循证医学教学对研究生相关知识、技能、态度和行为的影响研究

Can Training Courses Improve Medical Postgraduates’ Knowledge, Skill, Attitude and Behavior Related to Evidence-based Medicine A Before-and-after Study

目的探讨循证医学课程对医学研究生知识、技能、态度和行为的影响以及循证临床实践中的障碍,为进一步有效地开展循证医学教学和循证临床实践提供参考。方法采用封闭式问题和开放式问题相结合的自填问卷对四川大学2004年秋选修《循证医学》的111名医学研究生进行调查,比较选修前后学生在循证医学知识、技能、态度、行为,以及循证临床实践中障碍方面的差异。结果医学研究生在选修“循证医学”课程前后,其循证医学知识、技能、态度、行为,以及在循证临床实践的障碍方面有一定差异。在知识和技能方面:选修后学生对循证医学相关专业术语的理解有显著提高(75%项目差异有统计学意义),特别是对绝对危险度、系统评价、Meta分析和发表偏倚(P<0.01);认为自己在熟练使用检索工具这一技能上有所提高(P<0.05)。在态度方面:选修前,有55%左右的条目分值均较高(>4分);选修后“现在多数用于病人诊治的干预措施缺乏强有力的证据支持”和“循证医学实践需要考虑病人的意愿”这两项分值提高明显(P<0.01)。“在医疗实践中采用循证医学是合理的要求”和“循证医学不受临床实践场所的限制”这两个条目选修前后的分值都偏低(<3分),在“日常工作中需要增加医学证据的使用”和“对应用循证医学进行临床实践和改进临床技能有兴趣”两项上,分值接近。在行为方面:选修后医学生对文献的使用仍不十分重视。如选修前后都有60%左右的医学生基本上不阅读相关的专业文献。虽然检索MEDLINE和其他电子数据库次数较多(>6次/月,选修前60.3%,选修后65.7%),但在临床实践中应用却不多(>6次/月,课前仅占29%,课后仅占35.1%)。学生对临床实践指南的应用情况,选修前后差异无统计学意义。在障碍方面:选修前后学生均认为最大的障碍是严格评价文献的能力有限,但排名第2与第3的障碍有差别。选修前缺乏查询循证医学的相关技能排在缺乏信息资源前,而选修后相反。结论目前的循证医学课程对提高医学研究生循证医学知识的效果显著,对其对待循证医学的态度和行为也有一定的提高。在临床实践中,医学研究生应用循证医学的三大障碍是严格评价文献能力有限,缺乏查询循证医学相关的技能和缺乏信息资源。

Objective To investigate the effect of training courses of evidence-based medicine （EBM） on the knowledge, skill, attitude and behavior of medical postgraduates and to explore the barriers to evidence-based practice （EBP）, so as to provide knowledge to improve further EBM teaching and EBP. Methods A total of 110 medical postgraduates of Sichuan University who selected EBM courses in the autumn semester of 2004 were given questionnaires that combined both open and closed questions. The KAB （knowledge, attitude and behavior） of EBM and barriers to EBPwere compared before and after the training courses. Results Differences were observed in KAB of EBM and barriers to EBPafter the training courses, compared to the assessments done before the courses. In ＂Knowledge＂： there was a significant increase in the understanding of specific terms in EBM after the training courses （75% of the items showed a statistically significant improvement）. This was especially marked for ＂absolute risk＂, ＂systematic review＂, ＂meta-anaiysis＂ and ＂publication bias＂ （P〈0.01）. We also found an improvement in familiarity with medical searchengines （P〈0.05）. In ＂Attitude＂： the mean scores for most items （55%） were relatively highbothbefore and after the training courses （〉4）, and a significant improvement was observed in 2 items. These were ＂Strong evidence is lacking to support most of the interventions I use with my patients＂ and ＂EBP needs to take into account patient preferences＂ （P〈0.01）. The mean scores of 2 items were relatively low bothbefore and after the training courses （〈3）. These were ＂the adoption of EBPplaces an reasonable demand on physical therapists＂ and ＂EBPdoes not take into account the limitations of my clinical setting＂. Another 2 items had mean scores close to 5： ＂I need to increase the use of evidence in my daily practice＂ and ＂I am interested in learning or improving the skills necessary to incorporate EBP into my practice＂. In terms of ＂Behavior＂： the medical postgraduates continued not to think highly of the use of literature after the training courses. About 60% of the postgraduates did not read any literature related to their specialties at all. Although searching of MEDLINE and other electronic databases was relatively frequent （〉6 times/ month： 60.3% before training and 65.7% after training）, using professional literature and research findings in the process of clinical decision-making was not equal （〉6 times/month： 29% before training and 35.1% after training）. No significant difference was observed in applying clinical practice guidelines before and after the training courses. As for ＂Barriers＂： the postgraduates considered ＂poor ability to critically appraise literature＂ as the most important barrier bothbefore and after the training courses. The second and third most important barriers were different compared to after the training courses. The barrier of ＂lack of research skills＂ was larger than that of ＂lack of information resources＂ before the training courses, but after that the course, the order of these was reversed. Conclusion The knowledge of medical postgraduates increased significantly after the EBM. Some improvement was current training courses of also found in attitude and behavior. The top three barriers to EBPwere ＂Poor ability to critically appraise literature＂, ＂Lack of information resources＂, and ＂Lack of researchskills＂