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e-Learning Evidence-based Medicine. Katrien Oude Rengerink Academic Medical Center Dept. of Obstetrics and Gynaecology The Netherlands. Contents. What is Evidence-based Medicine? Why e-learning modules EBM? e-learning basic principles EBM e-learning modules Teach-the-Teacher EBM.

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E learning evidence based medicine

e-LearningEvidence-based Medicine

Katrien Oude Rengerink

Academic Medical CenterDept. of Obstetrics and Gynaecology

The Netherlands

EBayesMet conference October 2011


  • What is Evidence-based Medicine?

  • Why e-learning modules EBM?

  • e-learning basic principles EBM

  • e-learning modules Teach-the-Teacher EBM

What is ebm
What is EBM?

DaveSackett BMJ 1996: “Good doctors use individual clinical expertise, the best available external evidence as well as patient preferences, and neither alone is enough.”

Reduction number needed to read
Reduction Number Needed to Read

  • 120+ journals scanned

    • 50,000 articles

  • Is it valid? (<5%)

    • Intervention: RCT

    • Prognosis: inception cohort

    • Etc

  • Is it relevant?

    • 6-12 GPs & specialists asked:Relevant? Newsworthy?

  • < 0.5% selected


Number Needed to Read

is 200+

Why ebm
Why EBM?

  • Exponential growth knowledge

  • Integration research into clinical practice slow

     evidence summaries important

     skills for knowledge translation important

Theory of the stork vs theory of sexual reproduction
Theory of the Stork vs Theory of Sexual Reproduction

R2 0.49, p<0.05

Evidence supporting theory of stork
Evidence supporting Theory of Stork

Storks exist

Unexplained features fetal development

Sexual intercourse without delivery

Correlation birth rate - stork population

Storks not seen in hospitals: apparently medical interventions may replace storks

EBM: hierarchy in evidence sources

Parachute use to prevent death systematic review of rcts
Parachute use to prevent death: systematic review of RCTs

  • Parachutes used to prevent death and major injury due to gravitational challenge

  • Free fall studies: no 100% mortality

  • No RCT: basis use purely observational. Apparent efficacy potentially explained by a ‘healthy’ cohort effect.

  • No evidence  do not use intervention

     Some effects not need RCT

Why e learning ebm
Why e-learning EBM?

  • Clinical professionals value EBM important, but slow integration and application in practice

  • Huge variation EBM content and education Europe

  • Interactive, clinically integrated education best way learning and applying EBM

  • Current available courses useful, but: - minimum integration clinical practice- low flexibility

Leonardo i

Leonardo I

An European e-learning course in Evidence Based Medicine


  • UK

    • University of Birmingham/Birmingham Womens’ Hospital

    • CASP International

  • Germany - Agency for Quality in Medicine

  • Poland - CASPolska

  • Spain - CASPe

  • Hungary - TUDOR

  • Italy - Universita Cattolica del Sacro Cuore

  • Switserland - Basel Institute for Clinical Epidemiology

  • The Netherlands - AMC

    Independent steering commitee

E learning evidence based medicine

  • Familiarise participants with EBM basics to help incorporate evidence from systematic reviews on therapeutic interventions into daily clinical practice

  • Harmonise EBM teaching across Europe

  • Short, individual e-learning sessions

  • On-the-job training

Course content
Course content

1.Defining clinical questions

2. Searching the evidence

3. Appraisal of the systematic review

a. Validity of RCTs

b. relative risk and 2x2 table

4. Applying evidence to patient

5. Implementation of evidence into practice

Instruments for evaluating education in ebm
Instruments for evaluating education in EBM

4 EBP domains:

  • Knowledge

  • Skills

  • Attitude

  • Behavior

    • enacting EBP steps in practice

    • permorning evidence-based clinical manoevers

    • affecting patient outcomes

Course evaluation
Course evaluation

  • 101 participants from Switserland, Germany, Hungary, Spain, UK

  • Pre- and postcourse assessment

    • Knowledge/skills: modelled Berlin Questionnaire

    • Attitudes: questionnaire by Taylor L. et al.


  • Across all countries, knowledge scores improved from pre- to post-course for all five modules (p<0.001) (paired Wilcoxon signed ranks test)

  • After completing course participants felt more confident that they can assess research evidence

    E-learning at least equally effective as regular teaching

Leonardo ii

Leonardo II

Evidence Based Medicine: Training the Trainers across the healthcare sector


  • During Leonardo I & Sicily EBM conference: need support teaching EBM in practice

    • low level EBM teaching in clinical practice possibly due to lack of confidence to teach EBM in workplace

  • Complementary to existing EBM programmes: exploit learning opportunities in clinical setting

     Leonardo II


England (lead):

University of Birmingham/Birmingham Women’s Hospital

J&B Associates

Italy – Universita Cattolica del Sacro Cuore

Poland - CASPolska

Hungary - TUDOR

Switserland - Basel institute of clinical epidemiology

Netherlands – AMC

Germany – AzQ

E learning evidence based medicine

  • Train trainers to teach EBM through on-the-job training, by demonstration of applied EBM, to encourage clinically relevant teaching of EBM in post-graduate education

  • Develop European standard in EBM education

  • Target: clinical teachers who teach EBM in clinical practice to postgraduates

Course contents
Course contents

Based on teaching opportunities modules developed for 6 clinical settings:

Learner-centered (e-learning)


Video clip incorporated

Applicable in Europe

Example teaching and learning ebm during ward rounds
Example: Teaching and learning EBM during ward rounds


Learning objectives

Pre-requisites to undertake the module

Learning opportunities

EBM steps


Video clip (3 min)

Teaching and learning lesson


Course evaluation1
Course evaluation

  • 5 countries: about 10 clinical teachers who teach EBM to postgraduates per country piloted

  • Pre- and postcourse assessment using ‘Basel questionnaire’

     e-learning course on how to teach EBM in various settings is feasible and effective.

Barriers ebm teaching
Barriers EBM teaching

  • 120 clinical EBM teachers from 11 countries completed questionnaire regarding barriers for EBM teaching

  • Barriers:

    • lack of time in busy practice

    • lack of requirements for EBM skills

    • pyramid hierarchy in health care management structure.

       Teaching EBM in clinical settings is most successful where EBM principles are culturally embedded and form part and parcel of everyday clinical decisions and medical practice.


Free available in:






Accessible through: www.ebm-unity.org


  • Sackett, BMJ 1996 EBM what is it and what isn’t it?

  • Höfer T, Przyrembel H, Verleger S. New evidence for the Theory of the Stork. Paediatric and perinatal epidemiology. 2004(18):88-92.

  • Smith GCS, Pell JP. Parachute use to prevent dath and major trauma related to gravitational challenge: systematic review of randomised controlled trials. BMJ 2003.

  • Khan AT, Mehr MN, Gaynor AM, Bowcock M, Khan KS. Is general inpatient obstetrics and gynaecology evidence-based? A survey of practice with critical review of methodological issues. BMC Women’s Health 2006(6):5.

  • Khan KS, Coomarasamy A. A hierarchy of effective teaching and learning to acquire competence in evidence-based medicine. BMC Med Educ 2006:15(6):59.

  • Coppus SFPJ, Emperanza JI, hadley J et al. A clinically integrated curriculum in Evidence-based medicine for just-in-time learning through on-the-job training: The EU-EBM project. BMC Medical Education 2007(7):46.

  • Shaneyfelt T, Baum KD. Instruments for evaluating education in evidence-based practice: a systematic review. JAMA 2006;296(9):1116-1127.

  • Kulier R, Hadley J, Weinbrenner S et al. Harmonising Evidence-based medicine teaching: a study of the outomes of e-learning in five European countries. BMC Medical Education 2008(8):27.

  • Taranganitam S, Barnfield G et al. Teaching trainers to incorporate evidence-based medicine (EBM) teaching in clinical practice: the EU-EBM project.

  • Oude Rengerink K, Thangaratinam S. How can we teach EBM in clinical practice? An analysis of barriers to implementation of on-the-job EBM teaching and learning.

Thanks to
Thanks to

Leonardo I

Regina Kulier

Julie Hadley

Susanne Weinbrenner

Berrit Meyerrose

Tamas Decsi

Andrea Horvath

Eva Nagy

Jose Emparanza

Sjors Coppus

Theodoris Arvantis

Amanda Burls

Juan Cabello

Marcin Kaczor

Gianni Zanrei

Karen Pierer

Katarzyna Stawiarz

Regina Kunz

Ben Willem Mol

Khalid Khan

Steering committee

Leonardo II

Shakila Thangaratinam

Gemma Barnfield

Theodoros Arvanitis

Susanne Weinbrenner

Khalid Khan

Berit Meyerrose

Andrea Horvath

Gianni Zanrei

Regina Kunz

Katja Suter

Jacek Walczak

Anna Kaleta

Javier Zamora

Harry Gee

Ben Willem Mol

Maciej Nogas

Bernard Burnand

Chantal Arditi

E learning evidence based medicine

Katrien Oude Rengerink: K.OudeRengerink@amc.uva.nl