Teaching EBP in the Classroom

Jonathan Koffel

Bio-Medical Library

How did you learn EBP concepts?

Was it in a classroom?

Was it effective?

• Ask– Formulating PICO-style question– Patient oriented vs disease oriented

• Acquire– Information sources and search techniques– Levels of evidence

• Appraise– Critical appraisal– Clinical vs statistical significance

• Apply– Patient preference– Decision making

Three Modes of Teaching

• Role Modeling

• Integrating evidence when discussing clinical topics

• Teaching EBP skills explicitly

• Ideally, we use all three as appropriate

Straus et al. Evidence-based medicine: how to practice and teach it. Churchill-Livingstone; 2011.

Teaching Methods

• Standard didactics (“sage on a stage”)

• Flipped classroom

• Case-based learning

• Clinical integration

• Self-paced online modules

• Interprofessional groups

• Journal clubs/presentations

What Works?

• Didactic instruction better than problem-based learning (PBL)

• Online instruction better than no instruction

• Students in a PBL group with a librarian did better than those in a group without one

Ilic et al. Methods of teaching medical trainees evidence-based medicine: a systematic review. Medical Education 2014; 48:124-135.

What Does Not?

• Librarian-led workshop on searching and question formation vs. nothing

• Interprofessional education vs medical only

• Live lecture vs electronic lectures

• Tutor-led instruction vs self-directed on CD

• Lectures vs small group (PBL)

Ilic et al. Methods of teaching medical trainees evidence-based medicine: a systematic review. Medical Education 2014; 48:124-135.

?

Works•Didactic instruction•Online/Computer-based instruction•Librarian involvement

Doesn’t Work•Didactic instruction•Online/Computer-based instruction•Librarian involvement

“These outcomes contradict those of the other six included studies…it is not possible to confirm, or refute, that one teaching modality is more effective than any other in teaching EBM in medical trainees”

“…it was concluded that there was good evidence to support than any form of teaching EBM significantly increases learner competency in EBM knowledge, skills, attitudes and behavior”

Suggested Hierarchy

• Level 1: Interactive and clinically-integrated

• Level 2: Interactive, classroom-based teaching OR didactic, but clinically-integrated

• Level 3: Didactic and classroom-based

Khan et al. A hierarchy of effective teaching and learning to acquire competence in evidenced-based medicine. BMC Medical Education 2006; 6(59).

Suggested Timing

• Spiral Curriculum– Provide multiple, successive encounters to

a concept at different levels– Adjust to the level of the learner– Reinforces through repetition in varied

contexts

Implementation

• Published undergraduate medical education interventions (n=20)– Level 1: 40%– Level 2: 40%– Level 3: 20%– 25% one-shot sessions– 60% spread over a single year

Maggio et al. Evidence-based medicine training in undergraduate medical education: a review and critique of the literature published 2006-2011. Academic Medicine 2013;88(7):1022-1028.

A Traditional Model

• Question formation

• Search strategies

• Critical appraisal techniques

• Patient preference/application

• Quality improvement

• GO!

A Suggested Model

• Whole task approach– Introduce and practice the combined steps

from day one

• Four Component Instructional Design– Learning tasks– Supportive information– Procedural information– Part-task practice

Maggio et al. Designing Evidence-Based Medicine Training to Optimize the Transfer of Skills From the Classroom to Clinical Practice. Academic Medicine in press.

Learning Tasks

• Allows learners to practice all parts of a complex task in an integrated fashion– Task that includes all 4 A’s– Draw on real-life examples– Can be overwhelming, especially to new

learners– Scale from simple to complex to mirror

learner levels

Supportive Information

• Bridges what they know with what they need for the task (esp. nonrecurrent)

• Background information– Critical appraisal overview, searching

demo

• Mental models:– Expert modeling behavior and rationale

• Provided just before task and relevant to the task

Procedural Information

• Step-by-step approach to a recurrent task– Critical appraisal sheet, PICO guide– “Over the shoulder” mentoring

• Provided just-in-time

• Removed as the learner advances

Part-Task Practice

• Practice of individual elements once the whole task is introduced.

• Increases the speed and comfort around the task.

Advantages

• Better relevance and acceptance

• Adaptable to the level and skills of the learner

• Allows practice of the whole task from day 1

Disadvantages

• Requires more than a single session

• Requires longitudinal integration through the curriculum

Medicine

• “Mastering Clinical Information” in the first-year fall Essentials of Clinical Medicine curriculum

• Flipped classroom model centered around article types

• Short quiz that informs discussion• Mini-lectures• Journal club led by faculty expert• SNAPPS-Plus• Family Medicine/Primary Care Clerkship

Engagement

• Lots of clinical examples of how evidence changed practice

• Keep it funny and light

• Bring in other faculty

• Multiple classes

Veterinary Medicine

• “Critical Reading” in first-year fall

• Focused around journal clubs and critical appraisal using set tools

• Faculty lead and model review

• No lectures on statistics/methodology

• Wide range of articles covered

Engagement

• Whole task (sort of)

• Faculty model behaviors and provide coaching

Dentistry

• Required first-year course

• Standard model

• Emphasis is on creating understanding and enthusiasm rather than specific skills

• Students are given question bank with all test answers/information

Engagement

• Clinically relevant examples, focus on quality of life

• Presentation by student in other course of winning researcher paper and methodology

Nursing

• Required 4-credit course for DNP students

• Mainly online, 3 face to face sessions

• Traditional topic progression

• Frequent online discussions tied to clinically relevant topics

• Two papers: critical review, implementation

Engagement

• Single topic carried from PICO to papers

• Movie/product review synthesis

• Guideline critiques

• Frequent searching

• Stress implementation

Pharmacy

• 18 hours embedded within the curriculum, no stand-alone course

• First year, 4 A’s

• Second year, synthesis

• Fourth year, information prescriptions

• Regular assessments

Engagement

• Therapeutics debates

• Assessment to drive assignments and improving clinical integration