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Evidence-Based Problem Solving: Liberal Education and Preparation for the Health Professions
n recent years the health professions have moved from “eminence-based” solutions to “evidence-based” problem solving, an evolution that provides new opportunities to implement integrative curricula for students preparing for careers in the health professions. These new curricula can be built on the Essential Learning Outcomes identified through the Association of American Colleges and Universities’ (AAC&U) Liberal Education and America’s Promise (LEAP) initiative (see fig. 1).
Evidence-based problem solving represents an integrative approach to the application of scientific principles across the natural, behavioral, and social sciences. As opposed to the traditional reductionist approach that examines the impact of one factor at a time, evidence-based problem solving examines interactions between factors and brings together a range of disciplines. In addition, it goes beyond explanation to implementation and evaluation. Evidence-based problem solving can be an especially effective method for achieving the fourth LEAP Essential Learning Outcome: integrative and applied learning. That is, it can provide a basis for “synthesis and advanced accomplishment across general and specialized studies demonstrated through the application of knowledge, skill, and responsibilities to new settings and complex problems.”
Evidence-based problem solving has become increasingly important for the preparation of health professional students as well as students in a range of other disciplines, from education to business. The Educated Citizen and Public Health movement currently being led by AAC&U in collaboration with public health education groups has stimulated discussion of how to connect the LEAP initiative with the preparation of public health professionals. Similarly, the Association of Schools of Public Health, in collaboration with AAC&U, has developed and is now disseminating a set of undergraduate public health learning outcomes that are built upon the LEAP Essential Learning Outcomes.1
In medicine, the need for evidence-based problem solving has led to the “evidence-based medicine” movement. Preparation to learn evidence-based medicine requires that an understanding of basic principles be built into undergraduate education. Accordingly, a great deal of attention is now focused on the new Medical College Admission Test (MCAT), which will be introduced in 2015. The new test will incorporate scientific inquiry and reasoning skills (SIRS) into the natural sciences sections as well as a new behavioral and social sciences section. (For discussion of SIRS and why they are important, see sidebar at the end of article.)
Figure 1. LEAP Essential Learning Outcomes
Beginning in school, and continuing at successively higher levels across their college studies, students should prepare for twenty-first-century challenges by gaining:
Source: Association of American Colleges and Universities, College Learning for the New Global Century: A Report from the National Leadership Council for Liberal Education and America’s Promise (Washington, DC: Association of American Colleges and Universities), 12.
A framework for evidence-based problem solving
Figure 2 depicts five phases in evidence-based problem solving: problem description, etiology, recommendations, implementation, and evaluation. As the figure indicates, evidence-based problem solving is an iterative process; each successive cycle builds on the previous cycle. The process can be structured and facilitated by posing a series of questions (see fig. 3). The following case studies illustrate the use of evidence-based problem solving to address two important health problems, Reye’s syndrome and the association of male circumcision and HIV (Riegelman 2010, 2011).
Figure 3. Questions to ask: Evidence-based problem solving
Problem—What is the health problem?
Etiology/Efficacy—Have contributory causes or efficacy of interventions been established?
Recommendations—What intervention(s) works to reduce the health impacts?
Implementations—How can we get the job done?
Evaluation—How well does the intervention perform when put into practice?
Problem. Reye’s syndrome is a potentially fatal disease of childhood that is characterized by progressive stages of nausea and vomiting, liver dysfunction, and mental impairment that often progresses over hours to days and results in a range of symptoms, from irritability to confusion to deepening stages of loss of consciousness. Reye’s syndrome was first defined as a distinct condition with the development of a case definition in the early 1960s. By the 1980s, over five hundred cases per year were being diagnosed in the United States alone. When Reye’s syndrome was diagnosed, the chance of death was greater than 30 percent. There is no known cure for Reye’s syndrome, but early diagnosis and aggressive efforts to prevent brain damage have been shown to reduce the number of deaths and limit the mental complications. Reye’s syndrome typically occurs in the winter months at the end of an episode of influenza, chicken pox, or other acute viral infection. It is diagnosed by putting together a pattern of signs and symptoms. There is no definitive diagnostic test.
Etiology. In the late 1970s and early 1980s, a series of case-control or retrospective studies compared children with Reye’s syndrome to similar children who had also had an acute viral infection but did not develop the syndrome. These studies suggested that the use of aspirin, then called “baby aspirin,” was strongly associated with Reye’s syndrome; over 90 percent of the children afflicted with the syndrome had recently used aspirin. There was no association with acetaminophen (e.g., Tylenol). Cohort studies were not practical because they would require observation of very large numbers of children who would be given or not given aspirin. Randomized controlled trials were neither feasible nor ethical.
Recommendations. As early as 1980, the Centers for Disease Control and Prevention cautioned clinicians and parents about the potential dangers of aspirin. It was considered safe and acceptable in terms of costs to reduce or eliminate aspirin use in children because a widely-used alternative, acetaminophen, was not implicated in the studies of Reye’s syndrome. In 1982, the American Academy of Pediatrics recommended that aspirin products not be given to children, and the US surgeon general issued an advisory on the danger of aspirin for use in children.
Implementation and evaluation. By 1986, the US Food and Drug Administration required that a Reye’s syndrome warning label be placed on all aspirin-containing medications. This effort was coupled with public service announcements, informational brochures, and patient education by pediatricians and other health professionals who cared for children. The use of the term “baby aspirin” was strongly discouraged. In the early 1980s, there were over five hundred cases of Reye’s syndrome per year in the United States. In recent years, there have often been fewer than five per year.
The Reye’s syndrome success story is unfortunately the exception, rather than the rule. Often, as with HIV/AIDS, each advance leads to new challenges and the need to recycle the process. This is illustrated in the summary of the second case below,
Male circumcision and HIV
Problem. Until recently, little progress has been made in the prevention of HIV/AIDS in the areas of Africa with the highest rates of HIV infection (10–20 percent of the population). In the 1980s, it was found that an association existed between geographic areas of Africa with
Etiology/efficacy. During the 1980s and 1990s, a series of case-control and cohort studies provided consistent data summarized in a meta-analysis supporting the contention that male circumcision reduces the risk of HIV by 50 percent or more. Prior to the use of an invasive and potentially harmful intervention such as male circumcision, it was considered ethically important to demonstrate its efficacy and safety through
The World Health Organization, the National Institutes of Health, and the Centers for Disease Control and Prevention collaborated on three large, well-conducted, randomized controlled trials in Africa to study the impact of male circumcision among predominately heterosexual males. In all three studies, the volunteers were randomized to one of two groups: an intervention group received medically supervised cost-free circumcision,
The results of the three studies were very similar. Participants in one of the studies were followed up for eighteen months before the investigation was stopped early because of the impressive results. In this study, there were twenty cases of HIV among the approximately 1,862 young men randomized to the circumcision group, and forty-nine cases among the approximately 1,862 young men
Recommendations. Analysis of the results helps us estimate the potential magnitude of the impact of male circumcision, suggesting that up to
60 percent of the risk of HIV infection among uncircumcised males may be eliminated by use of circumcision in high-risk areas of Africa. Unfortunately, there has been little evidence that male circumcision reduces the risk to women, at least in the short run. Widespread acceptance of these finding led to recognition of a biological mechanism that could explain the “target cells” (white cells in close proximity to the surface).
In terms of potential harms, male circumcision performed under unhygienic conditions can cause infection, penile damage, and a range of other complications. However, there is agreement among experts that adolescent and adult male circumcision can be done safely under medical supervision to ensure hygienic and technically competent implementation.
The World Bank estimated the cost of medically supervised adolescent and young adult male circumcision to be about twenty-five dollars per procedure in African countries. This surprisingly low cost is largely due to the dramatically lower local labor costs. Further, the World Bank estimated that fewer than
Implementation and Evaluation. In 2007, the President’s Emergency Plan for AIDS Relief, the US initiative to control HIV/AIDS in areas of high prevalence around the world, accepted male circumcision conducted under medical supervision as an integral part of an HIV-control program, along with education, safer sex practices, and use of antiretroviral drugs. Efforts to evaluate the impact of these programs
Using case studies to teach evidence-based problem solving
A wide range of relevant case studies can be used to engage students in evidence-based problem solving. At the George Washington University School of Public Health and Health Services, for example, students use
Moreover, as stated above, the approach enables students to build upon key LEAP Essential Learning Outcomes. For instance, as illustrated by the Reye’s syndrome and HIV/AIDS examples above, case studies provide and utilize “knowledge of human cultures and the physical and natural world,” and they engage students with “big questions, both contemporary and enduring.” Evidence-based problem solving also builds on intellectual and practical skills, including inquiry and analysis, critical thinking, quantitative literacy, and, of course, problem solving. Using case studies in a small group setting can provide practice in information literacy and teamwork. Personal and social responsibility can also be readily integrated into the cases, as illustrated by the issues related to the recommendation of male circumcision in Africa. Case studies for evidence-based problem solving should be designed to stimulate
The evidence-based public health approach can be introduced as part of a general education course that aims to improve critical thinking and problem solving. More advanced case studies can be utilized in specialty courses in the social sciences, in science courses such as biology, or as part of a capstone or synthesis course for a wide variety of majors. With an introductory course as a prerequisite, an evidence-based problem-solving course can build upon the basics and tie the pieces together.
Evidence-based problem solving is fast becoming an expected part of the preparation for graduate-level education in the health professions. Undergraduate institutions can take advantage of this evolution in the health professions to help students achieve many “LEAP” into the health professions.
What Are SIRS, and Why Are They Important?
Scientific inquiry and reasoning skills (SIRS) have been approved for incorporation into the new Medical College Admissions Test (MCAT). SIRS will be integrated into the two natural sciences components as well as the behavioral and social sciences component, which is currently being planned as a new section of the examination. The aim is to provide an overall framework for testing examinees’ ability to apply scientific and evidence-based principles to a wide range of disciplines, including physics, chemistry/ biochemistry, biology, behavioral sciences, and social sciences.
To integrate scientific inquiry and reasoning skills into the examinations, four foundational concepts have been defined:
1. Knowledge of Scientific Concepts and Principles. This foundational concept requires the ability to state, recognize, and use basic representations of scientific concepts, including mathematical and graphical forms of representation. It does not require synthesis or problem-solving skills.
2. Scientific Reasoning and Evidence-Based Problem Solving. This foundational concept addresses the key skills required for drawing conclusions and solving problems, including working with scientific models and theories to solve problems, generating hypothesis and making claims, identifying assumptions and logical inconsistencies, identifying and applying appropriate formulae, and implementing and evaluating proposed solutions.
3. Reasoning about the Design and Execution of Research. This foundational concept requires skills in identifying and evaluating the appropriateness of research designs; critiquing research design, including sample size and sources of bias and confounding; evaluating research designs to determine the appropriateness of conclusions; and recognizing ethical issues inherent in research investigations.
4. Data-Based and Statistical Reasoning. This foundational concept requires the ability to analyze data from research studies, including using descriptive statistics, interpreting patterns in data to draw or evaluate conclusions or make predictions, and using inferential statistics to evaluate hypotheses and the strength of relationships. It also requires skills in interpreting data patterns presented in tables, figures, and graphs to make comparisons, interpret results, and draw conclusions.
These foundational concepts will be cross linked with clusters of foundational concepts from the two natural sciences sections as well as the behavioral and social sciences section. Thus, scientific inquiry and reasoning skills will be integrated throughout the content components of the MCAT, providing a unique opportunity for educators to integrate evidence-based thinking throughout the preparation for the health professions.
Riegelman, R. K. 2010. Public Health 101: Healthy People-Healthy Populations. Sudbury MA: Jones and Bartlett Learning.
———. 2011. “Male Circumcision and HIV: An Evidence-Based Public Health Approach.” In Essential Case Studies in Public Health: Putting Public Health into Practice, edited by H. L. Hunting and B. L. Gleason, 23–32. Sudbury MA: Jones and Bartlett Learning.
1. Information about the Educated Citizen and Public Health initiative can be found online at www.aacu.org/public_health. For information about the Undergraduate Public Health Learning Outcomes Model developed by the Association of Schools of Public Health, visit www.asph.org/document
Richard Riegelman is professor and founding dean at the George Washington University School of Public Health and Health Services.
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