Examining aptitude and barriers to evidence-based medicine among trainees at an ACGME-I accredited program

Background The aims of Evidence-Based medicine (EBM) are to promote critical thinking and produces better patients’ outcome (Profetto-McGrath J, J Prof Nurs Off J Am Assoc Coll Nurs 21:364-371, 2005). Accreditation Council for Graduate Medical Education (ACGME) competencies require trainees to locate, appraise and apply clinical evidence to patients’ care. Despite the emphasis that ACGME place on EBM, few organizations provide adequate training in EBM. This is even more critical in regions where medical trainees matriculate from diverse backgrounds of undergraduate medical education, where EBM may not be emphasized nor taught at all. EBM practice has a history of research in the West, however, EBM has not been widely studied in the Middle East. Methods Clinicians and trainees at Hamad Medical Corporation (HMC) matriculate from many countries in the Middle East and North Africa (MENA) and Asia. Because trainees in Graduate Medical Education (GME) come to HMC from a variety of geographic backgrounds, it is assumed that they also have a variety of experiences and aptitudes in EBM. To assess trainees EBM attitudes and knowledge in the internal medicine department at HMC in Doha, Qatar, the authors surveyed residents and fellows using a two-part survey. The first part was adapted from the evidence-based practice inventory by Kaper to assess trainees’ attitudes and perceptions of EBM. Trainees were also asked to complete the Assessing Competency in Evidence Based Medicine (ACE) tool to evaluate their aptitude in different elements of EBM. The results from the two parts were analyzed. Results The average score on the ACE tool among the participants was 8.9 (±1.6). Most participants rated themselves as beginners or intermediate in their EBM capabilities. Higher ACE scores were observed from participants with educational background from South Asia, and among those with more favorable attitudes towards EBM. There was no clear pattern that early incorporation of EBM into practice will result in better ACE score. Participants also reported reasonable abilities in EBM tasks and a favorable work atmosphere for EBM implementation. Lack of knowledge, resources, and time were the most reported barriers to utilizing EBM. Conclusions While it is clear that participants are enthusiastic about EBM and see it as a useful method for clinical decision making, their aptitude in EBM is not optimal and there are gaps and barriers for them to practice. Supplementary Information The online version contains supplementary material available at 10.1186/s12909-020-02341-9.

be linked to one-another and must be completed in one setting. Both surveys will also be completely anonymous and no one from the research team, representatives from Weill Cornell Medicine -Qatar, or Hamad Medical Corporation will be advised of the identities of respondents.
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ACE Tool of Competency in Evidence Based Medicine
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Directions: Read through the following information on patient scenario, clinical question, search strategy and article extract before answering the questions that follow. .

Patient scenario
"Jane is a 42 year-old female Caucasian, who lives with her partner in metropolitan Melbourne, Australia. Jane is a lawyer, who quit smoking three years ago, after being a 'pack-a-day' smoker since her early 20s. Since her late 30s, Jane has received treatment for hypertension. Her medical history is otherwise unremarkable. At her most recent visit to her family doctor, Jane mentions that she has seen reports on the television about a new study investigating the preventive effects of aspirin. She has heard that aspirin may be beneficial in protecting against cardiovascular disease. Jane wonders whether she should be taking aspirin, given her history with hypertension, but wonders whether also being a diabetic might negate any benefit." .

Clinical Question
"Is aspirin effective in reducing the risk of cardiovascular disease?" . Aspirin is effective in the treatment of acute myocardial infarction and prevention of cardiovascular disease in men and women. Previous studies on the use of aspirin in primary prevention of cardiovascular disease have demonstrated a positive effect in men, yet the benefit in women remains uncertain. The aim of this study was to assess the effect of aspirin in the prevention of cardiovascular disease in women.

Methods
The study design was a randomised, double-blinded, placebo-controlled, trial of low-dose aspirin in the prevention of cardiovascular disease in women. The design of the study has previously been described in detail. In brief, between January 2002 and January 2012, letters of invitation were mailed to 500,000 women in the greater city of Melbourne, Victoria, Australia. A total of 63,250 volunteered to enrol in the study. Women were eligible if they were 40 years of age or older; had no history of coronary heart disease, cerebrovascular disease, no previous side-effects to taking aspirin and were not currently taking aspirin or any non-steroidal anti-inflammatory drug (NSAID) medication. A total of 31,150 women met the inclusion criteria of which 15,100 were randomised (through the generation of a computer generated scheme) to receive aspirin and 15,102 were randomised to receive the placebo. Written informed consent was obtained from all participants prior to commencement in the study. The trial was approved by the ethics board at the governing hospital and university institution. Participants in both groups were required to present every 6 months at the study site centre for assessment and to receive their medication. Medication was provided by the site pharmacy, which allocated identical appearing aspirin and placebo tablet in blister packs to the study's participants independent to the study's investigators. All participants were followed for myocardial infarction, stroke or death from cardiovascular causes. Medical records were obtained for all women in whom a cardiovascular event was recorded. These records were reviewed by an end-point committee, consisting of study investigators blinded to the treatment. The primary end point was cardiovascular events -a combination of myocardial infarction, stroke or death from cardiovascular causes. Only confirmed end-points of cardiovascular events were included in this study. Cox proportional hazard models were used to calculate hazard ratios and 95% confidence intervals for the comparison of event rates in the aspirin and placebo groups after adjustment for age.

Results
Both aspirin and placebo groups were similar with respect to baseline characteristics ( Table  1). The average duration of follow-up from randomisation to the end of the trial was 4.2 years (range, 2.3 to 5.0 years). Throughout the duration of the trial, drop-outs occurred. Data presented is based on participants that completed the trial during the study period. A total of 422 women in the aspirin group and 478 women in the placebo group had a cardiovascular event (Hazard Ratio, 0.83; 95% confidence interval, 0.77 to 1.01). There was no evidence that any of the cardiovascular risk factors considered, except smoking status and hyperlipidemia, modified the effect of aspirin on the primary end-point.

Discussion
In this large study, involving 63,250 women, a 100 mg daily dose of prophylactic aspirin is associated with a reduced risk of major cardiovascular events. No significant evidence was found that age, hypertension, diabetes or BMI modified the effect of aspirin. Middle aged women who adhere to a daily low dose of aspirin can significantly reduce the risk of cardiovascular disease. The rate of benefit is large, with a cardiovascular event prevented for every 269 women treated with aspirin.