So. Good morning, everyone. I'm Paul Glacier.
I'm the director for the Centre for Evidence based Medicine and I'm a part time general practitioner as well.
I worked in Beaumont St opposite the Ashmolean Museum, a very privileged place to work.
I'm glad you all managed to make it through the snow to get here.
I think we've had most people turn up, so that's great news. And I'm sorry we're a little bit late, but a few people do have difficulty coming in.
I'm I'm going to talk in a moment about an introduction to evidence based medicine, but just a couple of little practicalities before we start.
You should all have a pack, which has two components.
There's a workbook and there's a set of readings. We've all got those.
The other really important thing is you should you should have got a list of the group that you're in, and they'll be a room on it.
But you'll have to find that's your first task after this lecture is to find your room.
That's the room that you'll be in for the entire three days.
Most of this workshop is about getting you guys to do things to get, practice hands on, work at critical appraisal, searching, etcetera.
So develop the skills in this area. We'll talk at you a little bit, but that's mostly for orientation to different areas.
Most of the real work is you actually practising things.
So find out where that room is because that's the place where you'll do the real work and we'll get you there straight after this lecture.
The other thing is that you are sent out a programme and you, some of your managers probably brought along with you on this.
A couple of small modifications to that, and they're printing all those off at the moment.
So before we finish this session, we'll get you a new copy of the programme as well with those couple of small modifications.
Okay. I'm going to talk about the basics of evidence based practice.
And in a sense, I'm going to talk about two things.
One is about the sort of skills that you need to process the traditional four steps of evidence based medicine about formulating questions,
searching skills, appraising the evidence, and applying it to individual patients.
And in particular, I want to talk about the formulation of questions this morning.
But the other thing we're trying to get you to learn is about some of the practicalities.
How does this work in practice? That's where I'd actually like to start this morning,
is to give you a sort of snapshot of when you go back to wherever you're working, how would this look when you're actually doing it?
So there's a set of skills that you need, but there's also a set of processes that you need to learn about.
How would you put this into practice? And I want to give you a picture.
So I'm actually, in a sense, going to start at the end. Before I do that, though, I want to know why you're here.
And you'll do this in your small groups will start with asking you what you want
to get out of this process because it's not a completely fixed program for this,
particularly in the small group sessions. In a sense, you can make up your own workshop, at least persuade your tutor to modify it to fit your needs.
But I want to know a sort of big picture thing, first of all, and I want to find out why you're here.
You're here to learn ABM because and it can be all five if you like, but I'd like you to put your hand up for each one that you think you're here for.
So he is who's here primarily because they're working in clinical practice and they want to use this in clinical practice.
Hands up. Okay. That's about half of you.
That's great. Here because you're working on evidence resources such as reviews, guidelines, evidence reports, those sorts of things.
Okay. It's probably about a third of you and some doubling up obviously here because you want to help others use evidence.
You're okay. Here because you plan to teach him.
My goodness. Quite a lot of you. That's great. And here.
Because your boss said you had to come. Okay, that's a few of you, too.
I noticed some people from the centre put up their hands too. I didn't tell you you had to come.
So just to orient you, what we're going to do now is I'm going to talk, as I said, about the basics of evidence based practice.
Then you'll go to your small group for an important thing you've got to find after this session.
And we'll have a tutorial about about the question formulation component.
Then we'll have morning tea come back, and Rafael's going to do a session on rapid critical appraisal where we'll teach you the
basic our simplified version of critical appraisal based on Rod Jackson's gait process.
And there are just two acronyms you have to learn, and that's Pico and Rambo.
We'll teach you those two acronyms. If you know those, you know, about two thirds of what you need to know about IB and then in the afternoon,
after and after lunch will be sending you off to a computer lab about 100 yards down the road here so that you can do some hands on searching.
We'll look at you to formulate some questions before that, hopefully,
but we'll have one of the librarians teach you about hands on searching, and then you'll have your final session this afternoon.
That's a relatively fixed program with some flexibility in it.
There are two days following it tomorrow and Wednesday. Actually, the program is much more flexible.
And so part of what you'll need to do today in your small groups is just decide which bits you want to emphasise,
which bits do you need to know more about that and discuss that with your tutor.
Okay. What I'm going to talk about in this session is two things, as I said.
One is what is evidence based medicine? What does it look like in practice?
So I want to give you some sort of picture of that. And then I'm going to talk about mostly about the first of those four steps,
about the formulation of questions and the different styles of question that you can have and what research would fit them best.
Okay. In order to warm up for this, what I'd like you to do is you should all have a sheet that doesn't have my full set of slides on it,
but it's got the critical ones on the back of that sheet. Is a set of changes in practice.
What I'd like I'm going to give you about 103 seconds to write on that.
Things that you have changed in your practice, whatever your practice is.
So what things have you changed in the last 12 months?
And then I'd like you to think, okay, how did that change come about?
Where did you learn it from? And what was the evidence behind it?
Since. It's.
Okay. I can see many of you racking your brains to think of more.
I'm sure if I gave you a longer period that you'd actually think of many more.
Well, I just want to get some sense of how many changes people have made over the last 12 months.
Anyone with more than ten hands up. Between six and ten.
Okay. Let's do the countdown. Five. That's two for.
Six three. It's about ten to.
That's about ten one. 12345670.
Okay. So that looks like somewhere between two and three is the most common number of changes.
Now, I put that up for a couple of reasons.
One is just to illustrate that we feel like we've been that there's a lot of information coming through and that we're reading lots of stuff.
But actually the number of changes that we make in practice is actually fairly small.
And what we'd like to do is actually make your life easier by trying to find more things that actually change your practice,
that influence patient care, but without increasing and maybe even decreasing the amount of work you need to do to do that.
Okay. So we'd like to get these numbers up more towards this end of things.
So next year, when you come back and answer this question and again, you can probably write down ten, but you've actually been reading less.
The only thing I'd like to ask you, though, is what drove those changes.
Maybe you want to discuss this for a moment with your neighbour.
But can I just ask how many how many people had a change that was driven by a systematic review of randomised trials?
Nobody. Not that I could remember anyone.
Okay, so you just want to confer with your neighbour about what your changes were and where did they come from?
Okay. Can I have your attention again?
I can see we're going to have no problem getting you guys to work in tutorials.
That's fantastic. Talkative Bunch. Can I just ask for examples of where you learn things from?
What sorts of places did you actually get the learnings from the change your practice?
Sorry, I'm embarrassed to say it's not everything.
No, no. So please, please be truthful.
I'm not expecting you to say, Oh, you read the BMJ Journal and you were really.
You know, you don't have to say that except you.
So it was a team that you learned it from sorry, regulations from about regulations from above.
So it was a guideline that you read that said this is what you've got to do. You're also from a team.
From research. From the research.
Was. This is your own research, is it? No, it's not my. Okay.
So you read research, so that's an even process. Fantastic. But I think there's a variety of means, isn't there?
You might get a directive from from the National Institute for Clinical Excellence or some guideline from colleagues.
Anyone else have something different? Yeah, I'm very comfortable.
Okay. So your boss said no, you've got to do it this way, or this is new way of doing things.
Anyone else from a course like you went to a session specifically to learn about something, you went, Oh, that's a good idea.
I'll do that in practice. Discussion with colleagues. Okay.
Discussion with colleagues just sitting around the tea room or something or saying, I have this problem.
We're meeting to have a meeting like other stuff.
Uh huh. Well, what we have is to support that.
Okay, fantastic. Sorry. From email group, we have an email group and someone sent in a response and you thought, oh, that's not interesting.
Okay. Like fantastic. Any other reflection on your own practice from reflection on.
Okay, just thinking about it. Oh, okay. I should probably do that differently.
Lessons in that experience. Mm hmm. Okay.
Okay. Sorry. Anyone else?
Project orders like you didn't order.
Oh, my goodness. I know. And you want.
Sorry. Experts in the field. So personal communication with them.
You went to a lecture or you were talking to them in the corridor or something?
Okay. Anyone get it from a patient? Oh, yes.
Email the Daily Mail. Okay. That the media as well.
Yeah. Yeah. Yeah.
So what was the one for them? You remember one from the media. A country at a country.
The one recent one for us was the example of the antidepressants,
which in the media a couple of weeks ago there had been a recent systematic review in PLOS Medicine based on FDA submitted data.
So when we actually did in our own journal called because we expected patients to come in asking about that.
So we wanted to look at the paper. Okay, great. So I wanted to illustrate that.
First of all, we don't make a lot of changes. And actually at the moment they come from a variety of sources.
How many of those do you think were explicitly evidence based?
That is, that you knew what the evidence was, that that somebody was suggesting a change to you and you knew what their evidence was,
hands up, who had announced they felt pretty secure about the evidence.
So I'm mostly not okay. Now, I'm I think we should be honest about this.
We do learn things from a variety of places. Sometimes we're in a hurry and we just ask a colleague, What would you do about this?
And you go, Oh, that sounds pretty good. I'll go and do that. And we have to recognise that's where our changes come from.
The one thing I'd suggest is, okay, if you think this is going to be something, I'm a problem, I'm going to come across repeatedly.
Maybe you want to think, maybe I should check the evidence on that as well.
Ask them that. Maybe do a search yourself. Okay.
So a few interesting learnings from that. I want to contrast that with our feeling of huge amounts of information coming in.
So I'm going to assess your Jasper score, which has five components to it.
Do you feel ambivalent about renewing your journal subscriptions?
Do you feel anger towards prolific authors like me? Do you ever use journals to help you sleep?
Are you surrounded by piles of periodicals? Do you feel anxious when journals arrive?
You get one point for each. Yes, that you might.
To that I want you to add up your score from 0 to 5.
How many yeses? Okay.
Hands up the zeros. One, two, three.
Four or five. Okay. You're pretty normal sort of audience then.
They've done some standardisation and it's good to see we have no liars in the group.
Most of you are in what's called the normal range. That may not be the healthy range that I like, but that is said to be the normal range.
And the few of you are in trouble and need to go and see an information specialist.
Okay. Why do we feel that way? One is just the amount of research that's being published and that can come through us for a variety of means.
This is just one illustration of the number of medical articles being published per year.
Actually, this is slightly out of date. Medline is now over half a million per year.
I think last year it was about 600,000. Articles in Medline, of course, is very restrictive.
It's just part of the world literature, which is probably more like a couple of million articles per year.
And even if you just want to just confine yourself to the randomised trials,
there are about 30,000 randomised trials being published every year as well.
So the title this comes from one of the few practical books I read going through medicine called Kill
As Few Patients as Possible by Oscar London and Rule 31 was review the World Literature Fortnightly,
which turns out to be a pretty tough task. In fact, if you put it just in Daily Times, we're talking about 55 trials per day,
101,500 Medline articles per day, and probably about 5000 biomedical articles per day.
The literature is huge and try to find your way through.
That is very difficult, even though you may have a narrow speciality area that you're working in.
Often that literature is really scattered. It might.
Some of it will be maybe about a third of it in your in your in all the speciality journals.
But then another third of it will be in general medical journals.
In fact, the the big stuff will probably be in the major general medical journals, even if it's a speciality topic.
So even specialists have to read their own subspecialty journals, plus all the general medical literature.
The remaining third will be scattered across a huge array of different areas.
So it's very difficult to find. Okay.
So the key problem that evidence based medicine addresses is the the issue of trying to sift out
the best evidence that's coming out through research and using it to improve our patient care,
to change the way that we practice. And it's there isn't one solution to this problem, and we may invent new solutions during this workshop.
This is an evolving science, if you like. So there isn't one magic answer to this.
But the definition is evidence based. Medicine is the integration of best research, evidence with clinical expertise and patient values.
And for us two of those and motherhood, we wouldn't expect to do this without clinical expertise.
We wouldn't expect to do it without involving the patient in the decision making process in some way and
finding out what their objectives are and what they want and the magic ingredient that we'd like to add.
The extra thing that Eben wants is to add the best research evidence and patients.
If you tell them that we don't do that at the moment,
I'm really surprised you try and explain evidence based medicine to patients and they go, You mean you aren't doing that already?
You mean you don't use the best research evidence when you make decisions about me?
And we go, Well, that's almost impossible on the other side of it.
So DBM is the sort of trying to get those the nexus between those three things.
What I want to do is just talk about a couple of models of how this might work,
the practicality, what would it look like if you were going to do this in practice?
And I'm beginning I'm going to begin with the impossible version of it.
So bear that in mind, this is the impossible version of it, which is why have the the rings down the bottom here?
I'm going to talk about the Olympic champions of evidence based medicine.
Dave Sackett was the founder of the Centre for Evidence based Medicine.
And when he was here in the 1990s, he was an internal medicine physician working up at the John Radcliffe Hospital
and on the ward rounds they used to take a thing called the evidence cart,
which had a data projector and a laptop computer,
and on the laptop they had Medline, the beginnings of the Cochrane Library of Best Evidence,
which is of all the things from the ICP Journal Club, etc., and things that they had previously appraised.
And they're all set up on the laptop and during the ward round. They would ask questions now.
Gee, I wonder if we should use X or y? Should we give this patient with heart failure a beta blocker?
What does should we use, etc.? And they would look that up during the ward round.
They'd look up two or three questions per patient. It took about 15 to 90 seconds.
And I'll show you the data in a moment to find the piece of evidence that they needed to answer that question.
And it changed about one third of their decisions. So in most in most patients, they are actually making some decisional change.
Every patient that they were seeing. I can't.
You think that's impossible, isn't it? Well, one fact is that the ward rounds took a little bit longer.
Is Carl here? No, he's actually John. Carl was a medical student during the so he actually experienced some of these ward races.
I hear rumours that the ward rounds could take anything up to 5 hours.
Carl. Yeah. He could actually sleep all day. Going left with that many people with down clothing, too.
Yeah. Carl. So you may say this is this is not feasible and and not possible.
So two caveats that I'll make about that.
One is that most people do several hours of continuing medical education per week when I've assessed this in workshops.
Most people on average are doing that 3 hours a week.
When you add up all the journals, reading the lectures that you go to, etc., if you put it all together, it's about 3 hours per week.
What Sackett was doing was moving that 3 hours of continuing medical education and putting it adding it into the ward round.
So the ward ran was lengthened because that's where he was going to put the continuing medical education,
where it was going to be most effective with individual patient care.
They were learning on the fly just in time learning. So when I put up the top here, a sort of different approach to education.
The other thing is being able to answer things that quickly.
I don't even expect you to do that at the end of this workshop. Right.
Sackett had been doing this for 20 years by the time he got here and Sharon Strauss and that's why I say these are the Olympic champions.
At the end of this workshop, you might be able to find the best piece of evidence for something in maybe 15 minutes,
but the first time can take an hour to do, and you get progressively faster at it.
One thing you'll learn is that trial finding no evidence.
When there's no evidence there, it actually takes you longer because you're never sure.
Have I exhausted all possible search terms? So learning when to stop is actually a difficult thing as well, but it takes a while.
Lots of practice, hundreds of questions before you can get down to this sort of pace of being able to
find the information of realising where to search and what the search term should be,
and then being able to appraise it rapidly as well. That just takes time in practice and I don't expect you to start there.
This, by the way, is the data. When they looked at previously appraised topics, it took them about 15 seconds.
If they use the back issues of the Journal and ACP Journal Club,
it took them about 30 seconds and going to Medline took them about 90 seconds on average.
Sharon Strauss, who was his registrar at the time, took the took the data.
Okay. So I'm going to suggest instead that what we're aiming to learn here is three other practical things that you may be able to do.
And these are the suggestions that I'd make. One is to read some sort of evidence based journal, some practical journal, such as for primary care.
Internal Medicine is the ABM Journal. The ACP Journal clobbers evidence based, nursing evidence based mental health.
Evidence based child health, I think has just come out.
So there are a series of abstraction services and it's useful to read those rather than trying to keep up with the literature yourself,
get somebody else to do it for you to find the best things.
This is the sort of alerting service and that's what we might call push.
One of the new things I need to know. The other is your own questions.
The things that arise out of practice that you're going to go and ask somebody about.
And what we suggest is you just keep a logbook of those and we'll give you out a logbook card.
You've got them. They're going to hand them out now. So we'll give you out a little logbook that you can keep in practice of your own questions.
You don't have to be ambitious here. Remember, you've probably made only less than ten changes in the year.
If you could make an answer one question a week and every second week make a change,
you would actually at least double the number of changes you're making. Okay, so just don't be too ambitious.
You start off with an aim of answering one question per week would be sufficient.
Okay. And the other thing to do is to share this. Both things can feed into a team based discussion.
Let's talk about this as a practice for half an hour, a week or an hour a week, if you can spare it.
Shifting this sort of content, don't do more stuff, but change the way you do your continuing medical education to run a case focussed journal club.
Using eBay materials. So three suggestions.
There are probably others. And as I say, this is an evolving thing.
We don't know the best way of doing evidence based practice,
but we know there's a lot of good research out there that isn't being used in practice, and we're trying to work out how to bridge that gap.
And if you guys come up with otherwise, we'd love to share them during this workshop or after the workshop.
So these are just three suggestions. I'm just going to show you one slot on each of those to tell you how they work.
The process for the IBN journalists that we scan about 120 journals, including the major general medical journals such as JAMA, Lancet, BMJ, etc.
And check the 60,000 articles in those to see whether they passed some simple validity criteria.
If it's therapy, then it should be a randomised trial with at least 80% follow up.
If it's a prognostic question though,
we just want what's called an inception cohort and you'll go through all of these study types in your in your workshop.
Okay. About 5% of the material passes that. So that filters out 95% of it.
So the number needed to read defined one valid articles about 20.
Then we ask, is it relevant? We get various people to say, Would this change your practice?
Is it newsworthy? Is it relevant? Is it going to be a major change in practice?
And we actually select a much smaller percentage then. So the number needed to read there is about 200 in order to get one relevant and valid article.
There's a message about that for journal clubs.
By the way, if you're running a journal club, if you just haphazardly search the literature and then appraise it at the journal club,
mostly you'll come up with things that you trash and don't change your practice using.
And it gets very disappointing then to run the journal.
And every time you just trash the article and say, we're not going to change our practice on the basis of that.
Actually, a journal club you'd like to get down to these mostly the things that are going to change your practice,
the positive hits so that each time you journal club, you're actually learning about what practice change you should make.
Mostly, sometimes it'll be something where there's pressure on you to change.
But when you look at the article, you say, Well, actually the evidence for that is pretty weak.
We're not going to go with that fashion. So that's one thing.
The second thing is just to keep a simple log book of questions like the one you've got,
it's spiral bound so you can keep it open on your desk, use it any way you like.
Answer a couple of important questions. You can discuss the evidence with colleagues in a journal hub.
You don't have to do a search. Maybe you should ask somebody, but also do a search and compare the two.
What did my best colleagues tell me compared with what Medline came up with?
Use it in all sorts of ways, but start out with just not trying to record every question because that will be too much.
But aim to answer one important question of which. Okay.
And the final thing is to run an ABM Journal club. This should be fun.
One of the principles is to have fun and to have food. This is why I want to buy Mont St.
You probably can't pick it here, but this is actually a blind tasting of different types of margarines and butters.
So they label with a post-it note here to say which ones they coded so we could break the code afterwards.
Because we're interested in the cholesterol lowering margarines. Did they taste any different?
Okay, so it's a bit of fun as well. We've had yoghurt tastings and all sorts of things, demonstrations of the Epley manoeuvre.
We do all sorts of things at the Journal Club and these are some of the questions that we've done.
Antidepressants in adolescence are ten long for hypertension, etc. and of bold, the ones that have actually come from the ABM Journal.
So what we do is when the ABM Journal comes out,
I get people to vote on which things they want to look at in the journal club, which are the practice changing things.
So that's the sort of push side of things, things that we've been alerted to.
The others were specific questions that came up in practice because a patient had alerted us to it and we wanted to discuss that.
And we did the search and found the evidence. And you can see that there's actually a mix of the two we use both for these discussions.
Sometimes it's driven by a patient question, sometimes it's driven because new evidence has come along about our combined hail
inhalers better for asthma or pelvic floor exercises for erectile dysfunction,
which you probably never would have thought of as a question. But you say, well, this is an important problem in for us in primary care.
Let's actually learn about that. Okay.
That's useful in the journal clubs as you'll have in the little room to have some tools like a flip chart,
a whiteboard where we used to keep our questions,
we now keep them on an intranet, some good sources of evidence and plenty of coffee to wait people like this up.
Okay. So I'm going to move on to part two.
I said I'd talk to you a little bit about the skills, and I'm going to talk to you particularly about the formulating the question.
But these are the the usual four steps of ABM. This is all in your workbooks in the book that you've got, so you don't need to take notes.
But this is the skill part here, and I give you the example of a stethoscope as a sort of illustration of the amount of work that it takes,
I think, to learn the process of critical appraisal. It's a bit like learning to use a stethoscope.
You actually need a bit of practice there to actually be able to hear the heart sounds even, and then for the abnormalities.
And some one clinician was telling me the other day it wasn't until his second year as a registrar that actually heard his first third heart sound.
So it's a skill you'll gradually develop.
You might have to fake it at first, like he'd obviously done for many years, saying, Oh, yes, I can hear that.
Third heart's in. Okay.
So let's just talk about formulating answer more questions.
The big messages are that there are different types of questions.
We need to be able to structure them with a pinecone. Can I ask who's heard of Paco before?
Okay. Who's heard of variants of pinecone supposed questions, for example?
Okay. A few people. So let me go through them.
Pica was a very useful way of breaking down the questions, and it's particularly useful for an intervention question, a therapy question.
But I'm going to show you that we can think about other types of questions using the same structure.
Sometimes we're just interested in the outcome itself.
What's important to patients and this on a pre question mark question, we don't know what the outcomes are.
That are important to patients. Let me give you one specific example of this patient with rheumatoid arthritis.
What do you think the most important symptom or problem for a patient with rheumatoid arthritis is?
PYNE Okay, that's number two. Sorry.
Function. Number three, reform, cosmetics, deformity.
I think that's about number five yet. Anyone know what number one is?
Stiffness, pi. Now, that's probably number four. I think going to the moon, going to the loo could be number six or seven.
Amanda, as a patient with rheumatoid arthritis, do you want to tell us what?
Number one is exhaustion, tiredness, fatigue?
Yes. And the way this is now part of the measures that they use in rheumatoid arthritis.
But it actually took the rheumatologists a long time.
It's a group called Omer Act, which has been trying to standardise the measures that they use for clinical trials of rheumatoid arthritis.
And I think it was in their third or fourth meeting that they decided to include patients.
And the patients said, Oh, your tools are great, but they leave out our worst symptom, our biggest problem.
And I said, What's that?
And I said, Fatigue, exhaustion, knowing, oh, my goodness, why then did a survey of patients to find out the frequency of that problem?
Indeed, the patients were right. It was the number one problem. So the second type of question you might have is about the prevalence or incidence.
You need to know what the phenomena are first. And often that's qualitative research.
You need to find out what's going on. Then you can start to quantify it.
So we could have asked what's the prevalence of fatigue, pain, dysfunction, etc. in patients with rheumatoid arthritis either as a snapshot?
What's it like it now that's a prevalence snapshot or incidence.
How does it develop over time? So they're both PO type questions, prevalence being just a simple pill and the incidence when you add the T of the go.
Okay. So we might ask the question, how common is an Eli Friess CEO?
Eli Christakis check your neighbour to see if I've got one. It shows you a picture of one here.
Normal. Eli. Eli. Chris. Okay.
They actually increased with age. They've been said to be a risk factor for cardiovascular disease.
But actually the confounder here is age that I just become more common with age and of course, cardiovascular disease does as well.
So it's a potential confounder. So sorting out that is a risk factor.
We need to know this prevalence by age as well. Okay.
The next type of question is a PI code question. And here we've got the AC in.
So I want to emphasise that not all questions have all four elements of the pi go in them.
They can just be simple po questions or even the PO question mark.
One's next type is a risk factor. Do patients with rheumatoid arthritis have a higher mortality?
How do we tell that? How would you know with a risk?
Rheumatoid arthritis patients. What study would you do to do that?
Like like I can, you know, not using the word cohort.
Can you just describe what you'd actually do for the patient from the time of the census and see how many of those people could.
Compared to another group? Compared to another group.
Okay. So the patient group would be patients with the initial diagnosis that's the inception cohort
of rheumatoid arthritis would be the indicator here versus a group that don't have that,
no rheumatoid arthritis. And we'd have to argue about what the appropriate controls are and the outcome would be more death, mortality, death.
Okay. No randomisation involved in that, by the way, because here we're just interested in the natural history.
Do they have a higher mortality rate if you've got rheumatoid arthritis?
If they did, we could start to say, what's the causation of that?
Think about that. But the first thing we want to know is, is this true? Do they have a higher mortality?
So that's a prognostic factor. Treatment might be do patients with rheumatoid arthritis benefit from methotrexate?
So what's the population? Maybe rheumatoid arthritis?
What's the intervention comparator? Not methotrexate and the outcome.
Pain and fatigue?
Yes. Fatigue, dysfunction, all of those things that we said we want to measure all them.
Which things does it actually change? It may reduce pain, but not change the incidence of the fatigue or the flu like episodes that patients get.
And that would be of interest to patients. Okay. So it's the same structure.
But here we'd probably like to have a randomised trial as our best evidence patients randomised to methotrexate or no methotrexate.
Okay. So one important message there is the best evidence will depend upon the type of question.
If we're just interested in the phenomena, what if patients with rheumatoid arthritis experience, what troubles them?
What outcomes are they interested in? That's qualitative research.
We sit down with a bunch of people and ask them. Okay.
If we want to know the frequency of that problem,
then we want to get a sample of patients with the condition and ask them about them and preferably a representative sample.
My way of getting that is usually a random sample. I didn't talk about this one, but this is also a picture of structure.
How does the person have the problem? How do we diagnose rheumatoid arthritis?
And we can look at CERP or other new techniques of diagnosing rheumatoid arthritis and compare that with a gold standard.
That's a Tyco structure as well. The prognosis we said that's a follow up or inception cohort, the mortality from rheumatoid arthritis.
And finally, we want to fix the problem and this is probably our most common question in practice,
by the way, when people have kept log books or looked at questions sent into services,
about 70% of our questions actually turn out to be about therapy,
which is why there's a special emphasis in evidence based medicine on randomised trials.
But for all these others you don't need randomised trials.
In fact they wouldn't be as good an answering the question for this, the randomised trials, the ideal thing.
Which is why we have these hierarchies of evidence.
The one that you mostly see is for treatment where randomised trial is the so-called level two evidence.
Right. But if we're talking about prognosis, the level two evidence would actually be an inception cohort.
A randomised trial may not be as good because of the selection process into it.
You'll get a limited number of people in. With an inception cohort, you usually get a broader representation of folks,
so it's actually a better thing to use and randomised trials would be under inception cohort as a lesser thing for prognosis and diagnosis.
You need a simple cross-sectional study. Okay.
And the ideal thing, the level one evidence for all of those would be a systematic review of whatever the level two evidence is.
Systematic review of inception, cohorts for rheumatoid arthritis, mortality, etc.
So it's important. One thing you'll you'll start to notice when you look at levels of evidence,
people fail to mention that when they're talking about that, they're really talking only about treatment.
It's an important misconception. Like this afternoon you'll find out how to filter down to those things using PubMed
in a special thing called pubmed clinical queries whose use pubmed clinical queries.
About a third of you. That's great. One of the special features is that it has you can click on diagnosis, therapy, prognosis,
etc. There are a number of categories here so that when you search you get some filters that will filter down to the randomised trials for therapy.
The inception cohorts for prognosis. ET cetera. And I filter by about an order of magnitude.
So it makes your searching much, much easier to use those filters.
But remember, you've got to use the right filter depending on the question that you're asking.
And that's a table of the filters developed by Brian Haines by using what the filtering process that we
use for the ABM Journal to try and find out what the most sensitive and specific filter terms would be.
And you can see they're quite complex. On the right hand side, they're the best filters for each of those types of article.
You don't have to type in. Anything you want to do is click on a little button and it types everything for you.
It's really nice of it. Okay. I just wanted to finish by saying there are other hierarchies of evidence.
There are lots of different levels of evidence that you'll see. The Grey Group is trying to standardise this whole process of the levels of evidence,
but other ones are the levels of evidence for anecdote based medicine.
For example, level one is a very old jump from the Royal College level to is a doctor with an air of credibility, an honest face.
I can see several around here.
I'm only level three academic with a mad stare and level four as an NHS manager with their trust in financial crisis is the least reliable thing.
Okay, where to now? You need to find out your rooms because we're now going to break up into small groups before we go for coffee.
So just make sure you can work out where your room is.
And I'm like it. The tutors to stand up.