Teaching Evidence-Based Medicine Across the Curriculum

Gundy Sweet, PharmD, FASHPClinical Associate Professor

University of Michigan, College of Pharmacy

Objectives

• Provide a brief overview of the UofM College of Pharmacy curriculum specific to the development of evidence-based medicine skills and concepts

• Briefly discuss how the curriculum revision process will strive to further develop these skills

What is EBM?

• Combine the best evidence from clinically relevant studies

• Add in your clinical expertise to determine if it applies to the individual patient

• And incorporate the patient’s values

All done to make the best decision for a given situation

Sackett D, 1996

Common Student (mis)Perception

• You don’t need to teach me this stuff….• I already know how to look for things….• I’m a Gen-Nexter • But few students have a systematic process to

identify the best evidence specific to a given situation

• Why is that important?

Too many sourcesof information

• 2006: 20,824 journals (medical sciences) •2009: > 679,000 citations added to Medline

Information explosion

• Research information doubles every 10 years• Explosion of mis-information

2X

Traditional resourcesoften inadequate

• Textbooks can be outdated • Many books take 1-3 years to get to print

Readily available search tools

• 1986: Medline available via librarians• Today: numerous search tools readily available

More knowledgeablepatient

• 30% of adults seeing MD discuss a drug they saw through DTC advertising• almost ½ of these patients received a RX for the drug

Daily need for validinformation

Increase in number, sophistication, and safety concerns with

drugs/medical interventions

• 10% of drugs on market between 1975-1999 pulled from market/black box warning added• 1/2 of all withdrawals within 2 years

Feeling Overwhelmed???

Information explosion

Increase in numberand sophistication

of drugs/medical interventions

Too many sourcesof information

Traditional resourcesoften inadequate

Readily available search tools

Daily need for validinformation

More knowledgeablepatient

How and where are the skills taught?

• EBM Course– EBM concepts– How to formulate a clinical question

• Importance of clarity of the question• Helps direct you to the most appropriate resources• Helps ensure communication of a clear response

– How to apply the systematic approach to handling requests for information

What is the Systematic Approach• The systematic approach is an integral part of the EBM

strategy• Helps search for the most relevant literature to

enhance efficiency and effectiveness• The systematic approach is comprised of 7 steps:

• BUT… conducting a systematic search requires knowledge of the advantages/disadvantages associated with each type of information resource

1. Classify 2. Clarifying information 3. Systematic Search (3o2o1o) 4. Evaluate 5. Apply 6. Communicate 7. Follow-up

Where Students Learn About Resources

• EBM Course– Textbooks and general drug information resources– Searching the biomedical literature

• What to use when– PubMed, Embase, Google, IPA, Cochrane, others

– Using the internet - is it reliable? • Author credentials• Currency of the information• Source of funding• Awareness of extensions (.biz .com .edu .gov)• External validation of content

What about the primary literature?

• EBM Course– How to find the primary literature

• Efficient and effective searching

– How to read and interpret the primary literature• Terminology (R, DB, PC, DD, etc)• Different types of trials (systematic reviews, economic

analyses, randomized controlled trials, case reports)• Levels of evidence• Appropriate statistical tests• Assess all elements of the study, practicing on different

published clinical trials

Using EBM Skills

• EBM Course and beyond – How do I apply the information?

• Does the information found apply to the clinical situation (indication, age group, etc)?

• Are the results clinically important (and not just statistically significant)?

– Is the information found sufficient to answer the question?

– How should I communicate the information?– Are there any ethical considerations to take into

account?

Application of EBM Principles

P1 Year•EBM Course (W)

P2 Year•Therapeutics (F/W)•Research Principles (W)

Therapeutics•Reinforce identification of best evidence•Integrate critical appraisal to clinical situations

Research Principles•Practical, application-based course where students write a ‘practice’ research proposal•Requires they understand and apply EBM principles

• Study terminology• Study design• Searching primary literature

•Learn to logically think through a problem and define a plan

Application of EBM Principles

P1 Year•EBM Course (W)

P3 Year•Therapeutics (F/W)•Pcare (IPPE)•PharmD Research (W)

P2 Year•Therapeutics (F/W)•Research Principles (W)

Therapeutics•Reinforce identification of best evidence/integrate critical appraisal

Pcare (IPPE)•Discuss patient cases that requires use of best evidence•Reinforce primary literature review (journal clubs)

PharmD Research Project•Application of research principles•Emphasis on process of conducting research

Application of EBM Principles

P1 Year• EBM Course (W)

P2 Year•Therapeutics (F/W)•Research Principles (W)

P4 Year• Clinical Rotations• PharmD Research• PharmD Seminar

Clinical Rotations•Manage patients on rotations•Reinforce primary literature review•Drug Information is a required rotation

• Conduct systematic review of topic• Critically evaluate literature on a topic• Retrieve/analyze/apply DI in practice

PharmD Research Project•Application of research principles

PharmD Seminar•Formal presentation

• PharmD research or topic review•Requires application of all EBM skills

• Search/analyze/apply information to a given situation

Application of EBM Principles

P1 Year• EBM Course (W)

P3 Year• Pcare (IPPE)

• Therapeutics (F/W)• PharmD Research (W)

P2 Year•Therapeutics (F/W)•Research Principles (W)

P4 Year• Clinical Rotations• PharmD Research• PharmD Seminar

EBM in New Curriculum

P1 Year• Introduce DI skills, resources, terminology•Begin to build a toolbox

P3 Year•EBM/ethics course•Pcare (IPPE)•Therapeutics (F/W)•PharmD Research (W)

P2 Year• EBM: focus on literature evaluation and searching (F)• Research Principles (W)•Therapeutics (F/W)

P4 Year•Clinical Rotations•PharmD Research•PharmD Seminar

Curriculum revision is an

ongoing, dynamic process

Goals with the New Curriculum

• Maximize active learning– Students more involved in learning by DOING

• Increase opportunities in all courses for students to ….– not just KNOW the information but …. – to have the ability to APPLY information in practice

In your packet is a document for your toolbox…

A Guide to INFORMATION RESOURCES

University of Michigan, College of Pharmacy

TAUBMAN LIBRARY RESOURCES

RESOURCES BASED ON TYPE OF QUESTION

Questions