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Clinical Scenario

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CLINICAL SCENARIO Scenario 1

You are an attending physician in your hospital's intensive care unit (ICU) doing morning rounds on a patient with septic shock. The resident notes that the patient is still hypotensive after receiving 5 L of intravenous Ringer's lactate solution and asks if starch solution should be administered.

Scenario 2

You are awaiting the noon conference in the ICU where a patient admitted that week will be discussed in detail with 2 attending physicians, a fellow, 2 senior residents, and 2 junior residents. The fellow is now addressing preventive interventions as part of admission orders, noting that this patient did not receive heparin thromboprophylaxis when first admitted because his admitting diagnosis was ruptured abdominal aortic aneurysm. Now, 2 days after the patient's surgery, the fellow is wondering which type of heparin to prescribe.

Scenario 3

You are the faculty adviser for journal club in your surgical residency program. The resident assigned to lead this month's session attended the patient admitted from the emergency department with ruptured aortic aneurysm from scenario 2. She proposes to review the literature on the choice of low-molecular-weight heparin vs other prophylactic alternatives for postoperative patients.

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These 3 scenarios raise issues related to teaching evidence-based clinical practice (EBCP) to practicing clinicians and clinicians in training. Readers of the Users' Guides to the Medical Literature (Users' Guides) who are clinical educators have doubtless already begun to ponder how to incorporate its concepts into their teaching. In this chapter, we provide some suggestions. A theme that will pervade this discussion is our increasing emphasis on systematic reviews and practice guidelines as bread-and-butter content for EBCP teaching on all levels. The scope of EBCP is rapidly evolving, and the settings for EBCP teaching are broadening. In this chapter, we identify some related challenges to educators and provide examples of innovative responses. We then return to the opening scenarios and to some additional examples.

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Teaching EBCP in an Expanding Universe of Evidence and Education

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During the more than 2 decades since it was introduced as an educational intervention at the residency and house officer level, EBCP has been widely accepted as an important component of medical education. Evidence-based clinical practice skills are included in competency-based frameworks for graduate medical education, including the Outcome Project of the US Accreditation Council for Graduate Medical Education (ACGME)1 and the Canadian Royal College of Physicians' CanMEDS program.2,3 These frameworks, in turn, have been widely adopted as guides for clinical education at other levels, including undergraduate education. In some cases, they have undergone further transformation.4

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The competency-based frameworks have served to reinforce a practice-based orientation, further shifting emphasis away from the predominant emphasis on critical appraisal and toward what have been termed “initiation skills” (ie, skills required to initiate exploration of research literature in response to actual clinical encounters).5,6 Published ...

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