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Teaching evidence-based clinical practice to neurology and neurosurgery residents
Clinical Neurology and Neurosurgery 109 (2007) 418–421
Teaching evidence-based clinical practice to neurology and neurosurgery residents J.G. Burneo ∗ , M.E. Jenkins, the UWO Evidence-Based Neurology Group Department of Clinical Neurological Sciences, University of Western Ontario, Canada Received 21 January 2007; received in revised form 7 March 2007; accepted 9 March 2007
Abstract The primary objective of education in evidence-based clinical practice (EBCP) is to provide a resident or student with the requisite skills to satisfactorily solve real everyday clinical problems throughout their careers and to translate those solutions into better care for patients. At the University of Western Ontario in London, Canada, there is a well-developed and highly successful evidence-based neurology curriculum primarily aimed at residents. This article summarizes the current context of EBCP postgraduate training in the neurological sciences and a detailed description of its purpose, learning outcomes, required resources, content, teaching strategies, and assessment tools. In this program, we teach the principles of EBCP through the review of pertinent neurological clinical questions. The summary of each topic is recorded on our website in the form of critically appraised topics (CATs) in electronically accessible CAT banks. © 2007 Elsevier B.V. All rights reserved. Keywords: Evidence-based neurology; Neurology; Neurosurgery; Education
1. Introduction There has been an incredible “boom” of teaching evidence-based clinical practice (EBCP) across different specialties in medicine and surgery. Neurology and neurosurgery lag behind. There have been a efforts, such as the ones put by the association of British neurologists as well as the creation of the Cochrane neurological network. However, teaching of EBCP to neurology and neurosurgery residents and students is almost non-existent. Since EBCP is about solving clinical problems [1], it acknowledges that intuition, unsystematic clinical experience, and pathophysiologic rationale are not enough to make a clinical decision, and stresses the examination of evidence from clinical research. Clinical problem solving is very applicable to the daily practice in the neurological sciences. That ∗
Corresponding author at: Epilepsy Programme, University of Western Ontario, 339 Windermere Road, London, Ontario, Canada N6A 5A5. Tel.: +1 519 663 3464; fax: +1 519 663 3498. E-mail address: [email protected] (J.G. Burneo). 0303-8467/$ – see front matter © 2007 Elsevier B.V. All rights reserved. doi:10.1016/j.clineuro.2007.03.001
is why EBCP needs to be fostered among our neurology and neurosurgery residents and students. At the University of Western Ontario in London, Canada, there is a well-developed and highly successful evidencebased neurology curriculum primarily aimed at residents [2]. In this program, we teach the principles of EBCP through the review of pertinent neurological clinical questions. The summary of each topic is recorded on our website in the form of critically appraised topics (CATs) in electronically accessible CAT banks. Our objectives are to describe the current curriculum at our center and to criticize some of the flaws and obstacles encounter since its development.
2. EBCP curricula At each, 90-min EBCP session, relevant neurological topics, chosen by the residents are explored, following the EBCP principles of creating a specific question, finding the best evidence, and critically appraising the evidence.
J.G. Burneo, M.E. Jenkins / Clinical Neurology and Neurosurgery 109 (2007) 418–421
The clinical topics (12–24 topics/year) are annually assembled by surveying all neurology trainees and teaching neurologists in the department and in this way generating a list of clinically important neurological themes or topics. These topics are then ranked by EBCP participants and faculty according to frequency of occurrence, level of relevance, clinical importance, amount of interest and enthusiasm, and question answerability. The most highly ranked topics become the basis for the clinical evidence-based neurology content for the upcoming academic year. The topics are screened additionally to ensure they fulfill the educational recommendations of the training program (postgraduate education committee) and Royal College of Physicians and Surgeons of Canada Advisory Committee. The content is flexible and modifications are made periodically to better satisfy trainee needs. Annual and semiannual meeting of participants are held to review what has been done and what still needs to be addressed. In addition, a formal program evaluation survey is completed by all attendees. The entire curriculum content is designed to be responsive to results of evaluation and feedback. All the topics are equally divided amongst the neurology trainees. Schedules indicating dates, times, locations, names of topics, responsible resident, and faculty facilitator are posted on the website to inform other residents and faculty of upcoming topics. 2.1. Pre-tutorial Resident designated for each session chooses a personal clinical experience, which falls under the category indicated by the scheduled topic, and a focused clinical question is constructed based on a real patient encounter. A literature search strategy is developed to best answer this question and the search is subsequently conducted and refined. The available literature is screened according to predefined criteria and one to four articles are selected. The selection will follow the hierarchy of evidence available. The resident in charge will make copies of the clinical scenario, question, search strategy, and literature, and he circulates them among all trainees and faculty facilitators at least one week in advance of tutorial. The presenter will prepare a CAT in advance. The entire pre-tutorial process is reviewed and facilitated at each step by one or both of the program directors (JB, MJ). All trainees arrive at tutorial prepared to participate. 2.2. Tutorial The tutorials are designed to be interactive, informal discussions led by the designated resident and facilitated by the program directors (JB, MJ). In the initial 5 min, the resident will lead a presentation and discussion of the clinical scenario and the focused question. This is followed by a 10-min power point presentation on the topic, particularly if the neurological condition, treatment, or diagnostic test to be reviewed is rare or of low prevalence.
419
The presentation and discussion of the literature search strategy and yield is done in 5 min, and then 45 min are dedicated for critical appraisal of the evidence. For the appraisal, the participants are divided in three or more groups depending on the number of attendees. Each small group reviews the article and prepares to discuss the questions from the applicable rating scales for that session. These rating scales are derived from the JAMA articles on “Users’ guides to appraise the medical literature” [3] and relate to critical appraisal of articles in the realm of diagnosis, treatment, prognosis, etc. These rating scales are also available on the website. The final part of the session is dedicated to a whole group discussion of the interpretation of results and application to the case at hand (5 min), to define the clinical bottom lines (5 min), and to approve the CAT prepared by the presenter (5 min). At the end, a brief evaluation of the session is done by the presenters and the facilitators (10 min). 2.3. Post-tutorial The evidence-based neurology facilitators and resident edit and submit the final CAT product to a resident in charge of the website, for publication and circulation in electronic form [2]. All trainees are encouraged to use their acquired evidencebased medicine practice skills in other clinical venues, including clinics, wards, rounds, teaching sessions, and in dialogue with their peers and the teaching neurologists. 2.4. Critically appraised form (CAT) The CAT is a concise, user-friendly, accessible EBCP summary that can help clinicians’ needs for relevant, up-to-date EBCP information, and assist in clinical decisionmaking. A collection of updateable, peer-reviewed CATs covering a wide range of neuroscience topics can help clinicians implement EBCP without having to engage in the entire EBCP process. For the preparation of the CAT, one has to assess whether the evidence is valid and whether we can apply it to our daily life (our patients). The task is made easier by following rating scales and working sheets already prepared, based on the “Users’ guides to appraise the medical literature [3]. These rating scales and working sheets are available at the EBN website of the University of Western Ontario [2]. These rating scales have three different parts: (1) analysis of the validity of the study by assessing the methods used, (2) assessment of the final results presented, including the accuracy and clinical importance of these results, and (3) appraisal of how the results help in caring for our patients. Each rating scale has some modifications depending on the type of article (i.e., diagnosis, prognosis, therapy, meta-analysis, guidelines, or decision analysis).
420
J.G. Burneo, M.E. Jenkins / Clinical Neurology and Neurosurgery 109 (2007) 418–421
3. Resources
3.6. Computer and informatics
3.1. Financial
There is a dedicated personal computer for the evidencebased neurology program. Additionally, faculty has access to a laptop computer and projection unit to enable facilitators to use Power Point technology during presentations and teaching sessions.
The Department of Clinical Neurological Sciences has resources allocated to the EBCP program. This covers for lunch (as the sessions take place during lunch hour) and facilitates research endeavors. 3.2. Faculty There are two full-time teaching neurologists in the department qualified to teach evidence-based medicine, clinical epidemiology, and biostatistics. Senior residents, having been exposed to evidence based medicine training and practice in the program, become highly skilled and have a graduated level of responsibility regarding the teaching role. An invitation to all neurology and neurosurgery faculty is done in advanced; special invitations are extended to faculty of different sub-specialties in Neurology, when a specific topic of their concern is presented. Neurosurgery residents are always invited, although they do not participate as active as the neurology residents in the preparation of the sessions and the CATs. Teaching physicians through other departments, for example, internal medicine, with EBM training occasionally participate through invitation. The evidence-based neurology trainees vary in number from a total of 10–14 each year.
4. Objectives [5] The overall goals of the curriculum are to foster life-long self-learning, to encourage self-evaluation, and to promote improvement of care for neurological patients. More specific aims discussed below include acquisition of skills, developmental of attitudes and behaviors of EBCP, and attainment of knowledge. 4.1. Skills By the end of postgraduate neurological training, residents will be able to: (1) construct a focused, answerable question when faced with uncertainty in a clinical scenario; (2) devise a strategy and conduct efficient literature searches on a variety of available databases; (3) critically appraise a published report of a clinical study; (4) apply the appraised evidence to their clinical problem; (5) incorporate the evidence into their decision-making for individual patients.
3.3. Time
4.2. Attitudes and behavior
The EBN tutorial sessions are ninety minute in duration, held monthly, 12 months per year, throughout the 5-year training program. The sessions fit into protected educational half-day time for neurology trainees. Preparatory time for trainees and faculty is informal and unscheduled.
By the end of postgraduate neurological training, residents will: (1) appreciate the advantages of practicing EBCP; (2) find the EBCP curriculum to be valuable and feasible; (3) increase their use of evidence from clinical research to help solve the neurological problems they may encounter; (4) continue to practice and teach EBM throughout their neurological careers.
3.4. Space The monthly tutorials are held in an available hospital conference room. The departmental library houses the evidence-based medicine library, computer, links to require databases, all necessary software, in addition to desks, tables, book shelves, and chairs. 3.5. Educational material A resource binder containing the most valuable evidencebased medicine literature is compiled and distributed to the trainees. A compilation of critically appraised topics are processed and printed in pocket size form to allow trainees to have easy access to the fruits of their labor during subsequent and clinical encounters. A book on evidence-based medicine is given to all new residents as part of the welcoming package [4].
4.3. Knowledge By the end of postgraduate neurological training, residents will have: (1) acquired knowledge of the most current best evidence for neurological practice in all the various subdisciplines of the clinical neurosciences; (2) developed the skills (see above), to update this knowledge, as it evolves, over the time span of their careers.
5. Discussion The direction toward which post- and under-graduate neurological education must move is clear. Ensuring that our residents acquire the skills to articulate answerable questions, search and appraise literature, and interpret and apply the results to the care of individual patients is essential.
J.G. Burneo, M.E. Jenkins / Clinical Neurology and Neurosurgery 109 (2007) 418–421
The primary objective of education in EBCP is to provide a resident or student with the requisite skills to satisfactorily solve real everyday clinical problems throughout their careers and to translate those solutions into better care for patients [6]. Our curriculum for the introduction of EBCP into neurological training is clearly a work in progress. A curriculum, by its very nature, is a never-ending winding path. This article summarizes the current context of EBCP postgraduate training in the neurological sciences and a detailed description of its purpose, learning outcomes, required resources, content, teaching strategies, and assessment tools. Throughout the development of the program, many problems have been faced by previous EBCP curricula innovators and new solutions for overcoming the majority of recognized barriers are always being sought out. Just as it may take ten years for results of clinical research to find their way from the literature to routine use at the bedside, the diffusion of educational innovation is recognizably slow [5]. Our curriculum has several strengths. The current curricula of structured workshops for EBCP teaching in neurological training has allowed residents to develop skills need to practice EBCP. We are using an innovative educational intervention addressing the shortcomings of traditional teaching. This curriculum and the way it is delivered has been formally evaluated [7]. Residents and graduates from our residency program reported that the EBCP curriculum increased their confidence in knowledge of existing evidence and developed their skills in EBCP principles. The shortcoming of this curriculum lies on recognized barriers. Firstly, the skills have not been consistently transferred to daily patient encounters, often due to time constraints [8,9]. In an effort to overcome this, we created an “evidence based neurology” elective rotation for medical students. The student selected, attended rounds on the neurology ward, with the purpose to act as a facilitator and teacher about the principles and integration of EBCP. This rotation successfully enhanced the use of EBCP knowledge and practice by the neurology residents in their daily activities. The results of this intervention have been submitted to the Annual Meeting of the American Academy of Neurology. Secondly, there continues to be hesitance from some staff neurologists to accept this new but important educational strategy to replace the traditional journal clubs or the standard didactic lecture format; although, attitudes are changing. With regards to educators, more information is needed about the best techniques and strategies for teaching EBCP.
421
In addition, educators must embrace the notion that different levels of evaluation of programs and of process ensure that EBCP skills and knowledge are effectively addressed [4,10]. Neurological literature is relatively silent on the issue of how to teach and evaluate skills required for EBCP. There is ongoing debate on the value of teaching EBCP skills, particularly in terms of the impact on patient outcomes [11]. In this paper, we present our methods to teach EBCP, but further research is needed to evaluate effective teaching and evaluation strategies for EBCP. In conclusion, this is an exciting time for education in neurology and neurosurgery. EBCP enhances a clinician’s ability to investigate and evaluate his or her own patient care, to appraise and assimilate scientific evidence, and to ultimately improve care. The training also encourages awareness of the larger context and system of health care. It is then essential that EBCP principles are incorporated into neurology education programs, with the ultimate goals of incorporating these principles into daily practice, facilitating lifelong learning, and improving care of our neurological patients. References [1] Haynes RB, Sackett DL, Gray JM, Cook DJ, Guyatt GH. Transferring evidence from research into practice. 1 The role of clinical care research evidence in clinical decisions. ACP J Club 1996;125(3):A14–6. [2] University of Western Ontario’s Evidence Based Neurology Web site. Available at http://www.uwo.ca/cns/ebn/ (accessed January 18, 2007). [3] Guyatt GH, Rennie D. Users’ guides to the medical literature. A manual for evidence-based clinical practice. Chicago: AMA Press; 2002. [4] Sackett DL, Strauss SE, Richardson WS. Evidence-based medicine: how to practice and teach EBM. 2nd ed London: Churchill Livingstone; 2000. [5] Wiebe S, Demaerschalk B, Jenkins M. Evidence-based neurology: an innovative curriculum for post-graduate training in the neurological sciences, at: http://www.uwo.ca/cns/ebn; 2001 (accessed August 3, 2005). [6] Demaerschalk BM. Evidence-based clinical practice education in cerebrovascular disease. Stroke 2004;35(2):392–6. [7] Burneo JG, Jenkins ME, Bussiere M. Evaluating a formal evidencebased clinical practice curriculum in a neurology residency program. J Neurol Sci 2006;250(1/2):10–9. [8] Burneo JG, Jenkins ME, Bussiere M. Evaluating a formal evidencebased clinical practice curriculum in a neurology residency program. Neurology 2006;66(Suppl. 2):A16. [9] Burneo JG, Jenkins ME, Bussiere M. An evaluation of a formal evidence-based clinical practice (EBCP) curriculum in a neurology residency program: influence in graduates’ practice. Can J Neurol Sci 2006;33(Suppl. 1):S38. [10] Sackett DL, Parkes J. Teaching critical appraisal: no quick fixes. CMAJ 1998;158(2):203–4. [11] Parkes J, Hyde C, Deeks J, Milne RL. Teaching critical appraisal skills in health care settings. Cochr Database Syst Rev 2001;3.
Teaching evidence-based clinical practice to neurology and neurosurgery residents J.G. Burneo ∗ , M.E. Jenkins, the UWO Evidence-Based Neurology Group Department of Clinical Neurological Sciences, University of Western Ontario, Canada Received 21 January 2007; received in revised form 7 March 2007; accepted 9 March 2007
Abstract The primary objective of education in evidence-based clinical practice (EBCP) is to provide a resident or student with the requisite skills to satisfactorily solve real everyday clinical problems throughout their careers and to translate those solutions into better care for patients. At the University of Western Ontario in London, Canada, there is a well-developed and highly successful evidence-based neurology curriculum primarily aimed at residents. This article summarizes the current context of EBCP postgraduate training in the neurological sciences and a detailed description of its purpose, learning outcomes, required resources, content, teaching strategies, and assessment tools. In this program, we teach the principles of EBCP through the review of pertinent neurological clinical questions. The summary of each topic is recorded on our website in the form of critically appraised topics (CATs) in electronically accessible CAT banks. © 2007 Elsevier B.V. All rights reserved. Keywords: Evidence-based neurology; Neurology; Neurosurgery; Education
1. Introduction There has been an incredible “boom” of teaching evidence-based clinical practice (EBCP) across different specialties in medicine and surgery. Neurology and neurosurgery lag behind. There have been a efforts, such as the ones put by the association of British neurologists as well as the creation of the Cochrane neurological network. However, teaching of EBCP to neurology and neurosurgery residents and students is almost non-existent. Since EBCP is about solving clinical problems [1], it acknowledges that intuition, unsystematic clinical experience, and pathophysiologic rationale are not enough to make a clinical decision, and stresses the examination of evidence from clinical research. Clinical problem solving is very applicable to the daily practice in the neurological sciences. That ∗
Corresponding author at: Epilepsy Programme, University of Western Ontario, 339 Windermere Road, London, Ontario, Canada N6A 5A5. Tel.: +1 519 663 3464; fax: +1 519 663 3498. E-mail address: [email protected] (J.G. Burneo). 0303-8467/$ – see front matter © 2007 Elsevier B.V. All rights reserved. doi:10.1016/j.clineuro.2007.03.001
is why EBCP needs to be fostered among our neurology and neurosurgery residents and students. At the University of Western Ontario in London, Canada, there is a well-developed and highly successful evidencebased neurology curriculum primarily aimed at residents [2]. In this program, we teach the principles of EBCP through the review of pertinent neurological clinical questions. The summary of each topic is recorded on our website in the form of critically appraised topics (CATs) in electronically accessible CAT banks. Our objectives are to describe the current curriculum at our center and to criticize some of the flaws and obstacles encounter since its development.
2. EBCP curricula At each, 90-min EBCP session, relevant neurological topics, chosen by the residents are explored, following the EBCP principles of creating a specific question, finding the best evidence, and critically appraising the evidence.
J.G. Burneo, M.E. Jenkins / Clinical Neurology and Neurosurgery 109 (2007) 418–421
The clinical topics (12–24 topics/year) are annually assembled by surveying all neurology trainees and teaching neurologists in the department and in this way generating a list of clinically important neurological themes or topics. These topics are then ranked by EBCP participants and faculty according to frequency of occurrence, level of relevance, clinical importance, amount of interest and enthusiasm, and question answerability. The most highly ranked topics become the basis for the clinical evidence-based neurology content for the upcoming academic year. The topics are screened additionally to ensure they fulfill the educational recommendations of the training program (postgraduate education committee) and Royal College of Physicians and Surgeons of Canada Advisory Committee. The content is flexible and modifications are made periodically to better satisfy trainee needs. Annual and semiannual meeting of participants are held to review what has been done and what still needs to be addressed. In addition, a formal program evaluation survey is completed by all attendees. The entire curriculum content is designed to be responsive to results of evaluation and feedback. All the topics are equally divided amongst the neurology trainees. Schedules indicating dates, times, locations, names of topics, responsible resident, and faculty facilitator are posted on the website to inform other residents and faculty of upcoming topics. 2.1. Pre-tutorial Resident designated for each session chooses a personal clinical experience, which falls under the category indicated by the scheduled topic, and a focused clinical question is constructed based on a real patient encounter. A literature search strategy is developed to best answer this question and the search is subsequently conducted and refined. The available literature is screened according to predefined criteria and one to four articles are selected. The selection will follow the hierarchy of evidence available. The resident in charge will make copies of the clinical scenario, question, search strategy, and literature, and he circulates them among all trainees and faculty facilitators at least one week in advance of tutorial. The presenter will prepare a CAT in advance. The entire pre-tutorial process is reviewed and facilitated at each step by one or both of the program directors (JB, MJ). All trainees arrive at tutorial prepared to participate. 2.2. Tutorial The tutorials are designed to be interactive, informal discussions led by the designated resident and facilitated by the program directors (JB, MJ). In the initial 5 min, the resident will lead a presentation and discussion of the clinical scenario and the focused question. This is followed by a 10-min power point presentation on the topic, particularly if the neurological condition, treatment, or diagnostic test to be reviewed is rare or of low prevalence.
419
The presentation and discussion of the literature search strategy and yield is done in 5 min, and then 45 min are dedicated for critical appraisal of the evidence. For the appraisal, the participants are divided in three or more groups depending on the number of attendees. Each small group reviews the article and prepares to discuss the questions from the applicable rating scales for that session. These rating scales are derived from the JAMA articles on “Users’ guides to appraise the medical literature” [3] and relate to critical appraisal of articles in the realm of diagnosis, treatment, prognosis, etc. These rating scales are also available on the website. The final part of the session is dedicated to a whole group discussion of the interpretation of results and application to the case at hand (5 min), to define the clinical bottom lines (5 min), and to approve the CAT prepared by the presenter (5 min). At the end, a brief evaluation of the session is done by the presenters and the facilitators (10 min). 2.3. Post-tutorial The evidence-based neurology facilitators and resident edit and submit the final CAT product to a resident in charge of the website, for publication and circulation in electronic form [2]. All trainees are encouraged to use their acquired evidencebased medicine practice skills in other clinical venues, including clinics, wards, rounds, teaching sessions, and in dialogue with their peers and the teaching neurologists. 2.4. Critically appraised form (CAT) The CAT is a concise, user-friendly, accessible EBCP summary that can help clinicians’ needs for relevant, up-to-date EBCP information, and assist in clinical decisionmaking. A collection of updateable, peer-reviewed CATs covering a wide range of neuroscience topics can help clinicians implement EBCP without having to engage in the entire EBCP process. For the preparation of the CAT, one has to assess whether the evidence is valid and whether we can apply it to our daily life (our patients). The task is made easier by following rating scales and working sheets already prepared, based on the “Users’ guides to appraise the medical literature [3]. These rating scales and working sheets are available at the EBN website of the University of Western Ontario [2]. These rating scales have three different parts: (1) analysis of the validity of the study by assessing the methods used, (2) assessment of the final results presented, including the accuracy and clinical importance of these results, and (3) appraisal of how the results help in caring for our patients. Each rating scale has some modifications depending on the type of article (i.e., diagnosis, prognosis, therapy, meta-analysis, guidelines, or decision analysis).
420
J.G. Burneo, M.E. Jenkins / Clinical Neurology and Neurosurgery 109 (2007) 418–421
3. Resources
3.6. Computer and informatics
3.1. Financial
There is a dedicated personal computer for the evidencebased neurology program. Additionally, faculty has access to a laptop computer and projection unit to enable facilitators to use Power Point technology during presentations and teaching sessions.
The Department of Clinical Neurological Sciences has resources allocated to the EBCP program. This covers for lunch (as the sessions take place during lunch hour) and facilitates research endeavors. 3.2. Faculty There are two full-time teaching neurologists in the department qualified to teach evidence-based medicine, clinical epidemiology, and biostatistics. Senior residents, having been exposed to evidence based medicine training and practice in the program, become highly skilled and have a graduated level of responsibility regarding the teaching role. An invitation to all neurology and neurosurgery faculty is done in advanced; special invitations are extended to faculty of different sub-specialties in Neurology, when a specific topic of their concern is presented. Neurosurgery residents are always invited, although they do not participate as active as the neurology residents in the preparation of the sessions and the CATs. Teaching physicians through other departments, for example, internal medicine, with EBM training occasionally participate through invitation. The evidence-based neurology trainees vary in number from a total of 10–14 each year.
4. Objectives [5] The overall goals of the curriculum are to foster life-long self-learning, to encourage self-evaluation, and to promote improvement of care for neurological patients. More specific aims discussed below include acquisition of skills, developmental of attitudes and behaviors of EBCP, and attainment of knowledge. 4.1. Skills By the end of postgraduate neurological training, residents will be able to: (1) construct a focused, answerable question when faced with uncertainty in a clinical scenario; (2) devise a strategy and conduct efficient literature searches on a variety of available databases; (3) critically appraise a published report of a clinical study; (4) apply the appraised evidence to their clinical problem; (5) incorporate the evidence into their decision-making for individual patients.
3.3. Time
4.2. Attitudes and behavior
The EBN tutorial sessions are ninety minute in duration, held monthly, 12 months per year, throughout the 5-year training program. The sessions fit into protected educational half-day time for neurology trainees. Preparatory time for trainees and faculty is informal and unscheduled.
By the end of postgraduate neurological training, residents will: (1) appreciate the advantages of practicing EBCP; (2) find the EBCP curriculum to be valuable and feasible; (3) increase their use of evidence from clinical research to help solve the neurological problems they may encounter; (4) continue to practice and teach EBM throughout their neurological careers.
3.4. Space The monthly tutorials are held in an available hospital conference room. The departmental library houses the evidence-based medicine library, computer, links to require databases, all necessary software, in addition to desks, tables, book shelves, and chairs. 3.5. Educational material A resource binder containing the most valuable evidencebased medicine literature is compiled and distributed to the trainees. A compilation of critically appraised topics are processed and printed in pocket size form to allow trainees to have easy access to the fruits of their labor during subsequent and clinical encounters. A book on evidence-based medicine is given to all new residents as part of the welcoming package [4].
4.3. Knowledge By the end of postgraduate neurological training, residents will have: (1) acquired knowledge of the most current best evidence for neurological practice in all the various subdisciplines of the clinical neurosciences; (2) developed the skills (see above), to update this knowledge, as it evolves, over the time span of their careers.
5. Discussion The direction toward which post- and under-graduate neurological education must move is clear. Ensuring that our residents acquire the skills to articulate answerable questions, search and appraise literature, and interpret and apply the results to the care of individual patients is essential.
J.G. Burneo, M.E. Jenkins / Clinical Neurology and Neurosurgery 109 (2007) 418–421
The primary objective of education in EBCP is to provide a resident or student with the requisite skills to satisfactorily solve real everyday clinical problems throughout their careers and to translate those solutions into better care for patients [6]. Our curriculum for the introduction of EBCP into neurological training is clearly a work in progress. A curriculum, by its very nature, is a never-ending winding path. This article summarizes the current context of EBCP postgraduate training in the neurological sciences and a detailed description of its purpose, learning outcomes, required resources, content, teaching strategies, and assessment tools. Throughout the development of the program, many problems have been faced by previous EBCP curricula innovators and new solutions for overcoming the majority of recognized barriers are always being sought out. Just as it may take ten years for results of clinical research to find their way from the literature to routine use at the bedside, the diffusion of educational innovation is recognizably slow [5]. Our curriculum has several strengths. The current curricula of structured workshops for EBCP teaching in neurological training has allowed residents to develop skills need to practice EBCP. We are using an innovative educational intervention addressing the shortcomings of traditional teaching. This curriculum and the way it is delivered has been formally evaluated [7]. Residents and graduates from our residency program reported that the EBCP curriculum increased their confidence in knowledge of existing evidence and developed their skills in EBCP principles. The shortcoming of this curriculum lies on recognized barriers. Firstly, the skills have not been consistently transferred to daily patient encounters, often due to time constraints [8,9]. In an effort to overcome this, we created an “evidence based neurology” elective rotation for medical students. The student selected, attended rounds on the neurology ward, with the purpose to act as a facilitator and teacher about the principles and integration of EBCP. This rotation successfully enhanced the use of EBCP knowledge and practice by the neurology residents in their daily activities. The results of this intervention have been submitted to the Annual Meeting of the American Academy of Neurology. Secondly, there continues to be hesitance from some staff neurologists to accept this new but important educational strategy to replace the traditional journal clubs or the standard didactic lecture format; although, attitudes are changing. With regards to educators, more information is needed about the best techniques and strategies for teaching EBCP.
421
In addition, educators must embrace the notion that different levels of evaluation of programs and of process ensure that EBCP skills and knowledge are effectively addressed [4,10]. Neurological literature is relatively silent on the issue of how to teach and evaluate skills required for EBCP. There is ongoing debate on the value of teaching EBCP skills, particularly in terms of the impact on patient outcomes [11]. In this paper, we present our methods to teach EBCP, but further research is needed to evaluate effective teaching and evaluation strategies for EBCP. In conclusion, this is an exciting time for education in neurology and neurosurgery. EBCP enhances a clinician’s ability to investigate and evaluate his or her own patient care, to appraise and assimilate scientific evidence, and to ultimately improve care. The training also encourages awareness of the larger context and system of health care. It is then essential that EBCP principles are incorporated into neurology education programs, with the ultimate goals of incorporating these principles into daily practice, facilitating lifelong learning, and improving care of our neurological patients. References [1] Haynes RB, Sackett DL, Gray JM, Cook DJ, Guyatt GH. Transferring evidence from research into practice. 1 The role of clinical care research evidence in clinical decisions. ACP J Club 1996;125(3):A14–6. [2] University of Western Ontario’s Evidence Based Neurology Web site. Available at http://www.uwo.ca/cns/ebn/ (accessed January 18, 2007). [3] Guyatt GH, Rennie D. Users’ guides to the medical literature. A manual for evidence-based clinical practice. Chicago: AMA Press; 2002. [4] Sackett DL, Strauss SE, Richardson WS. Evidence-based medicine: how to practice and teach EBM. 2nd ed London: Churchill Livingstone; 2000. [5] Wiebe S, Demaerschalk B, Jenkins M. Evidence-based neurology: an innovative curriculum for post-graduate training in the neurological sciences, at: http://www.uwo.ca/cns/ebn; 2001 (accessed August 3, 2005). [6] Demaerschalk BM. Evidence-based clinical practice education in cerebrovascular disease. Stroke 2004;35(2):392–6. [7] Burneo JG, Jenkins ME, Bussiere M. Evaluating a formal evidencebased clinical practice curriculum in a neurology residency program. J Neurol Sci 2006;250(1/2):10–9. [8] Burneo JG, Jenkins ME, Bussiere M. Evaluating a formal evidencebased clinical practice curriculum in a neurology residency program. Neurology 2006;66(Suppl. 2):A16. [9] Burneo JG, Jenkins ME, Bussiere M. An evaluation of a formal evidence-based clinical practice (EBCP) curriculum in a neurology residency program: influence in graduates’ practice. Can J Neurol Sci 2006;33(Suppl. 1):S38. [10] Sackett DL, Parkes J. Teaching critical appraisal: no quick fixes. CMAJ 1998;158(2):203–4. [11] Parkes J, Hyde C, Deeks J, Milne RL. Teaching critical appraisal skills in health care settings. Cochr Database Syst Rev 2001;3.