Over the last years it the amount of biomedical information published has reached an unstoppable progression. One ophthalmologist fully dedicated would only reach a very little proportion of the information published, during his working day. Testing if the studies’ conclusions are generalizable and applicable to his environment would also require knowledge and basic skills, to systematize and interpret the scientific literature. Today it has become increasingly crucial that ophthalmologists be able to make clinical decisions based on the best levels of evidence (1,2):
Therefore, the practice of Evidence-Based Ophthalmology (EBO) not only requires reading scientific articles, but also reading the right articles at the right time and then modifying the physician’s behavior in light of what has been found. All the information searched and critical evaluation will be futile, if similar effort is not made towards the valid application of the evidence and in the measurement of progress towards the objectives.
There are many advantages described for patients and ophthalmologists coming from the practice of EBO, that could be summarized as (3,4):
Greenhalgh (5) published an article in the British Medical Journal proposing an 8-stage model of a checklist to assess the weight that EBO had on the clinical practice of health professionals:
All ophthalmologists should know the principles of Evidence Based Medicine (EBM) and have a critical attitude to their own practice and what the evidence provides. Without these professional skills, it is not possible to provide the best possible practice (6).
For a correct joint decision making it is required that ophthalmologists and patients identify and integrate the most relevant evidence. However, the authors of the “Evidence Manifesto” (7) reflect on the fact that patients health care may be is affected by serious defects in creation, disclosure and implementation of medical research.
Ophthalmologists and patients often do not recognize the importance of this problem and how it can profoundly affect the levels of health care they provide or receive. According to published data in the literature, between 20% and 50% of all health services provided in the United States of America (USA) could be inadequate, wasting resources and/or not improving the health status of patient’s health (8-12). Although there are many causes for this problem, the majority can be attributed to the poor information quality that doctors and patients rely on to make decisions about the health services they provide or receive.
The lack of information in medicine and ophthalmology includes 4 problems fundamentally (13):
A survey was conducted to obtain information regarding the sources ophthalmologists rely on to incorporate new medical knowledge into their practice, that was mainly distributed to USA physicians (14). Most of the respondents preferred recommendations from consensus of their most prominent academic colleagues, as well as leaders’ opinion.
Regarding authorship of a journal article, ophthalmologists selected a superior opinion leader, or any opinion leader trained at a university. Overwhelmingly, they preferred articles in a subspecialty journal or in a high-impact, multi-specialty publication. Journals were considered the most important source of information, while a conference in a large congress was also highly qualified.
The authors of the “Evidence Manifesto” reflected on the possible measures to obtain more reliable Evidence. Among the recommendations that stood out was to encourage the next generation of leaders in medicine to acquire skills to evaluate and apply the best available evidence to the patient’s care. Therefore, they also considered it a priority to educate professionals, political representatives and public in EBM. High-quality and important research must be understandable and informative for a large audience, however, most of the currently published research is not aimed at a non-specialized public, it is often poorly constructed and is based on lack of training and orientation in this area. To make fair and informed judgments about the value and relevance of the evidence, people should have access to research and have the proper skills to make informed decisions that support their own health (7).
It has been published by a systematic review of teaching EBM in postgraduate settings (15) that standalone teaching improves knowledge, but has not effects on skills, attitudes or behavior. On the contrary, all these improve by clinically integrated teaching. Only two randomized controlled trials (RCTs) support these results.
The authors explain that clinically integrated teaching of EBM is likely to bring about changes in attitudes, skills and behavior. Changes in attitude would be beneficial for patient care, due to patient’s behavioral changes. They suggest the importance of integrating and incorporating teaching of critical appraisal in daily clinical practice. Moreover, the importance of availability of resources and facilities should include teaching as a “real time” event with the objective of teaching EBM skills and improving care with the best evidence. Only when real time teaching is not possible, traditional teaching settings, such as journal clubs, can be adapted to actual clinical problems. In other words, this process is not an academic exercise, but how doctors obtain and provide information of care.
One of the objectives of EBM is to combine the best research evidence with clinical abilities and patient’s preferences, including as a final objective to improve care. Not only changes in knowledge and skills would be necessary, but changes in attitudes and behavior would also be required. As it was explained before, although it requires considerable effort, teachers of critical appraisal should bring teaching out of classrooms into the clinic. The authors suggest for future studies to examine the results as long-term outcomes, because learning outcomes can deteriorate over time.
A hierarchy of different teaching strategies was introduced by Khan and Coomarasamy (16). They suggest that interactive classroom-based activities would bring about better learning outcomes compared to didactic but clinically integrated and standalone teaching. Multiple different strategies are explained in the literature, that could be used by EBM teachers, who should try to find how to best use them. Teaching and learning EBM can be associated to different efficacy levels to improve knowledge, skills, attitudes and clinician’s behavior. To solve this, based on educational evidence, the authors of this review propose a hierarchy of teaching and learning methods for EBM:
Nowadays it is very easy to find information about health, although the quality of this information is variable. There is not a clear way to evaluate claims about health interventions, which makes people’s health decisions misinformed and sometimes unsafe. Cusack et al. conducted a systematic review with the primary objective of identifying and assessing studies of educational interventions designed to improve people’s understanding of concepts needed for the evaluation of claims about the effects of health interventions. In the short-term, people’s knowledge and skills can improve due to the educational interventions, although the effects on confidence, attitude and behavior are not clear enough. Several studies were at moderate risk of bias. There is a need to improve quality of studies as well as measurements of long-term effects to improve the confidence in estimates of the effects of educational interventions with the objective of improving people’s understanding the essential ideas for evaluating health intervention demands (17).
Clinical decisions should be based on the Evidence. As it has been shown the EBO provides many advantages not only for patients but also for doctors. Furthermore, all ophthalmologists should know and put into practice the principles of EBM to provide the best possible care with the best evidence.
