1. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 21 Evidence in Learning and Teaching

2. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter Overview Recognize the elements necessary for successful learning and teaching in an evidence-based curriculum. Clinical research often does not provide the “black and white” answers we seek. Skill development is fostered by discussion and constructive feedback. Making decisions about individual patients is the central focus of clinical epidemiology. The reality of clinical practice is that most cases involve common diagnoses with patients responding to conventional interventions and natural history. Learning and teaching from a body of evidence requires active pursuit of the best available evidence by the student. Case analysis must not focus on the decisions of the individual care provider. Evidence is insufficient to fully guide clinical practice.

3. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Learning Critical Appraisal Clinical research often does not provide the “black and white” answers we seek. Critical appraisal is a skill that is developed with practice over time. Skill development is fostered by discussion and constructive feedback. Students working in small groups to address a clinically relevant question often results in dynamic discussion regarding the strength of the clinical literature. When the groups report out, further discussion allows a large number of students to learn and develop their skills.

4. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Learning Critical Appraisal Helping Students Acquire Critical Appraisal Skills Students can be provided with specific papers to read, appraise, and discuss. Students can be provided with a specific topic and directed to particular databases. Students can be given very loose guidelines for selecting the clinical question, choosing the databases to search, and reporting the results of their work. Students can be provided with guidelines on which to base their critical appraisal, or they can be asked to base their appraisal on criteria of their choosing.

5. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Learning and Teaching from a Body of Evidence Staying current and teaching from a body of evidence depends more on perspective and strategy than on effort. Teachers are often viewed as conveyors of knowledge and truth. Students are often viewed as recipients rather than active participants. It is difficult to strike a balance between developing a topic- specific knowledge base and developing a skill set to support critical appraisal and lifelong learning. Learning and teaching from a body of evidence requires active pursuit of the best available evidence by students who, while becoming a labor force, gain the experience necessary to support a lifetime of independent learning.

6. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Problem-Based Learning Central focus of clinical epidemiology: Making decisions about individual patients. Clinical epidemiology: the vehicle that permits integration of the best available research with clinician experience and patient values in the hospital and clinic environment. Case- or problem-based learning: effectively integrates the continuum of the patient care process into the learning process. Case analysis: offers the opportunity to integrate classroom and clinical experiences.

7. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Problem-Based Learning: Case Analysis Obtaining permission to use personal information in case analyses is essential. It is best to secure permission to discuss a case rather than assuming the steps taken to secure confidentiality will be sufficient. Cases are analyzed to help students learn to make clinical decisions based on the best available evidence. The reality is that often the evidence is insufficient to fully guide clinical practice and that the case analysis is completed outside of the influence of clinical experience, patient preferences, and other factors influencing care.

8. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Problem-Based Learning: Final Considerations The case analysis must not focus on the decisions of the individual care provider but rather on how the research literature can inform practice when similar cases are encountered. Most cases in clinical practice involve common diagnoses with patients responding to conventional interventions and natural history. Critical review of routine practices will have the greatest impact on the broadest spectrum of patients.

9. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Promoting Learning and Assessing Outcomes The goal of developing an understanding of clinical epidemiology in students: –to foster individual preparation and ultimately to cultivate a culture prepared to practice evidence-based health care. It is not possible to separate clinical epidemiology and evidence-based practice into unique entities. It is not possible to separate preparation in clinical epidemiology from the development of a talented clinician.

10. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Instruction and Assessment Must Occur Along a Continuum Begins: With a general understanding of clinical epidemiology and the paradigm of evidence-based practice Continues into: Information retrieval and critical appraisal Ends: When students demonstrate the integration of the best-available research into their patient management decisions.

11. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Promoting Learning and Assessing Outcomes Successful integration of clinical epidemiology and evidence-based care can be assessed only once students are completing clinical experiences or have graduated and begun practice. Assessment of a student’s application of the principles developed in the classroom must continue into their clinical experiences. The truest test of success comes from the assessment of practicing alumni.

12. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter Summary Research skills must be learned, and to do so, they must be taught and practiced. These skills include written and oral communication, information gathering, critical analysis, interpersonal competence, and the ability to use data and make informed judgments following an evidence-based best practice model. Process is content: the belief that the learning process is equally as important as the subject discipline content. Cognitive learning theory (constructivist approach to knowledge): do not look for what students can repeat, but for what they can generate, demonstrate, and exhibit. Problem-based learning is an active learning strategy. Active learning suggests that students demonstrate what they know and are able to do. Problem-based learning emphasizes the application and use of knowledge in research methods and EBM.

13. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Key Points One of the greatest classroom challenges is the desire of students to “have the right answer” and “know how to examine, evaluate, diagnose, and treat patients.” Contradictory findings are common. Critical appraisal is a skill that is developed with practice over time. Skill development is fostered by discussion and constructive feedback. Staying current requires a commitment of time to identify, read, appraise, and integrate new research. Students often assume that the cases and problems they investigate must be unique. The connections between clinical epidemiology and evidence-based practice must be appreciated when developing instructional strategies and assessment instruments. Instruction and assessment must occur along a continuum. Assessment requires a planned communication between faculty, clinical instructors, coordinators of clinical education, and students.