Teaching evidence-based medicine: Difference between revisions

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==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<ref name="pmid17082828">{{cite journal |author=Patel MR ''et al.'' |title=Randomized trial for answers to clinical questions: evaluating a pre-appraised versus a [[MEDLINE]] search protocol |journal=JMLA |volume=94 |pages=382–7 |year=2006 |pmid=17082828 |doi=}}</ref> and two negative studies<ref name="pmid17683300"/><ref name="pmid11532204"/> 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<ref name="pmid10435959">{{cite journal |author=Ely JW ''et al.'' |title=Analysis of questions asked by family doctors regarding patient care |journal=BMJ |volume=319 |pages=358–61 |year=1999 |pmid=10435959 |doi=}}</ref>, whereas using MEDLINE may take 20 minutes or more.<ref name="pmid8708623">{{cite journal |author=Chambliss ML, Conley J |title=Answering clinical questions |journal=The Journal of Family Practice |volume=43  |pages=140–4 |year=1996 |pmid=8708623 |doi=}}</ref><ref name="pmid11903763">{{cite journal |author=Cabell CH ''et al.'' |title=Resident utilization of information technology |journal=J Gen Intern Med |volume=16|pages=838–44 |year=2001 |pmid=11903763 |doi=}}</ref>
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.<ref name="pmid16186614">{{cite journal |author=Gruppen LD ''et al.''|title=A controlled comparison study of the efficacy of training medical students in evidence-based medicine literature searching skills |journal=Academic medicine |volume=80  |pages=940–4 |year=2005 |pmid=16186614 |doi=}}</ref> The mnemonic PEARL may guide how to each.<ref name="pmid16501264">{{cite journal |author=Silk H ''et al.''|title=A new way to integrate clinically relevant technology into small-group teaching |journal=Academic Medicine  |volume=81 |pages=239–44 |year=2006 |pmid=16501264 |doi=}}</ref> PEARL stands for:
# "Choose a ''''P'''replanned search intervention'"
# "Allow learners to ''''E'''xecute the search,' thus committing themselves"
# "''''A'''llow learners to teach other learners' about their search process
# "''''R'''eview the quality of evidence' for the information found"
# "Discuss ''''L'''essons of the search.'"
===Clinical reasoning===
There are various methods of clinical reasoning include probabilistic (Bayesian), causal (physiologic), and deterministic (rule-based).<ref name="pmid2655522">{{cite journal | author = Kassirer JP | title = Diagnostic reasoning | journal = Ann Intern Med | volume = 110 | pages = 893–900 | year = 1989 | pmid = 2655522 | doi = }}</ref>  In addition, medical experts rely more on pattern recognition which is faster and less prone to error<ref name="pmid7503827">{{cite journal | author = Leape LL | title = Error in medicine | journal = JAMA | volume = 272 | pages = 1851–7 | year = 1994 | pmid = 7503827 | doi = }}</ref>; however, clinical experts seem flexible and may use whichever method of reasoning most easily represents and solves a given problem.<ref name="pmid17124025">{{cite journal | author = Norman G | title = Building on experience--the development of clinical reasoning | journal = N Engl J Med | volume = 355  | pages = 2251–2 | year = 2006 | pmid = 17124025 | doi = 10.1056/NEJMe068134}}</ref> Scales to measure clinical reasoning have been proposed.<ref name="pmid9231115">{{cite journal | author = Boshuizen HP ''et al.''| title = Measuring knowledge and clinical reasoning skills in a problem-based curriculum | journal = Medical education | volume = 31 | pages = 115–21 | year = 1997 | pmid = 9231115 | doi = }}</ref> Explicit Bayesian thinking with precise numbers is rarely done.<ref name="pmid3277516">{{cite journal | author = Moskowitz AJ ''et al.''| title = Dealing with uncertainty, risks, and tradeoffs in clinical decisions. A cognitive science approach | journal = Ann. Intern. Med. | volume = 108| pages = 435–49 | year = 1988 | pmid = 3277516 | doi = }}</ref><ref name="pmid9576412">{{cite journal |author=Reid MC, Lane DA, Feinstein AR |title=Academic calculations versus clinical judgments: practicing physicians' use of quantitative measures of test accuracy |journal=Am J Med |volume=104 |pages=374–80 |year=1998 |pmid=9576412 |doi=}}</ref> Basic science knowledge is probably "encapsulated" into clinical knowledge.<ref name="pmid16043534">{{cite journal | author = de Bruin AB ''et al.'' | title = The role of basic science knowledge and clinical knowledge in diagnostic reasoning: a structural equation modeling approach | journal = Academic Medicine  | volume = 80 |  pages = 765–73 | year = 2005 | pmid = 16043534 | doi = }}</ref>
{| align="right" border="1"
|+'''Competing-hypotheses heuristic'''<ref name="pmid3385753">{{cite journal | author = Wolf FM ''et al.'' | title = Use of the competing-hypotheses heuristic to reduce 'pseudodiagnosticity' | journal = J Med Educ | volume = 63 | pages = 548–54 | year = 1988 | pmid = 3385753 | doi = }}</ref>
! Finding || Disease A || Disease B
|-
| Fever || 66%  || cell B
|-
| Rash || cell C  || cell D
|-
| Colspan="3" | The most important missing information is cell B
|}
Possible strategies to improve clinical reasoning have been reviewed<ref name="pmid17124019">{{cite journal |author=Bowen JL |title=Educational strategies to promote clinical diagnostic reasoning |journal=N Engl J Med |volume=355  |pages=2217–25 |year=2006 |pmid=17124019 |doi=10.1056/NEJMra054782}}</ref><ref name="pmid12377672">{{cite journal |author=Graber M ''et al.'' |title=Reducing diagnostic errors in medicine: what's the goal? |journal=Academic Medicine |volume=77  |pages=981–92 |year=2002 |pmid=12377672 |doi=}}</ref> and using problem-based learning<ref name="pmid12377672"/>, include teaching appropriate problem representation creating a one-sentence summary of a case<ref name="pmid17124019"/>, standardized patients<ref name="pmid16423099">{{cite journal |author=Windish DM ''et al.'' |title=Teaching medical students the important connection between communication and clinical reasoning |journal=J Gen Intern Med |volume=20 |pages=1108–13 |year=2005 |pmid=16423099 |doi=10.1111/j.1525-1497.2005.0244.x}}</ref>, teaching hypothetico-deductive reasoning<ref name="pmid11893348">{{cite journal |author=Wiese J ''et al.''|title=Improving oral presentation skills with a clinical reasoning curriculum: a prospective controlled study |journal=Am J Med |volume=112 |pages=212–8 |year=2002 |pmid=11893348 |doi=}}</ref><ref name="pmid7070446">{{cite journal |author=Eddy DM, Clanton CH |title=The art of diagnosis: solving the clinicopathological exercise |journal=N Engl J Med |volume=306 |pages=1263–8 |year=1982 |pmid=7070446 |doi=}}</ref>, cognitive forcing strategies<ref name="pmid11073470">{{cite journal |author=Croskerry P |title=The cognitive imperative: thinking about how we think |journal=Academic Emergency Medicine |volume=7 |pages=1223–31 |year=2000 |pmid=11073470 |doi=}}</ref><ref name="pmid12414468">{{cite journal |author=Croskerry P |title=Achieving quality in clinical decision making: cognitive strategies and detection of bias |journal=Academic Emergency Medicine |volume=9 |pages=1184–204 |year=2002 |pmid=12414468 |doi=}}</ref> to avoid premature closure<ref name="pmid3736379">{{cite journal |author=Dubeau CE ''et al.''|title=Premature conclusions in the diagnosis of iron-deficiency anemia: cause and effect |journal=Medical Decision Making  |volume=6  |pages=169–73 |year=1986 |pmid=3736379 |doi=}}</ref>, teaching the competing-hypotheses heuristic<ref name="pmid3385753">{{cite journal | author = Wolf FM ''et al.'' | title = Use of the competing-hypotheses heuristic to reduce 'pseudodiagnosticity' | journal = J Med Educ | volume = 63 | pages = 548–54 | year = 1988 | pmid = 3385753 | doi = }}</ref>, and using fuzzy-trace theory<ref name="pmid11251760">{{cite journal |author=Lloyd FJ, Reyna VF |title=A web exercise in evidence-based medicine using cognitive theory |journal=J Gen Intern Med|volume=16 |pages=94–9 |year=2001 |pmid=11251760 |doi=}} [http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=11251760 PubMed Central]</ref>.
Studies are inconclusive on using cognitive feedback<ref name="pmid7898300">{{cite journal |author=Poses RM ''et al.''|title=You can lead a horse to water--improving physicians' knowledge of probabilities may not affect their decisions |journal=Medical Decision Making |volume=15  |pages=65–75 |year=1995 |pmid=7898300 |doi=}}</ref> and teaching logic<ref name="pmid3742999">{{cite journal |author=Cheng PW ''et al.'' |title=Pragmatic versus syntactic approaches to training deductive reasoning |journal=Cognitive Psychology |volume=18 |pages=293–328 |year=1986 |pmid=3742999 |doi=10.1016/0010-0285(86)90002-2}}</ref><ref name="pmid16907682">{{cite journal | author = Jenicek M | title = The hard art of soft science: Evidence-Based Medicine, Reasoned Medicine or both? | journal = Journal of Evaluation in Clinical Practice | volume = 12  | pages = 410–9 | year = 2006 | pmid = 16907682 | doi = 10.1111/j.1365-2753.2006.00718.x}}</ref>.
==Studies of the effectiveness of [[teaching evidence-based medicine]]==
==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."<ref name="pmid15514348">{{cite journal |author=Coomarasamy A, Khan KS |title=What is the evidence that postgraduate teaching in evidence based medicine changes anything? A systematic review |journal=BMJ |volume=329 |pages=1017 |year=2004 |pmid=15514348 |doi=10.1136/bmj.329.7473.1017}}</ref> A second review concluded improvements in unvalidated measures of "knowledge, skills, attitudes or behavior."<ref name="pmid17655743">{{cite journal |author=Flores-Mateo G, Argimon JM |title=Evidence based practice in postgraduate healthcare education: a systematic review |journal=BMC Health Services Research |volume=7 |pages=119 |year=2007 |pmid=17655743 |doi=10.1186/1472-6963-7-119}}</ref> Neither review examined improvements in clinical care.
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."<ref name="pmid15514348">{{cite journal |author=Coomarasamy A, Khan KS |title=What is the evidence that postgraduate teaching in evidence based medicine changes anything? A systematic review |journal=BMJ |volume=329 |pages=1017 |year=2004 |pmid=15514348 |doi=10.1136/bmj.329.7473.1017}}</ref> A second review concluded improvements in unvalidated measures of "knowledge, skills, attitudes or behavior."<ref name="pmid17655743">{{cite journal |author=Flores-Mateo G, Argimon JM |title=Evidence based practice in postgraduate healthcare education: a systematic review |journal=BMC Health Services Research |volume=7 |pages=119 |year=2007 |pmid=17655743 |doi=10.1186/1472-6963-7-119}}</ref> Neither review examined improvements in clinical care.

Revision as of 06:30, 19 November 2007

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[1] and two negative studies[2][3] 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[4], whereas using MEDLINE may take 20 minutes or more.[5][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.[7] The mnemonic PEARL may guide how to each.[8] 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.'"

Clinical reasoning

There are various methods of clinical reasoning include probabilistic (Bayesian), causal (physiologic), and deterministic (rule-based).[9] In addition, medical experts rely more on pattern recognition which is faster and less prone to error[10]; however, clinical experts seem flexible and may use whichever method of reasoning most easily represents and solves a given problem.[11] Scales to measure clinical reasoning have been proposed.[12] Explicit Bayesian thinking with precise numbers is rarely done.[13][14] Basic science knowledge is probably "encapsulated" into clinical knowledge.[15]

Competing-hypotheses heuristic[16]
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[17][18] and using problem-based learning[18], include teaching appropriate problem representation creating a one-sentence summary of a case[17], standardized patients[19], teaching hypothetico-deductive reasoning[20][21], cognitive forcing strategies[22][23] to avoid premature closure[24], teaching the competing-hypotheses heuristic[16], and using fuzzy-trace theory[25].

Studies are inconclusive on using cognitive feedback[26] and teaching logic[27][28].

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."[29] A second review concluded improvements in unvalidated measures of "knowledge, skills, attitudes or behavior."[30] Neither review examined improvements in clinical care.

Two systematic reviews of EBM provide the framework below for measuring outcomes.[31][32]

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.[33] 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.[2] 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.[34] A quasi-randomized, controlled investigation of teaching medical students the use of studies, syntheses, and synopses using an automated search engine was negative.[3]

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."[35]

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."[36]

References

  1. ↑ 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]
  2. ↑ 2.0 2.1 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.
  3. ↑ 3.0 3.1 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
  4. ↑ Ely JW et al. (1999). "Analysis of questions asked by family doctors regarding patient care". BMJ 319: 358–61. PMID 10435959. [e]
  5. ↑ Chambliss ML, Conley J (1996). "Answering clinical questions". The Journal of Family Practice 43: 140–4. PMID 8708623. [e]
  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. ↑ 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]
  8. ↑ 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]
  9. ↑ Kassirer JP (1989). "Diagnostic reasoning". Ann Intern Med 110: 893–900. PMID 2655522. [e]
  10. ↑ Leape LL (1994). "Error in medicine". JAMA 272: 1851–7. PMID 7503827. [e]
  11. ↑ Norman G (2006). "Building on experience--the development of clinical reasoning". N Engl J Med 355: 2251–2. DOI:10.1056/NEJMe068134. PMID 17124025. Research Blogging.
  12. ↑ Boshuizen HP et al. (1997). "Measuring knowledge and clinical reasoning skills in a problem-based curriculum". Medical education 31: 115–21. PMID 9231115. [e]
  13. ↑ Moskowitz AJ et al. (1988). "Dealing with uncertainty, risks, and tradeoffs in clinical decisions. A cognitive science approach". Ann. Intern. Med. 108: 435–49. PMID 3277516. [e]
  14. ↑ Reid MC, Lane DA, Feinstein AR (1998). "Academic calculations versus clinical judgments: practicing physicians' use of quantitative measures of test accuracy". Am J Med 104: 374–80. PMID 9576412. [e]
  15. ↑ de Bruin AB et al. (2005). "The role of basic science knowledge and clinical knowledge in diagnostic reasoning: a structural equation modeling approach". Academic Medicine 80: 765–73. PMID 16043534. [e]
  16. ↑ 16.0 16.1 Wolf FM et al. (1988). "Use of the competing-hypotheses heuristic to reduce 'pseudodiagnosticity'". J Med Educ 63: 548–54. PMID 3385753. [e]
  17. ↑ 17.0 17.1 Bowen JL (2006). "Educational strategies to promote clinical diagnostic reasoning". N Engl J Med 355: 2217–25. DOI:10.1056/NEJMra054782. PMID 17124019. Research Blogging.
  18. ↑ 18.0 18.1 Graber M et al. (2002). "Reducing diagnostic errors in medicine: what's the goal?". Academic Medicine 77: 981–92. PMID 12377672. [e]
  19. ↑ Windish DM et al. (2005). "Teaching medical students the important connection between communication and clinical reasoning". J Gen Intern Med 20: 1108–13. DOI:10.1111/j.1525-1497.2005.0244.x. PMID 16423099. Research Blogging.
  20. ↑ Wiese J et al. (2002). "Improving oral presentation skills with a clinical reasoning curriculum: a prospective controlled study". Am J Med 112: 212–8. PMID 11893348. [e]
  21. ↑ Eddy DM, Clanton CH (1982). "The art of diagnosis: solving the clinicopathological exercise". N Engl J Med 306: 1263–8. PMID 7070446. [e]
  22. ↑ Croskerry P (2000). "The cognitive imperative: thinking about how we think". Academic Emergency Medicine 7: 1223–31. PMID 11073470. [e]
  23. ↑ Croskerry P (2002). "Achieving quality in clinical decision making: cognitive strategies and detection of bias". Academic Emergency Medicine 9: 1184–204. PMID 12414468. [e]
  24. ↑ Dubeau CE et al. (1986). "Premature conclusions in the diagnosis of iron-deficiency anemia: cause and effect". Medical Decision Making 6: 169–73. PMID 3736379. [e]
  25. ↑ Lloyd FJ, Reyna VF (2001). "A web exercise in evidence-based medicine using cognitive theory". J Gen Intern Med 16: 94–9. PMID 11251760. [e] PubMed Central
  26. ↑ Poses RM et al. (1995). "You can lead a horse to water--improving physicians' knowledge of probabilities may not affect their decisions". Medical Decision Making 15: 65–75. PMID 7898300. [e]
  27. ↑ Cheng PW et al. (1986). "Pragmatic versus syntactic approaches to training deductive reasoning". Cognitive Psychology 18: 293–328. DOI:10.1016/0010-0285(86)90002-2. PMID 3742999. Research Blogging.
  28. ↑ Jenicek M (2006). "The hard art of soft science: Evidence-Based Medicine, Reasoned Medicine or both?". Journal of Evaluation in Clinical Practice 12: 410–9. DOI:10.1111/j.1365-2753.2006.00718.x. PMID 16907682. Research Blogging.
  29. ↑ 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.
  30. ↑ 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.
  31. ↑ 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.
  32. ↑ 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.
  33. ↑ 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.
  34. ↑ 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]
  35. ↑ 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.
  36. ↑ 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]
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