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					Using the Internet to Practice Evidence-
          Based Dermatology

             David A. Barzilai, M.D., Ph.D.
                          Brown University
                        Department of Dermatology
                 Presentation Home:
       Last Update: 1.9.07 (check for latest updates)
               Presentation Objectives

This Presentation Addresses:

  What is Evidence-Based Medicine (EBM)?

  How does one practice EBM?

  What tools are available to practice EBM?
   – Emphasis on internet tools (available at
   – Special resources of dermatological interest will be highlighted
          Evidence-Based Medicine

"the conscientious, explicit, and judicious use of
current best evidence in making clinical
decisions about the care of individual patients."
– Dr. David Sackett, “father” of EBM

EBM is not “cookbook medicine”

Evidence is thoughtfully integrated w/:
– Patient preferences
– Provider expertise (including knowledge what makes
  this patient unique)

The Goal: Providing exemplary care for our patients,
using the current best evidence

The Challenge:
– Minutes per patient encounter to seek out best evidence
– Minutes to hours per week of reading to “stay current”
– Research data is accruing faster than our ability to read!

The Issue: how do we best make use of our limited
time for:
– Information retrieval and “reading time”
– Information management
– Evidence-based medical practice
           Overview: EBM Search Algorithm
1.   Formulating a well-built clinical question

2.   Finding the current best evidence*

3.   Critically appraising the evidence for validity

4.   Application of this evidence, integrating the data with
     patient values and clinical expertise.

5.   Storing the data and evaluating performance of steps 1-
     4 for continuous quality improvement

     * We emphasize step 2 in this brief presentation
      The Well-Built Clinical Question

 Includes the following (P.I.C.O.):
1.   A Patient or population
2.   An Intervention or “exposure”
3.   A Comparison intervention (if appropriate)
4.   A clinical Outcome (diagnosis/screening,
     prognosis, therapy, event, harm, or prevention)
Well-Built Clinical Question (WBCQ) – an

“In a 22 year old woman with mild non-
comedonal acne (Patient), does monthly use of
salicylic acid (Intervention) or benzoyl peroxide
(Comparison) prevent more acneiform lesions
from developing (Outcome)?” Resources to
facilitate WBCQ’s
               The WBCQ- Resources

Anatomy of a well-built clinical question (University of Sheffield)

Contstruct a well-built clinical question using PICO (University of

Further reading on well-built clinical question, from University of
Medicine and Denistry of New Jersey.

Sackett et. al (see References)

When you have created your well-built clinical question, consider
using this as the basis for contributing a Critically Appraised Topic to, which is a practice-based learning tool for conducing
evidence-based searches and evaluations.
   What Kind of Study to Answer my

Keep in mind the Hierarchy of Evidence:
– Systematic review of RCTs > RCT>Cohort>x-
  sectional >case report> anecdote (“rule of thumb”)
– However, a good observational study beats a poorly
  conducted Randomized Controlled Trial (RCT).

Also, the best design varies by the question:
– Prognosis, harm: Cross Sectional or Cohort Study
– Natural history, Diagnosis: Cohort Study
– Therapy & prevention, other interventions: RCT’s
       Critically Examine All Sources

Foundation is epidemiology and biostatistics
– Is this study important?
– Is this study valid?
– Does this study apply to my patient population?

Learn Critical Appraisal Skills (free):
– Synopsis of JAMA review of EBM
– University of Alberta EBM Toolkit
– Basic Biostatistics 1 and Basic Biostatistics 2 (BMJ)
        Seeking the Evidence (overview)

 Evidence-Based Resources:
1.   Evidence-Based Systematic Review Databases
2.   Secondary journals
3.   EBM textbooks and guidelines
4.   Medline / electronic databases

 Consult Medline first for very latest research
What About Consulting Colleagues and

     Image source:
    Least Reliable Sources of Evidence

Colleagues, experts, & “throw-away” journals
– Convenient and fast
– Often invalid , incomplete, and biased information

Textbooks (usually)
–   Generally not systematically researched
–   Usually based on “expert opinion”
–   Most are out of date - check for recent citations
–   Great exception (explicit protocols):
 1. Evidence-Based Systematic Review
Traditional narrative reviews are often expert-
based, biased, and incomplete (unreliable).

Systematic reviews are characterized by:
– Clear and focused study question
– Explicit definition of study criteria to be included
– A priori protocol for collating the evidence
– Exhaustive search, including“hand-searching” and
  unpublished studies
– Explicit or implicit factoring of study quality

Most comprehensive resource for therapy Q’s
         Systematic Review Databases

The Cochrane Library :
– Best source for structured, systematic reviews
– Explicit search & quality criteria (free abstracts)

Database of Abstracts of Reviews of Effectiveness
– Structured abstracts of systematic reviews meeting highest
  quality standards
– A (free) part of the Cochrane Library

Evidence-Based Medicine Reviews (EBMR) integrates
the above with secondary journal content:
– ACP Journal Club / Best Evidence
– Medline searching and some full-text journals.
              2. Secondary Journals
Evidence-Based “secondary journals” provide structured
abstracts with balanced commentary
Selected from high quality publications
Can be best resource to start with when investigating rare
clinical conditions (saves time).
– Evidence-Based Medicine, ACP Journal Club (free)
– Specialty-specific resources: Evidence-Based Dermatology
  section of Archives of Dermatology
– Bandolier (free) brief EBM summaries of summaries
Journal Watch Dermatology, a product of the publishers
of the New England Journal of Medicine, provides month
summaries with expert commentary for 13-15
                    3. EBM Textbooks

Most efficient source for simple clinical queries, but
most quickly outdated
– Evidence-Based Dermatology the definitive book on evidence-based
  dermatology (link to review).
– Clinical Evidence, by BMJ Publishing Group and ACP, meets the highest
  evidence-based medicine standards.
– UpToDate meets a high standard of evidence-based content and
  periodically updated.
– ACP Medicine, developed from WebMD Scientific American®
  Medicine available online by subscription.
           Evidence-Based Guidelines

The best sources rate the strength of evidence
Always consider external validity to your patient
 – The National Guideline Clearinghouse is the most well known of the high
   quality clinical guideline databases (free).

 – The Guide to Clinical Preventative Services includes the latest clinical
   prevention recommendations by the U.S. Preventive Services Task
   Force (free)

 – The UK National Electronic Library for Health Guidelines has over 2000
   guidelines produced in the United KIngdom (free).

 – The Guidelines International Network permits guideline searches with a
   more international focus with membership.

 – For skin-related guideilnes developed through by two large dermatology
   associations, you can visit the American Academy of Dermatology
   guidelines and the British Association of Dermatologists guidelines.
                          4. Medline

If the Cochrane Library has not addressed our question, next try
The largest biomedical literature database, but:
 – Misses some journal articles, misclassifies others
 – Can be overwhelming if not searching selectively
PubMed is a free Medline service with Boolean and other
search capabilities.
Sample PubMed queries can be found at Sample Clinical Query
(from the New York Academy of Medicine) (free)
Clinical query filter facilitates clinical searches
Medline searching tips from the New York Academy of Medicine
helps you take advantage of the power of Medline (free)
            Meta-Search Engines

Permit integrated multi-source searches
– Evidence Based Medicine Reviews, by Ovid:
  searches Cochrane, DARE, ACP Journal Club, and
– Tripdatabase: Cochrane Library, DARE, the National
  Guideline Clearinghouse, clinical questions answering
  services, online books, and Medline
    Quality more variable
– SUMSearch: Cochrane, National Guide
  Clearinghouse and other sources
    Incorporates data quality in results.
       Critically Appraised Topics (CATs)

Practice-based learning of EBM
Results vary by author, source
– will host an international CAT bank specific to skin
– Spanish Language dermatology CAT bank available at
– BestBets
– The CAT Bank
– CAT Crawler is a search engine for CATs from multiple sources,
  but currently does not search or for
  skin-related CATs.
          Information Management
Use Science Citation Index to search for newer
articles that cited an older classic paper of interest.

EMBASE is a Medline alternative
– More extensive European journal representation
– Wider array of health science disciplines represented

Invest in a citation manager program such as
– Download abstracts from Medline
– Label abstracts for quick searches later
– Effortless reference resorting
         Guidelines for Reading

Choose 2-3 gold standard journals relevant to
your patients for weekly reading

Devote weekly protected time for reading

Subscribe to e-mail TOC’s of 1-3 other high
quality journals (e.g. Lancet, JAMA).

Consider specialty-specific services:
– Dermlinx (
– Medscape Dermatology (
Selected Comprehensive Web-Based EBD

  Evidence-Based Dermatology
  Centre for Evidence-Based Dermatology
  Netting the Evidence
  Centre For Evidence Based Medicine
  Evidence-Based Medicine Resource
        Some Final Suggestions

The most effective way to learn evidence-
based dermatology is to practice it:
– Consider creating a Critically Appraised Topic
  (CAT) on

Consider joining IDEA (International
DermatoEpidemiology Network)

Get involved with the Cochrane Skin Group
              Distribution Statement

You may distribute freely, provided that
this presentation is preserved in its
entirety without changes

Questions / comments:
 – David A. Barzilai, MD PhD (
 – For presentation updates see:
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Dermatoepidemiology. J Am Acad Dermatol. 2005 Apr;52(4):559-73; quiz
574-8 [CME Review].
Bigby M: Evidence-based medicine in dermatology. Dermatol Clin 18:261-
276, 2000 (much like the above – choose one)
The Challenge of Dermato-epidemiology by Hywell Williams (Book)
Cook DJ, Meade MO, Fink MP: How to keep up with the critical care
literature and avoid being buried alive. Crit Care Med 24:1757-1768, 1996
Evidence-Based Medicine: How to Practice and Teach EBM by David
How to Read a Paper: The Basics of evidence based medicine by Trisha
Studying a Study and Testing a Test by Richard Riegelman and Robert