David Keahey

An Integrated Evidence-Based Medicine Curriculum in Physician Assistant Training: From Undergraduate to Postgraduate

&NA; Physician assistant educators must equip their students with the skills to competently practice medicine not only today but also in the future. Our graduates are faced with an overwhelming array of new information and it is imperative that they be competent in managing and using this evidence to improve the health of their patients. Future PAs must have the ability to construct answerable clinical questions, develop effective searches of the literature for evidence, appraise the evidence, and ultimately apply it to patients. Evidence‐based medicine (EBM) provides the framework and skill set that enables PAs to efficiently become lifelong learners and critical thinkers. This article is an overview of the University of Utah Physician Assistant Programs (UPAP) EBM curriculum that is focused on clinical relevance and utility. It also outlines how programs can adapt for themselves UPAPs EBM curriculum to satisfy graduate‐level educational requirements, as the masters degree becomes the standard for PA education.

Evidence-based medicine databases: changing needs along the path from physician assistant student to clinician.

their clinical questions. INTRODUCTION A common question we get from our students is, “What’s the best electronic medical database that will help me answer questions during PA school?” Common to our role as medical educators, our usual response is “it depends.” This conundrum brings to mind the choice we faced as students three decades ago when deciding whether to reach for a voluminous Harrison’s Principles of Internal Medicine or the concise and timely Lange Current Medical Diagnosis and Treatment. In the precomputer era, the choices were perhaps simpler, but less satisfying from an evidence standpoint. A recent study identified more than 30 databases available free or by subscription to students.1 They range from the unscreened, open access breadth of PubMed to carefully appraised and highly clinicianfriendly DynaMed and Essential Evidence Plus. Our noncommittal answer is driven by the need to choose the right tool for the right job. And that job evolves throughout the educational process. The educational and clinical evidence needs of PA students change depending on their stage of training and the depth of their foundational knowledge. The requirements of didactic year students preparing for a gastroenterology final or a problembased learning module differ from those of a student sitting in an examination room with a patient. As a result, it may be prudent for educators responding to this question to be mindful of matching the tool to the student’s stage of training and the setting where the learning takes place.

Demonstrating Evidence-Based Medicine Skills and Comprehension with a Student Capstone Project

Editor’s Note: In this column, the EBM feature editors highlight an example of the capstone project that all students at their institution must complete at the end of the program’s EBM curriculum. The high quality of the student-written paper illustrates the lasting value for the profession of teaching students the principles of searching, evaluating, integrating, and presenting

Evidence-Based Medicine Resources for Physician Assistant Faculty: DynaMed

INTRODUCTION When we took the first tentative steps years ago to develop a new clinical problem-solving curriculum that embraced the concepts of evidencebased medicine (EBM), there was little we could say to students who asked, “But how are we going to do this in the clinic”? The concepts were sound but the immediate application to patients, the only thing that really matters, was stymied by the lack of useful tools. Fortunately, innovation and technology have progressed rapidly and placed a number of devices in the hands of clinician educators that they can use at the bedside and in the exam room. The computer-based electronic health record (EHR) has become ubiquitous. The dog-eared notebook “peripheral brains” of our generation, loaded with clinical facts and held together by a rubber band, have been replaced by sleek and speedy PDAs with instantly accessible voluminous libraries and databases. Many clinicians have become so dependent on these tools that to suffer a system crash, or even to leave them by accident at home, produces instant anxiety. I (DK) have made a mad dash from clinic back to home to retrieve mine more than a few times. Since purchasing Epocrates, a medication database, I have not looked at a Physicians’ Desk Reference text. I’m not even sure the clinic still has one. PDAs have become a necessity for the majority of PA educator/clinicians; however, the choice of software can be overwhelming and is often made with the gut rather than the head. The decision to purchase Epocrates, for example, was made after a brief exposure through a colleague and a free trial. There was no careful weighing of the pros and cons of other products — and this is probably true of many clinical educators. As a new tool is used, we grow familiar and comfortable with the interface and it becomes literally an extension of our bodies. We tend to stay with the same tools not only because they are good, but also because we don’t want to take time to learn a new system. For instance, we have colleagues who swear by LexiComp, another medication database, but we have no interest in investing time to learn a new tool that would replace one that has already become indispensable. Our students often have technology skills that exceed those of faculty. It is important for faculty to become facile with the available resources to support our students’ evidence-based clinical practice. For this reason, the EBM feature in this journal will occasionally review tools that may assist PA educators with their EBM curriculum and help them make choices in a more systematic way. The focus of this review is a computer and PDA database application called DynaMed, which has been designed from the ground up on the principles of EBM.

The Patient-Centered Medical Home: Preparation of the Workforce, More Questions than Answers

As American medicine continues to undergo significant transformation, the patient-centered medical home (PCMH) is emerging as an interprofessional primary care model designed to deliver the right care for patients, by the right professional, at the right time, in the right setting, for the right cost. A review of local, state, regional and national initiatives to train professionals in delivering care within the PCMH model reveals some successes, but substantial challenges. Workforce policy recommendations designed to improve PCMH effectiveness and efficiency include 1) adoption of an expanded definition of primary care, 2) fundamental redesign of health professions education, 3) payment reform, 4) responsiveness to local needs assessments, and 5) systems improvement to emphasize quality, population health, and health disparities.

Evidence for Evidence-Based Medicine

INTRODUCTION As we try to inculcate in our students the value of using evidence-based medicine and refine our teaching of EBM, a fundamental question needs to be posed (and more than one student has asked this!) — what is the evidence that teaching evidencebased medicine actually changes patient outcomes? This question is not new in the medical literature. In fact, one of the chapters in the JAMA Users’ Guides to the Medical Literature posed this question back in 1992,1 and again in 2000,2 noting there was little literature to indicate whether teaching EBM improves patient outcomes. Because we are clearly investing a lot of faculty and student effort in EBM, we need to have a good answer for our students when they ask this question. EBM proponents argue that “it is impossible to design such a randomized study ... because no investigative team or research granting agency has yet overcome the problems of sample size, contamination, blinding, and long-term follow up which such a trial requires.”3 Is it even ethical to consider withholding evidence from clinicians or patients? For this column, we thought we’d try to tackle this question to see if there has been any mounting evidence for EBM improving patient outcomes, especially since it has seemingly become more integrated into clinical practice. Our goal is also to demonstrate the first few steps of the EBM process as we attempt to answer the question in this column.

The evidence-based medicine write-up: a tool for EBM skill development and patient-centered evidence application.

INTRODUCTION In 2004, David Keahey and I published a broad overview of the evidence-based medicine (EBM) curriculum delivered at the University of Utah Physician Assistant (PA) Program.1 Over the intervening years, we have shared tools, databases, texts, and various approaches to teaching EBM through this column. In 2010, we published an example of our students’ capstone paper for the master’s curriculum.2 It then occurred to us that we hadn’t des-cribed something we consider to be the lynchpin of this curriculum, the evidence-based medicine writeup (EBMWU). Although the EBMWU has evolved through a number of iterations since we launched our EBM curriculum in 2001, the guiding principle for this endeavor has remained constant: to directly connect the application of evidence to patient care with an active and reflective process. In 2008, after assessment of student evaluations of the EBMWUs, we realized the EBMWU had become cumbersome and weighed down by trying to accomplish objectives outside of the goal of honing EBM skills. After reflection on the essence of what we hoped students were getting from the EBWMU and analysis of the evaluative data, a sleeker and more compact version emerged, which we will describe here.

Actively and Formatively Teaching Statistics To Physician Assistant Students

INTRODUCTION Although it is unlikely that it is the opportunity to study statistics that attracts physician assistant (PA) students to study medicine, PAs need to have some understanding of the subject for reading the medical literature as well as practicing evidence-based medicine (EBM). EBM needs to be taught in all PA programs regardless of the degree offered1 and statistics is an important component of EBM. A key to teaching statistics to PA students is recognizing that knowledge and a primary application of statistics is required in order to read the medical literature. Physician assistant and biostatistics educators agree that health professions students do not need to become statisticians themselves.1,2 Curricular emphasis therefore needs to be placed on interpretation, rather than on computation. Keahey and Goldgar explain, “Our goal is not to train researchers or academicians; it is to train physician assistants who can practice medicine using the most advanced resources available to uncover the best evidence that will help them care for their patients.”1 Even with statistics as a prerequisite to a masters level program, it may be necessary to reteach it as part of a research or EBM course. Statistics tends to be daunting to students, and many have a negative perception of it.3,4 In fact, a specific form of math anxiety—known as “statistics anxiety”—has been identified.3 Furthermore, instructors in PA classrooms traditionally use lecture-based teaching formats, which may not be optimal for this topic.2,3,4 Lastly, instructors are challenged to find ways to address varying levels of student recall of prior learning as well as methods to stimulate and maintain student interest in the topic. We describe the curriculum, teaching strategies, and assessment activities employed at Idaho State University to teach statistics within a research/evidence-based medicine course in the first semester of the program. Our goal is to highlight the active and formative nature of assessment in this course and how it enhances the teaching of statistics. The PA program at Idaho State University is a 24-month graduate program. The research/evidencebased medicine course is offered during the first semester, but its topics are threaded throughout the curriculum, culminating in an evidencebased master’s-level case presentation. The primary objective of the course is to build a foundation in EBM. However, the course lays the groundwork for students’ success in the final project and in the program. The goal of the statistics segment of the course is for students to use their knowledge of statistics to critically evaluate medical research literature; for example, to identify what might produce a Type I error and determine the likelihood of its happening. Furthermore, and arguably of greatest import, the skills introduced in the first semester and reinforced The intent of this feature is to present a forum for PA educators to share their approaches to teaching EBM. Areas of interest might include reviews of EBM resources; mini-tutorials in areas such as statistics, epidemiology, and study design; ethical, historical, or philosophical perspectives of EBM; and discussion of practice or technological tools that enhance application of EBM. Prospective authors are encouraged to contact the feature editors to receive approval of topics in advance. Authors desiring to contribute to EvidenceBased Medicine should forward submissions to:

Durability of Expanded Physician Assistant Training Positions Following the End of Health Resources and Services Administration Expansion of Physician Assistant Training Funding.

Purpose The purpose of this study was to assess the number of Health Resources and Services Administration Expansion of Physician Assistant Training (EPAT)-funded physician assistant (PA) programs planning to maintain class size at expanded levels after grant funds expire and to report proposed financing methods. The 5-year EPAT grant expired in 2015, and the effect of this funding on creating a durable expansion of PA training seats has not yet been investigated. Methods The study used an anonymous, 9-question, Web-based survey sent to the program directors at each of the PA programs that received EPAT funding. Data were analyzed in Excel and using SAS statistical analysis software for both simple percentages and for Fishers exact test. Results The survey response rate was 81.48%. Eighty-two percent of responding programs indicated that they planned to maintain all expanded positions. Fourteen percent will revert to their previous student class size, and 4% will maintain a portion of the expanded positions. A majority of the 18 programs (66%) maintaining all EPAT seats will be funded by tuition pass-through, and one program (6%) will increase tuition. There was no statistical association between the program type and the decision to maintain expanded positions (P = .820). Conclusions This study demonstrates that the one-time EPAT PA grant funding opportunity created a durable expansion in PA training seats. Future research should focus on the effectiveness of the program in increasing the number of graduates choosing to practice in primary care and the durability of expansion several years after funding expiration.

McAllen, Texas, Evidence-Based Medicine, and President Obama

INTRODUCTION In April we traveled to McAllen, Texas, to present an evidence-based medicine (EBM) seminar to the faculty of the University of Texas Pan American (UTPA) PA Program in nearby Edinburg. On our route to the UTPA campus, we drove by what seemed to be a plethora of medical facilities ranging from family medical clinics and those focusing on pediatrics and women’s health to subspecialty clinics. There were numerous ambulatory surgical facilities and at least four home health businesses. The hospitals we stumbled across seemed, from the road, to be modern and attractively designed. We agreed that the number of health care facilities seemed out of proportion to what we perceived to be average for a community of McAllen’s size. To our knowledge, McAllen and its suburbs were not known as a research or tertiary care center that would create the need for health care organizations in greater-than-expected numbers. We did not think much more about this as we were focused on effectively delivering our presentation and not getting lost on the way to UTPA. The 21⁄2-day EBM seminar went well and we were impressed with a dynamic UTPA faculty, supported by visionary leadership. As is often the case, we returned home with a number of ideas from our attendees that will likely improve our own curriculum. Shortly after our return I (DK) received an email from a health policy and access listserve that I belong to about the June 1, 2009, New Yorker magazine article1 by staff writer Atul Gawande, MD. Dr. Gawande is on the medical staff at Brigham and Women’s Hospital in Boston and has been a writer for the New Yorker since 1998. What drew me to the article was not only my interest in health policy, but also the fact that it focused on McAllen, Texas. Dr. Gawande’s article compared McAllen to El Paso, Texas, and found what he termed “overutilization” of health care services. This was consistent with our decidedly nonsystematic observation that there was an overrepresentation of health facilities in McAllen. Intrigued, I read the article and have since followed the ensuing debate about the factual foundation of his reporting. Dr. Gawande’s finding that McAllen’s 2006 Medicare costs per enrollee of