Trip Database Blog

I heard an interview on today’s Today programme on Radio 4 with Sir Michael Rawlins, the chairman of NICE. In the interview he highlighted the need for post-research evaluation to ensure the research promise of an intervention is realised.

This notion of experience as a form of evidence has been of interest to me for many years, ever since I was approached by a GP who was using bupropion in smoking cessation. His perspective was that bupropion was pretty rubbish for his patients and wanted to understand why the discrepancy with the evidence (which stated it was effective and evidence-based).

My own perspective is that the experience of ‘coal face’ clinicians is crucial in addressing some of the biases seen in clinical research. In a very nicely funded and implemented randomised controlled trial (RCT) you may very well exclude patients with co-morbidities – alas, in the ‘real world’ clinicians don’t have that luxury. Take an intervention such as cognitive behaviour therapy (CBT) for depression, those carrying out the trial will use an experienced CBTer as opposed to a ‘coal face’ clinician who may have basic training in the matter. The bottom line is that conditions in a RCT cannot be the same as those of the ‘coal face’ – that should surely be a worry.

Currently, the ‘evidence’ used in EBM is overwhelmingly devoted to the hard evidence obtained from trials such as a RCT. I’m not suggesting that RCTs are not useful, far from it. However, I’m increasingly of the opinion that harnessing the experience of clinicians is vital to supplement the evidence found in clinical trials. Experience can be a form of evidence.
Interestingly, in my previous post highlighting 16 years of EBM (that linked to this JAMA article) the JAMA article had the following passage (from their 1992 article):

“A new paradigm for medical practice is emerging. Evidence-based medicine de-emphasizes intuition, unsystematic clinical experience, and pathophysiologic rationale as sufficient grounds for clinical decision making and stresses the examination of evidence from clinical research. Evidence- based medicine requires new skills of the physician, including efficient literature searching and the application of formal rules of evidence evaluating the clinical literature.”

In the passage they highlight that EBM de-emphasises, amongst other factors, the ‘unsystematic clinical experience’. While I completely agree with that sentiment, it opens the door for the emphasis of SYSTEMATIC clinical experience.

So, who’s for the systematic collection of clinical experience?

A review of 16 years of EBM in JAMA – Progress in Evidence-Based Medicine.

Following on from my previous blog post is another article (click here) on web 2.0, this time on ReadWriteWeb, which examines the effects of the economic downturn. But my interest in this article is the following passage on innovation:

“During boom times, companies direct development and occupy great talent with at best evolutionary improvements over the state of the art. Companies are great chasers of new things, but aren’t great at making new things. A recession means technologists cease to be paid vast amounts to duplicate the work of others.”

The above feels right to me. Over the years I’ve noticed that nothing focuses my mind than bad times, I suppose it brings out the survival instinct.

When I was studying for my PhD on innovation I was always intrigued by the distinction between evolutionary changes/innovation and radical changes/innovation. The sociologists tended to highlight that evolutionary changes came from those integrated into a particular system. The argument being that those people tended to have been trained in a particular system and think in a similar way, making radical change difficult.

For truly radical changes what is needed are people not integrated into a particular system, in other words outsiders. They haven’t been indoctrinated by ‘the system’ and are better able to think for themselves and think ‘outside the box’.

If the above analysis is correct we’re in for some interesting times ahead. Time for everyone to get their thinking caps on.

One of my favourite blogs is TechCrunch and the main guy there is Mike Arrington and he’s written about the end of web 2.0 – An Ignoble But Much Needed End To Web 2.0, Marked By A Party In Cyprus.

Web 2.0 has been associated with blogs, social networks, wikis and generally user generated content. I doubt it’s dead, but I’m guessing that’s not what Mike meant.

My view is that user-generated content is no longer new, its an integral part of the web and therefore why should it be seen as distinct? I’m guessing that we’ve got the situation where you had the ‘old’ (static web pages) then web 2.0 (user-generated content) and it’s now settling down to just being one web, which will mean the old sites will simply absorb sections of web 2.0 into their domains.

So the days of a ‘separate’ web 2.0 may well me dead or dying, roll on the next innovation.

Why do I like this article?

Save you all clicking to view the abstract, here it is:

Locating the desired evidenced-based literature via the internet is usually time-consuming and not particularly straight-forward. Websites offering evidence-based information should be accessible, efficient and user friendly. Many of these websites, however, only make their own content available, making it necessary to change websites in order to get a complete picture of the required information.The so-called website of ”Turning Research Into Practice” is a positive exception.This website makes it possible to search the whole range of evidence-based publications on a certain subject with 1 search action, is straight-forward and practical to use, and the presentation is exceptionally good.

…Are More Likely to Be Answered by UpToDate Than PubMed has just been published in the Journal of Medical Internet Research. This is proving an interesting journal. Due to the wide coverage I find many articles of little interest, but the occasional gem appears.

Perhaps unsurprisingly the authors conclude:

“Specialists and residents in internal medicine generally use less than 5 minutes to answer patient-related questions in daily care. More questions are answered using UpToDate than PubMed on all major medical topics.”

If you asked 100 information specialists to predict the outcome, I’d be surprised if many would have thought PubMed would do better!

The results were more interesting:

“We analyzed 1305 patient-related questions sent to PubMed and/or UpToDate between October 1, 2005 and March 31, 2007 using our portal. A complete answer was found in 594/1125 (53%) questions sent to PubMed or UpToDate. A partial or full answer was obtained in 729/883 (83%) UpToDate searches and 152/242 (63%) PubMed searches (P < .001). UpToDate answered more questions than PubMed on all major medical topics, but a significant difference was detected only when the question was related to etiology (P < .001) or therapy (P = .002). Time to answer was 241 seconds (SD 24) for UpToDate and 291 seconds (SD 7) for PubMed."

I’d be interested to know if clinicians were satisfied with partial answers. The authors state “Whether an answer is partial or complete is a subjective qualification. We therefore combined partial and full answers when determining significance of our findings” – am I the only one thinking that’s inappropriate? At least give us the results separately as well as combined and let us make draw the conclusions.

Another issue, not restricted to this paper but all papers on Q&A, is the assumption that the clinician knows that they’ve answered the question. They may well have found an answer, but whose to say it’s right?

Anyway, if anyone reads the article, I’d be interested to hear what you make of it.

I want a treadmill desk.

A while ago it was pointed out that the NEJM was missing from TRIP. We had an e-mail from an embarrassed librarian who had been demonstrating TRIP to a visiting academic. When the academic tried to find their premier paper in the NEJM they failed. The librarian wanted to know what she’d done wrong. Basically, nothing – it was all our fault! All the big 5 journals (NEJM, JAMA, Lancet, BMJ and Annals of Internal Medicine) were missing.

We’re not exactly sure how it happened and its taken a while to fix, but they’re back now.

Unfortunately, it looks like TRIP Answers won’t be going live this week. The site is ready to go and there’s load of content. We loaded it onto the ‘live’ server but that was one load too much for our servers and it – effectively – stopped working.

So the solution:

• Temporary – we’ll try and get it added to a different server.
• Long-term – increase our hardware capacity by purchasing some new servers. This will take some weeks to achieve, hence the need for the temporary measure. This increase in server capacity will also increase the speed of the TRIP Database.

There is a chance TRIP Answers will go live this week, but it’s more likely the first week of October.

Developing websites can be such a pain!