Recognizing the limitations of journal clubs, many internal medicine programs are developing EBM curricula or transforming their traditional journal clubs, but few curricula have been reported.14,15
This national survey found that 37% of programs dedicate curricular time to a freestanding EBM curriculum. The 4 most commonly cited objectives exactly conform to the 4 steps in evidence based decision-making.16
This represents an advance over journal clubs, which consistently target critical appraisal but rarely focus on the other 3 steps.11,13
As adult learners, residents should thrive in curricula informed by adult learning theory.17
Learners, in this paradigm, must understand why
they need to learn something, take responsibility
for their learning, exploit their experience
as a resource, and link their readiness to learn
with the exigency of real-life situations. The characteristics of the EBM curricula in this survey reflect attention to adult learning theory in their development. In most of the curricula, residents chose the cases, which often represented real clinical scenarios involving their actual patients. The seminars were usually interactive and 58% of the time were directed or codirected by the residents. The effectiveness of this approach has been confirmed in a controlled trial.15
To efficiently practice EBM, residents need access to a range of information resources. medline
is an important resource but is limited by the predominance of basic science articles, imperfect indexing, and its complex search requirements. Furthermore, busy clinicians cannot practically identify, read, and appraise the entire literature addressing each of their questions. As a more realistic alternative, physicians can seek and apply evidence-based summaries of articles and systematic reviews.18
In one report of EBM on hospital rounds, most clinical questions were answered quickly with these resources as early options in a searching algorithm.19
Though most of the programs in this survey provided medline
, only about 30% provided Best Evidence
or the Cochrane Library
, two collections of this readily accessible information.
Thirty-six percent of the programs evaluated their curricula. In over 50% of these, residents completed an exercise involving the critical appraisal of an actual journal article or the application of scientific evidence to an individual patient. This realistic measurement of skills represents an advance over the evaluation of journal clubs, which most commonly measure surrogate outcomes such as clinical epidemiology knowledge on multiple choice examinations.11,12
In addition to measuring the impact of a curriculum on skills, evaluators must ask: are residents more frequently acquiring, appraising, and applying “the evidence” in their day-to-day practice? In this survey, only 14% of the programs that conducted an evaluation of their EBM curriculum (and 5% of the programs with established curricula) documented the residents' actual practice of EBM in clinical settings. The questionnaire lacked sufficient detail to determine the exact outcome measures they used. The reported curriculum evaluations that measured behavior relied on self-report of hours spent reading, attention to methods and results sections, preferred sources of information, or frequency of referral to original articles to answer clinical questions.11
However, retrospective self-reporting may underestimate physicians' information needs and overestimate their information-seeking behaviors.3
In a promising report, Flynn and Helwig described using audiotapes of teaching sessions to directly determine the frequency with which residents use the evidence in their practices.20
Though freestanding curricula can help residents improve their EBM skills, this format does not confront the actual logistical problems and time constraints faced by busy clinicians. Clinicians will not fully embrace EBM unless it allows them to ask and answer most of their questions at the time that they emerge in the flow of patient care. This survey confirms that many training programs have undertaken efforts to teach and exemplify EBM in established venues.
In recent years, medical educators have explored ways to accomplish this type of integrated EBM training, but little has been reported.14,21
To successfully integrate EBM teaching, programs will most likely require on-site electronic medical information and site-specific faculty development. In this survey, 31% to 64% of programs provided these elements, depending on the particular venue. Furthermore, only the 10% to 23% of programs that tracked residents' EBM behaviors will be able to determine the impact of their curricular efforts.
There are a few important limitations of this study. The response rate of 65% may not have captured a completely representative group of programs. However, the programs that failed to respond had the same proportion of university-based programs and the same geographic distribution. With the exception of the question about curriculum objectives, the remainder of the survey questions required yes/no, multiple choice, or numeric answers. With these limits, some program directors may have been constrained in attempting to describe important curricular innovations. Finally, this type of survey is susceptible to overreporting, because respondents can list what they offer without reporting on quality or effectiveness.
In conclusion, at the time of this survey, approximately one third of U.S. training programs offered freestanding EBM curricula, which commonly targeted important EBM skills, utilized the residents' actual experience, and employed an interactive seminar format. Less than one half of these, however, offered faculty development or performed an evaluation, and many failed to provide some useful medical information sources. Most programs reported efforts to integrate EBM teaching into established clinical and educational venues, but many of these attempts lacked important structural elements. As graduate medical education curricula in this area evolve, educators should focus on innovative ways to integrate EBM into the flow of patient care, with access to a broad range of information resources, and curriculum evaluation (particularly for behavioral outcomes).