Revelation of mindlines in the setting of crisis.

During the devastating early months of the unfolding COVID-19 pandemic in New York, healthcare systems and clinicians dynamically adapted to drastically changing everyday practice despite having little guidance from formal research evidence in the face of a novel virus. Through new, silo-breaking networks of communication, clinical teams transformed and synthesized provisional recommendations, rudimentary published research findings and numerous other sources of knowledge to address the immediate patient care needs they faced during the pandemic surge. These experiences illustrated underlying social processes that are always at play as clinicians integrate information from various sources, including research and published guidelines, with their own tacit knowledge to develop shared yet personal approaches to practice.

On crowns, caravans and windmills: Commentary on an essay by Turcotte P., et al.

Patient-oriented research (POR) is a trend that has emerged over several decades and is particularly prominent in Canada, the United States and the United Kingdom. It involves patient and other stakeholder participation in the planning, conduct and dissemination of biomedical and health services research and it can be seen as a form of public participation and engagement in activities that affect the lives and well-being of communities. Criticisms of POR revolve around its susceptibility to tokenistic treatment of patient participants and paternalistic dominance of the research agenda by professional researchers, academics and clinicians.

Evidence-based medicine and problem based learning a critical re-evaluation.

Evidence-based medicine (EBM) has been the subject of controversy since it was introduced in 1992. However, it has yet to be critically examined as an alternative paradigm for medical education, which is how it was proposed. This commentary examines EBM on the terms on which it was originally advanced and within the context that gave rise to it, the problem-based learning (PBL) environment at McMaster University in the 1970s and 80s.

From MARS to MAGIC: The remarkable journey through time and space of the Grading of Recommendations Assessment, Development and Evaluation initiative.

For over 30 years, "evidence-based" clinical guidelines remained entrenched in an oversimplified, design-based, framework for rating the strength of evidence supporting clinical recommendations. The approach frequently equated the rating of evidence with that of the recommendations themselves. "Grading Recommendations Assessment, Development and Evaluation (GRADE)" has emerged as a proposed antidote to obsolete guideline methodology.

Stakeholder-Driven Quality Improvement: A Compelling Force for Clinical Practice Guidelines.

Clinical practice guideline development should be driven by rigorous methodology, but what is less clear is where quality improvement enters the process: should it be a priority-guiding force, or should it enter only after recommendations are formulated? We argue for a stakeholder-driven approach to guideline development, with an overriding goal of quality improvement based on stakeholder perceptions of needs, uncertainties, and knowledge gaps. In contrast, the widely used topic-driven approach, which often makes recommendations based only on randomized controlled trials, is driven by epidemiologic purity and evidence rigor, with quality improvement a downstream consideration. The advantages of a stakeholder-driven versus a topic-driven approach are highlighted by comparisons of guidelines for otitis media with effusion, thyroid nodules, sepsis, and acute bacterial rhinosinusitis.

Teaching Evidence Assimilation for Collaborative Health Care (TEACH) 2009-2014: Building Evidence-Based Capacity within Health Care Provider Organizations.

Background: Clinical guidelines, prediction tools, and computerized decision support (CDS) are underutilized outside of research contexts, and conventional teaching of evidence-based practice (EBP) skills fails to change practitioner behavior. Overcoming these challenges requires traversing practice, policy, and implementation domains. In this article, we describe a program's conceptual design, the results of institutional participation, and the program's evolution.

Relationship-centred care: antidote, guidepost or blind alley? The epistemology of 21st century health care.

Contemporary health care is increasing in complexity and lacks a unifying understanding of epistemology, methodology and goals. Lack of conceptual consistency in concepts such as 'patient-centred care' (PCC) typifies system-wide discordance. We contrast the fragmented descriptions of PCC and related tools to its own origins in the writings of Balint and to a subsequent construct, relationship-centred care (RCC).

Eating a larger number of high-salt foods is not associated with short-term risk of acute decompensation in patients with chronic heart failure.

Background: Risk factors for exacerbation of congestive heart failure have not been consistently validated.

Objective: Our objective was to examine the role of short-term dietary sodium intake in acute decompensated heart failure.

Methods: Patients with chronic congestive heart failure presenting to the Emergency Department for either acute decompensated heart failure (cases) or for other reasons (controls) were included in a case-control study.

The marriage of evidence and narrative: scientific nurturance within clinical practice.

Rationale, Aims And Objectives: Published elaborations of evidence-based medicine (EBM) have failed to materially integrate the domains of interpersonal sensibility and relationship with tools intended to facilitate attention to biomedical research and knowledge within clinical practice. Furthermore, the elaboration of EBM skills has been confined to a narrow range of clinical research. As a result, crucial tools required to connect much clinically relevant research and practice remain hidden, and explorations of the deeper challenges faced by practitioners in their struggle to integrate sound science and shared clinical action remain elusive.

Where is the wisdom? I--a conceptual history of evidence-based medicine.

Rationale Evidence-based medicine (EBM) has been acclaimed as a major advance in medical science, but criticized as a proposed alternative model for the practice and teaching of medicine. Ambiguity regarding the proper role of the contributions of EBM within the fabric of medicine and health care has contributed to this discrepancy. Aims and objectives We undertook a critical review of the history of the EBM movement, beginning with its origins in the 1970s and continuing through this century.

Mapping cognitive overlaps between practice-based learning and improvement and evidence-based medicine: an operational definition for assessing resident physician competence.

Purpose: The complex competency labeled practice-based learning and improvement (PBLI) by the Accreditation Council for Graduate Medical Education (ACGME) incorporates core knowledge in evidence-based medicine (EBM). The purpose of this study was to operationally define a "PBLI-EBM" domain for assessing resident physician competence.

Method: The authors used an iterative design process to first content analyze and map correspondences between ACGME and EBM literature sources.

Subgroup hypotheses: clinician's friend or researcher's fiction?

Researchers and clinicians may be tempted to consider apparent differences in effects of interventions in subgroups of study populations for the purposes of individualizing care or directing subsequent focused research efforts. Such "subgroup hypotheses" have a high propensity of being artifacts of chance and are rarely supported when stringent criteria are applied. Subgroup hypotheses emerging from single trials should rarely if ever be considered for application.

Tips for teachers of evidence-based medicine: making sense of decision analysis using a decision tree.

Decision analysis is a tool that clinicians can use to choose an option that maximizes the overall net benefit to a patient. It is an explicit, quantitative, and systematic approach to decision making under conditions of uncertainty. In this article, we present two teaching tips aimed at helping clinical learners understand the use and relevance of decision analysis.

'A local habitation and a name': how narrative evidence-based medicine transforms the translational research paradigm.

Rationale: We propose narrative evidence-based medicine as a necessary elaboration of the NIH translational research roadmap. The roadmap defined two complex obstacles, T1 and T2, to the progress of research from the 'bench' or basic laboratory science to the 'bedside' or clinical application, the traversal of which requires emergence of complex transformative relationships between the parties and stakeholders. It fails to encompass patient interactions, hesitancies and alliances with medical care.

Do workshops in evidence-based practice equip participants to identify and answer questions requiring consideration of clinical research? A diagnostic skill assessment.

Evidence-based practice (EBP) requires practitioners to identify and formulate questions in response to patient encounters, and to seek, select, and appraise applicable clinical research. A standardized workshop format serves as the model for training of medical educators in these skills. We developed an evaluation exercise to assess the ability to identify and solve a problem requiring the use of targeted skills and administered it to 47 North American junior faculty and residents in various specialties at the close of two short workshops in EBP.

Tips for teachers of evidence-based medicine: clinical prediction rules (CPRs) and estimating pretest probability.

Background: Clinical prediction rules (CPR) are tools that clinicians can use to predict the most likely diagnosis, prognosis, or response to treatment in a patient based on individual characteristics. CPRs attempt to standardize, simplify, and increase the accuracy of clinicians' diagnostic and prognostic assessments. The teaching tips series is designed to give teachers advice and materials they can use to attain specific educational objectives.