Teaching Information Gathering Skills to the Google Generation: Emphasizing the Intellectual Rigor of Family Medicine Kristen Goodell MD, Molly Cohen-Osher MD Tufts University School of Medicine, Boston MA

Objectives Describe the benefits of an information mastery workshop and exercise for medical students Explain major information mastery concepts including POEMs, the PICO format, and the usefulness equation Adapt our information mastery learning exercise for their own institution

Information Mastery Set of skills to keep a physician up to date with most current evidence in order to use this information to guide patient care decisions

Information Management for the Google generation Task: What are the characteristics of the Google generation? Are you a digital immigrant?

The Google Generation Why info mastery makes sense Students from the Google generation think about information differently  “Why put it in your brain if you could look it up”  Need to stay connected at all time  Synthesized data vs raw data Synthesized EBM databases are very intuitive to the Google generation  Point of care resources

Teaching Information Mastery to Family Medicine Clerks 1 hour interactive hands-on workshop Instructions for assignment 10 minute IME presentation to peers with grading done that day, and feedback given to students

Information Mastery An Introduction Allen F. Shaughnessy, PharmD Professor of Family Medicine

Please define Epistemology

Not All Information Is Useful Usefulness of any= Relevance of the information X Validity of the information Information sourcethe Work required to get the information Two options:  Find relevant information yourself and determine its validity  Find sources of information you can trust to do the finding and validating

Relevance: Disease vs. Patient- Oriented Evidence Patient-Oriented Evidence that Matters  They measure outcomes that our patients care about: symptoms, morbidity, quality of life, and mortality  They have the potential to change the way we practice. Disease Oriented Evidence  Measures outcomes that are markers for disease Lab value/biochemical markers Plaque size Blood pressure Shaughnessy AF, Slawson DC, Bennett JH. Becoming an Information Master: A Guidebook to the Medical Information Jungle. The Journal of Family Practice 1994;39(5):

Patient-oriented evidence contradicts disease- oriented evidence Disease-Oriented OutcomePatient-Oriented Outcome Fit test respirator mask filters airborne pathogens Surgical mask = fit test respirator mask in preventing influenza Intensive glucose lowering can decrease A1c Intensive glucose lowering does not decrease mortality Beta-carotene, Vit E are good antioxidants Neither prevents cancer or CV disease Procrit in patients with CRF increases Hgb Procrit increases mortality in patients with CRF Abx treatment of AOM in children can sterilize the middle ear Abx treatment of AOM does not affect sx, increases likelihood of recurrence

Hunting for Information Work Relevance Transparency WorkRelevance Transparency WorkReliability Transparency To be the most useful: You want little work, with high relevance and transparency

Point of Care Resources WorkReliability Transparency

Drilling for the Most Useful Information Cochrane Library E-B Guidelines Specialty-specific POEMs Best Evidence, ACP Journal Club Clinical Evidence Clinical Inquiries Textbooks, Up-to- Date, 5-Minute Clinical Consult Usefulness Medline

Which Tool is Best? Unfortunately there is currently no one- size-fits-all electronic database The best source is based on the type of question Just-in-time vs. just-in-case sources

Clinical Problem Example #1: A 36 year-old female who works as a hairdresser presents with bilateral carpal tunnel syndrome (CTS). She would like to try conservative measures before resorting to steroid injections or surgery. You want to find out what conservative measures have been shown to be effective in CTS. Resource: Dynamed

The Information Mastery Exercise Instructions Step 1. Identify a question Step 2. Convert the question to the PICO format  Patient, Population or Problem What are the characteristics of the patient or population? What is the condition/disease you are interested in?  Intervention or exposure What do you want to do with this patient (e.g. treat, diagnose, observe)?  Comparison What is the alternative to the intervention (e.g. placebo, different drug, surgery)?  Outcome What are the relevant outcomes (e.g. morbidity, death, complications)?

The Information Mastery Exercise Instructions Step 3. Select one or more point of care resources to find the answer Cochrane Database of Systematic Reviews ACP Physician's Information & Education Resource (PIER) ACP Journal Club DynaMed BMJ Clinical Evidence TRIP Database Step 4. Determine the answer to the clinical question. What is the strength of your recommendation? A “Strength of recommendation” is based on the quality of the available evidence and the degree to which the evidence has evaluated patient-oriented outcomes. Several of these resources offer a rating of the evidence quality and you will need to convert this ranking to a strength of recommendation. See: Strength of recommendation taxonomyStrength of recommendation taxonomy SOR = A consists of high quality evidence focused on patient-oriented outcomes SOR = B consists of inconsistent or limited-quality evidence focused on patient- oriented outcomes SOR = C Low quality evidence or evidence focused on disease-oriented outcomes or risk factors

The Information Mastery Exercise Instructions Step 5. Describe how you applied the answer to the original patient situation Step 6. Prepare a 10 minute presentation following slides: The original clinical question The PICO question The method you used to search the resources (e.g., “I started with BMJ Clinical Evidence and then checked Dynamed) What you found From what you found, your conclusions, and the strength of your recommendation What you did with the answer

Naomi Ross Family Medicine Rotation Block 2A

 HPI: A 53 yo man presents to the office 5 days after hiking in the woods with his dog. The morning after hiking he found a tick attached to his left flank.  ROS: No fever, fatigue, arthralgias, myalgias, or headache  PE:  HEENT: No inguinal adenopathy  Skin: On the left flank there is a well marginated erythematous 8 mm circular macule with a central bite mark.  Rx: should we provide prophylactic antibiotics for Lyme disease?

 Patient, Population, or Problem: Tick bites in Lyme Disease endemic areas  Intervention or Exposure: Antibiotic prophylaxis  Comparison: Watch and wait  Outcome: Development of Lyme Disease

 Should a patient who lives in an endemic area for Lyme Disease who presents 5 days after getting a tick bite receive prophylactic antibiotic therapy or simply undergo observation to prevent/treat Lyme Disease?

 “ prophylactic single-dose doxycycline may be warranted after tick bite if sufficient risk for Lyme disease” If all the following criteria are met…  attached tick can be readily identified as adult or nymphal Ixodes scapularis tick attached for > 36 hours (based on tick engorgement or certainty of time tick was removed)  prophylaxis is within 72 hours of time that tick was removed  local rate of infection of ticks with B. burgdorferi > 20%  SOR: DynaMed Level 1

 “What are the effects of measures to prevent Lyme Disease?” “Compared with placebo A single dose of doxycycline is more effective at reducing the proportion of people with erythema migrans, or with any evidence of Lyme disease at the site of the tick bite in the preceding 72 hours.” Sources: One systematic review: No statistical significance One RCT: ARR 2.8%, 95% CI 0.4% to 5.2%; NNT 36, 95% CI 20 to 250 SOR: “Moderate-quality evidence Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.

 Our patient was at low risk for Lyme Disease since the tick was attached for less than 24 hrs.  Presentation to the office was greater than 72 hours after tick bite.  Conclusion: no prophylactic antibiotics! Watch and wait for S/S of Lyme Disease!

Ixodes Scapularis

Grading Rubric Student:RangeScore Topic: Background -- Establishes a clear clinical question (1) -- Properly translates clinical question into a correct PICO format (1) -- Provides useful background information about importance of topic (+1) 0-3 Search Process -- Discusses search process using appropriate resources (1) -- Reviews strength of recommendation for each source (1) -- Search is comprehensive yet concise, and well described (+1) 0-3 Result Summary and Recommendations -- Summarizes findings from evidence reviewed (1) -- Discusses some shortfalls of studies and current available evidence (1) -- Gives recommendations for clinical practice, and specific patient situation (1) -- Analysis of evidence is particularly organized and insightful (+1) 0-4 Content and Organization -- Presents information clearly (1) -- Power point slides are not cluttered and add to presentation (1) -- Makes eye contact, has appropriate posture and gestures (1) -- Voice has a good tempo and tone, few filler words (um, like) (1) -- Exceptional Presentation Skills (+1) 0-5 Deductions -- For each 15+ minutes late (-1) [-2 for 30+ minutes late, -3 for 45+ minutes late, etc.] -- Power point slides not available (-2) Total Score15

Student’s Perspective Take it away, Naomi!

Benefits? Emphasizes the academic rigor of Family Medicine Makes the breadth of information manageable in a way that makes sense to the Google generation Gives students a strategy to embrace intellectually challenging clinical problems on their own Students facile with electronic point of care resources provide a helpful service to their preceptors Provides stealth faculty development in information mastery Applicable to other disciplines – a successful exercise that can be adapted to other rotations Provides students with a strategy for lifelong learning

How can this work for you?