Evidence-Based Practice of Surgery: Training for Residents

1. Welcome… Training Residents in the Evidence-Based Practice of Surgery Presented by: Lori J. Toedter, PhD, Department of Research Co-Developers:Lora L. Thompson, MSLIS, AHIP, Medical Library DirectorChand Rohatgi, MD, FACS, Department of Surgery

2. Purpose of this Workshop • Familiarize participants with EBP/S concepts • Describe skill sets for collaborating instructors [Overview: See pp. 2-3] • Provide details on how to start and run a program like ours [Quick overview: See p. 1] • Demonstrate the ways in which our evidence-based approach assists in fulfilling ACGME competencies

3. Workshop Organization • PART 1: Overview of the Evidence-Based Practice of Surgery & Related Concepts • PART 2: The “How To’s” of Starting a Program

4. PART 1The Roots of the Evidence-Based Practice of Surgery: EBM [p. 2] • “the conscientious, explicit, and judicious use of the current best evidence in making decisions about the care of individual patients.” • -SACKETT DL, ROSENBERG WMC, HAYNES RB, et al. EVIDENCE-BASED MEDICINE: WHAT IT IS AND WHAT IT ISN’T. BMJ 1996; 312: 71-2.

5. Defining EBM: From the Surgeon’s Perspective • “EBM is about integrating individual clinical expertise and the best external evidence derived from research.” • -BLACK N. EVIDENCE-BASED SURGERY: A PASSING FAD? WORLD J SURG 1999; 23: 789-793.

6. The Controversy [See Appendix, pp. 21-22] The pros and cons of evidence-based surgery Evidence-based science: A worthwhile mode of surgical inquiry? Surgical practice is evidence based Evidence-based surgical practice: What is it and do we need it? Evidence-based surgery: A passing fad?

7. Role of the ACS • Formation of the Office of Evidence-Based Surgery (2003) (Appendix: p. 24) • Accessible sources of best evidence • Reliable outcome studies & clinical trials • Name Change: Office of Continuous Quality Improvement • Initiation of evidence-based reviews in surgery (2005) (Appendix: p. 22)

8. What the Training Programs Need to Do • Recognize the difficulties of conducting randomized controlled trials in surgery • Acknowledge that there will never be enough Cochrane reviews to cover all the questions surgeons have • Commit to training residents in the “how to” of answering clinical questions with the best evidence available

9. Evidence-Based Practice of Surgery in Resident Training • Literature is over-focused on critical appraisal skills (World J Surg May, 2005) • Databases lead the user to be overconfident • Many practicing surgeons lack access to medical library services • Forming searchable patient care questions is a teachable skill

10. 4 Steps in the • Evidence-Based Practice of Surgery [p. 2] • 1.Formulate a question based on clinical situation • encountered in daily practice. • 2. Do a focused search of the relevant literature. • 3. Critically appraise the literature obtained to • find the best evidence. • Integrate information (both internal and • external) and act in accordance with thebest • available evidence.

11. Formulating the Clinical Question • Not all questions are created equal !! • Where do the questions come from? • One’s own experience in patient care • One’s attending/mentor • The patient

12. Formulating the Question From a breast cancer patient: “ Should I be taking arimidex? I read about it in the newspaper.”

13. What the EBP/S Novice Does • Uses your MEDLINE search engine to enter the logical words (see p. 8): • Breast Cancer/tamoxifen/arimidex • Gets 6950 ‘hits’ and looks at the first abstract (p. 9) • Sees no relevance to patient care & walks away annoyed or angry!

14. What the EBP Trained Resident Does: The PICO Model [p. 4] Well-framed clinical questions contain the following components: P – The Patient or Problem addressed I – The Intervention (or Exposure) being considered C – A Comparison intervention or exposure O – The clinical Outcome of interest

15. Reframing the Question Using PICO P – Women with advanced breast cancer taking tamoxifen I – Adding arimidex to tamoxifen C – Tamoxifen alone O – Increased length of disease-free survival

16. Question in PICO Format “Will adding arimidex to tamoxifen in the adjuvant treatment of advanced breast cancer increase the patient’s disease-free survival?”

17. The PICO-Guided Search • Search an inexperienced searcher can perform after initial training (See pp. 5-7) • Searcher is now using: medical subject headings, text words and limiters (See p. 10) • RESULTS: 31 hits with first abstract a best evidence article (See p. 11) • Note to surgical trainees: EBP saves time and gets better results!!

18. PART 2The “How To” Starting a Training Program in the Evidence-Based Practice of Surgery

19. Your Key Personnel (See p. 12 for detail on skill sets ) • Attending Surgeon • Medical Librarian • Research Coordinator/Clinical Research Specialist PLUS!!The good will and support of the Program Director and Residency Coordinator

20. What the Attending Surgeon Contributes • Professional expertise in the subject matter • Enthusiasm as a role model and mentor • An inquiring mind!

21. What Your Medical Librarian Contributes • Information literacy education (One-on-one and group instruction) • Expert help with multiple databases • Interlibrary loan for accessing articles not available in the library

22. What Your Research Coordinator (or Clinical Research Specialist) Contributes • Training in critical analysis of the literature • Liaison with attending surgeon and librarian • Assistance in the selection of best evidence

23. Overview of the Evidence-Based Practice in Surgery (EBP/S) Curriculum [pp. 1&12] Session 1 Introduction to EBS, the EBS Controversy & the Focused Clinical Question Attending, Librarian & Research Coordinator Session 2 Introduction to the Literature Search Librarian Session 3 Critical Analysis of the Results of a Literature Search Attending & Research Coordinator Sessions 4+ The Evidence-Based Practice in Surgery Journal Club Attending, Librarian & Research Coordinator

24. Session 1 (Orientation Week) • Introduction to the Evidence-Based Practice of Surgery (Appendix, pp. 21-22) • Discussion of the Controversy (Appendix, pp. 21-22) • PICOPractice • Journal Club Overview (pp. 16-17) & Schedule (p.18) Approx. 1 hour in length (see p.1)

25. Session 2 (Early Summer) • Introduction to Literature Searching • Librarian-led search on topic of interest from previous year’s clubs • Review of Search Help Sheets (pp. 5-7) • Practice Search Assignment distributed Approx. 1 hour in length (see p.1)

26. Session 3 (Late Summer) • Critical Analysis of the Literature • Tips for Selecting Best Evidence (Using abstracts obtained in practice search) • Levels of Evidence & Users’ Guides • Assign Critical Analysis exercise Approx. 1 hour in length (see p.1)

27. Tips for Selecting Best Evidence[p.12] • Directly answers PICO question • Well-respected journal • Highest quality of evidence • Larger sample size • More recent • Not sponsored by those with vested interest

28. Oxford Centre for Evidence-based Medicine Levels of Evidence Level 1a: Systematic Review (i.e. Meta-analysis) with homogeneous RCTs Level 1b: Individual RCT with narrow confidence intervals for primary outcomes Level 2a: Systematic Review with homogeneous cohort studies Level 2b: Individual Cohort Study (including low quality RCT- e.g.<80% follow-up)

29. Oxford Centre for Evidence-based Medicine Levels of Evidence Level 3a: Systematic Review with homogeneous case-control studies Level 3b: Individual Case-control study Level 4: Case Series (and poor quality cohort & case-control studies) Level 5: Expert opinion

30. Users’ Guides to the Surgical Literature Three Main Questions: (See Annotated Bibliography, pp. 24-25) • Are the results of the study valid? • What were the results? • Will the results help me in caring for my patients?

31. Session 4 (Early Fall) • Literature Search II: Tailored to Individual Resident Needs • 1-on-1 and small group sessions with medical librarian and/or research coordinator • First assignment given (due in 2 weeks) Approx. 1 hour in length (see p.1)

32. Resident Search Assignment • Advantages of Using Assignments: • · Gives the attending surgeon, medical librarian and • research coordinator objective data upon which to • base their evaluation of residents • · Provides assessment of learning needs of residents to facilitate program planning • · Training streamlines future searches for residents • · Involves a hands-on strategy oriented to professional adult learners

33. Sample Assignment (See bottom, p. 13) The Question: In diabetic patients with foot ulcers or gangrene, does hyperbaric oxygen therapy quicken wound healing?

34. The Assignment 1. Perform a literature search using Medline in EBSCO. 2. Print your search results and your search history (see librarian if not sure how to do this). 3. Review the abstracts; indicate which articles represent the best evidence in answer to the question posed. 4.Drop your materials off in the Medical Library no later than Friday, April 15.

35. Evaluating Assignments • Master search is completed by librarian (See p. 14 top) • Summary of best evidence completed by attending & research coordinator (See p. 14 bottom) • EELSEF Form completed (See p. 15): Copy for resident & copy for files)

36. The Evidence-Based Practice of Surgery Journal Club: Purpose [pp. 16-17] • Assist residents in learning library search skills to obtain the most relevant articles in answer to a well-framed clinical question • Train residents in the critical appraisal of the literature • Assist residents in refining their professional presentation skills • Update attendees on contemporary clinical issues relevant to patient care • Allow discussion & debate of newly emerging issues in the surgical literature

37. The EBP of Surgery Journal Club • Run quarterly (can cover 2 topics in 1 hour) • Dates scheduled at beginning of academic year (See sample schedule, p. 18 & sample club announcement, p. 19) • Due dates on sample schedule appear on monthly calendar prepared by Residency Coordinator

38. Journal Club Process • Residents must comply with dates for getting question to attending, consulting on literature search & critical analysis, getting articles to attendees • Brief presentation of best evidence articles and approach to their selection (5-10 minutes) • Discussion focuses on whether the answer to the question will change clinical practice (15-20 minutes)

39. Good EBS/P topics are ones that. . . • Question the “traditional wisdom” • Example: The need for nasogastric tube or • decompression after GI surgery.

40. Good EBP/S topics are ones that. . . • Are part of a paradigm shift due to changing technology • Example: The need for exploration of all 4 parathyroid glands in contemporary hyperparathyroid • surgery with evolution of (1) the hand held • gamma probe; (2) the quick PTH assay

41. Good EBS topics are ones that. . . • Have a potential for impact on • practice/patient care • Example: Use of ultrasound in breast/surgical procedure • Example: Use of lymphatic mapping in breast and other solid cancers

42. Good EBS topics are ones that. . . • Have potential for generating resident • research projects • Example: Use of ultrasound in diagnosing acute cholecystitis in the university vs. community hospital setting

43. EBP/S in Helping to Meet • the ACGME Competencies • Patient Care • Medical Knowledge • Practice Based Learning and Improvement

44. The EBP/S Journal Club and the ACGME Competencies • PATIENT CARE • · Make informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment. • · Use information technology to support patient care decisions and patient education.

45. The EBP/S Journal Club and the ACGME Competencies • MEDICAL KNOWLEDGE • · Demonstrate an investigatory and analytical thinking approach to clinical situations.

46. The EBP/S Journal Club and the ACGME Competencies • PRACTICE-BASED LEARNING AND IMPROVEMENT • · Locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems. • · Apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness. • · Facilitate the learning of students and other health care professionals.

47. The EBP/S Program: Documenting Performance in Resident Evaluation • Assignments/Continuous Improvement • Journal Club Discussion and preparation • See p. 20: Items 5, 6, 7 completed every 6 months by surgical attending, librarian & research coordinator

48. Thank You! We welcome feedback so that we can continue to improve our program.