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: Health Science Literature

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!

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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.

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!

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.