Teaching evidence-based medicine

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Teaching evidence based medicine (EBM) is difficult for several reasons including lack of consensus on what skills physicians need to have and also due to physicians' possibly being over confident in their EBM skills.[1]

Most of this article is about teaching evidence-based individual decision making and not about evidence-based medicine at the institutional level. This first part of this article covers studies or reports of methods in EBM. The second part reviews studies on the effectiveness of teaching evidence-based medicine. Both sections may guide the teacher of EBM in selecting strategies, but the teacher should note that only ideas on the second section have empiric data on effectiveness.

Methods for teaching EBM

A multinational European group has used the Delphi method to design a comprehensive EBM course based on five steps of EBM.[2] The course is clinically integrated. Its effectiveness is at least as good as traditional teaching.[3] Their proposed learning objectives are available online:

  • 'generate structured questions arising from clinical problems in practice'
  • 'search relevant literature, identifying systematic reviews wherever possible'
  • 'assess the quality (validity) of systematic reviews and primary research included within them'
  • 'assess the applicability of research findings in clinical practice'
  • 'effectively implement the output from above activities into clinical practice'

The 6Ts Teaching Tips have been recommended by experienced teachers of evidence-based medicine:[4]

  1. Time management. Plan in advance how class time will be used.
  2. Teamwork. Encourage all of the class to participate.
  3. Tools. Use audio, visual, and multimedia to improve learning.
  4. Triage. Be prepared to triage class content and to eliminate content if time is short.
  5. Tone. Create a respectful and non-threatening tone in the class.
  6. Take home messages. End with take home messages.

Formulation of the clinical question ('PICO')

The 'PICO' format, which is mnemonic for:[5]

  • P - patients, problems, or population
  • I - intervention, exposure, or test
  • C - comparison
  • O - outcome

Although PICO cannot represent all clinical question, especially questions that are not about interventions[6], use of PICO may improve the precision of searches[7].

Search strategies

A strategy for information retrieval similar to the 5S strategy should be taught for use when the searcher has limited time available during clinical care. This is based on one positive study of its use[8] and two negative studies[9][10] of teaching the use using secondary and primary publications. In addition, indirect evidence on the time needed to search also supports the emphasis on using tertiary publications. Doctors may have two minutes available to search[11], whereas using MEDLINE may take 20 minutes or more.[12][13]

Teaching MEDLINE searching would be appropriate for Doers who might be willing to invest time in searching MEDLINE when not hurried by clinical care. Based on studies of common errors in searching MEDLINE, learners should be taught Medical Subject Headings (MeSH) terms and their explosion, appropriate limits, and best evidence to search for.[14] The mnemonic PEARL may guide how to each.[15] PEARL stands for:

  1. "Choose a 'Preplanned search intervention'"
  2. "Allow learners to 'Execute the search,' thus committing themselves"
  3. "'Allow learners to teach other learners' about their search process
  4. "'Review the quality of evidence' for the information found"
  5. "Discuss 'Lessons of the search.'"

A subsequent negative study has been published about the effect of a single session of learning to search.[16]

Critical appraisal

It is very common to read only the abstract of an article.[17] However, many abstracts contain errors compared to the body of the article.[18] Fortunately, these are usually errors of omission rather than contradiction.

One strategy for teaching critical appraisal has been to make a goal of a journal club include the goal "composing, editing, and submitting a [group] letter to the editor[19]

Clinical reasoning

There are various methods of clinical reasoning include probabilistic (Bayesian), causal (physiologic), and deterministic (rule-based).[20] In addition, medical experts rely more on pattern recognition which is faster[21]; however, clinical experts seem flexible and may use whichever method of reasoning most easily represents and solves a given problem.[22] When confronted with non-challenging cases physicians may use 'nonanalytical reasoning' such as pattern recognition; however, during more difficult cases physicians may switch to 'reflective reasoning'.[23] Reflective reasoning may especially help complex cases.[24] Explicit Bayesian thinking with precise numbers is rarely done.[25][26] Basic science knowledge is probably "encapsulated" into clinical knowledge.[27]

Successfully distilling complex information into a short summary, perhaps using semantic qualifiers, may help diagnostic accuracy.[28][29][30][31]

Competing-hypotheses heuristic[32]
Finding Disease A Disease B
Fever 66% cell B
Rash cell C cell D
The most important missing information is cell B

Possible strategies to improve clinical reasoning have been reviewed[33][34] and using problem-based learning[34], include teaching appropriate problem representation creating a one-sentence summary of a case[33], standardized patients[35], teaching hypothetico-deductive reasoning[36][37], cognitive forcing strategies[38][39][40] to avoid premature closure[41], teaching the competing-hypotheses heuristic[32], using fuzzy-trace theory[42] and mixed-methods interventions[43][44][43]. Studies are unclear about teaching logic.[45][46] Regarding hypothetico-deductive reasoning, an observational study on the methods used by experts solving clinicopathological exercises reported that these experts use the following six steps:[37]

  1. aggregation of groups of findings into patterns
  2. selection of a "pivot" or key finding
  3. generation of a cause list
  4. pruning of the cause list
  5. selection of a diagnosis
  6. validation of the diagnosis

Scales to measure clinical reasoning have been proposed.[47]

Numeracy

Various methods have been proposed for improving quantitative literacy. For diagnosis, likelihood ratios[48] or sensitivity and specificity are two methods. It is unclear which method is better according to the results of a controlled trial.[49]

Studies are inconclusive on using cognitive feedback.[50].

Framing bias is best avoided by using numeracy with absolute measures of efficacy.[51]

Assessing the teaching of evidence-based medicine

Two systematic reviews of EBM provide the framework below for measuring outcomes.[52][53] Two instruments, the Berlin questionnaire[54] and the Fresno test[55] are the most validated.[52][53] These questionnaires have been used in diverse settings.[56][57] The Fresno test is more thorough but the Berlin Questionnaire is easier to administer.[52]

Studies of the effectiveness of teaching evidence-based medicine

A systematic review of the effectiveness of teaching EBM concluded "standalone teaching improved knowledge but not skills, attitudes or behaviour. Clinically integrated teaching improved knowledge, skills, attitudes and behaviour."[58] A second review concluded improvements in unvalidated measures of "knowledge, skills, attitudes or behavior."[59] Neither review examined improvements in clinical care.

Information retrieval

Increasing use of information

A randomized controlled trial of volunteer senior medical students found that access to information portal on a handheld computer increased self-reported use of information.[60] The information portal contained multiple pre-appraised resources, including a textbook and drug resource, and would best resemble the "user" mode. The study was not able to isolate which resources in the portal had increased use. It is possible that the benefit was solely due to the textbook or drug resource.

A randomized controlled trial of teaching and encouraging use of MEDLINE by medical resident physicians showed increased searching for evidence during 6-8 weeks of observation.[13] Based on the median number of searches and hours spent searching, each search averaged 22 minutes, which may not be sustainable over the long term.

A randomized controlled trial studied the effect of a searching tutorial that met for up to 6 1-hour small group sessions to search for answers to questions about their hospitalized patients. The intervention did not improve their success or speed in completing an Objective Structured Searching Evaluation (OSSE).[61]

An evidence-based medicine course consisting of six 2-hour workshop sessions shifted the types of resources learners used during a patient vignette.[62]

Improving clinical care

Teaching "user" mode only using syntheses and synopses, without summaries, has not shown benefit in two studies. A controlled trial of teaching the "user" mode (see above) was negative.[9] However, this study encouraged the use of syntheses and synopses and did not encourage the more practical "summaries" (evidence-based textbooks) of the "5S" search strategy.[63] A quasi-randomized, controlled investigation of teaching medical students the use of studies, syntheses, and synopses using an automated search engine was negative.[10]

Information awareness

A cluster randomized trial of McMaster Premium LiteratUre Service (PLUS) led to " increased the utilization of evidence-based information from a digital library by practicing physicians."[64]

No controlled studies have addressed improving clinical care by use of information awareness strategies.

A controlled trial of teaching Bayes Theorem (probabilistic reasoning) "improves the efficiency of test ordering."[65]

Clinical reasoning

Teaching Bayesian understanding of diagnostic testing improved actual test ordering in a controlled trial.[65]

Improving physicians' probability judgments did not lead to improvements in clinical decision making in a controlled before and after study.[50]

Encouraging the use of reflecting reasoning by suggesting to diagnosticians that a case is especially difficult may improve diagnositc accuracy.[66]

Teaching the SNAPPS method of student and preceptor interaction may help:[67]

  • Summarize history and findings
  • Narrow the differential
  • Analyze the differential
  • Probe preceptor about uncertainties
  • Plan management
  • Select case-related issues for self-study

Critical appraisal

There are no studies that teaching critical appraisal (including journal clubs), in isolation, improves clinical care. A systematic review was inconclusive whether journal clubs improved information habits.[68]

However, randomized controlled trials have found that the READER model (Relevance, Education, Applicability, Discrimination, overall Evaluation)[69] and other methods[70] increase the critical appraisal skills of learners.

If being a successful journal club is defined as one that has high attendance or is long-standing, then successful attributes are "associated with smaller residency programs, making attendance mandatory, promoting a journal club independent of faculty, providing formal teaching of critical appraisal skills, making food available, and emphasizing original research articles."[71]

See also

References

  1. ↑ Caspi O, McKnight P, Kruse L, Cunningham V, Figueredo AJ, Sechrest L (2006). "Evidence-based medicine: discrepancy between perceived competence and actual performance among graduating medical students". Med Teach 28 (4): 318–25. DOI:10.1080/01421590600624422. PMID 16807169. Research Blogging.
  2. ↑ Coppus SF, Emparanza JI, Hadley J, et al (2007). "A clinically integrated Curriculum in Evidence-based Medicine for just-in-time learning through on-the-job training: The EU-EBM project". BMC Med Educ 7 (1): 46. DOI:10.1186/1472-6920-7-46. PMID 18042271. Research Blogging.
  3. ↑ Kulier R, Coppus SF, Zamora J, Hadley J, Malick S, Das K, Weinbrenner S, Meyerrose B, Decsi T, Horvath AR, Nagy E, Emparanza JI, Arvanitis TN, Burls A, Cabello JB, Kaczor M, Zanrei G, Pierer K, Stawiarz K, Kunz R, Mol BW, Khan KS. The effectiveness of a clinically integrated e-learning course in evidence-based medicine: a cluster randomised controlled trial. BMC Med Educ. 2009 May 12;9:21. PMID 19435520
  4. ↑ Cook D, Figurski J, Patel R, Burneo J, Langlands S, Keitz S (2007). "6Ts teaching tips for evidence-based practitioners". Evid Based Med 12 (4): 100–1. DOI:10.1136/ebm.12.4.100. PMID 17885149. Research Blogging.
  5. ↑ Richardson WS, Wilson MC, Nishikawa J, Hayward RS (1995). "The well-built clinical question: a key to evidence-based decisions". ACP J. Club 123 (3): A12–3. PMID 7582737. [e]
  6. ↑ Huang X, Lin J, Demner-Fushman D (2006). "Evaluation of PICO as a knowledge representation for clinical questions". AMIA Annu Symp Proc: 359–63. PMID 17238363. PMC 1839740. [e]
  7. ↑ Schardt C, Adams MB, Owens T, Keitz S, Fontelo P (2007). "Utilization of the PICO framework to improve searching PubMed for clinical questions". BMC Med Inform Decis Mak 7: 16. DOI:10.1186/1472-6947-7-16. PMID 17573961. PMC 1904193. Research Blogging.
  8. ↑ Patel MR et al. (2006). "Randomized trial for answers to clinical questions: evaluating a pre-appraised versus a MEDLINE search protocol". JMLA 94: 382–7. PMID 17082828. [e]
  9. ↑ 9.0 9.1 Shuval K, Berkovits E, Netzer D, et al (2007). "Evaluating the impact of an evidence-based medicine educational intervention on primary care doctors' attitudes, knowledge and clinical behaviour: a controlled trial and before and after study". Journal of evaluation in clinical practice 13 (4): 581–98. DOI:10.1111/j.1365-2753.2007.00859.x. PMID 17683300. Research Blogging. Cite error: Invalid <ref> tag; name "pmid17683300" defined multiple times with different content
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  49. ↑ Puhan MA, Steurer J, Bachmann LM, ter Riet G (2005). "A randomized trial of ways to describe test accuracy: the effect on physicians' post-test probability estimates". Ann. Intern. Med. 143 (3): 184–9. PMID 16061916. [e]
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  52. ↑ 52.0 52.1 52.2 Shaneyfelt T, Baum KD, Bell D, Feldstein D, Houston TK, Kaatz S, Whelan C, Green M (2006). "Instruments for evaluating education in evidence-based practice: a systematic review". JAMA 296: 1116–27. DOI:10.1001/jama.296.9.1116. PMID 16954491. Research Blogging. Cite error: Invalid <ref> tag; name "pmid16954491" defined multiple times with different content
  53. ↑ 53.0 53.1 Straus SE, Green ML, Bell DS, Badgett R, Davis D, Gerrity M, Ortiz E, Shaneyfelt TM, Whelan C, Mangrulkar R; Society of General Internal Medicine Evidence-Based Medicine Task Force (2004). "Evaluating the teaching of evidence based medicine: conceptual framework". BMJ 329: 1029–32. DOI:10.1136/bmj.329.7473.1029. PMID 15514352. Research Blogging. Cite error: Invalid <ref> tag; name "pmid15514352" defined multiple times with different content
  54. ↑ Fritsche L, Greenhalgh T, Falck-Ytter Y, Neumayer HH, Kunz R (2002). "Do short courses in evidence based medicine improve knowledge and skills? Validation of Berlin questionnaire and before and after study of courses in evidence based medicine.". BMJ 325 (7376): 1338-41. PMID 12468485. PMC PMC137813. [e]
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  56. ↑ Kunz R, Wegscheider K, Fritsche L, Schünemann HJ, Moyer V, Miller D et al. (2010). "Determinants of knowledge gain in evidence-based medicine short courses: an international assessment.". Open Med 4 (1): e3-e10. PMID 21686291. PMC PMC3116678. [e]
  57. ↑ West CP, Jaeger TM, McDonald FS (2011). "Extended evaluation of a longitudinal medical school evidence-based medicine curriculum.". J Gen Intern Med 26 (6): 611-5. DOI:10.1007/s11606-011-1642-8. PMID 21286836. PMC PMC3101983. Research Blogging.
  58. ↑ Coomarasamy A, Khan KS (2004). "What is the evidence that postgraduate teaching in evidence based medicine changes anything? A systematic review". BMJ 329: 1017. DOI:10.1136/bmj.329.7473.1017. PMID 15514348. Research Blogging.
  59. ↑ Flores-Mateo G, Argimon JM (2007). "Evidence based practice in postgraduate healthcare education: a systematic review". BMC Health Services Research 7: 119. DOI:10.1186/1472-6963-7-119. PMID 17655743. Research Blogging.
  60. ↑ Leung GM et al. (2003). "Randomised controlled trial of clinical decision support tools to improve learning of evidence based medicine in medical students". BMJ 327: 1090. DOI:10.1136/bmj.327.7423.1090. PMID 14604933. Research Blogging.
  61. ↑ Stark R, Helenius IM, Schimming LM, Takahara N, Kronish I, Korenstein D (2007). "Real-time EBM: from bed board to keyboard and back". J Gen Intern Med 22 (12): 1656–60. DOI:10.1007/s11606-007-0387-x. PMID 17922170. Research Blogging.
  62. ↑ Kim S, Willett LR, Murphy DJ, O'Rourke K, Sharma R, Shea JA (November 2008). "Impact of an evidence-based medicine curriculum on resident use of electronic resources: a randomized controlled study". J Gen Intern Med 23 (11): 1804–8. DOI:10.1007/s11606-008-0766-y. PMID 18769979. Research Blogging.
  63. ↑ Haynes RB (2006). "Of studies, syntheses, synopses, summaries, and systems: the "5S" evolution of information services for evidence-based health care decisions". ACP J Club 145: A8. PMID 17080967. [e]
  64. ↑ Haynes RB et al. (2006). "McMaster PLUS: a cluster randomized clinical trial of an intervention to accelerate clinical use of evidence-based information from digital libraries". Journal of the American Medical Informatics Association : JAMIA 13: 593–600. DOI:10.1197/jamia.M2158. PMID 16929034. Research Blogging.
  65. ↑ 65.0 65.1 Davidoff F et al. (1989). "Changing test ordering behavior. A randomized controlled trial comparing probabilistic reasoning with cost-containment education". Medical care 27: 45–58. PMID 2492066. [e] Cite error: Invalid <ref> tag; name "pmid2492066" defined multiple times with different content
  66. ↑ Mamede S, et al. (2008) Influence of Perceived Difficulty of Cases on Physicians' Diagnostic Reasoning. Academic Medicine. 83(12):1210-1216. DOI:10.1097/ACM.0b013e31818c71d7
  67. ↑ Wolpaw, T, MHPE; Papp, KK; Bordage, G. Using SNAPPS to Facilitate the Expression of Clinical Reasoning and Uncertainties: A Randomized Comparison Group Trial. Academic Medicine April 2009;84(4):517-524 Template:DOI
  68. ↑ Audet N, Gagnon R, Ladouceur R, Marcil M (1993). "[How effective is the teaching of critical analysis of scientific publications? Review of studies and their methodological quality]" (in French). CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne 148 (6): 945–52. PMID 8448709. [e]
  69. ↑ MacAuley D, McCrum E, Brown C (1998). "Randomised controlled trial of the READER method of critical appraisal in general practice". BMJ 316 (7138): 1134–7. PMID 9552953. [e]
  70. ↑ Harewood GC, Hendrick LM (2010). "Prospective, controlled assessment of the impact of formal evidence-based medicine teaching workshop on ability to appraise the medical literature.". Ir J Med Sci 179 (1): 91-4. DOI:10.1007/s11845-009-0411-8. PMID 19707728. Research Blogging.
  71. ↑ Sidorov J (1995). "How are internal medicine residency journal clubs organized, and what makes them successful?". Arch. Intern. Med. 155 (11): 1193–7. PMID 7763125. [e]
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