Society for EBHC - 6th International Conference for EBHC Teachers - - PowerPoint PPT Presentation

2nd Conference of International Society for EBHC - 6th International Conference for EBHC Teachers and Developers Taormina- Italy 29th Oct – 2nd Nov; 2013

Nov 1 2013

• Dr. Mazen Ferwana, MD, ABFM, JBFM, PhD

Consultant & trainer Family Medicine Associate Prof. King Saud Bin Abdul Aziz University-HS Co-Director, NGCEBHP Chairman, COM EBM Committee

3

4

National & Gulf Center for Evidence Based Health Practice

5

FOUR FOUR QUESTION QUESTIONS

Why? What? How? IMPACT?

6

Introduction

Many medical schools around the world have incorporated EBM teaching into their curricula

7

8

EBM? EBM??

Evidence-based medicine (EBM) is a movement which aims to increase the use of high quality clinical research in clinical decision making.

Pr Practice actice Of Of Evidence Evidence Based Medicine Based Medicine

5

As As

Assess Your Performance Ask Clinical Questions Acquire The Best Evidence Apply the best Evidence Appraise The Evidence

Objectives of the integration

10

Clinical

Behavior

Skills

Knowledge & Attitude

Why?

11

Mana Managing ging Medical Medical Inf Infor

• rma

mation tion Explosion Explosion

Daily: 2000 medical articles 75 RCTs 11 SR PubMed: SR : > 5000

12

13

Incr Increas easing Inf ing Infor

• rma

mation tion

Example: HTN

1000 2000 3000 4000 5000 6000 7000 8000 1966 1976 1986 1996 Articles

14

Incr Increas easing Inf ing Infor

• rma

mation tion

Example: HTN

50000 100000 150000 200000 250000 300000 350000 400000 1966 1976 1986 1996 2013 Articles

Doubling time:

• in 1950, 50 years
• in 1980, 7 years
• in 2010, 3.5 years
• In 2020, 73 days !

TRANSACTIONS OF THE AMERICAN CLINICAL AND CLIMATOLOGICAL ASSOCIATION, VOL. 122, 2011

Why hy EBM EBM a appr pproac

• ach?

h?

15

Mana Managing ging Medical Medical Inf Infor

• rma

mation tion Explosion Explosion

At the individual level:

1. Which resources 2. Proper searching skills 3. Appraisal, Interpretation and use 4. Point of care 5. Mobile medicine 6. Push & Pull

16

Med Medical Decision ical Decision Mak Making ing (MDM) (MDM) EBM approach Assists health professionals in guiding their decisions & manage uncertainty .

17

Quality Quality Of Of Car Care e & & Patient tient Saf Safety ety

EBM mandates the use of best current evidence practices that are effective, whilst eliminating those that are ineffective or harmful

18

Major Major Accr Accredita editation tion Bodies Bodies

ACGME (Accreditation Council for Graduate Medical Education) AAMC (Association of American Medical Colleges) GMC (General Medical Council) CanMEDS (Royal College of Physicians & Surgeons of Canada)

19

WH WHAT ? AT ?

20

EBM Curriculum

Sicily statement 2005

21

Sicily Statement

This statement was conceived by the delegates of the second international conference

• f

EBHC Teachers and Developers held in Sicily in Sep 2003 "Signposting the future of EBHC“

GIMBE: http://www.ebhc.org

22

Sicily Statement

5 EBM steps

This five-step model forms the basis for both clinical practice and teaching EBP “An immediate attraction of evidence-based medicine is that it integrates medical education with clinical practice“

Rosenberg and Donald; BMJ, 1995

23

Pr Practice actice Of Of Evidence Evidence Based Medicine Based Medicine

5

As As

Assess Your Performance Ask Clinical Questions Acquire The Best Evidence Apply the best Evidence Appraise The Evidence

EBP EBP Cur Curriculum riculum Educa Educational tional Outcome Outcomes

5 5

Educational Outcomes

Evaluation of performance Translation of uncertainty into an answerable question Search for and retrieval of evidence Application of appraised evidence to practice

Critical appraisal of evidence for validity and clinical importance

25

What Researches Say?

Although students of medicine at University of Split School of Medicine are taught EBM from the first day of their study and in all courses. . . . their experience of evidence searching and critical appraisal of the evidence, in real time with real patient in front of them is not large

Vrdoljak D: Teaching evidence based medicine in family medicine. Acta medica academica 2012, 41(1):88-92.

26

What Researches Say?

Since its arrival to the scene of medicine and despite its worldwide incorporation into both undergraduate and postgraduate curricula, the implementation of evidence has been extremely slow

27

McAlister FA, Graham I, Karr GW, Laupacis A: Evidence-based medicine and the practicing clinician. Journal of general internal medicine 1999, 14(4):236-242. McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA: The quality of health care delivered to adults in the United States. The New England journal of medicine 2003, 348(26):2635-2645. Grol R: Successes and failures in the implementation of evidence-based guidelines for clinical practice. Medical care 2001, 39(8 Suppl 2):II46-54. Ayanian JZ, Hauptman PJ, Guadagnoli E, Antman EM, Pashos CL, McNeil BJ: Knowledge and practices of generalist and specialist physicians regarding drug therapy for acute myocardial infarction. The New England journal of medicine 1994, 331(17):1136-1142. Brand DA, Newcomer LN, Freiburger A, Tian H: Cardiologists' practices compared with practice guidelines: use of beta-blockade after acute myocardial infarction. Journal of the American College of Cardiology 1995, 26(6):1432-1436 Hassan IA: Moving from knowledge to practice: is it time to move from teaching evidence-based medicine (EBM ) to knowledge translation competency ?Perspect Med Educ , 2013 (2) 104-105 Slawson DC, Shaughnessy AF: Teaching evidence-based medicine: should we be teaching information management instead? Academic medicine : journal of the Association of American Medical Colleges 2005, 80(7):685-689. Ebell MH, Shaughnessy A: Information mastery: integrating continuing medical education with the information needs of clinicians. The Journal of continuing education in the health professions 2003 ,Suppl 1:S53-62.

28

There are many barriers!! But . . . Is teaching the 5 steps sufficient to do the move from evidence to practice?

29

Miller Theory (Pyramid)

30

Does Shows How Knows How Knows

Daily patient care Patient: Demonstration of clinical skills How to apply knowledge Knowledge

Adapted from: RamaniS, Leister S, AMEE Guide no 34: Teaching in the clinical environment Medical Teacher, 2008:30 (4): 347-364

Behavior Cognition

Anatomy-Surgery Model

Basic Anatomy Applied anatomy Clinical (Surgery)

31

Beyond Appraisal Teaching

Applied EBM Science Clinical EBM Practice

Slawson & Shaughenssy, J Assoc AMC, 2005 Ebell & Shaughensyy J Cont edu in health professional, 2003 Hassan IA, Prospectus med edu, 2013 Jane P. 2012 Lai 2009

32

• 1. Applied EBM Science
• 1. Point of care
• 2. Clinical Practice Guidelines
• 3. Knowledge Translation
• 4. Medical Decision Making

33

• 2. Clinical EBM Practice

Unless taught in clinical settings, it doesn’t work Real Time EBM Post-call round Morning rounds Out-patient clinic

34

Clinical EBM Science

35

HOW ? HOW ?

36

Link Betw Link Between T een Theor heory And y And Decision Making Decision Making

A Norwegian study on undergrad: medical students & uptake of EBM principles may be positively modified if educators can demonstrate the link between competency in EBM & its direct influence on medical decision making

Pradly P et al, Evaluation Review, 2005

37

EBM Teaching Methods

38

1

Clinically integrated teaching is more effective than theoretical teaching

39

BMC Medical Education 2006

A variety of methods exists for teaching and learning EBM. There is much debate about the effectiveness of various EBM teaching and learning activities. Two factors:

• 1. Clinical Vs. Classroom based (standalone)
• 2. Interactive Vs. Didactic

40

Empirical and theoretical evidence suggests that there is a hierarchy of teaching and learning activities in terms of their educational effectiveness:

41

A hierarchy of evidence-based medicine (EBM) teaching and learning Level I: Interactive, and clinically integrated teaching and learning activities Level 2: (a) Interactive, classroom based teaching and learning activities (b) Didactic, but clinically integrated teaching and learning activities Level 3: Didactic, and classroom or standalone teaching and learning activities

42

ST STAN ANDAL ALON ONE E DID DIDACTIC CTIC TE TEACHIN CHING

EDUCATIONAL NEED

• No active learning need

assessment

• Learner receives topic from

course organizers

• Lack of clinical context

REINFORCEMENT OF LEARNING

• In the absence of a clinical

context acquired knowledge, if retained, is seldom applied to patient care.

• There is no active strategy to

remove barriers at workplace

TEACHING & LEARNING

• Educational content delivered by

teacher without interaction

• Knowledge and skills taught in

hypothetical case scenarios

• The practicalities of EBM cannot

be grasped

• Lack of learner activity

encourages superficial learning

USE OF INFORMATION TAUGHT

• Information is quickly forgotten
• It cannot be easily retrieved

when required

43

IN INTE TEGR GRATE TED D IN INTE TERA RACTIV CTIVE E TE TEACHIN CHING

EDUCATIONAL NEED

• Learning needs determined by

learner’s requirements

• Learner identifies a real clinical

problem

• Evidence is sought actively

REINFORCEMENT OF LEARNING

• Practical use of acquired

knowledge and skills reinforces deeper learning

• Resolution of clinical

problems emphasizes relevance of learning

• Barriers are identified and

dealt with at workplace

TEACHING & LEARNING

• Learner activity encourages deep

learning

• Knowledge and skills learned

while solving real clinical problems

• Ward round, Journal clubs, case

discussions all used to learn how to incorporate evidence into practice

USE OF INFORMATION LEARNT

• Information is directly relevant

to practice

• If stored electronically or

included in local guidelines, can be easily retrieved and applied

2

Long-term teaching is more effective than short-term courses

Green 1997

44

Spiral Model

45

A spiral model is not simply the repetition of a topic taught. It requires also the deepening of it, with each successive encounter building on the previous

• ne

Phase 1

Year 1 & 2

Phase 2

Year 3

Phase 3

Year 4 & 5 Normal Structure function and behavior Abormal Structure function and behavior Clinical Practice

Medical curriculum

Internship

Behavior Cognition Skills On-the-Job learning

Levels of difficulty are increased, new learning is related to previous learning, and the students‘ competency is increased.

46

Khan’s Hierarchy Needs To Be Expanded Khan’s hierarchy is suitable for CME and CPD curricula Two more factors for undergraduate

• 1. Curriculum Contents

(Basic/Applied/Clinical)

• 2. Longitudinal (Spiral Vs. Single course)

47

48

Teac eaching hing Patter tterns ns

Green’s literature review of approaches to teaching EBM revealed few important modalities to teachers of EBM:

• 1. Small-group, learner-centered format
• 2. Immediate clinical relevance (Real time

EBM)

• 3. Role modeling of EBM

Green 1997

49

Immedia Immediate te Cli Clinical nical Rele elevance vance

Any opportunity at different setting to discuss, explain, and challenge students with EBM interpretation: Search the secondary EBM resources Sn, Sp, LHR, SnOUT, SpPIN ?? RR, NNT ?? Applicability of the results to a specific patient?

50

Role

• le Modeling

Modeling Of Of EBM EBM

When the trainer applies EBM on his daily practice, students consider it the norm and they will follow his steps. One of the barriers to implementation is the disengagement between senior clinicians & EBM

3

EBM should be clearly incorporated in the curriculum as part of the clinical training.

Radack & Valanis University of Michigan 2001 51

• Unless clearly incorporated in the clinical

curriculum (with assessment scores)

• The other clinical demands of students will
• verpower their attention

Heller RF. 1984, Frasca MA, et al. 1992, Radack KL. 1986, Landry FJ, et al. 1994 , Bennett KJ, et al. 1987

52

53

Impact Impact

54

Systema Systematic R tic Review view

23 studies (RCTs & NRCTs) It compared:

• Classroom (Standalone)
• Clinically integrated teaching.

Coomarasamy A, Khan K , 2004

55

Classroom-based Vs. Clinical-based  Both improved knowledge  Clinically integrated improved attitude, behavior and skills

Coomarasamy A, Khan K , 2004

• Teaching the principles of EBM to medical

students increases knowledge, improves critical appraisal skills & attitude in both undergrad & postgrad

Coomarsamy A & Khan K, BMJ 2004 BradlyP et al, Med Edu 2005 Ghali WA et al, Med Edu 2000 Smith CA et al, JGIM, 2000 Tylor R et al, BMC Med Edu, 2001 Parks J et al, Cochrane rev Database, 2001 Widyahening IS et al, Prospect Med Edu, 2012

56

Impact of Teaching EBM on Undergraduate

• SR of 17 studies of effectiveness of

instruction in critical appraisal.

• Result: interventions implemented in the

undergraduate programs resulted in significance gains in knowledge

Norman GR, Shannon SI. Effectiveness of instruction in critical appraisal (evidence- based medicine) skills: a critical appraisal. CMAJ. 1998;158:177–181.

57

The principles & application of EBM is perceived by medical students to be important in both their current clinical training & perceived future work as clinicians

Dragan I & Kristian F, BMC Med Edu, 2010

58

Improves KAP

• A systematic review that includes two RCTs of

teaching EBM to undergraduate medical students showed that EBP knowledge, skills and behavior has improved significantly.

• (Ilic D, 2009)

60

Summar Summary

• EBM approach assists managing Info explosion
• Sicily Statement Plus Applied and Clinical EBM
• Four Factors to consider when assessing EBM

curriculum

• 1. Clinical Vs. Standalone
• 2. Interactive Vs. Didactic
• 3. Curriculum Contents
• 4. Spiral Vs. Single course

ferwanam@ngha.med.sa drmazen99@yahoo.com www.ngcebm.org

61