Evidence-Based Medicine in Pediatric Residency Programs: Where Are We Now?

Using Self-Determination Theory to Drive an Evidence-Based Medicine Curriculum for Pediatric Residents: A Mixed Methods Study

OBJECTIVE

The ability to incorporate evidence-based medicine (EBM) into clinical practice is an Accreditation Council for Graduate Medical Education competency, yet many pediatric residents have limited knowledge in this area. The objective of this study is to describe the effect of an EBM curriculum on resident attitudes and clinical use of EBM.

METHODS

We implemented a longitudinal EBM curriculum to review key literature and guidelines and teach EBM principles. In this Institutional Review Board-exempt mixed methods study, we surveyed residents, fellows, and faculty about resident use of EBM at baseline, 6 months, and 12 months after the beginning of the intervention. We conducted point prevalence surveys of faculty about residents' EBM use on rounds. Residents participated in focus groups, which were audio-recorded, transcribed, and coded using conventional content analysis to develop themes.

RESULTS

Residents (N = 61 pre- and 70 post-curriculum) reported an increased appreciation for the importance of EBM and comfort generating a search question. Faculty reported that residents cited EBM on rounds, with an average of 2.4 citations/week. Cited evidence reinforced faculty's plans 79% of the time, taught faculty something new 57% of the time, and changed management 21% of the time. Focus groups with 22 trainees yielded 4 themes: 1) increased competence in understanding methodology and evidence quality; 2) greater autonomy in application of EBM; 3) a call for relatedness from faculty role models and a culture that promotes EBM; and 4) several barriers to successful use of EBM.

CONCLUSIONS

After implementation of a longitudinal EBM curriculum, trainees described increased use of EBM in clinical practice.

Evidence-Based Medicine in the Clinical Learning Environment of Pediatric Hospital Medicine

The article begins with an overview of evidence-based medicine (EBM), including its history and core principles. Next, the article discusses how the current clinical learning environment has shaped EBM, including the accessibility and portability of technology; the access to electronic search engines and libraries; and the movement toward applying the best evidence through order sets, clinical guidelines, and pathways to work toward standardizing care. The article ends with a focus on how educators can influence a trainee's knowledge, skills, attitudes, and behaviors regarding EBM.

The role of librarians in teaching evidence-based medicine to pediatric residents: a survey of pediatric residency program directors

Objective:

The research sought to identify the general use of medical librarians in pediatric residency training, to define the role of medical librarians in teaching evidence-based medicine (EBM) to pediatric residents, and to describe strategies and curricula for teaching EBM used in pediatric residency training programs.

Methods:

We sent a 13-question web-based survey through the Association of Pediatric Program Directors to 200 pediatric residency program directors between August and December 2015.

Results:

A total of 91 (46%) pediatric residency program directors responded. Most (76%) programs had formal EBM curricula, and more than 75% of curricula addressed question formation, searching, assessment of validity, generalizability, quantitative importance, statistical significance, and applicability. The venues for teaching EBM that program directors perceived to be most effective included journal clubs (84%), conferences (44%), and morning report (36%). While 80% of programs utilized medical librarians, most of these librarians assisted with scholarly or research projects (74%), addressed clinical questions (62%), and taught on any topic not necessarily EBM (58%). Only 17% of program directors stated that librarians were involved in teaching EBM on a regular basis. The use of a librarian was not associated with having an EBM curriculum but was significantly associated with the size of the program. Smaller programs were more likely to utilize librarians (100%) than were medium (71%) or large programs (75%).

Conclusions:

While most pediatric residency programs have an EBM curriculum and engage medical librarians in various ways, librarians’ expertise in teaching EBM is underutilized. Programs should work to better integrate librarians’ expertise, both in the didactic and clinical teaching of EBM.

Teaching trainees how to critically evaluate the literature - a crossover study at two pediatric residency programs

OBJECTIVES

The purpose of this study was to assess the efficacy of a concise, evidence based medicine curriculum in improving the knowledge of pediatric residents at two institutions.

METHODS

Sixty first and second year pediatric residents at MassGeneral Hospital for Children and MedStar Georgetown University Hospital participated in a crossover study. The evidence based medicine curriculum, consisting of 4 ninety minute sessions grounded in adult learning theory principles, was developed using the methodology described in the book 'Studying a Study'. A validated 20 question evidence based medicine multiple choice test was administered on three separate occasions to measure baseline knowledge, efficacy of the curriculum in improving knowledge, and long term retention of that knowledge.

RESULTS

Post curriculum, the fall group's scores improved 23% from baseline (M=10.3, SD=2.4) to (M=12.7, SD=3.0) students (t₍₂₆₎=-3.29, p=0.0018) while the spring group improved by 41% (M=10.0, SD=2.8) to (M=14.1, SD=2.2) students (t₍₃₂₎=-6.46, p<0.0001).  When re-tested 4-6 months later, the fall group's scores did not significantly decline from their immediate post curriculum scores (M=12.7, SD=3.0) to (M=11.7, SD=3.0) students (t₍₃₂₎ =1.33, p=0.190). There was an association between number of sessions attended and increase in post curriculum score (χ²(3, N=60) =11.75, p=0.0083).

CONCLUSIONS

Findings demonstrate our curriculum was effective in teaching evidence based medicine to pediatric residents, and fostered long term retention of knowledge.  Based on these results, we believe this curriculum could be implemented at any institution.

The impact of a dedicated research education month for anesthesiology residents

An educational intervention was implemented at the University of Michigan starting in 2008, in which anesthesiology interns complete a dedicated month-long didactic rotation in evidence-based medicine (EBM) and research methodology. We sought to assess its utility. Scores on a validated EBM test before and after the rotation were compared and assessed for significance of improvement. A survey was also given to gauge satisfaction with the quality of the rotation and self-reported improvement in understanding of EBM topics. Fourteen consecutive interns completed the research rotation during the study period. One hundred percent completed both the pre- and postrotation test. The mean pretest score was 7.78 ± 2.46 (median = 7.5, 0–15 scale, and interquartile range 7.0–10.0) and the mean posttest score was 10.00 ± 2.35 (median = 9.5, interquartile range 8.0–12.3), which represented a statistically significant increase (P = 0.011, Wilcoxon signed-rank test). All fourteen of the residents “agreed” or “strongly agreed” that they would recommend the course to future interns and that the course increased their ability to critically review the literature. Our findings demonstrate that this can be an effective means of improving understanding of EBM topics and anesthesiology research.

Using tablet computers to teach evidence-based medicine to pediatrics residents: a prospective study

OBJECTIVE

We sought to determine if tablet computers-supported by a laboratory experience focused upon skill-development-would improve not only evidence-based medicine (EBM) knowledge but also skills and behavior.

METHODS

We conducted a prospective cohort study where we provided tablet computers to our pediatric residents and then held a series of laboratory sessions focused on speed and efficiency in performing EBM at the bedside. We evaluated the intervention with pre- and postintervention tests and surveys based on a validated tool available for use on MedEdPORTAL. The attending pediatric hospitalists also completed surveys regarding their observations of the residents' behavior.

RESULTS

All 38 pediatric residents completed the preintervention test and the pre- and postintervention surveys. All but one completed the posttest. All 7 attending pediatric hospitalists completed their surveys. The testing, targeted to assess EBM knowledge, revealed a median increase of 16 points out of a possible 60 points (P < .0001). We found substantial increases in individual resident's test scores across all 3 years of residency. Resident responses demonstrated statistically significant improvements in self-reported comfort with 6 out of 6 EBM skills and statistically significant increases in self-reported frequencies for 4 out of 7 EBM behaviors. Attending pediatric hospitalists reported improvements in 5 of 7 resident behaviors.

CONCLUSIONS

This novel approach for teaching EBM to pediatric residents improved knowledge, skills, and behavior through the introduction of a tablet computer and laboratory sessions designed to teach the quick and efficient application of EBM at the bedside.

Morning report: can an established medical education tradition be validated?

BACKGROUND

Morning report is accepted as an essential component of residency education throughout different parts of the world.

OBJECTIVE

To review the evidence of the educational value, purpose, methods, and outcomes of morning report.

METHODS

A literature search of PubMed, Ovid, and the Cochrane Library for English-language studies published between January 1, 1966, and October 31, 2011, was performed. We searched for keywords and Medical Subject Heading terms related to medical education, methods, attitudes, and outcomes in regard to "morning report." Title and abstract review, followed by a full-text review by 3 authors, was performed to identify all pertinent articles.

RESULTS

We identified 71 citations; 40 articles were original studies and 31 were commentaries, editorials, or review articles; 56 studies (79%) originated from internal medicine residency programs; 6 studies (8%) focused on ambulatory morning report; and 63 (89%) originated from the United States. Identified studies varied in objectives, methods, and outcome measures, and were not suitable for meta-analysis. Main outcome measures were resident satisfaction, faculty satisfaction, preparation for professional examinations, use of evidence-based medicine, clinical effects on patient care, adverse event detection, and utilization of a curriculum in case selection.

CONCLUSIONS

Morning report has heterogeneous purposes, methods, and settings. As an educational tool, morning report is challenging to define, its outcome is difficult to measure, and this precludes firm conclusions about its contribution to resident education or patient care. Residency programs should tailor morning report to meet their own unique educational objectives and needs.

A practical educational tool for teaching child-care hospital professionals attending evidence-based practice courses for continuing medical education to appraise internal validity in systematic reviews

RATIONALE, AIMS AND OBJECTIVES

Having a quick, practical, educational tool designed for busy child-care professionals to check whether systematic reviews (SRs) contain valid information would help them regularly update their evidence-based knowledge and apply it to their patients. Continuing our annual workshop courses encouraging paediatric hospital professionals to use evidence-based information, in a preliminary study, we compared the commonly used Critical Appraisal Skill Programme (CASP) questionnaire for appraising overall internal validity in SRs with a new, practical tool designed to check internal validity quickly.

METHOD

During a course in 2010, two 'teacher-brokers' taught experienced paediatric hospital professionals to use and compare the CASP and the new practical tool to appraise a Cochrane SR on beclomethasone for asthma in children by assessing internal validity only from the two most weighted randomized controlled trials in the forest plot. At 15 days and 6 months, participants then answered questionnaires designed to assess qualitative data including feelings about working together, memorization and possibly provide feedback for Cochrane reviewers.

RESULTS

Using the CASP, participants agreed that the Cochrane SR analysed contained overall valid results. Conversely, using the new quick tool, they found poor internal validity. Participants worked well together in a group, took less time to apply the new tool than the CASP (1 vs. 2.5 hours) and provided Cochrane feedback.

CONCLUSIONS

Our quick practical tool for teaching critical appraisal encourages busy child-care hospital professionals to work together, carefully check validity in SRs, apply the findings in clinical practice and provide useful feedback for Cochrane reviewers.

The status of evidence-based medicine education in urology residency

INTRODUCTION

Evidence-based medicine (EBM) is the conscientious, explicit, and judicious use of the current best evidence in decision-making for the care of patients. Teaching best evidence practice in residency should include both formal or freestanding content, as well as integration into clinical scenarios and patient care. We sought to assess the attitudes, experience and knowledge of EBM in urology residency training across Canada.

METHODS

An anonymous, cross-sectional, self-report questionnaire was completed by a convenience sample of 29 residents, including all chief urology residents in English-speaking programs across Canada. The survey included both open-ended and closed-ended questions designed to assess familiarity and attitudes towards EBM and potential barriers to developing EBM skills in a surgical training program. Questions were formatted to determine the understanding of statistical and analytical concepts, as well as familiarity of available EBM resources. Descriptive and correlative statistics were used to analyze the responses.

RESULTS

The response rate was 100%. An overwhelming majority of residents felt that EBM is an important component of the urology residency and journal club was the most common vehicle for discussing best evidence concepts. However, there was significant variation in the presence of freestanding, formal curricula across programs, with only 28% of residents signifying that they received any formal training in their program. The apparent level of understanding of important EBM terminology and resources appears to be limited. The most frequently stated barriers to incorporating EBM curricula into urology training were time constraints and a perceived lack of expert educators.

CONCLUSION

This self-report survey of urology chief residents identified the overwhelming acceptance of the importance of EBM in their training. Although best evidence practices appears to be addressed in journal clubs and in real-life clinical experiences, the obvious lack of familiarity and understanding of EBM content and resources would suggest a need for redoubling efforts to ensure appropriate exposure and instruction in our training programs.

Physician numeracy as the basis for an evidence-based medicine curriculum

Most medical schools and postgraduate programs devote some time to teaching evidence-based medicine (EBM). EBM encompasses five essential skills, including constructing a sound clinical question, literature searching, critical appraisal, gaining a full understanding of study results, and integration of results into patient care. Gaining a full understanding of results requires understanding the statistical aspects of and terminology associated with the design, analysis, and results of original research--hereby referred to as physician numeracy. Physicians and physicians-in-training recognize the importance of these concepts but are uncomfortable with and demonstrate poor knowledge of the quantitative aspects of research. This is not surprising since few curricula include physician numeracy. Current approaches to teaching EBM rely on journal clubs, which have not been shown to improve participants' self-perceived EBM skills. In this paper we describe a novel approach to teaching EBM which makes use of five guiding principles: (1) Journal clubs have important limitations, (2) understanding the quantitative aspects of research promotes an in-depth understanding of papers, (3) physician numeracy can form the basis of an EBM course, (4) consumers of original research ought to determine what is useful about a paper rather than whether or not it is useful, and (5) numeracy should encompass only those concepts needed to accurately interpret evidence and apply it to individual patients. An EBM curriculum based on physician numeracy is described, together with the challenges inherent to this approach.

The use of evidence-based medicine in pediatrics: past, present and future

PURPOSE OF REVIEW

Evidence-based medicine is a process that seeks to integrate the best research evidence with clinical expertise and patient values in order to optimize clinical outcomes for our patients. This article will review the benefits of and barriers to the use of evidence-based medicine in pediatrics in the twenty-first century, discuss various implementation strategies and outline the resources that pediatricians could use to increase their knowledge and skills and apply them to their clinical practice.

RECENT FINDINGS

Although physicians have generally welcomed evidence-based medicine, the benefits and limitations are often debated, and studies reveal that physicians feel that practicing evidence-based medicine could be difficult in a busy clinical practice because they lack the time, knowledge and resources. There have been many recent developments to help pediatricians overcome these barriers and to use best evidence in their practice.

SUMMARY

Pediatricians must be able to use the evidence-based medicine process to identify, access, apply and integrate new knowledge into their practice to provide high-quality care for their patients. The resources discussed in this review will help pediatricians make clinical decisions about patient care that are based on the best, most current, valid, and relevant evidence available.