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Host Inquiry Worksheet document sample
Document Sample
Writing a Clinical Inquiry
A Collaborative Tool for Learning and Teaching
Evidence-based Medicine
Presenters
Gary Kelsberg, MD, University of Washington
Valerie King, MD, MPH, Oregon Health and Sciences University
Jim Stevermer, MD, MPH, University of Missouri – Columbia
Peter C. Smith, MD, University of Colorado
Kristin Hitchcock, MSI, The University of Chicago
Goals & Objectives
1. To understand the unique collaborative
process of writing a Clinical Inquiry (CI)
2. To understand each of the steps required to
write a CI
3. To understand the FPIN review process
4. Orient participants to the use of critical
appraisal and systematic review techniques in
authoring CIs
5. Link participants to appropriate resources
within FPIN to help them undertake authorship
of a CI.
Family Physicians Inquiries Network
What is FPIN?
What is FPIN?
FPIN is an international academic consortium
FPIN is a virtual community focused on the generation
and synthesis of clinical knowledge
FPIN is a membership organization
FPIN is self governing & not for profit
FPIN members include family medicine departments,
residency programs, academic health science
librarians, practice based research networks…..
Family Physicians Inquiries Network
Mission
The mission of the Family Physicians
Inquiries Network is to use information
technology to:
• Translate Research into Practice
• Teach Clinical Scholarship
• Generate Research from Practice
How do we achieve our mission…
Family Physicians Inquiries Network
Clinical Inquiries (CI)
Clinical Inquiries provide the ideal answers
to clinical questions: using a structured
search, critical appraisal, authoritative
recommendations, clinical perspective, and
rigorous peer review. Clinical Inquiries
deliver best evidence for point of care use.
Family Physicians Inquiries Network
Why write a CI?
• Earn a publication in a peer reviewed journal –
the Journal of Family Practice or American
Family Physician.
• Receive a 3 month FREE subscription to the
Evidence-Based Practice Newsletter.
• Support provided by medical librarians, co-author
mentors and editors.
• Reach department goals, ACGME requirements,
promotion and tenure expectations
Family Physicians Inquiries Network
Anatomy of a Clinical Inquiry:
7 Elements
1. Clinical Question
2. Evidence Based Answer
3. Evidence Summary
4. Recommendations from Others
5. Clinical Commentary
6. References
7. Search Strategy
Family Physicians Inquiries Network
Size and shape
• The paper version (in JFP) is limited to
one to two pages
• That‘s 1100-1400 words
Family Physicians Inquiries Network
Question
• Question
– Based on a question that arose in practice
– Modified for generalizability and clarity
• One sentence
Family Physicians Inquiries Network
Evidence based answer
• Short summary (100-150 words) of best
evidence
• This may be the only part read….
– Strength of recommendations given
• A – Multiple RCT
• C – Expert opinion
Family Physicians Inquiries Network
Evidence summary
• About 600 words of review of evidence
• Write tight!
• Rationale for the evidence based answer
Family Physicians Inquiries Network
Recommendations from others
• Recommendations from others
– A summary of the leading authorities in that
area
– USPSTF, AAFP
– ACOG, ACP, ACS
– Expert opinion
• Words: 150
Family Physicians Inquiries Network
Authors
• Authors include the clinician authors
– AFP – resident/students can not be 1st author
– JFP – student can not be 1st author
• Librarian is a co-author
Clinical commentary
• 100-150 words by an experienced clinician
about their own slant on this problem
• Not author‘s responsibility
Family Physicians Inquiries Network
References
• About ten (150 words or less)
• Pick the best and the brightest
Table
• Nice way to summarize large amounts of data,
concepts, studies
• More efficient use of space
• Clinically relevant tables allow more efficient
transfer of information
Family Physicians Inquiries Network
Philosophy behind the Anatomy
• Evidence based information
• Authority based information
• Peer based information
Family Physicians Inquiries Network
Search strategy
• Generated by librarian
• Purpose
• Peer reviewer and editor can use for
evaluation of search
• Future use by librarians to up-date searches
• Published on-line only
Family Physicians Inquiries Network
Editorial Process
• Manuscript reviewed by:
– FPIN Assistant Editor
– Peer reviewer
– Associate editor
• Following appropriate revisions, manuscript
submitted to JFP or AFP for publication
• Review by editor in chief and managing editor at
JFP or AFP – appropriate revisions made
NOTE: IN AFP PUBLICATIONS, RESIDENTS CANNOT BE LISTED AS FIRST AUTHOR AND
MEDICAL STUDENTS CANNOT BE LISTED AS AUTHORS AT ALL.
Family Physicians Inquiries Network
Advantages to CI Editing process…
• Assistant Editor works more closely with authors
than is typical. Often leads to more feedback.
• More a team approach than usual
• Extra ―sets of eyes‖ provide oversight and
improve quality control
• Greater opportunity to learn
• 97% publication rate
Family Physicians Inquiries Network
Where do questions come from?
• Submitted by clinicians
• Edited to be generalizable and answerable
– Many rejected at this stage
– This is harder than it looks
– Consensus process of three editors
• Make questions answerable
– Generalizable
– Focused
– Of general interest
Family Physicians Inquiries Network
Some are rejected
• Should a 4 year old with symptoms of a UTI who refuses
to provide a urine specimen be catheterized to obtain a
sample and treat infection?
• Does a 6 month course of bactrim prevent recurrence of
pyelonephritis in infants less than one year of age with
previous pyelonephritis?
• Is there any correlation between FSH and LH and fluid
retention among adult women?
Family Physicians Inquiries Network
Some are modified
• Is propanolol or sumitriptan better for
prevention of migraine headaches in adult
patients?
– To
• What are the most effective prophylactic
therapies for migraine headaches?
Family Physicians Inquiries Network
Approving the question
• Clinicians vote on questions
• Rank list generated
• In general, need to reach 50th percentile to
be accepted
Family Physicians Inquiries Network
Changing question
• With negotiation with editor, can be
changed
– What is the prognosis of low back pain?
– To
– What is the prognosis of acute low back pain?
Family Physicians Inquiries Network
Choosing your CI question
Choosing your CI question
• Where do I find them?
They are found at www.fpin.org – a list of
edited questions from docs in practice that
are available for authors to request
Family Physicians Inquiries Network
List of Available Questions
Family Physicians Inquiries Network
More questions
Family Physicians Inquiries Network
Choosing your CI question
• What happens if you sign up?
– You receive a confirmation email along with
the author agreement (expectations &
requirements)
• What are you committing yourself to?
– Working with an FPIN Librarian Co-author
– Working with an assistant editor
– A 6-9 month publication process
Family Physicians Inquiries Network
Choosing your CI question
• What would be a good one?
• First major PITFALL: picking question
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Making a good choice
• Interesting to author – will be working on it
for a while
• Suitable scope
– not too general
• what is the best treatment for hypertension?
– not too specific
• what is the ideal LDL target in patients over 110
years of age?‖
Family Physicians Inquiries Network
Making a good choice
Type of question…
some kinds of questions tend to have more
evidence available to answer them, such as:
• Treatment questions
– What is the best medication for hypertriglyceridemia?
• Diagnosis questions
– What is the best provocative test for evaluating a man
with atypical chest pain?
Family Physicians Inquiries Network
Making a good choice
Type of question…
some types have less evidence available,
such as:
• Etiology questions
– What are the causes of hyponatremia?
• Diagnosis questions
– What is the differential diagnosis for tremor?
Family Physicians Inquiries Network
Good choices for first-time authors
Which of these might be easier to answer well?
• What is the best way to evaluate chronic
hoarseness?
• What is the appropriate evaluation for possible
Cushing syndrome?
• How effectively does surgical treatment for a
herniated disk relieve pain?
Family Physicians Inquiries Network
Making a good choice
• What to do if you can‘t tell by looking at
the question?
• Don‘t sign up for it (yet)!
• Do a quick evidence search and see if
what turns up is about the right type and
amount of evidence to make a satisfying
experience.
Family Physicians Inquiries Network
Collaborating with your
Librarian Co-Author
Librarians bring to FPIN . . .
– Complementary expertise
• Complexity of evidence-based searching
• A host of sources where this content is located
– Standardization of processes
• comprehensive, and reproducible methodology for
identifying literature
– Building local relationships to support clinical
and research information needs.
Family Physicians Inquiries Network
Librarian Co-Author Accountability
- knowledge of the search results
- description of the search methods used
- content of the manuscript, as it relates to the
interpretation of the search results by the author
- accuracy of the references
- and any other content in the document that he/she
feels qualified to address
Family Physicians Inquiries Network
What is an FPIN Search?
A structured search of prescribed databases
which uses specific, evidence-based filters.
The search methodology is fully documented,
and results are reported to the primary author in
a standard format.
Family Physicians Inquiries Network
Collaborating with your co-author
1. Librarian volunteers to serve as co-author on a
CI with an assigned physician author.
2. Librarian contacts physician to discuss the topic
and parameters of the initial search.
– Useful background information, including the ―clinical point‖ of a
question
– Terminology, subject headings
– Any database ―limits‖: age, sex, etc.
Family Physicians Inquiries Network
What does the question
mean?
Reaching agreement with your
Librarian Co-author
Example CI 254:
What is the correct age to refer a
child with an undescended testicle?
Family Physicians Inquiries Network
What is the correct age to refer a child
with an undescended testicle?
• What would be most useful to you when
reading this answer?
• Answer for doc in practice: If I had an
infant in my office with undescended
testes, the most useful answer would tell
me the age when I should refer him to the
urologist for orchiopexy (and tell me why).
Family Physicians Inquiries Network
What is the correct age to refer a child
with an undescended testicle?
• What kind of evidence would answer this
question best?
• What is the question asking?
• What is the intervention?
– ―to refer‖ implies ―orchiopexy‖
• What is the alternative?
– the natural history of undescended testis)
Family Physicians Inquiries Network
What is the correct age to refer a child with
an undescended testicle?
• What are the outcomes?
– what outcomes would be different if a child
underwent orchiopexy by the ―correct age‖?
• ―Revised‖ question:
– At what age would it make a difference
in outcome(s) if a child underwent
orchiopexy versus expectant
management?
Family Physicians Inquiries Network
What is the correct age to refer a child
with an undescended testicle?
• Ideal evidence - any articles addressing:
– ―What is the natural history of undescended
testis?‖
– ―What outcomes occur without intervention
(orchiopexy)?‖
– ―What outcomes occur with intervention?‖
– ―Are the outcomes different?‖
Family Physicians Inquiries Network
Now for the search . . .
Collaborating with your co-author
3. Librarian performs search according to the FPIN
Search Protocol.
4. Initial results are forwarded to the physician
author:
– Search Summary Form
– Overview of results from each database
– Complete search strategy
– Search Results
– Citations/abstracts/links
– Author is responsible for retrieving full articles
5. Discussion of initial results and adjustments
made, as necessary.
Family Physicians Inquiries Network
Collaborating with your co-author
6. Update search performed during the
authoring/reviewing process, if necessary.
7. Librarian assistant editor reviews all searches
for completed CIs.
8. Draft of completed manuscript should be sent
to the librarian co-author to:
- verify the references
- verify his/her name & affiliation as co-author
Family Physicians Inquiries Network
FPIN Search Protocol
http://www.fpin.org/ci/librarian/SearchProtocol.aspx
Tier I resources:
– Clinical Evidence
– Cochrane Database of Systematic Reviews
– Database of Abstracts of Reviews of Effectiveness
(DARE)
– AHRQ Evidence Reports
– National Guideline Clearinghouse
– FPIN Clinical Inquiries
– MEDLINE & MEDLINE In-Process **
Tier II resources:
– Other databases, at discretion of the authors
Family Physicians Inquiries Network
FPIN Search Protocol: MEDLINE
• Each MEDLINE search uses a search filter
– Search terms systematically used to refine
search results.
– Retrieve high-quality EBM articles.
– Developed based upon:
• published search filters
• expertise of a committee of experienced searchers.
http://www.fpin.org/CI/librarian/Default.aspx
Ward D, Meadows SE, Nashelsky JE. The role of expert searching in
the Family Physicians' Inquiries Network (FPIN). J Med Libr Assoc.
2005 Jan;93(1):88-96.
Family Physicians Inquiries Network
Excerpt –Therapy Filter (PubMed)
Meta Analysis[pt] OR meta analy*[tw] OR
metaanaly*[tw] OR systematic review*[tw] OR
"published studies"[tw] OR medline[tw] OR
embase[tw] OR data synthesis[tw] OR data
extraction[tw] OR Cochrane Database Syst Rev[ta]
Randomized Controlled Trial[pt] OR Randomized
Controlled Trials[mh] OR random*[tw]
Clinical Trial[pt] OR Multicenter Study[pt] OR Clinical
Trials[mh] OR trial[tw] OR trials[tw] OR
multicenter[tw] OR multicentre[tw] OR multi
center[tw] OR multi centre[tw] OR placebo*[tw] OR
double blind*[tw]
Family Physicians Inquiries Network
FPIN Search Results
Family Physicians Inquiries Network
Selecting Evidence
Is it RELEVANT?
Steps in Study Selection
• Get clear on the question
• Develop selection criteria from question
• Apply criteria to list of titles and abstracts
– Include
– Exclude
– Can‘t Tell (get article to include or exclude)
• Read articles and apply criteria again
• Select final study set for CI
Family Physicians Inquiries Network
From Question to Criteria
Treatment or Etiology or Diagnosis or
Prevention Prognosis Screening
Population Population Population
Intervention Exposure Study Test
Comparison Unexposed Reference
Standard
Outcome Outcome Test
Performance
Study Design Study Design Study Design
Family Physicians Inquiries Network
Study Selection Worksheet
Your CI Question:
Population:
(the patients & condition)
Intervention:
(treatment, test, exposure)
Comparison:
(alternate treatment or diagnostic strategy, comparison
population, if any)
Outcome(s):
(patient-oriented outcomes)
Family Physicians Inquiries Network
Develop Criteria for Your CI
Criteria for Criteria for
INCLUDING Studies EXCLUDING Studies
Family Physicians Inquiries Network
Study Selection Form
Family Physicians Inquiries Network
Personalize for Your CI
Study Characteristic Yes No ?
1. Includes target population
2. Includes intervention of interest
3. Includes appropriate comparison
4. Includes outcomes of interest
5. Includes primary data on outcome
6. Data is in extractable format
7. Appropriate study design(s)
Family Physicians Inquiries Network
In or Out?
Include
Exclude
Pull Full Article for
Review
Pull Article for
Background
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Tips for Selecting Evidence
• Generalizability of evidence
– E.g. question on fluoxetine, consider all SSRIs
• Beware the ―elephant in the room‖
– major guidelines/policy statements
• Is it VALID? Is it RELEVANT?
• What would be most useful to you if you
were reading this answer?
Family Physicians Inquiries Network
Oops…Wrong question…?
Contact the Managing Editor
Keeping Track
• Using a study flow diagram
• Based on QUOROM guidelines
– Moher D, Cook DJ, Eastwood S, Olkin I,
Rennie D, Stroup DF, for the QUOROM
Group. Improving the quality of reports of
meta-analyses of randomised controlled trials:
the QUOROM statement. Lancet 1999;
354:1896-1900.
– www.consort-statement.org/QUOROM.pdf
Family Physicians Inquiries Network
Family Physicians Inquiries Network
Appraising the Evidence
Is it VALID?
Critical Appraisal Tools
• Tools specific to each type of study design:
– Users‘ Guides
– CEBM
– SIGN Checklists
• CIs often use:
– Systematic Reviews
– RCTs
– Observations Studies
– Diagnostic Studies
Family Physicians Inquiries Network
Users’ Guides
http://www.cche.net/usersguides/main.asp
Family Physicians Inquiries Network
CEBM
http://www.cebm.utoronto.ca
Family Physicians Inquiries Network
SIGN
http://www.sign.ac.uk
Family Physicians Inquiries Network
Summarizing Evidence
• Use ―Evidence Tables‖
• Customize table for your CI
• Organize by study design
– e.g. all the RCTs together
• Organize by outcome
• Can input in spreadsheet for easy sorting
• Tabular display helps you to understand
the evidence and answer the question
Family Physicians Inquiries Network
Sample Evidence Tables
• Treatment or Prevention
• Prognosis or Etiology
• Diagnosis or Screening
Family Physicians Inquiries Network
Grading
Recommendations
Grading Recommendations
• Evidence-Based Answer
– Grade strength of evidence
– Develop recommendation statements
– Answer the question
– Grade the recommendations
• Use CEBM Grades of Recommendation
– Editors ―walk over‖ GOR to SORT system
Family Physicians Inquiries Network
Oxford CEBM
Levels of Evidence
http://www.cebm.net/downloads/Oxford_CEBM_Levels_5.rtf
Family Physicians Inquiries Network
Oxford CEBM
Grades of Recommendation
Family Physicians Inquiries Network
Grade of Recommendation
• Use Grade of Recommendation (GOR)
• Based upon Oxford Center for EBM Levels
of Evidence
– A = consistent level 1 studies (RCT)
– B = consistent level 2 (cohort) or 3 (case control)
studies, or extrapolations from level 1
– C = level 4 studies or extrapolation level 2 or 3
– D = level 5 (expert opinion without explicit
critical appraisal)
Family Physicians Inquiries Network
Strength of Recommendation
• Converted to Strength of Recommendation
(SOR)
• Uses the SORT system (Strength of
Recommendation Taxonomy) (A, B or C)
• Based Upon Method Developed by the
Editors of:
– AFP (Ebell and Siwek)
– JFP (Susman)
– JABFP (Bowman)
– Family Medicine (Weiss)
– FPIN (Ewigman)
Family Physicians Inquiries Network
Strength of Recommendation
• Family Medical Journals are using SORT
• FPIN is in the process of determinin
Family Physicians Inquiries Network
Writing your CI
Writing your CI
• Format
– Question
– Evidence-based Answer (2-3 sentences)
– Evidence Summary
– Recommendations from Others
– Clinical Commentary
– References
– Word counts: 450-750
Family Physicians Inquiries Network
First Step: Write Evidence
Summary
• Format
– Question
– Evidence-based Answer (2-3 sentences)
– Evidence Summary
– Recommendations from Others
– Clinical Commentary
– References
– Word counts: 450-750
Family Physicians Inquiries Network
Organizing the Evidence:
Using an Evidence Table
Evidence Table displays the critically-
appraised studies for 2 purposes:
1) Choosing the best evidence: Allows
grouping the studies by type, population,
intervention, quality
2) Assists creation of logical structure for the
Evidence Summary section
Family Physicians Inquiries Network
Using the Evidence Table to
Choose the Best Evidence
Family Physicians Inquiries Network
Using the Evidence Table to
Create a Logical Structure
• ―Undescended Testes‖ CI – with only
limited evidence available, the ―Evidence
Table‖ in this case serves mostly to
organize CI logically
• There are only 7 articles, which can be
arranged in groups of similar studies
Family Physicians Inquiries Network
Using the Evidence Table to
Create a Logical Structure
Studies organized into 3 logical groups:
– 3 cohort studies describing natural history in
first 2 years
– 2 observational studies describing germ cell
changes and paternity in boys after
orchiopexy
– 2 cohort studies assessing testicular cancer
mortality in boys after orchiopexy
Family Physicians Inquiries Network
Using the Evidence Table to write a
Logical Evidence Summary
Original question:
– What is the correct age to refer a child with an
undescended testicle?
―Revised‖ question:
– At what age would it make a difference in outcome(s) if
a child underwent orchiopexy versus expectant
management?
What kind of evidence did we think would answer
this question best?
Family Physicians Inquiries Network
What evidence were we looking for?
Any articles addressing:
What is the natural history of undescended
testis?
What outcomes occur without intervention
(orchiopexy)?
What outcomes occur with intervention?
Are the outcomes different?
Family Physicians Inquiries Network
Creating Logical Evidence summary
What is the natural history of undescended testis?
– 3 cohort studies describing natural history in first 2 years
What outcomes occur without intervention (orchiopexy)?
– No studies of long term effects
What outcomes occur with intervention (orchiopexy)?
– 2 observational studies describing germ cell changes and
paternity in boys at orchiopexy
– 2 cohort studies assessing testicular cancer mortality in boys
after orchiopexy
Are the outcomes different?
– No studies compare outcomes with and without intervention
Family Physicians Inquiries Network
Writing Evidence Summary
• Summarize the studies with a paragraph
for each ―logical cluster‖
• Convert cryptic info in Evidence Table into
concise English
Family Physicians Inquiries Network
Writing the Evidence-based
Answer (bottom-up method)
• Reading first sentence of each paragraph
of Evidence Summary should be
approximately the Evidence-based answer
• Add Grades of Recommendation
• Convert to standard English
• Make sure it answers the question
Family Physicians Inquiries Network
Could a Table Help?
• Tables very useful for summarizing data
• Visually interesting for reader
Family Physicians Inquiries Network
Alternatively, top-down
• After reading and summarizing the
literature….
• Assume you have 45 secs to answer a
resident‘s question
• Write that down
• Write an evidence summary to support
that answer
Family Physicians Inquiries Network
Dr. Smiths Top 10
FPIN Author Errors
―I'm all in favor of keeping dangerous
weapons out of the hands of fools.
Let's start with typewriters.‖
- Solomon Short
Family Physicians Inquiries Network
Good Writing is Hard!!
―...writing, like motor-car driving and love-
making, is one of those activities which
almost every Englishman thinks he can
do well without instruction.
The results are of course...
...usually abominable.‖
-Tom Margerison
Family Physicians Inquiries Network
# 10:Basic Grammar
Dangling Participles
―The risks of surgery is something patients
and families should be made aware of.‖
"That is nonsense up with which I shall
not put." - Winston Churchill
Family Physicians Inquiries Network
# 10:Basic Grammar
“Perpendicular” phrases =
Non-Parallel phrases
– ―The authors found that 23% of children
improved, 52% stayed the same, and 25%
worse.‖
– ―He went to the office, answered emails,
saw 10 patients, ate lunch…
...then 24 more patients.” (!)
Family Physicians Inquiries Network
# 10: Basic Grammar
Number disagreement
– This thing and that thing ARE
– Data ARE
– The study of this thing and that thing IS
– Careful consideration of this, that, and the
other thing IS
―A multidisciplinary approach, including diet, education,
behavior modification and exercise have been
shown to be effective.‖
Family Physicians Inquiries Network
# 10: Basic Grammar
Number disagreement
Family Physicians Inquiries Network
# 10: Basic Grammar
Passive voice
• Elimination of passive voice is recommended
– Eliminate passive voice!!!
• There is little evidence
– Little evidence exists.
• This problem has been studied
– Researchers have studied this problem
• The following are recommended by the AAFP
– The AAFP recommends the following
Family Physicians Inquiries Network
# 10: Basic Grammar
Passive voice
– ―Significant reductions in total body fat were
shown in this trial. Measurements were taken at
baseline, 10 weeks and 1 year. Significant
changes in weight, percent of ideal body weight
and percent body-fat were observed in all
patients.‖
– This trial showed significant reductions in body fat.
Investigators measured patients at baseline, 10
weeks, and 1 year. Weight, percent of ideal body
weight, and percent body fat changed significantly
in all patients.
Family Physicians Inquiries Network
# 9: AJaMUTRAC
AJaMUTRAC
• Acronyms:
– OK: AAFP, NIH, NNT, ACOG, etc.
– Not OK: HRSA, AAOHNSCG
• Jargon
– Crit, DC‘d, ―Bounce-back‖, Trade names
Family Physicians Inquiries Network
# 9: AJaMUTRAC
AJaMUTRAC
• “Mis-Underestimating” The Reader
Assume some common knowledge
– ―Athlete‘s foot is a cutaneous fungal infection that is
very prevalent and infectious.‖
Can be OK if specific definitions required
– ―Otitis media with effusion‘ is defined as fluid in the
middle ear without signs or symptoms of infection.‖
Family Physicians Inquiries Network
# 9: AJaMUTRAC
AJaMUTRAC
…And Chattiness
– ―Writers should be read, but neither seen
nor heard.‖ -Daphne du Maurier
• ―Finally, don‘t forget that some patients will
complain...‖
• ―What is the evidence for this vexing problem?‖
• ―I think we‘ve all had this experience‖
Family Physicians Inquiries Network
# 8: Logorrhea
noun: The unnecessary extraneous
irrelevant redundant excessive
unwarranted and surplus utilization of
superfluous verbiage.
OR
Too many words
Family Physicians Inquiries Network
# 8: Logorrhea
―Affected Phraseology‖ (Doctor-speak)
• ―in regards to‖
• ―it would appear that‖
• ―have been considered to‖
―Diagnosis is clinically established using the
following schema which requires at a minimum 3
out of 4 criteria to be present…‖
vs.
Diagnose patients using at least 3 of 4 criteria.
Family Physicians Inquiries Network
# 8: Logorrhea
• Unreadable sentences:
– Usually from distance between subject and verb
• ―If an infectious etiology is not found, then a more
detailed history including hygiene practices,
chemical or allergenic exposures and review of
systems should be done to help in the search for
one of the non-infectious causes of vaginitis.
• ―Presence of a purulent cervical discharge
especially associated with prior unprotected sex or
with new sexual partners should prompt cultures
for gonorrhea and chlamydia.‖
Family Physicians Inquiries Network
# 8: Logorrhea
• Dependent clauses & run-on sentences
• ―Results of the limited research on behavioral
mediators of familial patterns of overweight
indicate that parents‘ own eating behaviors and
their parenting practices influence the
development of children‘s eating behaviors,
especially parents who are overweight, who
have problems controlling their own food
intake, and may use coercive feeding practices
of restricting food or pressuring children to eat.‖
Family Physicians Inquiries Network
# 8: Logorrhea
―Vigorous writing is concise.‖
-William Strunk Jr.
―I have made this letter longer, because I
have not had the time to make it
shorter.‖ – Pascal
Family Physicians Inquiries Network
# 7: Submitting a first draft
―I was working on the proof of one of my poems all
the morning, and took out a comma. In the afternoon
I put it back again.‖ - Oscar Wilde
―I believe more in the scissors than I do in the pencil.‖
- Truman Capote
―Read over your compositions, and wherever you
meet with a passage which you think is particularly
fine, strike it out.‖ - Samuel Johnson
Family Physicians Inquiries Network
# 7: Submitting a first draft
―Spill Czech‖ing is not checking spelling
– for/or/of
– to/two/toe
– Hear/here
– There/their/they‘re
– Its/it‘s
– Greater/grater
– ―Randomizer comptroller trail‖
Family Physicians Inquiries Network
Ode to the Spell Checker
Eye halve a spilling checker,
It came with my pea sea.
It plainly marks four my revue,
Miss steaks eye kin not sea.
Eye strike a cay and type a word and weight four it to say,
Weather eye am wrong oar write. It shows me strait a weigh.
As soon as a mist ache is maid, it nose bee fore two long,
And eye can put the error rite. It is rare lea ever wrong.
Eye have run this poem threw it, eye am shore your pleased
two no.
Its litter perfect awl the weigh. My checker tolled me sew.
Family Physicians Inquiries Network
# 6: Not planning or outline
• Planning
– Concise yet comprehensive
– Remember your audience
• ―Advice to writers: Sometimes you just have to
stop writing. Even before you begin.‖
-Stanislaw J. Lec
• ―Of writing well the source and fountainhead is
wise thinking.‖ -Horace
Family Physicians Inquiries Network
# 6: Choose wisely
• Choose your question carefully!
– “What is the best treatment for acute
coronary syndrome”
– Is surgery effective for obstructive
sleep apnea?
Family Physicians Inquiries Network
# 6: Choose wisely
• Choose your evidence carefully
• Start with other valid reviews
– Cochrane, Inforetriever, Meta-analyses, Systematic
Reviews, DynaMed, Nat'l Guideline Clearinghouse,
DARE, TRIP…
• Consolidate
– Does it fit the question?
– Dealing with Conflicting Evidence
• Validity
• Different populations?
• Level of evidence (CEBM, Oxford)
• Valid and Relevant!
Family Physicians Inquiries Network
# 6: Choose wisely
• Valid But Not Relevant
– Use of sucralfate in the treatment of oral and genital ulceration of
Behcet disease: a randomized, placebo-controlled, double-blind
study.
• Relevant But Invalid
– Management of aphthous ulcers. American Family Physician
• Invalid and Not Relevant
– Sutton's disease (periadenitis mucosa necrotica
recurrens). [Review] Annals of Otology, Rhinology &
Laryngology
• Valid and Relevant
– Effect of a mouth rinse...on recurrent aphthous ulcers The aim of
this investigation was, in a pre-study and a double-blind,
crossover study, to report if a mouth rinse was effective against
aphthous ulcers....
Family Physicians Inquiries Network
# 6: Choose wisely
• Setting and population
Primary care? Specialty care?
Age or Gender limited?
Family Physicians Inquiries Network
# 5: Know Your Audience
Usefulness = Relevance x Validity
Work
Tables…
―The skill of writing is to create a context in
which other people can think.‖
-Edwin Schlossberg
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# 4: Any old answer will do
• Make sure your Evidence-Based
Answer is Evidence-Based!
• Levels of Evidence (LOE) vs. Grade of
Recommendation (GOR)
• Include benefits and harms when
possible
Family Physicians Inquiries Network
# 3: Imprecision
Quantify your statements
―There's nothing more exciting than science.
You get all the fun of sitting still, being quiet,
writing down numbers, paying attention.
Science has it all.‖
- Principle Seymour Skinner
- The Simpsons
Family Physicians Inquiries Network
# 3: Imprecision
Quantify your statements
"In science as in love, too much concentration on
technique can often lead to impotence.‖
-P. L. Berger
• Quantitative vs. comprehensible
• Concise vs. comprehensive
• Useful? (―slightly more‖ vs. ―5% more)
• Apples to apples (NNT, NNH, OR, RR, ARR)
• Measures of certainty (95% CI‘s, P values)
• Clinical vs. Statistical significance
Family Physicians Inquiries Network
# 2: Thinking you are Faulkner
Follow the Format!
―There are three rules for writing the
novel…
…Unfortunately, no one knows
what they are.‖
-W. Somerset Maugham
Family Physicians Inquiries Network
# 2: Thinking you are Faulkner
Follow the Format!
• Wrong format
• References
– Too many
– Not enough
– Wrong format
• Authorship – remember your librarian!
• Word counts:
– ―My writing is like a ten gallon spring‖ - Su Shih
Family Physicians Inquiries Network
# 1: “I am not bound to please thee…”
• ―I am not bound to please thee with my
answers.‖ -Shakespeare
• Answer the question!
– Read the question carefully
– Ensure a proper focus for the search
OR
• Get approval to change the question
– DDx Chronic Diarrhea
– Allergic Asthma
– Recurrent vaginitis
– Pediatric obesity prevention
Family Physicians Inquiries Network
# 1: “I am not bound to please thee…”
―What is the answer?
In that case,
what is the question?‖
- Gertrude Stein‘s last words
―If love is the answer…
could you rephrase the question?‖
-Lily Tomlin
Family Physicians Inquiries Network
Recommendations from
Others
Recommendations from Others
• Present a sense of the national standard of care
• Provide an ‗expert‘ opinion on this topic
• Provide a contrast between different
organizations‘ recommendations
• Based on a hierarchy of sources
• Evidence-based and primary-care oriented are
the gold standards
– USPSTF, AAFP Clinical Policies
• Other organizations' recommendations
– ACOG, ADA, AHA
• Expert opinion
– Consensus panels, etc
Family Physicians Inquiries Network
What happens if nothing is there
• Guidelines.gov is a good starting place
• If nothing found
– Check leading textbook
– Check not-so-leading textbook
– Check review articles
Family Physicians Inquiries Network
Recommendations from Others
• Should be short ~ 150 words
• Sometimes a table/graphic is helpful
– Contrasting recommendations
– Complex recommendations
Coming up empty
• Rarely
• ―We were unable to find any
recommendations about this topic.‖
Family Physicians Inquiries Network
Working with your Editor
“Interventionist Editing”
―Editor: a person employed by a
newspaper, whose business it is to
separate the wheat from the chaff,
and to see that the chaff is printed.‖
- Elbert Hubbard
―An editor should have a pimp for a brother,
so he‘d have someone to look up to.‖
- Gene Fowler
Family Physicians Inquiries Network
Question
What is the best treatment for impacted cerumen?
Evidence Based Answer
To facilitate cerumen removal during the same office visit as it is diagnosed, docusate sodium 15 minutes prior to irrigation was the most effective wax softener. 1-4 (Grade B:
head-to-head trials that lacked irrigation only arms)
To facilitate cerumen removal between office visits and thereby require less irrigation, 5% urea hydrogen peroxide in glycerol was most effective. 5-12 (Grade B-: lack of rigorous
Rough draft
randomization, lack of definition of cerumen impaction, only 1 placebo-controlled trial)
Wax softening is more effective in children1,7 (Grade A), and less effective in nursing home patients. 13 (Grade C)
Search Strategy
The Cochran Database of Systematic Reviews, the Turning Research Into Practice (TRIP) database, the national Guideline Clearinghouse Database, British National Health
Service Technology Assessment Database (HTA), Database of Abstracts of Review of Effectiveness (DARE) and InfoRetriever were searched.
Medline (1966-2001) search strategy: [(cerumen, mp or cerumen or earwax or ear wax)] AND [(meta analysis.pt or meta analysis.tw or metaanalysis.tw or cochrane.jw) OR
(systematic review.tw or published studies.ab or medline.ab or embase.ab) OR (consensus development conference nih.pt) or (consensus development conference.pt) OR (clinical
trials/or randomized controlled trials)]
Current Contents and Pre-Medline search strategy: [(ear wax.mp or earwax.mp or cerumen.mp or cerumenolytic.mp or ceruminolytic)] and [metaanalysis or metanalysis or
systematic.mp) OR (published studies or Medline or embase or cochran or data synthesis or data extract).ab OR (published studies or Medline or embase or cochran or data
synthesis or data extract).mp OR (random.or double blind or placebo or trial or multicenter or multicentre or multi centre).mp OR (outcome or evidence based).mp OR (guideline
or consensus).mp
Evidence summary
Interest in cerumen impaction pre-dates the Civil War. 14 It is the otologic condition most encountered by physicians, affecting up to 6% of the general population, with greater
prevalence in mentally retarded and nursing home patients. 15 Reason for cerumen disimpaction include: occluded view of tympanic membrane (TM), contribution to infection,
contact with TM causing vertigo or discomfort, hearing loss. 6 Removal of occlusive cerumen can restore 5dB of hearing across tested frequencies. 16
There were two study types: 1) One time softening in the office prior to irrigation in order to ease the process (less discomfort or amount of irrigant); 1-4 and 2) attempted
cerumenolysis for 3-14 days to alleviate the need for syringing or to make it easier. 5-11
In type 1 studies, a pre-soak of the wax with docusate was best, but was not studied against water. This may or may not be significant since in Keane's type 2 study, sterile water,
cerumenol and sodium bicarbonate in glycerol were of equal efficacy, and all were more effective than no treatment. Notably, after 5 days of no treatment, 5% of impaction
resolved completely and another 26% became moderately clear. Time may be the best treatment of 1/3 of adults.
One small, carefully done study of ear candles, demonstrated no benefit. There was no evidence of the purported mechanism of action (negative pressure in the ear), and in the
eight ears tested there was more evidence of candle wax addition than ear wax removal.
Complications of syringing include otitis externa, perforation, EAC trauma, pain, cough, tinnitus, vertigo, otitis media, treatment failure and time consumption. 17 The harm of wax
softeners is minimal (Table) and they tend to decrease the need for irrigation and increase the ease with which it is done (Table). There is no reason to recommend against them
for harm reason. However, till more placebo (water or nothing) controlled data is generated, recommendation have to be based on the primarily head-to-head trials that have been
done and upon the fact that they have a good safety profile.
For wax softening at home, Cerumenol, water and sodium bicarbonate were equally effective. Sodium bicarbonate was equally effective with 2.5% acetic acid. Cerumenol was as
effective as ethyleneoxide polyoxypropelene. 5% urea hydrogen peroxide in glycerol was more effective than Cerumenol. (Table)
For in office softening followed by irrigation, Cerumenex was more effective than Debrox and equally effective as olive oil. Colace was more effective than Cerumenex. (Table)
Consistently, children benefitted more from wax softeners than adults (Table).
Recommendations from Others
The 2001 edition of 5-Minute Clinical Consult recommended Cerumenex followed by irrigation for in office cerumen removal.
According to Clinical Evidence 2001, the consensus clinically accepted standards of treatment are ear syringing and manual disimpaction, though there are no RCTs addressing
benefit or harm.18 No specific recommendation were made due to inconsistent, unclear study design or undefined terms (e.g., cerumen impaction).
Brand Names of Some of the Studied Agents
2% acetic acid (VoSol, Domeboro)
isopropanol (Swim-Ear)
triethanolamine (Cerumenex)
carbamide peroxide (Debrox, Murine ear)
arachis oil, chlorobutanol, p-dichlorobenzene (Cerumenol)
docusate sodium (Colace)
I would like to thank Caryn Scoville for her literature search and the librarians at UPMC St. Margaret Hospital, Nancy Hartung and Amy Hough, for helping with the acquisition of
articles.
Family Physicians Inquiries Network
Question
What is the best treatment for impacted cerumen?
Evidence Based Answer
To facilitate cerumen removal during the same office visit as in which it is diagnosed, docusate sodium 15 minutes prior to irrigation was is the most effective wax softener.1-4
(Grade B: head-to-head trials that lacked irrigation only arms)
To facilitate cerumen removal between office visits and thereby require less irrigation, 5% urea hydrogen peroxide in glycerol was is most effective.5-12 (Grade B-: lack of
rigorous randomization, lack of definition of cerumen impaction, only 1 placebo-controlled trial)
Wax softening is more effective in children1,7 (Grade A), and less effective in nursing home patients. 13 (Grade C)
First edit
Search Strategy
The Cochran Database of Systematic Reviews, the Turning Research Into Practice (TRIP) database, the national Guideline Clearinghouse Database, British National Health
Service Technology Assessment Database (HTA), Database of Abstracts of Review of Effectiveness (DARE) and InfoRetriever were searched.
Medline (1966-2001) search strategy: [(cerumen, mp or cerumen or earwax or ear wax)] AND [(meta analysis.pt or meta analysis.tw or metaanalysis.tw or cochrane.jw) OR
(systematic review.tw or published studies.ab or medline.ab or embase.ab) OR (consensus development conference nih.pt) or (consensus development conference.pt) OR (clinical
trials/or randomized controlled trials)]
Current Contents and Pre-Medline search strategy: [(ear wax.mp or earwax.mp or cerumen.mp or cerumenolytic.mp or cerumi nolytic)] and [metaanalysis or metanalysis or
systematic.mp) OR (published studies or Medline or embase or cochran or data synthesis or data extract).ab OR (published studies or Medline or embase or cochran or data
synthesis or data extract).mp OR (random.or double blind or placebo or trial or multicenter or multicentre or multi centre).mp OR (outcome or evidence based).mp OR (guideline
or consensus).mp
Evidence summary
Interest in cerumen impaction pre-dates the Civil War. 14 It Cerumen impaction is the otologic condition most encountered by physicians, affecting up to 6% of the general
population, with greater prevalence in mentally retarded and nursing home patients. 145 Reasons for cerumen disimpaction include: occluded view of tympanic membrane (TM),
hearing loss, contribution to infection, contact with TM causing vertigo or and discomfort, hearing loss.6 Removal of occlusive cerumen can restore 5dB of hearing across tested
frequencies. 156
There were tWe found articles evaluating twowo study types of interventions:. Type 1 studies evaluated) Oone time softening in the office prior to irrigation in order to ease the
process (less discomfort or amount of irrigant);.1-4 and Type 2 studies evaluated) attempted cerumenolysis for 3-14 days to alleviate the need for syringing or to make it easier. 5-11
In type 1 studies, a pre-soak of the wax with docusate was best(editor’s note – vs what?), but was not studied against water. This may or may not be significant since iIn Keane's a
type 2 study by Keane, sterile water, cerumenol and sodium bicarbonate in glycerol were of equal efficacy, and all were more effective than no treatment. (Editor’s note – can you
put an NNT in here?) Notably, after 5 days of no treatment, 5% of impaction resolved completely and another 26% became moderately clear. Time may be the best treatment of
1/3 of adults.
One small, carefully done study of ear candles, demonstrated no benefit. There was no evidence of the purported mechanism of action (negative pressure in the ear), and in the
eight ears tested there was more evidence of candle wax addition than ear wax removal.
Complications of syringing include otitis externa, perforation, EAC (editor’s note – need to explain acronyms for 1st use, or just say “canal”)trauma, pain, cough, tinnitus, vertigo,
otitis media, treatment failure and time consumption. 17 16 The harm of wax softeners is minimal (Table) and they tend to decrease the need for irrigation and increase the ease with
which it is done (Table). There is no reason to recommend against them for harm reason. However, untill more placebo (water or nothing) controlled data is generated,
recommendations have toshould be based on the primarily head-to-head trials that have been done and upon the fact that they have a good safety profile. relative safety.
For wax softening at home, Cerumenol (editor’s note – please use generic names only. If needed, you can place brand names after in parentheses but you have to include all bra nd
name, but I like the table. For a long one like cerumenol, you can spell it out the 1st time then use an acronym like “acpd”), water and sodium bicarbonate were equally effective.
Sodium bicarbonate was equally effective with 2.5% acetic acid. Cerumenol (editor’s note – as above)was as effective as ethyleneoxide polyoxypropelene. 5% urea hydrogen
peroxide in glycerol was more effective than Cerumenol. (Table)
For in office softening followed by irrigation, Cerumenex (editor’s note – as above)was more effective than Debrox and equally effective as olive oil. Colace (editor’s note – as
above)was more effective than Cerumenex (editor’s note – as above). (Table)
Consistently, children benefittedbenefited more from wax softeners than adults (Table).
Recommendations from Others
The 2001 edition of 5-Minute Clinical Consult recommended Cerumenex (editor’s note – as above) followed by irrigation for in office cerumen removal.
According to Clinical Evidence 2001, the consensus clinically accepted standards of treatment are ear syringing and manual disimpaction, though there are no RCTs addressing
benefit or harm.187 No specific recommendation were made due to inconsistent, unclear study design or undefined terms (e.g., cerumen impaction).
Brand Names of Some of the Studied Agents
2% acetic acid (VoSol, Domeboro)
isopropanol (Swim-Ear)
triethanolamine (Cerumenex)
carbamide peroxide (Debrox, Murine ear)
arachis oil, chlorobutanol, p-dichlorobenzene (Cerumenol)
docusate sodium (Colace)
Family Physicians Inquiries Network
I would like to thank Caryn Scoville for her literature search and the librarians at UPMC St. Margaret Hospital, Nancy Hartung and Amy Hough, for helping with the acquisition of
articles.
Sweet Home Chicago!
• Communicate with your Assistant Editor like
Chicagoans vote…
– Early and Often!
• ―Constantly talking isn't necessarily
communicating.‖ -Charlie Kaufman
• ―I wish people who have trouble communicating
would just shut up.‖ -Tom Lehrer
Family Physicians Inquiries Network
Peer Review
Peer Reviewers
• Assist the editor in determining whether:
– The CI is well written?
– The CI presents information clearly?
– The most relevant studies have been included?
– The validity of the studies is correctly
interpreted and applied?
– Key recommendations have been identified?
– The CI reaches appropriate conclusions?
Family Physicians Inquiries Network
Peer Reviews
• Completed by other members of FPIN.
• FPIN community responsibility.
• Treat others‘ projects with same respect that
you‘d ask for your own.
Family Physicians Inquiries Network
What to do with PR comments
• Respond to all reviewer comments by
writing to the editor
• These can be in the document or in an
email
– Make changes with which you agree
– Justify changes you didn‘t make
– Your editor can be very helpful during this
process
Family Physicians Inquiries Network
Peer Review Workshop
The Art of Peer Reviewing: Providing a
Comprehensive Review of a Manuscript
Friday - 10:30 – 12:00
Regency A
Family Physicians Inquiries Network
Clinical Commentators
Clinical Commentary
• To provide peer suggestions about topic
• Short commentary about the problem
– ~150 words or so
Family Physicians Inquiries Network
Clinical Commentary
• What would you tell a learner about this
problem?
• What is left out of the CI?
– Patient preference, accessibility, cost, etc
• What do you wish you had know?
• What are your pearls?
Family Physicians Inquiries Network
Clinical Commentary
• We don‘t particularly need:
• ―This is a good CI. It is what I will do from
now on. So should you.‖
• Relatively easy to write
• Short turn-around
• Consider writing one or two
– Medline authorship
Family Physicians Inquiries Network
Clinical Commentary
• We allow more variability in writing
style and tone
• We edit for grammar, spelling and
consistency
• Rarely, we‘ll include an additional
reference, if it is relevant and
important to CC
Family Physicians Inquiries Network
Introduce FPIN to your
program
First…
• Buy in from at least 2 other faculty
members
• Begin by doing a Peer Review and Clinical
Commentary
• Start working with the FPIN Membership
Coordinator on Membership
– You need to be a member of FPIN to write a
Clinical Inquiry
Family Physicians Inquiries Network
OHSU’s Plan
• Create a plan to teach key faculty about
FPIN and writing a Clinical Inquiry
• OHSU‘s FPIN Scholarship Curriculum
– 7 one hour sessions
– Complete syllabus, slides, handouts
– Faculty Development
– Fellow and Resident involvement
• Leadership and administrative support
Family Physicians Inquiries Network
UW’s Plan: Working with Residents
Start early and develop a plan:
• Buy-in from program director & faculty,
librarians
• Resources—time and money—to support
program
• Faculty members to serve as co-author
mentors
– experience in writing CIs, PR, or Clinical
Commentary
Family Physicians Inquiries Network
UW’s Plan: Working with Residents
• Identify interested residents
• Communicate clear expectations
– what constitutes completion
– rewards & consequences
• Provide supervision & mentoring
Family Physicians Inquiries Network
Clinical Inquiries Team
FPIN Associate Editors
– Jim Stevermer, MD, MPH, stevermerj@health.missouri.edu
– John Epling, MD, MSEd, eplingj@upstate.edu
JFP Editor
– Jeff Susman, MD, jfp@fammed.uc.edu
AFP Deputy Editor for EBM
– Mark Ebell, MD, MS, ebell@msu.edu
FPIN Editor-in-Chief
Jim Stevermer, MD, MPH, stevermerj@health.missouri.edu
Executive Editor
– Bernard Ewigman, MD, MPH, bewigman@uchicago.edu
CI Managing Editor
– Heather Stewart, heather@fpin.org
CI Publications Coordinator
– Jon Crowell, jonw@fpin.org
FPIN Librarian Coordinator
– Kristin Hitchcock, kristin@fpin.org
Family Physicians Inquiries Network
Want more information?
• Go to the FPIN web site – http://www.fpin.org
and look for Clinical Inquiries
• If you‘re having trouble, email Heather Stewart at
heather@fpin.org . She can assist you with
getting your FPIN user id and password to view
list of available questions
Family Physicians Inquiries Network
With Gratitude
The Family Practice Inquiries Network
Consortium would like to extend its deepest
gratitude to this distinguished group for their
generous support and continued commitment.
AAFP National Network
Family Physicians Inquiries Network
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