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Review of Year Y2 Medical Essentials (PHAR 216)

• Course occurs in the fall term of Year 2.

• Course Director – Sarah J. Freemantle, PhD (co-director) David Nierenberg, MD

• Course has 33 curricular hours (plus the Final Exam and Narrative Assessment evaluation events)

• Course was last reviewed in April 2012. The formal review is missing, however, and annual summary letters from Dr Nierenberg are substituted for this purpose. Action Plan from Prior Review

From David Nierenberg's letter dated Oct 30, 2012: Overall, well organized with excellent scores and logical organization. Suggestions - Provide written notes in addition to lecture PPT Involve all students in each small group conference, not just the students presenting the cases. Have other lecturers use the “pharm card” system to help students focus on the most important information they need to know.

From David Nierenberg's letter dated Oct 28, 2013: New method of student survey through Oasis, however, the overall evaluation was “good to very good”, with the overall evaluation of 3.71. The students really loved the “clinical correlations” and the use of the Pharm cards. Suggestions - Provide written notes in addition to the PPT files, which most but not all lecturers do. Get all students involved with the small groups, not just the student presenters. Also, prepare “model” answers to the cases discussed. Having all lecturers use the Pharm card system, in order to help students know the most important information about each . Old Course Objectives (Ilios)

Course Objectives (CO) Links (GO) Sessions (CO)

1 Explain the basic concepts of drug-receptor interactions and second messenger systems how MS2,MS1 40 dose response curves can be used to define safe dosing practice. 2 Demonstrate the ability to assess pharmacodynamic and pharmacokinetic parameters using MS2,MS1 23 commonly prescribed as examples. 3 Solve common pharmacokinetic calculations including loading doses and maintenance doses MS2,MS1 11 using knowledge of volume, distribution and clearance. 4 Formulate different regimens for special patient groups (e.g. pregnant women, patients with MS2,MS1, 11 compromised immune/kidney/liver function etc.) MS5,CC13,PH2 5 Recognize and anticipate common drug-drug interactions including those interactions that can MS2,MS1,CC6,CC 16 be predicted from genetic testing of metabolizing enzymes e.g. P450 isozyme testing, 10,CC1,P7,PPLD3 6 Recognize and anticipate common drug interactions with OTC , herbal or MS2,MS1,CC6,CC 7 nutritional supplements and specific food groups. 10,CC1,P7,PPLD3 7 Discriminate between pharmacological substances, based on generic drug name, MS2,MS1,CC6,CC 67 pharmacological classification (using class representative compounds), , major clinical indications and most clinically relevant adverse effects. 10,P1,P6 8 Distinguish treatments, which may become the standard of care on the horizon based on MS2,MS1,MS5,PP 2 their proximity to FDA approval e.g. Qnexa for weight loss. LD1,MS4,CC14,EI M2,PH4 GO = New Geisel Objectives Old Course Objectives (continued)

Course Objectives (CO) Links (GO) Sessions (CO) 9 Recognize signs of common drug overdose, and propose how to initiate therapy where appropriate MS1,MS2,CC13, 0 when the causal agent is known or unknown. PH2 10 Integrate their knowledge from years 1 and 2 of anatomy, biochemistry, genetics, microbiology, MS1,MS2 49 physiology, and pathophysiology with the actions of drugs at all levels from the receptor to the cell, organ, circulatory systems and whole-body levels. 11 Access and evaluate different levels of biomedical literature relevant to the treatment of disease MS1,MS5 3 through experts, Internet sources, books, and other databases 12 Discuss the principals of evidence based and be familiar with the current resources MS1,MS5 1 available online and through the biomedical library 13 Discuss procedures relevant to disease diagnosis and alternatives to medical therapy (e.g., MS1,MS2,MS5,C 4 percutaneous coronary intervention, arrhythmia ablation, implantable defibulator) C8,CS6,CS1,PH1 14 Discuss how to serve patients interest when evaluating brand name vs. generic drugs, and CC13,PH2,P2,PP 6 pharmaceutical advertising to patients and clinicians. LD1,PH3,CC7,EI M2,PH1,EIM5,EI M3,P5 15 Explain what is required to write a complete, unambiguous, and legal prescription and also what is MS2,CC13,PH2, 0 required to insure the patient is fully counseled about medications, their drug history is comprehensively evaluated and they have printed drug information. P2,PPLD1,PH3,C C7,EIM2,PH1 Old Course Objectives (continued)

Course Objectives (CO) Links (GO) Sessions (CO) 16 Recognize signs of drug/ abuse and describe potential treatment strategies. CC13,PH2,P5,PH 0 5 17 Communicate effectively with fellow students and faculty. CC8,CS6,CS1 4 18 Demonstrate team skills by participating effectively in team exercises. CC1,P7 3 19 Take responsibility for his- or her-own medical education. PPLD1 16 20 Search efficiently for and obtain recent, high quality, relevant medical information and scientific MS1,MS4 4 literature to solve problems. 21 Read critically, evaluate, and assess medical information and scientific literature about important MS1,MS4 3 neurological topics and questions. 22 Practice clinical reasoning skills in the context of a simulated patient scenario. CC6,CC7 6 23 Demonstrate skills necessary for assisting patients to understand treatment options and the need for CC12,CS4,CS7 4 care. 24 To help colleagues by contributing constructive suggestions during peer review PPLD3, 3

25 To meet professional responsibilities fully, including being punctual, present, and engaged, and being P7 6 reliable in commitment to tasks. Updated Course Objectives

Geisel Competenc How # Course Objectives (CO) Sessions y Assessed Describe an overview of drug pharmacokinetic properties (e.g. absorption, distribution, metabolism, and excretion) that apply 1to all therapeutic agents 1, 3, 4, 5, 6, 8, 24 MS Exam Describe how drugs interact with receptors, cells, tissues, and organs to produce their desired and unintended 2pharamcodynamic effects 1, 5, 8 MS Exam Calculate a loading dose, maintenance dose, and half-life of a drug, using previously validated measurement of drug , clearance, and volume of distribution

3 1,3,4,7,28 MS Exam Explain the basic concepts of drug-receptor interactions)e.g. , antagonists, partial agonists, ED50, potency) 5,6 4 MS Exam Describe how drug-receptor binding can lead to a cascade of intracellular changes through second messenger systems and 5,6 beyond (e.g. cyclic AMP, cyclic GMP, etc.) 5 MS Exam Describe in detail the most common pathways in man for drug metabolism, and their pharmacogenetic importance and 8, 24 implications (e.g. ultraslow or ultrafast metabolizers)

6 MS Exam Describe the purpose, neuroanatomy, neutrotransmitters, and phsiological effects of the two branches of the autonomic 9 nervous system (sympathetic, parasympathetic)

7 MS Exam Describe in detail the most common drugs used clinically as agonists and antagonists at the various adrenergic receptors (e.g. 10, 11 beta-receptor agonists and antagonists, alpha-receptor agonists and antagonists)

8 MS Exam Describe in detail the most common drugs used clinically as agonists and antagonists at the various receptors (e.g. 12, 13 muscarinic-receptor agonists and antagonists, nicotinic-receptor agonists and antagonists)

9 MS Exam Describe the most common adverse drug reactions for drugs presented in the course, as well as the most common drug-drug 1, 5, 6, 8, 10, 11, 12, interactions (e.g. tremor from albuterol, sedation from clonidine) 13, 15, 16, 17, 20, 21, 22, 26, 27, 29

10 Updated Course Objectives

Explain how foods, herbal products, nutritional supplements, and over-the-counter drugs can cause clinically 8, 17 important interactions with commonly used therapeutic drugs

11 MS, CC Exam Describe how each class of therapeutic drugs is named in a common fashion, and also how generic and branded drugs 1 have different types of testing prior to approval, naming, and pricing strategies

12 MS, CC Exam Describe the basic and clinical pharmacology of the most common drugs used to treat hypertension and coronary 15, 16, 22 artery disease (e.g. angina, MI, etc.) 13 MS, CC Exam Describe the basic anc clinical pharmacology of the most common drugs used to treat hyperlipidemia and cardiac 21, 26 arrhythmias 14 MS, CC Exam Describe the basic and clinical pharmacology of the most common drugs used to treat congestive heart failure 27, 29

15 MS, CC Exam Describe the most common drugs used to treat respiratory conditions such as asthma, reactive airways disease, 20, 25 chronic obstructive pulmonary disease, and cough

16 MS, CC Exam While discussing clinical cases in small groups, demonstrate the ability to reason from symptoms and signs to a 14, 18, 23 diagnosis, and from a diagnosis to recommendations for treatment of that condition, including the ability to access and evaluate different current reliable sources of biomedical information

17 CC, Conf While discussing clinical cases in small groups, demonstrate the ability to communicate clearly and effectively with 14, 18, 23 students and faculty, and to participate effectively as a team member

18 CS,CT Conf By completing all assignments on time, and coming to each conference on time and well prepared, demonstrate the 14, 18, 23 ability to behave professionally, and to take responsibility for your own medical educaton Conf, 19 PP, Prof modules Discuss the concepts of value-based care and medical ethics, that relate to such drug-related issues as periods of patent 1, 29 protection, pricing of drug products, appropriate use of genertic drug products, direct-to-consumer advertising, direct- to-physician drug detailing, and direct-to-physician consulting fees PH, PPL, EIM, 20 Prof Conf Course Objectives – Geisel Competencies

There are 20 updated course objectives that fulfill Geisel competencies as follows:

• 15 address specific medical science knowledge • 7 address clinical care • 1 addresses population health • 1 addresses communication skills • 1 addresses personal, professional & leadership development • 1 addresses evaluation and improvement in medicine • 2 address professionalism • 1 addresses collaboration and teamwork Course Objectives – Geisel Program Objectives

The Old Course objectives #9, #15 and #16 did not map to any particular session and have been changed accordingly in the new objectives. Course Objectives – Format/Distribution

• 3 overarching Course objectives are provided in the syllabus in Canvas, however, the 20 new course objectives are only in Ilios. These should be added to Canvas to ease student availability. Course Objectives – USMLE Brochure

http://www.usmle.org/pdfs/usmlecontentoutline.pdf General Principles of Foundational Science Pharmacodynamic and pharmacokinetic processes: general principles, absorption, distribution, metabolism, excretion, dosage intervals Mechanisms of drug action, structure-activity relationships (eg, anticancer drugs) Concentration and dose-effect relationships (eg, efficacy, potency), types of agonists (eg, full, partial, inverse) and antagonists and their actions Individual factors altering and (eg, age, gender, disease, tolerance, compliance, body weight, metabolic proficiency, pharmacogenetics) Mechanisms of drug adverse effects, overdosage, toxicology Mechanisms of drug interactions Signal transduction, including structure/function of all components of signal transduction pathways such as receptors, ligands (eg, general principles of nitric oxide, autocrine and paracrine signaling) USMLE continued

Systems Pharmacology: Immune System Adverse effects of drugs on the immune system: Jarisch-Herxheimer reaction; Drugs affecting the immune system (eg, prednisone, azathioprine, cyclosporine, methotrexate, monoclonal antibody drugs [eg, abciximab, ; bevacizumab, infliximab, omalizumab, ]); Behavioral Health Adverse effects of drugs: -induced psychosis; varenicline and suicide; drug-induced psychogenic polydipsia Skin & Subcutaneous Tissue Adverse effects of drugs on skin and subcutaneous tissue: drug reactions, eruptions, Musculoskeletal System Adverse effects of drugs on the musculoskeletal system: drug-induced myopathy (eg, , , , AZT); malignant hyperthermia USMLE 1 continued

Systems Pharmacology Continued Adverse effects of drugs on the cardiovascular system: adriamycin; cocaine, , PCP; ACE inhibitors, calcium channel blockers, alpha blockers, minoxidil Adverse effects of drugs on the respiratory system: , amiodarone; adverse effects of 100% oxygen; tobacco, inhalants, cocaine Adverse effects of drugs on the gastrointestinal system: drug-induced changes in motility (chronic laxative abuse, ); drug-induced gastritis, duodenitis, peptic ulcer disease (NSAIDs); drug-induced hepatitis (eg, acetaminophen, isoniazid); drug-induced pancreatitis (eg, ) Adverse effects of drugs on the renal and urinary system: ACE inhibitors; aminoglycosides; amphotericin B; cisplatin; furosemide; gadolinium (nephrogenic systemic fibrosis); ; iodinated contrast dye; ; NSAIDs; penicillins; sulfa drugs; tenofovir; drug - induced urinary retention Adverse effects of drugs on pregnancy, childbirth, and the puerperium: alcohol, tobacco, and other drugs (ATOD); prenatal radiation exposure; teratology (eg, ACE inhibitors, SSRIs, warfarin, infections, toxins) Adverse effects of drugs on the female reproductive system and breast: , H2-receptor blockers; ; beta-adrenergic blockers; hormone replacement; opioids; ; selective serotonin reuptake inhibitors; tricyclic USMLE 1 continued

Systems Pharmacology continued Adverse effects of drugs on the male reproductive system: alcohol; , testosterone; , antidepressants including selective serotonin reuptake inhibitors; betaadrenergic blockers; including ; drug-induced priapism (eg, trazodone); , ; sildenafil, tadalafil, vardenafil; marijuana; nitric oxide reductase inhibitors Adverse effects of drugs on the endocrine system: drug, medicinal, and biologic substance effects; exogenous steroid suppression of adrenal glands, anabolic steroids

Medical Error Pharmacology errors Ordering, transcribing, dispensing, administration (wrong quantity, wrong route, wrong drug) Medication reconciliation USMLE final thoughts

Between Pharm 216 and Pharm 217, all areas listed in the USMLE content brochure appear to be accounted for according to the Syllabus.

The USMLE listed details for the topic of Pharmacology (e.g.- names specific drugs and effects).

Suggestion - The Lecturer’s responsible for the sessions on these topics should review their lectures and to be sure they include each item on the USMLE list. Consider the creation of Pharm Cards on each listed drug. Course Objectives – AMSPC

1.GENERAL PRINCIPLES 2.DRUGS ACTING AT SYNAPTIC AND NEUROEFFECTOR JUNCTIONAL SITES AUTONOMIC AND NEUROMUSCULAR PHARMACOLOGY 3.DRUGS ACTING ON THE CENTRAL NERVOUS SYSTEM (21) 4.AUTACOIDS/NONSTEROIDAL ANTIINFLAMMATORY/ASTHMATIC DRUGS 5.CARDIOVASCULAR AND RESPIRATORY PHARMACOLOGY 6.DIURETICS AND DRUGS AFFECTING RENAL FUNCTION, WATER, AND ELECTROLYTE METABOLISM 7.GASTROINTESTINAL DRUGS Covered 8.CHEMOTHERAPY elsewhere 9.HEMOSTASIS AND BLOOD FORMING ORGANS 10.ENDOCRINE PHARMACOLOGY Covered in 4th 11.TOXICOLOGY AND THERAPY OF INTOXICATION year 12.VITAMINS 13.HERBALS Session Objectives – Format/Distribution

• Session objectives are provided in the course materials for each session. • Session objectives are mainly written in the correct format. • A few of the session objectives use the word “Understand” and a few simply list facts such as “The students are expected to ….The only antiarrhythmic that has ever been shown to improve mortality in the post infarct patient is a ” Session Objectives - Redundancy

• Pharmacology touches each system. The depth of coverage of the drugs in this course appears planned. Course Learning Opportunities

• Lecture 21 hrs. (64%) – this includes flipped sessions with pre-work and is well received by students. • Small groups 6 hrs. (18%) • Large Groups 2 hrs. (6%) • Online tutorials 4 hrs. (12%) • = 100% • Exam – 1 event • Narrative Assessment – (a comment about the students general attendance and contribution) Course Learning Opportunities

• Some of the lectures have pre-lecture materials • Students liked Dr Nierenberg's pre-lecture prep materials, ie - Camtasia previews Assessment

• Phar 216 is Pass/Fail • “Students who perform more than 2 standard deviations below the class mean or students whose grades are outliers are at risk of receiving a grade of fail” From the syllabus • Final Exam – ~80 question/~3 per lecture • Other Grading - 16 points/4 each from each of the online sessions. Assessment – Final Exam

• The syllabus states there is an 80 question exam. The Sept 2014 Exam (submitted for review) is 65 questions. • Questions 5, 13, 18, ask “Which of the following statements are true?” • Suggestion - Re-write these 3 questions. Measures of Quality – AAMC GQ

“Indicate how well you think that instruction in [basic science topic] prepared you for clinical clerkships and electives.” [1=poor; 2=fair; 3=good; 4=excellent] Geisel Geisel Geisel Geisel MeasurGeisel All schools mean 2010 mean 2011 mean 2012 mean 2013 mean 2014 means 2014 Biochemistry 2.7 2.5 2.6 2.6 es of 2.8 2.7 Biostatistics/Epidemiology 2.9 3.2 3.2 2.9 3.2 2.8 Genetics 2.9 2.8 2.8 2.6 Quality 2.8 2.9 Gross anatomy/Embryology 3.6 3.5 3.6 3.4 3.6 3.4 Immunology 2.9 3.0 3.1 2.7 – AAMC 2.7 3.1 Intro to Clin Med/On Doc 3.5 3.4 3.5 3.0 3.3 3.5 Microanatomy/Histology 2.8 2.9 3.1 2.8 3.1GQ 2.9 Microbiology 3.1 3.2 3.3 3.0 3.1 3.2 Neuroscience 3.2 3.0 3.0 3.0 3.2 3.2 Pathology 3.2 3.1 3.4 2.8 3.1 3.3 Pharmacology 3.4 3.1 3.1 2.6 3.1 3.1 Physiology 3.6 3.6 3.5 3.1 3.4 3.4 Behavioral Science 3.2 3.3 3.3 3.0 3.2 3.2 Pathophysiology of Disease 3.5 3.5 3.5 3.3 3.5 3.5 Measures of Quality – Step I

2012* 2013* 2014* Means 12-14 TRADITIONAL CORE DISCIPLINES Biochemistry 0.30 0.20 0.22 0.24 Biostatistics/Epidemiology 0.43 0.40 N/A N/A Biostatistics 0.08 0.08 Genetics 0.28 0.18 0.28 0.25 Gross anatomy/Embryology 0.33 0.26 0.14 0.24 Histology/Cell 0.37 0.26 0.23 0.29 Microbiology/Immunology 0.31 0.47 0.39 0.39 Pathology 0.26 0.24 0.20 0.23 Pharmacology 0.22 0.22 0.12 0.19 Physiology 0.38 0.35 0.25 0.33 *values reported for core disciplines are SD above the US/Can mean for Geisel mean scores Measures of Quality – Step I

SYSTEMS-BASED TOPICS 2012* 2013* 2014* Means 12-14 Behavioral sciences 0.43 0.26 0.15 0.28 Biostatistics, Epidemiology, Pop Health 0.01 0.01 Cardiovascular system 0.20 0.47 0.02 0.23 Endocrine system 0.39 0.39 Gastrointestinal system 0.32 0.59 0.54 0.48 General Principles of Found Sciences 0.25 0.25 Hematopoietic/lymph systems 0.14 0.18 0.09 0.14 Immune system 0.22 0.53 0.16 0.30 Multisystem Processes & Disorders 0.23 0.23 Musculoskeletal, skin, CT systems 0.24 0.34 -0.02 0.19 Nervous system 0.25 0.21 N/A Nervous system and Behavioral Health 0.06 0.06 Nutrition 0.56 0.39 0.22 0.39 Renal/urinary system 0.42 0.21 0.23 0.29 Reproductive/endocrine systems 0.42 0.39 N/A Reproductive system 0.39 0.39 Respiratorysystem 0.29 0.31 0.18 0.26 *values reported for core disciplines are SD above the US/Can mean for Geisel mean scores Measures of Quality – Course Reviews

Year 1 courses Overall Satisfaction AY 2013-2014 Human Anatomy and Embryology II Measur4.57 Human Anatomy and Embryology I 4.33 Physiology-Renal 4.32es of Biostatistics and Epidemiology 4.28 Metabolic Basis of Disease Quality 4.23 Biochemical and Genetic Basis of Medicine 3.97 Neuroscience –3.90AAMC Physiology-Endocrine 3.81 CTO 3.79 GQ Basic Science of Microbial Disease 3.78 Virology 3.71 General Pathology 3.46 Physiology-Cardiovascular 3.45 Physiology-Respiration 3.38 Immunology 2.35 scale [1=poor; 2=fair; 3=good; 4=very good; 5=excellent] Measures of Quality – Course Reviews

Year 1 courses (fall, winter) Overall Satisfaction AY 2014-2015 Human Anatomy and Embryology II 4.57 Human Anatomy and Embryology I 4.35 Metabolic Basis of Disease 4.35 Biochemical and Genetic Basis of Medicine 4.34 Physiology-Renal 4.19 CTO 4.07 Virology 3.77 Physiology-Endocrine 3.76 Immunology 3.67 Physiology-Respiration 3.34 Physiology-Cardiovascular 3.23

scale [1=poor; 2=fair; 3=good; 4=very good; 5=excellent] Measures of Quality – Course Reviews

Year 2 courses Overall Satisfaction AY 2013-2014 Respiration 4.39Measur Cardiology 4.29 Hematology 4.29es of FEK 4.28 Dermatology 4.24Quality Endocrine 3.97– AAMC GI 3.96 CT & Bone 3.82 GQ Infectious Diseases 3.79 Pharmacology I 3.71 Psychiatry 3.44 Neurology 3.34 Reproduction 3.25

scale [1=poor; 2=fair; 3=good; 4=very good; 5=excellent] Measures of Quality – Course Reviews

Year 2 courses Overall Satisfaction AY 2014-2015 Respiration 4.38Measur Cardiology 4.27 Pharmacology 4.15es of Hematology 4.44 Nervous system 3.46Quality Psychiatry 4.20– AAMC Endocrine 4.09 FEK 4.19 GQ CT & Bone 3.62 Dermatology 4.11 GI 4.47 Infectious diseases not yet available Reproduction not yet available

scale [1=poor; 2=fair; 3=good; 4=very good; 5=excellent] Measures of Quality – Course Evaluation scale [1=poor; 2=fair; 3=good; 4=very good; 5=excellent]

Course X Course X Course X 2012 (97%)* 2013 (97%)* 2014 (99%)*

Overall satisfaction of course 3.43 3.71 4.15

Clarity of learning objectives 3.49 3.60 4.06

Organization of the course n/a 3.84 3.91

How well the course introduced me to 3.87 n/a 4.15 this discipline Congruence of assessment questions to 3.80 3.84 3.98 material emphasized in course

*student participation rate on course evaluation Measures of Quality – Course Reviews

Strengths (summary): 1 – Good overall organization of the course, “the flow of the course matched the topics in other courses”. “well organized” 2- The pre-lecture material, esp the Camtasia previews 3- the Pharm Cards 4- The case based practice problems throughout some lectures. Measures of Quality – Course Reviews

Suggestions for Improvement (summary): 1- The List of Drugs on Canvas ought to be updated at the beginning of the course, and made more complete; to include the important drugs from all sessions and on the USMLE1 2- Consider Pharm cards for all sessions (esp ) 3- Try to coordinate the teaching of anti-arrhythmics with the cardiology course 4- Re-structure small groups to include/involve more students in all of the cases Final Recommendations (1 of 2)

I. Course Objectives I. Updated (done) II. Add the full list of updated Course Objectives to the Syllabus in Canvas II. USMLE 1 I. Review the drug list in Canvas to be sure each drug listed in the USMLE1 content list in included. Consider Pharm Cards. Distribute the list of USMLEs drug to each appropriate session teacher. Final Recommendations (2 of 2) I. Session Objectives – consider re-write of objectives that state facts rather than objectives. II. Syllabus – I. Update the syllabus front page to the current year II. Update summary of Final Exam (states 80 Q exam) III. Final Exam (2014) I. Questions #5, 13 and 18 are True/False lead questions and should be re-written. IV. Coordinate with the Cardiology is possible V. All small session cases should be completed and discussed by all students. A few students can moderate, but all should be involved. Action Plan (1 of 3)

I. Course Objectives I. Updated (done) II. Add the full list of updated Course Objectives to the Syllabus in Canvas (on canvas site for 2015-16 and in “Medical Pharmacology Essentials” document) II. USMLE 1 I. Review the drug list in Canvas to be sure each drug listed in the USMLE1 content list in included. Consider Pharm Cards. Distribute the list of USMLEs drug to each appropriate session teacher. (We are reviewing USMLE resources to ensure our drug list is up to date and will be updating the drug lists and lectures where appropriate. Commonly used drug class members can be listed). Action Plan (2 of 3) I. Session Objectives – consider re-write of objectives that state facts rather than objectives (will review format with lecturers and adjust as appropriate). II. Syllabus – I. Update the syllabus front page to the current year (done) II. Update summary of Final Exam (done) Action Plan (3 of 3) I. Final Exam (2014) I. Questions #5, 13 and 18 are True/False lead questions and should be re-written (these questions will be removed from our question bank and new ones written). II. Coordinate with the Cardiology is possible (this was a specific problem with 1 session and we will attempt to align this content with SBM. Our lecturer for this session retired this year so potentially this might be an online session) III. All small session cases should be completed and discussed by all students. A few students can moderate, but all should be involved (this year we will change the format of these sessions so while specific students lead a case ALL students are expected to have studied the material and be able to discuss it).