Defining the scope of the problem

EBM has been defined as the “conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients” . It requires the integration of the best available evidence with physician clinical experience. EBM is not just about the evidence for treatment of a medical problem, it goes beyond that to refer to the practice of applying the literature to specific and individual patient care decisions. Eddy calls this process “Evidence-based individual decision making,” which is perhaps a good alternate name for EBM.

Evidence-based guidelines are systematic reviews of evidence by experts that synthesize a summary concerning a particular treatment problem. These documents rigorously review the best available evidence and create a summary. Although these guidelines can be very useful, EBM as defined for this article refers to more than just knowing the evidence or formulating a guideline. It refers to providing evidence-based treatment to individual patients.

The major benefit of practicing EBM is that it ensures the practice of up-to-date medicine. Every clinician knows that the treatment and management of diseases can change, and management guidelines can be updated as new information becomes available. Sometimes, in a paradigm shift, previously accepted treatments are found to be ineffective or even harmful. For example, hormone replacement therapy in postmenopausal women was long thought to have positive effects on health. However, recent evidence has shown that this therapy may increase the risk of stroke , which has drastically changed the indications for its use. Thus, EBM constantly incorporates the best available evidence into patient care decisions, leading to the practice of the best possible medicine.

Practicing up-to-date medicine has additional advantages, such as when the contemporary treatment is less invasive with similar or improved outcomes. For example, many previously open vascular procedures, such as aortic aneurysm repair, have been replaced with less invasive interventional procedures with good results. In otolaryngology, endoscopic sinus surgery has almost entirely replaced most open sinus surgery with excellent results. In addition, when EBM is practiced and applied to many patients by many physicians, the overall result should be better population outcomes and reduced overall complications.

Although many physicians understand the value of EBM in improving practice, misconceptions still exist. A common misconception is that EBM limits the physician’s ability to practice, or that it is “cookbook” medicine. There is concern that the evidence will limit the physician’s freedom in the decision-making process and restrict medical care to only following guidelines and algorithms. This is inaccurate. In EBM, the evidence is only one component of treating the individual patient. Clinical experience and patient preferences must also be combined with the literature to make clinical decisions. Indeed, some have likened EBM to a three-legged stool—with evidence forming only one of the legs . Patient preferences and clinical judgment are the other two legs; removal of any one leg will cause the stool to fall over. Thus, published evidence should not limit the physician, but rather should inform him or her as part of the clinical decision process .

Some are also concerned that practicing EBM means using only evidence from randomized control trials (RCTs) in clinical practice, as RCTs are considered the highest level of evidence. Using the “best available evidence” is not the same as using “only the best” evidence. Although it is true that RCTs provide a highly rigorous and systematic evaluation of a treatment’s effectiveness, not all problems are amenable to such evaluation. A mock systematic review of RCTs on the effectiveness of parachutes in preventing major trauma , for example, was one author’s tongue-in-cheek method of expressing that RCTs cannot be performed to answer all clinical questions. The judicious review of other available types of evidence—cohort, case control, case reports, and even expert opinion—can provide significant guidance in clinical decision making. A related misconception about EBM is that “lack of evidence” means “lack of effectiveness.” This is also untrue. Many effective treatments have not been studied systematically, and external evidence cannot answer every question.

Practicing EBM is not acquired instantaneously. It is developed over time, and learning should begin with resident physicians in training. Indeed, EBM involves appraisal of one’s own practice experience and assessing whether it could be improved, which is part of practice-based learning and improvement—a core competency for residency training. However, unlike taking a good history or performing a thorough physical exam, the process of acquiring and critically analyzing literature to inform clinical decision making is not uniformly well taught in medical schools. In one study, Caspi and colleagues evaluated the perceived competence and performance of graduating medical students in EBM techniques across the United States. They first evaluated the respondents’ self-assessment of competency in critically evaluating evidence, and then tested their actual skills using an online instrument. The study found that although respondents felt competent about their ability to evaluate problems across multiple competencies, the average score of 55% correct on the assessment instrument suggested otherwise. This is further evidence that residency training programs need to refine the skills of graduating medical students as they proceed toward becoming active physicians.

Residency programs have always provided residents with strong training in the “clinical judgment” and “physician experience” aspects of medical care, as well as the art of integrating patient preference and expectation into decision making. However, searching, identifying, and appraising the best evidence are often relegated to monthly “journal club” conferences and maybe one or two didactic lectures, often from a nonphysician (ie, a statistician). Teaching the process of EBM to residents should be a key skill in their training.

Barriers to teaching

Teaching EBM to residents remains a significant challenge because barriers exist at multiple levels. These barriers can be divided into three broad categories: institutional, resident related, and attending staff related. Much of this section is derived from an excellent study by Bhandari and colleagues . This study used structured interviews to assess surgical resident perspectives at a major teaching institution on learning EBM. Some of the barriers identified in their study are detailed below.

Two major institutional barriers to teaching EBM are the availability of resource materials, and the time needed to obtain them. The digital age has hopefully improved the availability of resources. In the past, obtaining the evidence required going to the library and spending time searching, retrieving, and photocopying. Today, electronic resources are immediately available through online MEDLINE searches and digital PDF (portable document format) documents. At the present authors’ institution, multiple computers are connected to the Internet on all in-patient floors, which allows for quick literature searches to be performed when clinical questions arise during routine patient care activities. In addition, there are hundreds of journals available online through the institution’s library that can be accessed from these locations. Some facilities also have institutional subscriptions to online resources that present evidence-based reviews of available clinical evidence on a topical basis . The digital availability of these resources for residents who are under time pressure is critical for the incorporation of published evidence into their clinical practice. An institutional commitment to having these resources easily available dramatically reduces this barrier to the physician’s practice of EBM.

Another institutional barrier identified was staff shortages. Again, performing literature searches and evaluating the evidence take time. When there is a shortage of staff—for example, in an outpatient clinic—less time is available to the physician to gather and review evidence. Instead, there is a pressing need to complete the clinical tasks needed to get patients seen. Thus, adequate staff coverage is one of the resources needed to provide time for the physician to pursue the reading, review, and incorporation of the literature into his or her practice.

Multiple barriers at the resident level were identified in Bhandari and colleagues study. Some residents lacked the motivation or desire to analyze and apply published literature to their practice. Heavy call requirements and fatigue on some rotations often influenced this feeling. Some residents also felt that EBM training would not be useful because they sensed resistance or apathy on the part of the attending staff. It was also suggested that discussions with faculty surgeons about evidence that may conflict with current practice might result in a backlash or repercussions. In general, resident attitudes were strongly shaped by the faculty surgeons.

At the attending level, a lack of EBM knowledge and practice amongst attending surgeons was noted as a potential barrier . Since patients are ultimately the responsibility of the attending physician, lack of interest by the faculty in EBM provides no motivation for residents to acquire these skills. In addition, a lack of expertise or experience with EBM at the faculty level limits the capability to teach these skills to residents. Finally, even worse than a lack of knowledge or interest, negative attitudes by faculty concerning applying evidence toward patient care can be a serious barrier.

Taken together, many barriers can exist to the teaching of EBM in residency. These barriers lie in three areas: resident, attending, and institutional. Strategies and mechanisms to overcome institutional barriers to teaching EBM are beyond the scope of this article. However, assuming that resources are available, the ability to provide good EBM teaching is mostly limited by attending and resident physician factors.

The ability to provide EBM teaching to residents necessarily begins with a commitment by attending surgeons. Many of the factors identified in Bhandari and colleagues stem from a lack of background or commitment amongst attending physicians. Establishing a fundamental knowledge base in EBM and widespread acceptance of its value are important steps to overcome these key barriers to teaching EBM. In an upcoming section, structured strategies that have been reported by training programs to teach EBM are discussed.

Barriers to teaching

Teaching EBM to residents remains a significant challenge because barriers exist at multiple levels. These barriers can be divided into three broad categories: institutional, resident related, and attending staff related. Much of this section is derived from an excellent study by Bhandari and colleagues . This study used structured interviews to assess surgical resident perspectives at a major teaching institution on learning EBM. Some of the barriers identified in their study are detailed below.

Two major institutional barriers to teaching EBM are the availability of resource materials, and the time needed to obtain them. The digital age has hopefully improved the availability of resources. In the past, obtaining the evidence required going to the library and spending time searching, retrieving, and photocopying. Today, electronic resources are immediately available through online MEDLINE searches and digital PDF (portable document format) documents. At the present authors’ institution, multiple computers are connected to the Internet on all in-patient floors, which allows for quick literature searches to be performed when clinical questions arise during routine patient care activities. In addition, there are hundreds of journals available online through the institution’s library that can be accessed from these locations. Some facilities also have institutional subscriptions to online resources that present evidence-based reviews of available clinical evidence on a topical basis . The digital availability of these resources for residents who are under time pressure is critical for the incorporation of published evidence into their clinical practice. An institutional commitment to having these resources easily available dramatically reduces this barrier to the physician’s practice of EBM.

Another institutional barrier identified was staff shortages. Again, performing literature searches and evaluating the evidence take time. When there is a shortage of staff—for example, in an outpatient clinic—less time is available to the physician to gather and review evidence. Instead, there is a pressing need to complete the clinical tasks needed to get patients seen. Thus, adequate staff coverage is one of the resources needed to provide time for the physician to pursue the reading, review, and incorporation of the literature into his or her practice.

Multiple barriers at the resident level were identified in Bhandari and colleagues study. Some residents lacked the motivation or desire to analyze and apply published literature to their practice. Heavy call requirements and fatigue on some rotations often influenced this feeling. Some residents also felt that EBM training would not be useful because they sensed resistance or apathy on the part of the attending staff. It was also suggested that discussions with faculty surgeons about evidence that may conflict with current practice might result in a backlash or repercussions. In general, resident attitudes were strongly shaped by the faculty surgeons.

At the attending level, a lack of EBM knowledge and practice amongst attending surgeons was noted as a potential barrier . Since patients are ultimately the responsibility of the attending physician, lack of interest by the faculty in EBM provides no motivation for residents to acquire these skills. In addition, a lack of expertise or experience with EBM at the faculty level limits the capability to teach these skills to residents. Finally, even worse than a lack of knowledge or interest, negative attitudes by faculty concerning applying evidence toward patient care can be a serious barrier.

Taken together, many barriers can exist to the teaching of EBM in residency. These barriers lie in three areas: resident, attending, and institutional. Strategies and mechanisms to overcome institutional barriers to teaching EBM are beyond the scope of this article. However, assuming that resources are available, the ability to provide good EBM teaching is mostly limited by attending and resident physician factors.

The ability to provide EBM teaching to residents necessarily begins with a commitment by attending surgeons. Many of the factors identified in Bhandari and colleagues stem from a lack of background or commitment amongst attending physicians. Establishing a fundamental knowledge base in EBM and widespread acceptance of its value are important steps to overcome these key barriers to teaching EBM. In an upcoming section, structured strategies that have been reported by training programs to teach EBM are discussed.