Evidence-based practitioners are the future leaders of chiropractic, because they possess the ability to apply research and are likely to deliver more effective and less costly interventions. The abilities to assess data critically, evaluate study methods, and evaluate study outcomes are essential cognitive competencies used by successful health care practitioners in caring for their patients in this era of accountability and continual quality improvement. Like most cognitive skills, EBHC principles need to be reinforced through application and repetition [15
]. Noted experts have straightforwardly stated that chiropractic practitioners using the EBHC approach benefit from being able to:
Be more effective and efficient.
Deal with expanded demands for accountability.
Manage rapidly expanding sources of information.
Maintain professional competence.
Provide an increased quality of care .
The results of this study suggest that our educational intervention enhanced practitioners' EBHC knowledge. Workshop participants reported high scores for the quality of the workshop presentation.
The response rate to the surveys and tests was good. Overall, these participants might be considered more interested in research evidence and peer reviewed journals than the average chiropractor. However, more than two-thirds of the participants read no peer reviewed journals on a regular basis. This is not unexpected, because subscription rates to peer reviewed journals are low within the profession.
As expected, participants scored poorly before the workshop intervention and performed exceedingly well in post intervention testing. For the 15-item pre-posttest, the effect size was very large. A mean score of 88% on the 59-item test is considered noteworthy. We compared baseline knowledge scores with participants' ages and found a weak inverse relationship. Also, we compared baseline knowledge scores with participants' years in practice and found a very weak inverse relationship. These findings are not discordant with indecisive findings from a systematic review that reported that medical physicians who have been in practice longer may be at risk for providing lower-quality care and posses less up-to-date knowledge . Posttest scores measuring knowledge gain likewise were not related to participant age or years in practice (i.e., older participants grasped the EBHC concepts just as well as the younger participants).
The quality of the presentation is an important variable in the education process. In this study, participants rated the quality of presentation very high. Free text comments primarily indicated appreciation of the preparation and implementation of the workshop. Because of the anonymity with which data were collected, participants were likely to be honest in their feedback. It is difficult to imagine a poor quality presentation yielding respectable knowledge gains, improving practitioner behavior or improving patient outcomes [2, 29]. Thus, participant perception of the presentation's quality is an important element in educational courses.
Our workshop's effectiveness, we believe, derives largely from its fidelity to adult learning theory and implementation of effective health care CE strategies. Educational interventions involving active participant involvement lead to "deeper processing of information" and, consequently, improved recollection of factual information . Interactive educational meetings (participation of healthcare providers in workshops that include discussion and/or practice) are generally effective [2, 44]. Passive dissemination of information (e.g., chiefly didactic lecture) is generally ineffective.
The research design used for this study limits inferences that should be drawn from the study's conclusions. This study is a before-after design without controls and is not as strong as a randomized trial. Participants were self-selected, and were possibly more motivated and more likely to benefit from the intervention than the general population of chiropractors.
Our study may also be criticized for reporting on process measures (knowledge gained, quality of presentation), rather than practitioner behavior and clinical outcomes. The long-term goal of continuing education is not merely to impart new knowledge, but rather to change learners' behaviors . However, patient outcomes are difficult to measure and are affected by many other unrelated variables . Measures farther away from the intervention can easily be influenced by un-measurable untoward events compared with the more proximal and easier-to-measure items of competence: knowledge, skills and attitudes. Ideal outcomes would include estimates of a continuum of measures: competence to performance to health care outcomes . Also, our evaluation was short-term, so we cannot assess the durability of the knowledge.
Measurement bias might have occurred, because our test to measure EBHC knowledge had not been previously assessed. However, the impressive improvement between pre- and post-testing scores provides support for the instrument's psychometric qualities. The educational literature recognizes that pre-assessment may lead to a higher post-assessment score due to an item-practice effect . There is a possibility of a test-training effect, because we used an identical posttest; that is, it is possible that participants learned how to take the same test better the second time around, rather than really learning new knowledge. However, participants' scores for the 59-item test were high. It is unlikely that participants inflated their test scores, because they submitted their scores anonymously, and we found no differences between self-reported scoring and instructor scoring.
Future studies should incorporate more rigorous design, including validation of outcome measures, larger sample size, use of a control group, and follow-up. Ideally, upcoming studies should measure the effect of the intervention on patient outcomes, preferably in randomized controlled trials. It is difficult to predict the generalisability of our findings; it is unknown whether other instructors with different content and context would achieve similar improvements [47, 48]. Despite these limitations, our evaluation demonstrated a positive impact on the participants' EBHC knowledge and a high perception of the workshop presentation's quality.