Reflections on Evidence-based Medicine

It was really great to see the other residents, both hospital and community alike. Although by the end of a Friday afternoon it was tough to sit in one spot for 7-8 hours, there are many things to unpack and revisit throughout the residency year when it comes to appraising the literature, always having a critical lens, and (what I found to be an important talk) keeping your patient’s wishes in mind. So, how did I do on my goals?

Goal #1: Develop an efficient process for appraising a variety of literature, including RCTs, observational studies, meta-analyses, systematic reviews, and guidelines. I’d like to believe I have achieved this in that I have a good foundation and framework for approaching a variety of literature. For all the “checklists” and “scores”, I don’t think I’ll be using them for every single study I come across, but they are good for keeping in mind what elements make up a quality study.
– For observational studies, I have the STROBE checklist
– For guidelines, I have the AGREE II scoresheet
– For meta-analyses, there is the PRISMA checklist and AMSTAR score. I liked AMSTAR because it is fast, and a quick hit on what “big-picture” things to look out for in a meta-analysis.

Goal #2: Develop a process to approaching clinical dilemmas and treatment choice with patients. Achieved. Dr. Slavik provided us the 10 step workflow to doing this. The main idea I got from this was to start big when explaining medication choice, such as:
Condition (what it is) –> Drug class options –> Individual drugs –> Tangible risks (don’t give an NNT) –> Tangible benefits –> side effects, cost, other factors

Overall, the surprising thing I learned during this week was that meta-analyses are not as necessarily bulletproof as I’d like to believe. I think during undergrad, it was drilled into our heads that RCTs have a lot of areas where investigators can improve on, but I was part of a large group of my colleagues who imagined that as we were told that meta-analyses are at the “top of the evidence food chain”, they have to be of a higher quality.

Another thing that made me reflect and give me more pause was that certain research questions may be better answered by a cohort or case-control study, such as in the cases of rare adverse events, hypothesis-generating studies, or ones where larger studies may be impractical or too expensive.

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