Evidence-Based Medicine Training in Undergraduate Medical Education: A Review and Critique of the Literature Published 20062011

Maggio, Lauren A. MS(LIS), MA; Tannery, Nancy H. MLS; Chen, H. Carrie MD, MSEd; Cate, Olle ten PhD; O’Brien, Bridget PhD

Academic Medicine:
doi: 10.1097/ACM.0b013e3182951959

Purpose: To characterize recent evidence-based medicine (EBM) educational interventions for medical students and suggest future directions for EBM education.

Method: The authors searched the MEDLINE, Scopus, Educational Resource Information Center, and Evidence-Based Medicine Reviews databases for English-language articles published between 2006 and 2011 that featured medical students and interventions addressing multiple EBM skills. They extracted data on learner and instructor characteristics, educational settings, teaching methods, and EBM skills covered.

Results: The 20 included articles described interventions delivered in 12 countries in classroom (75%), clinic (25%), and/or online (20%) environments. The majority (60%) focused on clinical students, whereas 30% targeted preclinical students and 10% included both. EBM skills addressed included recognizing a knowledge gap (20%), asking a clinical question (90%), searching for information (90%), appraising information (85%), applying information (65%), and evaluating practice change (5%). Physicians were most often identified as instructors (60%); co-teachers included librarians (20%), allied health professionals (10%), and faculty from other disciplines (10%). Many studies (60%) included interventions at multiple points during one year, but none were longitudinal across students’ tenures. Teaching methods varied. Intervention efficacy could not be determined.

Conclusions: Settings, learner levels and instructors, teaching methods, and covered skills differed across interventions. Authors writing about EBM interventions should include detailed descriptions and employ more rigorous research methods to allow others to draw conclusions about efficacy. When designing EBM interventions, educators should consider trends in medical education (e.g., online learning, interprofessional education) and in health care (e.g., patient-centered care, electronic health records).

Author Information

Ms. Maggio is director of research and instruction, Lane Medical Library, Stanford University School of Medicine, Stanford, California.

Ms. Tannery is senior associate director, Health Sciences Library System, University of Pittsburgh, Pittsburgh, Pennsylvania.

Dr. Chen is professor of clinical pediatrics, Department of Pediatrics, University of California, San Francisco, School of Medicine, San Francisco, California.

Dr. ten Cate is professor of medical education and director, Center for Research and Development of Education, University Medical Center Utrecht, Utrecht, the Netherlands, and adjunct professor, Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California.

Dr. O’Brien is assistant professor of medicine, Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California.

Correspondence should be addressed to Ms. Maggio, Stanford University School of Medicine, 300 Pasteur Dr., Room L-109, Stanford, CA 94035; telephone: (650) 725-5493; e-mail: lmaggio@stanford.edu.

Article Outline

Although evidence-based medicine (EBM) has been included in undergraduate medical education (UGME) for more than 20 years,1 many physicians and residents lack the knowledge and skills to incorporate evidence into practice.2 EBM is the judicious use of the best current evidence in making decisions about the care of individual patients3 and has been linked to reduction of medical errors, promotion of individualized care, and increased application of best practices.4,5 Since the concept of EBM was introduced in 1991,5 it has been adopted by medical schools worldwide. Competence in EBM (also known as evidence-based practice) is now required by many health profession organizations for licensing and certification purposes.6

Today most medical schools include EBM in their curricula,6,7 but its implementation is not standardized.8–10 For example, EBM may be introduced in the first year at one institution11 but in the final six weeks at another.7 It is taught using a wide variety of methods and settings, ranging from online instruction8 to bedside teaching.12 Furthermore, while many institutions focus on some combination of the traditionally defined steps of EBM—formulating a clinical question, searching the literature, critically appraising found literature, and applying evidence to patient care13—they stress certain domains and pay less attention to others.14

We conducted this literature review to characterize educational initiatives targeting the improvement of medical students’ EBM skills. After our preliminary review of PubMed citations dating back to the early 1990s revealed rapid advances in technology that have modified the practice and teaching of EBM, we decided to focus on studies published from 2006 to 2011 in order to present examples of EBM interventions relevant to the current educational environment. We limited the review to interventions at the UGME level to explore how physicians first acquire basic EBM skills. After providing an overview of UGME interventions, we suggest future directions for EBM in the contexts of medical education and health care based on our findings and our experience with EBM education.

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Search strategy and data sources

Using published search strategy guidelines,15 one of us (L.M., a medical librarian) searched the MEDLINE (via PubMed), Scopus, Educational Resource Information Center (ERIC), and Evidence-Based Medicine Reviews databases using a combination of National Library of Medicine medical subject headings and key word variants, including evidence-based medicine; EBM; evidence-based practice; EBP; students, medical; education, medical, undergraduate; education; training; teaching; curriculum; and workshops. The initial searches were run on November 17, 2011, and were limited to English-language articles focusing on UGME published since January 1, 2006. These searches were rerun on June 6, 2012, to capture articles published through the end of 2011. To ensure comprehensive retrieval, L.M. cross-checked the database searches by hand-searching relevant medical education journals (Academic Medicine, Teaching and Learning in Medicine, Medical Teacher, Medical Education) and the reference lists of all papers selected for full-text review. (The full search strategies are available from L.M. on request.)

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Inclusion and exclusion criteria

We considered studies that included (a) medical students, defined as students in MD training programs, and (b) an EBM educational intervention, defined broadly as instruction designed to improve students’ understanding of EBM and to enhance their EBM skills. We excluded studies that only focused on a single EBM skill (e.g., literature searching) because we felt such interventions were narrow in scope and did not address EBM holistically. We also excluded studies that only evaluated existing EBM knowledge, skills, or attitudes, as they did not feature an intervention. In the two instances in which an intervention was described in multiple articles, we selected the article that provided the most complete description for analysis7,16 and excluded the other.

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Title and abstract review

Two of us (L.M., N.T.) independently reviewed all titles and abstracts of articles identified through the database searches to select studies for full-text review. If these authors disagreed on an article’s eligibility, the article was included in the set for full-text review.

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Data extraction and full-text review

To facilitate our full-text review of articles, we created a modified version of the Best Evidence in Medical Education (BEME) data extraction tool for systematic reviews.17 This was available to all of us online via the Qualtrics18 survey tool and enabled us to collect information on

* educational settings (classroom, clinical, online),

* study participants: instructor type (e.g., physician, librarian) and learner level (preclinical, clinical, both),

* EBM skills covered (four traditional steps13 plus recognizing a knowledge gap and evaluating the change in practice), and

* teaching methods used.

We defined classroom settings as traditional classrooms, conference rooms, ward-based team rooms, lecture halls, and computer labs. We defined clinical settings as environments within the context of clinical care (e.g., bedside rounds).

To evaluate the quality of the EBM interventions, we used Kirkpatrick’s19 hierarchy, which describes the impact of a training intervention based on the level of learning achieved. To characterize teaching methods, we used Khan and Coomarasamy’s20 hierarchy of EBM teaching and learning methods, which describes three levels of interactivity and integration with clinical activities.

Two of us independently reviewed the full text of each article: L.M. reviewed all articles, whereas the rest of us (N.T., B.O., O.t.C., C.C.) each reviewed a quarter of the total articles. We completed our reviews using the data extraction tool. Any differences in data extraction were resolved through discussion between L.M. and the other author who reviewed the relevant article.

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Data synthesis and analysis

We used Qualtrics18 to generate summary reports and descriptive statistics to characterize the educational interventions. Through this process, we determined that, because of the lack of rigor in the study design and methodology of the included articles, it was not possible to draw conclusions about the effectiveness of the interventions. Therefore, we excluded classification by Kirkpatrick’s19 hierarchy from our analysis.

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Our database and hand searches identified 357 articles. After excluding duplicates, we reviewed the titles and abstracts of the remaining 217 articles and determined that 34 studies met criteria for full-text review. Fourteen were excluded following full-text review, leaving us a final sample of 20 articles7–10,16,21–35 (see Figure 1 and Appendix 1).

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Educational settings

These 20 studies presented a global sample of interventions and included 7 (35%) from the United States, 2 (10%) each from the United Kingdom and Thailand, and 1 (5%) each from Australia, China, Czech Republic, Iran, Japan, Jordan, Malaysia, Nigeria, and Pakistan. All described an EBM educational intervention at a single institution, with the exception of one30 that included two institutions in the United Kingdom.

EBM instruction was delivered in classroom, clinical, and online environments, or a combination of settings. Most interventions (n = 15; 75%) included classroom instruction, whereas 8 (40%) involved clinical settings (e.g., bedside rounds). Three interventions (15%) included online environments; one of these was completely online.30

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Study participants
Learner levels.

Interventions targeted medical students at all years of study. Six interventions (30%) were aimed at preclinical students, whereas 12 (60%) focused specifically on clinical students. Two (10%) of the interventions16,35 included both preclinical and clinical students, and 1 (5%) included clinical, nursing, and pharmacy students.25

Seven (58%) of the 12 interventions focused on clinical students were integrated into clerkships. Five studies named specific clerkships—pediatrics,7,27,28 family medicine,32 and internal medicine31—whereas 2 studies8,33 indicated that EBM interventions were implemented across all clerkships. The other 5 clinical-level interventions were stand-alone courses or workshops.

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We were not able to determine the instructor’s profession from the descriptions provided in 8 (40%) of the included studies, including the online-only intervention.30 All 12 (60%) of the articles that provided this information identified physicians as instructors, and more than half of these interventions (n = 7) also included collaborating librarians,21,26,28,32 medical educators,35 business school faculty,29 or nurses and pharmacists.25 Residents served as instructors in 1 intervention.7 Six (30%) of the included studies described faculty development initiatives related to the EBM intervention, ranging from faculty being provided the workshop materials that would be distributed to the students34 to a half-day EBM workshop.33

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EBM skills addressed

Each study described an intervention that addressed a combination of EBM skills: recognizing a knowledge gap (n = 4; 20%), asking a clinical question (n = 18; 90%), searching for literature (n = 18; 90%), appraising evidence (n = 17; 85%), applying evidence to patient care (n = 13; 65%), and evaluating the change in practice (n = 1; 5%).

Although none of the interventions addressed all six skills, 5 (25%) covered five skills. Four of these—such as the intervention for preclinical students described by Nieman et al26 that included a two-hour workshop and the completion of EBM assignments during preclinical preceptorship activities—did not address the skill of evaluating changes in practice. Although Liabsuetrakul et al10 did address evaluating changes in practice in the longitudinal classroom-based EBM course they implemented across two years of their institution’s curriculum, they did not include activities related to recognizing knowledge gaps. Eleven (55%) interventions addressed the four traditional EBM steps introduced by Strauss13: ask, acquire, appraise, and apply.

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Teaching methods

Five (25%) of the articles described a one-time educational intervention, such as a three-hour workshop designed to improve clerkship students’ clinical question formulation and literature search skills.31 Twelve (60%) included a series of interventions occurring over a single year. For example, Aronoff et al8 described a yearlong EBM course that included several sessions delivered concurrently with the first clinical year. None of the studies included longitudinal EBM curricula taught across the student’s entire tenure, but 3 (15%) described interventions implemented across more than one year.10,16,35 For example, West et al16 reported on a formal EBM curriculum that students begin in their second preclinical year and conclude in their third clinical year. We identified only one other intervention35 that trained students at both the preclinical and clinical levels.

Using Khan and Coomarasamy’s20 three-level hierarchy of EBM teaching and learning methods, we determined that 8 (40%) of the 20 interventions used level 1 (interactive, clinically integrated), 8 (40%) used level 2 (interactive, classroom-based or didactic, but clinically integrated), and 4 (20%) used level 3 (didactic, classroom-based, or stand-alone) methods. Aronoff and colleagues8 provided an example of level 1 methods in their description of a multipart EBM course that included online instructional modules and formalized activities generated from students’ formulating their own clinical questions based on their clerkship experiences.

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Physicians’ failure to engage in EBM has repercussions for the health of individuals and populations.4,5 It is therefore essential that medical students receive foundational training in EBM. To provide medical educators with an overview of current EBM training, which has become a common topic covered in medical education,36 we reviewed 20 recent studies describing a range of educational interventions taught in a variety of settings and aimed at students at all levels of UGME. Among these interventions, we identified an emphasis on the skills of forming clinical questions, searching the literature, and appraising evidence critically. Our findings suggest there is a need for broader, more comprehensive EBM training, especially in the domains of recognizing a knowledge gap and evaluating changes in practice.

As the reviewed studies lacked robust outcome measures, it was not possible to determine the efficacy of interventions. Therefore, we consider our findings within the broader contexts of UGME and health care. Then, on the basis of evidence from the reviewed literature and our professional experience—as a physician, as medical educators, and as medical librarians—we offer recommendations for modifying current EBM training.

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Implications and recommendations for UGME
Timing of EBM instruction.

There is little evidence as to the most efficacious timing for EBM instruction.37 Yet, our review confirms earlier findings that most EBM educational interventions take place in the clinical years of medical school.38,39 This timing is generally based on the rationale that the clerkship setting enhances the clinical relevance of the training.40 However, the trend toward providing students with early clinical experiences41 may provide opportunities for introducing EBM earlier, in the context of patient care in the preclinical years. For example, one study demonstrated that first-year medical students who received EBM training prior to a primary care preclinical preceptorship reported increases in self-efficacy and a likelihood that they will continue to use EBM.26 We suggest that medical educators consider integrating EBM instruction into early clinical experiences, as doing so may increase students’ self-efficacy and provide a framework that helps students deal with the uncertainty of being new to the clinical setting.

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Longitudinal EBM training.

Although multiple exposures to EBM training were common in the studies reviewed, longitudinal curricula were lacking. In 75% of the included interventions, medical students received EBM training on more than one occasion, a practice that has been linked generally with increased learning.42 Yet most of the interventions were delivered over short, intensive time periods. The compressed nature of these learning opportunities limits medical educators’ ability to successively build EBM skills across levels of student development. In a spiral curriculum43—a format that has been adopted to teach some components of medical education—learners are provided multiple, successive exposures to a concept at different levels of their development so that each encounter builds on the previous encounter.44 We suggest that integrating EBM training as a spiral curriculum across all levels of UGME may be an effective model.

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Interprofessional approach.

We identified only one intervention that included both medical students and learners from other health professions.25 Given the trend in medical education toward recommending the use of interprofessional education (IPE)45 and the adoption of evidence-based practice by a spectrum of allied health professions, we encourage medical educators to consider taking an IPE approach to EBM instruction. Teaching EBM in an IPE environment could expand students’ exposure to a variety of discipline-specific, evidence-based resources and provide them with insight into the ways in which learners and professionals in other fields cope with uncertainty.

Related to IPE, we found several interventions that were taught by both physicians and instructors from other disciplines. Some included medical librarians, whose participation has been shown to add authenticity to EBM training.28 Of note, one intervention29 reached beyond the medical school’s resources to integrate business school faculty, who shared their expertise in change management techniques and organizational behavior. We recommend that medical educators consider including instructors from a variety of disciplines and think beyond the classroom setting when integrating multidisciplinary teachers. For example, all of the interventions that involved medical librarians as instructors were set in classrooms. A classroom-based approach, however, does not enable clinical librarians, who have been working at the point of care for over 30 years,46 to demonstrate real-time information retrieval and interprofessional collaboration.

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Active and online learning environments.

Recently, Prober and Heath47 declared, “It’s time to change the way we educate doctors,” and advocated a shift from a lecture-based format to an active learning approach that blends online learning with more-interactive classroom activities, such as case studies.47 We found that EBM interventions for medical students are already using interactive teaching methods and online learning. Three interventions28,30,32 employed an online format to decompress classroom time, extend the reach of strained faculty resources, mitigate scheduling difficulties, and/or reach students at diffuse clinical sites. As online instruction—which has been shown to be as effective as in-person instruction for EBM32,48—continues to evolve, we suggest that educators look for opportunities to increase the use of online components in EBM curricula.

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Gaps in knowledge.

Finally, medical educators have dedicated much attention to the physician’s ability to self-monitor, that is, to recognize the limitations of one’s skill and knowledge to act in a specific situation.49,50 In the context of EBM, this self-monitoring connects with the practitioner’s ability to recognize gaps in his or her knowledge, which has been dubbed “step zero” in evidence-based practice.51 Being able to identify awareness of a knowledge gap is critical, as doing so acts as the fuel that ignites the EBM process and prompts the physician to ask clinical questions and proceed through the subsequent steps. Yet, whereas 90% of reviewed interventions addressed the mechanics of asking a clinical question, only 20% addressed the necessary precursor of identifying knowledge gaps. For example, one intervention26 challenged students to identify and record at least four knowledge gaps generated by encounters with patients. On the basis of our review findings, and research showing that physicians tend to be weak in recognizing when they have clinical questions,52 we suggest that all EBM training should cover the essential skill of recognizing a knowledge gap.

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Implications for health care and related recommendations
Patient-centered care.

In the Patient Protection and Affordable Care Act of 2010, the United States committed funding to support patients and clinicians in making shared, evidence-based decisions.53 Although a handful of included interventions7,8,16,28,29,33 required students to generate clinical questions based on their patient encounters and contemplate how they might apply evidence to patients’ care, none included training on discussing evidence with patients. We suggest that medical educators consider how to provide opportunities for students to engage in sharing evidence with patients to facilitate decision-making activities.

The related scenario of the patient as the bearer of evidence was also absent from the reviewed interventions. Recent research has demonstrated that physicians “experience considerable anxiety in response to patients bringing information from the internet to a consultation,”54 which suggests that this is an area ripe for improvement. As it is probable that patients will increasingly bring information to appointments, we recommend that medical educators train students to evaluate the evidence retrieved by patients and to engage in productive conversations in which the student and patient can reflect on the information and, if appropriate, integrate it into the patient’s care.

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Electronic health records.

Although all of the reviewed interventions included instruction on how to search the literature using traditional resources (e.g., PubMed), none addressed how to access information via electronic health records (EHRs). EHRs are becoming increasingly prevalent in medical practice, and their capabilities are improving with regard to delivering information and prompting clinical questions within the workflow via alerts and “infobuttons.”55 Educators therefore need to ensure that EBM training accommodates these evolving resources. For example, they may need to shift emphasis from PubMed search skills to information management skills, such that students learn to manage or triage point-of-care information presented within EHRs. Additionally, educators should seize the opportunity to use EHRs to facilitate EBM teaching. For example, students could be asked to summarize any information they consulted in caring for a patient and attach the summary to the patient’s EHR. This would provide students with authentic EBM opportunities and also broaden the evidence base of all health professionals who interact with the patient’s EHR.

The increasing use of EHRs may also expand the types of available evidence. Recently, a physician team at Stanford was temporarily stymied by the lack of published evidence related to the treatment of a complicated pediatric case. However, by querying the EHR system, they identified a cohort of similar patients and analyzed outcomes data to make an informed treatment decision.56 Although this is currently considered a “novel” process, such use of EHR data is likely to become increasingly prevalent. We therefore recommend that medical educators expand the coverage of searching the biomedical literature to include querying EHRs.

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This review must be considered in the context of its limitations. We only captured descriptions of UGME interventions that targeted multiple EBM skills and were published during 2006–2011. It is also possible that there are institutions that have robust EBM education programs but have not published studies on these programs. Further, we were not able to judge the strength of the interventions and make recommendations accordingly.

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Given the importance of EBM to providing high-quality patient care and widespread application of this approach across health professions, it is surprising that UGME training programs for EBM skill development have not been well described in the literature. Better descriptions of interventions and more rigorous research methods are needed so that educators and researchers can draw conclusions about the efficacy of interventions and, if so desired, replicate them. We encourage educators to consider designing EBM interventions that are in alignment with major trends in medical education and health care, including IPE, EHRs, and patient-centered care, and publishing their findings.

Acknowledgments: The authors wish to thank Dr. David Irby for his feedback on an earlier version of the manuscript and Ms. Olya Gary for her assistance with the search strategy figure.

Funding/Support: None.

Other disclosures: None.

Ethical approval: Not applicable.

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