An Evidence-based Medicine Curriculum for Medical Students

Objective: One goal of undergraduate medical education is to help students direct their own learning when faced with clinical uncertainty. To address this challenge, in 1998 we introduced an evidence-based medicine (EBM) curriculum for third-year medical students during their four-week ambulatory clerkship. Our learning objectives were for students to identify their emerging information needs, convert them into focused clinical questions, select and search the most appropriate information sources for their type of question, and apply the evidence to decision making for their patients. We also expected students to appreciate the clinical value of EBM and to increase their confidence in practicing it. Description: During the first week of their clerkship, students participate in a 60-minute interactive workshop introducing the “art” of translating information needs into focused, answerable questions. We solicit their clinical questions arising from recent patient encounters and distinguish between “background” and “foreground” questions (e.g., background questions are usually more appropriate for searching textbooks and foreground for original studies). Students then articulate “well-built” questions consisting of key patient information, intervention(s), comparison, and specific outcome(s). Students also classify their questions by clinical task (e.g., therapy) and learn simple methodologic “filters” for each question type (e.g., for therapy, “clinical trial”) to maximize the yield and relevance of their Medline searches. During the second week, students participate in a more extensive 60-minute workshop on searching Medline and secondary databases (e.g., Best Evidence, Cochrane), facilitated by an expert medical librarian. Each student completes an EBM project linked to morning report occurring on Monday and Thursday every week. One student presents an actual case, and the group of 10–12 students gives feedback to help identify the most important question (20 minutes allowed). At the subsequent morning report, the same student briefly presents the clinical question, the evidence, and how this affected decision making (5–10 minutes). Students also distribute a one-page report summarizing the case, the question, the information source, the “bottom line” (evidence), application of the evidence, decision (action), and rationale. We are developing a numerical grading system to assess the quality of the written projects. Discussion: We emphasized the skill of converting information needs into answerable questions because we have found that this is a major stumbling block for students and residents learning to practice EBM. We expect students to practice EBM in real time, and therefore we try to minimize potential time barriers in preparing their reports. In terms of curriculum resources, students receive one-on-one coaching during and after workshops and have access to excellent computer information facilities and expert medical librarians. We have encountered a few barriers to teaching EBM. For example, during the introductory workshop when we solicit students' clinical questions arising from their practices, we sometimes receive blank stares and opinions that there is not much uncertainty in ambulatory practice. This leads to a fruitful discussion of the information needs among practicing physicians. We are evaluating the degree to which students are meeting the curriculum's learning objectives, practicing EBM during their clerkships during and after participating in the curriculum, and encountering any barriers.