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Evidence-Based Dermatology: Original Contribution |

Assessing Evidence-Based Dermatology and Evidence-Based Internal Medicine Curricula in US Residency Training Programs:  A National Survey FREE

Robert P. Dellavalle, MD, PhD; Deborah L. Stegner, MD; Ann M. Deas, MSPH; Eric J. Hester, MD; Michael H. McCeney, MD; Lori A. Crane, MPH, PhD; Lisa M. Schilling, MD
[+] Author Affiliations

Section Editor: Michael Bigby, MD
Section Editor: Rosamaria Corona, DSc, MD
Section Editor: Damiano Abeni, MD, MPH
Section Editor: Paolo Pasquini, MD, MPH
Section Editor: Moyses Szklo, MD, MPH, DrPH
Section Editor: Hywel Williams, MSc, PhD, FRCP

More Author Information
Arch Dermatol. 2003;139(3):369-372. doi:10.1001/archderm.139.3.369.
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Published online

Objectives  To examine attitudes toward evidence-based medicine and evidence-based dermatology and to assess evidence-based training in US internal medicine and dermatology residency programs.

Methods  A 1-page self-administered questionnaire was mailed to residency training directors and chief residents at 104 dermatology and 103 internal medicine residency programs from the same or affiliated medical centers.

Results  Questionnaires were returned by respondents from 70 (68%) of 103 internal medicine programs and 86 (83%) of 104 dermatology programs. Most respondents (91% internal medicine and 70% dermatology) strongly agreed or agreed that evidence-based internal medicine/dermatology is valuable and should be included in residency training (93% internal medicine and 70% dermatology). Respondents from internal medicine programs agreed more strongly with both statements than respondents from dermatology programs (P = .001). Dedicated evidence-based curricula were in place at significantly more internal medicine programs (50 [71%] of 70) than dermatology programs (20 [23%] of 86) (P<.001). Curricula at internal medicine programs offered significantly more evidence-based medicine training sessions (24 vs 6; P<.001) and biostatistics sessions (10 vs 2.3; P = .03), and internal medicine programs more frequently evaluated the curricula using clinical question applications (56% vs 30%; P = .04).

Conclusion  Despite favorable attitudes toward evidence-based dermatology, compared with internal medicine programs, dedicated evidence-based training is underdeveloped in dermatology programs.

Figures in this Article

IN MEDICAL practice, clinical decisions require the integration of clinical expertise, individual patient needs, and the best available information. The Accreditation Council for Graduate Medical Education and the Association of American Medical Colleges have recently called for the increased integration of epidemiology, biostatistics, critical appraisal, and medical informatics into the curriculum of both medical schools and graduate medical education programs to increase clinician information skills.15 Increased training in evidence-based medicine (EBM), defined as the conscientious, explicit, and judicious use of the current best evidence in making decisions about the care of individual patients, may begin to answer this call.6,7

Despite its promise, EBM remains a contentious topic. Critics have argued that EBM does not reflect the art of medicine, inadequately addresses certain clinical concerns, requires too much time, or is inadequately evaluated.811 The attitudes toward EBM and prevalence of evidence-based training in dermatology has never been assessed or compared with those in other medical specialties. The purpose of this article is to assess these attitudes and the prevalence of dedicated evidence-based training curriculum in dermatology and internal medicine residency programs.

PROGRAMS

All 104 US dermatology residency training programs and 103 corresponding internal medicine programs at the same or affiliated institution were surveyed.12 One dermatology program (National Institutes of Health Clinical Center Program) was not paired with an internal medicine program.

DATA COLLECTION

A 1-page self-administered questionnaire asked respondents to rate their level of agreement on a Likert 5-point scale13 (1 = strongly agree to 5 = strongly disagree) with statements about the value of evidence-based training and the importance of incorporating evidence-based training into all dermatology and internal medicine residency programs (Figure 1). Surveys sent to respondents at internal medicine programs were identical except that the words "evidence-based dermatology (EBD)" were replaced with "evidence-based medicine (EBM)." The survey contained additional questions assessing dedicated curriculum time for evidence-based training; EBM textbook use; the number of EBM sessions; the number of sessions focusing on epidemiology, biostatistics, or informatics; leaders of the training sessions, faculty attendance, outside training for session leaders, and evaluation of the EBM curriculum. The study was approved by the Colorado Multiple Institution Review Board, Denver.

Place holder to copy figure label and caption

Evidence-based dermatology survey. Asterisk denotes publication by Sackett et al.14

Graphic Jump Location

The questionnaire was modified following pilot testing. Average completion time for the final survey was 6 minutes. The survey was mailed in October 2001 to all program directors. Program directors not responding to the initial mailing were sent questionnaires via regular mail or electronic mail in December 2001. The questionnaire was also mailed to the "chief resident" of all the programs in December 2001. Responses were received through February 2002.

Results represent the responses of all program directors returning surveys and the responses of chief residents when program directors failed to respond. A computer database was compiled and entered by 1 author (D.L.S.) and verified by 3 other authors (A.M.D, M.H.M., and R.P.D.).

DATA ANALYSIS

Means and frequencies were calculated on a univariate level to describe the data. For bivariate comparisons, contingency table analysis was performed assuming a type I error of α = .05. Comparisons of internal medicine and dermatology responses were performed using the Wilcoxon rank sum test for Likert scale variables, χ2 test for categorical variables, and t test for continuous variables. Intrarater reliability tests comparing responses from the same residency programs were performed using a κ statistic. Analysis was performed using SPSS statistical software (SPSS Inc, Chicago, Ill; http://www.SPSS.com).

ATTITUDES REGARDING EVIDENCE-BASED CURRICULUM

Surveys were received from 86 dermatology (83%) and 70 internal medicine (68%) residency programs (Table 1). Responses from 75 dermatology residency directors, 11 dermatology chief residents, 56 internal medicine residency directors, and 14 internal medicine chief residents comprised the analyzed pool. Despite favorable attitudes in both disciplines, attitudes were significantly more positive at internal medicine programs for the value of EBM (2.2 vs 1.5; P<.001) and toward the integration of EBM into training (2.1 vs 1.4; P<.001).

DEDICATED EVIDENCE-BASED CURRICULUM

Significantly more internal medicine programs (71% vs 23%; P<.001) reported having a dedicated evidence-based curriculum. Responses from both program directors and residents were obtained from 38 dermatology programs and 17 internal medicine programs. Overall agreement between director and resident responses on whether the program had a dedicated evidence-based curriculum (yes or no) was 84% for dermatology programs and 76% for internal medicine programs (dermatology, κ = 0.77; internal medicine, κ = 0.55).

Of the dermatology programs with dedicated EBD curricula, an average of 6 EBD sessions per year were held. Only 1 dermatology program reported using a specific textbook for the training. Evidence-based dermatology sessions were most frequently led by faculty (70%) and lasted approximately 1.3 hours. More than 2 annual EBD sessions focused on epidemiology, 3.6 on biostatistics, and 2.3 on informatics. Of session leaders, 40% received training in EBD.

Internal medicine programs held an average of 24 EBM sessions per year. Sessions averaged 1.5 hours long and were led primarily by faculty (52%). Of session leaders, 58% received training in EBM. Nearly 9 annual EBM sessions focused on epidemiology, 10.3 on biostatistics, and 9.2 on informatics. The most frequent teaching text used was Evidence-Based Medicine: How to Practice and Teach EBM14 followed by the Users' Guides to the Medical Literature series published by The Journal of the American Medical Association.

Given that medical residents generate 2 clinical questions for every 3 patient encounters and more than 50% of these questions go unanswered,15 it is not surprising that evidence-based training is considered valuable by most respondents from the dermatology and internal medicine programs surveyed. Evidence-based training may provide a more efficient way to address patient-driven questions and better utilize adult learning principles: efficient adult learners (1) understand why they need to learn something, (2) take responsibility for their learning, (3) exploit experience as a resource, and (4) link learning with real-world requirements.16

Compared with dermatology residency programs, internal medicine programs are more dedicated to formal evidence-based training: internal medicine programs had more favorable attitudes toward EBM, were more likely to have a dedicated EBM curriculum, and, compared with dermatology programs with EBD curricula, had more evidence-based training sessions. These findings are consistent with EBM originating in the field of internal medicine and may reflect increased familiarity with the paradigm of EBM in internal medicine.6 Still, despite the long history of EBM within the field of internal medicine, this survey reflects that only recently have most internal medicine programs within the United States adopted formal EBM training. The last national survey of internal medicine programs in 1998 found that 37% offered a freestanding EBM curriculum compared with 71% surveyed in the present study.17

While evidence-based training has not been analyzed in dermatology, journal club training has.18 A survey of 89 dermatology programs in 2001 reported that most dermatology journal clubs have 1 to 3 faculty members in attendance, which correlates well with the average dermatology faculty attendance of 2 at EBD sessions reported in this study.

A 1-page survey format with most questions requiring yes/no or numeric answers helped this project obtain response rates relatively high for a physician survey.19,20 Moreover, comparison of responses from residents and faculty within the same program yielded strong agreement.21 The limited disagreement found might be explained by multiple factors, such as (1) change in curricula during the survey period, (2) lack of knowledge about the full components of the residency programs curriculum, and/or (3) disagreement on what constitutes evidence-based curriculum.

Study limitations include the following: (1) not all US internal medicine programs were surveyed, and the surveyed subsets were not randomly selected from all programs; (2) the brevity and format of this survey may have constrained a fuller description of some respondents' attitudes and curricula; (3) the survey did not address the specific objectives of EBM curricula; and (4) since residency programs have traditionally incorporated evidence-based teaching into journal clubs, it is possible that journal clubs alone may account for programs reporting dedicated EBM curricula.17 The last limitation would lead to overestimation of EBM curricula because typically the objectives of journal clubs are aimed toward critical appraisal of medical literature, only 1 aspect of the 4-step EBM practice,22 which includes (1) asking a patient-driven structured question, (2) searching for relevant information, (3) critically appraising the information, and (4) applying this information to the patient.

Despite favorable attitudes toward EBD, dermatology programs offer dedicated evidence-based curricula much less frequently than internal medicine programs. Evidence-based medicine provides residents and clinicians the skills to address individual patient problems and to reach an answer based on clinical expertise and the best external clinical evidence. Perhaps more than any other field, the practice of medicine requires a lifetime dedication to self-directed learning. Physicians need to formulate concise clinical questions, efficiently access medical knowledge, and critically appraise advancements in diagnosis, prognosis, and treatment. To this end, all residency programs should consider increasing emphasis on formal evidence-based training.

Corresponding author and reprints: Robert Dellavalle, MD, PhD, Department of Dermatology University of Colorado Health Sciences Center, 4200 E Ninth Ave, Box B-153, Denver, CO 80262 (e-mail: robert.dellavalle@uchsc.edu).

Accepted for publication October 8, 2002.

Dr Dellavalle was supported by grant K-07 CA92550-01A1 from the National Cancer Institute, Bethesda, Md, and Dr Hester was supported by grant T32 AR07411 from the National Institutes of Health, Bethesda.

This study was presented by Ms Deas at the American Academy of Dermatology meeting of the Dermatology Teachers Exchange Group, New Orleans, La, February 24, 2002.

We thank William Weston, MD, Kristie McNealy, BA, Patrick Diaz, BA, and David Norris, MD, for stimulating discussion and support.

A cooperative effort of the Clinical Epidemiology Unit of the Istituto Dermopatico dell'Immacolata–Istituto di Ricovero e Cura a Carattere Scientifico (IDI-IRCCS) and the Archives of Dermatology

Association of American Medical Colleges, Medical School Objectives Project Report II. Contemporary Issues in Medicine: Medical Informatics and Population Health.  June1998;Available at:http://www.aamc.org/meded/msop/start.htmAccessed September 24, 2002
Ramsey  PGCarline  JDInui  TS  et al.  Changes over time in the knowledge base of practicing internist. JAMA. 1991;2661103- 1107
Link to Article
McKibbon  KAHaynes  RBWalker-Dilked  CJ  et al.  How good are MEDLINE searches? a comparative study of clinical end user and librarian searches. Comput Biomed Res. 1990;23583- 593
Link to Article
Wennberg  J Dealing with medical practice variations: a proposal for action. Health Aff (Millwood). 1984;36- 32
Link to Article
Richardson  WWilson  MNishikawa  JHayward  R The well-built clinical question: a key to evidence based decisions. ACP J Club. 1995;123A12- A13
Sackett  DLRosenberg  WMMuir Gray  JAHaynes  RBRichardson  WS Evidence-based medicine: what it is and what it isn't. BMJ. 1996;31271- 72
Link to Article
Bigby  ML Evidence-based medicine in a nutshell: a guide to finding and using the best evidence in caring for patients. Arch Dermatol. 1998;1341609- 1618
Gibbs  S Losing touch with the healing art: dermatology and the decline of pastoral doctoring. J Am Acad Dermatol. 2000;43875- 878
Link to Article
Rees  J Evidence-based medicine: the epistemology that isn't. J Am Acad Dermatol. 2000;43727- 729
Link to Article
Rees  JL Two cultures? J Am Acad Dermatol. 2002;46313- 316
Link to Article
Hatala  RGuyatt  G Evaluating the teaching of evidence-based medicine. JAMA. 2002;2881110- 1112
Link to Article
American Medical Association, The Graduate Medical Education Directory 2001-2002.  Chicago, Ill Fred Donini-Lenhoff Medical Education Products2000-2001;492-500627- 656
Likert  R A technique for the measurement of attitudes. Arch Psychol. 1932;2244- 55
Sackett  DLStraus  SERichardson  WSRosenberg  WHaynes  RB Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. Edinburgh, Scotland Churchill Livingstone2000;
Green  MLCiamp  MAEllis  PJ Residents' medical information needs in clinic: are they being met? Am J Med. 2000;109218- 223
Link to Article
Green  MLEllis  PJ Impact of evidence based medicine curricula based on adult learning theory. J Gen Intern Med. 1997;12742- 50
Link to Article
Green  ML Evidence-based medicine training in internal medicine residency programs: a national survey. J Gen Intern Med. 2000;15129- 133
Link to Article
Anderson  BE Continue reading. Arch Dermatol. 2001;1371105- 1106
Asch  DAJedrziewski  MKChristakis  NA Response rates to mailed surveys published in medical journals. J Clin Epidemiol. 1997;501129- 1136
Link to Article
Cummings  SMSavitz  LAKonrad  TR Reported response rate to mailed physician questionnaires. Health Serv Res. 2001;351347- 1355
Rosner  B The kappa statistic. Fundamentals of Biostatistics 5th ed. Pacific Grove, Calif Duxbury2000;407- 410
Williams  H Dowling Oration 2001: evidence-based dermatology—a bridge too far? Clin Exp Dermatol. 2001;26714- 724
Link to Article

Figures

Place holder to copy figure label and caption

Evidence-based dermatology survey. Asterisk denotes publication by Sackett et al.14

Graphic Jump Location

References

Association of American Medical Colleges, Medical School Objectives Project Report II. Contemporary Issues in Medicine: Medical Informatics and Population Health.  June1998;Available at:http://www.aamc.org/meded/msop/start.htmAccessed September 24, 2002
Ramsey  PGCarline  JDInui  TS  et al.  Changes over time in the knowledge base of practicing internist. JAMA. 1991;2661103- 1107
Link to Article
McKibbon  KAHaynes  RBWalker-Dilked  CJ  et al.  How good are MEDLINE searches? a comparative study of clinical end user and librarian searches. Comput Biomed Res. 1990;23583- 593
Link to Article
Wennberg  J Dealing with medical practice variations: a proposal for action. Health Aff (Millwood). 1984;36- 32
Link to Article
Richardson  WWilson  MNishikawa  JHayward  R The well-built clinical question: a key to evidence based decisions. ACP J Club. 1995;123A12- A13
Sackett  DLRosenberg  WMMuir Gray  JAHaynes  RBRichardson  WS Evidence-based medicine: what it is and what it isn't. BMJ. 1996;31271- 72
Link to Article
Bigby  ML Evidence-based medicine in a nutshell: a guide to finding and using the best evidence in caring for patients. Arch Dermatol. 1998;1341609- 1618
Gibbs  S Losing touch with the healing art: dermatology and the decline of pastoral doctoring. J Am Acad Dermatol. 2000;43875- 878
Link to Article
Rees  J Evidence-based medicine: the epistemology that isn't. J Am Acad Dermatol. 2000;43727- 729
Link to Article
Rees  JL Two cultures? J Am Acad Dermatol. 2002;46313- 316
Link to Article
Hatala  RGuyatt  G Evaluating the teaching of evidence-based medicine. JAMA. 2002;2881110- 1112
Link to Article
American Medical Association, The Graduate Medical Education Directory 2001-2002.  Chicago, Ill Fred Donini-Lenhoff Medical Education Products2000-2001;492-500627- 656
Likert  R A technique for the measurement of attitudes. Arch Psychol. 1932;2244- 55
Sackett  DLStraus  SERichardson  WSRosenberg  WHaynes  RB Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. Edinburgh, Scotland Churchill Livingstone2000;
Green  MLCiamp  MAEllis  PJ Residents' medical information needs in clinic: are they being met? Am J Med. 2000;109218- 223
Link to Article
Green  MLEllis  PJ Impact of evidence based medicine curricula based on adult learning theory. J Gen Intern Med. 1997;12742- 50
Link to Article
Green  ML Evidence-based medicine training in internal medicine residency programs: a national survey. J Gen Intern Med. 2000;15129- 133
Link to Article
Anderson  BE Continue reading. Arch Dermatol. 2001;1371105- 1106
Asch  DAJedrziewski  MKChristakis  NA Response rates to mailed surveys published in medical journals. J Clin Epidemiol. 1997;501129- 1136
Link to Article
Cummings  SMSavitz  LAKonrad  TR Reported response rate to mailed physician questionnaires. Health Serv Res. 2001;351347- 1355
Rosner  B The kappa statistic. Fundamentals of Biostatistics 5th ed. Pacific Grove, Calif Duxbury2000;407- 410
Williams  H Dowling Oration 2001: evidence-based dermatology—a bridge too far? Clin Exp Dermatol. 2001;26714- 724
Link to Article

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