Center for Evidence Based Medicine
The Center for Evidence-Based Medicine (CEBM) was established to teach and conduct research related to EBM, which is a formal method of translating research into practice [4]. It uses the best current evidence to assist in making clinical decisions. EBM also takes into account the patient's wishes, values, and expectations. The CEBM is headed by a director and assisted by a research associate and administrative assistant. The CEBM was established in 2004 and is currently responsible for an EBM faculty development lecture series, teaching medical students and residents, and conducting EBM related research projects and scholarly activities.
To meet these aims, an EBM curriculum was created to provide instruction on how to ask answerable questions, search the medical literature, choose relevant studies, and assess the evidence for its validity, importance, and applicability (Objective 1.1). The EBM curriculum is taught in a journal club format rather than didactic lectures alone. The curriculum is composed of 6 sessions (each session is approximately 1 hour and 30 minutes) as shown in Table 1. The first 45 minutes of the session is a PowerPoint® presentation and the remainder of the session is used to appraise an article and discuss its applicability to clinical care. This allows participants to immediately apply the principles that were learned. They are also provided another article to critique and read before the next class. Worksheets are used to structure the discussions and train participants to be systematic in their evaluation and assessment of the literature. Examples of the lectures and worksheets can be found at the CEBM's website (Objective 1.3) [5]. Evaluations of the lectures found that participants appreciated the small classroom environment. Additionally, this EBM course gives participants exposure to landmark studies that shape current controversies in diagnosis and treatment. Clinicians receive one category 1 American Medical Association or 1A American Osteopathic Association CME credit for each lecture (Objective 1.2). These sessions have been offered in the 2004–2005 and 2005–2006 academic years (Objective 1.4) and will be offered yearly.
Faculty members are encouraged to use EBM principles with students during clinic and daily hospital rounds. Faculty are encouraged to move away from asking ambiguous factoids (i.e. "pimp" questions), such as "What is the Cushing's reflex?," instead asking students such questions as the sensitivity and specificity of imaging modalities, the absolute risk reduction of tPA in thrombotic stroke, and the applicability of evidence to a particular patient. These are sophisticated questions that require investigation rather than recall. In this context, EBM is being used to move students beyond obtaining the correct diagnosis to formulating and following through with a treatment plan. The CEBM does not dictate the exact format for teaching EBM to students and residents, but strongly encourages using the principles that are taught in the EBM curriculum to ensure a continuity of learning (Objective 1.4). The CEBM offers the training and resources for the faculty to teach EBM, including how to search and locate evidence on the Internet. EBM prescription pads [6] are provided to students and residents to help guide them in creating EBM-specific questions. Faculty members are encouraged to review and use them daily as teaching points and apply them to the patients.
The CEBM has also published papers on how to teach EBM to medical students during family medicine rotations [7] and has conducted research on the accuracy of pharmaceutical advertising [8]. To secure funding and to conduct interventional studies related to EBM has been a great challenge. Time, personnel, research faculty, and funding opportunities would aid in overcoming these obstacles.
The North Texas Primary Care Practice-Based Research Network (NorTex)
NorTex, a practice-based research network (Objective 2.1), was formed to function as a laboratory to serve the common goal of clinicians, researchers, and community members – to improve the health of their community. This endeavor began by seeking support from the institution, including its president, vice-president, deans, and other leaders. The importance of creating NorTex was recognized and seed-funding was provided to assist in NorTex's recruitment efforts (Objective 2.3). Recruitment efforts consisted primarily of mail-outs to all primary care clinicians (family medicine, general internal medicine, pediatrics, and obstetrics and gynecology) in several counties in north Texas. These mail-outs included information about NorTex and membership forms. A NorTex website was also developed to help disseminate and post information [9].
NorTex's organization includes of a director, research coordinator, and the scientific review and community advisory boards (Objective 2.2). These boards' primary function are to maintain the integrity of the research agenda and to approve or reject proposals that are submitted to NorTex. This ensures a balanced research agenda and validates the importance, scientific merit, and feasibility of the projects. The scientific review board (SRB) is comprised of experts in the areas of research design, methodology, and biostatistics from the medical school, school of public health, and graduate school of biomedical sciences. The community advisory board (CAB) consists of community leaders and representatives of NorTex member organizations, such as the county hospital district and health department.
Currently, NorTex has over 54 member clinics and 105 individual members from the medical school, school of public health, graduate school of biomedical sciences, county health department, private clinics, and community leaders. Members meet regularly, either in-person or by conference call. Current studies include understanding how life stressors are related to cardiovascular disease (National Institutes of Health funded study), the impact of psychosocial factors on highly-active antiretroviral therapy (HAART) among individuals infected with HIV (UNTHSC intramural study), and ethnic differences in visceral abdominal fat as risk factors for cardiovascular disease (National Institutes of Health funded study) (Objective 2.4).
Primary Care Clinical Research Program
Sustaining primary care research relies on training medical students in an environment that values research and provides career tracks for investigators. The primary care clinical research program offers students a Master of Science in Clinical Research which is completed during the four year Doctor of Osteopathy curriculum. This program began in 2003 and was funded by a pre-doctoral training grant from the Health Resources and Services Administration (Objective 3.1). It is now in the process of being institutionalized at UNTHSC. The program selects about two incoming medical students per year. The recruitment strategy consists of mail outs, a website [10], word-of-mouth, and a presentation during student orientation week. Applicants are required to submit an essay and provide transcripts and Medical College Admission Test scores. These applicants are thoroughly screened by the program faculty and only highly qualified applicants are invited for an interview. Currently, there are 8 students in the program. The program celebrated its first graduate in May 2006 (Objective 3.2). The grant partially covers the salaries of a research associate, administrative assistant, fellowship director, and several faculty members involved with advising and teaching courses. Each student receives a stipend to help offset the cost of graduate school courses and a small monetary award to help cover research costs (copies, supplies, etc.). Each student is assigned to an advisor/mentor and is required to have an approved degree plan early in their first year.
The curriculum includes coursework in biostatistics, epidemiology, research methods, scientific communication, evidence-based medicine, and ethical and legal issues in research (Table 2), as well as two small-scale projects and an intensive thesis (Objective 3.3). Students take these courses primarily in the evening and during the summer when medical school is not in session. Students are mentored throughout the research process, which includes formulating a study question, conducting a literature review, building a protocol, applying for funding, submitting an institutional review board application, collecting and analyzing data, and writing a manuscript for publication. The curriculum is designed to develop critical thinking and cultivate a positive research attitude among clinician-researchers in training. Mentoring is highly emphasized to facilitate the vigorous four-year curriculum these students must endure.
Students study topics of their choosing and thesis committees are established to provide guidance. Students have studied important primary care questions such as:
• Does osteopathic manipulative treatment relieve low back pain? [11]
• Does the patient-doctor relationship account for health disparities?
• Does acculturation affect glycemic control among Mexican-Americans with Type II Diabetes?
• Do experiences of racism impact preventive screening utilization?
The recasting of family medicine as a specialty with research capabilities promises to increase medical students' interest in family medicine as a career.
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