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Developing an integrated_evidence_based_medicine.16[1]

  1. 1. Residents’ EducationDeveloping an Integrated Evidence-BasedMedicine Curriculum for Family MedicineResidency at the University of AlbertaG. Michael Allan, MD, Christina Korownyk, MD, Amy Tan, MD, Hugh Hindle, MD,Lina Kung, PhD, MD, and Donna Manca, MDAbstractThere is general consensus in the committee drafted goals and objectives, practice; and a journal club to supportacademic community that evidence- the primary of which were to assist peer learning and growth of rapidbased medicine (EBM) teaching is residents to (1) become competent self- appraisal skills. Issues including time use,essential. Unfortunately, many directed, lifelong learners with skills to costs, and change management arepostgraduate programs have significant effectively and efficiently keep up to discussed. Ongoing evaluation of theweakness in their EBM programs. The date, and 2) develop EBM skills to solve curriculum and its components is aFamily Medicine Residency committee at problems encountered in daily practice. principal factor of the design, allowingthe University of Alberta felt their EBM New curriculum components, each critical review and adaptation of thecurriculum would benefit from critical evidence based, were introduced in 2005 curriculum. The first two years of thereview and revision. An EBM Curriculum and include a family medicine EBM curriculum have yielded positive feedbackCommittee was created to evaluate workshop to establish basic EBM from faculty and statistically significantprevious components and develop new knowledge; a Web-based Family improvement in multiple areas of residents’strategies as needed. Input from Medicine Desktop promoting easier opinions of the curriculum and comfortstakeholders including faculty and access to evidence-based Internet with evidence-based practice.residents was sought, and evidence resources; a brief evidence-basedregarding the teaching and practical assessment of the research project Acad Med. 2008; 83:581–587.application of EBM was gathered. The enhancing integration of EBM into dailyThere is general consensus in the curricula often fail2 and that teaching management, and details of each newlyacademic community that evidence- critical appraisal yields small changes in introduced component, including costsbased medicine (EBM) teaching is knowledge but no change in application.3 and evaluation. Finally, we review andessential.1 Unfortunately, research has Although classroom education improves discuss the evidence for this curriculumshown that critical-appraisal-based knowledge, integrated EBM curricula and its components. improve skills, attitudes, and behavior4 and result in incorporation of EBM in patient care.5 Furthermore, research BackgroundDr. Allan is assistant professor, Department ofFamily Medicine, University of Alberta, Edmonton, shows that practicing clinicians do not The University of Alberta FamilyAlberta, Canada; and research fellow, Institute of perform critical appraisals to answer their Medicine Residency Program is a two-Health Economics, Edmonton, Alberta, Canada. daily questions6 but choose preappraised, year program with approximately 60Dr. Korownyk is assistant professor, Department summarized sites.6,7 An integrated EBM residents in each year (currently, 40of Family Medicine, University of Alberta, Edmonton, curriculum designed to improve urban-area-based residents, 12 rural-Alberta, Canada. knowledge, skills, attitudes, and area-based residents, 2 military-Dr. Tan is clinical lecturer, Department of Family incorporation into clinical practice might sponsored residents, 6 AlbertaMedicine, University of Alberta, Edmonton, Alberta, include EBM-teaching methods of proven International Medical Graduate ProgramCanada. success such as workshops,8,9 journal residents, and 1 to 3 externally sponsoredDr. Hindle is rural academic development clubs,10,11 daily generation of clinical residents). There are five clinical teachingcoordinator, Rural Physician Action Plan, Edmonton, questions,12 summarized evidence-based units in Edmonton and two rural centers.Alberta, Canada; and a family physician, Sylvan Lake,Alberta, Canada. resources, and Web-based activities.13 In their first year, the residents have a Unfortunately, there is very little four-month family medicine rotationDr. Kung is a family physician, Calgary, Alberta,Canada. information available in the literature (three months for rural-area-based describing integrated, practical EBM residents) at one of the teaching unitsDr. Manca is assistant professor, Department ofFamily Medicine, University of Alberta, Edmonton, curricula, particularly in family medicine. and have access to a desktop computerAlberta, Canada; and clinical director, Alberta Family while there.Practice Research Network, Edmonton, Alberta, We describe an integrated EBMCanada. curriculum for a family medicine At a monthly residency programCorrespondence should be addressed to Dr. Allan, residency that was implemented at the committee meeting in 2004, residentsDepartment of Family Medicine, University of University of Alberta in 2005. In this raised concerns that components of theAlberta, 901 College Plaza, Edmonton, Alberta,Canada, T6G 2C8; telephone: (780) 472-5038; fax: article, we outline the background of the family medicine residency curriculum(780) 4 72-5192; e-mail: (michael.allan@ualberta.ca). curriculum, the process of change involving EBM were labor intensive butAcademic Medicine, Vol. 83, No. 6 / June 2008 581
  2. 2. Residents’ Educationoffered minimal benefit. There wasconsensus among residents and List 2faculty that the EBM curriculum had Learning Objectives of the University of Alberta Family Medicine Residentdeficiencies. The EBM curricular Evidence-Based Medicine (EBM) Curriculumcomponents at that time consisted Knowledge componentof a critical appraisal project, a librarian/ 1. Understand the rationale and benefits of EBM.informatics session, a journal club, and a 2. Provide a strong foundation in the basic principles of EBM, includingpractice audit and quality-improvement ● Recognizing and formulating clinical questions;project. An EBM curriculum (EBMC)committee was formed to investigate the ● Finding and accessing information (refining questions and searching the most suitable resource);concerns and develop a new curriculum. ● Interpreting information (appropriately evaluating information in a quick, reliable format);EBMC committee members and the chair andwere nominated and approved by ● Applying information.members of the residency programcommittee. 3. Provide and identify online resources, educational tools, and web-links. Skill componentThe EBMC committee consisted of two 1. Learn to identify problems/questions encountered in practice and seek solutions by rapidlyurban faculty members, one rural faculty answering clinical questions with best evidence.member, two urban residents, and one 2. Build skills and comfort in knowledge transfer (primarily through oral presentation skills andrural resident. The committee chair discussion with patients).completed a detailed literature search of Attitude componentEBM teaching, the application of EBM to 1. Facilitate appreciation and enthusiasm forpractice, and answering questions in ● The judicious use of current evidence to optimize patient care, andclinical practice, and the summarized ● Maintenance of skills and knowledge through life-long self-directed learning.findings were made available to thecommittee. Guided by the informationgathered in the literature search, the little in gaining the skills to regularly second-year resident to review andcommittee developed goals and answer clinical questions. present in a didactic format. Becauseobjectives (Lists 1 and 2) and then topics did not stem from resident The librarian/informatics session, a interest, there was little motivation forreviewed components of the curriculum yearly, hourlong, large-group didacticand concerns of residents and faculty. resident involvement. session including an assigned literatureReview of previous curriculum searching project, needed modification. The practice and quality-improvement The EBMC committee determined that, project, a one-time, second-year project,Once during the first year, each resident in this form, the session was minimally required each resident to review clinicsearched the literature and selected an effective in teaching residents the skills charts to determine whether practicearticle he or she felt best addressed one of necessary to formulate clinical questions patterns followed established practicetheir clinical questions. Each resident and identify resources applicable to guidelines for specific clinical concerns.then critically appraised the article and family medicine. The EBMC committee thought thepresented the findings to the faculty and practice and quality-improvementresidents at his or her teaching site. This The journal club, a monthly, one-hour, project offered good insight into practicecritical appraisal project was eliminated small-group session during academic patterns and factors influencing bestbecause it was time consuming, not half-day (AHD), was unpopular. Articles practice.relevant to daily practice, and offered were selected by faculty and provided to a On considering the curriculum overall, many residents felt they lacked adequateList 1 training in EBM, and a survey of residentGoals of the University of Alberta Family Medicine Resident Evidence-Based opinion supported this sentiment.14 InMedicine (EBM) Curriculum addition, some informally expressed concern that some preceptors may lackPrimary goals evidence-based practice skills.1. Train competent self-directed life-long learners with the skills to effectively and efficiently keep up-to-date.2. Cultivate residents’ EBM skills to enable them to solve problems encountered in daily practice. New Curriculum ComponentsSecondary goals The EBMC committee developed a1. Review EBM components within the present curriculum to number of suggestions that were based ● Eliminate or modify components that are evaluated negatively or perform poorly; on discussion, identified goals and ● Enhance other areas of the curriculum to promote EBM; and objectives, and literature-based evidence ● Add new or additional education time only to achieve the gains in life-long learning skills. available about EBM practices. From the2. Promote the development of skills in residents to critique educational opportunities to suggestions, four main curricular maximize learning and recognize low-quality biased activities. components (workshop, Family3. Promote and encourage residents seeking additional skills, training or experience in EBM, Medicine Desktop, brief evidence-based knowledge transfer, and/or research. assessment of the research [BEAR], and582 Academic Medicine, Vol. 83, No. 6 / June 2008
  3. 3. Residents’ Educationjournal club) were developed and event rates, absolute risk, number needed The yearly cost for the Family Medicineimplemented in 2005. We describe these to treat, and likelihood ratios. Desktop is $5,000 (Canadian dollars) forin detail below. After the primary all residents and full-time faculty in thecomponents were drafted, the EBMC The yearly cost for this session is $6,000 department. The site is monitored forcommittee developed a comprehensive (Canadian dollars), including facilities, frequency and duration of use by CCHE.evaluation strategy to monitor and catering (two breakfasts and two Faculty committee members review theseresearch each component. Faculty lunches), materials, and gifts. At the data annually. These data will be used tomembers of the EBMC committee had beginning of the workshop, before any determine whether residents’ use ofmultiple meetings to secure funding for teaching, residents complete (1) a survey Family Medicine Desktop-based EBMthe various components, arrange and to determine their self-assessed skills, past resources changes throughout residencydevelop the Family Medicine Desktop training, and objectives in EBM, and 2) a or during particular periods (such ascomponent (which required more initial preworkshop quiz of 15 questions, immediately after the workshop or whiletime and resources than the other derived in part from two previous EBM completing BEARs).components), and seek input from tests.9,20 At the conclusion of thestakeholders (particularly those whose conference, at the end of their last small- group session, residents complete (1) a BEAReducational activities were changing, suchas the librarians). Once these aspects were postworkshop evaluation of the The BEAR project helps residents identifyfinalized, the committee began the conference, and (2) a postworkshop quiz daily clinical questions, focus their searchprocess of promoting change in the (same as the preworkshop quiz). Of note, for answers, get answers rapidly, anddepartment. the residents were not given answers for reflect on the utility of those answers. the preworkshop quiz, and small-group During their family medicine rotation inFamily medicine EBM workshop instructors were not aware of the content the first year, residents record questionsBecause studies have demonstrated of the quiz. Analysis (in process) of the arising from their clinical practice andimproved knowledge with workshops multiyear results will allow validation of complete one BEAR assignment monthly.and courses in EBM,8,9,15,16 the the tool for assessing EBM knowledge. The BEAR form (Appendix 1) guidescommittee called for a formal EBM residents through the exercise with a Family Medicine Desktop target time of less than one hour perworkshop to take place early in theresidency. The two-day workshop for The Family Medicine Desktop is an question. Suggested resources includefirst-year residents is broken up into four Internet resource for each resident to guidelines, filtered resources (e.g., EBMhalf-days, each consisting of a one-hour reduce search time, identify information and ACP Journal Club), summary siteslecture followed by a two-hour, small- resources, and develop skills as EBM (e.g., Bandolier and UpToDate), reviewgroup session. Three of the lectures are users. It uses a graphically displayed front sites (e.g., Cochrane), and researchdevoted to appraising articles (one each page with links to relevant resources as studies (including RCT, Cohort,of therapy, diagnosis, and meta-analysis), well as tabs to pages of various themes. Qualitative). Faculty challenge residentsand one is an overview of family The front page (browser) includes rapid to look at different questions (diagnostic,practice research. All lectures are given links to Cochrane, PubMed, Google, ACP therapeutic, harm, practice management,by University of Alberta faculty, but the Journal Club, Evidence-Based Medicine, etc.) and experiment with a variety offirst three topics are taught from the Clinical Evidence, Bandolier, UpToDate, resources. Each BEAR is presented inprinciples of the Users’ Guides to the InfoPOEMS, Therapeutics Initiative, and approximately 15 minutes or less duringMedical Literature.17 In three small- BestBETs. There are tabs to Guides rounds and is scored simply as pass forgroup sessions, 8 to 10 residents, led by (Users’ Guides to the Medical Literature), completion. To help generate discussion ina faculty member and a second-year Profession (links to the Web pages of rounds, the presentations include the case,resident facilitator, appraise previously differing professional bodies), Activities the clinical question, resources examined,unseen papers on therapy, diagnosis, and (residency program-specific features like and practice reflection. Family medicinemeta-analysis. In the other small-group BEAR presentations, journal club, and rotations in first year at the University ofsession, faculty librarians lead residents in previous faculty presentations), Clinical Alberta are generally 16 weeks (12 in thethe computer lab through question (guidelines and local practice tools) and rural program), meaning four (or three indevelopment, efficient Medline search e-library (an extensive list of Internet rural) BEARs per resident.techniques, and identification of medical resources). The Family Medicinesummary resources (available on the Desktop is created and managed by the Integrating EBM exercises into clinicalFamily Medicine Desktop, which is Canadian Centre for Health Evidence work improves residents’ adaptationdetailed below). Librarian faculty (CCHE), but it is amended and updated to evidence-based practice.4,21,22participation has proven to be an by members of the faculty. The Family Furthermore, the use of preappraised andimportant part of EBM education.18,19 Medicine Desktop can be accessed from summarized evidence is required if any computer with Internet access. clinicians are to achieve evidence-basedThe workshop also includes a brief Because all residents have access to a practice6,7,23,24 and become “evidencelecture on why EBM is important, a desktop computer during their three- or users.”25 Lastly, the element of reflection, intutorial on basic statistical concepts, and four-month first-year family medicine both completing the BEAR form anda short, “game show”-type quiz with rotation, the Family Medicine Desktop during presentation with group discussion,prizes during the last session. The component is available to all residents at enhances the likelihood of residentsstatistical session includes working some point, regardless of whether they integrating EBM into practice and changingthrough control event rates, experimental have access to the Internet outside work. behavior for the long term.26Academic Medicine, Vol. 83, No. 6 / June 2008 583
  4. 4. Residents’ EducationThere is no yearly cost for the BEAR sources, the original, complete article is hour reviewing and discussing thecurricular component. The residents’ brought to AHD for review. suggested changes. The planned changesfaculty advisor reviews each BEAR. were also presented to all urban residentsResident evaluation of the BEAR project There is no yearly cost for the journal at a program-wide AHD. The proposalis collected as part of the annual survey of club component. Resident evaluation of was presented and discussed at thethe EBM curriculum. Full review of the the journal club occurs at each AHD and departmental geographic full-time facultyBEAR projects is in process to examine as part of the annual survey of the EBM meeting.the type of questions asked in clinical curriculum.practice, resources used (summary sites, After feedback from both residents andoriginal research, guidelines, etc.), Additional components faculty, the EBMC committee decided toanswers obtained, and practice impact. Other components of the curriculum offer a two-day faculty developmentActivity records from the Family include teaching on industry–physician workshop in evidence-based practice forMedicine Desktop and direct observation interaction, presentation skills, and a faculty members. The workshop was aof residents will be correlated with quarterly review of the literature. For the small-group seminar with didactic,resource use reported in the BEARs to quarterly review, a faculty member interactive, and computer learning time.determine the reliability of these data. presents a five-minute EBM teaching To allow for maximum attendance, it ranThe results of this work will be reported point, a summary of five to seven family- on two separate occasions before the startin a subsequent publication. medicine-relevant articles from the last of the new curriculum. The importance year, and an introduction to an evidence- of faculty development and roleResident journal club (academic based practice tool (e.g., links to modeling to promote resident learning inhalf-day) calculators for stroke risk in atrial EBM is well known.29,30Each month, the small-group AHD has fibrillation). In addition, the previouslyan established theme (e.g., neurology). In mentioned practice audit and quality- One month before the start of the newpreparation for the upcoming AHD, a improvement project continues curriculum, the final description wassecond-year resident generates a case and unchanged. distributed to all staff and faculty. Aclinical question related to the monthly faculty member from the EBMCtopic and completes a literature search. Although organization differed from past committee visited each teaching site andHe or she then reviews the abstracts of curriculum elements, the overall time use met with faculty and staff to review anythe resulting articles and selects two to three for faculty and residents was cost neutral, last questions. Finally, two months afterpapers to best address the question, without apart from two clinical days to attend the the start of the curriculum, e-mail wascritically appraising the papers. Whereas family medicine EBM workshop. distributed to each site director and sitethe preparation of the case and question coordinating staff, and another follow-upshould take no more than 30 minutes, the There is no yearly cost for the additional visit was offered. Although a few briefsearch and selection of two to three papers components. Residents complete concerns were reviewed over e-mail,could take up to two hours. evaluations after each teaching session. A none of the site directors or the site year-end summative evaluation/survey coordinating staff felt a follow-up visitAt the AHD, the designated resident obtains residents’ opinions regarding the was necessary. Initial conception topresents the case, question, and four primary components and the implementation took nine months.summarized search in approximately five curriculum overall. It also includesminutes. Papers are then distributed, and attitude questions regarding evidence- based practice in general. This Outcomesthe residents break into two to threesubgroups, based on the number of information is used to assess the The annual EBM curriculum evaluationpapers to be reviewed. Each subgroup curriculum and to modify areas found to has now been completed by two groupsreviews one of the papers as a team. Each be inadequate. of residents (2005–2006 and 2006 –2007)subgroup has 30 to 40 minutes to browse since implementation, and the resultsand appraise the article as a team to were compared with those from the year Change Management before implementation (2004 –2005). Thedevelop consensus. After that, eachsubgroup shares the information with A number of steps were taken to ensure evaluation was distributed to residentsthe entire group. The total time is that faculty, staff, and residents had the attending an AHD in the last quarter ofapproximately 60 minutes. Peer group opportunity to learn and discuss the academic year and was emailed oncelearning and teaching has been described concerns as well as generate feedback for to all those reporting as absent from thein previous EBM education models.27,28 the EBMC committee to improve the AHD. The survey lacked any personal new curriculum. Urban and rural identifiable features. This research wasAfter the first year of the new curriculum, residents’ opinions were surveyed approved by the health research ethicsresidents indicated that the articles regarding EBM in general and the board of the University of Alberta.chosen by colleagues were frequently low previous curriculum specifically.14 Thein quality and not relevant. As a result, draft proposal was distributed to all The combined response rate for the threearticles are now selected from those members of the residency program years was 60% (181 returned out of aabstracted or listed in the other articles committee approximately one month possible 304). There was significantnoted section of ACP Journal Club or in before a planned review. Faculty, staff, improvement in all areas of comfort withthe Evidence-Based Medicine journal. and resident representatives of the evidence-based practice and opinionsWhereas the article is picked from these residency program committee spent one regarding the curriculum (Table 1). Three584 Academic Medicine, Vol. 83, No. 6 / June 2008
  5. 5. Residents’ Education Table 1 Comparison of Resident Opinion Before and After Implementation of the Integrated Evidence-Based Medicine (EBM) Curriculum in the University of Alberta Family Medicine Residency in 2005 Resident mean Resident mean Two-tailed Question* score before (n) score after (n) t test† I feel comfortable accessing the literature. 2.95 (60) 3.97 (115) P Ͻ .0001 ................................................................................................................................................................................................................................................................................................................... I feel comfortable appraising articles (all types). 2.51 (60) 3.69 (114) P Ͻ .0001 ................................................................................................................................................................................................................................................................................................................... How comfortable are you with your ability to recognize 3.51 (61) 4.12 (115) P Ͻ .0001 and refine clinical questions? ................................................................................................................................................................................................................................................................................................................... How comfortable are you with your basic computer skills? 4.07 (61) 4.53 (115) P ϭ .0005 ................................................................................................................................................................................................................................................................................................................... How comfortable are you with your knowledge and 3.46 (61) 4.17 (114) P Ͻ .0001 comfort with accessing the literature? ................................................................................................................................................................................................................................................................................................................... How comfortable are you with your knowledge and 3.11 (61) 3.87 (115) P Ͻ .0001 comfort in appraising the literature? ................................................................................................................................................................................................................................................................................................................... How comfortable are you with the time necessary to 2.80 (61) 3.37 (115) P ϭ .0003 answer clinical questions? ................................................................................................................................................................................................................................................................................................................... Overall, I feel the EBM curriculum is well organized and 2.86 (59) 3.90 (114) P Ͻ .0001 integrated. ................................................................................................................................................................................................................................................................................................................... Overall, I feel the EBM curriculum has improved my 2.76 (58) 3.86 (114) P Ͻ .0001 comfort with evidence-based practice. ................................................................................................................................................................................................................................................................................................................... The practice of EBM results in better patient care. 3.88 (60) 4.17 (115) P ϭ .0110 ................................................................................................................................................................................................................................................................................................................... I have a positive attitude to the current promotion of EBM. 3.77 (60) 4.17 (115) P ϭ .0004 ................................................................................................................................................................................................................................................................................................................... Most of my colleagues have a positive attitude 3.56 (59) 3.81 (115) P ϭ .0451 to the current promotion of EBM. ................................................................................................................................................................................................................................................................................................................... How often do you use EBM in clinical practice? 3.37 (60) 3.53 (114) P ϭ .1547* Residents rated their opinions on a five-point Likert scale.† All t tests compare mean of the year before implementation to the mean of the two years since implementation. of four questions of general opinion (e.g., ACP Journal Club or the Evidence-Based amount of time (1–10 minutes) to The practice of EBM results in better patient Medicine journal. This change effectively answering clinical questions.6,33,34 Our care) showed improvement as well, albeit to addressed this concern for the residents. curriculum focused on this issue. The a lesser degree. Family Medicine Desktop introduced Evaluations of other specific components residents to the variety of EBM resources, In addition to the formal evaluation, (such as the workshop and the BEARs) with an emphasis on preappraised, resident and faculty feedback was sought are too large and complex to present summarized sites (i.e., BestBETs, ACP at meetings and during presentations. here, but they will be published in Journal Club) that will serve as the tools Faculty have been strong supporters of subsequent articles. for their future as evidence users.6,23,25 By the new curriculum and were particularly collecting these in one location and satisfied with the BEARs. Informal Discussion accessing any with a single click, residents comments from faculty exemplified a can search different sites rapidly. view that the BEARs were more This new integrated EBM curriculum is applicable to daily practice as compared based on goals and objectives felt to be with the previous critical appraisal The workshop and journal club do not important to residents and faculty, and it projects. Residents reported satisfaction include prereading papers, because it is incorporates the best available evidence with the workshop and the didactic not realistic to read papers entirely and in teaching EBM. Comparison of the literature reviews of the AHD. Some then spend another hour discussing goals and objectives with components of residents struggled with the simplicity of them. Additionally, journal clubs often the curriculum reveals significant overlap. the BEAR project and, at times, put much Surveys of other EBM curricula find that have trouble with some participants not more effort than would be possible for components such as faculty development, reading articles.10 We focus on helping questions in practice. They requested a accessible electronic information resources, residents gain practical skills to review tutorial on the BEAR, and this will be and evaluation mechanism are frequently and appraise papers in a rapid, integrated into the EBM workshop. As missing,31 and some authors have provided abbreviated fashion so that they may mentioned earlier, although residents suggestions for future EBM curricula.21,22 efficiently obtain answers to questions. thought the journal club had improved, Our curriculum targeted these areas and Finally, the BEAR is the key feature to they felt that many papers chosen by their more. help residents become time-efficient colleagues were poor in quality and evidence users because it promotes relevance. The EBMC committee decided Time is perhaps the most significant focusing their clinical questions, that residents would select journal club barrier to evidence-based practice,7,32 and accessing information from summarized articles from those abstracted or noted in most clinicians will dedicate only a small and preappraised resources, and Academic Medicine, Vol. 83, No. 6 / June 2008 585
  6. 6. Residents’ Educationreflecting on the level of influence the with improvement in skills and evidence based medicine improve knowledgeresults have on daily practice. knowledge.38,39 Unfortunately, linking and skills? Validation of Berlin questionnaire and before and after study of courses in self-reported improvements after EBM evidence based medicine. BMJ. 2002;325:Knowledge is often cited as a barrier to educational interventions with persistent 1338 –1341.evidence-based practice,35,36 and, clearly, behavioral changes does not seem to have 10 Elnicki DM, Halperin AK, Shockcor WT,there is a place for learning the basic been studied. Therefore, although it Aronoff SC. Multidisciplinary evidence-basedprinciples of EBM, even for evidence might be reasonable to assume that medicine journal clubs: Curriculum designusers.25 Interpreting the quality of and participants’ reactions. Am J Med Sci. residents’ skills and knowledge have 1999;317:243–246.preappraised, summarized evidence improved with this curriculum, actual 11 Ebbert JO, Victor MM, Schultz HJ. Therequires a basic understanding of EBM long-term behavioral changes remain journal club in postgraduate medicalterms and statistics. Furthermore, uncertain. education: A systematic review. Med Teach.occasionally preappraised sources will 2001;23:455– 461.not have the required information.25 The In summary, this integrated EBM 12 Ozuah PO, Orbe J, Sharif I. Ambulatory rounds: A venue for evidence-basedworkshop provides these foundations, curriculum provides a foundation of medicine. Acad Med. 2002;77:740 –741.and the journal club builds the knowledge, supplies easy access to 13 Crowley SD, Owens TA, Schardt CM, et al. Aknowledge and skills. resources, promotes point-of-care and Web-based compendium of clinical questions team learning, and develops applicable and medical evidence to educate internalAccess to resources is also frequently cited skills for lifelong learning while achieving medicine residents. Acad Med. 2003;78:270 –as a barrier to evidence-based practice.7,31,36 274. faculty goals of being evidence based, low 14 Allan GM, Manca DP, Szafran O, KorownykThe Family Medicine Desktop provides cost, and time sensitive. C. EBM a challenge for international medicaleasily accessible evidence-based resources, graduates. Fam Med. 2007;39:612.and the BEAR promotes the use of the 15 Ghali WA, Saitz R, Eskew AH, Gupta M,resources and helps users gain familiarity Acknowledgments Quan H, Hershman WY. Successful teachingwith these preappraised, filtered, and The authors would like to thank Olga Szafran in evidence-based medicine. Med Educ. 2000; with her assistance in the process of securing 34:18 –22.summarized sites. 16 Smith CA, Ganschow PS, Reilly BM, et al. ethical approval for this project and the evaluation work, as well as Victoria Ma for her Teaching residents evidence-based medicineEvaluation is recommended as essential skills: A controlled trial of effectiveness andto EBM-teaching programs,31 and the assistance in the compilation of the evaluation assessment of durability. J Gen Intern Med. data. The authors would also like to thank Dr.EBMC committee felt it integral to each Paul Humphries and the residency program 2000;15:710 –715.component and the curriculum in 17 Guyatt G, Rennie D, eds. Users’ Guides to the committee for their support in moving this Medical Literature. Chicago, Ill: Americangeneral. Evaluation allows faculty to project forward. Medical Association Press; 2002.adapt the curriculum according to 18 Finkel ML, Brown HA, Gerber LM, Supinochanging needs or outcomes (such as PG. Teaching evidence-based medicine toFamily Medicine Desktop use). Although References medical students. Med Teach. 2003;25:202–rigorous research of EBM teaching is 1 Whitcomb ME. Why we must teach 204. evidence-based medicine. Acad Med. 2005; 19 Dorsch JL, Jacobson S, Scherrer CS. Teachingideal,37 we needed to introduce a new EBM teachers: A team approach. Med Ref 80:1–2.curriculum within a limited time. Also, 2 Green ML. Graduate medical education Serv Q. 2003;22:107–114.funding prohibited a trial with a training in clinical epidemiology, critical 20 Ross R, Verdieck A. Introducing an evidence-comparator group, the examination of appraisal, and evidence-based medicine: A based medicine curriculum into a familypatient outcomes, and accounting for critical review of curricula. Acad Med. 1999; practice residency—Is it effective? Acad Med. 74:686 – 694. 2003;78:412– 417.confounders. Previous authors used or 21 Del Mar C, Glasziou P, Mayer D. Teaching 3 Norman GR, Shannon SI. Effectiveness ofencouraged testing knowledge, assessing instruction in critical appraisal (evidence- evidence based medicine. BMJ. 2004;329:attitudes/opinions, and evaluating based medicine) skills: A critical appraisal. 989 –990.learners around specific curriculum CMAJ. 1998;158:177–181. 22 Dobbie AE, Schneider FD, Anderson AD, 4 Coomarasamy A, Khan KS. What is the Littlefield J. What evidence supports teachingcomponents.20,22 They provide excellent evidence that postgraduate teaching in evidence-based medicine? Acad Med. 2000;assessment of the curriculum while evidence based medicine changes anything? 75:1184 –1185.offering potentially useful research A systematic review. BMJ. 2004;329:1017– 23 Smith R. What clinical information doinformation. Additionally, we are 1019. doctors need? BMJ. 1996;313:1062–1068.monitoring Family Medicine Desktop use 5 Korenstein D, Dunn A, McGinn T. Mixing 24 Shaughnessy AF, Slawson DC. Are we it up: Integrating evidence-based medicine providing doctors with the training andand directly observing residents in clinics tools for life-long learning? BMJ. 1999;319: and patient care. Acad Med. 2002;77:741–(before and after the workshop) to 742. 1280.determine the types of questions asked in 6 Ely JW, Osheroff JA, Ebell MH, et al. Analysis 25 Guyatt GH, O Meade M, Jaeschke RZ, Cookclinical practice and the utility of of questions asked by family doctors DJ, Haynes RB. Practitioners of evidenceevidence-based resources in answering regarding patient care. BMJ. 1999;319:358 – based care. BMJ. 2000;320:954 –955. 361. 26 Robertson K. Reflection in professionaltheir questions. We will compare these 7 McColl A, Smith H, White P, Field J. General practice and education. Aust Fam Phys. 2005;results with the questions and resources practitioners’ perceptions of the route to 34:781–783.used in BEAR assignments. evidence based medicine: A questionnaire 27 Hunt DP, Haidet P, Coverdale JH, Richards survey. BMJ. 1998;316:361–365. B. The effect of using team learning in anIn this article, we report a statistically 8 Schoenfeld P, Cruess D, Peterson W. Effect of evidence-based medicine course forsignificant improvement in resident an evidence-based medicine seminar on medical students. Teach Learn Med. 2003; participants’ interpretations of clinical trials: 15:131–139.attitude and self-reported abilities. Self- A pilot study. Acad Med. 2000;75:1212–1214. 28 Edwards K, Wolf PK, Hetlzer T. Pediatricreported improvements after EBM 9 Fritsche L, Greenhalgh T, Falck-Ytter Y, residents as learners and teachers of evidence-educational intervention can correlate Neumayer HH, Kunz R. Do short courses in based medicine. 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  7. 7. Residents’ Education29 Bhandari M, Montori V, Devereaux PJ, medicine: A representative national survey. medicine in Saudi Arabia. J Cont Educ Dosanjh S, Sprague S, Guyatt GH. Challenges Intern Med J. 2005;35:9 –17. Health. 2004;24:163–170. to the practice of evidence-based medicine 33 Ramos K, Linscheid R, Schafer S. Real-time 37 Hatala R, Guyatt G. Evaluating the teaching during residents’ surgical training: A information-seeking behavior of residency of evidence-based medicine. JAMA. 2002;288: qualitative study using grounded theory. physicians. Fam Med. 2003;35:257–260. 1110 –1112. Acad Med. 2003;78:1183–1190. 34 Schilling LM, Steimer JF, Lundahl K, 38 Green ML, Ellis PJ. Impact of an evidence-30 Lam WW, Fielding R, Johnston JM, Tin KY, Anderson RJ. Residents’ patient-specific based medicine curriculum based on adult Leung GM. Identifying barriers to the clinical questions: Opportunities for learning theory. J Gen Intern Med. 1997;12: adoption of evidence-based medicine practice evidence-based learning. Acad Med. 2005;80: 742–750. in clinical clerks: A longitudinal focus group 51–56. 39 Stark R, Helenius IM, Schimming LM, study. Med Educ. 2004;38:987–997. 35 McAlister FA, Graham I, Karr GW, Laupacis Takahara N, Kronish I, Korenstein D. Real-31 Green ML. Evidence-based medicine training A. Evidence-based medicine and the time EBM: From bed board to keyboard and in internal medicine residency programs. practicing clinician. J Gen Intern Med. 1999; back. J Gen Intern Med. 2007;22:1656 –1660. J Gen Intern Med. 2000;15:129 –133. 14:236 –242. Available at: (http://www.springerlink.com/32 Toulkidis V, Donnelly NJ, Ward JE. Engaging 36 Al-Almaie SM, Al-Baghli N. Barriers facing content/27p764108v1404q7/fulltext.html). Australian physicians in evidence-based physicians practicing evidence-based Accessed February 27, 2008.Appendix 1Brief Evidence-Based Assessment of the Research (BEAR) Form from theUniversity of Alberta Family Medicine Resident Evidence-Based MedicineCurriculum BEAR Work-Sheet Name of Resident: Date: Question: _______________________________________________________________ _______________________________________________________________________ Search: (Check all that apply) Pubmed/Ovid/Medline:  Filtered Resources:  Summary/Review Sites:  College/Society/Guidelines:  Other:  ( Describe: ___________________ ) Number of Resources Reviewed: ____ Resources (Top 3) #1 Resource: Abstract  Paper  Filtered Article  Summary  Review/Meta-Analysis  College/Society/Guideline Paper  Other Research  - Abbreviated Citation: _________________________________________ - Strengths:___________________________________________________ - Weaknesses:_________________________________________________ Take-Home Message:______________________________________________________ #2 Resource: Abstract  Paper  Filtered Article  Summary  Review/Meta-Analysis  College/Society/Guideline Paper  Other Research  - Abbreviated Citation: _________________________________________ - Strengths:___________________________________________________ - Weaknesses:_________________________________________________ Take-Home Message: _____________________________________________________ #3 Resource: Abstract  Paper  Filtered Article  Summary  Review/Meta-Analysis  College/Society/Guideline Paper  Other Research  - Abbreviated Citation: _________________________________________ - Strengths:___________________________________________________ - Weaknesses:_________________________________________________ Take-Home Message: _____________________________________________________ Bottom-line: ____________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Practice (These findings had a): Large Change  Small Change  Reassured  No Help Academic Medicine, Vol. 83, No. 6 / June 2008 587

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