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Evidence-Based

Medicine
in Sherlock Holmes’ Footsteps
Evidence-Based

Medicine
in Sherlock Holmes’ Footsteps

Jorgen Nordenstrom, MD, PhD

Professor of Surgery
Karolinska University Hospital
Karolinska Institutet
Sweden
© 2007 Jörgen Nordenström
Published by Blackwell Publishing Ltd
Blackwell Publishing, Inc., 350 Main Street, Malden, MA 02148 5020, USA
Blackwell Publishing Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK
Blackwell Publishing Asia Pty Ltd, 550 Swanston Street, Carlton, Victoria 3053, Australia
The right of the Author to be identified as the Author of this Work has been asserted in accor-
dance with the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system,
or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording
or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without
the prior permission of the publisher.
First published 2007
1 2007
Originally published in Swedish by Karolinska University Press, Stockholm, Sweden
Library of Congress Cataloging-in-Publication Data
Nordenström, Jörgen.
[Evidensbaserad medicin i Sherlock Holmes fotspår. English]
Evidence-based medicine in Sherlock Holmes’ footsteps / Jörgen
Nordenström.
p. ; cm.
Includes bibliographical references and index.
ISBN-13: 978-1-4051-5713-1 (alk. paper)
ISBN-10: 1-4051-5713-5 (alk. paper)
1. Evidence-based medicinevHandbooks, manuals, etc. I. Title.
[DNLM: 1. Evidence-Based Medicine–methods–Handbooks.
WB 39 N832e 2007a]
R723.7.N67 2007
616–dc22 2000602167
A catalogue record for this title is available from the British Library
Set in 8.75/11 pts Minion by Charon Tec Ltd (A Macmillan Company), Chennai, India,
www.charontec.com
Printed and bound in Singapore by COS Printers Pte Ltd
Commissioning Editor: Martin Sugden
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Text and cover designer: Sarah Dickinson
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used have met acceptable environmental accreditation standards.
Blackwell Publishing makes no representation, express or implied, that the drug dosages in
this book are correct. Readers must therefore always check that any product mentioned in
this publication is used in accordance with the prescribing information prepared by the
manufacturers. The author and the publishers do not accept responsibility or legal liability
for any errors in the text or for the misuse or misapplication of material in this book.
Contents

Foreword, vi
Introduction, ix

S T E P 1 Formulate an Answerable Question, 1

S T E P 2 Information Search, 19

S T E P 3 Review of Information and Critical Appraisal, 35

S T E P 4 Employ the Results in Your Daily Practice, 69

Deduction, Analysis and Medicine, 75

References, 78

Summary of Information Sources and Search Engines, 79

Internet-Based Spreadsheets, 81

Sherlock Holmes References, 82

List of Illustrations, 83

Recommended EBM Literature, 84

Glossary, 85

Index, 89

v
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Foreword

When I discuss EBM with patients or the public, they are always surprised to
find this is not something that doctors are not already routinely doing.
Surely medical decisions with such important consequences are informed by
the best available research evidence? Patients may doubt a doctor's diagnos-
tic or procedural skills, but they rarely question a doctor's ability to access
knowledge. We know the reality is different. As Dr Nordenstrom points out:

"Today students and practitioners of medicine have a huge amount of informa-

tion resources at their fingertips, yet many feel uncertain about how to find
the right articles to read and even more uncertain about how to interpret
scientific data."

I would hope that all health care students everywhere now get a ground-
ing in the principles of evidence-based practice. However, I suspect that is
still not so – many medical schools I know spend more time on the inser-
tions of muscles or the Kreb's cycle than on the principles of using medical
research at the bedside. And even when it is taught it can often be seen as
boring. This lively little book makes EBM both appealing and simple. The
appeal to detective work as an analogy and the intimate style make the read-
ing very accessible. And yet, despite its informal style and brevity, it manages
to convey many of the essentials of EBM. Students could read this in a single
evening, and would be much better armed to find and appraise the research
literature relevant to the care of patients.
I hope this short book will stimulate you to read more widely about EBM,
but if not you will have gotten the essentials. I am sure you will remember
the FIRE by PICO matrix and ask better questions and perform better

vi
 Foreword vii

searches. Of course, the book covers just the basic scales of EBM, and you
will need to practice, experiment and improvise to embed these skills as part
of your lifelong learning about medicine. And you may just hear Holmes
leaning over your shoulder saying "Education never ends, Watson. It is a
series of lessons with the greatest for the last."

Paul Glasziou
Professor of Evidence-Based Medicine
University of Oxford
May 2006
viii Foreword

Any truth is better than indefinite doubt.

Sherlock Holmes in The Yellow Face.
Introduction

Evidence-based medicine (EBM) may be defined as “the integration of the

best research evidence with clinical expertise and patient values” [1] and has
been launched as a process by means of which advances in medical research
may come into practical use so as to yield safer, better and more cost-effective
health care. When the EBM concept first began to take hold critical voices
were raised, claiming, among other things, that there was a risk of replacing
clinical judgement with “cookbook medicine”. But EBM has gradually defined
itself and few people would now question its importance, which boils down to
integrating clinical skills with the best available basic information obtainable
based on systematically conducted clinical research.
Evidence is a fundamental concept for many practices (e.g. law and science)
and professions (e.g. detectives and clinicians) and refers to the grounds for
beliefs or judgements. In medicine, evidence is derived from many different
activities including experimentation, observation and experience. The major
contribution of EBM lies in the emphasis it places on a hierarchy of evidential
reliability in which controlled experiments are accorded greater credibility
than other types of evidence [2].
The application of EBM is based on three important principles. Firstly,
high-quality health care rests on objective and clinically relevant information.
Secondly, there is a hierarchy of evidence in which some types of evidence are
stronger than others. Evidence as high up as possible in the hierarchy should
be used and one must know the level at which a clinical decision is based.
Thirdly, scientific data alone will not suffice for making clinical decisions and
issuing recommendations; scientific information needs to be integrated with
sound clinical judgement and the perceptions of patients as to the relative
importance of different interventions and their results.
Today students and practitioners of medicine have a huge amount of
information resources at their fingertips, yet many feel uncertain about
how to find the right articles to read and even more uncertain about how to

ix
x Introduction

interpret scientific data. Additional problems include time shortages in the

health services and a limited knowledge of the tools required (EBM portals,
electronic library resources, etc.).
Information technology and the Internet have radically changed the way in
which we produce data, store information and communicate. These develop-
ments have resulted in a democratization of the availability of information.
More and more patients avail themselves of unsystematic and opinionated
information, which makes new demands on all who work in the health care
services. To guide and inform patients in the face of this torrent of informa-
tion is a new and demanding challenge.
The need for EBM in health care work has gradually increased, partly
owing to the fact that the medical knowledge pool is expanding exponen-
tially. Consider the following:
• More than 15 million medical papers have been published.
• The number of medical journals is in excess of 5000.
• It has been estimated that only some 10–15% of what is published today
will be of lasting scientific value.
• It has been estimated that half of today’s medical knowledge base will be
out-of-date, erroneous or irrelevant in 10 years.

The increased amount of information is usually characterized by such terms

as a superabundance of information, a flood of information and a biblio-
metric explosion – expressions that lead one’s thoughts to natural catastro-
phes and helplessness. Against this background, it is not surprising that the
traditional sources of medical information function poorly:
• Textbooks quickly become outdated.
• As for journals, there are too many of them and they are often irrelevant to
the immediate need.
• Experts may be wrong.

The increase in available information will continue and the ability to handle
new information in general and new scientific data in particular will be a
necessary component of the lifelong learning process. Skills in searching,
evaluating and implementing are more important today than ever before.
When should I change my processing routines? What new developments
should be accepted? And which should be rejected?
The practice of EBM has similarities to detective work. In both instances,
the initial stage consists in being confronted with a “case” in which certain
events have preceded the current situation. In the detective work situation, a
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 Introduction xi

crime has been committed, there is a crime scene, there is a victim and a per-
petrator, and events have occurred that need to be analysed. In the medical
case, there is a patient who presents with certain symptoms and the task at
hand is to make a diagnosis based on these symptoms and try to establish
what preceded the onset of the illness. Both cases require a line of reasoning
involving a temporal review and analysis, the so-called “backward reasoning”,
in order to establish causal relationships. This type of reasoning backwards in
time constitutes an important principle in both health care work and problem-
based learning (PBL). This pedagogic strategy was developed by Barrows
towards the end of the 1970s at McMaster University in Canada, and it is no
coincidence that the EBM concept was later developed at the same university.
Sherlock Holmes is the most famous private detective in history. His cre-
ator, Sir Arthur Conan Doyle, was a physician himself. The prototype of
Sherlock Holmes was Dr Joseph Bell, one of Doyle’s teachers at Edinburgh
University. Doyle has reported how Bell usually tried to diagnose his patients
at the very first consultation, even before they had uttered a single word. He is
said to have been able to recount the symptoms of his patients, give an
account of their medical history and relate details of their daily life with an
amazing degree of accuracy. Sherlock Holmes’ constant companion, Dr
Watson, was a practising physician and Doyle’s alter ego. Thus the two detec-
tives’ technique and modus operandi have, in part, a medical background.
Conan Doyle once stated, “I thought I would try my hand at writing a story
where the hero would treat crime as Dr Bell treated disease.” According to leg-
end, Sherlock Holmes was born on 6 January 1854 and since no obituary has
appeared as yet in The Times, one must assume that he is still alive and in
good health despite his age of more than 150 years. Unconfirmed reports
assert that he is now active as a bee-cultivator in Sussex.
There are a large number of textbooks on EBM. Many of them are of high
quality but have the disadvantage of being too comprehensive to provide a
good initial foundation for the subject. They overshoot the mark as far as
most students and health care professionals are concerned. It is against this
background that this handbook on EBM came about. It has been written
primarily for medical and other health care students, but also for persons
already working in health care.
This handbook is organized in such a way that the reader is led step by
step through a process starting with a patient’s medical history and leading,
via information searches and critical appraisal, to a treatment recommenda-
tion. The handbook lays no claim to being all-embracing but rather is aimed
at giving an introduction to EBM. A list of publications for further study is
xii Introduction

presented at the end of the manual. This would suggest that the famous
quote, “Elementary, my Dear Watson”, might apply to this handbook on the
fundamentals of EBM, but that would be to do Holmes an injustice. In fact,
this quote does not appear anywhere in the Sherlock Holmes stories; it is
only a myth. But EBM is not a myth: it is a valuable tool for achieving an
updated health care service based on scientific data.
The EBM process consists of four steps: “FIRE”.

Step 1: Step 2: Step 3: Step 4:

Formulate an Information Review of information Employ the results in
answerable question search and critical appraisal your clinical practice

Remember FIRE. The different steps in the process will be illustrated in the
following sections.

When a doctor does wrong he is the first of criminals.

He has nerve and he has knowledge.
Sherlock Holmes in The Adventure of the Speckled Band.
 Evidence-Based Medicine in Sherlock Holmes’ Footsteps
Jorgen Nordenstrom
Copyright © 2007 by Jörgen Nordenström
STEP 1 1
Formulate an 2
3
Answerable Question 4

The first step in the EBM process is to Formulate a focused question (FIRE).
A well-formulated question is a prerequisite for getting a useful answer. The
question must be specific and concrete in order to be searchable in databases
and capable of being answered after a critical appraisal of the available infor-
mation. The formulation of an answerable question is neither perfectly
obvious nor easy; it is a matter of finding, among tens of thousands of art-
icles, information that best answers a clinical question pertaining to a specific
patient, action or diagnostic test.
When formulating clinical questions the “PICO” approach can be used,
defining the patient, intervention, comparator, and outcome [1].

P  Patient, population or problem

Which type of patient is the focus of interest, i.e. what is the patient diagno-
sis, population or problem?
The subject in most EBM issues is a patient with a particular diagnosis.
Try to be as exact as possible in your characterization: diagnosis, stage of the
illness if known, age, gender, etc. The subject may, however, also be a diag-
nostic test or clinical measure.

I  Intervention
What is the intervention (often the new alternative) with which you wish to
compare the standard treatment, i.e. what experiment group is it?
Is the intervention a new drug, surgery, radiotherapy, etc.? Is the interven-
tion a new diagnostic test, a new surgical method, acupuncture, etc.?

C  Comparator
What do you want to compare the intervention with? What is the control arm?

1
2 Evidence-Based Medicine in Sherlock Holmes’ Footsteps

Your control is probably the treatment, test or action that is standard

or most common today. Is the current standard a drug, surgical treatment,
physiotherapy, etc.? Or perhaps the alternative hitherto has been not to give
any treatment at all? Then a placebo may be the alternative with which the
new treatment can be compared.

O  Outcome
What outcome(s) are you interested in? Does your question apply to such
outcomes as survival, symptom reduction, quality of life, reduced sick-listed
time, side-effects, relapses, etc.? Are health-economic effects involved? Is a
new diagnostic test cheaper or more reliable?

Remember PICO!

Your well-thought-out question will now be used in the standard table below.
It is the starting point for the formulation of your question (Step 1) and for
your information search (Step 2):

P I C O
Patient Intervention Control, Outcome
diagnosis/ standard
Problem

Step 1 Your clinical

F Formulate a data, queries
question

Step 2 Your own

I Information search words/
search textwords

MeSH terms

Step 3
R Review of
information and
critical appraisal

Step 4
E Employ the
results
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