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Introduction to Teaching Evidence-based Health Care. Sharon E. Straus MD MSc FRCPC Associate Professor, University of Toronto Knowledge Translation Program. Objectives. To outline a potential framework for teaching EBM

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Introduction to Teaching Evidence-based Health Care

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Introduction to teaching evidence based health care l.jpg

Introduction to Teaching Evidence-based Health Care

Sharon E. Straus MD MSc FRCPC

Associate Professor, University of Toronto

Knowledge Translation Program


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Objectives

  • To outline a potential framework for teaching EBM

  • To describe how this framework can be used for evaluating our EBM educational initiatives

  • To discuss some of your objectives for this workshop


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What is EBHC?

  • EBHC requires the integration of the best available research evidence with

  • our clinical expertise and

  • our patient’s unique values and circumstances


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Its practice requires:

  • Asking

  • Acquiring

  • Appraising

  • Applying

  • Assessing


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A framework for teaching EBHC and evaluating our efforts

  • Who is the learner?

  • What is the intervention?

  • What are the outcomes?


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Who is the learner?

  • We must identify our learners, their needs and their learning styles

  • Learners include clinicians who want to practise EBHC and the patients they care for

  • Do all clinicians want or need to learn how to practise all 5 steps?


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Who is the learner?

  • Targeted Clinicians:

    • EBHC Doers

    • EBHC Users

    • EBHC Replicators

  • The extent to which each of the 5 steps is performed is determined by:

    • The nature of the encountered condition

    • Time constraints

    • Level of expertise with each of the 5 skills


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What is the intervention?

  • The 5 steps of practising EBHC – but what is the appropriate dose, formulation and method of delivery?

    • 1 minute or 60 hours

    • Journal clubs and/or freestanding courses

    • At the bedside, in the classroom or online


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What is the intervention?

  • If our learners are interested in the ‘using’ mode, the intervention should focus on formulation of questions, searching for preappraised evidence and applying that evidence

  • If the learners are interested in the ‘doing’ mode, they should receive training in all 5 skills

  • The intervention should match the clinical setting, available time and other circumstances


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What is the intervention?

One approach doesn’t meet all our learners’ needs

  • Some studies use an approach to clinical practice and others use training in discrete microskills of EBHC

  • Review of graduate medical education found 18 reports of curricula and most commonly focused on critical appraisal

  • Some courses last 90 minutes, others weeks to months

  • Acad Med 1999;74:686-94

  • Depending on the targeted learner, different skills emphasized


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    What are the relevant outcomes?

    • Attitudes

    • Knowledge

    • Skills

    • Behaviours

    • Clinical outcomes


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    What are the relevant outcomes?

    • Attitudes

      • There are several studies that have looked at attitudes towards EBM but little psychometric data available

      • Self-Directed Learning Readiness Scale can be used to assess readiness and is defined as the ‘degree to which the individual possesses the attitudes, abilities, and personality characteristics necessary for SDL’


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    What are the relevant outcomes?

    • Knowledge and Skills

      • Changes in clinicians’ knowledge and skills are relatively easy to detect and demonstrate

      • Several instruments developed to evaluate these

      • However, these instruments primarily focus on evaluating skills of clinicians who want to practise in the ‘doing’ mode rather than the ‘using’ mode


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    Effect of teaching strategies on critical appraisal skills

    • Review of 7 studies showed gain in knowledge (assessed by written test) in undergrads

    • Cochrane review identified 1 study that met inclusion criteria:

      • Critical appraisal course increased knowledge of critical appraisal

    • No studies found increased use of medical literature or change in other behaviours

      • CMAJ 1998;158:177-81; Cochrane Library; Update Software, Issue 3, 2005 (review updated, 2001 )


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    What are the relevant outcomes?

    • Behaviours

      • More difficult to measure because they require assessment in the practice setting

      • One study included videotaping of resident-patient interactions and analysing them for EBHC content

      • A recent before and after study found that a multi-component EBHC intervention significantly improved evidence-based practice patterns (JGIM, 2005)

    • Clinical Outcomes

      • The most difficult to measure


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    Consider your most recent EBM teaching experience:

    • Who was the learner, what was the intervention, what was the outcome

    • What worked during this session?

    • What didn’t work during this session?


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    The top 10 successes that we’ve had or seen in teaching EBM

    • Teaching EBM succeeds:

      • When it centers around real clinical decisions

      • When it focuses on learners’ actual learning needs

      • When it balances passive with active learning

      • When it connects new knowledge to old

      • When it involves everyone on the team


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    Top 10 successes

    • Teaching EBM succeeds:

      • When it matches and takes advantage of, the clinical setting, available time, and other circumstances

      • When it balances preparedness with opportunism

      • When it makes explicit how to make judgments, whether about the evidence itself or how to integrate evidence with other knowledge, clinical expertise and patient preferences

      • When it builds learners’ lifelong learning abilities


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    Top 10 mistakes we’ve made or see when teaching EBM

    • Teaching EBM fails:

      • When learning how to do research is emphasised over how to use it

      • When learning how to do statistics is emphasised over how to interpret them

      • When teaching EBM is limited to finding flaws in published research

      • When teaching portrays EBM as substituting research evidence for, rather than adding it to clinical expertise, patient values and circumstances


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    Top 10 mistakes we’ve made or see when teaching EBM

    • Teaching EBM fails:

      • When teaching with or about evidence is disconnected from the team’s learning needs about the patient’s illness or their own clinical skills

      • When teaching occurs at the speed of the teacher’s speech or mouse clicks rather than the pace of the learner’s understanding

      • When the teacher strives for full educational closure by the end of each session rather than leaving plenty to think about and learn between sessions


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    Top 10 mistakes we’ve made or see when teaching EBM

    • Teaching EBM fails:

      • When it humiliates learners for not already knowing the ‘right’ fact or answer

      • When it bullies learners to decide to act based on fear of others’ authority or power, rather than on authoritative evidence and rational argument

      • When the amount of teaching exceeds the available time or the learner’s attention


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    Have fun!


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    What are some barriers to teaching EBHC?

    • Time constraints – for teachers and learners

    • Lack of resources

    • Paucity of evidence that EBHC works


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    What can we do in 1 minute?


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    What can we do in 5 minutes?


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    Time constraints

    • Post-call rounds:

      • Learners: all members of the medical team

      • Objectives: decide on working diagnosis and initial therapy of newly admitted patients

      • Evidence of highest relevance: accuracy and precision of the clinical examination and other diagnostic tests; effectiveness and safety of therapy

      • Strategies/Intervention: demonstrate e-b exam, carry a PDA with synopses of evidence, write educational prescriptions, add a clinical librarian to the team


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    • Morning Report

      • Learners: all members of the medical teams

      • Objectives: briefly review new patient(s) and discuss/debate diagnostic and management strategies

      • Evidence of highest relevance: accuracy and precision of diagnostic tests, effectiveness and safety of therapy

      • Strategies: educational prescriptions for foreground questions (CQ log), fact follow-ups for background questions, 1-2 minute summaries of critically appraised topics


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    Limited time and resources for EBHC Teachers

    • Educational sessions can target the different modes of practising EBHC

    • We can

      • Share educational materials

      • Share teaching tips (www.cma.ca/cmaj)

      • Share evaluation instruments

        • Development of evaluation clearinghouse/database

        • www.sgim.org/ebm.cfm


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    Paucity of Evidence that EBHC works

    • No evidence from RCTs showing impact on clinical outcomes

    • Evidence from process studies

    • Evidence from outcomes research


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    What’s the ‘E’ for EBHC?

    • Are we asking the right question?

    • Providing evidence from clinical research is necessary but not sufficient for the provision of optimal care

    • Changing behaviour is a complex process requiring comprehensive approaches directed towards patients, physicians, managers and policy makers

    • Provision of evidence is but one component

      • BMJ 2003;327:33-5


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    Outcomes research

    When cared for by evidence-based neurologists:

    • Patients with stroke 44% more likely to receive warfarin and more likely to be placed in a stroke unit

    • Patients were 22% less likely to die in the next 90 days

      • Stroke 1996;27:1937-43.


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    In a city-wide study of E-B practice vs. outcome in carotid stenosis:

    • Generated E-B indications for endarterectomy and reviewed 291 patients

    • Found the surgical indications

      • Appropriate in 33%

      • Questionable in 49%

      • Inappropriate in 18%


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    Stroke or expected death within the next 30 days:

    • Expected (if left alone)0.5%

    • Expected (if appropriate selection)

      1.5%

    • Observed among operated patients

      >5%

      Stroke 1997;28:891-8.


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