Introduction to Teaching Evidence-based Health Care

1
Introduction to Teaching Evidence-based Health
Care

• Sharon E. Straus MD MSc FRCPC
• Associate Professor, University of Toronto
• Knowledge Translation Program

2
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

3
What is EBHC?

• EBHC requires the integration of the best
  available research evidence with
• our clinical expertise and
• our patients unique values and circumstances

4
Its practice requires

• Asking
• Acquiring
• Appraising
• Applying
• Assessing

5
A framework for teaching EBHC and evaluating our
efforts

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

6
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?

7
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

8
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

9
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

10
What is the intervention?

• One approach doesnt 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 199974686-94
• Depending on the targeted learner, different
  skills emphasized

11
What are the relevant outcomes?

• Attitudes
• Knowledge
• Skills
• Behaviours
• Clinical outcomes

12
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

13
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

14
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 1998158177-81 Cochrane Library Update
  Software, Issue 3, 2005 (review updated, 2001 )

15
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

16
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 didnt work during this session?

17
The top 10 successes that weve 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

18
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

19
Top 10 mistakes weve 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

20
Top 10 mistakes weve made or see when teaching
EBM

• Teaching EBM fails
• When teaching with or about evidence is
  disconnected from the teams learning needs about
  the patients illness or their own clinical
  skills
• When teaching occurs at the speed of the
  teachers speech or mouse clicks rather than the
  pace of the learners 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

21
Top 10 mistakes weve 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 learners attention

22
Have fun!
23
What are some barriers to teaching EBHC?

• Time constraints for teachers and learners
• Lack of resources
• Paucity of evidence that EBHC works

24
What can we do in 1 minute?
25
(No Transcript)
26
(No Transcript)
27
What can we do in 5 minutes?
28
(No Transcript)
29
(No Transcript)
30
(No Transcript)
31
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

32

• 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

33
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

34
Paucity of Evidence that EBHC works

• No evidence from RCTs showing impact on clinical
  outcomes
• Evidence from process studies
• Evidence from outcomes research

35
Whats 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 200332733-5

36
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 1996271937-43.

37

• 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

38

• 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
• gt5
• Stroke 199728891-8.