The best moment teaching EBM-searching skills?

6 04 2008

When you are a (future) doctor you will obviously need to look for publications at one stage or another. PubMed is the place to look for relevant medical papers. Usually medical students begin to feel the urge to learn the ins and outs of PubMed (and searching in general) once they do their scientific training (4th year) or their internship, especially when they have to perform a CAT, critically appraised topic. Then it turns out their superficial knowledge of PubMed is one of the main hurdles. They find too many hits or too few and/or miss the relevant ones.

To help them I started a monthly class of 2 hours in which I learn interns (at the dept. Gynaecology) the basics of EBM, at least the first two steps: constructing a well answerable question using the PICO method (including defining the domain/levels of evidence) and finding the evidence in PubMed as well as in aggregate resources. (these two steps are called EBS or evidence based searching). Interns are asked to prepare 4 questions, all based on previous CATs. The first question is answered during an interactive power point presentation (first hour), the other 3 are practised ‘hands on’. If needed I give them personal aftercare.

It is a highly appreciated course, and it helped to improve the quality of the CATs. So that’s very encouraging.

I often get the same feedback from the user surveys:

  • well structured and informative
  • why didn’t we get this earlier?
  • too much information at once (especially at the end of the day)

To meet their wish my colleagues started a short introduction in PubMed prior to this ‘advanced’ class. As a result, the students are better acquainted with PubMed and we can delve more in depth into the subject. Last session they even prepared all questions. I wasn’t aware and asked one of the students (quite disappointed) why he still put the words in one string in the search bar instead of looking up each word separately and checking whether the words mapped correctly to the appropriate MeSH. He replied: “But I already did this at home. I checked out all the words.” showing his notes. And I must admit his search was quite good. So I was very satisfied with this group of students.

But the feedback remains the same. well structured and informative – why didn’t we get this earlier? – too much information at once. (especially at the end of the day)

Thus one would be inclined to think there is a need to teach students earlier on.

Now coincidently, a new curriculum has started in our academic hospital, in which EBM is incorporated into the clinical modules. The 1st year students learn about information resources and study designs. In the 2nd year they learn the basics of PubMed, EBM, PICO’s, Evidence Based Searching and Systematic Reviews.

Our library is involved in the educational process with respect to information resources, PICO’s and searching. Most of the teaching is in the form of e-learning (Dutch: COO, computer ondersteunend onderwijs) using the QMP (question mark perception) system, which is basically designed to test knowledge.

We have made a tutorial for PubMed (a-basic-learn-the-buttons-and-MeSH-course) and I prepared an e-learning module on PICO’s, study-designs and aggregate evidence, for the Cardiology block. This took me 6 weeks! It was reasonably well received by the students… That is, who bothered to give feedback.

During the course “Pulmonology” (february/march) we gave 30 “Finding the Evidence Search Workshops” to 6-12 students.
I had quite high expectations, since in theory these students should have a good theoretical basis (considering the earlier e-learning tutorials).

However their knowledge was quite disappointing, and even more so were their motivation and attitude. They were just a bunch of kids, most of them not very interested in PubMed, searching, EBM or whatsoever. They were often giggling and chatting, which I find rather distracting, or were passive, silent and gazing, which is even more distracting. And when I took a glimpse at their screens I often saw g-mail and unfamiliar colourful sites instead of PubMed.

I wondered at what point these students would pupate and transform into the butterflies called interns? And at this stage I couldn’t imagine them sitting on my bedside as a doctor I would trust unconditionally.

Was it really this bad? No, I’m a bit exaggerating. When I sound them out it appeared that they find the scientific methodology courses to fragmented, too basic and not the core of their study: firstly they want to pass their exams and secondly they want to become a doctor(!), not a scientist nor a librarian. I suppose E-learning and tutorials are not the ideal tools, not even for the computer generation. E-learning has to be dosed and is not as inspiring as a good tutor (at least that is what I think).

Anyway after one hour yawning, sighing and bewildered looks and after a much needed coffee break with cookies (a brilliant move of two of my collegues) I got the impression the penny finally dropped. Some students mumbled: “Mmm, I think I come to understand it” others smiled and uttered “Yes!” and the remaining questions were answered rather swiftly by most students. It even turned out that some of the glossy sites I had seen were on-line medical dictionaries, they used to look up the correct terms. Yes, this young generation is capable of multitasking.

If these courses were evaluated the same way as the above mentioned CAT-course, I guess the outcome would be as follows:

  • not particularly interesting
  • why do we have to learn this now? can’t it wait?
  • too much information….

We still need to find the ideal timing for these courses and also a better dosing. The best timing is when they need it the most, I suppose. The students who absorbed the information best were those who needed the information right now or found out that needed it before (i.e. they now realized that their previous searches were far from ideal). The form is also something to workat. Especially the e-learning modules should be better integrated into the clinical blocks. It is not sufficient to tune in with the subject. For students to appreciate and retain information, searching skills need to be taught in tandem with assignments. Students need to see the relevance of what they learning.


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