The ‘ripple effect’ of introducing evidence-based medicine into a curriculum

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Context and setting The practice of medicine in Pakistan is guided by expert opinion, giving rise to an environment defined by the dictum ‘the professor is always right’. Evidence-based medicine (EBM) has not been recognised as a competency in most Pakistani medical school curricula. As we have the benefit of being imbedded in an innovative institution, we designed an educational experience in EBM with the aim of encouraging students to use scientific inquiry to question common clinical practices. Why the idea was necessary The college mission clearly states its goal of graduating students who are ready to practise medicine in the 21st century. Although the importance of evidence-based practice has been well documented in the literature, formal teaching of EBM in our curricula was non-existent. What was done The strategy included a plan for educating both faculty and students. Four internal medicine faculty members, trained in EBM, conducted a small-group workshop for 12 interested clinical faculty staff. Subsequently, two of the original trainers provided two ‘EBM for Beginners’ workshops for 21 students each, prior to the students’ fifth (final) year clinical clerkships. Students learned to ‘ask a well-built, searchable clinical question’ and ‘acquire the appropriate evidence’ on MEDLINE using various search strategies – the first two steps of the four EBM practice model steps. The workshops were conducted in an informatics laboratory equipped with 20 online work stations. A student handbook was developed for quick reference. Evaluation of results and impact Gains in faculty’s knowledge of and skills in EBM were assessed by pre- and post-workshop Berlin questionnaires. During the EBM for Beginners workshops, students completed a questionnaire that assessed their baseline computer skills, knowledge about study designs, and perceptions about the use of evidence in patient care. Students also completed a pre- and post-workshop paper case that required them to search MEDLINE in order to answer items pertaining to developing a clinical question and acquiring appropriate evidence. At the end of the workshop, self-rated skills and attitudes were also recorded on a retrospective pre- and post-test. Five months post-workshop, students self-rated their EBM skills and attitudes. In the first year of implementation, we demonstrated that both faculty and students could learn relatively quickly to apply the first two steps of EBM. The workshops were welcomed by both students and faculty. After the workshop, students expressed concerns that doctors in Pakistan may not be familiar with the idea of EBM. In addition to these intended outcomes, there were several other ways that this educational intervention affected behaviour within and the environment of our institution. The workshops brought the word ‘evidence’ to the fore in an environment not generally conducive to the questioning of clinical practices. Informal observation of routine clinical teaching indicated that faculty and students began to request evidence for clinical practices in clinical teaching activities. The effect rippled on to the College of Nursing’s research module, internal medicine morning reports, generating interest in medical education projects and international recognition of the institution at medical education conferences at which several oral and poster presentations were made. The project was eventually incorporated into the newly implemented integrated medical curriculum.