A set of strategies designed to assist clinicians in their attempts to base their practice on the best available evidence were first developed at McMaster University in Canada and are often referred to collectively as evidence-based medicine. (11) Evidence-based medicine is a problem-based approach and splits the process into five stages (Fig 1). The process of evidence-based medicine also leads on to another stage—the identification of clinical questions in need of more research.
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Fig. 1 The five stages of evidence-based medicine.
To make evidence-based practice feasible in real-life clinical practice, a number of problems need to be solved at each stage of the process. Formulating a structured clinical question
When uncertainty arises in clinical practice, the clinician needs to formulate a structured clinical question. This step is fundamental to the process of evidence-based medicine because it allows the clinician first to classify the question, second to identify the research architecture that is most likely to yield a reliable result, and finally to determine the most efficient way of looking for the most reliable research.
Consider a patient who is suffering from a chronic mild depressive disorder. The clinician diagnoses dysthymic disorder but may be uncertain whether recommending an antidepressant would offer any benefit over offering non-specific support for a few sessions. The process of rapidly finding the best answer begins by formulating a clinical question:
1. in patients with dysthymia (the problem)
2. how effective are antidepressants (the intervention)
3. compared with alternative treatments (including none) (the comparison intervention)
4. in alleviating depressive symptoms and improving psychosocial functioning (the outcome)?
The next step is to classify the question. This example obviously concerns a question about therapy. Most of the questions that arise in clinical practice concern therapy, diagnosis, prognosis, or aetiology. Once the question has been formulated and classified, this suggests the most reliable research architecture ( TableJ.).
Table 1 Types of clinical question and most reliable study architecture
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