SURMEPI Stellenbosch University Rural Medical Education Partnership Initiative 2012/07/19 SURMEPI Website http://surmepi.sun.ac.za Page 1 of 29 Evidence-based Health Care (EBHC) tutorials February – October 2012 INTERIM REPORT Venue: Worcester Rural Clinical School A Rohwer, T Young, A Schoonees Centre for Evidence-based Health Care Faculty of Health Sciences Stellenbosch University www.sun.ac.za/cebhc Date: 19 July 2012
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SURMEPI Stellenbosch University Rural Medical Education Partnership Initiative
2012/07/19 SURMEPI Website http://surmepi.sun.ac.za Page 1 of 29
SURMEPI Stellenbosch University Rural Medical Education Partnership Initiative
2012/07/19 SURMEPI Website http://surmepi.sun.ac.za Page 2 of 29
1. Background
Stellenbosch University has obtained funding for the Stellenbosch University Rural Medical
Educational Partnership Initiative (SURMEPI), aiming to enhance the skills of medical professionals in
HIV/AIDS and TB care, as well as increasing the research capacity in this field. Strengthening
evidence-based health care (EBHC) knowledge and skills at an undergraduate level is particularly
important within this context.
In 2011 Taryn Young and Anke Rohwer visited the Rural Clinical School (RCS) in Worcester to learn
more about the students doing their student internship (6th year of the MB,ChB) on the rural
platform. We met with Prof Hoffie Conradie and talked to him about the work we are doing at the
Centre for Evidence-based Health Care (CEBHC) related to the SURMEPI project. We also had lunch
with the students, giving us an opportunity to talk to them about EBHC. In addition we used the
opportunity to show the students a screencast developed by our team on How to search PubMed
using MeSH terms, which they found very useful and asked for similar online resources to build their
capacity in EBHC. We also attended one of their tutorial sessions, which are presented once a week
on Wednesday afternoons. After some discussions with Prof Hoffie Conradie, he managed to secure
six EBHC tutorial sessions for the 2012 student interns on the rural platform, spread throughout the
year.
2. General information about the tutorial sessions
Twenty one student interns from Worcester (17), Swellendam (2) and Robertson (2) participate in
the 2012 tutorial sessions. These are predominantly Afrikaans speaking students (see Appendix 1 for
list of participants). At least two staff members from the CEBHC facilitate each tutorial session.
We developed a structured plan for the six sessions (Appendix 2), covering the following topics:
Introduction to EBHC and formulating questions; Searching databases for relevant studies; How to
read a randomised controlled trial (RCT); How to read a systematic review; How to read a clinical
guideline and revision.
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Each two hour tutorial consists of didactic input followed by hands-on class exercises and
discussions. Students were given a folder with relevant reading material and worksheets for
exercises at the first session. Before the first and after the last tutorial, students are being asked to
complete a questionnaire to rate their confidence in EBHC by completing questions based on the
EPIC scale1, and to assess their attitude towards EBHC by using a Likert-scale to answer a second set
of questions2.
During all tutorials, we also make use of interactive teaching techniques to revise content and to
encourage students’ participation in the session. Each student receives a set of flash-cards, a pack
containing five differently coloured cards. Students then answer MCQ-type questions with colour-
coded answers, displayed on the PowerPoint slides, by holding up the coloured card of the
appropriate answer that best fit the question.
After each session, students are asked to complete an evaluation form and relevant reading material
for the following session is handed out.
The reading material includes three excellent books related to EBHC. SURMEPI funding allowed us to
procure copies of the following books which we are distributing in the appropriate sessions:
Questions Log: A tool for ‘just-in-time’ learning by Carl Henegan and Paul Glasziou
Searching Skills Toolkit: Finding the evidence by Caroline De Brun and Nicola Pearce-Smith
How to read a paper: The basics of evidence-based medicine by Trisha Greenhalgh
3. Communication and interaction with students between tutorial sessions
We set up an email list which we are using to communicate with the students. They are encouraged
to contact us with any queries they may have related to content and application of EBHC. In
addition, a set of key resources for EBHC has been developed and made available to students. This
together with the screen cast has been placed on the online learning platform of the RCS.
1 EPIC scale (Salbach 2012) that measures self-perceived EBHC competence on a scale from 0% (no confidence)
to 100% (completely confident) 2 Likert scale ratings of EBHC statements adapted from Baum 2003, from strongly disagree to strongly agree
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4. Session 1, 15 February 2012: Introduction to EBHC and formulating questions
Facilitated by Anke Rohwer and Charles Okwundu
Aim:
o The aim of this tutorial was to familiarise students with the basic principles and
application of EBHC and reinforce students’ knowledge and skills in formulating
answerable questions using the PICO approach.
Learning outcomes:
o After the tutorial students should be able to:
Explain what is meant by EBHC
Explain the importance of practicing EBHC
Name the five steps of EBHC
Identify knowledge gaps
Formulate focused answerable questions using the PICO format when faced with an
uncertain situation
Identify the various types of questions
Identify the various types of study designs
Explain what is meant by hierarchy of evidence
Programme
Anke started the tutorial with a welcome and introduction of the CEBHC. Before starting with
any didactic input, we asked students to rate their self-perceived confidence in EBHC by
completing questions based on the EPIC scale. See Appendix 4 for results of the pre-course
questionnaire.
Anke gave the first presentation on Principles and application of Evidence-based Medicine (EBM),
followed by a presentation by Charles on Formulating an answerable question.
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Students were then given a variety of scenarios and had to work in groups to phrase appropriate
PICO questions. These included questions on therapy, prognosis, diagnosis, risk factors and
harm. Each scenario and PCIO question was then discussed with the whole class.
In order to make the theory more applicable to students’ own practice, we encouraged them to
send us questions arising from their own clinical experiences via email. We gave them feedback
on their questions, so that they could refine and use them to build their search strategy at the
next tutorial session. We also gave each student a copy of the pocket book Questions Log: A tool
for ‘just-in-time’ learning by Carl Henegan and Paul Glasziou. This can be used as a record of
students’ own questions and answers and is small enough to carry with them while working in
the clinical field.
Evaluation
Overall, we received positive feedback from the students. See Appendix 3 for the full evaluation
report.
o The practical session was very good and helped to understand the work better. Both
session were helpful and well presented
o I learnt what study to use when asking or trying to get answers to various questions. Was
presented in an interesting format
o Interactive learning opportunity and the sparkles
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5. Session 2, 6 June 2012: Searching databases for relevant studies
Facilitated by Anke Rohwer and Anel Schoonees
Aim:
o The aim of this tutorial was to familiarise students with searching different databases
Learning outcomes:
o After the tutorial students should be able to:
Identify appropriate search terms
Use Medical Subject Headings (MeSH) terms in search
Use appropriate limits (e.g. age, gender, publication type)
Use Boolean operators correctly
Combine search concepts in final search strategy
Identify the best sources of evidence for each type of question
Explain why this source would be the best
Design a search strategy relevant to the question
Identify appropriate databases
Search effectively and efficiently for evidence-based resources
Programme
Anel started off the session with a set of flash-card questions to revise the content of the
previous tutorial. Questions covered the basic principles of EBHC, as well as formulating
questions.
Anke then gave a PowerPoint presentation on Finding the evidence. This included a
demonstration on how to search Medline, The Cochrane Library and TRIP database. Students
then watched a screencast on Searching PubMed using MeSH terms.
For the second part of the tutorial, students had the opportunity to take the questions they had
formulated, develop a search strategy and do hands-on searching of the different databases.
Anke and Anel were available to give support and advice on searching techniques.
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Evaluation
Overall, we received positive feedback from the students. They liked the interactive nature of
the session and found searching various databases much easier with the tools we gave them.
During the hands-on session, most of the students found suitable articles to answer their
question. See Appendix 3 for the full evaluation report.
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6. Session 3, 18 July 2012: How to read a RCT
Facilitated by Anke Rohwer and Mark Engel
Aim:
o The aim of this tutorial was to familiarise students with the basic principles of a
randomised controlled trial (RCT) and the basic principles of critical appraisal of a RCT.
Learning outcomes:
o After the tutorial students should be able to:
Explain the basic principles of a RCT
Explain the general approach to critical appraisal
Appraise a randomized controlled trial for validity, reliability, and applicability
using the GATE framework
Interpret the research findings for both
Dichotomous outcomes
Continuous outcomes
Explain confidence intervals and p-values
Interpret confidence intervals and p-values
Explain and apply the approach to assessing applicability and generalizability of
research findings in clinical practice
Programme
Anke started the session with a set of flashcard questions, revising the content of the previous
tutorial. Questions covered the basic principles of accessing the literature.
Mark then presented an overview of study designs, the basic principles of a RCT, as well as
measures of effect (risk ratios, odds ratios) and statistical concepts (95% confidence intervals
and p-values).
After a short break, Anke then explained critical appraisal, using the GATE framework and the
RAMMbo acronym, to the students. The presentation included a videoclip on allocation
concealment.
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For the practical part of the tutorial, students critically appraised the RCT given to them during
the previous session, in groups of three. This particular RCT was selected based on one of the
student’s PICO questions that she formulated after the first EBHC tutorial. Students were also
given the RCT worksheet by the Oxford Centre for Evidence-based Medicine, which is based on
the GATE framework and the RAMMbo acronym, to use as a guide.
We ended the session with a class discussion on the critical appraisal. Students were each given
a copy of the Searching skills toolkit booklet as well as Trisha Greenhalgh’s How to read a paper.
Evaluation
Overall, we received positive feedback from the students, although some felt that there was
too much information to digest in one session. They enjoyed the interactive nature of the
presentations, as well as the practical session. See Appendix 3 for the full evaluation report.
o I will definitely use this knowledge (soon)!
o Use of different teaching methods.
o Practical – to critically appraise an article and to see how to think about it.
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7. Conclusion
The first three EBHC tutorial sessions were very successful. The student interns actively participated
in sessions, asking questions and engaging with the content. Overall, we received very positive
feedback for all the sessions. Evaluation of the sessions showed that students enjoyed the
interactive nature of the sessions and acknowledged their need to revise EBHC concepts.
This is an interim report on the first three EBHC tutorials held at the RCS in Worcester. The last two
EBHC tutorial sessions for 2012 will cover How to read a systematic review and How to read a
guideline. This report will be updated after each session and finalised after the last session.
It is essential that undergraduate medical students have EBHC competencies when they graduate.
Not only does this equip them with the necessary tools to deal with the information overload we are
facing and encourage them to adopt a philosophy of life-long learning; but it enables them to make
more informed decisions about health care. In a country like South Africa, where the burden of
disease is high and resources are scarce, it is essential that beneficial and effective practices are
adopted and harmful, ineffective ones abandoned. This is also highlighted in the recent Lancet
report on the health professional for the 21st century3, which proposes that health care professional
training should become transformative. One of the fundamental shifts of transformative learning
aligns almost perfectly with the steps of EBHC; the shift from memorization of facts to “critical
reasoning that can guide the capacity to search, analyse, assess and synthesise information for
decision-making”.
3 Frenk et al. Health professionals for a new century: transforming education to strengthen health systems
in an interdependent world. The Lancet 2010, 376:1923-58
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Appendices
Appendix 1 - Participants
Name Student nr District Sex Home language 15 Feb 6 June 18 July 22 Aug 17 Oct
Jeanne-Marie Louw 14272571 Worcester F Afrikaans Yes Yes Yes
Virgilio Da Conceicao 14816903 Worcester M Yes Yes No
Petronella Magagula 15106500 Worcester F Swati Yes Yes Yes
Elouise Kroon 14102528 Worcester F Afrikaans Yes Yes Yes
Jasper van Zyl 15061833 Worcester M Afrikaans Yes Yes Yes
Sheldon Marais 14821869 Worcester M Afrikaans Yes Yes Yes
Ilze van Wyk 15019233 Worcester F Afrikaans Yes Yes No
Rohan du Plessis 14314258 Worcester M Afrikaans Yes Yes No
Marcia Vermeulen 15040437 Worcester F Afrikaans Yes Yes Yes
Vimbai Tembo 15100324 Worcester F Shona Yes Yes Yes
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Willem Naude Worcester M Afrikaans Yes Yes No
Jaco Cilliers 15058788 Worcester M Afrikaans Yes Yes No
Loretha Compion 14775719 Swellendam F Afrikaans Yes Yes Yes
Hane Stander 15019063 Swellendam F Afrikaans Yes Yes Yes
Rethe Maree 14826119 Worcester F Afrikaans Yes Yes No
Kristi Steyn 14798999 Worcester F Afrikaans Yes Yes Yes
Sanele Mjekevu 15127834 Robertson M Zulu Yes Yes Yes
CJ Fouche 14790181 Worcester M Afrikaans Yes Yes No
Niel Bruwer 15061639 Worcester M Afrikaans Yes Yes No
HJ Retief 15082016 Worcester M Afrikaans Yes Yes No
Zinhle Shozi 15101320 Robertson F Zulu Yes Yes No
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Appendix 2 – Session outlines
15 February: Introduction to EBHC and formulating questions
Objectives:
To familiarise students with the basic principles and application of EBHC and
reinforce students’ knowledge and skills in formulating answerable questions
using the PICO approach.
Content:
o Basic principles of EBHC
o Application of EBHC
o Principles of phrasing different types of questions
Learning outcomes:
o After the session students should be able to:
i. Explain what is meant by EBHC
ii. Explain the importance of practicing EBHC
iii. Name the five steps of EBHC
iv. Identify knowledge gaps
v. Formulate focused answerable questions using the PICO format when
faced with an uncertain situation
vi. Identify the various types of questions
vii. Identify the various types of study designs
viii. Explain what is meant by hierarchy of evidence
Handouts/resources:
o EBHC resource page
o Worksheet on PICO and phrasing questions
o Worksheet with different scenarios
o Akobeng, AK. Principles of evidence based medicine. Arch Dis Child 2005;
90:837-840
o Akobeng AK. Evidence in practice Arch Dis Child 2005;90:849–852.
o Glasziou P, Haynes B. The paths from research to improved health outcomes.
ACP Journal Club 2005:142(2);8-10
o Questions log book from Oxford
Class exercises
o Scenarios of different types of questions – students to work in groups of 3 to
phrase PICO questions
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o Students to use PICO hand-out
Facilitators
o Anke
o Charles
Student preparation for next tutorial:
o Students to email at least one scenario from their own clinical work as well as
the PICO question to the class and tutors for discussion before 30 May 2012
o Bring PICO question to next session
o Look at screencasts on LMS (basic searching and MeSH terms)
6 June: Searching databases for relevant studies
1. Objectives of the session:
To familiarise students with searching different databases
2. Content
Principles of searching electronic databases
Demonstration of searches on PubMed, The Cochrane Library, TRIP database
3. Learning outcomes
After the session, students should be able to: i. Identify appropriate search terms
ii. Use Medical Subject Headings (MeSH) terms in search iii. Use appropriate limits (e.g. age, gender, publication type) iv. Use Boolean operators correctly v. Combine search concepts in final search strategy
vi. Identify the best sources of evidence for each type of question vii. Explain why this source would be the best
viii. Design a search strategy relevant to the question ix. Identify appropriate databases x. Search effectively and efficiently for evidence-based resources
4. Hand-outs/resources
Screencast on Search strategy and MeSH terms
PICO worksheet to identify keywords
Searching skills tool kit (Oxford)
5. Class exercises:
Students to use their PICO question from their clinical work to identify keywords
and develop a search strategy
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Hands-on searching
6. Facilitators
Anke
Charles
Anel
7. Student preparation and hand outs for next session: