Well Raj, that was another really great example of how to walk a student through every single step of going through the evidence based medicine chain. And what I was wondering is, I noticed sometimes you're very interactive with the student. And sometimes it becomes a little bit more didactic. So how do you balance the two of those? >> That's a great observation Jen. It is a challenge and I'm not sure I do it optimally well all the time. As I think about what just happened with that student, I feel like at the beginning I was a bit more interactive and then later on I just started walking her through the results. And what I find with students is they're actually interested in the process but it's not what motivates you. You're not really interested as much in what's under the hood in the engine, but really what the output is of the car. And so you're really much more interested in discussing the results and how it matters to patients. And sometimes in our teaching encounters we can spend so much time engaging them on the question, the type of resource to go to, what is the secondary versus primary literature, whether the methodologies are good. All of which are incredibly important in order to get to a point where you trust the results. But if we spend too much time in the clinical encounter there then we won't spend enough time talking about the results in a way that engages the student. Keeps them motivated and actually gets them to critically think about the hardest part of using evidence at the bedside and that is clinical decision making, shared decision making. So I think that happened here. I think I spent a little too much time on engaging the students early on. And then when I started walking them through the table I was really doing a lot of teaching at the student instead of understanding their way of comprehending the data. So for example, sometimes when I'm sitting with a student we're just looking at a table and we see the relative risk reduction and the number needed to treat. There's a fantastic moment there where you can talk about how relative risk reduction can look big, but if the risk at baseline is small, the number needed to treat actually is not that impressive. And that dichotomy, that paradox, is something that is a really important learning moment that if we're not engaging the student around that, we lose that opportunity. So and looking back, I would've preferred to have spent a lot more time going over the table and asking, boy what is a number needed to treat mean to you? How do you talk about a number needed to treat with the patient? You have a good way of thinking about that? And there aren't necessarily great ways to do that, but it's a great discussion to have. And then it also translates more to the what are we going to do with this patient as a result of the data that we're looking at. So I would have prefered to spend more time engaging with them on the table. >> Okay, and one of the things that I know is very challenging when teaching a learner how to use evidence based medicine is to get them to actually commit to a clinical decision. How do you go about doing that? >> Yeah, that I think is Is really important. I think we sometimes worry too much that our learners don't have enough knowledge in order to commit to a decision. And I believe that's false. I think we make decisions all the time in life, sometimes with a little bit of information, sometimes with a lot of information. And I think it's still important to commit as long as we are aware of the strength of the information that is driving our commitment. So I use a very simple tool, I think you might have seen it, where I just ask people on a scale of one to ten indicate how confident are you in starting this particular therapy? Sometimes you can say that at the beginning of the discussion with a student. And then you can come back to it after you've reviewed the data and say did this change your number? At the beginning you were at three, are you higher? Are you lower? It's a very arbitrary nonscientific way but it's something that we can relate to as humans to say no, I moved up to a seven. Or you know what, I actually am still at a three because I didn't understand anything of what this study told me. Those are important ways to kind of trigger the next set of conversations. And then it's a good bridge then to go into the patient room. And talk about what you're recommending to the patient. So that's one way I try to do it with students. I do think it's critical that we do that almost every time with the students to engage them in the process that we all go through. >> It really makes them think and commit. >> Yeah, exactly. >> All right, well thank you so much. >> Great, Jen, thank you, this has been fun.
