Evidence-based Medicine

CL Teng (tengcl@gmail.com)
Professor
Family Medicine
Seremban Campus
International Medical University
6 April 2020
 Learning objectives
1. Appreciate the importance of evidence
based medicine in clinical practice.
2. Identify three types of clinical evidence
(diagnosis, prognosis and therapy)
3. Identify the four steps of EBM (ask,
assess, appraise and apply)
In the consultation room

"Doc, is bitter gourd good

for my diabetes? I hate to
take diabetic pills!"
 Which is the "best" answer?
A. My 90 y.o. granny drinks this juice daily
and she is healthy and no diabetes.
B. Diabetic rats given bitter gourd seeds
showed reduction of blood glucose.
C. A vegetable "insulin" has been isolated
from fresh bitter gourd juice.
D. I saw this great video in YouTube.
A much better answer

active drug

placebo
 A much better answer
Bitter gourd capsule

HbA1c
7.08%
7.87%
60

Placebo 3 months

HbA1c
7.83% 60 7.62%

Suthar AC et al. Efficacy and safety of Glycebal (PDM011011) capsules as adjuvant therapy in
subjects with type 2 diabetes mellitus: an open label, randomized, active controlled, phase II trial. Clin
Diabetol. 2016;5:88-94. doi:10.5603/DK.2016.0015
 Data --- evidence
• Bitter gourd: HbA1c reduced 0.78%
• Placebo: HbA1c reduced 0.20%
• Evidence: Both groups show reduction in
HbA1c, more in bitter gourd group
• Difference = 0.58% in favour of bitter
gourd (p=0.06, not statistically significant)
 More evidence
• Peter EL, Kasali FM, Deyno S, Mtewa A, Nagendrappa PB, Tolo CU,
Ogwang PE, Sesaazi D. Momordica charantia L. lowers elevated
glycaemia in type 2 diabetes mellitus patients: Systematic review
and meta-analysis. J Ethnopharmacol. 2019;231:311-24..
• Systematic review of 5 RCTs (n=243).
• Change in HbA1c = 0.26% (95%CI: 0.03
to 0.49%)
• Bitter gourd supplementation compared
with no treatment show significant
glycaemic improvements on HbA1c 
 Evidence --- application
• Randomised controlled trial provides the
best clinical evidence for treatment
decision (systematic review of RCTs may
be even better)
• Need to put in perspective for the patient:
– Bitter gourd capsule: reduce HbA1c by 0.26%
– Diabetic pills: reduce HbA1c by 0.5 to 1.0%
– (Real) insulin: reduce HbA1c by 1.0 to 2.0%
 Patient 1: your niece
• Your 10 year-old • She has small posterior cervical lymph
nodes. Throat looks normal. (physical
niece is having mild findings, signs)
• Her temperature is 37.4oC.
sore throat, coughing
and runny nose for
two days. (history,
symptoms)
 Patient 2: your nephew
You also found that he has tender and
•
• Your 10 year-old nephew is having
enlarged cervical lymphsore
nodes and
purulent exudates in the tonsils
throat and fever for two (Physical
daysfindings,
but no signs)cough

or runny nose. (history, symptoms) You

noted his temp is 38.5oC.
Patient 2 Two URTIs Patient 1

Mild sore throat

Cough
Runny nose

Sore throat
No cough
No runny nose

DIAGNOSIS: DIAGNOSIS:
Streptococcal tonsillitis Coryza

Pathogen: Pathogen:
Group A -haemolytic Rhinovirus
Streptococcus (GAS)
 Chance of bacterial infection
• Patient 1: 2.5%
• Patient 2: 53%
 Chance of bacterial infection
Is influenced by the number of clinical features (“predictors”)

McIsaacs et al. Can Med Assoc J 1998;158:75-83

 Diagnosis
• Influenced by type and number of clinical
features.
• Can be computed mathematically by
calculating sensitivity, specificity, positive
predictive value and negative predictive
value (more… likelihood ratio…)
 Chance of getting heart attack
or die in 20 years
• 10,000 healthy women: 68
• 10,000 women with diabetes: 290
• 10,000 women with heart attack: 308
• Having diabetes is almost as bad as
having heart disease
• "Cardiac equivalent" of diabetes
 Hu FB, Stampfer MJ, Solomon CG, et al. The impact of diabetes
mellitus on mortality from all causes and coronary heart disease in
women. 20 years of follow-up. Arch Intern Med. 2001;161(14):1717-23
Prognosis
• The natural history of
illness/disease if
untreated.
• The chance of
adverse events in the
future.
• Usually serious
outcomes, e.g. stroke,
heart attack, death,
etc.
 EBM
• Ask questions
• Access evidence-based resources
– journals, cochrane review, PubMed, point-of-
care resource, etc
• Assess validity of evidence
– Can I trust this information?
• Apply
– Can I use this information for my patient?
 Resources
• Diao D, Galm B, Shamon S. Evidence-based medicine: an introduction for medical
students. UBCMJ. 2009;1(1):16-8.
http://www.ubcmj.com/pdf/ubcmj_1_1_2009_16-18.pdf

EBM series from Malaysian Family Physician

1. Lai NM. Evidence Based Medicine Series. Part 1. Evidence-based medicine: an
overview. Malaysian Family Physician. 2009;4(1):19-22.
http://www.e-mfp.org/2009v4n1/pdf/EBM.pdf
2. Lai NM. Evidence Based Medicine Series. Part 2. Asking focused answerable clinical
questions. Malaysian Family Physician. 2009;4(1):23-5.
http://www.e-mfp.org/2009v4n1/pdf/Asking_questions.pdf
3. Lai NM. Evidence Based Medicine Series. Part 3. Appraising the evidence. Are the
results valid and clinically important? Malaysian Family Physician. 2009;4(2):57-62.
http://www.e-mfp.org/2009v4n2_3/pdf/ebm1.pdf
4. Lai NM. Evidence Based Medicine Series. Part 4. Why some good studies with
clinically important results cannot be applied to our patients. Malaysian Family Physician.
2009;4(2):63-5. http://www.e-mfp.org/2009v4n2_3/pdf/ebm2.pdf