Why Bother with EBR?

"Medical practice is largely based on clinical anecdotes, uncontrolled investigations and expert opinion. The demand for scientific evaluation to guide patient care is increasing because financial resources are limited and because practice based on such influences may be inappropriate. In radiology, the situation is especially problematic…. Few radiology programs address and encourage critical thinking skills." [1]

"Radiologists need to be able to critique studies in the literature – in other words, how reliable is this information and does it apply to the population of patients in the radiologist’s practice?" [2].

"To improve understanding of the value and methods of research, all trainees and faculty should receive basic instruction in critically reading the medical literature, experimental design and biostatistics. Those wishing to conduct research should receive more extensive training" [3]

Patients are becoming ever more aware of their options yet for us, the practising radiologists, finding reliable, up-to-date evidence on current problems in radiology may be complex and daunting. When we try to decide between imaging or interventional options, we may find that our textbooks are out of date, guidelines are not specific enough and there are conflicting or apparently unreliable reports in the literature. Expert opinions and policies vary from centre to centre and even the definition of what ‘evidence’ means varies between experts.

Some recommend we use the ‘consensus of experts’ approach. The reliability and reproducibility of this type of evidence is questionable [4, 5]. Others recommend the use of guidelines that are based on expert appraisal of the literature [6, 7]. These are roughly equivalent to a consultation with experts but may not answer our specific question well, be based on strong evidence or take into account new developments and local circumstances. When we go to the literature ourselves, the first problem we encounter is the volume of literature being published and the next is (for most of us) lack of training in how to separate the good studies from the weak ones.

These problems exist in Internal Medicine and other specialities also. In the early 1990’s, a group of physician-epidemiologists in McMaster University responded with what has since become known as the ‘Evidence-Based Medicine’ (EBM) paradigm [8]. In the late 1990’s, one of these people (Dave Sackett) moved to Oxford and began similar work within the NHS [9]. These doctors developed ways of efficiently tracking down and appraising literature and ‘wrote them up’ so that other doctors, who did not have formal epidemiological training, could use them. With the advent of the Internet, any radiologist who is willing to put some time aside for ‘problem solving’ as part of his / her continuous professional development can now use these methods do a great deal of literature exploration, targeted to finding ‘best current evidence’ on problems encountered in day-to-day practice. The retrieved literature can be evaluated in his / her own Department or Office without needing academic input or library facilities on-site. Solutions that work for individual problems and circumstances can be derived and put into practice, with a clear awareness of their limitations. This is the paradigm that Glasziou has named 'Bottom-up' Evidence-Based Practice (EBP). This website deals with issues arising from the application of this paradigm to the practice of Radiology - 'Evidence-Based Radiology' (EBR)

If you want to learn more about EBR, we suggest you explore our website and incorporate it into your personal information management strategy. You will get the most out of this site if you bring a ‘knowledge gap’ question from your own practice to the site and try to work through it in several 1-hour sessions using these techniques. Speed comes with familiarity – take your time initially. It may help to work with an interested colleague.

Summary
The purpose of this website is to help radiologists who, like us, have no postgraduate specialist training in research to use ‘Evidence-Based Medicine’ (EBM) and, where appropriate, ‘Technology Assessment’ principles to find answers that are based on best current evidence for problems arising in their practice. This website should allow radiologists to:

• Design questions that will form the basis for literature searches.
• Search the literature efficiently, using easily accessed web resources.
• Manage references
• Get the relevant papers (even if they do not have a local medical library)
• Critically appraise retrieved literature on diagnostic and interventional radiology.
• Access ‘Evidence-Based’ publications on critical appraisal of other types of papers.
• Access ‘Evidence-Based’ literature on the application and evaluation of research findings in practice.
• Look at examples of ‘Single Searches’, ‘Critically Appraised Topics’ and ‘Evidence-Based Radiology’ Reviews. The latter were prepared by the Residents (R2, R3) and Fellows (R5) of our ‘problem-based learning’ group. The contribution of those Residents and Fellows to the quality of our health care delivery is gratefully acknowledged.

Use the following Notes on Related Concepts for more background information.
Notes on 'Bottom-up' EBP: This explains the background theory of the McMaster / CEBM EBP process.
Notes on Technology Assessment: This will be of interest to radiologists primarily interested in designing research studies.
Notes on Problem-based Learning: How adults learn best and how this can be to your advantage in the EBR / CPD interface.

References
1. Hillman BJ, Noninterpretive skills for radiology residents. Critical thinking: deciding whether to incorporate the recommendations of radiology publications and presentations into practice.
AJR Am J Roentgenol 2000; 174 (4):943-946. [ link ]

2. Thornbury JR, Why should radiologists be interested in technology assessment and outcomes research?
AJR Am J Roentgenol 1994; 163 (5):1027-1030. [ link ]

3. Beam C, Blackmore C, Karlik S ,Reinhold C, Editors' introduction to the series.
AJR Am J Roentgenol 2001; 176 (2):323-325. [ link ]

4. Skrabanek P, Nonsensus consensus.
Lancet 1990; 335 (8703):1446-1447. [ link ]

5. Sackett DL, Strauss SE, Richardson WS, Rosenberg W ,Haynes RB, Introduction, in Evidence Based Medicine; How to Practice and Teach EBM. 2000, Churchill Livingstone: Edinburgh. p. 1-4. [ link ]

6. The Royal College of Radiologists, Making the Best Use of a Department of Clinical Radiology (4th Ed.). 1998; [ link ]

7. ACR Appropriateness Criteria. [ link ]
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8. Health Information Research Unit (HIRU): Evidence-Based Health Informatics. McMaster University, Hamilton, Ontario, Canada. [ link ]

9. Centre for Evidence Based Medicine. Oxford University, Levels of Evidence and Grades of Recommendations. [ link ]