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J Dent Educ. 68(9): 995-1003 2004
© 2004 American Dental Education Association
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Evidence-Based Dentistry

Implementing Evidence-Based Practice in Undergraduate Teaching Clinics: A Systematic Review and Recommendations

Sara B. Werb, Hon.B.Sc., M.S.Ed.; David W. Matear, B.D.S., B.M.Sc., M.Sc., D.D.P.H.

Ms. Werb is a Research Student, and Dr. Matear is Associate Professor, Discipline of Community Dentistry—both at the Faculty of Dentistry, University of Toronto. Direct correspondence and requests for reprints to Dr. David W. Matear, Faculty of Dentistry, University of Toronto, 124 Edward Street, Toronto M5G 1G6, Ontario, Canada; 416-979-4907, ext. 4499 phone; 416-979-4938 fax; david.matear{at}utoronto.ca.

Key words: evidence-based dentistry, evidence-based medicine, dental education, medical education, educational modules

Submitted for publication 05/19/04; accepted 07/06/04


   Abstract
Top
 Abstract
Methods
 Results
 Discussion
 Conclusions and Suggested model
 References
 
The objective of this project was to identify an effective methodology of approaching and implementing evidence-based principles in undergraduate teaching clinics to promote evidence-based dentistry in future clinical practice. A systematic review was undertaken to examine evidence-based clinical teaching and faculty continuing education. Research published from 1996 to 2002 was retrieved by searching several databases and the Internet, along with conducting hand searches and reviewing bibliographies maintained by faculty experts. Qualitative checklists for different types of studies were created to evaluate the literature. Relevant studies were selected if they met all four predetermined essential criteria and a minimum of two out of three desirable criteria. Systematic reviews were chosen if they met all five essential criteria. Data from selected articles were extracted, and study quality was assessed. We found that three systematic reviews and nine original research articles were deemed methodologically acceptable. Problem-based learning and evidence-based health care interventions increased student knowledge of medical topics and their ability to search, evaluate, and appraise medical literature. Dental students in a problem-based learning curriculum, emphasizing evidence-based practices, scored higher on the NDB I (National Dentistry Boards, Part I) than students in traditional curricula. While effective modules in implementing theoretical evidence-based principles exist, very few high-quality studies are available that examine these principles in dental undergraduate teaching clinics. No methodologically appropriate studies on the education of faculty in the implementation of evidence-based principles are available. Some studies promote promising theories and methodologies of teaching evidence-based care; based on these theories, a comprehensive model is proposed in this article. Considering the strength of evidence in the reviewed literature, we concluded that an evidence-based approach to clinical care is effective.

Historically, the teaching of clinical dentistry has often been based on individual opinions and not always on available research. Because the teaching of clinical practice has not been evidence-based, this "in my experience" approach to teaching can lead to a lack of consistency in clinical practice. In a landmark study, Elderton and Nuttal found considerable variation among dentists in assessment and treatment planning.1 They called for schools to educate dentists to practice dentistry supported by research.2 Subsequently, Elderton et al.2 considered evidence-based dentistry to be an essential component in the education of dental students. Almost twenty years later, evidence-based dentistry is starting to take hold in dental education.

Evidence-based dentistry is based on the method of evidence-based health care, which Sackett et al. define as the "conscientious, explicit and judicious use of the current best evidence in making decisions about individual patients."3 The principles of practicing evidence-based care are to:

  1. Structure and pose a clinical question,
  2. Search for the best available evidence,
  3. Critically appraise the information found, and
  4. Apply relevant information to patient problems, questions, or clinical treatment.4

These principles are currently being taught in continuing, graduate, and undergraduate programs.5

The aim of teaching evidence-based care is to encourage future health care practitioners to apply the methodology to everyday patient care.6 Four common educational methods are available to teach the principles of evidence-based care:

  1. Evidence-based learning (EBL),
  2. Problem-based learning (PBL),
  3. Case-based learning (CBL), and
  4. Patient-based learning (PatientBL).6

To ensure that students are encouraged to apply the principles in the future, Sutherland contends that evidence-based care must be implemented in undergraduate teaching, clinic practice, and faculty development.7 While theoretical principles are taught in the classroom, it appears to us that no formal, consistent method of applying evidence-based principles in clinical education exists. In order to be successful, a comprehensive education in evidence-based care must include continuity between theory and practice. Therefore a systematic review of the literature is required to identify an effective methodology of approaching and implementing evidence-based principles in undergraduate dental clinics to promote evidence-based dentistry in clinical practice.

Elderton, Sutherland, Richards, and Lawrence recommend that an effective model for teaching evidence-based principles be based upon a strategy that integrates theoretical principles, clinical practice, and faculty development.1,5,6 Accordingly, the aim of this study was to conduct a systematic review of the literature to identify effective strategies for promoting and implementing evidence-based clinical practice in undergraduate dental education.


   Methods
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 Abstract
 Methods
Results
 Discussion
 Conclusions and Suggested model
 References
 
Medline (Ovid and NLM Gateway), Embase, The Cochrane Library, CDSR, DARE, CINAHL, PsychInfo, ERIC, and OMNI were searched from 1996 to 2002 using combinations of these key words: evidence-based medicine, dentistry, evidence-based dentistry, problem-based learning, dental education, evidence-based learning, patient-based learning, case-based learning, medical undergraduate education, curriculum, education models, learning, medical education, community medicine, program evaluation, and teaching. The Internet search engines Dogpile and Google were searched for information on evidence-based dentistry and evidence-based medicine. Bibliographies from identified faculty experts along with textbooks on medical education and evidence-based medicine were consulted. Finally, relevant journals including Academic Medicine, Medical Education, Journal of Dental Education, Journal of Dental Hygiene, and Journal of Nursing Education were hand searched from 1996 to 2002.

Potential articles were excluded at the title stage if they were of no relevance to the study (that is, editorials, description studies). Abstracts of potentially relevant studies were reviewed to determine if they were case-controlled studies as a higher level of evidence. Copies of all remaining articles were retrieved, and one of us conducted a quality assessment of the articles. The Evidence-Based Medicine Working Group published guidelines to assess the validity of research.8,9 These were adapted from patient decision making to meet our criteria for educational research (Figures 1Go and 2Go). Original research was included if it met all four essential criteria and two desirable criteria. This was done to ensure studies included were at least well-designed, case-controlled studies. Systematic reviews were included if they met all five essential criteria required of a systematic review.



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  		Figure 1. Checklist for original research

 


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  		Figure 2. Checklist for systematic review

 
Data extracted from selected systematic reviews included author, date, number of studies included, methodology, aim, and results. Data extracted from original research studies included: author, date, aim, participants, study groups, methodology, and results. All studies were then evaluated on their level and strength of evidence based on the Canadian guide to clinical preventive health care guidelines (see Tables 1Go and 2Go).10


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  		Table 1. Recommendations of grades for specific clinical preventive actions
 

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  		Table 2. Levels of evidence: research design rating
 

   Results
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 Methods
 Results
Discussion
 Conclusions and Suggested model
 References
 
Table 3Go lists the number of studies chosen or rejected at various stages of evaluation. Four hundred twenty-nine articles were found with matching terms, and twenty-eight were identified by other means. Two hundred forty-seven articles were rejected at the title stage and 125 at the abstract stage. A total of eighty-five articles were retrieved and copied; forty-three articles on further reading did not meet our inclusion criteria. The remaining forty-two articles were scored. In all, twelve studies were selected (nine original research and three systematic reviews) and subjected to further analysis. Tables 4Go and 5Go display the data extracted from the systematic reviews and original research papers respectively. Table 6Go shows a summary of relevant information including the level and strength of evidence for all twelve studies.


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  		Table 3. Table of studies
 

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  		Table 4. Synthesis of original research

 

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  		Table 5. Synthesis of systematic reviews

 

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  		Table 6. Summary of results

 

   Discussion
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 Abstract
 Methods
 Results
 Discussion
Conclusions and Suggested model
 References
 
The methodology for this systematic review was developed from RevMan 4.1 software.11 The Evidence-Based Medicine Working Group’s User’s Guide to the Medical Literature was used to help evaluate the quality of the selected literature.8,9 The user’s guide consists of published guidelines intended to aid practitioners to adopt evidence-based practice on an everyday basis, which was consistent with the stated aims of this study. The Journal of the Canadian Dental Association published these guides in a series of articles to educate dentists in Canada in the principles and practice of evidence-based dentistry.7 The guides were adapted to evaluate educational interventions.

Educational research is unique in that traditional research designs and statistical procedures are more difficult to implement.12 Since problems with feasibility and design make it difficult for a randomized controlled trial approach to be used for educational research, this was excluded from our essential criteria. Instead it was decided that all studies should meet essential criteria in order to be included (Figures 1Go and 2Go). Checklists were developed that were simple, easy to implement and describe, and would meet the Cochrane Collaboration criteria for suitable checklists.13

The evaluative approach used in the twelve included studies was student self-assessment. Self-assessment is often considered of limited value in traditional quantitative research designs, but in mixed method educational research that employs a qualitative component, self-perception is considered an important indicator of learning, along with other markers of performance.13

Of the four recognized methods in teaching evidence-based care, only those that utilized problem-based and evidence-based learning met the pre-established criteria.6 From the results of this review, we found that students who have completed didactic courses in evidence-based health care and problem-based learning showed an improvement in the following areas: knowledge of statistics and medical therapies; attitude towards critical appraisal; NBDE I (National Board of Dental Examinations Part I) scores; and their perceived use of evidence-based principles in clinic.14–17

Three studies assessed students’ attitude towards the use of medical literature following a course on evidence-based medicine. Slawson and Shaughnessy18 showed a significant (p<0.05) increase in students’ willingness to use medical literature after completing a course on information mastery. Based on the article’s description, information mastery is similar to the first three steps of practicing evidence-based health care as outlined by Sackett et al.4 Wadland et al.19 showed that graduates of Michigan State University used evidence-based medicine. This study did not control for the rest of medical schools that teach evidence-based medicine; however, results still demonstrate positive student attitude to using evidence-based principles in clinical settings. Angel et al. found similar results in their study of undergraduate nursing students’ acquisition of appraisal skills in clinical setting following a series of lectures on critical appraisal.20

No studies were found on educating faculty on supporting the implementation of evidence-based principles that met the stipulated criteria. While Sackett et al. state in their seven notions of teaching evidence-based medicine that clinicians have to be experts and model evidence-based practice, no suggestions on how to achieve this status were provided.4

Problem-based learning and evidence-based health care courses have been shown to be effective in delivering the theory of evidence-based principles and encouraging students’ positive attitude towards its use in clinical practice. However, only three studies (those by Fagan and Griffith,21 Ghali et al.,22 and Sackett et al.4) examined the use of evidence-based principles in clinical clerkships. The other studies14–16,18–20 evaluated clinical application and involved predetermined scenarios using simulated patients that do not reflect everyday practice.24

A systematic review by Parks et al.24 showed a 25 percent improvement in medical knowledge when teaching critical appraisal skills. This data was from only one study, which was judged by the authors to be difficult to assess. Parks et al. included only articles from 1966 to 1997 in their review. The review mentions an ongoing randomized-controlled trial on teaching critical appraisal that measures changes in professional behavior, but no record of this article was found in Medline. Parks et al. recommended that more research in the area of educating health care professionals in the practices of critical appraisal and evidence-based care was needed.

Ghali et al.22 evaluated Medline use and the use of original research in undergraduate medical education by comparing a medical clerkship that taught interns how to use critical appraisal in clinical settings with a program that did not integrate critical appraisal skills in teaching patient care. The program that emphasized critical appraisal showed a statistically significant (p<0.008) increase in the use of the literature to guide patient care. The reasons that this program was judged successful were the active involvement of the faculty and students, clinical relevance of the teaching exercises, and the integration of the exercises into clinical practices.22

Fagan and Griffith also found that medical students’ knowledge about physical diagnosis significantly increased (p<0.01) when rounds required evidence-based practices in comparison to traditional authoritative practices.21 Sackett et al. showed that outpatient clinical care programs are an effective classroom for teaching and implementing evidence-based care.4 Their recommended program involves preclinical conferences that review the diagnosis and management of common disorders and a structured, evidence-based diagnosis before treatment is initiated.

Taken together, the strategies described by Fagan and Griffith,21 Ghali et al.,22 and Sackett et al.4 present an effective model for teaching evidence-based practices in a clinical setting. This model includes providing education about the theoretical principles of evidence-based health care, integrating teaching with actual clinical scenarios to make material more relevant, active involvement of faculty and students, and the adaptation of a standard form to facilitate student learning during patient care.


   Conclusions and Suggested Model
Top
 Abstract
 Methods
 Results
 Discussion
 Conclusions and Suggested model
References
 
Only one of the three desired aims of the review was achieved. Problem-based and evidence-based learning in a classroom environment with a predetermined teaching scenario is an effective method for introducing the principles of evidence-based health care. This method is currently applied at the University of Toronto’s Faculty of Dentistry in the evidence-based care module in year II and a case-based learning series in years three and four of the undergraduate curriculum. However, questions still remain concerning the ideal curriculum and approach, along with how to apply and support the best research to patient care to future dentists and the education of clinical teachers.

Fagan and Griffith,21 Ghali et al.,22 and Sackett et al.4 presented promising theories for clinical teaching of an evidence-based approach. These theories are also supported by both National Health Science Centre for Reviews and Dissemination25 and Best Evidence Medical Education Conference.26 The theories have been adapted for use in the University of Toronto undergraduate dental clinic and serve as a potential model for effective teaching of evidence-based dental care. This model is described in the following paragraphs.

In developing a treatment plan, students should demonstrate that their recommendations for the most advanced treatment plans are based on the best available evidence by completing an EBD Rx (Figure 3Go) for complex parts of treatment options.4 The EBD Rx reviews can be held in the clinics as a resource for other students provided that the review is current (for example, less than four months old, the equivalent of an academic term). At the beginning of the entry to clinical practice, students should be taught how to complete the review by their clinic supervisors. Groups of students could meet periodically in patient-based learning, group practice meetings to present newly completed EBD Rx forms to their peers.



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  		Figure 3. EBD RX

 
This model ensures that students utilize evidence-based health care as part of their everyday clinical practice and also encourages faculty development. Faculty misapprehension is a common barrier to implementing evidence-based clinical practice as clinical supervisors may feel that it ignores the didactic aspects of clinical training and clinical expertise.5 This barrier can be addressed by familiarizing clinical instructors with the principles of evidence-based dentistry and encouraging improved knowledge and participation through faculty development.

The aim of this review was to identify and suggest the best approach to developing an evidence-based clinical education program based on the best available research about teaching strategies. Scenarios introduced in the classroom appear to be the best way to introduce the principles of evidence-based care to students. A complementary clinical component and related faculty development are recommended to support evidence-based care. The model is recommended because it takes into account limited resources of the undergraduate clinical environment, while encouraging students to demonstrate their abilities in executing an evidence-based approach to care.


   REFERENCES
Top
 Abstract
 Methods
 Results
 Discussion
 Conclusions and Suggested model
 References
 

  1. Elderton RJ, Nuttal NM. Variation among dentists in planning treatment. Br Dent J 1983;154:201–6.[Medline]
  2. Elderton RJ, Nuttal NM, Eddie S, Davies JA. Dental health services research in Scotland: a review of some 5-year results. Community Dent Oral Epidemiol 1985;13(5): 249–52.[Medline]
  3. Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. Evidence-based medicine: what it is and what it isn’t. BMJ 1996;312:71–2.[Free Full Text]
  4. Sackett D, Richardson W, Rosenberg W, Haynes R. Evidence-based medicine: how to practice and teach EBM. London: Churchill Livingstone, 2000.
  5. Sutherland SE. Evidence-based dentistry: part I—getting started. J Can Dent Assoc 2001;67(4):204–6.
  6. Richards D, Lawrence A. Evidence-based dentistry. Br Dent J 1995;179(7):270–3.[Medline]
  7. Sutherland SE. Evidence-based dentistry: part V—research design and levels of evidence. J Can Dent Assoc 2001;67(7):375–8.
  8. Guyat G, Sackett D, Cook D. Users’ guide to the medical literature II: how to use an article about therapy or prevention: a. are the results of the study valid? JAMA 1993;270(21):2598–601.[Free Full Text]
  9. Oxman A, Cook D, Guyatt G. Users’ guide to the medical literature VI: how to use an overview. JAMA 1994;272(17):1367–71.[Medline]
  10. Canadian Task Force on Periodic Health Examination. The Canadian guide to clinical preventive health care. Ottawa, Canada: Health Canada, 1994.
  11. Cochrane Collaboration 2002. RevMan (4.1) [computer software], downloaded from www.cochrane-net.org/revman.
  12. Lechner S. Evaluation of teaching and learning strategies. Medical Education Online 2002. At: www.med-edonline.org/f000024. Accessed: July 10, 2002.
  13. Cochrane Collaboration. The Cochrane manual. Cochrane Library 2002;4:1–136.
  14. Taylor R, Reeves B, Ewings P, Binns S, Keast J, Mears R. A systematic review of the effectiveness of critical appraisal skills training for clinicians. Med Educ 2000;34:120–5.[Medline]
  15. Farrell T, Albanese M, Pomrehn P. Problem-based learning in ophthalmology: a pilot program for curricular renewal. Arch Opthalmol 1999;117:1223–6.
  16. Steele DJ, Medder JD, Turner P. A comparison of learning outcomes and attitudes in student- versus faculty-led problem-based learning: an experimental study. Med Educ 2000;34:23–9.[Medline]
  17. Fincham A, Shuler C. The changing face of dental education. J Dent Educ 2001;34:406–21.
  18. Slawson D, Shaughnessy A. Teaching information mastery: creating informed consumers of medical information J Am Board Fam Pract 1999;12(6):444–9.[Abstract]
  19. Wadland W, Barry H, Farquhar L, Holzman C, White A. Training medical students in evidence-based medicine: a community campus approach. Fam Med 1999;31(10): 703–8.[Medline]
  20. Angel B, Duffey M, Belyea M. An evidence-based project for evaluating strategies to improve knowledge acquisition and critical-thinking performance in nursing students. J Nurs Educ 2000;39(5):219–28.[Medline]
  21. Fagan M, Griffith R. An evidence-based physical diagnosis curriculum for third-year internal medicine clerks. Acad Med 2000;75(5):528–9.[Medline]
  22. Ghali W, Staitz R, Eskew A, Gupta M, Quan H, Hershman W. Successful teaching in evidence-based medicine. Med Educ 2000;34:18–22.[Medline]
  23. Neville A, Reiter H, Eva K, Norman G. Critical appraisal turkey shoot: linking critical appraisal to clinical decision making. Acad Med 2000;75(10):S87–89.[Medline]
  24. Parks J, Hyde C, Deeks J, Milne R. Teaching critical appraisal skills in health care settings (Cochrane Review). The Cochrane Library, Issue 2, 2002. Oxford: Update Software.
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  26. Best evidence medical education (BEME): report on meeting 3–5 December 1999, London. Med Teacher 2000;22(3):242–5.



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