Teaching residents evidence-based medicine skills

OBJECTIVES: To measure the effectiveness of an educational intervention designed to teach residents four essential evidence-based medicine (EBM) skills: question formulation, literature searching, understanding quantitative outcomes, and critical appraisal. DESIGN: Firm-based, controlled trial. SETTING: Urban public hospital. PARTICIPANTS: Fifty-five first-year internal medicine residents: 18 in the experimental group and 37 in the control group. INTERVENTION: An EBM course, taught 2 hours per week for 7 consecutive weeks by senior faculty and chief residents focusing on the four essential EBM skills. MEASUREMENTS AND MAIN RESULTS: The main outcome measure was performance on an EBM skills test that was administered four times over 11 months: at baseline and at three time points postcourse. Postcourse test 1 assessed the effectiveness of the intervention in the experimental group (primary outcome); postcourse test 2 assessed the control group after it crossed over to receive the intervention; and postcourse test 3 assessed durability. Baseline EBM skills were similar in the two groups. After receiving the EBM course, the experimental group achieved significantly higher postcourse test scores (adjusted mean difference, 21%; 95% confidence interval, 13% to 28%; P<.001). Postcourse improvements were noted in three of the four EBM skill domains (formulating questions, searching, and quantitative understanding [P<.005 for all], but not in critical appraisal skills [P=.4]). After crossing over to receive the educational intervention, the control group achieved similar improvements. Both groups sustained these improvements over 6 to 9 months of follow-up. CONCLUSIONS: A brief structured educational intervention produced substantial and durable improvements in residents’ cognitive and technical EBM skills. Presented in part at the annual meeting of the Society of General Internal Medicine, San Francisco, Calif, April 30, 1999. The Department of Medicine of Cook County Hospital provided all funding and support for this project.     

Evidence-based medicine training in internal medicine residency programs

To characterize evidence-based medicine (EBM) curricula in internal medicine residency programs, a written survey was mailed to 417 program directors of U.S. internal medicine residency programs. For programs offering a freestanding (dedicated curricular time) EBM curriculum, the survey inquired about its objectives, format, curricular time, attendance, faculty development, resources, and evaluation. All directors responded to questions regarding integrating EBM teaching into established educational venues. Of 417 program directors, 269 (65%) responded. Of these 269 programs, 99 (37%) offered a freestanding EBM curriculum. Among these, the most common objectives were performing critical appraisal (78%), searching for evidence (53%), posing a focused question (44%), and applying the evidence in decision making (35%). Although 97% of the programs provided medline, only 33% provided Best Evidence or the Cochrane Library. Evaluation was performed in 37% of the freestanding curricula. Considering all respondents, most programs reported efforts to integrate EBM teaching into established venues, including attending rounds (84%), resident report (82%), continuity clinic (76%), bedside rounds (68%), and emergency department (35%). However, only 51% to 64% of the programs provided on-site electronic information and 31% to 45% provided site-specific faculty development. One third of the training programs reported offering freestanding EBM curricula, which commonly targeted important EBM skills, utilized the residents’ experiences, and employed an interactive format. Less than one half of the curricula however, included curriculum evaluation, and many failed to provide important medical information sources. Most programs reported efforts to integrate EBM teaching, but many of these attempts lacked important structural elements.     

Teaching evidence-based medicine skills can change practice in a community hospital

OBJECTIVES: Several studies have evaluated whether evidence-based medicine (EBM) training courses can improve skills such as literature searching and critical appraisal but to date, few data exist on whether teaching EBM skills and providing evidence-based resources result in change in behavior or clinical outcomes. This study was conducted to evaluate whether a multifaceted EBM intervention consisting of teaching EBM skills and provision of electronic evidence resources changed clinical practice. DESIGN: Before/after study. SETTING: The medical inpatient units at a district general hospital. PARTICIPANTS: Thirty-five attending physicians and 12 medicine residents. INTERVENTION: A multicomponent EBM intervention was provided including an EBM training course of seven 1-hour sessions, an EBM syllabus and textbook, and provision of evidence-based resources on the hospital network. MEASUREMENTS AND MAIN RESULTS: The primary outcome of the study was the quality of evidence in support of therapies initiated for the primary diagnoses in 483 consecutive patients admitted during the month before and the month after the intervention. Patients admitted after implementation of the EBM intervention were significantly more likely to receive therapies proven to be beneficial in randomized controlled trials (62% vs 49%; P= .016). Of these trial-proven therapies, those offered after the EBM intervention were significantly more likely to be based on high-quality randomized controlled trials (95% vs 87%; P= .023). CONCLUSIONS: A multifaceted intervention designed to teach and support EBM significantly improved evidence-based practice patterns in a district general hospital.     

Introduction of evidence-based medicine into an ambulatory clinical clerkship

Evidence-based medicine (EBM) has emerged has a critical clinical competency in the 21st century. Medical schools usually introduce students to critical appraisal in the preclinical years, but there have been few evaluated interventions in teaching EBM in the clinical years. We describe a strategy to encourage students to practice EBM during a required ambulatory medicine clerkship. During this clerkship, our students are required to submit an EBM report, which is prompted by an individual case, and structured with a 5-step approach. One small-group session is devoted to modeling this approach with a case of chest pain. Using a checklist to grade 216 consecutive EBM reports, we found that students were quite successful with the exercise, achieving on average 89.6% of possible checklist points. Students who followed the structure of the exercise closely were more likely to extend their discussions beyond that required and to suggest potential further areas of investigation or design.     

Principles to consider in defining new directions in internal medicine training and certification

SGIM endorses seven principles related to current thinking about internal medicine training: 1) internal medicine requires a full three years of residency training before subspecialization; 2) internal medicine residency programs must dramatically increase support for training in the ambulatory setting and offer equivalent opportunities for training in both inpatient and outpatient medicine; 3) in settings where adequate support and time are devoted to ambulatory training, the third year of residency could offer an opportunity to develop further expertise or mastery in a specific type or setting of care; 4) further certification in specific specialties within internal medicine requires the completion of an approved fellowship program; 5) areas of mastery in internal medicine can be demonstrated through modified board certification and recertification examinations; 6) certification processes throughout internal medicine should focus increasingly on demonstration of clinical competence through adherence to validated standards of care within and across practice settings; and 7) regardless of the setting in which General Internists practice, we should unite to promote the critical role that this specialty serves in patient care.     

Outcomes of a national faculty development program in teaching skills

BACKGROUND: Awareness of the need for ambulatory care teaching skills training for clinician-educators is increasing. A recent Health Resources and Services Administration (HRSA)-funded national initiative trained 110 teams from U.S. teaching hospitals to implement local faculty development (FD) in teaching skills. OBJECTIVE: To assess the rate of successful implementation of local FD initiatives by these teams. METHODS: A prospective observational study followed the 110 teams for up to 24 months. Self-reported implementation, our outcome, was defined as the time from the training conference until the team reported that implementation of their FD project was completely accomplished. Factors associated with success were assessed using Kaplan-Meier analysis. RESULTS: The median follow-up was 18 months. Fifty-nine of the teams (54%) implemented their local FD project and subsequently trained over 1,400 faculty, of whom over 500 were community based. Teams that implemented their FD projects were more likely than those that did not to have the following attributes: met more frequently (P=.001), had less turnover (P=.01), had protected time (P=.01), rated their likelihood of success high (P=.03), had some project or institutional funding for FD (P=.03), and came from institutions with more than 75 department of medicine faculty (P=.03). The cost to the HRSA was $22,033 per successful team and $533 per faculty member trained. CONCLUSIONS: This national initiative was able to disseminate teaching skills training to large numbers of faculty at modest cost. Smaller teaching hospitals may have limited success without additional support or targeted funding.     

Managed care, attitudes, and career choices of internal medicine residents

The influence of managed care on internal medicine residents' attitudes and career choices has not yet been determined and could be substantial. In a survey of 1,390 third-year internal medicine residents, 21% believed that managed care was the best model of health care for the United States, and 31% stated they would be satisfied working in a managed care system. Those from high managed care communities (>30% penetration) were only slightly more accepting of managed care, but were more likely to choose general internal medicine as a career (54%, p = .0009) than those from communities with lower managed care penetration.     

Brief report: Multiprogram evaluation of reading habits of primary care internal medicine residents on ambulatory rotations

OBJECTIVE: To assess the reading habits and educational resources of primary care internal medicine residents for their ambulatory medicine education. DESIGN: Cross-sectional, multiprogram survey of primary care internal medicine residents. PARTICIPANTS/SETTING: Second- and third-year residents on ambulatory care rotations at 9 primary care medicine programs (124 eligible residents; 71% response rate). MEASUREMENTS AND MAIN RESULTS: Participants were asked open-ended and 5-point Likert-scaled questions about reading habits: time spent reading, preferred resources, and motivating and inhibiting factors. Participants reported reading medical topics for a mean of 4.3+/-3.0 SD hours weekly. Online-only sources were the most frequently utilized medical resource (mean Likert response 4.16+/-0.87). Respondents most commonly cited specific patients' cases (4.38+/-0.65) and preparation for talks (4.08+/-0.89) as motivating factors, and family responsibilities (3.99+/-0.65) and lack of motivation (3.93+/-0.81) as inhibiting factors. CONCLUSIONS: To stimulate residents' reading, residency programs should encourage patient- and case-based learning; require teaching assignments; and provide easy access to online curricula.     

老年医学继续教育对社区医务人员“知信行”的影响

目的调查社区医务人员对老年医学理念的理解及知晓程度,探讨老年医学继续教育及相应的工作指导对社区医务人员老年医学知识接受及应用的影响。方法入选2013年11月至2015年9月期间在岗的社区上门服务机构医务人员70人。采用"知信行"(KABP)调查问卷,对社区医务人员在老年医学继续教育培训前后的KABP行为进行调查评估,并比较培训前后的变化。结果培训前调查回收有效问卷58人;培训后调查回收有效问卷70人。培训后与培训前比较,医务人员对老年共病、老年综合征、前列腺增生、良性位置性眩晕、骨质疏松、肿瘤筛查、营养不良、肌少症、跌倒、痴呆、谵妄、尿失禁、睡眠障碍及压疮认知程度的提高均达到统计学意义(P0.05),对于便秘、营养不良、多重用药、尿失禁、睡眠障碍、肌少症、痴呆和谵妄的处理及行为均得到显著提升(P0.05)。结论社区医务工作者对老年医学知识掌握普遍不足,有针对性的老年医学继续教育,以及对社区进行的老年医学实践指导,可以有效提高社区医务人员的认知水平和实践能力。     

Systematic outpatient screening for the elderly: care of the vulnerable elderly practice improvement module to assess resident care of older adults

OBJECTIVES: To determine the feasibility of using the American Board of Internal Medicine Care of the Vulnerable Elderly Practice Improvement Module (CoVE PIM) in an internal medicine residency program and to assess aggregate resident documentation of geriatric screening in continuity clinics. DESIGN: Needs assessment chart review for single‐site pre‐/postintervention study. SETTING: Internal medicine resident primary care continuity clinics. PARTICIPANTS: Thirty‐seven postgraduate year (PGY)‐1 and PGY‐2 internal medicine residents. MEASUREMENTS: Completion rate and time of CoVE PIM chart review, CoVE PIM user difficulty, and aggregate percentage of charts documenting geriatric screening measures. RESULTS: Sixty‐five percent of residents completed the CoVE PIM in an average of 47 minutes (range 30–90 minutes); 72% of resident surveys rated the CoVE PIM as easy to use. Residents demonstrated very good documentation of chronic medical conditions, smoking status, height, weight, and blood pressure and poor documentation of falls and fall risk, hearing assessment, postural hypotension, balance, rigidity, bradykinesia, home safety assessment, seat belt counseling, code status, and surrogate decision‐maker. CONCLUSION: The CoVE PIM can be used to assess aggregate resident performance of geriatric screening measures. In resident clinics, general adult screening performed by nurses is well documented, whereas geriatric‐specific screening performed by physicians is poorly documented.     

Testing the exportability of a tool for detecting operational problems in VA teaching clinics

BACKGROUND: Recurrent operational problems in teaching clinics may be caused by the different medical preferences of patients, residents, faculty, and administrators. These preference differences can be identified by cultural consensus analysis (CCA), a standard anthropologic tool. OBJECTIVE: This study tests the exportability of a unique CCA tool to identify site-specific operational problems at 5 different VA teaching clinics. DESIGN: We used the CCA tool at 5 teaching clinics to identify group preference differences between the above groups. We averaged the CCA results for all 5 sites. We compared each site with the averages in order to isolate each site's most anomalous responses. Major operational problems were independently identified by workgroups at each site. Cultural consensus analysis performance was then evaluated by comparison with workgroup results. PARTICIPANTS: Twenty patients, 10 residents, 10 faculty, members, and 10 administrators at each site completed the CCA. Workgroups included at minimum: a patient, resident, faculty member, nurse, and receptionist or clinic administrator. APPROACH: Cultural consensus analysis was performed at each site. Problems were identified by multidisciplinary workgroups, prioritized by anonymous multivoting, and confirmed by limited field observations and interviews. Cultural consensus analysis results were compared with workgroup results. RESULTS: The CCA detected systematic, group-specific preference differences at each site. These were moderately to strongly associated with the problems independently identified by the workgroups. The CCA proved to be a useful tool for exploring the problems in depth and for detecting previously unrecognized problems. CONCLUSIONS: This CCA worked in multiple VA sites. It may be adapted to work in other settings or to better detect other clinic problems.     

Australian resident doctors want more palliative medicine education: a survey of attitudes and perceived needs

Most expected deaths occur in acute hospitals, and medical staff providing end-of-life care are generally not palliative medicine specialists. Through a voluntary self-administered survey, this study explored resident doctors' attitudes to palliative medicine and their perceived educational needs. Fifty-two resident doctors participated (response rate 39%), mostly acknowledging the importance of palliative medicine to their practice and emphasising that further postgraduate education is necessary.     

A national survey on the current status of general internal medicine residency education in geriatric medicine

OBJECTIVES: The dramatic increase in the U.S. elderly population expected over the coming decades will place a heavy strain on the current health care system. General internal medicine (GIM) residents need to be prepared to take care of this population. In this study, we document the current and future trends in geriatric education in GIM residency programs. DESIGN, SETTING, PARTICIPANTS: An original survey was mailed to all the GIM residency directors in the United States (N = 390). RESULTS: A 53% response rate was achieved (n = 206). Ninety-three percent of GIM residencies had a required geriatrics curriculum. Seventy one percent of the programs required 13 to 36 half days of geriatric medicine clinical training during the 3-year residency, and 29% required 12 half days or less of clinical training. Nursing homes, outpatient geriatric assessment centers, and nongeriatric ambulatory settings were the predominant training sites for geriatrics in GIM. Training was most often offered in a block format. The average number of physician faculty available to teach geriatrics was 6.4 per program (2.8 full-time equivalents). Conflicting time demands with other curricula was ranked as the most significant barrier to geriatric education. CONCLUSIONS: A required geriatric medicine curriculum is now included in most GIM residency programs. Variability in the amount of time devoted to geriatrics exists across GIM residencies. Residents in some programs spend very little time in specific, required geriatric medicine clinical experiences. The results of this survey can guide the development of future curricular content and structure. Emphasizing geriatrics in GIM residencies helps ensure that these residents are equipped to care for the expanding aging population.     

Faculty perceptions of effective ambulatory care teaching

The authors interviewed faculty members to determine their perceptions of what constitutes effective teaching in the ambulatory setting. They conducted semistructured interviews with experienced clinician-tutors who supervise residents in two internal medicine clinics. Tutors identified similarities as well as important differences between inpatient teaching and outpatient teaching. Questioning, role modeling, and emphasizing general principles and concept comprehension can be used effectively in both settings. On the other hand, the two settings differ strikingly in teaching of problem solving, bedside teaching, and provision of feedback. Many characteristics of the setting influence outpatient teaching, but the tutors offered differing viewpoints about whether these characteristics are beneficial or detrimental. Received from the Division of General Internal Medicine, McGill University, Montreal, Quebec, Canada. Presented at the Innovations in Medical Education Exhibits, annual meeting of the Association of American Medical Colleges, October 19–25, 1990, San Francisco, California. Supported in part by the Association of Canadian Medical Colleges, the Royal College of Physicians and Surgeons of Canada, the Departments of Medicine at Royal Victoria and Montreal General Hospitals, and Merck Frosst Canada Inc.     

Economic effects of community versus hospital-based faculty pneumonia care

To compare the length of stay and charges for patients with pneumonia admitted in 1995 to the teaching and nonteaching services of a Northeastern teaching hospital, we reviewed the charts of 237 patients. Patients cared for by hospital-based generalists working with housestaff (teaching service) were discharged more quickly and with lower or equivalent charges than patients cared for by community-based attending physicians working either with housestaff (private teaching service) or alone (nonteaching service). Academic teaching services staffed by general medicine faculty may provide efficient inpatient pneumonia care.     

The Impact of an Evidence-Based Medicine Educational Intervention on Primary Care Physicians: A Qualitative Study

Background Attitudes and barriers to implementing EBM have been examined extensively, but scant evidence exists regarding the impact of EBM teaching on primary care physicians’ point of care behavior. Objective Gaining insight into behavioral and attitudinal changes of facilitators and participants during a multifaceted EBM educational intervention. Design, setting, and participants A qualitative study on primary care physicians and facilitators from a large HMO selected from the intervention arm of a parallel controlled trial using purposeful sampling. We conducted focus groups with 13 facilitators and 17 physicians and semi-structured interviews with 10 facilitators and 11 physicians. Results Both facilitators and participants believed EBM enhanced the quality of their practice. The intervention affected attitudes and knowledge, but had little impact on physicians’ ability to utilize pre-appraised resources at the point of care. Using EBM resources during consultation was perceived to be a complex task and impractical in a busy setting. Conversely, a positive impact on using medication databases was noted. Medication databases were perceived as easy to use during consultations in which the benefits outweighed the barriers. The intervention prompted physicians to write down clinical questions more frequently and to search for answers at home. Conclusions This study underlines the need not only to enhance EBM skills, but also to improve the ease of use of EBM resources at the point of care. Tasks should be simplified by tailoring evidence-based information retrieval systems to the busy clinical schedule. Participants’ recommendations to establish an HMO decision support service should be considered.