COMPONENT 1: EVIDENCE-BASED MEDICINE

There are two important principles on which EBM is based. The first principle is that physicians must stay current on treatment protocols that will address the specific needs of their patients. Learning in medicine doesn’t stop outside the classroom and doesn’t end after training. Much of what physicians learn in medical school will be outdated or disproved within 10 years; hence, for the sake of their patients’ well-being, physicians must acquire the ability to evaluate current medical knowledge and treatment and incorporate it into practice.

The second important principle of EBM is that one must be able to critically appraise and validly assess reported evidence. This process requires basic knowledge of study design and statistics to judge the internal and external validity of a study. There are many different systems to define levels of evidence and grade of recommendation.^1–4 These systems are similar, although no single system is used across all disciplines. The level of evidence (usually scaled from I to V) is used to describe the quality of evidence from a particular study. The grade of recommendation (usually scaled from A to D) is based on the quality and quantity of that evidence. The Cochrane Collaboration publishes a helpful glossary of related terminology.⁵

Critical analysis of lay and academic literature is even more important in the age of the Internet as patients come to doctors’ offices more informed by resources that may be incomplete or inaccurate. The Internet has become an invaluable source of information offering easy access at the point of care. However, ensuring the quality of the content can be extremely difficult. Traditional medical journals offer some reassurances that the authors’ materials have been peer reviewed and that the authors have no conflict of interest, financial or otherwise. Identifying the authorship of material on the Web is often difficult, and ensuring intellectual integrity and quality may be impossible. Medical societies are becoming valuable tools to help ensure the intellectual integrity and validity of materials by offering a portal to relevant information. Several sites, such as those from the American College of Surgeons (ACS; www.facs.org) or the American Association of Medical Colleges (AAMC; www.aamc.org), offer access to peer-reviewed educational material.

In addition to online medical journals and the sites of various medical societies, an important tool in researching new techniques and treatments is the use of review articles and consensus statements. One caveat about review articles is that they must be read carefully to determine whether a thorough literature search has been done and to ensure that the review results are not impacted by author bias. Consensus statements are usually promulgated by national organizations and offer concise and complete reviews of clinical issues. The clinical treatment options outlined in consensus statements emphasize patient care and outcomes. For example, the American Society of Colon and Rectal Surgeons (ASCRS) published an article, “Practice Parameters for Sigmoid Diverticulitis,” published in Diseases of the Colon and Rectum.⁶ The Standards Committee of the ASCRS assembled a group of experts who reviewed the best evidence available and developed a set of clinical practice guidelines. Collecting and archiving such guidelines for accessible review is a practice that can be helpful throughout your career.

There are several important tools to use when searching for information in surgery. The Surgical Index (TSI), located on the ACS’s Web site under “periodicals,”⁷ is a monthly review of the current surgical literature distilled into abstract form, sometimes with editorial commentary. The Cochrane Library (www.cochrane.org), which is not specific to surgery, is a collection of evidence-based medicine databases. These quarterly reviews rigorously examine the effectiveness and appropriateness of interventions and treatments and include a “plain language summary.”