Should we teach evidence based medicine or information management?

So asks an article in Clinical Orthopaedics and Related Research this month. Evidence Based Medicine seeks to encourage the appraisal of the best evidence to answer clinical questions but this is not always practical in clinical practice: who has time to do a systematic review at the bedside?

The authors of the paper say that in order to triumph opinion and established methods in orthopaedic surgery clinicians need to be able to move beyond critical appraisal and know what sorts of information to use. The article distinguishes between ‘foraging’ and ‘hunting’ tools: ‘foraging’ tools are current awareness tools that alert a clinician to new resources in their field.

However, information obtained in this way rarely results in the clinician’s learning more than simply that the actual information exists (life would be so much easier if we could read something once, reflect on it, and thenremember it flawlessly when it is needed). Thus, a hunting tool is needed to retrieve relevant and valid information quickly when it is required in the care of patients. (page 2335-6)

These are clinical decision making aids and they summarise actions whilst including evidence quality gradings and take into account patient outcomes. This of course is not revolutionary, just interesting to read from a clinical point of view what library services are useful for and how to differentiate them and sell them in the language used by clinicians. Importantly the articles says that not all clinicians need to be fully competent in all 5 levels of EBM knowledge and practice (developing a quesiont, finding the evidence, evaluating the evidence, applying the evidence and reviewing ongoing practice) but in a competency based model of the 3 stages of information management they have different needs at different stages in their career or depending on their role. The information management framework says that they should at level 1 manage information at the point of care, at level 2 select the appropriate hunting tool and by level 3 they should be making patient-centered (and interestingly not evidence-centered) decisions. Perhaps it could be termed moving from the academic view of EBM to a more pragmatic applied view.

Orthopaedic surgeons work in a world in which access to medical information can provide rapid answers to queries. Taking that information access a step further would be to have access to high quality information that gives answers based upon EBM, that is relevant to the patient, has been analyzed and validated by EBM experts and is now ready to use. Information management is the engineering science that connects the surgeon to the high quality information when and where it’s needed. Working backward toward our orthopaedists in training, learning to apply information management to patient-centered care requires a shift. That shift is away from wrestling with the 5 steps of EBM and moving to the appropriate level of IM. (page 2638)