A Session on Teaching critical appraisal for medicos and non-medicos

A Session on Teaching critical appraisal for medicos and non-medicos ( part 1)

(Part 2.0, 2.1, 2.2, and so on.. will be my blogs/links to student blogs having real patient with real problem having done critical appraisal. Feel free post link to your blog in comment section if you do this exercise.)

The key difference for medicos and non-medicos is just about the knowledge base.

A non medico person may know less than a non medico patient, A non medico patient may know less than a medico, a medico may know less than a specialist, and a specialist may know less than a medico patient (or a self taught & empowered patient citizen scientist)

So, as we begin learning *critical appraisal* so we can progress further to practice and develop skill in it to be good at *evidence based medicine*

My first question is, should there be learning of medicine without a patient at the center of the exercise?

No. I guess, everyone agrees.

So, let's start with the person at center. A person who may be sick and so came to us to provide us a learning opportunity.

We have a video about patient as a teacher, as all patients are our teachers giving us, the medico fraternity, lifelong learning opportunities. It's not important watch the video right now, but it have a glimpse of everything we are going to learn ahead.

https://youtu.be/xvE5b8Xk3vM?si=2GE-4ehkcO8Whmjo

A person is there with us now. We need to know their problems. Is that all?

No. We need to make them comfortable, be empathetic, respectful, make them feel supported, etc etc. Refer to AETCOM.

So, the first step for active learning - *taking patient history*

History is story of the patient.  It can be taken as taught in medical school to take in detail, or can be in narrative format which is easier for non-medicos and even medico newbies. A good history can be detailed, with a timeline, from reliable source/sources, etc. Refer to any clinical medicine book and you will find more in initial chapters. Patient problems can be detailed

- qualitatively (eg. shooting pain), 

- quantitatively (eg. 100 degree temperature),

- narrative way (eg. paining so badly since morning that unable to do household work).

Updating patient history with time is important, and you must note that a good patient history (data capture) is extremely useful and most important part of our efforts.

Step 2 is *clinical examination* (look, feel, touch, etc. Refer to any clinical medicine book to learn more)

You can also take pictures, record audio/video, etc.

With history and examination alone, most of diseases happening to mankind can be identified.

Next step is investigations as they help us conform our provisional diagnosis, and look more deeply into the human body to get clear picture of the problems.

All these cover 2 important concerns for our patient.

- *What is the problem* (listen)

- *Where is the problems* (examine)

Now, as we go to the next patient concern, we gets our hands dirty into EBM. But wait, was taking history and examination were not EBM? They were. The examinations have their sensitivity, specificity, protocols, etc. The history taking helps us understand patient priorities and lot more.

So the next concern is

- *what can be done about it*

Or the treatment plan, or the questions that we may get from our patient or ourselves when trying to create a robust treatment plan.

Before diving deep into it, let me first tell you about

- *SOAP notes*

- *PaJR*

- Identifying fake news.

*SOAP notes*.

SOAP means Subjective, Objective, Assessment and Plan.

It's a way of documentation and hence communication, for medical team providing care.

To simplify,

S means write in your narrative way about what is patient concern today/now.

O means write objective values like temperature readings, investigation outcomes, etc.

A means your observation/examination/assessment of the patient now.

P treatment plan.

So as a medico/non-medico/patient/caretaker you can also follow this template for recording daily data. Detailed and good data is important.

*PaJR* - patient journey record. The concept is applied in many way, but what I want to convey is, you can document the patient's journey as

daily patient update + picture of their food plates + sleep routine + exercise routine etc. Can add as many parameters as patient and you want but keeping it focused on clinically meaningful parameters relevant to patient may increase adherence to regularly updating data.

*Identifying fake news*

How can you do it? Fake news are so common that there is a term for it now called infodemic. I think you may be already doing it by

1) checking the news to know if it's not a clickbait

2)checking same news from multiple source.

3) checking news from authentic and more reliable source.

So, by doing any of these steps, you kept skepticism and didn't accept the information as it is, and also you critically analysed it to confirm it's authenticity. This is an example of critical appraisal of information. We are going to do same for medical evidence published in research papers. It's going to be exciting.

EBM is not just the information from best research.

When we look into research, these are types of clinical research studies. There are invitro and invivo studies at pre-clincial levels too. They can go at the bottom below the pyramid. The pyramid gives an idea about levels of clinical usefulness of type of study but it must not create an illusion that something at lower levels is useless in comparison to something at higher level, as every study type have it's pros and cons and so all have their importance and the raking gets blurred.

Even a type of research study can have sub types, having it's own pros and cons.

Eg. For clinical trials

Above 3 images gives basic idea for anyone to go ahead. It's advised to dive deeper as you learn by doing critical appraisal of evidence around clinical questions.

So, I will first share the easy way of critical appraisal and then I will also share the hard way.

Easy way is quick and gives important details. Hard way is time consuming and gives more understanding.

Here comes the easy way -

- identify the type of study (in research paper you are going to practice critical appraisal)

- download the critical appraisal tool for that type of study, from any of these websites and try it.

https://www.cebm.ox.ac.uk/resources/ebm-tools/critical-appraisal-tools

https://casp-uk.net/casp-tools-checklists/

(There are many, can search on internet "critical appraisal tools")

The easy way can get you started quickly, the hard way is to go through paper in detail, look for data and statistical analysis in detail, look for even the data about individual patients, look for possible biases and fundings, etc. It may be overkill sometimes.

Pro tip - various CDSS apps (clinical decision support system) are available that have pre-appriased evidence summaries to common clinical questions.

Ohh, are we missing something?

Yes..  The clinical question..or we are also missing the patient.. damn..that is what happen frequently in medical education where the key beneficiary goes out of the picture, that's so bad.. 

Let's stop here and I give you home work to

1) bring your patient to us by sharing the patient story and findings (or can also say it history and examination) in form of a blog where you have consent from the patient for doing it and whole of it is properly de-identfied.

2) share patient's/your clinical questions so we can start looking into evidence for it.

If you want an example case record, here it is - https://classworkdecjan.blogspot.com/2019/05/42-f-with-severe-regular-edema-with_17.html

Pro tip - there is a giant website where we can search most of medical research papers. https://pubmed.ncbi.nlm.nih.gov/ (Googling is not a bad idea though)

https://classworkdecjan.blogspot.com/2017/11/de-identifying-patient-data.html