INTRODUCTION
"Evidence
Based Medicine is the conscientious, explicit and judicious use of the current
best evidence in making decisions about the care of individual patients…"David L. Sackett
"The fact that an opinion has been widely held is no evidence whatever that it is not utterly absurd."
Bertrand Russell (1872-1970)
Evidence-Based Medicine can be an intimidating topic for health professionals at any level of training. This site is designed to quickly familiarize UW students, staff, and faculty with available sources and to suggest when different sources can be most useful.
For a good editorial about EBM see EBM what it is and what it isn’t by Sackett, DL, et al.
THINKING ABOUT YOUR SEARCH
When clinical questions arise, you should consider the level and type of information needed to answer the question and choose your sources accordingly:
BACKGROUND RESOURCES - You need to get basic information on a condition, treatment, diagnostic test, etc. The overwhelming majority of questions that surface in clinics are background in nature. These sources can get you up to speed quickly.
FOREGROUND RESOURCES - You are fairly familiar with a condition, treatment, test, etc., and trying to determine a new or alternative course of action with a patient, and want to find an answer based on evidence. Before utilizing foreground resources, it is helpful to create a clinical question in the PICO format.
There are generally two types of sources to answer foreground questions:
(1) Pre-Appraised or EBM Literature – these sources review available research on a topic, provide synopses of important studies, and/or offer useful summaries or commentaries based on good evidence-based medicine principles. For more on the types of EBM literature.
(2) Primary Literature – If pre-appraised sources don’t sufficiently answer your question, you can turn to original studies on a topic. Be aware that all studies are not created equal; certain study types (particularly randomized controlled trials) provide the strongest empirical evidence. For more on study types.
BACKGROUND RESOURCES
Good background resources (such as up to date textbooks, current review articles, or medical review databases) are the place to turn when you need to find quick facts or stats about a condition, test, etc.
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TRIP Database
TRIP (Turning Research into Practice) Database is really a search engine that aims to provide quick access to a collection of evidence-based and other high quality medical information resources via a single interface. It identifies and searches numerous high-quality Internet resources that allow access to their content (source list). These resources are then categorized by type: Evidence based synopses, Clinical Questions, Systematic Reviews, Guidelines, Core Primary Research, E-textbooks, and Calculators.
UpToDate is an excellent background resource for medical students and residents interested in efficiently filling holes in their knowledge base. UpToDate is a large on-line medical textbook that contains short, well-written discussions of medical topics in internal medicine, pediatrics, ob/gyn and family medicine. Each review article is written by an expert in the field being discussed, and is designed to provide a quick way to get up to speed.
MDConsult can be thought of as a mini-library, and is a good source
for electronically available medical textbooks. It allows you to search their
entire collection of medical books by topic, making it easy to find relevant
passages or chapters in multiple textbooks with a single search. Searches
in MDConsult will find information on a topic not just from textbooks, but
from a variety of sources divided by type of source. Its database includes
online textbooks, fulltext journals, best-practices guidelines, patient
handouts and medical articles from the lay press, as well as some original
content.
Stat!Ref is a conglomeration of e-books and other medical tools. Included in the collection are approximately two dozen general textbooks covering a variety of medicine specialties, pharmacology and physiology. Stat!Ref allows you to search their entire collection of medical books by topic, making it easy to find relevant passages or chapters in multiple textbooks with a single search. Stat!Ref also includes other useful resources like MedCalc 3000, as well as some online study aids for medical students.
Harrison's Principles of Internal Medicine Online
Harrison's Principles of Internal Medicine is a well respected general internal medicine textbook, and has long been a staple of any medical library. The book takes a largely organ system based approach to medical topics. It also has several general chapters, as well as a large appendix devoted to normal lab values. The online version contains all of the text and graphics of the printed version, but has the advantages of being searchable and continually updated. With a free personal account, articles can be downloaded to a PDA or emailed.
Merck Manual of Diagnosis & Therapy
The Merck Manual is a large general medical textbook, covering internal medicine,
pediatrics, ob/gyn and a variety of medical subspecialties. The online version
contains all of the text and graphics of the printed version and is searchable.
It also contains some corrections and updates on the most recent printed
version, as well as some additional graphics and sound files.
Current Medical Diagnosis and Treatment
Single-source reference for practitioners in both hospital and ambulatory settings, including coverage of more than 1,000 common diseases and disorders along with a clear synopsis of treatment and diagnosis. This book emphasizes the practical features of clinical diagnosis and patient management in all fields of internal medicine and in specialties of interest to primary care practitioners and subspecialists who provide generalist care
Other Textbooks
The Ebling Library website provides access to the full content of nearly 500 electronic books on health topics. Many of these books are standard clinical texts (Goroll, Cecil, Kelley, etc.) that provide good background material on many topics.
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FOREGROUND RESOURCES - EBM LITERATURE
The goal of EBM movement is to integrate individual clinical experience and the needs of the patient with the best available clinical research.. There are a variety of resources that "pre-appraise" research, analyzing the available studies and providing summary answers to common clinical questions. Resources in this section are designed to help make EBM a practical reality at the bedside. For more on the types of EBM literature.
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TRIP Database
TRIP (Turning Research into Practice) Database is really a search engine that aims to provide quick access to a collection of evidence-based and other high quality medical information resources via a single interface. It identifies and searches numerous high-quality Internet resources that allow access to their content (source list). These resources are then categorized by type: Evidence based synopses, Clinical Questions, Systematic Reviews, Guidelines, Core Primary Research, E-textbooks, and Calculators.
Clinical Evidence
BMJ's Clinical Evidence provides a concise summary of the current state of knowledge, ignorance, and uncertainty about the prevention and treatment of a wide range of clinical conditions based on thorough literature searches and the best available evidence from systematic reviews, RCTs, and even observational studies (when appropriate). Clinical Evidence focuses on primary and hospital care, is continually updated, and includes entries for 200+ medical conditions and over 2400 treatments.
Cochrane Library
The Cochrane Library is an international project designed to quickly provide authoritative evidence-based answers to clinical questions. Reviews are created in a structured format and developed from an extensive and systematic search of the literature (generally randomized controlled trials). The Cochrane Collaboration has developed a strict methodology detailing how their reviews are performed, which they use to make best-practices recommendations for clinicians. This is an excellent source of EBM data for the busy clinician.
Connect to the
Cochrane Library
More Info
Evidence-based Obstetrics & Gynecology
From 1999 to 2006, Evidence-based Obstetrics & Gynecology editors aimed to provide clinicians with the best evidence in the field in this electronic journal. For each issue key articles from 70 authoritative and respected journals in the field were selected and reviewed in the form of a structured abstract and expert commentary. The journal covered a broad scope including general gynecology, reproductive endocrinology and maternal-fetal medicine. This journal is not included in PubMed and thus must be searched on its own. Ebling Library has electronic access through MD Consult. We await word if this journal will continue in 2007.
bmjupdates+
This new service to keep clinicians up to date uses explicit criteria to select and review articles from over 110 of the top clinical journals. All articles that pass the criteria are assessed for relevance and newsworthiness. These ratings are specific for each pertinent clinical discipline for a given article. Additionally, one can register (free) to receive alerts whenever an article is judged by the raters in your discipline to meet the cut-off scores for relevance and newsworthiness that you set. bmjupdates+ also includes a searchable database of alerts.
Essential Evidence Plus
Essential Evidence Plus is a compendium of tools designed to be useful at the bedside. InfoPOEMS (Patient Oriented Evidence that MatterS) are short evidence-based summaries of various conditions and treatments, and are the core of the package. POEMS are based on the best evidence available (and the evidence is graded). Essential Evidence Plus also features a series of medical calculators, a medical test database and evidence-based practice guidelines. Essential Evidence Plus can either be used on the web or can be downloaded to a PDA.
Database of Abstracts and Reviews of Effectiveness (DARE)
DARE is a complement to the Cochrane Database. DARE quality-assesses and summarizes systematic reviews found in the literature on health topics not covered by (or not yet carried out) by Cochrane. DARE covers a broad range of health related interventions and includes over 3000 abstracts of systematic reviews in fields as diverse as diagnostic tests, public health, health promotion, pharmacology, surgery, psychology and the organization and delivery of healthcare.
The ACP Journal Club is intended to provide internal medicine doctors with a manageable way to keep up with the research in their field. ACP editors scan over 100 journals and select articles (single studies and reviews) that warrant the immediate attention of its readers. Highlighted articles must meet a strict set of standards for quality to be included in ACP Journal Club. Each entry includes a summary of the study in question, a commentary written by the ACP staff of the strengths and weaknesses of the study, and the clinical implications.
Bandolier is a site produced by scientists at Oxford which is designed to quickly summarize good evidence based medicine that appears in other sources, such as the Cochrane database. The summaries are short and easy to read, with lots of bullet points (hence the name "Bandolier”). These summaries are both useful and often entertaining in a very British way.
PubMed, the free version of MEDLINE, is the largest health literature database (indexing over 4500 journals). While somewhat complicated, the search engine is very powerful for those who know how to use it. PubMed is most often used to find individual studies, but it can also be used specifically to locate evidence-based systematic review articles using the built-in systematic review search filter within PubMed's Clinical Queries.
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FOREGROUND RESOURCES - PRIMARY LITERATURE
If you are unable to find sufficient current evidence using background information or pre-appraised resources, you can turn to individual studies on a topic. There are several places to find individual studies on a topic, but the first place to look is PubMed (MEDLINE). Keep in mind that there is a hierarchy of study types (i.e. all studies are not created equal). For more on study types.
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TRIP Database
TRIP (Turning Research into Practice) Database is really a search engine that aims to provide quick access to a collection of evidence-based and other high quality medical information resources via a single interface. It identifies and searches numerous high-quality Internet resources that allow access to their content (source list). These resources are then categorized by type: Evidence based synopses, Clinical Questions, Systematic Reviews, Guidelines, Core Primary Research, E-textbooks, and Calculators.
PubMed, the free version of MEDLINE, is the largest health literature database (indexing over 4500 journals). While somewhat complicated, the search engine is very powerful for those who know how to use it. When looking for answers to clinical questions, systematic reviews should be consulted first. If no recent or relevant reviews exist, one should use the PubMed Clinical Queries filter to find the best individual studies on a topic. This filter is designed specifically to limit your results to those studies atop the evidence hierarchy (e.g. RCTs).
Google Scholar is a search engine produced by the Google Corp. that is designed to search scholarly journals and websites with the ease of a Google web search. Google Scholar does not use a controlled vocabulary (such as MeSH). Rather, articles are searched by keyword and sorted with a relevance algorithm, which places highly cited sources atop the list. However, the quality (and thoroughness) of the result set is still being debated; therefore, at this point, Google Scholar should be used as a compliment to MEDLINE. Journal articles found on Google Scholar are linked to UW's online full-text collection (via Find It).
Cochrane Central Register of Controlled Trials (CENTRAL)
Developed to facilitate the creation of the Cochrane Database of Systematic Reviews, CENTRAL is the most complete database of randomized controlled trials (and articles relating to specific RCT's) currently available. The database includes not only the RCT’s listed in MEDLINE, but also other electronic searches and manually indexed journals from around the world. CENTRAL should not be the first choice search engine for the average clinical query, and is more designed for researchers looking for a complete list of all the RCT’s on a given topic.
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OTHER CLINICAL RESOURCES
This section contains useful databases and tools that will help you in your
day to day practice.
MICROMEDEX is an excellent source of drug indication, dosage, drug interaction and side effect information, as well as poison control information. Unlike similar resources like ePocrates, which only list more common side effects, MICROMEDEX also includes case reports of very rare effects. It covers all FDA approved medications as well as a database of alternative medicines. It can produce patient-specific PALS and ACLS emergency dosing sheets for use at the bedside in an ICU situation. In addition, MICROMEDEX contains a variety of dosing tools, patient education handouts, and "clinical pearls", which is a collection of useful medical tables on a variety of topics.
Epocrates Online, an online version of the popular PDA resource, is an easy-to-use drug database that is geared towards use on the wards or in clinic. It includes short descriptions of each drug with enough key detail to be useful in a clinical situation. It's an excellent source of drug indication, dosing, contraindication, and adverse effect data, and contains lists of common and serious side effects, as well as pregnancy and lactation safety information. Like MICROMEDEX, it can perform drug interaction checks. The online version features more detailed monographs for each drug, and tools such as a pill identifier.
Lab Tests Online is a site geared more towards patients, but also helpful
for medical students. It provides clearly written information on
lab testing written without too much medical terminology. It includes
information on what the test is for, how it is collected, what other tests
tend to be given for a particular condition, and summaries of many of the diseases
the tests are designed to detect. Lab Tests Online can search by test, by
disease or by common screening tests for any age patient. It does not contain test characteristics data (i.e. sensitivity, specificity).
The Washington Manual of Medical Therapeutics
The Washington Manual of Medical Therapeutics is a quick reference
handbook designed to be used on the inpatient wards by resident physicians
in internal medicine. The manual provides succinct descriptions of
a broad range of medical topics, focusing on therapy. The e-book
version of The Washington Manual contains all of the text and
graphics of the most recent print edition, and is searchable.
Developed by the Department of Health and Human Services, the National Guideline Clearinghouse collects best practice guidelines produced by medical facilities, agencies and organizations around the world. The site is searchable by disease, and there is a guideline comparison tool that allows different guidelines for the same disease to be compared. Guidelines can be downloaded to a PDA. Be aware that the guidelines included do run the gamut from those using explicit EBM principles to some that are big on advocacy but low on evidence.
The Harriet Lane Handbook
The Harriet Lane Handbook is a quick reference handbook designed
to be used on the inpatient wards by resident physicians in pediatrics. The
manual provides succinct descriptions of a broad range of pediatric topics,
and includes normal lab values for children of different ages, formula
preparations and other useful pediatrics-specific information. The
e-book version of Harriet Lane contains all of the text and graphics
of the most recent print edition, and is searchable.
Clinical Rules and Calculators
Similar to MedCalc, Essential Evidence Plus features a huge number of automated medical calculators for common (and not so common) medical equations, such as anion gaps, APACHE II scores, and so on. It also contains "clinical rule calculators", essentially interactive guidelines for different medical conditions, where the data entered by the clinician is used to suggest a treatment or a probable outcome.
Diagnostic Test Databases
A very useful database that can be searched either by disease or symptom. Essential Evidence Plus provides a list of appropriate medical tests with test characteristics data (sensitivity, specificity, and likelihood ratios). The list of tests can be modified to show the best screening test, the best rule-out test, etc. Pretest probability can be factored in to calculate sensitivities and specificities for a specific patient. Essential Evidence Plus also includes a similar database for tests performed as part of a physical exam. These databases contain less explanatory detail than the descriptions in Lab Tests Online, but more technical data.
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EBM ANALYSIS
Finding the evidence (literature) is only the first step of the evidence based medicine process. Next, you need to determine whether the evidence you have found has validity and is applicable to your patient. There are several excellent websites, article series, and e-books that provide education and guidance for this process. Below is our list of some of the best guides available for the validation/analysis side of evidence based medicine. We have also included a variety of online tools and calculators for assistance.
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The User's Guide to the Medical Literature
The ebook The User's Guide to the Medical Literature is an excellent resource for those interested in pursuing the evaluation side of EBM in depth. Based on a series of articles that have appeared in JAMA and written by many of the founders of the EBM movement, the Guide clearly explains the criteria doctors use to determine if a study is valid and relevant for a particular patient. It discusses the issues of diagnosis, therapy, harm, and moving from evidence to action in separate, well written chapters. There is also an EBM glossary and links to EBM calculators.
Connect to The User's Guide to the Medical Literature
The User's Guide to Evidence Based Practice
Similar to the User's Guide to the Medical Literature ebook, and produced by the same authors, this resource provides the original JAMA series of articles about EBM. These articles are somewhat more condensed than the ebook version, and useful for someone trying to understand the basics of EBM analysis quickly. There are separate sections for diagnosis, therapy and harm, each with clinical examples.
Connect to The User's Guide to EBP
Basic Statistics for Clinicians
This series of four articles clearly explains the statistics that are commonly used in medical literature when reporting results. This series is aimed at clinicians, the consumers of statistics, rather than researchers. It also describes the common ways that statistics can be used deceptively in research to make results look more solid than they really are. This is a good place for students of EBM without a strong statistical background to start their reading.
Connect to Basic Statistics for Clinicians
The Centre for Evidence Based Medicine (Toronto)
This Toronto based organization is a good source for tutorials, educational material, calculators and other tools for learning about, teaching and practicing EBM. It includes links to EBM resources that are tailored to particular medical specialties, such as pediatrics or surgery. It supplements the book "Evidence-based Medicine:
How to Practice and Teach EBM," a popular EBM textbook.
Connect to The Centre for EBM (Toronto)
The Centre for Evidence Based Medicine (Oxford)
This Oxford, England based organization is a good source for tutorials, educational material, calculators and other tools for learning about, teaching and practicing EBM. Of particular interest are the resources in the toolbox section of the site, which are very useful for understanding EBM concepts and working with statistics.
Connect to The Centre for EBM (Oxford)
Center for Evidence Based Medicine EBM Calculator
This EBM Calculator is four EBM calculators in one, designed to calculate relevant statistics for diagnostic studies, prospective studies, case control studies, and randomized control trials. It is available in both a web version and for handhelds.
Connect to the EBM Calculator
UIC Diagnostic Test Calculator
This EBM statistics calculator allows you to enter statistical data for diagnostic tests in a variety of forms, and then automatically converts the data into the other common EBM statistics. In a nice touch, it dynamically generates a nomagram graphically depicting the relationship between the likelihood ratios and the probabilities for your data set.
Connect to the Diagnostic Test Calculator
University of British Colombia Bayesian Calculator
This diagnostic test calculator can be used to gives you three starting options based on what data you already have, and then can be used to calculate the EBM statistical indicators you don't know.
Connect to the Bayesian Calculator
University of British Colombia Clinical Significance Calculator
This calculator is useful for analyzing the statistics in a research paper, and allows you to enter key results data to quickly calculate NNT or other EBM statistics that may not have been reported by the authors
Connect to the Clinical Significance Calculator
Evidence Based Medicine Appraisal Sheets
These appraisal worksheets are designed to help clinicians formulate
appropriate clinical questions, answer those questions and evaluate the
research they find during their search. There are different sheets for
diagnosis, therapy and so on, each intended to be used when working with
patients on the wards or in the clinic.
Connect to the EBM Appraisal Sheets
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Page last updated: February 8, 2008
Questions or suggestions? Contact Chris Hooper-Lane
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