2. What Happens After Medical Graduation? Knowledge of best current pneumonia care Years in medical school graduation

3. Medical School Education Did you learn about AIDS? Amphotericin in kalazar CT Scans? Indium scans Zithromycin

4. Usefulness of Medical Information Relevance X Validity Work Adapted from : Slawson et al; J.Fam. Pract. 1994;38:505- 513

5. How do you learn about new developments in medicine? Pharmaceutical industry. Consultants. CME. Grazing through medical literature.

6. Clinical Decision Making Patient circumstances Evidence from research Preference, values and rights

7. Relevance x Validity work 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.

8. Medical Publishing Annually: 20,000 Journals 17,000 New books Medline 4,000 Journals. 6 Million references 400,000 New entries annually.

9. 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?

10. 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.

11. Reasons to Read Medical Journals Number of unread Medical Journals Guilt Excessive Mild Moderate

12. 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

13. What developments in medicine do I need to keep up with? Those which impact on clinical decision making.

14. Evidence Based Medicine Definition The conscientious, explicit and judicious application. The current based evidence. In making decisions about the care of individual patient.

15. Evidence Based Medicine SKILL Formulate a clinically relevant and searchable question.

16. 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.

17. Types of clinical question (Contd) Prognosis:Prognosis: How to estimate the patients likely clinical course over time. DiagnosticDiagnostic 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.

18. Steps in EBM One Formulate a question Two Find the evidence

19. Anatomy of a good clinical question Patient problem Intervention, prognostic factor, or exposure Comparison Outcome

20. Brief history of Ajaya Sah, 8 years Master Ajaya, from Janakpur was referred from a private clinic where he was treated with various antibiotics and antimalarial suspecting 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? Practice

21. 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

22. 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 % ?

23. Steps in EBM (contd) Step three Are the methods valid? Likely to be true Free from bias

24. 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.

25. 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

26. Individual clinical expertise Increasing proficiency and judgement over the:Increasing proficiency and judgement 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.

27. Best available external clinical evidence Clinically relevant research, usually patient centered to determine:Clinically relevant research, usually patient 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.

28. BOTH ARE NEEDED Without individual clinical expertise: Practice risk becoming evidence tyrannized. Even excellent external evidencemay be inapplicable or inappropriate or an individual patient. Without the best available external evidence: Practice risk becoming rapidly out of date, to the detriment of patients and patient care.

29. 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.

30. Which is why you feel like you never up-to-date and your JALCO score is so high

31. CONFLICTING RESULTS! WHAT IS THE TRUTH? Guide line 1 Guide line 2 CME Expert Article 2 Article 1 Textbook