Faculty Bibliography

Medical schools must teach core biomedical informatics competencies that address health information technology (HIT), including explaining electronic medical record systems and computerized provider order entry systems and their role in patient safety; describing the research uses and limitations of a clinical data warehouse; understanding the concepts and importance of information system interoperability; explaining the difference between biomedical informatics and HIT; and explaining the ways clinical information systems can fail. Barriers to including these topics in the curricula include lack of teachers; the perception that informatics competencies are not applicable during preclinical courses and there is no place in the clerkships to teach them; and the legal and policy issues that conflict with students' need to develop skills. However, curricular reform efforts are creating opportunities to teach these topics with new emphasis on patient safety, team-based medical practice, and evidence-based care. Overarching HIT competencies empower our students to be lifelong technology learners.

Many education research questions cannot be answered using participants from one institution or short periods of follow-up. In response to societal demands for accountability and evidence of effectiveness, new models of research must be developed to study the outcomes of educational activities. Following the 2007 Millennium Conference on Medical Education Research, organizers assigned a task force to explore the use of longitudinal databases in education research. This article summarizes the task force's findings. Similar to the Framingham studies in clinical medicine, longitudinal databases assemble prospectively collected information to retrospectively answer questions of interest. Many studies using such databases have been published. The task force identified three general approaches to database-type research. First, institutions can obtain identified information from existing sources, link it with school-specific information and other identified information, deidentify it, and merge it with similar information from other collaborating schools. Second, researchers can obtain from existing sources deidentified information on large samples and explore associations within this dataset. Third, investigators can design and implement databases to prospectively collect trainee information over time and across multiple institutions for the purpose of education research. Although costly, such comprehensive, purpose-built databases would ensure the availability of information needed to answer a variety of medical education research questions. Millennium Conference participants believed that stakeholders should explore the funding and development of such prospective databases. In the meantime, education researchers should use existing sources of individualized learner data to better understand how to develop competent, compassionate clinicians

PURPOSE: Educators increasingly use virtual patients (computerized clinical case simulations) in health professions training. The authors summarize the effect of virtual patients compared with no intervention and alternate instructional methods, and elucidate features of effective virtual patient design. METHOD: The authors searched MEDLINE, EMBASE, CINAHL, ERIC, PsychINFO, and Scopus through February 2009 for studies describing virtual patients for practicing and student physicians, nurses, and other health professionals. Reviewers, working in duplicate, abstracted information on instructional design and outcomes. Effect sizes were pooled using a random-effects model. RESULTS: Four qualitative, 18 no-intervention controlled, 21 noncomputer instruction-comparative, and 11 computer-assisted instruction-comparative studies were found. Heterogeneity was large (I>50%) in most analyses. Compared with no intervention, the pooled effect size (95% confidence interval; number of studies) was 0.94 (0.69 to 1.19; N=11) for knowledge outcomes, 0.80 (0.52 to 1.08; N=5) for clinical reasoning, and 0.90 (0.61 to 1.19; N=9) for other skills. Compared with noncomputer instruction, pooled effect size (positive numbers favoring virtual patients) was -0.17 (-0.57 to 0.24; N=8) for satisfaction, 0.06 (-0.14 to 0.25; N=5) for knowledge, -0.004 (-0.30 to 0.29; N=10) for reasoning, and 0.10 (-0.21 to 0.42; N=11) for other skills. Comparisons of different virtual patient designs suggest that repetition until demonstration of mastery, advance organizers, enhanced feedback, and explicitly contrasting cases can improve learning outcomes. CONCLUSIONS: Virtual patients are associated with large positive effects compared with no intervention. Effects in comparison with noncomputer instruction are on average small. Further research clarifying how to effectively implement virtual patients is needed

Objective. To determine whether statin treatment can lower cardiovascular events in men and women with normal low-density lipoprotein (LDL) cholesterol and elevated C-reactive protein levels. Design. Justification for the Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin (JUPITER), a randomized, double-blind, placebo-controlled trial. Setting and participants.17,802 men (aged [greater-than or equal to] 50 years) and women (aged [greater-than or equal to] 60 years) from 1315 sites in 26 countries with LDL cholesterol < 130 mg/dL, high-sensitivity-reactive protein(hs-CRP) level [greater-than or equal to] 2.0 mg/L, and triglycerides < 500 mg/dL were randomizedto either rosuvastatin 20 mg daily or placebo. Patients were excluded if they werecurrently or had previously been on lipid-lowering therapy or were actively beingtreated with hormone replacement therapy; had evidence of hepatic dysfunction,a creatine kinase level [greater-than or equal to] 3 times the upper limit of normal, serum creatininelevel [greater-than or equal to] 2.0 mg/dL; a recent history of alcohol or drug abuse, cancer within 5years, diabetes, uncontrolled hypertension or hypothyroidism, or an inflammatorydisorder such as severe arthritis, inflammatory bowel disease, orlupus; or wereon immunosuppressant therapy. Patients were included in thefinal sample ifthey had 80% compliance during a 4-week pla-cebo run-in period.At enrollment,the median LDL level was 108 mg/dL in both arms, andhs-CRP levels were 4.2 and 4.3 mg/L in the rosuvastatin and placebo arms,respectively. Mainoutcome measure. Combined primary endpoint of anycardiovascular event, including myocardial infarction,stroke,arterialrevascularization, hospitalization for unstable angina, or death fromcardiovascular causes. Main results. The trial was stopped short oftheplanned 4 years of follow-upbecause the prespecified number of primaryendpoints in the trial was reached earlier than expected. After a medianfollow-up of 1.9 years, patients in the rosuvastatin group had a 44% lower rateof the combined endpoint than the placebo group (0.77 vs. 1.36 person-years offollow-up, respectively; hazard ratio [HR], 0.56 [95% confidence interval {CI},0.46-0.69]; P < 0.001). The trend for a reduced rate ofcardiovascularoutcomes was evident for each of the individual outcomes aswell, including death from cardiovascular causes (HR, 0.53 [95% CI,0.40-0.69]; P< 0.001) and death from any cause (HR, 0.80 [95% CI,0.67-0.97]; P=0.02).Rosuvastatin decreased LDL cholesterol by 50% and hs-CRP by 37%. After 12months of follow-up, the median LDL cholesterol and hs-CRP levels were 55 mg/dL and 2.2 mg/L in the rosuvastatin arm as compared with 110 mg/dLand 3.5 mg/L in the placebo arm. Triglycerides were also significantly lower inthe rosuvastatin group at 1 year (99 mg/dL vs. 119 mg/dL). No increase inmyopathy or cancer was noted in the rosuvastatin group, although there was ahigher incidence of physician-reported diabetes. Conclusion. In patients with highhs-CRP and normal LDL cholesterol, statin treatment lowers the risk of majorcardiovascular events.

CONTEXT: The opposing forces of increased training expectations and reduced training resources have greatly impacted health professions education. Virtual patients (VPs), which take the form of interactive computer-based clinical scenarios, may help to reconcile this paradox. METHODS: We summarise research on VPs, highlight the spectrum of potential variation and identify an agenda for future research. We also critically consider the role of VPs in the educational armamentarium. RESULTS: We propose that VPs' most unique and cost-effective function is to facilitate and assess the development of clinical reasoning. Clinical reasoning in experts involves a non-analytical process that matures through deliberate practice with multiple and varied clinical cases. Virtual patients are ideally suited to this task. Virtual patients can also be used in learner assessment, but scoring rubrics should emphasise non-analytical clinical reasoning rather than completeness of information or algorithmic approaches. Potential variations in VP design are practically limitless, yet few studies have rigorously explored design issues. More research is needed to inform instructional design and curricular integration. CONCLUSIONS: Virtual patients should be designed and used to promote clinical reasoning skills. More research is needed to inform how to effectively use VPs

OBJECTIVE: Dental professionals with proper training and integration into existing protocols for mobilization can be one additional resource during catastrophic events. A pilot project on training of dental school faculty in telephone triage in the event of an avian flu pandemic is described. A partnership was established with a grant from the Department of Justice/Department of Homeland Security, between the New York City Department of Health and Mental Hygiene, and New York University to initiate a pilot program to increase the manpower resources available to the health agency should an overwhelming public health event be present in the New York City area. METHODS: Eight faculties from New York University College of Dentistry were selected to receive telephone triage training consisting of 15 hours of formal presentations. This training was specifically designed to give participants a background in "outbreak investigations," and included a mock influenza outbreak. Also, a "phone triaging" training during a surge event was practiced. RESULTS: The training resulted in enabling alternative healthcare providers as capable personnel and one alternative source for a surge manpower pool. This was the innovative use of dental school faculty to bolster critically understaffed and overwhelmed areas in the NYCDOHMH infrastructure, such as call centers and for telephone triage, in their disaster scenarios, particularly in their response to avian flu. CONCLUSIONS: The established public health systems and medical community must understand the need to preplan for medical surge events and accept that a potential source of additional manpower could be the dental profession or other nontraditional healthcare personnel.