Chapter 1
Evidence-based neurology in health education

Lawrence Korngut1, Miguel Bussière2 and Bart M. Demaerschalk3

1Calgary ALS and Motor Neuron Disease Clinic, Clinical Neurosciences, South Health Campus, Calgary, AB, Canada

2Neurology and Interventional Neuroradiology, Division of Neurology, Grey Nuns Hospital, Edmonton, AB, Canada

3Department of Neurology, Mayo Clinic, Phoenix, AZ, USA

Introduction

Clinical neurology trainees undergo a lengthy and complex process requiring integration of many fundamental skills that coalesce into sound diagnosis and decision making. Beyond the core knowledge of anatomy, physiology, biochemistry, pathology, and the medical sciences, there is an essential requirement for the clinical student, in the arena of evidence-based clinical practice, to acquire skills and expertise in the principles and practice of critical appraisal and to have a working knowledge of the best evidence from the diverse multiple subspecialties that comprise neurology today. Maintaining competence in the current best evidence over a neurologist's career is essential to making accurate diagnoses, providing high-quality neurological care, and selecting appropriate tests and therapies.

Developing the skills necessary for critical appraisal is a difficult process, particularly when competing with the rigorous demands of a residency training program. An evidence-based curriculum in neurology education provides the opportunity for teaching the fundamentals of critical appraisal and engaging in discussion of current clinical questions, hot topics, and continued controversies. Fostering an understanding of what comprises an appropriately comprehensive rigorous literature search, the levels of evidence, the different types of studies, and the methodologies are difficult to consolidate outside of a formalized curriculum or graduate-level training in evidence-based medicine, health research methodology, and clinical epidemiology.

In this chapter, we discuss the development of an evidence-based neurology (EBN) curriculum in health education.

Objectives

Teaching and acquisition of critical appraisal skills is the primary objective of an evidence-based clinical practice curriculum. Fundamental critical appraisal skills include the following: awareness of a clinical knowledge gap, formulation of answerable questions based on clinical uncertainty, performance of a literature search, identification of the highest quality evidence from the search yield, and critical appraisal of the studies to address the original clinical question. Students should become familiar with the different classifications of clinical studies (e.g. prognosis, diagnosis, therapy or harm) and the main methodological and statistical questions that must be addressed in each type of study. The students should also be able to determine whether or not the study findings are worth considering given the methodological quality of the study and its generalizability in reference to the patient population in question.

Students should develop an understanding of both the importance and the limitations of clinical evidence. Emphasis should remain on high-quality patient care and the use of the current best evidence to guide clinical practice within the context of the patient's wishes and the clinician's judgment and reasoning. It must be emphasized that lack of evidence for efficacy does not necessarily mean lack of benefit with treatment, and vice versa for lack of evidence against certain therapies or diagnostic tests.

As a result of the evidence-based medicine, curriculum knowledge about best current evidence practices is accumulated and stored for future use. Owing to the discussion of common clinical scenarios and review of the relevant best evidence, the students develop a working knowledge of the current evidence (Table 1.1).

Table 1.1 Objectives of evidence-based neurology curriculum

1. Students of neurology should develop critical appraisal skills to
   1. formulate answerable questions based on clinical uncertainty
   2. perform an appropriate literature search
   3. identify the best quality evidence from the studies identified
   4. critically appraise the identified studies to answer the original clinical question
   5. be familiar with prognostic, diagnostic, and therapeutic clinical studies and the key methodological and statistical questions that should be addressed in each type of study
   6. determine whether the study findings are valid and useful, considering the methodological quality of the study and the applicability to a particular patient population
2. Students of neurology should develop a working understanding of the importance of high-quality evidence and also realize its limitations
3. Students should accumulate knowledge about best current evidence practices in neurology

The following sections describe an example of an EBN curriculum based on two longstanding, mature, and successful programs targeting clinical neurology residents: the EBN curriculum from the Western University (WU) in London, Canada [1-4]; and the Mayo Clinic Evidence-Based Clinical Practice, Research, Informatics, and Training (MERIT) Curriculum, Mayo Clinic, Phoenix, AZ [5, 6]. Another third valuable resource designed to help educators teach students of neurology to understand and use evidence-based medicine is the web-based American Academy of Neurology (AAN) Evidence-Based Medicine Curriculum [7].

Topic selection

Generating the clinical questions

Once annually EBN curriculum facilitators survey all neurology students and faculty members to generate a list of neurological questions for potential review. These clinical questions are then rank ordered by the trainees and facilitators according to multiple factors including clinical importance, relevance, frequency of occurrence, and interest. The most highly ranked questions are reviewed in the upcoming year. The topics are screened to ensure that they are congruent with the educational recommendations of the training program (post-graduate education committee): Royal College of Physicians and Surgeons of Canada Advisory Committee and/or Accreditation Council for Graduate Medical Education - Neurology Residency and American Board of Psychiatry and Neurology [1-6].

Preparing for the tutorial session

Students each select one or two clinical questions per academic year and prepare their critically appraised topic for general discussion with the group. For each clinical topic, a clinical scenario and a focused clinical question are formulated. A focused clinical question should include considerations of the specific patient group, the intervention or exposure, the method of comparison, and the outcome measures. The acronym PICO can serve as a helpful reminder [8] (Table 1.2).

Table 1.2 PICO acronym [8]

For a given clinical question, the presenting trainee performs a literature search and identifies studies representing the highest level of evidence [9]. Expert librarians and informatics specialists can be called upon to assist in efficient and comprehensive literature searching. Studies are evaluated according to the generally accepted hierarchy of clinical evidence. High-quality meta-analyses, systematic reviews, and randomized clinic trials are preferred over observational studies and case reports. One to four studies are selected for critical appraisal and discussion. A summary of this information is prepared in advance of the discussion in the form of a critically appraised topic (CAT) as described later. One week prior to the session, the presenting trainee circulates copies of the clinical scenario, focusing clinical question, search strategy, and articles for review to the participants. The pre-tutorial process is supervised by one of the facilitators. The faculty often provides instruction and advice on the search strategy and reasons for inclusion or exclusion of studies. Trainees are introduced to different search engines (e.g. PubMed [10], SUMSearch [11], Cochrane Library [12]). Discussions on Medical Subject Headings (MeSH headings), keywords, and their uses are helpful.

Flexibility is available to adjust the clinical topics to suit the needs and training level of the trainees. Semi-annual meetings of the curriculum trainees and facilitators allow for appropriate curriculum content changes and adjustment of group discussion objectives to cover specific epidemiological or biostatistical topics.

Tutorial

Each tutorial session focuses on a trainee presenting one clinical question. The session begins with a 5-min description of the clinical scenario and focused clinical question. This is followed by a 10-min presentation of the background topic including clinical information about the condition, treatment, or diagnostic test. The trainee then presents and discusses the search strategy for 5 min.

The following 45 min is dedicated to critical appraisal of the evidence.

The study type is identified (e.g. prognosis, diagnosis, therapy, or harm), and the appropriate rating scale or worksheet is utilized to assist the presenting trainee and faculty members guide the group through the...