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Clinical Reasoning Workshop

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Heather Edmonds

on 19 January 2012

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Transcript of Clinical Reasoning Workshop

clinical reasoning
things to keep in mind
determining the best treatment for your patient
finding and evaluating
EBM resources

understanding, finding, and using quality resources
thank you!
How do you determine the best treatment for your patient?
With CLINICAL EXPERTISE: the ability to use clinical skills and experience at all stages of clinical work with patients.

By taking into account PATIENTS' VALUES: each individual's unique preference, concerns, and expectations related to clinical decisions. Their psychological state and the familial and socioeconomic context in which they live may modify -- or even nullify -- therapeutic decisions based on scientific research.

By using CLINICALLY RELEVANT research; i.e., evidence. Peer-reviewed and published evidence influences treatment.
Clinically relevant research often turns into medical and scientific literature.
"In essence, any medical article is, and must be, an exercise in
logic
and
critical thinking
applied to
OBTAINING,
EVALUATING,
and USING
the best possible
evidence
."
Structure of a scientific article:
Introduction

Materials and Methods

Results

Discussion

Conclusions
Introduction
The problem is explained. Objects of inquiry are given, and the hypothesis on which the objective(s) are based are formulated.
Research subjects and all variable factors (possible causes, characteristics, time, place, etc.) are defined and described in operational and reproducible terms. How the information was gathered is also noted.
Materials and Methods
Results
Discussion
Conclusions
Discussion
and
Conclusions
=
the "Message"
What could go wrong?
Deficiencies in

Conclusions
Conclusions
could:

be based on an inadequately-stated hypothesis

be ambiguously phrased

fail to acknowledge negative findings

not be supported by the data

use fallacious reasoning

fail to consider alternative explanations

These are all reasons why the review process for published articles is very important.
Types of evidence:
Clinical Trials

Observational Studies
:
Case Reports
Case Series
Cross-Sectional Studies
Case-Controlled Studies
Cohort
Registry Studies
Qualitative Studies
Etc.
Clinical Trials: the Gold Standard
Why is this type of study so powerful?

Prospective: follows study subjects forward in time

Experimental

Uses control groups

Often randomized (reduces bias)

Often blinded/masked (reduces bias)
What are the limitations of Clinical Trials?
Unreliable for detection of rare or late adverse effects

Limited values for detection of unexpected adverse effects

Ethical limitations
What are the strengths of Observational Studies?
Greater access to large, diverse populations

Provide a quicker result, and cost less

An alternative for when clinical trials are not possible and/or ethical

Important for determining adverse reactions that are uncommon, unexpected, or occur late

May be descriptive or comparative

Valuable for generating new hypotheses
Case Reports
Case Series
Cross-Sectional Studies
Case-Controlled Studies
Cohort
Registry Studies
Qualitative Studies
What are the limitations of
Observational Studies?
Retrospective nature may limit data quality

Recall bias

Group comparability is a critical factor (selection bias)

General lack of control
Interpreting statistics: resources
Takeaways
Determining the best plan of treatment for your patient involves:

Making the most of your clinical expertise

Taking the patient's values, concerns, and expectations into account

Relying on clinically-relevant research (evidence), including scientific articles such as clinical trials and observational studies
So quick...so easy...so familiar

...so why isn't it the best solution this time?
Big-box store
(Google)
Specialty store
(Scientific databases)
vs.
And what about
?
Street vendor
(Wikipedia)
vs.
High-end shop
(Scientific databases)
Remember: not all information sources
are created equal
Be
critical
of where your information is coming from.  

Ask yourself:
WHO wrote this?
Are they qualified?
Could they have a hidden agenda?
For what PURPOSE was it written?
Who is the intended AUDIENCE?
 
The bottom line: you need to make sure your source is
reliable
.   
 
Poor, inadequate, and/or unreliable information could
put your patients' health at risk
.
contact us:

email
: library@neco.edu

in person
: face-to-face anytime

by appointment
: for BIG research questions

"What do I need to know for this project,
and how do I go about getting it?"
Hint: it's all available here.
Use the research guide to find the treatment and standards of care for your patient's disease.
kristin motte, dir. of library services
heather edmonds, tech. services librarian

Observations and crude findings are presented (i.e., data).
The meanings of the findings are interpreted.
What can be done with the findings is summarized, as are the research implications and uses of the findings in practical decision making.
The
Discussion
and
Conclusions
sections present the logical arguments drawn from the preceding sections.

They are an opportunity to argue about findings, give them meaning, outline strengths and weaknesses of the studies, and stress their relevance for further research or discussion in clinical practice.
Introduction
Materials and Methods
Results
Discussion
Conclusions
Introduction
Materials and Methods
Results
Discussion
Conclusions
Introduction
Materials and Methods
Results
Discussion
Conclusions
Introduction
Materials and Methods
Results
Discussion
Conclusions
Introduction
Materials and Methods
Results
Discussion
Conclusions
Remember:
Always cite your sources!
If you don't properly cite the sources you use -- including books, online resources, photos, etc. --
it's considered plagiarism.
Zotero:
The secret to quick citation formatting
Google Docs
Cool Tools
http://necolib-cooltools.wikispaces.com
Questions?
Mindmapping:
The perfect way to plan a search
What's your question, or the problem that needs to be solved?
This should go in the center of the page.
Mr. Smith has cataracts. What do we need to know about cataracts in order to
treat his condition effectively?
Next, put the things you need to know to answer the question/problem around it. 
Mr. Smith has cataracts. What do we need to know about cataracts in order to
treat his condition effectively?
case history
diagnostic tests
risk factors
etiology (causes)
of condition
symptoms
study that impacted
treatment
effects of condition at tissue/cell level
parts of the eye involved
standards of care/
treatment
general
description
of condition
Mr. Smith has cataracts. What do we need to know about cataracts in order to
treat his condition effectively?
case history
diagnostic tests
risk factors
etiology (causes)
of condition
symptoms
study that impacted
treatment
effects of condition at tissue/cell level
parts of the eye involved
standards of care/
treatment
general
description
of condition
patient
interview
PubMed Clinical
Queries

ClinicalTrials.gov

Cochrane Library
textbook
AOA Practice
Guideline

textbook
AOA Practice
Guideline
textbook

clinical manuals
AOA Practice
Guideline
Wills Eye
Manual

Mass. Eye and
Ear Manual
dictionary

atlas

encyclopedia

internet

textbook
textbook
What resources should you use
to find each particular information need? 
Write these next to each.
Mindmapping Tools
mindmeister.com
bubbl.us
mind42.com
mindomo.com
Activity!
Boolean Searching
is a fancy term for...
using conjunctions such as
AND
OR
NOT
,
,
and
to eliminate the results you don't want.
AND
glaucoma
women
purple
= all results with glaucoma AND women.
narrows a search, resulting in fewer hits.
AND
Activity!
1. Open PubMed Clinical Queries.
2. Use a keyword of your choosing to conduct a search.

How many results did you get?
3. Choose a related term, and conduct a second search.

How many results did you get?
4. Now, combine the two terms with an AND, and conduct a third search.

How many results this time?
herpes zoster
shingles
OR
teal
= all results with either just SHINGLES,
just HERPES ZOSTER, or both SHINGLES
and HERPES ZOSTER.
OR
broadens a search, resulting in more hits.
Activity!
1. Open PubMed Clinical Queries.
2. Use two keywords of your choosing, combine them with
AND
, and conduct a search.

How many results did you get?
3. Use the same keywords, but this time, combine them with
OR
.

How many results did you get?
NOT
Caucasian
glaucoma
pink
= all results with glaucoma and
EXCLUDING Caucasian.
NOT
excludes terms that you specifically
do not want to include.
Activity!
1. Open the library’s online catalog.
2. Use two keywords of your choosing, combine them with
OR
, and conduct a search.

How many results did you get?
3. Use the same keywords, but this time, combine them with
NOT
.

How many results did you get?
Parentheses (Nesting)
You can use parentheses
for an even more precise search.
for example:

(
cataract
OR
glaucoma
) AND
retina

will include all items with
[
cataract
and
retina
] and
[
glaucoma
and
retina
].
Truncation
Truncating
– adding an asterisk (
*
)
at the end of a word stem –
will retrieve all words that begin with that stem. for example:
opto
*
will retrieve results with
optometry
,
optometrist
,
optometer
,
optokinetic
,
optophone
,
optotype
, etc.

Jenicek M, Hitchcock D. Evidence-based practice: logic and critical thinking in medicine, p. 149.
Petrie, Aviva. Medical statistics at a glance. 2nd ed. Blackwell, 2005.
R853.S7 P48 2005

Scott, Ian. Statistics for health care professionals: an introduction. SAGE, 2005.
RA409 .S365 2005

Everitt, Brian. Medical statistics from A to Z: a guide for clinicians and medical students. Cambridge University Press, 2003.
R853.S7 E94 2003

Banerjee, Ashis. Medical statistics made clear: an introduction to basic concepts. Royal Society of Medicine, 2003.
R853.S7 B36 2003

Coggon, David. Statistics in clinical practice. BMJ, 2003.
RA409 .C64 2003

Cleophas, Ton J.M. Statistics applied to clinical trials. Kluwer, 2002.

R853.C55 C54 2002
http://en.wikipedia.org/wiki/Contact_lens
http://www.tinyurl.com/clinicalresearchproject
Library home page
Clinical Reasoning Patient Project guide
http://www.neco.edu/library
Fenway Libraries Online and Using the library catalog
http://tinyurl.com/NECOLibraryHelp
Get full text
http://www.neco.edu/library
Jenicek M, Hitchcock D. Evidence-based practice: logic and critical thinking in medicine. American Medical Association, 2005.
R723.7 .J465 2005

Paul R, Elder L. A miniature guide for students and faculty to scientific thinking. 2nd ed. Pearson/Prentice Hall, 2006.
BF441 .P38 2006

Hulley S. Designing clinical research. 3rd ed. Lippincott, Williams & Wilkins, 2007.
R853.C55 D47 2007

National Center for Teaching Thinking: 16th Annual International Summer Institute.
http://www.nctt.net

Furberg B, Furberg C. Evaluating clinical research: all that glitters is not gold. 2nd ed. Springer, 2007.
R853.C55 .F87 2007
References
Photo by Curtis Gregory Perry under a Creative Commons License.
(c) mindmeister.com
(c) bubbl.us
(c) mind42.com
(c) mindomo.com
Photo by carlandkalah under a Creative Commons License.
Photo available for use under a Creative Commons License.
(c) wikipedia.org
Photo available for use under a Creative Commons license.
Photo available for use under a Creative Commons license.
http://zotero.org
Full transcript