Abstract

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This article will outline the background and development of a longitudinal curriculum in information mastery in the Oregon Health & Science University (OHSU) Family Medicine Residency program.

Introduction

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Introduction

Over 2.79 million pages of journal articles are published annually in MEDLINE.  This number has likely increased since the time of the publication of the manuscript that highlighted this information (2005), given the fact that the number had increased by nearly a million pages per year from the prior decade.[1]  Academic clinicians and teachers often comment on the inability to “keep up” with the information overload that is happening in medicine.  Due to the dramatic increase in available information in the literature and a desire to move away from anecdotal practices in medicine the field of evidence-based medicine (EBM) was born.  While some resources would site EBM’s philosophical origins dating back to the mid-19th century,[2] frequently cited sources in the field of Family Medicine date to the more recent 1990’s as a time when EBM began to take its roots in primary care education and training.[3]  Despite having had these important perspectives in the medical literature for over the past 20 years, many Family Medicine residency programs have struggled with the development and incorporation of a curriculum in ‘information mastery’.  Only recently have quality articles appeared reviewing newly developed curricula in information mastery and evidence-based medicine.[4]  This article will outline the background and development of a longitudinal curriculum in information mastery in the Oregon Health & Science University (OHSU) Family Medicine Residency program.

Background

The information mastery longitudinal curriculum was one component of the revision of the entire Family Medicine Residency program at OHSU as it transitioned from a three-year to a four-year training program in July 2012.  The program is taking part in the four-year Family Medicine Residency Pilot, which has been approved by the ACGME and will be overseen by a specially designated committee from the Review Committee for Family Medicine.[5]  Along with rotation modifications and transitions, the residency program incorporated three new longitudinal curricular threads into the training program: Information Mastery, Leadership and the Patient-Centered Medical Home.  Each curricular thread targeted a specific year in the residency-training program and the Information Mastery curriculum was placed in the second year of the residency.  The residency leadership anticipated that, being in the second year, the residents in the program would have been exposed to some evidence-based medicine practices in the clinics and hospital settings, observed some of the data and reports that were being distributed to the clinicians in the practices, and had an opportunity to migrate away from a focus through internship that was largely concentrated on the immediacy of patient care.

Literature and Relevance to Family Medicine Residency Training

Khan and Coomarasamy describe a hierarchical approach to effective teaching and learning in order to acquire competence in evidence-based medicine.[6]  The lowest level in this hierarchy includes content that is solely didactic, classroom or standalone teaching time.  As one progresses up to higher levels in the hierarchy clinically integrated and interactive activities are included.  At the highest level of the ranking interactive and clinically integrated activities are combined.  We decided to incorporate this highest-level approach in the development of the information mastery curriculum, to ensure that we had the best chance of the residents developing competency in this important area.  Thangaratinam et al. compare the traditional learning environment with the 21st century learning environment.  In their article, the authors describe how traditional clinical teaching occurred through ‘osmosis’ of the senior clinician imparting their experience and authoritative practice upon the medical decision making of the learner.  This is contrasted with the modern learning environment where learners should be asking an answerable question, acquiring and appraising the evidence, and subsequently integrating this evidence into practice and applying the evidence in the learners’ medical decision making.[7]  Slawson and Shaughnessy have also argued that, “There is a need to teach the applied science of information management along with, or perhaps even instead of, teaching the basic science of EBM.”[8]

The current version of the ACGME (Accreditation Council for Graduate Medical Education) Program Requirements for Graduate Medical Education in Family Medicine, which went into effect in July 2007, specifically identifies areas of practice-based learning and improvement (one of the six core competencies) including the ability to locate, appraise, and assimilate evidence from

scientific studies related to their patients’ health problems and using information technology to optimize learning.[9]  The more recently developed “milestones”, which are a joint venture of the Accreditation Council for Graduate Medical Education and the American Board of Family Medicine, identify the highest obtainable level (Level 5) of practice-based learning and improvement (PBLI-1) as, “Incorporates principles of evidence-based care and information mastery into clinical practice.”[10]  Residency programs will be held accountable for meeting these important milestones in the future.  The American Academy of Family Physicians (AAFP) has developed recommended curriculum guidelines for Family Medicine residents relating to scholarly activity and information mastery, which have also been endorsed by the

Association of Departments of Family Medicine(ADFM), the Association of Family Medicine Residency Directors(AFMRD), and the Society of Teachers of Family Medicine(STFM).[11]  The guidelines include recommendations regarding the expected knowledge, skills and attitudes of residents towards specific elements of information mastery.  Lastly, a new online resource is available to Family Medicine residencies: the Family Medicine Residency Curriculum Resource (http://www.fammedrcr.org/).[12]  This website includes a large number of curricular resources for Family Medicine residency programs, including content relating to information management.

Methods

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Development of the Curriculum

See Table 1 for a list of the concepts and issues that were considered in the development of the new Information Mastery Curriculum.  Using the Kern six step approach to curriculum development,[13] we first identified the ‘problem’ we were trying to address: the data from our electronic health record (EHR) was demonstrating inadequate and inconsistent application of preventive health services in our clinic populations (including immunizations, screening tests, etc.), resulting in suboptimal patient care.  We also recognized that our Family Medicine residents did not have a unified curriculum in information mastery and evidence-based medicine and were receiving information about these areas in an ad-hoc fashion during our regular didactic time.  In terms of a needs assessment of the targeted learners, we recognized that there was variable understanding of the basic principles of EBM and basic statistics, which would need to be addressed as a component of the curriculum.

The residency program decided to provide 2 hours of weekly time to the curriculum, spanning a total of 16 weeks.  The use of 16 weeks was arbitrary but strategic, given the fact that the residency has three outpatient practice sites with 12 residents at each site.  Time in the second year of training would be equally split amongst the residents from the three training sites, totaling 48 weeks (in addition to 4 weeks of “intensives” – one week blocks of dedicated didactic time, spaced throughout the year).  In order to maximize the incorporation of adult learning theory principles we decided to have a self-directed learning session precede each small group session.  Research has demonstrated that active learning can enhance academic achievement,[14] promote superior skills in social and cognitive performance,[15] superior professional competencies, [16] [17] retention and application of knowledge, [18] enhanced understanding and mastery of course content, [19] and mastery of difficult subjects.[20]  The small group sessions in the week following the self-directed learning session were with a faculty member who possessed some extra knowledge or expertise in the content area for that session.  The faculty-facilitated sessions would allow the residents an opportunity to review the work and concepts from the self-directed session the prior week.  Goals and objectives were developed for each of the self-directed and faculty facilitated sessions.

Table 1: See Illustration 1

Table 2 itemizes the 16 sessions that were included in the Information Mastery Curriculum.

See Illustration 2

Results

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Evaluation and Outcomes

In this first year of implementation of the Information Mastery curriculum, feedback about the curriculum has come from both residents and faculty.  A summary of the salient themes in terms of feedback from residents and faculty in the Family Medicine Residency program can be found in Table 3.

Discussion

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Various evaluation tools have been utilized in publications relating to information mastery and EBM curricula. Cabell and colleagues measured the number of Ovid log-ins during resident rotations[21] and Ross et al. measured the number of EBM terms used during continuity clinics after introducing an EBM curriculum into a Family Medicine Residency.  Others have utilized resident ratings of self-confidence in EBM knowledge and skills after implementing an EBM curriculum[22] [23]or resident attitude and knowledge quiz scores after working with a learning coach.[24]  A modified version of the Fresno test of EBM[25] was also utilized in one Family Medicine Residency after implementation of an information mastery curriculum, though the authors admitted the use of the grading rubric difficult to apply and “required several practice sessions to calibrate grading”.[4] A systematic review of instruments used for evaluating education in evidence-based practice identified 104 unique instruments.[26]  Since it was the first year of implementation of the information mastery curriculum at the OHSU Family Medicine Residency, a specific evaluation tool has not been utilized yet.  There has been concern expressed by the leadership in the residency and faculty involved in the curriculum that there does not appear to be a validated instrument that would adequately capture the anticipated outcomes from this new and innovative curriculum, since many of the sessions explore novel content.

Conclusion(s)

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The OHSU Family Medicine Residency has successfully implemented a new information mastery curriculum as one component of the new four year residency program. Mixed feedback from the involved residents demonstrates ample opportunities for refinement and improvement of the curriculum.  The greatest challenge though will be finding a suitable evaluation tool or instrument that can measure the resident outcomes after participation in the longitudinal curriculum. While the measurement of EBM knowledge, skills, attitudes and behaviors would be very useful, perhaps the most important variables relate to patient-oriented outcomes, which have been infrequently measured in the EBM literature. This is an area that requires attention in EBM research moving forward.  Additionally, while assessing resident awareness and use of EBM during their training is valuable, continuing to practice the use of EBM after residency is of utmost importance.  Unfortunately, an exploratory study of residency graduates’ practice habits found that residents instructed in EBM skills did not regularly practice these skills after graduation, in large part due to time and workload pressures,[27] emphasizing the importance of also studying long-term clinically oriented behaviors in trainees.

Abbreviation(s)

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evidence-based medicine (EBM)

Oregon Health & Science University (OHSU)

Acknowledgement(s)

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OHSU Family Medicine Residency

References

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Source(s) of Funding

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No funding reported.

Competing Interests

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No conflicts of interest reported.

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