EVIDENCE BASED MEDICINE SEBAGAI GAYA BELAJAR MAHASISWA FAKULTAS KEDOKTERAN
BAB I
PENDAHULUAN
A. LATAR BELAKANG
Semakin berkembangnya zaman, sistem pendidikan dokter di seluruh dunia juga semakin berkembang. Demikian pula sistem pendidikan dokter di Indonesia. Dulu proses pendidikan kedokteran di Indonesia cenderung masih tradisional dan sangat mengandalkan kuliah yang berpusat pada dosen, yang cenderung menekankan pada transfer pengetahuan, bukan pada pemfasilitasan pembelajaran. Proses pendidikan kedokteran yang seperti itu sudah tidak cocok dengan tuntutan keadaan saat ini. Untuk saat ini, didalam pendidikannya, dokter sangat harus dididik dan dituntut untuk belajar secara mandiri yang berkonsep pada konsep dasar belajar berbasis bukti ilmiah (evidence based medicine), yang bertujuan agar mahasiswa kedepannya dapat benar – benar siap dan mampu untuk menjadi seorang dokter yang dapat membantu pasien sesuai dengan yang diharapkan.
Bukan hanya didalam sistem pendidikan saja, demikian juga dengan berkembangnya teknologi informatika yang dapat dilihat dari semakin pesatnya perkembangan bioinformatika dan teknologi informasi yang mempunyai kontribusi besar pada munculnya era ledakan informasi ilmiah yang secara mendasar merubah cara dokter mendefinisikan, mendiagnosis, memberikan terapi, dan mencegah penyakit. Semakin pesatnya perkembangan informasi tentang cara melakukan praktik kedokteran dan perubahan informasi juga sangat membantu dokter didalam mencari dan mengambil informasi catatan-catatan medis elektronik melalui internet. Dari semuanya tersebut, tujuan utama dari seorang dokter adalah mengobati pasien sampai pasien benar-benar sembuh. Oleh karena itu, maka berkembanglah seni kedokteran yang sangat diperlukan dalam praktik kedokteran yang berbasis ilmiah atau yang sering disebut dengan Evidance Based Medicine.
B. RUMUSAN MASALAH
1. Apakah pengertian dari evidence based medicine?
2. Bagaimanakah penerapan evidence based medicine dalam belajar?
3. Apa pentingnya evidence based medicine bagi mahasiswa kedokteran?
4. Bagaimana cara mencari publikasi ilmiah?
5. Bagaimana penerapan publikasi ilmiah?
6. Apa saja situs – situs yang digunakan dalam pencarian publikasi ilmiah?
7. Apa yang dimaksud accountable dari aspek ilmiah dan accountable dari metodologinya?
8. Bagaimana cara menggunakan Boolean logic?
C. TUJUAN
Laporan ini ditulis sebagai hasil tutorial ketiga Blok I "Evidence Based Medicine", agar tercapai pemahaman mahasiswa secara teori, diantaranya :
1. Definisi istilah – istilah didalam gaya belajar dengan menggunakan evidence based medicine
2. Cara pelacakan dan penerapan publikasi ilmiah
3. Urutan penggunaan Boolean logic
4. Website – website pencarian / pelacakan publikasi ilmiah
D. MANFAAT
1. Mahasiswa mengerti dan memahami bagaimana cara belajar dengan menggunakan evidence based medicine.
2. Mahasiswa mengerti dan memahami tentang cara pelacakan publikasi ilmiah beserta penerapannya
3. Mahasiswa mengetahui dan memahami bagaimana langkah / proses urutan dalam menggunakan Boolean logic.
4. Mahasiswa mengetahui apa saja situs – situs web untuk pencarian / pelacakan publikasi ilmiah lainnya selain www.pubmed.com dan www.proquest.com.
BAB II
STUDI PUSTAKA
A. TINJAUAN PUSTAKA
- Evidence Based Medicine
Menurut Sackett et al. Evidence-based medicine (EBM) adalah suatu pendekatan medik yang didasarkan pada bukti-bukti ilmiah terkini untuk kepentingan pelayanan kesehatan penderita. Dengan demikian, dalam prakteknya, EBM memadukan antara kemampuan dan pengalaman klinik dengan bukti-bukti ilmiah terkini yang paling dapat dipercaya.
Pengertian lain dari evidence based medicine (EBM) adalah proses yang digunakan secara sistematik untuk menemukan, menelaah/me-review, dan memanfaatkan hasil-hasil studi sebagai dasar dari pengambilan keputusan klinik. Jadi secara lebih rincinya lagi, EBM merupakan keterpaduan antara (1) bukti-bukti ilmiah, yang berasal dari studi yang terpercaya (best research evidence); dengan (2) keahlian klinis (clinical expertise) dan (3) nilai-nilai yang ada pada masyarakat (patient values).
Publikasi ilmiah adalah suatu pempublikasian hasil penelitian atau sebuah hasil pemikiran yang telah ditelaaah dan disetujui dengan beberapa petimbangan baik dari acountable aspek metodologi maupun acountable aspek ilmiah yang berupa jurnal, artikel, e-book atau buku yang diakui.
Adapun acountable aspek ilmiah adalah mensurvey secara langsung tentang suatu permasalahan dengan penelitian untuk mendapatkan dasar yang valid dan dapat dipertanggung jawabkan. Maksudnya adalah :
1. Melalui evidence based medicine kita mengadakan survei tentang keluhan sejumlah penderita.
2. Melalui evidence based medicine kita mengadakan survei tentang kelainan fisik sejumlah penderita penyakit tertentu.
3. Selain mensurvei keluhan dan kelainan fisik penderita, melaui evidence based medicine kita juga dapat mensurvei hasil terapinya.(Wiryo, 2002)
Sedangkan acountable aspek metodologis adalah ilmu yang digunakan untuk memperoleh kebenaran menggunakan tata cara tertentu dalam pengumpulan data hasil penelitian yang telah ditelaah dan diakui kebenarannya.
http://www.dkk-bpp.com/index.php?option=com_content&task=view&id=144&Itemid=47
II. Penerapan Evidence Based Medicine
Penerapan evidence based medicine dalam pembelajaran mahasiswa diantaranya adalah
1. Dalam menyusun dan memformulasikan pertanyaan ilmiah yang berkaitan dengan masalah
2. Menelusuri informasi ilmiah yang berkaitan dengan masalah yang dihadapi
3. Menelaah terhadap bukti-bukti ilmiah yang didapat
4. Penerapan hasil-hasil penelaah bukti-bukti ilmiah tadi yang sudah dipercaya ke dalam praktek pengambilan keputusan
5. Kemudian pengevaluasian terhadap efficacy dan effectiveness
http:/lib:atmajaya.ac.id/default.spx
III. Pentingnya Evidence Based Learning
Beberapa alasan utama mengapa EBM diperlukan :
- Bahwa informasi-informasi tradisional (misalnya yang terdapat dalam text-book) sudah sangat tidak akurat pada saat ini. Beberapa justru sering keliru dan menyesatkan (misalnya informasi dari pabrik obat yang disampaikan oleh duta-duta farmasi/cfete//er), tidak efektif (misalnya continuing medical education yang bersifat didaktik), atau bisa saja terlalu banyak sehingga justru sering membingungkan (misalnya jurnal-jurnal biomedik/ kedokteran yang saat ini berjumlah lebih dari 25.000 jenis).
- Dalam pendidikannya, dengan bertambahnya pengalaman klinik seseorang maka kemampuan/ketrampilan untuk mendiagnosis dan menetapkan bentuk terapi (clinical judgement) juga meningkat. Namun pada saat yang bersamaan, kemampuan ilmiah (akibat terbatasnya informasi yang dapat diakses) serta kinerja klinik (akibat hanya mengandalkan pengalaman, yang sering tidak dapat dipertanggungjawabkan secara ilmiah) menurun secara signifikan.
- Meningkatkan kinerja mahasiswa dalam mencari dan mengidentifikasi literatur klinis terbaik untuk menyelesaikan masalah.
http://www.medev.ac.uk/resources/features/AMEE_summaries/BEME1.pdf.
IV. Cara Mencari Publikasi Ilmiah dan Penerpannya
Publikasi ilmiah dapat kita cari dari perpustakaan di kampus, internet, kuliah pakar, dll. Pelacakan publikasi ilmiah yang baik diantaranya adalah
1. Pelacakan yang spesifik, akan lebih cepat dan berpeluang untuk menemukan artikel yang diinginkan.
2. Penggunaan frase yang tepat agar memudahkan dalam pencarian
3. Pelacak memiliki pengetahuan dan pengalaman sebelumnya
4. Dengan menggunakan Boolean logic
V. Penerapan Publikasi Ilmiah
Dalam dunia perkuliahan, contoh penerapan publikasi ilmiah adalah sebagai berikut :
1. Karya Tulis
2. Paper
3. Makalah
4. Laporan
5. Skripsi
6. Tesis
7. Disertasi
8. Buku teks/text book
9. Diktat
10. Jurnal
11. Buletin
12. Referat, dll
VI. Website – Website Yang Digunakan Untuk Mengakses Jurnal
Selain www.pubmed.com dan www,proquest.com, ada beberapa website yang diperuntukkan dalam pencarian jurnal. Diantaranya :
Dalam mencari sebuah jurnal atau artikel, biasanya kita menggunakan www.pubmed.com atau www.proquest.com ,dll dengan menggunakan cara boolean logic. Didalam menggunakannya, terdapat kata bantu, yaitu AND, OR, NOT, dan NEAR.
1. OR
Contohnya dalam melacak "Stroke OR therapy". Semua artikel atau jurnal yang ditemukan hanya mengandung kata stroke saja atau therapy saja.
2. AND
AND berfungsi sebagai penghubung. Dalam melacak, misal "Hypertension AND therapy", mesin pencari tersebut akan mengeluarkan semua artikel atau jurnal yang mengandung kedua kata tersebut, yaitu hypertension dan therapy.
3. NOT
NOT sendiri berfungsi untuk eksklusi. Dalam menggunakannya, missal dalam mencari "Hyperextension NOT eclampsia", semua artikel yang mengandung kata hyperextesion akan keluar, namun yang mengandung kata eclampsia tidak akan dikeluarkan walaupun mengandung kata hyperextension.
4. Dari ketiga kata bantu tersebut dapat digabungkan
Misalnya dalam mencari ("Signal transduction "AND (phosphorylation OR kinase)) NOT xenopous, akan diketemukan artikel atau jurnal yang mengandung kata signal transduction dan phosporylation tanpa mengandung kata xenopous, atau yang mengadung kata signal transduction dan kinase tanpa mengandung kata xenopous.
5. Huruf Kapital
Didalam pencarian dengan menggunakan Boolean logic harus menggunakan huruf kapital.
6. Frase / fragmen
Gunakan yang namanya "Quotation Marks". Misalnya dalam mencari "Life and death of a cell" akan mendapatkan artikel dan jurnal yang lebih spesifik. Tanpa "Quotation Marks" akan didapatkan artikel yang hanya berisi life, death, atau cell saja.
7. Batasan Waktu
Dengan menggunakan batasan waktu didalam pencarian dapat berguna dalam menyempitkan pelacakan. Misalnya kita ingin mencari artikel tentang hal yang kita cari tersebut dalam lima tahun terakhir atau 10 tahun terakhir atau dll. Kita juga dapat membatasi hanya pada artikel yang dapat diakses "full text".
8. Wildcards
Wildcards digunakan untuk meluaskan pencarian. Caranya adalah dengan menambahkan tanda (*). Contohnya dalam mencari child*, kita akan memperoleh artikel yang berisi child, children, childcare, dsb.
Dari cara penggunaan Boolean logic tersebut jika masih saja gagal didalam pencariannya mungkin terdapat masalah pada program search engine atau mungkin juga karena tidak adanya artikel yang sesuai dengan pencarian dari kata yang dicari. Oleh Karena itu, terdapat tips didalam pencarian artikel dengan menggunakan Boolean logic, yaitu :
1. Jangan terlalu spesifik
2. Cek ejaan
3. Bila ragu-ragu akan ejaan jangan masukkan kata tersebut
4. Gunakan wildcard
BAB III
PEMBAHASAN
Analisis Skenario
Dari skenario III "Evidence Based Medicine" telah didapatkan informasi sebagai berikut :
1. Ani, seorang mahasiswi kedokteran tingkat pertama, harus belajar menyesuaikan banyak hal mengenai gaya belajarnya. Salah satu yang menjadi fokus perhatiannya adalah balajar berbasis bukti ilmiah atau dalam banyak percakapan dengan dosennya dikenal dengan evidence based medicine.
2. Ahmad, kakak kelas menjelaskan bahwa dalam evidence based medicine, sumber belajar kita berasal dari pelacakan publikasi ilmiah.
3. Sumber publikasi ilmiah itu harus accountable, dari aspek ilmiah dan metodologinya.
4. Biasanya Ahmad mencari di internet dengan alamat www.pubmed.com atau www.proquest.com, memakai hot spot kampus, kita bisa mengakses naskah publikasi secara gratis dan bisa memilih full text.
5. Untuk mengaksesnya memakai Boolean logic.
Berikut merupakan pembahasan scenario :
1. Ani, mahasiswa semester tingkat pertama memfokuskan perhatiannya mengenai evidence based medicine. Evidence based medicine adalah proses yang digunakan secara sistematik untuk menemukan, menelaah dan memanfaatkan hasil – hasil studi sebagai dasar dari pengambilan keputusan klinis dan berasal dari bukti – bukti ilmiah.
2. Didalamnya, sumber belajar kita berasal dari pelacakan publikasi ilmiah. Publikasi ilmiah adalah sistem publikasi yang dilakukan berdasarkan peer review dalam rangka mencapai objektivitas serinci mungkin.
3. Sumber publikasi itu harus Accountable. Accountable adalah sumber dari bukti – bukti ilmiah yang dapat dipertanggungjawabkan dari aspek ilmiah dan metodologinya.
4. Yaitu yang bersumber dari aspek ilmiah. Aspek ilmiah adalah berdasarkan pada ciri-ciri keilmuan, yaitu rasional, empiris, dan sistematis.
5. Dan bersumber dari metodologinya. Metodologi adalah ilmu – ilmu yang digunakan untuk memperoleh kebenaran menggunakan penelusuran dengan tata cara tertentu dalam menemukan realitas yang sedang dikaji.
6. Sumber publikasi tersebut biasa dicari melalui internet. Internet adalah Kependekan dari kata "inter-network", yaitu merupakan jaringan komputer yang menghimpun sumber informasi sangat luas, manjangkau seluruh dunia, cepat, efisien
7. Yaitu melalui situs www.pubmed.com. www.pubmed.com
adalah mesin pencari gratis untuk mengakses database medline yang berisi sitasi dan abstrak artikel riset biomedis.
adalah mesin pencari gratis untuk mengakses database medline yang berisi sitasi dan abstrak artikel riset biomedis.
8. Ataupun melalui situs www.proquest.com. www.proquest.com adalah penyedia akses informasi journal – journal elektronik bertaraf internasional, namun untuk dapat mengakses database ini tidak setiap orang bisa mengaksesnya, sebab hak akses hanya diberikan kepada pihak yang telah berlangganan database mereka
9. Biasanya mereka mencarinya melalui hot spot yang disediakan di kampus. Hot spot adalah layanan internet tanpa kabel dengan menggunakan teknologi wi-fi. Dengan ini, setiap orang dapat mengakses jaringan internet melalui computer / laptop melalui wi-fi dimana hotspot disediakan.
10. Dari hotspot tersebut, kita dapat mengakses naskah secara gratis dan full text. Full text adalah pendeskripsian artikel, journal, dan sebagainya dalam hasil browsing dalam bentuk teks penuh secara keseluruhan.
11. Untuk mengakses full text tersebut, digunakanlah Boolean logic. Boolean logic adalah sistem simbolis logika yang dibuat oleh George boole yang digunakan dalam proses pencarian jurnal, artikel, dsb.
BAB IV
PENUTUP
A. KESIMPULAN
1. Evidence Based Medicine merupakan suatu pendekatan medik dengan bukti-bukti ilmiah terkini yang disusun secara sistematik untuk membantu pengambilan keputusan dibidang medik.
2. Latar belakang munculnya EBM adalah adanya perkembangan ilmu kedokteran yang signifikan dari tahun ke tahun.
3. Dalam penggunaannya, EBM menjadikan publikasi ilmiah sebagai sumber belajar yang acountable dan sesuai dengan metodologinya. Publikasi ilmiah dapat berupa jurnal atau makalah.
4. Tujuan dari EBM adalah membantu klinisi dan praktisi dan praktisi medik dalam proses pengambilan keputusan yang dapat dipertanggung- jawabkan.
5. Langkah-langkah dalam EBM antara lain menyusun dan memformasikan pertanyaan ilmiah, penelusuran informasi ilmiah, penelaahan terhadap bukti-bukti ilmiah, menerapkan hasil penelaahan bukti-bukti ilmiah kedalam pengambilan keputusan, melakukan evaluasi terhadap efikasi dan efektivitas intervensi
6. Struktur pertanyaan klinik yang digunakan dalam EBM adalah P= patient or problem ( permasalahan ), I=intervention ( penanggulangan ), C=comparison ( membandingkan ), O=out comes ( evaluasi hasil akhir )
7. Boolean Logic adalah logika sederhana yang dapat membantu kita dalam pencarian bukti-bukti ilmiah yang lebih spesifik dengan menggunakan kata-kata AND, OR, atau NOT
B. SARAN
1. Sebaiknya mahasiswa menggunakan Evidence Based Medicine dalam pembelajarannya di kedokteran serta menerapkannya di dalam dunia nyata dan dunia kerja nantinya
2. Seharusnya mahasiswa dapat mengambil keputusan yang tepat setelah menggunakan EBM dalam pembelajarannya
3. Sebaiknya mahasiswa menggunakan database yang valid agar mendapat bukti-bukti ilmiah yang valid dan dapat dipertanggung jawabkan seperti dari www.pubmed.com, www.proquest.com, dll.
4. Sebaiknya mahasiswa menggunakan Boolean logic untuk mempermudah dalam pencarian bukti-bukti ilmiah dan mendapatkan bukti yang lebih spesifik.
DAFTAR PUSTAKA
http://www.kalbe.co.id/files/cdk/files/23_169Strategionline.pdf/23_169Strategionline.html
http://www.medev.ac.uk/resources/features/AMEE_summaries/BEME1.pdf.
http://ad71ck.staff.uns.ac.id/archives/date/2009/02
Wiryo H, 2002. Kajian Kritis Makalah Ilmiah Kedokteran Klinik Menurut Kedokteran Berbasis Bukti (KBB). Jakarta :CV. Agung Seto.
Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson W S (2002)Evidence Based Medicine: what it is and what isn't . BMJ312:71-72.
http://library.ums.ac.id/pelacakan +publikasi+ilmiah
Skenario
Ana, seorang mahasiswa kedokteran, sedang mempelajari evidence based medicine sebagai gaya belajar di dalam kuliahnya, tetapi dia masih bingung dengan aplikasi EBM di dalam realita nyata. Padahal kata dosen dia harus bisa menerapkannya didalam pembelajarannya untuk menjadi seorang dokter yang profesional.
Population/problem : profesional doctor
Intervention : evidence based medicine aplication
Outcome : medical student outcome
THE EFFECTIVENESS OF A CLINICALLY INTEGRATED E-LEARNING COURSE IN EVIDENCE-BASED MEDICINE
A cluster randomised controlled trial
Regina Kulier,1 Sjors FPJ Coppus,2,3 Javier Zamora,4,14 Julie Hadley,5 Sadia Malick,5 Kausik Das,6 Susanne Weinbrenner,7 Berrit Meyerrose,7 Tamas Decsi,8 Andrea R Horvath,9 Eva Nagy,9 Jose I Emparanza,10 Theodoros N Arvanitis,1 Amanda Burls,1 Juan B Cabello,10 Marcin Kaczor,11 Gianni Zanrei,12 Karen Pierer,13 Katarzyna Stawiarz,11 Regina Kunz,13 Ben WJ Mol,2,3 and Khalid S Khan1,5
1The University of Birmingham, Edgbaston, Birmingham B15 2TG, UK
2Academic Medical Center, University of Amsterdam, Department of Obstetrics and Gynaecology, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
3Academic Medical Center, University of Amsterdam, Department of Clinical Epidemiology and Biostatistics, Meibergdreef 9, 1105 AZ Amsterdam, Amsterdam, the Netherlands
4Clinical Biostatistics Unit, Hospital Ramon y Cajal, Ctra Colmenar, km 9.100 28034, Madrid, Spain
5Birmingham Women's Hospital, Metchley Park Road, Edgbaston, Birmingham, B15 2TG, UK
6Heart of England NHS Foundation Trust, Solihull Hospital, Lode Lane, Solihull, B91 2JL, UK
7Agency for Quality in Medicine, Weglelystrasse 3, 10623 Berlin, Germany
8University of Pécs, Department of Paediatrics, József Attila u. 7, Pécs, H-7623, Hungary
9TUDOR, University of Szeged, Albert Szent-Gyorgyi Medical and Pharmacological Centre, Somogyi Bela ter 1, Szeged, H-6725, Hungary
10CASPe (CASP Espana), Joaquin Orozco 6, 1°-F, 03006 Alicante, Spain
11CASPolska, 30–347 Krakow, ul. Wadowicka 3, Poland
12Universitá Cattolica del Sacro Cuore, Via Emilia Parmense 84, 29100 Piacenza, Italy
13Basel Institute for Clinical Epidemiology, Hebelstrasse 10, CH 4031 Basel, Switzerland
14CIBER Epidemiologia y Salud Publica (CIBERESP), Barcelona, Spain
Corresponding author.
Regina Kulier: r.kulier@bham.ac.uk; Sjors FPJ Coppus: s.f.coppus@amc.uva.nl; Javier Zamora: javier.zamora@hrc.es; Julie Hadley: j.a.hadley@staffs.ac.uk; Sadia Malick: malicks1@doctors.org.uk; Kausik Das: kausik.das@heartofengland.nhs.uk; Susanne Weinbrenner: weinbrenner@azq.de; Berrit Meyerrose: meyerrose@azq.de; Tamas Decsi: tamas.decsi@aok.pte.hu; Andrea R Horvath: Horvath@clab.szote.u-szeged.hu; Eva Nagy: neva@clab.szote.u-szeged.hu; Jose I Emparanza: joseignacio.emperanza@osakidetza.net; Theodoros N Arvanitis: t.arvanitis@bham.ac.uk; Amanda Burls: a.j.burls@bham.ac.uk; Juan B Cabello: jbcabello@redcaspe.org; Marcin Kaczor: katarzyna.stawiarz@vp.pl; Gianni Zanrei: gianni.zanrei@unicatt.it; Karen Pierer: piererk@uhbs.ch; Katarzyna Stawiarz: katarzyna.stawiarz@vp.pl; Regina Kunz: Rkunz@uhbs.ch; Ben WJ Mol: b.w.mol@amc.uva.nl; Khalid S Khan: k.s.khan@bham.ac.uk
Received December 10, 2008; Accepted May 12, 2009.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Background
To evaluate the educational effects of a clinically integrated e-learning course for teaching basic evidence-based medicine (EBM) among postgraduates compared to a traditional lecture-based course of equivalent content.
Methods
We conducted a cluster randomised controlled trial in the Netherlands and the UK involving postgraduate trainees in six obstetrics and gynaecology departments. Outcomes (knowledge gain and change in attitude towards EBM) were compared between the clinically integrated e-learning course (intervention) and the traditional lecture based course (control). We measured change from pre- to post-intervention scores using a validated questionnaire assessing knowledge (primary outcome) and attitudes (secondary outcome).
Results
There were six clusters involving teaching of 61 postgraduate trainees (28 in the intervention and 33 in the control group). The intervention group achieved slightly higher scores for knowledge gain compared to the control, but these results were not statistically significant (difference in knowledge gain: 3.5 points, 95% CI -2.7 to 9.8, p = 0.27). The attitudinal changes were similar for both groups.
Conclusion
A clinically integrated e-learning course was at least as effective as a traditional lecture based course and was well accepted. Being less costly than traditional teaching and allowing for more independent learning through materials that can be easily updated, there is a place for incorporating e-learning into postgraduate EBM curricula that offer on-the-job training for just-in-time learning.
Trial registration
Trial registration number: ACTRN12609000022268.
Background
Evidence-based medicine (EBM) requires healthcare professionals to engage with contemporaneous research evidence in clinical decision making.[1] To achieve this, EBM curricula need to inculcate amongst learners the skills to acquire, assess and apply new knowledge in the clinical setting. However, training programs to improve evidence-based decision making have generally not been robustly evaluated. There has been much debate about the various EBM teaching and learning methods, but now there is consensus that best educational practice should be clinically integrated.[2] It should result not only in improvements in knowledge and appraisal skills, but also in attitudes and behaviour, which in the end leads to improved practice.[2]
Various models of teaching and learning strategies have been described, taking into account the different needs of adult learners, such as self-directed and problem-centred learning. [3]
However, traditionally, postgraduate education is generally delivered via lecture-based courses and workshops which do not directly exploit learning opportunities in the workplace. The EU-EBM Unity project was developed to address these shortcomings. [4] The project was conducted within the European Union's Leonardo da Vinci vocational training programme involving 11 European partners. [4,5] We used established methodology to develop a learner-centred, problem-based course that employs e-learning to provide on-the-job training exploiting learning opportunities during the course of clinical activity. [4-6] In brief, the course consists of five modules, to be followed consecutively and is outlined in table 1. Each module consists of a self-directed e-learning part and practical assignments that have to be completed and discussed with the facilitator before moving on to the next module. Our piloting showed that this course can be adapted to different clinical settings in different languages and it is well accepted by the trainees and tutors. [5]. In this trial, we set out to evaluate the educational effectiveness of our clinically integrated e-learning course for teaching basic EBM to postgraduates compared to a traditional lecture based course of equivalent content in terms of knowledge gain and change in attitude towards EBM.
| Table 1 Overview of the clinically integrated e-learning course compared to lecture based course in evidence-based medicine (EBM) |
Methods
We conducted a cluster randomised controlled trial [7] to compare the clinically integrated e-learning EBM course to a lecture-based course for its effect on knowledge and attitudes after obtaining approval from the relevant authorities. We chose this approach to avoid the risk of contamination, i.e. the inadvertent delivery of intervention to members of the control group, associated with individual randomisation in educational research.[8] Random allocation sequence was generated by computer to either intervention or control group and was stratified by country. The trial procedures were tested for feasibility in Switzerland in different clinical departments, after which the study was conducted in four centres in the Netherlands and two centres in the United Kingdom between August and December 2007. The participants were obstetrics and gynaecology trainees in clinical teaching hospitals who did not rotate between clusters during the study period. The trainees were all junior medical doctors who had not previously received formal EBM teaching in their postgraduate training. All trainees provided consent for use of their data anonymously at the start of the trial.
The clinically integrated course consisted of five modules, each comprising self-directed e-learning components and clinically related activities, under the guidance of a facilitator (table 1). The curriculum http://www.ebm-unity.org, described in detail elsewhere,[4] was delivered at each site over a 4–6 week time period. In the control group, the material covered in the e-learning module was presented by a tutor during classical lecture-based teaching sessions over the same time period. The tutors presented from the same power point slides used in the intervention group. We assessed gain in knowledge and change in attitude towards EBM by comparing pre and post intervention scores. We adapted previously validated questionnaires for measurements of knowledge and attitudes which is described in detail elsewhere. [4,9-11] We adapted these questions to match the content and learning objectives of our course. The maximum possible knowledge score was 62 points. Responses to questions about attitude towards EBM were possible on a five point Likert-scale, ranging from 'strongly agree' to 'strongly disagree'.
Data were collected online for the intervention group and on paper for the control group. Before starting the course, trainees in both groups completed all knowledge and attitude questionnaires. Post-course questions were completed immediately after each lecture in the control group. In the intervention group, trainees could complete the questions in their own time after completing the various modules of the course. Additional materials were not allowed to be used during the exams. Attitude questionnaires were re-administered at the end of the course in both groups.
Responses to the knowledge questionnaires were scored and between group comparisons were made taking into account the cluster design of the study. Characteristics of individual doctors in the same cluster, as well as their scores, are likely to be correlated. This correlation should be taken into account in the analyses. Generalized estimating equations (GEE)[9] allow to extend linear models to take into account the correlation between individuals in the same cluster. For a cluster randomized trial, this matrix is assumed to be exchangeable, i.e. all correlations between individuals in the same cluster are the same. The proposed model could also be extended to adjust for individual covariates at baseline. Thus, in our model, the dependent variable was the final score and the intervention and baseline scoring were the independent variables. Attitudinal gain was defined as any change of whatever magnitude towards a more positive attitude towards EBM as measured with a Likert scale. All analyses were performed using Stata (StataCorp. 2007. Stata Statistical Software: Release 10. College Station, TX: StataCorp LP).
Results
The total number of postgraduate trainees included in the analysis was 61, 28 in the intervention group and 33 in the control group (figure (figure1)1) recruited from six clusters (three clusters in each arm). The baseline knowledge scores were the same for the intervention and control groups and were generally high (43.3 points corresponding to 70% of the maximum possible scoring). Post-course scores were improved in both groups compared to baseline (figure (figure2).2). After adjusting for baseline knowledge, the intervention group outperformed the control group by 3.5 scoring points (95% CI -2.7 to 9.8) but this difference was not statistically significant (figure (figure2).2). In relative terms the difference was 5.6% (95% CI -4.4 to 15.8). About 18% of trainees in the intervention group and 27% in the control group had lower scores post course than pre course. Although a slightly higher proportion of participants in the control group showed an attitudinal gain towards EBM compared to the intervention group, the low number of participants did not allow to show any statistically significant difference (figure (figure33).
| Figure 1 Flow chart of participants in the trial. | |
| Figure 2 Pre-and post-course scores adjusted for baseline knowledge. |
| Figure 3 Attitudinal gain. (A): Original research is confusing (B) Study design is important in article selection (C) Evidence-based decision making is ' health care by numbers' (D) Contracts for health care professionals should include time taken away from patient (more ...) |
While previous research has shown that computer based EBM teaching is equivalent to face-to-face teaching, [12] there has been a lack of studies evaluating educational provision in the workplace via e-learning fitted around doctors' daily practice. A previous study in complementary and allied health had shown that a tailor-made web-based learning experience in EBM was educationally useful, but this was not a randomised evaluation. [13] Contamination of members of the control group in an individual randomised trial tends to shift their outcome in the same direction as the outcome in the intervention group. Thus the effectiveness of the intervention, estimated as the ratio or difference between intervention and control groups, tends to be underestimated biasing trial results towards the null. [8] We used a cluster design that eliminated contamination and employed previously validated and pre-tested tools for outcome measures, thus increasing the validity of our results.
Several issues may raise concern about the interpretation of our findings. Trainees in both groups showed high baseline knowledge for all modules, which left only a small room for improvement in the scores. The pre course scores may have been high due to a pre-existing EBM culture within the participating sites. The modest sample size may have contributed to a limitation in statistical power to detect a small improvement in knowledge between the groups. A small proportion in both groups had shown lower scores post course compared to pre course, but such an observation has also been made in other studies [14] and might be attributed to cognitive test anxiety. [15] Post-course knowledge assessments had been conducted immediately after the lectures in the control group. This may have put the intervention group at a disadvantage as delayed and unsupervised knowledge assessment may have influenced the outcome adversely. Despite these concerns, on average, the intervention group had a tendency towards better performance. We are therefore confident that our findings merit consideration.
Previous studies have shown the value of computer based learning. [12,16-18] Since the costs of delivering e-learning courses after initial investment are small, this may also provide a less costly solution for EBM training than lecture based courses. Moreover, e-learning allows for independent and flexible study, with the possibility of a standardised provision that can be easily updated. The trial's generalisability may be considered limited as participating centres were all obstetrics and gynaecology departments. However, the results of the pilot testing conducted in different medical departments in Switzerland showed that the course was adaptable to different medical specialties. This was further reinforcement of the finding of adaptability across languages and settings in our earlier study. [5]
Conclusion
We conclude that the clinically integrated e-learning course for basic EBM proved to be at least as effective as a conventional lecture based course and merits consideration for incorporation in on-the-job training for just-in-time learning. Further research should address changes in behaviour after long term follow-up.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
The trial was conceived by KSK, BWM and the Leonardo project team. RK, JZ, BWM, KSK, SFC and JH wrote the manuscript. RK provided central coordination for the project. SFC and JH obtained local regulatory approval. SFC, BWM conducted the trial in the Netherlands and JH, KD, SM, KSK conducted it in the UK. GZ provided internet based data collection for the e-learning group. JZ performed the statistical analysis. All authors were involved in the development of the project and all authors reviewed and commented to the manuscript.
Pre-publication history
The pre-publication history for this paper can be accessed here:
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