2011; 33: e306–e312
Teaching evidence-based medicine: Impact
on students’ literature use and inpatient
ELIZABETH ANN SASTRE, JOSHUA C. DENNY, JACOB A. McCOY, ALLISON B. McCOY
& ANDERSON SPICKARD III
Vanderbilt University Medical Center, USA
Background: Effective teaching of evidence-based medicine (EBM) to medical students is important for lifelong self-directed
Aims: We implemented a brief workshop designed to teach literature searching skills to third-year medical students. We assessed
its impact on students’ utilization of EBM resources during their clinical rotation and the quality of EBM integration in inpatient
Methods: We developed a physician-led, hands-on workshop to introduce EBM resources to all internal medicine clerks. Pre- and
post-workshop measures included student’s attitudes to EBM, citations of EBM resources in their clinical notes, and quality of the
EBM component of the discussion in the note. Computer log analysis recorded students’ online search attempts.
Results: After the workshop, students reported improved comfort using EBM and increased utilization of EBM resources. EBM
integration into the discussion component of the notes also showed significant improvement. Computer log analysis of students’
searches demonstrated increased utilization of EBM resources following the workshop.
Conclusions: We describe the successful implementation of a workshop designed to teach third-year medical students how to
perform an efficient EBM literature search. We demonstrated improvements in students’ confidence regarding EBM, increased
utilization of EBM resources, and improved integration of EBM into inpatient notes.
Evidence based medicine (EBM) encourages utilization of
evidence from clinical research to support clinical decision-
making for individual patients (Sackett et al. 2000). According
to Sackett, this involves five sequential steps: forming an
answerable clinical question, searching the literature, critically
appraising the studies available, applying the data to the
individual patient and assessing the intervention’s results
(Sackett et al. 1996). In this manner, practitioners are able to
deliver high-quality care by basing decisions on both the
patient’s wishes and the best available evidence found in the
literature (Evidence-Based Medicine Working Group 1992).
There is broad support to integrate EBM into undergraduate
curricula (Hatala & Guyatt 2002). There are many reports of
teaching steps one through three of Sackett’s model; however,
outcome measures in these studies have been limited to self-
reported searching, improved quality of literature searches,
and increased use of MEDLINE (Bennett et al. 1987; Landry
et al. 1994; Rosenberg et al. 1998; Srinivasan et al. 2002; Cayley
2005; Gruppen et al. 2005; Schilling et al. 2006). It is still
unknown whether or not these learned skills are applied to the
care of patients in the clinical setting.
We used a physician-led, hands-on workshop to train third-
year medical student clerks to design an answerable clinical
question and perform a time-efficient medical literature search.
Our primary outcome was evaluation of whether students’
utilization of EBM resources changed following our interven-
tion as demonstrated by analysis of students’ inpatient note
citations. We also measured students’ attitudes and knowledge
about literature searching, as well as their ability to incorporate
what they learned about EBM into write-ups they completed as
part of their responsibilities of taking care of patients on the
. Effective methods to teach EBM skills to medical
students are paramount.
. A physician-led hands-on workshop teaching literature
searching sills was associated with increased comfort
and confidence with EBM.
. Students demonstrated increased use of EBM and
improved incorporation of EBM into their inpatient
clinical notes following the workshop.
Correspondence: E. A. Sastre, Vanderbilt University Medical Center, Medical Center East, 7th Floor, Suite 4, Nashville, TN 37232, USA. Tel: 615 936
3216; fax: 615 936 3156; email: email@example.com
ISSN 0142–159X print/ISSN 1466–187X online/11/060306–7 ? 2011 Informa UK Ltd.
Population and setting
Third-year students on the inpatient portion of their internal
medicine clerkship (12 weeks) at Vanderbilt Medical School
are required to create written evaluations (‘‘history and
physical’’ notes) for two to three new patient admissions per
week. Clerkship goals require students to read about their
patients and discuss their findings from literature reviews in
the assessment and plan section of the admission note. For
over a decade, all student inpatient history and physical notes
have been expected to include literature citations relevant to
the patient’s presentation. Students have access to a medical
library that provides publicly available and proprietary
evidence-based electronic databases and journals. All students
received a single didactic session led by a medical librarian
during their first year of medical school designed to teach
MEDLINE skills, however, no further specific training program
had been established to address literature searching and
critical assessment skills.
We implemented a single, physician-led, hands-on 3h work-
shop to teach medical students clinical question formation and
literature retrieval skills according to the first two steps of EBM
as outlined by Sackett et al. (1996). In recognition of the
resources by busy practicing physicians (Montori & Guyatt
2008), we focused on teaching students how to locate and use
these resources. This included guidelines such as the National
Services Task Force guidelines, and the CDC as well as
systematic reviews such as ACP Journal Club, Cochrane
Database, and EBM. Selection of the EBM resources intro-
duced to the students was based on the instructor’s prior
continuing medical education classes related to teaching EBM
as well as personal use and experience. The instructor (EAS)
has 6 years experience in EBM training. The session consisted
of an interactive lecture and a hands-on practicum. The
didactic component covered three topics: (1) formulating the
clinical question; (2) devising a search strategy to answer
clinical questions; and (3) introduction to the strengths and
weakness of available pre-appraised resources, such as clinical
guidelines and systematic reviews. Throughout this overview,
the instructor led students through sample literature searches
at their own individual computers.
The workshop was delivered during each of the four
internal medicine clerkship blocks during the 2007–2008
academic year. Each clerkship block has approximately 30
students. In order to maintain a small group setting, we
randomly assigned students to one of five small groups (4–6
students per group) and offered the workshop to one small
group weekly for the first 5 weeks of the rotation. Therefore,
the workshop was delivered both at different times during the
rotation as well as during all four clerkship blocks. At the
beginning of each clerkship block, we invited students to
participate in the study. All third-year students, regardless of
United States Preventive
whether they agreed to be in the study, had the opportunity to
participate in the workshop. The Institutional Review Board
approved the study design.
Evaluation and outcome measures
Outcome measures included pre- and post-surveys, physician
analysis of student write-ups, and computer log data of
students’ searches. After reviewing the literature, we designed
a 16-item multiple-choice and free response survey that
assessed students’ attitudes toward literature searches, their
prior use of EBM resources, and their knowledge of clinical
question formation and searching techniques. Students com-
pleted the survey before the workshop (‘‘pre-workshop
survey’’), at the conclusion of the workshop (‘‘post-workshop
survey’’), and on the final day of the clerkship (‘‘end of
clerkship survey’’) which occurred 8–12 weeks following the
workshop depending on to which group the student was
randomized. The pre-workshop survey had additional items
regarding baseline characteristics of participants; the post-
workshop survey had additional items to assess their satisfac-
tion with the workshop.
All internal medicine clerks are expected to include
evidence from the literature in their inpatient notes as it
relates to care of their specific patients. However, prior to our
workshop, students were not formally instructed on how to
locate or utilize EBM resources because it had been assumed
that this instruction would be part of the informal curriculum
on the wards. Therefore, we evaluated changes in behavior
following the intervention by analyzing students’ inpatient
admission notes and using these notes as a surrogate marker of
impact on patient care. At our institution, all notes written by
students during their clerkship rotations are stored in the
Learning Portfolio system, an online, secure, HIPAA-compliant
web application (Spickard et al. 2008). Two trained physicians
used a standardized scoring sheet to score students’ notes
accessed through Learning Portfolio. Our standardized scoring
sheet was based on our prior work (Spickard et al. 2008),
which utilized a previously reported inpatient note evaluation
instrument (Kogan & Shea 2005). Our scoring metric included
a quantitative component to record the number of citations
and the type of resource cited. Our scoring metric also
included a quantitative component to record the number of
citations and the type of resource cited. Additionally, elements
from the Kogan and Shea (2005) evaluation instrument
applicable to our study included prioritization of a problem
list and formulation of a differential diagnosis. We further
evaluated the overall quality of the discussion portion of the
note by assessing the quality of the EBM citations, the
application of the information from the citations back to
the patient case, and an overall ability to demonstrate how the
information from EBM citations might influence the patient’s
clinical care. These five qualitative components were scored
on a five-point Likert scale.
Two physician raters evaluated student notes written
immediately before and after the workshop. Given limitations
of faculty and financial support available for this study, we
randomly selected (using a random number generator) 51 of
our participating students to be evaluated by the two raters.
Teaching evidence-based medicine
Raters scored the three admission notes written immediately
prior to the workshop and the three admission notes written
immediately following the workshop for each student evalu-
ated. Admission notes were chosen consecutively based on
their timing with respect to the workshop. The two raters were
presented each of these 51 students’ notes via the Learning
Portfolio system in a random order (using a random number
generator) with respect to both student and timing. Raters
were blinded to the date of the note and to whether the note
was written before or after the workshop. To ensure similarity
between raters, both raters jointly rated a test set of 10
documents, then independently rated 20 documents. Inter-
rater reliability for all metrics on 20 admission notes before the
start of the study was acceptable with a linearly weighted
kappa of 0.51.
Finally, we analyzed computer log data that tracked student
searches to various EBM resources using hyperlinks and
search tools integrated within the electronic medical record
system. Students are oriented to these tools as they begin their
third-year medicine clerkship (prior to the EBM workshop).
Since use of each EMR-linked resource is logged with a unique
identifier for each student, we were able to characterize each
resource use as before or after the specific date of each
student’s EBM workshop. This analysis did not include student
access that may have occurred from home, as a result of
directly entering in web addresses (i.e., URLs), or from
computer systems outside the Vanderbilt system.
Data from all questionnaires and evaluation tools were
collated into a Microsoft
sion notes from both before and after the intervention were
matched according to the student’s study number. In this
manner, each student’s pre-intervention notes could serve as a
control to be compared to post-intervention clinical documen-
tation. Pre- and post-intervention note ratings were averaged
for each student. Analyses used Fisher’s Exact test for
categorical data and two-tailed paired t-tests for the physician
review of clinical notes. All analyses were two-tailed where
applicable. Analyses of proportions used the binomial exact
test (for binomial distributions) or a two-sample test of
proportional equality (when comparing two proportions).
?Excel spreadsheet. Inpatient admis-
Cohen’s kappa was used to assess inter-rater agreement. All
statistical analyses were performed using Stata, version 9.2
(College Station, TX).
The study began in July 2007 and concluded in June 2008. All
115 medical students rotating through the internal medicine
clerkship were eligible to participate in the study; however,
only 100 students were able to attend the workshop and
consented to the study. Of those participants, 98 students
(85%) completed all three surveys (pre, post, and final). The
mean age of participants was 25.6, 42% were female, and all
participants had prior research experience. Ninety-seven
percent of the students reported the workshop to be useful
and 490% would recommend it to fellow students. In
addition, 94% reported they would incorporate the skills
learned into the clinical care of patients.
Table 1 demonstrates results of student’s pre- and post-
workshop attitudes toward EBM. Improvements in students’
confidence in using EBM and perceived value of the applica-
tion of EBM in clinical medicine persisted through the end of
the clerkship. After the workshop, fewer students believed
that literature searches were excessively time consuming. In
addition, less students believed that questions could be more
quickly answered using textbooks or consultants rather than
by performing literature searches. These changes persisted to
the end of the clerkship.
Students also reported an overall shift in the type of
information resource they used with increased utilization of
evidence-based resources such as systematic reviews and
reduced use of more general resources such as Google
(Figure 1). Analysis of data within each of the four clerkship
rotations in the academic year did not show any significant
Table 2 presents the data from the individual physician
reviews of 289 clinical notes from 51 unique students
participating in the study who served as a representative of
all participants in our study. Analysis of admission notes
showed the number of citations per inpatient note was
generally low, and there was no significant difference in the
number of citations before and after the workshop. Most (75%)
citations in both pre- and post-analyses were to primary
Table 1. Self-reported percentages of attitude outcomes among 98 students before and after a third-year EBM clerkship intervention.
End of clerkship
I feel comfortable using EBM to answer clinical questions
After performing a literature search, I feel confident
I have found the best evidence to answer the question
EBM helps clinical decision making
EBM is useful on a daily basis
Literature searches are too time-consuming to
do in the hospital or clinic
Questions can be more quickly answered with textbooks or
consultants rather than literature searches
Note: *p-Value50.05, Fisher’s exact test.
E. A. Sastre et al.
journal articles. There was a trend toward increased utilization
of both clinical guidelines and systematic reviews following
Table 3 presents the data from the qualitative assessment of
the student clinical notes (n¼270 from 46 students). Only 46
of our randomly selected 51 students had notes that were
complete enough within the Learning Portfolio system to be
able to be assessed using our scoring metric. Despite the lack
of difference in number of citations, physician qualitative
judgment of overall quality of the EBM incorporation into the
discussion of the patient’s problems improved following
the intervention (3.62 vs. 3.91, p¼0.02, using a two-tailed
paired t-test). While changes in other ratings of general
assessment and plan quality that were not tied to EBM
utilization were not significant, each trended toward improve-
ment after the workshop (p¼0.07–0.15, using a two-tailed
paired t-test). Inter-rater agreement for physician reviewer was
good; the kappa ranged from 0.76 to 1.00 for numerical
assessments; the linearly weighted kappa for the note quality
assessment was 0.52.
Figure 2 presents the results of the computer log analysis.
Usage for all electronic resources increased (odds ratio 6.82
[95% confidence interval, 6.00–7.75], p50.0001), with stu-
dents clicking on 289 resources (0.12/week) before the
workshop and 1775 resources (0.66/week) following the
workshop. The proportion of systematic peer-reviewed
databases (such as Cochrane Database, Clinical Guidelines,
etc.) utilized in searches increased dramatically (odds ratio
accounting for only 13% of all resources accessed before the
workshop but 59% of the resources accessed following the
EBM is a powerful tool that enables students to attain the skills
and knowledge needed for lifelong self-directed learning. With
the current rapid influx of new information in the biomedical
literature, students must learn how to navigate the information
thoroughly and efficiently to apply the best evidence available
to their patients. Previous studies have demonstrated that
Table 2. Number and type of EBM citations in clerkship notes.
Mean citations per note (95% CI)
Total number of citations per note
Textbook citations per note
UpToDate citations per note
Journal citations per note
Guideline citations per note
Systematic Review citations per note
Notes: Numbers represent mean citations per note for 298 notes written by 51 unique students. p-Values were calculated using two-tailed t-tests.
Table 3. Quality of EBM content in clerkship notes.
Mean quality score (95% CI)
Pre-workshop Post-workshopImprovement (95% CI)
Quality of EBM discussion and application to patient
Prioritizes problem list
Formulates complete differential diagnosis
Discusses likelihood of differential diagnosis and plan
0.29 (0.04 –0.53)
Notes: Numbers represent mean physician ratings for each note’s assessment and plan according to a 5-point Likert scale (1, poor; 5, excellent). p-Values were
calculated using a two-tailed paired t-test. *p50.05.
Number of times per week
a literature resource was reported utilized before and after the
Survey data of average number of times per week
Teaching evidence-based medicine
third-year students are unable to construct efficient search
strategies and more than three-quarters of those studied were
unable to find search results adequate to affect clinical care
(Burrows & Tylman 1999). Effective and feasible methods to
teach EBM searching skills are paramount.
We demonstrate a positive impact of a short EBM work-
shop on student’s attitudes about EBM, personal confidence in
using EBM, student’s utilization of EBM concepts in clinical
notes, and student usage of EBM-based websites. Previous
studies have been able to demonstrate positive changes in
students’ attitudes toward EBM and resource utilization
following similar interventions (Bennett et al. 1987; Landry
et al. 1994; Srinivasan et al. 2002; Cayley 2005; Schilling et al.
2006). However, prior reports of studies teaching medical
students how to form a clinical question and perform a
literature search have had a different focus than our own in
that they have been limited to preclinical students not involved
in patient care (Rosenberg et al. 1998) or have involved
resource intensive curricula on the order of eight sit down
sessions (Dorsch et al. 2004), a 4–week elective (Gruppen
et al. 2005), or a 4-year comprehensive EBM curriculum
(Barnett et al. 2000). Other studies have focused more on
outcome measures related to search analysis of hypothetical
cases, rather than real time patient care situations (Rosenberg
et al. 1998; Burrows & Tylman 1999; Dorsch et al. 2004;
Gruppen et al. 2005). Schilling et al. (2006) showed that an
online course was associated with improved ability of students
to formulate a question, perform and effective search strategy,
and use more MEDLINE resources during the clerkship.
Landry, however, reported a curriculum focused on critical
appraisal skills did not have an effect on the frequency of
literature citations found in students’ inpatient write-ups
(Landry et al. 1994). Others have not been able to show
improved student attitudes about EBM, formation of an
answerable question, or ability to answer the question
efficiently (Burrows & Tylman 1999; Badgett et al. 2001)
suggesting that there is still work to be done in finding the
optimal methods to teach literature searching skills to medical
Our study demonstrated pre–post changes in attitudes
about EBM, confidence in using EBM resources, and self-
reported increase use of EBM resources that lasted for several
weeks following an intervention designed to teach compre-
hensive literature searching skills. In addition, the self-reported
increase in utilization of EBM resources was verified by our
computer log analysis which demonstrated a greater increase
in student use of EBM resources than of non-EBM resources.
Our personal review of 289 student inpatient notes demon-
strated no significant change in the overall number of citations
following the intervention, as we expected; however, the
quality of those citations did improve in as much as they
reflected more EBM resource utilization.
Our study is unique in that our students demonstrated both
a trend toward increased citation of peer-reviewed databases
and clinical guidelines as well as improved quality of EBM
incorporation into students’ notes discussing real-time patient
issues following the workshop. Not only did the quality of the
citations improve with increased utilization of pre-appraised
EBM resources in the notes, but students were better able to
apply the data back to their patient’s case and use that
information to formulate more evidence-based assessments
and plans. Though, the number of citations per note is small
and our sample size is limited, we consider that these trends in
student behavior may suggest a possible association with the
workshop. Perhaps, even more important is the demonstration
of the increased utilization of EBM resources as documented
by student log-ins. Although optimally, we would like to be
able to measure the effect of our intervention on actual patient
After workshop Before workshop
US preventive services task force
National guidelines clearinghouse
McMaster EBM protocols
BMJ evidence based medicine
BMC clinical evidence
Percent utilization of EBM resources and non-EBM resources as determined by computer log analysis before and after
E. A. Sastre et al.
care outcomes, in practice this is difficult, and we believe it is
likely that the demonstration of increased citation of quality
EBM resources suggestsincreased
resources which may lead to increased implementation of
evidence-based decisions in clinical care. In addition, instead
of focusing solely on MEDLINE skills, we sought to expand
students’ EBM toolkit to include systematic reviews and clinical
guidelines. We believe that by focusing on pre-appraised EBM
resources rather than original studies as has been done by
others (Landry et al. 1994; Rosenberg et al. 1998; Burrows &
Tylman 1999; Barnett et al. 2000; Dorsch et al. 2004; Cayley
2005; Gruppen et al. 2005), we have helped students to find
quality information in a streamlined fashion. Of course,
students still need to know how to search for original articles
when previously evaluated resources are unavailable or do not
directly address their patient’s unique situations, however
since busy physicians may not find the time for routine
MEDLINE searches (Cook et al. 1997; Guyatt 2000), it is
important to equip our students with the skills to use these pre-
Our study findings should be interpreted in the context of
their limitations. First, our work at a single institution limits our
ability to generalize our findings to other institutions.
However, other schools could easily adopt a similar short-
workshop approach. Second, without a control group, it is
difficult to know whether the improvements demonstrated by
students were due to the workshop, to repeated exposure to
the survey, or other unexplained factors related to participating
in the clerkship. The students were exposed to the same
survey three times in the 12-week clerkship and this may have
impacted our results. Additionally, all students may have
improved knowing that learning about and using search
strategies was an important part of their clerkship work.
Analysis of the effect of time of workshop on pre–post
outcomes showed ongoing improvements in students’ atti-
tudes and reported used of EBM searches whether they had
participated in the workshop early in the year versus late, or
early during a particular block rotation versus later. This
supports a workshop effect, for students who had several
months of other clinic rotations or several weeks of internal
medicine before the workshop still showed improvement in
post-workshop analysis. Third, the analysis of the student
notes showed fewer literature citations than expected. This
limits the power to detect differences in integration of EBM
resources into the note. Computer log data, however, demon-
strated that students were performing more literature searches
and preferentially selecting more evidence-based resources
over summative resources such as UpToDate and Google. Our
computer log data, however, is limited to those searches
performed through the EMR and thus could represent better
knowledge of the EMR specific search tool. In addition, while
our computer log data showed a low number of searches per
student, it is similar to other studies of students’ online
searching and likely represent the limitation in current systems
to capture all of a given students’ information retrieval efforts
(Tannery et al. 2002; Schilling et al. 2006). Fourth, our inter-
rater reliability is modest and this can be a source of bias,
however, our percent agreement for subjective measures was
improvements that lasted several weeks after the intervention,
longer follow-up is needed to determine if the newly
acquired changes in attitudes and behaviors can be maintained
In summary, we demonstrate a feasible workshop to teach
literature searching skills to third-year medicine clerks.
Students enjoy the workshop and report more confidence in
and utilization of EBM resources, used more evidence-based
resources, and better utilized these in their notes. The
workshop has easily been incorporated as an ongoing part
of the third-year clerkship internal medicine rotation. Future
studies will be needed to address step five of Sackett’s model
and further evaluate the impact of EBM curricula, such as ours,
on actual patient outcomes.
This study is supported in part by a GIVME Medical Education
grant provided through Vanderbilt University School of
Medicine and a grant from the D.W. Reynolds Foundation.
Declaration of interest: The authors have no declarations
of interest to report.
Notes on contributors
ELIZABETH ANN SASTRE, MD, is an assistant professor in Internal
Medicine at Vanderbilt University Medical Center.
JOSHUA DENNY, MD, MS, is an assistant professor in Internal Medicine
and Biomedical Informatics at Vanderbilt University Medical Center.
JACOB McCOY, MS, is completing his graduate study in the Department of
ALLISON McCOY, MS, is completing her graduate study in the Department
of Biomedical Informatics.
ANDERSON SPICKARD III, MD, MS, is an associate professor in Internal
Medicine at Vanderbilt University Medical Center.
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