EBM and Clinical Support Librarians@UCHC

A blog for medical students, faculty and librarians about their use of evidence based medicine, clinical literature, Web 2.0, sources and search strategies

Category Archives: EBM/Clinical Decisionmaking

Teaching & Learning in Medicine, Research Methodology, Biostatistics: Show Me the Evidence (Part 4): Causality, Airplanes and GIDEON

As accident re-enactments go, this one is pretty Riveting

Links courtesy of NJ.com and Exosphere3D – All rights reserved – Copyright 2011

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The focus and calm of U.S. Airways Captain Chesley Sullenberger can be appreciated by listening to the audio portion of this re-enactment, as he made critical analyses – over a period of only a few minutes – on how (and where) to land a disabled aircraft sinking earthward over a densely populated area. His decisions saved 100% of the lives on board that day.

Hang out with a bunch of epidemiologists long enough and eventually the conversation while turn to Causality. They will tell you that there are some big differences in semantics between linking causation, etiology and “proof” that X exposure caused Z disease or health condition. When I looked up the terms “causation” and “causality” (on Google) there were major sidetracks, such as WBA (Why-Because-Analysis) as in, Why did the airplane crash? Why did the reactor experience a meltdown?

Why? From the viewpoint of a physician, an engineer or an epidemiologist… because of X-Y-Z.  

X-Y-Z could be bird strikes, human error, engine failure, weather conditions, crazed people bearing guns, lack of fuel or a thousand other accidents waiting to happen. Often the causes can be identified. Sometimes one can only attribute unanticipated events to gauzy, fuzzy concepts such as “it was a one in a million chance” or “this was God’s will”,  “causes unknown” or just plain Karma. The harder (non-fuzzy) data can be applied towards improvements in systems design, development of new vaccines, engineering safety… all targeted towards avoidance of future accidents (or disease outbreaks).

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Epidemiologists save lives.  Sometimes this association accumulates slowly… as in proving associations between Exposure X and development of Disease Y decades later.  In other cases, evidence mounts up as an emergency, such as the identification of a novel virus identified as SARS in 2002.  But linking health effects of exposures over a human life-span is so much more elusive than showing evidence that birds got sucked into a jet engine at 2,500 feet (as above).

Turning to the PubMed database, a screenshot below from Medical Subject Headings List (MeSH) reveals how the term “causation” is mapped in the online thesaurus of medical indexing terms:

Image Source: NLM (http://www.ncbi.nlm.nih.gov/mesh) – All rights reserved – copyright 2011

One way to search a large database such as PubMed is to simply type in some words – for an example, Liver Cancer AND Epidemiology.  This pulls up over 18,000 retrievals…  too many (!), but by then selecting and applying standard Limit Fields such as Language, Journal Subset, Age Group, Gender and others, the retrievals can be filtered down to a more-manageable number.

A more precise way to search a large database like PubMed is to use the Medical Subject Headings list. In the example below, the term Liver Cancer was typed into the MeSH search page, which maps automatically to the preferred MeSH term — Liver Neoplasms. While this search still retrieves thousands of citation, they can be limited by selecting and applying any MeSH Subheading (or clinical qualifiers) that are appropriate to the search. These subheadings include clinical concepts such as Virology, Immunology, Genetics, Epidemiology, Transmission and 80 others.  Following is a screenshot of that type of search:

Image Source: NLM (http://www.ncbi.nlm.nih.gov/mesh) – All rights reserved – copyright 2011

Remember that a librarian’s idea of “causality” could be defined, in part, by the number or types of clinical subqualifiers selected (immunology, virology, epidemiology and those types of “background” concepts) to be combined with the formal MeSH term.

There are many ways to search. It helps a novice medical searcher sometimes to tell them just that: There is no one right way to search. Sounds enigmatic and it is.

Here is an example which I found recently in the medical literature, a 2010 article which discusses application of Bradford Hill criteria (listed here):

  • strength of association
  • consistency
  • specificity
  • temporality
  • biological gradient (dose-response)
  • biological plausibility
  • biological coherence
  • experimental evidence and
  • analogy

 Image: http://www.ncbi.nlm.nih.gov/pubmed/20644061 – All rights reserved – Copyright 2011

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Those searching for practical answers about causality, transmissible agents, disease etiology, global prevalence or current treatments might want to search GIDEON (Global Infectious Disease Epidemiology Online Network), an interesting “niche” information source targeting the research requirements of epidemiologists, clinical & translational researchers, MPH students, toxicologists or anyone interested in tracking or diagnosing infectious diseases on a country- or world-wide scale (subscription required). Updated weekly, the database is produced by Gideon Informatics and hosted on the EBSCO platform.

A search for causality or epidemiology done in the resources indexed by GIDEON is quite unlike a search done in PubMed about the etiology of Liver Cancer. The producers collect, review and index factual data collected from around the globe; their data encompasses a wide and diverse group of human cultures, agricultural, societal, economic or environmental practices.

Below is a screenshot of one example of the type of data that can be searched on GIDEON: bacterium (causative agent), typhoid (identifiable infectious agent) and United States (location, recorded incidence over time):

.Finally, a screenshot of What’s New at GIDEON (May 11 2011):

Image Source: GIDEON – All rights reserved – copyright 2011


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News, Clinical Resources, iPhone Apps: FirstConsult

Here’s some good news!  On Nov 6 2010, Elsevier Health, producer of the MD Consult/FirstConsult database, announced their free FirstConsult app for iPhone, iPod Touch or iPad .

UCHC Library is an institutional subscriber to the MD Consult database, which enables any registered library user to access the First Consult database via their mobile device.  If you haven’t used FirstConsult before, it is a clinical point-of-care resource designed for busy clinicians who need fast answers in a “wherever, whenever” wireless environment.  Below is a screenshot of  First Consult apps page from iTunes:

Source: http://www.mdconsult.com/php/227775087-4/homepage – All rights reserved – Copyright 2010

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Here are instructions on how to make it work on your iPhone/iPad:

1.       If you have not previously set up an account with MD Consult, first you’ll need to create one (which is free and quick).  Go to http://library.uchc.edu, then click on Databases, then scroll down to the MD Consult link.

The “Create Account” button is in the upper right-hand corner. (Without this step, your free FirstConsult app will only work for 60 days).  See the screenshot below:

Image Source: http://www.mdconsult.com/php/227775087-4/homepage – All rights reserved – Copyright 2010

2.      Next, using your mobile device, log into your MD Consult account.  Then go to the iPhone App Store.  Download the FirstConsult app into your device.  Medical topics download occurs automatically; you should budget 30 minutes for the initial data downloading.

If you have any questions or problems with getting this to work, please call UCHC Library Computer Education Center staff at 860-679-3772.

Teaching & Learning in Medicine, Research Methodology, Biostatistics: Show Me the Evidence (Part 3)

This post is the third in a series entitled Show Me the Evidence. It is about the evidence gained from bibliometric data and journal impact factor analysis.

Let’s start with an excerpt from an 2008 article:

The assumption that Impact Factor (IF) is a number absolutely proportional to science quality has led to misuses beyond the index’s original scope, even in the opinion of its devisor*. When the IF is inappropriately attributed to all articles within a single journal, it leads to false applications regarding the  evaluation of individual scientists or research groups. This is, unfortunately, a common practice, especially among governmental funding boards and academic institutions entitled to judge scientists for positioning and grant allocation. The IF has thus accumulated huge strength and importance, mainly implied by its, at least to a degree, undue application as an index of overall scientific quality“.

Excerpt on page 1 from “The Top-Ten in Journal Impact Factor Manipulation” by ME Falagas and VG Alexiou, published in Arch Immunol Ther Exp (Warsz). 2008 Jul-Aug;56(4):223-6 – All rights reserved – Copyright 2010

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This post was sparked by a recent reference question from a retired professor who needed some assistance on how to find and search the Journal Citation Reports® database*, which is described by its’ producer, Thomson Reuters,  in this way:

Journal Citation Reports® (JCR) offers a systematic, objective means to critically evaluate the world’s leading journals, with quantifiable, statistical information based on citation data. By compiling articles’ cited references, JCR® helps to measure research influence and impact at the journal and category levels, and shows the relationship between citing and cited journals. “

Text source: Thomson-Reuters –http://wokinfo.com/products_tools/analytical/jcr/ – All rights reserved – Copyright 2010

So let’s take a look ways to find current evidence about publication patterns in the biomedical literature.

There were two things about JCR® that needed explanation for the professor.  First, the latest annual edition of JCR® was released in June 2010 and indexes journal citation data for the 2008 calendar year only (not 2009).  Second, only those journal titles indexed in the Web of Science database* are searchable in JCR®.

As one example: Let’s say that you’re a scientist working on stem cell research and you subscribe to ten international journals that are critical to your continuing professional knowledge, lab work and research.  It’ll be a good idea to check the list of 6,600+ journals that are included in the Web of Science database in order to determine if your “best” journals are searchable in Journal Citation Reports®.  If those titles are not covered in JCR®, you’ll be missing essential facts for comparing bibliometric data.

Here is a screenshot of a search done on the 2009 JCR® database for journals indexed under Cell and Tissue Engineering:

Image source: Thomson-Reuters – All rights reserved – Copyright 2010

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Some folks assume that “every journal in the world” is included in Journal Citation Reports, but that’s not the case.  9,100 journal titles were indexed in the 2009 edition.

Another thing to know is that there are six subsets available for annual subscription from  JCR® and UConn Libraries subscribes only to these two: Science Citation Index Expanded (indexing of 7,100 major journals across 150 disciplines and Social Sciences Citation Index (2,474 journals across 50 social science disciplines).

Below is a screenshot from an online tutorial about ways to search Journal Citations Reports® (with my added comment in the upper left-hand corner):

Image source: Thomson-Reuters – http://thomsonreuters.com/products_services/science/science_products/a-z/journal_citation_reports – All rights reserved – Copyright 2010

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Next, the professor asked: “I have a manuscript to submit for publication.  Is this the only place I should use to look at statistics about specific journal titles? “.

While JCR® is an important reference resource, it’s neither free or the only one available worldwide for researchers to search.  Below are sites which provide evidence that there are other ways to do citation analysis in year 2010 (some are free, some are via subscription).

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SCImago Journal & Country Rank Indicator (SJR). I like this site – it is easy to learn to use.  There are many ways to search their datasets (ranked by country, by journal title, by countries grouped by continent, etc.).  I also found their Map generators intriguing, which show comparative relationships between discipline or subject-specific citations.

Below is a screenshot of the SCImago Journal & Country Rank page showing a search done on Year “2008”,  “Medicine” as a general category, “Emergency Medicine” as a specialty and USA for the “country, with a limit for displaying journals that had at minimum 12 citable documents over 8 years:

Image source: http://www.scimagojr.com/journalrank.php – All rights reserved – Copyright 2010

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Link here to a 2007 paper written by the creators of SCImago which describe the process by which journals are ranked on their site.

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Those who have access to the Scopus database* through their library may have already discovered the Scopus Journal Analyzer, where allows one to select a discipline (shown below as “Biochemistry, Genetics and Molecular Biology”) and a journal title (“Cell” was searched below) and then choose method of analysis to determine journal impact.  Elsevier is the producer of the Scopus database. 15,000 journal titles are indexed for inclusion in Scopus analytics.

A screenshot below shows results of a search performed in Scopus Journal Analyzer recently for the broad topic of Biochemistry, Genetics and Molecular Biology.  The journal Cell holds the most-cited place in the list (no surprise there):

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The journal analyzer can be sorted using the following criteria: SJR versus SNIP.  I  found out that four years of data are necessary for sorting results using these filters.  Below, see a different screenshot:  rankings by SJR and SNIP for the same subject area:

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Explanations for SJR and SNIP were easily found in the Scopus Help section (screenshots shown below):   

Credit for all Scopus Images shown above: Elsevier B.V. – All rights reserved – Copyright 2010

Want a different way to search Scopus analytics for evidence? Use the search feature in Journal Analyzer to select and compare up to ten Scopus sources on number of citations, documents, and percentage not cited.

A 12-page PDF white paper (from 2006) is available to download from Scopus, entitled “Using Scopus for Bibliometric Analysis: A Users’ Guide“.  Following is an excerpt from that document:

Introduced in January 2006, the Scopus Citation Tracker enables users to easily evaluate research by using citation data. This tool offers at-a-glance
intelligence about the influence of a set of articles, an author or group of authors over time, so users can quickly spot trends using a visual table of citations broken down by article and chronology
. “

Text Source:  Courtesy of Elsevier B.V. – All rights reserved – Copyright 2010

Two other Scopus pages which I found useful were the Scopus Top Cited page and Scopus Journal Metrics Factsheet.

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No use trying to make this post pithy.  It would be an error not to mention the following means of assessing the scientific literature:  Eigenfactor, h-index and JANE.

University of Washington biology professor Carl Bergstrom and colleagues created the  Eigenfactor Project™.   The main webpage is  http://www.eigenfactor.org.

Give the interactive map a try: click here. Here is an example for Molecular & Cell Biology Map:

Image Credit:  http://www.eigenfactor.org/map/ –  All rights reserved – Copyright 2010

Following is an excerpt from a May 2007 article that Dr. Bergstrom wrote for the Association of College and Research Libraries publication, College & Research Library News:

We can view the Eigenfactor score of a journal as a rough estimate of how often a journal will be used by scholars. The Eigenfactor algorithm corresponds to a simple model of research in which readers follow citations as they move from journal to journal. The algorithm effectively calculates the trajectory of a hypothetical “random researcher” who behaves as follows: Our random researcher begins by going to the library and selecting a journal article at random. After reading the article, she selects at random one of the citations from the article. She then proceeds to the cited work and reads a random article there. She selects a new citation from this article, and follows that citation to her next journal volume. The researcher does this ad infinitum.

” Since we lack the time to carry out this experiment in practice, Eigenfactor uses mathematics to simulate this process.

” Because our random researcher moves among journals according to the citation network that connects them, the frequency with which she visits each journal gives us a measure of that journal’s importance within network of academic citations. Moreover, if real researchers find a sizable fraction of the articles that they read by following citation chains, the amount of time that our random researcher spends with each journal may give us a reasonable estimate of the amount of time that real researchers spend with each journal.

Text source: College & Research Library News – Vol 68:5 (May 2007) – All rights reserved – Copyright 2010

A slideshow presentation created by Dr. Bergstrom and presented at a conference hosted by Microsoft in 2009 can be viewed here.

Professor Alan Fersht wrote an article in 2009 published in PNAS Vol. 106(17):6883-4 (Apr 28 2009) entitled “The Most Influential Journals: Impact Factor and Eigenfactor” which is available free online on the PubMedCentral website.

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Physics professor Jorge E. Hirsch wrote a paper published in 2005 in PNAS entitled “An Index to Quantify an Individual’s Scientific Research Output“, in which he outlined the algorithm known as the Hirsch Index (or h-Index).

And – LOL – according to Scopus, that PNAS paper by Dr. Hirsch has been cited 575 times!

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JANE (or Journal Author/Name Estimator) is a software tool created in 2007 by members of the Biosemantics Group, a collaborative group at the Medical Informatics department of the Erasmus MC University Medical Center of Rotterdam and the Center for Human and Clinical Genetics of the Leiden University Medical Center.  Following is  how the creators of JANE describe the purpose of the tool:

Have you recently written a paper, but you’re not sure to which journal you should submit it? Or are you an editor, and do you need to find reviewers for a particular paper? JANE can help!  Just enter the title and/or abstract of the paper in the box, and click on ‘Find journals’ or ‘Find authors”.  JANE will then compare your document to millions of documents in Medline [over 10 years] to find the best matching journals or authors. ”  —

Source: http://www.biosemantics.org/index.php?page=jane – All rights reserved – Copyright 2010

M. J. Schuemie and J.A. Kors – two of the creators of JANE – published a paper about the software in the journal Bioinformatics – Vol 24:5 (Mar 1 2008).

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* Dr. Eugene Garfield was a co-founder of the Institute for Scientific Information, the producer of Science Citation Index.  A professor at the University of Pennsylvania and a prolific author, Dr. Garfield is now 85 years old.  Here is a link to his website.

In 1955, he wrote a paper titled “Citation Indexes to Science: A New Dimension in Documentation through Association of Ideas“, published in the journal Science (Vol. 122:108-111).  The online version is available to be read at this link.

From looking around on his Library website (url above), I think he has a sense of humor and the soul of an archivist. A great deal of his professional life has been taken up thinking about information management, and the ways in which scientists use their literature. I – and other librarians everywhere – should thank him for being an early adopter!

For example, in a commentary he wrote in 1963 published in the journal Science (Vol. 141:3579 – Aug 2 1963), titled “Citations in Popular and Interpretive Science Writing“, he admonishes mainstream periodical editors for not including basic volume and issue information.  Here is a direct quote: ” Librarians and scientists spend hundreds of hours tracking down precise literature citations which are missing in articles published in otherwise reputable publications like Scientific American, the New York Times, or The Sciences-a task that could be eliminated if brief but complete citations were given. This is certainly false economy and annoying “.  Garfield… You go!

The text of a presentation he gave at the International Congress on Peer Review And Biomedical Publication (2005) can be read online at  “The Agony and the Ecstasy: The History and Meaning of the Journal Impact Factor“.

I performed an author search on PubMed for his publications and created a small group of citations, those search results can be viewed here.

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In addition to thanking Dr. Garfield for creating this field of citation analysis, there are many fellow health science or academic librarians whose work has helped me understand this complex subject, or who have made public their own instruction for others to benefit from. These folks deserve recognition (and applause!).

Thanks to UCHC collection management librarian, Arta Dobbs, for her suggestions and explanations of sources and methods of bibliometric analysis.

Thanks to Janice Flahiff and Jolene Miller, librarians at Mulford Health Science, University of Toledo (Ohio) who have written a great fact sheet on the uses and misuses of interpreting journal impact factors.

Props to Kathi Sarli, health science librarian at Bernard Becker Medical Library of Washington University of St. Louis,  wrote a very useful library guide called “Tools for Authors“… check the section-tab for “Preparing for Publication“.

I enjoyed watching an excellent tutorial on Journal Impact Factors produced by librarians at the Ebling Library for the Health Sciences, University of Wisconsin-Madison.

Finally, remember this is all about Publish or Perish.


* Subscription via UCHC Library.  If off-campus, use your library proxy number to connect.

Teaching & Learning in Medicine, Research Methodology, Biostatistics: Show Me the Evidence (Part 2)

May is the time of year when I get to sit in the back of a classroom with my mouth shut, listening (as opposed to standing in the front of a classroom, yakking about searching).

This post, Part 2 of “Show Me the Evidence“, is not about how to search a database better or when to find a systematic literature review… or anything about a library or its collections.

The “evidence” in this case isn’t a tangible product, nor can it be measured in ounces or liters.  This evidence is formed during years spent in a classroom and framed by clinical experience, listening to a patient describe their symptoms or the way a tumor feels under one’s hand or scalpel.  This evidence dwells in a scientists’ mind, whether they practice medicine or perform experiments, collecting images and allowing a peripheral brain to develop.  This knowledge has been informed by a hundred nights on call, scrutinizing CT scans, dissecting mice, examining EKG strips, observing the gait and balance of a child, listening to the characteristic sounds of COPD through a stethoscope. It could be the red flag raised by how a patient’s liver appears in a CT scan, or a questionable lab value.

This evidence-base has been formed by workdays lasting 18 hours, hunkered down in a pathology lab or an operating room.  It allows a collection of “clinical suspicions” to coalesce.  It improves diagnostic accuracy and surgical intuition.  It dwells in the life of the mind, it could be called intellectual rigor.

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A newer graduate program offered at UConn Health Center is the Masters in Clinical and Translational Research (MCTR) program.  There are over 50 faculty who teach individual components for this course, and it is a varied group: senior researchers, epidemiologists, a couple of psychiatrists, a pharmacologist, two biostatisticians, a health law attorney, an IT specialist, hospital administrators.

As the only librarian in the group, my main contribution is to spend three hours teaching the students about the range of information available to them through the UConn libraries and how to best choose, search and evaluate the sources that complement their clinical areas.  Following are key areas of course content:

  • Clinical Research Fundamentals.  Trial Design, Execution, Management. The role of the Principal Investigator.
  • Selecting the Type of Study: Observational Prospective Studies.  Experimental Intervention Studies.  Non-Randomized Intervention Studies.  Case-control and Non-Randomization Study Design.
  • Measurement of Exposure; Principles for Inferring Causation.  Group Interventions, Intention to Treat Analysis.
  • Application of Pharmacokinetic Principles in Design or Execution of Phase I or Phase II Studies.
  • Patient Recruitment, Retention and Management.
  • Elements of Informed Consent; Drafting the Form.  HIPAA Rules.
  • Ethical Treatment of Human Subjects.  The Common Rule. Federal Regulations. Scientific Misconduct.
  • Survey Design: Questionnaires, Sampling, Response Rates, Recruitment.  Cross-sectional versus longitudinal surveys.
  • Working with the Institutional Review Board (IRB).
  • Studies in Genetics.
  • Computerized Data Management: Storage and Retrieval Needs, Data Elements, Data Entry; System Security, Backup and Storage. Data Archiving.

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Each student in the program presents a capstone research project at year-end; the assignment is to design a clinical study of their choice from beginning to end with special care taken to select the “correct” potential patient subjects and to choose the “best” study design. The individual who writes the proposal serves as the PI (principal investigator).  There were six students in the class this year. Four are physicians, the others are in physical therapy or dentistry.

Their presentations were awe-inspiring. They have such a sure technical grasp of  methodologies (that remain dense to me) and confidence in planning the micro- and macro-aspects of their clinical research project. Certainly I hope they will succeed in securing funding for these proposals.

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So I sit in the back of the room, and am reminded annually of just how much I’ll never understand about gene expression profiles, how vectors are designed or how chromosome 10 got lost.  It is a humbling experience.

Didn’t Ben Franklin say: “It is better to keep one’s mouth closed and to be thought a fool, than to open it and remove all doubt“?  That’s excellent advice.

But the students also showed that they have become better searchers and THAT evidence is awesome, too! 🙂

Teaching & Learning in Medicine, Research Methodology, Biostatistics: Show Me the Evidence (Part 1)

Question everything… especially what you read.

A 2009 quote from Dr. P,  PBL facilitator

.One of the many tasks for first-year graduate students in clinical or research areas is building a healthy skepticism about what one reads in the medical literature.

Ideally, as they progress through four years of medical education, students find that they must change their approach to searching as well as exploring what new resources will answer their questions of increasing complexity.  What answered their learning issues in their first year often doesn’t carry over to their third-year clerkship, when they are faced with finding solutions to the care of actual living patients.

This evolution (both practical and intellectual) asks that they grow a set of appraisal techniques for examining, embracing or rejecting what they find in the ever-increasing assortment of health science, pharmacology or social science databases available to them. (Note that I’m not referring to what can be found by simply plugging a few words into a search engine.)

And very likely, they jettison the use of a few previously well-used resources  as their clinical questions and experience become more complex.

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.Separate what is of statistical importance from what is clinically significant.

Another 2009 quote from Dr. P

As a facilitator for PBL, many first-year students have stated in class that they rely most on the library’s subscription to the Access Medicine* collection – including Harrisons’ Online – as a “first place” to go to do research.

It is what the librarians consider as a sort of a “package product”.  This subscription resource has developed in major ways over the years which UCHC Library has been providing it for our users.

As examples: there are now 60 core medical textbooks on the site, lists of DDx criteria, audio cases, calculators and clinical videos, podcasts, study guides for USMLE.  The library added subscriptions to Access Surgery and Access Emergency Medicine when they became available from the company.

Residents especially appreciate having 24×7 access to these resources.

And truly, we librarians were thrilled back in 1999 when the subscription to a digital version of Harrisons’ Principals of Internal Medicine was rolled out.  LOL.  (Link here to an academic paper from 1999 reviewing the resource.)  Back then, the medical and dental students were excited about this 16th digital edition too, although most of them elected to purchase their own hardbound copy of the textbook.  These memories seem a little quaint from eleven years on.

In 2010, here’s a screenshot of the newly-redesigned Access Medicine front page:

Photo/Text source: http://www.accessmedicine.com/features.aspx – All rights reserved – Copyright 2010
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What are other examples of what librarians consider garden-variety “packaged databases” that are frequently mentioned by first year students as essential to their research?

MD-Consult*, Up to Date* and for locating primary studies (or for “just shopping around” as one student said), PubMed.

As librarians (and instructors) a major teaching role for us is to encourage their exploration… and also to model the effective use of these information resources.  Feedback from students or faculty on the nature of their experiences as they  “consume” these products is very important.

And (dare I mention!) the librarians are there in the classrooms to also reinforce that using sources such as Google or Google Scholar to do credible clinical research represent truly two of the least satisfactory choices but also the ones most easily or readily available.   (Sigh.)

There are many free information sites in the world… the librarians don’t use or teach (or endorse) many of them. Why? Not because we are close-minded, too traditional, or old and cranky. This is a conversation thread that will be continued in Part 2 of this post.

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Seeing a dozen patients with XYZ syndrome will significantly increase their practical assessment skills.  So will participating in the care of a patient that even the seasoned clinicians and experts haven’t yet figured out a diagnosis for. A common short-hand for diagnostic skills is Horses versus Zebras.

Learning to comb the literature for clinically-sound research studies – and weighing what has been found for validity or predictive value – are skills not easily learned.  Is four years sufficient time for practice in this pick-and-choose process?

Many students in their third and fourth year of study come back to meet with the reference librarians for a “refresher course” on how to search more efficiently, as they begin their required fourth year individual research project (called their “selective“).

I consider these reference training sessions with students as excellent indicators that they are growing quite sophisticated about what they consider to be “good” evidence.  Getting choosy is a wonderful thing.

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* Please note: Resources mentioned are subscriptions and limited to UCHC students, staff and faculty only.  If off-site, use the Library’s proxy access to connect to them.

Clinical Reasoning, Mobile Computing, Point of Care Tools: Medical Knowledge in Your Pocket

This month, the second-year medical students at UCHC are in the process of selecting and purchasing their mobile computing devices (PDAs or SmartPhones) in preparation for the beginning of their clinical clerkship year when they’ll be using them to keep a log of patient encounters, check for drug interactions, calculate laboratory test results, look up point-of-care medical/reference facts or other essential activities like checking email and sharing files.

I’ve noticed that quite a few of the first-year medical students are already using PDAs, Blackberries and iPhones, thus getting ahead of the learning curve.  Several are already using EpocratesRX, a basic mobile drug reference resource available at no cost from Epocrates.com.

Other free downloads popular with medical students are Diagnosaurus 2.0, a differential diagnosis tool from McGraw-Hill, and Archimedes, a medical calculator, provided by Skyscape.

A desirable feature when evaluating potential new library subscription products is the availability of a mobile computing version.  Examples of highly-useful clinical resources which come with a mobile version are DynaMed, Essential Evidence Plus, Lexi-Comp, Micromedex, MD-Consult/First Consult, and two integrative-complementary-alternative medicines resources, Natural Medicines and Natural Standard.

These last two resources are especially important when clinicians need to determine potentially hazardous drug interactions between “over-the-counter” homeopathic or dietary supplements and allopathic prescription medicines.

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It is a rapidly changing world of devices, products, access, cost (and choices).  To review more of what is available in hand-helds for medical applications, visit a few pages* written for UCHC students by library staff :

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Wikipedia.org has a page about Open Source Healthcare Software.

Recently I came across a free clinical calculator site which anyone can use: MD+Calc.  Thanks to Graham Walker for putting this site up. Below is a screenshot of the topic page “Endocrine/Metabolic“:

Image/Source credit: http://www.mdcalc.com/ – All rights reserved – Copyright 2010
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Finally, here is a brief list of other free clinically-oriented sites**:

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* Note: Access to the clinical subscription databases described here is limited to UCHC students, staff and faculty.

** These links are provided for educational use only – not for clinical decision-making in the care of actual patients.



Instruction, Information Seeking Behaviors, Clinical Evidence: Teaching with EBM Databases

This has been a busy month. The final first-year PBL class will be wrapping up, as the semester ends on Friday, Dec 18 2009.

On Monday, I taught an evidence-based medicine class for 28 third-year medical students (which I’ve done since 2001).  It is part of a week-long curriculum that all third-years attend as regular breaks from their clerkship rotation schedules.  They come back to the Health Center (for “Home Week”).

This 90-minute course represents a real opportunity for a librarian to connect with advanced students who are already savvy users of the medical literature.  They have completed two years of basic science and human systems curriculum, and have participated in four semesters of problem-based learning.  Each has passed the USMLE Step 1.  By this point in their graduate education, they are dedicated users of PubMed and Up to Date.

The location is one of the large classrooms equipped with computers, or students use their own laptops so that everyone gets to use a resource together.  Sometimes it gets pretty loud in that room!  The instructional challenge is to keep the content fast-paced and interesting enough for these experienced searchers while introducing (and convincing them to test out) some new clinical resources and search techniques.

Utilizing a PICO strategy (Patient or Problem-Intervention-Comparison of Treatments-Outcome) is briefly discussed.  The first half of the class is devoted to locating and applying MeSH headings and subheadings for effective search strategies and showing them ways to use the Clinical Queries search engine.  The student are asked to register for their own MyNCBI account in order to begin to organize their searches or create collections of documents in the future.

Always I ask this group if any are currently searching the SCOPUS database in addition to PubMed.  Their response?  Most are not, and that surprises me a bit.  However, once they view the links to online reference lists and “cited reference searching” capability in SCOPUS*, I’d venture a guess that 100% of this group will be using it from that day forward!  It is a database that generates instant loyalty for most users.  

Other EBM resources covered briefly are the five segments and uses of Cochrane Library, ACP Journal Club, JAMA Evidence-Guide to the Medical Literature (a digital subscription resource), and the classic BMJ series on How to Read a Paper (open access).  Ideally I end up with sufficient time to demonstrate using the TRIP (Turning Research Into Practice) clinical search engine.

The LibGuide used for the class is linked here.

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During their clerkship year, third-year students favor putting as many of the subscription resources as are available onto their PDAs.  Having drug-interactions databases, clinical DDx or algorithm calculators and a disease photo-atlas in their coat pocket comes in very handy (no pun intended) as they travel to different hospitals for their clinical rotations.

PDA resources popular with this group include Lexi-DrugsDynaMed and Diagnosaurus (which is free).

Two of the databases that I featured in the EBM class this week were ACP-PIER (American College of Physicians-Physicians Information & Education Resource) which UCHC library subscribes to via Stat!Ref, and Essential Evidence Plus (EEP) from Wiley-Blackwell.

Here’s a screenshot from EEP:

Image credit: http://www.essentialevidenceplus.com/content/eee – All rights reserved – Copyright 2009

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A press release from the company, issued Dec 14 2009, describes their new ‘point of care’ product:

Wiley-Blackwell today announced the launch of Essential Evidence (EE), a new product for PDAs which has been added to its online evidence-based, peer-reviewed subscription Essential Evidence Plus, a source which provides access to: Practice Guidelines, Decision Support Tools, History and Physical Exam Calculators, Diagnostic Test Calculators, the Derm Expert, ICD-9 Lookup Tool, Patient Education Handouts, links to Cochrane Systematic Reviews, and 950+ high quality photographs. Essential Evidence Plus links to Daily POEMs (Patient Oriented Evidence that Matters).

EE for PDAs is a topic-oriented clinical resource tool designed to help clinicians to effectively make diagnoses, chart treatment plans, and determine prognoses.  EE can be searched via the web or loaded onto a handheld computer (Pocket PC or Palm OS). EE currently features 700 structured medical topics and approximately 100 more are in development and will be added to the site soon…”

Text Source: http://www.essentialevidenceplus.com/articles/EE_Launch_12.09.pdf – All rights reserved – Copyright 2009

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And that’s my final formal class for 2009!

( Happy! )

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* How did we (i.e., those of us in academic-health science libraries) function without SCOPUS?  It’s like thinking about the days before cell phones – a time dimly remembered, difficult to recall… sort of like pre-historic times.

News, Medical Research, UCHC Faculty: Immune Levels + Holiday Stress? Not Beneficial

If you ever thought the stress of seeing your extended family over the holidays was slowly killing you—the bad news: a new research report in the December 2009 print issue of Journal of Leukocyte Biology shows that you might be right. Here’s the good news: results from the same study might lead to entirely new treatments that help keep autoimmune diseases like lupus, arthritis, and eczema under control. “

Text credit: Press Release from Eurekalert (Nov 30 2009)

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Recently published research by scientists from UCHC examine the effects of psychological stress on the human immune system.  The paper was published this month in the Journal of Leukocyte Biolology – Vol. 86: 1275 (Dec 2009); the abstract is available to read here: http://www.jleukbio.org/cgi/content/abstract/86/6/1275.

The citation found on PubMed can be viewed here.

News, Public Health, Public Service: H1N1 Fact Page from Ebsco

This year, Ebsco Publishing has created an evidence-based medicine source for current factual diagnostic or treatment information for H1N1 influenza virus, written for clinicians, nurses and the general public.

This site is open to anyone in the world to access, at no cost.  Following is a brief description found on the front page of Ebsco Publishing Influenza Evidence-Based Information Portal:

Due to Pandemic H1N1 Influenza (formerly known as Swine Flu) and concerns about the 2009/2010 flu season, the EBSCO Publishing Medical and Nursing editors of DynaMed, Nursing Reference Center™ (NRC) and Patient Education Reference Center™ (PERC) have made key influenza information from these resources freely available to health care providers worldwide. The information is designed to inform patients and their families, and provide information to clinicians to help them with H1N1 diagnosis and H1N1 treatment by making up-to-date diagnosis and treatment information availableThis site includes more than 50 evidence-based topics including patient education information in 17 languages.”

Source/ text credit: http://www.ebscohost.com/flu/ – All rights reserved – Copyright 2009
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As shown in this screenshot below, there are sections written for clinicians, nurses and patients.

Photo credit: http://www.ebscohost.com/flu/ – All rights reserved – Copyright 2009
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If you treat patients who speak Arabic, French, German, Hindi, Chinese (traditional or simplified), Japanese, Italian, Korean, Portuguese, Russian, Spanish, Farsi, Polish, Tagalog, Vietnamese (or English), this is an excellent free resource – bookmark it!

Thanks to Ebsco for producing this EBM influenza page.

News, EBM, Library Resources: JAMA Evidence now available

For those interested in learning strategies for practicing evidence-based medicine, check out the latest digital subscription from UCHC Library:

JAMA Evidence

JAMAEvidence
Image Credit: http://www.jamaevidence.com/ – All rights reserved – Copyright 2009

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Produced by American Medical Association editors and publisher McGraw Hill, content from the digital textbook is also available for mobile applications.

I particularly liked the JAMA Evidence glossary.

If off-campus, connect via your UCHC library proxy account.