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The Collaborative Role of Medical Librarians in Facilitating the EBCAM Faculty Development Workshop

Linda S. Murphy, MLISHealth Sciences Librarian

UCI Science Library Desiree Lie, MD, MSEdUCI CAM Taskforce, Chair

UCI Dept. of Family Medicine

Presented at the NCNMLG Presented at the NCNMLG MLGSCA MLGSCA PNC/MLA PNC/MLA Joint Meeting Joint Meeting Sacramento, Jan 28-31, 2004 Sacramento, Jan 28-31, 2004

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Background New CAM Center (Susan Samueli

Center for CAM) established in 2001 New CAM curriculum to be introduced

starting 2002• CAM Task Force: Multidisciplinary

membership AMSA Grant (2003)

Provided faculty with skills to integrate CAM instruction into a variety of teaching programs and clinical settings.

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Workshop Development & Implementation A small working group (2 MD faculty, a PhD

and a librarian). Workshop planning

Established goals and objectives Discussed presentation methods Pre-designed 3 patient cases. Identified literature, speakers, pre- and post

workshop assessment tools to evaluate learners’ EBCAM skills and knowledge

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Program Contents

Welcome, Current state of CAM Education Small Group Discussions

Group 1: Discussed EBM search and critical appraisal.

Group 2: Divided into 3 smaller groups to discuss and use model patient cases for future CAM instruction.

Lunch Break Evaluating CAM instruction and competencies Wrap up and suggestions for next year’s

program

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Clinical Scenario 1: Back pain

Pt: a 25-yr male restaurant manager, 6-months of neck and LBP

Px: localized pain in neck/shoulder; persistent ache in L2-4; occasional headaches

Dx: x-ray of the neck and lumbar spine was normal

Tx: given NSAIDs, exercise and PT without resolution

PtQ: will chiropractic manipulation or acupuncture Rx improve pain and function and what risks might be involved?

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Clinical Scenario 2:Women’s health and Menopause

Pt: a 50-yr female teacher with menopausal symptoms, started HRT a yr ago working

with her physician to discontinueHx: breast cancer and heart disease Dx: re-experiencing symptoms of hot flushes,

mood swings, and night sweats.Tx: was treated with HRT. PtQ: Black Cohosh, Red Clover, and Estroven

relieve menopausal symptoms; risk of breast cancer and heart disease

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Clinical Scenario 3:Congestive Heart Failure and Herbals

Pt: Mr. Mitchell, a 73 year old retired bus driverDx: hypertension and atrial fibrillation; insomnia;

gastrointestinal discomfort; Tx: Digoxin (control heart rate) and Coumadin

(prevent thrombotic emboli); hydrochlorothiazide (for hypertension)

Self Med: St. Johns Wart, Valerian (help with sleep); Ginger (for GI Discomfort); Vitamin E (for memory problems)

Probls: Digoxin and coumadin levels are unstable.

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Why Keep Up With the Literature?

Decide what diagnostic test to use What treatment to choose What expected outcome might be Keeping up with the latest news in health

care Stay abreast of what patients bring in from

the media, from the Internet, from friends

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What is EBCAM?

Integrates the best research evidence with clinical expertise and patient values.

Seeks to inform, leaving the final decision to the clinician and patient.

Effective means to bridge the gap between information and practice.

Facilitates interaction between conventional and CAM practitioners.

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Why is EBCAM needed? Growing national interest in CAM A billion dollar industry, need evidence for

efficacy of CAM modalities. Recent movement to integrate CAM

content into allopathic curricula. Increased funding for CAM education. Faculty need updated knowledge for CAM

to be comfortable teaching students and residents.

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The EBCAM Process

Ask a well-structured clinical question; Conduct a high-quality literature search. Identify evidence most relevant to

addressing the clinical question; Appraise the quality of this evidence; Apply the evidence to the care of the

patient.

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Formulating Questions

Background questions Foreground questions PICO Select appropriate database/sources Search Strategy

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Background Questions General clinical questions for background

knowledge. Can be answered by using “background”

resources, e.g., current textbooks, and narrative reviews.

Foreground Questions Specific questions (Diagnosis, Etiology,

Prognosis, Therapy) about your patient: Need latest resources Answered by primary (original research) and

secondary (systematic reviews and practice guidelines) sources

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Internet Searching

Google search “back pain" +acupuncture (120,000 hits)

“low back pain” +acupuncture (27,900) “chronic low back pan” +acupuncture (5,020)

“red clover” + “Hot Flushes” (3,760 hits) “red clover” +"menopausal symptoms”

(5,570) St. Johns Wort +Coumadin (9,090 hits)

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Researching Background Questions What are the standard treatment

for back injury? What is acupuncture? What are Black Cohosh, Red Clover,

and Estroven used for today? What is atrial fibrillation? What are St. Johns Wart, and

Valerian used for?

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Background CAM Resources

The Natural Medicines Comprehensive Database

Provides evidence-based clinical data on dietary supplements and natural products.

Designed for medical professions and updated daily.

Products can be searched by scientific names, common names, or brand names or by ingredients. Search: Black Cohosh

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Search Results

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• 1998, a division of NIH. • Exploring CAM and alternative healing

practices in the context of rigorous science. • Educating and training CAM researchers,

disseminating authoritative info. to the public and professions <http://www.nccam.nih.gov/>

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MEDLINEplus • Access to info about specific diseases and

conditions.• Links to self-help groups, consumer health info,

clearinghouses, list of CAM practitioners. in Spanish and other languages, and clinical trials.

• Alternative Medicine <http://www.nlm.nih.gov/medlineplus/alternativemedicine.html>

• Back pain <http://www.nlm.nih.gov/medlineplus/backpain.html>• Interactive Tutorial

<http://www.nlm.nih.gov/medlineplus/tutorials/backpain.html>• Chiropractic

<http://www.nlm.nih.gov/medlineplus/chiropractic.html>• Acupuncture

<http://www.nlm.nih.gov/medlineplus/acupuncture.html>

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Researching Foreground Questions

• How effective is spinal manipulation or acupuncture compared with NSAID in reducing back pain in your patient?

• What are the risks of HRT use, particularly with respect to CHD events, compared with no HRT?

• What are the efficacy of black cohosh, red clover and estroven in reducing menopausal symptoms?

• What is the efficacy of St. John Wart in treating a hypertensive patient with depression and atrial fibrillation?

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Formulating Patient Centered Questions

P = Patient/Population/Problem I = Intervention/exposure or

prognostic factor C = Comparison/Control O = Outcome/s

Framing PICOCase #1: Back pain

• Given a 25-yr male restaurant manager with chronic neck/back pain (P), does acupuncture or chiropractic Rx (I) compared with ibuprofen and/or naprosyn (C) reduce symptoms of neck and back pain (O)?

Case #2: Women’s Health and Menopause

• In female with menopausal symptoms, do natural hormones (estroven, black cohosh, and red clover) compared to HRT or no Rx, relieve menopausal symptoms and reduce the risk of heart disease?

Case #3: Congestive Heart Failure and Herbals

• In elderly men with hypertension and atrial fibrillation, do multiple supplements, herbs and vitamins interact with heart and blood thinner medications, compared to medications only produce poor control of Digoxin and unstable Coumadin levels?

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Primary vs.

Secondary Sources

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Primary Source: Original Research, RCTS - CAM on PubMED

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PubMed Search Results

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Critical Appraisal

Protocols for validating quality of research articles • Therapy = RCT• Diagnosis = Sensitivity/Specificity, Predictive Value

of Tests• Etiology = Cohort, Case-Controlled Studies• Prognosis = Cohort, Follow-up Studies, Mortality• Screening/Prevention• Systematic Review • Practice Guidelines• Economic Analyses

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Critical Appraisal - Therapy

Are the Rx and control groups similar?• Were patients randomized?• Were the benefits of randomization preserved

through use of concealment and intention-to-treat analyses?

Did the treatment and control groups remain the same with respect to important prognostic factors?

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Application to Patient

What were the results?• What is the estimate of the effect?• How precise is this estimate of the effect?

Can the results be applied to your patient?• Is your patient similar to the patients in the

study?• Were all important outcomes examined?

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Secondary SourcesExample 1: PubMed Clinical Queries – Systematic

Reviews

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Secondary SourcesExample 2: The Cochrane Library Systematic

Reviews

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Secondary SourcesExample 3: ACP Journal Club• A publication of the American College of

Physicians, and BMJ Evidence. • Screen and identify studies, then provide

abstracts with commentary.

Tertiary evidenceBandolier Complementary and Alternative

Therapies • Include acupuncture, homeopathy, massage,

herbal medicine, supplements, and safety concerns.

• Provides abstracts of systematic reviews, meta-analyses on CAM studies.

• Extracts info from secondary reviews of primary trials.

• Contains over 100 summaries on the effectiveness of CAM, e.g., Arthritis, bones and joints <http://www.jr2.ox.ac.uk/bandolier/booth/booths/bones.html>

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Workshop Summary

• Review EBCAM Process• The EBM Guidebook

http://www.ucihs.uci.edu/com/meded/pd/PDPFD/EBM%20Guidebook1.pdf

• The Critical Appraisal Worksheets http://www.cebm.utoronto.ca/teach/materials/caworksheets.htm

• Links UCI Libraries CAM Resources <http://www.lib.uci.edu/online/subject/clinical/clinalt.html>

• Evaluated learners EBCAM knowledge and skills : the interactive EBCAM case exam: <http://meded.lib.uci.edu/database/ebcam/camexam.php>

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Challenges

• Lack of clinical knowledge, e.g., Identify valid questions that are patient-based

• Finding the appropriate literature for a CAM case study

• Keeping up with the literature.• Self learning and motivation• Time• Teaching different levels of learners• Getting support from library administration

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Thank you!

Questions?