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Creating secondary learning resources from the BMJ Case Reports through social-media based discussion groups

28 Oct, 11 | by Emma

Social Networks like Facebook and the recently unveiled G+ besides the obvious connotations of helping to connect with friends, family and co-workers, have wider and rather far reaching implications in the domain of Healthcare which is traditionally dictated by strict one to one communication between the attending doctor and the patient.

However with the Internet being a vast treasure trove of each and every kind of resource, reliable information is not solely confined to the medical tomes available to practicing physicians. With the changing times the modern age physician too needs to adapt. Hence the term user is confined not only to the patient but includes medical students, physicians, nurses and allied healthcare workers. In fact it is anyone who carries a fingerprint in the virtual domain and who has a certain agenda in the conversation that occurs.

Tabula Rasa, Latin for clean slate clearly exists to present a platform for doctors, medical students , patients and ‘users’ on the popular social network Facebook. Anyone who has a Facebook user name can join in the discussions. (http://www.tiny.cc/bkdq3)

What sets User Driven Health care (UDHC) apart from Evidence Based Health Care (EBHC) is that while EBHC solely concentrates on pre-existing data or literature to reach a conclusion, UDHC tries to propagate both pre-existing evidence as well as individual inputs from doctors or people who may have prior experience in contextually dealing with the same topics.
The UDHC hypothesis is that interactive conversational learning between multiple stakeholders in health care (such as patients and health profession students) who present a topic related to a case uncertainty or a general uncertainty around treatment decisions can create stimulating secondary learning resources in medicine.

From the perspective of a medical student, this is, learning without any pre-existing structure or a rigid framework. It enables them to face real life clinical problems and solve them in a step by step approach. By not following any particular set of rules it simulates the uncertainty that they may face as practicing physicians.

One such case involving “A Young Man with Fever and Lymph Node Enlargement” in the BMJ case reports was chosen for an interesting discussion. (http://www.irma-international.org/viewtitle/58372/)
The clinical problem is gradually opened, layer by layer, through the discussions generated by the participants and the original poster. The responses from the participants sometimes rely on their background knowledge and sometimes draws on foreground knowledge with evidence based links to further information supporting their contention. Responses have been edited for relevance to avoid repetition.

This is an exploratory approach in creating stimulating medical education resources in the form of interactive conversational learning between medical students and facilitators who dissect a case previously published in BMJ to which the students do not have access so as to bring out the learning points in an exploratory manner. Through these conversations, students discover the subject and learn actively along with a facilitator who gradually guides them through the case based problem. BMJ Case reports presents a unique platform for this case based PBL (problem based learning) activity. In this illustrative example this has been done by the students and facilitators in a nearly asynchronous manner on a web based forum. We hope these illustrative samples attract other teaching institutions to pilot a similar strategy.
A departure from traditional methods of education, this may help students to think in a free uncluttered manner, which is miles different from the rigid structured thinking that is generally instituted in them through conventional structured learning approaches. By promoting lateral thinking, it prepares them to face situations that they may frequently encounter later on as a practicing physician.

We invite the reader to place their comments on whether this could be a valuable secondary learning resource toward contextual medical learning in the near future.

Authors:
Tamoghna Biswas, Medical College, Kolkata, India
Kaustav Bera, Medical College, Kolkata, India
Rakesh Biswas, People’s College of Medical Sciences, India

PatientsLikeMe study refutes Lithium use in motorneurone disease

25 Apr, 11 | by Dr Dean Jenkins

Case Reports usually involve just the one patient. When patients get together and join a social network their shared experiences could be used to evaluate research questions that would otherwise go unexplored or take time to answer. This is exactly what the website PatientsLikeMe claim to have done with the use of Lithium Carbonate in the treatment of Amyotrophic Lateral Sclerosis – a type of motorneurone disease – and they have published the work in Nature Biotechnology (1).

“To reduce potential bias owing to lack of randomization, we developed an algorithm to match 149 treated patients to multiple controls (447 total) based on the progression of their disease course. At 12 months after treatment, we found no effect of lithium on disease progression. Although observational studies using unblinded data are not a substitute for double-blind randomized control trials, this study reached the same conclusion as subsequent randomized trials, suggesting that data reported by patients over the internet may be useful for accelerating clinical discovery and evaluating the effectiveness of drugs already in use.”

The sample of patients from a particular social media website will, by definition, be self-selected. Perhaps such groups would be better at generating qualitative rather than quantitative information. However, this approach could be used to evaluate off-label uses of drugs.

It is an interesting technique but care should be taken in interpreting such observations and it would be good to see other examples of this type of study and more analysis of the case-control selection algorithm. Small effects may be missed without careful elimination of bias.

1. Wicks P, Vaughan TE, Massagli MP, Heywood J. Accelerated clinical discovery using self-reported patient data collected online and a patient-matching algorithm. Nat Biotech. 2011;advance online publication. Available at: http://dx.doi.org/10.1038/nbt.1837. Accessed April 25, 2011.

‘Quality and Safety in Medicine’ Series

30 Mar, 11 | by Emma

Markers to measure quality and safety in health care are much debated. A decline in adverse event reporting may represent a genuine decline in adverse events or merely a decline in their reporting; just as a rise in the reporting of poor outcomes may represent significant cultural changes in a healthcare system more vigilant or more responsible. While audits of quality control or patient satisfaction have their place, case reports are an opportunity to present well managed patients who have received good care; and, at the same time near misses promptly dealt with and complex cases well worked through.

Our aim is to become a repository of well managed cases. The cases need not be rare, indeed we learn much more from each other’s experience of pitfalls in common cases and rare presentations of common diseases. In the upcoming weeks we will present a series of cases that illustrate aspects of quality and safety in medicine and invite you to submit your experience of quality and safety in healthcare.

Seema Biswas
Editor-in-Chief

This is an example of a rare presentation of a common condition, recognised because of the vigilance of the medical team.

Optic nerve involvement as a first manifestation of acute lymphoblastic leukaemia after remission

Searching whilst feeding

21 Jan, 11 | by Dr Dean Jenkins

Had one of those yes-this-is-how-it-could-work moments recently.

I was sat at the back of a departmental lunchtime meeting (in Turo) recently eating a cake and clocking up some CPD. There was a presentation on ‘refeeding syndrome’ and I managed to search BMJ Case Reports for ‘refeeding syndrome’ on my recently acquired smartphone and found several cases.

It would be good for future meetings to perhaps highlight such cases and the associated media that would come with them. For example, including the case reports as examples of other presentations of ‘refeeding syndrome’ would reinforce the message of the meeting. The message was more on ‘phosphate’ and could have been more on possible presentations of refeeding syndrome and who is at risk.

Using the now enormous database of BMJ Case Reports to supplement case presentations at work is becoming a real opportunity. For a department that has a license to the collection they can then use the cases, images, diagrams etc. in their own teaching.

Dean Jenkins
Editor at Large

360 degree case reports – e.g. rheumatoid arthritis

5 Jan, 11 | by Dr Dean Jenkins

I highly recommend reading a recent case report published in the BMJ that talks about rheumatoid arthritis from the perspectives of the patient, her clinician and the National Rheumatoid Society that she represents. (1)

It is an historic account of her disease from presentation, how treatments have changed over the last 20 years, and the effect of the disease on her work and life. I really enjoy reading patient perspectives and especially when as well written as this with multiple view points. They help us gain a broader understanding of the condition.

In this time of 360 degree appraisals maybe it is time for more of these types of perspective?

1) Bosworth A, Steuer A. Rheumatoid arthritis. BMJ 2010; 341:c7095

Dean Jenkins
Editor at Large

Case Reports in the era of Evidence-Based Medicine

2 Dec, 10 | by Dr Dean Jenkins

Had a debate at the recent Warwick Medical School Journal Club workshop on case reports.

“This house believes that case reports are a waste of time in the era of evidence-based medicine.”

The  students from medical schools over the UK came up with many of the arguments for and against the motion.

for the motion and against case reports

  • case reports are rarities that are of no relevance outside the case
  • n=1 is often not of much use as it doesn’t lend itself to statistics

against the motion and for case reports

  • first line of evidence especially for new treatments / conditions or harmful drugs
  • they provide a trail of evidence especially for rarer conditions
  • educational especially for those topic areas that don’t lend themselves to quantitative study

I’ve discussed these arguments before in what shall we do with case reports?

It was a really useful way for setting the scene for discussing what makes a good case report and, in particular, what BMJ Case Reports looks for in submissions. This was the purpose of the workshop and there was a lively discussion and many queries afterwards about certain pictures that might make a good “Images in …” article and a lot of questions about patient consent.

The main interest among the students was that case reports are a good way to learn about academic writing – by responding to criticisms from colleagues, editors and peer reviewers – and a first step in publications. Whilst not wanting to encourage any and all case assignments (which would make for dreary reading) we did explore some suggestions for choosing good cases that they may want to start writing up.

  • Present your case at medical meetings and see what discussion (if any) occurs afterwards. This will help identify the key messages and whether they are educational or scientific. If there is no discussion then maybe it isn’t that interesting a case.
  • Learn to search the medical literature and find existing case reports, evidence and opinion, already published that are relevant to your case. Even if something has been published before does not necessarily mean a well written, educational reminder linking the often un-cited existing reports together can be a useful publication.

It was a very enjoyable event and well organised by the WMS Journal Club.

Looking forward to taking the BMJ Case Reports roadshow to other medical schools / societies / colleges … but perhaps when the snow has thawed.

Dean Jenkins
Editor at Large

BMJ Case Reports wins Best New Journal 2010

10 Sep, 10 | by Dr Dean Jenkins

BMJ Case Reports wins Best New Journal 2010 at The Association of Learned and Professional Society Publishers (ALPSP) awards.

I spent yesterday evening at the awards dinner in Bedfordshire where the journal picked up the award of best new journal. This is a great achievement for Janet O’Flaherty, journals publisher at BMJ Group, and her team. Congratulations!

The best new journal category was open to journals launched within the last three years and the judgement was based on the four main aspects of the journal and its launch: market research, editorial strategy, marketing and commercial success.

“Pediatric” case reports now in vogue?

11 Jan, 10 | by Dr Dean Jenkins

The American Academy of Pediatrics’ journal ‘Pediatrics’ has made public its New Year’s resolutions in an editorial called “The Next Generation of Pediatrics”.

First LR, Moyer VA, Puskarz J. The Next Generation of Pediatrics. PEDIATRICS. 2010 1;125(1):193-194.

In it they announce the relaunch of case reports with some excellent selection criteria namely reports that:

“(1) challenge an existing clinical or pathophysiological paradigm; (2) provide a starting point for novel hypothesis-testing, clinical research; and/or (3) offer a clinical “lesson” that may allow pediatric colleagues to provide improved care.”

Dr Jeffrey Malatack, associate editor, will direct the online case report collection after their 1 year “sabbatical” from the journal.

This is encouraging news for those of us who believe that case reports are a valuable source of early evidence and education.

What value is there in broader, more comprehensive collections of case reports BMJ Case Reports? Often challenging cases can span disciplines or, especially in diseases familiar to paediatricians, present at different ages such as in adulthood.

We look forward to more publications and increasing enthusiasm for Case Reports.

Finding your doctor through their published case reports

15 Sep, 09 | by Dr Dean Jenkins

Had a very interesting communication from a BMJ Case Reports author who was contacted by a patient’s family because the patient was suffering from a similar condition to that which the author had just published.

This raises interesting points about the role of the medical literature and the increasing ability of patients and their relatives to research the professional credibility of doctors. This is the modern world but it is it new? Before the Internet patients and relatives would contact by telephone or fax and before the telephone they would probably have written a letter. They always travel if they think the doctor has particular expertise.

There is a limitation of course since you may very well find a doctor with expertise but they may be in another continent and your selective research may have missed a world authority in your local hospital.

Another aspect of this is the networking between the authors themselves. Finding others with similar clinical interests and in publishing their work could lead to the exchange of information and collaboration.

Case Report CAT

2 Sep, 09 | by Dr Dean Jenkins

This is a draft critical appraisal sheet for case reports. Would be interested in your views.

Critical Appraisal is used to glean scientific evidence from papers. Case reports or case series are not normally considered as part of this process. The reason is that there is usually no hypothesis testing or comparison within a case report and generalising the conclusions to other circumstances is difficult.

However, case reports have value which could be scientific or educational. When reading a case report it is important to be critical and judge the value of the report to the medical literature and to your own clinical practice. This checklist may help.

Checklist Item Comment
Has the case report been peer-reviewed? Is it clear from the publisher what the peer-review process was?

Case reports may be in topic areas, or include topic areas, that are unfamiliar and they should have been reviewed by experts in those topics. You may need to check the publication or the website to understand the peer-review process for their case reports.

Does the case report have a clearly defined focus?

It should be easy to understand if the case reports a rare condition, a novel finding, a reminder of an important clinical lesson, a myth exploded, an unexpected adverse / beneficial outcome of treatment etc. Cases without a focus may not have been properly thought through by the authors.

Are all the necessary facts presented?

Check that there is sufficient detail in the presentation, past medical / drug / social history, examination, investigations and follow-up of the case.

Is the case report linked to the existing literature?

The discussion should highlight if the case is claimed to be unique or if other similar cases have been reported. If unique the authors should describe the search process, terms and synonyms that they used to research the literature. If other cases have been reported then information about how those cases were similar or different to this case report. All cases should be referenced and the authors should again describe the search that they used to find them.

Is the discussion relevant?

The discussion should explore the potential learning points or novel findings from the case but not over-generalise, make recommendations that are not upheld by a single experience, or discuss issues that are not directly involved in the case. The case report should not be a lame excuse for a review of the literature. If there is a call for further research it should be clear in the discussion what this is.

Does the case provide any quantitative evidence?

Are there numbers that could be useful from this case report? It may provide a measure of a physiological variable, a time period or a drug quantity that could help in probability estimates or clinical judgements in future cases. The numbers, if adequately described, could be combined with other published case reports to improve the estimate in a process similar to meta-analysis.

Is the case report important to your clinical practice?

Although interesting and of educational value the paper may be about a condition that you would never be likely to encounter. Judge how relevant the case, the lessons or scientific leads are to your clinical practice. Is it one that your colleagues should read?

BMJ Case Reports: publishing, sharing and learning through experience

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