Editor’s Note: This is the third in a series of BoringEM research week posts. Dr. Murray is an editor at BoringEM and an expert at teaching medical students about research and the art of critical appraisal. She has been at the helm of designing and implementing a critical appraisal and research curriculum for the undergraduate medical students at Queen’s University. The graduated curriculum spans all four years and sets students up with a strong foundation in both evidence-based medicine and basic research skills. In this post Dr. Murray provides insight about how she stays on top of new evidence and how she uses it to at the point of care to provide the best care for patients. She also provides a few tips for students looking to get started
I start my first class of the year: “Hi everyone – I’m Dr. Murray. I’m an emergency doctor.” The first year medical class perks up at the mention of emergency doctoring. “And my job in the medical school is to teach you guys the skills for effectively reading published evidence and for producing your own research.” When the word “research” hits their ears, the computer screens suddenly get new attention, windows on Facebook and Twitter are surreptitiously opened and interest fades.
Why does the mere mention of “research” elicit moans of despair from otherwise bright, engaged students? Ground-breaking clinical trials and medical advances are constantly changing the way we practice medicine and furthering our understanding of human illness and recovery. Becoming an educated consumer of research is an essential part of becoming an effective clinician, even if your career aspirations don’t involve any kind of research creation. No modern day clinician can provide high quality medical care without a good approach to finding valid information for day-to-day questions. And yet I’m struggling for engagement, turning cartwheels in the front of the classroom in order to keep the attention focused on the critical appraisal task at hand.
Below are three common research-related issues that face doctors at all stages of medical training and practice. The undergraduate critical appraisal and research curriculum at Queen’s targets each of these three key questions to set a strong foundation for future practice. Below each question I have provided some tips that should be useful, regardless of stage of training.
How do I learn how to read and understand published research?
Few of us pick up the latest trial on hemodynamic monitoring or infection control or subarachnoid hemorrhage to read as the relaxing antidote to a challenging day. The concepts are often complex, the statistical tests have long names and are unfamiliar or incomprehensible, and it takes a lot of mental effort to see the paper through to its conclusion. You want to stay up to date but how can you get good at reading these things, let alone at identifying weak spots?
In this, as in all things, practice makes perfect. In order to get good at reading the literature, you have to read the literature. Don’t be intimidated! In our critical appraisal activities at Queen’s, students work in groups to appraise papers and then practice applying the evidence to relevant patient cases. Students each bring something unique to the table and have a different perspective on the analysis and implications, stimulating rich classroom discussions. Your experience with consuming evidence should be no different and the FOAM community is here to help you. There are a multitude of different online resources, ranging from overviews of the latest and best research to guided deep dives into selected papers. In fact, there are so many excellent options, I had a hard time limiting my recommended list of samplers to these:
- Richard Lehman writes a weekly blog for the BMJ summarizing the week’s best papers from NEJM, JAMA, BMJ, the Lancet, and Annals of Internal Medicine. Scan the blog and his pithy take home messages and entertaining commentary will guide you to the best research of the week.
- Ryan Radecki is an emergency physician who posts overviews and commentary on recent research relevant to emergency physicians in his blog Emergency Medicine Literature of Note. His near-daily updates and brief take-home messages will help you keep on top of the specialty.
- The folks at The Bottom Line will walk you through the details of the important critical care trials step by step using a standardized template and a clear take home message. Their searchable index is an incredible gateway to a huge collection of important research.
- Annals of Emergency Medicine has a journal club feature offering a series of structured review questions (tagged novice, intermediate or advanced) for readers to use as they appraise the selected article. The answers are published in a later issue, but many of the previous versions are available online now and can be incorporated into student or resident journal clubs for discussion.
- Research and Reviews from Life in the Fast Lane. A collection of papers that include new and re-discovered research, this is a treasure trove of pre-appraised papers classified by relevance using a unique, awesome tagging system. (The only thing that could make this blog better is if the impressive list of international contributors included some of our impressive Canadian EM researchers… but I digress).
- Speaking of Canadians, Dr. Ken Milne runs a podcast called The Skeptic’s Guide to Emergency Medicine that features a weekly review of recent cutting edge evidence, critiqued using the BEEM (Best Evidence Emergency Medicine) template, and always involving some cheesy 80’s music. Enhance your research skills while you exercise, commute or just chill on the couch.
These are just the tip of the iceberg, but are some good places to get started. The FOAM world is friendly and inclusive, and no one will snub you for not knowing the difference between a T-test and a one way Analysis of Variance. Join the discussion!
How do I find specific research to answer my patient’s immediate problem?
You have a patient with a clinical problem to which you don’t know the answer. Your quick online literature search brings up 8000 hits and every clinician you ask has a different answer to your question. How can you get your hands on reliable evidence quickly? And yes, you have a paid subscription to UpToDate, but don’t you want to be a little more sophisticated?! In the clinical years our medical students are required to complete an assignments in each rotation where they briefly review the literature on a clinically relevant question, formulated while caring for patients. It is during clerkship that they start to understand that applying the best available evidence to a specific patient context is what the art of EBM is all about.
Once again, the FOAM world is here to help you answer your clinical questions. I’ll highlight the TRIP Database. “TRIP” stands for “Turning Research into Practice.” Their motto is “find research fast” and it is a super place to go for this exact purpose. Enter a query using either the basic or more advanced search functions and the results come out colour-coded.
Green is for evidence summaries (systematic reviews and practice guidelines), red for key primary research and so on, all the way down to yellow for e-textbooks. It’s a nice way to find collections of pre-appraised evidence like Best Bets, and sometimes someone has asked the very question you are looking for. It taps into Cochrane as well as a variety of other sources – check it out the next time you have a clinical question.
How can I get started doing my own research?
At Queen’s we group students with a clinician-scientist mentor in a 3:1 ratio during a course that spans the second (pre-clinical) year. Guided by the mentor, students complete a series of structured assignments, which culminate in the development of research proposal. Many students go on to carry out their proposal during the summer, and the course deadlines are aligned with funding application deadlines in order to facilitate this. Sometimes I get pushback about this part of the curriculum. If I had a dollar for every medical student or resident who has told me that they already know how to do research and shouldn’t have to do any more… well, I’d have a lot of dollars.
The reality is that every time you involve yourself in a research project, you reap additional benefits that have nothing to do with the actual research results. Successfully taking a research project from start to finish requires persistence and determination, and makes you a much better consumer of published work as a result. Engaging in clinical practice research gives you the opportunity to become intimately familiar with a clinical area and the nuances and questions specific to that topic. It enables you to look closely at local practices (and regionally or nationally if your research is multi-centre) and identify areas where patient care can be improved. It allows you to form relationships with others involved in the same research area, including faculty mentors, colleagues and non-physician collaborators. Completed research projects on your cv are career-enhancing, opening doors and creating opportunities – and the dose-response curve is impressive. More completed projects lead to more knowledge, connections and professional opportunities, as well as improving your care and the care environment in which you work.
So, take the first step: Study something that bugs you. Maybe you are horrified by the amount of garbage generated in a single ED visit. Perhaps you have seen 10 different ED doctors in the same centre use 10 different doses of GTN for acute pulmonary edema. Possibly you have wondered why every single patient with an arrhythmia gets a chest Xray during his or her ED visit. Here is an opportunity to educate yourself and use your research to try to improve care in your own local venue. Check out the posts this week on Boring EM’s research week to find resources and learn about the research process. Start with a systematic review of the literature, and find out what is already there. Make it your thing – do a presentation on it, and use your newfound knowledge to educate others. Create patient information packages. Do an education session for your nursing colleagues. Make connections with local practitioners and researchers to develop a research proposal to evaluate some aspect of your work. Find a mentor who is active in this area or interested in the topic (ideally both). And along the way, don’t forget to share your work on one of the many FOAM sites that encourage international input and dialogue.