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Evidence-based Radiology Series |
1 From the Department of Radiology, Carver College of Medicine, JPP 3895, 200 Hawkins Dr, Iowa City, IA 52242-1077 (E.J.R.v.B.); and Department of Radiology, St Vincent's University Hospital, Dublin, Ireland (D.E.M.). Received June 29, 2005; revision requested August 25; revision received March 26, 2006; accepted May 2; final version accepted May 8. Address correspondence to E.J.R.v.B. (e-mail: edwin-vanbeek{at}uiowa.edu).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONEBP: BOTTOM-UP VERSUS TOP-DOWNWHY SHOULD RADIOLOGISTS BE...HOW SHOULD BOTTOM-UP EBP...INTEGRATION OF EBP INTO...DOES TEACHING EBP WORK?SETTING UP WORKING EBR...SUMMARYReferences |
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© RSNA, 2007
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONEBP: BOTTOM-UP VERSUS TOP-DOWNWHY SHOULD RADIOLOGISTS BE...HOW SHOULD BOTTOM-UP EBP...INTEGRATION OF EBP INTO...DOES TEACHING EBP WORK?SETTING UP WORKING EBR...SUMMARYReferences |
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EBP: BOTTOM-UP VERSUS TOP-DOWN |
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TOPABSTRACTINTRODUCTIONEBP: BOTTOM-UP VERSUS TOP-DOWNWHY SHOULD RADIOLOGISTS BE...HOW SHOULD BOTTOM-UP EBP...INTEGRATION OF EBP INTO...DOES TEACHING EBP WORK?SETTING UP WORKING EBR...SUMMARYReferences |
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There are two ways in which one can address EBR. The first way ("top-down" EBR) is through a central resource, such as the Cochrane Collaboration, government-sponsored health technology assessments, or working groups set up by professional bodies. For example, in the United States, a series of centers have been charged with producing evidence reports and technology assessments to support guideline development by other groups (2). Alternatively, these groups may engage in the centralized production of guidelines and their integration into practice (eg, the Royal College of Radiology guidelines "Making the Best Use of a Department of Clinical Radiology" or the American College of Radiology appropriateness criteria). Such national guidelines related to radiologic practice often consider the identification of the level of evidence available and current gaps in knowledge as part of their brief. Thus, this work is carried out without the direct involvement of the medical practitioner and instead relies on a limited number of people who are regarded as experts in their field. As a result, the guidelines may be "best practice" only for those people who have access to the diagnostic tests and therapies that are advised. This has led some practitioners to feel removed from the process. While the systematic reviews and the meta-analyses produced by top-down EBR centers (3,4) are widely welcomed, top-down EBR guidelines have been criticized because guidelines (which are discretionary) may be confused with standards of practice (which are obligatory) by the legal and lay populations, while many of the guidelines cannot be adhered to outside academic institutions.
The second method ("bottom-up" EBR) starts during the working day of the practicing radiologist. At its heart, EBR is the identification of a problem affecting the working of that practitioner and/or the treatment and outcome of the patient. The problem-solving methodology is explicit and was developed, as has been explained earlier in this series, by the researchers at McMaster University (Hamilton, Ontario, Canada) (5) and the National Health Service Centre for Evidence-Based Medicine (CEBM) (University of Oxford, Oxford, England) (6). Although some academicians and government institutions may frown on the McMaster-CEBM paradigm of EBP, which is a decentralized approach, it is in fact equally important to the top-down method described above. It should be remembered that this kind of EBP will apply directly to the workplace, will often include a search for relevant guidelines, and will have a more immediate effect in comparison with top-down guidelines, which are typically disseminated "en masse" and out of context—a factor that contributes to the problem of getting practitioners to use guidelines in the workplace.
Obviously, the two methods are not mutually exclusive. It is essential that during bottom-up EBR, current best evidence is identified and that during top-down EBR, researchers address the current gaps in knowledge in order to bring medicine forward and improve the lives of patients. The need for knowledge in the identification of knowledge gaps makes it essential that top-down EBR processes produce print and online resources that become rapidly and freely available to practitioners of bottom-up EBR. The optimal structure for evidence categorization has not yet been determined but is being developed (7). The Internet and the main radiologic journals are the appropriate places for this development, and the increasing availability of online resources has already had a huge effect on medical practice in general. Practitioners will also have to constantly address the question of whether the findings in studies are applicable to their own situation and to the patients that they deal with (many studies and trials have limited inclusion criteria) (8). Furthermore, practitioners will increasingly be met by patients who are more completely informed and therefore more critical of the methods employed in their clinical care. Finally, as in all areas of medicine, we have to realize that best practice is sometimes difficult to test within a clinical trial and yet is based on empirical evidence and founded in authority. As already stated in a discussion of "caveats" earlier in this series, when the best current evidence is weak, reliance on expert judgment gained from traditional specialist training and practical experience is both appropriate and required (9).
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WHY SHOULD RADIOLOGISTS BE TAUGHT ABOUT EBR? |
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TOPABSTRACTINTRODUCTIONEBP: BOTTOM-UP VERSUS TOP-DOWNWHY SHOULD RADIOLOGISTS BE...HOW SHOULD BOTTOM-UP EBP...INTEGRATION OF EBP INTO...DOES TEACHING EBP WORK?SETTING UP WORKING EBR...SUMMARYReferences |
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Several important international reports should be considered at this point, as they demonstrate the worldwide movement toward incorporating EBR into radiology education. In the United States, a report by the Accreditation Council for Graduate Medical Education Outcome Project was evaluated by radiology educators and put into the context of our profession (10). Six main competencies were identified: patient care, medical knowledge, interpretation and communication, professionalism, practice-based learning and improvement, and systems-based practice. These competencies are also incorporated into the recertification process for the American Board of Radiology. EBR will be an essential component of recertification to practice because it has a direct effect on many of the competencies described. The competency of "practice-based learning" specifically requires knowledge of evidence-based medicine; competence in the bottom-up EBR skills should form a fundamental part of this curriculum. This report highlights the notion that education in this area will be a requirement, while it advocates that assessment will take place on a more continuous and practical basis. In Canada, a report from the Royal College of Physicians and Surgeons of Canada described the physician roles that must be developed during resident training as medical expert/clinical decision maker, communicator, collaborator, manager, health advocate, scholar, and professional (12). Our report thus incorporates critical assessment of the available evidence into the curricular requirements as it critically affects the functioning in at least four of the roles described. Furthermore, this report suggests how the various aspects of EBR should be incorporated into a more self-directed learning curriculum (with more independent learning and case-based experience). We also highlight changes in examination methods, which lead away from the routine written examinations so common in radiology, and advocate altering much of the assessment to practical and lifelike simulations (12).
In Europe, British radiology training has undergone changes, and the Royal College of Radiologists emphasizes an aspect of EBP when it mentions that it is essential to develop "those basic skills in research methodology which are necessary to structure and perform research under appropriate guidance" (13). Furthermore, the report states that these skills should include the ability to review published articles critically and to perform effective literature searches on a given topic. An appreciation of the effective application of research findings in everyday practice will also be required (13). This notion is reinforced in another previous report, which details the requirements for further professional development (18).
These ideas should not be considered revolutionary but rather should be viewed as evolutionary. The spectrum of scholarly activities in radiology, as described by Lentle (19) in 1994 and shown in the Figure, has already been referred to in this series (9). This spectrum gives the ideas expressed in the reports described in the previous paragraph an overall context that is easy to understand. The activities of "professionalism," which are required for all practicing radiologists, would be assisted by bottom-up EBR training in residency. Residents who choose an academic radiology career path would be better prepared to begin the activities of "creative science," which could mean basic science and research but in the context of EBR equates to top-down EBR. At present, these academic activities would need to be underpinned by traditional training in biostatistics, epidemiology, and public health, as well as by that in radiology; bottom-up EBR training alone would not be sufficient preparation for a career in academic radiology research. The relationship between EBR and technology assessment will be considered in more detail later in this series.
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HOW SHOULD BOTTOM-UP EBP METHODS BE TAUGHT TO RADIOLOGISTS? |
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TOPABSTRACTINTRODUCTIONEBP: BOTTOM-UP VERSUS TOP-DOWNWHY SHOULD RADIOLOGISTS BE...HOW SHOULD BOTTOM-UP EBP...INTEGRATION OF EBP INTO...DOES TEACHING EBP WORK?SETTING UP WORKING EBR...SUMMARYReferences |
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Many undergraduate medical curricula now use problem-based self-directed learning, and most of the radiology curriculum relies on a practical setting (which effectively is problem-based learning). However, much of the formal teaching in radiology still tends to take place in a lecture format. Lectures induce relative passivity with our resident students, who are subsequently expected to gain factual knowledge that they can apply to case-based problem solving. Although this form of teacher-trainer education is vital to impart the factual database that is so much a part of the clinical basis of radiology, it may not be transferable into the teaching of EBR skills.
Some may say that journal clubs serve the purpose of attaining the EBR skills needed to remain up-to-date in our specialty. Indeed, journal clubs are a good medium to get residents to read outside of the textbook requirements for examinations. However, we cannot expect our residents to be able to critically reflect on the literature without some form of primary understanding of clinical epidemiologic practices, background knowledge on how research is conducted, and understanding of the broader literature in the context of the article under review. Hence, EBR teaching has a major role to play in this context, including in the stimulation of debate about the literature in a structured fashion by asking explicit critical appraisal questions and allowing the students to expand and gain deeper understanding of research and its relationship to everyday practice.
In contrast with the traditional setting of student passivity, the writings of Rogers (23), Kolb (24), Hyland (25), and Barnett (26,27) are at the heart of student empowerment and critical thinking as components to higher education. First, one needs to realize that adult learning is different from children's learning in that adult learning is life centered rather than subject centered (28,29). This means that the adult learner will identify with problems in a real-life setting, which transcends the boundaries of subjects. This makes the adult learner an ideal student for problem-solving and case-based education, in which the learner must use all available knowledge and integrate it to reach his or her goal of solving the problem (30–33).
The self-directed student is used to finding his or her own way through the subject matter and will ask independent questions of what is being offered. Naturally, this is just what we want later on in life, when these students have to question their practice and gather the evidence on which their patient care is based. In the words of Barnett, "The critical mind is in essence an inquisitive mind" (27). However, so far, within radiology training we have mainly focused on only one aspect of critical thinking, disciplinary competence (epistemic critical thinking), whereas practical knowledge (reflexive practice) is less important during residency. If we accept the statement by Rogers (23) that "a person learns significantly only those things which he perceives as being involved in the maintenance of, or enhancement of, the structure of self," we have to assume that the inclusion of EBR in the curriculum from an early stage of radiology training and in the "exit" examinations at the end of training would have an important effect on our students (23). Thus, were our residents to be convinced early in their training of the importance of EBR for their ongoing development and practice, it would become a natural component of being a fully trained radiologist.
Kolb (24) explains this principle when he describes experiential learning as a way to stimulate higher-order learning, such as critical thinking, while also paving the way for self-directed learning. His theory focuses on the transformation of experience into knowledge (or events into experiences), whereby learners engage with their experience through action (active experimentation) or reflection (reflective observation). The second part of Kolb's model relates to how the experience is handled intellectually (prehension) and emotionally (apprehension). With conceptual interpretation and symbolic representation, the learner will be able to develop abstract conceptualization, which is the key to comprehension (24). Although this principle sounds very much like the current vocational training in radiology residency, it is not sufficient to reach the goals set out above.
Hyland (25) actually attacks the vocational learning approach, such as is applicable for radiology, by demonstrating that the behaviorist approach of studying for particular examination questions actually narrows the course content and negatively influences the learning process and the deeper learning that is required to develop the critical mind of the practicing radiologist.
Ultimately, we also need to somehow measure the effects of EBR teaching. The activities of professionalism apply to both academic and nonacademic levels of practice. The key measures of efficacy would be the rapid identification and integration of valid and strong research into the problems encountered during local professional practice of radiology, the avoidance of inappropriate industry-driven initiatives in general diagnostic and interventional practice, and the existence of well-thought-out local audit and/or retrospective research programs. It is also suggested that scientific output and retention of radiologists in teaching hospitals and academic environments should eventually be a very important measure of the evaluation of the effectiveness of EBR teaching—that is, a good bottom-up EBR program should both stimulate individual residents' interest in prospective research (and their belief that they have the capability to engage in it) and facilitate a smooth progression to a career in clinically subspecialized academic radiology for suitably motivated residents. Thus, EBR may in the future form an essential component of the foundation on which the "creative science" activities of technology assessment (Figure) are built.
If one accepts the above logic it is now inevitable that, although it has not been done in the past, some of the teaching methods that have proved effective in other disciplines should be incorporated into radiology education. We are already excellent in training our residents in the interpretation of radiographs. As has been widely acknowledged by radiology colleges worldwide (and built into the core competencies), a more well-rounded education of radiologists will hopefully ensure that the specialty will continue to thrive. This strategy, being founded in and contributing to EBP in more general terms, will hopefully promote and enhance the place of radiologists at the core of patient care strategies and the trend toward "evidence-based medicine" practitioners regarding radiologists as technical staff who read images from the tests that the "real doctor" has ordered, often without clinical information or context (9), will be halted or reversed. Thus, intelligent integration of EBR teaching, practice-based learning, system-based practice, and case-based learning will be the prerequisite to maintain the high quality standards historically required from radiologists in general in the environment of 21st century practice.
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INTEGRATION OF EBP INTO THE CURRICULUM |
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TOPABSTRACTINTRODUCTIONEBP: BOTTOM-UP VERSUS TOP-DOWNWHY SHOULD RADIOLOGISTS BE...HOW SHOULD BOTTOM-UP EBP...INTEGRATION OF EBP INTO...DOES TEACHING EBP WORK?SETTING UP WORKING EBR...SUMMARYReferences |
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DOES TEACHING EBP WORK? |
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TOPABSTRACTINTRODUCTIONEBP: BOTTOM-UP VERSUS TOP-DOWNWHY SHOULD RADIOLOGISTS BE...HOW SHOULD BOTTOM-UP EBP...INTEGRATION OF EBP INTO...DOES TEACHING EBP WORK?SETTING UP WORKING EBR...SUMMARYReferences |
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A controlled trial in 55 1st-year internal medicine residents compared 17 residents who participated in a 7-week course of evidence-based medicine (2 h/wk) with 37 control subjects to whom this course was not offered (39). The intervention was assessed through a skills test, and this evaluation demonstrated substantial and durable improvements in cognitive and technical evidence-based medicine skills. More recently, findings of a review of all available literature also demonstrated a positive effect of evidence-based medicine teaching, but the findings emphasized that this effect was most pronounced if the teaching took place within an integrated setting in clinical practice (40). Thus, the results of this study support both the effectiveness of EBP education and the notion that this education needs to be integrated in the radiology residency curriculum.
Something that has not been assessed in the literature is the effect of EBR education on motivation of residents toward research and/or academic careers. Authors of one small-scale study suggested that the effect was substantial (17). In this study, which was focused on the development of an EBR course for radiology residents, one of the outcome measures was the number of residents who took a position in a teaching hospital. Within the 3 years of the course being developed, 55% of residents took a position in a teaching hospital, 25% went to perform a fellowship, and only 20% went into a position at a district hospital, which was against the national trend in England (17). More recent information suggests that the academic retention has decreased again since this study was completed, which thus suggests direct causality between the course and academic interest creation in residents.
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SETTING UP WORKING EBR GROUPS: INTERNATIONAL MODELS IN PRACTICE |
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TOPABSTRACTINTRODUCTIONEBP: BOTTOM-UP VERSUS TOP-DOWNWHY SHOULD RADIOLOGISTS BE...HOW SHOULD BOTTOM-UP EBP...INTEGRATION OF EBP INTO...DOES TEACHING EBP WORK?SETTING UP WORKING EBR...SUMMARYReferences |
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EBR groups do exist but are made up mainly of faculty who try to test the evidence in the literature. Many of these people are involved in developing policy documents as described above. The development of resident-driven EBR groups is mainly organized around journal clubs, which often lack faculty input. It is strongly suggested that formalized training in EBP will be an essential component of radiology education. One of the authors (E.J.R.v.B.) of this article developed a 13-week course (30 minutes each week) that incorporates the essentials of EBR, such as the basic concepts of clinical epidemiology, how to read and evaluate the literature, the essential components of setting up a research project, and how to write abstracts, posters, and articles. This course can be followed by a student-led discussion group, where residents can present new ideas, discuss research topics, and have structured literature discussion. The other author (D.E.M.) teaches radiology residents the basic principles of learning theory, technology assessment, and bottom-up EBR in a small-group format during the academic year. This format begins with didactic teaching and blends into practice-based learning as the residents take on outstanding clinical radiology issues within the department; each resident takes on and solves a clinical problem with the support of the group and tutor. As the year goes on, the group becomes more resident-directed. These projects are then presented at national and international meetings. Some are eventually published (41–46), but this is a slow process that is usually completed after a highly motivated resident has completed his or her final radiology examination (9).
On the basis of the experience of the authors themselves and of others who have participated in EBP programs, several options are open in order to put teaching of EBR into practice. The options have an immediate effect on the faculty requirements, such as prior training in EBP methodology, amount of time spent teaching, and the emphasis that is placed on scientific productivity.
One model relies on trained faculty (who have attended the McMaster University, University of Oxford, or other short "evidence-based clinical practice" courses) who are capable of producing handout materials and generating a supportive tutorial infrastructure within which residents and fellows may ask questions and receive advice. This course model will typically develop in regular weekly sessions from initial didactic and interactive offering of the basic background theory (ask, search, appraise, apply, and evaluate) to increasingly self-directed learning and application of EBP to local departmental problems by using a bottom-up approach. As described above, first experiences with this model are that it has already generated a number of "critically appraised topic"–type presentations and some similar publications, which tend to be based on relevant questions derived during daily radiologic practice (41–51). These publications illustrate the types of end points toward which residents or fellows in an EBR tutorial group may work. In practice, it has been found that these critical reviews are of interest both to the general radiology practitioner (for whom they provide a reliable overview of conventional wisdom on the topic in question) and to academic radiologists (for whom they define the end points of current conventional wisdom, sometimes identifying key issues for active researchers in the topic). Paradoxically, although such articles may be of as much interest to readers as the front-end basic research that constitutes the predominant content of scientific journals, it is difficult to know exactly where they fit best in the current radiology literature, and peers and peer reviewers frequently criticize such projects as not being "real research."
A second model relies on training radiologists during a later stage in their career, such as during workshops at postgraduate meetings. These workshops can take place during a single event (such as an annual meeting), may be spread over a period of several days (with 45–90-minute slots), or may run as a categorical course. The workshops tend to bring the basic aspects of the bottom-up approach across, illustrating the ask, search, appraise, apply, and evaluate modules in a focused program. The faculty needs to be well trained in the practice of EBR and interactive teaching, both (a) to effectively engage with registrants who have submitted their own current departmental problems to be investigated by using EBR methods and (b) to cope with a wide range of different registrant backgrounds (as registrants range from residents through community radiologists to the professorial level). The students may develop an interest and mature into EBR workshop faculty for subsequent annual meetings, as has been demonstrated by the European Society of Gastrointestinal and Abdominal Radiology, or ESGAR, EBP workshop series, which began in 2003 and is now an established feature of the annual ESGAR meeting.
Either of the above models may give satisfactory results, such as the introduction of EBR in practice and the research and publication of evidence-based reviews by participants. From anecdotal experience, other options, such as a short workshop or single lecture, seem to improve understanding of EBR and its place in the overall context of radiology practice without stimulating the incorporation of EBR skills into registrants' practice patterns.
Finally, as was evident from some of the responses to our questionnaire, many researchers teach EBR as part of their supervision of research students at both undergraduate and postgraduate levels. This teaching is part of ongoing mentorship during the conduct of experiments, the analysis of data, and the writing up of findings and dissertations. Although this form of EBR teaching is considered very valuable, it is not considered a mainstream option, since many radiologists will never have the opportunity to be involved in hands-on front-line research projects during the initial phases of their training.
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SUMMARY |
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TOPABSTRACTINTRODUCTIONEBP: BOTTOM-UP VERSUS TOP-DOWNWHY SHOULD RADIOLOGISTS BE...HOW SHOULD BOTTOM-UP EBP...INTEGRATION OF EBP INTO...DOES TEACHING EBP WORK?SETTING UP WORKING EBR...SUMMARYReferences |
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EBR has been identified as an area of need both to attain better practice and care for patients and to shape the future application of radiology. Thus, educators around the globe have included EBR into the list of needs for training. However, as of yet there is no clear plan of how EBR should be introduced into practice, and there seems to be a severe lack of impetus to make time available (and recognize the efforts by dedicated educators) to put wishes into practice. Nevertheless, it appears that EBR can be introduced into the curriculum, and early suggestions are that this will improve understanding, self-directed critical thinking, and ultimately, perhaps, the potential number of residents choosing career paths with an academic dimension; these developments are, it is suggested, essential for the optimal development of radiology as a whole.
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FOOTNOTES |
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Abbreviations: CEBM = National Health Service Centre for Evidence-Based Medicine • EBP = evidence-based practice • EBR = EBP in radiology
Authors stated no financial relationship to disclose.
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References |
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TOPABSTRACTINTRODUCTIONEBP: BOTTOM-UP VERSUS TOP-DOWNWHY SHOULD RADIOLOGISTS BE...HOW SHOULD BOTTOM-UP EBP...INTEGRATION OF EBP INTO...DOES TEACHING EBP WORK?SETTING UP WORKING EBR...SUMMARYReferences |
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This article has been cited by other articles:
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  E. J. Heffernan, J. D. Dodd, and D. E. Malone Cardiac Multidetector CT: Technical and Diagnostic Evaluation with Evidence-based Practice Techniques Radiology, August 1, 2008; 248(2): 366 - 377. [Abstract] [Full Text] [PDF]
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L. S. Medina and C. C. Blackmore Evidence-based Radiology: Review and Dissemination Radiology, August 1, 2007; 244(2): 331 - 336. [Abstract] [Full Text] [PDF]
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W. Hollingworth and J. G. Jarvik Technology Assessment in Radiology: Putting the Evidence in Evidence-based Radiology Radiology, July 1, 2007; 244(1): 31 - 38. [Abstract] [Full Text] [PDF]
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