JOURNAL OF HOSPITAL MEDICINE

GUIDELINES FOR REVIEWERS Please use the following guidelines when conducting your review for the Journal of Hospital Medicine: To gain the most understanding out of the manuscript, we recommend that you read through the manuscript at least two times. In general, comments should be constructive and suggestions should be offered in the spirit of improving the quality of the manuscript. Harsh remarks and negative criticism, unaccompanied by suggestions for improvements, will help neither the authors nor the editors. Please make sure to offer specifications and examples for all comments, positive and negative. In your general evaluation, please look for any problems that arise in the following areas:

1) Overall Content Is the topic of the manuscript appropriate for the Journal? Please remark if you think the information is of significant interest to our readers or if it is a new or important contribution to the field of Hospital Medicine.

2) Science Problems can arise from the lack of specific knowledge. Please make sure that the science expounded in the article meets the standards of the journal and has applied all relevant basic scientific principles.

3) Ethics Please reveal any inconsistent results, possible plagiarism, or fraud.

4) Presentation Make sure you are aware of the authors exact intent. Note if there are any redundancies, irrelevancies, jargon, or lack of focus.

Once you have determined the above, please consider the following more specific questions in your review of the article:

1) Methods Are the methods appropriate for the type of study and scientifically sound? Is there adequate description of methodology used and why this approach was taken? If a manuscript is based on data, do the data represent an adequate population and is a

valid statistical justification included to support the conclusions? 2) Results

Are appropriate statistical tests used? Are the results relevant to problem posed? Credible? Well presented? Are the tables and figures well designed and add to understanding of the text?

3) Discussion and Conclusions Are the interpretation and conclusions warranted by the data? Reasonable speculation? Are the conclusions clear? Are limitations of the study identified and explained Are references cited the most appropriate to support the manuscript? Are they up to date

and relevant? Are there any glaring omissions? 4) Imagery

Are all figures, tables, charts relevant and necessary for the understanding of the article? Are all digital images in a readable format?

To complete your evaluation, you will need to write up comments for both the Editor and the Authors. Comments to the Editor should be short (no more than 200 words) and should follow the approach below.

1) Summarize the topic of the study, indicate the basic approach, select the main findings and paraphrase the authors main conclusions.

2) List main criticisms and questions in order of importance but postpone the full explanation until the Comments to the Authors.

3) Indicate your recommendations. *Please acknowledge any major help you have received, especially if it is from a Fellow or Junior Faculty member so that the Journal may contact them to review in the future. Comments to the Authors: This section may be longer and comprised of clear, targeted questions and comments. Please make your analysis clear and respectful.

1) This can be a copy of the first summary paragraph in the Comments to the Editor. 2) Major Comments - start with the main points made in the Comments to the Editor. Please

explain each question/criticism to the authors and supply supporting statements. 3) Minor Comments this may pertain more to the presentation of the article, redundancies,

grammar issues, etc. Please list these comments in the order they appear in the text and identify them by page, paragraph and line.

Thank you for agreeing to serve as a reviewer for the Journal of Hospital Medicine. We truly value your contributions. If you have any questions, please contact the appropriate Associate Editor or the Editor-in-Chief. Please see the following examples of reviews below: Helpful review Confidential Comments to Executive Editor

See review to authors: important topic but not convincing; several methods issues.

Comments to the Author

This is an important topic and you do a good job of explaining this and have good background. There are two main questions: 1. Does the CD ROM educational intervention improve knowledge base more than a conventional educational program on anticoagulation issues? 2. Does the CD ROM intervention lead to an important and sustainable improvement in physician performance? I think the paper suggests the answers to these questions could be yes, yet I was not sufficiently convinced. The reasons for my skepticism are two-fold: 1. The large amount of evidence demonstrating the relatively ineffective role education plays in changing complex behavior, in the absence of systems change or continued reinforcement. A study refuting this evidence would need to be convincing and well designed. 2. Study design issues My questions / concerns with study design and analysis: The CD ROM educational program did have convincing before and after scores at the home institution. An attempt was made to analyze whether the improvement was more pronounced due to the CD ROM component, but offering an educational program at a comparable institution. However, I am not convinced the institutions or residents in them were comparable. There is no evidence presented to convince me of this, and the baseline scores of the control hospital are lower than the intervention center. The more important question is whether or not the CD ROM education influences care patterns. My problems with the methodology here are: 1. The audit tool used to assess adequacy of VTE prophylaxis is not described. Were the same observers used? Was there any attempt to look at agreement of the assessments between observers? How did they look for contraindications?

2. The baseline sample on which all comparisons are made is only 40 patients. While the differences were statistically significant, that assumes the samples were either 100% of the population available, or that the sample is a random sample, not a convenience sample. 3. There is also a distinct possibility that there was some system change made in the interim which affected resident behavior. Reminders in the charts, new order sets, a hospital protocol which places IPC devices more aggressively, or independent educational programs could have all played a role. This could have been explored to some extent if VTE prophylaxis was examined in the control hospital in the same manner you used the control hospital to assess the impact on test scores. 4. The CD ROM was based on the 2000 guidelines, but the assessment of efficacy started in 2004, when the updated guidelines became available. Did the residents improve their performance because of the buzz around the updated versions (we hand out the guidelines to all of our residents every time there is an update in our institution). Was the audit based on 2000 standards or the updated standards? In summary, I applaud you for your work and addressing the issue of alternate educational models and their impact on knowledge and behavior. I think this work is important, but I think the design issues and lack of convincing control groups leaves the questions at hand in doubt. I think this work is a good pilot study, but need more convincing controls and robust numbers to warrant publication as a full fledged research article. Less helpful review Comments to the Author

Stimulation technology is clearly underused in the postgraduate training and it is extremely important to collect the data on its effects on knowledge and skills. It is unclear what was the time frame in your study between intervention and follow up training. If it was done immediately the scores could improve but the long term effects would still remain unclear. Using real patients and faculty to supervise and evaluate procedural skills after intervention for example every year during internal medicine residency training could answer the question if this technology makes any difference in future hospitalists training. I really support the idea of using Stimulation technology for procedural skills in training of Hospitalist in practice and as far as I know there is no data to support the effects of it and this area is needed further research.