1. EBP Workshop: RMH November 2012 searching the literature
Peter Greenberg
Physician: Department of General Medicine and Melbourne EpiCentre, The Royal Melbourne Hospital (RMH)
& Honorary Principal Fellow: Schools of Medicine & Population Health, The University of Melbourne
Catherine Voutier
Clinical Librarian, Health Sciences Library, Royal Melbourne Hospital

2. searching the literature
managing clinical research evidence
evidence based practice (EBP)
information, knowledge and wisdom
search techniques and strategies

3. managing clinical research evidence information can be pushed or pulled
pushed: alerts us to information we might need * ‘just in case’ learning: a) lay resources radio; films; television; books; newspapers b) professional resources textbooks; journals; e-subscriptions; “e-feeds”....
pulled: access information when we need it * ‘just in time’ learning: useful whenever questions arise!

4. evidence-based clinical practice (EBP)
begins by clarifying patients’ issues, which arise during consultations
EBP involves a series of ‘steps’:
asking questions
seeking answers
critical appraisal of retrieved literature
applying data to patients’ problems
integrating information with the patients’ values

5. information, knowledge and wisdom what do literature searches deliver?
information which is considered and applicable
“wisdom” knowledge applied with experience
see “The Rock” by T.S. Eliot (1934) for the difference between information, knowledge and wisdom

6. more about asking questions
1) what is the question about? therapy? diagnosis? cause? risk? prognosis?……..
2) is the question general (‘background’) or specific for this patient (‘foreground’)?
3) how are questions best structured to facilitate searches for answers?

7. ‘background’ and ‘foreground’ questions
background * topic (e.g. ‘disease’) orientated * general rather than specific
* begin with: ‘how’; ‘what’; ‘which’; ‘why’; ‘do’; ‘does’….....
foreground
* patient-problem oriented
* specific* rather then general * structured format
foreground question components become search terms!

8. ‘background’ and ‘foreground’ questions
in reality, there is a continuous spectrum from ‘background’ to ‘foreground’ questions

9. why structure ‘foreground’ questions in PICO(T) format
why structure ‘foreground’ questions in PICO(T) format? Patient (Population) Intervention Comparison Outcome Time
1) requires you to consider questions carefully++
2) you can search with some (or all) PICO(T) terms!
3) practice is needed to choose terms which: * precisely address your questions * are not too specific to provide answers

10. searching the literature
managing clinical research evidence
evidence based practice (EBP)
information, knowledge and wisdom
search techniques and strategies

11. search techniques
available e-resources
MeSH* terms * medical subject heading
searching ‘secondary’ data sources
searching ‘primary’ data sources

12. search techniques available e-resources*
via “Clinicians Health Channel”
via Hospital (University or other) library
via private subscription
via www at no cost

16. search techniques available e-resources
via “Clinicians Health Channel”
via Hospital (University or other) library
via private subscription
via www at no cost
* ‘PubMed’ (free ‘Medline’ access)
* The Cochrane Library
* ‘TRIP database’
* ’BMJ/McMaster Evidence Updates’
* ‘NHMRC (NICS) Clinical Guidelines Portal ‘
* ‘Google’ & ‘Google Scholar’

17. search techniques
available e-resources
MeSH* terms * medical subject heading
searching ‘secondary’ sources
searching ‘primary’ sources

18. searching with Medical Subject Headings (MeSH) terms

19. Entry(MeSH) Term: Diabetes Mellitus, Type 1
Diabetes Mellitus, Brittle
Brittle Diabetes Mellitus
Diabetes Mellitus, Insulin-Dependent
Insulin-Dependent Diabetes Mellitus
Diabetes Mellitus, Juvenile-Onset
Juvenile-Onset Diabetes Mellitus
Diabetes Mellitus, Ketosis Prone
Ketosis-Prone Diabetes Mellitus
Diabetes Mellitus, Sudden-Onset
Mellitus, Sudden-Onset Diabetes
Sudden-Onset Diabetes Mellitus
Diabetes Mellitus, Type I
IDDM
Type 1 Diabetes Mellitus
Diabetes, Autoimmune
Autoimmune Diabetes

20. MeSH
MEDLINE entries are indexed with ~30,000 thesaurus terms and ~85 sub-headings for sensitive, specific and efficient searching
MeSH terms * applied to publications as specifically as possible * cover ~106 concepts
each publication has ~10-20 MeSH terms
MEDLINE# & ‘The Cochrane Library’ have: * MeSH browsers: which assign ‘MeSH’ to ‘text’ terms * MeSH tree displays * automatic mapping of text to MeSH terms # accessed through ‘PubMed’, ‘EBSCO’ (Clinicians Health Channel); Institute for Scientific Information (ISI): Thompson Scientific. (The University of Melbourne), “OVID”…….

21. search techniques
available resources
MeSH* terms * medical subject heading
searching ‘secondary’ sources
searching ‘primary’ sources

22. search techniques
‘secondary’ databases * ‘filtered’ or derived from research publications e.g. ‘critical appraisals’; comments; summaries; syntheses, texts… * fewer citations * faster, efficient, easier searching * less sensitive, but more specific searches fewer citations, both relevant and irrelevant
‘primary’ databases * original research publications * many citations * harder, slower searching * more sensitive, but less specific searches more citations, both relevant and irrelevant

23. examples of ‘secondary’ databases content example
evidence summaries
texts
systematic reviews
‘filtered’ by peers for relevance/importance
structured abstracts and commentaries
‘Clinical Evidence’ see “Best Practice” (CHC)
CHC resources see ‘Best Practice’ & ‘DynaMed’
other resources “UpToDate”……...
‘Cochrane Reviews’ see ‘The Cochrane Library’
‘BMJ/McMaster Evidence Updates’
‘ACP* Journal Club’ * American College of Physicians

24. other secondary sources of evidence
clinical practice guidelines*: ‘systematically developed statements to assist practitioner (and patient) -decisions about appropriate health care for specific clinical circumstances’
(integrated) clinical pathways*: “multidisciplinary outlines of anticipated care, placed in an appropriate timeframe, to help a patient with a specific condition or set of symptoms move progressively through a clinical experience to positive outcomes.”
*their value depends on the rigour of the development process

25. search techniques
available resources
MeSH* terms * medical subject heading
searching ‘secondary’ sources
searching ‘primary’ sources

26. search techniques
‘primary’ databases * original research publications * many citations * harder, slower searching * more sensitive, but less specific searches more citations, both relevant and irrelevant
‘secondary’ databases * ‘filtered’ or derived from research publications e.g. ‘critical appraisals’; comments; summaries; syntheses, texts… * fewer citations * faster, efficient, easier searching * less sensitive, but more specific searches fewer citations, both relevant and irrelevant

27. examples of ‘primary’ databases
‘MEDLINE’ access: * ‘PubMed’ * ‘ISI’ Institute for Scientific Information: Thompson Scientific. (The University of Melbourne.) * ‘EBSCO’ (Clinicians Health Channel) * ‘OVID’……...
Cochrane Library: “Clinical Trials”
‘CINAHL’ Cumulative Index to Nursing and Allied Health Literature
‘EMBASE’ Excerpta Medica Database (drugs)
PsycINFO American Psychological Association (psychological abstracts)
other…. ?

28. searching ‘Medline’ (‘PubMed’) some tips
MeSH browser note the 2 option boxes below the sub-headings: * “Restrict to MeSH Major Topic” * “Do not include MeSH terms found below this term in the MeSH hierarchy”
after retrieving publications, check: * “ Search details” to see how the search was undertaken # # truncation (e.g. Palliat*) removes ‘mapping’ to MeSH terms * “Related citations in PubMed” for additional, relevant citations * “Search History” to combine searches: see “Advanced” * MeSH terms allocated: alternative MeSH terms are displayed beneath citations
“Clinical Queries” provides efficient, specific searching with “in-built” search filters
limits or qualifiers avoid these unless absolutely necessary, at the end of search

30. searching ‘The Cochrane Library’ some tips
always do a MeSH search as well – type in a single term and locate appropriate MeSH term by clicking on “Thesaurus” button’
– select best term from list
– click on “View Results”
• if searches involve > 1 search term, repeat the above
• combine search results via ‘Search History’
avoid adding limits or qualifiers until necessary

31. search strategy depends on…
what the question is about: therapy, diagnosis, cause, risk……..
question type: ‘background’, ‘foreground’
availability of and experience with particular databases
the purpose of the literature search
write a paper use primary sources of research data
systematic review use primary sources of research data
research project use primary sources of research data
manage a patient use secondary resources first
time available secondary sources if there is little time
prevalence of issue secondary sources for common issues

34. search techniques and strategy summary
formulate the best PICO(T) question
use MeSH terms
use secondary databases first

35. further reading asking questions
Straus S, Richardson SR, Glasziou P, Haynes BR. Evidence-Based Medicine. How to practice and teach EBM. 3rd ed. Elsevier Churchill Livingstone. 2005
Glasziou , Del Mar C. Evidence-based Practice Workbook, 2nd Ed.Blackwell/BMJ Books. 2007
Oxman AD, Sackett DL, Guyatt GH, for the Evidence-Based Medicine Working Group. Users’ guides to the medical literature: I. How to get started. JAMA 1993:270:
Richardson WS, Wilson MC, Nishikawa J, Hayward RSA. The well-built clinical question: a key to evidence-based decisions. [Editorial]. ACP J Club 1995; 123(3):A12-13
Richardson WS. Ask, and ye shall retrieve. [EBM Note]. Evidence Based Medicine 1998; 3:
Mitchell G. Reframing the question. A way of applying evidence based medicine to a common clinical situation. Aust Fam Physician 1998; 27:875-6.
Stone PW. Popping the (PICO) question in research and evidence-based practice. Appl Nurs Res 2002; 15:197-8.
Onady GM, Raslich MA. Evidence-based medicine: asking the answerable question (question templates as tools). Pediatr Rev 2003; 24:
Southern Health Centre for Clinical Effectiveness: Evidence-Based Answers to Clinical Questions for Busy Clinicians. Workbook
‘Asking focused questions”. Centre for Evidence-Based Medicine Oxford(UK)
An interactive tool from the Centre for Evidence Based Medicine Toronto

36. searching the literature for answers
further reading
searching the literature for answers
Straus S, Richardson SR, Glasziou P, Haynes BR. Evidence-Based Medicine. How to practice and teach EBM. 3rd ed. Elsevier Churchill Livingstone. 2005
Glasziou , Del Mar C. Evidence-based Practice Workbook, 2nd Ed.Blackwell/BMJ Books. 2007
“Help” and “Tutorials” sections within e-databases
JAMA ‘Users’ guides’ series. Oxman AD, Sackett DL, Guyatt GH, for the Evidence-Based Medicine Working Group. Users’ guides to the medical literature: I. How to get started. JAMA. 1993;270:
Greenhalgh T. How to read a paper: the basics of Evidence-based Medicine. BMJ, London.1997
Ebbert JO, Dupras DM, Erwin PJ. Searching the medical literature using PubMed: a tutorial. Mayo Clin Proc.2003; 78:87-91).
Robinson A, Day S. The value of PubMed and HighWire Press for the busy general practitioner. Australian Prescriber 2004; 27(Number 1):16-18.
Sood A, Erwin PJ, Ebbert JO. Using advanced search tools on PubMed for citation retrieval. Mayo Clin Proc 2004; 79:
Giustini G. How Google is changing medicine. BMJ 2005; 331:
Steinbrook R. Searching for the right search -Reaching the medical literature. N Eng J Med 2006; 354:4-7
Tank H, Ng JHK. Googling for a diagnosis-use of Google as a diagnostic aid: internet based study. BMJ 2006; 333: