“We believe that the way EBM is taught deserves the same scrutiny as the research articles EBM is designed to evaluate.” Rao and Kanter.1
I have been trying to learn how to effectively teach evidence-based medicine for years and I still feel intimidated by the topic. I know I am not the only one. I am not a math/statistics/probabilities expert, (I would say, quite the contrary!) and despite a lot of money spent on “made ridiculously simple”-like books and many, many seminars and courses, understanding and explaining EBM concepts still doesn’t come easily. However, I believe that with every attempt at understanding this “stuff,” I become a better doctor and I think it will make my students better doctors, too. American and European medical education organizations agree with this, and EBM-teaching is now part of most medical schools’ curriculums and it is also part of the Practice-based Learning and Improvement (PBLI) skills in which physicians must demonstrate competency.1
So, why is it so hard to teach?!!Is teaching EBM important?
First, we must agree that practicing EBM is important. Most physicians would acknowledge that practicing evidence-based health care promotes safe, effective patient care and that it promotes lifelong learning. EBM has its detractors however, some calling it “cookbook medicine”; and health care industries are inappropriately using EBM to measure physicians “effectiveness” disregarding patient preferences, leading to physicians (and patients) frustration and anger.
Why do clinical educators shy away from teaching EBM?
EBM is the process through which a physician combines her/his experience, the best research available and patient preferences in order to take clinical decisions.2 The EBM process is usually described as five steps easy to remember by the 5 A's: ASKING a clinical question, ACQUIRING the evidence, APPRAISING the evidence, APPLYING to patient care and then ASSESSING our performance.
As a clinician, combining my clinical experience with patient preferences was really not an issue. The problem was combining those two with the available evidence; and not only that, the real issue was determining what was the best evidence and explaining results to a patient in layman terms. According to surveys of physician faculty, I am not alone in my despair. Rao and Kanter described that many clinical educators feel uncomfortable about teaching evidence-based principles due to poor “physician numeracy” – defined as “understanding the statistical aspects of and terminology associated with the design, analysis, and results of original research.” Their review revealed that EBM curriculums are dominated by activities that teach the “ask, acquire and appraise” steps without emphasis on numeracy and with a weak “application” (of the evidence) component. They suggested that clinical educators would benefit from training on statistical aspects of EBM.1 Welch and Lurie explained that even though EBM has become a paradigm in medicine, teachers of EBM are challenged by situations in which the evidence is poor: “how to prepare residents to take decisions in the face of lack of evidence?”3 EBM teachers have also reported they lack enough time for teaching EBM, that EBM is not a requirement for trainees and that trainees lack enough EBM knowledge and skills.4-8 All of these reasons account for the lack of EBM champions in our institutions.
What about our students? What do they think about EBM learning and practice? In a systematic review about the barriers for practicing EBM, van Dijk et al found that residents felt they had a limited amount of time available to learn EBM principles. In one of the studies included in this review, surgical residents described that barriers to practice EBM included lack of education in EBM, time constraints, fear of staff disapproval and also lack of ready access to EBM resource materials.6
So, what characterizes successful EBM teaching strategies?
Of course, EBM teaching strategies that take into account the above mentioned barriers might be more likely to succeed. The evidence on EBM teaching strategies unfortunately is quite heterogeneous in terms of interventions and outcome measures, making it difficult to draw strong conclusions and to find standardized approaches.6 If you are interested in obtaining an idea of the current status of EBM teaching, I would recommend reading the dissertation thesis of Dr. Lauren Maggio, from Stanford University, available HERE. 7
Maggio et al performed an analysis of 20 published articles with descriptions of successful EBM teaching activities. The characteristics of effective EBM teaching initiatives included:6
- EBM teaching should happen in the setting of clinical experiences that provide relevance to the learning.
- EBM training should be longitudinal, with multiple exposures through undergraduate training and consider including instructors and learners from other health professions therefore enhancing interprofessional education.
- EBM education should combine active and online learning.
- EBM education should include the essential skill of recognizing knowledge gaps also referred as step “zero.”
Currently, the most commonly used approach to teach EBM is “Journal Club” sessions in which, the majority of the time is spent appraising articles. Unfortunately, a recent systematic review found that the evidence supporting its effectiveness is not clear. The same review identified that the aspects that might make some journal clubs more effective than others include the availability of mentors, brief training in clinical epidemiology, use of critical appraisal tools, use of adult-learning principles, and integration with clinical activities and use of multiple educational approaches.9
Several other educational strategies have been described in the literature. Most of these strategies have been targeted to medical students and include a combination of lecture series, workshops, computer-based training and integrated EBM/clinical experiences.
So in conclusion, learning and teaching EBM is difficult but not impossible. We teachers need to seek opportunities to improve our confidence and comfort in teaching these skills because our students need them.
- Rao, G., & Kanter, S. (2010). Physician numeracy as the basis for an evidence-based medicine curriculum. Academic Medicine : Journal of the Association of American Medical Colleges, 85(11), 1794-9.
- Maggio, L., Cate, O., Irby, D., & O’Brien, B. (2015). Designing Evidence-Based Medicine Training to Optimize the Transfer of Skills From the Classroom to Clinical Practice: Applying the Four Component Instructional Design Model. Academic Medicine : Journal of the Association of American Medical Colleges, 90(11), 1457-61.
- Welch, H. Gilbert, & Lurie, Jon D. (2000). Teaching Evidence-based Medicine: Caveats and Challenges. Academic Medicine, 75(3), 235-40.
- Maggio, L., Ten Cate, O., Chen, H., Irby, D., & O’Brien, B. (2016). Challenges to Learning Evidence-Based Medicine and Educational Approaches to Meet These Challenges: A Qualitative Study of Selected EBM Curricula in U.S. and Canadian Medical Schools. Academic Medicine : Journal of the Association of American Medical Colleges, 91(1), 101-6.
- Van Dijk, N., Hooft, L., & Wieringa-de Waard, M. (2010). What are the barriers to residents’ practicing evidence-based medicine? A systematic review. Academic Medicine : Journal of the Association of American Medical Colleges, 85(7), 1163-70.
- Maggio, L., Tannery, N., Chen, H., Ten Cate, O., & O’Brien, B. (2013). Evidence-based medicine training in undergraduate medical education: A review and critique of the literature published 2006-2011. Academic Medicine : Journal of the Association of American Medical Colleges, 88(7), 1022-8.
- Maggio, L., Cate, Th.J. Ten, Irby, D.M., & O’Brien, B.C. (2015). Educating Physicians in Evidence Based Medicine: Current Practices and Curricular Strategies. Dissertation. Utrecht University.
- Oude Rengerink, K., Thangaratinam, S., Barnfield, G., Suter, K., Horvath, A., Walczak, J., . . . Mol, B. (2011). How can we teach EBM in clinical practice An analysis of barriers to implementation of on-the-job EBM teaching and learning. Medical Teacher, 2011, Vol.33(3), P.e125-e130, 33(3), E125-E130.
- Harris, J., Kearley, K., Heneghan, C., Meats, E., Roberts, N., Perera, R., & Kearley-Shiers, K. (2011). Are journal clubs effective in supporting evidence-based decision making A systematic review. BEME Guide No. 16. Medical Teacher, 2011, Vol.33(1), P.9-23, 33(1), 9-23.
Written for March 2016 by
Shadia S. Constantine, MD MPH FACP
Co-Director. Junior Residency Training Program
Teine Keijinkai Hospital, Sapporo, Japan