TEACHING EVIDENCE BASED PRACTICE Random thoughts in a nutshell
Robert J. Weyant, DMD, DrPH Chair, Department of Dental Public Health University of Pittsburgh School of Dental Medicine
Who we teach •
Dental students
•
Dental faculty
•
Practicing dentists
What do we teach •
Just in time (not just in case) individual patient treatment decisions.
•
Some use of guidelines.
Challenges: Dental Students Challenges •
Lack of clinical knowledge
•
Lack of vocabulary
•
Lack of understanding of practice needs
•
Busy with “real” dental courses
Opportunities
Challenges: Faculty Members Challenges
Opportunities
•
Already know everything
•
Captive audience
•
Busy
•
•
Don’t “get it”
Access to medical library (online resources)
•
Don’t want to look foolish
•
Don’t want to look foolish
Challenges: Practicing Dentists Challenges •
Busy
•
Lack access to online resources
•
Economic concerns
Opportunities •
Eager (if paying for CE)
Didactic Teaching First Year EBD Course Second Year Research Course
Start with a strong rationale Dental Students • •
Just want the “answers”
Practitioners •
•
Lack Perspective •
Don’t understand that science/practice changes
Strong Rationale
Need to see examples.
•
They already practice EBD…
Manage fear of change
Demanding evidence… she averted a US tragedy.
Strong Rationale
Francis Kelsey, MD Carl Henegan, Oxford
Julies Back to Sleep slide Bad things happens when we don’t look at evidence
Strong Rationale
Many “Leaks” from research to practice
Aware Accept Target Doable Recall Agree Done
Valid Research If 80% achieved at each stage then 0.8 x 0.8 x 0.8 x 0.8 x 0.8 x 0.8 x 0.8 = 0.21 Strong Rationale Paul Glasziou
Teaching Philosophy: Dental Students •
Start early in curriculum
•
Easy and Rewarding
•
Reinforce for all four years
•
Skill development
EBD Taught Early and Often D1 Didactic
EBD/Stats
Clinical
Case presentation Adolescent clinic
Start Early
D2
D3
D4
First-year course •
Classic EBD material
•
Just enough stats
•
Asking (PICO)
•
Descriptive (review)
•
Accessing
•
P-value
•
Assessing
•
Confidence interval
•
Applying
•
Measure of effect
•
Diagnostic Test
Weyant’s Rules for Easy and Rewarding EBF Secondary Sources ONLY (at first) No wild goose chases Keep it simple (at first)
Search Strategy Question (PICO) Check MeSH
Check for 2nd Sources Here: • TRIP • Cochrane • ADA EBD • NGC
Search 2nd Sources
No PICO – search strategies for PubMed
PubMed (Clinical Queries)
Yes STOP
Weyant’s Rules for Teaching Statistics Formulas = Failure
Less is More Teach for Consumption Make it Sticky
Important concepts:
Education is the path from cocky ignorance to miserable uncertainty. Mark Twain
Uncertainty
Important concepts:
Lack of Evidence
There is insufficient evidence to determine the effects of routine scale and polish treatments. High quality trials conducted in general dental practice settings with sufficiently long follow-up periods (five years or more) are required to address the objectives of this review.
In three studies, the panel found no benefit of using prophylaxis pastes containing fluoride on the primary or permanent teeth of children.
Worthington et al., Routine scale and polish for periodontal health in adults. Cochrane Review, 2013
Weyant et al., Topical fluoride recommendations, JADA 2013
Absence of Evidence
Evidence of Absence
Important concepts: Study size and p-value? Surrogate endpoints NNT
Clinical Significance
EBD Taught Early and Often D1 Didactic
EBD/Stats
Clinical
Case presentation Adolescent clinic
Reinforce in clinic 4 yrs
D2
D3
D4
EBD Taught Early and Often D1 Didactic
EBD/Stats
Clinical
Case presentation Adolescent clinic
Reinforce in clinic 4 yrs
D2 Research Skills Course
D3
D4
[Case Presentation]
Senior Case Presentation
EBD Clinical Worksheets
EBD Clinical Worksheets
Experiential Learning EBP is a SKILL and requires PRACTICE
POGIL Sessions
Simulated Cases
Clinical EBD Worksheets
Small Group Teaching POGIL Case-Based Learning (HPDP)
Processed Oriented Guided Inquiry Learning (POGIL) https://pogil.org/about Self managed teams Guided exploration to construct learning Focuses on higher level thinking skills
POGIL: The Model Model 1
Model 3
The POGIL Process Learning Cycle
Process Skills
1. A Question 2. Observation or data collection to DEVELOP concept. 3. Guide to conclusion 4. Application
• • • • • •
Teamwork Oral + written communication Management Problem solving Critical Thinking Assessment
Small Group Case Based Learning • • • •
SES: High Knowledge of oral disease: good Medical: Type 1 Diabetes Dental: – –
Regular utilization of dental services. No sealants
• • • • •
Minor Plaque No calculus Slight gingivitis No Caries or restorations Occlusion – •
under treatment for overjet and crossbite
ADA Sealant Recommendations
ADA Guidelines on topical fluoride
31
Clinical Teaching EBD Worksheet Senior Case
What’s different about teaching graduates (faculty and practicing dentists)?
Adult Learning Model Shorter course Different rationale More cognitive bias and cognitive dissonance
Where do we go from here…
Full implementation of Evidence-based Program • • •
Risk Assessment Diagnostic Codes Summary Reports
axiUm Faculty training (coaching)
Policy changes
Robert J. Weyant, DMD, DrPH Chair, Department of Dental Public Health University of Pittsburgh School of Dental Medicine
[email protected]
37