근거중심 의학교육(Evidence-Based Medicine Training) : 환자중심진료(Patient-Centered Care)와 전자의무기록(EMR, EHR)

(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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보건의료에 미치는 영향과 관련된 제언

Implications for health care and related recommendations

환자 중심적 진료

Patient-centered care. 

2010년 법안에 따라서 정부는 상호 합의된, 근거중심 의사결정을 내리는 의사와 환자에게 돈을 지원한다. 학생들이 환자의 상황에 맞춰서 임상적 질문을 던지고, 그 근거를 환자 진료에 어떻게 적용해야 할지를 가르치는 것은 많지만, 그 근거들을 놓고 환자와 함께 상의(토론)하는 방법을 가르치는 훈련은 없다. 우리는 학생들이 환자와 근거를 공유하여 의사결정을 내리는 것을 연습할 기회를 주어야 한다.

In the Patient Protection and Affordable Care Act of 2010, the United States committed funding to support patients and clinicians in making shared, evidence-based decisions.53 Although a handful of included interventions7,8,16,28,29,33 required students to generate clinical questions based on their patient encounters and contemplate how they might apply evidence to patients’ care, none included training on discussing evidence with patients. We suggest that medical educators consider how to provide opportunities for students to engage in sharing evidence with patients to facilitate decision making activities.

환자들이 근거의 공급원(bearer)가 되어가는 시나리오에 맞춰 준비하는 프로그램도 없었다. 최근의 연구에서 의사들은 "환자들이 인터넷에서 정보를 가져와 상의를 하는 것에 엄청난 불안감을 느낀다"라고 밝혀진 바가 있다. 이 부분에 있어서 좀 더 성숙한 자세가 필요하다. 환자가 이런식으로 정보를 가져올 가능성이 점차 높아지는 만큼, 학생들은 환자로부터 받은 정보를 평가하고, 생산적인 대화를 통해서 학생과 의사가 그 정보에 대해 심사숙고하고, 필요한 경우 환자 진료에 포함시키는 것을 연습해야 한다.

The related scenario of the patient as the bearer of evidence was also absent from the reviewed interventions. Recent research has demonstrated that physicians “experience considerable anxiety in response to patients bringing information from the internet to a consultation,”54 which suggests that this is an area ripe for improvement. As it is probable that patients will increasingly bring information to appointments, we recommend that medical educators train students to evaluate the evidence retrieved by patients and to engage in productive conversations in which the student and patient can reflect on the information and, if appropriate, integrate it into the patient’s care.

전자의무기록

Electronic health records. 

대부분의 개입방법이 어떻게 전통적인 정보원(PubMed 등)에서 자료를 찾는가를 다루고 있지만, 전자의무기록으로부터 정보를 모으는 방법은 다루고 있지 않다. 전자의무기록은 점차 널리 퍼지고 있고, 정보를 제공하고 경고를 띄움으로서 중요한 임상적 질문을 하도록 하는 식으로 의료의 질을 향상시키고 있다.

Although all of the reviewed interventions included instruction on how to search the literature using traditional resources (e.g., PubMed), none addressed how to access information via electronic health records (EHRs). EHRs are becoming increasingly prevalent in medical practice, and their capabilities are improving with regard to delivering information and prompting clinical questions within the workflow via alerts and “infobuttons.”55 

따라서 이렇게 발전하는 전자의무기록을 활용할 수 있게 해주는 EBM훈련이 필요하다. 

Educators therefore need to ensure that EBM training accommodates these evolving resources. For example, they may need to shift emphasis from PubMed search skills to information management skills, such that students learn to manage or triage point-of-care information presented within EHRs. Additionally, educators should seize the opportunity to use EHRs to facilitate EBM teaching.

전자의무기록의 사용은 활용가능한 정보의 종류를 확장시켜준다. 어려운 케이스가 생겼을 때 기존의 환자 정보를 근거로 치료 방침을 결정하는 방식이 지금은 '새로운' 방식이지만, 이러한 전자의무기록의 활용이 점차 많아질 것이다. 

The increasing use of EHRs may also expand the types of available evidence. Recently, a physician team at Stanford was temporarily stymied by the lack of published evidence related to the treatment of a complicated pediatric case. However, by querying the EHR system, they identified a cohort of similar patients and analyzed outcomes data to make an informed treatment decision.56 Although this is currently considered a “novel” process, such use of EHR data is likely to become increasingly prevalent.

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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).