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					 Active Learning,
Evidence, and the
Clinical Classroom
  Michelle Barber, MSW, DC
     Assistant Professor
Palmer College of Chiropractic
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• Here we go…!
Fish is Fish

  Leo Leonni
           The 5 A’s of EBCP
1. ASK = Develop a clinically relevant question
2. ACQUIRE = Search the literature to find the best
   available evidence to answer your question
3. APPRAISE = Evaluate the evidence for validity
   and applicability to the clinical circumstances
4. APPLY = Use the relevant evidence in the clinical
   situation
5. ASSESS = Evaluate your effectiveness in carrying
   out steps 1 through 4 and revise if necessary
                     Ask


                               Patient
                               dilemma

Acquire



              Evidence Cycle
                                                 Assess the results
                                                 of the action with
                                                      patient




   Appraise

                                         Apply
                    PICO
     A format for developing clinical questions

P:   Patient, population

I:   Intervention or therapy

C:   Comparison, control

O:   Outcome
               Patient Scenario
• You have an 8 year old
  female patient diagnosed
  with ADHD brought in by
  her mother, as she would
  prefer to treat her child
  with more natural, holistic
  methods
• At a recent visit, Mom tells   • She asks you if you think this
  you that she saw something       is something she should do
  in a pamphlet that               or if you can make any other
  suggested a diet restricting     diet/supplement
  dairy and sugar would help       recommendations
  her daughter’s symptoms
       PICO: Focused Clinical Question
                   Consider                            Your Question
P   Patient or     Describes patient                   • 8 year old/pediatric
    problem        (age, gender, race,                 • Female
                   condition/symptom, etc)             • ADHD

I   Intervention   What treatment, diagnostic test,    • Diet restricting dairy and
                   intervention is being considered?   sugar


C   Comparison     Compared to what?                   • Other dietary changes
                   Another intervention, Gold          • Supplementation
                   Standard, Nothing

O   Outcomes       What is the desired effect of the   • Reduction of symptoms
                   intervention?                       • Reduced need for
                   (decreased symptoms, improved       medication
                   function, etc)
                     Ask


                               Patient
                               dilemma

Acquire



              Evidence Cycle
                                                 Assess the results
                                                 of the action with
                                                      patient




   Appraise

                                         Apply
                          Acquire
• Quick database search
  – Some of my favorites
     • Index to Chiropractic
       Literature
     • PubMed
     • Natural Standard
       Database
     • Dynamed
     • Rehabilitation
       Reference Center
Hierarchy of Evidence
                Systematic
               Reviews and
Randomized     Meta-analyses
 Controlled
Double Blind
  Studies
    Review…
    Strong…
  More recent
  publication…
Let’s look at this
       one
                     Ask


                               Patient
                               dilemma

Acquire



              Evidence Cycle
                                                 Assess the results
                                                 of the action with
                                                      patient




   Appraise

                                         Apply
                                            JTASS

 Journal                    Title                Author                      Site              Summary




Adapted from: Department of Clinical Epidemiology & Biostatistics, McMaster University Health Sciences Center. How
   to read clinical journals: I. Why to read them and how to start reading them critically. CMAJ 1981;124:555-8.
 Journal          Title       Authors           Site         Summary

                                                              Most evidence is
                                                                sparse and
                Relevant to   Rucklidge,                        conflicting
   Expert
               our question     Julia J       Review, so
 Review of                                                     Best evidence:
                                               multiple
   Neuro-                                                       Zinc (2 RCTs)
                                                sites
therapeutics                                                  Mixed evidence:
                   Looks                                         carnitine,
                               Primary                        pycnogenol, EFAs
                interesting
                              author, 25                         Inconclusive:
                               articles       Population      vitamins, Mg, Fe,
                                                             Sam-e, tryptophan,
    Peer       Keywords:                       similarity,       Ginko biloba
                                                                  w/Ginseng
 reviewed,     • Supplemen-                      able to
 indexed in      tation       18 of 25 re:    reproduce        No support: St
  PubMed       • Treatment                   intervention       John’s Wort,
                                ADHD                              tyrosine,
                 of ADHD                         if valid      phenylalinine
                     Ask


                               Patient
                               dilemma

Acquire



              Evidence Cycle
                                                 Assess the results
                                                 of the action with
                                                      patient




   Appraise

                                         Apply
                       APPLY
• Consider the best available evidence, combine
  this with your clinical experience, and
  incorporate the patient’s preferences
  into the final recommendations
     • present the pros and cons of the different options to
       patients in a way they can understand, and let them
       choose how they would like to proceed
                          APPLY
• Shared with Mom that there is little evidence to support
  dietary restriction
• Recommended supplementation with Zinc to help decrease
  symptoms of ADHD and perhaps reduce need for stimulant
  medication
   – Evidence suggests approx. 15 mg of Zinc/day
• Mom excited to receive the information, going to try Zinc
  on a trial basis
   – Good use of EBCP, incorporating patient values
           Student Assessment
• Students were then given 4
  clinical scenarios to choose
  from
• Had to go through process
    (“Ask, Acquire, Appraise, Apply”)
• Completed worksheets for
  each step of process
• Turned in worksheets along
  with chosen article
Additional Samples of
 Clicker Questions…
     The hormone that most directly
 influences Na+ balance in the body is
1.   Vasopressin                                       25% 25%
                                 22%
2.   Angiotensin
                                              17%
3.   Rennin
                                                                                 12%
4.   Aldosterone
5.   Atrial natriuretic
     peptide
                              sin




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    A 65-year-old man has difficulty rising from a seated
 position and straightening his trunk, but he has no difficulty
flexing his leg. Which of the following muscles is most likely
                    to have been injured?

      1. Gluteus maximus
                                     20%
      2. Gluteus minimus
                                  18%
      3. Hamstrings
                                           23%
      4. Iliopsoas
                               17%
      5. Obturator internus
                                        22%
What is the most likely Dx?
   1. Lytic metastasis
             17%
   2. Osteoporosis
           15%
   3. Multiple myeloma
                 20%
   4. Paget’s Disease
          14%
   5. lymphoma
                         34%
     Both pleural effusion and lobar pneumonia are
     characterized by _____ heard on percussion.

1.   Tympany                                                         34%

2.   Dullness                                         28%

3.   Resonance                    22%
                                            17%
4.   Hyperresonance



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posted:5/1/2011
language:English
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