Medical Residents: EBM Review and Practice

Provides general clinical search examples for practicing the EBM steps related to asking clinical questions and acquiring evidence.

EBM Definition

3 parts of EBM

EBM integrates:

  • the best available research evidence;
  • the clinician's expertise;
  • and the patient's values & preferences.

EBM in Medicine

1.    “Residency programs are now charged with integrating principles of cost awareness and health care value into medical training. Our well-received, resident-designed cost awareness curriculum for internal medicine residents explicitly links evidence-based medicine to cost consciousness in a case-based fashion. These attributes should be considered as some of the guiding principles for designing successful resident cost curricula.”

Moriates C, Soni K, Lai A, Ranji S. The value in the evidence: teaching residents to "choose wisely". JAMA Intern Med. 2013 Feb 25;173(4):308-10.

2.  “Residency curricula to promote EBM and information mastery skills show promise. A community-based internal medicine residency using a multi-component EBM intervention improved residents’ practice of EBM. Another intervention demonstrated efficacy of team mentoring in teaching EBM skills.  A family medicine residency redesigned its EBM curriculum with the introduction of resident workshops and Web-based tools and found improved resident comfort with EBM. Other interventions also demonstrate success in improving residents’ EBM skills.”

George P, Reis S, Nothnagle M. Using a learning coach to teach residents evidence-based medicine. Fam Med. 2012 May;44(5):351-5.

3.  “The benefits of an e-learning approach to teaching should be considered as a viable way in meeting these challenges, as it can support a wide range of learning activities, which are readily accessible and can be tailor-made to meet specific learning objectives. As our trial implies, e-learning teaching provides knowledge gains equivalent to that of standard classroom-based teaching. Particularly, the benefits should be considered when planning EBM curricula as it allows standardization of teaching materials and is a potential cost-effective alternative to standard lecture-based sessions.”

Hadley J, Kulier R, Zamora J, Coppus SF, Weinbrenner S, Meyerrose B, Decsi T, Horvath AR, Nagy E, Emparanza JI, Arvanitis TN, Burls A, Cabello JB, Kaczor M, Zanrei G, Pierer K, Kunz R, Wilkie V, Wall D, Mol BW, Khan KS. Effectiveness of an e-learning course in evidence-based medicine for foundation (internship) training. J R Soc Med. 2010 Jul;103(7):288-94.

Background Information

Some clinical questions, particularly in the early years of building clincial expertise during residency, can be answered or informed by using textbooks and other synthesized resources. These resources provide a quick way to determine what is known about a topic at a specific point in time. As pointed out in the quotes above, standard practices can change over time in response to new research so it is very important to stay current with the research in your field and to search journal databases for topics that are undergoing re-evaluation.

Sources for background information:

Lifecycle of Asking Clinical Questions

The 5 steps of EBM: Assess, Ask, Acquire, Appraise, and Apply

 

Assess Ask Acquire Appraise Apply

 

PICOTT: Ask Clear Complete Clinical Questions

PICO is a tool that clarifies and focuses questions that arise during a patient assessment. It identifies and organizes the key aspects of a complex patient presentation: P=Patient or Population; I=Intervention or Indicator; C=Comparison or Control (not part of all questions; O=Outcome.

Adding Type of Question and Type of Study to the PICO framework to create PICOTT reminds you that different types of study designs are used to answer different types of questions.

Parts of PICOTT

Levels of Evidence

Systematic Reviews of RCTs, RCTS, SRs of Cohort Studies, Cohort

Evidence hierarchies provide a short-cut to help you filter your searches to the most likely best evidence for the kind of question you are asking.

For prevention and treatment questions, start by searching for evidence at the top of the list, systematic reviews of randomized trials. Consider the publication date in the selection process. If the systematic review you find was published a number of years ago and found inconclusive evidence, then look for newer randomized trials as your next step. If no evidence is found at the top levels, move down the list looking for systematic reviews and then single studies of first cohort studies and then case-series or case-control studies.

Remember that all evidence must be critically appraised. A poorly conducted or reported randomized trial does not provide stronger evidence than the results of a well conducted cohort study.

Critical Appraisal

The next step in the EBM process, Appraise, is beyond the scope of this module. Here are some tools that will help you with that step.

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