Teaching EBM

Natapong Kosachunhanun, M.D.

Why Teach and Practice EBM? It is required to be taught by TMC. Outcomes research has documented

that patients who do receive evidence-based therapies have better outcomes than those who don’t.

It may be a more efficient means of remaining current than traditional methods (e.g. journal subscriptions).

A host of developments make EBM more possible than ever.

Its practice requires: Asking Acquiring Appraising Applying Assessing

Putting Skills into Practice

Find evidence supporting one clinical decision made on each of your inpatients.

Find evidence supporting one clinical decision made on one patient per clinic day.

Encourage the students and colleagues you work with to follow your lead.

Work as a team to find evidence-based answers.

What is the intervention? The 5 steps of practising EBHC – but what

is the appropriate dose, formulation and method of delivery? Standing courses Lectures Conferences Journal clubs At the bedside Online Others

Course Structure - 8 week cycleWeek 1• Introduction• Asking a clinical question• Critical appraisal of therapy articles• Therapy questions• Searching

Week 2• Critically appraise therapy

articles• Write CAT• New question and real-time

practice session

Week 3• Review asking a clinical question• Critical appraisal of prognosis

articles• Prognosis questions• Searching

Week 4• Critically appraise prognosis

articles• Write CAT• New question and real-time

practice session

Week 5• Introduction• Asking a clinical question• Critical appraisal of diagnosis

articles• Diagnosis questions• Searching

Week 6• Critically appraise diagnosis

articles• Write CAT• New question and real-time practice

session

Week 7• Review asking a clinical question• Critical appraisal of articles about

harm• Searching

Week 8• Critically appraise harm

articles• Write CAT• New question and real-time

practice session

Think of Therapy ?’s

Think of Prognosis ?’s

Think of Diagnosis ?’s

Think of Harm ?’s

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:

Cased-BasedJournal Clubs Case focused Vote on topics Simple appraisal Note further actions

More information Equipment Training etc

H

What are the relevant outcomes? Attitudes Knowledge Skills Behaviours Clinical outcomes

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’

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

What are the relevant outcomes? Behaviours

More difficult to measure because they require assessment in the practice setting

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 are some barriers to teaching EBHC? Time constraints – for teachers and

learners Lack of resources Paucity of evidence that EBHC works

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 physical exams and 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, add a clinical librarian to the team

Some Tips for Good journal clubs

Use high quality articles relevant to your clinicians

Have clear roles

Use visual aids

Keep a record – paper or intranet

Follow-up decisions – “next actions”

How to choose questions

List possible topics1. From own patients

2. From EBM journals

Vote on best topics

Get best evidence for next journal club

The top 10 successes that we’ve 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

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

Top 10 mistakes we’ve 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

Top 10 mistakes we’ve made or 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 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 learner’s attention