1. Teaching Evidence-Based Medicine Across the Curriculum
Good morning and thank you for joining us for today’s preceptor symposium. Today we will be discussing a topic near and dear to my heart, as you might have guessed given my career choice in drug information. Over the next few hours we will discover the many amazing resources available to all of us as preceptors of the College of Pharmacy. We will learn tricks about google that will allow us to become more effective and efficient in our searches, whether for health-care related topics or to find the best buy on those new shoes or boat. And, we will discover the many applications available on hand held devices for those who may not have continuous ready access to a computer in their clinical practice. I will start, though, by providing you will a brief overview of the COP curriculum specific to developing evidence-based medicine skills so that you have an understanding of what students are taught prior to their arrival in your practice setting.
Gundy Sweet, PharmD, FASHP
Clinical Associate Professor
University of Michigan, College of Pharmacy

2. Objectives
Provide a brief overview of the UofM College of Pharmacy curriculum specific to the development of evidence-based medicine skills and concepts
Briefly discuss how the curriculum revision process will strive to further develop these skills

3. Evidence-Based Medicine
What is it?
EBM is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.
Integrating individual clinical expertise with the best available external clinical evidence from systematic research.
Sackett D, 1996

4. All done to make the best decision
What is EBM?
Combine the best evidence from clinically relevant studies
Add in your clinical expertise to determine if it applies to the individual patient
And incorporate the patient’s values
All done to make the best decision
for a given situation
Sackett D, 1996

5. Common Student (mis)Perception
You don’t need to teach me this stuff….
I already know how to look for things….
I’m a Gen-Nexter
But few students have a systematic process to identify the best evidence specific to a given situation
Why is that important?

6. 2006: 20,824 journals (medical sciences)
2009: > 679,000 citations added to Medline
Too many sources
of information

7. 2X Information explosion Research information doubles every 10 years
Explosion of mis-information

8. Traditional resources
often inadequate
Textbooks can be outdated
Many books take 1-3 years to get to print

9. 1986: Medline available via librarians
Readily available
search tools
1986: Medline available via librarians
Today: numerous search tools readily available

10. More knowledgeable
patient
30% of adults seeing MD discuss a drug they saw through DTC advertising
almost ½ of these patients received a RX for the drug

11. Daily need for valid
information

12. 1/2 of all withdrawals within 2 years
10% of drugs on market between pulled from market/black box warning added
1/2 of all withdrawals within 2 years
Increase in number, sophistication,
and safety concerns with
drugs/medical interventions

13. Feeling Overwhelmed??? Traditional resources often inadequate
Readily available
search tools
Information
explosion
More knowledgeable
patient
Too many sources
of information
Increase in number
and sophistication
of drugs/medical interventions
Daily need for valid
information

14. How and where are the skills taught?
EBM Course
EBM concepts
How to formulate a clinical question
Importance of clarity of the question
Helps direct you to the most appropriate resources
Helps ensure communication of a clear response
How to apply the systematic approach to handling requests for information

15. What is the Systematic Approach
The systematic approach is an integral part of the EBM strategy
Helps search for the most relevant literature to enhance efficiency and effectiveness
The systematic approach is comprised of 7 steps:
BUT… conducting a systematic search requires knowledge of the advantages/disadvantages associated with each type of information resource
1. Classify  2. Clarifying information  3. Systematic Search (3o2o1o) 
4. Evaluate  5. Apply  6. Communicate  7. Follow-up

16. Where Students Learn About Resources
EBM Course
Textbooks and general drug information resources
Searching the biomedical literature
What to use when
PubMed, Embase, Google, IPA, Cochrane, others
Using the internet - is it reliable?
Author credentials
Currency of the information
Source of funding
Awareness of extensions (.biz .com .edu .gov)
External validation of content
Within this, we teach students the advantages and disadvantages of each source, recognizing that what used to be distinct differences are becoming more grey.
Health on the Net Foundation (
Established in 1995 in Geneva, Switzerland
HON code of 8 principles that must be abided by in order to receive this accreditation
Look for HON code Icon when evaluating web-sites

17. What about the primary literature?
EBM Course
How to find the primary literature
Efficient and effective searching
How to read and interpret the primary literature
Terminology (R, DB, PC, DD, etc)
Different types of trials (systematic reviews, economic analyses, randomized controlled trials, case reports)
Levels of evidence
Appropriate statistical tests
Assess all elements of the study, practicing on different published clinical trials
Within this, we teach students the advantages and disadvantages of each source, recognizing that what used to be distinct differences are becoming more grey.

18. Using EBM Skills EBM Course and beyond How do I apply the information?
Does the information found apply to the clinical situation (indication, age group, etc)?
Are the results clinically important (and not just statistically significant)?
Is the information found sufficient to answer the question?
How should I communicate the information?
Are there any ethical considerations to take into account?
Using these skills is touched upon in the EBM course, but is also revisited throughout the curriculum. Having said that, though, we recognize that this is one of the opportunities for improvement in the curriculum revision. We’ll talk about that more later.

19. Application of EBM Principles
P1 Year
EBM Course (W)
Therapeutics
Reinforce identification of best evidence
Integrate critical appraisal to clinical situations
Research Principles
Practical, application-based course where students write a ‘practice’ research proposal
Requires they understand and apply EBM principles
Study terminology
Study design
Searching primary literature
Learn to logically think through a problem and define a plan
P2 Year
Therapeutics (F/W)
Research Principles (W)

20. Application of EBM Principles
Research Principles (P2 year)
Teach process of defining a logical plan to solving a problem
Practical, application-based course where students write a ‘practice’ research proposal
Requires that they understand and apply EBM principles
Study terminology and study design to test a hypothesis
Searching the primary literature
Logically think through a problem and define a plan

21. Application of EBM Principles
Therapeutics
Reinforce identification of best evidence/integrate critical appraisal
Pcare (IPPE)
Discuss patient cases that requires use of best evidence
Reinforce primary literature review (journal clubs)
PharmD Research Project
Application of research principles
Emphasis on process of conducting research
P1 Year
EBM Course (W)
P3 Year
Therapeutics (F/W)
Pcare (IPPE)
PharmD Research (W)
P2 Year
Therapeutics (F/W)
Research Principles (W)

22. Application of EBM Principles
Therapeutics (P2 and P3 years)
Reinforce identification of best evidence
Integrate critical appraisal to given clinical situations
Introductory Practice Experiences (IPPEs, P3)
Discussion of patient cases that includes use of best evidence
Reinforcement of reviewing the primary literature
2 journal clubs – one group-based and one individual

23. Application of EBM Principles
Clinical Rotations
Manage patients on rotations
Reinforce primary literature review
Drug Information is a required rotation
Conduct systematic review of topic
Critically evaluate literature on a topic
Retrieve/analyze/apply DI in practice
PharmD Research Project
Application of research principles
PharmD Seminar
Formal presentation
PharmD research or topic review
Requires application of all EBM skills
Search/analyze/apply information to a given situation
P1 Year
EBM Course (W)
P2 Year
Therapeutics (F/W)
Research Principles (W)
P4 Year
Clinical Rotations
PharmD Research
PharmD Seminar

24. Application of EBM Principles
Advanced Practice Experiences (APPEs, P4)
Management of patients on clinical rotations
Reinforcement of reviewing the primary literature
Journal clubs
Written or oral topic reviews (inservices)
Required drug information rotation
Conduct systematic searches for information
Retrieve, analyze and apply drug information in practice
Critically evaluate the literature on a given topic

25. Application of EBM Principles
P1 Year
EBM Course (W)
P3 Year
Pcare (IPPE)
Therapeutics (F/W)
PharmD Research (W)
P2 Year
Therapeutics (F/W)
Research Principles (W)
P4 Year
Clinical Rotations
PharmD Research
PharmD Seminar

26. Application of EBM Principles
PharmD Research Project (P3-P4 years)
Students work with faculty mentor to conduct a research study
Emphasis is on the process of conducting research (defining a logical plan)
PharmD Seminar (P4 year)
Formal presentation of either their PharmD research or a clinical review of a topic
Requires application of all EBM skills
Search, analyze, and apply information to a given situation

27. What does curriculum achieve?
Advantage:
EBM skills taught early (P1 year)
Skills are revisited throughout the curriculum
Disadvantages:
P1 students don’t see the need for these skills
believe they already know how to find information
don’t know what they don’t know
EBM course is taught in isolation of clinical application
prior to therapeutics and pharmacology
Application of EBM skills is not adequately reinforced across the curriculum

28. Curriculum revision is an ongoing, dynamic process
EBM in New Curriculum
P1 Year
Introduce DI skills, resources, terminology
Begin to build a toolbox
Curriculum revision is an ongoing, dynamic process
P3 Year
EBM/ethics course
Pcare (IPPE)
Therapeutics (F/W)
PharmD Research (W)
P2 Year
EBM: focus on literature evaluation and searching (F)
Research Principles (W)
Therapeutics (F/W)
P4 Year
Clinical Rotations
PharmD Research
PharmD Seminar

29. Goals with the New Curriculum
Maintain existing infrastructure for teaching EBM
Shift (some) drug information component into the P1 year
Provide students with a toolbox of resources early in training
Allow for additional time in P2 year to focus on lit evaluation
Ensure application of EBM skills builds across the P1-P4 years
Improve integration of EBM skills into other courses (eg, therapeutics)
Provide greater clarity to students for how skills are essential for pharmacy practice
Increase opportunities for students to practice and apply these skills

30. Goals with the New Curriculum
Maximize active learning
Students more involved in learning by DOING
Increase opportunities in all courses for students to ….
not just KNOW the information but ….
to have the ability to APPLY information in practice

31. In your packet is a document for your toolbox…
A Guide to
INFORMATION RESOURCES
University of Michigan, College of Pharmacy
TAUBMAN LIBRARY RESOURCES
RESOURCES BASED ON TYPE OF QUESTION

32. Questions
With that as a brief summary of the curriculum behind development of EBM skills, we can delve into the heart of today’s program – how can we all become more effective and efficient at searching for medical literature. It is my pleasure to introduce my colleague, Mark MacEachern, who will share with us the many resources available to all preceptors through the Taubman Library.