“Morning POEMs ( P atient O riented E vidence that M atters)” Teaching point-of-care, patient focused evidence-based

1. “Morning POEMs (Patient Oriented Evidence that Matters)”Teaching point-of-care, patient focused evidence-based medicine Eamon C. Armstrong, MD Lehigh Valley Hospital Family Practice Residency Program Allentown, PA

2. Physician and patient needs for high quality information at the point of care often go unmet. This has detrimental consequences on patient care and outcomes and valuable learning opportunities for the physician are lost. Expanding body of medical knowledge Practitioner’s capacity to recall and organize relevant medical information Growing relative ignorance and uncertainty TIME

3. “Morning POEMs”The educational vehicle that has changed our residency culture • “Morning POEMs” starts and finishes with the patient. Not knowing, the chaos of real life clinical questions, a healthy skepticism, appreciation of the rapid turnover of information and the realization that active and interactive learners learn, are the energies that fuel “Morning POEMs”. • The goal is to graduate physicians who are effective “evidence-based users” (BMJ 2000; 320:954-955) = Efficiently track down and use sourcesof pre-appraised evidence at the point of care, that provideimmediately applicable conclusions = “just-in-time” information and learning. • Having mastered a restrictedset of numeracy, critical appraisal and searching skills, these clinicians canbecome highly competent, up to date practitioners who deliverevidence-based care.

4. “Morning POEMs” Process • 4 mornings each week - 45 minutes. • The presenter (2nd or 3rd year resident or faculty member) gives a brief presentation of a patient recently seen in the office. • Frame a four-partclinical question and propose a search strategy – “Which database is most likely to efficiently yield the answer I’m looking for?” • Efficient real time Internet search for the “best available” evidence - where appropriate, making “integrated EBM sites”, “EBM search engines” and “evidence-based journals of secondary publication” (such as DynaMed, InfoRetriever and the American College of Physicians Journal Club respectively) the first port of call, as they catalogue POEMs. • Once found, they critically appraise the evidence for its validity (Does it approximate the “truth”?) and clinical applicability(Is it relevant to their patient?). • The presenter then discusses whether the evidence found answers their clinical question, and if so, how it might alter the management of the patient in question = ACTION.

5. “Morning POEMs” Process • The ensuing group discussion, usually facilitated by a faculty member, seeks common ground between the clinical impression, best external evidence and the patient’s unique values and expectations as depicted in the 3-circle representation of the “EBM Triad”.

6. Initial Results/Observations • Skills fostered by “Morning POEMs” are now integral to our residency’s culture and our senior residents are using them often and effectively while seeing patients. • These skills are reinforced by faculty through their supervision and teaching of residents. • We have ready access to desktop computers with Internet access in each examination room and the teaching areas of our residency practice and sub-notebook computers with wireless Internet access in the hospital. • Eighteen months after its initiation residents used electronic resources of EBM more often than textbooks (21% to 15%). • Those in the final year of residency training used electronic EBM resources 50% of the time, compared with 16% for their junior counterparts.

7. Observations • We have found that finding the appropriate “POEM” or high quality pre-digested evidence with which to answer a question is often relatively straightforward. • The biggest challenge for the faculty facilitators has been keeping “Morning POEMs” patient-centered and paying adequate attention to the “patient values and expectations” circle of the “EBM Triad”. • It is our experience that residents and medical students often struggle with a format where the primary focus is the patient and is question driven and where the emphasis is in large part on process and skill acquisition rather than finding “the right answer”. • It requires that they become comfortable saying they don’t know and embrace this as a positive phenomenon, which will over time, drive their desire to know and keep up to date in a world of medicine where the only constant is change.