Patients and Populations: Medical Decision-Making - M1

GENERAL OBJECTIVES FOR LIFELONG LEARNING
1. Ask well-defined clinical questions from case scenarios, the answer to which will inform decisions concerning the use of diagnostic tests and medical therapies.
2. Acquire information by selecting and searching the most appropriate resources likely to answer these therapeutic and diagnostic questions.
3. Appraise the medical literature using the basic foundations of biostatistics, research design and clinical epidemiology.
4. Apply the results of the appraisal of medical references to make sound, reasoned clinical decisions concerning the use of diagnostic tests and medical therapies.

OVERALL LEARNING OBJECTIVES FOR THIS COMPONENT
1. Construct well-defined clinical questions from case scenarios, designed to improve general knowledge about a topic, and to help make decisions regarding the use of diagnostic tests.
2. Understand the differences between foreground and background questions and the implications for the types of information resources best suited to answer these questions.
3. Become familiar with the U-M information environment, and learn to effectively search several core biomedical resources to answer specific clinical questions.
4. Develop an understanding of the basic foundations of biostatistics, research design and epidemiology to begin to apply scientific data to the understanding of clinical conditions.
5. Effectively and logically apply probabilistic reasoning to diagnostic questions that arise in patient case scenarios.

LEARNING OBJECTIVES FOR EACH MEDICAL DECISION-MAKING ELEMENT

Information Retrieval Thread

Lecture #1: The Value of Uncertainty
By the end of this lecture, students will…
(1) summarize how new medical knowledge is created and applied
(2) describe how common diagnostic testing can lead to uncertainty in diagnostic reasoning
(3) describe Bayesian probabilistic rules, as they apply to a basic diagnostic question
(4) summarize how uncertainty in diagnostic reasoning interacts with trust of the practitioner.

Lecture #2: The Information Cycle
By the end of this lecture, students will…
(1) explain the difference between background and foreground clinical questions
(2) recognize how individual targeted searches for the answers to clinical questions drive self-directed learning that is crucial for all practitioners
(3) be able to craft foreground questions for both diagnosis and treatment, using the PICO format

Computer Sessions Learning Outcomes

Knowledge Outcome #1
Each student should be able to describe the medical information environment, in order to lay a foundation for lifelong information management skills.
Background/Significance
The knowledge of medicine continues to evolve at a rapid pace with the development of new therapies, improved diagnostic tools, better understanding of the mechanisms of disease, and expanded emphasis on psychosocial aspects of health care.  It is imperative that clinicians are able to access and manage this new knowledge.  At the same time, information resources will continue to be redesigned and new resources will be developed.  In order to navigate through this complex and dynamic environment, students must gain a solid understanding of the types of resources available to them and be able to match the appropriate resources to the information need at hand.
How learning will occur:

1. Lectures
2. Demonstrations and group discussions of a variety of information resources
3. Hands-on practice exercises
4. Assignment

How learning will be demonstrated:

1. Take home assignment to compare and contrast information resources, including evaluative comments and identification of foreground and background aspects.
2. Participation in group discussions and debriefing of practice exercises and assignment.
3. Skills Outcome #1

Each student should be able to formulate clinical questions that facilitate locating appropriate information to answer patient care questions.

Background/Significance
The ability to take a complex clinical scenario and from it, formulate a well-built clinical question is considered a basic competency in today’s practice of medicine. The student should be able to identify the key components of the clinical question from a clinical scenario.  This allows the student to understand and execute the process of (1) identifying the relevant information from a clinical scenario quickly, (2) searching the medical literature efficiently and (3) addressing the clinical problem in a timely manner.  Therefore students must have the skills to construct a clinical question because it is a primary building block in creating effective search strategies and locating information. 
How learning will occur:

1. Lecture on the PICO question format and concepts of background and foreground information
2. Group discussion and formulation of several clinical questions based on a patient  scenario

How learning will be demonstrated:

1. Participation in group discussion and formulation of several clinical questions
2. In class practice exercises

Skills Outcome #2
Each student should be able to search for biomedical journal literature using MEDLINE.

Background/Significance
MEDLINE is the largest and most comprehensive database of biomedical journal literature in the world.  While textbooks provide much of the background information that students need, the MEDLINE database is the core resource for primary biomedical literature.  As clinicians and future physicians, students must know how to search MEDLINE effectively in order to locate information for patient care, research, teaching, and continuing education for lifelong learning.
How learning will occur:

1. Demonstration and discussion of PubMed and Ovid MEDLINE.
2. Hands-on searching exercises, with assistance from instructors, to answer clinical questions generated through group discussions.
3. Take-home practice searching assignment.

How learning will be demonstrated:

1. Participation in group discussions of developing effective search strategies and differences between the two search interfaces
2. Hands-on searching exercises, observed by instructors
3. Take-home practice searching assignment

Skills Outcome #3

Each student should be able to identify and to search sources of background information as appropriate.

Background/Significance
Early in their medical education, students tend to ask far more background questions than foreground questions.  As students progress in their education, they increasingly ask more foreground questions.  However, there will still be instances throughout their careers when they will need to consult background resources to fill in gaps in their knowledge base.  Therefore, it is essential that students are able to identify and to search sources of background information as needed. These background resources, such as electronic textbooks, provide basic biomedical information, assist in answering general clinical questions, and also introduce complex clinical information. 

How learning will occur:

1. Demonstration and discussion of MD Consult Books, Stat!Ref, and the PubMed Bookshelf.
2. Take-home practice searching assignment.

How learning will be demonstrated:

1. Take home assignment to compare and contrast information resources.
2. Participation in group discussions and debriefing of practice exercises and assignment.

Biostatistics, Clinical Epidemiology, and Public Health Thread
Lecture: Introduction to Biostatistics
Lectures: Observational Studies
Lecture: Introduction to Public Health
Small Group session #1: Observational Studies and Basic Biostatistics

By the end of this set of lectures and small groups, students will…

(1) be able to define, explain the differences between, and recognize cohort studies, case control studies and prospective studies
(2) identify potential confounders in a cohort study and understand how they impact interpretation of scientific study results
(3) explain the concept of statistical significance and how it differs from clinical significance
(4) define and interpret statistically significant findings and confidence intervals
(5) explain how hypothesis generation, testing and sampling all contribute to the creation of new knowledge
(6) apply principles of biostatistical interpretation to basic scientific abstracts
(7) describe aspects of the field of public health, including its component disciplines
(8) explain principles of vaccination, the global eradication of smallpox, and progress towards polio eradication
(9) explain the principles of power, sample size, Type I and Type II errors

Diagnostic Reasoning Thread
Lectures: Diagnostic Reasoning
Small Group session #2: Diagnostic Reasoning
Small Group session #3: Diagnostic Reasoning Applied to Colon Cancer

By the end of this set of lectures and small groups, students will…

(1) be able to define and distinguish between prevalence and incidence, and understand how they relate to prior probability.
(2) list the important features of a well-constructed diagnostic study, recognizing the importance of a well-accepted gold standard and blinded assessment.
(3) define and calculate sensitivity and specificity for certain diagnostic tests from results in a diagnostic study.
(4) apply these test characteristics to diagnostic reasoning using Bayesian probability theory.
(5) explain that test predictive values are linked to prevalence, where sensitivity/specificity are relatively prevalence-independent.
(6) be able to calculate likelihood ratios from the sensitivity and specificity of a test, and understand how they can be combined with pre-test odds to obtain post-test odds.
(7) demonstrate how a Receiver-Operator Characteristic (ROC) curve can help depict the tradeoffs between sensitivity and specificity of a diagnostic test, as thresholds are adjusted for abnormal values.