Berner ES, Boulware DW. Medical Informatics for Medical Students: Medical Education Online 1996;1:3. Not Just Because It's There. Medical Informatics for Medical Students: Not Just Because It's There

There has been increasing interest in the use of computers in medical education, but there has been less attention given to the rationale for the use and selection of applications. This article discusses an approach to the selection of medical informatics applications for the undergraduate medical curriculum.

Medical schools have long recognized the need to revise their teaching methodology, but have been slow to change. 1 The University of Alabama School of Medicine (UASOM) is celebrating its fiftieth anniversary and has rapidly grown into a respected research and clinical institution.With a desire to achieve equal recognition for its educational efforts and driven by a desire to educate physicians for a future career in the quickly evolving health care environment, the UASOM initiated Project Curriculum 2000.This faculty driven effort established the goals and objectives felt essential to achieve our desires.
The recognition that computers should play an increasingly important role in medical education is a key element of Curriculum 2000 . 2 The computer can make information processing and management faster, more efficient, more extensive, more interactive, and, in some cases, may enable activities that could not be performed any other way.These ideas are neither new, nor unique to UASOM, but like other medical schools, we have had difficulty institutionalizing them in our curriculum. 3The UASOM Medical Education Committee charged its Medical Informatics Subcommittee with making recommendations in this regard.
In the past, reasons to increase student use of computers have included the exponential growth of medical information, the increasing sophistication and availability of technology, and the potential that computer-assisted instruction has for fostering independent learning and compensating for decreased lecture time.As the ACME-TRI report testifies, these rationales, while legitimate, have not been sufficient to bring about major curricular change 1 , perhaps because technology has always been evolving, there is rarely enough time for teaching, and there has always been an "information overload."More importantly, one of the problems has been the focus on increasing computer use, in and of itself, as a goal of the curriculum.
Contrary to this position, we believe that increasing the use of computers must be seen as a means to an end, rather than a goal by itself.Furthermore, as Friedman and Dev have articulated, computer use must be seen as more than multimedia instructional programs and must include medical informatics applications that are part of clinical practice. 2Although the Medical Informatics Subcommittee is also responsible for making recommendations related to multimedia instructional programs, this article will focus on our conception of medical informatics, the goals of the curriculum, the curricular recommendations, and the implications for faculty and students.

Medical Informatics
Medical informatics has been defined as the field that "concerns itself with the cognitive, information processing, and communication tasks of medical practice, education, and research, including information science and the technology to support these tasks." 4 The responsibilities of the Medical Informatics Subcommittee encompass a variety of computer learning experiences for medical students.These include computer-aided instruction, learning about computers and their applications, use of computer-based information resources, use of computers as a tool and as a mechanism for information management, decision support and communication.This conception is similar to that discussed by Koschmann. 5While medical informatics includes computer applications, it is not limited only to the use of computers, but includes the knowledge, skills and attitudes involved in seeking, manipulating and using biomedical information.

Goals of Curriculum 2000
What is different now from previous years, and previous efforts at curriculum reform in regard to computers, is that the health care delivery system itself is undergoing rapid change.Project Curriculum 2000 established goals based on the projected needs and anticipated roles of the physician in the 21st century.Current estimates suggest that our physician work force is greatly over-represented by subspecialists and underrepresented by primary care physicians. 6In addition, the roles that physicians will be expected to assume are likely to be different than they were in the past, and even are currently. 7The physician of tomorrow will likely work in a managed care environment as a direct patient care provider and coordinator of physician extenders.
Although the specific organizational structure may not match all aspects of today's concepts of managed care, it is likely that most of this work will take place in settings that will require coordination of clinical data, utilization of consultants and physician extenders, literature retrieval and health care delivery. 7,8Proficiency at this type of coordination will become a critical skill for the future physician.Therefore, our goals to increase the number of underrepresented generalist physicians require us to hone the skills necessary to effectively function in the future health care environment.These skills include becoming proficient in medical informatics applications.Thus, it is toward the goal of preparing our students for this role of information manager that our recommendations regarding medical informatics are focused.

Curriculum Recommendations to Prepare Students to Function as Information Managers
Our recommendations begin by trying to determine how the practicing physician will function in terms of information management in the new health care environment.We can then work backwards from that vision to identify what is, and what should be, taught during each year to enable students to accomplish what they need to do.By this type of "back planning," the specific goals and activities for each year can be identified by determining what students must be able to do at specific points in the curriculum and what experiences are prerequisite to enable them to accomplish these goals.Even though we may not know all of the ways that health care will change, we do know that physicians will need to broaden their current roles and functions.Among others, the following five changes in physician roles have been suggested. 7,8,9These changes have direct implications for the design of medical informatics curricula.
1. Managing the health care needs of a population -Physicians will be responsible for the health of a defined population of individuals, rather than just assuming responsibility for the smaller numbers of individuals who seek the physician's help when they are ill.This will require physicians to be more engaged with routinely scheduled preventive activities for their whole patient population.Physicians will need to become proficient with clinical epidemiology skills and apply them to their own patient population.
Informatics implications: Students need to become familiar with patient information systems and be able to use the data to create databases that can be used for identifying and remedying health problems of their population.They will also need to use the computer-based epidemiological and statistical tools to analyze the data and will need to become familiar with computer-based patient tracking and reminder systems.

Increased diagnostic and therapeutic
responsibilities for the primary care physician -More physicians will be in primary care gatekeeper roles and will be required to do more of the diagnostic process themselves before referring to specialists.
Informatics implications: Students need to be able to use a variety of decision support tools, including expert systems, drug databases, and online information resources.

Practicing medicine in a cost-conscious
environment -Physicians will need to be more cognizant of the cost-effectiveness of their diagnostic and treatment decisions.This will require skills in critical appraisal of the literature, effectively using decision analysis and other decision making strategies, and combining multiple sources and types of information to reach decisions.
Informatics implications: Students need to become proficient with literature searching, biostatistics, decision analysis, and the computer-based tools that facilitate the efficient application of these skills in the clinical setting.

Increased external monitoring of physician
practices -Cost concerns will lead to more monitoring of individual physician decisionmaking and increased pressure for physicians to practice medicine in a more uniform manner.
Computer-based patient records, online alerting and reminder systems and online clinical guidelines and critiquing programs will facilitate this monitoring.
Informatics implications: Students need to become accustomed to more self-and outside evaluation of their performance.They also need to be able to use a computer-based patient record, clinical guidelines, reminder systems, and tailored educational programs for selfimprovement.

Integrating generalist practice in a larger
system -Integrated health care networks will require extensive communication among physicians in the network.Electronic communication (e.g., e-mail, file transfer) will likely provide an easy mechanism for this communication among physicians, and between the physician and individual patients as well.
Informatics implications: Students need to use electronic communication mechanisms proficiently.
Although the particular medical informatics recommendations may be similar to those advocated by others, 2,10,11 by having as a goal preparing students to be information managers and seeing increasing students' use of computer applications as a means to that end, we have a mechanism to prioritize and select the particular computer applications we will incorporate.

Implications for Students and Faculty
Faculty must identify the prerequisite information and skills that students need to enable them to access electronic information sources, as well as the course content the student needs to "know" and the information the student needs to "know how to access" electronically.This process can help insure that the computer applications are well integrated into the course structures.
Students' attitudes toward their education may also have to change.Students need to learn that they must be information seekers as well as information managers.They also need to acquire knowledge about relevant sources of information, and the skills to access electronic information.
By focusing o n what is needed to prepare students for new roles, we can have a basis for designing core applications that all students will need.
Given the potentially limitless opportunities for students to interact with computers, we feel that our recommendations should be targeted to those competencies which the general physician graduating from medical school should have.Competencies for which clerical personnel, information systems personnel, or other members of the health care team are primarily responsible are not included, although we recognize that some students will be interested in acquiring expertise in these areas.Similarly, we would not discourage any faculty members from initiating additional activities, as long as they were not in conflict with our primary recommendations.
Finally, and most importantly, because our goals are to have the medical informatics applications incorporated as a routine part of the students' daily activities, we advocate that the medical informatics activities be integrated with the relevant basic science and clinical activities, rather than teaching them as a separate course on information management.This approach has been advocated by others, 5,12 and has been implemented in a number of universities. 10,11

Conclusion
Helping students to become independent learners, information seekers, and proficient users of computer technology have long been goals that were often inadequately implemented throughout the medical school curriculum.The changing role of physicians in a new health care environment provides a stronger impetus than ever before for these goals to be incorporated.By making our primary goal the preparation of students to be medical information managers, we have a strong rationale for the inclusion of medical informatics applications into the curriculum.This goal also provides a criterion by which the appropriateness of curricular offerings can be judged and the outcomes of instruction can be evaluated.insightful comments on previous drafts of this manuscript.

Dr. Berner is Professor of Education in Medicine and
Associate Director of the Office of Educational Development, University of Alabama School of Medicine (UASOM).She chairs the Medical Informatics Subcommittee.She can be reached via e-mail at: eberner@uasom.meis.uab.eduDr. Boulware is Professor of Medicine and Associate Dean for Undergraduate Medical Education, UASOM.He chairs the UASOM Medical Education Committee and has overseen Project Curriculum 2000.The other members of the Medical Informatics Subcommittee who participated in the deliberations related to the curriculum in medical informatics are: