EVIDENCE-BASED MEDICINE CURRICULUM FOR THE PEDIATRICS CLERKSHIP

Dear Pediatrics Clerkship Student,

Welcome to Pediatrics and welcome to the Evidence-Based Medicine (EBM) Curriculum. Below, please find information on goals, competencies, activities, and responsibilities. This curriculum may be considered a continuation of your work with EBM in the ECM course. The difference is that now you will now have an opportunity to re-learn and apply the tools of EBM in an actual clinical context.

Each student has been assigned a mentor (click on “Mentor assignments and list of mentors” below). Your mentor is eager to work with you on this important learning program. While there are a few required activities, much of the learning that hopefully will occur is predicated on your initiative. Section 2 under “Curricular Activities” in your workbook was specifically designed as a resource for self-directed learning.

Your Pediatrics Clerkship is designed to facilitate learning of both pediatric background and foreground information. Background information in pediatrics encompasses the basic set of facts about child health and disease. Medical schools are traditionally quite good at providing educational curricula for acquiring background information. Examples of questions that a learner may ask to gather background information are:

What are the physical findings in bronchiolitis? How is iron deficiency anemia routinely diagnosed? What is the known life expectancy for a child with sickle cell anemia? What is the standard treatment for attention deficit, hyperactivity disorder? What are the recommended immunizations for a well baby in the first twelve months of life? What resources are available to help a depressed adolescent?

Good sources of this kind of information are: involvement in patient care, mentors, textbooks, and MD Consult. Most of your clerkship activities should focus on acquiring background information. A smaller proportion of your activities in the clerkship should focus on acquiring foreground information, which is the subject of this EBM curriculum.

Foreground information is what is obtained by answering higher level questions. Examples of this type of information would include clinical evidence for the therapeutic efficacy of a new or an existing treatment, and the diagnostic accuracy of a newly proposed diagnostic test. Until recently, there were few, if any, formal curricula designed to facilitate learning of foreground information. The EBM Curriculum for the Pediatrics Clerkship is an educational intervention to address this learning need.

To better illustrate the difference between background and foreground information gathering, please see the table below. Note that a foreground question is often a thoughtful follow-up question to a background question.

Background	Foreground
What are the physical findings in bronchiolitis?	In babies with new-onset wheezing, what is the diagnostic accuracy of the history and physical examination, compared to viral cultures, in diagnosing bronchiolitis? (a diagnosis question)
How is iron deficiency anemia routinely diagnosed?	In children with suspected iron deficiency anemia, what is the diagnostic accuracy of serum ferritin versus using the MCV and hemoglobin count, compared to bone marrow aspiration (or some other suitable gold standard), in diagnosing iron deficiency anemia? (a diagnosis question)
What is the known life expectancy for a child with sickle cell anemia?	In children with sickle cell anemia, what is the prognostic significance of frequent episodes of acute chest syndrome, compared to no episodes, on probability of survival at age forty? (a prognosis question)
What is the standard treatment for attention deficit, hyperactivity disorder?	In children with ritalin-resistant attention deficit, hyperactivity disorder, what is the therapeutic efficacy of clonidine, compared to adderall, as measured by parental report on the Connors Scale? (a therapy question)
What are the recommended immunizations for a well baby in the first twelve months of life?	In the population of otherwise healthy infants, what is the efficacy of the pneumococcal vaccine Prevnar, compared to placebo, in preventing pneumococcal meningitis? (a type of therapy question)
What resources are available to help a depressed adolescent?	Among mildly depressed adolescents, what is the therapeutic efficacy of outpatient cognitive therapy plus anti-depressants, compared to outpatient cognitive therapy alone, in reducing the frequency of depression six months following initiation of treatment?

Answers to foreground questions are rarely found in textbooks. By their nature, foreground questions require up-to-date answers. Textbooks are often a number of years out of date by the time they are published. The online clinical research bibliographic databases, or study syntheses (meta-analyses, methodologically sound guidelines) are much more likely to provide answers to foreground questions.

By achieving the basic competencies of the EBM Curriculum for the Pediatrics Clerkship (see the beginning of your workbook), we anticipate that you will have attained a beginner-level ability to formulate clear foreground questions ("answerable clinical questions") based on real patient encounters, search for answers (clinical studies), evaluate study methodology, analyze study results, and approach the application of results to your patients. These EBM tools are likely to be of aid to you in all of your future clinical endeavors.

Sincerely,

Jordan Hupert

Jerry Niederman

Larry Roy

Alan Schwartz

for the EBM mentoring group.