Educational Resource Column
University of Colorado Department of Psychiatry
Evidence-Based Medicine Educational Project
Robert E. Feinstein, M.D., Brian Rothberg, M.D., Neil Weiner, M.D.
Daniel M. Savin, M.D.
I n July 2005, the University of Colorado Department of
Psychiatry Evidence-Based Medicine (EBM) Project
began to investigate whether formal educational interven-
tions could help residents develop a positive attitude to-
ward EBM, acquire EBM knowledge and skills, and fa-
cilitate the daily use of EBM with patients in a psychiatric
outpatient residency-training site. We developed our cur-
riculum and teaching approach by reviewing the world lit-
erature, three published EBM curricula (1–3), and addi-
tional EBM curricula presented at American Association
of Directors of Psychiatric Residency Training (AADPRT)
meetings. In December 2006, we found no published com-
prehensive EBM curricula from any specialties reporting
effectiveness data.
Two common approaches to EBM education found in
the literature include the use of problem/case-based learn-
ing methods (4–9) and adult learning theory (10). These
approaches emphasize active learning to link knowledge
and skill with clinical practice. In 1995, a systematic review
of 102 trials (8) revealed that didactic approaches had little
effect on physicians’ clinical practice. A recent 2004 meta-
analysis (9) reviewing 18 studies using standalone EBM
teaching methods demonstrated that these methods im-
proved EBM knowledge, but failed to change attitudes to-
ward EBM or foster clinical use of EBM with patients.
Table 1 reviews empirically validated, clinically integrated
teaching methods (9, 11–14), utilized by nonpsychiatric
colleagues, fostering clinical use of EBM.
We believe our study may be unique as the first pro-
spective psychiatry study designed to research the cumu-
Received February 18, 2007; revised June 22 and September 2, 2007;
accepted October 1, 2007. The authors are affiliated with the De-
partment of Psychiatry at the University of Colorado Health Sciences
Center. Address correspondence to Robert E. Feinstein, M.D., Se-
nior Associate Dean of Education, University of Colorado Denver
School of Medicine, Mail Stop F523, 13001 East 17th Place, Room
E1330, Aurora, CO 80045; Robert.Feinstein@ucdenver.edu (e-mail).
Copyright 䊚 2008 Academic Psychiatry
Academic Psychiatry, 32:6, November-December 2008
lative effectiveness of a curriculum with educational inter-
ventions. The goal is to significantly increase resident
knowledge, skills, and clinical use of EBM with psychiatric
outpatients. The project includes curriculum development,
implementation of four educational interventions, devel-
opment of two attitude questionnaires, development and
validation of a psychiatry EBM knowledge exam, and cur-
riculum evaluation using a pre/post-intervention design.
This article describes the curriculum, study instruments,
and preliminary evidence about the program’s effective-
ness using data from 37 psychiatry residents who volun-
tarily enrolled in the study.
Psychiatry-EBM Curriculum
The resident curriculum is progressive over 3 years
(postgraduate years 1–3) and follows a traditional EBM
approach of teaching the 6As (Assess a patient, Ask
TABLE 1. Clinically Integrated Teaching Methods which
Improve Attitudes, Knowledge, and Use of EBM in
Clinical Practice
‘‘Real time’’ question formulation and literature searching
(Coomarasamy et al, 2004)
EBM daily ward teaching rounds (Coomarasamy et al, 2004)
EBM journal club based on queries from the ward or
outpatient clinics (Coomarasamy et al, 2004; Hatala et
al, 2006)
EBM teaching rounds based on case presented in clinical
rounds (Coomarasamy et al, 2004)
8-week session based on problems encountered in clinical
practice (Coomarasamy et al, 2004)
2-hour EBM ward rounds, every other week, based on
patients currently being treated (Coomarasamy et al,
2004)
2-week internal medicine EBM elective rotation (Akl et al,
2004)
‘‘Real time’’ evidence-based general medical attending month
(Korenstein et al, 2002; McGinn et al, 2002)
EBM in morning report (Hatala et al, 2006)
EBM⳱evidence-based medicine
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EVIDENCE-BASED MEDICINE EDUCATIONAL PROJECT
a clinical question, Acquire the information, Appraise the
information, Apply the information with a patient, Assess
the outcome with the patient) (3–5). Residents learn and
practice assessing a patient, asking an EBM question using
the PICO-QQ format (Population, Interventions, Com-
parison group, Outcome, Question type, Quality of the
study), acquiring the information using online library
searching of textbooks and the world literature, appraising
the literature using EBM mathematics, applying the liter-
ature with a patient, and assessing patient outcomes. All
courses are highly interactive and use computers, mini-lec-
tures, problem/case-based learning, and resident teaching.
The PGY-1 course consists of three weekly, 2-hour ses-
sions, designed to introduce EBM and create interest in
the 3As (Assess a patient, Ask a question, Acquire the
information), while avoiding EBM mathematics. The con-
tent addresses the question, “What is EBM and why use
it?” as well as assessing, asking, and acquiring articles from
online searches.
The PGY-2 course meets weekly and consecutively for
6 hours. Two sessions are devoted to practicing the 3As.
Residents choose one randomized controlled trial to eval-
uate. Three sessions focus on critical appraisal skills and
an introduction to EBM mathematics (1–6). The last ses-
sion covers outcomes and application of information with
patients, with consideration of patient values and prefer-
ences.
The PGY-3 course consists of 25 75-minute classes. The
first 15 sessions solidify use of the 6As and EBM mathe-
matics. Faculty members model an ideal case for two ses-
sions. In 13 sessions, residents present their own cases to
practice and teach all 6As. With faculty support, residents
lead critical appraisals of therapy, use EBM mathematics,
and learn to use outcome measures. The remaining 10 ses-
sions use the 6As with practice guidelines, systematic re-
views, and a wider variety of outcome measures. Practice
guidelines are critically appraised, using the AGREE (15)
assessment. Meta-analyses/systematic reviews are critically
appraised using guidelines described elsewhere (4–6, 16).
Clinically Integrated Teaching Activities
Use of EBM in daily psychiatric care is strongly empha-
sized in the PGY-3 outpatient year. Midway into the PGY-
3 course, we add four educational interventions designed
to facilitate residents’ clinical use of EBM.
Intervention 1: Index Case and EBM Reminder Sur-
vey. Residents in PGY-3 participate in a 3-hour session.
In the first hour, the resident sees a patient called the “in-
526 http://ap.psychiatryonline.org
dex case.” In the subsequent hours, the resident discusses
with faculty any knowledge gaps in using the 6As. Together
they set individualized learning goals. By the end of this
session, the resident will have selected an outcome mea-
sure, from a rating scale book (17) or CD, which will be
used with the index patient. The resident is also introduced
to the EBM Reminder Survey and completes the first sur-
vey detailing usage of EBM practices during the session.
Intervention 2: Outcome Measure at the Index Pa-
tient’s Second Visit. During the second visit with the
index patient, the resident explains, negotiates, and begins
use of an outcome measure with the patient. Using the
EBM Reminder Survey, the resident details EBM activi-
ties during this and all subsequent patient visits.
Intervention 3: Four Additional Resident Cases:
EBM Reminder Surveys. After completing the initial
index patient visit, the resident chooses four additional
cases. A staff member from medical records attaches the
EBM Reminder Survey to the front of the additional
charts for the next five visits of each patient. After each
patient visit, the resident completes a survey. Over many
months, each resident can complete a total of 25 surveys.
Intervention 4: 1-Minute-Preceptor. Once PGY-3
residents begin working with their index cases, four EBM
attendings, who precept all PGY-3 residents, begin using
a 1-minute preceptor “microskills” (14, 18, 19) approach,
which is supportive of EBM. The attending tries to elicit
a commitment from the resident regarding a case formu-
lation and treatment plan, probe the resident’s thinking
and evidence supporting all decisions, teach something
new about EBM, reinforce what was done correctly, and
correct mistakes.
Environment for Implementation
A critical component of curriculum implementation in-
volves availability of faculty knowledgeable in EBM. With
only one expert EBM teacher, we formed a four-member
EBM faculty self-teaching group, designed to help all fac-
ulty learn EBM and prepare to co-teach EBM courses. We
also scored exams and supervised in the outpatient clinic
using microskills. These attendings all work in the outpa-
tient department, a major teaching site for all residents.
Close resident-faculty working relationships may have in-
fluenced the 100% willingness of 37 eligible residents to
enroll, with only one resident opting out of the clinical
component of the study. Senior psychiatric research and
clinical faculty volunteered to take, and completed, an
Academic Psychiatry, 32:6, November-December 2008

early version of the EBM exam, revealing a very receptive
environment.
Curriculum Study
Based on the literature and prior experience teaching
EBM to residents, we assumed that residents would have
little prior exposure to EBM. We hypothesized that atti-
tudes toward EBM and EBM knowledge, as measured by
the Colorado Psychiatry Evidenced-Based Medicine Ex-
amination (CP-EBM Exam), would increase progressively
with this curriculum. After six sessions, we expected resi-
dents would do more searching using PICO-QQ. After 25
sessions, we hypothesized that R3 scores on the CP-EBM
Exam would substantially increase. Furthermore, we hy-
pothesized that application of EBM with patients would
not significantly increase until PGY-3 residents had a 3-
hour teaching session, saw patients, completed the EBM
Reminder Survey, and received feedback from attendings
using the 1-minute preceptor. To evaluate these hypothe-
ses, we conducted a prospective pre/post-intervention
study examining changes in resident attitudes/beliefs,
knowledge, and clinical use of EBM at multiple time
points.
Instrumentation
Three instruments were prospectively designed to assess
program impact: the EBM Attitudes and Beliefs Survey;
the EBM Reminder Survey, designed to prompt and track
resident use of EBM with patients; and an EBM knowl-
edge exam.
The EBM Attitudes and Beliefs Survey is a 72-item
questionnaire assessing prior computer use and experi-
ence, prior experience with EBM, perceived importance of
using EBM, perceived confidence in EBM skills, and per-
ceived barriers or facilitators to EBM use. The attitude
questionnaire is administered before and after each course
and after clinical teaching interventions.
The EBM Reminder Survey is placed on the front of
patient charts, prompting residents to use EBM during
clinical care. Nine questions ask residents to detail their
use, or nonuse, of EBM practices after each of 25 visits.
Investigators are blinded to which residents complete the
surveys and any identifying patient information, except for
the initial index patient visit.
The Colorado Psychiatry Evidenced-Based Medicine
Examination (CP-EBM Exam) is a 14-question exam as-
sessing EBM knowledge and skills. Based on the Fresno
Test of Competence in Evidence-Based Medicine (20), the
psychiatry version and scoring rubric were developed in
Academic Psychiatry, 32:6, November-December 2008
FEINSTEIN ET AL.
consultation with Dr. Ramous. The 14 open-ended ques-
tions attempt to reproduce the 6As clinical thinking used
during a patient encounter. The exam is administered to
residents with an open time frame of 60–120 minutes.
To validate the exam and scoring rubric, at random we
chose 8 out of 20 exams previously completed by PGY-4
or PGY-5 child fellows not enrolled in the study but re-
ceiving EBM instruction from the first author. Initially, rat-
ers independently scored the same exam and compared
results on each of 14 items. We discussed all items on
which our scorings disagreed. After three rounds, using
three different exams, we agreed on all answers. Interrater
reliability was obtained using our four investigators, scor-
ing two rounds of five additional exams. Raters were
blinded to resident and resident year. One common exam
was embedded in each group of five exams for each rater,
and raters were blinded to the common exams. Reliability
was estimated using average interrater correlations on the
total score and by the intraclass correlation. The interrater
reliability for the two rounds of five tests was 0.95, and the
intraclass correlation was 0.93. Given these high reliabili-
ties, we were comfortable having a single investigator score
resident exams. Preliminary EBM scores are reported by
number of sessions, while pre/post-improvement in scores
is reported in the Results section.
To validate the exam, psychiatry EBM experts were
identified using the AADPRT list of e-mail addresses. All
experts identified themselves as EBM teachers in their re-
spective psychiatry residency training programs. Five ex-
perts volunteered to complete the exams via the honor sys-
tem following the same test conditions offered to residents.
Two investigators scored the expert exams. With 226 as a
perfect score, four experts scored in the range of 211–221,
and one expert scored 178.
The CP-EBM Exam, scoring rubric, and both survey in-
struments are available from the first author.
Sample. After 1 year of implementation, preliminary
results of our attitudes and beliefs survey consist of data
from four resident groups, totaling 37 residents in all 4
years. Table 2 details the number for each year, the number
of residents who took and completed the attitudes and be-
liefs survey at different points in time, and the numbers
from our sample that were available for our preliminary
analysis.
Analyses. Attitude questionnaire responses are sum-
marized in the Results section, using parametric statistics
and pre/post analyses employing paired t tests. Given the
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EVIDENCE-BASED MEDICINE EDUCATIONAL PROJECT
limited sample with full data, results should be considered
preliminary and cautiously interpreted.
Preliminary analysis of performance on the CP-EBM
Exam’s knowledge portion was based on a group of seven
PGY-2 residents. Results of these exams were analyzed by
comparing means across groups based on number of EBM
sessions attended using ANOVA. A paired t test estimated
improvement in knowledge for the seven residents with
exam scores prior to receiving any EBM training and after
completing six EBM sessions.
Preliminary Results
EBM Attitudes and Beliefs Survey
Before any EBM session, all residents reported using
the computer at least once a day at work and a few times
a week at home. Residents in PGY-1 indicated more fre-
quent computer usage than either those in PGY-2 or PGY-
3 who had completed six EBM sessions. Likewise, a larger
percentage of PGY-1 residents had some prior experience
with epidemiology/statistics/EBM, some formerly working
as research assistants or researchers.
In the questionnaire domain of importance of EBM for
patient care, six items were analyzed. These items assessed
reading and understanding the psychiatric literature, self-
questioning about optimal patient care after each diag-
nostic assessment and routine visit, finding and applying
the pertinent literature to the patient’s care, using risk/
benefit calculations to make treatment decisions, and using
measurable outcomes or rating scales to follow patient
progress. Paired t tests of differences in level of impor-
tance, measured on a 5-point scale (1⳱not important,
5⳱extremely important) before and after six sessions
(PGY-1/PGY-2) and before and after 25 sessions (PGY-
3) showed no statistical differences. Residents rated that
use of the literature, skills in finding and applying the lit-
erature, and self-questioning about best patient care to be
“very important.” Residents found using risk/benefit cal-
culations to make treatment decisions and rating scales to
follow patient progress “important.”
TABLE 2. Number and Level of Residents Completing Attitude-Belief Survey at Various Points in Training
Posttest after
Year in Residency n Pretest
PGY-1 9 9
PGY-2 15 14
PGY-3 6 —
PGY-4 7 —
Total 37 23
528 http://ap.psychiatryonline.org
In the questionnaire domain of residents’ level of con-
fidence for performing 26 EBM skills, mean responses of
residents prior to completing any sessions (PGY-1 and
PGY-2), after six sessions (PGY-1–PGY-3), and after 25
sessions (PGY-3 and PGY-4) indicate an increase in con-
fidence on all skills. Paired t tests were conducted to ex-
plore whether changes after six sessions (PGY-1 and PGY-
2) and between 6 and 25 sessions (PGY-3) were significant.
For significant results, see Table 3. Because sample sizes
are small, these results are tentative at best.
Fourteen residents completed data prior to and after
completing six sessions. The mean reported level of con-
fidence increased significantly (meanpre⳱1.29, meanpost⳱
2.29, p⳱0.01) only for their ability to “construct a well-
formulated (six-part PICO QQ) clinical question.” Be-
cause only four residents had complete data after 6 and 25
sessions, no preliminary statistical analyses are appropri-
ate. Even in this sample of four, an examination of areas
where level of confidence exceeded 2 standard deviations
in the pretest group, four is considered noteworthy. On
average, residents participating in 25 sessions gained more
than 2 standard deviations, compared with their level of
confidence after participating in six sessions, in their level
of confidence to perform six skills: understand the basic
statistical concepts; clinical epidemiology and study design/
methodology; determine the effectiveness of a treatment
intervention by calculating risk/benefit numbers; write/
summarize a concise, thoughtful, one-page critical ap-
praisal of a therapy; determine if a relevant study can be
applied to a patient; and utilize librarians and EBM su-
pervisors as needed.
This questionnaire also included 14 items about EBM
practices. Some questions were anticipated to change
based on postgraduate year alone (e.g., number of patients
seen each day), whereas others were thought to be subject
to change as a result of improved EBM skills (e.g., number
of article searches each week). Comparing residents after
six sessions, only the number of background searches done
each week significantly changed, with the number of lit-
erature searches declining. After 25 sessions, residents
Posttest after Pre/Post Total
six sessions 25 sessions Scores Available
9 — 9
15 — 14
5 5 4
— 7 —
29 12 27
Academic Psychiatry, 32:6, November-December 2008

showed an increase of 2 pretest standard deviations in the
“number of treatment decisions changed due to EBM in
the last month,” from a mean of 0.75 to 2.5 (with 0⳱none,
1.5⳱1–2, 3.5⳱3–4, 5.5⳱5–6, 7⳱7 or more). These results
are summarized in Table 3.
Colorado Psychiatry EBM Exam
A perfect score on the Colorado Psychiatry EBM Exam
is 226 points. We scored 17 resident examinations. Thir-
teen residents were in PGY-2, who received six EBM
teaching sessions; two residents were in PGY-4 or 5, who
received 10 teaching sessions; and two residents were in
PGY-3, who received 25 teaching sessions. Descriptive sta-
tistics for groups receiving six sessions (13 PGY-2), 10 ses-
sions (2 PGY-4–5), and 25 sessions (2 PGY-3) indicate
that means increase with number of sessions, as expected
(106.7 after six sessions, 144.5 after 10 sessions, and 195
after 25 sessions). This sample of 17 residents was too
small for statistical analyses (n⳱13, 2, and 2, respectively),
and therefore our data are only suggestive of trends we
expected.
Because we are reporting preliminary data, we only
scored seven out of the 13 PGY-2 EBM exams that were
taken. A paired t test was estimated to assess improvement
in resident knowledge after participating in six EBM ses-
sions. Of seven residents, scored with both pre- and post-
test data, performance improved significantly from a mean
of 37.0 (SD⳱23.9) to a mean of 102.6 (SD⳱49.9), a sig-
nificant improvement (t⳱2.814, p⳱0.03).
Discussion
Our experience suggests that an effective, comprehen-
sive EBM curriculum can be developed and delivered to
psychiatric residents. Data on the effectiveness of the cur-
riculum is generally favorable, although the limited num-
ber of residents completing questionnaires and exams re-
quires that all results be interpreted as very preliminary.
TABLE 3. EBM Attitudes and Beliefs Survey Results
Domain Year in Residency
Confidence performing six-part PICO QQ PGY-2
Number of background searches completed PGY-2
Number of treatment decisions PGY-3
EBM⳱evidence-based medicine
PICO QQ format⳱Population, Interventions, Comparison group, Outcome, Question type, Quality of the study
*paired t test
Academic Psychiatry, 32:6, November-December 2008
FEINSTEIN ET AL.
The effects of our clinically integrated interventions in
PGY-3 are awaiting further data and analysis.
Keeping these limitations in mind, we discuss our results
according to our initial assumptions and hypotheses. First,
our assessment of prior exposure to EBM confirms our
assumption that current residents in PGY-2 and PGY-3
have little experience. On the other hand, current residents
in PGY-1 have greater experience with epidemiology/sta-
tistics/EBM and more experience working as research as-
sistants/researchers. We are not sure whether this is a local
phenomenon or whether it reflects a national trend of in-
creasing EBM teaching in medical school. It has clear im-
plications for the starting point in the curriculum of the
future, because it reinforces the need for a knowledge ex-
amination to appropriately match teaching to resident
needs.
Current attitudes data provide no obvious progression
in perceived importance of EBM in patient care. This un-
anticipated result may be explained by the high level of
importance ascribed to EBM prior to participation in the
program. Changes in resident level of confidence reflect
our hypothesis with specific areas of confidence paralleling
curriculum topics.
Results from our attitudes survey indicate that when
combining confidence and knowledge data, six sessions ap-
pear sufficient to introduce residents in PGY-2 to EBM
and facilitate their knowledge and use of literature and
PICO-QQ searching. Likewise, 25 sessions appear suffi-
cient to extend PGY-3 residents’ level of confidence in
their ability to understand EBM concepts/study design, de-
termine the effectiveness of a treatment using EBM math-
ematics, write a critical appraisal, apply EBM with a pa-
tient, and regularly utilize librarians and EBM supervisors
as needed.
Knowledge of EBM, as measured by the Colorado Psy-
chiatry EBM Exam, indicates that even a limited, six-ses-
sion curriculum can result in substantial improvement in
Number of Sessions
Pretest Posttest n t* p
0 6 14 3.02 0.01
0 6 12 2.42 0.03
6 25 4 2.11 0.12
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EVIDENCE-BASED MEDICINE EDUCATIONAL PROJECT
searching skills. These trends in knowledge acquisition
lead us to cautiously suggest that the sequence and depth
of instruction appears appropriate.
The final tasks and results of our efforts to facilitate
resident use of EBM skills with patients in daily practice
are awaiting future data on the effect of these components.
We would like to thank Gretchen Guiton, Ph.D., for her invalu-
able support with survey designs and statistics.
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