TOPIC PAPER

Education and training in evidence-based urology

Charles D. Scales Jr. •

for the International Evidence-Based Urology Working Group

Received: 16 November 2010 / Accepted: 18 January 2011 / Published online: 4 February 2011

� Springer-Verlag 2011

Abstract

Objectives Urologists believe evidence-based clinical

practice improves patient care. Competence in critical

appraisal skills is necessary to successfully implement

evidence-based practice. However, practicing urologists,

urology program training directors, and residents have

identified the need for urology-specific resources to promote

competence in evidence-based practice. The objective of this

review is to identify urology-specific educational resources

for critical appraisal skills.

Methods The PubMed� database was searched using the

terms ‘‘evidence-based urology’’, ‘‘training’’ and ‘‘medical

education.’’ Results were limited to systematic reviews.

Reference lists for manuscripts were manually searched

to identify additional relevant publications. Additional

educational resources and training opportunities were

identified via direct communication with authors.

Results New urology-specific educational resources are

being developed to support evidence-based clinical prac-

tice. Resources exist in the medical literature, including the

User’s Guide to the Urological Literature series and the

Evidence-Based Urology in Practice series. Electronic

resources include the Evidence Based Reviews in Urology

program sponsored by the American Urological Associa-

tion. Finally, workshops exist for live training to develop

expertise in teaching EBM skills to others.

Conclusion Educational support for the nascent evidence-

based clinical practice movement in urology is growing.

Journals provide the majority of urology-specific educa-

tional material for evidence-based medicine training.

Additional online and live training opportunities should be

developed to encourage competence and leadership in

evidence-based urology.

Keywords Evidence-based clinical practice � Medical

education � Training

Introduction

Evidence-based clinical practice (EBCP) has been defined

as ‘‘the conscientious, judicious and explicit use of current

best evidence in making decisions about the care of indi-

vidual patients’’ [1]. The EBCP movement is growing in

urology. Urologists believe that EBCP improves quality of

care and that all urologists should be familiar with critical

appraisal skills [2, 3]. Surveys of urology program directors

and residents suggest that education in EBCP skills should

commence during residency training [4, 5].

Despite apparent widespread endorsement of the value

of EBCP, however, urologists and residents report concerns

regarding competence in EBCP skills. For example, only

18% of urologists surveyed felt that they could ‘‘understand

and explain to others’’ the term ‘‘level of evidence’’ [3].

Only 34% of residents surveyed reported that they could

‘‘understand and explain to others’’ the concept of an odds

ratio [5]. These data suggest that while urologists and

residents desire to practice evidence-based urology, they

may not feel competent in the necessary critical appraisal

skills.

In fact, urologists report lack of knowledge and training

in critical appraisal skills as an important barrier to EBCP

[6]. Residents and training directors also report that lack of

urology-specific educational materials and lack of expertise

in EBCP among educators (faculty development) pose a

C. D. Scales Jr. (&)

Division of Urologic Surgery, Duke University Medical Center,

Box 2922, Durham, NC 27710, USA

e-mail: Chuck.scales@duke.edu

123

World J Urol (2011) 29:325–329

DOI 10.1007/s00345-011-0651-x

significant challenge for applying critical appraisal skills

during residency training [4, 5]. Therefore, a significant

demand for urology-specific educational resources exists.

Given this context, the present review sought to identify

urology-specific resources for graduate and continuing

medical education in EBCP skills.

Methods

An online search of the PubMed database was performed

using the term ‘‘evidence-base urology’’ combined with

‘‘medical education’’ or ‘‘training’’, resulting in 48 articles.

Limiting these articles to systematic reviews resulted in 32

publications (search performed Nov 2010). Abstracts were

then reviewed to identify articles with urology-specific

educational resources for EBCP. Reference lists were

searched to identify other articles not located in the original

literature search. Finally, to identify training resources for

skill acquisition and faculty development outside of the

medical literature, an internet search using the term ‘‘EBM

workshop’’ (http://www.google.com, date of search 03

January 2011) was performed, and experts in the field were

contacted.

Results

Literature resources

Users’ guides to the urological literature

A series of 8 articles published in The Journal of Urology

comprises the Users’ Guides to the Urological Literature.

Based on the Users’ Guides to the Medical Literature [7],

this series of full-length review articles provides urology-

specific examples of the central critical appraisal skills

necessary for an evidence-based clinical practice. The first

article in the series [8] provides an overview of the phi-

losophy and practice of EBM (Table 1).

Other articles in the series provide a review of funda-

mental skills for evidence-based practice. One fundamental

skill is the ability to acquire evidence to address a clinical

question. Optimal techniques for acquiring evidence

through a literature search are outlined [9]. This article

denotes sources of pre-appraised and un-appraised evi-

dence. A second fundamental skill is the ability to under-

stand the results of a study. Methods for understanding the

results of studies, with strong consideration of effect size

and precision are detailed by Breau et al. [10].

Finally, different study designs are utilized to address

questions in different domains, such as diagnosis or ther-

apy. The remainder of review articles in this series

addresses specific types of study designs or domains. These

include randomized controlled trials (therapy), systematic

reviews and meta-analysis, diagnosis, clinical practice

guidelines, and prognosis. Each of these articles provide

step-by-step urology-specific examples of how to critically

appraise various study designs (Table 1).

Evidence based urology in practice

In contrast to the full-length reviews of the Users’ Guide to

the Urological Literature series, Evidence-Based Urology

in Practice, published in BJU International, is a series of

brief, focused articles on individual topics critical to the

understanding of evidence-based practice (Table 2).

Among these, two articles delineate concepts related to the

EBM framework: levels of evidence [11] and incorporating

patient values into clinical decision-making [12]. An

additional two articles address principal sources of evi-

dence: PubMed [13] (un-appraised evidence) and the

Cochrane Library [14]. (pre-appraised evidence, consisting

of systematic reviews and meta-analyses).

Additional articles in the series examine specific topics

under the umbrella of understanding results of studies. In

the therapy domain, one report explains the concept of

number needed to treat [15], while another vignette dis-

cusses the interpretation and use of likelihood ratios [16]

for studies evaluating diagnostic tests. Other topics include

Table 1 Topics in the users’

guide to the urological literature

series, The Journal of Urology

Topic Reference

Evidence-based clinical practice: a primer for urologists Scales et al. [8]

How to perform a literature search? Krupski et al. [9]

How to use an article about a diagnostic test? Scales et al. [23]

How to use a systematic literature review and meta-analysis? Tseng et al. [24]

How to use an article about therapy? Bajammal et al. [25]

How to use a clinical practice guideline? Dahm et al. [26]

Understanding results Breau et al. [10]

How to use an article about prognosis? Dahm et al. [27]

326 World J Urol (2011) 29:325–329

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the use of composite endpoints [17] and understanding the

differences between and utility of P values and confidence

intervals [18]. Finally, other articles in the series introduce

more advance topics in evidence-based clinical practice,

including subgroup analysis, [19] heterogeneity, [20]

intention to treat analysis, [21] and stopping trials early

[22].

Electronic resources

Recognizing the broad interest in evidence-based clinical

practice among its membership, the American Urological

Association Office of Education initiated the Evidence-

Based Reviews in Urology program (http://www.auanet.

org/content/education-and-meetings/on-line-education/ebru.

cfm). Currently in its second year, this program offers

online education in the skills of EBCP through appraisal of

prominent articles published in the urology literature. This

program is a valuable resource for residency training, as it

incorporates background reading on critical appraisal as

well as evaluation of the investigation of interest. In

addition, practicing urologists may receive continuing

medical education credit for completing the series. The

program is structured with one article per month, with

expert content and methodology reviews posted for dis-

cussion. Participants may discuss articles via an on-line

board, with experts in evidence-based practice serving as

moderators.

An additional on-line resource for learning about evi-

dence-based urology is the website of the International

Evidence-Based Urology Working Group (http://www.

evidence-based.urology.ufl.edu/). This website offers

links to the Users’ Guides and Evidence-Based Urology in

Practice series, as well as the latest publications about the

quality of research methods and reporting in the urology

literature. In addition, links to educational seminars on

practicing and teaching EBM are included.

Courses

Training in fundamentals of evidence-based clinical

practice

Many urologists express concern about their perceived

level of competence in the skills necessary to practice

evidence-based urology [3]. Thus, urologists may be

interested in seeking live training in evidence-based clini-

cal practice. For those interested in urology-specific train-

ing, an annual course exists at the American Urological

Association meeting (Table 3). In 2011, the course Evi-

dence-Based Decision-Making in Urology will focus on

skills empowering urologists to seek and acquire the best

evidence to address clinical questions that may arise in

their practice.

For those interested in more extensive training, a num-

ber of workshops exist that introduce participants to the

fundamental skills of evidence-based clinical practice

(Table 2). Among the most prominent of these is ‘‘How to

Practice Evidence-Based Healthcare’’ at the University of

Oxford. This is a 3 day workshop with world renowned

experts in EBCP, hosted in Oxford, England. Another

workshop is the Rocky Mountain Workshop on How to

Table 2 Topics in the evidence-based urology in practice series, BJUInternational

Topic Reference

Number needed to treat Breau et al. [15]

How to use PubMed effectively? Krupski et al. [13]

What are levels of evidence? Singh et al. [11]

P values vs. confidence intervals MacDonald et al. [18]

Composite endpoints Lavallee et al. [17]

Publication bias Tseng et al. [28]

Loss to follow-up Karl et al. [29]

Kaplan–Meier analysis Sur et al. [30]

Heterogeneity in a systematic

review meta-analysis

Imamura et al. [20]

When to believe a subgroup analysis? Wang et al. [19]

Incorporating patient values

in evidence-based clinical

decision making

Canfield et al. [12]

Likelihood ratios Scales et al. [16]

The Cochrane library Hajebrahimi et al. [14]

Intention to treat analysis Mazel et al. [21]

Randomized trials stopped

early for benefit

Canfield et al. [22]

Table 3 Workshops in evidence-based practice skills and faculty

development

Evidence-based decision making in urology, AUA meeting course

http://www.auanet.org/content/education-and-meetings/

education-and-meetings.cfm

Teaching and leading EBM, Duke University

http://www.mclibrary.duke.edu/training/courses/ebmworkshop/

How to teach evidence-based clinical practice, McMaster University

http://www.ebm.mcmaster.ca/index.html

How to practice evidence-based healthcare, University of Oxford

http://www.cebm.net/

Teaching evidence-based practice, University of Oxford

http://www.cebm.net/

Rocky mountain workshop on how to practice evidence-

based healthcare

http://www.ebhc.ucdenver.edu/

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Practice Evidence-Based Healthcare, which again features

an international faculty. This workshop is 5 days, located

in Vail, Colorado.

Faculty development

Program directors and residents identify the need for fac-

ulty development and expertise in teaching EBCP as an

important barrier to learning evidence-based urology dur-

ing residency training [4, 5]. Several workshops exist to

provide faculty development in the skills necessary to teach

EBCP (Table 3). Among the more prominent of these

workshops is ‘‘How to Teach Evidence-Based Clinical

Practice’’ at McMaster University in Canada. In England,

the University of Oxford hosts ‘‘Teaching Evidence-Based

Practice.’’ Finally, Duke University sponsors a workshop

entitled ‘‘Teaching and Leading EBM.’’

Teaching evidence-based clinical practice

The existence of urology-specific educational resources

facilitates teaching evidence-based clinical practice. What

techniques should be applied to communicate these skills

to learners in the graduate and continuing medical educa-

tion settings? The Users’ Guides to the Medical Literature

identify three techniques which can be used to incorporate

teaching of EBM: role modeling, integrated teaching, and

direct skills instruction [7]. During role modeling, the

instructor demonstrates the incorporation of evidence into

every-day clinical decisions, with the main focus on

showing learners how to practice EBM. This technique

works best in clinical settings (clinic or inpatient wards),

but may not be as useful in a didactic setting, such as

continuing medical education.

Integrated teaching combines a more didactic approach

to teaching a specific skill or topic with the clinical care

experience [7]. This technique can be used in longer

teaching rounds, or venues such as morbidity/mortality or

quality improvement conference. Finally, direct skills

instruction, as the name implies, involves didactic

instruction using clinical examples, and in the continuing

medical education setting is a common technique.

Even when using direct skills instruction, either in

graduate medical education or in continuing medical edu-

cation, teaching in evidence-based clinical practice should

incorporate case-based teaching, rather than discussing

skills in the absence of a clinical context. Notably, most of

the urology-specific resources identified in this review

incorporate a clinical scenario which can be utilized for

instruction. Instructors should also use a variety of settings,

including small group and large group teaching, in order to

accommodate variation in learning styles.

Conclusion

A number of urology-specific resources have been devel-

oped over the past 3 years to support education in the

principles and practice of evidence-based urology. Educa-

tional resources exist in multiple media, including print,

electronic, and live training. Ideally, availability of these

resources will help urologists improve patient care by

facilitating evidence-based clinical practice.

Conflict of interest Dr. Scales is a member of the Steering Com-

mittee for the Evidence-Based Reviews in Urology program spon-

sored by the Office of Education of the American Urological

Association. In addition, he has been invited to serve on the faculty of

the 2011 Teaching and Leading EBM workshop at Duke University.

Dr. Scales is the Resident Member of the Review Committee

for Urology of the Accreditation Council for Graduate Medical

Education.

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