Incorporation of Research-Enhanced Practice Into Graduate Medical Education

As a result of increasing governmental support for medical investigators, the volume and complexity of clinical research have increased significantly since World War II. The proliferation of print and online medical journals along with secondary peer-review sources produces an environment in which every clinician is flooded with allegedly superior tests or treatments on a daily basis. In fact, the “number needed to read” to identify one clinically pertinent manuscript in one emergency medicine journal has been estimated to be 26 [1]. The low signal-to-noise ratio for the information overload often causes clinicians to tune out the majority of research as a self-defense mechanism [2]. The unintended consequences of truly revolutionary clinical advances are an unacceptable delay in the incorporation of the advances into routine practice and guideline-driven care, sometimes as long as a decade [3].

A means of avoiding this delay in knowledge translation is building a sound foundation in evidence-based medicine (EBM), which is often established during residency training [4]. However, numerous barriers need to be overcome to ensure that emergency medicine residents acquire and maintain the skill sets necessary to efficiently find, appraise, and archive medical science germane to their daily practice [5, 6]. One challenge is finding the optimal format and setting to teach EBM [7, 8]. Although the bulk of nonbedside learning has traditionally occurred in didactic settings, an increasing body of educational research suggests that knowledge acquisition and retention in classroom and continuing medical education settings is unacceptably low [9]. Journal club is another mechanism to review research findings, but educational trials have not demonstrated that this technique is superior to traditional didactics [10–16]. If EBM lessons could be encapsulated succinctly at the bedside during clinical rounds, new knowledge retention would probably be more likely. Unfortunately, such “knowledge translation shifts” have not yet been systematically evaluated either.

The barriers to integrating EBM into graduate medical education (GME) curricula extend beyond the format. Significant obstacles can be identified among those who would teach the skills, too. One survey of emergency medicine program directors revealed several barriers to EBM curricula. Only about 20% of programs had at least one faculty member who had attended well-recognized EBM workshops such as the McMaster University Evidence-Based Clinical Practice course [17]. Accordingly, the survey respondents noted the following barriers to incorporating EBM lessons into GME curricula: lack of faculty time (71%), lack of trained faculty (60%), lack of interested faculty (49%), and insufficient funding (43%). Nonetheless, more than half of their program directors teach EBM principles to their trainees and 25% have an established journal club curriculum [5]. GME leaders believe that the most important outcome of an effective EBM curriculum is enabling graduates to differentiate between minimally and significantly flawed studies. Emergency medicine program directors believe that residents should become familiar with secondary peer-reviewed sources rather than becoming experts at critical appraisal [4].

Worldwide Access to Biomedical Information via The Internet

Several useful electronic resources are available to assist EBM scholars without ready access to a medical library [18]. The National Institutes of Health/U.S. National Library of Medicine maintain several online resources that are accessible from anywhere in the world. PUBMED (http://www.ncbi.nlm.nih.gov/pubmed) is a massive database of citations from the biomedical literature and can be freely accessed from anywhere in the world [19, 20]. MedlinePlus (www.MedlinePlus.gov) offers consumer health information without the advertising bias of other online resources. The Turning Research Into Practice (TRIP, http://www.tripdatabase.com/) database is a free online resource that simultaneously searches several electronic databases before providing a hierarchy of evidence quality [21]. The TRIP database can also translate search findings into six different languages. Additional customizable search engines that find research evidence and stratify by the strength of study design are being developed [22].

Regional medical libraries can obtain manuscripts at a reduced cost and help rural physicians to locate an ordering library and set up a Loansome Doc account (http://www.nlm.nih.gov/pubs/factsheets/loansome_doc.html). Small hospital libraries with at least 25 lendable holdings can participate in DOCLINE (http://www.nlm.nih.gov/docline/), an interlibrary loan system. The HINARI Programme (http://www.who.int/hinari/en/) is a collaboration between the World Health Organization and publishing companies. Its purpose is to provide clinicians in developing countries free or low-cost access to biomedical and health information. At the time of writing this chapter, 160 publishers were participating in this program, providing access to 8000 information resources.

Characteristics of Poor Evidence-Based Medicine/Journal Club Curricula

Many design and organizational flaws limit the usefulness of journal club and EBM curricula in GME (Table 11.1). The single most important determinant of a journal club that fails to provide residents with lifelong learning skills to find and appraise practice-changing research is the lack of an opinion leader who is solely responsible for the content and quality of every lesson each year [23, 24]. Without a solitary figure, the journal club can devolve into a disorganized, anecdotal-opinion-laden shouting match without a structured take-home lesson. Some programs leave journal club organization to the chief residents with sporadic and highly variable faculty support. This approach fails to tap the educational, research, and clinical expertise of seasoned faculty and burdens residents with a task for which they are only partially trained. Without formal EBM training or supervision, residents often select lower-quality manuscripts [25]. If the articles selected for review lack applicability to emergency medicine populations or possess fatal flaws that limit their validity, residents learn to believe that clinical research is usually erroneous, never ready for the bedside, and therefore should remain in the purview of the academicians (research nihilism).

Table 11.1 Characteristics of an unsuccessful journal club.

Lacks single faculty opinion leader

Suboptimal manuscript selection

Failure to use formal critical appraisal instruments or archive results for asynchronous learning

Research nihilism

Statistical uncertainty

Insufficient individualized feedback

Evidence-based medicine decision making is not supported at the bedside

Residents and faculty members commonly misunderstand or misinterpret statistical concepts [26]. While an understanding of hypothesis testing and related statistical assumptions is a component of every original research manuscript, healthy skepticism mandates that astute clinician–scientists incorporate new findings within the context of their own medical experience [27]. This process requires clinicians to understand the difference between statistical and clinical significance while contemplating the myriad forms of bias that can distort the summary estimates of any medical research. Nonetheless, simple statistical tests such as kappa values can be computed during journal club sessions using sample data to illustrate the computational concepts and perhaps remove some of the mystery behind these numbers [28]. All medical skill sets (e.g., history taking, physical examination, procedures) require repetition with structured mentoring to isolate and correct errors. Similarly, the evolution of a resident’s critical appraisal skills requires repeated exposure to structured evaluation forms with graded feedback on a predictable basis [29]. Without a structured evaluation form, residents might ask the wrong questions of the available evidence and miss essential take-home points that even the most biased, inaccurate research can provide.

Another obvious deficiency of journal club formats is that they are physically and temporally disconnected from clinical care, thus giving the appearance that they are a purely intellectual exercise. If journal club and didactic EBM leaders fail to summarize the results of the search strategy, the critical appraisal of the article, and the group’s opinion in a readily accessible format, those who could not attend the session will not have the opportunity to learn from the session. In addition, those who did participate are likely to forget the specifics of the discussion except for the most poignant lessons.

Attributes of the Successful Evidence-Based Medicine Curriculum and Journal Club

The perfect journal club has yet to be described, and the concept of EBM has yet to demonstrate evidence of superiority or improved/cost-effective patient-centric outcomes [30]. Nonetheless, EBM does provide a theoretical framework on which clinician–educators can begin to link research evidence with physicians facing an information overload. However, several high-yield formats that facilitate residents’ uptake of EBM knowledge have been described and are summarized in Table 11.2 [23, 31]. First, recognized EBM curricular leaders generally funnel these efforts through a single-thought leader and established journal club format. These opinion leaders usually share responsibilities of the monthly journal club with other faculty members in order to teach the teacher how to provide structured EBM lessons in a controlled environment away from the busy ED. Inviting faculty members to participate in these sessions builds a critical mass of EBM expertise within an institution while motivating less confident teachers to seek training through widely accessible and critically acclaimed courses [17, 32]. Faculty buy-in can be enhanced by ensuring that the quality of the end product is sufficiently high to merit a peer-reviewed publication in most cases, thereby providing busy clinicians with academic currency for their efforts rendered [4].

Table 11.2 Successful journal club attributes.

Having a single faculty leader

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