Better evidence: prospective cohort study assessing the utility of an evidence-based clinical resource at the University of Rwanda

Abstract

Objective: Evidence-based clinical resources (EBCRs) have the potential to improve diagnostic and therapeutic accuracy. The majority of US teaching medical institutions have incorporated them into clinical training. Many EBCRs are subscription based, and their cost is prohibitive for most clinicians and trainees in low-income and middle-income countries. We sought to determine the utility of EBCRs in an East African medical school.

Setting: The University of Rwanda (UR), a medical school located in East Africa.

Participants: Medical students and faculty members at UR.

Interventions: We offered medical students and faculty at UR free access to UpToDate, a leading EBCR and conducted a cohort study to assess its uptake and usage. Students completed two surveys on their study habits and gave us permission to access their activity on UpToDate and their grades.

Results: Of the 980 medical students invited to enrol over 2 years, 547 did (56%). Of eligible final year students, 88% enrolled. At baseline, 92% of students reported ownership of an internet-capable device, and the majority indicated using free online resources frequently for medical education. Enrolled final year students viewed, on average, 1.24 topics per day and continued to use UpToDate frequently after graduation from medical school. Graduating class exam performance was better after introduction of UpToDate than in previous years.

Conclusions: Removal of the cost barrier was sufficient to generate high uptake of a leading EBCR by senior medical students and habituate them to continued usage after graduation.

Keywords: EBCR, global medical education; general medicine (see internal medicine); global health; information technology.

Figure 1

Baseline survey of Rwandan medical students. (A) The percentage of students at UR reporting that they own a particular internet capable device or use it in medical education. ‘Any device’ refers to any of the following: tablet, smartphone, laptop and desktop. (B) The percentage of students indicating that they use a specific resource to study for coursework or prepare for examinations. n=547 UR students UR, University of Rwanda.

Figure 2

Predictor of UpToDate usage. The average daily usage during the study period by UR students broken down by class year at enrolment. Students who did not log onto their accounts after enrolling into the study were assigned a daily topic viewing frequency of zero. n=547 UR students. UR, University of Rwanda.

Figure 3

Changes in the usage of electronic resources. Figures show the percentage of respondents who reported using a particular resource ‘almost every day’ at enrolment and 1 year later at the time of annual evaluation. Shading added to highlight responses for UpToDate. (A) Responses of UR users who had graduated at the time of annual evaluation and were practising physicians. (B) Responses of UR clinical students (Doc1 at the time of enrolment) who were still in school at the time of annual evaluation. n=62 UR graduates, and 66 UR students. UR, University of Rwanda.

Figure 4

Impact of EBCR provision on class exam performance at UR. (A) The average grades of graduating Doc4 students over time. Each dot represents one student and shows the average of their grades in the following eight exams: written and clinical exams in internal medicine, paediatrics, obstetrics and gynaecology and surgery. (B) The average grades of students pre-UpToDate (UTD) (2012–2015) and post-UpToDate (2016–2017). The p value represents a two-sided heteroscedastic t-test. The error bars represent standard error of the mean. EBCR, evidence-based clinical resource.

Figure 5

EBCR utilisation over time by UR students and faculty. Lines show the average number of topics viewed per user per month by each user group. Only users who enrolled before 01 March 16 are included in this analysis (n=185 faculty, 70 Doc4 students). Call-outs are added to describe events in the careers of Doc4 students.