Teaching Evidence-Based Medicine Across the Curriculum Good morning and thank you for joining us for today’s preceptor symposium. Today we will be discussing a topic near and dear to my heart, as you might have guessed given my career choice in drug information. Over the next few hours we will discover the many amazing resources available to all of us as preceptors of the College of Pharmacy. We will learn tricks about google that will allow us to become more effective and efficient in our searches, whether for health-care related topics or to find the best buy on those new shoes or boat. And, we will discover the many applications available on hand held devices for those who may not have continuous ready access to a computer in their clinical practice. I will start, though, by providing you will a brief overview of the COP curriculum specific to developing evidence-based medicine skills so that you have an understanding of what students are taught prior to their arrival in your practice setting. Gundy Sweet, PharmD, FASHP Clinical Associate Professor University of Michigan, College of Pharmacy

Objectives Provide a brief overview of the UofM College of Pharmacy curriculum specific to the development of evidence-based medicine skills and concepts Briefly discuss how the curriculum revision process will strive to further develop these skills

Evidence-Based Medicine What is it? EBM is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. Integrating individual clinical expertise with the best available external clinical evidence from systematic research. Sackett D, 1996

All done to make the best decision What is EBM? Combine the best evidence from clinically relevant studies Add in your clinical expertise to determine if it applies to the individual patient And incorporate the patient’s values All done to make the best decision for a given situation Sackett D, 1996

Common Student (mis)Perception You don’t need to teach me this stuff…. I already know how to look for things…. I’m a Gen-Nexter But few students have a systematic process to identify the best evidence specific to a given situation Why is that important?

2006: 20,824 journals (medical sciences) 2009: > 679,000 citations added to Medline Too many sources of information

2X Information explosion Research information doubles every 10 years Explosion of mis-information

Traditional resources often inadequate Textbooks can be outdated Many books take 1-3 years to get to print

1986: Medline available via librarians Readily available search tools 1986: Medline available via librarians Today: numerous search tools readily available

More knowledgeable patient 30% of adults seeing MD discuss a drug they saw through DTC advertising almost ½ of these patients received a RX for the drug

Daily need for valid information

1/2 of all withdrawals within 2 years 10% of drugs on market between 1975-1999 pulled from market/black box warning added 1/2 of all withdrawals within 2 years Increase in number, sophistication, and safety concerns with drugs/medical interventions

Feeling Overwhelmed??? Traditional resources often inadequate Readily available search tools Information explosion More knowledgeable patient Too many sources of information Increase in number and sophistication of drugs/medical interventions Daily need for valid information

How and where are the skills taught? EBM Course EBM concepts How to formulate a clinical question Importance of clarity of the question Helps direct you to the most appropriate resources Helps ensure communication of a clear response How to apply the systematic approach to handling requests for information

What is the Systematic Approach The systematic approach is an integral part of the EBM strategy Helps search for the most relevant literature to enhance efficiency and effectiveness The systematic approach is comprised of 7 steps: BUT… conducting a systematic search requires knowledge of the advantages/disadvantages associated with each type of information resource 1. Classify  2. Clarifying information  3. Systematic Search (3o2o1o)  4. Evaluate  5. Apply  6. Communicate  7. Follow-up

Where Students Learn About Resources EBM Course Textbooks and general drug information resources Searching the biomedical literature What to use when PubMed, Embase, Google, IPA, Cochrane, others Using the internet - is it reliable? Author credentials Currency of the information Source of funding Awareness of extensions (.biz .com .edu .gov) External validation of content Within this, we teach students the advantages and disadvantages of each source, recognizing that what used to be distinct differences are becoming more grey. Health on the Net Foundation (www.hon.ch/) Established in 1995 in Geneva, Switzerland HON code of 8 principles that must be abided by in order to receive this accreditation Look for HON code Icon when evaluating web-sites

What about the primary literature? EBM Course How to find the primary literature Efficient and effective searching How to read and interpret the primary literature Terminology (R, DB, PC, DD, etc) Different types of trials (systematic reviews, economic analyses, randomized controlled trials, case reports) Levels of evidence Appropriate statistical tests Assess all elements of the study, practicing on different published clinical trials Within this, we teach students the advantages and disadvantages of each source, recognizing that what used to be distinct differences are becoming more grey.

Using EBM Skills EBM Course and beyond How do I apply the information? Does the information found apply to the clinical situation (indication, age group, etc)? Are the results clinically important (and not just statistically significant)? Is the information found sufficient to answer the question? How should I communicate the information? Are there any ethical considerations to take into account? Using these skills is touched upon in the EBM course, but is also revisited throughout the curriculum. Having said that, though, we recognize that this is one of the opportunities for improvement in the curriculum revision. We’ll talk about that more later.

Application of EBM Principles P1 Year EBM Course (W) Therapeutics Reinforce identification of best evidence Integrate critical appraisal to clinical situations Research Principles Practical, application-based course where students write a ‘practice’ research proposal Requires they understand and apply EBM principles Study terminology Study design Searching primary literature Learn to logically think through a problem and define a plan P2 Year Therapeutics (F/W) Research Principles (W)

Application of EBM Principles Research Principles (P2 year) Teach process of defining a logical plan to solving a problem Practical, application-based course where students write a ‘practice’ research proposal Requires that they understand and apply EBM principles Study terminology and study design to test a hypothesis Searching the primary literature Logically think through a problem and define a plan

Application of EBM Principles Therapeutics Reinforce identification of best evidence/integrate critical appraisal Pcare (IPPE) Discuss patient cases that requires use of best evidence Reinforce primary literature review (journal clubs) PharmD Research Project Application of research principles Emphasis on process of conducting research P1 Year EBM Course (W) P3 Year Therapeutics (F/W) Pcare (IPPE) PharmD Research (W) P2 Year Therapeutics (F/W) Research Principles (W)

Application of EBM Principles Therapeutics (P2 and P3 years) Reinforce identification of best evidence Integrate critical appraisal to given clinical situations Introductory Practice Experiences (IPPEs, P3) Discussion of patient cases that includes use of best evidence Reinforcement of reviewing the primary literature 2 journal clubs – one group-based and one individual

Application of EBM Principles Clinical Rotations Manage patients on rotations Reinforce primary literature review Drug Information is a required rotation Conduct systematic review of topic Critically evaluate literature on a topic Retrieve/analyze/apply DI in practice PharmD Research Project Application of research principles PharmD Seminar Formal presentation PharmD research or topic review Requires application of all EBM skills Search/analyze/apply information to a given situation P1 Year EBM Course (W) P2 Year Therapeutics (F/W) Research Principles (W) P4 Year Clinical Rotations PharmD Research PharmD Seminar

Application of EBM Principles Advanced Practice Experiences (APPEs, P4) Management of patients on clinical rotations Reinforcement of reviewing the primary literature Journal clubs Written or oral topic reviews (inservices) Required drug information rotation Conduct systematic searches for information Retrieve, analyze and apply drug information in practice Critically evaluate the literature on a given topic

Application of EBM Principles P1 Year EBM Course (W) P3 Year Pcare (IPPE) Therapeutics (F/W) PharmD Research (W) P2 Year Therapeutics (F/W) Research Principles (W) P4 Year Clinical Rotations PharmD Research PharmD Seminar

Application of EBM Principles PharmD Research Project (P3-P4 years) Students work with faculty mentor to conduct a research study Emphasis is on the process of conducting research (defining a logical plan) PharmD Seminar (P4 year) Formal presentation of either their PharmD research or a clinical review of a topic Requires application of all EBM skills Search, analyze, and apply information to a given situation

What does curriculum achieve? Advantage: EBM skills taught early (P1 year) Skills are revisited throughout the curriculum Disadvantages: P1 students don’t see the need for these skills believe they already know how to find information don’t know what they don’t know EBM course is taught in isolation of clinical application prior to therapeutics and pharmacology Application of EBM skills is not adequately reinforced across the curriculum

Curriculum revision is an ongoing, dynamic process EBM in New Curriculum P1 Year Introduce DI skills, resources, terminology Begin to build a toolbox Curriculum revision is an ongoing, dynamic process P3 Year EBM/ethics course Pcare (IPPE) Therapeutics (F/W) PharmD Research (W) P2 Year EBM: focus on literature evaluation and searching (F) Research Principles (W) Therapeutics (F/W) P4 Year Clinical Rotations PharmD Research PharmD Seminar

Goals with the New Curriculum Maintain existing infrastructure for teaching EBM Shift (some) drug information component into the P1 year Provide students with a toolbox of resources early in training Allow for additional time in P2 year to focus on lit evaluation Ensure application of EBM skills builds across the P1-P4 years Improve integration of EBM skills into other courses (eg, therapeutics) Provide greater clarity to students for how skills are essential for pharmacy practice Increase opportunities for students to practice and apply these skills

Goals with the New Curriculum Maximize active learning Students more involved in learning by DOING Increase opportunities in all courses for students to …. not just KNOW the information but …. to have the ability to APPLY information in practice

In your packet is a document for your toolbox… A Guide to INFORMATION RESOURCES University of Michigan, College of Pharmacy TAUBMAN LIBRARY RESOURCES RESOURCES BASED ON TYPE OF QUESTION

Questions With that as a brief summary of the curriculum behind development of EBM skills, we can delve into the heart of today’s program – how can we all become more effective and efficient at searching for medical literature. It is my pleasure to introduce my colleague, Mark MacEachern, who will share with us the many resources available to all preceptors through the Taubman Library.