근거중심 의학교육(Evidence-Based Medicine Training) : 학부 의학교육(Undergraduate Medical Education)에 대한 제언

(출처 : http://www.psmag.com/health/evidence-of-a-need-for-change-4241/)

근거중심의학(EBM)이 학부 의학교육(UGME)에 도입된지는 20년이 지났지만, 많은 의사와 레지던트들은 실제 진료에 근거를 활용하는 지식이나 기술이 부족하다. EBM은 의학적 의사결정을 하는데 있어서 가장 최신의 근거를 신중하게 사용하는 것으로서 의료 과오를 줄이고, 개별화된 진료를 향상시키며, 최선의 진료를 하는 것과 연결된다.

Although evidence-based medicine (EBM) has been included in undergraduate medical education (UGME) for more than 20 years,1 many physicians and residents lack the knowledge and skills to incorporate evidence into practice.2 EBM is the judicious use of the best current evidence in making decisions about the care of individual patients3 and has been linked to reduction of medical errors, promotion of individualized care, and increased application of best practices.4,5 

EBM의 개념이 1991년 도입된 이후로, 전세계 의과대학에서는 이를 빠르게 받아들였다. EBM을 할 수 있는 역량(Competence)은 이제 보건의료 관련 면허를 발급받기 위해서는 반드시 필요하다.

Since the concept of EBM was introduced in 1991,5 it has been adopted by medical schools worldwide. Competence in EBM (also known as evidence-based practice) is now required by many health profession organizations for licensing and certification purposes.6

많은 의과대학이 EBM을 교육과정에 도입하고 있으나, 표준화되어있지 않다.

Today most medical schools include EBM in their curricula,6,7 but its implementation is not standardized.8–10

여기서는 의과대학 학생들의 EBM기술을 향상시키기 위한 교육적 이니셔티브를 집중적으로 다뤄보고자 한다.

We conducted this literature review to characterize educational initiatives targeting the improvement of medical students’ EBM skills

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Data extraction and full-text review

To facilitate our full-text review of articles, we created a modified version of the Best Evidence in Medical Education (BEME) data extraction tool for systematic reviews.17 This was available to all of us online via the Qualtrics18 survey tool and enabled us to collect information on 

• educational settings (classroom, clinical, online),

• study participants: instructor type (e.g., physician, librarian) and learner level (preclinical, clinical, both),

• EBM skills covered (four traditional steps13 plus recognizing a knowledge gap and evaluating the change in practice), and 

• teaching methods used.

We used Qualtrics18 to generate summary reports and descriptive statistics to characterize the educational interventions

Educational settings

These 20 studies presented a global sample of interventions and included 7 (35%) from the United States, 2 (10%) each from the United Kingdom and Thailand, and 1 (5%) each from Australia, China, Czech Republic, Iran, Japan, Jordan, Malaysia, Nigeria, and Pakistan

Study participants

Learner levels. 

Interventions targeted medical students at all years of study. 

Six interventions (30%) were aimed at preclinical students, 

whereas 12 (60%) focused specifically on clinical students

Instructors. 

We were not able to determine the instructor’s profession from the descriptions provided in 8 (40%) of the included studies, including the online-only intervention.30 

All 12 (60%) of the articles that provided this information identified physicians as instructors, and more than half of these interventions (n = 7) also included collaborating librarians,21,26,28,32 medical educators,35 business school faculty,29 or nurses and pharmacists.25

EBM skills addressed

Each study described an intervention that addressed a combination of EBM skills: 

recognizing a knowledge gap (n = 4; 20%), 

asking a clinical question (n = 18; 90%), 

searching for literature (n = 18; 90%), 

appraising evidence (n = 17; 85%), 

applying evidence to patient care (n = 13; 65%), 

and evaluating the change in practice (n = 1; 5%).

Teaching methods

Five (25%) of the articles described a one-time educational intervention, such as a three-hour workshop designed to improve clerkship students’ clinical question formulation and literature search skills.31 

Twelve (60%) included a series of interventions occurring over a single year.

Using Khan and Coomarasamy’s20 three-level hierarchy of EBM teaching and learning methods, we determined that

8 (40%) of the 20 interventions used level 1 (interactive, clinically integrated), 

8 (40%) used level 2 (interactive, classroom-based or didactic, but clinically integrated), and 

4 (20%) used level 3 (didactic, classroom-based, or standalone) methods.

Discussion

이제 EBM을 하지 못하면 대중들로부터 역풍을 맞게 되었다. 

따라서 의과대학에서 EBM에 대한 기본적인 훈련을 받는 것이 중요하다.

Physicians’ failure to engage in EBM has repercussions for the health of individuals and populations.4,5 It is therefore essential that medical students receive foundational training in EBM. To provide medical educators with an overview of current EBM training, which has become a common topic covered in medical education,36 we reviewed 20 recent studies describing a range of educational interventions taught in a variety of settings and aimed at students at all levels of UGME.

학부 의학교육에 미치는 영향과 제언

Implications and recommendations for UGME

EBM을 가르치는 시기

Timing of EBM instruction. 

EBM을 가르치는 가장 이상적인 시기에 대한 근거는 부족하다. 하지만 이 리뷰에서는 EBM교육이 대부분 임상실습을 도는 시기에 시행된다는 것이 다시 한번 확인되었다. 이 시기를 선택하는 논리적 근거는 임상실습의 환경과의 연계성이 훈련의 효과를 높일 것이라는 생각 때문이다. 하지만, 점차 더 일찍 임상 경험을 하는 쪽으로 추세가 변하고 있고, EBM도 preclinical year의 환경에 맞춰서 더 일찍 가르쳐야 할 것이다.

There is little evidence as to the most efficacious timing for EBM instruction.37 Yet, our review confirms earlier findings that most EBM educational interventions take place in the clinical years of medical school.38,39 This timing is generally based on the rationale that the clerkship setting enhances the clinical relevance of the training.40 However, the trend toward providing students with early clinical experiences41 may provide opportunities for introducing EBM earlier, in the context of patient care in the preclinical years.

우리는 EBM을 임상경험의 초기에 가르칠 것을 권한다. 그 과정에서 학생들은 임상환경에을 처음 접하더라도 불확실성에 잘 대처할 수 있는 뼈대(framework)과 자기효능감을 가질 수 있을 것이다.

We suggest that medical educators consider integrating EBM instruction into early clinical experiences, as doing so may increase students’ self-efficacy and provide a framework that helps students deal with the uncertainty of being new to the clinical setting.

장기적이고 지속적인 EBM훈련

Longitudinal EBM training. 

EBM훈련에 반복적으로 노출되는 경우가 흔했지만, 장기적이고 지속적인(longitudinal) 교육과정을 갖춘 경우는 별로 없었다. 대부분은 짧고 집중적으로 교육되었으며, 이러한 압축된 교육환경에서는 EBM skill을 학생의 발달에 맞춰서 가르치기가 힘들다.

Although multiple exposures to EBM training were common in the studies reviewed, longitudinal curricula were lacking. In 75% of the included interventions, medical students received EBM training on more than one occasion, a practice that has been linked generally with increased learning.42 Yet most of the interventions were delivered over short, intensive time periods. The compressed nature of these learning opportunities limits medical educators’ ability to successively build EBM skills across levels of student development. 

나선형 교과과정에서 학습자는 여러 차례 반복적으로 서로 다른 수준의 개념에 노출됨으로써, 앞서 했던 경험을 바탕으로 새로운 경험을 쌓아간다. 우리는 EBM 훈련과정을 이러한 나선형 교과과정식으로, 모든 단계의 UGME에 도입할 것을 권한다.

In a spiral curriculum43—a format that has been adopted to teach some components of medical education—learners are provided multiple, successive exposures to a concept at different levels of their development so that each encounter builds on the previous encounter.44 We suggest that integrating EBM training as a spiral curriculum across all levels of UGME may be an effective model.

다직업군적 접근법

Interprofessional approach. 

의학교육의 추세가 전문직업군간 교육을 권장하고, 여러 보건의료 전문직이 함께 근거중심 진료를 하는 방향으로 가고 있기 때문에 의학교육도 전문직업군간 접근을 시도해야 한다.

We identified only one intervention that included both medical students and learners from other health professions.25 Given the trend in medical education toward recommending the use of interprofessional education (IPE)45 and the adoption of evidence-based practice by a spectrum of allied health professions, we encourage medical educators to consider taking an IPE approach to EBM instruction.

또한 다양한 전공의 교육자를 포함시킬 것과 더불어, 이 때 교육 환경적 측면에서 교실 셋팅을 벗어나는 사고를 해 볼 것을 권고한다. (다른 전공의 전공자가 가장 자신의 교수능력을 잘 발휘할 수 있는 환경의 활용)

We recommend that medical educators consider including instructors from a variety of disciplines and think beyond the classroom setting when integrating multidisciplinary teachers.

능동적 온라인 학습 환경

Active and online learning environments. 

최근, Prober와 Heath는 "의사를 가르치는 방법을 바꿀 때다"라고 하며, 강의 중심의 형태에서 온라인 학습을 중심으로 교실에서는 사례 학습과 같이 더 많은 상호작용을 유도하는 방식으로 바꿔야 한다고 주장했다.

Recently, Prober and Heath47 declared, “It’s time to change the way we educate doctors,” and advocated a shift from a lecture-based format to an active learning approach that blends online learning with more interactive classroom activities, such as case studies.47 

의과대학생들에게 EBM을 가르치는 것에 있어서 이미 인터엑티브한 교수방법, 온라인 교육이 사용되고 있다. 온라인 형식을 활용하여 수업시간의 압박을 줄이고, 제한된 교수자원을 더 확대하고, 스케쥴의 한계를 극복하고, 학생들을 더 많이 임상 현장으로 보낼 수 있다.

We found that EBM interventions for medical students are already using interactive teaching methods and online learning. Three interventions28,30,32 employed an online format to decompress classroom time, extend the reach of strained faculty resources, mitigate scheduling difficulties, and/or reach students at diffuse clinical sites.

지식의 공백

Gaps in knowledge. 

마지막으로 의학교육자들은 의사들이 스스로에 대한 평가를 통해, 특정한 상황에서 자신의 지식이나 기술이 부족할 수도 있다는 것을 인지하도록 해야 한다.

Finally, medical educators have dedicated much attention to the physician’s ability to self-monitor, that is, to recognize the limitations of one’s skill and knowledge to act in a specific situation.49,50

이러한 지식의 공백을 인지하는 것은, 그렇게 함으로써 EBM과정을 더 촉진시키고, 의사들로 핵심적인 질문을 던져 그 다음 단계를 진행할 수 있도록 해주기 때문에 중요하다.

Being able to identify awareness of a knowledge gap is critical, as doing so acts as the fuel that ignites the EBM process and prompts the physician to ask clinical questions and proceed through the subsequent steps

우리 리뷰와 여러 연구에 따르면 의사들은 임상적 의문을 가졌을 때, 그 사실(의문을 가졌다는 사실)을 인지하는 것에 약점을 보인다.  따라서 우리는 EBM훈련을 통해 이러한 지식의 공백을 인지하는 기술을 익힐 것을 권고한다.

On the basis of our review findings, and research showing that physicians tend to be weak in recognizing when they have clinical questions,52 we suggest that all EBM training should cover the essential skill of recognizing a knowledge gap.

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Acad Med. 2013 Jul;88(7):1022-1028.

Evidence-Based Medicine Training in Undergraduate Medical Education: A Review and Critique of the LiteraturePublished 2006-2011.

Maggio LA, Tannery NH, Chen HC, Cate OT, O'Brien B.

Source

Ms. Maggio is director of research and instruction, Lane Medical Library, Stanford University School of Medicine, Stanford, California. Ms. Tannery is senior associate director, Health Sciences Library System, University of Pittsburgh, Pittsburgh, Pennsylvania. Dr. Chen is professor of clinical pediatrics, Department of Pediatrics, University of California, San Francisco, School of Medicine, San Francisco, California. Dr. ten Cate is professor of medical education and director, Center for Research and Development of Education, University Medical Center Utrecht, Utrecht, the Netherlands, and adjunct professor, Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California. Dr. O'Brien is assistant professor of medicine, Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California.

Abstract

PURPOSE:

To characterize recent evidence-based medicine (EBM) educational interventions for medical students and suggest future directions for EBM education.

METHOD:

The authors searched the MEDLINE, Scopus, Educational Resource Information Center, and Evidence-Based Medicine Reviews databases for English-language articles published between 2006 and 2011 that featured medical students and interventions addressing multiple EBM skills. They extracted data on learner and instructor characteristics, educational settings, teaching methods, and EBM skills covered.

RESULTS:

The 20 included articles described interventions delivered in 12 countries in classroom (75%), clinic (25%), and/or online (20%) environments. The majority (60%) focused on clinical students, whereas 30% targeted preclinical students and 10% included both. EBM skills addressed included recognizing a knowledge gap (20%), asking a clinical question (90%), searching for information (90%), appraising information (85%), applying information (65%), and evaluating practice change (5%). Physicians were most often identified as instructors (60%); co-teachers included librarians (20%), allied health professionals (10%), and faculty from other disciplines (10%). Many studies (60%) included interventions at multiple points during one year, but none were longitudinal across students' tenures. Teaching methods varied. Intervention efficacy could not be determined.

CONCLUSIONS:

Settings, learner levels and instructors, teaching methods, and covered skills differed across interventions. Authors writing about EBM interventions should include detailed descriptions and employ more rigorous research methods to allow others to draw conclusions about efficacy. When designing EBM interventions, educators should consider trends in medical education (e.g., online learning, interprofessionaleducation) and in health care (e.g., patient-centered care, electronic health records).