Biochemistry by Computer

Am. J. Hum. Genet. 44:597-604, 1989 FEATURE ARTICLE Teaching Human Genetics in Biochemistry by Computer Literature Searching _HUMAN Q ~GENETICS Virginia K. Proud,* Francis J. Schmidtt EDUCATION E. Diane Johnson, and Joyce A. Mitchell*,t - * Department of Child Health, University of Missouri Hospital and Clinics, Columbia; tdepartment of Biochemistry and $Information Science Group, University of Missouri School of Medicine, Columbia; and J. Otto Lottes Health Sciences Library, University of Missouri, Columbia E Summary We describe a new user-intense-learning experience that incorporates the teaching of clinical and research applications of human genetics in biochemistry while training first-year medical students to develop skills in computer access to the literature. Human genetics was incorporated into the biochemistry curriculum by providing each student with experience in on-line literature searching in MEDLINE, using Grateful Med, in order to write an abstract about a specific inherited biochemical disorder. We stressed the need for the students to obtain current information in order to understand and interpret the rapidly changing field of human genetics. We taught the students that the most efficient method of obtaining such information was by searching the medical literature via computer. Introduction Human genetics is nationally recognized as essential in the practice of medicine and yet is neglected in many medical education programs (Childs 1987). Information-seeking skills and literature retrieval are also inadequately taught (AAMC 1986). Neither residents nor attending physicians routinely access the literature for information to make patient care decisions (DaRosa et al. 1983; Northrup et al. 1983). In order to begin to address the deficiencies in teaching medical genetics and computer access skills, we conducted a pilot project which required first-year medical students to search MEDLINE for current information on genetics topics in biochemistry (Proud et al. 1988). This exercise was developed from experience of one of the authors (V.K.P.) in a similar educational exercise, Received November 16, 1988. Address for correspondence: Virginia K. Proud, M.D., Division of Medical Genetics, Department of Child Health, University of Missouri Hospital and Clinics, Columbia, MO 65212. i 1989 by The American Society of Human Genetics. All rights reserved. 0002-9297/89/4404-0023$02.00 "updating McKusick" (Bocurtha et al. 1986, 1987), which required manual literature searching. The purpose of "updating McKusick" was to increase student awareness and use of the vast medical literature available to them, while expanding the teaching of the principles of human genetics within the cell biology course. One of the problems was the amount of time the students needed to complete the exercise; greater than 50 percent of the students spent 11-20 h on the exercise. In our project, the students were assigned a specific biochemical topic and were taught to use the Grateful Med software to search MEDLINE to obtain information necessary to prepare a brief abstract about information reported in the recent literature. We hypothesized that teaching computer access would expedite the mechanics of searching and allow the students to focus on critically reviewing the pertinent articles. This project taught human genetics and computer access to the medical literature, while stressing the need for the students and faculty to obtain up-to-date information in order to understand genetic disorders. We taught that the most efficient method of obtaining such information was by computer access to MEDLINE. Specific goals of the project included the following: 597

598 1. to teach medical students computer access to MED- LINE as part of the basic science curriculum in biochemistry 2. to increase the exposure to and awareness of human genetics by integration into the required curriculum 3. to analyze the students' search behavior to determine the conditions under which they used computer access, and to determine how they applied the skills learned to other subject areas. The GPEP report (AAMC 1984) recommended that programs in medical education focus on skills for independent learning to the same extent that they focus on acquisition of knowledge. Our project had the dual purpose of teaching computer-data-base access skills for independent learning, while focusing on content in the rapidly expanding field of human genetics. Material and Methods Human genetics is taught throughout our medical school curriculum by lectures, laboratories, and small group discussions when topics apply to a variety of courses. This exercise was integrated into the first-year biochemistry course in order to reinforce concepts stressed in the lectures. Time was derived by substituting this exercise for two 1-h discussion sessions about assigned recent journal articles. The time line for the exercise is shown in figure 1. One hundred fifteen first-year medical students were each given a topic about a specific genetic biochemical disorder selected from Mendelian Inheritance in Man Proud et al. (McKusick 1986). After a 2-h introductory lecture in the use of Grateful Med to access MEDLINE, they were encouraged, but not required, to attend a small group computer-lab training session. The computer lab consisted of three instructors (a geneticist, an information scientist, and a library search analyst), 12 students, and six IBM PC's with modems. Because of the research protocol, the National Library of Medicine (NLM) provided complimentary access time for the S wk of the project. The students were encouraged to use Grateful Med to search MEDLINE for other topics, and, with signed release, the traffic files of their searches were reviewed. After completing the literature search, each student was required to critically review pertinent journal articles and prepare a one-page abstract of new information about the disorder. The students were expected to know the metabolic reactions involved in the specific disorder and were directed to concentrate on genetic aspects of the new information, including chromosome mapping, linkage analysis, carrier testing, prenatal diagnosis, and new therapies. Abstracts were presented at 2-h discussion sessions of 15 students each, led by a geneticist and a biochemist. Topics in each discussion session were grouped by category of disorder (e.g., neurologic disorders, amino acid disorders, or storage disorders). The latest references from the Online Mendelian Inheritance in Man (OMIM; McKusick 1988), which is partially sponsored by the Howard Hughes Medical Institute, were provided to the instructors and were useful in defining the scope of recent publications. The project was evaluated by analysis of data col- Timeline 1988- Genetics in Biochemistry Feb21 28 *March7 14 21 28 NLM Sponsored Access to MEDLINE L---- ---, i I _ IIIIIIIIIIIIIIIIE rrzzzzzzzrz4 I 11 III Cr77rJFlOlorljFldFAq I L c 111111 iluuuumnnuu Lecture 2/22 C uter Labs 2126-3/2 Spnng Break Data Analysis Discussion Sessions / & Questioa 3/28 Absftwts Due 3/23 Figure I Time line of educational exercise: teaching genetics in biochemistry by computer literature searching Ia 0 April 4 I.Es

Teaching Genetics by Computer Searching lected from the following three sources: (1) questionnaires, completed at the end of the exercise, which asked about the students' experience with computers, literature searching, genetics, and biochemistry, as well as their opinions about the exercise; (2) NLM traffic files of student searches; and (3) evaluation of the abstracts by both a geneticist and biochemist. For satisfactory completion of the assignment, the students were given credit for two biochemistry quizzes, which were deleted. Results A. Student Questionnaires The student questionnaires completed at the end of the discussion session contained descriptive information about the students' perceptions of the exercise, as well as background information about their expertise in genetics and computer use. Ninety-two (80%) of 115 students completed the questionnaires. A summary of 599 questionnaire results is given in table 1. Eighty-four percent (77/92) of the students had an undergraduate course in genetics and 27% (25/92) had some knowledge about their specific topic before beginning their literature search. Eighty-six percent (79/92) had used a computer before, but only 33% (30/92) had used the computer for literature searching. An overwhelming majority (98%) of the students thought that this was a "satisfactory" or "excellent" method for learning computer access to the literature. Most of the students (69% for genetics and 75% for biochemistry) thought that this was a "satisfactory" or "excellent" way to learn principles of genetics or biochemistry. Seventy-eight percent (72/92) of the students desired continued access to the literature throughout medical school. Ninetysix percent (88/92) spent less than 6 h in the library completing the project, but 67% (62/92) reported spending 3-4 h in additional independent computer searching. Table I Summary of Results of Analyses of Student Questionnaries and of Data from National Library of Medicine Traffic Files A. Questionnaires (92 students) Prior course in genetics.... Experience using computer for library search... Spent <6 hr searching... Spent 1-5 h independent computer searching... Described value of experience as satisfactory/excellent way to learn: Biochemistry... Genetics... Computer access... Recommended repeating the exercise in other courses... Desired continued free access to the medical literature... B. Independent Search Experiencea 77 (84%) 30 (33%) 88 (96%) 70 (85%) 69 (75%) 63 (69%) 90 (98%) 40 (43%) 72 (78%) No. of students... 91 No. of searches... 829 (mean 9.1 searches/student) (range 1-31 searches/student) Average time/ search... 3.1 minutes (min. 12 s; max. 38 min) Searches <5 min... 82% Average no. of articles retrieved/search...... 84 Average no. of articles printed/search... 5 Assigned... Topic No. of Searches No. of Students 262 (31.6%) 50 Other genetic... 39 (4.7%) 10 Other medical 5... 28 (63.9%) 78 a A majority of students completed the assignment while performing 375 searches in the training labs.

600 150 Searches by Date mu Training Proud et al. Non-Genetics an U) o 100 S) * Genetics 0 a) Sm50 - z 0 Figure 2 search time. C-4 y qt -_ N.04NN -N FEBRUARY MARCH APRIL t Computer J_ A-Spring Break--+d LDiscussion Sessions Training Abstract Due Distribution of number of MEDLINE literature searches, using Grateful Med, during the training labs and independent B. MEDLINE Traffic Files Ninety-one students performed 829 independent searches during the 5 wk of complimentary computer access time, in addition to the 375 searches which were performed during the training labs (see fig. 2). A summary of data analysis of MEDLINE traffic files is given in table 1. The frequency distribution of the independent searches is illustrated in figure 3. There were an average of nine searches per student, with a range of 1-31. Twenty-four (21%) of the students did not do any independent searches outside the training labs. Four of these students reported having had no prior computer experience. Sixty-five students completed the searches on the genetics exercise during the training lab. The independent searches were sorted according to categories: genetics topics, other students' genetics topics, and other medical topics. Two hundred sixty-two (31.6%) of the 829 independent searches were on the assigned genetics topics. A small proportion (39 searches, 4.7%) were on genetic topics other than that assigned to the searcher, but the majority (528 searches, 63.9%) were on other medical topics. Several students used the computer access to undertake searches on current independent laboratory-research projects or to review the bibliographies of faculty members for whom they were considering working in summer research projects. The students quickly learned efficient, appropriate search strategies. Eighty percent of the searches were performed with no error in search strategy or format. Of the 86 searches that contained an error, the majority (43%) of the errors were a result of simple misunderstanding of the AND/OR structure of the Grateful Med-form screen. Each search retrieved an average of 84 citations with abstracts; however, on the average, only five refer-

Teaching Genetics by Computer Searching 40 - MEDLINE Searches Q 601 DONon -Genetics * Genetics c) 0 co Q) 30-20 - nf z 10 0 30 60 90 Individual Students Figure 3 Frequency distribution of 8i> independent searches done by 91 students, showing proportion of searches related to genetics topics compared with other medical topics. The students readily applied the skills of computer access to search topics in other courses. ences were downloaded. Only one student was unable to find any pertinent recent articles cited in MEDLINE. The 78 students who did searches on the 528 other medical topics generally structured more complex searches. Although the NLM provided both training and individual codes for complimentary access for the 5 wk of this project, if charged at full rates, actual cost breakdown from the NLM would be $2,598. Since students are usually charged at approximately 50% of full rate, estimated cost would be about $1,300 for this project. Since the NLM would provide complimentary training codes for other institutions, a final cost for 5 wk of independent searching for 115 students would be approximately $900 for computer access time when using Grateful Med. C. Correlations between Questionnaires, Traffic Mile Data, and Grades on Abstracts Correlations, cross tabulations, and regression analyses were performed on all possible pairwise combinations of data from the following two groups of items: 1. previous course work in genetics, previous computer experience, number of years owing a personal computer, number of hours spent on the exercise, number of references read, number of hours of reported computer use, grade in biochemistry, and class rank in biochemistry 2. total number of searches, total number of search sessions, and total on-line time. These analysis were done for the two subsets of data (genetic and nongenetic) in addition to the total data.

602 40 MEDLINE Searches Proud et al. n 30 C) U) Sw 1420 :z 010. z - 0 0 0 0 Ln 0 LO 0 LO 0 0 0 0 0 U') 0 0 0 0 0 0 0 T- %- N N n n * 110-0 0 w w rl-_ rl-l m m m 0) 0 0 V- T- I-- Class Rank Figure 4 Frequency distribution of 829 independent searches as a function of class rank in biochemistry. This graph demonstrates the lack ofcorrelation between the two variables. Our interpretation is that Grateful Med is easy to use for students of all abilities and backgrounds. There were no significant correlations found between any of these data items, suggesting to us that learning Grateful Med did not require any particular expertise and that all students readily applied the search techniques. We were unable to identify subpopulations of students, such as (a) those who might have had more computer experience and who therefore might have done a greater number of independent searches or (b) those who might have had minimal computer experience and who therefore required a large number of searches in order to complete the task. The search frequency as a function of class rank in biochemistry is shown in figure 4. Clearly, there was no correlation between student rank in biochemistry class and the number of independent searches performed. Discussion We have described a new experience for first-year medical students which consolidates the teaching of clinical and research applications of human genetics and biochemistry with training and skills necessary for computer access to the literature. This was done by vertically inserting the exercise into the standard biochemistry curriculum. The project required cooperation between the faculties of the division of medical genetics, department of child health, department of biochemistry, information science group, andj. Otto Lottes Health Sciences Library, all interacting with on-line medical literature data bases (i.e., the OMIM) at Johns Hopkins University and the NLM in Bethesda, MD (see

Teaching Genetics by Computer Searching * 603 OMIM (JHU) BIOCHEMISTRY t MEDLINE (NLM) GENETIC Discussion Laboratory Sessions INFORMATION SCIENCE GROUP & MEDICAL LIBRARY 115 FIRST YEAR MEDICAL STUDENTS Learn computer access to MedLine Prepare an Abstract At Learn Genetics Learn Biochemistry Figure 5 Dynamic interaction and communication, within the medical center, facilitated by this exercise. fig. 5). Response was enthusiastic from both students and faculty. The medical students quickly learned the readily transferrable skills of computer access to the literature. They gained experience in preparing an abstract and in discussing the abstract with their peers, while developing an appreciation of the basic principles of human genetics and an understanding of a specific inherited biochemical disorder. The exercise encouraged communication between geneticists, biochemists, medical librarians, and information scientists, all ofwhom developed a personal appreciation of computer literature searching while exchanging information about new developments in their respective fields. Medical students need to become aware, early in their medical school career, of the vast literature available to them, and they must be required to use that information in a relevant manner in order to gain expertise in literature searching. We have demonstrated that students of all abilities and backgrounds can easily be taught to search the literature effectively by computer to complete an exercise in genetics and biochemistry. Data from Bodurtha et al. (1986) showed that 27% of the students spent >20 h in the library portion of the assignment, whereas 92% of our students completed the exercise in less than <5 h in the library. The use of Grateful Med to search the literature about genetic disorders is an efficient use of time for busy medical students. This exercise was inserted into the curriculum without needing to add additional hours of lecture time to an already crowded curriculum. In addition, we demonstrated that the skills learned were quickly applied to other courses, as 78 students went on to perform 528 additional searches on other medical topics. We are not the first group to teach medical students to do computer searching by MEDLINE or to study end-user search behavior (e.g., see Kirby and Miller 1986; Wood et al. 1986). We strongly believe that computer literature searching should be integrated within the curriculum and that students should be required to perform such searches routinely. The implementation of this program at other institutions could take different forms to access MEDLINE files. Access to MEDLINE files locally through mini-medline or on CD-ROM, or remotely via BRS-Colleague or Paper Chase, could be used to modify the exercise, to meet the needs and facilities available. By focusing the content of literature searching on human genomes, we are expanding exposure to the principles of human genetics and intend that medical students will begin to apply their knowledge to both the basic sciences and clinical rotations. Integrating exercises in genetics-literature searching into the curriculum could be implemented in a variety of courses in the basic sciences or in clinical clerkships. We have recently completed a follow-up exercise by these students in a second-year pathology course. We developed an efficient exercise to teach human genetics and computer literature searching. We would like to go beyond this to answer the more important question of whether training in computerized literature retrieval and further education in human genetics can affect the practice of medicine. We would like our students to depend on the computer for literature access in order to provide the best possible care, through information, for their patients. A 10-min videotape discussing the mechanics of the exercise is available on loan from Joyce A. Mitchell, Ph.D., Director, Information Science Group, University of Missouri School of Medicine, 605 Lewis Hall, Columbia, MO 65211. Acknowledgments This work was supported in part by a grant from the Mizzou Alumni Association, with computer time donated by the National Library of Medicine. The authors wish to acknowledge the contribution, in data entry and analysis, by Ken Proud, James H. Cutts III, and Margie Ross, and the secretarial support of Dorothy Longnecker. References AAMC. 1984. Physicians for the twenty-first century: the GPEP report. Association of American. Medical Colleges, Washington, DC.

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