Successful teaching in evidence-based medicine.

OBJECTIVES: Several published articles have described the importance of exposing medical trainees to the 'new paradigm' of evidence-based medicine (EBM). Recognizing this, we sought to develop and objectively evaluate a mini-course in EBM for third-year medical students. DESIGN: We developed a mini-course consisting of four sessions in which students learn to derive sequentially focused questions, search MEDLINE, review articles critically and apply information from the literature to specific clinical questions. To evaluate the teaching intervention, we performed a controlled educational study. Students at the intervention site (n=34) attended the EBM mini-course, while students at the control site (n=26) received more 'traditional' didactic teaching on various clinical topics. Intervention and control students were surveyed immediately before and after the mini-course to assess changes in reading and literature searching skills, as well as a tendency to use the literature to answer clinical questions. SETTING: Boston University School of Medicine. SUBJECTS: Third-year medical students. RESULTS: The intervention was associated with significant changes in students' self-assessed skills and attitudes. MEDLINE and critical appraisal skills increased significantly in the intervention group relative to the control group (significance of between group differences: P=0.002 for MEDLINE and P=0.0002 for critical appraisal), as did students' tendency to use MEDLINE and original research articles to solve clinical problems (significance of between group differences: P=0.002 and P=0.0008, respectively). CONCLUSIONS: We conclude that this brief teaching intervention in EBM has had a positive impact on student skills and attitudes at our medical school. We believe that the key elements of this intervention are (1) active student involvement, (2), clinical relevance of exercises and (3) integrated teaching targeting each of the component skills of EBM.

Evidence-based medicine and the real world: understanding the controversy.

Controversy has surrounded the 'paradigm' of evidence-based medicine since its introduction in 1992 as a new approach to the teaching and practice of medicine. Here, we address two questions: (1) is evidence-based medicine a good thing?; and (2) why has so much controversy arisen? In addressing these questions, we propose that the discussion surrounding evidence-based medicine should no longer be about whether the application of evidence in clinical practice is a good thing, because it obviously is. Instead, the debate ought to focus on the more difficult question of how to enhance its acceptability among busy clinicians practising in the 'real world'. For the future, we optimistically anticipate an enhanced adoption of evidence-based medicine, as clinicians will become increasingly capable of efficiently accessing existing and forthcoming evidence resources.

Practical approaches to a major educational challenge. Training students in the ambulatory setting.

Medical schools and residency training programs are recognizing the need to expand education in ambulatory medicine. Inpatients wards increasingly provide treatment for only the most critically ill patients and are required only for very specialized procedure-oriented technology. Most diagnostic and management decisions are being made in outpatient settings. This shift in where medical care occurs has led to a reassessment of the educational value of training students and house staff primarily on hospital-based wards. New training initiatives in ambulatory medicine are being developed in medicine, pediatrics, and family medicine, and the principal sites for most of this training are primary care offices, clinics, and health maintenance organizations. Program planners and individual preceptors are confronting numerous obstacles in their efforts to find effective solutions to the dilemmas raised by the need to train large numbers of students in these settings. This article will explore many of these obstacles, including the unique learning requirements of third-year students, the elements of a quality clinical training environment, and the precepting skills needed for this educational task. Finally, we propose for debate a model for ambulatory medical education that focuses on strengthening the ties between academia and the numerous training sites. By taking optimal advantage of academic and community attributes, we are more likely to be assured quality medical education, skilled teaching, and rigorous scholarship in ambulatory medicine.

Exercise counseling: how do general internists do?

OBJECTIVE: To assess how often physicians counsel patients about exercise and to identify which primary care internists infrequently counsel about it. DESIGN: Cross-sectional survey of a random sample of primary care internists in Massachusetts. Questions covered physicians' attitudes, beliefs, and practices with respect to counseling about exercise; physicians' perceived barriers to counseling about exercise; physicians' personal exercise frequency; and physician demographics. PARTICIPANTS: Of 1,000 physicians, 687 were eligible and 422 returned usable questionnaires (response rate 61%). RESULTS: Data describing physician demographics, practice setting, measures of personal fitness, and beliefs regarding exercise were entered into a logistic regression model. The characteristic that best identified physicians who infrequently counsel about exercise was their perceived lack of success at counseling (OR 22.83, 95% CI 8.36-62.31). Other independent predictors of infrequent counselling were physicians' lack of conviction that exercise is very important (OR 4.86, 95% CI 1.70-13.91), physician age < or = 40 years (OR 3.08, 95% CI 1.33-7.15), and higher physician resting heart rate (OR 3.45, 95% CI 1.46-8.18). CONCLUSIONS: Several factors were found to be independently associated with the likelihood of a physician's counseling about exercise. These included physician perceived success at counseling, physician belief that exercise is important, physician age, and physician resting heart rate. These results suggest possible strategies to improve physician's counseling efforts.

Utility of echocardiography in patients with suspected mitral valve prolapse.

PURPOSE: Echocardiography has become a widely utilized test since its introduction into clinical medicine in the early 1970s. Although it has frequently been performed in patients suspected of having mitral valve prolapse (MVP), its usefulness in this setting has not been systematically studied. To investigate the use and value of echocardiography in patients suspected of having MVP, we conducted a prospective study in which physicians were interviewed before and after ordering echocardiographic testing for patients in whom there was a suspicion of MVP. PATIENTS AND METHODS: The study population included consecutive patients referred to the echocardiography laboratory at Boston University Medical Center because of suspected MVP between January 1 and December 31, 1987. Two standardized telephone interviews were conducted with the physician most responsible for ordering the echocardiogram. The following information was obtained during the first interview, which was always conducted before the echocardiogram was performed: patient demographic and clinical data; the reason for ordering the echocardiogram; the physician's most likely clinical diagnosis; the physician's estimate of the likelihood that the patient had MVP; and the physician's proposed management plans. After the referring physician received the echocardiographic results, a second interview was conducted to determine changes in the most likely clinical diagnosis and management plans. The impact of the echocardiogram on diagnosis and management was evaluated by comparing physician responses before and after reception of echocardiographic results. Receiver operating characteristic (ROC) curves were constructed to assess the physician's skills at distinguishing patients with echocardiographic-documented MVP from those without MVP. RESULTS: A total of 106 echocardiograms were ordered by 45 different physicians. More than 80% of all echocardiograms were ordered to address diagnostic or therapeutic concerns. On echocardiography, 47 (44%) patients were found to have MVP, six (6%) had mitral regurgitation without prolapse, and 53 (50%) had normal results. On the basis of the ROC curve analysis, the physician's ability to discriminate between patients with and without echocardiographic MVP varied significantly by physician specialty and practice setting. The echocardiographic results led to a change in diagnosis in 59 (56%) patients. A change in management occurred in 29 (27%) patients, with 25 of these 29 changes (86%) related to the initiation or discontinuation of antibiotics. CONCLUSIONS: Echocardiography frequently alters diagnostic assessments and leads to therapeutic changes in some patients suspected of having MVP. However, the benefits of such changes have not yet been demonstrated.