CMAJ • May 24, 2005; 172 (11). doi:10.1503/cmaj.1041708.
© 2005 CMA Media Inc. or its licensors
All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association.
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Letters
Correspondance

Challenges of teaching EBM

Gerry E. Burns

Family Doctor, National Health Service, Belfast, Northern Ireland

I am just finishing a master's degree in medical education, and my thesis work is closely related to the series on learning and teaching EBM.1 I have used the name DIETS (for "Disease management Interactive Teaching Script") for my system, which incorporates up-to-date EBM in teaching the management of chronic disease to primary care doctors and nurses. The DIETS system includes presentations on topics such as hypertension and diabetes, which take the form of mini-lessons or "slide sets." In contrast to the teaching tips articles,2 which a reader can dip into and out of, each DIETS talk must be presented in its entirety, as a reflection of the longitudinal nature of primary care. Another difference is that feedback in DIETS is formalized, appearing in the third slide of each set, whereas feedback is less structured in the teaching tips. An important similarity between the scripts used in the DIETS system and those in the EBM series is that the teaching of particular points conforms with the suggestions of Peile and colleagues,3 who discussed the notion of threshold concepts — key concepts that, once understood, allow learners to understand, interpret or view something in a different way. Until that threshold is crossed, the student will struggle to progress.

I have used part 1 of the teaching tips series2 to analyze the synopsis4 (published recently in CMAJ) of the Collaborative Atorvastatin Diabetes Study (CARDS) and can suggest 2 additional exercises related to this study. First, in CARDS, the reduction in the death rate for diabetic patients who received atorvastatin was from 5.8% to 4.3%, an absolute risk reduction of 1.5% over 4 years (1.5%/4 = 0.375% annually), which yields a number needed to treat of 100/0.375 or about 275. If atorvastatin costs about £20 per month (about Can$47), how much did it cost to save one life? The answer is 20 12 275 or £66 000 (Can$154 500). Is this cost-effective? Second, from the CARDS data, we can calculate the 10-year risk of coronary artery disease for diabetic patients not receiving statin treatment. The overall rate of cardiovascular events in the placebo group was 13.4%, and median follow-up was 4 years. Therefore, the annual rate would be 13.4%/4 (3.35%) and the 10-year rate would be 33.5%. The rate of coronary artery disease was approximately three-quarters of the total cardiovascular risk5,6 or about 25%.

References

  1. Wyer PC, Keitz S, Hatala R, Hayward R, Barratt A, Montori V, et al. Tips for learning and teaching evidence-based medicine: introduction to the series [editorial]. CMAJ 2004;171(4):347-8.[Free Full Text]
  2. Barratt A, Wyer PC, Hatala R, McGinn T, Dans AL, Keitz S, et al, for the Evidence-Based Medicine Teaching Tips Working Group. Tips for teachers of evidence-based medicine: 1. Relative risk reduction, absolute risk reduction and number needed to treat [online]. CMAJ 2004;171(4): Online-1–8. Available: www.cmaj.ca/cgi/data/171/4/353/DC1/1 (accessed 2004 Nov 18).
  3. Peile E, Macdougall C, McCarthy L. What the educators are saying. BMJ 2004;328:692.[Free Full Text]
  4. Hackam DG. Should a statin be routinely prescribed for primary prevention of cardiovascular disease in diabetes mellitus? CMAJ 2004;171(8):857.[Free Full Text]
  5. Wallis EJ, Ramsay LE, Ul Haq I, Ghahramani P, Jackson PR, Rowland-Yeo K, et al. Coronary and cardiovascular risk estimation for primary prevention: validation of a new Sheffield table in the 1995 Scottish health survey population. BMJ 2000;320:671-6.[Abstract/Free Full Text]
  6. Ramsay LE, Williams B, Johnston GD, MacGregor GA, Poston L, Potter JF, et al. British Hypertension Society guidelines for hypertension management 1999: summary. BMJ 1999;319:630-5.[Free Full Text]




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