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Shared decision making

26 Jul, 17 | by Bob Phillips

So the model of EBM that we espouse is one grounded in the patient ‘dilemma’ being the start and end point of the process. You’ll recall it’s a patient’s situation that triggers the asking of a PICO question, and particularly the selection of patient-oriented outcomes are vitally important. The acquisition and appraisal of studies that follow link to this, then applying the results of your deliberations needs to bring those thoughts back to the patient and discussing where to go with it. more…

Can our children’s trials work better than they do?

13 Jun, 17 | by Bob Phillips

We’re all well aware of the problems of doing randomised clinical trials in paediatrics – small numbers, uncertainty about sample size estimates, lack of funding to undertake the studies – but are we as aware of some alternative approaches that have been used [1]?

“Sequential design” studies look at comparing a series of treatments against each other, switching to the ‘better’ arm and comparing against the next candidate as time progresses… They need quickly and easily available outcomes and tend to be usable only for short-course treatments… but they’ve been estimated to reduce sample sizes by about 25%


Damned if you do, damned if you don’t?

19 Apr, 17 | by Bob Phillips

The field of systematic review, of which Archimedes we believe sneaks in under the ‘rapid review’ heading, has long since held a solid foundation to what a systematic review needs to do. It needs to have a clear question, with a comprehensive search, and assessment of included studies bias / quality, a synthesis (which may be mathematical; meta-analysis), and a set of conclusions that draw this together.

What it’s been long struggling with is how to ‘best do’ each of these areas. ‘Best’ is itself problematic – take ‘best’ searches for example. Do they find every single possible scraplette of possible information, taking 3 months of daily specialist work, where the qualitative bulk of the data, leading to the same practical conclusion, was found in the first week? (And how do you know – prospectively – when the tipple into ‘enough’ has been reached?) more…

Cases and controls

18 Dec, 16 | by Bob Phillips

F3.mediumI’ve noticed that there are a fair few phrases in the world where there actual meaning can be unclear or uncertain, or possibly interpreted differently by folk. Take “maybe later” when used by parent to child – clearly means “no” to the parent and “yes but not now” to the child. Or “brexit”.

But the world of science can’t be confused …  can it?

Just take a gander through the field of “case control” titled studies and you may find yourself upset to discover it can. Now I am fairly clear that what I mean by case/control is a design where the participants are chosen because they have developed (cases) or haven’t got (controls) the OUTCOME of interest – they died, developed neuroblastoma or had exclusion from school. The analysis then is about finding out if these groups had different levels of exposure to a proposed causative factor, such as blood transfusions, bacon, or X-factor viewing.

What is not a case control study is one where the groups are chosen for the exposure to a treatment or not. This is a comparative cohort study.

Now as is so often the case when appraising papers, it doesn’t sometimes matter what the authors have written. It’s what they did that counts – so discount their title if the design doesn’t fit it.

– Archi


But if it’s significant it must be true?

20 Sep, 16 | by Bob Phillips

One thing that I keep coming across, from a huge range of folks involved in clinical practice, is the idea that if something is statistically significant, then it’s true. Some folk nuance that a bit, and say things like “true 95% of the time” for confidence intervals or p=0.05 …

Of course, there’s an ongoing argument about exactly how to understand p-values in common, understandable language. A simplish and we hope right-enough version can be found here. But underlying that is a different, more important truth.

The stats tests work to assess what might be the product of chance variation. When the data they are testing come from hugely biased studies, with enormous flaws, and the poor little stats machine says p=0.001, the researcher and reader may conclude “this is true””. This is wrong: it is due to bias and poor research.

It may be better to think “this is unlikely to be due to chance” – in remembering that phrase, you’ll hopefully recollect the other reasons why something may not be due to chance too.

  • Archi

“We thank the reviewer …”

2 Aug, 16 | by Bob Phillips

tumblr_nh74xu5LnB1s6le2wo8_250In our previous post we unpeeled the sticker a little bit on how the magic process of submission to … well, let’s just stick with ‘publication’ and be optimistic … happens.

Step 11 compresses the process of being offered a second chance into a few brief words. It’s probably a good idea to think a bit about how you respond to a reviewer’s comments to make life easier for all of us. more…

Hard science in difficult areas

26 Jul, 16 | by Bob Phillips

Picture1It’s one of the delights of my professional clinical practice that (nearly) all the time, the diagnosis of a malignancy is hard & sound, reproducible, based on good data showing discrimination from other settings and with minimal interpersonal variation. Take a chunk of a particular renal tumour and show it to half a dozen paeds pathologists, and nearly all the time the Wilm’s tumour will be recognised and identified as such.

People who deal with the un-biopsiable, the disorders without a test and with a requirement for artistic flair, both overwhelm me with their skill and terrify me with the Emperors New Clothes potential. Things like interpreting chest radiographs, or diagnosing Kawasaki disease and ADHD spring to mind. The methods used to guard against the off-piste clinician: regular group review; diagnostic criteria, checklists and the like; analysis of yes/no cohorts to detect changes in proposed outcomes, are all essential and undertaken regularly.

One area which has been subject to huge scrutiny because of the challenging implications of making/unmaking a ‘diagnosis’ is child abuse and neglect. The CORE-INFO group in Cardiff who have collected and reviewed thousands of studies have piled up the evidence for us, and these have been used to help guidelines for reproducible practice become established, yet there remains some difficulty in the finding of unexplained bruising.


How the magic works

19 Jul, 16 | by Bob Phillips

pot_of_gold_rainbow (107x160)It’s become fairly clear that most people don’t really know how articles get from the pen into the ‘accepted’ queue at a journal.

At the most wonderful paediatric / child health journal on the planet (*) the process works like this:

* ADC of course!


Vague, unsure or imprecise?

12 Jul, 16 | by Bob Phillips

courseImageTrials and tribulations we all have. The not-knowing of the future can create anxiety, distress and an unhealthy desire for chocolate. Some days, knowing what’s for tea can provide the only concrete grounding in an otherwise fluctuant universe.

And along with that, the naming of things can sometimes be enlightening.

So, for un-knowing, you could consider using the following sorts of words:

Imprecision. The sort of not-knowing that is generated by small sample sizes with wide confidence intervals.Uncertainty in a mathematical sense.

Vagueness. Uncertainty about something because it has been poorly defined or described, the ambiguity of the written “How’re you doing?” – which may differ if from the melting voice of Joey Tribbiani or the concerned and serious tones of your Aunt Ethel.

Volatility. Uncertainty through a potentiality of futures that may be sweepingly different depending on as yet undetermined features … if only we’d had a referendum recently in the UK that might provide an example …

  • Bob Phillips

Does fear of missing a diagnosis drive your every action?

5 Jul, 16 | by Bob Phillips

download (3)If there was a chance that you missed a diagnosis about which you would be able to intervene 2:1,000 times, and that the test which could diagnose it cost about £3 and was minimally invasive – wouldn’t you be daft not to use it?

Or would you think “what a waste of time!” and wonder about the £3,000 you had spent to make £6 of a diagnosis?

The dilemma is common – there are a whole list of things that are traditionally associated with a differential diagnosis which may be exceptionally rare and sometimes coincidental rather than causative.

Take urinary tract infection in jaundiced babies.


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