Badri:
I also want to join those who applauded your attempt to assess the state of
our knowledge with 2 caveats only:
1) there is more to clinical reasoning/problem solving/decision making than
understanding and interpreting the quality of medical evidence
2) " a sample size" of 1 case might not be sufficient. As Albert Kirshen
suggested "selecting the whole series for 1 year" would be more valuable.
congratulations on your attempt!
ben d.
Benjamin Djulbegovic, MD
Associate Professor of Medicine
H. Lee Moffitt Cancer Center & Research Institute
at the University of South Florida
Division of Blood and Bone Marrow Transplant
12902 Magnolia Drive
Tampa, FL 33612
Editor: Evidence-based Oncology
e-mail:[log in to unmask]
http://www.hsc.usf.edu/~bdjulbeg/
phone:(813)979-7202
fax:(813)979-3071
> -----Original Message-----
> From: padmanabhan badrinath [SMTP:[log in to unmask]]
> Sent: Saturday, October 30, 1999 5:26 AM
> To: [log in to unmask]
> Subject: Audit of Authors Evidence (NEJM)
>
> Dear All,
> Greetings from Al-Ain, the Oasis city of the Middle East.
>
> Few weeks ago, on one of the week ends while I was scanning the journals
> for
> compilation of JSCAN, our professional news letter for local circulation,
> I
> came across this (1) clinical problem solving series in the NEJM. As the
> authors were dealing with diagnostic and management issues on a clinical
> scenario I wanted to look at the evidence they quoted to support their
> material. I initially proposed to undertake this exercise and share it
> with
> the list. Then I had a brain wave! Why can't I submit it as a letter to
> the
> Journal. The journal has come back to me saying that due to the tremendous
>
> pressure on the limited space available in NEJM, they regret that many
> worthwhile communications like mine cannot be printed. So I am keen to
> share
> this worthwhile communication with the audience to whom it was originally
> intended for.
>
> If you are not interested in this any more please delete the message. If
> you
> think it is ineresting and may be worthwhile then, here is the letter I
> sent
> to the NEJM. Any comments and criticisms will be gratefully received.
>
> As I cannot fit Table 1 in the mail I am sending it as an attachment.
> Though you have just begun your week end our week has just commenced.
>
> Cheers & warm regards,
>
> Badri
>
>
> Clinical problem - solving: Back to the basics - a reader's audit on the
> authors' evidence.
>
> To the Editor,
>
> In the recent article by Fisk et al(1)information about a real paraplegia
> patient with general and abdominal symptoms was presented in stages to an
> expert clinician, who responded sharing his/her reasoning with the reader.
>
> The authors' commentary, which followed attempted to provide evidence for
> the various steps, involved in diagnosing the patient's condition. As the
> case with NEJM other front line journals have introduced sections(2)that
> try
> to bring together the external clinical evidence in individual patient
> care.
> Evidence based medicine (EBM) has been defined as the conscientious,
> explicit and judicious use of current best evidence in making decisions
> about the care of individual patients(3. Hierarchy of evidence and the
> research methods through which evidence is generated form a part of this
> new
> paradigm(4).
>
> As a self-commissioned auditor I attempted to analyze the evidence
> presented
> by the authors for this article and classify them based on study designs
> and
> levels of evidence wherever appropriate. I went through all the references
>
> provided by the authors through Internet grateful Med(5)and accessed the
> abstracts and in some cases the full texts of the articles. Using the MeSH
>
> (Medical subject heading) terms of the key word in the references and
> applying the various limit functions, I also attempted to identify any
> higher level of evidence other than that provided by the authors (for
> e.g.,
> meta-analysis, randomized controlled trials etc)
>
> There were 17 references in the articles of which one referred to a book
> and
> another was a paper in press by the second author. The remaining 15 were
> articles in journals. Apart from a 1975 paper, others were published
> between
> 1985-1999 (mean 1994, SD 4.05). Table 1 shows the types of studies and
> their
> probable levels of evidence for the references.
>
> It is interesting that only 3 references could be classified as level I
> evidence (meta-analysis, evidence-based synthesis and a diagnostic study)
> and 40% were reviews (6/15). Though the attempt to classify the authors'
> commentary (the references provided) by levels of evidence was crude in
> nature, it is apparent that narrative reviews are still the main source of
>
> evidence in this example. One possible explanation could be due to the
> specific (narrow) nature of this clinical problem and it remains to be
> seen
> whether a commoner clinical problem would produce better quality evidence.
>
> [381 words]
>
>
>
> References
>
> 1) Fisk DT, Saint S, Tierney LM. Back to the basics. N Engl J Med 1999;
> 341:747-750.
>
> 2) Sackett DL, Rosenberg WMC, Gray JAM, Haynes BR, Richardson WS. Evidence
>
> based medicine: what it is and what it isn't. BMJ 1996; 312: 71-72.
>
> 3) http://cebm.jr2.ox.ac.uk/docs/levels.html visited on 05.09.99
>
> 4) Vause S, Macintosh M. Evidence based case report: Use of prostaglandins
>
> to induce labor in women with a caesarian section scar. BMJ
> 1999;318:1056-1058.
>
> 5) http://igm.nlm.nih.gov visited on 05.09.99
>
>
>
> Dr.P.Badrinath M.D.,M.Phil.,(Epid) PhD(Cantab)
> Assistant Professor and Epidemiologist,
> Department of Community Medicine,
> UAE University, PO Box 17666, Al Ain,
> United Arab Emirates.
> Tel: 00 971 3 5039 652
> Fax: 00 971 3 672022.
> [log in to unmask]
> [log in to unmask]
>
>
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