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Evidence-based medicine in practice
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  1. Sharon E Straus, MD
  1. University of Toronto 
 Toronto, Ontario, Canada

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    Seeing patients in a busy teaching clinic presents various challenges. One challenge we frequently encounter is trying to practise evidence-based medicine in “real time,” especially when trying to obtain and incorporate evidence in the few minutes we have with the residents. One method of tackling this problem is presented in the following scenario.

    Clinical scenario

    Our resident saw a 65 year old patient with congestive heart failure in the clinic. The patient brought in a news item from the internet stating that an “inexpensive drug cuts heart failure deaths by one third,” and he wanted to know whether he could begin taking spironolactone as discussed in the news report. His medical history included a myocardial infarction. An echocardiogram done 6 months previously showed an ejection fraction of 35%. He was breathless with New York Heart Association (NYHA) class III symptoms. His blood pressure was 130/70 mm Hg, and his heart rate was 60 beats/minute. His medications were aspirin, 81 mg; atenolol, 50 mg; furosemide, 40 mg; and nitrospray as needed.

    Search and appraisal

    The resident recalled having heard a presenter at Noon Rounds advocate the use of spironolactone in patients with congestive heart failure and mentioned a recent trial published in the New England Journal of Medicine. The audience was surveyed at the end of Noon Rounds, and most said they would use spironolactone in their patients with congestive heart failure. While the resident was waiting for the patient to disrobe for the physical examination, he attempted to retrieve the article from the New England Journal of Medicine website to show us. By using the search terms …

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