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 cycle Week 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

Recognise important knowledge gaps  Keep a logbook of questions  Answer a few important questions  Discuss evidence with colleagues (“journal club”)

Cased-Based Journal 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 topics 1. 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