Step 5 Recording the information for the future

Having done so much work pursuing the above "evidence-based prescription" from question to patient, it might be useful to others and yourself to make a record of that information for future use as a critically appraised topic (CAT), although these have a limited lifespan if not updated.2 The Cochrane Skin Group is now developing a site for storing and sharing dermatology CATs (http://www.nottingham.ac.uk~muzd). Such CATs could become the norm in dermatology journal clubs all over the country, replacing unstructured chats about articles selected for unclear reasons.

The key point to remember about the process of EBD is that it starts and ends with patients. A problem highlighted during an encounter with a patient is the best generator of an EBM problem.25 Even if one then searches and critically appraises the best data in the world, the utility of this exercise would be zero if it is not applied back to that patient or other similar patients. Developing the skills to undertake evidence-based prescription requires practice.

Dermatologists will participate in the practice of EBD to different degrees depending on their enthusiasm, skills, time pressures and interest.24 Some will be "doers", implying that they undertake at least steps 1-4 highlighted in Box 2.2. Others will be more inclined to adopt a "using mode", relying on searching for evidence-based summaries that others have constructed, thereby skipping step 3, at least to some degree. Finally, some will incorporate evidence into their practice in "replicating mode", following decisions of respected leaders (i.e. skipping steps 2 and 3). These categories bear some similarity to those of deduction, induction and seduction that Sackett used to describe the methods that physicians employ to make decisions about therapy.14 Such categories are not mutually exclusive, since even the most enthusiastic EBM practitioners in "doing" mode will flit to "user" and "replicating" mode according to whether they are dealing with a common or rare clinical problem.

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