A total of 94 trainees submitted a response to the study instrument. However, 14 of those didn’t attempt the ACE tool and had more than 50% missing data on the other items and thus were not included in the final analysis. The final sample size included 80 trainees (response rate=43.2%).
The majority of the participants were age 20-29 (83.8%) and male (65.8%). The majority obtained their medical education in the Middle East Region (60.6%). Interns accounted for 11.3% of participants and fellows accounted for 8.8% (table 1).
Table 1: Participants’ demographics and their ACE Score
|
|
|
|
ACE Score
|
|
|
N
|
%
|
Mean
|
SD
|
Age
|
20-29
|
67
|
83.8%
|
8.9
|
1.6
|
30-39
|
13
|
16.3%
|
9.2
|
1.4
|
Gender
|
Male
|
52
|
65.8%
|
8.9
|
1.5
|
Female
|
27
|
34.2%
|
8.9
|
1.7
|
Level of experience
|
Intern
|
9
|
11.3%
|
7.9
|
1.6
|
PGY1
|
35
|
43.8%
|
8.7
|
1.3
|
PGY2
|
11
|
13.8%
|
10.0
|
1.3
|
PGY3
|
10
|
12.5%
|
8.6
|
2.0
|
PGY4
|
8
|
10.0%
|
10.0
|
1.8
|
Fellow
|
7
|
8.8%
|
8.7
|
1.6
|
Region from where the Medical Education was received
|
Middle East (including Sudan)
|
48
|
60.6%
|
8.7
|
1.6
|
North Africa
|
12
|
15.0%
|
8.2
|
1.3
|
South Asia
|
18
|
22.5%
|
9.9
|
1.4
|
Other †
|
2
|
2.5%
|
8.5
|
0.7
|
†1 Eastern Europe and 1 unknown
Overall, participants’ scores on the ACE tool ranged from 5.0 to 12.0 (out of 15) with an average of 8.9±1.6 and a median of 9.0. This means that participants were able to correctly answer, on average, only 59.3% of the ACE questions. There were no apparent differences in the ACE scores between the two age groups or between genders. Although Interns had the lowest average ACE score among all other groups, there was no major pattern indicating, for example, that an increase in work experience might have a positive impact on the ACE score. For example, average ACE scores for PGY 2 (10.0 ± 1.3) and PGY 4 (10.0 ± 1.8) were slightly higher than that of the Fellows group (8.7 ± 1.6). Those with a medical educational background from South Asia scored the higher on the ACE tool than those graduating from other regions. The biggest difference was between South Asian graduates and those graduating from North Africa, with a difference of 1.7 points out of 15 questions (see Table 1)
Most of the participants learned about EBM in their undergraduate medical education (63.7%) utalizing mainly a mix of face to face and online learning modalities or only face to face (86.3%). The majority started incorporating EBM in their clinical decision-making processes during residency (61.3%). Those who learned about EBM during undergraduate medical education or during residency scored higher; by about 1.75 points, on the ACE tool as compared to those who reported that they haven’t learned about EBM. There was no clear pattern that early incorporation of EBM into practice will result in better ACE score. For example, those who reported not incorporate EBM into their practice had a higher average ACE score; by 1.1 points, compared with those who incorporated it after residency. There was no clear indication that the type of instructional setting has a major impact on the ACE score (see Table 2).
Table 2: EBM Educational, background and incorporation into practice and ACE score results
|
N
|
%
|
ACE Score
|
Mean
|
SD
|
At what stage of your medical career did you first learn about EBM?
|
During undergraduate medical education
|
51
|
63.7%
|
8.9
|
1.4
|
During residency
|
26
|
32.5%
|
9.2
|
1.9
|
I have not learned about EBM
|
3
|
3.8%
|
7.3
|
1.5
|
In what instructional setting did you learn EBM? - Selected Choice
|
Face to face (traditional classroom setting)
|
30
|
37.5%
|
8.6
|
1.5
|
Online (eLearning)
|
4
|
5.0%
|
9.0
|
0.0
|
Mix of online and face to face
|
39
|
48.8%
|
9.3
|
1.7
|
Self-study
|
6
|
7.5%
|
8.2
|
1.5
|
Other (not specified)
|
1
|
1.3%
|
7.0
|
-
|
When did you begin incorporating EBM within your clinical decision-making process?
|
Since undergraduate medical education
|
16
|
20.0%
|
9.4
|
1.3
|
Since residency
|
49
|
61.3%
|
9.0
|
1.6
|
After residency (fellowship & clinical practice)
|
9
|
11.3%
|
7.6
|
1.9
|
I have not incorporated EBM within my practice
|
6
|
7.5%
|
8.7
|
1.2
|
The self-reported comfort levels for each EBM component and for overall EBM ability are presented in table 3. For most categories, participants rated themselves as either 3 or 4 on a scale of 1 to 5, with 1 indicating least capable and 5 indicating most capable. In all those components, with the exception of applying EBM to a clinical decision, the percentage of participants who indicated that they are most capable did not exceed 12.5% or 1 in 8. Conversely, the vast majority of the participants rated themselves as beginner or intermediate (89.9%) on their overall EBM abilities (see table 3).
Table 3: Self-reported Comfort levels with EBM components, self-rated overall EBM abilities and ACE score results
outcome is the average score on Ace for each participant
|
N
|
%
|
ACE Score
|
Mean
|
SD
|
Applying EBM principles in my clinical decisions
|
Least capable
|
0
|
0.0%
|
|
|
2
|
3
|
3.8%
|
7.7
|
1.5
|
3
|
27
|
33.8%
|
8.6
|
1.9
|
4
|
36
|
45.0%
|
9.1
|
1.3
|
Most capable
|
14
|
17.5%
|
9.4
|
1.4
|
Translating my information needs into relevant and feasible clinical questions
|
Least capable
|
0
|
0.0%
|
|
|
2
|
6
|
7.5%
|
8.7
|
2.0
|
3
|
23
|
28.7%
|
8.8
|
.7
|
4
|
42
|
52.5%
|
9.1
|
1.5
|
Most capable
|
9
|
11.3%
|
8.3
|
1.7
|
Searching for research evidence in literature
|
Least capable
|
1
|
1.3%
|
7.0
|
-
|
2
|
4
|
5.0%
|
8.8
|
1.9
|
3
|
31
|
38.8%
|
8.7
|
1.6
|
4
|
34
|
42.5%
|
9.2
|
1.7
|
Most capable
|
10
|
12.5%
|
8.7
|
0.9
|
Critically appraising research evidence from literature
|
Least capable
|
4
|
5.0%
|
8.0
|
2.2
|
2
|
17
|
21.3%
|
8.5
|
1.6
|
3
|
26
|
32.5%
|
8.9
|
1.7
|
4
|
29
|
36.3%
|
9.2
|
1.5
|
Most capable
|
4
|
5.0%
|
9.8
|
1.0
|
Translating research evidence to the care of my individual patients
|
Least capable
|
2
|
2.5%
|
7.5
|
3.5
|
2
|
9
|
11.3%
|
8.0
|
1.7
|
3
|
21
|
26.3%
|
8.5
|
1.7
|
4
|
41
|
51.2%
|
9.3
|
1.4
|
Most capable
|
7
|
8.8%
|
9.7
|
0.8
|
Of regularly keeping up with latest research evidence from literature
|
Least capable
|
4
|
5.0%
|
6.0
|
2.0
|
2
|
12
|
15.0%
|
8.7
|
1.3
|
3
|
28
|
35.0%
|
9.0
|
1.5
|
4
|
29
|
36.3%
|
9.4
|
1.4
|
Most capable
|
7
|
8.8%
|
8.4
|
1.3
|
Rate your overall abilities in EBM
|
Beginner
|
30
|
38.0%
|
8.5
|
1.7
|
Intermediate
|
41
|
51.9%
|
9.1
|
1.6
|
Advanced
|
8
|
10.1%
|
9.6
|
1.2
|
There was a trend of increased average ACE scores with increased self-rating on applying EBM principals in clinical decision making, translating research evidence to the care of patients, critical appraisal of research evidence from literature, and overall ability in EBM. On those questions, difference between those who reported least capable (or beginner) and those who reported most capable (or advanced) ranged between 1.1 to 2.2 points. For the other questions, the increasing trend was observed except for a decrease in the score for the group who self-rated themselves as most capable (table 3).
Participants were asked to rate their perceptions of institutional attitudes and barriers to implementing EBM (table 4), the majority of participants gave the highest two possible scores; on a Likert scale from 1 to 5, for those questions indicating a general level of encouragement to apply EBM (59.2%), giving attention to EBM application in clinical decision making (72.6%), a strong level of support from supervisors to apply EBM within clinical decisions (77.2%) and a general atmosphere of frequent discussion of research evidence (57.6%).
Table 4: Attitudes and Barriers to EBM practice
|
|
N
|
%
|
My colleagues [...] me to apply EBM principles in my clinical decisions.
|
Discourage
|
0
|
0.0
|
2
|
1
|
1.9
|
3
|
21
|
38.9
|
4
|
20
|
37.0
|
Encourage
|
12
|
22.2
|
In my department, we pay [...] attention to applying EBM principles in our clinical decisions
|
No
|
0
|
0.0
|
2
|
2
|
2.5
|
3
|
20
|
25.0
|
4
|
37
|
46.3
|
A lot of
|
21
|
26.3
|
Supervisors in my department [...] me to apply EBM principles in my clinical decisions
|
Hinder
|
0
|
0.0
|
2
|
3
|
3.8
|
3
|
15
|
19.0
|
4
|
30
|
38.0
|
Support
|
31
|
39.2
|
My colleagues and I [...] discuss research evidence from literature.
|
Rarely
|
0
|
0.0
|
2
|
9
|
11.3
|
3
|
25
|
31.3
|
4
|
35
|
43.8
|
Frequently
|
11
|
13.8
|
When questioned about participants’ attitudes to EBM implementation to clinical care (table 5), almost all participants gave the two highest scores for EBM usefulness to improving patient outcomes (96.3%), for improving their clinical decisions (93.7%) for feeling that there is a synergy between EBM and their own clinical experience (87.3%). Finally, most participants identified their view of EBM’s most significant limitation, with 51.2% reporting not knowing how to practice EBM, 36.3% citing lack of available resources, and 28.7% identifying time limitations (see table 5 for more details). Except for a single instance with one participant, those who reported the highest two levels of positive attitudes towards EBM had on average higher score on the ACE tools. Again, the maximum difference between any of those two later groups and the other groups didn’t exceed 2.1 on the ACE score.
Table 5: Attitude toward EBM in clinical use and relation to ACE score.
|
|
N
|
%
|
Total ACE Score
|
Mean
|
SD
|
I feel that Evidence Based Medicine (EBM) is [useless/useful] to improve my patients' outcomes.
|
Useless
|
0
|
0.0%
|
--
|
--
|
2
|
0
|
0.0%
|
--
|
--
|
3
|
3
|
3.8%
|
7.0
|
1.7
|
4
|
18
|
22.5%
|
9.1
|
1.5
|
Useful
|
59
|
73.8%
|
9.0
|
1.6
|
I feel that EBM [worsens/improves] the quality of my clinical decisions.
|
Worsens
|
0
|
0.0%
|
|
|
2
|
1
|
1.3%
|
9.0
|
--
|
3
|
4
|
5.1%
|
7.8
|
2.1
|
4
|
20
|
25.3%
|
8.7
|
1.8
|
Improves
|
54
|
68.4%
|
9.1
|
1.5
|
I feel that EBM [disregards/incorporates] my clinical experience.
|
Disregards
|
0
|
0.0%
|
|
|
2
|
3
|
3.8%
|
8.0
|
1.0
|
3
|
7
|
8.9%
|
7.3
|
1.8
|
4
|
25
|
31.6%
|
9.3
|
1.6
|
Incorporates
|
44
|
55.7%
|
9.1
|
1.5
|
What do you believe are EBM's most significant limitations?
|
not knowing how to practice EBM
|
41
|
51.2%
|
|
available resources
|
29
|
36.3%
|
time limitation
|
23
|
28.7%
|
not enough support from colleagues
|
13
|
16.3%
|
not enough support from administration
|
3
|
3.8%
|
other
|
4
|
5.0%
|
The top 4 reported resources for searching for clinical evidence as an EBM process were PubMed (82.5%), Google (55%), Google Scholar (40%) and Wikipedia (30%). The most reported reason for selecting the resources of choice was due to ease of use (82.5%) and availability of articles (52.5%) (see appendix A).