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: Teaching-and-Learning in Medicine

News, A Look Back: Happy New Year and Picks for Best Posts

First:  Best wishes for a Happy and Healthy New Year 2011 to everyone! 

Since I have been writing this blog (which began in July 2007), I have yet to assemble a list of  “favorite posts” from the backlist.  The first week of a brand New Year seems like a good time to offer up this collection.

Here’s a list of top picks from the EBM & Clinical Support Librarians@UCHC blog (in no particular order):

  • Digital Natives (Jun 12 2008) compares the learning environment of today’s graduate students with those from my generation (i.e., circa 1970’s).
  • A continuing series called Show Me The EvidencePart 1 is linked here. Part 2 – go here.  And Part 3 (which has received the most hits over time) link is here.

That’s a compilation to start out the New Year, folks – and thanks for reading this blog.

 


 

News, Patient Education, Teaching & Learning in Medicine: October is Health Literacy Month

 

October is National Medical Librarians Month in the U.S.

The theme for 2010 is Health Literacy

Here is a screenshot of the poster created by Medical Library Association for this event:

Image credit: Medical Library Association – All rights reserved – Copyright 2010

Health science librarians are in a unique position to work with patients and their families who seek current, credible and authoritative medical information in order to learn more about their recent diagnosis, review options for choosing treatments, or to anticipate changes in their lifestyle or living situations after treatment has ended (as examples).

Medical Library Association (MLA), a nonprofit educational organization with 5,000 members worldwide, has devoted time and care over the past decade to develop websites and resource guides specifically targeted at training librarians who provide information services to patients or family members. Their Health Information Literacy page can be viewed at http://www.mlanet.org/resources/healthlit/

One of the larger special interest sections sponsored by MLA is Consumer and Patient Information Section (or CAPHIS). A related program directed by MLA staff is the Consumer Health Information initiative, and in 2007, the association created a formal certificate program in that specialty for information professionals.

Open to everyone on the MLA website are topic pages about educational resources. Here are two examples: Resources for Health Consumers and Deciphering Medspeak which links to medical terminology handouts (in English or Spanish languages), online medical dictionary, a prescription shorthand guide and a list of the “Top Ten Most Useful Medical Websites” for patients.

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For those pursuing research on strategies to address Low Health Literacy, Health Disparities or Health of Minority Populations, some valuable step-savers are available on the PubMed Special Queries” which provide links to pre-formulated, highly specific search statements (or search queries) that can be run singly in PubMed or combined with other relevant subject searches.

Below are screenshots from two Special Queries websites: Health Literacy and for Health Disparities & Minority Health Populations

and

Image credit(s): National Library of Medicine – All rights reserved – Copyright 2010

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Other teaching or service organizations that offer patient-centered tutorials, podcasts or written information addressing disparities in health care delivery can be found on this very brief list:

  • From a workshop in 2008 sponsored by Society for General Internal Medicine (SGIM), read a 3-page handout on teaching “Health Literacy for the Clinician Educator“at this link. There are many useful links in the bibliography section of this report.

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Finally: In May 2010, a 73-page report detailing a National Action Plan to Improve Health Literacy was announced by the U.S. Dept. of Health & Human Resources, Division of Health Literacy. Following is an excerpt from that HHS website, explaining this public health initiative:

Health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. Limited health literacy affects people of all ages, races, incomes, and education levels, but the impact of limited health literacy disproportionately affects lower socioeconomic and minority groups. “
” It affects people’s ability to search for and use health information, adopt healthy behaviors, and act on important public health alerts. Limited health literacy is also associated with worse health outcomes and higher costs….   ”
” This report contains seven goals that will improve health literacy and suggests strategies for achieving them: Develop and disseminate health and safety information that is accurate, accessible, and actionable ; promote changes in the health care system that improve health information, communication, informed decision-making, and access to health services ; incorporate accurate, standards-based and developmentally appropriate health and science information and curricula in child care and education through the university level ; support and expand local efforts to provide adult education, English language instruction, and culturally and linguistically appropriate health information services in the community ; build partnerships, develop guidance, and change policies ; increase basic research and the development, implementation, and evaluation of practices and interventions to improve health literacy and increase the dissemination and use of evidence-based health literacy practices and interventions“.
Text Source: http://www.health.gov/communication/HLActionPlan/ – All rights reserved – Copyright 2010

Clinical Tutorials, Teaching & Learning in Medicine: That Old Krebs Cycle, with Singing

I apologize for the lack of blog-posts this month… it’s been pretty busy around here.

Today’s post is about metabolic pathways, which the first-year students are deep into studying this month. Here is a link to a pretty illustration which was found on Wikipedia:

Image Source: http://en.wikipedia.org/wiki/Template:Metabolic_pathways – All rights reserved – Copyright 2010

Each year in PBL, I struggle to re-remember facts about biochemistry, cellular signaling and metabolism including steps in the Krebs cycle*. (Why? Because I never took biochemistry.) Two years ago, I found the illustration below so useful that I decided to post it on the blog for the second time!

Image Source: http://en.wikipedia.org/wiki/Krebs_cycle – All rights reserved – Copyright 2010
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Next, a small joke: WWSD (or, what would Setlow do)? He could sing along to this Krebs Cycle song, found on ScienceGroove.com.

Image Source: http://www.science-groove.org/Now/Krebs.html – All rights reserved – Copyright 2010
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Publisher McGraw-Hill has placed some content from their textbook Anatomy & Physiology (7th edition) online for free, including this tutorial and quiz titled “How the Krebs Cycle Works“.  After you take the quiz, relax by working a few of their Crossword Puzzles:

Image Source:  http://highered.mcgraw-hill.com/sites/0072507470/student_view0/chapter25/crossword_puzzles.html – All rights reserved – Copyright 2010
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Salman Khan founded a non-profit group, The Khan Academy, with the goal of providing high quality free online educational materials to anyone in the world.  This year, their collection of videos about Science, Math, Humanities, History, Finance and other academic subjects has grown to 1,800. A 10-minute video describing the educational content is here: Khan Academy.

Found on their ScienceBiology category: a 13-minute lecture describing the ATP (adenosine-triphosphate) process.

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On YouTube, author Faxe14011991 has posted this series of short animations/tutorials on cellular mechanisms, each of which is less than two minutes in length:

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Finally, a video found on YouTube called Cellular Respiration (hey there Delilah)

Image Source: http://YouTube.com – All rights reserved – Copyright 2010

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* Dr. Krebs was a Nobel Prize laureate.  Read the following text, found on the nobelprize.org page: ” The Nobel Prize in Physiology or Medicine 1953 was divided equally between Hans Adolf Krebs for his discovery of the citric acid cycle, and Fritz Albert Lipmann for his discovery of co-enzyme A and its importance for intermediary metabolism.

The Friday Post #52: Medical Students, Video: Tips on How to Survive Medical School

Welcome back, everyone!  This is the Friday Post #52 for Aug 27, 2010.

The area in the pink box (below) has been the focus of instructional activities this week:

Image source: http://library.uchc.edu – All rights reserved – copyright 2010

August is a challenging month for academic reference librarians.  This week at UCHC, an interactive instructional session for first year medical and dental students (140 of them) was our main event. In 2009, the reference librarians presented a mock PBL case, written with a fourth year student who narrated the case while the librarians linked to the databases on the overhead screen in one of the large teaching auditoriums.  As each clinical scenario was described in the case, librarians linked into an assortment of resources.

This year, the 90-minute instructional session was more interactive. Everyone was handed an electronic clicker (aka audience response system) to use to respond to our librarian-questions which were interspersed between live demonstrations of PubMed, Lexi-Comp, 3-D Tooth Atlas, ADAM (Interactive Anatomy) and others.

Their new laptops also came in handy as the students quickly tried a “test run” on each of the resources. The live interactive feedback from this group was something new to try in 2010, and it was both fun and instructive. Although perhaps next year we will skip the video procedure showing the skin punch biopsy… when it is projected onto a 24 ft. square overhead, it’s just way too graphic for the first week of medical school (LOL).

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The Girl with the Blue Stethoscope (a fourth-year medical student and blogger from Australia) began a series in July 2010 titled “How to Survive Medical School.  For the members of the Class of 2014 this should be pretty much essential reading.

Her first installment was “How To Survive Medical School Part 1: Friends“.  The second installment:  How To Survive Medical School Part 2: Ask For Help. Thank you, Girl with the Blue Stethoscope… I’m looking forward to the next installment!

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Then this: Tufts University medical students raise the bar with this video for – and about – first year medical students called 99 Problems til First Years Done!

Video source: http://youtube.com – All rights reserved – copyright 2010

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That’s the Friday Post #52 for Aug 27, 2010, folks.  Enjoy a summer weekend!

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.

News, Libraries, Librarianship: Medlib’s Round Carnival Edition 2.5!

This is the June 2010 edition of Medlib’s Round Carnival.

This collection of links have been submitted by a (worldwide) group of dedicated bloggers… veteran medical librarians along with a new health science librarian, physicians and scientists contributing to the mix!

The broad  topic of this Carnival is about service. Librarians talk a lot among themselves about providing quality information services and library collections for their core users.   We are great believers in training our library visitors to recognize quality information sources, showing them what to search,  how to search and how to appraise those sources effectively; we also spend considerable time, effort and money to create digital or physical library collections that meet the information needs of our users.  Doing these things well is (actually) more difficult than it appears…  not as difficult as climbing the summit of Mount Everest but definitely made more challenging in an era of rapidly rising costs, disappearing personnel and shrinking budgets.

So without further ado, here is the Medlib’s Round Blog Carnival 2.5.

Jacqueline, blogger at Laika‘s MedLibLog recently wrote:  “It is so important that you know the pros and cons of databases and that you think before you even start searching“. Read her evidence-based discussion here:  “PubMed versus Google Scholar for Retrieving Evidence” (Jun 6 2010).

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Medical Library Association holds an annual conference, which this year was held May 21-26 in Washington, DCKrafty Librarian blogger Michelle Kraft was a conference speaker and official blogger at MLA.  She wrote MLA ’10 Week in Review, an excellent summary and set of links to presentations and other conference activities on her blog – especially valuable to those of us who weren’t able to attend the meeting.

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As a library student, you don’t get many chances to really dig your teeth into searching databases, unless you’re working on a thesis or have a really extraordinary work opportunity. Basic reference as a student usually involves basic searches for patrons, maybe some instruction, more than a little help given to new or remedial library users. This is why my experience with a systematic search team will be so memorable as a learning experience as I begin to launch my career as a health librarian. “

So wrote recent MLS graduate, Daniel Hooker, who blogs about Health Libraries, Medicine and the Web in a recent post about performing his First Systematic Search using the OvidSP search platform.  Check out the vintage librarian cartoon – what a laugh!

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Psychiatrist Walter van den Broek, who blogs at Dr. Shock, wrote an interesting post for the Carnival entitled “What’s Wrong with the Disclosure of Conflicts of Interest?” (Jun 6 2010).

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Relying on donations, librarian-volunteers collect and ship medical textbooks to American military personnel stationed in war zones throughout the world.  Their service mission is described on the blog Operation Medical Libraries:

” The mission of Operation Medical Libraries is to collect and distribute current medical textbooks and journals to war-torn countries through a partnership with American medical schools, hospitals, and physicians and the United States military… and

to foster the creation of permanent medical libraries and support the expansion of existing collections in conflict regions where health care education and the practice of medicine are suffering “.

Text Source: http://operationmedicallibraries.blogspot.com/ – All rights reserved – Copyright 2010

This post on the OML blog is about books sent to Afghanistan in 2009 and the photo below shows a happy library user in that facility:

Photo source: http://operationmedicallibraries.blogspot.com/2009/05/oml-library-in-bagram-af-provides.html – All rights reserved – copyright 2010

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Patients or family members are a common sight in the medical library, seeking current, credible medical information, or advice on where to find those patient education materials.  Technologist-librarian PF Anderson contributes two items to this Carnival on those topics:

Video Source: http://www.youtube.com – All rights reserved – Copyright 2010

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  • BitesizeBio, a blog written by and for lab biologists, offers practical advice on giving, receiving, qualifying and implementing advice in the Apr 26 2010 post, “The Art of Giving of Advice“.

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And that’s Medlib’s Round Blog Carnival Edition 2.5, folks!  Hope you enjoyed reading it. To all those who sent in submissions, I am grateful and send you heartfelt thanks!

The next edition of MedLib’s Round (July 2010) will be hosted at Laika‘s MedLibLog.

If you have material to submit for that edition, please use this form.  To subscribe to an RSS feed for Medlib’s Round, click here here.

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.

Public Health, Medically Underserved in Connecticut, UCHC Students, News: Migrant Health Workers Clinic

It’s a measure of how behind at work I am, that I missed posting the following article during Public Health Week (April 5-11 2010) and – yikes – also forgot that last week was officially National Library Week as declared by the American Library Association Sorry!

This post describes a unique public service and community outreach effort provided by individuals who volunteer their clinical services to staff the Migrant Health Workers Clinic (MHWC), a medical-dental clinic for seasonal farm-workers in Connecticut.

This traveling health clinic was founded in 1997 by UCHC professor Dr. Bruce Gould (shown in the photo below with two patients at a clinic in 2008):

Photo Credit:  http://publichealth.uconn.edu/aboutus_mfwc.php – All rights reserved – Copyright 2010

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Here is are some facts and background about the mission of the Migrant Health Workers Clinic:

Migrant farm workers are among the most economically disadvantaged and most medically vulnerable groups in the United States having little, if any, access to health care or medication. In addition to barriers to access to health care that many citizens meet like affordable health insurance, language barriers, and lack of transportation, migrant workers also experience additional barriers such as fear of deportation, loss or garnished wages, and being dismissed or not invited back to work by the employer due to missed work or health issues.  A coalition of local organizations, along with the University of Connecticut, has formed a network to overcome these barriers and attend to the health care needs of migrant and seasonal farm workers. “

The UConn Migrant Farm Worker Clinic opened its doors in 1997, with the aid of the Connecticut Area Health Education Program (CT-AHEC).… the clinic operates annually from June to October offering diagnostic and treatment options [to workers] for a variety of conditions, both acute and chronic, including primary care screenings, oral health screenings, distribution of medications for mild and self-limiting conditions, as well as preventive health education“.

Text Source: http://publichealth.uconn.edu/aboutus_mfwc.php – All right reserved – Copyright 2010

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Click here to view a list of health or social services agencies and non-profit organizations from throughout Connecticut that contribute funding, advisory services and personnel to staff the rotating schedule.

Many students from the University who are enrolled in professional programs in medicine, dentistry, pharmacology or nursing volunteer at the MHWC; some have chosen to participate in the Urban Service Track.

There is a special need for volunteers who are native Spanish speakers.  For those graduate students interested in primary care – as well as developing their (medical) Spanish language skills – it is an excellent opportunity to practice hands-on health care, advising and counseling.

Next, a 2-minute video filmed in 2008, narrated by a UCHC medical student which shows a typical visit with patients at the end of their workday, held at a local farm:  click here to watch.

Image Source: http://publichealth.uconn.edu/images/MFWC_video/index.html – All rights reserved – Copyright 2010

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Open a schedule showing 2009 locations in Connecticut where the medical and dental Migrant Health Worker Clinics were held (PDF file).

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This week on the Public Health @ UConn Facebook page, the following announcement was posted (Apr 15 2010):  “The 11th Annual UConn Migrant Farm Worker Clinic Symposium will be held on Tuesday, June 29th from 8:30-2:30 at the UConn Health Center in Massey Auditorium…  Students – Mark Your Calendars!

If you’re interested in keeping up-to-date with public health/service program announcements about activities at UConn Storrs or UConn Health Center, become a friend of Public Health@ UConn.

There is also a Learning Community in Public Health for undergraduates at Storrs campus. A recent newsletter from that group can be opened here

Academic Medicine, Teaching & Learning in Medicine: Announcing a New Series called Learning Medicine

It’s looking more like spring each morning in the Northeast, after a nasty late winter. There are daffodils poking out of the ground. The days are growing longer. This morning I saw a green bagel in the cafeteria because tomorrow is St. Patrick’s Day*.

This makes it a good time to try something new on the blog. Today marks the first post in a series which I have titled Learning Medicine: Ten Questions.

The series is intended as an open dialog between current and former medical students, educators, clinical researchers, PBL facilitators, librarians (and anyone else I can rope into answering 10+ questions!). The content or questions in the interview may vary, depending on the background and professional experience of the interviewee.

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Today, please welcome esteemed veteran blogger and physician Graham Walker!

A Background Question – Who Are You?

Graham Walker describes himself in this way:

I’m a second-year Emergency Medicine resident at St. Luke’s-Roosevelt Hospital System in New York City. I was originally a medical school blogger (at the now-defunct Over  My Med Body! ) blog. Recently I’ve returned to blogging as a contributor to The Central Line, the official blog of the American College of Emergency Physicians.

My interests include: surviving residency, technology and web design, simulation medicine, informatics, health policy and caffeine highs.  I’m originally from Kansas, went to undergrad at Northwestern in Chicago, studying social policy/health policy, then went to Stanford for med school with a concentration in Community Health.

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Making the transition from undergraduate/or pre-med to graduate medical student

Can you name 4 or 5 key things that (in retrospect) you wished you had known before you began your first day of medical school?

Oh boy. Hopefully I can still remember anything about being a premed!  Here goes:

1) Know how you study, and develop good study skills in undergrad. Medical school is tough — they say it is like trying to drink water out of a firehose — so make sure that you’ve got a system in place to organize information in your head and commit it to memory.

For some people that’s flashcards, for others it’s study groups; for me, I *still* find I have to write things down in a notebook to get them to stick.

2) Know how you relax, and don’t give up doing that. For some people, that’s going to the gym. For others, that’s playing the guitar. Or doing a hobby. Or keeping in touch with your family. Medical school (and residency even more-so) requires copious coping mechanisms so have yours ready.

3) Get by with a little help from your friends. Don’t be a gunner in medical school. You’re in — You get to be a doctor — Yay!  Med school will be much easier if you work together with your classmates rather than view them as competition — *especially* once clinics start.

4) It is normal to feel overwhelmed. Accept it and embrace it, and it won’t be so stressful. There are parts of it that you’re going to hate, that are not going to be intuitive. But it will get better!

5) Try to get yourself all figured out. Know yourself by the time medical school starts, because while you’re in the thick of things, it’s easier to have as many of your own internal issues worked out before trying to ascend Mt. Medical School. “

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Being a Person AND a Medical Student

Please tell us about some moments in medical school or clerkship that:

Made You Angry: I remember two instances that made me upset: one was the way some OB-Gyn residents were talking disrespectfully about a terminal cancer patient. (I actually kind of understand their perspective as a resident now, but still don’t agree with it.)

The other was a grossly abnormal physical finding in a patient that I found that a group of residents chose to ignore, because I was a medical student. As the medical student, you are — more than anyone — your patient’s advocate. Know when to speak up.”

Made you wish you had Studied More: “ The Boards. But you always wish you could memorize more. Do your best, and move on “.

Brought Tears to your Eyes:  “ I remember it like it was yesterday. It was on my medicine rotation, one of the first patients that I really felt was “mine.” My residents let me “be in charge” as much as I could, and I fought for him to get a much-needed foot amputation. I was off or post-call one day, and I remember coming back the next morning and finding out he had died.

I wrote up the experience: Wonderful, Just Wonderful, Dr. Walker at: http://www.grahamazon.com/over/2006/02/wonderful-just-wonderful-dr-walker/ “.

Made you Roll on the Floor Laughing:  “ Slap-happy post-call. I’m known for being a little hyper and a bit of a morning person, which usually drives people crazy. Also any shift in the Emergency Department “.

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Learning Medicine, Becoming a Doctor. Empathy, gravitas, demeanor, honesty

Part A:  How does one learn to “act like a physician”?   (It’s not really in a textbook.)

I certainly steal bits and pieces from different mentors and heroes of mine. A phrase from this attending, a style from that one. Tips and tricks along the way.

There’s no one way to “act like a physician,” and often it changes for the situation and the patient. I’m a different type of doctor when I’m seeing an infant compared to when I’m evaluating a trauma patient or interviewing a 95 year-old. Being able to adapt and change: maybe that’s the ticket. ”

One area the third-year medical students are concerned with is effective communications with patients and their families when managing someone with a terminal illness, in palliative care or especially when attending unexpected deaths due to accidents, homicide, military, etc.

Part B:  How does a physician learn to “deliver bad news” to a patient or their family members?

Get at or below the patient or loved one’s level. Empathize. Speak in private. Speak their language, if you can. (Learn as many languages as you can.) Make eye contact. Be direct, calm, and compassionate. Tell them however they’re feeling or reacting is normal and okay: everyone reacts differently.

Be present in the moment.  This is one of the hardest things for me to do now, and I have to remind myself of it, especially in a busy emergency department. Don’t worry about what’s happening to the rest of the team, or the other patients, or the rest of the department. Just be there, if only for a few minutes.   Apply the Golden Rule “.

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Congratulations – You are now a resident!  Choosing a specialty.

Match Day is Thursday, March 18, 2010. Can you describe the process that allowed you to select a medical specialty (Emergency Medicine) and why?

Man, it’s hard to remember, because my view of the specialty has changed so much as a resident. I remember really connecting with the type of attendings and residents who went into Emergency Medicine.  My type of people, I guess.

They say it’s much easier to rule out specialties than rule any in, and that’s very true. I was the type of medical student who enjoyed most of my clerkships, but in the end, I chose the one that I thought I’d enjoy, be challenged by, and excel at. ”

What advice would you give fourth-year students as they learn their Match and prepare for residency?

Get excited, relax, and get scared. Residency is not anything like a harder version of medical school, like I imagined it to be.  Enjoy your last few free months. Travel. Get married. Spend time with the people who are important to you.

Do. NOT. Study. And most of all: learn Spanish “.

Do you ever get enough sleep?

Yes, I do. My program is pretty resident-friendly in that regard, and I think it makes us all better, happier, more efficient, and more compassionate doctors. It’s hard to go the extra mile (which is what you realize you have to do as a resident) when you’re exhausted and cranky. ”

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Since this blog is written to inform readers about health science literature, trends in medical or scholarly communications, effective search strategies and sources, the next question focuses on your experience in learning to effectively use health science literature, sources for evidence-based practice or anything digital.

Have your information needs and/or searching behavior(s) changed between medical school and residency?  Are mobile computing resources and technologies important to you?

Definitely.  In medical school it’s all about learning about the basics, and the basics of how you treat X.

In residency, it’s much more about management, when to use what, finesse, and pattern recognition. I think it’s different for every specialty, too.

Regarding searching for clinical evidence, which sources, journals or databases have you found most-useful in answering clinical or patient care questions over time?

Great question. If I’m going to anything, it’s usually either UpToDate or E-Medicine or straight to actual papers, via Pubmed.

I really like JAMA’s Rational Clinical Examination series, as well as BestBets, The TRIP Database, Cochrane Reviews, and often just… Google.  I also keep a private little blog of things I’ve learned and journal articles I want to hold onto for future reference.”

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What aspect of medicine/science digital communication and/or particular use of the Web for medicine or patient care interests you the most? (This is a completely open-ended question.)

I love Podcasts, Videos, Image Banks and clinically-useful blogs. It’s a whole other style of learning that helps you learn more when you’re tired of reading journal articles, review articles, or textbooks. ”

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Bonus Question: What question would you like to ask the readers? – or – What do you want medical students who read the EBM and Clinical Support Librarians@UCHC blog to learn from our interview?

I’d love to know how the students think medicine is going to change in their lifetime.

What do they think of the blurring of private/public life through [social media sites such as] Facebook?  Should we as doctors hide our private lives — that is, is it inappropriate for a patient to see a doctor, say, smoking or drinking on a site like Facebook?

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And that’s the first interview for Learning Medicine: Ten Questions series.  Special thanks again to Graham Walker for sharing his time, expertise, advice and experiences.

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Happy St. Patrick’s Day!