Clinical discussion based on evidence

EDITORIAL

Clinical discussion based on evidence

Fabio Biscegli Jatene; Wanderley Marques Bernardo; Sérgio Almeida de Oliveira

Heart Institute (INCOR) Hospital das Clínicas, Faculty of Medicine, University of São Paulo, São Paulo/SP, Brazil. E-mail: [e-mail]

The discussion of clinical cases with the objective of making decisions, regarding care with patients, is a reality for countless groups of health professionals all over the world. Such decisions are based most of the time, on the experience of the professionals participating in the discussions. Generally there is agreement regarding the procedure to be applied. Sometimes a majority decides, but in a fewer cases, a minority's decision is taken into account, depending on its relevance. Scientific evidence, when inventoried for discussions, is usually used to support opinions, seldom to point out controversies that oppose them. Articles and authors are usually mentioned in an incomplete and uncheckable way, and worse, with conclusions that are not part of the mentioned study.

However, inside the room where such discussions are happening, contributions can be given in an objective and dynamic way, to provide the best available evidence related to the theme in discussion, or to point out the absence of such relevant scientific evidence.

With this objective, we have adopted a new procedure for the discussion of clinical cases in the Thoracic Surgery Group: an online search engine has been set-up in the Group's discussion room, with the specific purpose of searching for available data in the appropriate data base archive. This procedure is set in motion whenever a controversy or doubt occurs. The system is based on a notebook connected to the internet and a primary database, basically PubMed.

A structured question is formulated for every clinical subject in a manner which can be answered, and reproduced in PubMed. The use of a structured question goes through patient identification to which are added the clinical doubts raised by participants in the following format: P: patient, I: intervention, C: control and O: outcome, combined among themselves, and interlinked by the Boolean operators AND, OR, or NOT. To the result of this search appropriate filters are applied which improve the quality of the obtained study, allowing a dynamic and immediate access to the best available studies.

In minutes, quality evidence relating to controversies and doubts becomes available to allow a critical evaluation of the case in study, as regards proposed course of action, probable outcome and conclusions. This contributes not only to decision making, but also to teaching, which is a bonus in an academic hospital.

It must be stressed that the evidence obtained during the discussions is not considered as the definitive result of a wide literature revision and much less, as a final critical evaluation, since only abstracts are read. Neither is the evidence used to reinforce personal opinions, determining who it is right or who is wrong, but, in association with the several opinions of the group, to contribute to arrive to the best decision.

In use for 6 months, this technique has brought interesting results. It has helped in clinical decision making, and stimulated the conception of several protocols based on doubts and relevant controversies. It is just the beginning of a process, unpublished in our environment that aims at having conducts to be discussed and decisions to be based on scientific evidence. We expect to improve results, to avoid errors, and to provide quality training for the next generation of residents an students.

Publication Dates

• Publication in this collection
  01 Mar 2005
• Date of issue
  Feb 2005