How to Promote Learning of Evidence-Based Medicine Among Japanese Medical Students

Evidence-based medicine (EBM) has become increasingly widespread over the last 30 years. However, the ideal curriculum for undergraduate EBM education has yet to be developed. To establish an EBM curriculum suitable for the educational environment in Japan, we conducted a qualitative study to identify the elements needed to facilitate undergraduate EBM learning among Japanese medical students. Participants were supervising physicians working in teaching hospitals or clinics. Six physicians were interviewed individually from October 2019 to January 2020. The interviewees were asked about their own EBM learning and teaching experiences, what they kept in mind when teaching EBM to medical students and what they felt was needed to improve current undergraduate EBM education. Interview transcripts were analyzed using thematic analysis. Thematic analysis extracted ve themes: awareness of foreground questions in clinical practice, motivating learning through observation of role models, awareness of the role of medical students and active learning, understanding patient background as a starting point for practicing EBM, and prioritizing understanding “why” rather than “how” in EBM. Japanese medical students with limited clinical experience may rst need to observe their supervisors practice EBM to develop the motivation to learn and grasp the bigger picture of EBM. It is important for medical students to develop an interest in their patients through conversations. Focusing on learning the rationale rather than the skills for practicing EBM may be the key to facilitating initial interest in undergraduate EBM education for subsequent continuous learning.


Introduction
Evidence-based medicine (EBM) has become prevalent as "the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients" since its introduction by Sackett et al. in the 1990s (Thoma and Eaves, 2015). The principles of EBM include asking appropriate clinical questions about patients, interventions, comparisons, and outcomes (PICO; step 1); searching related and relevant evidence (step 2); critically appraising the evidence (step 3); integrating the evidence with clinical expertise and with patient's unique biology, values, and circumstances (step 4); and evaluating the effectiveness and e ciency of steps 1 to 4 (step 5) (Straus et al., 2018).
EBM is considered one of the most important aspects of undergraduate medical education (Ahmadi-Abhari et al., 2008;EDUCATION, 2015). A number of studies have reported on undergraduate EBM curricula. The educational environment typically comprises classroom instruction, clinical settings (e.g., bedside rounds), and online learning (Maggio et al., 2013). The timing of education can be preclinical, clinical, or scattered over multiple grades as a longitudinal curriculum (Maggio et al., 2013). In terms of educational content, some curricula include more than one of the ve principles of EBM, but few include step 1 (asking questions) and step 5 (re ection on steps 1-4) ( When developing a medical education curriculum, it is important to identify the speci c challenges in learning, learner needs, and learning objectives (HARDEN et al., 1984), and the same is true for EBM education. Given that medical education systems vary from country to country, and differ in learning challenges and learning needs, it is important to establish an EBM curriculum that suits the actual educational situation in each country. Thus, it is necessary to rst understand the learning environment for EBM education in individual countries (Prideaux, 2007).
In Japan, a survey on the status of EBM education was conducted in 2001 (Matsumura et al., 2001;Ohno et al., 2001); however, there has been no comprehensive report since. Further, while there is a four-week EBM elective training course at a single university (Kojimahara et al., 2000) and a year-long EBM education course for those who wish to attend (Watanabe et al., 2017), these programs have not undergone any standardized evaluation. Thus, the speci c challenges in learning, learner needs and learning objectives required to build an EBM curriculum suitable for the realities of undergraduate education in Japan remain to be determined.
Further, despite the fact that acquiring EBM techniques forms one of the learning goals of the model core curriculum for undergraduate medical education (Committee, 2016), few residents reportedly use EBM skills on a daily basis (Risahmawati et al., 2011). It is possible that medical students do not fully understand the needs and objectives of EBM education. Thus, to determine the elements needed to engage medical students in EBM learning, it may be more effective, rather than focusing on the perceived needs of medical students as learners, to identify educatorperceived normative needs and learning goals (Grant, 2002).
We performed a qualitative study to identify factors that would facilitate medical students' learning of EBM through personal interviews with educators.

Methods
This was a qualitative study based on individual interviews (semi-structured interviews).

Participants
Participants were recruited by purposive sampling. They were university faculty and physicians in teaching hospitals or clinics who are involved in EBM education. The researcher (YK) contacted the participants via email and asked them to participate in the study.

Data acquisition
Semi-structured interviews were conducted with each participant individually between October 2019 and January 2020. Interviews were conducted using an interview guide developed by YK and TM. The interview questions mainly inquired about the contents of EBM education and what the interviewee keeps in mind when teaching EBM to medical students. The interviews were conducted in a private room at the participants' place of employment. Each interview was recorded on an IC recorder after obtaining consent from the participants. Notes were also taken during the interview. Each interview lasted 40-60 minutes.
Each participant was asked questions about the following: 1) their age, gender, years post-graduation, area of expertise, and years of experience in EBM education; 2) how and when they learned about EBM; 3) the curriculum and programs for EBM education at their institution; 4) their role in EBM education; 5) points they keep in mind when implementing EBM education; 6) their perception of medical students' competence in EBM; 7) what is needed to improve undergraduate EBM education.

Analysis
A verbatim record of each interview was made by transcribing the recorded audio data. The verbatim transcripts were checked by the participants for errors. Two researchers (YK, TM) analyzed the text data using a thematic analysis method. Coding of the data was mainly performed by YK and the contents were con rmed by TM. The themes were extracted deductively after the data were obtained. Additionally, speci c suggestions for EBM education strategy obtained from the interviews were listed separately from the themes.

Ethical issues
This study was conducted after obtaining approval from the Ethics Committee of the Faculty of Medicine, University of Tsukuba (notice number 1430). Participants were informed that they were free to decide whether or not to cooperate in the study, and that there were no disadvantages to not cooperating. In addition, they could choose to stop the interview midway through if they changed their minds about participating. There were no con icts of interest between the interviewees and the researchers. After the interviews had been transcribed, the interviewers were asked to review the contents and delete any information that they did not want to be used in the analysis.

Results
Six of the seven invited participants (two university faculty members and four teaching hospital/clinic physicians) gave consent to be interviewed. All interviewees were male, with an average age of 43.3 years, 19 ± 10.9 years since graduation and 11.5 ± 9.5 years of EBM education.
Thematic analysis extracted ve themes: awareness of foreground questions in clinical practice, motivating learning through observation of role models, students' awareness of their own role and active learning, understanding patient background as a starting point for practicing EBM, and prioritizing understanding "why" rather than "how" to practice EBM. Below, we detail the ve identi ed themes, providing supporting quotes from the interviewees. We have added supplemental text to the quotes in brackets when further context was needed to facilitate understanding. In addition, we have also detailed some of the interviewees' speci c suggestions for EBM education strategy.

Awareness of foreground questions in clinical practice
When one interviewee learned about the existence of EBM, vague questions in daily practice emerged as "clinical questions," which inspired him to learn more about EBM.
"[In daily practice,] I wasn't registering my questions in the form of 'I don't understand this.' I had a lot of vague questions, and when I read Sackett's book, I was able to recognize that these were concrete questions." (interviewee 1) "At least I didn't understand that I didn't understand. I thought, 'Well, this might be interesting.'" (interviewee 1) These statements suggest that the interviewee's act of questioning clinical decisions that he had considered to be obvious promoted his EBM learning. The interviewee noted that the rst step to practicing EBM was to realize the things he had been unaware of.
However, medical students have little clinical experience and little general knowledge of diseases and syndromes, making it di cult for them to generate foreground questions.
"I think most of what students learn in class is background questions, and that knowledge is what they learn. Foreground questions are the ones that come up in clinical practice, or rather, the ones that develop in the eld of clinical practice, so students who don't participate in clinical practice probably won't develop them at all." (interviewee 5)

Motivating learning through observation of role models
The interviewees suggested that for medical students, who were less likely to be aware of foreground questions, observing their supervisors practicing EBM could help them learn how EBM methods could be useful in a clinical setting.
"Personally, I think junior doctors would be inspired to see senior doctors enjoy learning and share the excitement of learning." (interviewee 4) "I think it's important to have the attitude that there are things we [supervising physicians] don't understand, and that we're doing our best to research our questions on a daily basis." (interviewee 4) Additionally, the interviewees suggested that it was important for supervising physicians to be role models for medical students and to practice EBM on a regular basis. Students' awareness of their own role and active learning Some interviewees thought that medical students needed to learn to become aware of their desire to help patients and their role within the medical team to enable them to actively learn EBM.
"In short, senior residents have to explain the patients' conditions to them and perform a variety of procedures, and even if they wanted to, they would not have enough time to nd and read papers. Junior residents and students can help with that part of the work. That's the kind of role we wanted them to play, and we wanted them to work as a team." (interviewee 2) One interviewee stated that he would sometimes try to stimulate passive students to make them aware of their role.
"I never treat them as students. It's not like, 'You're a student, so you'll have to watch.' In the mornings, I would deliberately ask, 'How is the patient who was admitted to hospital yesterday?' That means they would have had to have seen the patient before the round. That's what I try to get students to do. That's why they need to know their patients." (interviewee 3) The interviewees suggested that having a "patient-focused" perspective would make medical students more willing to learn apparently di cult skills, such as information seeking.
"The students actually learn that the process of searching for articles on clinical questions and applying them to their own patients is useful. This is the so-called 'aha moment,' and it is why the hurdle of searching for articles naturally becomes lower." (interviewee 3)

Understanding patient background as a starting point for practicing EBM
The interviewers suggested that it is important to communicate with each patient and to learn and understand their background and values. Several suggested that trying to understand the patient is the rst step in practicing EBM. Prioritizing understanding "why" rather than "how" to practice EBM Remarks from the interviewees suggested that medical students place less priority on learning speci c skills such as information retrieval and critical appraisal of articles because they think these skills can be acquired in the future when they become physicians. "At the time, I didn't understand the necessity of learning EBM, which is something I understand in hindsight; I don't really feel that I should have learned about EBM techniques rst." (interviewee 5) "Personally, I don't think students need to learn about critical appraisal at all. I think it's a craftsman's world to a certain extent." (interviewee 4) One interviewee suggested that a priority learning theme should be to understand the reason for the formulation of PICO, which is to understand patients' background.
"Formulation of questions by PICO is only a tool, and the purpose is to be curious and learn about patients' background. In that sense, I would like to introduce this tool to students at Step 1 of EBM." (interviewee 4) Suggestions of speci c strategies to help medical students learn EBM During the interviews, the participants suggested speci c strategies to help medical students learn EBM. One was to use the study of statistics and history of medicine during the pre-clinical phase to help medical students realize the impact of medical articles on clinical decisions. Another was to incorporate the EBM principles as additional learning in their areas of interest or an area in which the students feel they have a strong understanding once they have acquired some background knowledge in each clinical discipline. The interviewees also suggested that students could divide their role into two, as a doctor and as a patient, and explain the research-proven effects of a drug to patients as a way to learn how to apply the evidence into practice. Finally, rather than educating students about EBM in a speci c discipline, some interviewees suggested creating a curriculum that allows them to learn EBM across disciplines.

Discussion
Analysis of the interview transcripts led to the identi cation of several elements that could be used to promote undergraduate EBM education. While becoming aware of the foreground questions in clinical practice is a trigger for practicing and learning EBM, medical students with little clinical experience are rst motivated by observing their supervisor practice EBM as a role model. As medical students begin to realize their role in the care of patients, they will understand the signi cance of the EBM methodology, which is essentially to problem solve for patients. In learning EBM, it is important to rst understand patients' background and values to enable the formulation of questions through PICO, and an appropriate learning goal for students is to understand why EBM is practiced rather than how to practice it.
Although there are signs of gradual change in Japan, clinical practice is still often an observation-based learning method (Inada et al., 2010). By giving medical students certain roles in clinical practice, their learning changes from "observational" to "participatory" and they become able to proactively think about patients' health issues (Inada et al., 2010). Proactively interacting with patients enables students to think about what it means to be healthy and what is of high priority for the patient-the true outcomes for the patient-which leads to the generation of foreground questions based on PICO.
To enable medical students to formulate their own clinical questions, application of legitimate peripheral participation(MATUSOV et al., 1994) may be useful. Legitimate peripheral participation is a process in which the learner forms a "legitimate member" of a workplace and learns from the periphery by gradually deepening their degree of participation by emulating the person at the center of the workplace. By creating a learning environment in which medical students participate in ward teams or outpatient clinics as "legitimate members," they begin to acquire knowledge and skills in a step by step manner by observing how doctors practice EBM, even if they are unable to immediately learn EBM practices on the job. This will require a change in faculty awareness and curriculum to welcome medical students as part of the team.
Based on the remarks of educators in the interviews, it may be more important for medical students to learn why EBM is necessary for clinical practice than the speci c skills and knowledge content of EBM. Thus, it may be better for rsttime medical students to begin learning EBM from Step 4, understanding that Step 1 is the starting point, and then that information retrieval skills (Step 2) and critical appraisal (Step 3) are methods for obtaining answers to the questions raised in Step 1. Learning EBM in this order will increase students' internal motivation for learning and help them to re ne their EBM methods once they have graduated as physicians.
One interviewee suggested that pre-clinical students could learn EBM by thinking about how medical articles affect clinical practice through the study of statistics. How early-career medical students can effectively learn EBM without abundant medical knowledge is a major consideration when establishing an EBM curriculum (Maggio et al., 2016). This study gained insights from interviews with supervisors about ways to facilitate EBM learning among medical students. The ideas are compelling because they are derived from the supervisors' experiences with developing their own knowledge and skills in EBM and current teaching. One limitation of this study is that the interviewees were educators rather than learners. We interviewed educators to obtain their views on not only the challenges associated with facilitating EBM learning, but also the solutions to those challenges. Future studies asking medical students about their readiness to learn EBM and their past experiences with EBM will strengthen our ndings.
In conclusion, based on interviews with educators, we extracted several factors that may facilitate EBM learning among medical students. Initially, it is important for medical students to understand the signi cance of and reasons for using EBM methods through observing role models practicing EBM. Once students have gradually acquired clinical knowledge, they can start learning EBM by actively communicating with patients and formulating clinical questions via these conversations. Additionally, the focus of learning goals should not be on learning how to search for literature and critically appraising it, but rather to understand that the goal of EBM is to make decisions that are best for the patient.

Declarations
Consent for publication Not applicable.

Availability of data and materials
The datasets generated during and analysed during the current study are not publicly available to protect the privacy of personal information but are available from the corresponding author on reasonable request.