實證醫學簡介直覺式的認知過程 · 搜尋google 約有35,200項符合“Evidence based...

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實證醫學簡介（個別化的醫療品質促進）

財團法人彰化基督教醫院

實證醫學暨臨床流病中心

精神科

廖以誠醫師

與如何形成PICO問題

直覺式的認知過程-- 潛意識的推論

人類在處理外在刺激時，在無意識的層次具有推論外在世界的能力。

治療病人的決策，靠直覺？個人主觀經驗？

EBM 的源由 (1)

許多靠個人經驗的治療方式，被證明是無效，甚至有害的

醫療照顧日新月異，選項多樣化每日需要主動接收有效（validvalid）資訊

大量的醫療研究文獻，品質良莠不齊

資訊來源多樣化（各類資料庫，各式在職教育，種類繁多，如何選

擇？）

資料庫收錄文獻品質不一

在職教育可能演講者的資料過時且不夠完整

實務工作繁忙，再進修（閱讀文獻）的時間有限。

EBM 的源由 (2)

患者與家屬可以獲得相同醫療資訊，對醫療照護的

期待增高。

醫療資源有限，有效且高品質醫療服務是全球趨勢

醫療人員隨著畢業（受訓）後，知識與技能「不進

則退」。

臨床實務需要跟得上現時潮流，您做得到嗎？

如何節省時間？又能救治更多的生命？

(Save time & save lives)

The US Food and Drug Administration (FDA) reported in a public health advisory on Apr. 11, 2005that the use of second generation antipsychotic medications, aripiprazole, olanzapine, quetiapine, and risperidone, for the treatment of behavioral symptoms in elderly patients with dementia is associated with increased mortality.

英研究：服抗精神分裂藥老年癡呆更惡化

中國時報 2008.04.02• 阿茲海默氏症者慣常服用抗精神分裂病藥物，不過，英國最新

研究顯示，此舉反而會使病情更加惡化。• 根據倫敦國王學院、牛津大學與新堡大學最新聯合研究，長期

而言，服用抗精神分裂病藥物，對出現中度行為問題的阿茲海默症患者泰半並無助益；而且，持續服用六個月，還會令病患的口語溝通能力明顯惡化。已展開的後續研究也初步顯示，阿茲海默氏症患者服用抗精神分裂症藥物，也可能會提高死亡率。

• 這項刊登在最新一期《PLoS醫學》（Public Library of ScienceMedicine）期刊的研究，對象係居住在倫敦等四個城市看護中心的一六五名阿茲海默氏症末期患者，其中，約有六十％的病患被餵食抗精神分裂病藥物，以控制諸如攻擊性的行為。據統計，英國約有七十萬人罹患俗稱老年癡呆症的阿茲海默氏症，預估卅年後人數將會倍增。

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慎思熟慮的認知過程

-- 有目的地演繹推理過程

Knowledge is the enemy of the disease

What is EBM ?-- 證據醫學、實證醫學證據醫學、實證醫學

EBM:Evidence-based medicineEBM 的命名與概念成形乃1990 年加拿大McMaster 大學內科部醫師Gordon Guyatt於住院醫師訓練計畫中提出。

照顧個別病人（individual patients）時的臨床決策乃是基於以下四大層面的整合。• 可獲得最好的研究證據（ best available research evidence）• 臨床經驗與技術（clinical expertise ＆skills）• 病人價值觀與喜好（ patient values & preference）• 病人的環境與設施（ patient circumstances, clinical state &

setting ）

Evidence-Based Clinical Decisions的決定因素

LiveUpdateResearch evidences

P’t preferences and actions

Clinical states, circumstances and environmental resources

Clinical expertise & experienceClinical expertise & experience

Modified from R Brain Haynes et al.: Evid. Based Med. 2002;7;36-38.

EBM 的兩大目的

臨床專業醫療經驗與能力提升可獲得最佳外在研究證據

病人之喜好、價值觀與環境資源

降低醫療不確定性（ Uncertainty ↓）

降低醫療變異性（ Variation ↓）

EBM 的發展與被應用橫向觀點：

應用於各個專業領域

縱向觀點：個別病人（individual）

• 臨床第一線醫療人員• Bottom-up EBM

一群病人(population，community)• 衛生政策單位、醫院整體、醫療品質、醫療資訊或醫

療保險等

• Top-down EBMEBM的基本精神不變

Definition of EBN -- 實證護理實證護理

EBN:Evidence-based nursing practice is the conscientious, explicit, and judicious use of theory-derived, research-based information in making decisions about care delivery to individuals or group of patients and in consideration of individuals’ needs and preferences.

誠實、詳盡與明斷的運用「有理論、研究為基礎的資訊」於臨床護理決策（針對一個病人或一群病人），並考慮到個案的需求與喜好。

----Ingersoll, 2000

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實證心理執業American Psychological Association Statement (2005.08)

Evidence-based practice in psychology (EBPP)the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences.the purpose of EBPP is to promote effective psychological practice and enhance public health by applying empirically supported principles of psychological assessment, case formulation, therapeutic relationship, and intervention.

May–June 2006 American Psychologist, APA Presidential Task Force on Evidence-Based Practice

http://www.apa.org/practice/ebpreport.pdf.

Evidence-based occupational therapy（實證職能治療）Client-centred enablement of occupation based on • client information • a critical review of relevant research, • expert consensus and past experience.

Evidence-Based Pharmacotherapy（實證藥物治療）

Evidence-based pharmacotherapy is the systematic, explicit and judicious use of best evidence in making decisions about drug treatment for patients both at the individual and population (policy) levels. When defining the pharmacotherapeutic profile of a drug , in addition to risk-benefit considerations, the economic aspects are evaluated too so that the most cost-effective treatments can be adopted.

Evidence-Based Laboratory Medicine (EBLM)實證檢驗醫學搜尋google約有35,200項符合“Evidence

based Laboratory Medicine” 的查詢結果

搜尋PubMedEvidence-based laboratory medicine Field: Title 共21篇,最早1999年Moore RA發表在Am Clin Lab.Concepts and principles of evidence-based laboratory medicine.

出版日期: 2003ISBN 1890883905預覽此書

Evidence-Based Imaging實證影像醫學

ACGME 認為住院醫師需具備以下6大基本能力

Patient careMedical KnowledgePractice-based learning & improvementInterpersonal & communication skillsProfessionalismSystems-based practice

The Accreditation Council for Graduate Medical Education, 2001

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PRACTICE-BASED LEARNING AND IMPROVEMENT

Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices.就是實證醫學（EBM）的能力。

民國92年PGY1要求實證醫學至少8小時的訓練• 94-6月起 UGY相同要求

國外甚至臨床見習醫學生必需的訓練

The Accreditation Council for Graduate Medical Education, 2001

行政院衛生署教學醫院教學費用補助計畫

醫療法第96條規定，教學醫院辦理醫師及其他醫事人員訓練，並接受醫學院、校學生臨床見習、實習。教學費用不再齊頭式補助醫師、醫事人員畢業後2~4年需有教學計畫計畫目的：– 以病人為中心的醫療– 跨領域的醫療團隊工作–– 基於實證醫學的專業執行基於實證醫學的專業執行– 醫療品質促進– 資訊技術利用

EBM is a clinical skill

The skills needed to find potentially relevant studies quickly and reliably, to separate the wheat from the chaff, and to apply sound research findings to patient care have today become as essential as skills with a stethoscope. ( Paul Glasziou BMJ 2008;337:a1253)

執行EBM的五個步驟 5A ( I )Bottom-Up EBM: Problem-based approach

1. Asking 問問題（可以回答的問題）Converting the clinical uncertainties into an answerable question.

2.Accessing 找資料（可獲得最好的證據資訊）Search the database and tracking down the best available evidence.

3.Appraising 分析判斷（文獻的效度與重要性）Critical appraising that evidence for its validity and importance.

執行EBM的五個步驟 5A ( II )Bottom-Up EBM: Problem-based approach

4. Applying 臨床應用（整合四大層面）Integrating the critical appraising with our clinical expertise and our patient’s unique biology, values and circumstances.

5. Auditing 評估成果（執行EBM的效率）Evaluating our effectiveness and efficiency in executing step 1- 4 and seeking ways to improve them both for next time.

Ask an answerable question?問一個可以回答的問題？

Step 1

– Background & Foreground Questions (PICO)– Types of Questions– Priority to answer

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Searching for the best available evidence

搜尋可獲得最佳的證據

資料庫的種類 Databases搜尋技巧與策略 Searching strategies初步判定證據級數高低

Hierarchy of evidence(Keep searching until the BEST AVAILABLE

evidence is located, not just RCTs!)

Step 2資料庫的種類（醫學資訊）

Best evidence (Prefiltered) databasesBest evidence (Prefiltered) databases（（最佳證據資料庫）最佳證據資料庫）

Evidence-based guideline or Evidence-based textbook:NICE, Clinical Evidence, UpToDate….2o journals:EBM , EBN, ACPJC, EBM Review, Bandolier (article review)Cochrane database of systematic reviews

Primary (Unfiltered) databasesPrimary (Unfiltered) databases（（原始文獻資料庫）原始文獻資料庫）

中華民國期刊論文, Medline, PubMed, ProQuestNursing, CINAHL, …….

『Burn your paper textbooks』???網路電子書, background knowledge

Step 2

Evidence-based textbooks or EB-CPG

Modified from R Brain Haynes et al.: ACP Journal Club Nov/Dec 2006 | Vol 145 • Number 34;A8-A9.

Evidence-based journal abstracts

Systematic Reviews

Original journal articles

Prefiltered

Studies

Syntheses

Synopses

Summaries

Systems

5S LevelsComputerized decision support

Primary Study共9頁

Synopsis 只1頁

省時

經過專家篩選評論之 2ndJournal 文章（延後約半年出版，空窗期）

Levels of Evidence (Oxford CEBM 2001)

Expert opinion without explicit critical appraisal, or based on physiology bench research or “first principles”

Expert opinion without explicit critical appraisal, or based on physiology bench research or “first principles”

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Case-series (and poor quality prognostic cohort studies)

Case-series (and poor quality cohort and case-control studies)

4

Individual Case-Control Study3b

SR (with homogeneity*) of case-control studies

3a

“Outcomes” Research“Outcomes” Research2c

Retrospective cohort study or follow-up untreated control patients in an RCT; or CPG not validated in a test set.

Individual cohort study (include low quality RCT; e.g.,

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Users’ Guides

Are the results of the study valid?

What were the results?

Will the results help me in caring

for my patients?

（消費指南）

提供「快速文獻評讀的指南」

G Guyatt: Users’ Guides to The Medical Literature, 2002

Apply to your patient

實際應用到你的病人Evidence is never enough

只有證據，永遠不足

如何將證據“外推”，應用於個案

Can the results be applied to my patient? (Applicability)

有效且重要的證據能實際應用到我照顧的病人身上嗎？

適用性

Efficacy Effectiveness Efficiency

Step 4證據能否外推證據能否外推 ??

Oxford Centre for Evidence-based Medicine Grades of Recommendation(May 2001) 建議等級

A: consistent level 1 studies （與證據等級1一致）B: consistent level 2 or 3 studies （與證據等級2,3一致）

or extrapolations（外推） from level 1 studies C: level 4 studies （與證據等級4一致） or

extrapolations （外推） from level 2 or 3 studiesD: level 5 evidence （與證據等級5一致） or

troublingly inconsistent or inconclusive studies of anylevel. （研究結果不一致或是沒有結論）

證據若外推，則建議等級下降

如何將證據“外推”，應用於個案？

你的病人與研究文獻所收錄的病人，有無明顯差你的病人與研究文獻所收錄的病人，有無明顯差異？異？

例如：女性乳癌的研究，能否應用到男性乳癌患者？

評估你的病人接受與研究文獻所施行相同的治療評估你的病人接受與研究文獻所施行相同的治療（或處置），所得益處（及害處）將有多大？（或處置），所得益處（及害處）將有多大？

應用到您的個案前，需先藉此修正文獻結果

你的單位或是你自己是否有能力（資源）施行相同的治療（或處置）？執行品質是否與研究機構相當？

個案自己的價值觀與喜好？

是否清楚與個案（及家屬）說明溝通？是否清楚與個案（及家屬）說明溝通？

治療（或處置）的益處（與害處），個案（及家屬）是否清楚瞭解？

個案（與家屬）的價值觀及喜好，是否清楚評估？

是否有其他更好的取代治療方案？是否有其他更好的取代治療方案？

個案對治療（或處置）的遵從性？個案對治療（或處置）的遵從性？

是否理智上同意合作（或不好意思拒絕），但潛意識行為並不配合，導致實際遵從性變差？

實際追蹤你的個案的成果實際追蹤你的個案的成果（（outcomeoutcome））

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Evaluation our performance評估表現與施行效率

Self – Evaluation （自我評估）Evaluation (Audit) by Expert or peer

（專家監督或同儕彼此評估）

Audit by organizationAudit by third party (NHI, Insurance)Audit by computer ????

Step 5

EBM是思考與行為模式的改變

從研究證據到臨床實務的過程中有很多疏漏

Aware Accept Target Doable Recall Agree Done

ValidResearch

If 80% achieved at each stage then0.8 x 0.8 x 0.8 x 0.8 x 0.8 x 0.8 x 0.8 = 0.21

Glasziou, Haynes, EBM 2005

如何跨越醫療品質的鴻溝？

Institute of Medicine (IOM) 2003Health Professions Education: A Bridge to Quality

• Provide patient-center care• Work in interdisciplinary teams

• Employ evidence-based practice• Apply quality improvement• Utilize informatics

Aware Accepted Applicable Able Acted on Agreed Adhered to

Studies(primary research studies: sound & unsound)

Systems(bottomline +/- ref)

Synopses(user summary of research)

Systematic Reviews & CATs(search; appraise; synthesis)

Evidence-Based Medicine• Questioning• Skills in EBM 5 steps• Evidence Resources• Time (substitution)

Glasziou, Haynes, EBM 2005

將有效的研究結果應用到臨床實務EBM 能預防其過程中的”疏漏”

救治更多的患者

以實證為基礎的臨床診療指引Evidence-based Clinical Practice Guideline (EB-CPG)

臨床診療指引

乃針對一系列具體明確的臨床問題，有系統地發展適當之臨床規範，來協助醫療從業人員（與病人），做出適當醫療照護的決定。

以實證為基礎

有別於專家共識

需有一定的方法學，引用最佳的研究證據，做為臨床指引陳述的內容

是一系列證據的摘要彙整

何謂好的臨床診療指引？

有效性(valid)重造性(reproducible)多專業代表性(Representative/multidisciplinary)清楚(clear)彈性(flexible)臨床實用性(clinical applicable)可修訂性(reviewable)經得起臨床審查(clinical audit)合乎成本效益(cost-effective)

經過推廣後能改變醫療從業人員的臨床實務行為，最後改善病人的治療結果，促進醫療品質

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EBM 與「以病人為中心的安全醫療」的相關性？

臨床專業醫療（護理）經驗與能力提升（安全醫療講求減少錯誤與疏失）可獲得最佳外在研究證據

（安全醫療講求有效證據）

病人之價值觀、環境資源（以病人為中心的思維）

EBM的基本精神：

就是「以病人為中心的安全醫療」

Doing the right thing right

EBM EBM 與與醫療品質醫療品質相輔相成相輔相成

EBM就像「內功」，醫療品質就像「外功」，兩者實為一體之兩面。

每位醫療人員對病人的建議與處置，都是「以實證為基礎的臨床決策」，其結果（Outcome）將是醫療品質最

佳化。

3 modes of EBM practiceEvidence Doer Doer 實作者實作者 5A5A

“Asking, Accessing, Appraising, Applying & Auditing”provides E-B care, but is expensive in time and resources

Evidence User User 使用者使用者 3A 3A -- 4A4A“Asking, Accessing, Applying & Auditing (?)”much quicker and if carried out among Prefilered E-B resources, can provide E-B care

Evidence Asker & Replicator Asker & Replicator 發問發問與與複製者複製者 1A1AMaybe “Asking (?) only”Trust and directly follow the recommendations of respected EBM leaders (experts)quickest, but should distinguish evidence-based from ego-based recommendations

Modified from Sharon E Straus et al.: BMJ 2004;329:1029-32.

如何形成PICO問題

財團法人彰化基督教醫院

實證醫學暨臨床流病中心

精神科

廖以誠醫師

實例演練

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Does EBM mean everything ?

A mastery of clinical skills of Patient-interviewing, history-taking, and physical examination, without which you can neither begin the process of EBM nor end it.Practice of continuous, lifelong, self-directed learning, without which you will rapidly become dangerously out of date.

The spirit of Problem-Based Learning, PBLMaintain the humility without which you will become immune both to self-improvement and to advances in medicine.

(SE Staus et al.: Evidence-based medicine – how to practice & teach EBM, 2005. )PBL ─ 定義

• Problem-Based Learning:– 營造「以問題促進學習」的環境。– 也就是說在學員學習之前先給他們一個

問題，藉由這個問題，學員發現在解決問題以前，他們必需要學會一些新的知識。

– 學習過程有一定的思考模式與進行步驟

問題（個案劇場）的思考程序

• 澄清並定義問題• 分析問題• 產生假說（想法）或

可能之解釋

• 確認解決問題所需的知識與其特性

• 確認哪些知識已經知道，哪些未知

• 列出學習目標的優先次序

• 確認適當的學習資源• 自己學習準備新知識• 整合原有與新學到的

知識，應用到問題解決上

• 自我評估，回顧上述學習過程的效率，是否需改進

PBL於臨床工作的運用

• PBL能給您什麼？– Critical thinking and Active problem solving skills

• 批判性思考，熱誠、主動面對現實生活問題，以整合、彈性與有用的知識為基礎，有效地解決問題

• 學習記憶效果較佳。

– Self-directive, Self-assessed and lifetime learning• 運用有效的自我學習技巧，養成終身學習的習慣• 持續地自我監督與評估，強化學習成效

– Interdependence and small group• 當成為團隊的一員時，能有效地與人合作，互相學習

Ask an answerable question?問一個可以回答的問題？

Step 1

– Background & Foreground Questions (PICO)– Types of Questions– Priority to answer

臨床問題從哪裡來？(SE Straus et al. 2005: Evidence-based medicine – how to practice & teach EBM, 3rd ed.)

臨床發現 ( clinical findings )病因 ( etiology )疾病的臨床表徵( clinical menifestations of diseases )鑑別診斷與診斷檢查 ( DDx & diagnostic test )治療 ( therapy)預後 ( prognosis )預防措施 ( prevention )（生病）的經驗與意義 ( experience & meaning )自我進步 ( self-improvement )

Step 1

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個案與家屬關心的問題(Simon Hatcher: Evidence-based Mental health care, 2005)

What is wrong? (diagnosis)What else could it be? (differential diagnosis)What tests are helpful? (diagnostic tests)What treatments work? (therapy)What will happen? (prognosis)What prevents it? (prevention)What does it mean for me & my family? (meaning)What caused it? (etiology)Could it have been found sooner? (screening)

Step 1臨床問題的認知反應(SE Straus et al. 2005: Evidence-based medicine – how to practice & teach EBM, 3rd ed.)

Cognitive resonance知道“知道”

Cognitive dissonance知道“不知道”一般的Uncertainty

Ignorance不知道“不知道”需要平時的自我成長與新知Update

背景問題（Background questions）(SE Straus et al. 2005: Evidence-based medicine – how to practice & teach EBM, 3rd ed.)

詢問有關疾病的一般性知識的問題(Ask for general knowledge about a disorder)

Two components:A question root (5W1H: who, what, where, when, how, why)A disorder, or an aspect of disorder

““ What cause Schizophrenia?What cause Schizophrenia?””““ When do complications of Alcohol When do complications of Alcohol

dependence usually occur? dependence usually occur? ““

Step 1

前景問題 ( Foreground questions ) (SE Straus et al. 2005: Evidence-based medicine – how to practice & teach EBM, 3rd ed.)

詢問有關處理病人所需特別知識的問題(Ask for specific knowledge about managing patients with a disorder )

Four (or three): PICOPICOPPatient and/or ProblemIIntervention/ or EExposure CComparison intervention (if relevant)OOutcomesTime

EBM主要是針對 foreground questions

Step 1

Background 與 Foreground 問題

From: http://www.hsl.unc.edu/services/tutorials/ebm_searching/pages/intro.htm

Background 與 Foreground 問題的關係

新手問較多的 background questions老手問較多的 foreground questions

Foreground

Background

新手老手

11

建立PICO問題的小秘訣(http://www.cebm.net/index.aspx?o=1036) 臨床重要性臨床重要性

PatientPatient--OOriented riented EEvidence vidence that Matters (POEM)that Matters (POEM)實證醫學觀點，給予更多的重視實證醫學觀點，給予更多的重視

死亡死亡((mortalitymortality)), , 病態病態((morbiditymorbidity)), , 生活品質生活品質((quality of lifequality of life)), , 有良好信、效度的診斷工具或測驗有良好信、效度的診斷工具或測驗

DiseaseDisease--OOriented riented EEvidence vidence that Matters (DOEM)that Matters (DOEM)

實證醫學觀點，較少的重視實證醫學觀點，較少的重視

生理、藥理或病因等相關的結果生理、藥理或病因等相關的結果

背景劇場

個案為77歲阿茲海默氏失智症的女性患者。原本在神經內科，每天使用Galantamine 16mg治療。最近一個月開始出現明顯的被偷妄想，且合併情緒困擾與激動行為（會找同住的大媳婦理論）。

家屬深感困擾，尤其大媳婦原是主要照顧者，現在個案對她的敵意，明顯導致其照顧壓力，希望將個案送到安養中心。

當護士的大孫女，將祖母帶到精神科門診，希望能先用藥物治療

Uncertainty → PICO 問題

For old people suffering fromdementia with delusion, does atypical antipsychotics (like risperidone )compared to placebo, improve the delusion and agitation?


問題以問題以 P I C OP I C O 形式呈現形式呈現

Decrease delusion and agitation (NPI scale)Outcome

PlaceboComparison

Atypical antipsychotics(eg. Risperidone)

Intervention

77 Y/O female Dementia with deluison

Patient / Problem

Type of Question: Therpay

背景劇場

23 歲女性，半年前因為憂鬱症（第一次發作）到您的門診，您開給她SSRI抗憂鬱藥物治療，個案對藥物反應不錯且醫囑順從性好（同意持續治療9至12個月）。

最近新聞報導抗憂鬱藥物會導致自殺增加，個案看

到相關報導後產生焦慮，回診時向您詢問。

SSRI 會增加自殺嗎？我有此危險性嗎？可以停藥嗎？


12

SSRI 與自殺

?Uncertainty → PICO 問題

Do adults suffering from depression and taking SSRI medications, compared to patients taking placebo or TCA, may suffer an increased risk of suicide attempts ?


問題以問題以 P I C OP I C O 形式呈現形式呈現


Increased suicide attemptsOutcome

Placebo or TCAComparison

SSRIIntervention

23Y/O female Major depression

Patient / Problem

Type of Question: Harm

Determining question type

Therapy如何選擇好的治療、介入或預防措施

Harm / Etiology如何確認疾病的病因或醫源性傷害

Diagnosis (tests)如何選擇好的診斷工具或測驗

Prognosis如何評估（預測）可能的臨床病程與併發症

Step 1

確定問題的類別，才能找尋到最佳研究設計之證據

From: http://www.hsl.unc.edu/services/tutorials/ebm_searching/pages/intro.htm Example: Treatment

Increase cognition, Increase ADLOutcome

Placebo / or MemantineComparison

RivastigamineIntervention

83Y/O male ADPatient / Problem

Step 1

13

Example: Harm

body weight lossOutcome

Placebo / or MemantineComparison

RivastigamineIntervention

83Y/O female AD Patient / Problem

Step 1

Example: Diagnosis

Accuracy of the diagnosis of AD(golden reference standard)(better sensitivity/specificity, likelihood ratio, probability)

Outcome

Nil / or brain CTComparison

PET Intervention

67Y/O male, clinically diagnosed probable moderate ADPatient / Problem

Step 1

Example: Prognosis

Survival over next 5 yearsOutcome

No cerebrovascular disease Comparison

Additional cerebrovasculardisease

Intervention /Exposure

67Y/O male with mild ADPatient / Problem

Step 1

問題的形成與回答優先順序

「PICO問題的形成」需對該疾病的相關知識有一定程度的瞭解。

時間有限，必需將問題列出優先順序，一般考量

的觀點：

與病人健康福祉有關的問題

臨床上重複出現的問題

時間許可內，最方便回答的問題

與學習者自我需求有關的問題

Step 1

臨床問題處理三部曲- 3S(SE Straus et al. 2005: Evidence-based medicine – how to practice & teach EBM, 3rd ed.)

SelectingSchedulingSaving

http://www.wanfang.gov.tw/ebm/14_tools/files/7x02_Question%20Log_Depo.pub

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實證醫學簡介 直覺式的認知過程 · 搜尋google 約有35,200項符合“Evidence based...

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實證醫學簡介直覺式的認知過程 · 搜尋google 約有35,200項符合“Evidence based...