescription to
Tamiflu? Will it make him feel better and get
back to work sooner? Is it worth the cost?
You have heard the reports on the news but
need to review the evidence for yourself
before advising him. You tell him you will call
him right back.

ASK
the
Question

2. Construct a well-built clinical question

derived from the case

A. Is Tamiflu more effective than bed rest

and Tylenol for the flu?
B. How much does Tamiflu cost?
C. In healthy adults, does Tamiflu reduce
the severity of acute influenza?

A. Is Tamiflu more effective than bed rest

and Tylenol for the flu?
Not quite. The question makes a
comparison that is not being considered

 B. How much does Tamiflu cost?

Not again. Though this is an important
question, this should be asked only after
the question about effectiveness

C. In healthy adults, does Tamiflu reduce

the severity of acute influenza?
Good. This is a well-built clinical question.
We know our patient population (healthy
adults), our intervention (Tamiflu) and the
outcome we want to achieve (reduce the
severity of illness)

Case 2 : Acupuncture for old

knee
ASSESS
the
patient

1. Start with the patient -- a clinical

problem or question arises out of the care
of the patient

George is an active 83 year old male. He used

to swim three times a week for 45 minutes,
garden, and walk to church. But for the last
several months, he has had trouble walking
and bending his knees. It has made gardening
difficult and restricted his daily activities.
His family physician made the diagnosis of
osteoarthritis and prescribed Voltaren
(diclofenac), a nonsteroidal anti-inflammatory
drug. He is still in pain and wants to know if
acupuncture would help. He says he would
like to stay away from more medication. You
are not sure about the effectiveness of
acupuncture for this patient and need to do a

A. Can acupuncture help an elderly 83 yearold male?

B. Is acupuncture or diclofenac effective for a
painful knee?
C. In elderly patients with osteoarthritis of
the knee, can acupuncture combined with
an anti-steroidal inflammatory agent,
improve mobility and reduce pain?

A. Can acupuncture help an elderly 83

year-old male?

This question is too vague. We still need

to know why the patient needs therapy.
We also have to know what the therapy
will do to the patient (outcome)

 B. Is acupuncture or diclofenac effective

for a painful knee?
Not quite. This question is misleading and
implies that the treatment is either
acupunture or diclofenac.

 C. In elderly patients with osteoarthritis of

the knee, can acupuncture combined with
an anti-steroidal inflammatory agent,
improve mobility and reduce pain?
Good. We know the patient problem (OA
knee), the intervention (Acupuncture or
NSAID) and the expected outcome
(improved mobility and reduced pain).

Acknowledgment
Duke University Medical Center Libra
ry
(http://www.hsl.unc.edu/Services/Tutor
ials/EBM/index.htm
)