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Rapid Responses: Rapid Responses published:
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Working Smarter with Information
- Neal Maskrey, Scott Peglar, Jonathan Underhill (16 August 2005)
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Re: Working Smarter with Information
- Graeme Mackenzie (18 August 2005)
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Neal Maskrey, Medical Director National Prescribing Centre, 70 Pembroke Place, Liverpool. L69 3GF, Scott Peglar, Jonathan Underhill
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Sir, In his letter titled "Where next with revalidation', Dr MacKenzie describes how "journal articles are sent around the email system every day for discussion” [1] Unfortunately, Dr Mackenzie fails to describe how the journal articles are selected prior to circulation to his colleagues and the origin of these articles e.g. from personal reading, pharmaceutical representatives, national press? Does the content circulated reflect recently published primary and secondary research, or is there a process for regularly revisiting the evidence on common clinical conditions that the clinicians see most frequently? The concept of widespread critical appraisal by clinicians is flawed. With increasing clinical workloads and other commitments, few health care practitioners have either the time or indeed the expertise to permit detailed critical appraisal of clinical papers to influence their practice. Furthermore, relying on 'expert' reviews of clinical papers is also potentially flawed, as has been described recently. [2] We suggest that filtering articles, firstly for relevance and then for validity could potentially save much time and effort. The relevance filter is relatively easy to apply by only reading those papers that satisfy the following criteria (COFF): C – Does the article require me to Change my practice?
If any of these questions are answered ‘no’, then the paper can be rejected and the clinician does not need to read it further. Assessing validity is a much more difficult and lengthy process. For these reasons it may be better for busy clinicians to use syntheses of evidence from reliable sources (see below) where someone has 'done the critical appraisal bit for them'. This leaves clinicians more time to actually discuss the implications such papers may have on their own practice and, more importantly, greater time to actually apply the valid evidence to the benefit of patients. We use these sources for pre-appraised summaries of evidence and / or updates re newly published research: BMJ updates (http://bmjupdates.mcmaster.ca/index.asp)
These resources all have strengths and weaknesses. None of them alone can fulfil all of our needs, but synergistically we find they work well. In addition to using pre-appraised summaries of evidence from a trusted source, action may be required to recognise and then respond to the uncomfortable conclusion that current clinical practice may be based on biased ‘mindlines’ and may require reassessment.[3, 4] This is fundamentally different and is at least as important as circulating new research. That organisational factors are key to implementing changes in clinical practice is incontrovertible [5] and the approach of Mackenzie’s practice is one more laudable example of this. However, such changes need to be harnessed to both easily accessible summaries of evidence, and to educational initiatives that support examination, discussion and debate of how such evidence could be incorporated into clinical practice. Research findings (new and not so new) may (at last) then be adopted more easily. Our money too is on IT solutions, but only if linked to individualised learning focussed on commonly presenting conditions, and facilitated by appropriate organisational changes. Yours, Neal Maskrey
Scott Pegler
Jonathan Underhill
References:- 1. MacKenzie GM. Where next with revalidation?: Smart money is on using new communications technology effectively. BMJ 2005; 331: 352. 2 Shaugnessy AF, Slawson DC. What happened to the valid POEMs. A survey of review articles on the treatment of type II diabetes. BMJ 2003, 327: 266. 3. Klein JG. Five pitfalls in decisions about diagnosis and prescribing. BMJ 2005; 330: 781 – 4. 4. Gabbay J, le May A. Evidence based guidelines or collectively constructed "mindlines?" Ethnographic study of knowledge management in primary care. BMJ 2004; 329:1013 – 15. 5. Greenhalgh T, et al. How to spread good ideas: a systematic review of the literature on diffusion, dissemination and sustainability of innovations in health service delivery and organisation. Report for the National Coordinating Centre for NHS Service Delivery and organisation R&D (NCCSDO). April 2004. Competing interests: NM and JLU are salaried employees of the National Prescribing Centre (an NHS organisation funded by the Department of Health and NICE). The NPC produces MeReC Publications. SP is the distributor for InfoPOEM Inc. in the UK & Ireland. |
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Graeme Mackenzie, GP Whitehaven UK CA28 9RG
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I like this approach. We will change accordingly. Of course our system is not just papers. It includes sharing of many patient journeys throughout the team and means we can all have each others experience all of the time: an enormous learning experience and certainly exposes some of our prejudices every day! Competing interests: None declared |
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