The first step in using EBM is identification of a knowledge gap, followed by formulation of a clinical question. Box 2
provides a series of tips for teaching question framing skills to trainees. The traditional method of bedside teaching involves exploring trainees' knowledge and exposing any deficiencies.
Box 3. Tips for teaching question framing
- If trainees do not know the answers to questions, do not blame and shame: instead, use these knowledge gaps as learning opportunities
- Encourage trainees to use the PICO structure to formulate questions
- Select topics for question framing where you already know that good evidence exists to address the question (e.g. steroids for preterm birth, magnesium sulphate for pre-eclampsia / eclampsia)
- Frame questions in any clinical setting: ward round, outpatient clinics, delivery suite or in theatre, and use educational prescriptions as a routine part of the round
- Always close the learning loop by asking trainees to give answers to the question generated at some time in not too distant future
More compassionate teachers provide ready-made answers to fill the knowledge gaps before moving to the next patient. This makes matters worse: passive learning, or spoon-feeding of knowledge, is short term, with the information being lost soon after the ward round. How can we change this cycle of inefficient teaching and learning? Start by identifying knowledge gaps as learning opportunities. To have a lasting impact, senior clinicians should act as facilitators, encouraging trainees to learn actively. They should consciously foster a clinical environment where exposure of a knowledge gap is a cue for initiating the EBM steps outlined in Box 2
. As mentioned in the principles of adult learning theory, this should be done sensitively, so that as adult learners, the trainees see this as step towards their own professional development rather than as a judgemental or belittling exercise.
Box 2. Elements of EBM for clinical integration
- Formulating clinical questions (identifying knowledge gap)
- Tracking down the best evidence with which to answer that question (with input from clinical librarian if necessary)
- Critically appraising that evidence for its validity (closeness to the truth), impact (size of the effect), reliability (precision) and applicability (potential for improving outcomes in clinical practice)
- Integrating the findings of critical appraisal with clinical judgement taking into account clinical circumstances, choices and values of individual patients
- Bringing about change – implementing the evidence from research into practice by executing the preceding four steps and seeking ways to improve evidence-based practice through audit
The first step in evidence-based practice is to recognize that identification of a knowledge gap should lead the trainee to actively seek answers. Initiating this process is not easy. The teacher needs to help construct an answerable question, as without a clearly focused question, it is extremely difficult to find clinically useful answers to help with patient care. Questions arise regularly in busy clinical practice but they don't always get followed up because of clinical commitments or time constraints. Teachers need an approach that rapidly documents the questions and allocates it to the trainees to work on in their own time.
shows a PICO (Population, Intervention, Comparison, Outcome) structure, which is a useful tool that can be used quite easily to formulate a clearly focused clinical question. Moreover, the same tool can be used with advantage to follow the search strategy, as described in the next section.
PICO structures can be used as educational prescriptions
which can be quickly handed over to the trainees during a ward round for them to follow up when an opportunity arises. For example, post-call rounds are a rich environment for producing clinical questions but the trainees are usually too exhausted during these rounds for this type of exercise. In those circumstances educational prescriptions can be used to record the question for ‘filling’ at a later date. An educational prescription not only specifies the clinical problem that generated the question but it also states the question, in all of its key elements. It sets a time frame (taking into account the urgency of the clinical problem) and specifies who is responsible for answering it. A sample of educational prescription is available at http://www.cebm.utoronto.ca/doc/edupres.pdf