Misunderstandings, misperceptions, and mistakes

ebm_logo.gif  From  the February 2007 issue of Evidence-Based Medicine: [subscription required]

Straus S, Haynes B, Glasziou P, Dickersin K, Guyatt G. Misunderstandings, misperceptions, and mistakes. Evid Based Med 2007; 12(1):2-a.

Excerpt: Discussions about evidence-based medicine (EBM) have engendered both positive and negative reactions from clinicians, researchers, and policymakers since the term was first coined in the early 1990s. These discussions were brought to the forefront again in a recent commentary by Dr Bernadine Healy, former director of National Institutes of Health, in U.S. News & World Report. She raised several issues that EBM practitioners and teachers face when advocating this model of care. Firstly, she stated that EBM practitioners advocate using the “best” evidence which is mostly taken from randomised trials and cost benefit studies. Secondly, she raised the issues of the interpretation of evidence for screening mammography and prostate specific antigen as examples where EBM has failed because EBM proponents did not advocate for these tests based on the available evidence. Thirdly, she likened the practice of EBM to a “straitjacket” or a cookbook approach in . . .

Scott I. The evolving science of translating research evidence into clinical practice. Evid Based Med 2007; 12(1):4-7.

Practising clinicians have to swim in an ocean of clinical research evidence that varies in rigour, consistency, and applicability to the care of individual patients. They are expected to stay up to date, be authoritative, and practice to a high standard. They work in an environment that obliges them to reconcile patient preferences and societal/professional expectations with the need for cost restraint and accountability for quality and safety of care.

Numerous reports of variations in practice patterns and substandard care have placed increased pressure on clinicians, healthcare institutions, and professional organisations to improve their ability to provide optimal care. This is essential for the continuation of public trust and funding from public and private payers. While standards of care may not be definable in the absence of definitive evidence, the fact that clinical practice in many instances appears to be at odds with even clear-cut research evidence has . . .

Ghost authorship in industry-initiated randomised trials

ghost1.jpg  Published recently in PLoS Medicine, an Open Access journal. (Note: The authors limited their study to trials approved in 1994-1995. It would be interesting to know what the results would be for such a study of current trials.) 
Commentary: Authors, ghosts, damned lies, and statisticians    More reaction to this article

Gotzsche PC, Hrobjartsson A, Johansen HK, Haahr MT, Altman DG, Chan AW. Ghost authorship in industry-initiated randomised trials. PLoS Med 2007; 4(1):e19.

BACKGROUND: Ghost authorship, the failure to name, as an author, an individual who has made substantial contributions to an article, may result in lack of accountability. The prevalence and nature of ghost authorship in industry-initiated randomised trials is not known.
METHODS AND FINDINGS: We conducted a cohort study comparing protocols and corresponding publications for industry-initiated trials approved by the Scientific-Ethical Committees for
Copenhagen and Frederiksberg in 1994-1995. We defined ghost authorship as present if individuals who wrote the trial protocol, performed the statistical analyses, or wrote the manuscript, were not listed as authors of the publication, or as members of a study group or writing committee, or in an acknowledgment. We identified 44 industry-initiated trials. We did not find any trial protocol or publication that stated explicitly that the clinical study report or the manuscript was to be written or was written by the clinical investigators, and none of the protocols stated that clinical investigators were to be involved with data analysis. We found evidence of ghost authorship for 33 trials (75%; 95% confidence interval 60%-87%). The prevalence of ghost authorship was increased to 91% (40 of 44 articles; 95% confidence interval 78%-98%) when we included cases where a person qualifying for authorship was acknowledged rather than appearing as an author. In 31 trials, the ghost authors we identified were statisticians. It is likely that we have overlooked some ghost authors, as we had very limited information to identify the possible omission of other individuals who would have qualified as authors.
CONCLUSIONS: Ghost authorship in industry-initiated trials is very common. Its prevalence could be considerably reduced, and transparency improved, if existing guidelines were followed, and if protocols were publicly available.   

Chiropractic and CAM utilization: A descriptive review

bmc.gif This review was just published online in Chiropractic & Osteopathy. Free full text is available.

Lawrence DJ, Meeker WC. Chiropractic and CAM utilization: A descriptive review. Chiropr Osteopat 2007; 15(1):2.

OBJECTIVE: To conduct a descriptive review of the scientific literature examining use rates of modalities and procedures used by CAM clinicians to manage chronic LBP and other conditions.
DATA SOURCES: A literature of PubMed and MANTIS was performed using the key terms Chiropractic; Low Back Pain; Utilization Rate; Use Rate; Complementary and Alternative Medicine; and Health Services in various combinations.
DATA SELECTION: A total of 137 papers were selected, based upon including information about chiropractic utilization, CAM utilization and low back pain and other conditions.
DATA SYNTHESIS: Information was extracted from each paper addressing use of chiropractic and CAM, and is summarized in tabular form.
RESULTS: Thematic analysis of the paper topics indicated that there were 5 functional areas covered by the literature: back pain papers, general chiropractic papers, insurance-related papers, general CAM-related papers; and workers compensation papers.
CONCLUSION: Studies looking at chiropractic utilization demonstrate that the rates vary, but generally fall into a range from around 6% to 12% of the population, most of whom seek chiropractic care for low back pain and not for organic disease or visceral dysfunction. CAM is itself used by people suffering from a variety of conditions, though it is often used not as a primary intervention, but rather as an additional form of care. CAM and chiropractic often offer lower costs for comparable results compared to conventional medicine.
PubMed Record      Related Articles

Assessment in medical education

nejm2.gif  This review article and accompanying editorial appear in the January 25 issue of the New England Journal of Medicine. Free full text is available.

Epstein RM. Assessment in medical education [review]. N Engl J Med 2007; 356(4):387-396.
Excerpt: This article provides a conceptual framework for and a brief update on commonly used and emerging methods of assessment, discusses the strengths and limitations of each method, and identifies several challenges in the assessment of physicians’ professional competence and performance.

Klass D. Assessing doctors at work — Progress and challenges [editorial]. N Engl J Med 2007; 356(4):414-415.
Excerpt: A fair amount of scrutiny has been given recently to the assessment of medical students’ competence before they enter practice. In this issue of the Journal, Epstein provides a timely summary of advances in this arena. In contrast, little attention has been paid to the assessment of doctors who are already in practice. As Epstein points out, far from being a fixed attribute or trait, competence comprises multidimensional sets of behaviors that are dependent on both environmental and individual factors. As a result, the assessment of competence must go beyond the identification of who practitioners are, on the basis of evidence of their personal attributes or dated credentials, to capture what they actually do in the context of contemporary practice.

Jargon generators

jargonomatic1.gif The other day I read about the MWLS Random Business Jargon Generator. Just click on <Generate> and see the strange (but somehow familiar) phrases that appear.

I figured there were probably some other jargon generators out there, so I went looking, and here is what I found.

  • Jargon-o-Matic (pictured above): This startling innovation puts the power of plausible but utterly incomprehensible business jargon in your hands. To generate a unique report, click on the jargon generator … to produce paragraphs like this:

    Occasionally, the market enhances brand equity of integration influencing critical mass. It can be seen that a ground-breaking concern is a quick win for the potential industry. Blue-skies thinking associated with innovation is ubiquitous. Furthermore, the requirement adds value, and sufficient life-cycle refinances unbundling. Increasingly, technology strikes the market, but it will take a step change in risk management to outsource a consultancy.

  • Web Economy BS Generator
    Sample phrases: enhance synergistic interfaces; synthesize robust deliverables; transition scalable platforms

  • The BS Job Title Generator
    Sample phrases: Investor Functionality Developer; Future Mobility Manager; Human Interactions Administrator

  • The Educational Jargon Generator
    Sample phrases: drive top-down life-long learning; synergize strategic mastery learning; implement constructivist schemas

  • Leadership Jargon Generator
    Sample phrases: empowered productivity outcome; consultative international allocation; collaborative international result

  • I’ve saved my favourite for last. This is Random Jargon, which presents you with a random phrase and five different ways to modify this phrase.  Outstanding!

  • Check out more jargon generators [Who has time to do stuff like this, anyway?]

Research in medical education: balancing service and science

AHSC.gif From the February 2007 issue of Advances in Health Sciences Education: Theory and Practice:

Albert M, Hodges B, Regehr G. Research in medical education: balancing service and science. Adv Health Sci Educ Theory Pract 2007; 12(1):1573-1677.

Abstract: Since the latter part of the 1990’s, the English-speaking medical education community has been engaged in a debate concerning the types of research that should have priority. To shed light on this debate and to better understand its implications for the practice of research, 23 semi-structured interviews were conducted with “influential figures” from the community. The results were analyzed using the concept of “field” developed by the sociologist Pierre Bourdieu. The results reveal that a large majority of these influential figures believe that research in medical education continues to be of insufficient quality despite the progress that has taken place over the past 2 decades. According to this group, studies tend to be both redundant and opportunistic, and researchers tend to have limited understanding of both theory and methodological practice from the social sciences. Three factors were identified by the participants to explain the current problems in research: the working conditions of researchers, budgetary restraints in financing research in medical education, and the conception of research in the medical environment. Two principal means for improving research are presented: intensifying collaboration between PhD’s and clinicians, and encouraging the diversification of perspectives brought to bear on research in medical education.

Excerpt from the editorial by Geoffrey Norman: How bad is medical education research anyway?

There are times when I fear that our research community has taken a cue from the medieval monks in the practice of self-flagellation. Recently, a commentary appeared in the pages of BMJ from two researchers in
Maastricht (Schuwirth & van der Vleuten, 2006), in which a whole section was titled ‘‘Improve research standards’’, and began with the assertion that ‘‘Several factors could explain the poor quality of much published research’’. Well, some of the published research may be poor, but research from their institution is not, as their many articles which appear in these pages can attest. The same refrain was repeated in some sessions at the recent AMEE meeting in Genoa, where a number of groups reported on their findings regarding systematic reviews of particular educational questions like, ‘‘how good is self-assessment?’’ A routine comment during the course of each presentation was something like, ‘‘Of course, one problem was that the quality of the research was poor.’’

Relationship-Centered Care

jgim.gif  The January 2006 issue of the Journal of General Internal Medicine contains the proceedings of a conference entitled Re-Forming Relationships in Health Care: Creating A National Research Agenda for Relationship-Centered Care. Here are the issues abstracts; free full text is available. 

From September 29 to October 1, 2004, the Regenstrief Institute, a free-standing research institute of Indiana University School of Medicine, held its ninth bi-annual conference on health care research. The conference, entitled, Re-Forming Relationships in Health Care: Creating A National Research Agenda for Relationship-Centered Care, was attended by almost 100 invited participants and presenters who gathered to hear and discuss current concepts and research in relationship-centered care (RCC) and to help shape an agenda for research in this arena.
Excerpt from:

Frankel RM, Inui TS. Re-forming relationships in health care. Papers from the ninth biennual Regenstrief Conference. J Gen Intern Med 2006; 21 Suppl 1:S1-S2.


Haidet P, Stein HF. The role of the student-teacher relationship in the formation of physicians. The hidden curriculum as process. J Gen Intern Med 2006; 21 Suppl 1:S16-S20.
Abstract: Relationship-Centered Care acknowledges the central importance of relationships in medical care. In a similar fashion, relationships hold a central position in medical education, and are critical for achieving favorable learning outcomes. However, there is little empirical work in the medical literature that explores the development and meaning of relationships in medical education. In this essay, we explore the growing body of work on the culture of medical school, often termed the “hidden curriculum.” We suggest that relationships are a critical mediating factor in the hidden curriculum. We explore evidence from the educational literature with respect to the student-teacher relationship, and the relevance that these studies hold for medical education. We conclude with suggestions for future research on student-teacher relationships in medical education settings.

Cooper LA, Beach MC, Johnson RL, Inui TS. Delving below the surface. Understanding how race and ethnicity influence relationships in health care. J Gen Intern Med 2006; 21 Suppl 1:S21-S27.
Abstract: There is increasing evidence that racial and ethnic minority patients receive lower quality interpersonal care than white patients. Therapeutic relationships constitute the interpersonal milieu in which patients are diagnosed, given treatment recommendations, and referred for tests, procedures, or care by consultants in the health care system. This paper provides a review and perspective on the literature that explores the role of relationships and social interactions across racial and ethnic differences in health care. First, we examine the social and historical context for examining differences in interpersonal treatment in health care along racial and ethnic lines. Second, we discuss selected studies that examine how race and ethnicity influence clinician-patient relationships. While less is known about how race and ethnicity influence clinician-community, clinician-clinician, and clinician-self relationships, we briefly examine the potential roles of these relationships in overcoming disparities in health care. Finally, we suggest directions for future research on racial and ethnic health care disparities that uses a relationship-centered paradigm.

Roter DL, Frankel RM, Hall JA, Sluyter D. The expression of emotion through nonverbal behavior in medical visits. Mechanisms and outcomes. J Gen Intern Med 2006; 21 Suppl 1:S28-S34.
Abstract: Relationship-centered care reflects both knowing and feeling: the knowledge that physician and patient bring from their respective domains of expertise, and the physician’s and patient’s experience, expression, and perception of emotions during the medical encounter. These processes are conveyed and reciprocated in the care process through verbal and nonverbal communication. We suggest that the emotional context of care is especially related to nonverbal communication and that emotion-related communication skills, including sending and receiving nonverbal messages and emotional self-awareness, are critical elements of high-quality care. Although nonverbal behavior has received far less study than other care processes, the current review argues that it holds significance for the therapeutic relationship and influences important outcomes including satisfaction, adherence, and clinical outcomes of care.

Beach MC, Inui T. Relationship-centered care. A constructive reframing. J Gen Intern Med 2006; 21 Suppl 1:S3-S8.
Abstract: All illness, care, and healing processes occur in relationship–relationships of an individual with self and with others. Relationship-centered care (RCC) is an important framework for conceptualizing health care, recognizing that the nature and the quality of relationships are central to health care and the broader health care delivery system. RCC can be defined as care in which all participants appreciate the importance of their relationships with one another. RCC is founded upon 4 principles: (1) that relationships in health care ought to include the personhood of the participants, (2) that affect and emotion are important components of these relationships, (3) that all health care relationships occur in the context of reciprocal influence, and (4) that the formation and maintenance of genuine relationships in health care is morally valuable. In RCC, relationships between patients and clinicians remain central, although the relationships of clinicians with themselves, with each other and with community are also emphasized.

Weiner M, Biondich P. The influence of information technology on patient-physician relationships. J Gen Intern Med 2006; 21 Suppl 1:S35-S39.
Abstract: Interpersonal relationships and information are intertwined as essential cornerstones of health care. Although information technology (IT) has done much to advance medicine, we are not even close to realizing its full potential. Indeed, issues related to mismanaging health information often undermine relationship-centered care. Information technology must be implemented in ways that preserve and uplift relationships in care, while accommodating major deficiencies in managing information and making medical decisions. Increased collaboration between experts in IT and relationship-centered care is needed, along with inclusion of relationship-based measures in informatics research.

Suchman AL. A new theoretical foundation for relationship-centered care. Complex responsive processes of relating. J Gen Intern Med 2006; 21 Suppl 1:S40-S44.
Abstract: Relationship-centered care (RCC) is a clinical philosophy that stresses partnership, careful attention to relational process, shared decision-making, and self-awareness. A new complexity-inspired theory of human interaction called complex responsive processes of relating (CRPR) offers strong theoretical confirmation for the principles and practices of RCC, and thus may be of interest to communications researchers and reflective practitioners. It points out the nonlinear nature of human interaction and accounts for the emergence of self-organizing patterns of meaning (e.g., themes or ideas) and patterns of relating (e.g., power relations). CRPR offers fresh new perspectives on the mind, self, communication, and organizations. For observers of interaction, it focuses attention on the nature of moment-to-moment relational process, the value of difference and diversity, and the importance of authentic and responsive participation, thus closely corresponding to and providing theoretical support for RCC.

Duffy FD. Complexity and healing relationships [editorial]. J Gen Intern Med 2006; 21 Suppl 1:S45-S47.

Safran DG, Miller W, Beckman H. Organizational dimensions of relationship-centered care. Theory, evidence, and practice. J Gen Intern Med 2006; 21 Suppl 1:S9-S15.
Abstract: Four domains of relationship have been highlighted as the cornerstones of relationship-centered health care. Of these, clinician-patient relationships have been most thoroughly studied, with a rich empirical literature illuminating significant linkages between clinician-patient relationship quality and a wide range of outcomes. This paper explores the realm of clinician-colleague relationships, which we define to include the full array of relationships among clinicians, staff, and administrators in health care organizations. Building on a stream of relevant theories and empirical literature that have emerged over the past decade, we synthesize available evidence on the role of organizational culture and relationships in shaping outcomes, and posit a model of relationship-centered organizations. We conclude that turning attention to relationship-centered theory and practice in health care holds promise for advancing care to a new level, with breakthroughs in quality of care, quality of life for those who provide it, and organizational performance.

Nutrition Research and Industry Sponsorship

plos.gif  The following two articles were published in PLoS Medicine in January, 2007. Free full text is available.

Katan MB. Does industry sponsorship undermine the integrity of nutrition research? PLoS Med 2007; 4(1):e6.

Excerpt: The commercial success of foods depends more and more on what science says about the effects of these foods on health. Drug companies have tried to influence the scientific record so as to make their products look healthier; are food companies doing the same? In a study published in PLoS Medicine, Lesser et al. investigated this by analyzing 206 publications on the health effects of milk, soft drinks, and fruit juices. Twenty-four of these studies had been funded solely by the industry whose product was investigated, while 52 of the papers declared that they had had no industrial support. The other papers had mixed support or did not declare sponsorship.  The odds that a paper would report a favorable outcome were four to eight times higher when the study was funded by the manufacturer of the beverages in question than when the study was not funded by industry. PubMed Record 

Lesser LI, Ebbeling CB, Goozner M, Wypij D, Ludwig DS. Relationship between funding source and conclusion among nutrition-related scientific articles. PLoS Med 2007; 4(1):e5.

BACKGROUND: Industrial support of biomedical research may bias scientific conclusions, as demonstrated by recent analyses of pharmaceutical studies. However, this issue has not been systematically examined in the area of nutrition research. The purpose of this study is to characterize financial sponsorship of scientific articles addressing the health effects of three commonly consumed beverages, and to determine how sponsorship affects published conclusions.
METHODS AND FINDINGS: Medline searches of worldwide literature were used to identify three article types (interventional studies, observational studies, and scientific reviews) about soft drinks, juice, and milk published between 1 January, 1999 and 31 December, 2003. Financial sponsorship and article conclusions were classified by independent groups of coinvestigators. The relationship between sponsorship and conclusions was explored by exact tests and regression analyses, controlling for covariates. 206 articles were included in the study, of which 111 declared financial sponsorship. Of these, 22% had all industry funding, 47% had no industry funding, and 32% had mixed funding. Funding source was significantly related to conclusions when considering all article types (p = 0.037). For interventional studies, the proportion with unfavorable conclusions was 0% for all industry funding versus 37% for no industry funding (p = 0.009). The odds ratio of a favorable versus unfavorable conclusion was 7.61 (95% confidence interval 1.27 to 45.73), comparing articles with all industry funding to no industry funding.
CONCLUSIONS: Industry funding of nutrition-related scientific articles may bias conclusions in favor of sponsors’ products, with potentially significant implications for public health.  PubMed Record  

How to write a case report for publication

jcm.jpg  This helpful article was published in the Summer 2006 issue of the Journal of Chiropractic Medicine. See also Writing for Chiropractic Journals

Green BN, Johnson C. How to write a case report for publication. J Chiropr Med 2006; 5(2):72-82.

Objective: This paper describes how and why to write a case report for publication in a peer-reviewed journal.
Methods: PubMed, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Index to Chiropractic Literature were searched from 2000 through September 2006 using the following search terms: case report, authorship, peer review, and manuscript. Relevant manuscripts were retrieved and the results were used to update a previous narrative overview of the literature.
Discussion: Commensurate with the increased use of evidence-based health care and recent changes in publication requirements, new standards are expected of case reports. Case reports should present new information to the literature and be written succinctly. The types of case reports available are discussed. Steps for preparing a case report are described based upon the current available literature.
Conclusion: Case reports are important contributions to the health sciences literature. Proper preparation of this study design is necessary in order for it to be published. A self-evaluation check sheet for authors is included to assist in the writing process. [Appendix A. Case Report Check Sheet]

Writing narrative literature reviews for peer-reviewed journals: secrets of the trade

jcm.jpg  This article appears in the Fall 2006 issue of the Journal of Chiropractic Medicine. It was originally published in the Journal of Sports Chiropractic & Rehabilitation in 2001, and is reprinted with permission. (JSCR is indexed in the Index to Chiropractic Literature.)

Green BN, Johnson CD, Adams A. Writing narrative literature reviews for peer-reviewed journals: secrets of the trade. Journal of Chiropractic Medicine 2006; 5:101-114.  Full Text

Objective: To describe and discuss the process used to write a narrative review of the literature for publication in a peer-reviewed journal. The JSCR wishes to standardize its publication of narrative overviews of the literature to increase their objectivity.

Background: In the past decade numerous changes in research methodology pertaining to reviews of the literature have occurred. These changes necessitate authors of review articles to be familiar with current standards in the publication process.

Methods: Narrative overview of the literature synthesizing the findings of literature retrieved from searches of computerized databases, hand searches, and authoritative texts.

Discussion: An overview of the use of three types of reviews of the literature is resented. Step by step instructions for how to conduct and write a narrative overview utilizing a ‘best-evidence synthesis’ approach are discussed, starting with appropriate preparatory work and ending with how to create proper illustrations. Several resources for creating reviews of the literature are presented and a narrative overview critical appraisal worksheet is included. A bibliography of other useful reading is presented in an appendix.

Conclusion: Narrative overviews can be a valuable contribution to the literature if prepared properly. New and experienced authors wishing to write a narrative overview should find this article useful in constructing such a paper and carrying out the research process. It is hoped that this article will stimulate scholarly dialog amongst colleagues about this research design and other complex literature review methods.