Surgical Residents: EBM Review and Practice

Provides specialty based 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 Surgery

1.  ” Surgical residents are clinically busy, and academic teaching time is squeezed by a continuously increasing volume of knowledge coupled with a mandated decrease in work hours. Yet, critical appraisal cannot just be absorbed—these skills need to be taught explicitly and then reinforced during the care of specific patients. The weekly formal lecture series is one venue to integrate acquisition of these skills; however, dry lectures may not produce lasting retention. Self-directed learning alone may not be realistic for the busy surgical resident.”

Acquisition of evidence-based surgery skills in plastic surgery residency training.

Temple CL, Ross DC. J Surg Educ. 2011 May-Jun;68(3):167-71. doi: 10.1016/j.jsurg.2010.12.004. Epub 2011 Jan 15. PMID: 21481798

2.  “We suggest that successful EBM implementation at its core is about using the pre-existing cultures of surgical practice. The key aspect of EBM implementation, then, is to use culturally learnt ways of practice that manifests from one generation to the next to develop a surgical culture that includes EBM practice. By embedding EBM into clinical cultural practices, which are at the heart of surgical teaching and learning, a continuing education approach to change in practice would allow the possibility that practitioners become agents of change who initiate clinical practice transformation….

…The nature of surgical culture(s) suggests that the effective deployment of clinician and/or scientist surgeons as EBM instructors within the apprenticeship model of teaching, in combination with the expeditious use of the context-specific collegial nature of the surgical profession, are key elements in a successful EBM knowledge translation programme in surgery. Furthermore, the early integration of EBM into experientially based and culturally supported ways of learning in a surgeon's career may assist EBM uptake by individuals and surgical communities alike.”

Evidence-based medicine training and implementation in surgery: the role of surgical cultures.

Kitto S, Petrovic A, Gruen RL, Smith JA.  J Eval Clin Pract. 2011 Aug;17(4):819-26. doi: 10.1111/j.1365-2753.2010.01526.x. Epub 2010 Aug 4.   PMID: 20704631

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.”

Effectiveness of an e-learning course in evidence-based medicine for foundation (internship) training.

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.  J R Soc Med. 2010   [ul;103(7):288-94. doi: 10.1258/jrsm.2010.100036. Epub 2010 Jun 3.PMID: 20522698 [PubMed - indexed for MEDLINE] Free PMC Article

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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