TEACHING EVIDENCE-BASED MEDICINE (EBM)
January to April, 1998
On-line Discussion Summary

Articles discussed:

Bordley DR, Fagan M, Theige D. Evidence-based medicine: A powerful educational tool for clerkship education. Am J Med 1997;102(May):427-32.

Bloch RM, Swanson MS, Hannis MD. An extended evidence-based medicine curriculum for medical students. Acad Med 1997;72(5):431-2.

Flynn C, Helwig A. Evaluating an evidence-based medicine curriculum. Acad Med 1997;72(5):454-5

Green ML, Ellis PJ. Impact of an evidence-based medicine curriculum based on adult learning theory. J Gen Int Med 1997;12(12):742-50.99*

• Current growth due to more solid information, better research and data



• Sometimes EBM is positioned in opposition to experience-based medicine, rather than as two equally important, complementary elements of clinical care (only clinical experience can establish whether literature is relevant to a specific case)



• EBM can help deal with a continuously changing database, it promotes thoughtfulness and discussion



• EBM is particularly important for basic scientists and primary care physicians (the latter because they need to keep up with many different areas simultaneously)



• Weariness about negative reactions can result in an ambivalent approach to teaching or practicing EBM (e.g., simultaneously stressing its value and its limitations)



• There is a need for review articles that strengthen our understanding of the evidence



• EBM may soon reach the level of "political correctness"



• Literature evaluation skills require less content expertise - they are transferable



• One needs to have a balance between critical reading (line-by-line dissection of articles which is important for skills building but unsuitable for daily practice) and EBM (streamlined, yet well thought out answers to a limited set of practical questions that solve problems)



• Change to EBM is more likely an evolutionary than a revolutionary shift



• Once EBM becomes routine, a reduction in enthusiasm may set in

Barriers to EBM

• Innate resistance to change



• Clinical decision making is based on role models and pattern recognition, thus it is unlikely that physicians base their clinical decisions on their own independent evaluation of the literature



• May imply that past actions were not evidence-based



• Too much information can create confusion



• Lack of computer literacy ·



• Lack of quantitative skills - intimidation by statistics



• Time constraints



• Line-by-line dissection is too tedious, not practical enough



• Assumption that published literature is quality assured



• Literature versus expert conflict



• Experts may base their knowledge on different literature/evidence

Methods/Tips for Teaching EBM

General

• The curriculum itself should be evidence-based (not just depending on resource availability or politics)



• Role models are essential, they establish norms and influence behavior



• There has to be a large enough number of faculty who can role model the use of EBM in their daily teaching and clinical activities



• It is insufficient to have just a few committed faculty members teach/practice EBM, the approach has to be endorsed by chairs and deans



• Self-training or (in most cases) faculty development will be necessary



• It is unclear how much practice (e.g., number of cases in small group discussion) is needed in order to become competent in EBM



• Typical journal clubs have a primary reader who is likely to practice a more detailed dissection of the material than the rest of the group



• The outcome of a journal club will be affected by the level of active participation



• Hypothetical (simulated) studies may be a useful tool for evaluating learning gains because they permit standardization. However, in the case of teaching, real studies are preferable.



• EBM training needs to include training in determining when to stop pattern recognition, relying on role models and experts in order to turn to the literature



• Training programs need to be clear about their mission (training clinicians versus researchers) - they must find the appropriate balance



• Faculty must receive adequate rewards for their EBM teaching activities



• Set up a "respectable" evaluation system before it is too late



• Teaching this topic is more complex than most people might think initially

• EBM training needs to permeate the entire curriculum and must not be treated as artificial appendage



• Just throwing original articles at students is not sufficient



• Students need to learn the basic critical reading skills because the goal of their training is not so much managing current literature but getting tools to manage future literature



• Basic scientists should be more involved in teaching EBM



• EBM Principles should be taught in the first year and reinforced/elaborated on in the following years



• Use case-based small group sessions (good clinical scenarios with evidence-based solutions are bound to capture students' attention)



• EBM can be incorporated in a physical diagnosis course but one has to be careful that it does not replace necessary skills training with exercises in differential diagnosis



• Incorporating EBM teaching in clinical years is essential



• EBM could be brought to community-based preceptors - there students could assist practitioners in providing evidence from the literature and thus reducing their workload (this could result in "inverse role models")

Residency Programs

• Working with unrelated articles/class room tasks will not create enthusiasm for EBM among residents



• Getting residents involved in research projects can be an effective way to teach EBM



• Research projects can be facilitated by assigning a faculty mentor to each resident and making an epidemiology/biostatistics consultant available



• A critical review of the literature can result in the generation of a project or, alternatively, a project can result in the critical review of the literature (it is unclear as to what is a better educational strategy)



• Both, literature review and research project need to help answer real questions residents have



• Instructional methods which a literature review by Green and Ellis identified as preferred for EBM education (small-group, learner-centered format; generalist teachers; one-on-one resident-faculty opportunities; immediate clinical relevance; integration of EBM into mainstream of clinical work; faculty role modeling of EBM) are generally helpful in residency education



• Having residents teach EBM to students (in a well structured program) can be of benefit to both groups
  

Continuing Medical Education

• Dedicating a specific part of a meeting (e.g., 30%) to EBM in order to stimulate new discussions

Resources

Web Sites

http://hiro.mcmaster.ca(Teaching resource mentioned in Bordley et al.)
http://cebm.jr2.ox.ac.auk(Teaching resource mentioned in Bordley et al.)
http://www.micromedex.com/pd-cpc.htm#path(Clinical Pathway Constructor - software program)
http://www.uni-ulm.de/cebm(German)
http://www.sgim.orgforum/issues/forum9712.htm(Article about The Cochrane Collaboration)

Geyman JP. Evidence-based medicine in primary care: An overview. J Am Bd Fam Pract 1998;11(1):46-56 (Review of key articles and web sites good for planning EBM teaching program)

Slawson DC, Shaughnessy AF, Bennett JH. Becoming a medical information master: Feeling good about not knowing everything. J Fam Pract 1994;38(5):505-13

Shaughnessy AF, Slawson DC, Bennett JH. Becoming an information master: A guidebook to the medical information jungle. J Fam Pract 1994;39(5):489-99

Greengold NL, Weingarten SR. Developing evidence-based practice guidelines and pathways. J Qual Improv 1996;22(6):391-402

Nunn CM. Pathways, guidelines, and cookbook medicine: Are we all becoming Betty Crocker? JCOM Jan/Feb 1997;4(1):17-24

EBM Resource Center (sponsored by the American College of Physicians and the New York Academy of Medicine; will be accessible on-line as well as at NYAM)

1998 AAMC - Northeastern Group on Educational Affairs Conference (focuses on "Teaching and Learning in the Era of Evidence-Based Medicine," Boston, MA; April 17-19)

Wartman SA. Managed care and its effect on residency training in internal medicine. Arch Intern Med. 154(Nov 28):2539-44, 1994

Sheets KJ, Caruthers BS, Schwenk TL. Patient satisfaction with gynecologic care provided by family practice resident physicians in an academic HMO. Fam Pract Res J. 11:421-8, 1991

Veloski J, Barzansky B, Nash DB, Bastacky S, Stevens DP. Medical student education in managed care settings: Beyond HMOs. JAMA. 276(Sep 4):667-71, 1996

• Although most people agree that MC is different from fee-for-service-care, clear definitions are difficult to find. Furthermore, MC comes in many variations, from group or staff model HMOs in which teaching may be easiest) to independent practices that contract with multiple MC companies (the educational effect of those on students is still very unknown). Topics such as primary care, customer satisfaction or resource management may receive more emphasis in MC, however, they are not "new" to the world of medicine. Similarly, MC training programs suffer from many of the same ailments as other medical education enterprises (e.g., a lack of clearly defined objectives).



• Good patient care (a key criteria for selecting training sites) is not synonymous with any specific health care delivery system. Although MC emphasizes certain competencies that are very important for good patient care (e.g., prevention, patient satisfaction), sometimes they appear more on paper than in actual practice.



• The lack of future orientation and long-term responsibility which is characteristic of the current health care market, has a negative effect on good patient care (e.g., prevention) as well as medical education (e.g., investment in training future practitioners). For both the return on the investment may appear to take too long



• Some of the problems with the MC education literature is that it raises more questions than it provides answers and, since MC is such a fast changing field, it can quickly become outdated. Articles that, not too long ago, provided a refreshingly optimistic outlook, now might appear "sadly nostalgic."
  
  
• Educational partnerships need to be built not just with MC organizations but also with patients. In return for learning, trainees can provide patients with extra time, attention and information. These are commodities which practicing physicians sometimes do not have enough of. Such added value should not just prevent a decline in patient satisfaction, it should actually enhance it. If trainees are prepared for current practice conditions (e.g., high productivity quotas), they may lose the opportunity to provide such additional services.
  
  
• If patients are not blindsided and the boundaries of care-giving are clearly defined, they should not have more of a problem accepting care from a medical trainee than from a mid-level provider. Faculty need to be catalysts between patients and trainees and pass on true enthusiasm of being in a teaching system.
  
  
• The specialty split within medicine may make it more difficult to advance medical education interests in the current health care environment.
  

Greenlick MR. Educating physicians for population-based clinical practice. JAMA 267(12):1645-8, 1992

Boyer MH, Madoff MA, Bennett AJE, Dean DH, Hyde JN, Minihan PM, Barbeau EM. Tufts' four-year combined MD-MPH program: A training model for population-based medicine. Acad Med. 67(6):363-365, 1992

Raik B, Fein O, Wachspress S. Measuring the use of the population perspective on internal medicine attending rounds. Acad Med. 70(11):1047-9, 1995

Contributors(alphabetical order):
Mark Boyer (author), Kevin Cairns, Chisun Chun, Liesel Copeland, Darwin Deen, Richard Frankel, Stuart Green, Mariana Hewson, Jennifer Holtz, Elizabeth Kachur, Gregory Makoul, Barrie Raik (author), Kenneth Roberts, Susan Watson, Doug Waud

• Population-Based Medicine is neither easy to define nor easy to measure. Typically the concept is illustrated by juxtaposing 1-to-1 (the traditional medical model) with 1-to-N (the population-based medical model). Given that much of healthcare occurs in teams, it was proposed to reach beyond that to an "M-to-N" concept. Clearly this is a call for physicians to expand their roles and incorporate public health thinking in their daily work.


• The schism between medicine and public health occurred in the nineteen teens when the Welch-Rose report (a response to Flexner) resulted in the setting up of schools of public hygiene independent from medical schools. Paul Starr's "The Social Transformation of American Medicine" (1982) provides some valuable readings in this area.


• Subjects/topics, related to population-based medicine are: epidemiology, biostatistics, public health concepts and philosophy, policy and management, social behavior, informatics, prevention, resource allocation, scientific literacy.


• In many medical curricula the above topics have been marginalized. The turf war for curriculum time often resulted in token courses which have little prestige or impact. Although a few hours of lecture time (and that is what curriculum time is still often wrongly equated with) are better than nothing, they usually can't counteract the "heavy dose" of the traditional medical model provided throughout the four years.


• To reach more acceptance and wider utilization of population-based medicine, it will be essential to clearly demonstrate its relevance for daily medical work. Clearly, the task of curriculum development today is not just contemplating where to cut and what to add, but how to integrate. PBL does provide a golden opportunity here, but this type of teaching must be sustained in clinical rotations and residencies. There we need role models that don't just know what type of questions to ask but also what to do with the incoming information (e.g., the epidemiological implications of being divorced), how to utilize population data (e.g., age and gender distributions of their own practice) and who are committed to take epidemiological responsibility (e.g., regarding resource conservation). Faculty development in this area will be crucial, although we still have to figure out how to accomplish this task.


• Medical schools need to clarify whether they want to train students in the way medicine a) is practiced, b) will be practiced or c) should be practiced. The current health care changes (e.g., managed care) demand that we focus at least on b). Professional pride and moral obligation would call for c).


• Selected teaching methods discussed were: a community mock epidemic project that Eastern Virginia Medical School organizes for second year students in collaboration with public health agencies; inclusion of community issues in PBL tutorials and attendance at tumor board meetings at UMDNJ; community-based learning experiences and ambulatory care. Doctor-Patient courses often focus more on communication skills and the needs of individual patients. Thus they are not always suitable to simultaneously transmit the non-office based, non-physician centered approaches central to population-based medicine.


• Combined degree programs (MD/MPH, MD/MBA, MD/Engineering) are a time and cost efficient method for obtaining additional competencies that may prove beneficial in the tightening job market. Nonetheless, they are not for everyone. While they alone my not have the power to refocus medical education, the students who attend such programs will influence their peers as well as faculty.


• Although dual degree programs make much use of weekend and vacation times, they clearly also result in a reduction of the traditional medical curriculum. If MD/MPH students can do equally well (as evidenced by the Tufts study), why not drop some seemingly "necessary" elements of the traditional curriculum?


• Much of our discussion focused on the intricacies of "change" and here are some thoughts that kept coming up: We have to beware of "innovation without change." Band-aids won't work when surgical reconstruction is the actual need. Too much change can lead to a Ioss in accreditation. Will a change in medical education change medical practice or will a change in medical practice change the medical curriculum?


• Much of our discussion focused on the intricacies of "change" and here are some thoughts that kept coming up: We have to be beware of "innovation without change." Band-aids won't work when surgical reconstruction is the actual need. Too much change can lead to a Ioss in accreditation. Will a change in medical education change medical practice or will a change in medical practice change the medical curriculum?