Benefits of appraisal as perceived by general practitioners

Appraisal for general practitioners (GPs) has been in place since 2002. We conducted a review of current literature on what benefits GPs perceived appraisal to offer. GPs recognised that appraisal offers the chance to reflect on their personal development, and promotes educational activity. Furthermore, there is a strong perception that appraisal encourages changes in clinical practice and offers additional benefits such as mentorship and motivational support for the doctor. The conclusion we draw is that GPs, and the patients that they treat, should continue to benefit from outputs of medical appraisal after the introduction of medical revalidation.     

Effectiveness of instruction in critical appraisal (evidence-based medicine) skills: a critical appraisal

OBJECTIVE: To examine the evidence that the teaching of critical appraisal (evidence-based medicine) skills to undergraduate medical students or residents will result in significant gains in knowledge and increased use of the literature in clinical decision-making. DATA SOURCES: Articles published from 1966 to 1995, retrieved through a MEDLINE search supplemented by manual searches; review of bibliographies maintained by individuals involved in teaching critical appraisal skills; and a previous methodological review. STUDY SELECTION: Articles were selected if the study involved some form of control group, although strict randomization was not required, and a measure of performance followed the intervention. Articles were excluded if they simply reported the process of teaching critical appraisal skills or used some form of "happiness index." DATA SYNTHESIS: There were 10 studies of the impact of teaching critical appraisal skills, 6 involving medical students and 4 involving residents. Results from 3 of the studies were nearly uninterpretable and thus were excluded; the remaining 7 were methodologically acceptable. Analysis showed that interventions implemented in undergraduate programs resulted in significant gains in knowledge, as assessed by a written test (mean gain 17.0%; standard deviation [SD] 4.0%). Conversely, studies at the residency level consistently showed a small change in knowledge (mean gain 1.3%; SD 1.7%). Two studies that examined residents'' use of the literature were unable to demonstrate any positive changes. CONCLUSIONS: Studies of the effect of teaching critical appraisal skills on gains in knowledge at the undergraduate level showed consistent improvement. By contrast, changes in knowledge at the residency level were small. Several suggestions from the educational literature are offered to increase effectiveness of critical appraisal interventions.     

A critical appraisal of clinical practice guidelines for the treatment of lower-limb osteoarthritis

Clinical practice guidelines are important tools to assist clinical decision-making. Recently, several guidelines addressing the management of osteoarthritis (OA) have been published. Clinicians treating patients with OA must ensure that these guidelines are developed with consistency and methodological rigour. We undertook a qualitative summary and critical appraisal of six medical treatment guidelines for the management of lower-limb OA published in the medical literature within the past 5 years. A review of these six guidelines revealed that each possesses strengths and weakness. While most described the scope and intended patient populations, the guidelines varied considerably in the rigour of their development, coverage of implementation issues, and disclosure of conflicts of interest.     

A critical appraisal of clinical practice guidelines for the treatment of lower-limb osteoarthritis

Clinical practice guidelines are important tools to assist clinical decision-making. Recently, several guidelines addressing the management of osteoarthritis (OA) have been published. Clinicians treating patients with OA must ensure that these guidelines are developed with consistency and methodological rigour. We undertook a qualitative summary and critical appraisal of six medical treatment guidelines for the management of lower-limb OA published in the medical literature within the past 5 years. A review of these six guidelines revealed that each possesses strengths and weakness. While most described the scope and intended patient populations, the guidelines varied considerably in the rigour of their development, coverage of implementation issues, and disclosure of conflicts of interest.     

Listening to local voices: adapting rapid appraisal to assess health and social needs in general practice.

OBJECTIVES--To explore the use of rapid appraisal in defining the health and social needs of a community and to formulate joint action plans between the residents and service providers. DESIGN--Collection of data by an extended primary care team from three sources: existing documents about the neighbourhood, interviews with a range of informants, and direct observations to build a profile of the community. SETTING--Council estate of 670 homes in Edinburgh. MAIN OUTCOME MEASURES--Perceived problems of the community and suggestions for change. RESULTS--The interviews and focus groups identified six priorities for change, many of which were not health related. These changes have been or are being implemented. CONCLUSIONS--An expanded primary care team can use rapid appraisal as a first step in identifying and meeting local health needs. It facilitates a multidisciplinary approach and complements quantitative methods of assessing need.     

Randomised controlled trial of the READER method of critical appraisal in general practice

Objective: To evaluate the READER model for critical reading by comparing it with a free appraisal, and to explore what factors influence different components of the model. Design: A randomised controlled trial in which two groups of general practitioners assessed three papers from the general practice section of the BMJ. Setting: Northern Ireland. Subjects: 243 general practitioners. Main outcome measures: Scores given using the READER model (Relevance, Education, Applicability, Discrimination, overall Evaluation) and scores given using a free appraisal for scientific quality and an overall total. Results: The hierarchical order for the three papers was different for the two groups, according to the total scores. Participants using the READER method (intervention group) gave a significantly lower total score (P⩽0.01) and a lower score for the scientific quality (P⩽0.0001) for all three papers. Overall more than one in five (22%), and more men than women, read more than 5 articles a month (P⩽0.05). Those who were trainers tended to read more articles (P⩽0.05), and no trainers admitted to reading none. Overall, 58% (135/234) (68% (76/112) of the intervention group) believed that taking part in the exercise would encourage them to be more critical of published articles in the future (P⩽0.01). Conclusion: Participants using the READER model gave a consistently lower overall score and applied a more appropriate appraisal to the methodology of the studies. The method was both accurate and repeatable. No intrinsic factors influenced the scores, so the model is appropriate for use by all general practitioners regardless of their seniority, location, teaching or training experience, and the number of articles they read regularly.

Key messages

• The READER method of critical appraisal is simple and easy to apply
• The method is accurate and repeatable
• General practitioners using a structured appraisal are more critical of quality
• The model may be used by general practitioners with different backgrounds, seniority, and experience of teaching and training

     

Graphical modeling for gene set analysis: A critical appraisal

Current demand for understanding the behavior of groups of related genes, combined with the greater availability of data, has led to an increased focus on statistical methods in gene set analysis. In this paper, we aim to perform a critical appraisal of the methodology based on graphical models developed in Massa et al. ( 2010 ) that uses pathway signaling networks as a starting point to develop statistically sound procedures for gene set analysis. We pay attention to the potential of the methodology with respect to the organizational aspects of dealing with such complex but highly informative starting structures, that is pathways. We focus on three themes: the translation of a biological pathway into a graph suitable for modeling, the role of shrinkage when more genes than samples are obtained, the evaluation of respondence of the statistical models to the biological expectations. To study the impact of shrinkage, two simulation studies will be run. To evaluate the biological expectation we will use data from a network with known behavior that offer the possibility of carrying out a realistic check of respondence of the model to changes in the experimental conditions.     

Impact of patient care appraisal on physician behaviour in the office setting

The effect of patient care appraisal on physicians'' management of patients'' problems was assessed. Sixteen family physicians were involved. The eight in the experimental group helped in the selection of two of the five disease conditions to be audited and in the generation of optimal criteria of care for two of the conditions. Participation in the generation of optimal criteria was followed by a significant improvement in the physicians'' behaviour, but involvement in the selection of the conditions to be audited caused no change. The patient care appraisal did not lead to significant improvement of physicians'' management of the conditions. In a second analysis, in which only essential criteria of care were considered, the physicians who participated in the patient care appraisal significantly improved their management of patients'' problems. However, participation in the selection of the conditions and in the generation of the criteria of care had no effect on their performance. Patient care appraisal is an effective tool in continuing medical education and leads to improvement in the quality of care, provided the process focuses on essential criteria of care.     

A critical assessment of the European Commission's proposals for the risk assessment and registration of chemical substances in the European Union

In May, 2003, the European Commission published detailed proposals relating to its 2001 White Paper--Strategy for a Future Chemicals Policy. The White Paper described a new registration system called the REACH (Registration, Evaluation and Authorisation of Chemicals) system, for both new and existing chemicals. Subsequently, these detailed proposals were available for an eight-week consultation period for stakeholders to voice their views and concerns. In this paper, we describe our reactions to the Commissions more-detailed proposals. These include the creation of a European Chemicals Agency to implement the REACH system in conjunction with Competent Authorities (CAs) in Member States and the Commission itself. Unfortunately, many of our concerns and suggestions, previously voiced and shared with several other key stakeholders, remain unanswered, but are as relevant as when the White Paper was published. In particular, we are concerned about the lack of a clear and coherent strategy. There is no guidance for registrants on intelligent testing to maximise the use of non-animal approaches to safety testing, based on a combination of factors for estimating exposure levels, rather than mainly on production volumes. We are also concerned about the absence of a clear programme for the development, improvement and validation of new alternative methods, in conjunction with the Commissions own unit, the European Centre for the Validation of Alternative Methods, as well as other organisations with relevant expertise and experience, including FRAME. Finally, we explain why such measures should be introduced, together with clearer guidelines for the respective roles of the Agency, the CAs and the Commission in implementing and harmonising the REACH system at the European Union and Member State levels. A series of recommendations are made, to improve the situation and to improve the risk assessment process.     

A critical assessment of the European Commission's proposals for the risk assessment and registration of chemical substances in the European Union

In May, 2003, the European Commission published detailed proposals relating to its 2001 White Paper - Strategy for a Future Chemicals Policy. The White Paper described a new registration system called the REACH (Registration, Evaluation and Authorisation of Chemicals) system, for both new and existing chemicals. Subsequently, these detailed proposals were available for an eight-week consultation period for stakeholders to voice their views and concerns. In this paper, we describe our reactions to the Commission's more-detailed proposals. These include the creation of a European Chemicals Agency to implement the REACH system in conjunction with Competent Authorities (CAs) in Member States and the Commission itself. Unfortunately, many of our concerns and suggestions, previously voiced and shared with several other key stakeholders, remain unanswered, but are as relevant as when the White Paper was published. In particular, we are concerned about the lack of a clear and coherent strategy. There is no guidance for registrants on intelligent testing to maximise the use of non-animal approaches to safety testing, based on a combination of factors for estimating exposure levels, rather than mainly on production volumes. We are also concerned about the absence of a clear programme for the development, improvement and validation of new alternative methods, in conjunction with the Commission's own unit, the European Centre for the Validation of Alternative Methods, as well as other organisations with relevant expertise and experience, including FRAME. Finally, we explain why such measures should be introduced, together with clearer guidelines for the respective roles of the Agency, the CAs and the Commission in implementing and harmonising the REACH system at the European Union and Member State levels. A series of recommendations are made, to improve the situation and to improve the risk assessment process.     

Revisiting the comparative phylogeography of unglaciated eastern North America: 15 years of patterns and progress

In a landmark comparative phylogeographic study, “Comparative phylogeography of unglaciated eastern North America,” Soltis et al. (Molecular Ecology, 2006, 15, 4261) identified geographic discontinuities in genetic variation shared across taxa occupying unglaciated eastern North America and proposed several common biogeographical discontinuities related to past climate fluctuations and geographic barriers. Since 2006, researchers have published many phylogeographical studies and achieved many advances in genotyping and analytical techniques; however, it is unknown how this work has changed our understanding of the factors shaping the phylogeography of eastern North American taxa. We analyzed 184 phylogeographical studies of eastern North American taxa published between 2007 and 2019 to evaluate: (1) the taxonomic focus of studies and whether a previously detected taxonomic bias towards studies focused on vertebrates has changed over time, (2) the extent to which studies have adopted genotyping technologies that improve the resolution of genetic groups (i.e., NGS DNA sequencing) and analytical approaches that facilitate hypothesis‐testing (i.e., divergence time estimation and niche modeling), and (3) whether new studies support the hypothesized biogeographic discontinuities proposed by Soltis et al. (Molecular Ecology, 2006, 15, 4261) or instead support new, previously undetected discontinuities. We observed little change in taxonomic focus over time, with studies still biased toward vertebrates. Although many technological and analytical advances became available during the period, uptake was slow and they were employed in only a small proportion of studies. We found variable support for previously identified discontinuities and identified one new recurrent discontinuity. However, the limited resolution and taxonomic breadth of many studies hindered our ability to clarify the most important climatological or geographical factors affecting taxa in the region. Broadening the taxonomic focus to include more non‐vertebrate taxa, employing technologies that improve genetic resolution, and using analytical approaches that improve hypothesis testing are necessary to strengthen our inference of the forces shaping the phylogeography of eastern North America.     

Medical students' application of published evidence: randomised trial

ObjectivesTo determine how medical students apply research evidence that varies in validity of methods and importance of results to a clinical decision.DesignStudents examined a standardised patient with a whiplash injury, decided whether to order a cervical spine radiograph, and rated their confidence in their decision. They then read one of four randomly assigned variants of a structured abstract from a study of a decision rule that argued against such a procedure in this patient. Variants factorially combined two levels of validity of methods (prospective cohort or chart review) with two levels of importance of results (high sensitivity or high specificity rule). After reading the abstract, students repeated their choice and rated their confidence.SettingAcademic medical centre in the United States.Participants164 graduating medical students.ResultsWhen abstracts were of low importance students were more likely to shift their beliefs in favour of radiography, which was not supported by the evidence (odds ratio 3.42, 95% confidence interval 1.10 to 10.66). Neither methodological validity nor the interaction between validity and importance influenced decision shift. Few students acquired all necessary clinical data from the patient.ConclusionsAlthough the students could apply concepts of diagnostic testing, greater focus is needed on appraisal of validity and application of evidence to a particular patient.

What is already known on this topic

Evidence based medicine is increasingly emphasised and taught in medical schoolsFew studies have assessed the ability of physicians to apply literature findings to clinical decisions

What this paper adds

In making decisions about ordering investigations during a standardised patient exam students were sensitive to the importance of resultsThis effect was not moderated by validity of the study that produced the results or whether the students had collected enough information to apply the results     

Teaching plastic surgeons how to be better teachers

The purpose of this article is to introduce plastic surgeons to a theory of adult education. Most surgeons have been hired by their parent institution because of their clinical skills, and rightly so. At the same time, these same surgeons choose or are expected to be involved to varying degrees in the surgical education process with medical students, surgical residents, fellows, and allied health workers. Likewise, busy surgical residents are also expected to teach other residents and students, and yet these two groups of teachers of surgery have little or no training in the theory and practice of adult education. This article has four major sections. The first is a scenario designed to bring to mind a context and set of ideas with which the reader is already familiar. The second provides new information, Kolb's theory of adult learning and Arseneau and Rodenberg's teaching principles, and discusses their implications. The third section is designed to give the reader an opportunity to work with the new knowledge and practice possible applications, and the fourth encourages the reader to use the new knowledge in concrete ways in a real-world environment.     

Prevention of homozygous beta-thalassemia by carrier screening and prenatal diagnosis in Sardinia.

We report here results of a 3-year pilot voluntary screening program coupled with prenatal diagnosis directed to the prospective prevention of homozygous beta-thalassemia (beta-thal) in Sardinia. The screening program took two approaches: outreach community testing and hospital testing on request after a period of sensibilization. The outreach testing was very effective as, taking into account the already known number of couples at risk with an affected proband (20), 74% of the couple at risk expected (61) on the basis of the carrier rate were identified. Less effective was the hospital testing in which half of the couples at risk expected were detected (502 with the 199 without an affected proband). After nondirective genetic counseling, approximately 85% of the couples at risk, which had a pregnancy, with no statistically significant difference between those with and those without a proband, requested prenatal testing. This figure showed a steadily increase from the beginning in 1977 to 1980. All the pregnancies (42), but two carrying homozygous fetuses, were terminated on parental request. A continuous hospital survey of thal-major admissions in the different hospitals of the counties showed a steady decline in the incidence figure at birth from 1976 (1:213) to 1978 (1:290). These results showed that even in a medium-developed, rural, Catholic population screening coupled with prenatal diagnosis can be successful in the control of a fatal, recessively inherited disorder.     

An appraisal of the American and British health-care systems.

1. A dispassionate comparison of the British and American systems of medical care using conventional guidelines (structure, process, and outcomes) as applied to acknowledged national problems in health and medical care (expense, quality, and distribution) has been made. 2. Dissimilarities in the size of the countries, in the attitudes of physicians, and in homogeneity of populations make it unlikely that the two countries should have identical medical-care systems. 3. The "good features" of the NHS, which by implication might benefit the American system if adopted, are seen to be overshadowed by weakness: a) Relative expensiveness or extravagance of American medicine is seen as underfinancing of the British system. b) Quality of care in Britain is threatened by lack of professional stimulation of generalists, inadequate facilities, and rationing of medical care by prolonged waiting times for elective services. c) Distribution of services is a problem in both countries which will not be corrected by administrative controls but "pegged to incentives" as is true in America. 4. Administrative change in NHS in April 1974 is evidence of internal dissatisfaction. It also demonstrates the need for continual revision of the system; a similar need is made evident by recent legislative proposals in America. 5. Dr. Beeson's final recommendation for voluntary organizational effort by the profession in America has merit.     

Clinical effectiveness and cost effectiveness of zanamivir (Relenza): translating the evidence into clinical practice, a National Institute for Clinical Excellence view.

The UK National Institute for Clinical Excellence (NICE) is charged with the duty of providing informed guidance on clinical practice (clinical effectiveness and cost effectiveness) to patients and health professionals. The Appraisal Committee through its process of review of evidence advises NICE on the clinical effectiveness and cost effectiveness of new and existing technologies and their appropriate use within the National Health Service in England and Wales. The appraisal process takes into account both published and unpublished evidence as well as input from professional and patient and carer groups when coming to its decisions. The appraisal of a new technology often has to bridge the gap between the evidence required for licensing purposes and that needed to provide pragmatic advice to practising clinicians. The appraisal of zanamivir (Relenza) is an excellent working example of this difficult and important process.     

“分子与细胞”翻转课堂教学模式在临床专业教学中的探究

提高医学创新人才培养手段是医学教育改革的重点内容之一。"分子与细胞"是临床医学教育改革的重点专业基础课,也是一门全新的整合课程,具有学时多、难度大且要求和临床专业紧密结合的特点。如何转变临床专业课程的传统教学模式,是临床专业课程改革创新的焦点。该研究通过基于嵌入式文献阅读和临床案例式的翻转课堂教学模式,将传统的面对面授课转化为以学生为中心的授课方式,将课堂主阵地由线下转移至线上,为线下课堂提供了更多创新融合的方式,同时增强了医学生对于生命学基本原理的理解,为培养具有精准医学专业背景的医学生提供了理论基础。通过三年的翻转课堂实施,临床专业卓越医生试点班学生对教学满意度以及学生成绩显著提升,说明在临床专业整合课程开展翻转课堂教学具有积极意义。     

A critical evaluation of the 2011 ECHA reports on compliance with the REACH and CLP regulations and on the use of alternatives to testing on animals for compliance with the REACH regulation

On 30 June 2011, the European Chemicals Agency published two reports, one on the functioning of the REACH system, the other on the use of alternatives to animal testing in compliance with that system. The data presented are based on information gained during the first registration period under the REACH system, which included high production volume chemicals and substances of very high concern, which have the most extensive information requirements. A total of 25,460 registration dossiers were received, covering 3,400 existing, so-called 'phase-in', substances, and 900 new, so-called 'non-phase-in', substances. Data sharing and the joint submission of data are reported to have worked successfully. In the registration dossiers for these substances, results from new animal tests were included for less than 1% of all the endpoints; testing proposals (required for 'higher-tier' information requirements) were submitted for 711 in vivo tests involving vertebrate animals. The registrants mainly used old, existing experimental data, or options for the adaptation (waiving) of information requirements, before collecting new information. For predicting substance toxicity, 'read-across' was the second most-used approach, followed by 'weight-of-evidence'. In vitro toxicity tests played a minor role, and were only used when the respective test methods had gained the status of regulatory acceptance. All in all, a successful start to the REACH programme was reported, particularly since, in contrast to most predictions, it did not contribute to a significant increase in toxicity testing in animals.