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Outline
>> Objectives
>> Student
Assessment
Class of 2009, Second Year, Fall 2006
I. INTRODUCTORY LECTURE
A. Course objectives and logistics
B. Introduction and course overview
C. Explanation of conference format
II. LECTURE: Probability and Descriptive
Statistics
III. CONFERENCE: Probability
and Descriptive Statistics
A. Probability
1. Definitions of probability
2. Probability calculations
a. P(A or B)
(1) Mutually exclusive events
(2) Events which are not mutually exclusive
b. P(A and B)
(1) Independent events
(2) Events which are not independent
c. Conditional probability, P(A given B) = P(A|B)
3. Sensitivity, specificity, predictive value as conditional
probabilities
B. Descriptive statistics
1. Measures of central tendency: mean and median
2. Measures of variability: range, variance, standard deviation
IV. LECTURE: Distribution of the sample
mean
V. CONFERENCE: Normal
Distribution, Distribution of the Sample Mean, and
Confidence Intervals
A. Normal distribution
B. Populations and samples
C. Distribution of the sample mean
D. Confidence intervals
1. Calculation
2. Interpretation
VI. LECTURE: Hypothesis Testing
VII. CONFERENCE: Hypothesis
Testing
A. Null and alternative hypotheses
B. P-values
C. One-sided vs. two-sided tests
D. Significance level
E. Type I and type II errors
F. Statistical significance vs. medical importance
VIII. CONFERENCE: Comparing Two Means,
Comparing Proportions
A. Categorical vs. continuous variables
B. Choosing appropriate summary statistics
C. Choosing the appropriate statistical test
1. Two sample t-tests
2. Chi-square tests
D. Practice in interpreting output from statistical programs
E. Paired vs. unpaired comparisons
IX. LECTURE: Introduction
to Epidemiology
A. Role of Epidemiology in prevention
B. Role of Epidemiology in clinical diagnosis and treatment
C. Clinical and Public Health perspectives
D. Introduction to basic principles of epidemiology
1. Overview of common study designs
2. Introduction to epidemiologic measures
X. CONFERENCE: Epidemiologic
Measures
A. Case discussions: Clinical questions with epidemiologic
answers
B. Epidemiologic measures of disease occurrence
1. Risk
2. Prevalence
3. Incidence
C. Crude and adjusted rates
1. Age stratification and adjustment
D. Epidemiologic measures of effect and impact
1. Risk difference, relative risk, and attributable risk
2. Absolute and Relative Risk Reduction
XI. CONFERENCE: Clinical
Trials
A. Case discussion motivating reading of a clinical trial
report
B. Randomization
C. Blinding
D. Dropouts and non-compliers
E. Sample size and power
F. Survival analysis
1. Kaplan-Meier (univariate)
2. Proportional Hazards model (multivariable)
G. Interpreting results
H. Subgroup analyses
XII. CONFERENCE: Cohort studies
A. Critical appraisal of a cohort study of etiology of disease
B. Basic principles of cohort studies
C. Bias: Types and likely directions
1. Confounding
a. Definition, qualitative examples
b. Methods to control confounding
2. Information Bias
a. Misclassification of exposure and disease
b. Nondifferential and differential misclassification
D. Principles of causal inference
XIII. CONFERENCE: Case-Control
Studies
A. Critical appraisal of a case-control study
B. Basic principles of Case Control studies
C. Odds Ratio as estimate of Relative Risk
D. General criteria for judging validity of a study
E. Guidelines for making causal inferences in epidemiologic
studies of etiology
F. Bias: Types and likely directions.
a. Confounding (brief)
b. Selection Bias
c. Information Bias (Interviewer,recall, misclassification
bias)
XIV. REVIEW SESSION for
Midterm Exam
A. Review practice problem set
B. Bring your questions
XV. MIDTERM EXAMINATION
XVI. LECTURE: Introduction
to Clinical Epidemiology and Preventive Medicine
A. Basic principles of diagnostic testing.
1. Conditional probabilities.
2. Operating Characteristics of medical tests: sensitivity,
specificity, and dichotomous and multi-level likelihood ratios.
3. Bayes’ Theorem.
4. Medical decision making using clinical epidemiology.
B. Medical Screening
1. Medical conditions that can benefit from screening programs.
2. Potential benefit and harm from screening.
3. Application of Bayes’ Theorem to medical screening.
C. Basic Principles of Preventive Medicine
1. Levels of prevention.
2. Measures of effectiveness of preventive interventions.
3. Potential biases in studies of effectiveness of screening
tests
(Lead time bias, Length time bias, Compliance bias)
XVII. CONFERENCE: Preventive
Medicine and Medical Screening
A. Role of the physician in clinical prevention and public
health prevention
B. Case Studies: Levels of prevention and Measures of effectiveness
of preventive interventions.
1. Primary Prevention: Vaccination as an example of primary
prevention
2. Secondary Prevention: Medical Screening
a. Principles of screening for chronic diseases.
b. Application of Bayes’ Theorem to a screening test
3. Tertiary Prevention
a. Absolute Risk Reduction
b. Relative Risk Reduction
c. Number Needed to Treat
C. Communication with patients of information about risk and
prevention
XVIII. LECTURE: Diagnostic
and Screening Tests I
A. Application of principles of diagnostic and screening tests
to clinical
cases.
1. Probabilistic reasoning in clinical diagnosis.
2. Diagnostic and treatment thresholds.
3. Diagnostic test operating characteristics.
B. Calculating post-test probabilities of disease using 2x2
tables, a nomogram, likelihood ratios, and a
simple form of
Bayes' Theorem.
C. Medical decision making using likelihood ratios and pre-
and post-test probabilities to aid in
selection and interpretation
of diagnostic tests.
XIX. CONFERENCE: Diagnostic
and Screening Tests II
A. Case discussion.
B. Further exercises in application of Bayes’ Theorem
and likelihood ratios to clinical decision making.
C. Communicating with patients about risks and diagnostic
decisions.
XX. CONFERENCE: Diagnostic
and Screening Tests III
A. Case discussion and formulation of clinical questions.
B. Critical appraisal of study measuring operating characteristics
of a diagnostic / screening test
1. Comparison of test result with “gold standard”
diagnosis
2. Potential biases in study of diagnostic / screening test
XXI. LECTURE: Occupational /
Environmental Medicine: Prevention in Action, Part 1
A. Definitions & magnitude of the problem
B. Case presentations
C. Occupational & environmental medicine tools
1. Occupational sentinel health conditions
2. Clinical occupational toxicology
a. Dose-response relationships
b. Latency period and timing of exposure / disease
c. Routes of environmental exposure
d. Target organs
e. Biomarkers and biological monitoring
3. Brief screening occupational history
XXII. LECTURE: Occupational/Environmental
Medicine: Prevention in Action, Part 2
A. Case presentations
B. Review of clinical applications of preventive medicine.
XXIII. LECTURE: Occupational and Environmental
Clinical Toxicology
A. Case presentations in acute toxicology in the Emergency
Department.
1. Vital signs and other simple clinical signs
2. Specific toxins
3. “Don’t miss” diagnoses
B. Examples of clinical utility of basic toxicologic principles
1. Toxicokinetics
2. Metabolic pathways
3. Receptor physiology and other mechanisms
4. Applications to diagnosis, treatment and antidotes
C. Principles of Emergency Preparedness
XXIV. CONFERENCE: Literature Searching using
Medline (Optional)
XXV. REVIEW SESSION for
Final Exam
A. Review practice problem set
B. Bring your questions
XXVI. FINAL EXAMINATION
OVERALL COURSE CORE COMPETENCIES (OBJECTIVES)
Upon completion of this course, students will
be able to demonstrate understanding of key basic principles
of Epidemiology, Biostatistics, and Preventive Medicine. The
student should be able to apply these basic principles to
selected illustrative clinical and population level examples
in Evidence Based Medicine and Preventive Medicine.
Biostatistics.
The student should be able to:
• Compute summary descriptive statistics for continuous
and categorical variables.
• Perform simple probability calculations, including
conditional probabilities.
• Interpret a confidence interval.
• Interpret a P-value.
Epidemiology The
student should be able to:
• Define, calculate, and interpret commonly used epidemiologic
measures of disease occurrence and effect: Risk, Prevalence,
Incidence rate, Relative risk, Risk difference, Odds Ratio.
• Explain basic principles, study design, strengths,
and weaknesses of clinical trials, cohort studies, case-control
studies, and studies of diagnostic and screening tests.
• Describe and recognize major potential sources of
bias in epidemiologic studies (selection bias, information
bias, and confounding) and suggest appropriate methods to
control them.
• List and explain the criteria generally used to judge
whether associations found in epidemiologic studies are likely
to be causal, or not.
Clinical Epidemiology
and Evidence-Based Medicine The student should be able
to:
• Define, calculate, and interpret the operating characteristics
of diagnostic and screening tests (sensitivity, specificity,
likelihood ratios), as well as pre- and post-test probabilities
of disease.
• For several simple clinical scenarios, utilize evidence
from medical literature and Bayes' Theorem to support selection
and interpretation of diagnostic and screening tests, and
optimal cutoff points.
• Critically appraise a study of a diagnostic or screening
test.
• Find evidence to answer a clinical question using
a computerized search.
Preventive Medicine and Public Health.
The student should be able to:
• Explain the 3 levels of prevention, and principles
of medical screening.
• Calculate and interpret relative and absolute risk
reductions and number needed to treat for selected examples
of preventive interventions.
• Explain in simple language the implications of measures
of risk, disease risk factors, and measures of effectiveness
of preventive interventions (RRR, ARR, NNT).
• Describe selected occupational and environmental sentinel
health conditions, corresponding potential environmental etiologic
agents, and clinical clues that suggest possible environmental
etiology.
• Explain clinically relevant concepts of environmental
toxicology, as related to illustrative clinical cases.
• Take and interpret a brief screening occupational
history.
COURSE GRADING, CONFERENCE
PARTICIPATION, AND OBJECTIVES
The course consists of lectures and group
conferences. Generally, the PowerPoint slides from each lecture
will be posted on the course website shortly after the lecture,
in some cases before the lecture. Grades will be assessed
by a midterm and final examination and approximately 12 quizzes.
The midterm examination will cover Biostatistics and Descriptive
and Analytical Epidemiology. The final examination will cover
Clinical Epidemiology and Preventive Medicine. Grading will
be pass-fail, except for MD / PhD students, who will receive
letter grades. The worksheets will not be collected or graded.
Most of the small group conferences will have a brief quiz,
usually 2 questions, at the end. These quiz questions will
focus on key concepts from that session. We will drop 2 quizzes,
either your 2 lowest grades or quizzes you missed. There will
be no makeup quizzes. Written scores will not be sent to you
for each of the 12 quizzes, however, you will have the opportunity
for immediate feedback and discussion of the answers to the
quiz questions at the end of each conference. The correct
answers will be shown as you hand in the quizzes, and you
can stay a few minutes for an optional discussion of the answers.
To help you study for the midterm and final examinations,
we have prepared 2 practice problem sets. The first set is
in your syllabus, Part I, and the second problem set will
be included in Part II of the syllabus, which will be distributed
at the midterm exam. These problems are in multiple choice
format, in the same format as the exams. Answer keys are provided,
and we will discuss the solutions in the review sessions before
the exams. A minimum final cumulative weighted average of
65% is needed to pass the course, weighted 40% midterm, 40%
final, and 20% quizzes (after dropping lowest 2 scores), ie,
0.4x(Midterm %) + 0.4x(Final%) + 0.2x(Average
quiz %) ? 65%.
The final exam will not be cumulative
in the sense that its purpose is not to retest you on material
that has already been tested on the midterm. However, some
of the basic concepts from the first half of the course, for
example confidence intervals, prevalence, conditional probabilities,
and relative risk, are fundamental to the second half of the
course. You will need to understand and remember these basic
concepts and apply them in the second half of the course.
It will be clear from the material and discussions what these
fundamental concepts are. For example, in the clinical epidemiology
portion of the course, you will learn about relative risk
reduction. Understanding this depends on understanding risk
and relative risk, which you will have learned in the first
half of the course.
It is highly recommended that you prepare for the small group
conferences by doing the readings and worksheet exercises
before the session meets. The questions on the midterm and
final examinations and the quizzes, while multiple choice,
will be similar in content and concepts to the problems you
prepare for the conferences. Therefore, it is important that
you attempt each problem in the worksheets, try to think it
through before conference, and participate in each of the
conference discussions. In our experience, this is the most
time-efficient and effective way to study this material. We
expect each of you to participate and contribute to the discussions
in the conferences, and the work will be more evenly distributed
(and more fun) if each of you prepares before the sessions.
Participation in the conferences is a necessary part of the
course. A substantial part of the material covered in conferences
is not covered in any lecture. Some of this material is not
easily learned by simply reading the text or listening to
others explain the solutions.
Questions on the material being discussed are always welcome
during lectures or conferences. If after the session, you
have any questions on any of the material, or want to discuss
anything related to the course with either of the course directors,
please call or email us at the telephone numbers and addresses
on the course outline. Names and contact information for other
course faculty are also listed in the syllabus. You should
feel free to contact any of us with questions, concerns, comments
(and constructive criticisms or complements, if appropriate)
regarding material we have presented. In particular, the course
co-directors are very interested in any feedback, positive
or negative, that you might have on any aspect of the course.
Since your schedules as well as ours change from week to week,
our office hours are by appointment, and you can call or email
us to set up a date and time. Our offices are located in the
Epidemiology and Biostatistics office, at 650 First Avenue,
5th floor. That is between 37th and 38th Street on First Avenue.
Overall course objectives (core competencies) are in your
handout. More specific, measurable, competency-based objectives
are given in the worksheets for each session. The objectives,
especially the specific objectives on the worksheets, are
important and summarize most of the highlights of the course.
The purposes of the objectives are to help you see what is
expected of you in the course, in each session, and on the
examinations, and to help us to standardize what is covered
in each of the small conference groups led by different faculty.
We use the specific objectives from each session to help us
construct the exams and quizzes. Please read the objectives
carefully before you do the worksheets, and as you study for
the exams.
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