Experience-based, integrative evidence-based medicine
Teaching Module: Principles, Examples, and Tips
(Adapted from the ACGME Instructional Toolbox)

Christine A. Taylor, PhD
Director of Faculty Development
The Cleveland Clinic

Richard Schlenk, MD
Assistant Program Director, Neurosurgery
The Cleveland Clinic

Evidence-based medicine (EBM) is both a "content area" and a "process" for teaching and practicing medicine.  As a content area, residents must learn to become proficient in the basic skills of framing testable questions, searching for best evidence, and critically appraising that evidence.  To fully utilize EBM as a method for teaching and practicing medicine, residency faculty must model EBM when treating patients and when discussing patient care with residents during clinical experiences.  There have been criticisms of the EBM movement for ignoring  both the wisdom of experience and the wishes of the patient.  In their second edition, Sackett et al defined EBM as an "integration of best research evidence with clinical expertise and patient values."  This definition promotes the use of evidence and "informed opinion" in the unique context of the needs of the individual patient.  The following key characteristics of integrative, evidence-based medicine are consistent with the characteristics of "Teaching from a Competency Perspective."

• Online modules and journal club activities can be effective, efficient techniques for teaching the basics of EBM. For EBM to become a part of residents’ approach to practicing medicine, however, it must be integrated into the daily routine of examining and evaluating patients (explicit and real-life).

• Modeling an evidence-based approach to practicing medicine fosters the critical appraisal of personal assumptions as well as the framing and testing of good clinical questions that ultimately guide practice (self-assessment).

• Learning to practice medicine using an EBM approach includes learning how to weigh the value of clinical experience, patient values, and best evidence.  It also includes learning what to do when "best evidence" is not very enlightening (real-life).

• As defined above, EBM fosters accountability, as the integration of "documented best practice" and expert clinical opinion become the criterion set for patient care (accountability).

Example 1

Scenario: Focusing a clinical question to teach practice-based learning and improvement on the in-patient service.

You are an associate residency director in a busy neurosurgical residency program and are in charge of teaching residents on the inpatient service. A lecture was given on the topic of "formulating testable questions."  As a follow-up, you want to reinforce this skill in a patient  care setting through discussions of newly admitted patients.

The illustration below describes how you can address this and other practice-based learning    and improvement learning objectives on the inpatient service.  The objectives are that residents will be able to: (a) focus a clinical question and (b) search the literature and locate evidence that addresses the question.

Illustration Identifying a focused clinical question is the first step in evidence-based medicine.  Using the systematic approach developed by Sackett, et al., you provide the admitting resident with a worksheet outlining the "Patient, Intervention, Comparison, and Outcome" model for building an answerable question.  You guide the resident through the list by asking: "P" How would you describe a group of patients similar to this patient? "I" Which main intervention, prognostic factor, or exposure are you considering? "C" What is the main alternative to compare with the intervention?  (If appropriate) "O" What can you hope to accomplish, measure, improve, or effect? After a few attempts, the resident team arrives at the following questions: "In a 59 year-old male with known hypertension seen in the emergency room with a spontaneous intracerebral hemorrhagic stroke, does controlled reduction of mean arterial blood pressure decrease the risk of clot progression?;"  "Does alteration of blood pressure in the first 24 hours after hemorrhage improve clinical outcomes?;"  "Are there current societal recommendations or guidelines for specific antihypertensive pharmacological agents and blood pressure parameters available?"  Then using a database such as (InfoRetriever®) on one of the resident’s pocket PC, you search for clinical guidelines that may apply to this patient.  You find that there are liberal but nonspecific recommendations, based upon Class II and III evidence, which addresses blood pressure management in the setting of hemorrhagic stroke.  The team discusses the question and decides to expand the search.  By broadening the search, the team found 42 controlled studies examining issues pertaining to "cerebral hemorrhage," "blood pressure," and "outcomes," ten of which were pertinent to their patient.

Example 2

Scenario: Using a "real-time" EBM approach to teach practice-based learning and improvement and to increase medical knowledge on the inpatient service.

You are a faculty member in a large general surgery residency program, and have been asked by the director to coordinate the "evidence-based medicine" curriculum.  You would like to demonstrate that while actively seeing patients, residents may practice evidence-based medicine.  The residents are skeptical that this can be accomplished in the time allotted.

The illustration below describes how you may address Practice-Based Learning and Improvement and Medical Knowledge learning objectives on the inpatient wards.  The objectives are that residents (1) will obtain current, evidence-based information about the treatment of common medical conditions (medical knowledge); and (2) will be able to: (a) formulate a good clinical question; (b) efficiently search for appropriate evidence and guidelines of care; (c) critically appraise the evidence; and (d) decide whether evidence and guidelines apply to the care of a specific patient (Practice Based Learning and Improvement).

Illustration During the outpatient vascular surgery clinic, you are supervising the surgical resident.  Her patient is a 75-year-old male with a 60 year history of tobacco use and coronary artery disease who was referred by his primary care doctor after a carotid bruit was noted on physical exam. The patient comes to the clinic with a noninvasive vascular study which demonstrates 90 per-cent right-sided and 50 percent left-sided carotid stenosis.  Using an EBM approach, you want to demonstrate that new information with vascular problems is published on a continuous and regular basis.  You ask the resident the following:  "What are the most sensitive clinical examination findings in patients with carotid stenosis and when are vascular studies indicated?," and "When is carotid endarterectomy indicated in asymptomatic patients?."  The resident articulates that based upon prior guidelines, the patient has indications for a right-sided carotid endarterectomy.  The patient inquires about carotid stenting as an alternative to standard surgical intervention.  The resident is unsure whether the literature supports the use of carotid stenting in patients with asymptomatic carotid stenosis.  A computer with Internet access in the supervision room allows you to search for recent publications on the subject using the National Guideline Clearinghouse (NGC) and Cochrane Database.  Several recent studies on carotid stenting were identified after a four-minute search of the NGC.  You then review the articles and consider whether the published results are relevant for this patient and in this specific clinical setting.  In another residency setting that does not have ready access to the Internet, you could use CD-ROM materials, which are updated quarterly and may be used to answer common medical questions. By gathering and using these resources, residents learn new knowledge and sharpen their critical appraisal skills, while improving the outcomes for patients.

Example 3

Scenario: Using an experience-based integrative EBM approach to teach practice-based learning and improvement during administrative conferences.

You are the chief resident in a busy general surgery residency program.  You and your residency faculty advisor have been asked to suggest ways to improve teamwork and reduce the number   of medical errors attributed to failure of teamwork in the residency program.  You remember hearing a presentation at the surgical education conference about how improving team communi-cation reduced errors and improved patient satisfaction.  You wonder whether communication skill training would help solve these problems in your residency.

The illustration below describes how you may address Practice-Based Learning and Improvement learning objectives during administrative conference time.  The learning objectives are  that residents will be able to: (a) search for evidence to answer a focused question; (b) critically appraise the evidence; and (c) incorporate scientific evidence into decisions and plans for improving patient care.

Illustration Although EBM is typically used to help make informed decisions about patient care practices, systematic reviews related to a wide range of topics are also appearing in EBM databases.  In  this example, you and your faculty advisor decide to use an administrative resident meeting to approach a group practice and communication problem from an EBM perspective.  You and your advisor determine that including all residents in this process will increase participation should they find confirming evidence.  At the resident administrative meeting, you lead a short discussion on the problem, state the question, and divide the residents into two teams.  Using the computers provided, both teams of residents find systematic reviews (Cochrane Database of Systematic Reviews) and primary research addressing this subject in less than five minutes.  The first of six systematic reviews includes behavior change, as well as attitude change, as outcomes, and presents 12 studies that met criteria as controlled studies.  From this evidence, the residents agreed that communication training across the health care team was worth pursuing.  You and your faculty advisor take the recommendation to the residency director.

Tips for Using Experience-Based, Integrative Evidence-Based Medicine (EBM)

Teaching with an EBM approach fosters development of the skills needed to bring the most current information to the real-time practice of medicine.  With the advent of reliable, evidence databases that provide screened meta-analyses and systematic reviews, a residency director might wonder which skills are most needed and most practical.  Do residents need to be able to perform a systematic review of the primary research, or should they instead focus attention on learning to access already-prepared systematic reviews and integrate "best evidence" into the care of their patients?  Unfortunately, there is little evidence in the literature to help us answer this question.  Residency directors do not need to make this choice, however, because both methods may be learned during a three-year residency program.  The educational research examining the implementation of EBM curricula suggests the following:

1. There is little evidence to support the conclusion that learning EBM as a "content area" through didactics alone (or even through journal clubs) encourages residents to use EBM in their practices.  EBM must be integrated into clinical practice on the wards and in the clinics.
   
   
2. Faculty members need to both embrace the EBM approach to teaching medicine and to model its use in their own practice.  Some ways to do this might be to:

1. • cite systematic reviews when lecturing and expect residents to do the same when presenting;
   • keep an updated file of systematic reviews in your area of practice, update it quarterly, and use it while precepting (residents may also be responsible for updating a "practice database.");
   • use computer resources (both online and CD-ROM) on site;
   • expect "evidence" to be part of morning report, ambulatory rounds, work rounds, and etc.;
   • model integrating "best evidence" with expert opinion and the specific needs of patients; and
   • model "communicating best evidence" with patients.

Key Sources

Experience-Based, Integrative Evidence-Based Medicine (EBM)

Badgett RG, O’Keefe MO, Henderson MC.  Using systematic reviews in clinical education. Annals of Internal Medicine 1997;126:886-91.

Bazarian JJ, Davis CO, Spillane LL, Blumstein H, Schneider SM.  Teaching emergency medicine residents evidence-based critical appraisal skills: A controlled trial. Annals of Emergency Medicine 1999;34:148-54.

Edwards KS, Woolf PK, Hetzler T. Pediatric residents as learners and teachers of evidence-based medicine.  Academic Medicine 2002;77:748.

Epling J, Smucny J, Patil, A, Tudiver, F. Teaching evidence-based medicine skills through a residency-developed guideline.  Family Medicine 2002;34:646-48.

Geyman JP, Deyo RA, Ramsey, SD. Evidence-based clinical practice.  Concepts and approaches. Boston: Butterworth-Heinemann, 2000.

InfoRetriever. The Clinical awareness system. http://www.infoPoems.com, 2003.

Kellum JA, Rieker, JP, Power, M, Powner DJ.  Teaching critical appraisal during a critical care fellowship training: A foundation for evidence-based critical care medicine.  Critical Care Medicine 2000;28:3067-70.

Korenstein D, Dunn A, McGinn T.  Mixing it up: Integrating evidence-based medicine and patient care.  Academic Medicine 2002;77:741-42.

Ozuah PO, Orbe J, Sharif I.  Ambulatory rounds: A venue for evidence-based medicine. Academic Medicine 2002;77:740-41.

Pursley HG, Kwolek DS.  A women’s health track for internal medicine residents using evidence-based medicine.  Academic Medicine 2002;77:743-44.

Sackett DL, Straus, SE, Richardson WS, Rosengurg W, Haynes RB.  Evidence-based medicine: How to practice and teach EBM (2nd Edition).  Churchill Livingston, Edinburgh, London. 2000.

 

Online December 27, 2007