Two Strategies to Intensify Evidence-based Medicine Education of Undergraduate Students: A Randomised Controlled Trial

2012-02-14 | Admin MKKI

Original Article

Two Strategies to Intensify Evidence-based Medicine Education of Undergraduate Students: A Randomised Controlled Trial
Hao Min Cheng,MD, Fei Ran Guo,MD, Teh Fu Hsu,MD, Shao Yuan Chuang,PhD, Hung Tsang Yen,MD, PhD, Fa Yauh Lee,MD, Ying Ying Yang,MD, PhD, Te Li Chen,MD, PhD, Wen Shin Lee,MD, Chiao Lin Chuang,MD, Chen Huan Chen, MD, Low Tone Ho, MD

Introduction: Undergraduate evidence-based practice (EBP) is usually taught through standalone courses and workshops away from clinical practice. This study compared the effects of 2 clinically integrated educational strategies on final year medical students. Materials and Methods: Final year medical students rotating to the general medicine service for a 2-week internship were randomly assigned to participate in a weekly EBP-structured case conference focusing on students’ primary care patients (Group A, n = 47), or to receive a weekly didactic lecture about EBP (Group B, n = 47). The teaching effects of these 2 interventions were evaluated by a validated instrument for assessment of EBP related knowledge (EBP-K), attitude (EBP-A), personal application (EBP-P), and anticipated future use (EBP-F) on the first and last days of rotation. Results: All scores improved significantly after the 2-week EBM-teaching for both groups. When compared to Group B, students in Group A had significantly higher post-intervention scores of EBP-K (21.2 ± 3.5 vs 19.0 ± 4.6; ie. 57.8 ± 72.9% vs 29.1 ± 39.1%; P <0.01) and EBP-P (18.7 ± 4.3 vs 15.3 ± 3.9; ie. 28.5 ± 25.5 % vs 14.1 ± 18.7 %; P <0.001). In contrast, the scores of EBP-A and EBP-F were similar between the 2 groups. Conclusion: Structured case conference, when compared to the didactic lectures, significantly improved EBP-K and EBP-P for final year medical students.

Ann Acad Med Singapore 2012;41:4-11
Key words: Evidence-based medicine, Medical education, Preclinical medical student

Knowledge and skills of evidence-based medicine (EBM) can be taught by many methods, such as role modeling evidence-based care, using evidence for clinical medicine instruction, and teaching specific EBM skills. Standalone courses and workshops away from the clinical environment are usually the traditional educational designs for teachers to convey knowledge or skills of evidence-based practice (EBP). Previous systematic reviews have demonstrated the efficacy of integrated courses in teaching EBM and that these integrated strategies are superior to standalone teaching for postgraduates. Emphasis on incorporating EBM principles in undergraduate medical education has been stressed by many associations.

Most medical students usually have limited knowledge and skills in patient management. For medical students in the commencement of clinical training, principles of EBP can serve as the bridge between learning medical knowledge and clinical decision-making strategies. However, there is insufficient evidence supporting the efficacy of an undergraduate EBM curriculum. Although there is a growing body of literature exploring EBM teaching and learning in undergraduate learning environments, this evidence is often limited by their study designs, such as a lack of control groups, validated assessment instruments, or integrated strategies for undergraduate. We hypothesised that different intensity of clinical integration could have different efficacy of EBP-training courses for the undergraduates. We therefore conducted a randomised controlled trial with before and after assessments to examine the effects for final year medical students rotating to the general medicine service of 2 clinical integration strategies: (i) EBP-structured case conference for students to reflect on their own clinical practice cases and (ii) didactic EBP lectures arranged during clinical rotation. All participants were evaluated at the baseline and again 2 week later (post-intervention) on knowledge (EBP-K), attitude (EBP-A), personal application (EBP-P), and future anticipated use (EBP-F) of EBP. These 2 strategies were aimed at intensifying effects of EBP-teaching curriculum through clarifying EBP principles by didactic lectures or reflecting on problems from patient care experiences with an EBP approach by case conference.

Materials and Methods
Study Population
Medical students in our medical school receive a 7-year curriculum including 2 years premedical education, 2 years problem-based integrated basic and clinical medicine, and 3-years of clinical training (9 months’ core clerkship and 20 months’ internship). The targeted population of the present study was the final year medical students rotating to the general medicine service from January 2008 to February 2009, who were randomly assigned to participate in a weekly 1-hour EBP-structured case conference that involved the EBP on the students’ primary care patients (Group A, N = 47), or to receive a weekly 1-hour lecture about the essentials of EBM (Group B, N = 47). Blinding and allocation concealment were not possible in the present study because teachers and students were all aware of the courses they were going to attend. However, study hypothesis had not been disclosed to all participants. After rotating schedules were finalised, students were randomly allocated to the above 2 groups using a table of random numbers with even and odd in Group A and B, respectively. A research assistant who was blinded to outcome analysis performed the randomisation as well as allocation of participants. Our Institutional Review Board decided that informed consent was not required from the participating students.

Two Educational Intervention Strategies
Two researchers (HMC and FRG) designed the content of the educational interventions, which focused on teaching EBM via “User Mode”. The 2-week EBM-teaching for the final year students during clinical rotation to the general medicine service was incorporated into the daily ward round and patient care. Students in both groups were aware from the first day of the course that they had to receive the assessment for their EBP concepts at the end of the course and were requested to learn from our prepared on-line and e-learning material ( The learning objectives of both groups, which were set out the same since the commencement of the courses, had been familiarisation with the skills in the “3E-4Q-5A” process as well as determination of “level of evidence” of their acquired literature. During the ward round, students were encouraged by attending physicians to formulate clinical questions in “PICO” format and finish the steps of acquiring and appraising evidence. A companion in-depth reference book about core concepts of EBM and on-line web learning resources ( were provided for every student in the present study. In addition, Group A students attended a weekly 1-hour EBP-structured case conference held by EBM teachers for 2 consecutive weeks. In the first week conference, principles of EBP were summarised in addition to the introduction of rules and the format of case presentation as well as an example case demonstration. In the second week conference, Group A students (usually less than four) attended the conference to present the EBP application process on their own patient care, including case description, question formulation, evidence searching process, examination of internal and external validity of the selected literature and/or evidence, and self reflection. Group B students, however, received a weekly 1-hour didactic lecture for 2 weeks. In the lectures, EBM teachers instructed the core components of EBP, i.e., 3E (evidence, expertise, patients expectation), 4Q (therapy, diagnosis, harm, prognosis), and 5A (ask, acquire, appraise, apply, audit) using simulated or real teaching case examples. Group B students did not attend the EBP-structured conference, and vice versa. The former intervention in Group A was designed to have stronger degree of clinical integration because students in this group were asking to demonstrate the “3E-4Q-5A” process on their real clinical cases and whether the acquired evidence can be used for clinical decision process in the 2 week care. The didactic lectures and EBP-structured conferences were carried out in the format of small group activities with less than 10 participants by 3 experienced teachers with more than 4 years’ EBM teaching experience and 10 years’ clinical experiences. In addition, each student was assigned to 1 of the 4 service teams. The 4 attending physicians on general medicine service incorporated EBP during daily ward rounds. They had received a 12-hours faculty development programme focusing on teaching EBM before the commencement of this study. Skills and attitudes toward how to meet the learning objectives of the EBP courses for students had been demonstrated.

Aside from the randomly allocated 2-hour didactic lectures or EBP-structured conferences, all students in both groups were treated equally including the learning references, the teaching faculty, online education material, and core contents aimed at tutoring for problems formulation, evidence search, and critical appraisal. The teacher for didactic lecture in Group B was the same as the one who facilitate the EBP-structured conference in Group A. All students were also exposed to the same ward round hours (2 hours per day), assignments, and evaluation. The students received descriptive feedback by documents for their formulated PICO before the end of programme. The teaching effects of the interventions were evaluated by validated instruments for the assessment of EBP (see appendix) in terms of knowledge (EBP-K), personal application (EBP-P), attitudes (EBP-A), and anticipated future use (EBP-F) which were employed on the first and last days of the 2-week clinical rotation incorporating the EBM-teaching.

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