Adaptation of an Evidence-Based Intervention for Disability Prevention, Implemented by Community Health Workers Serving Ethnic Minority Elders.

INTRODUCTION: Changing demographics have created substantial unmet needs for mental health and physical disability services for immigrant and racial/ethnic minority elders. Workforce shortages can be reduced by task-shifting to community health workers (CHWs) who speak the same language and share the culture of these elders. Yet, implementation of interventions offered by CHWs requires adaptations of content and delivery, ideally under clinical supervision. OBJECTIVE: To culturally adapt two evidence-based interventions, offered in community settings, to address mental health and physical disability prevention for diverse minority elders. METHODS: We followed the Castro-Barrera stepped model for cultural adaptation of two evidence-based interventions into one combined program of disability management and prevention delivered by CHWs. We used feedback from key stakeholders, including four clinical supervisors, 16 CHWs, 17 exercise trainers, and 153 participants, collected at three time points to further adapt the intervention to a diverse population of elders. RESULTS: Adaptations for administration by CHWs/exercise trainers included: systematization of supervision process, increased flexibility in sessions offered per participants' needs, inclusion of self-care content, modification of materials to better reflect elders' daily life experiences, and greater focus on patient engagement in care. Areas for additional adaptation included enhancing examples with culturally relevant metaphors, incorporating visual aids, and training CHWs in the importance of building trust. CONCLUSION: This study identifies key aspects of the cultural adaptation process that facilitates broader cultural sensitivity of service delivery by CHWs to diverse elders in community settings.

For the general internist: a review of relevant 2013 innovations in medical education.

We conducted a review of articles published in 2013 to identify high-quality research in medical education that was relevant to general medicine education practice. Our review team consisted of six general internists with expertise in medical education of varying ranks, as well as a professional medical librarian. We manually searched 15 journals in pairs, and performed an online search using the PubMed search engine for all original research articles in medical education published in 2013. From the total 4,181 citations identified, we selected 65 articles considered most relevant to general medicine educational practice. Each team member then independently reviewed and rated the quality of each selected article using the modified Medical Education Research Study Quality Instrument. We then reviewed the quality and relevance of each selected study and grouped them into categories of propensity for inclusion. Nineteen studies were felt to be of adequate quality and were of moderate to high propensity for inclusion. Team members then independently voted for studies they felt to be of the highest relevance and quality within the 19 selected studies. The ten articles with the greatest number of votes were included in the review. We categorized the studies into five general themes: Improving Clinical Skills in UME, Inpatient Clinical Teaching Methods, Advancements in Continuity Clinic, Handoffs/Transitions in Care, and Trainee Assessment. Most studies in our review of the 2013 literature in general medical education were limited to single institutions and non-randomized study designs; we identified significant limitations of each study. Selected articles may inform future research and practice of medical educators.

The consequences of authentic early experience for medical students: creation of metis.

CONTEXT: Authentic early experience (AEE) describes experiences provided to new medical students to undertake 'human contact' to enhance learning. Although the concept of AEE is not new, and was commonplace prior to the Flexner Report of 1910, little is known about how or why meaning and knowledge are constructed through early student placements in medical, social and voluntary workplaces. Variance among settings means AEE is a collection of non-uniform, complex educational interventions which require students to make repeated transitions between different workplaces and their university institution. The purpose of this paper is to develop theory in this context. METHODS: We report on a study undertaken in a UK medical school using interviews and discussion groups to generate data from students, workplace supervisors and school faculty staff. We used narrative analysis to access knowledge and meaning construction, in combination with analytic tools drawn from thematic and interpretative approaches to phenomena. We sought to refine theoretical understanding through the application of metis, a socio-cultural theory novel to the field of medical education. RESULTS: Scott's concept of metis provides a useful theoretical framework for understanding how AEE works for students in terms of their creation of meaning and how they choose to use it in relation to formally recognised knowledge. Knowledge and meaning, generated as a consequence of AEE, contained dichotomies and paradoxes. Students improvised, in the face of unpredictability and uncertainty, to create a form of metis that allowed them to handle the perceived competing demands of AEE settings and the medical school. DISCUSSION: We demonstrate how meaning making can be conceived of as student metis arising from social processes in students' learning interactions. We suggest that the development of collaborative working with students could potentiate positive forms of student metis, thereby maximising desirable educational consequences. Further work is required to establish effective ways to do this.

Teaching evidence-based medicine in Mexico: a systematic review of medical doctor curriculums at a national level.

OBJECTIVES: To assess the teaching of evidence-based medicine (EBM) in medical curriculums. As a secondary objective, we assessed the representativeness of science courses related to EBM. DESIGN AND SETTING: Systematic review. Accredited curriculums by the Mexican Council for the Accreditation of Medical Education. MAIN OUTCOME MEASURES: We provided a descriptive analysis of the required or elective EBM courses and EBM-related courses, academic credits and teaching period. EBM-related courses included research methodology, epidemiology, biostatistics, clinical research, public health, clinical epidemiology, scientific dissemination and health informatics to explore scientific education and training offered by medical schools. Additionally, we examined the curriculum's structure, location, type of institution, total programme duration and academic credits. Data collection occurred from December 2020 to February 2021. RESULTS: We identified 171 registered curriculums, of which we assessed 60 unique programmes (50% public) in our analysis. We identified 16 EBM single courses on the fifth and sixth semesters, of which 12 (20%) were mandatory and 4 were electives (6.7%). The allocated academic credits for EBM courses are minimal, without difference between public or private institutions, representing 0.08% of the total curriculum. Public health, epidemiology, research methodology and biostatistics courses are offered with greater frequency (55% or less) and curricular value (0.6% or less). In some cases, they are taught as combined courses. Clinical research, health informatics and clinical epidemiology are taught less than EBM, while scientific dissemination is nil. CONCLUSION: In Mexico, EBM teaching is limited to only one of five curriculums with minimal curricular value. A comprehensive curricular review is necessary across programmes to incorporate EBM as a first step to improve medical education and, consequently, public health. We call to action through an online, collaborative platform with several applications to optimise teaching of EBM. REVIEW PROTOCOL REGISTRATION: The systematic review protocol is excluded from the International Prospective Register of Systematic Reviews since this platform only accepts systematic reviews with health-related outcomes. Review protocol registration: https://osf.io/3xm2q/.

Grading strength of recommendations and quality of evidence in clinical guidelines: report from an american college of chest physicians task force.

While grading the strength of recommendations and the quality of underlying evidence enhances the usefulness of clinical guidelines, the profusion of guideline grading systems undermines the value of the grading exercise. An American College of Chest Physicians (ACCP) task force formulated the criteria for a grading system to be utilized in all ACCP guidelines that included simplicity and transparency, explicitness of methodology, and consistency with current methodological approaches to the grading process. The working group examined currently available systems, and ultimately modified an approach formulated by the international GRADE group. The grading scheme classifies recommendations as strong (grade 1) or weak (grade 2), according to the balance among benefits, risks, burdens, and possibly cost, and the degree of confidence in estimates of benefits, risks, and burdens. The system classifies quality of evidence as high (grade A), moderate (grade B), or low (grade C) according to factors that include the study design, the consistency of the results, and the directness of the evidence. For all future ACCP guidelines, The College has adopted a simple, transparent approach to grading recommendations that is consistent with current developments in the field. The trend toward uniformity of approaches to grading will enhance the usefulness of practice guidelines for clinicians.

We must convince the government to invest in the health workforce.

In New York on 21 September, a potentially game-changing report was submitted to the secretary general of the United Nations.

Evidence-Based Approach to Advanced Wound Care Products.

There is increasing pressure from industry to use advanced wound care products and technologies. Many are very expensive but promise to reduce overall costs associated with wound care. Compelling anecdotal evidence is provided that inevitably shows wounds that failed all other treatments but responded positively to the subject product. Evidence-based medicine is the standard by which physician-scientists must make their clinical care decisions. In an attempt to provide policy makers with the most current evidence on advanced wound care products, the Department of Veteran Affairs conducted an Evidence-based Synthesis Program review of advanced wound care products. This paper suggests how to take this information and apply it to policy to drive evidence-based care to improve outcomes and fiduciary responsibility.

Evidence-based laboratory medicine as a tool for continuous professional improvement.

BACKGROUND: Evidence-based medicine (EBM), defined as "the conscientious, explicit, and judicious use of the current best evidence in making decisions about the care of patients," seems a tool (a "new paradigm") able to meet individual clinical experience with robust observations. EBM has been driven by the need to manage information overload by cost control and by public request for the best in diagnostics and treatment. METHODS: The application of EBM in laboratory medicine or evidence-based laboratory medicine (EBLM) is aimed to advance clinical diagnosis by researching and disseminating new knowledge, combining methods from clinical epidemiology, statistics, and social science with the traditional pathophysiological molecular approach. RESULTS: EBLM, by evaluating the role of diagnostic investigations in the clinical decision-making process with emphasis on measurable outcome, can help both in improving the quality of new scientific findings and in translating the results of good-quality research into everyday practice. CONCLUSIONS: Since there is a need to integrate many educational tools to focus the strategy on promoting the implementation of best practices, the STARD proposal for robust diagnostic test primary studies, the presence of systematic reviews of high quality, and the development of valid guidelines based on the best scientific evidence may be useful to promote an a evidence-based culture for appropriateness, efficiency, and effectiveness in laboratory medicine.

Primer on clinical practice guidelines.

Clinical practice guidelines (CPGs) are valuable tools for health care providers and support evidence-based medicine (EBM). Many organizations, including medical associations and government-affiliated agencies, develop and publish guidelines using varying methods. Unfortunately, many guidelines are not appropriately developed and certain recommendations are not based on the best available evidence. Recent efforts by EBM advocates are contributing to the improved quality of CPGs and more tools are becoming available to promote high-quality guideline development and use. This article describes the guideline development process and associated concerns and the advances in the field of CPGs. Tools to access and evaluate guidelines are also provided. Health care professionals equipped with an understanding of the process of guideline creation and tools for evaluation can appropriately utilize guidelines to improve patient care.

Conocimientos de medicina basada en evidencia en profesionales de la medicina / Knowledge of medical professionals on evidence - based medicine

La medicina basada en evidencia (MBE) representa un nuevo modelo de investigación y en la práctica médica es sinónimo de actualización. Esta práctica permite identificar la evidencia obteniendo resultados óptimos en la atención de pacientes. Objetivo: Determinar el conocimiento sobre el signifi-cado de medicina basada en evidencia y la forma correcta de aplicarla por parte de los profesionales de la medicina. Se aplicaron entrevistas en el Congreso Médico Nacional realizado en San Pedro Sula en el 2011. Metodos: Estudio descriptivo, de corte transversal sobre los conocimientos de los profesionales de la medicina en el tema de MBE previo consentimiento informado para la aplicación de la entrevista. Se entrevistaron un total de 428 médicos aprovechando la realización del Congreso Médico Nacional en la Ciudad de San Pedro Sula en Agosto del 2011. Resultados: La gran mayoría de los entrevistados no conocen el concepto de medicina basada en evidencia y no la aplicarán a su práctica clínica diaria. Conclusiones: El conocimiento sobre MBE del profesional de la medicina, es prácticamente nulo. Se evidencia la necesidad de formar desde estudiante al profesional de la medicina y aprofesores de pregrado en las escuelas de formación de recursos médicos...(AU)

Estudo da aplicação de evidências científicas na prática clínica pelos profissionais médicos do município de Juiz de Fora / Study of evidence-based practice of medical doctors in Juiz de Fora

A Medicina Baseada em Evidências (MBE) visa a melhoria da qualidade da abordagem do paciente, através da integração da melhor evidência científica disponível, da experiência clínica do médico e das particularidades de cada paciente. A prática da MBE permite ao médico uma atualização adequada sobre os temas relativos à sua área de atuação, pois proporciona a possibilidade de filtrar e selecionar as informações científicas, para, então, avaliá-las, julgá-las e utilizá-las em sua realidade profissional. Avaliou-se o conhecimento e a utilização da MBE, pelos médicos do município de Juiz de Fora - MG, na sua prática diária. Foi realizado estudo observacional transversal com análise de 102 questionários estruturados, respondidos pelos próprios médicos, de uma amostra aleatória simples. Dentre os entrevistados, 87 (85,2%) exercem alguma especialidade, 12 (11,7%) são generalistas, 35 (34,5%) são docentes e 52 (51,0%) atuam em hospital com residência médica. Falta de tempo foi apontada por 82 (80,4%) médicos como a maior dificuldade para a atualização profissional. O tipo de trabalho científico mais lido (27 - 26,9%) foi o artigo de caso clínico. O fator destacado como de maior peso na tomada de decisão foi a experiência pessoal (55 - 61,8%) e diferença estatisticamente significativa foi encontrada entre as respostas dadas em relação a esse fator, quando o médico era docente e/ou atuava como preceptor em hospital com residência médica. A MBE ainda não se encontra sistematicamente presente na prática profissional de significativa parcela de médicos do município e necessita receber uma maior valorização por parte destes.

Evidence-Based Medicine (EBM) aims to improve the medical approach to the patient through the integration of the best available scientific evidence, the physician's experience and the particular features of each patient. EBM makes it easier for the doctor to keep abreast of advances in their of expertise, as it can filter and select the most reliable scientific information before the latter is appraised and adapted to the professional reality. This study assessed knowledge about and use of EBM by physicians of the municipality of Juiz de Fora, MG, Brazil in their daily practice. The cross-sectional observational study used a structured questionnaire to be answered by 102 physicians from a simple random sample. 87 (85.2%) were specialists, 12 (11.7%) were general practitioners, 35 (34.5%) were medical teachers and 52 (51.0%) practiced in a hospital with a residency program. 82 (80.4%) physicians stated that lack of time was the main issue hindering continuing medical education. Case reports were the most frequently read material (27 physicians - 26.9%). Personal experience had the greatest weight in decision-making for 55 (61.8%) physicians, with a statistically significant difference being found regarding the answers to this item, when the physician was a medical teacher or worked as a tutor in a hospital with a residency program. Because EBM is not systematically present in the professional practice of a significant percentage of physicians of the Juiz de Fora municipality, its full value should still be understood.

Levels of evidence and grades of recommendations in general thoracic surgery.

OBJECTIVES: To determine the grades of recommendations and levels of evidence available if the formal practice of evidence-based medicine is applied to general thoracic surgery. METHODS: Three general thoracic surgeons, by consensus, developed a sample of 10 clinically important questions. The first 3 steps of evidence-based medicine (creation of answerable clinical questions, search for best external evidence, and critical appraisal of literature) were performed. Abstracts and appropriate articles were identified through Medline from January 1999 through December 2001. A hierarchical series of search strategies was employed to identify the best level of evidence. The best evidence found was categorized according to the Oxford Centre for Evidence-Based Medicine into 4 grades of recommendations (A-D) and 5 levels of evidence (1-5). RESULTS: The best evidence found for the 10 sample questions was categorized as grade A recommendations in 5 and grade B, also in 5 questions. The levels of evidence found were la in 3 studies, 1b in 5, and 2b in 2. CONCLUSIONS: A formal evidence-based-medicine approach to general thoracic surgery found the grades of recommendation and levels of evidence for a sample of clinically important questions to be high.