EBM and the Krebs Cycle

What’s the right dose of epidemiology, biostatistics, and evidence-based medicine that is useful for medical students, residents and practicing physicians?

A third year resident recently said to me, “I don’t understand why we have to do journal club…I’m going to be a clinician, not a researcher!”  I tried to summon my most patient, professorial look and channeled my inner Socrates by answering, “How do you expect to keep up on the latest in your practice next year if you don’t know how to read a journal article?”  As we were both in clinic at the time, the resident shuffled away with a consternated look.

But this off-the-cuff resident complaint masquerading as a question prompted the following reflections in me:

  1. Pay attention these sorts of statements (especially from busy residents) as feedback and learn from them.
  2. We don’t do a good enough job of teaching the epistemology of our discipline of medicine (especially primary care) to our learners.
  3. What is the appropriate dose of the basic sciences of epidemiology, biostatistics and critical appraisal of the literature for our learners destined to be full-time clinicians?

Despite having given a talk, not TWO WEEKS prior, that outlined the intent of our journal club, where I specifically stated that the intent was to train a skill for clinicians, not researchers, I am still clearly not getting through.  Not particularly surprising – we don’t have a lot of time in the curriculum for EBM, so it’s under-emphasized.  And despite having recently submitted an article about creating a culture of evidence-based medicine in residency programs, it’s clear I have not yet succeeded at home.

I do wonder (and haven’t yet asked) how this resident plans to keep up in their future practice.  I suspect they assume that yearly attendance at conferences will suffice.  They may hope to read our academy’s journal regularly (which would be great, but remains for most an aspirational goal).  Maybe they hope to be routinely visited by pharmaceutical reps…but, boy I sure hope not.  I don’t think we talk enough about HOW we know and learn things.  I worry that family docs are taking in way too much information every day to be sufficiently critical about it.  Patient stories, colleague stories, specialist recommendations, media advertisements…lots of information, very little curation.  We’re built to take in knowledge from stories.  And because of the emotional content of the stories (excitement, interest, fear, sadness), the information is imbued with importance from context, not from critical analysis of its validity and relevance.

So, it’s pretty clear to me that after more than 30 years of Clinical Epidemiology and Evidence-based Medicine, we still haven’t settled on the right amount and type of skill and knowledge in these fields that is required of medical learners at all the various levels we teach.  I believe that the basics of epidemiology, biostatistics and critical appraisal of original research studies should be taught and mainly in medical school.  And mainly in the first two years.  It’s a basic science.  krebsOf note, I’m also not one of those family docs who loudly disagrees with learning the Krebs cycle in medical school.  It’s a fundamental concept that forms the foundation for biochemistry and physiology that closely follows it.  No, practicing clinician, you don’t necessarily use the Krebs cycle every day.  But you DO use medications and treat diseases that have significant connection to the Krebs cycle.  Same is true for EBM.  The goal is to learn what research looks like, and how it is created and appraised, so that you can then: 1) find an information source that you can trust and 2) treat all new information with an appropriately critical eye.  In the clinical years of medical school and residency, teaching the use of systematic reviews, guidelines and pre-appraised sources is key – find the good information quickly and apply it to your patient’s problems.  But it relies the foundational knowledge of basic epi, biostats and critical appraisal.

Our journal club is meant to model this transition, by the way.  The first years review an article from the American Family Physician, second years review an original research article, and third years – a systematic review or guideline.  If I could guarantee that the basics had been taught in a reliable manner in medical school, maybe we could skip over the basics and focus on more on the pre-appraised sources.  My resident would undoubtedly find these exercises a little more relevant.  But I can’t guarantee the same preparation among our residents.  And, so, in residency, we must recapitulate the learning process for EBM. Interestingly, I probably can guarantee they have learned the Krebs cycle sufficiently, whichever medical school they came from.  Good thing I like teaching this EBM stuff….