TAFP PERSPECTIVE

How to Teach an Old Horse New Tricks
Training of Evidence-Based Medicine Should Start on Day One of Medical School

By Gil C. Grimes, M.D.

My training as a physician has come from many places and some of the greatest trainers I have met reside not within the halls of science, but within the confines of a barn. I have learned a great deal from my horses, even more from my horse trainer/wife that is directly applicable to my practice of medicine. These lessons are timeless and they certainly apply to many fields beyond the equestrian arena where they were hard learned. In fact, these lessons are very applicable to the concerns facing family medicine.

Family medicine has always been out of place at the traditional academic medical center. One only has to return to the “Ecology of Medical Care” by Green et al (NEJM 2001;344:2001-2025) to understand why family medicine seems so foreign and so misunderstood. It is our job to try to dispel this xenophobia and make our calling and mission clear. Many bright individuals have been considering this problem for some three decades, and it still seems insurmountable. It is as if we are trying in vain to get a 1,200-pound beast to bend to our will through force. This fight cannot be won through the use of force; in fact force will surely lead to our demise. As I have learned when working with horses, if my requests are not understood, then I must change the way that I ask the question. Within the academic medical centers, family medicine must change its approach. What follows is a modest proposal to teach an old horse a new trick.

In the training of horses it is important to understand that they have the significant advantage of weight and strength. Their basic defense mechanism is flight. To train the horse we must understand the horse’s world, then apply non-threatening change to that environment in order to encourage the behavior we are seeking. Very similar processes are present within the academic medical centers. There is a real tendency to flight, the closing of ranks to avoid change out of fear. As in equestrian training, gentle change can be obtained through a subtle alteration of the environment. The same holds true in the academic environment. This environmental change takes place through our students. When the change comes in this manner, from the ground up, it is not considered a threat; rather it seems to be a natural maturation of the learning environment. Evidence-based medicine offers the opportunity to change the learning environment in a subtle way that will lead to positive changes in the academic environment.

The key to this change is to make evidence-based medicine an integral part of medical education, and this is a great opportunity for family medicine to become an agent for that change. Family medicine has embraced evidence-based medicine in a way that few other disciplines have. It is clear that evidence-based medicine is a paradigm shift; it will change the way that medicine is practiced in the future. In this context, family medicine should assume a lead role in the teaching of evidence-based medicine to our learners. This begins with the first day of medical school and continues throughout the full four years.

The first contact for students with evidence-based medicine within the Texas A&M College of Medicine occurs through e-mail to first-year students. On a daily basis these students receive the Daily InfoPOEMSTM, affording them an opportunity to begin thinking about outcomes from day one. The students make the connection early on that family medicine is interested in outcomes that matter to our patients. It is important to make evidence-based medicine an ever-present part of the student’s life, making it an integral component of how they think about medicine, and it should start during the pre-clinical years. This concept also helps breathe life into the dry and seemingly unimportant courses in biostatistics and epidemiology. Family medicine should embrace these courses and bring to them clinical context. Remember that during the first two years, students hunger for clinical application of all the science that they are learning. By introducing clinical views, these courses can come to life for the students. These go from being boring and distant to immediate and compelling.

The clinical years allow for the fine-tuning of evidence-based medicine concepts taught pre-clinically. During these years family medicine must continue to provide the conceptual framework of evidence-based medicine to the students with every interaction. Through demonstration of the applicability of evidence-based medicine, our students can become information masters and as such their approach to every aspect of medicine will be altered. By integrating this basic approach to medicine, the students become the agents of change within the academic setting. If every student who approaches the third year has had a strong foundation in evidence-based medicine, has been exposed to the concept of outcomes that matter, change cannot be avoided. Yes there will be some turbulence along the way, but in the words of my horse trainer, “Pay it no mind.”

Through this approach something as small as a human can affect change in an animal as large as a horse. This is change that will extend beyond the academic centers, and in time will lead to a change in the practice of medicine for all physicians. This is the gift that we have to offer, the gift to our field, to our students and to our patients. It is change without force, change without fear. Embrace this challenge; commit yourself to change the way students look at medicine. Through this work, we can regenerate our discipline, stay true to our values and improve the care that our patients receive.

Dr. Gil C. Grimes is an assistant professor at the Texas A&M University College of Medicine, and he practices medicine at the Scott & White Killeen Clinic in Killeen, Texas.