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Evidence-based Medicine--How to Teach Critical Scientific Thinking to Medical Undergraduates.

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Title: Evidence-based Medicine--How to Teach Critical Scientific Thinking to Medical Undergraduates.
Language: English
Authors: Pitkala, K., Mantyranta, T., Strandberg, T. E., Makela, M., Vanhanen, H., Varonen, H.
Source: Medical Teacher. Jan 2000 22(1):22-26.
Peer Reviewed: Y
Page Count: 5
Publication Date: 2000
Document Type: Guides - Classroom - Teacher
Journal Articles
Descriptors: Critical Thinking, Higher Education, Medical Education, Student Attitudes, Teaching Methods
ISSN: 0142-159X
Abstract: Discusses an evidence-based course which activates students' critical thinking, enhances social learning and group processes, and promotes attitudes towards independent information retrieval and critical appraisal. (Author/CCM)
Entry Date: 2000
Accession Number: EJ605670
Database: ERIC
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  Value: <anid>AN0002723237;MCH01JAN.00;2000Feb07.16:06;v4.1</anid> <title id="AN0002723237-1">EVIDENCE-BASED MEDICINE--HOW TO TEACH CRITICAL SCIENTIFIC THINKING TO MEDICAL UNDERGRADUATES </title> <p>SUMMARY Evidence-based medicine (EBM) offers a systematic and structured approach to teaching critical scientific thinking. In the Faculty of Medicine at the University of Helsinki, after an extensive training of medical teachers and piloting the course with a small group of volunteer students, a 40-hour EBM course was organized for the fourth-year medical students. Feedback from students and teachers has been enthusiastic. The EBM course activated the students' critical thinking, enhanced social learning and group processes, and promoted theft attitudes towards independent information retrieval and critical appraisal. </p> <hd id="AN0002723237-2"> Introduction </hd> <p>Evidence-based medicine (EBM) is a methodology for appraising clinical studies critically and considering their applicability in clinical work. EBM was created during the 1980s and 1990s in the Anglo-Saxon medical community and since then has been spreading all over the world (Sackett et al., 1997). This has been especially promoted by EBM working groups at universities in McMaster and Oxford and articles in several scientific journals (Sackett et al., 1985, 1996). According to one definition, EBM is "A ... judicious and explicit use of current best evidence in making decisions about the care of individual patients" (Sackett et al., 1996). To be successful, EBM must combine the best external evidence with clinical expertise and also take into account individual patients' preferences and choices. </p> <p>The turnover of knowledge is faster than ever. The 1980s and 1990s have seen the blossoming of randomized, controlled trials and meta-analyses, some of which have uncovered quite surprising results affecting our everyday medical practice. New powerful and effective diagnostic tests and treatments invalidate older ones very quickly (Sackett et al., 1997). </p> <p>Unfortunately the new information does not always reach us or it is not in a usable form for everyday practice. Consulting textbooks means using yesterday's information, journals are too disorganized and often we lack the time to keep us up to date. As a result of this, our knowledge and performance tend to deteriorate with time (Sackett et al., 1997). Davis and others have shown that actually traditional lecture-based medical teaching has a limited capacity to change the way we practice medicine (Davis et al., 1995). </p> <p>We need new ways to master knowledge. The evidence-based method provides a systematic approach to obtain information and appraise it critically at the point when it is needed (Sackett et al., 1997). It also supports self-directed and lifelong learning. Instead of merely providing knowledge, the medical curriculum should challenge medical students to strive for true medical expertise: critical scientific thinking, clinical hypothesis testing, solving medical and ethical dilemmas and also communicating with patients. This creates new challenges for undergraduate education. EBM is easily combined with the increasingly popular and efficient method of medical education--problem-based learning (PBL) (Vernon & Blake, 1993; Sackett et al., 1997). </p> <hd id="AN0002723237-3"> Introducing EBM at the University of Helsinki </hd> <p>The process of introducing EBM into the medical curriculum took several years (Table 1). Promising experience and feedback from the pilot course for students and CME-courses supported the decision in the faculty to arrange the EBM course for all fourth-year medical students. An EBM course for tutors attracted 25 teachers from the faculty. A model of tutorial group work was introduced by experienced teachers and developed further by the participants. After this course the medical faculty was ready to extend the course for all fourth-year medical students. A renovation of the entire curriculum took place at the same time (autumn 1998), as the whole fourth-year medical education was transformed towards PBL. The EBM course also served as an introductory course for the PBL method. </p> <hd id="AN0002723237-4"> Content and organization of the EBM course </hd> <p>The aims of the EBM-course were to: </p> <ulist> <item> introduce the students to the evidence-based method; </item> <item> provide critical appraisal skills for clinical practice; </item> <item> support a more effective use and evaluation of knowledge in patient care. </item> </ulist> <p>All the 88 fourth-year medical students were divided into seven groups of 12-14 members. The EBM course took place during one whole week at the beginning of the autumn term. Clinical teachers and epidemiologists from several departments acted as tutors. In over half of the group sessions two teachers were present: the epidemiological expert worked as a source for the EBM substance and methodology such as statistical problems, while the clinician had the expertise for the applicability of the information. In order to avoid variations in teaching between the groups, careful written instructions were made for the teachers who were also systematically rotated between the groups. </p> <p>The course consisted of five lectures and 15 hours of group work. Each day started with an introductory lecture covering the basic elements of EBM (Table 2), followed by group work on the same subject (Table 3). The structure and teaching material of the course were adopted and modified from the Nordic EBM workshops (Oxman, 1997) and from McMaster and Oxford workshops. Students received a handout including all necessary material: a clinical problem for each day, a clinical article covering the same subject, methodological articles by the evidence-based working group published in JAMA (Guyatt et al., 1993, 1994; Oxman et al., 1993, 1994; Jaeschke et al., 1994a,b; Laupacis et al., 1994) providing guidelines for the critical appraisal of various clinical questions and worksheets including the questions from the JAMA articles. The students were instructed to study the material before the group work. </p> <p>Tutors were encouraged to steer the group by questioning in order to achieve critical thinking. Nearly all the students had read the material beforehand. Discussion was active in all the groups. Students spontaneously brought up topics that interested them, for example a discussion of the ethics of scientific research was initiated by students. A number of amusing insights were achieved in the groups. There was laughter in the sessions, and it was experienced that EBM and group learning is fun. In many groups students took an active role as one of them volunteered to be the chairperson and another the secretary leaving the tutor(s) to be facilitator(s). At the end of the group session the chairperson or secretary gave a summary of the topic of the session. The students evaluated their own performance as a group, gave feedback to their tutor(s) and to their own chairperson and secretary. </p> <hd id="AN0002723237-5"> Evaluation of teaching and learning </hd> <p>What was learned </p> <p>The course was evaluated by semi-structured questionnaires containing questions with fixed alternatives as well as open-ended questions. Sixty-two of the 88 students (70%) and 17/21 teachers (81%) returned their questionnaires. The students were asked with an open-ended question what was the most important thing they had learned. The most common responses were: </p> <ulist> <item> a more critical attitude towards medical knowledge (20 comments); </item> <item> an ability to read and appraise original research articles (17 comments); </item> <item> criteria for good clinical research and basics in statistics (9 comments); </item> <item> skills for cooperation in a group (5 comments); </item> <item> ability to use different databases (4 comments). </item> </ulist> <p>The most confusing things were asked accordingly. Statistical methods was the most common response (24 comments), although many students pointed out that statistics were not actually among the learning goals of the course. Some students wondered how an individual physician can apply the time-consuming EBM method in practical work. </p> <p>The students were asked with fixed alternatives whether the EBM course had changed their conceptions of medical knowledge. Four out of five students reported a change in their conceptions. In the open-ended follow-up question most students stated that their critical thinking had increased. Some brought up their surprise at how little scientific research and evidence there is about some common diseases and how a great deal of medical knowledge is actually based on clinical experience--not on scientific studies. Many students stated that the EBM course taught them the importance of lifelong learning. Some examples of students' answers are: </p> <ulist> <item> "I'm surprised at how little of the established treatment is based on scientific evidence. On the other hand I realized why the 'negative results' are missing." </item> <item> "I have learned a lot about how medical scientific knowledge may be used for the best of the patient. And one should not believe every authority..." </item> <item> "In the future I might pay more attention to methods and results instead of discussion when reading articles." </item> <item> "I learned to trust the capability of an ordinary reader to appraise critically the validity of medical research." </item> <item> "The EBM course increased my critical thinking and awareness of continuous education." </item> </ulist> <p>Both students and teachers evaluated the adequacy of learning (Table 4). The evaluations of the students and teachers were similar, especially concerning the last two questions. The students evaluated their ability to read epidemiological articles in English a little weaker than the teachers did. </p> <p>What helped and what hindered learning? </p> <p>The overall opinion about the learning method similar to the problem-based learning (PBL) was positive. About two out of five students had a positive attitude towards PBL and group work. Another two-fifths stated they had had a reserved preconception but were positively surprised by the method. Only three students didn't like the PBL-type method at all. All the teachers stated they were enthusiastic about the method and positively surprised by the industriousness and activity of the students. </p> <p>Some of the students' remarks about the method: </p> <ulist> <item> "More work, because one cannot believe everything black and white. This method will improve the quality of the substance studied." </item> <item> "I think I will remember things I have studied this way better in the long run." </item> </ulist> <p>The pairwork between the two teachers functioned very well at its best. There were some problems in some groups, as the teachers were used to working alone with their small groups. Role conflicts between the chairperson and the facilitator were experienced in some groups. The students evaluated their tutors to be interested, motivated and competent. However, some tutors were criticized for lecturing too much in a traditional way. In particular the use of different specialists and the rotation of them between the groups was well received by the students. </p> <p>According to the students, a skillful EBM tutor is a good clinician with skills in applying evidence into clinical medicine. The students also respect a tutor who has the ability to inspire students and to present questions which make the students realize things themselves. Some examples of the opinions: </p> <ulist> <item> "A good tutor guides the group discussion so that the students feel they have invented the core solution for the problem: that is very encouraging" </item> <item> Activates the students to ponder things independently, but still leads the discussion in the right direction'. </item> </ulist> <hd id="AN0002723237-6"> Discussion </hd> <p>The first EBM course at the University of Helsinki was well received by both students and teachers. A basic element of success was in our opinion the careful preparation and good structure (adopted from the Nordic EBM workshops) of the course. The teachers were all educated both in the substance and in the method of teaching, and they had detailed instructions for the course which ensured uniform quality. </p> <p>The objectives of the course were quite well achieved. The students' attitudes towards medical knowledge had changed and they reported an increase in their critical appraisal skills. The course served as a stimulus for critical thinking and insights. Many students realized that the value of medical knowledge is relative and dependent on the context where it is applied. They started thinking about the rapid turn-over of information in medicine and the need for lifelong learning. Besides the official aims, the students learned new aspects of group work and appreciated it. The teachers had readily taken on their new role as tutors, and this was well received by the students. </p> <p>The agreement between the student and teacher evaluations on the adequacy of learning was surprisingly high. It seems that the teachers were able to evaluate the learning of the students in the groups quite well. The evaluation of learning of individual students was one concern the teachers had had beforehand, due to the extensive size of the groups. Teacher education about activating learning methods probably helped make the atmosphere in the groups pleasant and thus made the students active and talkative. Students' sincerity both in terms of gaps in their knowledge and what was actually understood helped the teachers to evaluate the learning. </p> <p>For many students this was probably the first time they were reading original articles in English, which may have been quite time-consuming for most students. It may have been a surprising challenge for them. On the other hand, the teachers may have compared the students to themselves and were positively surprised by how motivated the students had been to read and understand the scientific texts. </p> <p>The division of labor--one teacher being the resource person for EBM and facilitator of the group work and the other chairing the group discussion--should be well emphasized in teachers' pair work. This should preferably be practised beforehand. Although the teachers were well instructed and nearly all had practised one of the roles in their tutor courses, the short course had not given all of them enough experience. Learning to be a tutor is a long experiential process requiring practice and feedback. The next courses will probably have better tutors as the teachers get more experience. </p> <p>Teaching evidence-based medicine is not new anymore, but it is seldom taught widely and systematically to undergraduates. David Sackett and his colleagues started to teach critical appraisal skills at McMaster University in Hamilton, Canada (Sackett et al., 1997). Critical appraisal skills and clinical epidemiology have been taught to undergraduates and teaching has been evaluated in some universities (Heller & Peach, 1984; Frasca et al., 1992). It was shown in a review that teaching critical appraisal skills was more effective in undergraduate programmes than at the residency level (Norman & Shannon, 1998). Short courses on EBM have been arranged, e.g. at the University of Bergen (Klovning, 1998). </p> <p>A variety of educational methods are referred to as PBL. However, the traditional PBL includes elements such as cases as stimuli for learning, student-directed learning and a certain sequence in which a problem is offered and information is acquired (Barrows, 1986). PBL at its best should enhance structuring of knowledge, develop clinical reasoning processes and increase motivation for self-directed learning (Barrows, 1986). EBM is often taught using a method very similar to the traditional problem-based learning method. Nevertheless, EBM is rather a methodology for applying the best possible evidence in clinical practice whereas problem-based learning (PBL) is basically an educational approach. Certain similarities, however, can been seen in these two learning techniques (Table 5). </p> <p>In practice the EBM group sessions are more structured and the tutor has a more active role than in traditional PBL. Whereas PBL offers cases as stimulus to find gaps in knowledge and to enhance self-directed studying during a certain time period, EBM gives both the case and its 'solution' (clinical article) at the same session and the main educational objective is to learn to appraise the evidence of the offered 'solution' critically and to apply the evidence. Both EBM and PBL have their origins in developing a knowledge base of human learning, especially cognitive and constructive theories of learning. </p> <p>The most suitable timing for the course seems to be during the clinical years. We chose the beginning of the fourth year for the course, because at that time students have already studied general internal medicine. They have met their first patients, and have a true motivation to apply the evidence from research to their own patients. The course supports the clinical studies and PBL method, as after this course students are able to search evidence for their needs of knowledge and critically appraise it. The clinical problems obviously give a good motivation for the students to study. </p> <p>The clinical articles chosen for critical appraisal during the course should be clinically relevant, and the students should ideally have some experience of the problem. The articles should be scientifically valid, although finding weaknesses in the articles from reputable journals gives insight for the group. It is an important experience to realize that valid scientific results may not be clinically meaningful or can be difficult to apply to one's own patients. </p> <p>Correspondence: Kaisu Pitkala M.D. Ph.D., Helsinki University Hospital, Department of Medicine, P.O. Box 340, FIN-00029 HYKS, Finland. </p> <hd id="AN0002723237-7">Table 1. The process of implementing the EBM-course into the medical curriculum at the University of Helsinki.</hd> <ct id="AN0002723237-8"> Legend for Chart: A - Time B - Steps C - Aims A B C 1995-1997 Single teachers at various departments piloting EBM 1996 First plans to integrate EBM into the curriculum June 1997 Three clinical teachers educated on Nordic EBM courses Gain knowledge and skills in critical appraisal September 1997 Pilot EBM-course organized for 21 volunteer fourth year medical students, seven teachers from several departments Test course concept, cases and educational material Create collaboration across departments 1997-1998 Four CME courses on EBM arranged for physicians by the Finnish branch of the Nordic Cochrane Centre. Teachers from the Faculty of Medicine act as tutors Get experience in the teaching technique August 1998 EBM-tutor courses organized for 25 teachers in the Faculty of Medicine Create collaboration with researchers Introduce the substance and tools of EBM to medical teachers and prepare them for the role of EBM-tutor September 1998 EBM course extended to all fourth year medical students</ct> <hd id="AN0002723237-9">Table 2. Contents of the evidence-based medicine course at the University of Helsinki.</hd> <ct id="AN0002723237-10"> Legend for Chart: B - Lectures C - Tutorial groups A B C Day 1 What is evidence-based medicine? How to formulate answerable questions to clinical problems? Effective searching from databases. Cochrane database demonstration Finding search terms from one's own patient's clinical problem and practicing searches from Medline and Cochrane databases Day 2 Effectiveness of treatment Critical appraisal of treatment trial Day 3 Systematic review and meta-analysis Critical appraisal of an article of systematic review and/or meta-analysis Day 4 Diagnostic tests Critical appraisal of an article concerning diagnostic test Day 5 Prognostic studies Critical appraisal of an article on prognosis</ct> <hd id="AN0002723237-11">Table 3. Timetable of tutorial sessions.</hd> <ct id="AN0002723237-12"> Legend for Chart: A - Task B - Time (min) A B Organization 10 -Selection of chairman and secretary -Timetable Reading time (optional) 5-10 Definition of the clinical problem 5-10 Definition of the main result of the article Work in pairs: critical appraisal of the article 10-20 [*] Criteria of scientific validity [*] What are the results of the article, what is the clinical meaning of them? [*] Can the results be applied to one's own patient care? Work in the group: critical discussion 60 Conclusion 5 Evaluation of the session 5</ct> <hd id="AN0002723237-13">Table 4. Evaluation of students' learning (mean scores).</hd> <ct id="AN0002723237-14"> Legend for Chart: B - Students (N=62) C - Teachers (N=17) A B C Searching scientific evidence 3.7 not asked Reading scientific articles 3.8 4.2 Understanding scientific art 3.8 4.0 Appraising scientific article 4.1 4.1 Evidence-based medicine 3.8 3.9 Response scale 1-5; 1 - did not learn at all ... 5 = learned extremely well.</ct> <hd id="AN0002723237-15">Table 5. Comparison between the teaching techniques of EBM and PBL.</hd> <ct id="AN0002723237-16"> Legend for Chart: B - Evidence-based medicine C - Problem-based learning A B C Place in medical curriculum Learning objectives Clinical studies, specialist training, CME Critical appraisal of medical science Application of best evidence in clinical practice Pre-clinical studies (clinical studies) To gain and to structure factual medical knowledge General principles or concepts Problem-solving skills, clinical reasoning Enhance self-directed learning Stimulus/problem to start with 'Steps' Clinical problem Creating an exact statement of the clinical problem Identifying the best evidence to answer the question Critically appraise the evidence for its validity, meaning and applicability (with the aid of structured worksheets) Apply the results of this appraisal in clinical practice Evaluate performance Pre-clinical or clinical problem or scenario Determining whether a problem exists Creating an exact statement of the problem Structuring what is already known and identifying information needed to understand the problem Identifying resources to be used to gather information Generating possible solutions Analysing the solutions Presenting the solution, orally and/or in writing Evaluating performance Tasks of teacher Facilitating learning and social processes Acting as resource person for EBM methodology Be an 'active model' in clinical practice Facilitate learning and social processes</ct> <hd1 id="AN0002723237-17"> References </hd1> <p>BARROWS, H.S. (1986) A taxonomy of problem-based learning methods. Medical Education, 20, pp. 481-486. </p> <p>DAVIS, D.A., THOMPSON, M.A., OXMAN, A.D. & HAYNES, R.B. (1995) Changing physician performance. A systematic review of the effect of continuing medical education strategies, The Journal of the American Medical Association, 274, pp. 700-705. </p> <p>FRASCA, M.A., DORSCH, J.L., ALDAG, J.C. & CHRISTENSEN, R.G. (1992) A multidisciplinary approach to information management and critical appraisal instruction: a controlled study, Bulletin of the Medical Library Association, 80, pp. 23-28. </p> <p>GUYATT, G.H., SACKETT, D.L. & COOK, D.J. (1993) Users' guides to the medical literature II. How to use an article about therapy and prevention. A: Are the results valid?, The Journal of the American Medical Association, 270, pp. 2598-2601. </p> <p>GUYATT, G.H., SACKETT, D.L. & COOK, D.J. (1994) Users' guides to the medical literature II. How to use an article about therapy and prevention. B: What are the results and will they help me in caring for my patients?, The Journal of the American Medical Association, 271, pp. 59-63. </p> <p>HELLER, R.F. & PEACH, H. (1984) Evaluation of a new course to teach the principles and clinical application of epidemiology to medical students, International Journal of Epidemiology, 13, pp. 533-537. </p> <p>JAESCHKE, R., GUYATT, G. & SACKETT, D.L. (1994a) Users' guides to the medical literature III. How to use an article about a diagnostic test. A. Are the results of the study valid?, The Journal of the American Medical Association, 271, pp. 389-391. </p> <p>JAESCHKE, R., GUYATT, R. & SACKETT, D.L. (1994b) Users' guides to the medical literature III. How to use an article about a diagnostic test. B. What are the results and will they help me in caring for my patients?, The Journal of the American Medical Association, 271, pp. 703-707. </p> <p>KLOVNING, A. (1998) EBM for medical students at the university of Bergen, Nordic Evidence-based Health Care Newsletter, January, pp. 4-5. </p> <p>LAUPACIS, A., WELLS, G., RICHARDSON, S. & TUGWELL, P. for the Evidence-based Medicine Group (1994) Users' guides to medical literature V: How to use an article about prognosis, The Journal of the American Medical Association, 272, pp. 234-237. </p> <p>NORMAN, G.R. & SHANNON, S.I. (1998) Effectiveness of instruction in critical appraisal (evidence-based medicine) skills: a critical appraisal, Canadian Medical Association Journal, 158, pp. 177-181. </p> <p>OXMAN, A. (1997) EBHC Workbook. How to Practice Evidence-based Health Care. The Second Nordic workshop on how to critically appraise and use evidence in decisions about health care, 1-5 June 1997 (Oslo, Norway, National Institute of Public Health). </p> <p>OXMAN, A.D., COOK, D.J. & GUYATT, G.H. (1994) Users' guides to the medical literature VI. How to use an overview, The Journal of the American Medical Association, 27, pp. 1367-1371. </p> <p>OXMAN, A.D., SACKETT, D.L. & GUYATT, G.H. for the Evidence-based Medicine Group (1993) Users' guides to the medical literature. I. How to get started, The Journal of the American Medical Association, 270, pp. 2093-2095. </p> <p>SACKETT, D., HAYES, R.B., GUYATT, G.H. & TUGWELL, P. (1985) Clinical Epidemiology. A Basic Science for Clinical Medicine, 2nd edition (Boston, Toronto, London, Little, Brown and Company). </p> <p>SACKETT, D.L., RICHARDSON, W.S., ROSENBERG, W. & HAYNES, R.B. (1997) Evidence-based Medicine. How to Practice and Teach it, pp. 5-17 (New York, Edinburgh, London, Madrid, Melbourne, San Francisco, Tokyo, Churchill Livingstone). </p> <p>SACKETT, D.L., ROSENBERG, W.M.C., GRAY, J.A.M., HAYNES, R.B. & RICHARDSON, W.S. (1996) Evidence-based medicine: what it is and what it isn't, British Medical Journal, 312, pp. 71-72. </p> <p>VERNON, D.T. & BLAKE, R.L. (1993) Does problem-based learning work? A meta-analysis of evaluative research, Academic Medicine, 68(<reflink idref="bib7" id="ref1">7</reflink>), pp. 542-544. </p> <aug> <p>By K. Pitkala; T. Mantyranta; T.E. Stranberg; M. Makela; H. Vanhanen and H. Varonen </p> </aug> <nolink nlid="nl1" bibid="bib7" firstref="ref1"></nolink>
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            NameFull: Strandberg, T. E.
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          Name:
            NameFull: Makela, M.
      – PersonEntity:
          Name:
            NameFull: Vanhanen, H.
      – PersonEntity:
          Name:
            NameFull: Varonen, H.
    IsPartOfRelationships:
      – BibEntity:
          Dates:
            – D: 01
              M: 01
              Type: published
              Y: 2000
          Identifiers:
            – Type: issn-print
              Value: 0142-159X
          Numbering:
            – Type: volume
              Value: 22
            – Type: issue
              Value: 1
          Titles:
            – TitleFull: Medical Teacher
              Type: main
ResultId 1