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Evidence-Based Medicine: A Framework for Clinical Practice
  1. David King, MBBS, MPH
  1. University of Queensland Buranda, Queensland, Australia

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    Friedland et al state that Evidence-Based Medicine: A Framework for Clinical Practice, “provides an introduction to the most important components of evidence-based decision making” for people at all levels of experience, from students to practising clinicians. This laudable intent is successful to varying degrees in its coverage of important, evidence-based topics.

    Friedland DJ. Evidence-based medicine: a framework for clinical practice. Maidenhead, Berkshire, UK: McGraw-Hill, 1998.

    The book is structured in a modular format and the layout includes workbook style question and answer exercises. The contents are arranged in 3 main areas: medical decision making, accessing medical information, and evaluating validity of information. My personal preference would be to place the first section at the end of the book, because chapters on decision analysis, treatment and testing thresholds, and cost effectiveness are heavy work for those not mathematically minded. However, these chapters and the chapter on deriving pre-test and post-test probabilities are comprehensive and logically structured, and include several methods of arriving at the same final answer. The explanation of probability, likelihood ratios, and odds is one of the most lucid I have encountered. Also, the application of evidence-based techniques is structured around well chosen, representative, clinical case scenarios.

    Most chapters end with a brief discussion of the application and limitations of each mathematical technique, but more discussion could have been devoted to the qualitative aspects of decision making. For example, the role of such factors as patient and physician desire for greater certainty, professional peer pressure, public health considerations, and the changing nature of the evidence would be useful.

    The section on accessing medical information is clear and comprehensive but the rapid “dating” of specific information diminishes its usefulness. The 2 databases discussed in detail in this book are Grateful Med and Melvyl Medline. I could only find 2 sentences in the entire book relating to the Cochrane Library, and PubMed received only passing mention. A discussion of the general principles that guide literature searching would have been more durable. The chapter on the structure and application of the internet was interesting, but with 1 exception, all the resource sites listed were North American.

    The final section of the book presents a generic study guide outline for critically appraising treatment, diagnosis, causation or harm, and prognosis study designs. A unique generic guide is also included for use with integrative study types. Both guides provide templates for analysing studies, but perhaps the trade off is the lack of focus on the sources of error unique to each study type, such as are described in the JAMA series “User Guides to the Medical Literature.”1 Brief discussions of such topics as bias and confounders and formulas for calculating common ratios, numbers needed to treat, mortality rates, and life expectancies follow the users guides.

    The strength of Evidence-Based Medicine: A Framework for Clinical Practice is the logical development of the statistical foundations of such areas as diagnostic testing and decision analysis. Therefore, it will appeal more to those readers studying clinical epidemiology or those motivated to complete the self tutorial style exercises. These exercises rightly start and finish with appropriate clinical scenarios. The information contained in this book is neither sufficient nor necessary for a comprehensive understanding of evidence-based practice, but a worthy component of the growing body of resources on the subject.


    Clinical usefulness: ★★☆☆☆


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