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EBM Curriculum at Duke
The following information is provided as resource material for the Evidence-based Medicine course directed by Sheri Keitz, M.D., Ph.D. of Duke University Medical Center. Faculty for the course include Drs. Sheri Keitz, David Edelman, Larry Greenblatt and Gene Oddone. This Website is maintained by Connie Schardt at the Medical Center Library. [reviewed and updated 2/14/06]

Contents:

  1. Components of the EBM Workshop

  2. Overview of EBM and Anatomy of a Question

  3. Type of Studies

  4. Example: Therapy

  5. Resources

  6. Medical Center Library: Evidence-based Medicine (EBM)

    1. Components of the EBM Workshop Curriculum

      Knowledge Attitudes Skills
    Question
    • The anatomy of a question
    • The Map
    • Basic clinical skills (H&P)
    • Curiosity
    • Comfort with Uncertainty
    • Value Active Listening
    • Formulate a Question
    Searching
    • MEDLINE
    • Understanding of search strategies (filters, etc.)
    • Computer Phobia
    • Deal with aversion to these technologies
    • Computer Literacy
    • Informatics
    • Tie question to specific information sources
    Critical Appraisal
    • Practical clinical epidemiology (User's Guides)
    • Survival Stats
    • Fatal Flaws (the hopeless to perfect scale)
    • Innumeracy
    • Readiness to challenge authority (Challenge them to be critical, do not accept it as it must be so)
    • Which article will answer your question
    • Apply these skills to real time settings
    Application
    • Getting the Individual Patient (NNT)
    • Going from pre-test to post-test probabilities (likelihood ratios)
    • Strength of inference
    • The recognition that value judgements are implicit in every clinical decision
    • Judgements are being made all the time by physicians based on the MD's value system
    • Adding to the notion of patient's values when you go from evidence to practice
    • Readiness and willingness to change
    • Solicit patient preferences
    • Assess co-morbidities and social support of patient
    • Assess where the patient's value system is on the paternalism to technical continuum

    2. Overview of EBM and Anatomy of a Question

    Evidence-based Medicine (EBM) combines individual clinical expertise with the best available clinical evidence from systematic research in making decisions about the care of individual patients. Clinical expertise is the proficiency and judgment that individual clinicians acquire through clinical experience and practice. Clinical evidence comes from patient centered clinical research which investigates the accuracy and precision of diagnostic tests, the efficacy and safety of therapeutic regimes, and the reliability of prognostic indicators. The powerful combination of clinical expertise and documented evidence results in safer, more efficacious and accurate care of the patient.

    According to David L. Sackett, author of Evidence-based Medicine: How to Practice and Teach EBM, the practice of EBM is a process of life-long, self-directed learning in which caring for the patient creates the need for clinically important information about diagnosis, prognosis, therapy and other clinical and health care issues.

    EBM is a process that involves the following steps:

    1. Construct a pertinent answerable question from a clinical case
    2. Plan and carry out a search of the clinical literature (MEDLINE, ACP Journal, Cochrane Database, etc.) that filters out irrelevant information
    3. Critically appraise the literature for validity and usefulness
    4. Apply the results of this appraisal to your clinical practice
    5. Evaluate your performance

        Anatomy of a Question

        Patient, Population or Problem How would I describe a group of patients similar to mine?
        Intervention, Prognostic Factor, or Exposure Which main intervention, prognostic factor, exposure am I considering?
        Comparison or Intervention (if appropriate) What is the main alternative to compare with the intervention?
        Outcome you would like to measure or achieve What can I hope to accomplish, measure , improve or affect?
        Type of Question you are asking How would I categorize this question?
        Type of Study you would want to find What would be the best study design in order to answer this question?

        Types of questions are related to clinical tasks:

        • Clinical examination -- how to properly gather and interpret findings from the history and physical examination
        • Etiology -- how to identify causes for disease (including iatrogenic forms)
        • Differential Diagnosis -- when considering the possible causes of a patient's clinical problem, how to rank them by likelihood, seriousness and treatability
        • Diagnostic Testing -- how to select and interpret diagnostic tests in order to confirm or exclude a diagnosis, based on considering their precision, accuracy, acceptability, expense, safety, etc.
        • Prognosis -- how to estimate the patient's likely clinical course over time and anticipate likely complications of disease
        • Therapy -- how to select treatments to offer patients that do more good than harm and that are worth the efforts and costs of using them
        • Prevention -- how to reduce the chance of disease by identifying and modifying risk factors and how to diagnose early by screening
        • Self-Improvement -- how to keep up to date, improve your clinical skills and run a better, more efficient clinical practice
        (from Evidence-based Medicine: How to Practice and Teach EBM. David L. Sackett. Churchill Livingstone, 1997, p.26)

        Type of study to answer the type of question:

        Clinical Examination Prospective, blind comparison to Gold Standard
        Diagnostic Testing Prospective, blind comparison to Gold Standard
        Prognosis Cohort Study>Case Control >Case Series
        Therapy RCT is really the only way we want to answer this question
        Etiology / Harm Cohort Study>Case Control>Case Series
        Prevention RCT>Cohort Study>Case Control>Case Series
        Cost Economic Analysis
        Self-Improvement/Education
        Quality Improvement
        Health Services Research
        Differential Diagnosis

        Synthesis articles may help you find information for any question:

        • Systematic Review / Meta-analysis
        • Practice Guideline 
        
  
        

  
        

  
        
  
        3. Types of Studies
        
  
        
  
          
    
          
    
        • Randomized Controlled Clinical 
    Trial/Controlled Clinical Trial (therapy, diagnosis)
          • A clinical 
    trial involving one or more test treatments, at least one control treatment, 
    specified outcome measures for evaluating the studied intervention, and a 
    bias free method for assigning patients to the test treatment. The treatment 
    may be drugs, devices, or procedures studied for diagnostic, therapeutic or 
    prophylactic effectiveness. Control measures include placebos, active 
    medicine, no treatment, dosage forms and regiments, historical comparisons, 
    etc. When randomization using mathematical techniques, such as the use of a 
    random numbers table, is employed to assign patients to test or control 
    treatments, the trial is characterized as a RANDOMIZED CONTROLLED TRIAL. 
    
          Trials employing treatment allocation methods such as coin flips, 
    odd-even numbers, patient social security numbers, days of the week, medical 
    record numbers, or other such pseudo- or quasi-random processes are simply 
    designated as CONTROLLED CLINICAL TRIALS. 
    
          Example of a randomized controlled trial: 
    Macknin ML, Medendorp SV, and Mason P. Zinc gluconate lozenges for 
    treating the common cold. A randomized, double-blind, placebo-controlled 
    study. Annals of Internal Medicine. 125(2):81-8, 1996 Jul 15.
    
          
    
            
      
          • Advantages: 
      
              
        
            1. unbiased distribution of confounders 
        
            2. blinding more likely 
        
            3. randomization facilitates statistical analysis 
            
      
          • Disadvantages: 
      
              
        
            1. expensive - time and money 
        
            2. volunteer bias 
        
            3. ethically problematic at times 
          
    
          Multicenter studies
          Controlled studies which are planned and 
    carried out by several cooperating institutions to assess certain variables 
    and outcomes in specific patient populations, for example, a multicenter 
    study of congenital anomalies in children. 
    
          
    
          
    
          
    
        • Cohort Study (prognosis, harm/etiology, 
    prevention)
          • Studies in which subsets of a defined population are 
    identified. These groups may or may not be exposed to factors hypothesized 
    to influence the probability of the occurrence of a particular disease or 
    other outcome. Cohorts are defined populations which, as a whole, are 
    followed in an attempt to determine distinguishing subgroup characteristics. 

    
          Example of a cohort study: Johansen C 
    and Olsen JH. Risk of cancer among Danish utility workers--a nationwide 
    cohort study. American Journal of Epidemiology. 147(6):548-55, 1998 
    Mar 15.
    
          
    
            
      
          • Advantages: 
      
              
        
            1. ethically safe 
        
            2. subjects can be matched 
        
            3. can establish timing and directionality of events 
        
            4. eligibility criteria and outcome assessments can be standardized 
        
            5. administratively easier and cheaper than RCT 
            
      
          • Disadvantages: 
      
              
        
            1. controls may be difficult to identify 
        
            2. exposure may be linked to a hidden confounder 
        
            3. blinding is difficult 
        
            4. randomization not present 
        
            5. for rare disease, large sample sizes or long follow-up necessary 
        
          
    
          Longitudinal Studies
          Studies in which variables relating to an 
    individual or group of individuals are assessed over a period of time.
    
          
    
            
      
          • Follow-up Studies
            Studies in which 
      individuals or populations are followed to assess the outcome of 
      exposures, procedures, or effects of a characteristic, e.g., occurrence of 
      disease.
      
            
      
          • Prospective Studies
            Observation of a 
      population for a sufficient number of persons over a sufficient number of 
      years to generate incidence or mortality rates subsequent to the selection 
      of the study group. 
          
    
          
    
          
    
        • Case-control Study (prognosis, 
    harm/etiology, prevention)
          • Studies which start with the 
    identification of persons with a disease of interest and a control 
    (comparison, referent) group without the disease. The relationship of an 
    attribute to the disease is examined by comparing diseased and non-diseased 
    persons with regard to the frequency or levels of the attribute in each 
    group. Involves identifying patients who have the outcome of interest 
    (cases) and control patients without the same outcome, and looking back to 
    see if they had the exposure of interest. 
    
          Example of a case control study: Del 
    Amo J, Petruckevitch A, Phillips AN, De Cock KM, Stephenson J, Desmond N, 
    Hanscheid T, Low N, Newell A, Obasi A, Paine K, Pym A, Theodore C, and 
    Johnson AM. Risk factors for tuberculosis in patients with AIDS in London: a 
    case-control study. International Journal of Tuberculosis & Lung 
    Disease. 3(1):12-7, 1999 Jan.
    
          
    
            
      
          • Advantages: 
      
              
        
            1. quick and cheap 
        
            2. only feasible method for very rare disorders or those with long lag 
        between exposure and outcome 
        
            3. fewer subjects needed than cross-sectional studies 
            
      
          • Disadvantages: 
      
              
        
            1. reliance on recall or records to determine exposure status 
        
            2. confounders 
        
            3. selection of control groups is difficult 
        
            4. potential bias: recall, selection 
          
    
          Retrospective Studies
          Studies used to test 
    etiologic hypotheses in which inferences about an exposure to putative 
    causal factors are derived from data relating to characteristics of persons 
    under study or to events or experiences in their past. The essential feature 
    is that some of the persons under study have the disease or outcome of 
    interest and their characteristics are compared with those of unaffected 
    persons. 
    
          
    
          
    
        • Cross-Sectional Study
          • Studies 
    in which the presence or absence of disease or other health-related 
    variables are determined in each member of the study population or in a 
    representative sample at one particular time. This contrasts with 
    LONGITUDINAL STUDIES which are followed over a period of time. The 
    observation of a defined population at a single point in time or time 
    interval. Exposure and outcome are determined simultaneously. 
    
          Example of a cross-sectional study: 
    Abrams K, Skolnik N, and Diamond JJ. Patterns and correlates 
    of tobacco use among suburban Philadelphia 6th through 12th grade students. 
    Family Medicine. 31(2):128-32, 1999 Feb.
    
          
    
            
      
          • Advantages: 
      
              
        
            1. cheap and simple 
        
            2. ethically safe 
            
      
          • Disadvantages: 
      
              
        
            1. establishes association at most, not causality 
        
            2. recall bias susceptibility 
        
            3. confounders may be unequally distributed 
        
            4. Neyman bias 
        
            5. group sizes may be unequal 
          
    
          
    
        • Review
          • An article published 
    after examination of published material on a subject. It may be 
    comprehensive to various degrees and the time range of material scrutinized 
    may be broad or narrow, but the reviews most often desired are reviews of 
    the current literature. The textual material examined may be equally broad 
    and can encompass, in medicine specifically, clinical material as well as 
    experimental research or case reports. State-of-the-art reviews tend to 
    address more current matters. Reviews of the literature must be 
    differentiated from historical reviews on the same subject, but a review of 
    historical literature is also within the scope of this publication type. 
    Specific headings for specific types of reviews (academic, literature, 
    multicase, reported cases, and tutorial) are also available. 
    
          Example of a review: Carlsen KH. 
    Exercise induced asthma in children and adolescents and the relationship to 
    sports. [Review] Pediatric Allergy & Immunology. 9(4):173-80, 
    1998 Nov. 
    
          
    
          
    
        • Systematic Review
          • A systematic 
    review usually focuses on a clinical topic and answers a specific question. 
    An extensive review of the evidence is presented after the methodology for 
    identifying the studies in the literature is presented. 
    
          Example of a systematic review: 
    McDonald M. et al. Single- versus multiple-dose antimicrobial prophylaxis 
    for major surgery: a systematic review Australian & New Zealand 
    Journal of Surgery 68(6):388-96, 1998 Jun. 
    
          
    
        • Meta Analysis
          • A quantitative 
    method of combining the results of independent studies (usually drawn for 
    the published literature) and synthesizing summaries and conclusions which 
    may be used to evaluate therapeutic effectiveness, plan new studies, etc. It 
    is often an overview of clinical trials. It is usually called a 
    meta-analysis by the author or sponsoring body and should be differentiated 
    from review of the literature. 
    
          Example of meta analysis: Kozyrskyj 
    AL. et al. Treatment of acute otitis media with a shortened course of 
    antibiotics: a meta-analysis JAMA. 279(21):1736-42, 1998 Jun 3. 
    
        
  
          
  
          This information is taken from the Evidence-based Medicine 
  Glossary at Oxford University and the National Library of Medicine. 
 
           
  
          

  
          Prioritizing your questions: 
  
            
    
          1. Which question is more important to my patient's well being? 
    
          2. Which question is most interesting? 
    
          3. Which question is most feasible to answer within the time frame 
    available? 
    
          4. Which question are you likely to encounter again in your practice? 
  
          
  
          

  
          
  
  
          4. Example: Therapy
          
  
          Clinical Scenario:
          A patient who is new to your practice 
  presents to the ER with mid-epigastric / right upper quadrant pain. The ER 
  attending calls you to review the plan and arrange follow up. She is a 47 year 
  old white woman without significant PMH. She presents with abdominal pain that 
  is 9/10 nonradiating and has been present for several hours. She is nauseous 
  but has not vomited. She reports no change in her bowel movements and has not 
  eaten anything out of the ordinary today. She did first note the onset of the 
  pain just following her evening meal which consisted of baked chicken, rice 
  and potatoes. On PE she is diffusely tender in her mid-epigastric region and 
  right upper quadrant. She has guarding but no rebound. She is guaiac negative. 
  She has hyperactive bowel sounds. Labs are sent and abdominal films ordered. 
  
          The ER attending enters, meets and examines the patient. The patient is 
  given IV Zantac and Maalox. Following these interventions, if the pain is not 
  relieved, the attending would like to give IV morphine for pain control. The 
  patient refuses. On further questioning, the ER attending discovers that she 
  is a physician who is worried that the administration of opioid analgesics 
  will interfere with your ability to determine the etiology of her pain. 
  Eventually, her pain subsides and she leaves the ER with plans to follow up 
  with you on Monday following a RUQ ultrasound. The ER attending would like to 
  give her Percocet to take home with her in case the pain returns, but she 
  refuses and leaves. 
  
          
  
          

  
          
  
          STEP 1: Construct a Question 
          
  
          (Print 
  as a separate worksheet) 
  
          
  
          
  
          
    
    
          
      Elements of a Good Therapy Question
      Your Case:
          
    
          
      Patient, Population or Problem
          How would I describe a 
        group 
          of patient's similar to mine?          		
      female, abdominal pain
          
    
          
      Intervention, Prognostic 
          Factor, or Exposure
          Which 
        main intervention, 
          exposure, prognostic
          factor am I considering? 
                		
      morphine, narcotics, opiate analgesics
          
    
          
      Comparison or Intervention
          (if appropriate)
          What is the 
        main alternative
          to compare with the intervention?          		
      none
          
    
          
      Outcomes you would
          like to measure or achieve?
          What can 
        I hope to accomplish
          measure, improve, or affect?          		
      pain relief; accurate diagnosis
          
    
          
       
       
    
          
      Type 
        of Question
          you are asking
          How would I categorize
          this 
        question?          		
      therapy, possibly diagnosis
          
    
          
      Type 
        of Study 
          you would want to find
          What would be the best 
        study
          design in order to answer 
          the question?          		
      randomized controlled trial
          

          
  
          

  
          
  
          STEP 2: Search the Literature (MEDLINE)
          
  
          A well built clinical question can lead directly to a well constructed 
  MEDLINE strategy.
          
  
          
  
            
    
          • Search statements 1 through 4 retrieve articles on the specific 
    subject - Abdominal pain and narcotics or opiate analgesics. 
    
              
      
            1. Explode "abdominal pain" as a MeSH heading 
      
            2. Explode "narcotics" or "analgesics, opioid" as MeSH headings 
      
            3. Combine sets 1 and (2 or 3) 
            
    
          • Search statements 5 through 9 are the "EBM 
    Filter" for randomized controlled trials (EBMRCTF) in our Ovid system. 
    
    
              
      
            1. Click on "run saved search" -- this will bring up the list of saved 
      search strategies 
      
            2. Select the desired saved strategy and click on "run strategy" -- the 
      system will automatically run the strategy and post it to the SEARCH 
      HISTORY screen. 
            
    
          • Search statement 10 combines the specific subject and randomized 
    controlled trials (RCT) 
    
          • Search statement 11 explodes "diagnosis" as a MeSH heading and 
    truncates the textword "diagnos$" 
    
          • Search statement 12 combines the concept of diagnosis with our 
    topic 
          
  
          
  
          

  
          
  
          
    
          
    
    
          
      #
      Search History
      Results
      Display
          
    
          
      1
      exp Abdominal pain/
      9362
      Display
          
    
          
      2
      exp Narcotics/
      50969
      Display
          
    
          
      3
      exp Analgesics, opioid/
      48456
      Display
          
    
          
      4
      1 and (2 or 3)
      158
      Display
          
    
          
      5
      exp Clinical trials/
      107838
      Display
          
    
          
      6
      (clinical trial or controlled clinical trial).pt.
      259980
      Display
          
    
          
      7
      (meta analysis or multicenter study).pt.
      34028
      Display
          
    
          
      8
      randomized controlled trial.pt.
      118851
      Display
          
    
          
      9
      5 or 6 or 7 or 8
      303117
      Display
          
    
          
      10
      9 and 4
      60
      Display
          
    
          
      11
      exp diagnosis/ or diagnos$.tw.
      2750592
      Display
          
    
          
      12
      10 and 11
      24
      Display
          
    
          
      13
      limit 12 to (human and english language)
      23
      Display
          
  
          
  
          

  
          
  
            
    
          • Results of the MEDLINE search: citations 1-10
           1. Vermeulen B. Morabia A. Unger PF. Goehring C. 
  Grangier C. Skljarov I. Terrier F. Acute appendicitis: 
  influence of early pain relief on the accuracy of 
  clinical and US findings in the decision to operate--a 
  randomized trial. 
  [Clinical Trial. Journal Article. 
  Randomized Controlled 
  Trial] Radiology. 210(3):639-43, 1999 Mar. 99223868 
    Abstract| Complete Reference 
  
           2. Larkin GL. Peacock WF 4th. Pearl 
  SM. Blair GA. D'Amico F. Efficacy of ketorolac 
  tromethamine versus meperidine in the ED treatment of acute renal colic. 
  [Clinical Trial. Journal Article. 
  Randomized Controlled 
  Trial] American Journal of Emergency Medicine. 17(1):6-10, 
  1999 Jan. 99125767   Abstract | Complete Reference> 
  
           3. Kovacs GT. Baker G. Dillon M. 
  Peters M. The microlaparoscope should be used routinely 
  for diagnostic laparoscopy. [Clinical 
  Trial. Controlled Clinical 
  Trial. Journal Article] Fertility & Sterility. 
  70(4):698-701, 1998 Oct. 99011125   Abstract| Complete Reference 

  
          
  
          
    
    
          
      4. LoVecchio F. Oster N. Sturmann K. Nelson LS. Flashner S. Finger 
        R. The use of analgesics in patients with acute 
        abdominal pain. 
        [Clinical Trial. Journal 
        Article. Randomized Controlled 
        Trial] Journal of Emergency Medicine. 15(6):775-9, 
        1997 Nov-Dec. 98067296  Abstract| 
    Complete Reference
          
  
           5. al-Sahlawi KS. Tawfik OM. Comparative study of the efficacy of lysine 
  acetylsalicylate, indomethacin and pethidine in acute renal colic. 
  [Clinical Trial. Journal Article. 
  Randomized Controlled 
  Trial] European Journal of Emergency Medicine. 3(3):183-6, 
  1996 Sep. 97175924   Abstract| Complete Reference 
  
           
  
          
    
    
          
      6. Pace S. Burke TF. Intravenous morphine for 
        early pain relief in patients with acute 
        abdominal pain [see comments]. 
        [Clinical Trial. Journal 
        Article. Randomized Controlled 
        Trial] Academic Emergency Medicine. 3(12):1086-92, 
        1996 Dec. 97118277   Abstract| Complete Reference 
    
          
  
           7. Bergus GR. Pain relief for renal colic. 
  [Clinical Trial. Journal Article. 
  Randomized Controlled 
  Trial] Journal of Family Practice. 43(5):438-40, 1996 
  Nov. 97074712   Abstract| Complete Reference 
  
           8. Jorgensen JO. Gillies RB. Hunt DR. 
  Caplehorn JR. Lumley T. A simple and effective way to 
  reduce postoperative pain after laparoscopic cholecystectomy. 
  [Clinical Trial. Journal Article. 
  Randomized Controlled 
  Trial] Australian & New Zealand Journal of Surgery. 
  65(7):466-9, 1995 Jul. 95336399   Abstract| Complete Reference
  
           9. Curry C. Kelly AM. Intravenous tenoxicam for the treatment of renal colic. 
  [Clinical Trial. Journal Article. 
  Randomized Controlled 
  Trial] New Zealand Medical Journal. 108(1001):229-30, 1995 
  Jun 14. 95327283   Abstract| Complete Reference 
  
           10. Scheinin B. Kellokumpu I. 
  Lindgren L. Haglund C. Rosenberg PH. Effect of 
  intraperitoneal bupivacaine on pain after laparoscopic 
  cholecystectomy. [Clinical Trial. 
  Journal Article. Randomized Controlled 
  Trial] Acta Anaesthesiologica Scandinavica. 39(2):195-8, 
  1995 Feb. 95313473   Abstract| Complete Reference 
 
          
  
          

  
          
  
          
  
          STEP 3: Critically Appraise the Article(s)
          Critical Appraisal 
  Worksheet for Therapy Article: 
  
          
  
          
  
          
    
    
          
      Questions 
      Article 
    
          
      Are the results Valid?
          Randomization:
          (Was the 
        assignment of patients to
          treatment randomized?)          		
       
          
    
          
      Patient Follow-Up 
          (Were all patients who entered the 
        trial
          properly accounted for and
          attributed at its conclusion?)          		
       
          
    
          
      Analysis of patients
          (Were patients analyzed in the 
        
          groups to which they were
          randomized?)          		
       
    
          
      Blinding
          (Were patients, health workers, and 
          study 
        personnel "blind"
          to treatment?)          		
       
          
    
          
      Baseline characteristics of patients
          (Were groups similar 
        at the start
          of the trial?)          		
       
          
    
          
      Treatments
          (Aside from the experimental
          intervention, 
        were the groups
          treated equally?)          		
       
          
    
          
      What are the results?
          (What is the Strength of 
          the 
        Outcomes?)
           
          How large was the treatment effect?)          		
       
          
    
          
      How precise was the treatment
          effect?
                     		
       
    
          
      Will the results help me in
          caring for my 
        patient?
           
          Are the results applicable
          to my 
        patient?
                     		
       
          
    
          
      Were all clinically important
          outcomes considered?          		
       
          
    
          
      Are the benefits worth the 
          potential harms and costs?          		
       
          
  
          Adapted from Users' Worksheet for an Article About Therapy from the 
  Evidence Based Medicine Working Group at McMaster University. 
  
          Guyatt, Gordon H.. Sackett, David L.. Cook, Deborah J.. Users' Guides to 
  the Medical Literature: II. 
  How to Use an Article About Therapy or Prevention: A. Are the Results of the 
  Study Valid? JAMA. 270(21):2598-2601, Dec 1, 1993. [Full text available only from a Duke IP address]
  
          Guyatt, Gordon H. MD, MSc. Sackett, David L. MD, MSc. Cook, Deborah J. MD, 
  MSc. for the Evidence-Based Medicine Working Group. Users' Guides to the 
  Medical Literature: II. 
  How to Use an Article About Therapy or Prevention: B. What Were the Results 
  and Will They Help Me in Caring for My Patients? JAMA. 
  271(1):59-63, January 5, 1994. [Full text available only from 
  a Duke IP address] 
  
          

  
          
  
  
          STEP 4: Application: Deciding What to Tell the Patient
          
  
          
  
          
    
    
          
      In words you would use to tell the patient, what else do we need 
        to know to assess the prognosis?
          
    
          
       
           
           
                     		
    
          
    
          
      In words you would use to tell the patient, describe the 
        prognosis for the patient.
    
          
       
           
           
           
          
  
          


          


          


          


          
  
          
  
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