Educating physicians in evidence based medicine: current practices and curricular strategies

Abstract

Evidence based medicine (EBM) is “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” The practice of EBM is an expectation of professional healthcare and requisite component in many medical school curricula. Yet, despite training, physicians sub-optimally practice EBM due to multiple factors. Education may mitigate these factors and improve EBM practice. However, there is limited knowledge on how is EBM practiced and taught in medical schools. To understand how EBM is practiced, specifically the first two steps of EBM (ask and acquire), we 1) interviewed American and Dutch physicians to identify clinical information needs. We next 2) developed a web log methodology that automates the mass retrieval of article-level metadata of articles accessed via PubMed and UpToDate and analyzed a year of Stanford University Hospitals’ web logs to understand information access in clinical care. To characterize how EBM is taught we 3) systematically reviewed the literature to identify EBM educational interventions. We also 4) interviewed faculty at North American medical schools, identified as graduating students confident in their EBM abilities, to identify challenges students face when learning EBM and how institutions approached these challenges. Based on 1) 22 interviews, we identified six information needs, including refreshing, confirming, logistics, teaching, information generating and personal learning, which align with physicians’ varied roles. Our 2) web log study revealed twice as much use of UpToDate (110,336 visits), a topical review resource, as PubMed (47,244 visits). Of total journal articles viewed (81,851), 30% (24,529) were review articles and 12% (10,261) clinical trials. Our 3) literature review described educational settings, learner levels, teaching methods and EBM skills covered. No intervention addressed all EBM steps and due to lack of details reported we were unable to draw conclusions about the efficacy of interventions. Based on 4) 31 interviews with educators at 17 medical schools, we identified six student learning challenges, including sub-optimal role models, and five learning approaches to overcome these challenges, such as incorporation of clinical content and faculty development. Study 1) presents information needs, which can help structure educational approaches to support physicians’ clinical inquiry in their varied roles, including teacher and lifelong learner. Study 2) demonstrates heavy use of review resources for EBM. This suggests the traditional approach to EBM training, which generally focuses on critically analyzing individual studies, should expand to include appraisal of review resources to better synchronize training and practice. Both studies provide a glimpse into practices potentially observed by students, therefore contributing to their EBM learning experience. Study 3) demonstrates a need for training to comprehensively cover all EBM skills and more detailed reporting of EBM interventions to enable evaluation and replication. Student challenges and educational approaches identified in Study 4) provide a window into students’ experience of EBM training, which medical educators can use to design learner-informed EBM curricula. This dissertation provides knowledge of how EBM is practiced and taught and equips medical educators with suggestions, drawn from practice, for examining and modifying their EBM curriculum.