Evidence-based Medicine Topics Research Articles

Letter to the Editor

Dr. Bharathy Kumaravel
 
 Journal of Medical Education Research
 University of Buckingham Press
 51 Gower Street
 London
 WC1E 6HJ
 
 9th June 2021
 
 Dear Editor,
 
 Evidence-based medicine (EBM) has become the gold standard for clinical decision-making and customary practice over the last few decades. As recently qualified junior NHS doctors, the COVID-19 pandemic has highlighted the practical relevance and importance of developing the skills of effective literature search and critical appraisal to be able to utilise it in our daily clinical practice.
 
 This letter is to bring to your kind attention our own reflection of training opportunities we had in relation to EBM and public health in our undergraduate curriculum. This training has helped us to survive our initial clinical years, made even more challenging by COVID-19 and ever-evolving medical knowledge. As per Meats, Heneghan, Crilly and Glasziou (2009) there is significant variation in EBM undergraduate teaching in medical schools in the UK and although core EBM topics are taught in theory, relatively few medical students gain the opportunity to practice or assess such skills. 
 
 As medical students at the University of Buckingham Medical School (UBMS), we formed a group called ‘UBMS public health crew’. We were able to go into community lunch clubs and conduct one-to-one interviews with the elderly ethnic minority communities to gain their perceptions and possible barriers they face regarding influenza vaccination uptake. We also had the annual EBM conference conducted by the medical school where we were able to submit our reports of concise and efficient implementation of EBM on clinical questions we formed during our clinical years. These were then showcased as posters, with the best examples also being presented with a prize of EBM champion for the best presentation. To our knowledge, student initiatives surrounding the clinical application of EBM is unique to University of Buckingham.
 
 The culmination of this training resulted in us continuing to incorporate EBM into our clinical practice and with the onset of the COVID-19 pandemic, it showed how EBM became almost a necessity in our clinical practice. During the initial wave, many junior doctors were redeployed to COVID specific wards. Clinicians caring for these patients were eager to learn more about the disease. As a result, at our hospital, a journal club was setup to critically analyse recent publications on COVID-19. A topic that was discussed was fluid administration in these patients. An initial management strategy had been to restrict fluid administration to these patients to avoid causing an acute respiratory distress syndrome. However, as more evidence emerged it became clear that this had potentially harmful effects. This led to the advocation of judicious fluid management. Our early exposure to the practical application of EBM has nurtured a dynamic approach to clinical medicine in a profession where what is best for the patient today is not necessarily the case tomorrow.
 
 In addition to our clinical application, we have also continued our research on EBM teaching for medical students. By presenting our research with posters and publications we are continuing to expand our research on this field with further opportunities.
 
 In conclusion, having formal modules on developing EBM skills as well as having interactive and real-time opportunities for medical students to expand on their EBM interests such as having community-based EBM projects and implementation of EBM in clinical practice are imperative to ensure future clinicians deliver scientifically sound clinical care that is in line with ever evolving medical research and to deal with unprecedented medical challenges.
 
 Sincerely,
 
 Dr. Fathima Rawther and Dr. Justin Collis
 Foundation Year 2 Doctors
 Royal Berkshire Hospital and Epsom & St Helier University Hospitals
 
 
 
 References
 Meats, E., Heneghan, C., Crilly, M. and Glasziou, P., 2009. Evidence-based medicine teaching in UK medical schools. Medical Teacher, 31(4), pp.332-337.

Cognitive levels in testing knowledge in evidence-based medicine: a cross sectional study

BackgroundKnowledge assessment in evidence-based medicine (EBM) is usually performed by the measurement of memorised facts, understanding of EBM concepts and application of learned knowledge in familiar situations, all of which are considered lower-level educational objectives. The aim of this study was to assess EBM knowledge both on higher and lower cognitive levels across EBM topics.MethodsIn order to assess knowledge on different EBM topics across learning levels, we created a knowledge test (Six Progressive Levels in Testing – SPLIT instrument), which consists of 36 multiple choice items and measures knowledge in EBM at six cognitive levels (Remembering, Understanding, Applying, Analysing, Evaluating and Creating) and addresses six EBM topics (Evidence-based practice, Internal validity, Clinical importance, Study design, Sources of evidence, Diagnostic studies). Three independent assessors defined the minimum passing score (MPS) for the overall test, based on the first-year course content and educational objectives. The instrument was assessed in a sample of first- (n = 119) and third-year medical students (n = 70) and EBM experts (n = 14).ResultsThe MPS was 16 correct answers out of total 36 questions, and was achieved by 21 out of 119 first-year students, 14 out of 70 third-year students and 9 out of 14 EBM experts (χ2 = 13.3; P < 0.001, with significantly higher proportion of experts passing compared to students). Although experts had the highest scores overall, none of the groups outperformed others on individual cognitive levels, but the experts outperformed students in EBM topics of Study design and Sources of evidence (P = 0.002 and 0.004, respectively, Kruskal-Wallis test). First- and third-year students performed better on specific course topics taught in that study year (Diagnostic studies and Clinical relevance, respectively).ConclusionEBM knowledge of students and experts differ according to the specificities of their education/expertise, but neither group had excellent knowledge in all areas. It may be difficult to develop a knowledge test that includes different EBM topics at different cognitive levels to follow the development of specific and general aspects of EBM knowledge.

TEACH Cards: Teaching Evidence-Based Medicine and Clinical Topics in the Hospital.

Inpatient training and evidence-based medicine (EBM) curricula are fundamental components of medical education. Teaching EBM And Clinical topics in the Hospital (TEACH) Cards is an inpatient curricular tool developed to help guide efficient, discussion-based teaching sessions. TEACH Cards aims to increase frequency of inpatient teaching, improve exposure to the breadth of inpatient topics, advance EBM skills, and improve efficiency in answering clinical questions. TEACH Cards is a set of 25 topic-based cards, each addressing an adult inpatient medicine topic by asking background questions and encouraging learners to write and answer foreground questions. Residents and faculty from a family medicine residency rotating on an adult inpatient medicine service during the 6-month study period were invited to complete a prerotation survey, use the TEACH Cards, and then complete a postrotation survey. Out of 54 potential participants, 35% completed both the pre- and postrotation surveys. Respondents used TEACH Cards on average three times per week, reporting significantly stronger agreement that they were both learning (P=0.034) and teaching (P=0.006) core inpatient topics. Respondents reported greater confidence in using EBM resources ( P=0.006) and significantly shorter time to find an evidence-based answer to a clinical question (pretest median=6-10 minutes vs posttest median=2-5 minutes, P=0.002). Use of TEACH Cards increased self-reported exposure to the breadth of core inpatient topics, confidence with EBM skills, and efficiency in finding answers to clinical questions.

Evidence-based medicine and life-long learning competency requirements in new residency teaching standards

The objective of this study is to compare accreditation standards across medical and surgical specialties in the USA to determine the requirements for evidence-based medicine (EBM) and information management (life-long...

The Impact of a Dedicated Research Education Month for Anesthesiology Residents

An educational intervention was implemented at the University of Michigan starting in 2008, in which anesthesiology interns complete a dedicated month-long didactic rotation in evidence-based medicine (EBM) and research methodology. We sought to assess its utility. Scores on a validated EBM test before and after the rotation were compared and assessed for significance of improvement. A survey was also given to gauge satisfaction with the quality of the rotation and self-reported improvement in understanding of EBM topics. Fourteen consecutive interns completed the research rotation during the study period. One hundred percent completed both the pre- and postrotation test. The mean pretest score was 7.78 ± 2.46 (median = 7.5, 0–15 scale, and interquartile range 7.0–10.0) and the mean posttest score was 10.00 ± 2.35 (median = 9.5, interquartile range 8.0–12.3), which represented a statistically significant increase (P = 0.011, Wilcoxon signed-rank test). All fourteen of the residents “agreed” or “strongly agreed” that they would recommend the course to future interns and that the course increased their ability to critically review the literature. Our findings demonstrate that this can be an effective means of improving understanding of EBM topics and anesthesiology research.

An Evidence-based Medicine Curriculum Implemented in Journal Club Improves Resident Performance on the Fresno Test

BackgroundJournal club is a standard component of residency education. Journal club focuses on review and interpretation of the medical literature with varying degrees of evidence-based medicine (EBM) education. ObjectivesTo evaluate learning of EBM principles with an EBM curriculum implemented as a component of journal club. EBM competency was established using the Fresno test, a validated 12-question instrument of short-answer and essay-style questions to assess competency in EBM. MethodsAn EBM curriculum was implemented that consisted of a focus on EBM topics (e.g., study validity, bias, confidence intervals, search strategies) using a structured journal club format using a peer instruction model. The Fresno test was used prior to and after the implementation of the first year of this curriculum to measure effectiveness of the intervention. A hierarchical multivariable model using generalized estimating equations was used to account for repeated measures in the primary outcome of change in total Fresno test score. ResultsThe total test scores did not increase significantly (105.4 vs. 120.9, p = 0.058) in the before–after analysis. The only subscore showing improvement was interpretation of study validity (32.1 vs. 40.4 points, p = 0.03). Attendance was significantly associated with Fresno test score, with those attending ≥ 6/11 sessions (55%) scoring 28.2 points higher (p = 0.003), and those attending fewer than six sessions scoring only 1.9 points higher (p = 0.81) than in the preintervention group. ConclusionAn EBM curriculum implemented as part of journal club improves performance on the Fresno test among residents who attended at least six journal club sessions.

Attending Rounds in the Current Era

General medicine rounds by attending physicians provide the foundation for patient care and education in teaching hospitals. However, the detailed activities of these rounds in the current era are not well characterized. To describe the characteristics of attending rounds for internal medicine inpatients in a large teaching hospital system. A cross-sectional observational study of attending rounds in internal medicine. Rounds were observed directly by research assistants. Four teaching hospitals associated with a large public medical school. Fifty-six attending physicians and 279 trainees treating 807 general medicine inpatients. Duration and location of rounds, composition of teams, and frequency of 19 potential activities during rounds. We observed 90 days of rounds. A typical rounding day consisted of 1 attending with 3 trainees visiting a median of 9 (range, 2-18 [SD, 2.9]) patients for a median of 2.0 hours (range, 25-241 [SD, 2.7] minutes). On rounds, teams most frequently discussed the patient care plan (96.7% of patients), reviewed diagnostic studies (90.7%), communicated with patients (73.4%), and discussed the medication list (68.8%). Teams infrequently discussed invasive lines or tubes (9.3%) or nursing notes (6.2%) and rarely communicated with nurses (12.0%) or taught physical examination skills (14.6%), evidence-based medicine topics (7.2%), or learner-identified topics (3.2%). Many commonly performed activities occurred infrequently at the bedside. Most activities on attending rounds do not take place at the bedside. The teams discuss patient care plans and test results most of the time but fail to include many items that may be of significant value, including specific aspects of patient care, interprofessional communication, and learner-centered education. Future studies are needed to further assess the implications of these observations.

Ovid MEDLINE Instruction can be Evaluated Using a Validated Search Assessment Tool

Objective – To determine the construct validity of a search assessment instrument that is used to evaluate search strategies in Ovid MEDLINE.&#x0D; &#x0D; Design – Cross-sectional, cohort study.&#x0D; &#x0D; Setting – The Academic Medical Center of the University of Michigan.&#x0D; &#x0D; Subjects – All 22 first-year residents in the Department of Pediatrics in 2004 (cohort 1); 10 senior pediatric residents in 2005 (cohort 2); and 9 faculty members who taught evidence based medicine (EBM) and published on EBM topics.&#x0D; Methods – Two methods were employed to determine whether the University of Michigan MEDLINE Search Assessment Instrument (UMMSA) could show differences between searchers’ construction of a MEDLINE search strategy. &#x0D; &#x0D; The first method tested the search skills of all 22 incoming pediatrics residents (cohort 1) after they received MEDLINE training in 2004, and again upon graduation in 2007. Only 15 of these residents were tested upon graduation; seven were either no longer in the residency program, or had quickly left the institution after graduation. The search test asked study participants to read a clinical scenario, identify the search question in the scenario, and perform an Ovid MEDLINE search. Two librarians scored the blinded search strategies. &#x0D; &#x0D; The second method compared the scores of the 22 residents with the scores of ten senior residents (cohort 2) and nine faculty volunteers. Unlike the first cohort, the ten senior residents had not received any MEDLINE training. The faculty members’ search strategies were used as the gold standard comparison for scoring the search skills of the two cohorts. &#x0D; &#x0D; Main Results – The search strategy scores of the 22 first-year residents, who received training, improved from 2004 to 2007 (mean improvement: 51.7 to 78.7; t(14)=5.43, P

The Levels of Evidence and Their Role in Evidence-Based Medicine

As the name suggests, evidence-based medicine (EBM), is about finding evidence and using that evidence to make clinical decisions. A cornerstone of EBM is the hierarchical system of classifying evidence. This hierarchy is known as the levels of evidence. Physicians are encouraged to find the highest level of evidence to answer clinical questions. Several papers published in Plastic Surgery journals concerning EBM topics have touched on this subject. 1–6 Specifically, previous papers have discussed the lack of higher level evidence in PRS and need to improve the evidence published in the journal. Before that can be accomplished, it is important to understand the history behind the levels and how they should be interpreted. This paper will focus on the origin of levels of evidence, their relevance to the EBM movement and the implications for the field of plastic surgery as well as the everyday practice of plastic surgery.

Evidence-based medicine teaching in UK medical schools

Background: It is recognized that clinicians need training in evidence-based medicine (EBM), however there is considerable variation in the content and methods of the EBM curriculum in UK medical schools.Aims: To determine current practice and variation in EBM undergraduate teaching in UK medical schools and inform the strategy of medical schools and the National Knowledge Service.Methods: We contacted all 32 medical schools in the UK and requested that the person primarily responsible for EBM undergraduate teaching complete a short online survey and provide their EBM curriculum.Results: The survey was completed by representatives from 20 (63%) medical schools and curriculum details were received from 5 (16%). There is considerable variation in the methods and content of the EBM curriculum. Although the majority of schools teach core EBM topics, relatively few allow students to practice the skills or assess such skills. EBM teaching is restricted by lack of curriculum time, trained tutors and teaching materials.Conclusions: Key elements to progress include the integration of EBM with clinical specialties, tutor training and the availability of high-quality teaching resources. The development of a national undergraduate EBM curriculum may help in promoting progress in EBM teaching and assessment in UK medical schools.

Mixing it up: integrating evidence-based medicine and patient care.

To teach internal medicine residents to use evidence-based medicine (EBM) in their interactions with patients by creating curricula that integrate EBM into clinical topics in internal medicine. The last several years have brought the wide-spread inclusion of EBM in internal medicine training programs in the United States. However, EBM is often taught as an independent topic and is poorly integrated into the clinical teaching of trainees. Most EBM education occurs in a journal-club format, focusing on question development, searching, and critical appraisal. The challenge of discussing the evidence with patients is rarely addressed. We set out to integrate EBM teaching into new curricula in women's health, addiction medicine, and topics in anticoagulation. During the first of two ambulatory blocks of the year, residents participate in an EBM seminar series in which they present cases, generate questions, and critically appraise the evidence. Second-year residents present articles on therapy or diagnosis and third-year residents present articles on diagnosis, meta-analysis, or decision and economic analysis. Both the women's health curriculum and the anticoagulation curriculum are presented during the second ambulatory block of the year as four half-day small-group seminars. The women's health curriculum is presented to the second-year residents and the anticoagulation curriculum is presented to the third-year residents. Both curricula are case-based and emphasize essential skills in patient care, including interview techniques, sensitivity to psychosocial issues, and skills in evidence-based patient care. Teaching EBM is not identified to the residents as a goal of these curricula; instead EBM, psychosocial medicine, and communication skills are woven into the content material and taught in the context of the broader subject matter. Learners are expected to integrate these concepts into actual practice. The curricula utilize clinical vignettes and role-plays to link EBM concepts such as number needed to treat or decision analysis to real-patient decisions. Residents are also asked to apply the evidence in their own patient encounters for further discussion at later sessions. Simpler concepts of therapy and diagnosis are covered during the second year in women's health and the more complex concepts of meta-analysis; decision analysis, and economic analysis are covered during the third year in anti-coagulation. The women's health curriculum was introduced in the spring of 2000; the anticoagulation curriculum was introduced in the spring of 2001. Both have been well received and seem to have impacted the ability of our housestaff to incorporate EBM into patient care. Currently under development in this series is a curriculum in addiction medicine for interns that will use a similar approach to provide an overview of EBM topics and their integration into the flow of patient care. We feel that these educational programs have helped EBM to bridge the gap between the classroom and the exam room.