By M. Barrack. Midwestern Baptist College.
In addition to supporting these domains feedback is often perceived as less critical and constructive of competency generic 6.5 mg nitroglycerin amex, collegiality by defnition engenders the kind of in criticism cheap nitroglycerin 2.5mg amex, when discussing topics of communication with mutual respect and support that helps to prevent the intimida- colleagues discount 2.5 mg nitroglycerin free shipping. This kind of evaluation process can ensure that the tion and harassment of colleagues. Moreover, where healthy resident is evaluated fairly by all members of the team and collegiality exists, physicians will not only support one another removes pressure off of the physician preceptor who may during good times, but will also protect one another’s health by have challenges providing critical feedback. For the residents recognizing when colleagues are in trouble and helping them involved, it builds skills in giving feedback on professional to get the support they need. Ottawa: departments that do not foster collegiality suffer from poor The Royal College of Physicians and Surgeons of Canada. Collegiality is an important predictor of job satisfaction, and Bulletin of the New York Academy of Medicine. For example, learning can be facilitated by group ac- and tivities such as workshops and tutorials. When well organized, • discuss the broader responsibilities associated with col- these activities expose each learner to a range of beliefs and legiality, especially with regard to physician colleagues. By serving both to broaden perspectives and foster the mutual Case respect of both, teacher and learner, this approach can also Although a second-year resident has been an important in- provide an important model for maintaining respect within novator and leader among their peers, over the past three the physician–patient relationship. By fostering collegiality, months they appear to have become more withdrawn and academic medicine has the opportunity to enhance the quality isolated. A formerly vibrant personality seems to have of medical graduates as well as, to provide a good basis for been replaced by moodiness and introversion. Some of the resident’s peers notice practised in a health care system that is constantly changing the resident drinking more alcohol than usual one night and increasingly demanding. There are also rumours that the effective communication to the delivery of quality medical care resident may have been in some sort of trouble with the is well recognized, and the term collegiality has come to refer law recently. In addition, a legal proceeding involving one to professionals working together as equals and sharing in de- of the resident’s cases, which had an adverse outcome two cision-making. Care of the patient can be a complex challenge years ago, is scheduled in civil court soon. In speaking of multidisciplinary care, we can forget that such care involves more than a multidisciplinary group comprised Introduction of physicians. True collegiality involves collaboration with Like college and colleagues, the word collegiality derives from other health care disciplines, and there is much that each can the Latin collegere: to read together. In fact, the reality is that team members setting, is often thought of in association with the concept of need one another in order to form a resilient and sustainable a collegium: “a collection, body, or society of persons engaged workforce. Having said that, collegiality between collaborators in common pursuits, or having common duties and interests, is not automatic. It needs to be fostered and nurtured with re- and sometimes, by charter, peculiar rights and privileges. When a collegial atmosphere exists in an academic centre it can create a safe and productive setting for both teachers and Collegiality offers the beneft of a safe and protective com- learners. Collegiality can create a culture in which uncertainty, munity that can help us to cope in the face of stressful work lack of knowledge and feelings of incompetence are both tol- environments. It maximizes open communication and or advantaged club: it implies certain duties and responsibilities. In such a setting, Society does not appreciate a self-protective collegiality that a collegial faculty would be one that values a commitment to circles the wagons around questionable professional behav- the sharing of knowledge. And so it is important to remember that, like everyone else, physicians get sick and grow old, and that in the process their competence can be compromised. As is discussed elsewhere in this handbook, certain aspects of the culture of medicine, together with typi- cal attributes that otherwise hold physicians in good stead, can make physicians reluctant to admit when they fnd themselves in diffculty. However, the physician’s responsibility to maintain his or her own health in order to practise safely also extends to a collegial duty to be aware of the health and ftness of others. Case resolution In the past, ill physicians, worried that their medical licence It is important for any organization or group to cultivate might be put in jeopardy, remained silent until a complaint was collegiality and mentorship. In this case, rumours are reported to a regulatory body or an adverse event occurred. The resident Even now, despite the availability of organized physician health might have a substance use disorder, a signifcant depres- programs in every Canadian province to assist physicians in sion, an adjustment disorder or some other reason for the diffculty, we cannot ignore our collegial responsibility to sup- apparent change in behaviour. Nor is it a colleague’s role wait until problems are of such severity that regulatory bodies to try to diagnose or to treat the resident. Workplaces should have mechanisms in however, for a trusted colleague or colleagues to respect- place to ensure that potentially impaired practitioners promptly fully ask to meet with the resident privately and to present cease practice until their ftness to practise can be assessed. It would be appropriate to offer assistance Too often, however, a misguided sense of collegiality makes in connecting the resident with a personal physician if the physicians hesitate to respond to a colleague in diffculty or resident doesn’t have one. In this case it would be appropriate for the colleague or colleagues to research contact information for the local An organized and responsible method for dealing with mat- physician health program and assist the resident in orga- ters of potential physician impairment would involve early nizing an appointment with medical staff there. It might identifcation of physicians who might require assistance and even be ftting for a colleague to accompany the resident to the provision of timely and caring intervention when it is such an appointment, but not to be part of that meeting. Help could include offering encouragement, covering Alternatively, it might be appropriate to follow up with practice duties, referral to remedial assistance and, eventually, the resident to try to ensure that they had indeed made mentorship for physicians returning to work after an absence. Academic departments or group It is to be hoped that incapacitated colleagues will respond practices should cultivate a resource list of primary care appropriately to support and advice, but at the end of the day physicians who are community based and not necessarily we cannot ignore our legal and ethical obligations to report associated with academic departments. These providers to the appropriate bodies impaired physicians who insist on should have experience in caring for physician colleagues practising despite reasonable offers of assistance. A supportive collegial group works proactively as a team to ensure the optimal function of all members. It is not focused Key references only on the individual practitioner’s health, but also on the Brown G, Rohin M, Manogue M. Effective Learning & Teaching in Medical, Dental & Veterinary contribute to the stress of health care staff, but also encour- Education. Although confict in acterization of confict, medical workplaces and academic settings is common, it can • describe factors that infuence styles of dealing with con- be diffcult to deal with, especially when its determinants fict, and are poorly understood. Given that interpersonal confict is • discuss collaborative attitudes and communication skills potentially all around us, it is important to learn strategies that that support the creative resolution of confict. Case Most instances of confict appear to have had an immediate, Two enthusiastic and ambitious residents seem to have observable trigger, a hot-button issue of some kind. In reality, butted heads regularly on several issues during their three the problem is usually more complex. Conficts occur repeatedly, other variables, of which the parties involved might not be whether it surrounds organizing the on-call rota, holiday fully aware. Such variables include the power relationships, true schedules, or topics for grand rounds. The confict seems needs as opposed to apparent wants, and styles in dealing with to be escalating, and each sees the other’s behaviour confict. As is typical of unresolved it is important to be aware of our own typical responses to confict, the situation is becoming personalized, and both confict—our “confict styles. It is normal The situation is becoming diffcult for the department as to make presumptions and assumptions on the basis of experi- a whole, as both residents each seek to recruit colleagues ence. In this module we focus on interpersonal con- When we are in confict we can demonstrate behaviour that fict, which occurs when human need or interest is frustrated. A defensive style is usually more has been defned as “a situation in which one or both persons adversarial, and refects the extent to which we are attempting in a relationship are experiencing diffculty in working or living to satisfy our own needs.
The information is delivered in a compact format that highlights the pertinent infor- mation while at the same time providing enough background information for further research if required cheap 2.5mg nitroglycerin with visa. DynaMed uses a seven-step evidence- based methodology to create topic summaries that are organized both alpha- betically and by category discount nitroglycerin 6.5mg with mastercard. The selection process includes daily monitoring of the content of over 500 medical journals and systematic review databases generic nitroglycerin 6.5mg. This includes a systematic search using such resources as PubMed’s Clinical Queries feature, the Cochrane Library databases, and the National Guidelines Clearing- house. Once this step is complete, relevance and validity are determined and the information is critically appraised. DynaMed uses the Users’ Guides to Evidence- Based Practice from the Evidence-Based Medicine Working Group, Centre for Health Evidence as a basis for determining the level of evidence. DynaMed ranks information into three levels: Level 1 (likely reliable), Level 2 (mid-level), and Level 3 (lacking direction). All authors and reviewers of DynaMed topics are required to have some clinical practice experience. Individual topics can be searched or can be browsed by subject, database, and tools. The bottom line provides the conclusion arrived at to answer the clinical question and provides a level of evi- dence ranking based on the ﬁve levels of evidence ranking from the Centre for Evidence-Based Medicine in Oxford. Clinical Evidence, published by the British Medical Journal is available on their website at www. An international group of peer reviewers publish summaries of systematic reviews of important clinical ques- tions. It is primarily focused on conditions in internal medicine and surgery and does cover many newer technologies. The evidence provided is rated as deﬁnitely beneﬁcial, probably beneﬁcial, uncertain, probably not beneﬁcial, or deﬁnitely not beneﬁcial. Created in 1999, it has been redesigned and revised by an international advi- sory board, clinicians, patient support groups, and contributors. They aim for sources that have high relevance and validity and require low time and effort by the user. Their reviews try to show when uncertainty stems from gaps in the best available evidence. It has been translated into Italian, Spanish, Russian, German, Hungarian, and Portuguese. Efﬁcient searching at the point of care databases The searching techniques described in this chapter are designed to ﬁnd pri- mary studies of medical research. These comprehensive searching processes will Searching the medical literature 53 Fig. The practice- based learner must ﬁnd primary sources at the point of care and will not per- form comprehensive PubMed searches on a regular basis. They will be looking for pre-appraised sources and well done meta-analyses such as those done by the Cochrane Collaboration. Most clinicians will want to do the most efﬁcient searching at the point of care possible to aid the patient sitting in front of them. An increasing number of sites on the Internet are available for doing this point of care searching. David Slawson and Allen Shaughnessy proposed an equation to determine the usefulness of evidence (or information) to practicing clinicians. They described the usefulness as equal to the relevance times validity divided by effort (to obtain). Always turning to primary sources of evidence whenever a clinical ques- tion comes up is very inefﬁcient at best and impossible for most busy practi- tioners. The busy clinician in need of rapid access to the most current literature requires quick access to high quality pre-appraised and summarized sources of evidence that can be accessed during a patient visit. For the “users,” the 5S schema of Haynes is a construct to help focus the skills of Information Mastery. The highest level is that of systems, which are decision support tools inte- grated into the daily practice of medicine through mechanisms such as com- puterized order entry systems or electronic medical records. The system links directly to the high quality information needed at the point of care and seam- lessly integrated into the care process. The next level is synthesis, which are critically appraised topics and guidelines. Many of these are through publishing enterprises such as Clinical Evidence pub- lished by the British Medical Journal. This print-based resource summarizes the best available evidence of prevention and treatment interventions for commonly eoncountered clinical problems in internal medicine. The primary ones in the category are from the Cochrane Database of System- atic Reviews, described earlier in the book as a database of systematic reviews authored and updated by the worldwide Cochrane Collaboration. Finally, the lowest level is “Expert Opinion” or Replication level, which is not considered bona ﬁde evidence, but only anecdote or unsubstanti- ated evidence. No matter how thorough a search strategy is, inevitably some resources will be missed and the process will need to be repeated and reﬁned. Use the results of an initial search to retrieve relevant papers which can then be used to further reﬁne the searches by searching the bibliographies of the relevant papers for arti- cles missed by the initial search and by performing a citation search using either Scopus or Web of Science databases. These identify papers that have cited the identiﬁed relevant studies, some of which may be subsequent primary research. These records can be used to design a strategy that can be executed within a more specialized database. Always remember that, if the information isn’t found in the ﬁrst source consulted, there are a myriad of options available to the searcher. Finally, the new reliance on electronic searching methods has increased the role of the health sciences librarian who can provide guidance and assis- tance in the searching process and should be consulted early in the process. Databases and websites are updated frequently and it is the librarian’s role to maintain a competency in expert searching techniques to help with the most difﬁcult searching challenge. Pierre Pachet, Professor of Physiology, Toulouse University, 1872 Learning objectives In this chapter you will learn: r the unique characteristics, strengths, and weaknesses of common clinical research study designs r descriptive – cross-sectional, case reports, case series r timed – prospective, retrospective r longitudinal – observational (case–control, cohort, non-concurrent cohort), interventional (clinical trial) r the levels of evidence and how study design affects the strength of evidence. Since various research study designs can accomplish different goals, not all studies will be able to show the same thing. Therefore, the ﬁrst step in assessing the validity of a research study is to determine the study design. The ability to prove causation and expected potential biases will largely be determined by the design of the study. Identify the study design When critically appraising a research study, you must ﬁrst understand what dif- ferent research study designs are able to accomplish. Characterizations in this manner, or so-called timed studies, have traditionally been divided into prospec- tive and retrospective study designs.
These include the type of variable cheap nitroglycerin 2.5mg free shipping, statisti- cal test cheap nitroglycerin 6.5mg line, degree of variability buy nitroglycerin 6.5 mg otc, effect size, and the sample size. The type of variable can be dichotomous, ordinal, or continuous, and for a high power, continuous variables are best. For the statistical test, a one-tailed test has more power than a two-tailed test. The degree of variability is based on the standard deviation, and in general, the smaller the standard deviation, the greater the power. The bigger the better is the basic principle when using the effect size and the sample size to increase a study’s power. These concepts are directly related to the concept of conﬁdence discussed√ in Chapter 10. The conﬁdence formula (conﬁdence = (signal/noise)√ × n) can be written as conﬁdence = (effect size/standard devia- tion) × n. According to this formula, as effect size or sample size increases, con- ﬁdence increases, thus the power increases. Effect of sample size on power Sample size (n) has the most obvious effect on the power of a study with power increasing in proportion to the square root of the sample size. If the sample size is very large, an experiment is more likely to show statistical signiﬁcance even if there is a small effect size. The smaller the sample size, the harder it is to ﬁnd statistical signiﬁcance even if one is look- ing for a large effect size. Remember the two groups of college psychology stu- dents at the start of this chapter. It turns out, when the scores for the two groups were combined, the results were statistically signiﬁcant. For example, one does a study to ﬁnd out if ibuprofen is good for relieving the pain of osteoarthritis. The results were that patients taking ibuprofen had 50% less pain than those taking placebo. If one then repeats the study and gets exactly the same results with 25 patients in each group, then the result turns out to be statistically signiﬁcant. In the extreme, studies of tens of thousands of patients will often ﬁnd very tiny effect sizes, such as 1% difference or less, to be statistically signiﬁcant. This is the most important reason to use the number needed to treat instead of only P < 0. Two variables with different sample sizes and the most likely have minimal, if any, beneﬁt from the treatment. The area ﬁdence intervals, a larger sample size will lead to narrower 95% conﬁdence under the curves is proportional intervals. The samples on the left with a small sample size are not statistically Effect of effect size on power signiﬁcantly different (p > 0. The ones on the right with Before an experiment is done, effect size is estimated as the difference between a larger sample size have an groups that will be clinically important. The sample size needed to detect the effect size that is statistically predetermined effect size can then be calculated. However, as discussed above, if the sample size is large enough, even a very small effect size may be statistically signiﬁcant but not clinically important. Effect of level of signiﬁcance on power The magnitude of the level of signiﬁcance, α, tells the reader how willing the researchers are to have a result that occurred only by chance. If α is large, the study will have more power to ﬁnd a statistically signiﬁcant difference between 134 Essential Evidence-Based Medicine δ 1 δ 2 P > 0. The results of the group on the left with a small effect size are not statistically signiﬁcantly different (p > 0. The ones on the right with a larger effect size have a result that is statistically signiﬁcant (p < 0. If α is very small, researchers are willing to accept only a tiny likelihood that the effect size found occurred by chance alone. In general, as the level of α increases, we are willing to have a greater likelihood that the effect size occurred by chance alone (Fig. We are more likely to ﬁnd the difference to be sta- tistically signiﬁcant if the level of α is larger rather than smaller. In thecaseontheleftthereisa large standard deviation, while Effect of standard deviation on power on the right there is a small standard deviation. The situation The smaller the standard deviation of the data-sets, the better the power of the on the right will be statistically study. If two samples each have small standard deviations, a statistical test is signiﬁcant (p < 0. When the two normal distributions are compared, the one with the smallest spread will have the most likelihood of being found statistically signiﬁcant (Fig. This is important because a negative result may not be due to the lack of an important effect, but simply because of the inability to detect that effect statistically. From an interpretation perspective, the question one asks is, “For a given β level and a difference that I consider clinically important, did the researcher use a large enough sample size? The three common ways of doing this are through the interpretation of the conﬁdence intervals, by 136 Essential Evidence-Based Medicine using sample size nomograms, and with published power tables. We will discuss the ﬁrst two methods since they can be done most simply without specialized references. For the difference between two groups, it gives the range of the most likely difference between the two groups under consideration. This suggests that a larger study could ﬁnd a difference that was statisti- cally signiﬁcant, although maybe not as large as 25mm. If there were no other evidence available, it might be rea- sonable to use the better drug until either a more powerful study or a well-done meta-analysis showed a clear-cut superiority of one treatment over the other, or showed equivalence of the two drugs. In this case, consider the study to be negative, at least until another and much larger study comes along. Evaluating negative studies using a nomogram There are two ways to analyze the results of a negative study using published nomograms from an article by Young and others. Either method will show, for a study with suf- ﬁcient power, what sample size was necessary or what effect size could be found to produce statistical signiﬁcance. In the ﬁrst method, use the nomogram to determine the effect size that the sample size of the study had the power to ﬁnd. If the effect size that could potentially have been found with this sample size was larger than the effect size that a clinician or patient would consider clinically important, accept the study as negative. In other words, in this study, the clinically important difference could have been found and was not. On the other hand, if the clinically important effect size could not have been found with the sample size that was enrolled, the study was too small. The second way of analyzing a negative study is to determine the sample size needed to get a clinically important effect size. Use the nomograms starting from the effect size that one considers clinically important and determine the sample size that would be needed to ﬁnd this effect size.
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