LIFE Photo Archive through Google

  When I was young, my family’s subscriptions included the Globe and Mail, the Toronto Telegram, The New Yorker and LIFE magazine. The newspapers were of interest to me mainly for their comics, particularly the coloured ones that were delivered on the weekend. The stories in The New Yorker (delivered on Saturdays – we still had Saturday mail delivery in those days) helped nurture my lifelong love of literature. But it was the pictures in LIFE that captured my imagination, from those early ones of my namesake Anne and her brother Charles (the picture above is from 1954), to the spreads on the young Senator Kennedy and his beautiful wife with her little round hats, to the scary coverage of the Cuban Missile Crisis. And, of course, I loved all those shots of such notables as Marilyn Monroe and Elvis Presley and The Beatles. (They’re here again and what a ruckus! )

Google has done it again. You can look at tons of pictures from LIFE magazine through Google’s LIFE photo archive. From the site:
Search millions of photographs from the LIFE photo archive, stretching from the 1750s to today. Most were never published and are now available for the first time through the joint work of LIFE and Google.

If you prefer, you can search the photo archive through Google Images and simply add source:life (e.g. sputnik source:life). This one is really fun: woodstock source:life.

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Tips for teaching evidence-based medicine in a clinical setting

Here is a two-part series published in the Journal of the Royal Society of Medicine [subscription required]:

Das K, Malick S, Khan KS. Tips for teaching evidence-based medicine in a clinical setting: lessons from adult learning theory. Part one. J R Soc Med 2008;101(10):493-500.

Abstract: Evidence-based medicine (EBM) is an indispensable tool in clinical practice. Teaching and training of EBM to trainee clinicians is patchy and fragmented at its best. Clinically integrated teaching of EBM is more likely to bring about changes in skills, attitudes and behaviour. Provision of evidence-based health care is the most ethical way to practice, as it integrates up-to-date, patient-oriented research into the clinical decision making process, thus improving patients’ outcomes. In this article, we aim to dispel the myth that EBM is an academic and statistical exercise removed from practice by providing practical tips for teaching the minimum skills required to ask questions and critically identify and appraise the evidence and presenting an approach to teaching EBM within the existing clinical and educational training infrastructure.   PubMed Link

Malick S, Das K, Khan KS. Tips for teaching evidence-based medicine in a clinical setting: lessons from adult learning theory. Part two. J R Soc Med 2008;101(11): 536-543.

Abstract: Evidence-based medicine (EBM) is the clinical use of current best available evidence from relevant, valid research. Provision of evidence-based healthcare is the most ethical way to practise as it integrates up-to-date patient-oriented research into the clinical decision-making to improve patients’ outcomes. This article provides tips for teachers to teach clinical trainees the final two steps of EBM: integrating evidence with clinical judgement and bringing about change.

Book Cart Drill Teams

Check out this video of the winners of the 2007 Medical Libary Association meeting book cart drill team competition: The Dewey Decimators!  You can read about the November 2008 competition in Wisconsin when the Baraboo Bookers shut out the Mad City Truckers.

Here is an ALA [American Library Association] wiki entry; there is even a manual for drill teams. And I just found a YouTube drill team playlist!

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On whose shoulders we stand: Lessons from Exemplar medical educators

The OED defines “exemplar” as “A person or thing which serves as a model for imitation; an example”.

This article from Advances in Health Sciences Education Theory & Practice [subscription required] describes 10 lessons learned from six Exemplars in medical education: Stephen Abrahamson, Charles Dohner, Arthur Elstein, Hilliard Jason, Christine McGuire and Frank Stritter.

Hitchcock MA, Anderson WA.  On whose shoulders we stand: Lessons from Exemplar medical educators. Adv Health Sci Educ Theory Pract 2008 Nov 16.

Abstract: The hiring of educators in medical schools (faculty who study the educational process and prepare others to become educators) has been one of the most successful educational innovations ever. Starting in 1954, through a collaboration between the Schools of Medicine and Education at the University of Buffalo, the innovation has spread to over half of the medical schools in the United States and to medical schools in several other countries. Practically every medical school and specialty now hires educators to conduct faculty development, evaluate learners, and develop or revise curricula. This article focuses on lessons learned by six-first-generation educators hired in medical education. These individuals made unique contributions that improved the process of educating and evaluating future physicians. Among their most important contributions have been the use of standardized patients, faculty development to improve instruction, and the use of clinical decision making theory. In addition, these professional educators created a home and career path for other professionals and nurtured protégés to continue the work they started. Ten lessons are reported from structured interviews using a standardized protocol. These lessons will hopefully inform current and future medical educators to help them sustain the effective collaboration between medical schools and educators.

Lesson #1: Focus on the faculty’s problems—collaborate
Lesson #2: Be prepared to answer the question: “what have you done for me lately?”
Lesson #3: Get smart about something specific
Lesson #4: Use a research-based approach and publish the results in reputable journals
Lesson #5: Be self-aware and interpersonally wise
Lesson #6: Maintain connection with your discipline
Lesson #7: Have fun and use humor as an effective teaching strategy
Lesson #8: Bring in independent funding
Lesson #9: Develop a network of colleagues
Lesson #10: Recruit and develop the next generation of educationists

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Bringing important research evidence into practice: Canadian developments

This article from Family Practice describes two Canadian  initiatives that are helping to transfer research into practice [subscription required]:

CAPRE: Critically Appraised Practice Reflection Exercise [Queen’s University, Kingston ON]
GAC: Guidelines Advisory Committee [Ontario]

Rosser W. Bringing important research evidence into practice: Canadian developments. Family Practice 2008 November 12.

BACKGROUND: The transfer of evidence from research into clinical practice is made almost impossible by enormous volume of literature on any topic. Consolidated evidence into guidelines is not very helpful as there are usually 50 guidelines existing on common clinical topics. Clinicians need assistance in identifying the best available evidence. This paper describes two strategies to transfer research evidence into clinical practice.
METHODS: The Guideline Advisory Committee (GAC) in Ontario has assessed all available guidelines on 70 clinical topics using a validated and transparent process involving community-based physicians as assessors. A single best guideline is selected and a summary of its evidence-based recommendations are produced for easy use by practitioners (http://www.gacguidelines.ca). The Critically Appraised Practice Reflection Exercise (CAPRE) programme takes the best available evidence on 40 common practice problems, presents a summary for clinician and patient, has a strategy for physician and patient to find common ground in applying the evidence and has the practitioner to carry out a reflection exercise to gain continuing education credits (http://www.capre.ca). Distribution of these strategies in practice-based research networks is a further step in making research more relevant to practice.
RESULTS: The GAC website has more than 100 000 ‘hits’ per month and 4500 identified regular users from Canada and the world. The numbers are steadily increasing. The CAPRE programme has not been formally evaluated but over 150 clinicians have used the programme with patients. With a national launch, the programme there between 60 000 and 80 000 hits per week with 100 physicians completing the programme for continuing medical education (CME) credits in the first month. Physicians report that their patients are very pleased with their physician using the latest evidence to address their problem. This is true even if the patient does not agree to follow the evidence-based recommendations. Using these programmes in practice-based research, networks should further promote making research more relevant to practice.
CONCLUSIONS: Transferring research-based evidence into clinical practice has many challenges. Two programmes developed to address these challenges are described. Although not fully evaluated, there is some evidence of success.

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Giving feedback in clinical settings

This practical and timely article was recently published online in the BMJ [subscription may be required]: 

Cantillon P, Sargeant J. Giving feedback in clinical settings. BMJ 2008 November 10;337:a1961.

Excerpt:
Think about a clinical teaching session that you supervised recently. How much feedback did you provide? How useful do you think your feedback was?

Feedback is the cornerstone of effective clinical teaching. Without feedback, good practice is not reinforced, poor performance is not corrected, and the path to improvement not identified. Though teachers believe that they give regular and sufficient feedback, often this is not how it is perceived by learners.

Feedback is about providing information to students with the intention of narrowing the gap between actual and desired performance. The purpose of giving feedback is to encourage learners to think about their performance and how they might improve. Surveys of learners’ preferences show that they want feedback that stimulates them to reflect on what they are doing.

Feedback is a concept that is strongly theory based. From a behaviourist perspective, feedback has been shown to reinforce or modify behaviour. However, feedback can also cause harm; negative feedback, if not carefully managed, can result in demotivation and deterioration in performance. Cognitive theorists have shown that feedback helps learners to reconstruct knowledge, change their performance, and feel motivated for future learning. Empirical evidence also shows that feedback enhances clinical performance. For example, in a recent systematic review, regular feedback significantly improved the clinical performance of consultant clinicians.

Of special note:
How best to do it : The following eight general principles of effective feedback are derived from educational theory and research literature addressing feedback in the fields of education and personnel management.

BMJ Link
Link to similar articles in the BMJ

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Research Methods and Reporting – new BMJ series

On October 22, 2008, the BMJ launched a new series entitled Research methods and reporting.

From the editorial:
Groves T. Research methods and reporting: A new section of the BMJ about how to do and write up research [editorial] BMJ 2008;337:a2201.

Nearly 15 years ago Doug Altman, the BMJ’s senior statistical adviser and professor of medical statistics, asked in this journal, “What should we think about researchers who use the wrong techniques (either wilfully or in ignorance), use the right techniques wrongly, misinterpret their results, report their results selectively, cite the literature selectively, and draw unjustified conclusions? We should be appalled. Yet numerous studies of the medical literature, in both general and specialist journals, have shown that all of the above phenomena are common.

The new section will contain “how to” articles—those that discuss the nuts and bolts of doing and writing up research—that will be both actionable and readable.2 We welcome articles on all kinds of medical and health services research that will be relevant and useful to BMJ readers—whether that research is quantitative or qualitative, clinical or not. Because this section is for the “how?” of research, the “what, why, when, and who cares?” will usually belong elsewhere. 

Articles in the series so far [Open Access]:

Improving the reporting of pragmatic trials: An extension of the CONSORT statement
Developing and evaluating complex interventions: The new Medical Research Council guidance

Some more relevant articles:

Rob Anderson. New MRC guidance on evaluating complex interventions. BMJ 2008 337: a1937.

Peter Craig, Paul Dieppe, Sally Macintyre, Susan Michie, Irwin Nazareth, and Mark Petticrew. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ 2008 337: a1655. 

Trish Groves. Mandatory disclosure of trial results for drugs and devices. BMJ 2008 336: 170.

D G Altman. The scandal of poor medical research. BMJ 1994 308: 283-284.

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Feel the warmth!

A November morning at the cottage that Bernie built …

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Obama Mania

My son was in Grant Park on November 4. He recorded this startling video during the moments after the announcement of the victory. (Follow along as he travels across America.)

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Who uses chiropractic?

 Here are a few studies examining the populations of patients who visit chiropractors. Click on Related Articles in PubMed to retrieve more records.

Blum C, Globe G, Terre L, Mirtz TA, Greene L, Globe D. Multinational survey of chiropractic patients: reasons for seeking care. JCCA: J Can Chiropr Assoc 2008 August;52(3):175-84. [Open Access]
INTRODUCTION: This study explores the extent to which consumers seek wellness care when choosing chiropractors whose practice methods are known to include periodic evaluative and interventional methods to maintain wellness and prevent illness.
METHODS: Using an international convenience sample of Sacro-Occipital Technique (SOT) practitioners, 1316 consecutive patients attending 27 different chiropractic clinics in the USA, Europe and Australia completed a one-page survey on intake to assess reason for seeking care. A forced choice response was obtained characterizing the patient’s reason for seeking chiropractic care.
RESULTS: More than 40% of chiropractic patient visits were initiated for the purposes of health enhancement and/or disease prevention.
CONCLUSION: Although prudence dictates great caution when generalizing from this study, if confirmed by subsequent research among other similar cohorts, the present results may lend support to continued arguments of consumer demand for a more comprehensive paradigm of chiropractic care, beyond routine musculoskeletal complaints, that conceptualizes the systemic, nonspecific effects of the chiropractic encounter in much broader terms.

Hurwitz EL, Chiang LM. A comparative analysis of chiropractic and general practitioner patients in North America: Findings from the joint Canada/United States Survey of Health, 2002-03. BMC Health Serv Res 2006 April 6;6:49.:49. [Oopen Access]
BACKGROUND: Scientifically rigorous general population-based studies comparing chiropractic with primary-care medical patients within and between countries have not been published. The objective of this study is to compare care seekers of doctors of chiropractic (DCs) and general practitioners (GPs) in the United States and Canada on a comprehensive set of sociodemographic, quality of life, and health-related variables.
METHODS: Data are from the Joint Canada/U.S. Survey of Health (JCUSH), 2002-03, a random sample of adults in Canada (N = 3505) and the U.S. (N = 5183). Respondents were categorized according to their pattern of health-care use in the past year. Distributions, percentages, and estimates (adjusted odds ratios) weighted to reflect the complex survey design were produced.
RESULTS: Nearly 80% of respondents sought care from GPs; 12% sought DC care. Compared with GP only patients, DC patients in both countries tend to be under 65 and white, with arthritis and disabling back or neck pain. U.S. DC patients are more likely than GP only patients to be obese and to lack a regular doctor; Canadian DC patients are more likely than GP only patients to be college educated, to have higher incomes, and dissatisfied with MD care. Compared with seekers of both GP and DC care, DC only patients in both countries have fewer chronic conditions, take fewer drugs, and have no regular doctor. U.S. DC only patients are more likely than GP+DC patients to be uninsured and dissatisfied with health care; Canadian DC only patients are more likely than GP+DC patients to be under 45, male, less educated, smokers, and not obese, without disabling back or neck pain, on fewer drugs, and lacking a regular doctor.
CONCLUSION: Chiropractic and GP patients are dissimilar in both Canada and the U.S., with key differences between countries and between DC patients who do and do not seek care from GPs. Such variation has broad and potentially far-reaching health policy and research implications.

Wolsko PM, Eisenberg DM, Davis RB, Kessler R, Phillips RS. Patterns and perceptions of care for treatment of back and neck pain: Results of a national survey. Spine 2003 February 1;28(3):292-7.
STUDY DESIGN: We conducted a nationally representative random household telephone survey to assess therapies used to treat back or neck pain.
OBJECTIVES: The main outcome was complementary therapies used in the last year to treat back or neck pain.
SUMMARY OF BACKGROUND DATA: Back pain and neck pain are common medical conditions that cause substantial morbidity. Despite the presumed importance of complementary therapies for these conditions, studies of care for back and neck pain have not gathered information about the use of complementary therapies.
METHODS: Our nationally representative survey sampled 2055 adults. The survey gathered detailed information about medical conditions, conventional and complementary therapies used to treat those conditions, and the perceived helpfulness of those therapies.
RESULTS: We found that of those reporting back or neck pain in the last 12 months, 37% had seen a conventional provider and 54% had used complementary therapies to treat their condition. Chiropractic, massage, and relaxation techniques were the most commonly used complementary treatments for back or neck pain (20%, 14%, and 12%, respectively, of those with back or neck pain). Chiropractic, massage, and relaxation techniques were rated as “very helpful” for back or neck pain among users (61%, 65%, and 43%, respectively), whereas conventional providers were rated as “very helpful” by 27% of users. We estimate that nearly one-third of all complementary provider visits in 1997 (203 million of 629 million) were made specifically for the treatment of back or neck pain.
CONCLUSIONS: Chiropractic, massage, relaxation techniques, and other complementary methods all play an important role in the care of patients with back or neck pain. Treatment for back and neck pain was responsible for a large proportion of all complementary provider visits made in 1997. The frequent use and perceived helpfulness of commonly used complementary methods for these conditions warrant further investigation.

Coulter ID, Hurwitz EL, Adams AH, Genovese BJ, Hays R, Shekelle PG. Patients using chiropractors in North America: Who are they, and why are they in chiropractic care? Spine 2002 February 1;27(3):291-6.
SUMMARY OF BACKGROUND DATA AND OBJECTIVES: Alternative health care was used by an estimated 42% of the U.S. population in 1997, and chiropractors accounted for 31% of the total estimated number of visits. Despite this high level of use, there is little empirical information about who uses chiropractic care or why.
METHODS: The authors surveyed randomly sampled chiropractors (n = 131) at six study sites and systematically sampled chiropractic patients seeking care from participating chiropractors on 1 day (n = 1275). Surveys collected data about the patient’s reason for seeking chiropractic care, health status, health attitude and beliefs, and satisfaction. In addition to descriptive statistics, the authors compared data between patients and chiropractors, and between patients and previously published data on health status from other populations, corrected for the clustering of patients within chiropractors.
RESULTS: More than 70% of patients specified back and neck problems as their health problem for which they sought chiropractic care. Chiropractic patients had significantly worse health status on all SF-36 scales than an age- and gender-matched general population sample. Compared with medical back pain patients, chiropractic back pain patients had significantly worse mental health (6-8 point decrement). Roland-Morris scores for chiropractic back pain patients were similar to values reported for medical back pain patients. The health attitudes and beliefs of chiropractors and their patients were similar. Patients were very satisfied with their care.
CONCLUSION: These data support the theory that patients seek chiropractic care almost exclusively for musculoskeletal symptoms and that chiropractors and their patients share a similar belief system.

Cote P, Cassidy JD, Carroll L. The treatment of neck and low back pain: who seeks care? who goes where? Med Care 2001 September;39(9):956-67.
BACKGROUND: Neck and low back pain are leading causes of morbidity and health care utilization. However, little is known about the characteristics that differentiate those who seek from those who do not seek health care for their pain.
OBJECTIVES: The objectives of this study were to: 1) describe health care utilization for neck and back pain; 2) determine the characteristics of individuals seeking health care for neck and back pain; and 3) identify the characteristics of patients who consult medical doctors, chiropractors, or both.
DESIGN: Population-based cross-sectional mailed survey. SUBJECTS: Subjects were randomly selected adults from the Saskatchewan Health Insurance and Registration File.
MEASURES: Demographic, socio-economic, general health, comorbidity, health-related-quality-of-life, pain severity and health care utilization data were collected. The main outcome was whether subjects with prevalent neck or low back pain visited a health care provider in the previous month.
RESULTS: Twenty-five percent of individuals with neck or low back pain visited a health care provider. Seeking health care was associated with disabling neck or back pain, digestive disorders, worse bodily pain and worse physical-role-functioning. Compared with medical patients, fewer chiropractic patients lived in rural areas or reported arthritis, but they reported better social and physical functioning. More patients consulting both providers reported disabling neck or back pain.
CONCLUSIONS: Individuals seeking care for neck or back pain have worse health status than those who do not seek care. Patients consulting chiropractors alone report fewer comorbidities and are less limited in their activities than those consulting medical doctors.

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