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Evaluating evidence-based practice performance
  1. Michael L Green, MD, MSc
  1. Department of Internal Medicine, Yale University School of Medicine
 New Haven, Connecticut, USA

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 Thought is the blossom; language the bud; action the fruit behind it.
 Ralph Waldo Emerson

    Evidence-based practice (EBP) educators need valid and feasible approaches to evaluate the impact of new curricula and to document the competence of individual trainees. As of 1999, however, the published evaluation instruments often lacked established validity and reliability, focused on critical appraisal to the exclusion of other EBP steps, and measured knowledge and skills but not behaviours in actual practice.1 Editorialists at the time lamented, “ironically, if one were to develop guidelines for how to teach EBM based on these results, they would be based on the lowest level of evidence.”2

    In the ensuing years, educators have responded to the challenge. We now have several instruments, supported by multiple types of evidence for validity, to evaluate EBP knowledge and skills. In the parlance of Miller’s pyramid,3 these instruments can document that a trainee “knows” and “knows how” to practice evidence-based medicine. And promising EBP objective structured clinical examinations, while supported by more limited psychometric testing, allow trainees to “show how” in realistic clinical settings (see Web extra at for references for these knowledge and skill instruments).

    This brings us to Miller’s “does” as we move from competence (or skills) to performance (or behaviours). To “bear fruit from the blossom,” we must ensure that trainees implement their EBP skills in actual practice. We can consider EBP performance at 2 levels. Firstly, we can ask: “does a trainee perform the 5 EBP steps (Ask, Acquire, Appraise, Apply, and Assess) in the course of patient care activities?” Alternatively, we can look further downstream and examine clinical practice data directly, asking “Does this clinician perform evidence-based clinical manoeuvres and affect desirable patient outcomes?”


    We can simply ask trainees if they, for example, consistently search …

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