TABLE OF CONTENTS SECTION I:
Introduction
SECTION II:
Small Group Problem-Based Learning
SECTION III:
Roadmap
SECTION IV:
Teaching Packages
SECTION I: INTRODUCTION A) THE WORKSHOP 1. Introduction and Background 2. Objectives 3. How We Achieve These Objectives B) HOW TO USE THIS MANUAL AND PREPARE FOR THE WORKSHOP 1. The Manual 2. Small Group Sessions 3. Searching Skills
A)
THE WORKSHOP
1. INTRODUCTION AND BACKGROUND What is Evidence-Based Clinical Practice? Evidence-based clinical practice has been variously defined as: • • •
an approach to practicing medicine in which the clinician is aware of the evidence in support of her clinical practice, and the strength of that evidence. the process of systematically finding, appraising, and using contemporaneous research findings as the basis for clinical decisions. the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.
However one defines EBCP, its practice involves a number of skills. These include: • • • • •
Defining clinical questions in a way that allows clear answers (Ask) Efficient searching for the best information to answer the question (Acquire) Appraising the evidence to determine its strength (Appraise) Extracting the clinical message from the information (Apply) Applying that information to ones’ patients, including weighing risks and benefits in the context of patient values and preferences (Act)
Clinicians trained in both medicine and in epidemiology and biostatistics have developed strategies to deal with these challenges. EBCP has become an international phenomenon, and medical students, physician-trainees, and practicing clinicians have become aware that to practice optimally, they need to develop these skills. They look to their teachers, mentors and colleagues for help. Our workshop is designed for those who are, or will be, the role models and teachers of EBCP.
2. OBJECTIVES • • • •
To help participants learn how to teach evidence-based clinical practice in different educational settings (on the wards, in out-patient clinics, tutorials, journal clubs, and large group sessions). To help participants advance their evidence-based clinical practice skills. To introduce participants to effective, interactive means of teaching small groups and in large groups. To renew and enhance participants’ excitement and enthusiasm about teaching EBCP, and kindle their imagination about ways to improve their teaching.
3. HOW WE ACHIEVE THESE OBJECTIVES While the workshop includes a mix of large-group and small-group sessions, the major venue for learning will be in your small group. We encourage participants to consider the settings in which they will do most of their teaching and the challenges they face there. For many members, these settings are mostly on the ward or in the outpatient setting where the teaching opportunities are from 30 seconds to 20 minutes. Other opportunities are more conventional - morning report, journal clubs, noon hour rounds, or medical student tutorials. The groups work together to help one another develop interactive teaching strategies for each of these settings.
B) HOW TO USE THIS MANUAL AND PREPARE FOR THE WORKSHOP
1. THE WORKSHOP MANUAL
The third section of this manual contains a set of teaching modules dealing with evidence-based clinical practice and critical appraisal issues in therapy, diagnosis, prognosis, harm, overview (systematic reviews), clinical practice guidelines, clinical prediction, and disease probability for differential diagnosis. The clinical problems in these packages are specialty-specific (according to the clinical area you named on your application and the best fit we could make with your background and those of other participants) but the overall format and methodologic documents are the same for all workshop participants. Each of these packages contains: • • • •
an outline of the goals and objectives of the package a clinical scenario describing a patient problem one or more clinical papers pertinent to the problem posed in the scenario some worksheets for organizing ideas as readers work through articles
Participants evaluate the clinical papers and complete the worksheet using the relevant section of an evidence-based practice text they receive, Users’ Guides to the Medical Literature.
2. SMALL GROUP SESSIONS As you will see from the program, we have scheduled ten small group sessions and these will be the primary learning forum of the workshop. Each group will have approximately eight participants, two tutors experienced in teaching evidence-based clinical practice and critical appraisal in the small group environment, a tutor-trainee and a librarian. Each group will meet on Sunday evening, review the members’ goals and, building on prior online interaction, begin to set its agenda for the week. As much as possible, participants are grouped according to clinical specialty and level of EBCP expertise. Each group will chart its own course. The small group sessions are highly interactive, and rely heavily on role play. Participants define a clinical setting (on the ward or in an outpatient clinic with house staff, a medical school tutorial, a journal club) in which they will be teaching EBCP (with the exception of didactic lectures or Power Point presentations, which generally do not fit well with the goals of these sessions.) One group member is designated as the instructor, teacher, or facilitator, and other members adopt the roles of medical students, residents, or colleagues interested in learning EBCP. What varies are the settings, who takes the facilitator role, and the content in terms of the type of article and specific clinical problem being addressed. The packages in the manual are suitable for one type of teaching exercise: a journal club or tutorial in which one has at least 30 minutes, and usually an hour or more, to review an article in some detail. We would encourage you to look over the packages before the workshop, and decide on the extent to which they interest you. Our expectation is that everyone will present at least once during the tutorial sessions. As with most educational activities, you are likely to get the most out of the workshop if you prepare beforehand. You will have the opportunity to interact online with your group, and to use a web aid to begin thinking about your first presentation. Ideally you will consider a teaching situation you have encountered in the patient care arena, or in a specific teaching setting, and challenges you have faced using these situations to teach evidence-based clinical practice. You will continue these activities when you arrive in Hamilton. Searching for appropriate articles related to clinical problems appropriate to your own practice setting will require library work. The Health Sciences Library, located within McMaster Health Sciences Centre, is open from 8:00 a.m. to 10:00 p.m. (Monday-Thursday), 8:00 a.m. to 8:00 p.m. (Friday), 10:00 a.m. to 6:00 p.m. (Saturday) and 10:00 a.m. to 10:00 p.m. (Sunday). A staff member will be available throughout the week to help locate articles. Searches on a number of databases can be conducted free in the library on CD-ROM or a librarian will conduct online mini-MEDLINE searches. You will have
access to a computer lab throughout the week, and can conduct your own searches with or without the help of a librarian. The idea of the small group sessions is to use the tutorial sessions as a laboratory for trying out approaches that you would like to use in your home centers. You may elect to have the participants in your tutorial group role play specific protagonists in your teaching scenario. This will augment the verisimilitude of your teaching experiment and create structure to your session.
3. SEARCHING SKILLS A key component of EBCP is ‘efficient searching for the best information to answer the question’. To help you to enhance your skills, most groups, and if we have enough librarians every group, will have its own librarian. The major roles of the librarian are to assist in the construction of wellbuilt questions; the identification of high quality evidence-based resources; the development and enhancement of searching skills. The librarian’s expertise can be used by the group in tutorial sessions, in a scheduled 2-hour computer lab session or by individual students and tutors during study time or drop-in lab sessions. Most groups choose to have one computer laboratory session, typically co-run by a participant and librarian or a participant who had worked out the session’s content with the librarian beforehand. How this session might be handled is up to each group, but it is important to remember that you have access to a skilled librarian who was chosen based upon her/his knowledge of EBM, small group teaching and searching. Please plan to take advantage of this opportunity!
SECTION II: SMALL GROUP PROBLEM-BASED LEARNING A) The Small Group Tutorial Self-directed Learning 1. Problem-based learning 2. Self-directed learning
A)
THE SMALL GROUP TUTORIAL SELF-DIRECTED LEARNING In this workshop, we will adopt educational methods that are used at McMaster, particularly in the undergraduate medical programme. We thought it would be useful to describe the rationale and strategies of 2 central features of the educational approach: • •
Problem-based learning Self-directed learning
1. PROBLEM-BASED LEARNING Rationale: A number of influences led to this educational concept: •
• •
The ‘founding fathers’ recalled their own medical education experiences. In particular, they recalled usually being unable to remember the facts (by which they had passed exams) from the first 2 years of medical school, for application to patients in the clinical years. They also remembered the difficulty of ‘integrating’ knowledge from a range of disciplines in the management of a single clinical problem. There was evidence from the general medical literature that retention is enhanced when facts are learned in a context which closely approximates real life, e.g., a clinical problem. More recent research into how physicians think has clarified the nature of the clinical reasoning process. These insights include the central role of hypotheses which occur early in the clinical encounter and which strongly influence the sequence and range of clinical data obtained. This thinking process can be replicated in an educational setting which begins with the analysis of a clinical case.
Strategies: Given this rationale, the following strategies are used: • • •
All learning begins with the analysis of a clinical problem. There are no ‘free standing’ educational offerings by separate disciplines. Clinical problems are used both to stimulate exploration of issues from a range of disciplines, as well as to synthesize new learning. The small tutorial group (n = 5 to 8) is thought to be the best forum for this activity. These are given highest priority. All other events (e.g., overview, lectures, clinical skills sessions, etc.) revolve around the tutorial.
•
•
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The faculty tutor’s role includes assisting students in problem analysis, stimulating critical thinking, making sure that groups work effectively, in a highly interactive manner, and evaluating student progress. A tutor is not primarily a ‘content expert’. The criteria on which problems are selected include frequency, prototype value, treatability (where evidence exists that treatment or preventive interventions do more good than harm), and suitability for exploring concepts from several disciplines. Special evaluations exercises have been devised which also require the analysis of clinical problems.
2. SELF-DIRECTED LEARNING Rationale: Again, several influences led to the adoption of this idea. • •
•
In general, it seems that health professionals have limited motivation and skills to continue their learning. This becomes more apparent as they get older. Medical information becomes obsolete as new knowledge supersedes or contradicts the old. Within a decade of graduation, only a small proportion of the knowledge used by physicians was learned in medical schools. Research in education suggests that there is enormous variation in which individuals learn, both in terms of content and ‘style’. It is therefore important to allow for flexibility and ‘individualization’ of the learning arrangement.
Strategies: This rationale leads to the following specific strategies: •
• •
•
Students are admitted from a variety of academic and experience backgrounds. Their needs therefore differ substantially. By putting students together in learning groups, they become resources to each other. The faculty tries to ‘free up’ the schedule so that students have sufficient time for self-study for group-work and for individual elective experiences. A delicate balance is struck between excessive structure (faculty guidance) and ‘total freedom’ (which, while desirable, may not be feasible given certain resources and schedule constraints). This balance is reflected in the way objectives are stated, in how tutors tute, in how ‘large group sessions’ are arranged and in the availability of learning resources. Students are given help with special techniques such as developing personal filing systems, scheduling their time, study habits, and learning how to read and evaluate the clinical literature.
SECTION III: ROADMAP The Roadmap was developed to facilitate your learning during the workshop and it is fully demonstrated in the interactive website, together with applications and exercises that we have developed to help you to prepare for the workshop in advance. It is embedded in an interactive site that, if you choose, you may visit prior to the workshop. To make optimal use of the roadmap, you should begin to explore the website as soon as possible. The site provides a framework for specific workshop preparations, including projects and presentations you will be leading in your small group sessions. The workshop experience provides an opportunity to advance knowledge and skills needed for critical appraisal of the medical literature and for integrating critical appraisal into clinical practice. The Roadmap provides you with a blueprint of evidence-based practice. It can help you make informed choices regarding the areas of learning you wish to emphasize during the workshop week, as well as to locate where a particular topic or session fits into the fabric of EBCP. To access the website, go to: http://www.ebcp.com.br/simple and register. You will receive an email confirmation. It may take another 48 hours to receive your login and password to access the system. Once you receive it proceed to login. You will first be required to complete a short survey that will provide us with information regarding your prior experience with EBM and your interests. On completion of the survey you will have access to the full site including the interactive tools to be found therein. The term “roadmap” refers to the pathway that leads across transition points connecting the subjective, individualized, domain of clinical interaction, interpretation and shared decisions, and the objective, generalized, world of scientific knowledge, including information derived from clinical research, represented in the Figure 1, below. The components of the map are shown in Figure 2. We suggest that you begin by visiting the ‘Tutorial’ under ‘Roadmap’, using the link from the main page. This tutorial will take you between 1 to 3 hours of time and will introduce you to, among other things, to evidence-based resources and databases that will remain available to you throughout the workshop period. Finally, after completing the tutorial, you may start developing the exercise that you are willing to use during your small group session and share it with your group through the function under ‘Activities’ named ‘Share with your team’. Once you have saved and shared
your project, you and others in your group (only) will be able to view it, including the saved files, by going into the “Sharing point” folder. You will see your project title in a menu box, and when you open it, you will also see the links to the files you uploaded. In the course of this work, the site will allow you to upload files and to communicate with your facilitator team, who may also choose to begin to review your work prior to your departure to Hamilton. The ‘Teaching Packages’ folder contains the materials that will be used during the course of the workshop and are the main source of content for your preparation to the small groups activities. The website is a relatively new aspect of the workshop - this is the second year in which it is part of the program. Last year, many participants found it extremely useful - others less so. We have modified the website extensively, and believe that it is likely to be helpful to most
participants, and very helpful to many. We encourage you to explore - and in due course to provide feedback.
Figure 1: A representation of individualized care subsuming identification and integration of relevant external scientific evidence into the substance of clinical action.
Figure 2: Each of 4 modes of clinical action calls for mastery of information skills if clinical evidence is to have an impact on clinical decisions and consequences. The action modes determine the specific content of the information skills.
SECTION IV: TEACHING PACKAGES The teaching packages are available in the main McMaster website, under TEACHING MATERIAL at http://ebm.mcmaster.ca/course_materials.html