Evidence-Based Education - A Fad or the Future?

Today we are going to address a highly debated topic: the advent of evidence-based clinical practice that has sparked a revolution in professional education. Should we teach students the way that we have always taught them, or is this traditional approach no longer relevant, given that the way clinicians practice is radically different today as compared to just a decade ago?

As we explore the shifts in health care practice that are forcing changes in traditional education programs today, I am going to offer you some challenges that will likely make you reconsider the way you teach and learn in light of the ways that you currently practice your profession. Most all of us “memorized” our way through school–memorized a chapter or crammed the night before the test. Those who memorized well were rewarded with the good grades---but, did they really learn how to solve a problem? Did they really remember all that they had crammed for, and could they apply it in a patient situation? Did they build the critical thinking, assessment, and judgment skills necessary to succeed? What happened when the gold standard in bedside practice changed---were they able to adapt? Chances are that these students of yesterday were not ready to handle the changes that the information age brought to their professional practice...

Welcome to the 1990s, when information technology literally exploded, creating a paradigm shift in virtually every profession. How did it impact medicine?

In 1992, evidence-based medicine (EBM) became a reality, an off-shoot of the radical changes that were happening in clinical epidemiology. Evidence from research studies began impacting clinical practice much faster–thanks to the acceleration of information transmittal via computers–than it ever had before. Standards of clinical practice that had literally been accepted for decades were suddenly much less “gold”---these were brought into question with almost every research report from the latest clinical trial that was presented in the professional literature. Fast forward to today---the reality now is that one of the accepted definitions of EBM is so broadly defined as to lose its real meaning and original purpose.

So Why EBM?

Historically, clinical practice guidelines were based more on experience and intuition and less on evidence, which was laborious to compile and not easily disseminated to practitioners. Once practitioners began combining the evidence from research trials that were literally available at their fingertips (through a search of internationally derived clinical databases or a “best practices” site on the World Wide Web), their clinical decision-making practices began to change. They didn't just treat patients in a particular way “because this is the way that is was always done” but instead would question whether or not there was a better way to treat based on the latest evidence.

And Why Now?

The technology explosion that started in the late 1960s began to spawn much more evidence from research studies that were widely disseminated, first via journals, and later via electronic repositories that could be mined for specifics. As information became more accessible to patients/consumers and practitioners, the demand for evidence-based practice increased, as studies tied this type of clinical decision-making to greater efficiency, improved care, cost savings, and scalability using scarce resources.

The rapid and ease of dissemination of information, coupled with the rise of managed care with its mandate to control costs and standards of care, created a relentless drive towards EBM, regardless of the definition.

The picture is not all rosy, however. The movement to EBM fostered some negative outcomes in health care as well. Think about how your practice has changed since EBM began impacting dental health care. In dentistry, EBM has given rise to The Cochrane Oral Health Group in 1996 and, subsequently, your own organization, The International Association of Dental Research, Evidence-based Dentistry Network, established in 2003. There is a risk that strict adherence to only statistically supported practices in treating patients can potentially obscure the science behind the study. Health professions used to be known as the “healing arts” for a reason – there was both art and science involved and a human dimension. Research findings can also be shifting sands that make way for quicksand. How many times have results from a research study been termed irrefutable, then in tomorrow's paper, the results are indeed, refuted. Aren't we still making decisions based on intuition and experience, especially when the evidence for which to base a patient's treatment is thin or non-existent? What about the difference between the bench scientist and the clinical practitioner in the real world?

Primary investigators managing research studies do not incur liability for their errors to the same degree, if at all, as a bedside practitioner does. Research protocols cannot possibly cover all individual case scenarios. RCTs are conducted under rigorous research controls which remove them from the real-life environment. Today's evidence is often invalidated by tomorrow's new study. Using EBM exclusively for all decision-making ignores the patient's values and the clinician's experience, intuition, and seasoned judgment. When there's a paucity of available evidence or it is thin, then the chance exists that practice decisions may be made more as a leap of faith and less as an evidence-basis decision.

While EBM has some clear limitations, the reality is that EBM is here to stay. It is now the most widely accepted clinical health care model for treating patients. So, how did this shift to EBM begin changing the way that educators teach new practitioners?

For EBM to really succeed, it must begin in the academic setting, when the education process for the new clinical practitioner begins.

To change the way practitioners learn, you must transform the way we teach—and that process starts by transforming the idea of what a classroom is.

How do we educate the educators? Simply put, by using the same principles that drive EBM to drive EBE.

Let's start by taking a closer look at exactly which knowledge and skills new clinicians need to possess to successfully practice in the real world, where EBM reigns. Most would agree that the heart of EBM is the use of randomized controlled trials (RCTs) as the basis for determining delivery of care. But, despite the high volume of information available to practitioners, there is still a dearth of coherent and consistent scientific evidence. Even those topics that have been researched extensively have fragmented evidence available to the practitioner, at best. That means that today's practitioner must be able to sift through an enormous amount of information generated from these research trials and judge whether or not it should impact the practice.

This situation in the health care arena gives rise to an issue for the educator of tomorrow's practitioners: Students and novice clinicians need to figure out how to obtain solid research results that they can trust and hone their skills in assessing that evidence to decide if it has any value to their practice—they don't have the years of actual clinical experience to guide their judgment or intuition, so they must be taught how to find, understand, and critically analyze the new clinical evidence that affects the treatment decisions that must be made on a daily basis. So, they need their instructors to help them develop this new skill set, which consists of identifying answerable questions, searching for evidence and making a critical appraisal of that evidence. More importantly, they need role models in the clinical environment who use EBM to guide their practice.

Does the traditional professional education equip the novice practitioner with these types of skills that are essential within an EBM practice environment? In a word: No. So, the question is not whether to teach EBM but how to teach EBM, which leads us to Evidence Based Education…

So, a definition for EBE---one that moves away from a passive approach to learning to an active, inquiry-oriented approach designed to equip students with the skills needed to practice in an evidence-driven or EBM-oriented world.

Why the need for EBE, and why now?

The forces that enabled EBM in clinical practice began to impact higher education as well.

Universities face similar issues:

However, not everyone subscribes to the theory that EBE is the preferred way of educating tomorrow's practitioners. The dissenting opinion about the value of EBE is that there is more to education than just learning how to read and interpret the evidence—the art is lost among the emphasis on the statistics and the science. Also, there is no such thing as totally impartial evidence: Evidence is not “value-free.” Educational research, just like medical research, carries its own values and objectives. The solution: Honest debate and discussion is often skewed by “concealed evidence”---this is a risk of opening up the environment to encouraging questioning.

Whether one supports the use of EBE over traditional education, the trend toward moving the teaching/learning process to EBE is clear. Traditional professional education programs are falling short in (1) producing enough new practitioners and moving them quickly into the labor force to help combat the staffing shortages that are escalating in severity; and (2) effectively preparing new clinicians for practice in a profession grounded in the EBM approach.

EBE better prepares practitioners by forcing them to use the skills that are needed to be successful in an evidence driven world. Traditional classroom lectures do not provide the skills needed to acquire and evaluate the evidence, nor to translate that evidence into best clinical practices.

What is the overall goal of EBE? To ultimately make better clinical practitioners.

If EBE is the framework that is used to guide the curriculum for new health care providers, then the result will be a better prepared graduate who can successfully practice in an EBM world. And, better prepared graduates translate into many tangible and intangible rewards, with improved patient care as the ultimate achievement for academicians, as well as those within the health care industry. The intangibles are not so bad, either: the school's reputation is likely to improve as more and more students achieve success—not only in the workplace as they embark on successful careers, but immediately upon graduation from the basic program, as the school's ability to produce graduates who achieve licensure or certification at a high rate and to establish a solid track record within the local, regional, or even national health care community as a producer of high skilled graduates becomes widely known as a result of using an EBE framework.

But there are no “magic-wands.” You must change the thought process of all the stakeholders. EBE requires ingraining a new thought process focused on the five ‘A’s:

You use the same steps in an EBM-clinical practice model that you also use in EBE---instead of patient-centered treatment questions, in EBE, when evaluating the effectiveness of teaching a particular concept or instructional unit, you would ask: “Would I teach this content the same way again? Are there ways to do it better? What does the evidence (student performance, for instance) say about the effectiveness of my teaching and of the curriculum plan? What changes need to be made? What is the best way to implement these changes, and when should evaluation occur again to see if they have been effective in achieving the desired program outcomes?”

Change is never easy. Veteran faculty don't always adapt well to “guide on the side” behavior --- they stick with “sage on the stage.” You may not have the resources immediately available, either, so that will hinder faculty's usage of computers, databases, electronic learning materials, etc.—tools essential to effective EBE. Also, as teaching loads increase there is less and less time for serious and informed debate.

Significant investment is required to make EBE happen. It's not just about filling seats in a classroom anymore. Expanding computer availability, for example, will be a costly investment up front; but in the long run, there will be more flexibility with the teaching/learning environment than can be accomplished by just adding titles to the library or chairs to a lecture hall.

There are no quick fixes. Many factors make implementing EBE a time-intensive and costly endeavor:

Despite these roadblocks, the rewards will make the journey worthwhile!

Effective EBE leads to many rewards: For example, the ability to scale your student enrollment --- enrollment is not dependent upon the local pool of applicants only, but potentially pulls candidates both nationally and internationally into your student body. By teaching students how to think critically and appraise/digest evidence in order to defend their clinical practice decisions, you are equipping employers with superior practitioners. For example, the average on-boarding cost to orient a new graduate nurse to an entry-level RN position in a hospital is $60,000. But, when a graduate nurse is hired who already has a high level of critical thinking ability and skills that enable him or her to thrive in an EBM-driven hospital environment, the employer's costs for orientation drop significantly, and the attrition rate among newly hired RNs plummets.

Technology and EBE are highly complementary. When eLearning is brought into the curriculum, the style of learning immediately shifts from passive to active. You begin to move the didactic learning (what students find the most boring) out of the classroom and focus on developing the critical skills necessary to succeed in today's workplace. Moving the didactic learning outside of the traditional lecture time frees time for more “value-added” learning activities.

One example of how to focus on these “value added” activities is formative assessment: one of the hottest trends in education. Formative assessment starts with a pre-quiz, followed by individualized remediation and then a post quiz to ensure complete knowledge gain. Some leading programs are forcing the students to take the pre-quiz prior to lecture, then spending a limited amount of time reviewing those areas where students struggled, then mandating completion of the post quiz prior to moving onto the next topic. They use the freed-up time to work on micro and macro simulations. For one program, implementing this approach lead to an improvement in their Board pass rates.

So, if EBE looks like an appealing option, how can professors make the move to an active learning approach in their curricula? There are 4 key elements to setting up EBE, and each of them requires a significant change in the educational environment.

How can you tell if your educational institution truly embraces a culture that values and supports EBE? There are some obvious and not-so-obvious indicators: for instance, “sage on a stage” behavior is no longer rewarded, so instructors are not encouraged to use lecture as their primary teaching methodology. Students who actively engage in debating issues and challenging practices that are not supported by clinical evidence are rewarded. No passive “slugs” sitting in the back of the classroom are allowed; students are expected—and, indeed, must—participate; they must come prepared to class or they will be lost because the teacher won't be spoon-feeding them knowledge from a podium, and they must demonstrate their understanding of the concepts and the the evidence (pros vs. cons) that is associated with current knowledge about these concepts. Students today learn very differently from students in years past.....

In the past, traditional education programs were “all about” teaching methodologies---what we should teach, how and when we should teach it, etc.

EBE is much more focused on the outcomes of an education program rather than the process that was used to achieve those outcomes.

Faculties who work in the EBE environment make curricular decisions based on an analysis of student outcomes---they employ practices that lead to achievement of outcomes and dump old ideas that are not achieving the program's goals.

Curricula goals are objectively defined and broken down into specific, measurable outcomes. Tracking these outcomes requires diligence and greater precision in measurement as compared to the traditional evaluation mechanisms used in the past. The evidence must be gathered and analyzed, and changes that are indicated will then be introduced into the curriculum plan based on these results. That means that curriculum planning becomes less static and more fluid---if outcomes are not being achieved at the desired levels, there is more motivation in an EBE-driven educational environment to make changes, and then re-evaluate the situation to see if the changes resulted in greater evidence of program outcome achievement.

In addition to changing your policies and procedures, you must set up reward structures. You must reward the behaviors you are seeking. Rewards can be monetary, but they can be non-monetary as well, such as preferred teaching spots, classrooms, etc.

Just as students are expected to take an active role in learning, the faculty's approach to learning must be active, not passive, as well. Students must be able to see role models in action who demonstrate how to use the tools needed to obtain the latest evidence available, judge the merits of these findings, and make decisions about the usefulness of the evidence in affecting clinical practice.

One computerized tool that greatly assists the instructor in implementing an EBE-oriented course or curriculum is the electronic Learning Management System (LMS). It is the organizing tool that brings together massive amounts of information that students must learn to process into a single location that is available to them 24/7.

When properly deployed and utilized, the LMS is the hub of all learning activity. It drives EBE. Faculty and administration can monitor the student's progress over time as well as compare cohorts year over year. Students can leverage the collaboration tools to begin building the EBE processes (i.e., the 5 As). Basically, the LMS becomes the repository for all the evidence on how effective the teaching-learning cycle is for all stakeholders.

There are other numerous tools that clinicians use within their EBM practice environments that can be introduced to students in an EBE-driven course. Learning how to effectively use these computerized tools during their educational programs ensures that they will have at least a part of the skill set needed when they move into an EBM clinical practice world.

Even as the tools change with ever-increasing morphs in technology, understanding how to manipulate today's computerized tools to obtain the information needed for practice decisions makes clinicians more likely to use these tools, and future tools, in their practices after they leave the academic program.

How do you offset the costs associated with scaling up the technology within your institutions that is critical to establishing EBE? Via your publishing and industry partners.

Here is an example of how industry partners and one university's grant-writing efforts were combined to result in the establishment of a virtual hospital for multidisciplinary health care education to drive EBE:

The University of Texas at Arlington (UTA) campus houses a new Smart Hospital for use by nursing and allied health programs. The Smart Hospital, a state-of-the-science education center, allows students to learn utilizing simulation technology including: full body interactive patient simulators (like SimMan® and SimBaby®), computerized scenario-based programs and individual trainers for specific skills like starting IV's. All of these allow students to be well prepared to intervene in all situations before entering into real life patient care. The need for increased simulation learning prompted the creation of the Smart Hospital which is being built in three phases.UTA partnered with Laerdal, which manufactures the high fidelity human simulation manikins, and Hill-Rom, the leading medical suppliers of beds, stretchers, and hospital room furnishings. The partnership provides these two industry leaders a showcase for their products, while the university's students receive innovative instruction made possible by the use of this high-tech facility as their safe, simulated hospital where they can practice and refine clinical skills. The project also benefits health care consumers, as faculty conduct research studies aimed at evaluating the effectiveness of the new educational techniques and efforts to prepare highly competent health care professionals who will practice in a variety of disciplines.

Elsevier also serves as a partner by providing e-learning products to students whose curriculum has been enhanced by participation in the Smart Hospital. Equipment and supplies that were not furnished by industry partners were partially underwritten by grant-funding bodies, who embraced the project when it was clear that the university had sought support from these companies, and would not be embarking on a project that they had no ability to support financially.

These types of simulation labs are popping up all across the country and are used collaboratively by medical, dental, nursing, and allied health students. Local hospitals, which eventually will be employers of many of these students when they graduate, are also eager to participate as partners, because they have realized cost savings by completing mandatory annual competency checks of their staff in the simulated environment. In fact, regional simulation centers are becoming commonplace in many states and may create a new standard for competency assessment of professionals as hospital accrediting agencies recognize the benefits of hands-on evaluations that incorporate the use of “standardized” patients who exhibit symptoms that require the application of life-saving skills that clinicians may not use frequently, but when used, require 100% proficiency.

The Smart Hospital is already here today....

...but what will the technology of tomorrow bring?

Clinical practitioner, instructor, and learner behaviors will continue to change and evolve as a result of decision-making within an EBM and EBE model.

EBM and EBE mandate time to think things through. Consequently, content-driven curricula will be forced to change, forcing content to be delivered and accessed in new ways.

EBE caters to the generation Y learner. Today's students are not satisfied with the “I told you so and that's why.” Students expect to be engaged in the learning process and lead, not forced through the learning process.

There are currently too many sources of evidence to make EBM and EBE optimally efficient processes, but the future of technology will likely impact this soon. Computer-based tools of the future will help users make sense out of the evidence and organize new evidence to its best advantage.

In closing, I would like to leave you with three observations:

Thanks very much for your time and attention today!