What Happens After Medical Graduation?

Knowledge ofbest current pneumoniacare

Years in medical school graduation

Medical School Education

Did you learn about

• AIDS?• Amphotericin in

kalazar• CT Scans?• Indium scans• Zithromycin

Usefulness of Medical Information

Relevance X Validity

Work

Adapted from : Slawson et al; J.Fam. Pract. 1994;38:505-513

How do you learn about new developments in medicine?

• Pharmaceutical industry.

• Consultants.• CME.• Grazing through

medical literature.

Clinical Decision Making

Patient circumstances

Evidence from research

Preference, values and rights

Relevance x Validitywork

• Will it change your practice?

• Generalize to your patient(s)?

• Clinically significant results?

• Patient oriented evidence?– Versus disease oriented evidence– How many assumptions to make the evidence

clinically meaningful?– Useful ness of medical information.

Medical Publishing

Annually:• 20,000 Journals• 17,000 New books

Medline• 4,000 Journals.• 6 Million references• 400,000 New entries

annually.

The Most Important Task for a Paediatrician

From: How do I keep up with new developments in Paediatrics ?

To: What developments in Paediatrics do I need to keep up with?

Why to Read the Medical Literature?

• To answer a specific patient related question.

• To keep up with new clinical developments

• To review previously learned information

• For enjoyment to keep up with interest.

Reasons to Read Medical Journals

Number of unreadMedical Journals

Guilt

Excessive

Mild

Moderate

JALCO* Journal Associated Learning Correlating

Opportunity• J- How often you think of a Medical

Journal?

• A- Are you afraid of reading a Journal?

• L- How often do you go to the library to look at a Journal?

• C- Do you relate your practice with recent advances?

• O- Do you have opportunity?• Modified from BMJ. 1995;311:: 1666-1668

What developments in medicine do I need to keep up with?

•Those which impact on clinical decision making.

Evidence Based MedicineDefinition

• The conscientious, explicit and judicious application.

• The current based evidence.

• In making decisions about the care of individual patient.

Evidence Based MedicineSKILL

Formulate a clinically relevant and

searchable question.

Types of clinical question

• Clinical findingClinical finding: How to properly gather

and interpret findings from history, physical examination etc.

• Aetiology:Aetiology: How to identify causes for diseases.

• Differential diagnosisDifferential diagnosis: When considering the possible causes of a patient’s clinical problem, how to rank them by likely hood, seriousness and treatibility.

Types of clinical question (Contd)

• Prognosis:Prognosis: How to estimate the patients likely clinical course over time.

• Diagnostic Diagnostic tests: How to select or exclude a diagnosis, based on their precision, accuracy, safety, acceptability etc.

• Therapy:Therapy: How to select treatments that do more good than harm.

• Prevention:Prevention: How to identify and modify risk factors, how to screen for early disease.

Steps in EBM

OneFormulate a question

Two Find the evidence

Anatomy of a good clinical question

• Patient problem

• Intervention, prognostic factor, or exposure

• Comparison

• Outcome

Brief history of Ajaya Sah, 8 yearsBrief history of Ajaya Sah, 8 years

Master Ajaya, from Janakpur was referred from a private clinicwhere he was treated with various antibiotics and antimalarialsuspecting Enteric/Malaria. As the fever persisted he was referred to exclude the diagnosis of Kalazar.

Ajaya had high fever, splenomegaly and low leukocyte count.You wanted to do a bone marrow to make the diagnosis. His father a medical representative knew about the Serological test that can diagnose the disease.

Ajaya’s father asks you whether or not ELISA test using the K39 antigen would be better better diagnostic tool for him?

PracticePractice

Important points for making a good clinical question

• Patient/ problem

• Diagnostic test

• Comparison, if any

• Outcome

• Fever

• Bone marrow

• ELISA using K39 antigen

• High specificity, sensitivity minimize adverse effects

For our patient the clinical question might be:

• In paediatric patients, is ELISA using a recombinant (K39) has a sensitivity and specificity close to 100 % ?

Steps in EBM (contd)

Step three

Are the methods valid?

Likely to be true Free from bias

Steps in EBM (contd)

• What are the results?What are the results?• Study design:Study design:

Case report

Case series

Case control

Prospective cohort

Randomized control trial.

EBM will not tell you what to do!

What will determine what to do?

INTIGRATION

Individual clinical expertise Best available external clinical evidence from research

Individual clinical expertise

• Increasing proficiency and judgement Increasing proficiency and judgement over the:over the:

-more effective and efficient diagnosis and

-more thoughtful identification and compassionate utilization of individual patients predicaments, rights, and preference in clinical decision making.

Best available external clinical evidence

• Clinically relevant research, usually patient Clinically relevant research, usually patient centered to determine:centered to determine:

- The accuracy and precision of diagnostic test.

- The power of prognostic markers.

- The efficacy and safety of therapeutic, rehabilitative and preventive regimens.

BOTH ARE NEEDED

Without individual clinical Without individual clinical expertise:expertise:

•Practice risk becoming evidence tyrannized.•Even excellent external evidencemay be inapplicable or inappropriate or an individual patient.

Without the best available Without the best available external evidence:external evidence:

•Practice risk becoming rapidly out of date, to the detriment of patients and patient care.

But External clinical evidence:

• Has short doubling time

• Invalidated previously accepted diagnostic tests and treatment.

• Replaces them with newer that are more powerful, more accurate, more efficient and safer.

Which is why you feel like you never up-to-date

and your JALCO score is so high

CONFLICTING RESULTS! WHAT IS THE TRUTH?

Guide line 1

Guide line 2

CME

Expert

Article 2

Article 1

Textbook