Prezi (http://www.prezi.com) provides you with a new method of presenting information to your students. It can move slide-driven presentations in new and interesting directions, because it works in a less linear fashion than does a standard PowerPoint presentation. It is a new evolution of presentation technology. I recall sitting in class as a student as instructors brought acetate overheads into class. Initially, they might have actually copied or drawn their own information on those sheets, but as technology evolved they could copy a table, for example, from a book onto the acetate and at least provide a more professional0looking overhead. And then, as technology further evolved, digital PowerPoint slide began to replace the slide carousels we carried around, and the ease with which we could make our presentations increased. But despite the comfort we now have with the use of slide/presentation technology- most of us use PowerPoint to one degree or another- there are problems with that technology, leading some experts to refer to something called “death by PowerPoint.”
Prezi calls itself a digital storytelling tool. Unlike PowerPoint, which allows you to present in a linear fashion, Prezi uses content to create a storyline. You can zoom in and out and all around, working instead on a “whiteboard.” Perhaps it would be best to demonstrate. Go to this link and view the presentation there to see a prezi in action:
http://prezi.com/recyyolzxm3e/how-to-create-a-great-prezi/
I should note what prezi is not.
It is not a way to simply reuse your slides in a new format. It is not a program which requires you to have design skills. It is not like other presentation software, nor is it a way to make weak art look good. And it is not just for presentations. It can be used, for example, for concept mapping. I order to use it, you must sign up, but you can do so under their free plan, which gives you 100mb of storage and the ability to work online. There are paid options as well that allow you to make work private and to work offline, and they also offer reduced rates for educators. When you log onto the site, there are 3 tabs across the top: Your Prezis (where the ones you create are stored), Learn (for learning how to use the technology in more detail), and Explore (where you can see other’s prezis and participate in message boards).
To use this, you need to think differently about how you wish to present information. You will be telling a story, so you need to plan differently. You have to think visually and in terms of movement. But this is a novel and interesting technology and I wish to suggest you play with it a little bit and see how it might help you to reinforce learning.
Monday, April 18, 2011
Monday, April 11, 2011
Making a Distribution List in Outlook
A distribution list is a set of contacts that you create that makes it easy for you to send a broadcast email to that group of people. For example, if you have just been asked to chair a search committee for a new position at the college, you can set up a distribution list for that team- which you might name “New Position Team- to allow you to easily communicate with the members of the team but without the need to type in each individual name each time you wish to send the team a message. You can use this distribution list not just to send email messages, but also to set up meetings or tasks on Outlook. And setting up the list is relatively easy to do.
The distribution list will be stored in your Contacts folder. It is possible to make this a global account or a personal account, and we will do the later here (the former would make your list available to everyone in the college, which you probably don’t want to do). However, you can share your list with others by sending it to them, or having them copy if from a message you send out to others.
To create the list, first go to the File menu, point to New and then click on Distribution List. A box will open that asks you to give this list a name; name it so that you will recognize what that list is for. We might call it, again, “New Position Team.” On the Distribution List tab, please then click on Select Members. In the Address Book drop-down list, click on the address book that contains all the email addresses you want to include in your new distribution list; in this case, this will be the Global Address List. A Search Box will appear, and in it you should type the name of one of the people you wish to include. When that name finally appears, click it, and then click Members. Do this for each person you want to add to the list, and when done click OK.
The list is then saved in your Contacts folder under the name you gave it. When you wish to send an email to that list, all you need to do is to go to your Contacts folder, double click on the “card” for the distribution list, and when it opens, click on the tab on the ribbon on top that says Email. A blank email will open up already set to be sent to the members of the list. You can then type your message and just click to send.
You can add or delete members easily by opening the file as noted just above. You can delete a name by highlighting it and clicking Delete; you can add new names as you did before. This is an easy way to make sure you do not have to replicate or duplicate work.
The distribution list will be stored in your Contacts folder. It is possible to make this a global account or a personal account, and we will do the later here (the former would make your list available to everyone in the college, which you probably don’t want to do). However, you can share your list with others by sending it to them, or having them copy if from a message you send out to others.
To create the list, first go to the File menu, point to New and then click on Distribution List. A box will open that asks you to give this list a name; name it so that you will recognize what that list is for. We might call it, again, “New Position Team.” On the Distribution List tab, please then click on Select Members. In the Address Book drop-down list, click on the address book that contains all the email addresses you want to include in your new distribution list; in this case, this will be the Global Address List. A Search Box will appear, and in it you should type the name of one of the people you wish to include. When that name finally appears, click it, and then click Members. Do this for each person you want to add to the list, and when done click OK.
The list is then saved in your Contacts folder under the name you gave it. When you wish to send an email to that list, all you need to do is to go to your Contacts folder, double click on the “card” for the distribution list, and when it opens, click on the tab on the ribbon on top that says Email. A blank email will open up already set to be sent to the members of the list. You can then type your message and just click to send.
You can add or delete members easily by opening the file as noted just above. You can delete a name by highlighting it and clicking Delete; you can add new names as you did before. This is an easy way to make sure you do not have to replicate or duplicate work.
Monday, April 4, 2011
The Hidden Curriculum
When we speak of the curriculum in a health care setting such as chiropractic education, we typically mean this to refer to what is more properly called the formal curriculum. This is the actual course of study offered by a chiropractic college, including its planned content, teaching, evaluation methods, syllabi, exercises, textbooks and other teaching aids, as used in classroom, laboratory or clinical settings (1). We might also add here our formal policy statements, competencies and so on.
But educators also understand that there is an informal curriculum as well; this refers to the teaching opportunities that come up over the course of the day that are unplanned but involve instruction. This can occur in a clinical setting (perhaps from a chance encounter with an unusual patient), but may also occur in faculty offices or hallway interactions where a teacher has a chance to interact with a student. And again, this informal curriculum supports what teachers feel students should be learning through the formal program, as well as in terms of appropriate skills and values.
Finally, there is the hidden curriculum, which includes “the ideological and subliminal messages of both the formal and informal curricula. The hidden curriculum can be both human and structural; that is, it can be transmitted through human behaviors and through the structures and practices of institutions” (2). The hidden curriculum was first defined by Philip Jackson, who did an ethnographic study on classroom teaching in 1968 (3). We can look at this as a “vast network of unwritten social and cultural values, rules, assumptions, and expectations.” And many feel this is as important as the formal curriculum in the process of educating students.
I find this example of the power of the hidden curriculum telling. Anderson notes this story concerning a colleague, that when he went to kindergarten he learned a whole set of facts he had not known before. He learned that he was fat, which he had not known before. He learned he was slower than his friends at almost everything he did. And he learned he was poor. And this is what he remembered many years later about this time in kindergarten (4).
It is important to note that everyone in our institution participates in the hidden curriculum- we all influence our students in ways we cannot know or predict; for example, in how we respond to a challenging question in class, or how we interact with a student who visits us in our office, or how we comment on a new initiative that the college has just advanced. Students will learn by observing us; this is also a part of professionalizing them to life as a physician. Let me ask: what are the unspoken messages within each of our academic departments, between administration and faculty, between faculty and students, and between clinic and academic teachers? Are we seen as treating everyone with respect? Whose voices are heard more than others, and why? As Alexander notes, the hidden curriculum supersedes the lecture series, and it starts long before classes start while not ending when classes end.
What is important for all of us to realize is that the hidden curriculum should be harmonious with the formal curriculum; one way of looking at this is from the perspective of “walking the walk and talking the talk.” What does it say for one of us to ask that we treat people with courtesy in the classroom but then have no time or patience for a student who seeks us in the office? We all come into contact with people, and we need to think about how our behavior, our words and our actions influence those around us. This is more powerful than we might realize.
References
1. Pinar W. Understanding curriculum. New York, NY; Peter Lang 1995
2. Wear D, Skillicom J. Hidden in plain sight: the formal, informal, and hidden curriculum of a psychiatry clerkship. Acad Med 2009;84:451-457
3. Jackson P. Life in classrooms. New York, NY; Holt, Rinehart and Winston, 1974
4. Anderson DJ. The hidden curriculum. Am J Roentgenol 1992;159:21-22
But educators also understand that there is an informal curriculum as well; this refers to the teaching opportunities that come up over the course of the day that are unplanned but involve instruction. This can occur in a clinical setting (perhaps from a chance encounter with an unusual patient), but may also occur in faculty offices or hallway interactions where a teacher has a chance to interact with a student. And again, this informal curriculum supports what teachers feel students should be learning through the formal program, as well as in terms of appropriate skills and values.
Finally, there is the hidden curriculum, which includes “the ideological and subliminal messages of both the formal and informal curricula. The hidden curriculum can be both human and structural; that is, it can be transmitted through human behaviors and through the structures and practices of institutions” (2). The hidden curriculum was first defined by Philip Jackson, who did an ethnographic study on classroom teaching in 1968 (3). We can look at this as a “vast network of unwritten social and cultural values, rules, assumptions, and expectations.” And many feel this is as important as the formal curriculum in the process of educating students.
I find this example of the power of the hidden curriculum telling. Anderson notes this story concerning a colleague, that when he went to kindergarten he learned a whole set of facts he had not known before. He learned that he was fat, which he had not known before. He learned he was slower than his friends at almost everything he did. And he learned he was poor. And this is what he remembered many years later about this time in kindergarten (4).
It is important to note that everyone in our institution participates in the hidden curriculum- we all influence our students in ways we cannot know or predict; for example, in how we respond to a challenging question in class, or how we interact with a student who visits us in our office, or how we comment on a new initiative that the college has just advanced. Students will learn by observing us; this is also a part of professionalizing them to life as a physician. Let me ask: what are the unspoken messages within each of our academic departments, between administration and faculty, between faculty and students, and between clinic and academic teachers? Are we seen as treating everyone with respect? Whose voices are heard more than others, and why? As Alexander notes, the hidden curriculum supersedes the lecture series, and it starts long before classes start while not ending when classes end.
What is important for all of us to realize is that the hidden curriculum should be harmonious with the formal curriculum; one way of looking at this is from the perspective of “walking the walk and talking the talk.” What does it say for one of us to ask that we treat people with courtesy in the classroom but then have no time or patience for a student who seeks us in the office? We all come into contact with people, and we need to think about how our behavior, our words and our actions influence those around us. This is more powerful than we might realize.
References
1. Pinar W. Understanding curriculum. New York, NY; Peter Lang 1995
2. Wear D, Skillicom J. Hidden in plain sight: the formal, informal, and hidden curriculum of a psychiatry clerkship. Acad Med 2009;84:451-457
3. Jackson P. Life in classrooms. New York, NY; Holt, Rinehart and Winston, 1974
4. Anderson DJ. The hidden curriculum. Am J Roentgenol 1992;159:21-22
Monday, March 28, 2011
A Little More from ACC-RAC 2011
Here are a few more abstracts from PCC faculty who presented at ACC-RAC.
Robert Rowell and Michael Tunning. Evidence-based clinical practice in chiropractic: description of a class assignment and survey of student knowledge and attitudes.
Introduction: Recognizing the importance of evidence-based clinical practice (EBCP), the authors initiated an assignment in which students use EBCPC. Following this assignment, a survey was conducted of attitudes and comfort with evidence-based practice. Methods: Students participated in a lecture introducing EBCP, then critiqued an article as a group discussion, then designed a PICO (Patient, Intervention, Comparison, Outcome) questions, searched the literature, and critiqued an article that they found. A short survey was conducted after they completed the assignment. Results: Out of 126 students registered for class, 86 surveys were collected (68%). Seventy students (81.4%) did a literature search. Discussion: These students had little training in EBCP prior to this assignment. They feel their skills in literature searching are generally good. However, several students did not perform a literature search. Most students used good sources of information, such as PubMed or Dynamed for their literature searches. Many students feel that they have some skills in EBCP. Conclusion: The topic of EBCP was introduced in a class assignment and students’ attitudes and self-rated understanding of EBCP were assessed.
Xiaohua He and Anne Canty. Empowering student learning through rubric-referenced self-assessment.
Objective: The purpose of this study was to investigate the effect of rubric-referenced self-assessment on performance of anatomy assignments in a group of chiropractic students. Methods: Participants (n=259) were first-quarter students who were divided into a treatment group (n=130) and a comparison group (n=129). The intervention for both groups involved the use of rubrics to complete the first draft of anatomy assignments. General feedback was given by the instructor and the students and the students had the opportunity to amend the assignments before resubmission (second draft). The treatment group, however, was also asked to perform rubric-referenced self-critique and self-assessment of their assignments during their second draft. Although the comparison group was also provided with the identical rubrics for the assignments, it did not perform rubric-referenced self-critique and self-assessment. Results: The results revealed that the students in the treatment group, who used a rubric-referenced self-assessing learning model, received statistically significant higher scores that their counterparts in the comparison group, who did not use a rubric-referenced self-assessing learning model, in performing assignments. Conclusion: This study suggests that practicing rubric-referenced self-assessment enhances students’ performance on anatomy assignments. However, educators continue to face the challenge of developing practical and useful rubric tools for students’ self-assessment. NOTE: This paper was awarded top prize at ACC-RAC for educational research and will be published in an upcoming issue of the Journal of Chiropractic Education.
Nancy Kime. Using evidence-based clinical practice principles to utilize and enhance student clinical reasoning skills in a classroom-based management course: a pilot project.
Introduction: With the intention to utilize concepts of adult learning, a teaching methodology was developed that incorporates evidence-based clinical practice (EBCP) principles into a case management classroom-based course. Methods: In order to train students in the knowledge, skills and attitudes necessary to implement EBCP, this pilot method consisted of three components: introductory lecture, guided work outside the classroom and faculty-guided small-group presentations within the classroom. Results: Student qualitative feedback was overwhelmingly positive. Students reported greater levels of confidence related to the development of patient care plans following application of evidence and related clue in professional dialogue with peers. Conclusion: This method represents a more credible approach to clinic-level student learning utilizing available classroom time to enhance high-level critical thinking and create familiarity and competence in use of EBCP, thereby benefitting patients by the use of the most valid and current evidence. I urge all of you to consider submitting an abstract next year for ACC-RAC, which will be held at Planet Hollywood hotel in Las Vegas. The theme is “Diversity in Chiropractic.”
Robert Rowell and Michael Tunning. Evidence-based clinical practice in chiropractic: description of a class assignment and survey of student knowledge and attitudes.
Introduction: Recognizing the importance of evidence-based clinical practice (EBCP), the authors initiated an assignment in which students use EBCPC. Following this assignment, a survey was conducted of attitudes and comfort with evidence-based practice. Methods: Students participated in a lecture introducing EBCP, then critiqued an article as a group discussion, then designed a PICO (Patient, Intervention, Comparison, Outcome) questions, searched the literature, and critiqued an article that they found. A short survey was conducted after they completed the assignment. Results: Out of 126 students registered for class, 86 surveys were collected (68%). Seventy students (81.4%) did a literature search. Discussion: These students had little training in EBCP prior to this assignment. They feel their skills in literature searching are generally good. However, several students did not perform a literature search. Most students used good sources of information, such as PubMed or Dynamed for their literature searches. Many students feel that they have some skills in EBCP. Conclusion: The topic of EBCP was introduced in a class assignment and students’ attitudes and self-rated understanding of EBCP were assessed.
Xiaohua He and Anne Canty. Empowering student learning through rubric-referenced self-assessment.
Objective: The purpose of this study was to investigate the effect of rubric-referenced self-assessment on performance of anatomy assignments in a group of chiropractic students. Methods: Participants (n=259) were first-quarter students who were divided into a treatment group (n=130) and a comparison group (n=129). The intervention for both groups involved the use of rubrics to complete the first draft of anatomy assignments. General feedback was given by the instructor and the students and the students had the opportunity to amend the assignments before resubmission (second draft). The treatment group, however, was also asked to perform rubric-referenced self-critique and self-assessment of their assignments during their second draft. Although the comparison group was also provided with the identical rubrics for the assignments, it did not perform rubric-referenced self-critique and self-assessment. Results: The results revealed that the students in the treatment group, who used a rubric-referenced self-assessing learning model, received statistically significant higher scores that their counterparts in the comparison group, who did not use a rubric-referenced self-assessing learning model, in performing assignments. Conclusion: This study suggests that practicing rubric-referenced self-assessment enhances students’ performance on anatomy assignments. However, educators continue to face the challenge of developing practical and useful rubric tools for students’ self-assessment. NOTE: This paper was awarded top prize at ACC-RAC for educational research and will be published in an upcoming issue of the Journal of Chiropractic Education.
Nancy Kime. Using evidence-based clinical practice principles to utilize and enhance student clinical reasoning skills in a classroom-based management course: a pilot project.
Introduction: With the intention to utilize concepts of adult learning, a teaching methodology was developed that incorporates evidence-based clinical practice (EBCP) principles into a case management classroom-based course. Methods: In order to train students in the knowledge, skills and attitudes necessary to implement EBCP, this pilot method consisted of three components: introductory lecture, guided work outside the classroom and faculty-guided small-group presentations within the classroom. Results: Student qualitative feedback was overwhelmingly positive. Students reported greater levels of confidence related to the development of patient care plans following application of evidence and related clue in professional dialogue with peers. Conclusion: This method represents a more credible approach to clinic-level student learning utilizing available classroom time to enhance high-level critical thinking and create familiarity and competence in use of EBCP, thereby benefitting patients by the use of the most valid and current evidence. I urge all of you to consider submitting an abstract next year for ACC-RAC, which will be held at Planet Hollywood hotel in Las Vegas. The theme is “Diversity in Chiropractic.”
Monday, March 21, 2011
A Little from ACC-RAC 2011
The annual Association of Chiropractic Colleges/Research Agenda Conference was held this past week at Caesar’s Palace in Las Vegas. Over the course of two days, there were well over a hundred platform presentations given, along with plenary sessions and poster sessions. Palmer College can take great pride in its impact at this program. We had over 34 presentations, posters and workshops, representing the work of individuals from academic teaching faculty, clinician faculty, researchers, administrators and staff. I thought I would highlight a small number of them here.
Platform Presentations
1. Lia Nightingale. Integration of evidence-based clinical practice into a basic science.
Introduction: Evidence-based clinical practice (EBCP) has permeated every health care profession, including chiropractic. The focus of this project was to incorporate EBCP concepts into a first-trimester nutritional biochemistry course at a chiropractic institution. Course learning outcomes were changed to integrate EBCP concepts, including interpretation of relative risk, absolute risk, odds ratios, and numbers needed to treat.
Methods: Four complete lectures were developed to teach EBCP concepts and its functionality in a chiropractic practice. Several new slides were added to each previously taught lecture to illustrate the importance of EBCP throughout the course. Quiz and exam questions were written to reflect the new material and as assignment was developed to guide students in the process of using evidence in practice via the four A’s (ask, acquire, appraise, and apply). Results: Initial examination illustrated improved student performance on exam questions and written papers, but further assessment is required.
Conclusion: Integration of EBCP concepts into a basic science course in a chiropractic curriculum promotes meaningful learning and enhances critical reasoning skills. Furthermore, addition of EBCP has taken a preclinical biochemistry course and made it relevant to patient care, enhancing student satisfaction.
2. Boesch R, Illingworth R. Wiki, a collaborative faculty development tool.
Background: Collaborating on scholarly material is limited to face-to-face meetings, e-mail, or teleconferencing. It is difficult to schedule meetings and teleconferences. E-mailing papers leads to version control problems.
Objective: To describe the development and implementation of a Wiki used to enhance faculty collaboration in the development of scientific publication.
Methods: A wiki for faculty collaboration was developed which linked faculty to the services of a professional scientific editor. Faculty were shown how to use this site via in-service sessions and were then invited to access the site.
Results: Success is shown by the production of scholarly material from the faculty. This demonstrates that scholarly activity is occurring. Three papers are completed, submitted, and accepted for publication; many more are in development. A number of posters have been produced from this process for presentation.
Discussion: The Wiki was introduced for collaboration in real time from anywhere people access the Internet. This allows authors from multiple locations to be part of the process. It provides application for the college and profession to enhance publications. Collaborating at any time reduces stress of scheduling meetings or working with incorrect version. The Wiki has an experienced editor as part of the process of providing feedback. This is a collaborative effort where all work together.
Conclusion: The Wiki is a useful tool to help faculty collaborate on the development of scholarly materials.
Posters
1. Anderson M, Butler C. Management considerations in a transtibial amputee with Charcot-Marie-Tooth disease.
2. Anderson M, Barber M. Kinetic chain dysfunction in a 16-year-old soccer player with ankle pain.
3. Boesch R, Owens J, Silverman S, Klimek M. Cervical spondylitic myelopathy: a case report.
4. Boesch R, Stick M, Illingworth R, Borcher E. Glioma with subdural hematoma initial management: a case report.
5. Cole R, Boesch R, Cole B. Chiropractic management of cycling induced median and ulnar neuropathy.
6. Hubbard T, Pickar J, Lawrence DJ, Duray S. Reliability of the Blair upper cervical radiographic analysis for the base posterior view: a feasibility study.
7. Hubbard T, Kane J. Essential tremor, migraine and upper cervical chiropractic: a case report.
8. Juehring D. A case study utilizing Vojta/dynamic neuromuscular stabilization therapy to control symptoms of a chronic migraine sufferer.
Platform Presentations
1. Lia Nightingale. Integration of evidence-based clinical practice into a basic science.
Introduction: Evidence-based clinical practice (EBCP) has permeated every health care profession, including chiropractic. The focus of this project was to incorporate EBCP concepts into a first-trimester nutritional biochemistry course at a chiropractic institution. Course learning outcomes were changed to integrate EBCP concepts, including interpretation of relative risk, absolute risk, odds ratios, and numbers needed to treat.
Methods: Four complete lectures were developed to teach EBCP concepts and its functionality in a chiropractic practice. Several new slides were added to each previously taught lecture to illustrate the importance of EBCP throughout the course. Quiz and exam questions were written to reflect the new material and as assignment was developed to guide students in the process of using evidence in practice via the four A’s (ask, acquire, appraise, and apply). Results: Initial examination illustrated improved student performance on exam questions and written papers, but further assessment is required.
Conclusion: Integration of EBCP concepts into a basic science course in a chiropractic curriculum promotes meaningful learning and enhances critical reasoning skills. Furthermore, addition of EBCP has taken a preclinical biochemistry course and made it relevant to patient care, enhancing student satisfaction.
2. Boesch R, Illingworth R. Wiki, a collaborative faculty development tool.
Background: Collaborating on scholarly material is limited to face-to-face meetings, e-mail, or teleconferencing. It is difficult to schedule meetings and teleconferences. E-mailing papers leads to version control problems.
Objective: To describe the development and implementation of a Wiki used to enhance faculty collaboration in the development of scientific publication.
Methods: A wiki for faculty collaboration was developed which linked faculty to the services of a professional scientific editor. Faculty were shown how to use this site via in-service sessions and were then invited to access the site.
Results: Success is shown by the production of scholarly material from the faculty. This demonstrates that scholarly activity is occurring. Three papers are completed, submitted, and accepted for publication; many more are in development. A number of posters have been produced from this process for presentation.
Discussion: The Wiki was introduced for collaboration in real time from anywhere people access the Internet. This allows authors from multiple locations to be part of the process. It provides application for the college and profession to enhance publications. Collaborating at any time reduces stress of scheduling meetings or working with incorrect version. The Wiki has an experienced editor as part of the process of providing feedback. This is a collaborative effort where all work together.
Conclusion: The Wiki is a useful tool to help faculty collaborate on the development of scholarly materials.
Posters
1. Anderson M, Butler C. Management considerations in a transtibial amputee with Charcot-Marie-Tooth disease.
2. Anderson M, Barber M. Kinetic chain dysfunction in a 16-year-old soccer player with ankle pain.
3. Boesch R, Owens J, Silverman S, Klimek M. Cervical spondylitic myelopathy: a case report.
4. Boesch R, Stick M, Illingworth R, Borcher E. Glioma with subdural hematoma initial management: a case report.
5. Cole R, Boesch R, Cole B. Chiropractic management of cycling induced median and ulnar neuropathy.
6. Hubbard T, Pickar J, Lawrence DJ, Duray S. Reliability of the Blair upper cervical radiographic analysis for the base posterior view: a feasibility study.
7. Hubbard T, Kane J. Essential tremor, migraine and upper cervical chiropractic: a case report.
8. Juehring D. A case study utilizing Vojta/dynamic neuromuscular stabilization therapy to control symptoms of a chronic migraine sufferer.
Monday, March 14, 2011
Questions to Ask When Reading a Diagnostic Paper, Part 2
Continuing my discussion from last week, these are additional questions from Greenhalgh (1) you should consider when you read a paper that discusses diagnostic testing.
6. Was the test shown to be reproducible both within and between observers? This is a question that gets at intra and inter-observer reliability. No matter what the test, if the same person conducts the same test on two occasions on a patient or subject who otherwise has remain unchanged, they will still get different results in some proportion of tests. This is true of all tests, but would trust a test with 99% reliability far more than we would one with 70% reliability. While this may be less of a problem for a diagnost9ic test where we read results in terms of numbers (such as blood cholesterol or heart rate), this can be more significant when applied to reading radiology results, for example.
7. What are the features of the test as derived from this validation study? You may have a test which is seen to be reliable, but the test itself could be invalid; that is, its sensitivity and specificity is far too low. If your test has too high a false negative rate it will mislead clinicians rather than illustrate features important and related to the patient. This is something that needs balance; for example, if we are looking at a test for color blindness and see that it is, say, 95% sensitive and 80% specific, we might not worry- no one dies from color blindness itself. On the other hand, as Greenhalgh points out, the Guthrie hell prick screening test done on infants to test for congenital hypothyroidism is 99% sensitive but has a positive predictive value of just 6% (meaning: it does a great job of identifying children with the condition at a very high rate of false positive findings) but here this may be okay because we cannot afford to miss any kid with this condition since it leads to mental handicap. For everyone else, you just need to repeat the test every now and again, which is small potatoes in the scheme of things.
8. Were the confidence intervals given for sensitivity, specificity and other features of the test? To refresh your memory, remember that the confidence interval demonstrates the possible range of results within which the true value lies. And also recall that the larger the sample size, the narrower the confidence interval, which is good.
9. Has a sensible “normal range” been derived from these results? If a test provides non-dichotomous results (such as temperature or blood pressure as examples) we have to determine when the results will be seen as abnormal. If our BP is 142/90, would we call that abnormal when we might see 138/90 as not? Or would we advise the patient that we might wish to recheck them in some short period of time? Defining “normal” can be rather difficult to do.
10. Has the test been placed in the context of other potential tests in the diagnostic sequence for the condition? In some cases, a single diagnostic test might suffice for us to begin treatment; i.e., such as blood pressure of 160/100. In other cases, there is a sequence of tests we use before we decide to being treating. We might use McMurray’s test as part of a sequence of tests for determining the presence of a torn meniscus but not take its findings on its own, since it has a low sensitivity and specificity.
These questions can help you determine whether or not you can apply the results of a paper looking at a diagnostic test to your patient.
References
1. Greenhalgh T. How to read a paper: the basics of evidence-based medicine. London; UK; BMJ Books, 2001:113-116
6. Was the test shown to be reproducible both within and between observers? This is a question that gets at intra and inter-observer reliability. No matter what the test, if the same person conducts the same test on two occasions on a patient or subject who otherwise has remain unchanged, they will still get different results in some proportion of tests. This is true of all tests, but would trust a test with 99% reliability far more than we would one with 70% reliability. While this may be less of a problem for a diagnost9ic test where we read results in terms of numbers (such as blood cholesterol or heart rate), this can be more significant when applied to reading radiology results, for example.
7. What are the features of the test as derived from this validation study? You may have a test which is seen to be reliable, but the test itself could be invalid; that is, its sensitivity and specificity is far too low. If your test has too high a false negative rate it will mislead clinicians rather than illustrate features important and related to the patient. This is something that needs balance; for example, if we are looking at a test for color blindness and see that it is, say, 95% sensitive and 80% specific, we might not worry- no one dies from color blindness itself. On the other hand, as Greenhalgh points out, the Guthrie hell prick screening test done on infants to test for congenital hypothyroidism is 99% sensitive but has a positive predictive value of just 6% (meaning: it does a great job of identifying children with the condition at a very high rate of false positive findings) but here this may be okay because we cannot afford to miss any kid with this condition since it leads to mental handicap. For everyone else, you just need to repeat the test every now and again, which is small potatoes in the scheme of things.
8. Were the confidence intervals given for sensitivity, specificity and other features of the test? To refresh your memory, remember that the confidence interval demonstrates the possible range of results within which the true value lies. And also recall that the larger the sample size, the narrower the confidence interval, which is good.
9. Has a sensible “normal range” been derived from these results? If a test provides non-dichotomous results (such as temperature or blood pressure as examples) we have to determine when the results will be seen as abnormal. If our BP is 142/90, would we call that abnormal when we might see 138/90 as not? Or would we advise the patient that we might wish to recheck them in some short period of time? Defining “normal” can be rather difficult to do.
10. Has the test been placed in the context of other potential tests in the diagnostic sequence for the condition? In some cases, a single diagnostic test might suffice for us to begin treatment; i.e., such as blood pressure of 160/100. In other cases, there is a sequence of tests we use before we decide to being treating. We might use McMurray’s test as part of a sequence of tests for determining the presence of a torn meniscus but not take its findings on its own, since it has a low sensitivity and specificity.
These questions can help you determine whether or not you can apply the results of a paper looking at a diagnostic test to your patient.
References
1. Greenhalgh T. How to read a paper: the basics of evidence-based medicine. London; UK; BMJ Books, 2001:113-116
Monday, March 7, 2011
Questions to Ask When Reading a Diagnostic Testing Paper
Trisha Greenhalgh has been one of the drivers in the evidence-based practice movement, and she is author of an excellent book entitled “How to read a paper: the basics of evidence-based medicine.” (1) Her text provides a clinician an overview of the basic concepts of EBP, and it is eminently readable and easy to follow. In one of her chapters she looks at diagnostic tests in specific, and she offers the reader a set of questions which can help you interpret the information in such a paper. These include:
1. Is the test potentially relevant to my practice? This is an examination of the utility of the test. Even if you knew the test was 100% reliable, would it actually help you in any way? Could you use it to identify a treatable disorder? And if it does, would it be better for you to use this test than the tests you are already using? Would it affect your treatment plan? If you can answer no to any of these, it might be best for you to not ready further into the paper.
2. Has the test been compared with a true gold standard? You need to ensure that the test has been compared to some other test which is seen by the profession as being the best possible test to use in that situation; for example, if you are looking at an orthopedic test for diagnosing lumbar disc herniation, your comparison test would be MRI. I should note that in some cases, there may not be a gold standard test, so you need to carefully examine what the new test is being compared against.
3. Did the validation study include an appropriate spectrum of subjects? One challenge here is that often, papers examining new diagnostic tests use patients who are truly ill. These patients represent only one part of the full spectrum of patients in which you can do the test and they are the ones most likely to be found positive. This creates what is called spectrum bias; you need to include a wide range of subjects to best study the sensitivity and specificity of the test. Thus, the paper should include subjects with both mild and severe disease, and those with other commonly confused conditions.
4. Has work-up bias been avoided? This question is actually asking whether or not everyone who got the new diagnostic test also got the gold standard and vice versa. You don’t want to read a study where the gold standard test is performed only on people who have already tested positive for the text being validated.
5. Has expectation bias been avoided? This occurs when the people who interpret a diagnostic test are subconsciously influenced by knowledge of the particular features of the case. An example might be the presence of low back pain and its specific manifestations when interpreting an MRI. Normally, all assessments should be blind and the person interpreting the test should not have any inkling what result is expected.
More to come on this next week…
References
1. Greenhalgh T. How to read a paper: the basics of evidence-based medicine. London; UK; BMJ Books, 2001:111-113
1. Is the test potentially relevant to my practice? This is an examination of the utility of the test. Even if you knew the test was 100% reliable, would it actually help you in any way? Could you use it to identify a treatable disorder? And if it does, would it be better for you to use this test than the tests you are already using? Would it affect your treatment plan? If you can answer no to any of these, it might be best for you to not ready further into the paper.
2. Has the test been compared with a true gold standard? You need to ensure that the test has been compared to some other test which is seen by the profession as being the best possible test to use in that situation; for example, if you are looking at an orthopedic test for diagnosing lumbar disc herniation, your comparison test would be MRI. I should note that in some cases, there may not be a gold standard test, so you need to carefully examine what the new test is being compared against.
3. Did the validation study include an appropriate spectrum of subjects? One challenge here is that often, papers examining new diagnostic tests use patients who are truly ill. These patients represent only one part of the full spectrum of patients in which you can do the test and they are the ones most likely to be found positive. This creates what is called spectrum bias; you need to include a wide range of subjects to best study the sensitivity and specificity of the test. Thus, the paper should include subjects with both mild and severe disease, and those with other commonly confused conditions.
4. Has work-up bias been avoided? This question is actually asking whether or not everyone who got the new diagnostic test also got the gold standard and vice versa. You don’t want to read a study where the gold standard test is performed only on people who have already tested positive for the text being validated.
5. Has expectation bias been avoided? This occurs when the people who interpret a diagnostic test are subconsciously influenced by knowledge of the particular features of the case. An example might be the presence of low back pain and its specific manifestations when interpreting an MRI. Normally, all assessments should be blind and the person interpreting the test should not have any inkling what result is expected.
More to come on this next week…
References
1. Greenhalgh T. How to read a paper: the basics of evidence-based medicine. London; UK; BMJ Books, 2001:111-113
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