Clinical and Experimental Optometry 90.4 July 2007 © 2007 The Author Journal compilation © 2007 Optometrists Association Australia 229 CLINICAL AND EXPERIMENTAL OPTOMETRY Clin Exp Optom 2007; 90: 4: 229–231 DOI:10.1111/j.1444-0938.2007.00132.x Mark G Coulthard MB BS FRACP FJFICM Paediatric Intensive Care Unit, Royal Children’s Hospital, Herston, Brisbane QLD The health-care professional-patient inter- action is a complex process in which a patient engages or allows the health-care professional into a special relationship, such that the professional’s skill, knowl- edge and experience can effect a benefi- cial health outcome for the patient. The success of this interaction depends not only on professional factors but also on myriad intra-personal, inter-personal, social and ethical determinants that over- lay the basic science that underpins the Western medical model. Evidence-based medicine (EBM) is de- fined precisely as the practice of medicine that ‘requires the integration of the best re- search evidence with our clinical expertise and our patient’s unique values and cir- cumstances’. 1 In other words, the clinical state and circumstances in combination with the patient’s preferences and personal actions provide a framework for making decisions, which also includes the current best research evidence. 2 The modern health-care professional is saturated with the latest knowledge and therefore both ex- perience and wisdom are required to make the best clinical decision for the patient. Where is the wisdom we have lost in knowledge? Where is the knowledge we have lost in information? From Choruses from the Rock by TS Eliot 3 The practice of evidence-based medi- cine requires the application of a process that includes five distinct steps. 1 1. asking an answerable clinical question 2. tracking down the best evidence 3. critical appraisal of the evidence 4. integration of the evidence with the patient’s situation 5. evaluation of our effectiveness. There is an important step that is often missed and that is step ‘0’ or ‘permission to ask a question’ in the first instance (Dr Ian Scott, personal communication). An answerable clinical question should be framed in a specific structured format and the most common is the PICO format. For example, in a preschool child (popula- tion) with acute otitis media, does treat- ment with oral antibiotics (intervention) compared with placebo (comparison) reduce the duration of ear pain and fever (outcome)? Tracking down the best available evi- dence requires some skills with the search engines PubMed or Medline, access to the Cochrane Library or the help of a librar- ian. The ability to track down a relevant article often depends on the precision of the clinical question and again under- scores the practicality of the structured format described above so that a librarian, who is not a clinician, can sort through the electronic maze and pull out the most rel- evant articles that best address the clinical question. Critical appraisal of the evidence requires an assessment of the scientific merit with which the research study was conducted. In other words, have the inves- tigators performed the study properly, such that I can believe their results? This involves some knowledge of clinical research study design; however, a number of critical appraisal tools are available to assist the appraiser in asking questions about the randomisation procedure, patient and researcher blinding, follow-up and intention to treat analysis. 4,5 Many of the journals now present research papers in a style that allows the reader to follow this critical appraisal process in a logical format. 6 Following our example above, a recently updated Cochrane review sug- gests that treating acute otitis media with antibiotics had no effect on reduction of pain at 24 hours but did reduce pain between two to seven days and had no effect on subsequent hearing problems due to otitis media. 7 The best available research evidence needs to be integrated with the patient’s particular clinical situation. In a child with full immunisation and ready access to medical review, the decision to treat acute otitis media may depend on patient or rather parent viewpoints. It would be dif- ficult to argue that a child must take anti- biotics for acute otitis media, when serious complications including meningitis or mastoiditis are rare, however, the decision- making process for a child with incom- plete immunisations living in a remote community would adjust the threshold for the decision to prescribe antibiotics. Finally, in an ideal world the effective- ness of each health-care intervention What is evidence-based medicine? A personal viewpoint GUEST EDITORIAL