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UBC Curriculum Guidelines

EVIDENCE BASED MEDICINE (EBM) January 2003, updated June 2003

UBC Curriculum Guidelines
EVIDENCE BASED MEDICINE (EBM)
January 2003, updated June 2003
 
UBC CENTRAL FP PG CURRICULUM ADVISOR: Dr. Colleen Kirkham
DEFINITION OF EVIDENCE BASED MEDICINE:
The term “evidence-based medicine”  (EBM) was coined by a group of medical educators at McMaster in the early 1990’s. Dr. Gordon Guyatt writes: “the goal of evidence-based medicine is to be aware of the evidence on which one’s practice is based, the soundness of the evidence and the strength of inference the evidence permits. Residents are taught to develop an attitude of “enlightened skepticism” toward the application of diagnostic, therapeutic and prognostic technologies in their day-to-day management of patients” 

Practicing EBM requires skills in the following areas:
1.    Formulating a focused and answerable clinical question
2.    Awareness of important and commonly used sources of medical evidence
3.    Searching the medical literature
4.    Critical appraisal of the medical literature
5.    Basic statistical concepts for family practice
6.    Applying the evidence to your patient
7.    evaluation of one’s performance and adherence to evidence

The Evidence-based Working Group at McMaster describes EBM as a distinctive approach to patient care, involving 2 fundamental principles.

1. Evidence alone is never sufficient to make a clinical decision (Clinical decisions also include consideration of benefits and risks of an intervention, inconvenience and costs associated with various management strategies as well as patients values and wishes.)
EVIDENCE + VALUES = CLINICAL DECISION
CLINICAL JUDGMENT /EXPERIENCE 

2. EBM relies on a hierarchy of evidence to guide clinical decision making

Along with good clinical skills and strong interpersonal skills (compassion, listening and communication skills), evidence-based medicine skills are one of 3 pillars required for high quality patient care. Because of the fundamental importance of EBM skills to clinical practice, the EBM faculty feels that teaching must be regularly integrated into both clinical rotations and the academic curriculum.


UBC Department of Family Practice teachers of EBM at various sites are often also teachers of research methods and informatics. The site faculty at recent retreats (June and October 2002) have clarified the core importance of both informatics and evidence based thinking to research. There is significant overlap between the objectives, learning activities and learning outcomes for research, evidence-based medicine and informatics. The coordinated curriculum in evidence-based medicine, research and informatics will be referred to as the “ERI curriculum”. It is suggested that the following objectives and activities be linked with research/informatics objectives and activities.
 
ADDITIONAL SITE INFORMATION:  Aboriginal | City | Chilliwack | Prince George | Rural | St. Paul’s  | Victoria –should act as links to site specific curriculum objectives and schedules
1. Basic Rationale
•    The family physician is a skilled clinician.
•    The doctor-patient relationship is central to the role of the family physician.
•    The family physician is a resource to a defined practice population.
•    Family medicine is community based
2. Objectives
     CFPC Musts:
     (source: Standards for Accreditation of Residency Training Progams, CFPC, 2002. Whereas Evidence Based Medicine (EBM) teaching is not specifically described, key elements of EBM are listed in the section of this publication entitled Scholarly Activity, p. 14)
•    Quality of scholarly activity should in part be demonstrated by spirit of enquiry during clinical discussions, rounds, and conferences. Scholarship implies an in-depth understanding of basic mechanisms of normal and abnormal states, and the application of current knowledge to practice. (My emphasis – the overlying objective of EBM).
•    Organized activities: e.g journal clubs, seminars or didactic sessions, which must include biostatistics and critical appraisal. Application to practice must be promoted.
     CFPC Shoulds:
 
     UBC FP:
     (source: Site Faculty for Research retreat, June 22 and October 25, 2002)
•    to stimulate discussion and questioning of clinical practice standards in view of current evidence in the medical literature
•    to promote application of important research results to clinical practice
•    to promote key activities on a regular basis which include:
o    asking important and answerable clinical questions
o    searching for suitable sources of information to answer these questions
o    critical appraisal of the evidence for its validity and usefulness
o    implementing the results of critical appraisal in daily practice
o    self-evaluation of performance
3. Pre-requisites
     UBC:
     •    none
4. Learning Outcomes
     UBC:
     1.    The family physician is a skilled clinician.
•    To develop an understanding that the knowledge of family medicine is vast and rapidly changing and to remain skilled, physicians must become lifelong learners.
•    To learn to recognize ‘clinical uncertainty’ and ‘clinical dissonance’
•    To develop the ability to ask structured clinical questions that facilitate the use of the medical literature. (Most questions have 3 parts –the population, the intervention or exposure and the outcome)
•    To develop a scholarly strategy for seeking answers to one’s personal clinical questions
•    To become skilled in seeking answers to clinical questions in evidence based medicine sources (electronic and print) and to understand which sources to use for different clinical questions.
•    To develop an appreciation for credible data sources on the Internet and to be comfortable and competent using these resources.
•    To identify, locate and understand pre-appraised evidence summaries and evidence-based recommendations. Should be familiar with commonly used “pre-filtered summative reviews” such as the Cochrane database, ACP Journal Club, Best Evidence, UpToDate etc.
•    To become skilled and efficient in searching the medical literature using PubMed or OVID. Should be familiar with MEDLINE and other commonly used databases.
•    To become skilled in critical appraisal of the medical literature. (We suggest that residents be familiar with the “User’s Guides to the Medical Literature” series.)
1.    read and appraise articles about diagnostic tests -required
2.    read and appraise articles about therapy and prevention -required
3.    read and appraise an article about harm -suggested
4.    read and appraise an article about prognosis –suggested
5.    read and appraise a review article –required
6.    read and appraise clinical practice guidelines - required
7.    discuss whether study results are valid
•    To develop an understanding of statistical concepts and epidemiological concepts used in designing clinical research and in managing data:
1.    determine the size of treatment effects, including RRR (relative risk reduction) ARR (absolute risk reduction) and NNT (number needed to treat)
2.    determine the precision of the treatment effect through the use of CI (confidence intervals) and p values
3.    to understand the properties of a diagnostic test, including LR (likelihood ratio), sensitivity, specificity, positive predictive value and negative predictive value
4.    to understand the terms prevalence and incidence
•    To understand the hierarchy of evidence (systematic reviews of randomized trials, single randomized trials, systematic reviews of observational studies, single observational study, physiologic studies, unsystematic clinical observations)
•    To develop an understanding of the design of clinical research (such as clinical trials, observational studies (cohort and case-control), qualitative, surveys, n of 1 etc.)

 

2.    The doctor-patient relationship is central to the role of the family physician.
•    to learn how to apply evidence to individual patients in clinical practice. (Exercises done in academic curriculum will involve clinical scenarios to illustrate the role of patient and physician values, judgment and communication, as well as evidence, in clinical decision making)

3.    The family physician is a resource to a defined practice population.
•    to be skilled in effectively communicating medical evidence to patients-residents should be skilled at providing evidence to patients in a manner that respects their autonomy and empowers them to “take charge” of their own health care and make decisions in their best interest.
•    to have effective strategies for self-directed , lifelong learning
•    to practice “evidence-based” use of resources in the health care system –considering both the needs of the individual and the community
•    be able to help guide patients through their own understanding the nature and potential limitations of consumer health information. Residents should be able to describe the nature of reputable consumer websites and be able to list at least one site for their patients.
•    to learn how to evaluate and improve one’s clinical skills, knowledge and practices, by developing expertise in practice-based clinical practice audit (CPA)

4.    Family medicine is community based
•    to be aware of consumer health information that is evidence-based and be comfortable reviewing such information for patients


5. Resources
     UBC:
     •    EBM knowledgeable faculty designated at each site to coordinate curriculum (funding for this role unclear at some sites)
•    Family Practice Department and Post graduate Evidence-based medicine website http://www.familypractice.ubc.ca/indexb.html  (click on evidence-based medicine in the left-hand side bar) –includes links to the User’s Guides to the Medical Literature
•    most community practices have protected on-site access to computers with high-speed internet servers (some rural locations do not have access to high-speed internet yet)
•    EBM faculty website where teaching materials and resources will be posted (password protected)
•    each site has a small library of text books on research design, statistics, evidence-based medicine (kept by site faculty)
6. Learning Activities:
     UBC (required):
    
The prefix 1 denotes 1st year activities
The prefix 2 denotes 2nd year activities
•    1,2Self-directed study of the UBC Department of Family Practice post-graduate education evidence-based medicine web-page, and the How to do research guides (covers information on statistical concepts and research design).
•    1,2Attendance and active participation in site-specific academic curriculum ERI sessions (Evidence Based Medicine, Research, and Informatics) Note: learning activities are conducted differently at each site, generally coordinated by the Site Faculty for Research.
•    1,2Attendance and active participation in site-specific family medicine clinical seminars: family practice chart rounds, clinical improvement activities and case presentations
•    1,2Allocated time during clinical practice to use Internet  and paper resources in 'real-time' to answer specific patient related clinical questions keeping in mind the importance of evidence based information
•    1Completion of Clinical Practice Audit (CPA) project
1Communication of CPA findings with practice preceptor (whose practice was audited), and the development of practice improvement recommendations in consultation with practice preceptor
•   
1Participation in 1st year resident June peer-review evaluation activities (June/03 pilot)
•    2Completion of Resident Project. A key component of the resident project is a detailed literature search on a topic and critical appraisal of the relevant literature
•    1, 2 Future: completion of on-line EBM module
7. Evaluation:
     Evaluation will occur through the new “ERI” (Evidence-based medicine, Research, Informatics) self evaluation forms and the Clinical Practice Audit evaluation.
 
•    Satisfactory completion of the Clinical Practice Audit project.
•    satisfactory completion of the resident project (including literature search and critical appraisal)
•    Attendance and participation in site-specific academic curriculum.
•    Completion of a peer-review exercise
•    Completion of the “ERI” self-assessment as discussed in the research objectives.
•    Future: completion of on-line EBM teaching modules
WebEVAL with Central and Site Specific outcomes identified and assessed - see Evaluation Web site
 
8. Feedback:
     As this is a dynamic guideline, please feel free to provide feedback at any time to the Advisor, the Lead, and the Site Faculty for curriculum: Dr. Colleen Kirkham
 
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