introduction to teaching evidence-based health care sharon e. straus md msc frcpc associate...

Introduction to Teaching Introduction to Teaching Evidence-based Health CareEvidence-based Health Care

Sharon E. Straus MD MSc FRCPC

Associate Professor, University of Toronto

Knowledge Translation Program

What is EBHC?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

Its practice requires:Its practice requires:

AskingAcquiringAppraisingApplyingAssessing

A framework for teaching A framework for teaching EBHC and evaluating our EBHC and evaluating our

effortsefforts

Who is the learner?What is the intervention?What are the outcomes?

Who is the learner?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?

Who is the learner?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

What is the intervention?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

What is the intervention?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

What are the relevant What are the relevant outcomes?outcomes?

AttitudesKnowledge SkillsBehavioursClinical 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’


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

Effect of teaching strategies Effect of teaching strategies on critical appraisal skillson 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 1, 2004 (review updated, 2001 )


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

Clinical Outcomes– The most difficult to measure

What challenges have you What challenges have you encountered when teaching encountered when teaching

EBM?EBM?

What are some barriers to What are some barriers to teaching EBHC?teaching EBHC?

Time constraints – for teachers and learnersLack of resourcesPaucity of evidence that EBHC works

What can we do in 1 minute?What can we do in 1 minute?

Presentations will cover: 1. search strategy; 2. search results; 3. the validity of this evidence; 4. the importance of this valid evidence; 5. can this valid, important evidence be applied to your patient; 6. your evaluation of this process.

3-part Clinical Question

Patient’s Name Learner:

Target Disorder:

Date and place to be filled:

Intervention (+/- comparison):

Outcome:

What can we do in 5 minutes?What can we do in 5 minutes?

Time constraintsTime 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

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

Limited time and resources for Limited time and resources for EBHC TeachersEBHC 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

Paucity of Evidence that Paucity of Evidence that EBHC worksEBHC works

No evidence from RCTs showing impact on clinical outcomes

Evidence from process studiesEvidence from outcomes research

What’s the ‘E’ for EBHC?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

Outcomes researchOutcomes 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.

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%

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.

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

EBMEBMTeaching 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

Top 10 successesTop 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

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


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


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

introduction to teaching evidence-based health care sharon e. straus md msc frcpc associate...

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