The Teacher’s Toolkit

In his book “Essential Skills for a Medical Teacher,” (1) Professor Ron Harden discusses what he terms the “teacher’s toolkit.” He likens it to the tools a carpenter has- a set of tools which together help to construct a structure, all of which are necessary but are used for different purposes. Hew views a teacher in similar fashion. The teacher also needs many tools. Among those tools, Harden lists:

Presentation tool:  This would be something like PowerPoint, used to help present content to students.

An audience response system: At Palmer, we have clickers, which are linked to the computer system, but you could equally use nothing more than a set of colored cards, as they do at the McMaster University evidence-based training program.

Simulated patients or simulators: to stand in for real patients during learning exercises.

Video clips: to use to demonstrate concepts and content.

Podcasts: for students to engage with learning at a later time.

Online information sources: we should all be providing this to our students.

Networking tools: can we figure out how to adapt social media platforms to educational purposes.

Peer-to-peer teaching opportunities: so students can support each other.

The point here is simply to note that we have many tools available to use, and we should both use them and use them in ways that optimize learning.

Let me take this opportunity to wish you a very happy holiday season and a great new year. I’ll be back in January, but hope that you are able to enjoy your time away and come back refreshed.

References

1.       Harden RM, Laidlaw JM. Essential skills for a medical teacher. New York, NY; Churchill Livingstone, 2014

Therapeutic Misconception

Much of the research that is conducted by teaching and clinical faculty at palmer as opposed to that done by our research faculty, is conducted in classroom settings and most often involves either survey research or the use of interview or focus groups. In the former case, where a survey is administered to a class (either on paper or using a tool such as SurveyMonkey), that research is typically exempt from consideration by the IRB because it is is low risk and has little danger for the participant. And when that happens, we often do not collect an explicit consent form from the student participant. His or her consent is implied by simply completing the survey; obviously, they consented if they did go and fill out the survey form.

But in clinical settings, such as the PCCR, consent is critically important. Informed consent documents (ICDs) need to be prepare for each study, and they are complex and complicated instruments. For example, there are 13 elements that must be included in an ICD. It has to be written at an appropriate level (which is usually 8^th-grade reading level), and the patient must not be coerced into signing. It can take a great deal of time and energy to prepare ICDs and there is now a growing body of evidence about how well they relay important information to research participants.

But there is a real challenge here as well. So much research occurs in clinical settings. And this blurs the line between what a physician would if allowed to simply treat a patient and what a physician or research is allowed to do if that same patient is a participant in a research project. In the former case, a doctor would do whatever he or she felt was in the patient’s best interests- vary treatment, frequency of visits, etc. But when there is a research protocol, that same doctor cannot vary from it. However, patients, despite being given an ICD which explains this to them, often misunderstand this.  They believe that everything being done to them and for them when they are in research is done because ti si the best thing for them. This is not the case in research.  Studies have shown that when asked, they will tell you that they are getting the best treatment, even when assigned to a placebo group or to a no-treatment group.  This is how Lidz and Appelbaum describe it: “The therapeutic misconception occurs when a research subject fails to appreciate the distinction between the imperatives of clinical research and of ordinary treatment, and therefore inaccurately attributes therapeutic intent to research procedures. The therapeutic misconception is a serious problem for informed consent in clinical research.” (1)

I am always on the look-out for this when new research is planned. Please read more on this to avoid such problems if ever you do research involving patients.

References

1.       Lidz CW, Appelbaum PS. The therapeutic misconception: problems and solutions. Med Care 2002;40(9Suppl):V55-63

National Collaborating Centre for Methods and Tools

I would like to draw your attention to the National Collaborating Centre for Methods and Tools website (www.nccmt.ca). it is one of several Canadian centers involved in sharing what works in public health. It is based on using evidence to inform the practice of public health and the website provides many tools to assist a healthcare practitioner in doing so. According to their website, their goals are:

·         To develop the organizational capacity and individual skills of those involved in public health to share what works in public health.

·         To identify, develop and evaluate relevant methods and tools for knowledge translation; and to make those methods and tools accessible to people involved in practice, program decision-making, policy-making and research.

·         To identify gaps in methods and tools for sharing what works in public health and to encourage researchers and others to fill these gaps.

·         To build active and sustainable networks that enable practitioners, program decision-makers, knowledge experts, policy-makers and researchers to share what works in public health; and to strengthen partnerships and links with other NCCs and their target audiences.

As you visit each web page on the site, you will find links to a registry of methods and tools used for knowledge translation (that is, from finding evidence, to using it on behalf of a patient). At present there are 188 links on the registry, and it provides a wealth of resources for your use. 

Even better is the page on the Learning Centre (http://www.nccmt.ca/learningcentre/index.php#main3.html). On this page you will find links to many free online educational modules. For example, one module is “Introduction to Evidence-Informed Decision Making,” another is “Quantitative Research designs,” and so on. These are not little module; most will take at least 3 hours to complete, and some will take longer, but they are great training programs.

As we return from Thanksgiving break, this would be a good way to have a refresher about evidence-based practice. I strongly recommend you bookmark this site.

Thanksgiving. Thank You.!

On this occasion of a short week and a time to celebrate thanks, I send mine to you. I am grateful to all who work here, who give so much of their time and their energy. I hope that you enjoy the time off later this week, I hope you are with family (as I will be- 3 children coming, with 3 spouses, 1 grandchild and 1 twin sister to a spouse), and I hope that you are able to eat, relax and catch your breath.

Happy Thanksgiving!

Three New Papers

Rowher A, Schoonees A, Young T. Methods used and lessons learnt in conducting document reviews of medical and allied health curricula - a key step in curriculum evaluation. BMC Medical Education 2014, 14:236  doi:10.1186/1472-6920-14-236

ABSTRACT

Background: This paper describes the process, our experience and the lessons learnt in doing document reviews of health science curricula. Since we could not find relevant literature to guide us on how to approach these reviews, we feel that sharing our experience would benefit researchers embarking on similar projects.

Methods: We followed a rigorous, transparent, pre-specified approach that included the preparation of a protocol, a pre-piloted data extraction form and coding schedule. Data were extracted, analysed and synthesised. Quality checks were included at all stages of the process.

Results: The main lessons we learnt related to time and project management, continuous quality assurance, selecting the software that meets the needs of the project, involving experts as needed and disseminating the findings to relevant stakeholders.

Conclusion: A complete curriculum evaluation comprises, apart from a document review, interviews with students and lecturers to assess the learnt and taught curricula respectively. Rigorous methods must be used to ensure an objective assessment.

Jones MR, West DJ, Harrington BJ, Cook CJ, Bracken RM, Shearer DA, Kilduff L. Match play performance characteristics that predict post-match creatine kinase responses in professional rugby union players. BMC Sports Science, Medicine and Rehabilitation 2014, 6:38  doi:10.1186/2052-1847-6-38

ABSTRACT
Background: Rugby union players can take several days to fully recover from competition. Muscle damage induced during the match has a major role in player recovery; however the specific characteristics of match play that predict post-match muscle damage remains unclear. We examined the relationships between a marker of muscle damage and performance characteristics associated with physical contacts and high-speed movement in professional rugby union players.

Methods: Twenty-eight professional rugby union players (15 forwards, 13 backs) participated in this study. Data were obtained from 4 European Cup games, with blood samples collected 2?h pre, and 16 and 40?h post-match, and were subsequently analysed for creatine kinase (CK). Relationships between changes in CK concentrations and number of physical contacts and high-speed running markers, derived from performance analysis and global positioning system (GPS) data, were assessed.

Results: Moderate and moderate-large effect-size correlations were identified between contact statistics from performance analysis and changes in CK at 16 and 40?h post-match in forwards and backs, respectively (e.g. backs; total impacts vs. ?CK (r?=?0.638, p?

Conclusions: Our data demonstrate that muscle damage induced by professional rugby union match play is to some extent predicted by the number of physical contacts induced during performance. Furthermore, we show for the first time that muscle damage in backs players is predicted by high-speed running measures derived from GPS. These data increase the understanding of the causes of muscle damage in rugby union; performance markers could potentially be used to tailor individual recovery strategies and subsequent training following rugby union competition.

Young KJ. Gimme that old time religion: the influence of the healthcare belief system of chiropractic’s early leaders on the development of x-ray imaging in the profession.School of Arts; Senior Lecturer, School of Health Professions, Murdoch University, South Street, Murdoch 6150, Australia  Chiropr ManTher 2014, 22:36  doi:10.1186/s12998-014-0036-5

ABSTRACT

Background: Chiropractic technique systems have been historically documented to advocate overutilization of radiography. Various rationales for this have been explored in the literature. However, little consideration has been given to the possibility that the healthcare belief system of prominent early chiropractors may have influenced the use of the diagnostic modality through the years. The original rationale was the visualisation of chiropractic subluxations, defined as bones slightly out of place, pressing on nerves, and ultimately causing disease. This paradigm of radiography has survived in parts of the chiropractic profession, despite lacking evidence of clinical validity. The purpose of this paper is to compare the characteristics of the chiropractic technique systems that have utilised radiography for subluxation detection with the characteristics of religion, and to discover potential historical links that may have facilitated the development of those characteristics.

Discussion: Twenty-three currently or previously existing technique systems requiring radiography for subluxation analysis were found using a search of the internet, books and consultation with experts. Evidence of religiosity from the early founders’ writings was compared with textbooks, published papers, and websites of subsequently developed systems. Six criteria denoting religious thinking were developed using definitions from various sources. They are: supernatural concepts, claims of supremacy, rules and rituals, sacred artefacts, sacred stories, and special language. All of these were found to a greater or lesser degree in the publicly available documents of all the subluxation-based chiropractic x-ray systems.

Summary: The founders and early pioneers of chiropractic did not benefit from the current understanding of science and research, and therefore substituted deductive and inductive reasoning to arrive at conclusions about health and disease in the human body. Some of this thinking and rationalisation demonstrably followed a religion-like pattern, including BJ Palmer’s use of radiography. Although access to scientific methods and research education became much advanced and more accessible during the past few decades, the publicly available documents of technique systems that used radiography for chiropractic subluxation detection examined in this paper employed a historically derived paradigm for radiography that displayed characteristics in common with religion.

 

Coursera

This will be a brief but an important post. You may have heard of Coursera. It is an education platform that “partners with top universities and organizations worldwide to offer courses online for anyone to take, for free.” And this is no small thing. Just to give you an idea of their power, I want to draw your attention to a program that was brought to my attention by my friend and colleague, Dr. Stephen Perle, of the University of Bridgeport College of Chiropractic. The specific course he told me about is entitled “Instructional Methods in Health Professions Education.”  It will be offered 4 times in the next year, with the next session beginning in February of 2015.

A link to information about this course can be found at https://www.coursera.org/course/instructmethodshpe. On this page, you can view an introductory video, look at the course objectives, and view the week-by-week format. It is free.

Please look this over and consider taking a course!

World Federation Educational Conference, Miami, October 30-November 1, 2014

I am just back from a program where I was fortunate enough to be a member of the planning committee. This was a program put on by the World Federation of Chiropractic, dedicated to looking at the educational advances and opportunities within the chiropractic profession. What follows below is the full list of presentations.

• A Case Example of Change: Chiropractic Education and Practice in Denmark.
• Ten-Year Experience of Chiropractic Services and Education in the US Veterans’ Administration Healthcare System.
• Integration of Chiropractic Services in Primary Care Teams and Hospitals in the Province of Ontario, Canada.
• Teaching an Inter-professional Approach to Managing Low Back Pain in the Primary Care Setting.
• Chiropractors in Academic Hospitals: Opportunities for Integrated Education.
• Interdisciplinary Clinical Training in a Chiropractic College Setting: Dental and Chiropractic Co-management of Temporomandibular Joint Disorders (TMD).
• Inter-professional Education Initiatives to Improve Pain Care: the VA Connecticut Healthcare System Experience.
• Interdisciplinary Clinical Education: Midwifery and Chiropractic Students’ Perceptions of Combined Service in a Chiropractic Teaching clinic in the UK.
• Healthcare Professional Education and Chiropractic.
• Establishing Interdisciplinary Practice in Two Challenging Environments: A View from the Field.
• Incorporating Inter-professional Education (IPE) in a Curriculum – Benefits, Methods, Challenges.
• Preparing Faculty and Students for Integrated Care – Values and Skills.
• Creating a Climate for Innovation.
• Scope of Diagnostic Imaging/Laboratory/Other Exams.
• SMT Remains the Core – But What Other Manual Treatments?
• McKenzie Method: Given its Evidence Base it Should be Core Curriculum.
• The Role of Chiroprctic in Wellness and Lifestyle Assessment and Advice.
• The Significance of Evidence-Based Care for Education and Practice Today.
• The Rise and Role of Spinal Care Pathways.
• The Jordan Hospital Spine Care Program.
• Outcomes Chosen for CareResponse and Reasons Why.
• EHR as the New Standard of Care: Empowering Outcomes, Evidence and Research.
• The Masters and Doctors Degree Programmes in Chiropractic Medicine at the University of Zurich Faculty of Medicine: An Example of Interdisciplinary Education.
• The Place of Anatomy Education in Inter-professional Health Curricula: An Example from Australia and New Zealand.
• A Descriptive Study Relating the Experience of Radiographic Film Interpretation by Graduating Interns: Preliminary Results.
• Faculty Development Increases Attitudes and Use of Evidence-Based Clinical Practice.
• A Study to Describe Process of Introducing Validated Outcome Measures (CareResponse) as Part of Final Year Clinic Training and Management of Patients at the Welsh Institute of Chiropractic.
• An Innovative Teaching Strategy Used to Address the Role of Chiropractors As Community Health Care Advocates: A Case Report .
• Creating an Evidence-Based Teaching Program.
• Establishing Inter-Professional Clinical Training Opportunities.
• Alternate Career Paths – Research and Education.
• Effective Use of the OSCE in Current Health Sciences Education.
• Clinical Skills Testing for Chiropractic Licensure in a Changing Healthcare Environment: Signposts of Change and Navigating the Transition.
• Accreditation Standards: Do they Require Amendment in the Changing Healthcare Environment: A North American View.
• Accreditation Standards: Do they Require Amendment in the Changing Healthcare Environment: A European View.
• Teaching Anatomy at Two New York City Medical Schools.
• Serving as a Medical Director for Chiropractic for the Washington State Department of Labor and Industries.
• For the NIH to PCORI and Lessons Learned.
• The Canadian Experience.
• The Role of a Chiropractic Researcher at Palladian Health.
• Environment for Innovation: Exploring Associations with Individual Disposition Toward Change, Organizational Conflict, Justice and Trust.
• Preparing the Leaders of Tomorrow – The Evolution of the Residency Program at the Canadian Memorial Chiropractic College.
• Alternative Careers for Doctors of Chiropractic through a Master of Science Program in Clinical Research.
• A Chiroprctic Academy of Educators.
• Insertion of Chiropractic in Public Health System.
• The “Flipped Classroom”.
• What the Best College Teachers and Students Do.
• Perspectives from Chiropractic Education.

The Rest of ASBH

And here are more programs from the recent conference of the American Society for Bioethics and Humanities. And may I say, Buffy the Vampire Slayer came up in one of the sessions!

• Made vulnerable: notes of privilege; or how when you say their name, the bodies go missing
• Assessing public attitudes about the ethics of research on medical practice
• Beneath the covers: film, philosophy and sex
• Moral sources for collaborative, practice-based ethics: a transformation for education and practice
• Theory confirmation, risk and hermeneutics in the early phases of medical research
• Shared vulnerabilities in research
• Guinea pigs for peace: why American World War II conscientious objectors volunteered as research subjects
• Fiction and bioethics: from speculation to practice 
• My donor taught me: reflections from anatomy lab
• Building research integrity and capacity: professional development for research support staff
• Ethics of authorship in interprofessional team-based research
• Big brother is watching? The ethics of electronic adherence monitoring- an interdisciplinary outlook
• Migration and health: opportunities and challenges from the bioethics perspective
• Industry-academy relations: ethical and policy concerns
• Whole genome sequencing: the devil in the DNA
• Ethics in the CTSA program: past, present and a changing future
• Understanding patients’ views on consent for research enrollment in the setting of acute cardiac illness
• Exploring ethics rationales for patient engagement in research
• Medical researchers’ ancillary care obligations: a relationship-based approach
• How to write an exam in bioethics

ASBH Annual Conference 2014

Later this week I will be attending the annual conference of the American Society for Bioethics and Humanities. This is the nation’s largest bioethics conference, and it is always highly entertaining and educational. It makes me consider issues from new perspectives and it shows the full gamut of bioethics scholarship across the country. It features some of the world’s leading ethicists and philosophers, and it also includes many sessions where people working in the field present their research. There are preconference workshops, plenary sessions, paper sessions and affinity group meetings. The affinity groups are groups who gather around common interests. For example, there is an affinity group on rural bioethics, one on Jewish bioethics, another on sexuality and gender identity, one on neuroethics, and so on. These are less formal meetings that occur over meal hours, where people can discuss common interests. I usually try to attend the affinity group on research, and then on whatever hits my fancy at the time.

Below is a list of the general sessions, which will give you an overview of the scope of the conference.

• Articulating the Goals and Assessing the Impact of Bioethics Projects: A Report from the ABPD Working Group

• Made Vulnerable: Notes on Privilege; or, How When You Say Their Names, the Bodies Go Missing

• Moral Sources for Collaborative, Practice-Based Ethics: A Transformation for Education and Practice

• Sanctity of Life, by L. J. Schneiderman: A Staged Reading

• Collaborative Solutions to Challenges in Health Care and Education: A Forum Theatre Workshop

• Bioethics Literacy Across the Lifespan

• Migration and Health: Opportunities and Challenges from the Bioethics Perspective

• A Global Perspective on Women’s Rights to Health and Safety: Progress or Regress?

• From Clinical to Community Sequencing: Emerging Ethical, Legal, and Social Issues in Genomics

We are off at the Davenport campus next week, so I will post upon my return.

The Common Rule: General requirements for Informed Consent

I know that a good number of us have been developing and conducting research in our educational setting. And there are times when we will need to consider developing a consent document; however, not all of us have experience in writing one. Federal law actually stipulates what must be in a consent document, and rather than me summarizing those elements for you, I thought I would simply provide you the specific language, from 45CFR46 (46.116)(1).

Except as provided elsewhere in this policy, no investigator may involve a human being as a subject in research covered by this policy unless the investigator has obtained the legally effective informed consent of the subject or the subject's legally authorized representative. An investigator shall seek such consent only under circumstances that provide the prospective subject or the representative sufficient opportunity to consider whether or not to participate and that minimize the possibility of coercion or undue influence. The information that is given to the subject or the representative shall be in language understandable to the subject or the representative. No informed consent, whether oral or written, may include any exculpatory language through which the subject or the representative is made to waive or appear to waive any of the subject's legal rights, or releases or appears to release the investigator, the sponsor, the institution or its agents from liability for negligence.

 (a) Basic elements of informed consent. Except as provided in paragraph (c) or (d) of this section, in seeking informed consent the following information shall be provided to each subject:

 (1) A statement that the study involves research, an explanation of the purposes of the research and the expected duration of the subject's participation, a description of the procedures to be followed, and identification of any procedures which are experimental;

 (2) A description of any reasonably foreseeable risks or discomforts to the subject;

 (3) A description of any benefits to the subject or to others which may reasonably be expected from the research;

 (4) A disclosure of appropriate alternative procedures or courses of treatment, if any, that might be advantageous to the subject;

 (5) A statement describing the extent, if any, to which confidentiality of records identifying the subject will be maintained;

 (6) For research involving more than minimal risk, an explanation as to whether any compensation and an explanation as to whether any medical treatments are available if injury occurs and, if so, what they consist of, or where further information may be obtained;

 (7) An explanation of whom to contact for answers to pertinent questions about the research and research subjects' rights, and whom to contact in the event of a research-related injury to the subject; and

 (8) A statement that participation is voluntary, refusal to participate will involve no penalty or loss of benefits to which the subject is otherwise entitled, and the subject may discontinue participation at any time without penalty or loss of benefits to which the subject is otherwise entitled.

 (b) Additional elements of informed consent. When appropriate, one or more of the following elements of information shall also be provided to each subject:

 (1) A statement that the particular treatment or procedure may involve risks to the subject (or to the embryo or fetus, if the subject is or may become pregnant) which are currently unforeseeable;

 (2) Anticipated circumstances under which the subject's participation may be terminated by the investigator without regard to the subject's consent;

 (3) Any additional costs to the subject that may result from participation in the research;

 (4) The consequences of a subject's decision to withdraw from the research and procedures for orderly termination of participation by the subject;

 (5) A statement that significant new findings developed during the course of the research which may relate to the subject's willingness to continue participation will be provided to the subject; and

 (6) The approximate number of subjects involved in the study.

 (c) An IRB may approve a consent procedure which does not include, or which alters, some or all of the elements of informed consent set forth above, or waive the requirement to obtain informed consent provided the IRB finds and documents that:

 (1) The research or demonstration project is to be conducted by or subject to the approval of state or local government officials and is designed to study, evaluate, or otherwise examine: (i) public benefit or service programs; (ii) procedures for obtaining benefits or services under those programs; (iii) possible changes in or alternatives to those programs or procedures; or (iv) possible changes in methods or levels of payment for benefits or services under those programs; and

 (2) The research could not practicably be carried out without the waiver or alteration.

 (d) An IRB may approve a consent procedure which does not include, or which alters, some or all of the elements of informed consent set forth in this section, or waive the requirements to obtain informed consent provided the IRB finds and documents that:

 (1) The research involves no more than minimal risk to the subjects;

 (2) The waiver or alteration will not adversely affect the rights and welfare of the subjects;

 (3) The research could not practicably be carried out without the waiver or alteration; and

 (4) Whenever appropriate, the subjects will be provided with additional pertinent information after participation.

 (e) The informed consent requirements in this policy are not intended to preempt any applicable federal, state, or local laws which require additional information to be disclosed in order for informed consent to be legally effective.

 (f) Nothing in this policy is intended to limit the authority of a physician to provide emergency medical care, to the extent the physician is permitted to do so under applicable federal, state, or local law.

References

1.       http://www.hhs.gov/ohrp/humansubjects/guidance/45cfr46.html, accessed October 3, 2014

Three New Papers from Biomed Central Journals

Emary PC, Stuber KJ. Chiropractors' attitudes toward drug prescription rights: a narrative review. Chiropr Man Ther 2014, 22:34  doi:10.1186/s12998-014-0034-7

ABSTRACT

Background: The right to prescribe drugs remains a contentious issue within the chiropractic profession. Nevertheless, drug prescription by manual therapy providers is currently an important topic. Notably, physiotherapists in the United Kingdom were recently granted limited independent prescribing rights. Reports suggest that physiotherapists in Australia now want those same rights, and as such a review of chiropractors? general attitudes toward drug prescription is needed.

Objective: To examine the literature concerning chiropractors’ attitudes toward drug prescription rights and to compare the opinions of chiropractors currently licensed to prescribe medication with those in the profession who are not.

Methods: This was a narrative review, consisting of a formal literature search and summary of included articles. Electronic databases searched included the Cumulative Index to Nursing and Allied Health Literature, PubMed, and the Index to Chiropractic Literature. Inclusion criteria consisted of prospective studies published in English in peer-reviewed journals. Studies were required to contain data on chiropractors’ opinions toward medication prescription rights.

Results: Of 33 articles identified, a total of seven surveys were included in the review. Of these, there was a general split in opinion among chiropractors regarding the right to prescribe drugs in chiropractic practice. Those supportive of prescribing rights favoured a limited number of over-the-counter and/or prescription-based medications such as analgesics, anti-inflammatories, and muscle relaxants. When questioned on full prescribing rights, however, chiropractors were generally opposed. In jurisdictions where chiropractors are currently licensed to prescribe from a limited formulary, such as in Switzerland, the majority perceived this right as an advantage for the profession. Moreover, continuing education in pharmacology was viewed as a necessary component of this privilege.

Conclusions: Based on the literature to date there is a general split in chiropractors? attitudes toward drug prescription rights. This split is most pronounced in countries where chiropractors are not licensed to prescribe medications. Notwithstanding, this is an important topic in chiropractic currently and warrants both further discussion and research to determine future directions and the implications of either pursuit or denial of prescription rights by chiropractors. Future surveys and/or qualitative studies of other chiropractors? opinions toward gaining prescription privileges would be timely.

 

Kairouz VF, Raad D, Fudyma J, Curtis AB, Schunemann HJ, Akl EA. Assessment of faculty productivity in academic departments of medicine in the United States: a national survey. BMC Medical Education 2014, 14:205  doi:10.1186/1472-6920-14-205

ABSTRACT

Background: Faculty productivity is essential for academic medical centers striving to achieve excellence and national recognition. The objective of this study was to evaluate whether and how academic Departments of Medicine in the United States measure faculty productivity for the purpose of salary compensation.

Methods: We surveyed the Chairs of academic Departments of Medicine in the United States in 2012. We sent a paper-based questionnaire along with a personalized invitation letter by postal mail. For non-responders, we sent reminder letters, then called them and faxed them the questionnaire. The questionnaire included 8 questions with 23 tabulated close-ended items about the types of productivity measured (clinical, research, teaching, administrative) and the measurement strategies used. We conducted descriptive analyses.

Results: Chairs of 78 of 152 eligible departments responded to the survey (51% response rate). Overall, 82% of respondents reported measuring at least one type of faculty productivity for the purpose of salary compensation. Amongst those measuring faculty productivity, types measured were: clinical (98%), research (61%), teaching (62%), and administrative (64%). Percentages of respondents who reported the use of standardized measurements units (e.g., Relative Value Units (RVUs)) varied from 17% for administrative productivity to 95% for research productivity. Departments reported a wide variation of what exact activities are measured and how they are monetarily compensated. Most compensation plans take into account academic rank (77%). The majority of compensation plans are in the form of a bonus on top of a fixed salary (66%) and/or an adjustment of salary based on previous period productivity (55%).

Conclusion: Our survey suggests that most academic Departments of Medicine in the United States measure faculty productivity and convert it into standardized units for the purpose of salary compensation. The exact activities that are measured and how they are monetarily compensated varied substantially across departments.

 

Habets MGJL, van delden JJM, Bredenoor AL. The social value of clinical research. BMC Medical Ethics 2014, 15:66  doi:10.1186/1472-6939-15-66

ABSTRACT

Background: International documents on ethical conduct in clinical research have in common the principle that potential harms to research participants must be proportional to anticipated benefits. The anticipated benefits that can justify human research consist of direct benefits to the research participant, and societal benefits, also called social value. In first-in-human research, no direct benefits are expected and the benefit component of the risks-benefit assessment thus merely exists in social value. The concept social value is ambiguous by nature and is used in numerous ways in the research ethics literature. Because social value justifies involving human participants, especially in early human trials, this is problematic.

Discussion: Our analysis and interpretation of the concept social value has led to three proposals. First, as no direct benefits are expected for the research participants in first-in-human trials, we believe it is better to discuss a risk- value assessment instead of a risk - benefit assessment. This will also make explicit the necessity to have a clear and common use for the concept social value. Second, to avoid confusion we propose to limit the concept social value to the intervention tested. It is the expected improvement the intervention can bring to the wellbeing of (future) patients or society that is referred to when we speak about social value. For the sole purpose of gaining knowledge, we should not expose humans to potential harm; the ultimate justification of involving humans in research lies in the anticipated social value of the intervention. Third, at the moment only the validity of the clinical research proposal is a prerequisite for research to take place. We recommend making the anticipated social value a prerequisite as well.

Summary: In this paper we analyze the use of the concept social value in research ethics. Despite its unavoidable ambiguity, we aim to find a best use of the concept, subject to its role in justifying involving humans in first-in-human research.

 

Citation Software

The new issue of Online Cl@ssroom has a nice little article devoted to citation software (1). Most of us are already familiar with at least one program that collects and organizes citations, namely RefWorks. For those in research, they use Refman, which is a more powerful citation tracker. But there are a number of other venders for these programs. Included among them are:

Zotero: available at www.zotero.com. This is a  free program that works across platforms and links itself to your browser. From its home page, it notes that it will automatically sense the content in your browser and then let you add it to your personal library. All the content is then placed into a single searchable interface, which is organized in a fashion similar to an iTunes library. Youdo not need to look through folders inside folders. And you have the ability to tag your contents, making it easier to locate required content. Finally you can easily place citations tinot your word profcessing papers without having to leave the program you are working in.

CiteThisForMe: available at www.citethisforme.com. This also allows you to automatically grab bibliographic information right form whatever web page you are on. It easily lets you denote the kind of reference you are grabbing, creates a master list of all of your references, but lets you create individual bibliographic lists, download other lists, and share those lists with a defined group. It can format the reference lists in a wide range of styles.

EasyBib: available at www.easybib.com. This program works with Google Drive, which I have to admit I do not use for myself. In its free version, it allows you to only create reference lists in MLA style, which may not work as well in standard scientific writing, which generally requires Vancouver style references. However, it can be upgraded, for a small fee.

ProQuest Flow: available at www.proquest.com/products-services/flow.html. This is a cloud-based product that “helps researchers better manage citations and full-text documents and gain control over the research workflow.” (As stated on its web-site). You can either automatically enter a citation with a one-click process, or you can manually enter information if necessary. This program has a huge database of reference styles.

References

1.       Require your students to use citation software. Online Cl@ssroom 2014;14(9),p4,8

CARE Guidelines

In my last blog post I discussed writing case reports. I noted at the end that there was new guideline for preparing case reports, known as CARE (http://www.care-statement.org/#), which my friend an colleague Dr. Karen Boulanger had written about in her most recent publication (1). Templates for CARE can be downloaded from the CARE website, at http://www.care-statement.org/case-report-writing-template.html

The elements which should be included in writing a case report are as follows:

Title: The guidelines now recommend the words “Case Report” be in the title. This is actually counter to recommendations I have made in the past, where it was felt that since a paper would likely be put in a section of the journal devoted to case reports it was no longer necessary to list it as part of the title. This is a change, but it clarifies what the paper is about.

Abstract: Typically, this uses a structured format, but some journals have moved away from that. In the abstract, you should include the reason for the repot, presenting concerns of the patient, diagnosis, intervention and outcomes.

Key Words: These should be MeSH terms, so select carefully.

Introduction: Provide background for your case and why it is important.

Presenting Concerns: Why did the patient seek care? Provide historical information about the patient.

Clinical Findings: Provide only those findings which are relevant to the case. No need to provide ling lists of normal findings. Be sure to support your diagnosis with the findings.

Timeline: What was the course of care. A table or figure can help illustrate this quite well.

Diagnostic Focus and Assessment: Summarize your diagnostic finding and your clinical reasoning arising from those findings.

Therapeutic Focus and Assessment: Discuss your treatment plan and how it was administered.

Follow-up and Outcomes: Summarize the clinical course of the case. How did the patient respond to care? What was the final outcome?

Discussion: What does this all mean? What was learned as a result of publishing the report? What gap in the literature was filled? What other interpretations of the results might be considered? What limitations exist?

Patient Perspective: This is a new part of the paper. Where possible and appropriate, the patient should provide a brief narrative of their case to accompany the paper.

Informed Consent: The patient should provide consent and permission for the paper

This is all pretty much what traditionally has been seen in case reports, but this codifies the format, making it easier to know how to organize information and construct a logical flow from it. Please use!

 References

1.       Munk N, Boulanger K. ASdaptation of the CARE guidelines for therapeutic massage and bodywork: efforts to improve the impact of case reports. Int J Ther Massage Bodywork 2014;7:32040

How to Prepare a Case Report

In the past couple of weeks I have had an opportunity to work with several faculty members who were interested in preparing case reports. It was my honor to do so. It led me to consider offering up a few thoughts on how to get them ready for publication.

The easiest way to prep a case report involves, really, just two issues: one is to have the case records at hand, and the second is to know the general template for putting that information into readable from. Assuming that you have the records available, I will focus on the second item here.

The general format or template for a case reports is: Structured Abstract, Introduction, Case Report, Discussion, Conclusion, References.

Structured Abstract: Really, this should be prepared last, after the paper is completed. But when you are ready, most journals require a structured abstract with specific subheadings: Objective (why are you writing the paper?); Clinical Features (what were the features the patient had when he or she came for care, leading you to your diagnosis?); Intervention and Outcome (what did you do and how did the patient respond?); Conclusion (what do you conclude for the above?). And you have to do all of this in 250 words or less.

Introduction: This usually will provide some background information on the condition of interest, as well as provide some context for the educational value of the case. Put it this way: what is unusual here, what gap in the literature will be filled by publishing the case?

Case Report: Well, this is the report of the case, of course. It needs to provide the reader only the essential information: on diagnosis and tests run, on treatment and on outcome. The reader should be able to confirm that you made a correct diagnosis, and they should be able to understand the intricacies of your treatment, and they should be able to assess the outcome instruments you used for monitoring progress.

Discussion: This explains the educational value of the paper. What did we learn here? How does what we learned here fit into the larger body of information available about this condition or topic? The primary function of a case report is to educate the reader, to help them learn something. That should be the focus of the paper- so, you may focus on teaching about the condition, or perhaps its management or perhaps something else.

Conclusion: This is really just a recapitulation of what came before. It should not offer any speculation, but may suggest directions for future research based on what you found.

References: Of course, references are important since they provide the foundation for the importance of your case.

I recommend that you pick up a case report or two from a chiropractic journal and look to see how well they fit into this template. Knowing these components can ease the fear you might feel in considering writing something for publication.

As I prepared to post this, I received a note from Dr. Karen Boulanger, about a new paper she co-wrote related to preparing case reports. It is excellent and can be accessed at http://ijtmb.org/index.php/ijtmb/article/view/251/303

 

Sampling

We are just a few days away from the deadline for submission to ACC-RAC. And I have had an opportunity to assist a number of faculty in developing their submissions. Each year, one of the things I see are projects that involve survey methodology. This got me thinking about what it means to use a sample. What methods exist for selecting a sample from a population? Peter Jarvis, is his text “The Practitioner-Researcher: Developing Theory from Practice” (pages 122-123) provides a full list of samples. Among them are:

• Random Sample: Here, all we do is select a sample for the population in a way that gives everybody in the population an equal chance of being selected.
• Systematic Random Sample: Here, we find our population and then use some system to select our sample. If we did this in a class, it might mean that we use every 3^rd student’s data or something similar.
• Stratified Random Sample: We divide our population into groups somehow, and then we select an equal number of people per group. For example, we could stratify by age range.
• Cluster Sample: Jarvis uses the example of doing research about teaching medicine and selecting a number of medical schools in a particular area and then study the teachers in just those schools.
• Stage Sample: This builds on a cluster sample, but then uses a second random sample in the population drawn from the cluster group.
• Convenience Sample: We select our sample from a convenient population. This is what we do with most of our clinical trials- the community is invited, some people respond, and then we get our sample from those that do.
• Quota Sample: We select a specific number of individuals from each category we seek to study.
• Purposive Sample: We hand pick the sample. Perhaps we invite our colleagues to participate in our research.
• Dimensional Sample: This is a modified quota sample where we also ensure that we capture all the dimensions of the practice to be studied.
• Snowball Sample: We ask, for example some experts to be in our study, and then ask them to suggest additional experts. The sample then “snowballs” in size.

Thus, there are many ways to find a sample, and as always, we just need to use the best one to answer out question.