Evidence-based medicine training in graduate medical education: past, present and future.

Evidence-based medicine (EBM) training remains a challenge to educators, particularly in graduate medical education. In this article, I trace the history of EBM in American medical education, review traditional journal clubs and contrast them to free-standing EBM curricula, petition for the advancement of integrated EBM teaching and propose an agenda for future work. Traditional journal clubs are unsuitable to teach evidence-based decision making because of their exclusive focus on critical appraisal. In contrast, EBM curricula cover the identification, appraisal and application of evidence in the context of individual patient scenarios. The effectiveness of some recent efforts reflects increasing attention to curriculum development principles and scientific rigour. The integration of EBM training into residents' established clinical venues offers theoretical educational advantages and confronts the challenge of practising EBM under the imperatives of 'real time' patient care. Initial responses to this formidable challenge show promise, but their feasibility and effectiveness remain to be explored. A more complete understanding of the epidemiology of residents' emerging clinical questions will inform continued curriculum development in integrated EBM training.