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Designing Evidence-Based Medicine Training to Optimize the Transfer of Skills From the Classroom to Clinical Practice

Applying the Four Component Instructional Design Model

Maggio, Lauren A. MS, MA; Cate, Olle ten PhD; Irby, David M. PhD; O’Brien, Bridget C. PhD

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doi: 10.1097/ACM.0000000000000769
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Abstract

Evidence-based medicine (EBM) combines a physician’s clinical experience and knowledge with the best available research findings and with the wishes of the patient.1 Important for facilitating a patient-centered approach to care2,3 and lifelong learning for physicians,4 EBM skills are taught in medical schools around the world to ensure the translation of evidence into clinical practice.5 Yet, this translation often takes place in a suboptimal environment because of a constellation of barriers, including systems factors (e.g., lack of time), attitudinal issues (e.g., negative associations with EBM), lack of skills (e.g., inability to locate evidence), and the tacit conviction that EBM may be a less effective approach to care than it was initially thought to be.6–8 Although each barrier is daunting, the reported lack of EBM skills in practice, despite the ubiquity of EBM training, may indicate a weakness in the design of such programs and may suggest that current training does not optimally enable learners to transfer EBM skills from the classroom to clinical practice. Although a variety of factors may hinder this transfer of EBM skills, we focus in this article on the structure of EBM training, which researchers have indicated may impede learners’ ability to transfer EBM knowledge and skills to clinical practice.9

Currently, no approach to teaching EBM at the undergraduate level is universally endorsed.10 However, methods that focus on teaching discrete components of EBM in various segments of the medical curriculum are common11 and have been recommended.12 We would characterize this as an atomistic approach that introduces each component EBM skill (e.g., asking clinical questions, searching for evidence, critically appraising articles) separately and then assumes that learners, after they have practiced each skill individually, are able to assemble the steps into a cohesive whole. Using such a stepwise approach, faculty members might first teach learners to formulate clinical questions and search the biomedical literature in one session, then train them to critically appraise articles a semester later, and finally require learners to put these skills together to practice the entire EBM process when delivering patient care during clerkship. However, atomistic or nonintegrated approaches to teaching complex cognitive skills have been associated with a fragmentation of learning and a lack of skill transfer,13,14 suggesting the need for a modified approach to designing EBM training to ensure the transfer of knowledge and skills to clinical practice.

To practice EBM, physicians must simultaneously integrate clinical knowledge, patient preferences, and external evidence to reach patient-centered decisions. This process makes EBM a complex task. Complex tasks generally feature multiple solutions, take many sessions of practice to master, and generally overload a learner’s cognitive system.15 They also require the execution of subskills16 including those that are consistent or recurrent from one scenario to the next (e.g., calculating a number needed to treat a patient) and those that are nonrecurrent or that vary between situations, such as applying evidence to a particular patient with a spectrum of conditions. In addition, EBM can be considered a complex cognitive task, requiring an instructional approach designed for complex learning. As one solution to the knowledge and skill transfer problem, educational scientists have suggested the use of whole-task approaches for designing such learning programs.16,17 Whole-task approaches introduce learners to the combined steps of an activity upfront and ask them to practice all of the requisite skills as a cohesive activity, with graded levels of task complexity and support that depend on the learner’s performance.17–19 One such whole-task approach is the Four Component Instructional Design (4C/ID) model.

We propose the use of the 4C/ID model to guide the design of EBM training. It is based on psychological theories of learning and information processing, including cognitive load theory.20 The advantage of the 4C/ID model over other whole-task approaches is that it supports whole-task learning with mental models to enhance skill transfer for nonrecurrent tasks and includes procedural knowledge and repetitive part-task practice to facilitate recurrent task learning (for a discussion of other whole-task approaches, see Merrill17). In this sense, the 4C/ID approach is a hybrid or blended model of both whole- and part-task instructional design. Unlike other educational approaches, part-task practice in the 4C/ID model is only recommended for learners who have already been acquainted with the whole task.

In this article, we describe the 4C/ID model and the benefits of its four components to guide the design of EBM training and to improve the transfer of EBM skills learned in the classroom to clinical practice. We include illustrative examples of each component, derived from a recent study by Maggio et al10 and our experiences teaching EBM, to demonstrate the feasibility of this approach.

The 4C/ID Model

The 4C/ID model has been successfully applied in primary and higher education16 and recently was adopted in medical education to teach the complex skill of communication.21 Some have suggested that it be adopted more broadly.22 It includes four components: learning tasks, supportive information, procedural information, and part-task practice.20 Together, these four components guide the creation of a training program that is designed to avoid overloading the learner’s cognitive abilities; to integrate the knowledge, skills, and attitudes needed to execute a complex task; and to increase the transfer of knowledge to new situations.13,20

Learning tasks

In the 4C/ID model, learning tasks are primarily presented as whole-task activities in which learners practice all the parts of a complex task in an integrated fashion. For example, students may be challenged to write a clinical question based on a patient’s condition, locate a relevant article, critically appraise that article, and present the findings to the clinical team in a brief presentation. This use of whole-task learning enables the transfer of skills by providing learners with a holistic model of how to practice EBM20 such that they can use it to approach clinical uncertainty in future situations.

A curriculum guided by the 4C/ID model includes multiple whole tasks based on authentic examples that are sequenced from simple to complex with varying levels of support depending on the difficulty of the task and the level of the learner. Providing learners with multiple and varied opportunities to practice authentic whole tasks gives them a realistic understanding of the variability of practice.23 Educators can achieve authenticity and variety in the whole tasks by drawing on real-life clinical experiences.21 For example, students may be required to complete whole-task EBM exercises in each of their core clerkship rotations (i.e., to ask a clinical question and propose a therapeutic approach based on recent literature). This repetition and use of a variety of learning tasks promotes the transfer of complex skills to the variety of contexts found in real-life practice.15,20

Working memory has a limited capacity to process information, and competition arises when many pieces of information are presented simultaneously, such as in a whole-task activity24 that uses authentic examples from practice. The use of whole-task learning then poses the risk of overloading learners’ cognitive capacity.25,26 This risk can be reduced by sequencing learning tasks from simple to complex and providing task-specific information.20,27 To sequence learning tasks appropriately, educators must consider a learner’s level relative to the degree of difficulty of the whole-task content (e.g., the complexity of a patient case) and to the format of the whole task. For example, first-year medical students can practice EBM based on narrowly defined paper cases with clinical content that previously has been covered in the curriculum, whereas clerkship students might be challenged by a more multifaceted patient presenting with a less familiar diagnosis. Educators should select learning task formats most appropriate for a learner’s level. So, instead of asking novice learners to undertake authentic whole-task learning, which provides no support and is cognitively taxing,19 the learner may be presented with a partially completed solution from which to work (e.g., a completion task). This scaffolded approach should lower the learner’s cognitive burden. As learners progress, the task content and format are modified by increasing the complexity and scaling back the support built into the task format,14 until the level of the task mirrors the reality of its execution in practice. The presentation of task-specific information also helps learners cope with practicing whole tasks.19 For example, if learners are asked to critically appraise a systematic review as the component of a whole-task learning activity, they will benefit from specific information about critical review criteria and the characteristics of this publication type to successfully complete the learning activity.

Although modification of whole-task learning through sequencing and the selection of task format and content reduces learners’ cognitive load, it may not lower it enough to ensure that learners will be able to undertake whole tasks.25 Therefore, the 4C/ID model recommends the use of supportive information, procedural information, and part-task practice. The inclusion of these components further reduces cognitive load and facilitates learners’ efforts to master whole tasks, which will enable the transfer of skills from one situation to another.18

Supportive information

Supportive information is generally presented before learners undertake a learning task to help bridge what they already know about the task with what they need to know to complete it.20 Supportive information helps learners tackle nonrecurrent aspects of a learning task, such as components that require reasoning or problem solving.13,14 By studying supportive information prior to undertaking a whole task, learners create flexible cognitive schema of how to approach the nonrecurrent aspects of the whole task.25 Then when they are performing the task, the learners are able to retrieve these related cognitive schema, an activity which is less cognitively taxing than being presented with the information during task performance. Thus, their overall cognitive load is reduced.

Supportive information generally takes two forms. The first includes systematic approaches to a problem and is sometimes labeled “the theory” or background information that provides general cognitive strategies to systematically approach a problem.20 In EBM, this type of supportive information might be an online module that describes how an information database is structured or that provides examples of how to critically appraise meta-analyses. Examples of this type of supportive information, such as modules focused on critical appraisal28 and question formulation,29 are available in MedEdPORTAL.30 Unlike the fragmented presentation of EBM skills, supportive information is provided just prior to whole-task activities and is directly applied in the practice of the whole task. Educators can provide learners with supportive information in several formats—online guides, assigned textbook chapters, and prerecorded or in-person lectures.

The second type of supportive information includes descriptive mental models of how an individual might approach the nonrecurrent aspects of a problem in practice.22 This type of supportive information might include a think-aloud presentation by a physician modeling her approach to searching for evidence based on a particular patient’s clinical questions. She would provide her rationale for why she took particular actions. This presentation would offer learners one approach to completing this task, but it would not serve as the only approach or as an algorithmic approach because searching for evidence is a varying or nonrecurrent task. Therefore, learners in their own settings would need to adapt this approach to fit their practice and particular patient (i.e., not simply mimic the approach presented). The ability to generalize from a presented approach or mental model is critical for the construction of new knowledge and for adapting existing schema to a wide variety of new experiences.19 To facilitate this process, educators should provide learners with supportive information multiple times and remind them of the variability of practice, which necessitates adapting approaches to the situation at hand.

Procedural information

Procedural information enables learners to engage in the recurrent or routine elements of a complex task by using a step-by-step or rules-based approach.20 For example, educators may provide learners with a worksheet during whole-task practice that includes a step-by-step approach to creating a clinical question using the mnemonic PICO (Patient, Intervention, Comparison, Outcome). Or, educators may provide learners with a step-by-step guide to the critical appraisal of articles, such as the User’s Guide to the Medical Literature: A Manual for Evidence-Based Clinical Practice.31 With practice, this procedural information enables learners to automate or make routine their approach to this recurrent task, therefore reducing their cognitive load.

Procedural knowledge, also known as “just-in-time” information because it should be delivered to the learner only when she needs it, is generally provided the first time a task is introduced and within the context of the whole task.20,22 As learners have multiple opportunities to practice the skill and automate their approach, thus gaining proficiency, educators should decrease the amount of procedural information they give.13 For example, in an EBM session, second-year medical students may be given a detailed worksheet that guides them step-by-step though the critical appraisal of a randomized controlled trial; however, by clerkship, after several opportunities to appraise randomized controlled trials, such information should be unnecessary. Procedural information can take several formats, such as a manual, quick reference guide, instruction embedded in assignments, or online help. For example, procedural information could be included in an online guide that provides step-by-step instructions for searching information resources (i.e., how to combine Boolean operators, apply limits, etc.) to complete a required EBM assignment.

Educators also can provide procedural information by acting as “over-the-shoulder” coaches20 offering in-the-moment guidance for learners as they engage in the recurrent components of learning tasks. Educators provide this just-in-time training via both in-person and technological means. For example, students could post questions and receive answers from instructors through an online platform while completing their EBM assignments. Or, librarians could circulate in a computer lab providing learners with just-in-time assistance as they perform literature searches.

Part-task practice

The fourth component of the 4C/ID model is part-task practice, which is introduced only after learners have practiced the particular task in the context of the whole task. It allows learners to situate the part-task component within the larger whole task.32 Part-task practice is the repeated practice of a recurrent component skill that learners must automate before undertaking higher-level tasks and performing the whole task under the time demands of real-world settings.20 For example, when practicing EBM, physicians dedicate on average two minutes to literature searching.33 Therefore, part-task practice of creating search strings in PubMed with an emphasis on quickly and correctly selecting Boolean operators (and/or) may facilitate the realistic and rapid completion of a search enabling a learner to locate evidence and practice EBM in a short period of time. In some cases, part-task practice may be omitted if learners complete sufficient practice of all recurrent and nonrecurrent skills through their general practice of the whole task.

Additional Considerations

We propose the use of the 4C/ID model to guide educators’ efforts to design EBM training programs. To facilitate the use of this model, we provide examples of EBM training activities at both the preclerkship and clerkship level in Table 1. EBM training based on the 4C/ID model requires educators to consider several important factors including curricular time, the level of the learning tasks, the potential role of technology, and faculty development. Below, we discuss these issues in more detail. General guidelines for implementing whole-task and part-task learning approaches in medical education, including in a 4C/ID model, are published elsewhere.34

T1-13
Table 1:
Examples of Evidence-Based Medicine (EBM) Training Activities Based on the Four Component Instructional Design (4C/ID) Modela

Training guided by the 4C/ID model is generally undertaken over many sessions so that learners have repeated opportunities to complete the learning activities and ensure mastery. Adding additional learning activities to already packed curricula, however, is problematic. Instead, EBM learning activities might be integrated into other curricular sessions, such as quality improvement; with other educational approaches, such as problem-based learning; or into clerkship rotations. Doing so would not add additional time to the curriculum and would provide whole-task practice of EBM concepts as well as the related content. Educators might also consider using online learning activities to reduce the need for face-to-face sessions.

The important role of learner level in the sequencing of learning activities raises the concern of how to provide customized learning activities for students so that they are undertaking learning tasks at the appropriate level.20 In North America, this may be of specific concern in light of the heterogeneity of medical school classes, which may include both students with backgrounds that are more aligned with EBM, such as biostatistics, and those with backgrounds that are less aligned, like history or sociology. Adaptive e-learning may be one possible solution; it would provide learners with learning activities that intelligently adapt to their needs on the basis of their performance on previous EBM tasks.20,35 For example, an online EBM program could challenge learners to undertake a series of patient cases. As an adaptive system, it would adjust the complexity of the patient cases and the amount of procedural information shared to match each learner’s level as she progressed through the program.

Using an approach guided by the 4C/ID model would challenge educators to depart from the more traditional compartmentalized approaches to teaching EBM. For example, faculty would have to design the whole-task activities and related supportive materials. Additionally, clinical instructors should recognize that they provide procedural information when they verbally describe to their learners the processes they undertake while practicing EBM. Educators also would be required to take on the role of coach, helping learners to select tasks appropriate for their level and to provide them with formative feedback. In addition, they would need to be able to determine the correct amount of support to offer a learner and when to decrease that support.19 These new types of curricular planning tasks and pedagogical skills would require faculty development.

Conclusion

In this article, we explored the use of the 4C/ID model to teach the complex task of EBM. We examined how the four model components—learning tasks, supportive information, procedural information, and part-task practice—might be applied to EBM, as well as the potential benefits that the model’s use would bring. The 4C/ID model takes a unique approach to education by providing learners with whole-task challenges, which facilitate the transfer of knowledge and skills to clinical practice, and by supporting learners in these tasks by offering mental models for nonrecurrent tasks, and procedural knowledge and repetitive part-task practice to facilitate performance of recurrent tasks. Medical educators tasked with designing an EBM curriculum should consider adopting this unique approach.

Acknowledgments: The authors wish to thank Christy Boscardin, Carrie Chen, Karen Hauer, Patricia O’Sullivan, Arianne Tehrani, and John Young, for their thoughtful comments on earlier drafts of this article.

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