Professional Documents
Culture Documents
Psychiatry Handbook
Compiled by
Nick Smith
Librarian
Worcestershire Royal Hospital
Nicholas.Smith@worcsacute.nhs.uk
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Contents
Contents 3
Glossary of terms used in evidence based healthcare 4
List of acronyms 9
1. Introduction 10
2. What is Journal Club? 10
3. Journal Club Organisation 10
4. Guidance for the presenter 10
4.1 Identify a knowledge gap and frame a clinical question 11
4.2 Literature search for best evidence to answer the question 12
4.3 Appraise the evidence 15
4.31 Appraisal tools 15
4.4 Prepare the presentation 15
4.5 Present the findings at Journal Club 15
5. The role of the consultant 16
6. The role of the librarian 16
7. Health Libraries in Worcestershire 16
8. Recommended reading 17
9. References 17
List of figures
Figure 1 Journal Club flow chart 11
Figure 2 The PICO Model 12
Figure 3 PICO questions 12
Figure 4 NHS Evidence search example 13
Figure 5 Example of search results 14
List of appendices
Appendix 1 Record sheet for clinical questions and example 18
Appendix 2 A working example of a Journal Club presentation 20
Appendix 3 Criteria for assessing Journal Club presenters 23
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Glossary of terms used in evidence based healthcare
Absolute risk reduction (ARR): the ARR is the difference in the risk of an event
occurring between two groups, for example, if 6% of patients die after receiving a
new experimental drug and 10% of patients die after having the existing drug
treatment then the ARR is 10% – 6% = 4%. Therefore, by using the new drug 4%
of patients can be prevented from dying.
Case control study: a study that starts with the identification of a group of
individuals sharing the same characteristics (eg people with a particular disease)
and a suitable comparison / control group (eg people without the disease). All
subjects are then assessed with respect to things that happened in the past that
might be related to contracting the disease. These studies are also called
retrospective as they look back in time from the outcome to the possible causes.
Cohort study: an observational study that takes a group (cohort) of patients and
follows their progress in order to measure outcomes such as disease or mortality
rates, and make comparisons according to the treatments that patients received.
Cohorts can be assembled in the present and followed into the future (a
concurrent or prospective cohort study) or identified from past records and
followed forward from that time up to the present.
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lie within a given degree of certainty. It is usual to interpret a 95% confidence
interval as the range of effects within which we are 95% confident that the true
effect lies.
Controlled clinical trial (CCT): a study testing a specific drug or other treatment
involving two or more groups of patients with the same disease. One (the
experimental group) receives the treatment that is being tested and the other (the
comparison or control group) receives an alternative treatment, a placebo or no
treatment. The two groups are followed to compare differences in outcomes to
determine the effectiveness of the experimental treatment.
Double blind study: a study in which both the subject (patient) and the observer
(investigator / clinician) is unaware of which treatment or intervention the patient
is receiving. The purpose of this blinding is to protect against bias.
Event rate: the proportion of patients in a group where a specified health event
or outcome is observed. For example, if in 100 patients the event is observed in
23, then event rate is 0.23. Control event rate (CER) and experimental event rate
(EER) are the terms used in control and experimental groups of patients.
Information bias: pertinent to all types of study and can be caused by poorly
designed questionnaires, observer or interviewer bias, response error and
measurement error.
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treatment or crossed over and received the alternative treatment. Intention to
treat analysis are favoured in assessments of clinical effectiveness as they reflect
the non compliance and treatment changes that are likely to occur when the
treatment is used in practice.
Odds ratio (OR): odds are a way of representing probability that provides an
estimate (usually with a confidence interval) for the effect of a treatment. Odds
are used to convey the idea of risk and an odds ratio of 1 between two treatment
groups implies that the risk of an adverse outcome is the same in each group.
Performance bias: the systematic difference in care provided (apart for the
intervention). For example, carers treating patients differently according to which
group they are in.
Prospective study: a study in which subjects are entered into research and then
followed up over a period of time with future events recorded as they happen.
Publication bias: studies with statistically significant (or positive) results are
more likely to be published than those with non significant (or negative) results.
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Quantitative research: research that generates numerical data.
Relative risk (RR): a summary measure that represents the ratio of the risk of a
given event or outcome (eg an adverse reaction to the drug being tested) in one
group of subjects compared with another. When the risk of events is the same in
the two groups the relative risk is one. In a study comparing two treatments, a
relative risk of two would indicate that patients receiving one of the treatments
had twice the risk of an adverse outcome than those receiving the other
treatment.
Retrospective study: a study that deals with the present / past and does not
involve studying future events.
Selection bias: selection bias occurs if the characteristics of the sample group
differ from those of the wider population or when there are systematic differences
between comparison groups of patients in a study in terms of prognosis or
responsiveness to treatment.
Single blind study: a study in which either the subject or the observer is
unaware of which treatment or intervention the subject is receiving.
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Specificity: in diagnostic testing specificity refers to the chance of having a
negative test result given that you do not have the disease. 100% specificity
means that all those without the disease will test negative, but this is not the
same the other way around. A patient could have a negative test result but still
have the disease - this is called a false negative. The specificity of a test is also
related to its positive predictive value (true positives) – a test with a specificity of
100% means that all those having a positive test result definitely have the
disease. To fully judge the accuracy of a test, its sensitivity must also be
considered.
Triple blind study: a study in which the statistical analysis is carried out without
knowing which treatment patients received, in addition to the patients and
clinicians being unaware of which treatment was used.
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List of acronyms
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Psychiatry Handbook
1. Introduction
Journal Club is a teaching programme that supports trainee doctors to learn the
principles and practice of EBH. It is an important feature of a doctor’s education
and the Royal College of Psychiatrists state that all trainees should present at a
journal club which form part of the workplace based assessments. The format of
Journal Club is group, problem based learning in which a presenter (typically a
trainee doctor) delivers a structured interactive presentation to an audience of
fellow practitioners. The content of the presentation is the critical appraisal of a
research paper with the aim of determining research that is trustworthy and can
directly apply to clinical practice; therefore the paper identified ideally needs to be
a ‘real’ problem or issue that has been encountered locally. The presentation is
followed by group discussion in which appraisal is continued in light of the
presenter’s findings, and application of findings into practice determined.
A rota is prepared indicating the date individual doctors are required to present in
Journal Club which is then issued to all psychiatry staff. Doctors familiar with the
process are allocated first on the rota to enable new doctors an opportunity to
look and learn. The Psychiatry Journal Club is held in the Charles Hastings
Education Centre every Friday (except last Friday of the month) at 12.00 – 12.30.
Each room has computers, a data projector and flip-chart to assist with
presentations.
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There are four stages to follow:
• Identify a knowledge gap and frame a clinical question
• Literature search for best evidence to answer that question
• Appraise the evidence
• Prepare the presentation and present the findings at Journal Club
Critically appraise
The first step in EBH is to define a structured clinical question. The question
should transpire during clinical practice (appendix 1 provides a record sheet for
noting clinical questions). Once an area of interest has been identified it is then
necessary to frame the question using the PICO model (population, intervention,
comparison and outcome). PICO is an approach to formulating a structured
question and is used to support understanding of the facets or separate parts of
a clinical query. It is also useful to help with identifying relevant search terms.
Figure 2 provides the facets and an explanation of each. Not every clinical query
will fit perfectly into the PICO model. Sometimes you will have only various
components of the PICO model; and the PICO method is not so useful for
diagnosis or prognosis queries; however it is a useful tool to get you thinking
about your clinical question and the different search terms you will use.
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PICO Explanation
Population or Patient Which patient group is the question
relating to?
Intervention Which intervention or type of therapy is
being used?
Comparison What is the intervention being compared
with? (placebo, nothing, another
treatment)
Outcome What is the outcome of interest?
The second stage in EBH is a literature search to identify a study that will help
answer your question. When searching for evidence use terms identified in PICO
and consider an appropriate research design (cross sectional study, qualitative
research, cohort study, randomised controlled trial). A good starting point is NHS
Evidence (NHSE) as this offers access to all relevant clinical databases (see
Figure 4). However an Athens username and password is needed, this can be
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freely obtained by any NHS employee from the NHSE website or ask your
librarian for more information. The Cochrane Library is also an excellent resource
for systematic reviews and is freely available on the web.
The paper selected for presentation at Journal Club should be clinically relevant.
It might also be that a senior clinician recommends a study, in which case a
complete literature search is not necessary. Below is a list of resources to
consider referring to for a feel of the literature. During the presentation it is useful
to provide details of relevant guidelines, for example, NICE / RCPSYCH /
WMHPT and to identify issues of concern such as that guidelines might be
unclear, outdated or unspecific to the question being presented.
WMHPT Guidelines
http://192.168.42.166/Policies_and_Procedures/DtGP.asp (Intranet site)
NHS Evidence
http://www.library.nhs.uk An Athens password is required.
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Figure 5: Examples of some of the results from previous search (Figure 4)
The above screenshot shows a selection of results from the search run in figure
4. Where possible links will be attached to the results pointing to the full-text
where available, for example, result number 3 has links explaining that the full-
text is available at Redditch Health Library. The article can then be photocopied
prior to journal club using the psychiatry photocopy card.
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4.3 Appraise the Evidence
The next stage is to critically appraise the selected study using an appraisal tool.
One such tool is the Graphic Appraisal Tool for Epidemiological studies (GATE
Frame) available at http://ebm.bmj.com/cgi/content/full/11/2/35, which can be
used for therapy and diagnostic questions. A second very useful tool is the
Critical Appraisal Skills Programme (CASP) resources available at
http://www.phru.nhs.uk/Pages/PHD/resources.htm that can be used for all type
questions. Finally, CATmaker, a computer assisted critical appraisal tool that
calculates useful clinical measures can be used to appraise most type questions.
Below is a series of links to appraisal tools that you may find of use when
preparing for journal club.
CASP tools - http://www.phru.nhs.uk/Pages/PHD/resources.htm
CEBM - http://www.cebm.net/index.aspx?o=1157
GATE - http://ebm.bmj.com/cgi/content/extract/11/2/35
RCPSYCH - http://www.rcpsych.ac.uk/pdf/app2.pdf
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5. The role of the consultant
Consultants can attend Journal Club whenever commitments allow, and similar
to the chairperson, play an active part in the discussion. Presenters may invite
individual consultants known to have a particular interest in the topic being
presented.
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8. Recommended reading
All the books below are available for loan from Worcestershire Health
libraries
Hamer S and G Collinson (2005). Achieving evidence based practice, 2nd Edition.
Bailliere Tindall. London.
Straus S et al (2005). Evidence based medicine: how to practice and teach EBM,
3rd Edition. Churchill Livingston. London.
10. References
Centre for Evidence Based Medicine (2007). Available at: http://www.cebm.net/
Daly A and Raza A (2008). Birmingham Women’s Hospital journal club handbook
Sackett DL (1996). Evidence based medicine: what it is and what it isn't. BMJ
312 (7023) 71-72.
Sackett DL (1997). Choosing the best research design for each question. BMJ
315 (7123) 1636. Also available
at:http://www.bmj.com/cgi/content/full/315/7123/1636 (Athens password
required).
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Appendix 1: Planning a Search Strategy
Please use the table below to help plan your search strategy. It is very important
to think about the separate terms you will need to use before starting your
search.
Library staff can help with any query you may have when compiling your search
strategy or performing your search, also see the worked example on the second
page for guidance.
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Search Strategy Example:
Clinical Scenario What information do you have? A patient with schizophrenia has
presented and is requesting
family intervention as opposed
to other psychological
treatments; you are not sure
about the effectiveness of family
therapy and need to find
literature to support your
actions.
Clinical Question What is the question behind the clinical For people with schizophrenia,
scenario? Or try and think what your do family interventions, when
ideal article title would be? compared to other psychological
treatments decrease the
likelihood of relapse?
Are you looking for a particular type of
Type of Research research paper? All types
(e.g. Systematic Reviews, RCTs, Case Studies)
Search Limits Do you want to restrict your search? English articles in the last ten
(e.g. by date of publication, by language etc.) years
Search Strategy How will you combine your words and Schizophrenia
phrases using AND, OR, NOT? AND
Family intervention
Are you going to do a MeSH (Medical AND
Subject Headings) or keyword search or Psychological Treatment
both? AND
Relapse
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Appendix 2: Example of a Journal Club presentation (paper available from
Library)
1. 2.
Anaesthesia and
Electroconvulsive Therapy: A
Retrospective Study Comparing
Etomidate and Propofol
3. 4.
5. 6
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7. 8.
9. 10.
11. 12.
2. Safety profile of the anaesthetic
3. Total number of missed fits
agents.
• No statistical difference between the two • No significant difference in missed fits
agents.
between the two groups.
• It is important to note that defining an
adverse event as one that occurs on more
than one occasion is not how adverse
anaesthetic reactions are recorded. All
adverse reactions are recorded. Death is
an adverse event which would apparently
only have been recorded had it occurred
twice in an ECT course!
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13. 14.
Will the results help look after
4. Initial, final and total ECT dose
patients?
• No significant difference between initial • Is it applicable to our patients?
seizure threshold between the two groups. • Do the findings if accurate have clinical
• Highly significant difference (P<0.0001) in implications?
final seizure threshold (etomidate
(etomidate 113.8,
SD 63.2 vs propofol 138.9, SD 195.7). • Is this study good enough to change our
practice?
• Highly significant difference (P<0.0001) in
total dose of ECT (mC
(mC)) (etomidate
(etomidate 1506.2,
SD 912.3 vs propofol 3077.0 SD 1608.5)
15. 16.
• This study for all its faults is really quite • Significantly higher amounts of electrical
applicable to current ECT treatment in the charge are delivered over the course of an
district general hospital setting in this ECT treatment in the propofol group and
country. they have a longer treatment course to
recovery.
• Though of economic significance it is not
possible to comment whether there are
clinical implications.
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Is it good enough to change what
we do?
• I don’
don’t think so as there are many
problems with the study design. Though
as the authors comment it is new data
which may warrant further study with a
well designed prospective RCT.
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Appendix 2: Journal Club presentation assessment sheet
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