NEW YORK UNIVERSITY SCHOOL OF MEDICINE MEETING OF THE CURRICULUM COMMITTEE Thursday, January 8, 2004 8:00 A.M.

. Deans Large Conference Room PRESENT: P. Aronson, B. Bogart, L. Boylan, K. Brewer, E. Cahill, V. Catanese, J. Chase, P. DEustachio, B. Dreyer, M.A. Hopkins, S. Kammerman, M. Manley, C. Moodhe, M Rosenfeld, B. Sadock, L. Tewksbury, K. Walton Dr. Rosenfeld called the meeting to order at 8:10 A.M. and thanked everyone for attending. The main agenda item was the Evidence Based Medicine curriculum. The minutes of the December meeting were approved as written. Dr. Dreyer began by saying that the Biomedical Informatics Content Discussion group, chaired by Drs. Nachbar and Dreyer, looked at areas of the curriculum that needed to be worked on. The group focused on teaching Evidence Based Medicine (EBM) and suggested that content go into four areas: 1. formulating clinical questions 2. searching medical literature 3. critical appraisal of literature 4. clinical decision-making They recommended that each clerkship provide formal education addressing at least some of these topics. Currently, in year one, PPS has an introduction to EBM. In year two, Epidemiology, Biostatistics and Preventive Medicine continues this introduction. In years three and four, Ambulatory Care has been teaching EBM for the last seven years, and Pediatrics began formal EBM activities last spring. Dr. Kammerman described the Ambulatory Care EBM curriculum. Students have a library session to analyze a question, learn search techniques, etc. It is a formal journal club with an EBM approach. There is a session where students review Rational Clinical Exam articles from JAMA with Dr. Buckvar-Keltz. Dr. Catanese added that the subspecialty electives include many journal clubs, and while the intention may not be to teach EBM, the analysis may incorporate these skills. Dr. Dreyer indicated that in the Resident Evaluations by program directors from the early 90s, our graduates were rated low in the use of literature and knowledge. Improved ratings in the 2002 evaluations demonstrates that the efforts of the Ambulatory Care Clerkship have made a difference, however there is still room for improvement. The evaluation queries the residents use of literature to make clinical decisions, and the use of knowledge in rounds and decision-making. Dr. Kammerman provided the clear definition of clinical decision-making as the judicial use of the best level of evidence available, along with the patients desires and wishes. It was noted that the use of literature is a continuum, rather than a clear distinction between research and the clinical application that is evaluated here. The cohort in the Residency Evaluation is the expectation of our graduates peers within the same residency program. Five years ago, our graduates were ranked lower than the cohort on decision-making, rounds and knowledge. Currently they are equal or above. If you look at comparisons for other clinical skills, our graduates are always rated higher than the cohort, across all specialties. Dr. Tewksbury talked about EBM in the Pediatrics clerkship. They devised an EBM exam to access students ability to form questions, search literature, screen abstracts, identify validity criteria, perform basic result calculations and identify bias. It was an anonymous case-based exam, utilizing both short answer and matching questions, with a half-hour time limit and total score of 48 points. An example of a question was where in the article would you find validity data? The exam was administered to 86 third and fourth year students between July and December 2003. About half the students had completed both Medicine and Surgery clerkships, and one-third completed Ambulatory Care. The average score was 355, or 72.510% correct. The only predictor of results was if the student completed Ambulatory Care (+2.5). Nothing else predicted performance, not even fourth-year status. The percentage of students able to formulate a question with specific criterion was 42%. Dr. Curriculum Comm. Mins 04/08/13 0:50 A4/P4

Tewksbury was looking for use of the PICO formula in focusing the search. PICO is taught in PPS, but tends to be forgotten if not reinforced, so the students were prompted with the letters to assess whether they knew it. Patient Population Intervention Control Outcome A simple asthma case was used. 76% of the students were able to correctly identify the initial search items, and 56% were able to accurately identify the article section yielding validity criteria. 40% of the students demonstrated a clear understanding of allocation bias, and 58% demonstrated a clear understanding of observer bias. With regard to risk reduction, 34% were able to calculate relative risk reduction, and 61% were able to calculate absolute risk reduction. 84% of the students correctly identified the most appropriate abstract. The Pediatrics Clerkship EBM curriculum is a four-week outpatient seminar series that integrates the concepts of prevention and screening with EBM skills. There is a seminar to review the EBM exam, an intro to prevention and screening, and presentations by groups of 3-4 students on selected topics in prevention. The EBM topics covered include critically appraising an article on prevention, study designs, relative risk, odds ratio and analysis of bias. Dr. Dreyer explained that the odds ratio is a ratio of the odds of having disease in a control group compared to the study group, calculate to determine relative risk. Mr. Aronson indicated that the students are capable of learning any difficult concept such as this, however they do not have a patient perspective in the first and second years, so it is a challenge to make these ideas significant. Dr. Bogart suggested that this reinforces the need to have third and fourth year students involved in the new student orientation because they are facing the issues of how the material affects care of the patients. Dr. Catanese expressed concern that EBM is being actively extinguished in that the students inpatient experience does not capture outcome. The housestaff doesnt think or present this way because it is not what drives the inpatient decision-making process, and this is effecting how/what the students are learning. EBM may be in their mind, but it isnt discussed on rounds. Dr. Kammerman added that she doesnt know how many of the faculty know the difference between relative and actual risk reduction; most faculty dont think through it this way. Dr. Hopkins agreed that most faculty cant do these calculations, but can understand whether a study is level one, two or three. Dr. Tewksbury indicated that students learn from the EBM test, but can not necessarily apply it. Mr. Aronson suggested adding it to the Clerkship Orientation, when students want to absorb everything they possibly can in preparation for the clerkships. Dr. Dreyer responded that we tried this in the first Orientation two years ago, but it was not well-received by the students. They thought it was a redundant literature search exercise. It was also suggested as an Advanced Science Selective. Dr. Catanese suggested that students spend three minutes during write-ups to answer basic questions about the study so it will become routine to them. Dr. Tewksbury also administered an end-of-clerkship EBM test. Of the first 31 students who have taken it, there has been a 6.3 point increase. There was no further business. The meeting was adjourned at 9:20 A.M. The next meeting of the Curriculum Committee is scheduled for Thursday, February 5th at 8AM. Respectfully submitted, Eileen B. Cahill, MPA Curriculum Coordinator Office of Medical Education Curriculum Comm. Mins 04/08/13 0:50 A4/P4