The motivation for teaching evidence-based practice is that, through the use of high-quality clinically relevant evidence, clinicians will make rationale decision that optimally improve patient health outcomes. Achieving that goal requires clinicians who are able to answer patient care–relevant clinical questions efficiently, which means that they must be able rapidly to retrieve, assess, and apply evidence of direct relevance to their patients. Educational programs designed to accomplish this vary in their effectiveness. This article reviews the evidence on educational approaches that may be beneficial when developing educational programs for both dental students and practicing dentists.
The benefits of providing dentists with evidence-based training are improvements in the quality of patient care.
The outcomes of evidence-based training on learning and behavior vary based on the type of educational programs used.
Educational research suggests that integrating didactic with clinical educational programs is important in developing sustained improvements in the use of evidence in clinical practice.
Contextual or cultural barriers to adopting evidence must be addressed for successful implementation of new evidence.
Statement of the Problem
The problems that occur when high-quality evidence fails to reach routine clinical practice was clearly identified by the Institute of Medicine’s review of the US health care system. They identified 3 concerns, which they classified as follows. First, they reported an overuse of treatments that were known to provide no patient benefit. Second, they reported an underuse of treatment know to provide benefit. Finally, they described a misuse of treatment such that care was misapplied to such an extent that patients failed to benefit fully from treatment. This characterization was referred to as the “know–do gap,” describing the difference between what is known to work in the way of beneficial treatment and what is actually done in routine patient care.
The attempt to remedy this problem was, in large part, the motivation behind the development of evidence-based practice (EBP) efforts in medicine and other health care professions that evolved from work at McMaster University in the 1990s.
The Sicily Statement, a consensus statement from 2005 on EBP, reads: “All health care professionals need to understand the principles of EBP, recognize EBP in action, implement evidence-based policies, and have a critical attitude to their own practice and to evidence.” Dawes and colleagues go on to define EBP and describe a curriculum required to practice in an evidence-based way. To accomplish this, they adopted the 5-step model first described by Cook and colleagues, which is presented in Table 1 .
|Sicily Statement||Young and colleagues [Rosenberg and Donald ]|
|Step 1: Translation of uncertainty to an answerable question||ASK: Identify knowledge gaps; Ask focused questions. [Requires knowledge to construct a question using the PICO mnemonic.]|
|Step 2: Systematic retrieval of best evidence available||ACCESS: Design search strategies; Identify appropriate databases: search effectively and efficiently. [Requires the acquisition and application of literature searching skills across a variety of databases.]|
|Step 3: Critical appraisal of evidence for validity, clinical relevance, and applicability||APPRAISE: Appraise research for validity, reliability, and applicability; Interpret research findings and translate outcomes into meaningful summary statistics. [Requires a certain level of expertise in epidemiology and biostatistics.]|
|Step 4: Application of results in practice.||APPLY: Know the approach to assess applicability and generalizability of research findings in clinical practice; evidence-informed decision making. [Requires an ability to synthesize and communicate the results to relevant parties (that is, other health professionals, patients).]|
|Step 5: Evaluation of performance||AUDIT: Be familiar with the approach to monitor and evaluate practice. [Requires the health professional to evaluate the EBP process and assess its impact within the clinical context in which it was implemented.]|
These steps have become the foundation for practicing and teaching EBP and are the core of contemporary EBP curricula in health professional schools. This article presents an introduction to current EBP teaching issues and strategies that build on this 5-step model. Where available in the literature, evaluation of EBP teaching effectiveness is reviewed. The evaluative literature in this area has grown substantially in recent years, but the majority of the literature continues to come from health care fields outside of dentistry. Thus, one must extrapolate from research done within other health professions, principally medicine and nursing, with the hope that similar findings will apply within dentistry. Additionally, it needs to be noted that this article is not a systematic review of EBP teaching methods. Neither is this a “how to” guide for creating an EBP curriculum, because any curriculum will need to be uniquely adapted based on local conditions, type of student, goals, budget, and other resources. Rather, this article is an introduction to the most salient issues that need to be considered when attempting to construct an EBP curriculum.
Goal of teaching evidence-based practice
The motivation for teaching EBP is the assumption that. through the use of high-quality clinically relevant evidence, clinicians will make rational clinical decisions that optimally improve patient health outcomes. To achieve that goal in a sustainable way, clinicians must be able to answer patient care–relevant clinical questions efficiently, which means that they must be able rapidly to retrieve evidence and assess its quality and relevance to their patients. The selection and application of relevant evidence to clinical decision making is understood to proceed most effectively through the use of these widely accepted 5 steps, each step requiring skill that must be learned through formal training programs. This skill development forms the basis for initial EBP educational efforts.
Beyond the 5-step process, effective EBP incorporates the concepts of clinical expertise and patient preferences. Clinical expertise refers to the ability of a health care provider to appropriately translate research findings into clinical care decisions as it applies to an individual patient. Without thoughtful consideration of the clinical status of a patient, the application of research evidence can easily be misapplied. The reason for this is that the clinical research that underlies EBP is typically based on either clinical or epidemiologic studies of populations of patients, with the outcomes of the study being expressed as population parameters such as a group mean response to therapy or other values that convey the likelihood of a given clinical outcome.
In the absence of additional clinical or other relevant information about a given patient, these population-derived values may be considered as the best bet for predicting an individual patient’s outcome. However, there are always known and unknown factors that will alter an individual’s response to treatment. Skilled clinicians understand this and adapt their application of scientific evidence to the unique circumstances of individual patients.
Patient preferences provide the basis for the ultimate decisions around treatment choices. As such, it is the responsibility of the health care provider to be able to explain the benefits and possible harms of alternative treatment options in an understandable way to each patient. This process also requires a thorough understanding of the relevant evidence as well as skill in communicating with patients (step 4). Communicating scientific information to patients in an understandable way has not be well-studied and tends often to be overlooked in EBP training. This area should not be overlooked in designing EBP educational interventions, especially with novice students, and practical exercises that develop students’ abilities in this area should be included in a comprehensive EBP curriculum.
In short, EBP boils down to using valid clinical reasoning informed by current best evidence from high-quality clinical research to recommend personalized approaches to patient care. Such evidence, to be useful for clinical practice, must be readily accessible and understandable to a busy clinician. The skill set required to efficiently find relevant clinical information, determine its validity, and apply that evidence in the care of a given patient is not unusually daunting; nevertheless, it must be learned. Thus, it is appropriate to think of EBP as a set of discrete clinical skills that require training and practice such that they become an ongoing part of routine patient care. The importance of EBP skill to clinical practice is underscored by Glasziou and colleagues, when they affirm that “the search engine is now as essential as the stethoscope” for effective clinical practice.
A chief goal of teaching EBP skills, therefore, is to encourage clinicians to have the confidence and ability to be their own knowledge producers. That concept means that they should be able, on their own, to find and absorb the current best evidence when it is needed for patient care and have the clinical skills to appropriately apply that evidence with individual patients. This should be the overarching goal of EBP teaching. Once mastered, these skills decrease the need to seek out (and pay for) continuing education courses or rely on anecdotal advice from colleagues. Herein, we examine this skill set and how teaching it to dentists can best be accomplished.
A paradigm shift in accessing information
Professionals generally understand their obligation to be up to date on current approaches to care. They also understand that new products and approaches to care occur frequently; that patients have access to vast amounts of information online, leading them to ask challenging questions; and that research is continually being published offering new information and critiques of even well-established treatments. In the best case, this leads to clinicians being curious and to routinely seeking answers to questions about what changes have occurred recently that could lead to improved patient care. In the worst case, the thousands of clinical research articles published each year (both high quality and not so high quality) leads to information overload and results in a sense of frustration over the inability to remain well-informed of current clinical developments. Professions and their regulators (eg, state licensing boards, hospital quality management and improvement committees) endeavor to ensure that practitioners make some effort to remain up to date through the use of policy mechanisms, such as mandatory continuing education. But these policies are at best minimal requirements for keeping current with best practices.
Clearly, all health care professionals use evidence in clinical practice. Concern arises primarily when that evidence is outdated, inaccurate, or highly biased and, thus, contributes to less than optimal decision making. Moreover, expanding one’s clinical knowledge base, particularly when that is done through reliance on passive, external training (eg, attending continuing education courses), requires the investment of substantial time and resources, often only leading to minimally acceptable compliance with licensure requirements. Moreover, there are often at best negligible quality filters used to ensure that the information delivered through continuing education courses is valid, unbiased, and comports with current scientific knowledge.
The 5-step model originally developed at McMaster University in the 1990s was designed to supplement traditional educational approaches for keeping up to date by taking advantage of changes in technology that were rapidly occurring. Several important changes were ongoing in the 1990s that allowed a reconceptualization of how evidence could be accessed and used in clinical practice. This period saw the World Wide Web go live globally and in so doing provide the necessary vehicle for rapid dissemination of scientific information over the Internet. In concert with that were advances in online storage of scientific information (eg, Medline) and the ability to efficiently search for information within these massive databases (eg, PubMed) using desktop computers. Capitalizing on these changes, the McMaster group effectively changed the paradigm of how evidence should be used in clinical practice. Rather than relying on random reading of journal articles or attending a continuing education course, it was now possible, in real time, to access highly relevant clinical evidence when and where it was needed in support of patient care decisions. This “just-in-time” approach relieved the burden of information overload and made each clinician his or her personal knowledge producers.
Teaching strategies aimed at improving health professionals’ knowledge, attitudes, and skills related to EBP have been evolving since the introduction of the concept of evidence-based medicine by Guyatt and colleagues in 1992. In the United States, accreditation standards associated with the teaching of EBP have resulted in all health care professional schools offering a curriculum in EBP, with the Sicily Statement 5-step model guiding most EBP curricula. These skills are considered essential to allow a clinician to practice in an evidence-based manner. The clinician who has mastered these skills will be able to quickly access valid and relevant evidence, interpret its relevance to their patients, and thus have an objective basis for clinical decision making.
Educational interventions leading to mastery of these skills, along with formal training in critical thinking and statistical reasoning, were a huge advance in creating scientifically literate clinicians. Once basic skills are learned, however, the challenge remains in establishing their application during routine clinical practice. Hurd claims that, when clinicians are comfortable using the scientific literature and it is a routine part of their practice, they move away from passive dependence on the ideas of others and become critical thinkers capable of creating their own new knowledge.
However, after several decades of using this model of EBP training in health professional schools, it is now understood that achieving competency in the 5-step model alone is rarely sufficient to lead to the desired clinical behavioral outcomes where clinicians routinely and rationally apply new evidence in support of patient care. This well-documented resistance to changes in clinician behavior as it relates to patient care must be addressed as part of a comprehensive EBP educational intervention. To accomplish this requires that both the individual and contextual barriers that prevent implementation of new evidence must be overcome. We are now beginning to understand what those barriers are and to develop teaching methods that can aid clinicians in overcoming them.
Where do clinicians typically get information?
Research suggests at present that we are failing in creating competent personal knowledge producers and effective evidence-based practitioners. Across health professionals, there is a lack of willingness to search for and understand evidence. It can be instructive to examine what evidence sources are preferred by various health care professionals. Physicians reportedly rely on guidelines, discussion with colleagues, expert consultants (eg, continuing medical education providers), and the pharmaceutical industry as their preferred information sources. Similar results were found among practicing nurses. Dentists report difficulty in applying information from research journal articles, literature searches, and clinical practice guidelines to clinical practice, preferring the more personalized reliance on colleagues and recognized experts (eg, continuing education courses), where evidence is packaged and sold in concise ways that often satisfy the continuing education requirements of licensing boards. Dental students have been shown to prefer seeking information most frequently from colleagues, the Internet (excluding Cochrane Database of Systematic Reviews), and textbooks.
It is worth stating that no source of clinical evidence is inherently inappropriate to inform clinical practice. What needs to be understood is that evidence sources vary in their relevance and validity in answering specific clinical care questions. Systematic reviews are one of the best sources for evidence on comparative treatment efficacy. Clinical practice guidelines play an important role in the dissemination of best practices for clearly specified patient types. Seeking advice from colleagues can be effective ways to gain insight regarding clinical techniques or how to manage unanticipated outcomes.
However, across all health professions, there is a general resistance to seeking out clinical evidence from searching and reading the clinical literature as a means to answer clinical questions. As a result, contrary to what would be hoped—namely, that clinicians personally seek out and implement high-quality evidence as the norm in daily practice—the majority of physicians, nurses, and other health care professionals do not consistently engage in EBP.
What are the barriers to accessing and using high-quality evidence?
Glasgow and colleagues make the case that effective implementation of evidence into routine practice requires attention to both individual provider factors (eg, knowledge, skill, attitudes related to EBP) and broader contextual factors (eg, organizational culture and leadership). Individual knowledge and attitudinal barriers are a significant problem that seem to be related to a lack of understanding of how clinical research is done and how it can inform clinical practice. When asked about their use of the scientific literature, dentists report a distrust or skepticism of evidence-based resources such as systematic reviews and clinical practice guidelines, doubting their validity and the authority of the sources. Hence, using evidence sources believed to be invalid can lead dentists to fear criticism from colleagues or concern over moving beyond a perceived standard of practice.
Structural factors related to the nature of clinical practice create a context for care delivery that reinforces the status quo and is understood to prevent behavior change. Factors commonly reported as barriers to implementing evidence-based changes in clinical care include busy clinic schedules, a potential for the loss of revenue when practice patterns change, workflow inertia, and poor access to high-quality online evidence resources. Large, multiprovider practices suffer from additional organizational barriers (eg, leadership, safety culture, organizational learning, teamwork, and communication issues) that also prevent behavior change.
The lack of easy access to much of the high-quality clinical literature has led Isham to conclude that current evidence dissemination systems and networks aimed at dentists are themselves a major barrier to accessing evidence and contribute to dentists’ preference for face-to-face communication, despite the availability of large quantities of quality information online.
Finally, knowledge barriers related to educational deficits can result in clinicians not having the necessary understanding and skill to efficiently search for and apply high-quality evidence in clinical practice. Isham and colleagues identified a lack of knowledge related to using technology (computers, tablets, search engines, etc) as a particular problem among dentists. Additionally, dentists report an inability to synthesize scientific information for clinical applications, an ability that depends on specific critical thinking skills related to scientific and probabilistic reasoning that is not commonly taught in dental schools.
Perceiving value in a task has been found to support effective learning. Accomplishing that for the EBP material in the dental curriculum can be challenging. Learning the technical or procedural skills (ie, operative or surgical skills) required to perform routine clinical dentistry rightly consumes much of the curricular time as well as students’ attention during dental training. These skills are essential and challenging and take time to master. Training students in these clinical skills typically is done through an apprenticeship model, where one practices clinical procedures under the watchful mentorship of clinical faculty members. This learning approach is necessary to safely develop clinical skills, but it can also reinforce students’ reliance on authority and focuses the student on the procedures that must be mastered rather than the underlying rationale for when it is appropriate to perform those procedures. The naïve student presumes that authority figures like teachers and experienced clinicians will always provide the right answer to clinical questions, which can undermine in students’ minds the relevance of reading research or looking for evidence beyond that provided by the clinical mentors.
Overcoming this dependent learning style is one of the first challenges in teaching EBP to dental students. The importance of developing critical thinking and EBP skills early in the curriculum is, thus, important in providing a learning framework that emphasizes independent, self-learning that will serve the students throughout their professional training and beyond. Providing a strong rationale for why EBP is being taught is thus important. Five areas are suggested as part developing a strong rationale for teaching EBP.
Change Is Not Only Inevitable, It Is Desirable
It is often unclear to the novice student (eg, the first-year dental student) that the knowledge base of the profession changes continually. The novice student’s limited perspective on the changing nature of professional practice can lead to a sense that once they learn what is offered in the first professional curriculum, they should be set for life for professional practice. This thinking leads to a reliance on authority figures like teachers and experienced clinicians as the sole source of relevant clinical information and a simultaneous discounting of the value of clinical research. Moreover, the actual approach to teaching used in most dental schools—that is, a reliance on a lecture format—reinforces this thinking. Instilling in students the concept that professional knowledge changes constantly and that it is a professional responsibility to keep up to date on those changes after one leaves their initial training program is an important concept that needs to be introduced early in the curriculum and strongly reinforced in EBP teaching.
A second skill lacking in most novice students is relevant critical thinking ability. Algen characterizes clinical practice as uncertain, ambiguous, and constantly changing. Effectively navigating the information needs of clinical practice depends on critical thinking and reasoning. Critical thinking encompasses many domains, but the ones central to EBP teaching are focused on sound judgements related to the validity of research findings and its relevance to patient care. Willignham identifies 3 domains of critical thinking: reasoning, making judgements and decisions, and problem solving. When effective, Willingham says that critical thinking leads to desired outcomes, such as seeing all sides of an argument, accepting new evidence when it disconfirms to your existing ideas, reasoning objectively rather than from passion, and other important traits that improve problem solving. Moreover, critical thinking is also self-directed, meaning that it empowers the individual to seek solutions rather than rely on others for motivation or guidance. Thus, the ability to think critically is foundational for effective EBP because it provides the foundation upon which the application of evidence to clinical practice depends.
Beyond the general critical thinking qualities described elsewhere in this article, there is an EBP subdomain that Zimmerman refers to as scientific reasoning. This notion implies the third concept required for students, namely, to understand and accept evidence derived from clinical research, which requires a solid foundation in interpreting clinical research studies. Students arrive for clinical training from a variety of backgrounds. Although most come with some sort of science background, it cannot be assumed that their prior training has prepared them for the specific type of scientific reasoning required to understand clinical research and apply it to patient care. Unlike many areas of science, clinical research relies on probabilistic arguments to support conclusions about causal relationships. Windish and colleagues found a lack of knowledge in biostatistics sufficient to interpret many of the results in published clinical research among medical residents. Individuals who understand conditional probabilities and statistical reasoning will more quickly grasp why some clinical research designs are stronger than others in managing bias and why causal arguments in biomedicine are rarely conclusive.
Straub-Morarend and colleagues found low levels of self-confidence among dental students in being able to critically appraise relevant clinical literature. They attributed this in part to students’ reported difficulty with statistical concepts and urged more statistical instruction in the predoctoral dental curriculum. Ensuring that learners understand statistical reasoning and probabilities should make it clearer why research study quality depends on methodologic issues, such as the use of control groups, sample size, management of confounding, and the use of statistics to quantify the role of chance. This foundation should include a clear understanding of the strengths and weaknesses of the clinical research designs and what information can be obtained from each.
Hurd frames the goal of teaching scientific reasoning as creating clinicians who are able to distinguish:
Facts from propaganda (advertisement),
Probability from certainty,
Data from assertions,
Rational belief from superstitions, and
Science from folklore.
Active Knowledge Acquisition
Conceptualizing EBP as an ongoing clinical activity is important. As highlighted elsewhere in this article, passive dependence on others for new knowledge is ineffective and will become a major barrier to keeping up to date once students leave training. The notion that students must be their own knowledge creators and actively pursue personal knowledge deficits must be emphasized as essential for maintaining current clinical skills and practicing in an ethical manner.
Willingness to Change
Being willing to change one’s views and approach to clinical practice in light of new high-quality evidence is perhaps the most challenging skill to teach. The understanding that change in knowledge occurs continually and that it is the responsibility of every health care provider to actively participate in the process of keeping up to date, with an emphasis that changing practice in light of new evidence, is laudable. The challenge lies in the fact that behavior change is bound up in a complex set of personality features and the degree to which one can engage in probabilistic reasoning. For example, presenting a clinician with new evidence that negates prior practice behavior can lead to cognitive dissonance and will often result in denial of the validity of the new evidence. Nevertheless, revising one’s behavior in the light of new evidence is clearly an essential skill for effective EBP practice. As Glasziou and colleagues say, “Health professionals cannot solely rely on what they were first taught if they want to do the best for their patients. It has repeatedly been shown that clinical performance deteriorates over time.”
Evidence-based practice as a clinical competency
Starting with a clear statement of the EBP learning objectives, framed as competency statements, is likely to improve outcomes of educational intervention as this supports both course content and student evaluation. Using competencies to guide the development of educational interventions can help to overcome two of the most commonly reported barriers to effective EBP practice—namely, poor knowledge of the process and skill deficits in performing EBP tasks (such as searching) and critical appraisal.
Competency in EBP is often divided into 4 domains: knowledge, attitudes, skills, and behaviors. Basic EBP competencies can be derived from the 5-step EBP model and additional competencies should be included related to critical thinking, statistical reasoning, clinical problem solving, and communication. Box 1 provides links to 5 sites that list EBP competencies that are available online.