Thursday, February 16, 2012

Evidence based medicine in second year courses: Too much too soon or just in time?

Once again sitting in the back of the neuroscience and behavior class, and I've noticed another interesting phenomenon as the course as gone on.  As we cover stroke, the clinical presenters are presenting much more clinical trial data than the other clinicians did (including myself for example as I the presentation on Parkinson's disease).  Part of this is due to the veritable glut of evidence from strokologists.  As stroke is very common, it is not hard to get large trials together, and the stroke literature is now quite robust.  And, rightfully so, the stroke physicians are proud of their work, and want to communicate the data.

This raises a bit of a tension in the second-year neuroscience class.  This tension is that these students were introduced to vascular anatomy yesterday, and stroke pathophysiology earlier in the morning.  So how soon is too soon to talk about EBM?  The focus of the course is more on learning the basic science, and getting an introduction to differetial diagnosis and treatment.  Hence, when I talked about the clinical context of Parkinson's disease, I presented a lot about the clinical syndrome, and the differential diagnosis, and initial treatment options with pharmacologic information.  As I'm a clinician, the pharmcology focused on adminstration route and side effects.  But I didn't really show any primary literature in my slides.  The stroke people showed a lot of primary literature - SPARKLE, CLOSURE, CREST, ECASS, NINDS tPA trial, the list of acronyms paraded across the screen.

So the tension lies in the fact that students do need to know that there is evidence which supports our clinical decisions.  This evidence is often cited when I do ward attending rounds with the residents and the fourth-year students.  But how much belongs in the first and second year coursework?  When does it become overload when the student is still trying to grasp the basic concepts of pathophysiology?  I'm not sure I have answers to these questions.  As my lectures tend to show, I'm more for presenting basic data, and pivotal trial data in measured doses at this stage in training, and allow the learners to delve more deeply into EBM during the clinical years, and into their residency training.  What do you think?

1 comment:

  1. I feel that most clinical presenters have a routine of presenting material to experienced clinicians, which includes primary literature. Of course this is expected, especially when offering new and updated standards of care. Unfortunately, they fail to realize that medical students have absolutely no background in previous treatments. You don't have to convince us that tPA is effective treatment for acute ischemic stroke when it has been standard of treatment for over 10 years now. It would be like reviewing the literature for the benefits of penicillin vs. placebo for the treatment of syphilis while you were in medical school. We need a starting point. Tell us what you are doing now.

    I'm not suggesting that EBM be eliminated from the 1st and 2nd year curriculum, but integrate it in a way that will benefit us in the future and allow us to make better decisions about changing our current guidelines (the ones we should be establishing now). Give us the scenarios that you have faced in your career when reading new literature. Perhaps small groups could be utilized to relive the experience of reading a revolutionary study for the first time and how to make decisions about future patient care. We need to understand this process to better help our patients in the future; however, memorizing trial names is far from the top of our current priority list.

    As added support for this side of the story, USMLE Step 1 doesn't seem to ask about the data supporting current treatments. We are simply expected to know what to do. "What is first line drug for absence seizures?", not "What data supports the use ethosuximide vs. valproic acid in the treatment of absence seizures?" Although we shouldn't use Step 1 to gauge how we practice, it is certainly in the forefront of our minds as we move through the spring of our second year.