Inpatient Internal Medicine Grand Rounds

 

Purpose:  To introduce the student to the principles of Evidence Based Medicine (EBM) through the use of a case-based presentation.  The student will demonstrate the ability to formulate a clinical question, perform an efficient literature search and apply the results to clinical practice.  The student will also gain experience educating peers.

 

Objectives: 

  1. Students will recognize clinical questions as they arise in the daily practice of medicine.
  2. Students will formulate an answerable clinical question.
  3. Students will be able to find current best evidence to answer their question by performing an effective medical literature search.
  4. Students will critically appraise the medical literature.
  5. Students will apply the information found to clinical practice.
  6. Students will gain experience educating peers about their topic.

 

What the Student Does:

The student should choose a clinical case that was seen during the inpatient internal medicine experience.  It does not need to be a “zebra” or “rare case.”  In fact, for teaching purposes it would be better to choose topics that are more commonly seen.  It is important to choose a topic that is of interest to you

 

Early in the rotation, Dr. Bruce Houghton will review the process of clinical question formulation, literature searching, information resource utilization and application of results to clinical practice---the basics of Evidence Based Clinical Practice---to prepare you for the exercise.

Steps of EBM

  1. Formulate a Clinical Question
  2. Find the Best Evidence
  3. Critically Appraise the Evidence
  4. Apply the Evidence to your patient

 

 

The student should formulate a well thought-out (i.e. answerable) clinical question based on a patient that was seen in the hospital.  It should be a “Four Component Question” (PICO)

 Question using the PICO criteria.

  1. Patient or Problem
  2. Intervention or Exposure
  3. Control or Comparison
  4. Outcome or Effect

 

Then the student will proceed with a search of the appropriate medical literature to find an answer to the question.  Students should provide primary literature sources if available.  The student should also provide to the group the search strategy used to find the information (in order to assist others and share experiences).

 

The Health Sciences Library Reference Desk is willing and eager to assist in your searches (though you should have a focused clinical question already developed).  You can contact the Reference Desk at phone 402 280 5138 or e-mail at refdesk@creighton.edu

The URL for the HSL Reference Desk searching tips is  http://www.hsl.creighton.edu/hsl/Guides.html#Tips

 

After you have located the Best Evidence you could find, you need to critically appraise the evidence.  Utilize the Users’ Guides to the Medical Literature http://www.usersguides.org/

Use the appropriate validity questions for the type of question and article you have chosen.  For example, if you have a therapy question, use the validity questions for a therapy article.  For a diagnostic question, use the validity questions for an article on diagnosis

 

Once you have an answer, decide if the information can be applied to your patient. You will need to judge the effect (or not) of the therapy you have chosen.  This will require calculating the Absolute Risk Reduction and Number Needed to Treat for a therapy article and the Likelihood Ratio for a diagnostic article.  Cite reasons for or against applying what you found to your patient. 

 Cite reasons for or against applying what you found to your patient. 

 

After you have gone through all of the above, all that remains is to prepare the presentation.  Ideally you should utilize overhead slides or PowerPoint slides (a computer will be available for you to use for the presentation and computers are available in the Medicine Department to prepare your slides).  Handouts may also be helpful for your learners (the Internal Medicine Department copy machines may be utilized). 

 

Present your patient’s hospital visit in the standard History and Physical Format.  You do not need a complete Review of Systems and Physical Exam.  The Past Medical History, Medication List, Allergies, Family and Social History should be briefly included in your presentation.   Then describe your clinical Assessment and Plan for the patient.

 Next review the clinical question you generated and how you found the answer to the question.  Describe the process you went through to find the answer and why you thought it was important to focus on that aspect of the case.  It may even be something not directly related to the patient’s Chief Complaint. Finally review with everyone what you found and decide if it can be applied to your patient’s care.  Again, cite reasons for or against applying the information to your patient.  Just because the literature supports one course of therapy or evaluation, it does not mean that it is necessarily appropriate for your individual patient---tell us why.  This is not “cookbook medicine”---you have to decide how best to apply medical information to your patient’s care.   

The entire session should take only about 15 to 20 minutes per student.  Try to allow time for questions and answers from you colleagues.  You may even “build in” some points in the talk to open it up to questions---ask your fellow students their differential diagnosis or how they would proceed with the workup, evaluation or treatment of the patient. 

 

 

Please turn into Dr. Sakowski or Dr. Houghton

  1. The SOAP Note
  2. The Clinical Question you Formulated
  3. Your Literature Search Process---where you looked.  If you did a Medline Search, what search terms did you use?
  4. The Discussion Section

 

As physicians we are often called upon to fulfill a role as “educator.” We want the Inpatient Internal Medicine Grand Rounds to provide you with the opportunity.  This entire process should be fun and we want you to enjoy giving the presentation as well as learning from your colleagues.  This type of learning will occur frequently during your residency and throughout the rest of your career. 

We also want you to become familiar with using PowerPoint or other computer resources in your presentations (even if it is only Microsoft Word to type up your handouts). 

Finally, we want you to gain experience applying Evidence-Based Clinical Practice skills to patient care.   The computer technology and bibliographic searching techniques you learned in your M-1 and M-2 years are important and we want you to apply them to real-life clinical scenarios.  We strongly believe the skills you gain through your Inpatient Internal Medicine Grand Rounds will serve you in your other endeavors, through medical school and beyond.

 

 

We do not wish to instill terror during this rotation.  If you have any questions about these sessions or need some help with getting started or ANYTHING, please contact

Hank Sakowski, M.D.  (hsakow@creighton.edu)

Or

Bruce Houghton, M.D. (houghton@creighton.edu)

 

 

 

    

 

 

 

    

 

 

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