Dragan Ilic: Where’s the evidence for teaching evidence based medicine?

dragan_ilicThis blog is part of a series of blogs linked with BMJ Clinical Evidence, a database of systematic overviews of the best available evidence on the effectiveness of commonly used interventions.

The term evidence based medicine (EBM) was first coined in the 1990s, with the aim of promoting the greater integration of evidence with clinical experience and patient values in medical decision making. EBM has since blossomed into an inter disciplinary field, being adopted across medicine, nursing, allied health, health policy, and biomedical and health research. What initially began as EBM, has since evolved into evidence based practice (EBP), evidence based clinical practice (EBCP) and evidence based healthcare (EBHC). The last decade has seen the discipline embedded as a foundation unit across many medical, nursing, and health science courses.
As someone who has been involved with the teaching of EBM to medical students for over a decade, I’ve always been curious to identify new strategies that may improve the student learning experience. Traditionally, the transfer of knowledge in the tertiary sector has been one-way, with the lecture an effective method of disseminating information to a bulk audience. However, training in medicine is not simply a case of retaining and regurgitating information. Clinical skills, professionalism, critical thinking, and communication are just a few competencies that students must obtain to complement their scientific knowledge.

Different teaching strategies have been developed and implemented in order to accommodate the teaching of these different competencies. Problem based learning (PBL) activities have been implemented to encourage students to develop their critical thinking skills whilst participating in a small group learning environment and increasing their content knowledge. Work based learning can be used to develop a student’s communication and interaction with patients. Similarly, simulators assist students in developing clinical skills. So what about EBM? What is the best method of teaching EBM?

Surprisingly, there is not a large evidence base to inform educators how best to teach EBM to students—be it at a post-graduate or undergraduate level. At a post-graduate level, it is apparent that teaching EBM to post-graduate students in a format that is clinically integrated has been demonstrated to increase knowledge, skills, attitudes, and behaviour. Any method of teaching EBM to undergraduate medical students increases learner competency in EBM. Interestingly, current evidence suggests that no single educational intervention appears to be better than any other at achieving higher rates of learner competency—be it lectures, PBL, online or clinically integrated.

Over the last decade there has been a growing trend within the medical literature to adopt a blended learning approach to teaching. As the name suggests, this form of education aims to blend various teaching strategies to accommodate the different learning styles of students. We recently completed a randomised controlled trial (RCT) comparing blended learning of EBM to traditional didactic learning with medical students. The blended component included online, face-to-face, and clinically integrated aspects. The results were surprising. No difference in student competency was observed between the teaching methods, but a higher level of self-efficacy was apparent in the group receiving the blended learning approach. We also noted a significant preference from students for the teaching of EBM to be delivered via a blended learning approach; their reasoning, it bridged the gap between theory and practice. It was apparent that students valued the blended learning technique, but what of the cost? Is it worth changing to a blended learning style of teaching?

Research in the field of medical education traditionally has had a primary focus on determining the effectiveness of an intervention on learning outcomes. Yet, few studies have examined the cost and value of different learning strategies. For example, what would you recommend if your new education intervention was associated with greater learner competencies than the previous teaching style, but was double the cost? As part of our study examining the effects of blended learning in EBM, we also conducted a cost effectiveness analysis. It demonstrated that costs were reduced by 24% using a blended learning model, in comparison to didactic teaching.

So what did we learn from our experience? Blended learning for EBM does not have any impact on learner competency, but students value it more than didactic teaching, and it costs less. Is this the definitive evidence that we needed to answer the question of how best to teach EBM? Perhaps not, but at least we are building an evidence base to inform our educators and provide them with an opportunity to integrate the best evidence (along with student preferences) when designing and implementing their courses on EBM. If we are to teach the benefits of EBM to a wider audience, then surely we must also practice what we preach in the educational setting.

Competing interests: None declared.

Dragan Ilic is associate professor and the head of the medical education research and quality (MERQ) unit at the School of Public Health and Preventive Medicine, Monash University.