In Search of Evidence

Teaching Evidence-Based Practice: Lessons From the Pioneers
said, “This should be in your exams.” It was only when it started getting into the
professional exams that it started getting into the curriculum. And for example, about
4 years ago, the General Medical Council produced a document called “Tomorrow’s
Doctors” that had nothing about evidence-based practice in it at all. So we wrote
letters and we suggested phrases, and I think we got one phrase in. That was a little
genuflection to evidence-based practice.
Guyatt: So yes, it has been very influential, it is in all the US medical schools, in both
undergraduate and graduate curricula. It’s part of what you’re supposed to do. Now,
how well is it done? How well do people understand it? Who cares whether it’s done
in the schools if it’s not done in the front lines of clinical practice? So, there are still big
questions, but it is accepted. In order to be accredited at either the residency level or
the undergraduate level, you are expected to show what you are doing to address this.
Is there now a standard, widely accepted way to teach evidence-based
medicine?
Guyatt: I’m not sure about that. But 30 years ago or so our workshop started as “How
to teach critical appraisal.” It then became “How to teach evidence-based medicine.”
It is now “How to teach evidence-based health care.” I have been helping to run our
workshop for the last 15 years or so. We’ve trained over a thousand people. Oxford
runs something similar. But everything is based on that McMaster model of teaching,
which is all small group, problem-based, and interactive.
You all keep referring to critical appraisal. Do you consider that to be
the core of evidence- based practice?
Guyatt: The connotation of the original critical appraisal is potentially unfortunate,
because it focuses you to ask, “How trustworthy is the evidence?” It is about being
critical about the evidence. But an equally big part of it, or even bigger part, is that
whether it’s good or not so good, if it’s the best available evidence you’ve got to use
it. So while critical appraisal has the connotation on the appraisal part, it doesn’t have
the connotation on the using it part. And in fact, even with pre-appraised evidence 1 ,
you still have to know how to use it. If somebody tells you “this is the best available
evidence,” you still have to understand the evidence in particular, so that you can use
it appropriately and deal with it in the decision- making process. So that’s why there
was another revolution. The initial guides were readers’ guides. The second guides
were users’ guides, with much less focus on critical appraisal, and a much bigger focus
1
Preappraised evidence is research literature that is already critically appraised by an author or a group of experts.