All good physicians are looking up questions during patient care. The skill of asking a good, clinically answerable question and then finding an answer that can be applied to the patient in a timely manner is possibly the most important skill to learn during residency. The EBM Morning Report has been developed to practice this skill in a more formal way.
During the inpatient month, each resident on the inpatient team will lead a 10-15 minute EBM presentation. The resident will present a clinical question formulated earlier in the rotations from a true patient encounter. The discussion could focus on how the question was created, what resources were used (Primary Literature vs Systems), how they did the search, or a critical appraisal of the answer. Sometimes, the best discussion is when an answer can not be found and the team can trouble shoot on alternative searches or questions.
The first step in this process, and possibly the most important, is developing a strong clinical question. Below is an excerpt from the Best Evidence Statement Development Process Manual from CCHMC. The manual is full of outstanding information and guidance. We encourage everyone to utilize it!
Step 1: Developing a Question
We utilize the PICO format for developing clinically answerable questions. PICO stands for: Patient population; Intervention; Comparison; Outcome.
P Patient / Population
Identify the condition-specific group (Population) for which outcome improvement is desired. Some examples of population characteristics may include but are not limited to:
Age
Gender
Disease / Condition
Care Setting
Example: Among school-aged children with candy cravings who are studying,
I Intervention
Identify specific Intervention that may affect the desired outcome. Intervention may be a clinical intervention or a process change.
Example: does eating peanut M&Ms
C Comparison
Identify the current clinical practice (may be no treatment).
Describe current practice, if known by team, based on collective experience.
Conduct an electronic survey of current practice, if not fully aware of current practices.
Conduct chart reviews to determine current practice, if other methods are not sufficient.
Example: compared to plain chocolate M&Ms
O Outcome
Identify clinical or functional outcomes or results that are desired. Outcome is measurable. Example: improve homework completion and/or grades?
Once all components have been identified, the clinical question can be written:
Example: Among school-aged children with candy cravings who are studying, do peanut M&Ms compared to plain chocolate M&Ms improve homework completion and/or grades?
Step 2: Literature Review
After you have a question, it is time to go find the answer! The manual sited above provides excellent guidance, and another great resource to provide guidance on where to start is the Boston Finding Information Framework. Based upon the type of question (background: foundational knowledge based questions; foreground: detailed questions that follow the typical PICO format).
Step 3: Evaluating the Evidence
You have the studies or study, now how to you review the quality of the study? You will not have the time to perform an exhaustive literature search nor will you have the time to perform a complete critical appraisal. This task is to help you gain the skills to practice EBM in the clinical setting, but like everything it takes practice. The first step in evaluating literature is deciding the domain for the question (intervention vs prognosis vs diagnosis etc) followed by evaluating the type of study you have found (Systematic Review or Meta–Analysis vs RCT vs cross sectional etc). To assist you with these steps, utilize the Study Design Algorithm produced by CCHMC. Once you have the two questions answered (type of question and type of study), utilize the Legend Appraisal Table to find the correct method to evaluate the quality of the study.
What if you run out of time?
Inpatient is busy and the above steps can be challenging if you have never done them (or even if you have done them just a couple of times). It is ok to not complete the task: that maybe the area to discuss. A wonderful EBM morning could be developing a good question or figuring out the type of question or the type of study or going through one of the evaluation forms. Do not spend hours on this: we will all learn from any of the steps you would like to discuss. Remember, this is for only 15-20 minutes.