Teaching evidence-based medicine: where next?

Because teaching (of most things) is not just about the content. It’s also about the context.

David Nunan, Senior Researcher and Director of Postgraduate Certificate in Teaching Evidence-Based Health Care.

I’ve been involved with Evidence Based Medicine for nearly a decade. My first introduction to the field was when I joined the Centre for Evidence-Based Medicine (CEBM) in Oxford. Shortly after I arrived, I attended a one-day workshop on EBM delivered by the then CEBM director, Paul Glasziou. I cannot recall many of the specifics from that workshop but what does come back to me easily is how inspired I was. Having been on my own EBM journey I realise now that what inspired me was not just the topic and content but also the way it was delivered. Because teaching (of most things) is not just about the content. It’s also about the context. The narratives used to bring a subject alive. The employment of different strategies for delivery.

However, as an ambassador for evidence-based medicine, an obvious question is what is the best available evidence for teaching EBM?

A 2004 systematic review (level 1 evidence) of teaching EBM in postgraduate settings revealed that standalone teaching improves knowledge, but has no effects on skills, attitudes, or behaviour. Whereas clinically integrated teaching improved knowledge, skills, attitudes, and behaviour, the important stuff. However, whilst the quality of the evidence was poor – there were only 2 RCTs to underpin these results – we can probably say that teaching should include moving from the classroom to clinical practice. However, in practice this proves difficult, and what might be better is to think about bringing clinical practice into the classroom.

And this is exactly what Paul Glasziou did in that first introduction session. He started with a patient. The session was then built around that case and the problem presented, using a mix of didactic and interactive teaching to engage further with the topic. Is the use of different delivery methods a good thing for EBM learners? Well, the same authors of the 2004 systematic review introduced a hierarchy of different teaching strategies, suggesting interactive but classroom-based activities result in better learning outcomes compared with didactic but clinically integrated one’s and didactic but a classroom or standalone teaching (Figure 1). What I found interesting in these papers is that there are multiple different strategies that can be used both within a single session or throughout an entire course, and as teachers of EBM we should be aware of and consider how best to employ them.

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1770917/pdf/1472-6920-6-59.pdf

When I reflect I also realise a few additional things that explain why I am a teacher; firstly I enjoy it. And I hope others enjoy my teaching because I enjoy it. Secondly, because I enjoy it I take an interest in it. This includes reading nerdy journals such as this one. And websites like this. And thirdly, through teaching I feel I am able to indirectly impact on patient care (at least as much as through my research). Providing health professionals with the skills and tools to practice EBM means that hopefully they’ll be applying them more readily with their patients, ensuring clinical decisions are evidence-informed and ultimately effective, empathetic care. Inspiring other teachers to want to deliver engaging and effective evidence-based medicine and health care to their learners creates a chain-effect, where even more health professionals and trainees are inspired to be the best evidence-based practitioners they can be.

So it was a real privilege to have just led the 24th iteration of the CEBM annual Teaching Evidence-Based Medicine course. Previous course leads include David Sackett, one of the founders of the EBM movement, Paul Glasziou, Sharon Straus, Carl Heneghan and Kamal Mahtani. I believe the saying goes ‘standing on the shoulders of giants’ and these are some shoulders.

But what next for those, like me, that have a passion for teaching evidence-based medicine? I am proud to announce, as director, the first ever postgraduate qualification in teaching evidence-based health care. This course aims to foster and develop future leaders in teaching evidence-based health care. And we will do this by exploring different teaching styles, identifying development needs and planning effective curriculum. Folk will have access to current leaders in research-led teaching and experts in medical education that know how to inspire others. I’m confident of this because they inspired me, and continue to do so every time I see them teach. We are excited about this new direction and look forward to welcoming our first students in Autumn 2019.

David Nunan is a Senior Researcher and Director of Postgraduate Certificate in Teaching Evidence-Based Health Care. He is based at the Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford.

You can follow him on Twitter @dnunan79

Acknowledgements: Kamal R Mahtani for helpful comments.

Competing interests: DN has received funding from the NHS NIHR SPCR programme and the Royal College of General Practitioners.

Disclaimer: The views expressed in this article represent the views of the author and not necessarily those of the host institution, the NHS, the NIHR, or the Department of Health.