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Chapter 14 Copyright 2014

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Chapter 14 Copyright 2014. LWW. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. Knowledge Management Where is the wisdom we have lost in knowledge? Where is the knowledge we have lost in information? —T.S. Eliot 1934 KEY WORDS Knowledge management Conflict of interest Scientific misconduct Point of care Just-in-time learning Clinical practice guidelines MEDLINE EMBASE PubMed Peer review Structured abstract Finding the best available answer to a specific clinical question is like finding a needle in a haystack. Essential information is mixed with a vast amount of less credible “factoids” and opinions, and it is a daunting task to sort the wheat from the chaff. Yet, that is what clinicians need to do. Critical reading is only as good as the information found. Knowledge management is the effective and efficient organization and use of knowledge. This was a difficult task in the days of print media only. Fortunately, knowledge management has become a great deal easier in the era of electronic information. There are more and better studies on a broad range of clinical questions, widely available access to research results, and efficient ways to rapidly sort articles by topic and scientific strength. These opportunities followed the widespread availability of computers, the World Wide Web, and electronic information for clinical purposes. Finding information may seem to be a low priority for clinicians still in training. They are surrounded by information, far more than they can handle comfortably, and they have countless experts to help them decide what they should take seriously and what they should disregard. However, developing one’s own plan for managing knowledge becomes crucial later on, whether in practice or academe. Even with recent developments, effective and efficient knowledge management is a challenging task. In this chapter, we review modern approaches to clinical knowledge management. We will discuss four basic tasks: looking up information, keeping up with new developments in your field, remaining connected to medicine as a profession, and helping patients find good health information themselves. BASIC PRINCIPLES Several aspects of knowledge management cut across all activities. Do It Yourself or Delegate? Clinicians must first ask themselves, “Will I find and judge clinical research results for myself or delegate this task to someone else?” The answer is both. Clinicians should be capable of finding and critiquing information on their own; it is a basic skill in clinical medicine. But as a practical matter, it is not possible to go it alone for all of one’s information needs. There are just too many questions in a day and too little time to answer them on one’s own. Therefore, clinicians must find trustworthy agents to help them manage knowledge. 225 EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 5/4/2021 10:07 PM via PURDUE UNIVERSITY GLOBAL AN: 1473039 ; Robert Fletcher, Suzanne W. Fletcher.; Clinical Epidemiology : The Essentials Account: ns019078.main.ehost 226 Clinical Epidemiology: The Essentials Which Medium? One can obtain information via a rich array of media. They range from printed books and journals to digital information on the Web accessed through stationary and handheld platforms. There are audiotapes, videotapes, and more. The information is neither more nor less sound because of how it happens to come to you. Validity depends on authors, reviewers, and editors, not the medium. However, the availability of various media, with complementary advantages and disadvantages, makes it easier to find ones that match every user’s preferences. A modern knowledge management plan should be based on electronic information on the Internet. The information base for clinical medicine is changing too fast for print media alone to be sufficient. For example, clinically important discoveries in antiviral therapy for HIV, innovative scanning technologies, and state-of-the-science cancer chemotherapy emerge from year to year, even month to month. The Internet can keep pace with such rapid change and also complement, but not replace, traditional sources. Grading Information Grading makes it possible for clinicians to grasp the basic value of information in seconds. Usually, the quality of the evidence (confidence in estimates of effects) and strength of recommendations are graded separately. Table 14.1 shows an example of one widely used grading scheme called GRADE, similar in principle to other approaches in general use. This grading is for interventions; grading of other kinds of information is less well developed. Notice that recommendations are based on the strength of the research evidence, depend on the balance of benefits and harms, and vary in how forcefully and widely the intervention should be offered to patients. Although criteria for grading are explicit, assigning grades still depends partly on judgment. Misleading Reports of Research Findings Until now, we have acted as if the only threats to the validity of published clinical research stem from the difficulties of applying good scientific principles to the study of human illness. That is, validity is about the management of bias and chance. Unfortunately, there are other threats to the validity of research results, related to the investigators themselves and the social, political, and economic environment in which they work. We are referring to the all-too-human tendency to report the results of research according to one’s own stake in the results. Conflict of interest exists when investigators’ private interests compete with their responsibilities to be unbiased investigators. There are many possible competing interests: ? ? ? ? ? Financial conflict of interest: When personal or family income is related to research results (this conflict is usually considered the most powerful and most difficult to detect) Personal relationships: Supporting friends and putting down rivals Intellectual passion: Being for one’s own ideas and against competing ones Institutional loyalties: Putting the interests of one’s own school, company, or organization above others Career advancement: Investigators get more academic credit for publishing interesting results in elite journals. Conflict of interest exists in relation to a specific topic, not in general, and regardless of whether it has actually changed behavior. How is conflict of interest expressed? Scientific misconduct—fraud, fabrication, and plagiarism— are extreme examples. Less extreme is selective reporting of research results, either by not reporting unwelcome results (publication bias) or reporting results according to whether they seem to be the “right” ones. Industry sponsors of research can sometimes block publication or alter how results are reported. To create a public record of whether this has occurred, randomized controlled trials are now registered on publically available Web sites before data collection, making to possible to follow-up on whether the results were published when expected and whether the reported endpoints were the same as when the trial began (1). More subtle and more difficult to detect are efforts to “spin” results by the way they are described, for example, by implying that a very low P value means the results are clinically important or by describing effects as “large” when most of us would think they were not (2). All of us depend on peer reviewers and editors to limit the worst of this kind of editorializing in scientific articles. We mention these somewhat sordid influences on the information clinicians (and their patients) depend on because they are, in some situations, every bit as real and important as the well-informed application of confidence intervals and control of confounding, the usual domain of clinical epidemiology. Research and its interpretation are human endeavors and will, therefore, always be tinged, to some extent, with EBSCOhost - printed on 5/4/2021 10:07 PM via PURDUE UNIVERSITY GLOBAL. All use subject to https://www.ebsco.com/terms-of-use Chapter 14: Knowledge Management 227 Table 14.1 Grading Recommendations for Treatment According to the Quality of Evidence (Confidence in Estimate of Effect, A–C) and Strength of Recommendation (1–2) with Implications. Based on GRADE Guidelines Grade of Recommendation Clarity of Risk/ Benefit Quality of Supporting Evidence 1A. Strong recommendation, highquality evidence Benefits clearly outweigh risks and burdens, or vice versa Consistent evidence from wellperformed randomized controlled trials, or overwhelming evidence in some other form. Further research is unlikely to change confidence in the estimates of benefits and risks Strong recommendations apply to most patients in most circumstances without reservation. Clinicians should follow a strong recommendation unless there is a clear and compelling rationale for an alternative approach. 1B. Strong recommendation, moderate-quality evidence Benefits clearly outweigh risks and burdens, or vice versa Evidence from randomized controlled trials with important limitations (inconsistent results, methodologic flaws, or imprecision), or very strong evidence of some other research design. Further research (if performed) is likely to change our confidence in the estimates of benefits and risk Strong recommendation that applies to most patients. Clinicians should follow a strong recommendation unless there is a clear and compelling rationale for an alternative approach. 1C. Strong recommendation, lowquality evidence Benefits appear to outweigh risk and burdens, or vice versa Evidence from observational studies, unsystematic clinical experience, or randomized controlled trials with serious flaws. Any estimate of effect is uncertain. Strong recommendation that applies to most patients. Some of the evidence base supporting the recommendation is of low quality. 2A. Weak recommendation, high-quality evidence Benefits closely balanced with risks and burdens Consistent evidence from wellperformed randomized controlled trials or overwhelming evidence of some other form. Further research is unlikely to change our confidence in the estimates of benefits and risks. Weak recommendation. Best action may differ depending on circumstances or patient or societal values 2B. Weak recommendation, moderate-quality evidence Benefits closely balanced with risks and burdens, with some uncertainty in the estimates of benefits, risks, and burdens Evidence from randomized controlled trials with important limitations (inconsistent results, methodologic flaws or imprecision), or very strong evidence from some other research design. Further research (if performed) is likely to change confidence in estimates of benefits and risks. Weak recommendation. Alternative approaches likely to be better for some patients under some circumstances. 2C. Weak recommendation, low-quality evidence Uncertainty in the estimates of benefits, risks, and burdens; benefits may be closely balanced with risks and burdens Evidence from observational studies, unsystematic clinical experience, or randomized controlled trials with serious flaws. Any estimate of effect is uncertain. Very weak recommendation. Other alternatives may be equally reasonable. Implications Adapted from Guyatt GH, Oxman AD, Vist GE, et al. for the GRADE Working Group. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008;336:924–926. EBSCOhost - printed on 5/4/2021 10:07 PM via PURDUE UNIVERSITY GLOBAL. All use subject to https://www.ebsco.com/terms-of-use 228 Clinical Epidemiology: The Essentials self-serving results. There are ongoing efforts to limit bias related to conflicts of interest, mainly by insisting on full disclosure but also by excluding people with obvious conflicts of interest from peer review of manuscripts and grants, authorship of review articles and editorials, and from guidelines panels. LOOKING UP ANSWERS TO CLINICAL QUESTIONS Clinicians need to be able to look up answers to questions that arise during the care of their patients. They need this for things they do not know but also to check facts they think they know but might not, because the information base for patient care is always changing. It is best to get answers to questions just at the time and place where they arise during the care of patients. This has been called the point of care and the associated learning just-in-time-learning. Answers can then be used to guide clinical decision making for the patient at hand. Also, what is learned is more likely to be retained than information encountered out of context in a classroom, lecture hall, book, or journal, apart from the need to know for a specific patient. In any case, postponing the answering of questions to a later time too often means they do not get answered at all. For just-in-time learning to happen, several conditions must be in place (Table 14.2). Most patient care settings are time-pressured, so the answer must come quickly. As an office pediatrician pointed out, “If I added just 1 to 2 extra minutes to each patient visit, I would get home an hour later at the end of the day!” What clinicians need is not an answer but the best available answer, given the state of knowledge at the time. They need information that corresponds as closely as possible to the specific clinical situation their patient is in; if the patient is elderly and has several diseases, the research information should be about elderly patients with comorbidities. Clinicians need information sources that move with them as they travel from their office to home (where they take night and weekend call) and to hospitals and nursing homes. When all this happens, and it certainly can, the results are extraordinarily powerful. Example A patient sees you because he will be traveling to Ghana and wants advice on malaria prophylaxis. You are aware that the malaria parasite’s Table 14.2 Conditions in Which Information Is Available at the Point of Care Condition Rationale Rapid access The information must be available within minutes for it to fit into the busy workflow of most patient care settings. Current Because the best information base for clinical decisions is continually changing, the information usually needs to be electronic (as a practical matter, on the Internet). Tailored to the specific question Clinicians need information that matches as closely as possible the actual situation of their individual patient. Sorted by scientific strength There is a vast amount of information for almost any clinical question but only a small proportion of it is scientifically strong and clinical relevant. Available in clinical situations Clinicians cannot leave their place of work to look up answers; they must find it right where they work. susceptibility to antimalarial drugs varies across the globe and that it is continually changing. The Centers for Disease Control and Prevention have a Web site (http://www.cdc.gov) with current information for travelers to all parts of the world. Using the computer in your clinic, you quickly find out which prophylactic drug this patient should take and for how long before, during, and after the trip. You are also reminded that he should have a booster dose of polio vaccine and be vaccinated for hepatitis A and B, typhoid, and yellow fever. The site lists clinics where these vaccines are available. The site also shows that northern Ghana, where your patient will be visiting, is in the “meningitis belt,” so he should also be vaccinated against meningococcal disease. The information you are relying on is an up-to-date synthesis of the world’s best advice and is available to you within seconds. Solutions Clinical Colleagues A network of colleagues with various and complementary expertise is a time-honored way of getting point of care information. Many clinicians have identified EBSCOhost - printed on 5/4/2021 10:07 PM via PURDUE UNIVERSITY GLOBAL. All use subject to https://www.ebsco.com/terms-of-use Chapter 14: Knowledge Management local opinion leaders for this purpose. Of course, those opinion leaders must have their own sources of information, presumably more than just other colleagues. Electronic Textbooks Textbooks, even libraries, are on the Internet and made available to clinicians by their medical schools, health systems, and professional societies. For example, UpToDate (http://www.uptodate.com) is an electronic information resource for clinicians, the product of thousands of physician–authors and editors covering 9,000 topics in the equivalent of 90,000 printed pages (if it were ever printed).† Information is continually updated, peer reviewed, searchable and linked to abstracts of the original research, and recommendations are graded. UpToDate is available at the point of care throughout the world wherever the Internet can be accessed by computers or mobile platforms. also make explicit the evidence base and rationale for those recommendations. Like evidence-based medicine, guidelines are meant to be a starting place for decision making about individual patients, to be modified by clinical judgment; that is, they are guidelines, not rules. High-quality guidelines represent the wise application of research evidence to the realities of clinical care, but guidelines vary in quality. Table 14.3 Table 14.3 Standards for Trustworthy Clinical Practice Guidelines Standard Explanation Transparency How the guideline was developed and funded has been made explicit and is publically accessible. Conflict of Interest Group members’ conflicts of interest related to financial, intellectual, institutional, and patient/public activities bearing on the guideline are disclosed. Group Composition Group membership was multidisciplinary and balanced, comprising a variety of methodological experts and clinicians, and populations expected to be affected by the guideline. Systematic Review Recommendations are based on systematic reviews that met high standards for quality. Evidence and Strength of Recommendation Each recommendation is accompanied by an explanation for its underlying reasoning, the level of confidence in the evidence, and the strength of the recommendation. Description of Recommendations The guideline states precisely what the recommended action is and under what circumstances it should be performed. External Review The guideline has been reviewed by the full spectrum of relevant stakeholders (e.g., scientific and clinical experts, organizations, and patients). Updating The guideline reports the date of publication and evidence review and plans for updating when there is new evidence that would substantially change the guideline. Example One author was seeing patients in Boston during the anthrax scare in 2001. Around that time, biologic terrorists spread anthrax spores through the U.S. postal system, resulting in dozens of cases and five deaths. A young woman came to urgent care because she was worried that a recent skin lesion was caused by anthrax. When told it was not, she responded (somewhat impolitely), “How do you know, you’ve never seen it?” To which her doctor responded, “Of course not, none of us has, but we know what it looks like. Come with me and I’ll show you.” Using UpToDate on an office computer, he was able to show the patient several pictures of anthrax skin lesions, which looked quite different from hers, and she gained confidence that she was not, in fact, the next anthrax victim. Other textbooks, such as ACP Medicine, Harrison’s Online, and many subspecialty textbooks, are also available in electronic form. Clinical Practice Guidelines Clinical practice guidelines are advice to clinicians about the care of patients with specific conditions. In addition to giving recommendations, good guidelines † Robert and Suzanne Fletcher are among hundreds the editors of UpToDate. 229 Modified from Institute of Medicine. Clinical Practice Guidelines We Can Trust. Washington, DC: National Academies Press; 2011. The standards were for developing guidelines and have been modified to guide users in recognize guidelines they can trust. EBSCOhost - printed on 5/4/2021 10:07 PM via PURDUE UNIVERSITY GLOBAL. All use subject to https://www.ebsco.com/terms-of-use 230 Clinical Epidemiology: The Essentials summarizes criteria for credible guidelines developed by the U.S. Institute of Medicine. A relatively comprehensive listing of guidelines can be found at the National Guideline Clearinghouse, which is available online at http://www.guidelines.gov. The Cochrane Library Clinical scientists throughout the world have volunteered to review the world’s literature on specific clinical questions, to synthesize this information, store it in a central site, and to keep it up to date. The collection of reviews is available at http://www.cochrane. org. Although the Cochrane Library is incomplete, given the vast number of questions it might address, it is an excellent source of systematic reviews, with meta-analyses when justified, on the effects of interventions and, more recently, of diagnostic test performance. Citation Databases (PubMed and Others) MEDLINE is a bibliographic database, compiled by the U.S. National Library of Medicine, covering approximately 5,000 journals in biomedicine and health, mostly published in English. It is available free of charge using a search engine, usually PubMed (http://www.ncbi.nlm.nih.gov/pubmed). MEDLINE can be searched by topic, journal, author, year, and research design. In addition to citations, some abstracts are available. EMBASE (http://www.embase. com) is also used and complements what is found in MEDLINE; beyond these two are many other bibliographic databases for more specialized purposes. PubMed searches are limited by two kinds of misclassification. First, they produce false-negative results; that is, they miss articles that really are wanted. Second, searches produce many false-positive results; that is, they find more citations than are actually wanted on the basis of scientific strength and clinical relevance. For example, when Canadian nephrologists were asked to use PubMed to answer unique clinical questions in their field, they were able to retrieve 46% of relevant articles and the ratio of relevant to nonrelevant articles was 1/16 (3). Both problems can be reduced, but not totally overcome, by better searching techniques. PubMed searches are a mainstay for investigators and educators who have the time to construct careful searches and sort through the resulting articles, but PubMed searches are too inefficient to be of much practical value in helping clinicians, especially in answering day-to-day questions quickly. However, PubMed is particularly useful for looking up whether rare events have been reported. Example You are seeing a patient who you thought had cat scratch disease and who now has abdominal pain. After ruling out other causes, you wonder whether the abdominal pain might be from lymphadenopathy. To find out if this has ever been reported, you do a PubMed search and find a case report of cat scratch fever and abdominal lymphadenopathy (4). Armed with this information, even though it is just a report of one case, you are somewhat more confident in your diagnosis and management. Other Sources on the Internet A vast amount of health information is posted on the Internet, some of which is quite helpful for health professionals. It can be found by a search engine such as Google or Google Scholar and by sites sponsored by the U.S. government such as MedlinePlus (http:// www.nlm.nih.gov/medlineplus) and HealthFinder (http://healthfinder.gov) for health information and Health Hotlines (http://healthhotlines.nlm.nih.gov) for contact information of health related organizations. Other countries have their own Internet resources. SURVEILLANCE ON NEW DEVELOPMENTS Keeping up with new developments in any clinical field is a daunting task. It is not that the pace of practice-changing discoveries is unmanageable. Rather, the relevant information is widely dispersed across many journals and mixed with a vast number of less important articles. Example How widely are the best articles in a field dispersed among journals? The editors of ACP Journal Club regularly review more than 100 journals and select scientifically strong, clinically relevant articles in internal medicine for publication every month. This process provides an opportunity to describe, at least for internal medicine, the degree to which key articles are dispersed among journals. Figure 14.1 shows the proportion of key articles a reader would EBSCOhost - printed on 5/4/2021 10:07 PM via PURDUE UNIVERSITY GLOBAL. All use subject to https://www.ebsco.com/terms-of-use Chapter 14: Knowledge Management 231 100 100.0 86.5 Percent of articles 80 79.3 72.8 69.9 66.3 62.0 55.5 60 48.3 40 38.9 28.8 20 17.3 0 5 10 15 20 25 30 35 40 Number of journals Figure 14.1 ? How many journals would you have to read to keep up with the literature in your field? The proportion of scientifically strong, clinically relevant articles in internal medicine according to the number of journals, in descending order of yield. (Data from ACP Journal Club, 2011). encounter according to the number of journals read, starting with the highest yield journal and adding journals in order of descending yield. One would need to regularly review 4 journals to find 50% of these articles, 8 journals to find 75%, and 20 journals to find 90% of the key articles in internal medicine. Therefore, it is not possible for individual readers, even with great effort, to find all of the essential articles in a field on their own. They need to delegate the task to a trusted intermediary, one who will review many journals and select articles according to criteria they agree with. Fortunately, help is available. Most clinical specialties sponsor publications that summarize major articles in their field. These publications vary in how explicit and rigorous their selection process is. At one extreme, ACP Journal Club publishes its criteria for each kind of article (e.g., studies of prevention, treatment, diagnosis, prognosis) and provides a critique of each article it selects. At the other extreme, many newsletters include summaries of articles without making explicit either how they were selected or what their strengths and limitations are. There are now various ways to have new information—published research articles, guidelines, white papers, and news articles—in your specific areas of interest sent to you. One way is to identify specific topics and have new information about them automatically sent to you as it arises by means of RSS feeds and other services. Another is to participate in one of a growing number of social media, such as Facebook and blogs, where other people discover and select information you might want to know about and send it to you, just as you send new information to them. Less structured examples are research teams who share articles and news stories related to their work and ward teams in teaching hospitals where residents, students, and attending physicians share articles about their patients’ medical problems. Social media can be effective and efficient if you choose the right colleagues to participate with. JOURNALS Journals have a central role in the health professions. Everything we have said about clinical epidemiology and knowledge management is based on a foundation of original research published in peer-reviewed journals. Research reports are selected and improved before publication by a rigorous process involving critical EBSCOhost - printed on 5/4/2021 10:07 PM via PURDUE UNIVERSITY GLOBAL. All use subject to https://www.ebsco.com/terms-of-use 232 Clinical Epidemiology: The Essentials review by editors guided by peer review, comments by experts in the article’s content area and methods who provide advice on whether to publish and how a manuscript (the term for the article before it is published) could be improved. The reviewers are advisors to the editor (or editorial team), not the ones who directly decide the fate of the manuscript. Peer-review and editing practices, along with the evidence base and rationale for them, are summarized on the official Web site of the World Association of Medical Editors (http://www.wame.org) and the International Committee of Medical Journal Editors (http://www. icmje.org). Peer review and editing improve manuscripts, but published articles are far from perfect (5); therefore, readers should be grateful for the journals’ efforts to make articles better but also maintain a healthy skepticism about the quality of the end result. Working groups have defined the information that should be in a complete research article according to the type of study (randomized controlled trial, diagnostic test evaluation, systematic review, etc.) (Table 14.4). Readers can use these checklists to see if all the necessary information is included in an article, just as investigators use them to assure that their articles are complete. Journals themselves are not particularly helpful for some elements of knowledge management. Reading individual journals is not a reliable way of keeping up with new scientific developments in a field or for looking up the answers to clinical questions. But journals do add another dimension: exposing readers to the full breadth of their profession. Opinions, stories, untested hypotheses, commentary on published articles, expressions of professional values, as well as descriptions of the historical, social, and political context of current-day medicine and much more, reflect the full nature of the profession (Table 14.5). The richness of this information completes the clinical picture for many readers. For example, when Annals of Internal Medicine began publishing stories about being a doctor (6), many readers remarked that while reports Table 14.4 Guidelines for Reporting Research Studies Study Type Name of Statement Citation Randomized Controlled Trials Consolidated Standards of Reporting Trials (CONSORT) http://www.consort-statement.org Diagnostic Tests Standards for Reporting of Diagnostic Test Accuracy (STARD) http://www.stard.org Observational Studies Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) http://www.strobe-statement.org Non-Randomized Studies of Educational, Behavioral, and Public Health Interventions Transparent Reporting of Evaluations with Nonrandomized Design (TREND) http://www.cdc.gov/trendstatement Meta-analyses of Randomized Controlled Trials Quality of Reporting of Meta-analyses (QUOROM) Moher D, Cook DJ, Eastwood S, et al. Improving the quality of reports of meta-analyses of randomized controlled trials: the QUOROM statement. Lancet 1999;354:1896–900. Meta-analyses of Observational Studies Meta-analyses of Observational Studies in Epidemiology (MOOSE) Stroup DF, Berlin JA, Morton SC, et al. Metaanalysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA 2000;283:2008–2012. Systematic Reviews of Diagnostic Accuracy Studies Quality Assessment of Diagnostic Accuracy Studies (QUADAS) Whiting PF, Rutjes AWS, Westwood ME, et al. QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med 2011;155:529–536. Genetic Risk Prediction Studies Genetic Risk Prediction Studies (GRIPS) Janssens AC, Ioannidis JP, van Duijn CM, et al. Strengthening the reporting of genetic risk prediction studies: the GRIPS statement. Ann Intern Med 2011;154:421–425. EBSCOhost - printed on 5/4/2021 10:07 PM via PURDUE UNIVERSITY GLOBAL. All use subject to https://www.ebsco.com/terms-of-use Chapter 14: Knowledge Management Table 14.5 The Diverse Contents of a General Medical Journal Science The Profession Original research Medical education Preliminary studies History Review articles Public policy Editorials (for synthesis and opinion) Book reviews Letters to the editor News Hypotheses Stories and poems of research and reviews were essential, the experience of being a doctor was what they cared about the most. ”Reading” Journals The ability to critique research on one’s own is a core skill for clinicians. But this skill is used selectively YOUR QUESTION and to different degrees, just as the completeness of the history and physical examination, which is part of a clinician’s repertoire, is used to a varying extent from one patient encounter to another. It is not necessary to read journals from cover to cover, any more than one would read a newspaper from front to back. Rather, one browses—reads in layers—according to the time available and the strength and relevance of each individual article. Approaches to streamlined reading vary. It is a good idea to at least survey the titles (analogous to newspaper headlines) of all articles in an issue to decide which articles matter most to you. For those that do, you might read more deeply, adjusting the depth as you go (Fig. 14.2). The abstract is the best place to start, and many responsible readers stop there. If the conclusions are interesting, the methods section might come next; there, one finds basic information bearing on whether the conclusions are credible. One might want to look at the results section to see a more detailed description of what was found. Key figures (e.g., a survival curve for the main results of a randomized trial) WHERE TO LOOK Cursory review (title and abstract) What is this study about? What was concluded? Is it likely to be true? To whom does it apply? What was found? Title Conclusions Design Patients, setting OPTION OPTION OPTION STOP OPTION Results In depth review (article) Importance of the research question? How big was the effect? How strong were the methods? Context 233 Introduction Figures and tables Methods OPTION OPTION STOP OPTION Discussion Figure 14.2 ? Reading a journal article in layers. Individual readers can progress deeper into an article or stop and go on to another, according to its scientific strength and clinical importance to them. EBSCOhost - printed on 5/4/2021 10:07 PM via PURDUE UNIVERSITY GLOBAL. All use subject to https://www.ebsco.com/terms-of-use 234 Clinical Epidemiology: The Essentials Table 14.6 The Organization of a Structured Abstract Heading Value to Reader Context Burden of suffering from the disease/ illness. Why is the research question important? What is already known? Objective What the investigators set out to learn Setting The setting to which results can be generalized, such as community, primary care practices, referral centers, and the like Participants What kinds of patients (regarding generalizability)? How many (regarding statistical power/precision)? Design How strong is the study? How well is it matched to the research question? Intervention (if any) Is the intervention state-of-the-art? Is it feasible in your setting?” Main outcome measures Are the outcomes clinically important? Results What was found? Limitations What aspects of the study threaten the validity of the conclusions? Conclusion Do the authors believe that the result answers their question? How convincingly? may communicate the “bottom line” efficiently. A few articles are so important, in relation to one’s particular needs, that they are worth reading word for word, perhaps for participation in a journal club. Structured abstracts are organized according to the kinds of information that critical readers depend on when deciding whether to believe a study’s results. Table 14.6 shows headings of abstracts in structured form, along with the kind of information associated with them. (Traditional abstracts, with headings for Introduction, Methods, Results, and Discussion, are a shortened version.) These headings make it easier for readers to find the information they need and also force authors to include this information, some of which might otherwise have been left out if the abstract were less structured. Unfortunately, many clinicians set goals for journal reading that are higher than they can achieve. They believe they must look at each article in detail, which requires a lot of time with each journal issue. Too often, this results in postponing reading and perhaps never getting to it at all, and it can generate a lot of anxiety, self-reproach, and cluttered workspaces. If such negative feelings are associated with reading medical journals, something is wrong. GUIDING PATIENTS’ QUEST FOR HEALTH INFORMATION Patients now look up health information on the Internet. As a result, clinicians have different responsibilities for teaching their patients. One responsibility is to guide patients to the most credible Web sites. Simple searches, such as for migraine headaches or weight loss, find a rich array of sites, some among the best in the world, others zealous and misguided, and still others commercial and self-serving. Clinicians should be able to suggest especially good Web sites for the patient’s particular questions. There are many that are sponsored by governments, medical schools, professional organizations, and patient advocacy groups. Clinicians can also help patients recognize the best health information on the Web, guided by criteria formulated by the Medical Library Association (Table 14.7). Another responsibility is to help patients weigh the value of information they do find. Here, clinicians have a great deal to offer based on their understanding of clinical epidemiology, the biology of Table 14.7 Criteria Patients Can Use to Evaluate Health Information on the Web 1. Sponsorship • Can you easily identify the site sponsor? Are advisory board members and consultants listed? • What is the Web address (gov = government, edu = educational institution, org = professional organization, com = commercial)? 2. Currency • The site should have been updated recently, and the date of the latest revision posted. 3. Factual Information • The information should be about facts, not opinions, and can be verified from primary sources such as professional articles. • When opinions are stated, the source (a qualified professional or organization) should be identified. 4. Audience • The Web site should clearly state whether the information is for consumers or health professionals. (Some sites have separate areas for consumers and health professionals). Modified from Medical Library Association. A User’s Guide to Finding and Evaluating Health Information on the Web. Available at http:// mlanet.org/resources/userguide.html. Accessed August 1, 2012. EBSCOhost - printed on 5/4/2021 10:07 PM via PURDUE UNIVERSITY GLOBAL. All use subject to https://www.ebsco.com/terms-of-use Chapter 14: Knowledge Management disease, the clinical presentations of illness, the difference between isolated observations and consistent patterns of evidence, and much more. All of this is a valuable complement to what patients bring to the encounter—intense interest in a specific clinical question and the willingness to spend lots of time searching for answers. PUTTING KNOWLEDGE MANAGEMENT INTO PRACTICE Clinical epidemiology, as described in this book, is intended to make clinicians’ professional lives easier and more satisfying. Armed with a sound grounding in the principles by which the validity and generalizability of clinical information are judged, clinicians can more quickly and accurately detect whether the scientific basis for assertions is sound. For example, they can see when confidence intervals are consistent with clinically important benefit or harm or that a study of the effects of an intervention includes neither randomization nor other efforts to deal with confounding. They are better prepared to participate in discussions with 235 colleagues outside their specialty about patient care decisions. They have a better basis for deciding how to delegate some aspects of their information needs. They can gain more confidence and experience greater satisfaction with the intellectual aspects of their work. Beyond that, every clinician should have a plan for knowledge management, one that fits his or her particular needs and resources. The Internet must be an important part of the plan because no other medium is so comprehensive, up-to-date, and flexible. Much of the information needed to guide patient care decisions should be available at the point of care so that it can be brought to bear on the patient at hand. There is no reason why the information you use cannot be the best available in the world at the time, as long as you have access to the Internet. A workable approach to knowledge management must be active. Clinicians should set aside time periodically to revisit their plan, to learn about new opportunities as they arise, and to acquire new skills as they are needed. There has never been a time when the evidence base for clinical medicine was so strong and accessible. Why not make the most of it? Review Questions Read the following statements and select the best answer. 14.1. You are finishing residency and will begin practice. You want to establish a plan for keeping up with new developments in your field even though there are few professional colleagues in your community. All of the following might be useful, but which will be most useful to you? A. Subscribe to a few good journals. B. Buy new editions of printed textbooks. C. Subscribe to a service that reviews the literature in your field. D. Search MEDLINE at regular intervals. E. Keep up contacts with colleagues in your training program by e-mail and telephone. 14.2. You can rely on the best general medical C. Guarantee that the information they contain is beyond reproach. D. Expose you to the many dimensions of your profession. 14.3. Many children in your practice have attacks of otitis media. You want to base your management on the best available evidence. Which of the following is the least credible source of information on this question? A. A clinical practice guideline by a major medical society B. A systematic review published in a major journal C. The Cochrane Database of Systematic Reviews D. The most recent research article on this question 14.4. A search of MEDLINE is especially useful journals in your field to: for which of the following? A. Provide answers to clinical questions. B. Assure that you have kept up with the medical literature. A. Finding all of the best articles bearing on a clinical question B. An efficient strategy for finding the good articles EBSCOhost - printed on 5/4/2021 10:07 PM via PURDUE UNIVERSITY GLOBAL. All use subject to https://www.ebsco.com/terms-of-use 236 Clinical Epidemiology: The Essentials C. Looking for reports of rare events D. Keeping up with the medical literature E. Being familiar with the medical profession as a whole 14.5. Which of the following is accomplished by peer review of research manuscripts before they are published? A. Exclude articles by authors with a conflict of interest. B. Make the published article accurate and trustworthy. C. Relieve readers of the need to be skeptical about the study. D. Decide for the editors about whether they should publish the manuscript. 14.6. An author of an article showing that screen- ing colonoscopy is more effective in preventing colorectal cancer than other forms of screening would have conflicts of interest if he or she had any of the following except: A. Clinical income from performing colonoscopies B. Investment in a company that makes colonoscopies C. Investment in medical products in general D. Publications of articles that have consistently advocated colonoscopy as the best screening test E. Rivalry with other scholars who advocate another screening test 14.7. Which of the following is the least useful way of looking up answers to clinical questions at the point of care? A. Subscribing to several journals and keeping them available where you see patients B. Guidelines on http://www.guidelines.gov C. The Cochrane Library on the Internet D. A continually updated electronic textbook 14.8. Which of the following should be least reas- suring to a patient about the quality of a Web site providing information about HIV? A. The site is sponsored by a governmental agency and names its advisory board members. B. The site provides facts, not opinions. C. The primary source of information is stated. D. The author is a well-known expert in the field. E. The date of the last revision is posted and recent. 14.9. Which of the following is not part of grading clinical recommendations using the GRADE system? A. Deciding whether to use a diagnostic test B. Takes into account the balance of benefits and harms C. Rates the quality of scientific evidence separately D. Suggests how commonly and how forcefully a treatment should be recommended E. Rates the strength of the evidence and of recommendations separately 14.10. A comprehensive approach to managing knowledge in your field would include which of the following? A. Subscribing to some journals and browsing them B. Establishing a plan for looking up information at the point of care C. Finding a publication that helps you keep up with new developments in your field D. Identifying Web sites you can recommend to your patients E. All of the above Answers are in Appendix A. REFERENCES 1. Laine C, Horton, R, DeAngelis CD, et al. Clinical trial registration: looking back and moving ahead. Lancet 2007;369:1909– 1911. 2. Fletcher RH, Black B. “Spin” in scientific writing: scientific mischief and legal jeopardy. Med Law 2007;26(3):511–525. 3. Shariff SZ, Sontrop JM, Haynes RB, et al. Impact of PubMed search filters on the retrieval of evidence for physicians. CMAJ 2012;184:303. 4. Losanoff JE, Sauter ER, Rider KD. Cat scratch disease presenting with abdominal pain and retroperitoneal lymphadenopathy. J Clin Gastroentrol 2004;38:300–301. 5. Goodman SN, Berlin J, Fletcher SW, et al. Manuscript quality before and after peer review and editing at Annals of Internal Medicine. Ann Intern Med 1994;121:11–21. 6. Lacombe MA, ed. On Being a Doctor. Philadelphia: American College of Physicians; 1995. EBSCOhost - printed on 5/4/2021 10:07 PM via PURDUE UNIVERSITY GLOBAL. All use subject to https://www.ebsco.com/terms-of-use