Teaching evidence-based medicine

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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."[1] A second review concluded improvements in unvalidated measures of "knowledge, skills, attitudes or behavior."[2] Neither review examined improvements in clinical care.

Two systematic reviews of EBM provide the framework below for measuring outcomes.[3][4]

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.[5] 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.[6] 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.

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.[7] 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.[8] A quasi-randomized, controlled investigation of teaching medical students the use of studies, syntheses, and synopses using an automated search engine was negative.[9]

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."[10]

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

A controlled trial of teaching Bayesian principles (probabilistic reasoning) "improves the efficiency of test ordering."[11]

Studies on how to teach evidence-based medicine

This sections includes implications based on the preceding discussion on studies of effectiveness. In addition, this section includes other studies or reports of teaching methods, even though these methods have not been subjected to study of effect on clinical outcomes.

Search strategies

A search strategy 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[12] and two negative studies[7][9] 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[13], whereas using MEDLINE may take 20 minutes or more.[14][6]

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.[15] The mnemonic PEARL may guide how to each.[16] 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.'"
  1. ↑ 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.
  2. ↑ 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.
  3. ↑ Shaneyfelt T et al (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.
  4. ↑ Straus SE et al (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.
  5. ↑ 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.
  6. ↑ 6.0 6.1 Cabell CH et al. (2001). "Resident utilization of information technology". J Gen Intern Med 16: 838–44. PMID 11903763. [e] Cite error: Invalid <ref> tag; name "pmid11903763" defined multiple times with different content
  7. ↑ 7.0 7.1 Shuval K 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: 581–98. DOI:10.1111/j.1365-2753.2007.00859.x. PMID 17683300. Research Blogging.
  8. ↑ 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]
  9. ↑ 9.0 9.1 Badgett RG et al. (2001). "Teaching clinical informatics to third-year medical students: negative results from two controlled trials". BMC Medical Education 1: 3. PMID 11532204. [e] PubMed Central
  10. ↑ 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.
  11. ↑ 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]
  12. ↑ 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]
  13. ↑ Ely JW et al. (1999). "Analysis of questions asked by family doctors regarding patient care". BMJ 319: 358–61. PMID 10435959. [e]
  14. ↑ Chambliss ML, Conley J (1996). "Answering clinical questions". The Journal of Family Practice 43: 140–4. PMID 8708623. [e]
  15. ↑ Gruppen LD et al. (2005). "A controlled comparison study of the efficacy of training medical students in evidence-based medicine literature searching skills". Academic medicine 80: 940–4. PMID 16186614. [e]
  16. ↑ Silk H et al. (2006). "A new way to integrate clinically relevant technology into small-group teaching". Academic Medicine 81: 239–44. PMID 16501264. [e]
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