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: Graduate Medical Education

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.

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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!

News, Searching the Medical Literature: Two Expert Opinions on Searching, or PubMed and Beyond

Today is a great day to highlight the recent posts of two fellow medical bloggers:  the first is from Laika’s MedLibLog, written by a Dutch research-scientist/medical-librarian; the second post is from Life in the Fast Lane, a blog written collectively by a group of Australian physicians.

Each author has written definitive posts about the mechanics – and utility – of searching the medical literature, and evaluating what has been found.

These posts should be seen as instant classics – and required reading for new graduate students in medicine, dental medicine or biomedical research or just about anyone with an interest in finding more-pertinent clinical information (in less time).

Their descriptive clarity in explaining what to search, and how to search is pitch-perfect.

Thank youLaika and SandNSurf – for writing them!

Please read:

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Next: Following are several quite different compilations of medical information resources written by librarians.

Elena Giglia, a medical librarian from Central Library of Medicine, University of Turin, Italy,  wrote in 2007 an excellent overview of the medical literature entitled “Beyond PubMed: Other Free Biomedical Databases.  This 11-page article was published in the European Journal of Physical and Rehabilitation Medicine (Europa Medicophysica) – Vol. 43(4):563-9 (Dec 2007). It is available online for anyone to read.

Ms. Giglia is the author of a very recent article, “Medline/PubMed revisited: new, semantic tools to explore the biomedical literature“, published June 2009 in Eur J Phys Rehabil Med – Vol. 45(2):293-7 (subscription required).

Law librarian Gloria Miccioli wrote a summary of medical sources targeted for legal professionals, entitled  “Researching Medical Literature on the Web” (published Sept 22 2008), found on LLRX.com.

The LLRX website also offers a list of links for librarians (or others) doing legal research.

My own Home Week: Evidence Based Medicine Resources page on Libguides.com was created – and is updated annually – as a source-sheet for third-year medical students at UCHC as they rotate throug h their clinical clerkship year.

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Finally:  Librarians working in academic health science libraries offer a variety of digital training tutorials or subject lists for orienting their students, residents and faculty to the technical aspects of searching the literature of medicine.

A quick search on Google for “tutorials searching medical literature” brings up an eclectic group of 968,000 retrievals.

The same search using Bing f0und 1,530,000 well-filtered retrievals.

Education, Instruction: One Heck of an Exam – The USMLE

American medical students who are nearing the end of their second year of graduate medical education face the prospect of preparing for one of the most important examinations of their career thus far : Step 1 of the United States Medical Licensing Exam (or USMLE).

There are three examinations in the USMLE process (Steps 1 through 3) and students must progress through each step at carefully defined points in their medical education. A passing score from the Step 1 exam must be reported for each student by USMLE to their institution prior to the start of the clinical clerkship year, which commences on July 1 2008.

To view a list of clinical subjects and areas covered by USMLE, click here. Following is an excerpt from the USMLE website, explaining the three examinations:

The Three Steps of the USMLE

Step 1 assesses whether you understand and can apply important concepts of the sciences basic to the practice of medicine, with special emphasis on principles and mechanisms underlying health, disease, and modes of therapy. Step 1 ensures mastery of not only the sciences that provide a foundation for the safe and competent practice of medicine in the present, but also the scientific principles required for maintenance of competence through lifelong learning.

Step 2 assesses whether you can apply medical knowledge, skills, and understanding of clinical science essential for the provision of patient care under supervision and includes emphasis on health promotion and disease prevention. Step 2 ensures that due attention is devoted to principles of clinical sciences and basic patient-centered skills that provide the foundation for the safe and competent practice of medicine.

Step 3 assesses whether you can apply medical knowledge and understanding of biomedical and clinical science essential for the unsupervised practice of medicine, with emphasis on patient management in ambulatory settings. Step 3 provides a final assessment of physicians assuming independent responsibility for delivering general medical care.

Source: http://USMLE.org – Copyright 2008 – All rights reserved

The USMLE is sponsored by the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME).

ExamMaster is a subscription test-prep resource available to UCHC students as they prepare for this important test. On-site registration and log-in to ExamMaster is required. Students can design their own tests, use standardized tests, save their scores and review results. Online tutorials are also available.

Here is a screenshot of the Start page, after I logged in to ExamMaster:

Screenshot - ExamMaster - Begin

Photo Credit/Source: ExamMaster Inc. – Copyright 2008 – All rights reserved

Note: Just to get a feel for the real test, I completed the ExamMaster test-bank for Psychiatry last week. My score? 70% correct… Wow! 😮

News, Academic Medicine, Medical Education: A New Clinical Enterprise

I read with interest a post by Jacob Goldstein on the Wall Street Journal Health Blog on Apr 4 2008 regarding plans for a new medical school on Long Island – which will be the first ever (and only) graduate medical educational institution in Nassau County (NY). His blog posting states that there are currently planned between 10-15 ‘start-up’ graduate medical schools to add to the existing 129 schools in the United States. Link here to the American Association of Medical Colleges for a list.

This new venture will be a collaboration between Hofstra University and North Shore-LIJ Health System, Long Island, NY. The proposed school has already chosen a founding dean, Dr. Lawrence G. Smith, and the first class is planned to enter in 2011. In the WSJ blog article, Dr. Smith is quoted:

There are two real costs to the startup of a medical school. One is the cost of staff and faculty prior to collecting tuition from students. That’s in the $15-$20 million range. And then you have to build a medical education center and a living facility. That’s the heart and soul of the medical school. Capitalizing both of the buildings together is going to be between $50 and $100 million. Nobody’s going to come up with money for that. That’s going to be a debt-service issue.

Also read a press release dated Jan 22 2008 from Dartmouth Medical School, in which Dr. David Goodman argues that increasing the numbers of medical students could place a financial burden on an already straining U.S. health care system.

Education for health professionals is not – and never should be – inexpensive.

Medical education takes many forms: seeing patients in all states of health, chronic and acute, young and old, in hospital or affiliated clinics (the buildings/facilities). Students learn in lectures from experienced physicians, researchers and allied health professionals (the clinician-educators) as well as hands-on learning from clinicians in the community.

On-site and at-hand for the graduate students are the core of the academy: men and women with years of experience in treating patients, teaching, demonstrating, researching, presenting, facilitating, guiding, giving advice. There are also many opportunities for laughter, sharing and collaboration.

The local community is another factor to consider, as students are required to travel around the state to observe healthcare delivery where it actually takes place. This semester, I have heard from 2nd year medical students who have – as observers – visited patients in residential nursing homes, met 13 and 14-year olds from urban Hartford neighborhoods and counseled them on safe sex practices and avoidance of STDs, sat in on Alcoholics Anonymous meetings, shadowed physicians in trauma/emergency rooms throughout the state (just to cite a few examples). Patients are a diverse group… those seen in an emergency room at 230am may differ demographically from those enrolled in a long-lasting clinical trial at the academic health center.

The people, the patients, the buildings and the resources for a medical school may be compared to a full symphony orchestra. Here are some of the things which come to mind that might keep Dr. Smith awake at night:

  • the ability of the institution to compete for, recruit, enroll and retain qualified applicants with a humanistic focus who can integrate and apply complex medical data in order to become successful practitioners. (Click here for AAMC links for future physicians).
  • recruit and retain a group of talented, experienced clinicians and biomedical researchers who are dedicated educators, academic scholars and proven grant-winners
  • sort out options of academic tenure; and unions for professional or clerical staff
  • recruit and retain a group of talented, experienced clinical hospital staff: nurses, allied health personnel, health care technologists, others
  • provide and maintain state of the art health care facilities which offer a diverse selection of clinical departments, hi-tech equipment and sufficient patient base to keep it funded
  • secure on-going financial support from the greater academic or governing institution
  • take actions to be in compliance with all accrediting bodies for hospital, higher education and also with a variety of state/local/federal laws governing healthcare facilities
  • devise strategies or plans for protection from potential threats to the viability of the enterprise… including political pressure from existing academic or clinical competitors
  • plan, construct, manage and maintain the physical buildings, systems and environments
  • finally, but not least of all: hire and retain non-teaching staff who are the daily face of the institution for everyone who enters the new building. These staff would be a diverse group of savvy, experienced administrators, managers, technicians and yes – librarians – who attend to the infrastructure, and complete the daily work of the facility seamlessly. These people will like working with the general public, patient and their families, students and faculty.

Now – what and who is missing from this list… Anyone care to comment?

Just as money, buildings and human talent are needed for a start-up academic health center to support the needs of Students, Patients, Staff, Facilities, Environmental Safety and IT… so are funds required for a health science library.

I wonder if the new medical school has plans for a new library and new staff? Everyone in the clinical enterprise requires access to current information in networked or print forms. Students need an attractive place to study and congregate (they study alot). Clinicians and graduate students need librarians to provide literature searches, train them to search efficiently, repair broken links to digital information, select pertinent databases to meet their needs for patient, research or grant funding knowledge management or demonstrate how to set up and run a new PDA or laptop.

We (in the library) aim to assist life-long learners. You could reasonably say that the health science library and the human staff there helps everyone in that new building.

Instruction, Tutorials, Patient-Oriented Evidence: AAMC MedEdPortal

The Association of American Medical Colleges (AAMC) is the professional society and advocate for academic institutions granting M.D. degrees. Members of AAMC include 129 medical colleges in the United States and 17 colleges in Canada. AAMC is the site sponsor for MedEdPortal, the purpose of which is described as “their web-based resource for sharing and publishing educational materials across institutions and [medical] disciplines”.

This week I received an email from MedEdPortal announcing that on Monday, Mar 17 2008, from 11:00AM to 11:45AM (ET), an online interactive tutorial will be given for those who want to learn more about contents and features of this educational collection. To sign up for the online class – click on this link. The class is free to those in the U.S., international users must pay a fee to AAMC to participate.

Here is an excerpt from the “About” page on MedEdPORTAL explaining the scope and purpose of the site:

  • MedEdPORTAL is new approach to online publication that offers peer review for teaching resources… including tutorials, virtual patients, cases, lab manuals, assessment instruments, faculty development materials and more.
  • MedEdPORTAL was designed to promote collaboration and educational scholarship by facilitating the open exchange of peer-reviewed teaching resources. The MedEdPORTAL Team launched the application in January 2006.
  • MedEdPORTAL is designed to help medical faculty publish and share educational resources… it focuses exclusively on the unique needs of medical educators.
  • MedEdPORTAL is available free to the general public and covers the continuum of medical education (i.e., undergraduate, graduate and continuing medical education).
  • MedEdPORTAL does not accept submissions for resources that are for sale. All resources published in MedEdPORTAL are available at no cost to the user (excluding possible duplication or mailing costs).
  • MedEdPORTAL is constantly being improved and refined through planned application releases.

Joining MedEdPORTAL is free, and anyone can sign up to become a user. Note that login is required to view the full contents of the site.

Following are two screenshots from MedEdPORTAL… the main page:

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and the “Collections” links page:

mededportalcollections.jpg