Better Evidence: Assessing the Utility of an Evidence-Based Clinical Resource in Two African Medical Schools

Abstract

Background: Evidence-based clinical resources (EBCRs) have the potential to improve diagnostic and therapeutic accuracy at the point of care. The majority of U.S. teaching medical institutions have integrated them into clinical training and practice. Many EBCRs are subscription-based, and their cost is prohibitive for clinicians and trainees in low-income countries (LICs). The current use of EBCRs by medical students in sub-Saharan Africa, as well as their utility and impact on students’ educational performance, is not known. Methods: We conducted the first prospective cohort study of African medical students and faculty. Participants were offered free 5-year subscriptions to UpToDate, a leading EBCR. Students completed two surveys on their study habits and gave permission for remote logging of all their activity on UpToDate. Their medical school grades were obtained as well. Results: 1518 students were invited to enroll and 704 did (46%). 88% of eligible Doc4 (6th year) students enrolled at the University of Rwanda (UR). At baseline, 92% of participating UR students and 97% of Muhimbili University of Health and Allied Sciences (MUHAS) students reported ownership of an internet capable device. Students at both institutions used online resources frequently in their education and primarily utilized free resources (Medscape, Wikipedia, Google). When offered free access to UpToDate, senior students used it frequently and continued to use it after graduation. One year after enrollment, self-reported usage of UpToDate increased significantly, while usage of most other resources decreased. Class performance in exams of graduating Rwandan students was better in 2016 and 2017 (after introduction of the EBCR) than in previous years. In a multivariable linear regression, controlling for prior educational performance, viewing of UpToDate topics in pediatrics was significantly associated with higher scores in the clinical pediatrics exam. 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. Among clinical students, access to the EBCR was associated with decreased reported usage of non-validated online resources like Wikipedia. The introduction of an EBCR was temporally associated with an overall improvement in the examination performance of medical students.