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

Tag Archives: Evidence Based Medicine

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.

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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.

Education, Instruction, PBL: Thinking about Trauma, Brains and Textbooks

This post is about participating in problem-based learning. As a non-clinician, sometimes I’m at a loss informationally in PBL. There are eight medical students and one experienced physician in the room with me and – frankly speaking – a certain amount of the clinical material is over my head.

Much of what is covered in problem-based learning focuses on recognizing classic or emergency symptoms in a hypothetical patient, parsing etiology, past medical or family history, looking at evidence presented through physical exam, lab data, radiological images, occasional photographs. Each case unfolds over a two-week period; students are given several pages of the case and time to discuss the “patient’s chief complaint“, list data, formulate questions. During the following days, they do research using clinical sources, then create a narrative, concept map or bulleted problem-list to bring to the class the next week.

One standard schematic used to manage patient data is to organize it in the following way: What is the Nature of… , What is the Meaning of… , What is the Significance of… , What is the Relationship of… (or WIN-WIM-WIS-WIR)? A different script, created by a student several years ago is: Etiology, Findings, Pathogenesis, Treatments, Psychosocial considerations.

The utility of this information sorting/schema matters to graduate students in their first two years of medicine, when they are learning basic medical science, organ systems, human health over the lifespan in addition to spending one day per week assisting at the office of a community physician. Time spent in PBL is for learning to think like a clinician in a low-risk setting, and to create a foundation for recognizing illness patterns. (Thanks to Diedre B who created this page found on Medical Education Wiki).

This week I picked up a new textbook from the New Book Shelf, titled Trauma Anesthesia, edited by Charles E. Smith (Cambridge University Press, 2008 ) and began reading through the chapters. This 606-page text is a gold-mine of technical information, evidence-based flowcharts, tables, dozens of photos and patient radiographs, and the strong point of the book is discussing typical presentations in trauma. I wasn’t aware that unintentional injury is the leading cause of death in U.S. for those under the age 45, that in 2002, 162,000 deaths were recorded due to traumatic injuries and the cost of medical treatments for treating these injuries total $200,000,000,000 each year (Source: MMWR, 2004:53:1-4). Trauma can be sustained in many ways… mechanical, chemical, thermal, radioactive or biological insults to the human body.

But a comatose patient can’t answer the question: “What brought you in today? Maybe that is one of the attractions about choosing emergency medicine: the adrenaline of in-coming, when the physician has to make the call in limited time and with information that is only partially forthcoming. This textbook, and books like it, provide the technical framework for making that call.

For example, the chapter on Head Trauma refers to the Brain Trauma Foundation where the following statistics about traumatic brain injuries were found:

Photo Image/Credit: http://www.braintrauma.org

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I recommend this textbook. Below is a brief list of related Trauma websites which may be useful for medical students or others interested in critical care teaching/learning links:

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Okay, so I will never be able to concept-map the Krebs cycle…

Image credit: http://wikipedia.org

… but I can show you several ways to search Medline effectively. I’m great at that.

EBM, Scientific Literature, Teaching & Learning in Medicine: Kicking it up a notch

This is the time of year when things get pretty busy for the Information & Education Services librarians at UCHC.

After library orientation sessions for new residents and fellows in July and finishing up the MPH Health Informatics course, the reference librarians begin to gear up for instructional sessions for incoming medical and dental students and greet 400+ returning students. There are many questions from individuals about using or downloading PDA based information; our academic computing specialists field those questions. And when all the good parking spaces suddenly disappear, summer is over and a new Academic year has begun around here!

During Fall semester, I teach a searching/training session for groups of third year medical students who are rotating through their ‘home’ institution (i.e. UCHC). These week-long rotations are collectively called Home Week; there are seven sessions spaced throughout the academic year.

Home Week searching/training sessions are a logical time to describe and demonstrate evidence-based medicine sources such as the Cochrane Library or advanced techniques for searching Medline using Medical Subject Headings, clinical subheadings and Clinical Queries for this group. Examples of comparisons of treatments found in ACP Journal Club or BMJ Clinical Evidence are given. Another function for the class is to provide updates on new database subscriptions or those which they may have used previously but which have been revamped – such as Essential Evidence (previously known as InfoRetriever). The biostatistical analyses and critical appraisal of clinical trials (BMJ “how to read a paper” stuff) is covered by a PhD later the same morning.

Insight for instructing the Home Week evidence based literature session is grounded by my participation in problem-based learning (PBL) as a facilitator for first or second-year groups. PBL classes meet once per week for three hours; there are eight students and two facilitators in each group. The majority of facilitators are physicians. A PBL case-study runs for two weeks, and there are 8-10 hypothetical patient/case studies per semester.

This shared small group experience has been a real-life learning lab for me… hearing directly from students as to how they begin to use scientific literature sources to solve diagnosis, medical problem-solving and treatment options presented by each hypothetical patient. Besides their textbooks, the students’ all-purpose “Big Three” clinical sources – used heavily during the first two years – tend to be Access Medicine, including Harrisons’ Principals of Internal Medicine, Up to Date and frequent searches of Medline to locate original research studies or clinical reviews.

The students also hear about accessing the Big Five journals (JAMA, Annals of Internal Medicine, BMJ, Lancet and the New England Journal of Medicine) from everybody (lecturers, clinical preceptors, librarians). Yes, the running joke is that while we all use Wikipedia… please try searching Medline too, OK? 🙂

The information requirements of third year students’ are not static either.

These digital natives were required to purchase a new laptop prior to beginning their first semester at medical school. Their laptops are configured once they arrive onsite to serve as their wireless docking station, course notebook and the instrument by which they take all exams. A new requirement for the incoming Class of 2012 is to arrive with both a new laptop and PDA.

As their clinical knowledge base expands, third year students’ choice of information sources widens. Their search strategies are affected by the types of patients that they have seen at their community preceptors’ medical practice, or where they may have volunteered in area health clinics, such as one UCHC runs each summer for migrant workers. As one of our core library user groups, students have considerable latitude to experiment and “grow through” various literature sources available to them from UCHC Library.

While they may never call it “evidence-based clinical reasoning”, this is an aspect of their education in which librarians and highly-knowledgeable curriculum support staff play a proactive role as “information consultants” for this group.

Many of the subscription databases are selected specifically because they offer both a web-based database with an accompanying PDA component. Examples: Lexi-Comp and Micromedex are standard pharmaceutical reference sources; dosing, drug interactions, algorithms or potential adverse affects can all be loaded onto a PDA which travels with the student during their rotations or accessed through the wireless network.

Significant time and money has been expended in selecting comprehensive “clinical decision support tools” like DynaMed or FirstConsult. There are several free PDA tools of use for the students, such as Diagnosaurus, Archimedes and ePocrates. While UCHC has access to Ovid, few students use the database so I no longer teach it for Home Week. Students are encouraged to pick and choose which source(s) to “specialize” in to answer their patient care questions, as any of these resources provide a specific utility and represent an “information niche”.

The hour in the Home Week session passes quickly. I do save the final ten minutes to discuss, demonstrate and convince this group of the utility and power of using Scopus for answering clinical questions. Why? Because the Scopus database represents (to me) an example of the future of searching.

Scopus does – and will – cover much of the literature needs required by clinicians, students and researchers for the next several years. Following is an excerpt from the Scopus “About” page:

Updated daily, Scopus covers 29 million abstracts of over 15,000 peer-reviewed titles from more than 4,000 publishers, 265 million references and 265 million quality web pages through Scirus‘ web search to cover the scientific web.

Scopus sets a new standard in contemporary clinical databases. Most students are already aware of how essential Medline is for their searches… what I enjoy describing for them is what access to the vast content in Scopus can mean for their clinical knowledge base and effective patient care.

And I am grateful that the clinical faculty give me 60-70 minutes to demonstrate these sources for the third year students, year after year.

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Note: Most of the sources mentioned above are subscription databases, available only onsite at UCHC, via proxy access for affiliates or at any other institution which subscribes to them.

EBM, Education: A Redesigned Database and the 150th blog post!

This is blog post number 150 for EBM and Clinical Support Librarians@UCHC. Please keep those comments coming, folks – and thanks for reading! 🙂

Medical students rotate through varied clinical sites throughout Connecticut during their third and fourth years of training… and their PDAs travel right along with them, serving as a portable wireless device, clinical calculator, drug encyclopedia and online collection of decision support tools to aid in practicing evidence based medicine.

This post is about one of those specialized EBM tools. Previously known as InfoRetriever, in late 2007, content and rights of this database were sold to publishing giant Wiley-Blackwell and renamed in January 2008 to become “Essential Evidence Plus” (EEP). It is now accessible to subscribers via the Wiley platform.

Below I have listed an outline of the specialized tools that Essential Evidence Plus offers:

  • diagnostic tests and physical/history calculators or algorithms
  • abstracts from the Cochrane Library
  • 3,000 InfoPOEMS (Patient Oriented Evidence that Matters)
  • current practice guidelines
  • weekly podcasts on 40+ clinical topics
  • medical photographs
  • ICD-9 diagnostic codes, E/M coding wizard (Medicare)
  • selected CME
  • sign-up for a daily EBM alert
  • Derm-Expert, a diagnosis tool
  • Levels of Evidence heirarchy
  • link-outs (in context) to PubMed
  • PDA version for subscribers
  • in conjunction with Finnish Medical Society, two new datasources have been added: 800 concise clinical summaries in e-Essential Evidence and Evidence-Based Medicine Guidelines.

I value having easy access to individual clinical calculators on my PDA, such as the Likelihood Ratios which require one to input actual patient data or labs in order to assess the patient, verify abnormal laboratory values, clinical decision aids (rule-in/rule-out), alerts for potential adverse events, etc. Following is a screenshot which shows a diagnostic calculator to assess whether a particular patient is likely to have Colon CA or other adenoma:

essentialevicolonscreening.jpg

Photo credit: Copyright 2008 – Wiley-Blackwell Inc. – All rights reserved

EBM, Education, PDAs: Getting Up to Speed with PDAs

It’s been a busy week here and so I am getting back to blogging. The second-year medical students have purchased new PDAs this month in preparation for their clinical clerkship which begins in July. They are also starting a formal course on clinical reasoning. Reference librarians are assisting them in getting up to speed with various clinical software – chiefly Lexi-Comp, DynaMed, Diagnosaurus, Archimedes, Shots – and “best ways” to use these decision support tools. As anyone who has used PDAs knows, what looks to be an easy and straightforward install can turn out to be anything but that… I spent hours trying to get an updated DynaMed on my PDA on Monday – with no luck at all so far. 😦

The standard rule of “smaller, cheaper, faster” definitely applies to PDAs. The newest models are slimmer, sleeker and offer more features including higher screen resolution than the model I am using currently (which is barely 3 years old). With a PDA in your pocket you can search for potentially dangerous drug interactions, calculate normal values (for example, determine a patient’s creatinine clearance rate), check your email or read an pertinent review article from NEJM using the hospital wireless network – all at bedside and without getting anywhere near the library! What a benefit for busy students and clinicians!

If you are interested, here are a few links to PDA resources. The first page was written by library staff for use by students, faculty and clinicians:

P.S. And I really like Lexi-Comp! *

lexicomp.jpg
Image/Photo Credit: Lexi-Comp Inc. – Copyright 2008 – All rights reserved.

* Just in case you are wondering: Lexi-Comp. Inc. did not pay me to say that. Our subscriptions to Lexi-Comp – accessible on the internet or the version for PDA use – are great products, updated daily and well-utilized in this clinical setting. Heck – only librarians would say they loved a database, anyway! 😉

EBM: EBMSearch.org

EBMSearch.org/pubmed is a site in beta-test, meant for use by clinical professionals and expert searchers. There is not a great deal of information that I could find out about who sponsors the site. Here is an excerpt from the EBMSearch “About” page:

“What is Evidence Based Medicine? It is the discipline of identifying and using the highest quality information in existence, which is needed to address specific medical problems of patients”.

“What is EBMSearch? EBMSearch is a specialized search engine for retrieving and managing high quality medical information from MEDLINE”.

“What level or grade of evidence is EBMSearch designed to identify in the treatment category? For treatment, EBMSearch returns Level 1 evidence with a Grade Recommendation of A as defined by the Centre for Evidence Based Medicine. Level 1 evidence constitutes systematic reviews and individual randomized controlled trials. “A” Grade Recommendation is evidence consistent with Level 1 studies”.

“Who can benefit from EBMSearch? Healthcare professionals can better introduce the best scientific knowledge in patient care. They can reduce their search times and increase the quality and comprehensiveness of the results when searching for methodologically valid articles that are needed to give them the best information on which to base critical decisions about patient care. These treatment additions may also allow for improved billing and reimbursement”.

EBMSearch.org requires that you first search MEDLINE (PubMed) to locate the appropriate Medical Subject Heading, then cut and paste that clinical term into the EBMSearch search box.

pubmed.jpg

Please give this new free beta-search site a try. This librarian likes it quite a lot.