Teaching Residents EBM:

Needs Assessment

Overheard at a Practice Quality Improvement Meeting...

"Our diabetes quality score is terrible. What are we gonna do about it?"

Denial

"I don't trust the data - I know I order A1cs on every diabetes patient I see, and I write more insulin than everyone else!"'

Anger

"I work very hard for my patients! It is infuriating that you're calling me a bad doctor!"

Bargaining

"Well, my patients are sicker AND poorer than whoever made up this quality metric has ever treated! It doesn't apply to me! I should be given at least 5 points slack on that measure!"

Depression

"This whole system sucks - I'm gonna go be a barista at Starbucks."

Acceptance

Maybe...I'm sure it happens somewhere...

Overheard at a faculty meeting...

"Our residents say we're not teaching EBM. What are we gonna do about it?"

Denial

"Residents complain about everything! I'm sure we're just generalizing from a few residents with a grudge."

Anger

"Residents today get SO much teaching compared to what we did!" [usually followed by a historical comparison of overnight call requirements]

Bargaining

"Sure, I'll teach evidence-based medicine when my chair knocks off one of my clinic sessions per week!"

Depression

"Is Pfizer hiring?"

Acceptance (or at least some steps to take toward acceptance):

- Feedback like this is just information - it must be vetted, interpreted, and contextualized.
- Feedback is not necessarily personal.
- Feedback like this can (and should) trigger an instructional design cycle - beginning with Needs Assessment

EBM Definitions

Evidence-based Medicine

"conscientious, judicious, and explicit use of evidence"

"decisions about care of individual patient"

"integrating clinical expertise and evidence from research"

Evidence-based Healthcare

Best Research Evidence

Clinical Expertise (not experience)

Patient's Values and Preferences

EBM for simple folk

Explicitness & Rigor

Apply to all information sources.

If you'll notice, I haven't even mentioned P-values yet...not even once...

What do we mean by Evidence-Based Medicine?

Evidence-based Clinical Medicine

Evidence-based Clinical Decision-Making

EBM Tools and Techniques

Information Mastery

The Role of Needs Assessment

What kinds of physicians are you producing?

How do you see those physicians using Evidence-based Medicine?

How do you currently teach Evidence-based Medicine?

Which category of EBM are YOU best at? (EB clinical medicine, EB decision-making, Tools/Stats, InfoMastery)

Which categories would you like to emphasize in your program? (EB clinical medicine, EB decision-making, Tools/Stats, InfoMastery)

Quick Wins

Be more explicit about your knowledge.

Say "I don't know" more.
Say "Not sure, I would normally look that up in <insert reference here>. How about you?"

Ask your learners - what's the evidence for that?

Set high expectations and happily help your learners achieve them. - i.e., be prepared to look for the answer together.

Break down your own decision-making

Which part is evidence, which part is patient values?
Why are you/are you not deviating from evidence or guidelines?

Open up your practice's clinical policy-making and involve residents

Be explicit about evidence
Rotate residents into decision-making

All of this is about creating the conditions of learning evidence-based medicine, not just "teaching" it.

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