Introduction to Teaching Evidence-based Health Care Sharon E. Straus MD MSc FRCPC Associate...
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Transcript of 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
What are the relevant What are the relevant outcomes?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’
What are the relevant What are the relevant outcomes?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
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 )
What are the relevant What are the relevant outcomes?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
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
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 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
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 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