Enough of "Real EBM" do we need "Real EBD"?

On Tuesday this week I was fortunate to be able to be in Oxford to listen to a number of "big" thinkers in the Evidence-Based Medicine (EBM) world discuss what "real EBM" is or should be compared to "rubbish EBM".

My sense was that there was a feeling that the EBM phrase had become muddied over time, perhaps as it has become used for political and persuasive methods rather than as a skill or tool to help us help our patients.

Below is a storify I created from the discussions on the Evidence Based Health JISC listserve (which I encourage anyone with an interest in evidence-based health to look at) before the meeting and from the tweets that went up during it.

But what was striking for me as a dentist is that this field is dominated by those with a medical background and, whilst many of the principles of EBM can be transferred to Evidence-Based Dentistry, I wonder if the way in which we encourage research use differs. For example, we work in very different payment systems from the Quality Outcomes Framework indebted system general medical practitioners work with. And we lack the large trials and guidelines that many parts of medicine are endowed with.

So do we want to begin updating our view of what real EBD is? But this time, can we do it bottom up so that EBD is meaningful for the primary care dentists who make up the majority of our profession?

My slight unease during the meeting on Tuesday was that I still feel the basic principle set out in the 1990s - that research is there to help the patient-doctor relationship come to better decisions for patients - is unchanged and that really what we should be discussing is how to keep the principles from being sullied, whilst learning to understand better in the dental clinical context, just how we can help the dentist-patient relationship use research where and when appropriate.

Anyway - here's what happened as recorded in Twitter and the Evidence Based Health Listserve...

TRIP and its PICO

TRIP now includes PICO search

TRIP Database has just been redesigned and now incorporates a PICO search box alongside the google-style one. I've blogged about PICOs before and it's great to see a major search engine innovating with them. There's a screencast here http://www.screenr.com/c9y8

One suggestion, though - I would avoid trying to fill each of the 4 boxes. It's likely you'll end up with very few papers if you do. When I begin a search I usually start with search terms around just two concepts - say the problem / population and the intervention or intervention and comparison. If I find then that there are loads of hits with irrelevant outcomes, say, I may then add terms for the outcome of interest to me. But this is rare.

Caring for patients: evidence, patient values and your experience

With the final year moving on to their post-undergraduate life I got to reflecting on my learning of their learning over the last year. Not to detract from their achievement a few things came up that I feel I need to work on with the next cohort:

1. Remembering to do the preventive work with their patients
2. Stabilising disease before starting on the restorative phase of the treatment plan
3. Understanding the evidence for the intended treatment and for the alternatives
4. Discussion with the patient about the treatment alternatives

As many of you will know, I am an enthusiast for asking questions and seeking evidence. I am also an enthusiast for including patients in making decisions about their care. Here are some questions I ask myself when managing patient care - plus one at the end for all you poor students ;) :

1. How uncertain am I about the diagnoses? (does this affect how I proceed?)
2. How uncertain am I about the prognosis of my patient's teeth? (what are the consequences for definitive restoration?)
3. How am I going to prevent further disease in this patient?
4. How good are those preventive methods at preventing what they're supposed to prevent?
5. How will I stabilise my patient's disease?
6. What happens if some teeth, despite my best efforts, fail to respond to my interventions?
7. What restorative treatment options are there?
8. What is the evidence about how effective they are?
9. How long can the patient expect to retain the restorations I place?
10. What is the patient prepared to have done and what are their preferences?
11. What are you going to do when two tutors tell you two different options for managing your patient?

The reason I raise these here is to encourage students to think holistically and in an evidence-based way.

As you will be aware, evidence-based dentistry combines three things:

• The best available evidence
• The patient's values
• Your own experience

You will have limited experience of many of the things you do but nonetheless you should draw on what you have - over time you will build on this.

You can ask your patient right from the outset what they would like to achieve through treatment, what they're willing to put up with, and what their preferences are.

And you can use those skills you learned a little while back to seek the best available evidence. Here's a reminder of how:

1. Form a clear question
2. search TRIPdatabase / Pumed for articles
3. filter out the low level studies
4. and appraise the ones you're left with

And if you've got any questions, get in touch.

TRIP Database

Some of the third (coming on fourth...) years out there will know I've been asking people to search the TRIP database to find out about when to recall patients for check-ups.

This database is useful if you want to get to higher level information quickly - that is, clinical practice guidelines, systematic reviews and good primary studies.

However, it will not provide you with an exhaustive list of papers. For this you'll need to go back to Medline or Embase.

A nice element of TRIP is being able to save your searches automatically and to record anything you learnt whilst reading the paper. For this you'll need to register - but it's free and very simple.

I encourage you to start asking questions and searching for answers using TRIP