Aio’s huisartsgeneeskunde hebben adequate kennis ten aanzien van evidence-based medicine (geneeskunde op basis van bewijs). In de huisartspraktijk is evidence-based gedrag vaak niet direct zichtbaar, maar artsen kunnen wel aangeven op welk aspect van evidence-based medicine de voorgeschreven behandelingen zijn gebaseerd. Sandra Zwolsman deed onderzoek naar het gebruik van evidence-based medicine door artsen in opleiding tot specialist huisartsgeneeskunde, de wijze waarop evidence-based medicine getoetst kan worden in de huisartsopleiding, en de factoren die het gebruik ervan in de huisartsenpraktijk belemmeren. Evidence-based medicine is de integratie van het beste bewijsmateriaal, de expertise van de arts en de situatie en voorkeur van de patiënt bij de zorg voor patiënten

Zwolsman, Sandra E.

Zwolsman, S.E.

International Migration, Integration and Social Cohesion online publications

UvA-DARE is a service provided by the library of the University of Amsterdam (https://dare.uva.nl)UvA-DARE (Digital Academic Repository)Evidence-based medicine in general practice specialty trainingZwolsman, S.E.Publication date2012Link to publicationCitation for published version (APA):Zwolsman, S. E. (2012). Evidence-based medicine in general practice specialty training.[Thesis, fully internal, Universiteit van Amsterdam].General rightsIt is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s)and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an opencontent license (like Creative Commons).Disclaimer/Complaints regulationsIf you believe that digital publication of certain material infringes any of your rights or (privacy) interests, pleaselet the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the materialinaccessible and/or remove it from the website. Please Ask the Library: https://uba.uva.nl/en/contact, or a letterto: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam, The Netherlands. Youwill be contacted as soon as possible.Download date:26 Oct 2023	  9 	   1 	   2 	   3 	   4 	   5 	   6 	   7 	   8 	   9 General	  Introduction	   10 	   11 	   12 	   13 	   14 	   15 	   16 	   17 	   18 	   19 	   20 	   21 	   22 	   23 	   24 	   25 	   26 	   27 	   28 	   29 EVIDENCE-­‐BASED	  MEDICINE	  IN	  GENERAL	  PRACTICE	  SPECIALTY	  TRAINING	  10 	   1 	   2 	   3 	   4 	   5 	   6 	   7 	   8 	   9 	   10 	   11 	   12 	   13 	   14 	   15 	   16 	   17 	   18 	   19 	   20 	   21 	   22 	   23 	   24 	   25 	   26 	   27 	   28 	   29 	   30 	   31 	   32 GENERAL	  INTRODUCTION	  11 Background	   1 	   2 Medical	   knowledge	   rapidly	   evolves,	   expands	   and	   even	   replaces	   itself.1	   3 Every	   year	   the	   speed	   of	   generation	   and	   dissemination	   of	   new	   evidence	   4 rises	  due	  to	  the	  use	  of	  new	  media	  and	  increased	  possibilities	  of	  information	   5 and	  communication	  technology.	  The	  resulting	  information	  overload	  makes	   6 it	  almost	  impossible	  for	  physicians	  to	  fulfil	  their	  ethical	  duty	  to	  keep	  up	  to	   7 date	  with	  current	  best	  evidence.2	  Medical	  education	  in	  the	  last	  decades	  has	   8 accordingly	  changed	  from	  an	  authoritarian-­‐based	  training	  programme,	  to	  a	   9 programme	   focusing	   on	   the	   competencies	   required	   for	   life-­‐long,	   self-­‐ 10 directed	   learning	   and	   critical	   use	   of	   new	   information.	   1	   Evidence-­‐based	   11 medicine	  (EBM)	  was	  even	  proclaimed	  by	  some	  to	  be	  the	  new	  paradigm	  for	   12 medical	  education.3	  	   13 	  	  	  	  	  EBM	   is	   the	   translation	   of	   the	   results	   of	   clinical	   epidemiological	   studies	   14 into	  daily	  medical	  practice.	  The	  contemporary	  definition	  states	  that	  EBM	  is	   15 the	   conscientious,	   explicit	   and	   judicious	   use	   of	   current	   best	   evidence	   in	   16 combination	   with	   the	   physician’s	   preferences,	   the	   patient’s	   preferences	   17 and	   the	   situation	   of	   the	   patient	   in	   making	   decisions	   about	   the	   care	   of	   18 individual	   patients.4-­‐7	  Depending	  on	   the	  medical	   speciality,	   EBM	  has	  been	   19 more	  or	   less	   integrated	   into	   the	  daily	  practice	  of	  medical	   specialists.8	  The	   20 uptake	  of	  EBM	  by	  General	  Practitioners,	  however,	   remains	   the	   subject	  of	   21 debate.	   9-­‐10	   Although	   GPs	   generally	   agree	   that	   the	   practice	   of	   EBM	   can	   22 improve	  patient	   care,	   they	   also	   experience	   specific	   barriers	   to	   the	  use	  of	   23 EBM	   in	   their	   practice.	   In	   a	   focus-­‐group	   study	   among	   Belgian	   GPs	   for	   24 instance,	  GPs	  stated	  that	  their	  decision-­‐making	  is	  mainly	  based	  on	  intuition,	   25 habits	   and	   experience	   instead	   of	   evidence.	   Additionally	   they	   feel	   the	   26 patients’	  symptoms	  are	  often	  too	  vague	  and	  the	  problems	  faced	  too	  broad	   27 to	   practice	   EBM.	   They	   say	   that	   for	   their	   specific	   specialism	   a	   continuous	   28 scientific	   update	   is	   not	   feasible.11	   The	   specific	   GP	   setting	   therefore	   has	   a	   29 significant	  influence	  on	  the	  actual	  use	  of	  EBM	  by	  this	  group.	  These	  results	   30 have	  been	  confirmed	  by	  a	  recent	  study	  among	  Dutch	  GP	  trainers,	  in	  which	   31 trainers	   stated	   they	   considered	   EBM	   an	   academic	   quality,	   not	   generally	   32 EVIDENCE-­‐BASED	  MEDICINE	  IN	  GENERAL	  PRACTICE	  SPECIALTY	  TRAINING	  12 related	  to	  daily	  General	  Practice.	  Most	  of	  them,	  however,	  do	  feel	  that	  the	   1 use	  of	  guidelines	   is	   important	  for	  GPs.	  Differences	   in	  the	   interpretation	  of	   2 the	  definition	  of	   EBM	   seems	   to	  be	  one	  of	   the	   causes	   of	   these	   seemingly	   3 opposite	  expressions.12	  	   4 	  	  	  	  	  The	   difficulties	   experienced	   by	   General	   Practitioners	   in	   using	   EBM	   5 combined	   with	   the	   attitude	   of	   GP	   trainers,	   acting	   as	   role-­‐models	   for	   GP	   6 trainees,	  potentially	  have	  a	  strong	  influence	  on	  the	  future	  practice	  of	  EBM	   7 by	  trainees.13	  To	  enhance	  the	  future	  use	  of	  EBM	  by	  trainees,	  a	  combination	   8 of	  train-­‐the-­‐trainers	  programmes	  and	  optimal	  formal	  education	  on	  EBM	  for	   9 GP	  trainees	  is	  important.	  	  In	  this	  thesis	  I	  am	  focusing	  on	  the	  learning	  of	  EBM	   10 by	  GP	  trainees	  and	  on	  the	  assessment	  of	  EBM	  in	  GP	  specialty	  training.	  	   11 	   12 	   13 	   14 	   15 	   16 	   17 	   18 	   19 	   20 	   21 	   22 	   23 	   24 	   25 	   26 	   27 	   28 	   29 	   30 	   31 	   32 GENERAL	  INTRODUCTION	  13 EBM	  stepsExperience	  &	  ExpertiseEducationEvidencePhysician’s	  preferencesPatient’s	  preferences	  and	  situationDecisionClinical	  problemGP	  Setting	   1 	   2 	   3 	   4 	   5 	   6 	   7 	   8 	   9 	   10 	   11 	   12 	   13 	   14 	   15 	   16 	   17 	   18 	   19 	   20 	   21 	   22 	   23 	   24 	   25 	   26 	   27 	   28 	   29 	   30 	   31 Figure	  1.	  Clinical	  Decision	  Making	  (Adapted	  from	  Offringa	  M,	  et	  al.)7,14	  EVIDENCE-­‐BASED	  MEDICINE	  IN	  GENERAL	  PRACTICE	  SPECIALTY	  TRAINING	  14 GuidelinesSyntheses	  &	  SynopsesSystematic ReviewsPrimary studiesGeneral	  Practice	  in	  the	  Netherlands	   1 	   2 In	   the	   Dutch	   healthcare	   system,	   GPs	   have	   an	   important	   function	   as	   3 gatekeepers.	  All	  Dutch	  citizens	  are	  registered	  in	  a	  GP	  practice	  and	  –	  except	   4 from	  medical	  emergencies	  –	   first	  visit	   their	  GP	  when	  they	  require	  medical	   5 care.	   Approximately	   96%	   of	   all	   the	   consultations	   are	   performed	   by	   GPs	   6 without	  interference	  of	  other	  healthcare	  professionals.	  15	  	   7 	  	  	  	  	  Dutch	  GPs	  frequently	  make	  use	  of	  the	  guidelines	  (99	  at	  present)	  of	  the	   8 Dutch	   Society	   of	   General	   Practitioners	   to	   find	   an	   answer	   to	   their	   clinical	   9 questions.16	   GPs	   generally	   show	   a	   positive	   attitude	   towards	   these	   10 guidelines17	  and	  66%	  of	  the	  decisions	  made	  by	  Dutch	  GPs	  are	  in	  accordance	   11 with	   the	   guidelines.18	   According	   to	   the	   hierarchical	   pyramid	   described	   by	   12 Haynes	  et	  al.	  showing	  the	  scientific	  value	  of	  evidence	  resources	  (figure	  2),	   13 these	   guidelines	   can	   be	   considered	   as	   the	   highest	   level	   of	   evidence	   14 available	  to	  GPs.19	  	   15 	   16 	   17 	   18 	   19 	   20 	   21 	   22 	   23 	   24 	   25 	   26 	   27 	   28 Figure	  2.	  Pyramid	  of	  evidence19	   29 	   30 	   31 	   32 GENERAL	  INTRODUCTION	  15 However,	   not	   all	   clinical	   questions	   can	   be	   answered	   with	   the	   use	   of	   1 guidelines,20	   in	  which	  case	  sources	  with	   lower	   levels	  of	  evidence	  must	  be	   2 used.	   When	   no	   evidence	   that	   falls	   within	   the	   pyramid	   is	   available,	   3 experience	   and	   expert	   opinion	   are	   also	   often	   used	   by	   GPs	   and	   count	   as	   4 ‘best	  available	  evidence’.21	  	   5 	   6 EBM	  in	  the	  GP	  specialty	  training	   7 	   8 The	   GP	   specialty	   training	   is	   a	   3-­‐year	   educational	   programme	   combining	   9 training	   in	   clinical	   practice	   (4	   days	   a	   week)	   with	   one	   day	   of	   formal	   10 education	   at	   the	   training	   institute.	   Since	   the	   emergence	   of	   clinical	   11 epidemiology	  in	  the	  early	  1980s,	  education	  in	  EBM	  has	  become	  embedded	   12 in	   medical	   teaching.4	   Medical	   trainees	   learn	   how	   to	   keep	   up	   with	   the	   13 growing	   pile	   of	   information	   and	   also	   how	   to	   assess	   and	   apply	   the	   14 information	  found.	  In	  the	  GP	  specialty	  training	  programme	  of	  the	  Academic	   15 Medical	   Center	   of	   the	   University	   of	   Amsterdam,	   EBM	   plays	   a	   prominent	   16 role:	  attention	  is	  paid	  to	  the	  knowledge	  and	  skills	  that	  are	  necessary	  for	  the	   17 application	  of	  evidence	  and	  for	  dealing	  with	  guidelines.	  As	  in	  most	  medical	   18 training	  programmes,	   training	   in	  EBM	  takes	  place	  according	   to	   the	  5-­‐step	   19 model.4;7	  	   20 	   21 	  	  	  	  	  1.	  Translation	  of	  a	  clinical	  problem	  into	  an	  answerable	  question	  (ask);	   22 	  	  	  	  	  2.	  Efficient	  search	  for	  the	  best	  evidence	  to	  fit	  the	  question	  	  	   23 	  	  	  	  	  	  	  	  	  (access/acquire);	   24 	  	  	  	  	  3.	  Appraising	  the	  evidence	  found	  regarding	  methodological	  quality	  and	  	  	   25 	  	  	  	  	  	  	  	  	  applicability	  for	  the	  patient	  -­‐	  assessment	  of	  internal	  and	  external	  	   26 	  	  	  	  	  	  	  	  	  validity	  (appraise);	   27 	  	  	  	  	  4.	  Making	  a	  decision	  in	  respect	  of	  available	  evidence,	  preferences	  and	  	   28 	  	  	  	  	  	  	  	  	  experience	  the	  GP	  and	  preferences	  and	  situation	  of	  the	  patient	  	   29 	  	  	  	  	  	  	  	  	  (apply);	  	   30 	  	  	  	  	  5.	  Regular	  evaluation	  of	  the	  quality	  of	  this	  process	  (audit/assess).	  	   31 	   32 EVIDENCE-­‐BASED	  MEDICINE	  IN	  GENERAL	  PRACTICE	  SPECIALTY	  TRAINING	  16 These	  5	  steps	  are	  to	  be	  used	  by	  GP	  trainees	  when	  facing	  a	  clinical	  question	   1 for	  which	  new	  or	  additional	  information	  is	  needed	  in	  order	  to	  answer	  these	   2 questions	   accurately.	   The	   EBM	   steps	   are	   used	   less	   explicitly	   when	   3 managing	   patients	   with	   more	   common	   clinical	   problems,	   since	   the	   GP	   4 trainee	  is	  already	  familiar	  with	  the	  policy	  regarding	  these	  problems.	  	   5 	  	  	  	  	  Thorough	  education	  in	  EBM	  is	  thus	  given	  in	  the	  GP	  specialty	  training.	  The	   6 main	  purpose	  of	   this	   formal	   training	   in	  EBM,	  however,	   is	   for	   the	  acquired	   7 skills	   to	   be	   applied	   when	   caring	   for	   patients	   in	   clinical	   practice.	   Multiple	   8 aspects	   influence	   the	   transfer	   of	   these	   EBM	   competencies	   to	   the	   clinical	   9 workplace	   of	   the	   GP	   trainee.	   The	   learning	   style	   of	   the	   trainee,	   barriers	   10 regarding	  practice	  of	  EBM	  in	  the	  specific	  GP	  setting,	  and	  the	  assessment	  of	   11 the	  required	  competencies	  are	  three	  of	  these	  aspects,	  which	  are	  discussed	   12 in	  this	  thesis.	  	   13 	   14 Learning	  Style	   15 	   16 As	  formal	  postgraduate	  education	   in	  EBM	   is	  generally	  not	  adapted	  to	  the	   17 individual	   learning	  needs	  and	  methods	  of	   the	   trainees,	   the	   learning	  styles	   18 of	   trainees	   could	   influence	   the	   uptake	   of	   the	   knowledge	   and	   skills	   as	   19 presented	   in	   formal	   education	   in	   EBM.22	   Additionally,	   preferred	  ways	   for	   20 acquiring	   new	   information	   during	   formal	   education	   (learning	   style)	   could	   21 be	   related	   to	   the	   methods	   used	   to	   solve	   patient	   problems	   (EBM	   or	   22 otherwise),	  which	  also	  requires	  obtaining	  and	  integrating	  new	  information.	   23 Chapter	   1	   therefore	   describes	   the	   outcomes	   of	   a	   study	   regarding	   the	   24 knowledge/skills,	   attitude	   and	   self-­‐reported	   behaviour	   of	   GP	   trainees	   25 regarding	  EBM.	   26 	   27 	   28 	   29 	   30 	   31 	   32 GENERAL	  INTRODUCTION	  17 Barriers	  towards	  the	  practice	  of	  EBM	   1 	   2 We	  know	  that	  barriers	  exist,	  limiting	  the	  use	  of	  EBM	  by	  trainees.	  In	  a	  recent	   3 systematic	   review	   by	   our	   group	   it	   was	   shown	   that	   time,	   attitude,	   4 knowledge	   and	   skills,	   and	   specific	   barriers	   related	   to	   the	   position	   of	   5 trainees	  of	  various	  specialties	  limit	  their	  use	  of	  EBM	  in	  clinical	  practice.23	  As	   6 speciality-­‐specific	   barriers	   have	   also	   been	   mentioned	   in	   general	   practice,	   7 we	  performed	  a	   systematic	   review	  of	   the	  barriers	  experienced	  by	  GPs,	   in	   8 order	  to	  obtain	  a	  complete	  view	  of	  the	  barriers	  potentially	  limiting	  the	  use	   9 of	   EBM	   by	   GP-­‐trainees	   (Chapter	   2).	   Based	   on	   the	   results	   of	   these	   10 systematic	   reviews,	   a	  questionnaire	  was	  developed	   to	  assess	   the	  barriers	   11 as	  experienced	  by	  Dutch	  GP	  trainees	  (Chapter	  3).	  	   12 	   13 Assessment	   14 	   15 As	  assessment	  is	  one	  of	  the	  most	  potent	  influences	  on	  learning,	  the	  format	   16 and	  content	  of	  the	  assessment	  of	  EBM	  competencies	  in	  GP	  trainees	  could	   17 significantly	   influence	   their	   learning.24	   Valid	   assessment	   tools	   are	   a	   first	   18 requirement	  to	  stimulate	   learning	   in	  this	  area.	  A	  recent	  systematic	  review	   19 showed	   that	   two	   instruments	   exist	   that	   validly	   identify	   EBM	   knowledge	   20 and	   skills	   of	   medical	   professionals.25	   Chapter	   4	   describes	   the	   translation	   21 and	  subsequent	  validation	  of	  one	  of	  these	  tools:	  the	  Berlin	  questionnaire.25	  	   22 Assessment	  can,	  however,	  take	  place	  at	  various	  levels	  of	  learning.	  The	  four	   23 levels	   of	   Miller’s	   pyramid	   of	   learning	   describe	   these	   potential	   learning	   24 outcomes	   (Figure	   3).26	   In	   line	   with	   the	   ideas	   on	   competence-­‐based	   25 education,	   ideally	   the	   top	   of	   the	   pyramid	   is	   reached	   in	   learning:	   trainees	   26 show	   the	  desired	  behaviour	   in	   daily	   clinical	   practice.	   In	   EBM,	   usually	   only	   27 the	   lowest	   two	   segments	  of	   the	  pyramid	   (knows/knows	  how)	  are	   taught	   28 and	  assessed.26-­‐27	   29 	   30 	   31 	   32 EVIDENCE-­‐BASED	  MEDICINE	  IN	  GENERAL	  PRACTICE	  SPECIALTY	  TRAINING	  18 DoesShows	  howKnows howKnows	   1 	   2 	   3 	   4 	   5 	   6 	   7 	   8 	   9 	   10 	   11 	   12 	   13 	   14 Figure	  3.	  Pyramid	  of	  learning	  outcomes25	   15 	   16 	   17 In	   order	   to	   assess	   EBM	  behaviour	   in	   practice	   at	   the	   highest	   levels	   of	   the	   18 pyramid,	  assessment	  tools	  are	  needed.	  Chapter	  5	  contains	  the	  results	  of	  a	   19 systematic	   review	   investigating	   whether	   valid	   assessment	   tools	   exist	   for	   20 the	   practice	   of	   EBM.	   As	   we	   concluded	   that	   no	   instruments	   exist	   that	   21 provide	   an	   integrated	   overview	  of	   EBM	   competencies	   in	   clinical	   practice,	   22 and	   also	   that	   no	   overview	   exists	   of	   expressions	   of	   competent	   EBM	   23 behaviour,	   Chapter	   6	   describes	   the	   results	   of	   an	   observational	   study	   on	   24 EBM-­‐behaviour	  in	  clinical	  practice.	  The	  results	  of	  this	  study	  can	  be	  used	  as	  a	   25 starting	  point	  for	  the	  development	  of	  new	  assessment	  instruments	  for	  this	   26 competence.	  	   27 	   28 	   29 	   30 	   31 	   32 	   33 

English

Evidence-based medicine in general practice specialty training

UvA-DARE is a service provided by the library of the University of Amsterdam (https://dare.uva.nl)UvA-DARE (Digital Academic Repository)Evidence-based medicine in general practice specialty trainingZwolsman, S.E.Publication date2012Link to publicationCitation for published version (APA):Zwolsman, S. E. (2012). Evidence-based medicine in general practice specialty training.General rightsIt is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s)and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an opencontent license (like Creative Commons).Disclaimer/Complaints regulationsIf you believe that digital publication of certain material infringes any of your rights or (privacy) interests, pleaselet the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the materialinaccessible and/or remove it from the website. Please Ask the Library: https://uba.uva.nl/en/contact, or a letterto: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam, The Netherlands. Youwill be contacted as soon as possible.Download date:25 Jul 2022	  9 	   1 	   2 	   3 	   4 	   5 	   6 	   7 	   8 	   9 General	  Introduction	   10 	   11 	   12 	   13 	   14 	   15 	   16 	   17 	   18 	   19 	   20 	   21 	   22 	   23 	   24 	   25 	   26 	   27 	   28 	   29 EVIDENCE-­‐BASED	  MEDICINE	  IN	  GENERAL	  PRACTICE	  SPECIALTY	  TRAINING	  10 	   1 	   2 	   3 	   4 	   5 	   6 	   7 	   8 	   9 	   10 	   11 	   12 	   13 	   14 	   15 	   16 	   17 	   18 	   19 	   20 	   21 	   22 	   23 	   24 	   25 	   26 	   27 	   28 	   29 	   30 	   31 	   32 GENERAL	  INTRODUCTION	  11 Background	   1 	   2 Medical	   knowledge	   rapidly	   evolves,	   expands	   and	   even	   replaces	   itself.1	   3 Every	   year	   the	   speed	   of	   generation	   and	   dissemination	   of	   new	   evidence	   4 rises	  due	  to	  the	  use	  of	  new	  media	  and	  increased	  possibilities	  of	  information	   5 and	  communication	  technology.	  The	  resulting	  information	  overload	  makes	   6 it	  almost	  impossible	  for	  physicians	  to	  fulfil	  their	  ethical	  duty	  to	  keep	  up	  to	   7 date	  with	  current	  best	  evidence.2	  Medical	  education	  in	  the	  last	  decades	  has	   8 accordingly	  changed	  from	  an	  authoritarian-­‐based	  training	  programme,	  to	  a	   9 programme	   focusing	   on	   the	   competencies	   required	   for	   life-­‐long,	   self-­‐ 10 directed	   learning	   and	   critical	   use	   of	   new	   information.	   1	   Evidence-­‐based	   11 medicine	  (EBM)	  was	  even	  proclaimed	  by	  some	  to	  be	  the	  new	  paradigm	  for	   12 medical	  education.3	  	   13 	  	  	  	  	  EBM	   is	   the	   translation	   of	   the	   results	   of	   clinical	   epidemiological	   studies	   14 into	  daily	  medical	  practice.	  The	  contemporary	  definition	  states	  that	  EBM	  is	   15 the	   conscientious,	   explicit	   and	   judicious	   use	   of	   current	   best	   evidence	   in	   16 combination	   with	   the	   physician’s	   preferences,	   the	   patient’s	   preferences	   17 and	   the	   situation	   of	   the	   patient	   in	   making	   decisions	   about	   the	   care	   of	   18 individual	   patients.4-­‐7	  Depending	  on	   the	  medical	   speciality,	   EBM	  has	  been	   19 more	  or	   less	   integrated	   into	   the	  daily	  practice	  of	  medical	   specialists.8	  The	   20 uptake	  of	  EBM	  by	  General	  Practitioners,	  however,	   remains	   the	   subject	  of	   21 debate.	   9-­‐10	   Although	   GPs	   generally	   agree	   that	   the	   practice	   of	   EBM	   can	   22 improve	  patient	   care,	   they	   also	   experience	   specific	   barriers	   to	   the	  use	  of	   23 EBM	   in	   their	   practice.	   In	   a	   focus-­‐group	   study	   among	   Belgian	   GPs	   for	   24 instance,	  GPs	  stated	  that	  their	  decision-­‐making	  is	  mainly	  based	  on	  intuition,	   25 habits	   and	   experience	   instead	   of	   evidence.	   Additionally	   they	   feel	   the	   26 patients’	  symptoms	  are	  often	  too	  vague	  and	  the	  problems	  faced	  too	  broad	   27 to	   practice	   EBM.	   They	   say	   that	   for	   their	   specific	   specialism	   a	   continuous	   28 scientific	   update	   is	   not	   feasible.11	   The	   specific	   GP	   setting	   therefore	   has	   a	   29 significant	  influence	  on	  the	  actual	  use	  of	  EBM	  by	  this	  group.	  These	  results	   30 have	  been	  confirmed	  by	  a	  recent	  study	  among	  Dutch	  GP	  trainers,	  in	  which	   31 trainers	   stated	   they	   considered	   EBM	   an	   academic	   quality,	   not	   generally	   32 EVIDENCE-­‐BASED	  MEDICINE	  IN	  GENERAL	  PRACTICE	  SPECIALTY	  TRAINING	  12 related	  to	  daily	  General	  Practice.	  Most	  of	  them,	  however,	  do	  feel	  that	  the	   1 use	  of	  guidelines	   is	   important	  for	  GPs.	  Differences	   in	  the	   interpretation	  of	   2 the	  definition	  of	   EBM	   seems	   to	  be	  one	  of	   the	   causes	   of	   these	   seemingly	   3 opposite	  expressions.12	  	   4 	  	  	  	  	  The	   difficulties	   experienced	   by	   General	   Practitioners	   in	   using	   EBM	   5 combined	   with	   the	   attitude	   of	   GP	   trainers,	   acting	   as	   role-­‐models	   for	   GP	   6 trainees,	  potentially	  have	  a	  strong	  influence	  on	  the	  future	  practice	  of	  EBM	   7 by	  trainees.13	  To	  enhance	  the	  future	  use	  of	  EBM	  by	  trainees,	  a	  combination	   8 of	  train-­‐the-­‐trainers	  programmes	  and	  optimal	  formal	  education	  on	  EBM	  for	   9 GP	  trainees	  is	  important.	  	  In	  this	  thesis	  I	  am	  focusing	  on	  the	  learning	  of	  EBM	   10 by	  GP	  trainees	  and	  on	  the	  assessment	  of	  EBM	  in	  GP	  specialty	  training.	  	   11 	   12 	   13 	   14 	   15 	   16 	   17 	   18 	   19 	   20 	   21 	   22 	   23 	   24 	   25 	   26 	   27 	   28 	   29 	   30 	   31 	   32 GENERAL	  INTRODUCTION	  13 EBM	  stepsExperience	  &	  ExpertiseEducationEvidencePhysician’s	  preferencesPatient’s	  preferences	  and	  situationDecisionClinical	  problemGP	  Setting	   1 	   2 	   3 	   4 	   5 	   6 	   7 	   8 	   9 	   10 	   11 	   12 	   13 	   14 	   15 	   16 	   17 	   18 	   19 	   20 	   21 	   22 	   23 	   24 	   25 	   26 	   27 	   28 	   29 	   30 	   31 Figure	  1.	  Clinical	  Decision	  Making	  (Adapted	  from	  Offringa	  M,	  et	  al.)7,14	  EVIDENCE-­‐BASED	  MEDICINE	  IN	  GENERAL	  PRACTICE	  SPECIALTY	  TRAINING	  14 GuidelinesSyntheses	  &	  SynopsesSystematic ReviewsPrimary studiesGeneral	  Practice	  in	  the	  Netherlands	   1 	   2 In	   the	   Dutch	   healthcare	   system,	   GPs	   have	   an	   important	   function	   as	   3 gatekeepers.	  All	  Dutch	  citizens	  are	  registered	  in	  a	  GP	  practice	  and	  –	  except	   4 from	  medical	  emergencies	  –	   first	  visit	   their	  GP	  when	  they	  require	  medical	   5 care.	   Approximately	   96%	   of	   all	   the	   consultations	   are	   performed	   by	   GPs	   6 without	  interference	  of	  other	  healthcare	  professionals.	  15	  	   7 	  	  	  	  	  Dutch	  GPs	  frequently	  make	  use	  of	  the	  guidelines	  (99	  at	  present)	  of	  the	   8 Dutch	   Society	   of	   General	   Practitioners	   to	   find	   an	   answer	   to	   their	   clinical	   9 questions.16	   GPs	   generally	   show	   a	   positive	   attitude	   towards	   these	   10 guidelines17	  and	  66%	  of	  the	  decisions	  made	  by	  Dutch	  GPs	  are	  in	  accordance	   11 with	   the	   guidelines.18	   According	   to	   the	   hierarchical	   pyramid	   described	   by	   12 Haynes	  et	  al.	  showing	  the	  scientific	  value	  of	  evidence	  resources	  (figure	  2),	   13 these	   guidelines	   can	   be	   considered	   as	   the	   highest	   level	   of	   evidence	   14 available	  to	  GPs.19	  	   15 	   16 	   17 	   18 	   19 	   20 	   21 	   22 	   23 	   24 	   25 	   26 	   27 	   28 Figure	  2.	  Pyramid	  of	  evidence19	   29 	   30 	   31 	   32 GENERAL	  INTRODUCTION	  15 However,	   not	   all	   clinical	   questions	   can	   be	   answered	   with	   the	   use	   of	   1 guidelines,20	   in	  which	  case	  sources	  with	   lower	   levels	  of	  evidence	  must	  be	   2 used.	   When	   no	   evidence	   that	   falls	   within	   the	   pyramid	   is	   available,	   3 experience	   and	   expert	   opinion	   are	   also	   often	   used	   by	   GPs	   and	   count	   as	   4 ‘best	  available	  evidence’.21	  	   5 	   6 EBM	  in	  the	  GP	  specialty	  training	   7 	   8 The	   GP	   specialty	   training	   is	   a	   3-­‐year	   educational	   programme	   combining	   9 training	   in	   clinical	   practice	   (4	   days	   a	   week)	   with	   one	   day	   of	   formal	   10 education	   at	   the	   training	   institute.	   Since	   the	   emergence	   of	   clinical	   11 epidemiology	  in	  the	  early	  1980s,	  education	  in	  EBM	  has	  become	  embedded	   12 in	   medical	   teaching.4	   Medical	   trainees	   learn	   how	   to	   keep	   up	   with	   the	   13 growing	   pile	   of	   information	   and	   also	   how	   to	   assess	   and	   apply	   the	   14 information	  found.	  In	  the	  GP	  specialty	  training	  programme	  of	  the	  Academic	   15 Medical	   Center	   of	   the	   University	   of	   Amsterdam,	   EBM	   plays	   a	   prominent	   16 role:	  attention	  is	  paid	  to	  the	  knowledge	  and	  skills	  that	  are	  necessary	  for	  the	   17 application	  of	  evidence	  and	  for	  dealing	  with	  guidelines.	  As	  in	  most	  medical	   18 training	  programmes,	   training	   in	  EBM	  takes	  place	  according	   to	   the	  5-­‐step	   19 model.4;7	  	   20 	   21 	  	  	  	  	  1.	  Translation	  of	  a	  clinical	  problem	  into	  an	  answerable	  question	  (ask);	   22 	  	  	  	  	  2.	  Efficient	  search	  for	  the	  best	  evidence	  to	  fit	  the	  question	  	  	   23 	  	  	  	  	  	  	  	  	  (access/acquire);	   24 	  	  	  	  	  3.	  Appraising	  the	  evidence	  found	  regarding	  methodological	  quality	  and	  	  	   25 	  	  	  	  	  	  	  	  	  applicability	  for	  the	  patient	  -­‐	  assessment	  of	  internal	  and	  external	  	   26 	  	  	  	  	  	  	  	  	  validity	  (appraise);	   27 	  	  	  	  	  4.	  Making	  a	  decision	  in	  respect	  of	  available	  evidence,	  preferences	  and	  	   28 	  	  	  	  	  	  	  	  	  experience	  the	  GP	  and	  preferences	  and	  situation	  of	  the	  patient	  	   29 	  	  	  	  	  	  	  	  	  (apply);	  	   30 	  	  	  	  	  5.	  Regular	  evaluation	  of	  the	  quality	  of	  this	  process	  (audit/assess).	  	   31 	   32 EVIDENCE-­‐BASED	  MEDICINE	  IN	  GENERAL	  PRACTICE	  SPECIALTY	  TRAINING	  16 These	  5	  steps	  are	  to	  be	  used	  by	  GP	  trainees	  when	  facing	  a	  clinical	  question	   1 for	  which	  new	  or	  additional	  information	  is	  needed	  in	  order	  to	  answer	  these	   2 questions	   accurately.	   The	   EBM	   steps	   are	   used	   less	   explicitly	   when	   3 managing	   patients	   with	   more	   common	   clinical	   problems,	   since	   the	   GP	   4 trainee	  is	  already	  familiar	  with	  the	  policy	  regarding	  these	  problems.	  	   5 	  	  	  	  	  Thorough	  education	  in	  EBM	  is	  thus	  given	  in	  the	  GP	  specialty	  training.	  The	   6 main	  purpose	  of	   this	   formal	   training	   in	  EBM,	  however,	   is	   for	   the	  acquired	   7 skills	   to	   be	   applied	   when	   caring	   for	   patients	   in	   clinical	   practice.	   Multiple	   8 aspects	   influence	   the	   transfer	   of	   these	   EBM	   competencies	   to	   the	   clinical	   9 workplace	   of	   the	   GP	   trainee.	   The	   learning	   style	   of	   the	   trainee,	   barriers	   10 regarding	  practice	  of	  EBM	  in	  the	  specific	  GP	  setting,	  and	  the	  assessment	  of	   11 the	  required	  competencies	  are	  three	  of	  these	  aspects,	  which	  are	  discussed	   12 in	  this	  thesis.	  	   13 	   14 Learning	  Style	   15 	   16 As	  formal	  postgraduate	  education	   in	  EBM	   is	  generally	  not	  adapted	  to	  the	   17 individual	   learning	  needs	  and	  methods	  of	   the	   trainees,	   the	   learning	  styles	   18 of	   trainees	   could	   influence	   the	   uptake	   of	   the	   knowledge	   and	   skills	   as	   19 presented	   in	   formal	   education	   in	   EBM.22	   Additionally,	   preferred	  ways	   for	   20 acquiring	   new	   information	   during	   formal	   education	   (learning	   style)	   could	   21 be	   related	   to	   the	   methods	   used	   to	   solve	   patient	   problems	   (EBM	   or	   22 otherwise),	  which	  also	  requires	  obtaining	  and	  integrating	  new	  information.	   23 Chapter	   1	   therefore	   describes	   the	   outcomes	   of	   a	   study	   regarding	   the	   24 knowledge/skills,	   attitude	   and	   self-­‐reported	   behaviour	   of	   GP	   trainees	   25 regarding	  EBM.	   26 	   27 	   28 	   29 	   30 	   31 	   32 GENERAL	  INTRODUCTION	  17 Barriers	  towards	  the	  practice	  of	  EBM	   1 	   2 We	  know	  that	  barriers	  exist,	  limiting	  the	  use	  of	  EBM	  by	  trainees.	  In	  a	  recent	   3 systematic	   review	   by	   our	   group	   it	   was	   shown	   that	   time,	   attitude,	   4 knowledge	   and	   skills,	   and	   specific	   barriers	   related	   to	   the	   position	   of	   5 trainees	  of	  various	  specialties	  limit	  their	  use	  of	  EBM	  in	  clinical	  practice.23	  As	   6 speciality-­‐specific	   barriers	   have	   also	   been	   mentioned	   in	   general	   practice,	   7 we	  performed	  a	   systematic	   review	  of	   the	  barriers	  experienced	  by	  GPs,	   in	   8 order	  to	  obtain	  a	  complete	  view	  of	  the	  barriers	  potentially	  limiting	  the	  use	   9 of	   EBM	   by	   GP-­‐trainees	   (Chapter	   2).	   Based	   on	   the	   results	   of	   these	   10 systematic	   reviews,	   a	  questionnaire	  was	  developed	   to	  assess	   the	  barriers	   11 as	  experienced	  by	  Dutch	  GP	  trainees	  (Chapter	  3).	  	   12 	   13 Assessment	   14 	   15 As	  assessment	  is	  one	  of	  the	  most	  potent	  influences	  on	  learning,	  the	  format	   16 and	  content	  of	  the	  assessment	  of	  EBM	  competencies	  in	  GP	  trainees	  could	   17 significantly	   influence	   their	   learning.24	   Valid	   assessment	   tools	   are	   a	   first	   18 requirement	  to	  stimulate	   learning	   in	  this	  area.	  A	  recent	  systematic	  review	   19 showed	   that	   two	   instruments	   exist	   that	   validly	   identify	   EBM	   knowledge	   20 and	   skills	   of	   medical	   professionals.25	   Chapter	   4	   describes	   the	   translation	   21 and	  subsequent	  validation	  of	  one	  of	  these	  tools:	  the	  Berlin	  questionnaire.25	  	   22 Assessment	  can,	  however,	  take	  place	  at	  various	  levels	  of	  learning.	  The	  four	   23 levels	   of	   Miller’s	   pyramid	   of	   learning	   describe	   these	   potential	   learning	   24 outcomes	   (Figure	   3).26	   In	   line	   with	   the	   ideas	   on	   competence-­‐based	   25 education,	   ideally	   the	   top	   of	   the	   pyramid	   is	   reached	   in	   learning:	   trainees	   26 show	   the	  desired	  behaviour	   in	   daily	   clinical	   practice.	   In	   EBM,	   usually	   only	   27 the	   lowest	   two	   segments	  of	   the	  pyramid	   (knows/knows	  how)	  are	   taught	   28 and	  assessed.26-­‐27	   29 	   30 	   31 	   32 EVIDENCE-­‐BASED	  MEDICINE	  IN	  GENERAL	  PRACTICE	  SPECIALTY	  TRAINING	  18 DoesShows	  howKnows howKnows	   1 	   2 	   3 	   4 	   5 	   6 	   7 	   8 	   9 	   10 	   11 	   12 	   13 	   14 Figure	  3.	  Pyramid	  of	  learning	  outcomes25	   15 	   16 	   17 In	   order	   to	   assess	   EBM	  behaviour	   in	   practice	   at	   the	   highest	   levels	   of	   the	   18 pyramid,	  assessment	  tools	  are	  needed.	  Chapter	  5	  contains	  the	  results	  of	  a	   19 systematic	   review	   investigating	   whether	   valid	   assessment	   tools	   exist	   for	   20 the	   practice	   of	   EBM.	   As	   we	   concluded	   that	   no	   instruments	   exist	   that	   21 provide	   an	   integrated	   overview	  of	   EBM	   competencies	   in	   clinical	   practice,	   22 and	   also	   that	   no	   overview	   exists	   of	   expressions	   of	   competent	   EBM	   23 behaviour,	   Chapter	   6	   describes	   the	   results	   of	   an	   observational	   study	   on	   24 EBM-­‐behaviour	  in	  clinical	  practice.	  The	  results	  of	  this	  study	  can	  be	  used	  as	  a	   25 starting	  point	  for	  the	  development	  of	  new	  assessment	  instruments	  for	  this	   26 competence.	  	   27 	   28 	   29 	   30 	   31 	   32 	   33 

Evidence-based medicine in general practice specialty training

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