Biostatistics Instruction at Meharry Medical College

Field: Health Professions (Health Sciences)

Given the many ways to offer biostatistics instruction, we base our particular way on certain learning principles and challenges about medical education. The principles are: learning is purposeful, learning is doing, learning is reinforcing, and biostatistics has a bedside, or applied, component. The challenges are: the expanding content in medicine, certification examination requirements, a fixed amount of curriculum time, and the perceived difficulty and irrelevance of biostatistics by medical students. A brief overview of our curriculum in which these principles and challenges are integrated is reported. Instruction in epidemiology and biostatistics occurs in the first, second, and clerkship years at Meharry Medical College. In the first year, as part of a 12-hour component of Behavioral Sciences I, 4 hours of vital statistics are given as a prelude to the leading causes of mortality and morbidity. In the second year, as part of a 26-hour component of Behavioral Sciences II, 20 hours of epidemiologic and biostatistic methods are given. Finally, these two disciplines are additionally allocated 50% of the grade and time during the four-week clerkship in community medicine. For each year, students are provided guides with learning modules for each topic that give an overview, the objectives, available resources, an outline of the topic, homework assignments, and a self-quiz for key terms. For the second and clerkship years, the guides also contain a special test that integrates material from all of the modules. The first principle on which we base instruction is that learning is purposeful. Learning biostatistics is part of the larger purpose of enhancing the student's ability to learn, first and foremost, to practice good medicine. Secondary purposes include providing students with the skills that they need to pass certification examinations and, for a few students, to perform research. Practicing medicine itself consists of many skills, including the ability to diagnose, treat, and prevent patient problems; a major source for maintaining and improving one's practice of good medicine is the medical literature. Our curriculum sequence and procedures follow from these purposes. From the opening two-hour session on variables, graphs, logic, and probability to the session on conceptual frameworks, the same four articles from the New England Journal of Medicine are distributed for reading, illustrating principles, and homework assignments. These four studies include the major types: a clinical trial, an analytic case-control study, a cross-sectional measurement study, and a descriptive cohort study. These articles become part of the common experience of the class and are referred to as examples of epidemiological and biostatistical principles throughout the course. Students are assigned homework based on the articles as well as the questions from the special test that focus on each article. Sessions with the instructor are used to answer any questions that arise on the assignments and to introduce the next topic. Second, learning is doing. If the purpose is to learn to read journal articles, then articles must be a part of the learning activities. This goal is accomplished by having students read the four articles just described and then taking a test on a fifth unknown article similar to the module tests. Students are encouraged to bring notes and so forth to the examination. Security is maintained by using more than one article for the exam and giving alternating students different articles. Third, learning is reinforcing. By repeatedly moving between the lecture and the journal-reading exercises, both biostatistical theory and the purposes of learning the topics are reinforced. Various misconceptions can be identified and then clarified and reclarified. To provide continuity of learning, epidemiologic and biostatistics principles are reviewed during the student's clerkship, following which students participate in and in an original community study. The community study is based on health risk appraisals that are offered to a random sample of community residents as a community service. The students design a short questionnaire that accompanies the health risk appraisals; subsequently, they analyze the data from the questionnaire, write the results in the form of a scientific paper, and present the paper to the faculty at the end of the clerkship. Fourth, biostatistics leaming is part of a meaningful whole. All medical students are familiar with rounds at the bedside, and the bedside counterpart in biostatistics is, of course, the journal article. Just as a patient is a great deal more than simply chemistry or anatomy, a journal article consists of more than just biostatistics, and the critical review of an article requires a student to integrate biostatistical concepts with epidemiology, the basic sciences, and clinical medicine. To make the reading rounds more in tune with students' interests, each clerk is asked to select a recent article from one of the leading journals in the specialty in which he or she is most interested. At each reading round, students present a portion of their critique of the article, including flow diagrams, fact-theory models, summary figures, summary paragraphs, and so forth, culminating in a letter to be submitted to the editor of the journal in which the article appeared. A wide spectrum of medical knowledge and research methodology is presented, and clerks find this a very useful and motivating experience; some are even successful in having their letters published. Several changes in the curriculum have occurred prior to the course description given, and these permit a naturalistic evaluation of the instruction. The first year in which the course was merged with Behavior Science, all biostatistic and epidemiologic instruction was omitted by error. In a comparison of National Board of Medical Examination (NBME) scores of cohorts who did not receive instruction *Richard A. Carter is with Meharry Medical College, Nashville, Tennessee 37208.