In Mexican medical schools, students learn to make clinical decisions based on experience rather than evidence, as is standard practice in most clinical scenarios. There is a need to develop the competence for evidence-based clinical decision-making in medical students; to achieve this, we have developed a blended-learning environment, in which we use real clinical cases that the students face and analyze in their clinical scenarios. Using these cases, we develop the ability to identify clinical problems, which are then transformed in structured questions that are answered based on scientific evidence. The process of answering the questions requires a search of medical articles relevant to the question, an appraisal of the level of evidence each scientific article provides, and analysis of the context of the patient, including the resources available in the clinic or hospital, and the social and cultural factors pertaining to the patient that might influence the clinical decision. This part of the process is internet-based. Once the students have presented their answers to the clinical questions, a reunion takes place in which the case, the questions derived from the case, and the answers are presented and discussed as to reach an agreement on which is the clinical approach that has the best evidence-based support. This technique has been tested to certify that the pretended competence can be achieved via this method. In order to aid in the process of developing the competence for evidence-based clinical decision-making, we have developed a learning object that serves both the students and the teachers. In this instrument, the students learn to systematize the process, from the building of the question to the analysis of the data to the final answer, which develops in them the ability to approach a clinical problem in an orderly and systematic way. The teachers can also use this instrument as an evaluation tool, as it provides evidence that the students understand and effectively perform each step required in the process of evidence-based clinical decision-making
Clinical expertise can be defined as the capacity to use clinical skills and experience to swiftly identify health status and specific diagnoses in each patient, as well as specific risks and potential benefits derived from different clinical interventions in specific scenarios. Although undoubtedly useful, it has been several decades since clinical expertise has been considered insufficient, given the constant advances in medical science and exponential growth of available information.
Evidence-based medicine (EBM) has emerged as a new model in the practice of medicine, with the intent to merge the best available evidence derived from clinical research with medical expertise in order to guide clinical decision-making.
The practice of EBM requires the following steps:
-Turning the need for information in an answerable question
-Search for the best evidence available to answer such question
-A critical appraisal of the validity, impact and applicability of such evidence
-An integration of the evidence with the clinical expertise and the clinical scenario, including patient preferences and sociocultural context, in order to reach a clinical decision
-Evaluation of the process of clinical decision-making
In order to develop the competence for evidence-based clinical decision-making, we have developed a strategy in which we obtain two main products: The competence itself, and learning objects which synthetize the process and are available for other students to learn about answers given to clinical questions in specific scenarios and how these answers are obtained. As our medical students spend approximately 4 hours a day in clinical scenarios in their 4th and 5th year of medical school, they have countless opportunities to identify clinical questions for which they do not have an answer, or to which the proper decision does not seem clear or seems debatable. Among these cases, they are required to select one and to present a brief summary of the patient’s history and clinical findings. They then upload the case in a teaching platform (Dokeos). The professor analyzes the different cases, and selects one that gives enough opportunities to derive answerable clinical questions for the group, regarding diagnostic methods, treatment options or preventive measures. Once the case has been selected, it is made available to the whole group of students via the Dokeos platform. The students are then instructed to provide a three-part clinical question derived from the case. The process of elaboration of such questions is guided in a forum on Dokeos, and the different questions are available to every student, to ensure each question is different from the others. This is a form of problem-based-learning Once the identified clinical problems have been turned into structured three-part clinical questions, the students do an internet-based search for available medical articles that could answer the clinical question. Once they have such articles, they critically evaluate and rate the quality of the evidence each article provides taking into consideration the design of each study, the amount of subjects in each study, the strengths and weaknesses and the statistical analysis. This is called a systematic review of medical literature. Having done that, they have to reach a decision as to which is the recommendation that has the best scientific support, given that such recommendation is feasible and available for the patient and is acceptable considering his or her sociocultural context. Once an answer to the clinical question has been obtained, they have to provide evidence of the process via Dokeos. In order to do this, we provide a form in which they provide the three-part question, the clinical elements of the case relevant to the question, the terms used in the internet search, and a list of the articles chosen, the main data obtained from them and the rating given to the level of evidence. They also provide an analysis of the information obtained from the article, and a final answer to the clinical question. This is called “Proof of Evidence” (“Ficha de Evidencias” in Spanish) The proof of evidence is evaluated, and the students get feedback on the evaluation given to the document via Dokeos. In a classroom session, the case is presented and analyzed, and all of the clinical questions and answers are included in the discussion, in order to reach an agreement on which decisions have the best supporting evidence and which diagnostic, therapeutic and preventive measures should be given to the patient. Each student is required to undergo the whole process at least six times a year, thus providing a great number of learning opportunities and proofs of evidence available for other students as learning objects that come directly from real clinical scenarios.
This course has been given for two years. The first year we enrolled 25% of the students, and proved that the competence could be developed within a year. The second year we randomly selected and enrolled 50% of the students, and compared them with the traditional course in terms of competence, faculty and student satisfaction. Both faculty and students have shown appreciation for this practice, considering it a better alternative than the traditional course. The final result is a competence that better prepares medical students for evidence-based clinical decision-making in real scenarios. The results of this comparative study are to be presented and published as a book on the CCITA conference (Conferencia Conjunta Iberoamericana sobre Teconologías para el Aprendizaje), on July, 2012.
In the past, the competence trained was that for structured analysis of medical literature. The professors were the ones who provided the clinical questions, and the answers were provided in paper. There was simply not enough time to train students in a competence as ambitious as evidence-based clinical decision-making. By incorporating online learning in a blended-learning environment, we became able to guide the process of developing the pretended competence. We have demonstrated that the competence is indeed developed in our students, which is evidently an improval compared to previous results.
Students have been surveyed, and they consider this to be a better learning technique and a course that should remain in the curricula.
This program has generated no additional cost to the institution, as Dokeos is free software. It has had no significant impact in the workload of faculty, while developing a more desirable final competence. Moodle, Blackboard and Web CT are suitable alternatives for this practice. Professors in other careers at our university have shown interest in implementing similar courses. Our experience has been presented on the 3rd International Congress on Medical Education in Puerto Vallarta, Mexico, and received an award for Research in Medical Education.
As free teaching platforms are readily available, access is guaranteed to any institution wishing to replicate our experience. In our institution, every student has access to the course. It must be kept in mind that this practice happens in a public university in a country with limited resources. Even so, the university provides free internet access and enough computers on campus for all of the students to effectively participate in the course. Incorporation of a teaching platform has made information dissemination and tutoring easily available.
Faculty involved in this practice find it a better alternative to traditional classroom-based teaching. It is considered a scenario in which integration of medical knowledge with real clinical problems occurs, in which medical students can train in evidence-based clinical decision-making skills in a supervised way with no consequences to the patients. All of those professors that have participated in the learning experience remain as teachers, and comments from new professors participating in the course have been positive, as this practice is considered to merge disciplinary knowledge and ethics.
Students are pleased with the blended-learning experience and learning outcomes. A survey has been made, in which all of the students surveyed rate the learning experience as good to excellent, a rating that is better than that obtained by the previous, classroom-based course.
A teaching platform, Dokeos, Moodle, Blackboard, Web CT or equivalent Internet access for students and faculty Access to medical databases, such as MD consult Access to clinical scenarios for medical students Teachers willing to implement the practice
As all of the requirements should be available in any medical school, probable cost is none.
Esperon-Hernandez Ramon, Gonzalez-Montalvo Pablo, Briceño-Abraham Anel Generación de Objetos de Aprendizaje mediante la estrategia Medicina Orientada por Evidencias en un ambiente combinado. To be published by CCITA 2012 (Conferencia Conjunta Iberoamericana sobre Tecnologías para el Aprendizaje)