Does Fresno assess real-life EBM skills?
Fresno's test may well be objective and standardised but does
it measure the EBM skills medical educators should be teaching? I work as
both a General Practioner (GP) and a Public Health Consultant, but don't
often get asked either / or questions of the type posed here.
As a GP, I was concerned about John only presenting with enuresis at
age 11. I wanted to involve the team (what did the health visitor or
social services know about the family?), and could think of more options
than drugs or alarms. Since John's inconvenience and embarrassment were
the real presenting problem, I would want to involve him in the planning
process. Addressing these issues requires effective gathering and
assessment of evidence but in quite different ways from those measured
In my Public Health role, I have recently led seminars developing
transparent and rigorous "rules" about how evidence could be used to
support local funding decisions. Primary Care Trust staff discussed
traditional hierarchies of evidence, but remembered that there were not
many RCTs to support or disprove large amounts of NHS provision let
alone the (often social) interventions that tackle major health threats
like inequalities and child poverty. I'm not sure how we'd score on
Fresno as we agreed that we would (in this order):
*Follow NICE, Cochrane etc recommendations ¡V if they existed;
* Look closely at local precedents;
*Look hard for evidence of harm (to strongly recommend against funding)
or no-harm (if there was some reason to consider funding an unproven
*Tailor our approach to evidence, depending on the type of intervention
whilst still considering design and quality of studies as well as
triangulation between different sources;
*Always consider exceptional individual circumstances;
*Think explicitly about the values underpinning our decisions;
*Review the process, and the decisions.
Finally, and maybe most importantly, Fresno doesn't even start on my
real learning problems with EBM--getting the time to do it, and knowing
when its "good enough". I had an immediate answer in my head to Lydia's
contraceptive problem: look at the clear WHO medical eligibility criteria
for contraceptives (on the web). I feel confident that this gives the
"best available" answer for the patient and clinician to consider. It
also frees me up to go on to another question. But is that good enough?
1: Validation of the Fresno test of competence in evidence based
Kathleen D Ramos, Sean Schafer, and Susan M Tracz
BMJ 2003; 326: 319-321.
Competing interests: No competing interests