Yes, we all admire how magically Sherlock Holmes either in movies or tv series like elementary can know the answers to so many critical questions by just so few data points.

But as doctors/medical students and healthcare providers, how can we adopt those same magical powers in our day-to-day practice and preaching. We’ll try to answer some of those questions in this article. Fasten your seat belts here we go.

What we admire in Sherlock Holmes, is the quality of deductive thinking, it has a formal name in our industry that is called as Evidence-based medicine. In the source reference given below the author of that book Dr. Jorgen Nordenstrom, he explains the FIRE by PICO framework.

FIRE stands for four critical steps in view of finding the high-value high priority information for our patients.

FFormulate an answerable question
I Information Search
RReview of information and critical appraisal
EEmploy the results in your clinical practice

Let’s see each of these steps in detail –

1. Formulate an answerable question

“Education never ends, Watson. It is aseries of lessons with the greatest for the last.” – Sherlock Holmes.

A well-formulated question is a requisite for getting a useful answer.

To formulate a question, the PICO approach can be used –

PPatient, population or problem – Which type of patient is the focus of interest, i.e. what is the patient diagnosis, population or problem?
IIntervention – What is the intervention (often the new alternative) with which you wish to compare the standard treatment, i.e. what experiment group is it?
CComparator – What do you want to compare the intervention with? What is the control arm?
OOutcome – What outcome(s) are you interested in? Does your question apply to such outcomes as survival, symptom reduction, quality of life, reduced sick-listed time, side effects, relapses, etc.? Are

health-economic effects involved? Is a new diagnostic test cheaper or more reliable?

2. Information Search

The main steps of the search procedure in databases are as follows:

A.Do a wide search (secure a high level of sensitivity in your search).

    B.Restrict your search results and reduce the number of irrelevant hits(increase the specificity).

    C. Use a good hit to find other relevant articles. 

3. Review of information and critical appraisal –

The next step in the application of EBM is to Review, and critically appraise the scientific data (FIRE). The ability to evaluate medical information (assess the evidence) is an important part of EBM. This process involves a systematic analysis of the validity and reliability of the information as well as of the results and relevance of the particular articles.

Medical practice is guided by knowledge, experience, experimentation, and value systems. These components have a variable evidence base that needs to be considered before making decisions about care for individual patients.

The experience of groups of practitioners offers stronger evidence than the experience of individual caregivers, and RCTs often yield stronger evidence than observational studies.

Quality assessment of the information includes:

 a. An analysis of the study design.
b. Grading the level of evidence.
c. Critical appraisal.
d. Grading the quality of the evidence.

4. Employ the results in your clinical practice –

Questions to ask in order to decide if the results of a study are applicable –

  •     Are the results of this study appropriate for my patient?
  •     Could my patient have been included in this study? (Does my patient meet the inclusion and exclusion criteria used in this study?)
  •     Is there any reason to believe that the results presented would not apply to my patient?
  •     Does the study cover all clinically important aspects?
  •     Do the treatment benefits outweigh the potential harm and costs?

The balance between benefit and harm – Before making a recommendation, you must consider whether or not the treatment benefits outweigh the potential harm and costs. To make this trade-off inevitably involves placing a relative value on the anticipated outcome(s).

The strength of a recommendation refers to the probability that the application of a given recommendation will result in an improvement in health and it depends on the applicability of the evidence and the net benefits of an intervention.

Your patient’s participation can be obtained by a step-wise procedure:

  • Understand the patient’s experience and expectations.
  • Build a partnership.
  • Provide evidence including a balanced discussion of uncertainties.
  • Present recommendations based on clinical findings, the available scientific evidence and your patient’s values.
  • Check for understanding and seek agreement.

Conclusion

Sherlock Holmes always gave importance to thinking logically and in a strict scientific way, in that keen unbiased Observation skill played a very strong role, also having all the evidence before forming any conclusions and stronghold of facts was the key to his success.

Similarly in medicine, following the above-stated Evidence-Based Medicine methods to practice is a good way to follow those Sherlock’s way.

As with time medical literature is only going to increase exponentially so getting a hold of these EBM methods in your early career is a very good way to ensure you become the doctor that every patient wishes he/she gets i.e. well informed, well behaved, well-skilled and well observant.

Source Reference: Nordenstrom, Jorgen. Evidence-based medicine: in Sherlock Holmes’ footsteps. John Wiley & Sons, 2008. DOI:10.1002/9780470750957

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