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Challenges to Learning Evidence-Based Medicine and Educational Approaches to Meet These Challenges

A Qualitative Study of Selected EBM Curricula in U.S. and Canadian Medical Schools

Maggio, Lauren A. MS(LIS); ten Cate, Olle PhD; Chen, H. Carrie MD, MSEd; Irby, David M. PhD; O’Brien, Bridget C. PhD

Author Information
doi: 10.1097/ACM.0000000000000814
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Abstract

In the last 20 years, evidence-based medicine (EBM) has become a standard component of the medical school curriculum.1 Despite this ubiquitous inclusion, physicians’ practice of EBM is suboptimal,2–4 which has implications for patient safety, cost-effectiveness, and consistency of care.5,6 The suboptimal practice of EBM has prompted researchers to explore challenges to physicians practicing, clinician educators teaching, and students learning EBM.

In research on barriers to practicing EBM in clinical settings, the challenges reported by physicians have included a lack of time, conflicts between evidence-based recommendations and patient preferences, and weak available evidence.4,7,8 Additionally, EBM instructors have described barriers to teaching EBM in clinical care. These barriers include a lack of time for teaching EBM, an absence of EBM requirements for trainees, and their own, as well as trainees’, lack of EBM knowledge and skills.8 On the basis of these studies, researchers have suggested that the challenges reported by physicians and EBM instructors be considered when designing EBM curricula, as they may have implications for student learning. For example, if physicians are challenged by time constraints and fail to practice EBM, then students may have limited exposure to optimal EBM role models, which could impact their learning experiences. Although research on these barriers may inform student training, it does not directly examine the challenges medical students may face when learning EBM, which may differ and contribute to the suboptimal practice of EBM.

Research on challenges to students learning EBM is limited and focused on training in clerkship settings. For example, two studies found that the challenges to learning EBM in clerkships included receiving minimal support from clinical teachers for using EBM and limited opportunities for practicing EBM.9,10 Knowledge of the EBM learning challenges faced in clerkships is important but narrow in scope, as EBM training can be offered across all years of medical school.11 Researchers have also studied barriers that faculty perceive in implementing EBM curricula.12–14 However, these studies focus on barriers to the delivery of EBM curricula such as lack of curricular time.13

Our study aims to identify learner-centered challenges that medical students face across medical schools when learning EBM. With these challenges identified, we then explore potential solutions by examining the educational approaches used by medical schools to overcome them. Thus, our study aims to identify and describe educational approaches for teaching EBM used by medical schools whose graduating students feel confident in their EBM abilities to provide medical educators with potential strategies to inform the design of their EBM curricula.

Method

We conducted a qualitative multi-institutional case study between December 2013 and July 2014. We selected this approach to gather in-depth information about how medical schools teach EBM and the challenges they perceive students face in learning EBM. The Stanford University Institutional Review Board deemed this study exempt.

We used purposive criterion sampling15 of medical school curricular deans. To generate the sample, L.A.M. requested the names of 22 Liaison Committee on Medical Education–accredited medical schools in the United States (n = 17) and Canada (n = 5) from the Association of American Medical Colleges, based on 2012 Medical School Graduation Questionnaire data.16 U.S. schools were selected if more than 50% of graduating students expressed confidence in their basic skills in clinical decision making and applying evidence-based information to medical practice. Canadian schools were selected if more than 25% of graduating students felt confident they had the knowledge and skill to incorporate evidence-informed decision making into patient care. We selected this sample based on the premise that institutions graduating students satisfied with their EBM abilities may have noteworthy educational approaches for teaching EBM. None of us were affiliated with the institutions included in the sample.

Via e-mail, L.A.M. invited the curricular dean from each institution to be interviewed or, if appropriate, to forward the invitation to the individual they believed was most knowledgeable about EBM instruction at their institution. Deans received up to three reminders, and if they still did not respond, L.A.M. searched the institution’s Web site to identify faculty involved in EBM and contacted them directly. If this second strategy failed, the institution was excluded. During the interviews, several participants recommended contacting other individuals involved in EBM at their institutions; L.A.M. invited those individuals to be interviewed as well. We chose to interview faculty instead of students because they would be most knowledgeable about the design and delivery of the EBM curriculum. Additionally, we felt that over time faculty would have observed how students experienced EBM learning challenges and how their institution’s curriculum may or may not have helped students overcome those challenges.

Using a semistructured interview protocol, L.A.M. interviewed all participants via telephone in January and February 2014. Participants were e-mailed the protocol 48 hours prior to the interview. The protocol asked the participants to describe their institution’s approach to designing the EBM curriculum that their 2012 graduates would have experienced and to identify elements of learning EBM that students find challenging and how their curriculum addresses these challenges (Appendix 1). The protocol design was based on the biomedical literature and our contributions as a multidisciplinary group of authors, including educators, physicians, and a librarian familiar with EBM. The interview protocol was pilot tested with EBM instructors at two U.S. MD-granting medical schools not included in our sample. Minimal refinements were made based on pilot and our own feedback. All interviews were audio-recorded and transcribed. L.A.M. deidentified the transcripts prior to analysis. Before the interview and, if necessary, at its conclusion, participants were asked to submit EBM curricular materials, such as syllabi, slides, and assignments.

Our study used an inductive approach to data analysis in an attempt to keep our findings consistent with what participants said regarding student EBM learning challenges and educational approaches to overcoming these challenges. To begin, L.A.M. and B.O’B. familiarized themselves with all transcripts by reading them multiple times. During this process, we identified preliminary common EBM learning challenges, which we captured in brief analytic memos to facilitate discussions.17 Following discussions based on the transcripts, analytic memos, and collected EBM curricular materials, L.A.M. created profiles of each institution’s EBM curriculum. The profiles included a working list of educational approaches (derived from the transcripts) that potentially addressed the identified EBM learning challenges. Participant transcripts, institutional profiles, and the working list of educational approaches were shared with B.O’B. and H.C.C. to independently revise and, if appropriate, confirm the learning challenges and educational approaches identified. B.O’B. and H.C.C. each reviewed six institutions, and L.A.M. reviewed all 17 institutions. We met to review the materials and reached a consensus via discussion on the identified learning challenges and educational approaches.

Results

We interviewed 31 EBM instructors from 17/22 (77%) medical schools in the United States (n = 13) and Canada (n = 4). Five schools in our sample were not included because of a lack of response. Although initially designed to focus on curricular deans, 13 deans referred us to other educators. Overall, we interviewed clinicians (n = 17; 4 of which were curricular deans), librarians (n = 11), educationalists (n = 2), and an epidemiologist (n = 1). Thirteen institutions shared EBM curricular materials, including syllabi, slides, and assignment guides. Where possible, we include participant quotes, which we selected for their appropriateness and, as much as possible, from various institutions. Each quote is identified by a letter code (e.g., “D”) that corresponds to a participating institution; letter codes were randomly assigned during our analysis.

EBM learning challenges

Although these institutions graduated students confident in their abilities to practice EBM, participants reported that their students face a variety of challenges when learning EBM. Participants spoke of a variety of EBM learning challenges; however, on the basis of our analysis we identified four common challenges that were prevalent across the institutions: suboptimal role models, students’ lack of willingness to admit uncertainty, a lack of clinical context, and students’ difficulty mastering EBM skills.

Suboptimal role models were the most frequently identified challenge to students learning EBM. Participants were concerned that because of role models exhibiting poor attitudes toward EBM, weak EBM skills, and a disinclination to make explicit their “invisible EBM process” (D), students experienced a disconnect between what they were being taught in the EBM curriculum and what they were witnessing in clinical settings. Participants underscored the need for optimal faculty role modeling of EBM and expressed an overwhelming concern that students’ EBM training could be readily “extinguished” (I) if learners failed to see EBM practiced.

Participants also reported students’ lack of willingness to admit uncertainty as a challenge. They felt that this caused learners to avoid EBM, which requires as its first steps recognizing and articulating uncertainty as a clinical question. Some participants felt that students’ lack of willingness to admit uncertainty was reinforced by faculty not explicitly role modeling EBM and, in particular, by faculty not voicing their own uncertainty in clinical care.

It’s a rare teacher who is verbalizing everything they’re thinking. It’s a rare teacher who will say, “I don’t really know why we do what we do” or “I don’t know what to do here.” (E)

Several participants identified a lack of clinical context as an EBM learning challenge, especially in the preclinical years. They felt that without clinical context, students struggled to view EBM as equally important to other content and noted that students failed to appreciate the relevance of EBM to the practice of medicine.

I teach EBM in the first week of medical school, which makes it hard because [students] don’t understand why they should care about it yet. (D)

Several participants also mentioned students’ difficulty mastering EBM skills as a challenge. They identified all core EBM skills as challenging, especially the application of evidence to patient care, and felt that students struggled to use evidence when making patient care decisions.

So one of the challenges in evidence-based medicine that I see all the time, whether I’m with residents or with students, is this whole ability to apply evidence. It’s hard for them. (C)

Educational approaches to overcome EBM learning challenges

Institutions used a variety of educational approaches to overcome these EBM learning challenges; however, through our analysis we identified five educational approaches that were common across the participating institutions: integrating EBM with other courses and content, incorporating clinical content into EBM training, EBM faculty development, EBM whole-task exercises, and longitudinal integration of EBM. In some instances, multiple approaches were used to address the four common EBM learning challenges (see Table 1).

Table 1
Table 1:
Educational Approaches Used to Overcome Evidence-Based Medicine (EBM) Learning Challengesa

Integrating EBM with other courses and content.

EBM was generally not taught as a stand-alone course. Frequently, EBM was integrated into other curricular courses and content to expose students to EBM in the context of related topics, provide opportunities to practice and master EBM skills, and increase students’ appreciation of the relevance of EBM to the practice of medicine.

We explicitly weave EBM through our other curricular themes so that it becomes the fabric of our curriculum rather than just a stand-alone course. (E)

EBM was commonly integrated into epidemiology and biostatistics courses, but was also integrated into community health, clinical exam skills, and ethics courses. For example, when teaching clinical exam skills, one institution required students to form questions about the efficacy of diagnostic maneuvers, locate relevant evidence, appraise it, and discuss the need to learn the maneuvers for future use. Integrating EBM with other courses and content created opportunities for subject matter experts like epidemiologists to role model EBM skills, potentially counterbalancing the suboptimal role models students may observe in practice. Many institutions integrated EBM with problem-based learning (PBL) sessions, with several schools introducing EBM within the context of PBL clinical cases, providing students with a clinical context for EBM. Participants also noted that integration with PBL provided students ongoing opportunities to pose questions, increasing their comfort with uncertainty.

EBM was also integrated into clerkships, which helped place students’ EBM experiences in a clinical context. Clerkship integration often focused on applying EBM skills to assignments that required students to identify a clinical question based on a patient and undertake the remaining EBM steps. Several institutions also included student-run EBM journal clubs in clerkships. Most institutions integrated EBM into a single clerkship, but in some cases EBM was featured in several clerkships, commonly internal medicine, family medicine, and/or pediatrics. One institution incorporated EBM into eight clerkships. This institution used an online EBM education prescription tool, which captured clinical questions, coached learners through the EBM process, and provided a structured interface for instructors to evaluate student submissions. To prepare students for the clinical workplace and ensure the transfer of skills learned in the preclinical years, EBM was often integrated into transition-to-clerkship courses. EBM coverage in transition courses often focused on refreshing EBM skills.

Incorporating clinical content into EBM training.

Institutions often incorporated clinical content into the EBM curriculum, with many schools emphasizing efforts to present EBM in the context of individual patient problems early and often. One participant described clinical content as “candy” (G) that provided students a context for learning EBM; it raised interest levels and increased the relevance of EBM training. Clinical content generally took the form of patient cases and/or patient-based examples delivered orally, on paper, and/or via video that were often integrated into EBM lectures, small-group discussions, and assignments. Several institutions also provided learners with exposure to physicians who were optimal role models in their approaches to EBM. These exposures often took the form of the “EBM rock stars” (J) of an institution presenting in-person and/or video-recorded clinical cases based on their own practice and describing how they would practice EBM within the context of the case. Because of students’ varied levels of clinical exposure and background knowledge, as well as a desire to incorporate clinical content early, institutions were mindful of how EBM was introduced, with the majority of schools using a simple to complex approach. Participants described providing novices with straightforward patient cases dealing with a single, familiar condition that had been previously addressed in the curriculum or that was under current discussion in other courses. As students progressed, instructors incrementally increased the complexity of the clinical content.

EBM faculty development.

EBM faculty development initiatives focused on bolstering faculty EBM skills and fostering a “cadre of faculty members that role model EBM practices in their routine care of patients” (L). Therefore, many institutions trained PBL facilitators, community preceptors, residents, fellows, and clinician educators in the hopes that optimal EBM role models would be present throughout a student’s training. Faculty development sessions generally covered core EBM skills. Several participants also described efforts to train EBM instructors to explicitly role model their EBM practice. To meet this goal, instructors were encouraged and trained to “talk out loud about their EBM thinking process” (E) to make EBM transparent to students and provide them with mental models of how a clinician might approach clinical uncertainty in practice. Additionally, faculty members were taught to encourage students to recognize uncertainty in their activities and to provide students time to pursue clinical questions to increase their comfort with uncertainty.

EBM whole-task exercises.

Most institutions had EBM training programs that included whole-task exercises. Whole-task exercises challenge students to practice all constituent parts of a complex task in an integrated fashion. In the case of EBM, the use of whole-task exercises translates to activities that start with a clinical question and include the execution of all EBM steps in a cohesive fashion, mirroring the way EBM would occur in practice, instead of practicing each EBM step separately. EBM whole-task exercises were most prevalent in clerkships where students were generally required to identify uncertainty in their practice and carry out the steps of EBM. At many institutions, students also completed EBM whole-task exercises at the preclerkship level. These exercises were generally based on written cases, or students would be asked to identify clinical questions based on their own health or the health of someone they knew. The repeated practice of EBM whole-task exercises provided multiple opportunities for students to confront uncertainty and practice EBM, increasing their comfort with uncertainty and their mastery of EBM skills.

Longitudinal integration of EBM.

Most institutions integrated EBM training longitudinally across all years of medical school; only two schools provided EBM training solely during preclinical instruction.

It’s clearly not a single encounter with the principles of EBM and then that’s it. We really cover EBM many different times throughout [students’] four years. (L)

Several participants described using a spiral curriculum design in which EBM basics were introduced early, revisited often, and increasingly made more complex as students progressed through medical school. As a longitudinal approach bridges both preclinical and clerkship experiences, it provides learners with the clinical context for practicing EBM and multiple opportunities to master EBM skills. The importance of longitudinal integration of EBM was underscored for the continuum of medical education.

I need to get medical students to a certain point with EBM. Then in residency we need to take them to the next step and then we need to reinforce it with practicing clinicians. (E)

To support the transition from undergraduate medical education to residency, two institutions provided fourth-year capstone sessions to reinforce EBM skills.

Discussion

In this study, we found that, when learning EBM skills, students are challenged by a variety of learning challenges, including suboptimal role models, their lack of willingness to admit uncertainty, a lack of clinical context, and their difficulty mastering EBM skills. These challenges expand on previously identified challenges which have been focused on the barriers to practicing and teaching EBM4,8,12–14 instead of on what makes EBM difficult for students to learn. Our learner-centric approach uncovered new challenges that may provide medical educators with additional insights into how students experience EBM training and may help guide the design of EBM curricula. To meet these EBM learning challenges, we identified five educational approaches that were common across the participating institutions, which we discuss here in light of available evidence.

Of the institutions that participated in our study, almost all of them wove EBM into other courses and content. EBM integration has been shown to improve students’ attitudes toward EBM,18 increase students’ satisfaction with EBM training,19 and raise students’ level of EBM knowledge,20 suggesting that this is a warranted approach for teaching EBM. Additionally, the integration of EBM into other courses and content may help decompress the curricular time needed to teach EBM, which has been identified as a barrier to teaching EBM.13 Also, the transition from preclinical training to workplace-based clerkships may be stressful for students, and many medical schools offer transition-to-clerkship courses to ease learners’ entry into the clinical workplace.21 Several schools integrated EBM training into such transition courses by providing skills-based sessions that revisited core EBM skills. Whereas skills-based training is a common approach in transition courses,22 researchers have also encouraged medical educators to emphasize self-directed learning approaches in transition courses.23 We did not identify any self-directed approaches offered by EBM instructors in transition courses at the schools in our sample.

Most institutions incorporated clinical content into EBM training to increase its relevance and connect EBM to clinical care. At many institutions, physicians presented clinical cases from their own experiences and described how they would practice EBM within the context of the case. This think-aloud approach is an example of supportive information that assists learners in carrying out learning tasks by assisting them in the creation of a mental model of how clinical uncertainty can be approached and how the steps of EBM can be undertaken.24

Several institutions provided EBM faculty development, which is key because faculty who receive EBM training are more likely to provide EBM instruction to trainees and encourage the application of EBM skills in practice.25 In addition to offering EBM skills training, faculty members were encouraged to explicitly act as EBM role models by exposing their uncertainty and describing their use of EBM to students. This supplement to traditional EBM faculty development is important because students regard EBM role models as major enablers to their practice of EBM.9 Although institutions trained a wide range of instructors in EBM skills, it is possible that students will still encounter suboptimal role models. Therefore, medical educators have suggested that students be trained to critically assess role models in order to select those worthy of imitation.26

Several institutions included whole-task exercises throughout their EBM curriculum to facilitate students’ mastery of EBM skills. Recently, the use of whole-task learning to teach complex tasks has become popular27 and has been applied in teaching medical topics.28 Researchers have identified that whole-task learning approaches provide learners with a holistic model of how to practice EBM and have linked these approaches to learners’ increased ability to transfer skills into practice.21,29 Whole-task learning approaches are the foundation for several instructional design approaches,30 which may be valuable for medical educators to review when designing future EBM curricula.

Most schools’ EBM training spanned both preclinical and clerkship learning to create a longitudinal experience. Several schools described the use of a spiral curriculum31—a design which has been demonstrated to be a useful model for structuring medical training32—to teach EBM longitudinally. Using this approach, learners are provided several successive presentations of EBM concepts at different levels of complexity that align with their developmental level so that each exposure builds on the previous exposure.

This study describes challenges to students learning EBM and the educational approaches used by a select sample of medical schools to overcome these challenges. Although the institutions used these educational approaches, we cannot claim that the approaches necessarily enabled the schools to overcome the EBM learning challenges we described or that the approaches are appropriate for other institutions or applicable to use with other students. However, some of the educational approaches we identified are consistent with theories of learning. For example, integrating EBM training into clinical settings aligns with situated learning theory. Situated learning theory tightly ties learning with the clinical activities the learner will experience in future practice and the context and culture in which the learning takes place.33 Additionally, the use of whole-task learning exercises aligns with instructional design principles used by several instructional models, such as the four-component instructional design model.30

In this study, we only interviewed representatives from U.S. and Canadian medical schools. Future researchers might interview a more global sample to shed light on additional learning challenges and educational approaches. We based our sample on self-reported survey data, which was the only indicator of satisfaction with EBM training available. Therefore, we cannot draw conclusions about the students’ EBM abilities or future EBM practice, which tempers our ability to recommend the identified educational approaches as best practices. Although we focused on student learning challenges, we did not interview students but instead relied on faculty members’ perceptions based on their experience of observing students over time. Future studies might directly involve students. We focused mainly on the formal EBM curriculum and less so on the informal curriculum, although aspects of the informal curriculum were identified as challenges. Future researchers might consider exploring the informal curriculum and its potential impact on students learning EBM.

Although EBM has long been a fixture in the medical school curriculum,1 students continue to face challenges when learning EBM, which may have implications for their future EBM practice. For EBM training to be successfully implemented, it is necessary for medical educators to be aware of these challenges and consider educational approaches for overcoming them. The identification of these four learner-centered EBM challenges expands on the literature on challenges in teaching and practicing EBM, and the identification of these five educational approaches to overcome these challenges provides potential strategies for medical educators that can be used to inform the design of EBM curricula.

Acknowledgments: The authors would like to thank the interview participants for their time and insights.

References

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Appendix 1

Semistructured Interview Protocol Used in a Study on Evidence-Based Medicine (EBM) Learning Challenges and Educational Approaches to Overcome These Challengesa

  1. What is your role in EBM?
  2. What do you think makes your graduates particularly confident in their ability to practice EBM and why? Please consider curricular and noncurricular factors.
  3. Please describe your approach to designing your EBM curriculum.
  4. Which elements of EBM do you feel students find challenging and how do you address these? In an ideal situation, how would you design EBM training to overcome these challenges?
  5. Is there anything else related to EBM at your institution that we have not yet addressed?

aThe authors interviewed 31 EBM educators from 17 U.S. and Canadian Liaison Committee on Medical Education–accredited medical schools in January and February 2014.

© 2016 by the Association of American Medical Colleges