Journal of Evidence-Based Medicine ISSN 1756-5391
ORIGINAL ARTICLE
Knowledge and attitude toward evidence-based medicine among medical students in Semnan, Iran Farahnaz Ghahremanfard, Mohammad Nassaji, Majid Mirmohammadkhani, Asghar Tanha, Mehdi Mosavi, Ali Ghaemi and Prastoo Shams Semnan University of Medical Science, Semnan, Iran
Keywords Attitude; evidence-based medicine; knowledge; medical students. Correspondence Mohammad Nassaji, Department of Infectious Diseases, Fatemieh Hospital, Semnan University of Medical Sciences, Semnan, Iran. Tel: +0098-9121318640; Fax: +0098-2313322242; Email: [email protected] Received 26 December 2013; accepted for publication 8 January 2014. doi: 10.1111/jebm.12084
Abstract Objectives: Evidence-based medicine (EBM) has gained widespread acceptance in medicine. Little is known about the attitudes, knowledge, and behavior of medical students toward EBM in developing countries. This study was designed to assess medical students’ awareness and attitudes toward EBM and to obtain the basis required for developing appropriate teaching and learning opportunities. Methods: This was a cross-sectional study in which medical students completed a questionnaire to determine their attitudes, knowledge, and perceptions regarding EBM. Results: Completed questionnaires were received from 84% (143) of 170 medical students. Only 24.5% of respondents had good basic information and familiarity with the term of EBM. The majority (89.3%) of participants had positive attitude toward EBM and agreed that it was useful in the management of patients. Mostly were interested in learning the skills of EBM. Most of the respondents (80.2%) had no or little awareness of EBM resources especially the Cochrane, DARE, and Bandolier clinical evidence database. Forty-two (29%) reported having had formal training in search strategies. Most of the respondents did not understand but would like to learn about technical terms used in EBM, and about a third felt able to explain to others the meaning of some of these terms. Conclusions: This study demonstrates lack of adequate knowledge about basic concepts of EBM among medical student. On the other hands, there is an overall positive attitude toward EBM. There is need for educational interventions and incorporating formal teaching of EBM at medical education.
Introduction Evidence-based medicine (EBM) is defined as the integration of clinical expertise, patient values, and judicious use of the current best evidence from systematic research into the decision-making process for patient care (1). It is one of the strategies that nowadays are used in medical sciences to improve health, patient care, and medical services. It has made a clear effect on the medicine and is taught in many world medical school curriculums (2). There is no doubt that both physicians and patients benefit from strategies that improve diagnosis, clinical judgment, and decisionmaking (3).
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EBM will help the physician deal with the increasingly growth of medical literature in biomedical research that is published with varying in quality and clinical relevance. Additionally, practicing EBM should allow clinicians an avenue for excellence and development in clinical practice (4). EBM has seen extraordinary development and gained widespread acceptance, as indicated by the increasing number of studies in the field of the development of EBM (5). Of course, accessing and retrieving valid and reliable evidence is not possible without knowing proper electronic databases and systematic and purposeful search strategies (6, 7). Obviously, physicians need to be familiar with the search strategies of EBM databases to access information
C 2014 Chinese Cochrane Center, West China Hospital of Sichuan University and Wiley Publishing Asia Pty Ltd JEBM 7 (2014) 32–37
F. Ghahremanfard et al.
systematically and inquire reliable, trustworthy, and beyond chance information for clinical decision-making (8, 9). For many years, medical students had minimal exposure to EBM during preclinical and clinical training (10). Now, in many countries, EBM is an important component of an undergraduate medical education curriculum that promotes lifelong learning and critical thinking. Unfortunately, this curricular change has not yet occurred in many of developing countries (11). Also, due to lack of basic understanding of the concepts and definitions in biostatistics, epidemiology, and EBM in subsequent, among many medical students and physicians, this can be considered as an important barrier to proper implementation of EBM into clinical practice (12). As future healthcare providers, medical students can be a receptive population to EBM concepts and it is important that they teach to offer the best possible care for their patients. This requires not only a sound educational base but also a good source of current best evidence to support their diagnosis and treatment recommendations (10). Some studies have been conducted to assess the familiarity, awareness, and attitudes toward EBM in medical students as well as in the general practitioners (13–17). For training of physicians, it is essential to undertake needs assessment and evaluate the level of knowledge and their attitudes. Some studies were conducted to assess the awareness of EBM in medical students; however, few data are available about the Iranian medical students. In most medical universities of Iran, teaching of the EBM is not yet a component of the undergraduate medical curriculum. In particular, little is known about the levels of awareness and knowledge, their ability to access and understand evidence, their information about methodological and epidemiological terms among medical students. Thus, it is required that the current state of EBM to be understood in order to plan long-term educational programs. Our study aimed to assess ability to access relevant databases, attitude toward evidence-based medicine, awareness, understanding of technical terms used in EBM, and to determine their educational needs for EBM in one Iranian University, Semnan University of Medical Science. Obviously, this information can help in recognizing their shortcomings and programming appropriate practical training for this group.
Material and Methods A cross-sectional study was carried out between October and December 2012 among medical students of Semnan University of Medical Science, Iran. Training physicians in Iran has a seven-year program: two years of basic sciences, three years of pre-clinical, and two years of clinical (internship) period.
Evidence-based medicine and medical students
At Semnan University faculties, hospitals and dormitories are computer facilities with 24-hour Internet connection. All computers could access to Iranian Ministry of Health and Medical Education electronic library, which have access to main electronic databases with a broad range of full text articles and evidence-based resources. For data gathering, a self-administered, structured questionnaire was developed and used. The primary version of questionnaire was developed from a comprehensive literature review (17–19). Its face and content validity was confirmed by two experts’ panel. A pilot study was conducted for reliability of questionnaire, which led to some modifications and local adaptations based on the feedbacks received. The individuals (n = 20) that participated in the pilot phase were excluded from the main study. According to the results of the pilot study, internal consistency of the questionnaire was assessed by a Cronbach’s alpha coefficient of 0.84. Participants were a randomly selected sample of medical students in their third to seventh year of education. The educational level consisted of pre-clinical (third to fifth years) and clinical (sixth to seventh years) level. The final questionnaire included five main sections with 35 questions: The first section asked respondents about their age, gender, educational level, and having any training in database search and EBM (4 items). The second section evaluated their access to various information sources including the Internet and databases relevant to EBM and their ability to perform searching in bibliographic databases and the world wide websites (7 items). The third section asked about participants’ attitudes toward EBM (5 items). The fourth section was about students’ awareness of extracting journals, review publications and databases relevant to EBM and their applications (9 items). The final section measured understanding of the technical terms related to epidemiology and biostatistics used in EBM (10 items). To measure students’ knowledge and attitude about EBM, we used the Likert Scale. The questionnaires were distributed anonymously between selected pre-clinical and clinical students by four research assistants gave the questionnaires through personal visits and also provided the proper explanations for correctly completing the forms. The study was approved by the Research and Ethics Committee of Semnan University of Medical Science. Data were analyzed with SPSS software (version 16.0). The distribution of students in the defined groups according to their characteristics was reported by the corresponding frequencies and percentages, while the mean and its standard deviation (SD) were reported for numerical scores.
Results Among the entire participants, 143 returned the filled questionnaire (response rate was 84%). Ninety-two (64.3%) of
C 2014 Chinese Cochrane Center, West China Hospital of Sichuan University and Wiley Publishing Asia Pty Ltd JEBM 7 (2014) 32–37
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Evidence-based medicine and medical students
F. Ghahremanfard et al.
Table 1 Semnan medical students’ access to various information sources and their ability to perform searching in evidence-based medicine bibliographic databases Socres (%)a Items
0
1
2
3
Mean ± SD
World Wide Web access Importance of Internet as an information source Familiarity with bibliographic databases search Familiarity with EBM Use of national digital library Use of EBM related bibliographic databases Evaluation of EBM related courses
31 (21.7) 4 (2.8) 16 (11.2) 53 (37.1) 67 (46.9) 82 (57.3) 97 (67.8)
46 (32.2) 8 (5.6) 51 (35.7) 55 (38.5) 45 (31.5) 40 (28.0) 37 (25.9)
47 (32.9) 39 (27.3) 64 (44.8) 31 (21.7) 27 (18.9) 17 (11.9) 8 (5.6)
19 (13.3) 92 (64.3) 12 (8.4) 4 (2.8) 4 (2.8) 4 (2.8) 1 (0.7)
1.38 2.53 1.50 0.90 0.78 0.60 0.39
a
± ± ± ± ± ± ±
0.97 0.72 0.80 0.83 0.85 0.80 0.63
Scoring: 0 = low/bad, 1 = medium, 2 = much/good, 3 = very much/excellent.
Table 2 Semnan medical students’ attitude toward evidence-based medicine Scores (%)* Statements
3
2
1
0
Mean ± SD
EBM improves patient care Healthcare costs are reduced by practicing EBM Using EBM is important in making medical decisions It is difficult to search for EBM-based information and use in clinical practice** Learning EBM is an important component of my training
42 (29.4) 41 (28.7) 43 (30.1) 39 (27.3) 65 (45.5)
90 (62.9) 80 (55.9) 0 (0.0) 75 (52.4) 63 (44.1)
9 (6.3) 20 (14.0) 86 (60.1) 26 (18.2) 13 (9.1)
2 (1.4) 2 (1.4) 14 (9.8) 3 (2.1) 2 (1.4)
2.20 2.12 2.20 2.33 0.95
± ± ± ± ±
0.61 0.69 0.59 0.70 0.73
*Scoring: 3 = strongly agree, 2 = agree, 1 = disagree, 0 = strongly disagree; **Reveres scoring.
respondents were female. Educational levels were as follows: 122 (85.3%) in preclinical and 21(14.7%) in clinical stage. Of these students, 42 (29%) reported having had formal training in search strategies. The majority of participants (91.6%) stated significant role for database sources but only 46.2% stated that they had good access to relevant databases and the Internet. The mean score about students’ access to various information sources and their ability to perform searching in bibliographic databases related to EBM database is showed in Table 1. Only 24.5% of surveyed students stayed that had good basic information and familiarity with the term of EBM. Nevertheless, 89.3% of participants agreed that EBM was useful in the management of patients and were interested in learning the skills of EBM. Table 2 shows the responding students attitudes toward evidence based medicine. Most of the respondents (80.2%) had no or little awareness of EBM resources. Our participants had the most familiarity with the Google Scholar and PubMed database and the least familiarity with the Cochrane, DARE, and Bandolier clinical evidence database (Table 3). Most of the respondents did not understand but would like to learn about technical terms used in evidence-based medicine, and about a third felt able to explain to others the meaning of some of these terms (Table 4).
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Discussion EBM encompasses all aspects of the clinical decision-making in medicine, from diagnosis to treatment. Acquisition of knowledge and skills for EBM is becoming a core competence to be acquired by all physicians (20). The response rate in this study was 84% which was a considerable achievement when compared with some other studies (14, 21–23), but lower than some studies (10, 13). This high response rate could be owing to the by-hand method of distribution. The present questionnaire survey demonstrated that the majority of medical student at Semnan University of Medical science lack adequate knowledge about basic concepts and familiarity with the term of EBM and obtained a low knowledge score. Kaderli et al. reported poor knowledge scores on EBM among medical students (21). Other studies showed a low level of awareness of extracting journals, review publications, and databases relevant to evidence-based medicine among general practitioners (18, 23, 24). In contrast, Stronge et al. reported good knowledge and awareness about EBM (25). Nearly, 90% of our respondents had positive attitudes toward EBM and the majority demonstrated a tendency to take part in training course about EBM. This finding was consistent with evidence from the other medical literature
C 2014 Chinese Cochrane Center, West China Hospital of Sichuan University and Wiley Publishing Asia Pty Ltd JEBM 7 (2014) 32–37
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Evidence-based medicine and medical students
Table 3 Semnan medical students’ awareness of various evidence-based medicine resources Scores (%)a
Bandolier BMJ Effective healthcare bulletins Cochrane DARE Evidence-based purchasing (R&D Bristol) PubMed Google Scholar Other a
0
1
2
3
Mean ± SD
121 (84.6) 96 (67.1) 114 (79.7) 113 (79.0) 124 (86.7) 111 (77.6) 25 (17.5) 8 (5.6) 0 (0.0)
12 (8.4) 21 (14.7) 13 (9.1) 17 (11.9) 10 (7.0) 19 (13.3) 30 (21.00 18 (12.6) 0 (0.0)
9 (6.3) 21 (14.7) 14 (9.8) 13 (9.1) 9 (6.3) 13 (9.1) 46 (32.2) 71 (49.7) 25 (17.5)
1 (0.7) 5 (3.5) 2 (1.4) 0 (0.0) 0 (0.0) 0 (0.0) 42 (29.4) 46 (32.2) 118 (82.5)
0.23 0.54 0.33 0.30 0.19 0.31 1.73 2.08 2.82
± ± ± ± ± ± ± ± ±
0.59 0.87 0.71 0.63 0.53 0.63 1.07 0.82 0.38
Scoring: 0 = unaware, 1 = aware but not used, 2 = aware but sometime used, 3 = aware and used.
Table 4 Medical students understanding of evidence-based medicine-related technical terms Scores (%)a Technical term
0
1
2
3
Mean ± SD
Relative risk Absolute risk Systematic review Odds ratio Meta-analysis Clinical effectiveness Confidence interval Publication bias Incidence rate Prevalence
19 (13.3) 16 (11.2) 11 (7.7) 15 (10.5) 21 (14.7) 14 (9.8) 14 (9.8) 12 (8.4) 12 (8.4) 58 (40.6)
50 (35.0) 55 (38.5) 57 (39.9) 53 (37.1) 74 (51.7) 65 (45.5) 67 (46.9) 42 (29.4) 23 (16.1) 57 (39.9)
48 (33.6) 49 (34.3) 45 (31.5) 52 (36.4) 33 (23.1) 44 (30.8) 40 (28.0) 58 (40.6) 54 (37.8) 20 (14.0)
26 (18.2) 23 (16.1) 30 (21.0) 23 (16.1) 15 (10.5) 20 (14.0) 22 (15.4) 31 (21.7) 54 (37.8) 8 (5.6)
1.57 1.55 1.65 1.58 1.29 1.48 1.49 1.75 2.05 0.85
± ± ± ± ± ± ± ± ± ±
0.94 0.89 0.89 0.88 0.85 0.85 0.85 0.89 0.94 0.86
Scoring: 0 = It would not be helpful to understand, 1 = Do not understand but would like to, 2 = Some understanding, 3 = I understand and could explain to others.
a
(16, 26–29). This might be a first step in motivating and was a good sign for promoting the teaching of EBM in medical students’ curriculum. In contrast, Scholten-Peeters study that was conducted among physical therapy students reported a weak positive attitude toward EBM among students (30). The majority of our respondents agreed that practicing EBM improved patient care and reduced healthcare costs. These findings were comparable to other previous studies (13, 21). Similarly in some studies that was conducted among postgraduate and general physician findings showed similar results (22, 23, 31). Despite ease and free of charge access to evidence-based resources, medical students in our university do not usually use these sources on a regular basis. Only a minority of respondents were aware of EBM resources, which were similar to some previous studies (26, 27, 30, 32) but considerably lower than the rate reported in the other studies (14, 18, 21, 25). Also, our study confirmed previous findings of low utilization of typical EBM information sources and frequent use of traditional sources (23, 33, 34). We found
that all respondents had never used the Cochrane, DARE, and evidence-based purchasing database. The Cochrane Library is the main source of systematic reviews and meta-analyses. However, unfortunately, there was little awareness about this database among students. A study done in Shiraz reported that 75% of the residents were unfamiliar with EBM databases especially Cochrane (35). In a Canada study, only 5% of practicing clinician used the Cochrane Library on a regular basis (24). Researches from other countries suggested that general practitioners were reluctant to use information technology to support evidencebased clinical decision-making (17, 34). Most of the participants (71.5%) declared that they did not have any education about using EBM and or online search. Medical students still mostly used and relied on textbooks and expert consultation when seeking information. Most students reported they do not understand but would like to understand some of the technical terms used in EBM. The term ‘Incidence rate’ was the best well understood, and the term ‘Prevalence’ the least. In Gwendolijne et al.’s
C 2014 Chinese Cochrane Center, West China Hospital of Sichuan University and Wiley Publishing Asia Pty Ltd JEBM 7 (2014) 32–37
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Evidence-based medicine and medical students
study, the term ‘odds ratio’ was the least well understood, while the term ‘systematic review’ the best (30). McColl et al.’s study on general practitioners reported that most of the respondents had some understanding of the technical terms used in evidence-based medicine, and a third felt able to explain to others the meaning of some of these terms (18). In a study conducted in Japan, respondents reported insufficient knowledge of methodological EBM terms, but the majority of respondents’ showed enthusiasm to learn more. The higher score of knowledge was for odds ratio and the lower for number need to treat (14). In a study among junior physicians of various specialties, Hadley et al. showed that clinicians lacked methodological competence necessary for practicing EBM (19). The concept of EBM is still alien between medical students because of lack of formal training. This would require a major initiative at medical universities and need to be targeted at all levels of medical education. Several studies showed that incorporating EBM into clerkship curriculum improved self-perception of medical students in the key areas of critical appraisal skills, such as formulating a clinical question, searching the literature, and evaluating the evidence. Also, medical students’ knowledge and attitudes toward EBM have improved after EBM training (27, 36–38). Teaching EBM to medical students in setting where they could directly apply their knowledge and skills in daily practice might encourage them to think more critically about therapeutic and diagnostic decisions (15). This study has some limitations. First, the design of the study was cross-sectional. Second, this was a questionnaire study and was subject to response bias. The questionnaire only assessed self-report and self-judgment of participants’ attitude, behaviors, and ability. We were being able to diminish response bias by achieving a very good response rate. Finally, the small convenience sample, without controlling for prior experience, might have allowed for both underestimation and overestimation of data.
Conclusions In conclusion, although medical students seem to have positive attitude toward participating in research, there appears to be a lack of perceived knowledge and of EBM behavior. Therefore, a general strengthening of the knowledge on EBM and statistics may be a good way of educating EBM and establish a good foundation for their future academic environment. To increase EBM knowledge and skills it is recommended to integrate EBM teaching training in curriculum of medical students especially during clinical stage and continue during postgraduate education. Further studies are required to assess the level of knowledge and degree of implementation of EBM concepts in medical universities.
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Acknowledgements The researchers acknowledge the medical students of Semnan Medical University that participated and cooperated in our study.
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ORIGINAL ARTICLE
Knowledge and attitude toward evidence-based medicine among medical students in Semnan, Iran Farahnaz Ghahremanfard, Mohammad Nassaji, Majid Mirmohammadkhani, Asghar Tanha, Mehdi Mosavi, Ali Ghaemi and Prastoo Shams Semnan University of Medical Science, Semnan, Iran
Keywords Attitude; evidence-based medicine; knowledge; medical students. Correspondence Mohammad Nassaji, Department of Infectious Diseases, Fatemieh Hospital, Semnan University of Medical Sciences, Semnan, Iran. Tel: +0098-9121318640; Fax: +0098-2313322242; Email: [email protected] Received 26 December 2013; accepted for publication 8 January 2014. doi: 10.1111/jebm.12084
Abstract Objectives: Evidence-based medicine (EBM) has gained widespread acceptance in medicine. Little is known about the attitudes, knowledge, and behavior of medical students toward EBM in developing countries. This study was designed to assess medical students’ awareness and attitudes toward EBM and to obtain the basis required for developing appropriate teaching and learning opportunities. Methods: This was a cross-sectional study in which medical students completed a questionnaire to determine their attitudes, knowledge, and perceptions regarding EBM. Results: Completed questionnaires were received from 84% (143) of 170 medical students. Only 24.5% of respondents had good basic information and familiarity with the term of EBM. The majority (89.3%) of participants had positive attitude toward EBM and agreed that it was useful in the management of patients. Mostly were interested in learning the skills of EBM. Most of the respondents (80.2%) had no or little awareness of EBM resources especially the Cochrane, DARE, and Bandolier clinical evidence database. Forty-two (29%) reported having had formal training in search strategies. Most of the respondents did not understand but would like to learn about technical terms used in EBM, and about a third felt able to explain to others the meaning of some of these terms. Conclusions: This study demonstrates lack of adequate knowledge about basic concepts of EBM among medical student. On the other hands, there is an overall positive attitude toward EBM. There is need for educational interventions and incorporating formal teaching of EBM at medical education.
Introduction Evidence-based medicine (EBM) is defined as the integration of clinical expertise, patient values, and judicious use of the current best evidence from systematic research into the decision-making process for patient care (1). It is one of the strategies that nowadays are used in medical sciences to improve health, patient care, and medical services. It has made a clear effect on the medicine and is taught in many world medical school curriculums (2). There is no doubt that both physicians and patients benefit from strategies that improve diagnosis, clinical judgment, and decisionmaking (3).
32
EBM will help the physician deal with the increasingly growth of medical literature in biomedical research that is published with varying in quality and clinical relevance. Additionally, practicing EBM should allow clinicians an avenue for excellence and development in clinical practice (4). EBM has seen extraordinary development and gained widespread acceptance, as indicated by the increasing number of studies in the field of the development of EBM (5). Of course, accessing and retrieving valid and reliable evidence is not possible without knowing proper electronic databases and systematic and purposeful search strategies (6, 7). Obviously, physicians need to be familiar with the search strategies of EBM databases to access information
C 2014 Chinese Cochrane Center, West China Hospital of Sichuan University and Wiley Publishing Asia Pty Ltd JEBM 7 (2014) 32–37
F. Ghahremanfard et al.
systematically and inquire reliable, trustworthy, and beyond chance information for clinical decision-making (8, 9). For many years, medical students had minimal exposure to EBM during preclinical and clinical training (10). Now, in many countries, EBM is an important component of an undergraduate medical education curriculum that promotes lifelong learning and critical thinking. Unfortunately, this curricular change has not yet occurred in many of developing countries (11). Also, due to lack of basic understanding of the concepts and definitions in biostatistics, epidemiology, and EBM in subsequent, among many medical students and physicians, this can be considered as an important barrier to proper implementation of EBM into clinical practice (12). As future healthcare providers, medical students can be a receptive population to EBM concepts and it is important that they teach to offer the best possible care for their patients. This requires not only a sound educational base but also a good source of current best evidence to support their diagnosis and treatment recommendations (10). Some studies have been conducted to assess the familiarity, awareness, and attitudes toward EBM in medical students as well as in the general practitioners (13–17). For training of physicians, it is essential to undertake needs assessment and evaluate the level of knowledge and their attitudes. Some studies were conducted to assess the awareness of EBM in medical students; however, few data are available about the Iranian medical students. In most medical universities of Iran, teaching of the EBM is not yet a component of the undergraduate medical curriculum. In particular, little is known about the levels of awareness and knowledge, their ability to access and understand evidence, their information about methodological and epidemiological terms among medical students. Thus, it is required that the current state of EBM to be understood in order to plan long-term educational programs. Our study aimed to assess ability to access relevant databases, attitude toward evidence-based medicine, awareness, understanding of technical terms used in EBM, and to determine their educational needs for EBM in one Iranian University, Semnan University of Medical Science. Obviously, this information can help in recognizing their shortcomings and programming appropriate practical training for this group.
Material and Methods A cross-sectional study was carried out between October and December 2012 among medical students of Semnan University of Medical Science, Iran. Training physicians in Iran has a seven-year program: two years of basic sciences, three years of pre-clinical, and two years of clinical (internship) period.
Evidence-based medicine and medical students
At Semnan University faculties, hospitals and dormitories are computer facilities with 24-hour Internet connection. All computers could access to Iranian Ministry of Health and Medical Education electronic library, which have access to main electronic databases with a broad range of full text articles and evidence-based resources. For data gathering, a self-administered, structured questionnaire was developed and used. The primary version of questionnaire was developed from a comprehensive literature review (17–19). Its face and content validity was confirmed by two experts’ panel. A pilot study was conducted for reliability of questionnaire, which led to some modifications and local adaptations based on the feedbacks received. The individuals (n = 20) that participated in the pilot phase were excluded from the main study. According to the results of the pilot study, internal consistency of the questionnaire was assessed by a Cronbach’s alpha coefficient of 0.84. Participants were a randomly selected sample of medical students in their third to seventh year of education. The educational level consisted of pre-clinical (third to fifth years) and clinical (sixth to seventh years) level. The final questionnaire included five main sections with 35 questions: The first section asked respondents about their age, gender, educational level, and having any training in database search and EBM (4 items). The second section evaluated their access to various information sources including the Internet and databases relevant to EBM and their ability to perform searching in bibliographic databases and the world wide websites (7 items). The third section asked about participants’ attitudes toward EBM (5 items). The fourth section was about students’ awareness of extracting journals, review publications and databases relevant to EBM and their applications (9 items). The final section measured understanding of the technical terms related to epidemiology and biostatistics used in EBM (10 items). To measure students’ knowledge and attitude about EBM, we used the Likert Scale. The questionnaires were distributed anonymously between selected pre-clinical and clinical students by four research assistants gave the questionnaires through personal visits and also provided the proper explanations for correctly completing the forms. The study was approved by the Research and Ethics Committee of Semnan University of Medical Science. Data were analyzed with SPSS software (version 16.0). The distribution of students in the defined groups according to their characteristics was reported by the corresponding frequencies and percentages, while the mean and its standard deviation (SD) were reported for numerical scores.
Results Among the entire participants, 143 returned the filled questionnaire (response rate was 84%). Ninety-two (64.3%) of
C 2014 Chinese Cochrane Center, West China Hospital of Sichuan University and Wiley Publishing Asia Pty Ltd JEBM 7 (2014) 32–37
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Table 1 Semnan medical students’ access to various information sources and their ability to perform searching in evidence-based medicine bibliographic databases Socres (%)a Items
0
1
2
3
Mean ± SD
World Wide Web access Importance of Internet as an information source Familiarity with bibliographic databases search Familiarity with EBM Use of national digital library Use of EBM related bibliographic databases Evaluation of EBM related courses
31 (21.7) 4 (2.8) 16 (11.2) 53 (37.1) 67 (46.9) 82 (57.3) 97 (67.8)
46 (32.2) 8 (5.6) 51 (35.7) 55 (38.5) 45 (31.5) 40 (28.0) 37 (25.9)
47 (32.9) 39 (27.3) 64 (44.8) 31 (21.7) 27 (18.9) 17 (11.9) 8 (5.6)
19 (13.3) 92 (64.3) 12 (8.4) 4 (2.8) 4 (2.8) 4 (2.8) 1 (0.7)
1.38 2.53 1.50 0.90 0.78 0.60 0.39
a
± ± ± ± ± ± ±
0.97 0.72 0.80 0.83 0.85 0.80 0.63
Scoring: 0 = low/bad, 1 = medium, 2 = much/good, 3 = very much/excellent.
Table 2 Semnan medical students’ attitude toward evidence-based medicine Scores (%)* Statements
3
2
1
0
Mean ± SD
EBM improves patient care Healthcare costs are reduced by practicing EBM Using EBM is important in making medical decisions It is difficult to search for EBM-based information and use in clinical practice** Learning EBM is an important component of my training
42 (29.4) 41 (28.7) 43 (30.1) 39 (27.3) 65 (45.5)
90 (62.9) 80 (55.9) 0 (0.0) 75 (52.4) 63 (44.1)
9 (6.3) 20 (14.0) 86 (60.1) 26 (18.2) 13 (9.1)
2 (1.4) 2 (1.4) 14 (9.8) 3 (2.1) 2 (1.4)
2.20 2.12 2.20 2.33 0.95
± ± ± ± ±
0.61 0.69 0.59 0.70 0.73
*Scoring: 3 = strongly agree, 2 = agree, 1 = disagree, 0 = strongly disagree; **Reveres scoring.
respondents were female. Educational levels were as follows: 122 (85.3%) in preclinical and 21(14.7%) in clinical stage. Of these students, 42 (29%) reported having had formal training in search strategies. The majority of participants (91.6%) stated significant role for database sources but only 46.2% stated that they had good access to relevant databases and the Internet. The mean score about students’ access to various information sources and their ability to perform searching in bibliographic databases related to EBM database is showed in Table 1. Only 24.5% of surveyed students stayed that had good basic information and familiarity with the term of EBM. Nevertheless, 89.3% of participants agreed that EBM was useful in the management of patients and were interested in learning the skills of EBM. Table 2 shows the responding students attitudes toward evidence based medicine. Most of the respondents (80.2%) had no or little awareness of EBM resources. Our participants had the most familiarity with the Google Scholar and PubMed database and the least familiarity with the Cochrane, DARE, and Bandolier clinical evidence database (Table 3). Most of the respondents did not understand but would like to learn about technical terms used in evidence-based medicine, and about a third felt able to explain to others the meaning of some of these terms (Table 4).
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Discussion EBM encompasses all aspects of the clinical decision-making in medicine, from diagnosis to treatment. Acquisition of knowledge and skills for EBM is becoming a core competence to be acquired by all physicians (20). The response rate in this study was 84% which was a considerable achievement when compared with some other studies (14, 21–23), but lower than some studies (10, 13). This high response rate could be owing to the by-hand method of distribution. The present questionnaire survey demonstrated that the majority of medical student at Semnan University of Medical science lack adequate knowledge about basic concepts and familiarity with the term of EBM and obtained a low knowledge score. Kaderli et al. reported poor knowledge scores on EBM among medical students (21). Other studies showed a low level of awareness of extracting journals, review publications, and databases relevant to evidence-based medicine among general practitioners (18, 23, 24). In contrast, Stronge et al. reported good knowledge and awareness about EBM (25). Nearly, 90% of our respondents had positive attitudes toward EBM and the majority demonstrated a tendency to take part in training course about EBM. This finding was consistent with evidence from the other medical literature
C 2014 Chinese Cochrane Center, West China Hospital of Sichuan University and Wiley Publishing Asia Pty Ltd JEBM 7 (2014) 32–37
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Evidence-based medicine and medical students
Table 3 Semnan medical students’ awareness of various evidence-based medicine resources Scores (%)a
Bandolier BMJ Effective healthcare bulletins Cochrane DARE Evidence-based purchasing (R&D Bristol) PubMed Google Scholar Other a
0
1
2
3
Mean ± SD
121 (84.6) 96 (67.1) 114 (79.7) 113 (79.0) 124 (86.7) 111 (77.6) 25 (17.5) 8 (5.6) 0 (0.0)
12 (8.4) 21 (14.7) 13 (9.1) 17 (11.9) 10 (7.0) 19 (13.3) 30 (21.00 18 (12.6) 0 (0.0)
9 (6.3) 21 (14.7) 14 (9.8) 13 (9.1) 9 (6.3) 13 (9.1) 46 (32.2) 71 (49.7) 25 (17.5)
1 (0.7) 5 (3.5) 2 (1.4) 0 (0.0) 0 (0.0) 0 (0.0) 42 (29.4) 46 (32.2) 118 (82.5)
0.23 0.54 0.33 0.30 0.19 0.31 1.73 2.08 2.82
± ± ± ± ± ± ± ± ±
0.59 0.87 0.71 0.63 0.53 0.63 1.07 0.82 0.38
Scoring: 0 = unaware, 1 = aware but not used, 2 = aware but sometime used, 3 = aware and used.
Table 4 Medical students understanding of evidence-based medicine-related technical terms Scores (%)a Technical term
0
1
2
3
Mean ± SD
Relative risk Absolute risk Systematic review Odds ratio Meta-analysis Clinical effectiveness Confidence interval Publication bias Incidence rate Prevalence
19 (13.3) 16 (11.2) 11 (7.7) 15 (10.5) 21 (14.7) 14 (9.8) 14 (9.8) 12 (8.4) 12 (8.4) 58 (40.6)
50 (35.0) 55 (38.5) 57 (39.9) 53 (37.1) 74 (51.7) 65 (45.5) 67 (46.9) 42 (29.4) 23 (16.1) 57 (39.9)
48 (33.6) 49 (34.3) 45 (31.5) 52 (36.4) 33 (23.1) 44 (30.8) 40 (28.0) 58 (40.6) 54 (37.8) 20 (14.0)
26 (18.2) 23 (16.1) 30 (21.0) 23 (16.1) 15 (10.5) 20 (14.0) 22 (15.4) 31 (21.7) 54 (37.8) 8 (5.6)
1.57 1.55 1.65 1.58 1.29 1.48 1.49 1.75 2.05 0.85
± ± ± ± ± ± ± ± ± ±
0.94 0.89 0.89 0.88 0.85 0.85 0.85 0.89 0.94 0.86
Scoring: 0 = It would not be helpful to understand, 1 = Do not understand but would like to, 2 = Some understanding, 3 = I understand and could explain to others.
a
(16, 26–29). This might be a first step in motivating and was a good sign for promoting the teaching of EBM in medical students’ curriculum. In contrast, Scholten-Peeters study that was conducted among physical therapy students reported a weak positive attitude toward EBM among students (30). The majority of our respondents agreed that practicing EBM improved patient care and reduced healthcare costs. These findings were comparable to other previous studies (13, 21). Similarly in some studies that was conducted among postgraduate and general physician findings showed similar results (22, 23, 31). Despite ease and free of charge access to evidence-based resources, medical students in our university do not usually use these sources on a regular basis. Only a minority of respondents were aware of EBM resources, which were similar to some previous studies (26, 27, 30, 32) but considerably lower than the rate reported in the other studies (14, 18, 21, 25). Also, our study confirmed previous findings of low utilization of typical EBM information sources and frequent use of traditional sources (23, 33, 34). We found
that all respondents had never used the Cochrane, DARE, and evidence-based purchasing database. The Cochrane Library is the main source of systematic reviews and meta-analyses. However, unfortunately, there was little awareness about this database among students. A study done in Shiraz reported that 75% of the residents were unfamiliar with EBM databases especially Cochrane (35). In a Canada study, only 5% of practicing clinician used the Cochrane Library on a regular basis (24). Researches from other countries suggested that general practitioners were reluctant to use information technology to support evidencebased clinical decision-making (17, 34). Most of the participants (71.5%) declared that they did not have any education about using EBM and or online search. Medical students still mostly used and relied on textbooks and expert consultation when seeking information. Most students reported they do not understand but would like to understand some of the technical terms used in EBM. The term ‘Incidence rate’ was the best well understood, and the term ‘Prevalence’ the least. In Gwendolijne et al.’s
C 2014 Chinese Cochrane Center, West China Hospital of Sichuan University and Wiley Publishing Asia Pty Ltd JEBM 7 (2014) 32–37
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study, the term ‘odds ratio’ was the least well understood, while the term ‘systematic review’ the best (30). McColl et al.’s study on general practitioners reported that most of the respondents had some understanding of the technical terms used in evidence-based medicine, and a third felt able to explain to others the meaning of some of these terms (18). In a study conducted in Japan, respondents reported insufficient knowledge of methodological EBM terms, but the majority of respondents’ showed enthusiasm to learn more. The higher score of knowledge was for odds ratio and the lower for number need to treat (14). In a study among junior physicians of various specialties, Hadley et al. showed that clinicians lacked methodological competence necessary for practicing EBM (19). The concept of EBM is still alien between medical students because of lack of formal training. This would require a major initiative at medical universities and need to be targeted at all levels of medical education. Several studies showed that incorporating EBM into clerkship curriculum improved self-perception of medical students in the key areas of critical appraisal skills, such as formulating a clinical question, searching the literature, and evaluating the evidence. Also, medical students’ knowledge and attitudes toward EBM have improved after EBM training (27, 36–38). Teaching EBM to medical students in setting where they could directly apply their knowledge and skills in daily practice might encourage them to think more critically about therapeutic and diagnostic decisions (15). This study has some limitations. First, the design of the study was cross-sectional. Second, this was a questionnaire study and was subject to response bias. The questionnaire only assessed self-report and self-judgment of participants’ attitude, behaviors, and ability. We were being able to diminish response bias by achieving a very good response rate. Finally, the small convenience sample, without controlling for prior experience, might have allowed for both underestimation and overestimation of data.
Conclusions In conclusion, although medical students seem to have positive attitude toward participating in research, there appears to be a lack of perceived knowledge and of EBM behavior. Therefore, a general strengthening of the knowledge on EBM and statistics may be a good way of educating EBM and establish a good foundation for their future academic environment. To increase EBM knowledge and skills it is recommended to integrate EBM teaching training in curriculum of medical students especially during clinical stage and continue during postgraduate education. Further studies are required to assess the level of knowledge and degree of implementation of EBM concepts in medical universities.
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Acknowledgements The researchers acknowledge the medical students of Semnan Medical University that participated and cooperated in our study.
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