Dec 23, 11 02:21AM
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Very up-to-date infographic about Bad Science: it includes (or was inspired by?) the recent fraud by Diederik Stapel, a well-known psychologist in the Netherlands.(e.g. see NY Times.com (2011/11/03/). I am not sure though, that I agree with the 3rd solution to make research more honest: anonymous publication. Created by: Clinical Psychology Hattip: @nutrigenomics, @Vansteenwinckel, @kitteybeth & @rawarrior via Twitter Related articles [...]
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Sign in nowI think that now a lot of carers don’t have the respect for their patients that they should have, this is particularly noticeable with people who work with the elderly.
Hi Laika,
I would usually search PreMedline for records which aren’t fully indexed in Medline – and I like to search it separately since it will be a textword only search. I know PubMed covers both Medline and PreMedline, and has content which is non-Medline. Is there any evidence that PubMed gets the unindexed content before PreMedline does?
Leone Snowden
NSW Medicines Information Centre
Sydney, Australia
Very generous of you to share this valuable information.
Thank You,
Leslie Radentz, MD
Dear Jacqueline,
This is a very interesting post. I agree that it is very important to search PubMed in addition to Medline. It’s something we do routinely at the Canadian Agency for Drugs and Technologies in Health (CADTH). However, I think there is a somewhat more precise approach for retrieving items in PubMed but not in Medline than you provided. Your PubMed search suggestion:
[Search string] NOT Medline
does retrieve items that are not in Medline, but it still retrieves some items that are in Medline (for example, oddly enough, those with a status of “PubMed not Medline” – these items are in Medline but not indexed). Also, this search will include items with a status of “In-Process”. These will also be in Medline as long as you make sure to search a complete version (such as Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid MEDLINE(R) 1948 to Present).
I have found that this search works more precisely:
[Search string] AND publisher [sb]
This search limits only to those articles that still have a status of “Publisher”, including most Epub ahead of print articles. It seems to do a very good job of retrieving all the citations that are only in PubMed. CADTH has created a poster that provides more detail. It’s available at: http://www.chla-absc.ca/2010/graphics/chla2010-poster07.pdf
Thanks,
Dave Kaunelis
CADTH
Ottawa, Canada
Dear commenters,
Thanks for commenting and sharing your valuable ideas and experience. I will update my post with some of the new insights I gained.
@Leslie Thnx for connecting on LinkedIn and directly responding to my blog post. Glad you find this rather technical post meaningful.
DEDUPLICATION:
@elaine : I use the following section: Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations and Ovid MEDLINE(R) 1948 to Present. At our library we have only accession to this segment, Ovid MEDLINE(R) 1948 to November Week 3 2011, Ovid MEDLINE(R) Daily Update November 16, 2011. It is an interesting suggestion though and I will ask whether we can get access to MEZZ as well. A question that remains is, which version do you prefer? The non-revised one or the revised one? I rather would have the latter
@dieuwke thanks for your tips and comments. You are right. First I thought, but these citations have different PMID’s, thus aren’t deduplicated. But they are! (by using the command: ..dedup.) This example is exceptional however, because it is a news item on the same page in Nature, written by the same author and with approximately the same title. Possibly (dependent on how you deduplicate) Reference Manager (RM) would consider them duplicates too.
I don’t find deduplication in RM more transparant. Of course you can set your own rules, but the reader of the systematic review doesn’t know which one you use and what has been deduplicated. I used to send duplicates to a separate RM-file, but the new RM version crashes so often that I stopped doing this. Thus I have no way to easily check whether the removed citations are true duplicates.
I find it more transparent to show what you have done in OVID MEDLINE, because everyone can repeat this exactly the way you did. (I always include at least one complete search in the appendix of the SR). But from now on I will check whether duplicates are true duplicates in OVID. Thnx for the note of caution!
EXTRA CITATIONS IN PUBMED VS OVID MEDLINE
@mairna. I haven’t been clear enough, I suppose. I forgot to mention that I do use OvidSP Medline In-Process & Other Non-Indexed Citations”. I find it so self-evident to use textwords in addition to MESH, that I didn’t mentioned this either. The conclusion of this piece was to show that you miss articles in OVID MEDLINE (incl non-indexed citations) even though you take care to include text words.
@Leone How do you search PreMedline? It is not any longer a separate database, thus do you use another comment than NOT medline [sb]? Or do you mean the PreMedline search is automatically retrieved in a PubMed search?
I’m not sure I understand your question ” Is there any evidence that PubMed gets the unindexed content before PreMedline does?” I would say, per definition it wouldn’t. But perhaps there are others knowing more abt PubMed who can answer your question.
@David
Thanks for sharing your findings and your excellent poster on this topic. It is good to know that CADTH routinely searches PubMed in addition to Medline.
You suggest to use publisher [sb] instead of the NOT medline [sb] comment that I have used.
I have checked it using the example I gave.
With AND publisher [sb] I find 9 references.
With NOT [medline [sb] I get 30 refrences
The entire publisher[sb] set is within the medline[sb] set. Most importantly, this publisher[sb] set contains the 3 relevant papers that I missed in OVID.
But I missed 2 other citations with publisher[sb] that were not in OVID MEDLINE.
1. One citation I found in PubMed and not in OVID MEDLINE, was present in OVID MEDLINE, but I rerieved it in PubMed because my PubMed search is much broader. I search for T4[tiab] OR T3[tiab], whereas my search in OVID using adjacency operators confines the meaning of T4 and T3 to hormones and not T cells, for instance.
My command for these hormones in OVID MEDLINE:
Thus this reference is not relevant because it is about T4 cells not the T4 hormone. Yet 1 irrelevant citation is no problem for a systematic review. It might become a problem though if you have a high retrieval and a very inaccurate PubMed search.
2. The other citation (18210580) was relevant to the topic, but apparently not included in OVID (1949, OLDMEDLINE).
My conclusion: limiting to publisher [sb] is a cleaner way to limit to a recent subset of publications, not yet included in OVID MEDLINE.
Limiting to the non-Medline set by applying the command: NOT medline[sb] retrieves not only the publisher [sb] subset, but also other publications that are not in PubMed but not in MEDLINE. Some of these citations are relevant. There is a great overlap with OVID MEDLINE however (pubmednotmedline [sb] and inprocess [sb]), but this is no problem if the citations are deduplicated using a database like RM. (see PRISM flow chart).
Thus it is up to the searcher & client to decide whether they only aim to find the “as supplied by publisher” subset, or that they want to find other non-MEDLINE articles as well. This must be balanced against the possibly higher noise level, inherent to PubMed searches.
Thanks for your update. Based on your comments, I think the below search may be most optimal if your goal is to retrieve everything that is in PubMed, but not in Medline:
[Search string] NOT (Medline [sb] OR inprocess [sb] OR pubmednotmedline [sb])
This will remove the overlap you mentioned and avoid having to remove duplicates in your reference manager software. As you mentioned, if your goal is to find only articles that have not yet been added to Medline, then using
[Search string ] AND publisher [sb]
is preferable, especially for larger searches.
That is a very apt analysis, David.
The difference between NOT (Medline [sb] OR inprocess [sb] OR pubmednotmedline [sb]) and AND publisher[sb] is marginal though. In my case just 1 paper (10 versus 9). But it seems better than NOT (MEDLINE[sb] alone [30 hits, 19 duplicates].
I think I will try the 3 commands the nest few times. Just to check that I don’t miss anything.
Hi Jacqueline,
Thanks for your further comments. After some thought, I would like to expand a little on what I said in my above post. First I would like to note why the two articles that were not retrieved using the publisher [sb] filter in the search example used above:
Article 1 was retrieved in PubMed due to a broadening of the search strategy. Since the article is in Medline, it would not be retrieved using the publisher [sb] filter. It would have been retrieved in the original Medline search if the same strategy had been used,
Article 2 was not retrieved because it has a status of OldMedline. It’s not in the Medline database, but is in the OldMedline database which is available as an Ovid database. If researchers are interested in older articles, OldMedline and Medline can be searched together in Ovid.
In all, there are five citation status subsets in PubMed: Medline, OldMedline, In Process, PubMedNotMedline and Publisher. Three of these (Medline, In-Process and PubMedNotMedline) are in found in Medline (or are added within a day or two).
The only two subsets not found in Medline are Publisher and OldMedline. So the alternative strategy I mentioned in my previous post:
[Search string] NOT (Medline [sb] OR inprocess [sb] OR pubmednotmedline [sb])
retrieves the same results as this one:
[Search string] AND (publisher [sb] OR oldmedline [sb])
And if you aren’t interested in older articles, then just using the publisher [sb] filter will find all citations in PubMed but not in Medline.
Thanks,
Dave
A response faster than light.
You are right (again). The only thing to “worry” about is the “a day or two difference” before the citations appear in MEDLINE. But now I’m splitting hairs, I suppose.
Yes, the time lag can be a problem if you won’t be maintaining alerts on your search. But if you are concerned, you can always run a second search without the publisher [sb] filter and limit to articles published within the past day or two. I think this hair is now fully split!
I agree! Have a nice weekend, David.
RT@ LibrarianGMIT: New useful search engine that returns full PDF scientific articles not subject to access fees: http://www.freefullpdf.com
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Thank you for this wonderful reminder.
It’s nice to see some of the early pioneers still following their individual blog journeys. Social media tools and services have evolved but blogs still have their unique place.
I’ve started more than 10 blogs on Blogger.com and I still keep some of them but the two that have gained more readers are:
CasesBlog http://casesblog.blogspot.com
Started 3/8/2005
Allergy Notes http://allergynotes.blogspot.com
Started 5/25/2007
Each of them has a companion website: ClinicalCases.org and AllergyCases.org
It would be nice if you could give some descriptive title to the spreadsheet:
https://docs.google.com/spreadsheet/ccc?key=0AqY7bhmA8k1jdElTa2FQWlRrMkNMMDRiU1dtZTRuOWc#gid=0
Most importantly, thank you for writing such a wonderful and well-researched blog. Some blog posts are as detailed and evidence-based as review articles or meta-analyses, and you have always set the benchmark high. I look forward to reading the blog in the future, and truly appreciate your finding the time and your research effort.
Thank you for the kind words for my blog. It’s just a digital notebook.
Thanks for mentioning my blog anniversary! And congrats to CasesBlog and Scienceroll on their anniversaries!
I still find the blog to be my own unique place where I can elaborate on things much more than in other “fast paced” social media like Twitter and Facebook.
What has changed over the years is that I don’t post as often as I used to do, but I put more time and effort into the posts I write.
My main challenge is still to write a meaningful blog on medical photography (most often) without my own photos, as most of the medical photos I take are not meant for the public.
You are an inspiration, Jacqueline! Thank you!
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), en de gebruikte criteria hadden wat helderder en hier en daar wat objectiever kunnen zijn. Laika Spoetnik (AMC) schrijft hier ook over op haar blog. [...]
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I must admit, @Laika, I have not kept up with nor participated in GR for quite a while. I was probably one of the last to be interviewed for a MEDSCAPE article when I hosted GRs. It is not an easy task to host or to write an article one hopes is kept for GRs. However, part of the reason I quit participating was the number of “put my post in GRs so my blog will be seen” articles which were submitted. It was so daunting a task to include them all that many of us who hosted (some much more than I) asked those submitting to include a synopsis of each post and all pertinent information. This kept the host from having to read so much.
I know there used to be a huge number of submissions. I’m not sure if there are now. I haven’t read it in a very long time. If there still are, I do believe some need weeded. The problem with that is those who edit are always biased. Yes, biased. What I think important is not what someone else thinks important. The way GRs worked, though, is that both you and I were able to host. It worked because those of many biases became hosts. A plethora of hosts from all walks of life (we are all part of the medical process, like it or not) does seem to work to average it all out.
It seems to me, in the long run, the reader must be the judge of validity. If the readers have dropped off, maybe the contents are not longer valid to those readers? I don’t know. I’m throwing out ideas. Has the idea become stale? Perhaps it is time for a change? Who says GRs has to be the only game in town?
Who are folks reading now? How about a Facebook page to link to? One to be shared? (Or is that there, too, and I didn’t know? Ha! )
Change can be good. It can mean things are happening and it can keep us on our toes.
I ♥♥ your posts.
Laika, Medscape declined to continuing sponsoring GR a few years back, and Instapundit’s support is hardly reliable (or desirable, for many). Publicity for GR will return, I’m confident, when quality rises.
We’ve surveyed the folks on our email list and found readers preferred a shorter edition with a heavier hand in editing. Fewer self-promotional submissions, and more high quality writing selected from around the web, including journalists. An edition that’s easier to host, and discuss.
One thing that may be confusing to people: the host’s link descriptions on the GR host edition need not be less than 140 characters. That was the last host’s prerogative. And folks don’t have to always submit someone else’s links — that was this week’s host wrinkle on the process.
Hosts still have a lot of leeway in this process to conduct GR as they like — maybe one of these initiatives will prove really successful, in the meantime they’re interesting variations on the theme. The only real change we’re asking of hosts is that they’ve got to exercise more editorial judgment and keep GR links concise and easy to share. Truthfully, I’m worried these changes aren’t bold or progressive enough… and I’m surprised that someone could interpret Bryan’s post as off-putting or even arrogant, especially when he’s asking readers to submit someone else’s content (which is more in that blog carnival spirit of discovering new writers than self-promotion).
Hi Robin, nice to see you here again. Thanks for sharing your ideas.
If the main reason for quitting to host(?) the GR was the number of “put my post in GRs so my blog will be seen”articles, than the stricter newer guidelines may persuade you to return
.
I never found the number of links to incorporate a problem and I read all posts. As a host you should, I think. The summaries did help me to summarize the posts in English (which I still find difficult as a non-native speaker). But, yeah, I did find it difficult to reject a submission when I found the topic less interesting or of lower difficulty. I can imagine that a little more pruning makes the Grand Rounds more attractive to read (and to host).
I don’t have the impression that there are more submissions nowadays, but many of the most prominent bloggers, like you and Ves Dimov have stopped contributing or contribute less. Other blogs as Margaret rightly noticed already produce aggregate feeds. Does that make the Grand Rounds less attractive? Perhaps, as does the shortage of time.
I heartily agree that the power is in the variation, the personal touch of the host, and that bias really doesn’t matter as long as different hosts have different biases.
Yes the readers are most important. But who are the readers? Is the GR audience still the same as seven years ago? And/or has their preference for topics changed? Or has the Grand Rounds changed? I wouldn’t know.
Yes GR has a Facebook page: http://www.facebook.com/grandrounds. Using Facebook, and Twitter to spread the word is essential, but I was concerned that tweets/short selected summaries would largely replace the old Grand Rounds.Then GR would loose its added value imo.
Thanks Nick for your prompt response.
It is reassuring that the GR will not be forced in the format of a tweet and that the future hosts will still have a lot of freedom to host the GR as they like. I agree that more editorial judgment and conciser summaries may make the GR more attractive.
However, I don’t understand what you mean by self-promotional submissions. Submitting one of your own posts is always self-promotional. What is wrong with that? As long as the post is good. It should never be a goal in itself, of coarse.
I was looking for other words than off-putting and arrogant, more a translation of “tegen het zere been” (against a sore leg, touched a raw nerve?), which puts more emphasis on the interpretation than on the writer’s intentions. Furthermore, it had nothing to do with the current rules for submission.
What I didn’t *like* is that former hosts are depicted as link-lovers, who go for quantity not quality: “This is Grand Rounds for quality rather than link love.”
We all have put a lot of time in preparing the GR as good as we could. Larger editions may be less effective, perhaps shorter versions are better, but long posts have nothing to do with link love.
I like the Grand Rounds and hope that the measures are sufficient to put the GR back on track. Thanks for creating and “guarding” it.
I am fairly new to the business of blogging have been in Medicine shorter than you all have been blogging, so I guess I have not seen or heard as much as you all, but I must say I am confused right now. Very confused. So what is going on with GR? Is it going to move into Twittersphere? Or is it just undergoing some changes in laws?
If people are not submitting their own links, it is highly unlikely they will submit someone else’s. So, that way, I believe the submissions for GR shall go down even more.
And I know everyone is going to say if one churns out quality content the post will eventually be picked up by GR but the truth is for newbie bloggers (like me) or ones that do not have a community of followers around them, shall hardly figure on GR anymore.
So what if the posts were submitted for link love? As the GR host you are not compelled to include each and every post that gets submitted, right? The more posts that get submitted, the better chance one has of getting good posts from a diverse sphere of bloggers.
As of now, it runs the risk of becoming a “Top 10″ kind of thing where all the best writing (which we all read just as it is) is churned out as GR. And if that happens, well, I am afraid that might be the last nail in the coffin for GR.
I do not intend to sound upstart-ish or anything, but I must say I like to read, and the very ephemeral nature of the tweets (which are very hard to retrieve, say 1/2 years down the line) stands contradictory to the same. I wish GR stayed the same, but it is not in my hands. And yes, I agree Dr. V sounded a little off-putting to me as well. But then again, English is not my native tongue as well, so, it maybe something I misconstrued…
Sorry for the long winded comment but I have been meaning to write about it for quite some time now, and I think reading your post just brought it all gushing out.
I’m looking at how to use haiku with nursing students in their pharmacology class. Thanks for posting yours here.
I have been corresponding with Jeffrey about this and I must say he is a fantastic person who is really on the edge of this rapidly growing field. We need sentinel surveillance by professionals like you and him so that people like me do not end up getting duped!
However, I must say every time I see an article or a blog post or a discussion thread about predatory OA it hurs and angers me at the same time.
Indeed… a good laugh!
Hi Jacqueline,
My name is Mike Corrao, and I’m the owner of MCAT Question of the Day, a free resource for pre-med students that prepares them for the MCAT one question at a time. In addition to MCAT questions, we also have an MCAT Wisdom section which features articles pertaining to test-taking strategies, pre-med life, etc.
In an effort to expand our site’s offering to pre-med students, we’re building this cool new feature called the Pre-Med Magazine, which is basically an online magazine that will be distributed to our mailing list and will be publicized (hopefully) around campuses and such. I was trying to find a great way to organize our Wisdom articles into an easy-to-consume format, and I feel like this may be it.
My question to you is: would you like to be a part of the first issue? I’d love to have you in it, as I’ve been reading you blog for quite some time now!
Let me know Jacqueline, I’d be really excited to work with you!
Thanks,
Michael Corrao
http://mcatquestionoftheday.com
michaelcorrao@ufl.edu
Ms Jacqueline Limpens posted interesting comments on her blog Laika’s MedLibLog regarding the search filter we developed for finding animal studies in PubMed (Hooijmans, 2010). We would like to respond to those comments.
In our article, we state that collecting and analysing all available literature before starting an animal experiment is of the utmost importance. It is a means of reducing unnecessary duplication of experiments and unnecessary animal use and of improving the safety of translating animal research into clinical benefits (since different species might react differently). It is an elaborate venture to obtain a complete overview of studies on a certain topic in laboratory animal science. Among factors that influence the current lack of systematic reviews (SR) in animal research are the intricacy of search options in bibliographic databases like PubMed and scientists’ unawareness of those options or their inability to use several options efficiently. To increase awareness and to facilitate more effective searching for animal studies in PubMed we created a search filter.
One of the comments that Ms Limpens’ raises is that the filter is too long (i.e. longer than necessary) and that not all MeSH terms are extremely useful. She notes that the first records missed with Mice[mesh] NOT Animals[mh:noexp] are from 1965, when they apparently didn’t use “animals” as a check tag in addition to specific ‘animal’ MeSH.
We agree with Ms Limpens that indeed most of the records missed when using the searchstring Mice[mesh] NOT Animals[mh:noexp] are from 1965 since in the last few years many mistakes have been retrospectively corrected by PubMed. Nevertheless the goal of this filter is to find all papers concerning experimental animal studies and therefore in our view publications older than 1965 should not be disregarded.
When we performed our first searches for all relevant papers concerning omega-3 fatty acid supplementation in experimental Alzheimer’s disease, some very relevant papers were not found. One of the missing papers was one of my own, which at that time (although it was about transgenic mice, and this was even a title word) did not receive the MesH term Animals. Another example of a paper clearly concerning animals, but which did not receive the MesH term Animals is the article by Molinari et al. (2002) on pigs. (The effect of testosterone on regional blood flow in prepubertal anaesthetized pigs; Molinari et al.)
Even though these may be rare omissions we decided to include the separate MeSH terms because of the considerable advantage of missing fewer relevant articles.
It is true that using the animal search filter will inevitably also result in many irrelevant hits especially because the search results will include studies on animal cells, animal products and names of species of strains used in diseases, e.g.swine flu. We welcome suggestions for improving the balance between precision and sensitivity of the search filter.
Last but not least; the length of the filter does not detract from the ease of use. We agree with Limpens that indeed it would have been a problem in case you had to type the entire filter into the search box every time you want to use it. We created a supplement, however, from which you can directly copy and paste the filter into the search box.
Other issues mentioned by Ms Limpens regarding the filter’s length are the lack of truncation and the fact that most animal terms do not seem relevant for most searches.
Our decision to leave out truncation, and describe all the relevant synonyms ourselves was motivated by the aim to prevent retrieval of even more irrelevant hits. Although many search terms included in the search filter may seem irrelevant in most searches, they are relevant in some searches. It is important to include those “more unusual animal models” in your search as well, because we ultimately want to improve the safe translation of the results from animal studies to the clinical situation. The filter was developed to be used by everyone searching for animal studies. In addition, when a specific species is not used in a specific research area, and is thus superfluous, this term will not yield many extra hits, and is therefore quite harmless.
Ms Limpens’also suggests to use the search string NOT (Humans[mh] NOT Animals[mh:noexp]) instead of the animal filter to safely exclude human studies.
Limpens’ approach is not in line with our aim to find all animal studies and exclude human studies in one go. Limpens’ approach also includes in vitro studies and other irrelevant topics which will lead to many irrelevant hits, and is likely to be even less specific compared to our search filter
One of the other comments Ms Limpens raises is that we did not validate the search filter in the strict sense of the word.
We agree with her that we indeed did not validate our search filter in the strict sense of the word and we explained the reasons extensively in the discussion (page 174 2nd column), but in short:
It would be practically unfeasible to formally validate the entire filter via the regular process (for arguments see discussion section of the paper) and was beyond the scope of our paper as well. Nevertheless we used a more informal way of validating the filter by comparing it with the only alternative currently available, the PubMed Limit: Animals, and calculate sensitivity relative
to this alternative.
Ms Limpens also states that only parts of the search filter seem useful for most systematic reviews, and especially if these reviews are not meant to give an overview of all findings in the universe, but are needed to check if a similar experiment hasn’t already be done. She deems it impractical for researchers each time they start a new experiment to have to make a systematic review, checking, summarizing and appraising 10,000 records.
We agree with Ms Limpens here. Our comment, however, is that the search filter is meant to help researchers to detect all animal studies in their specific field of research. In addition, from our own experience we can relate that when conducting and writing a SR in laboratory animal science using the search filter we end up with roughly 1000 abstracts. This is not more than is common in SR of humane studies. In addition, it is important to stress that the search filter for animal studies is only one component of the total search strategy (for more information; Leenaars et al., Lab Anim. 2012 Jan;46(1):24-31).
To conclude, we do not advocate performing a SR before starting a new experiment, but we do stress the importance of searching systematically for all original papers before the start of an experiment. In this way, unnecessary duplication of experiments may be prevented and experiments may be designed that really add to the existing knowledge. Our filter is an important tool in this context.
Not the shortest.
http://bssa.geoscienceworld.org/content/64/5/1363.abstract
That’s great! TY!
Genius.
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I would guess that someone imputed ‘yes’ in the abstract field because there was an abstract instead of putting the abstract in. Funny tho’ !
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Hello
Many thanks for this. I didn’t spot that the medical professors list was spammy and I should be good at this. To be fair they did add additional content etc.
Hi AnneMarie. You are right about the list. In itself it is a good list,(3-4-5) and it has added value. At least it gives a real description of the tweople and their tweets. The author is on Twitter (“she writes a lot”) and apparently a bit familiar to the field. For me it is sufficient to avoid lists if the list is published on a site fulfilling criterion 2. thedegree360.onlinedegrees.com typically belongs to the online degrees websites (how many of these copycats are there?)
Criteria 2.1-4 all apply.
These “blogposts” have many different authors (I have been approached by many for guestposts and links -not only to lists), some good, some not so good. It is the intention of the site that worries me the most.
I could not explain it better than Ellie Here I quot her once again:
Hey
Vooor de veiligheid schrijf je best eerst al je teksten in Word.
Verbeterd en klaar om te posten. Control v datwerkt wel hier bij mij maar kopieren en plakken met de muis weigert soms dienst!
Vandaar toch altijd op save spelen.
Bedankt voor je goede tip!
Geepee
I noticed it today (albeit without Volk et al). My Twitter account is only a couple of days old. It may be a coincidence, but I noticed this when @TheMarketaire (Brett Prince) followed me. As I said, it might be coincidental but he is another marketer.
The point, I guess, is that the auto follow thing is still around.
One problem is that few guidelines include guidance to explain to the patient that “we don’t really know what we’re doing here, and are pretty much just guessing. If you want to decide what to do for yourself, that might do better.”
A quick reply VIA my mobile phone.
…In that case i didn’t make myself clear (enough). Guidelinemakers (of ebm guidelines) don’t just make guesses. It is a lot of work to distill the questions, look for all the evidence in the literature, make a synthesis & then make recommendations on basis of the evidence, which may or may not be convincing. Guidelines and systematic reviews have often revealed current practice to be wrong (even causing many deaths). But people shouldn’t expect 100% certainty. And RCTs are no panacea, as i hope i have shown. Thus expecting that only evidence from 1 rct is good, is not good (sometimes it is, but not for bach and every question or population). That guidelines are not always based on the strongest evidence doesn’t mean everyone can just do whatever one likes. One should base decisions on the available evidence and use some common sense etc as well. For patients it is admittedly more difficult to grasp the guidelines and what is reasonably sound and what isn’t. The guidelines, though different, clearly state how they reach the evidence & recommendations, though.
“possible hijacking of EBM by purchasers and managers … “. In my experience in routine practice the proper caveats expressed in the preamble of good guidelines frequently are lost, unread, and forgotten. The result is they are frequently and regularly used as a substitute for critical and original thought and analysis by a host of different agencies, some of which are mentioned above. I am not sure how much changing the name, from guidelines (it is remarkable how frequently the word “should” pops up) to something else, would help, because the real problem is teaching people how to think critically. cf. As a slightly similar lesson, look how the DSM “cookbook” has been highjacked and the profoundly negative consequences of that.
Then there is the real danger of treatment becoming a rote procession of self-fulfilling mediocrity with the stifling of innovation and use of non-standard treatment: that, IMO, has already happened in the British NHS.
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As the author of the article you critique [1], I’d like to remark that you seem to have slightly missed my point. After writing “I do not agree with his conclusions”, you write a great deal that I not only agree with, but had explicitly in mind as I wrote the article. I’m actually rather keen on Evidence Based Medicine (EBM): as a graduate of Sackett’s Clinical Epidemiology primer course at McMaster, it would be surprising if I weren’t, since I spent a happy summer there learning how to track down “the best external evidence there is”, and have been using those skills for the last twenty years or so.
Perhaps we lost each other at the point (third paragraph) where I wrote “Guidelines committees are cast in the role of distilling evidence from the relevant literature to reduce it to a bullet pointed list or flow diagram, allowing busy practitioners to move on from practice based on mere anecdote and opinion.” That sentence has undergone a little editorial revision, and I think my original text made it slightly more evident that this “role”, thrust upon or adopted by guidelines committees, is not one I believe is appropriate or even sensible.
The rest of my piece flows from that point: medical colleagues, hospital managers and the legal profession regularly treat these distillations of the medical literature *as if* they were rules to be followed, rather than complicated bits of EBM subject to critical appraisal and doubt. In clinical practice, compliance with guidelines has becomes an end in itself, and that is the cause of my guideline fatigue syndrome.
But there is a point at which “the best external evidence there is” descends into a region in which “false positive” studies outweigh “true positives”. Ioannidis has been exploring that territory for some years, and the problem is eloquently described in his paper “Why most published research findings are false” [2], which should be required reading for all members of guidelines committees. We know experts can give diametrically opposed advice [3]; we know that early published research findings are often overturned or downgraded in effect size [4]; we know that early adoption of such findings can lead to harm to patients and later revision of guidelines as more evidence comes in [5][6]. Hence my plea that guidelines committees should be mindful of how their guidelines are being put to inappropriate use in the real world, and should therefore resist the temptation to issue guidelines based on such low-level evidence.
1. Hutchison, G. (2012). Guidelines can harm patients too. BMJ 344:e2685 doi: 10.1136/bmj.e2685
2. Ioannidis JPA (2005) Why most published research findings are false. PLoS Med 2(8):e124 doi: 10.1371/journal.pmed.0020124
3. 1. Cook TM, Morgan PJ, Hersch PE (2011) Equal and opposite expert opinion. Airway obstruction caused by a retrosternal thyroid mass: management and prospective international expert opinion. Anaesthesia 66:828-36 doi: 10.1111/j.1365-2044.2011.06650.x
4. Ioannidis JPA (2005) Contradicted and initially stronger effects in highly cited clinical research. JAMA 294(2):218-28
5. Sear JW, Foex P. (2010) Recommendations on perioperative beta-blockers: differing guidelines: so what should the clinician do? British Journal of Anaesthesia 104(3):273-5 doi: 10.1093/bja/aeq007
6. Webster NR, Galley HF (2009) Does strict glucose control improve outcome? British Journal of Anaesthesia 103(3): 331-4 doi:10.1093/bja/aep226
@Ken
You are right about the danger of hijacking by any agency. In reality this happens. I also agree that many guidelines (shouldn’t a better name be Evidence Based Recommendations?) often sound (or are meant to be) too imperative. I’m not sure whether the real problem is that people cannot or do not think properly. It seems like you consider “adherence to guidelines” and “critical thinking” as mutually exclusive. In my view it is still invaluable to have all the available evidence summarized, critically appraised and evaluated at one place. But that doesn’t mean that all recommendations should be taken for granted and that it relieves people from thinking. Furthermore, the other way about is dangerous too. In the past many interventions and screening methods have been applied that seemed to “make sense”, but later appeared to be ineffective or even harmful (see my previous posts about the CRASH-trial and antenatal corticosteroids in women expecting premature babies, Vitamin E and Selenium for prevention of prostate cancer, breast cancer and prostate cancer screening ).
IMO the comparison with the DSM “cookbook” doesn’t hold, for as far as I can tell this is a “handbook” (consensus-derived), not an evidence based guideline.
@Grant
) and that too is subject to interpretation.
First of all, I really appreciate that you make the effort to reply to my blog post and continue the discussion here (I’m pleasantly surprised you found it so quickly)
Of course I can only read what is written in the paper (
I agree with the following point you make:
Perhaps, as an informationspecialist, I’m a bit more naive to the pushing and “hijacking” by agencies and (some) guideline makers/medical specialists (Ken Gillman also referred to). I advise my clients just to use the EBM guidelines as “a source of evidence”, to assess the evidence themselves and to see if it is applicable to their situation (American guidelines for instance are not always applicable to the Dutch situation). But clinicians might be expected/”forced” to follow (some of) the guidelines.
There is yet another point where we lost each other, that is that I (still) don’t agree with your final conclusion:
I know the work of Ioanidis (as a matter of fact I often refered to his work at this blog). The references you cite here (and not in your orginal work) are very important, but I do not see how they support your view. Taken to the extreme, they indicate that you never can be absolutely sure that something actually works, but this also applies to “high” evidence, obtained by an RCT or a SR. In your piece you emphasize that you don’t object to recommendations based on “high evidence”, but recommendations based on “low evidence”. My point is that:
But as said, I assume that guidelines are synthesis of evidence coupled to recommendations and that clinicians must have the freedom to deviate from the recommendations. I also think there should be more differentiation among evidence (I would not call 1 RCT high level evidence per definition). On the other hand for some questions that cannot be answered by RCTs good observational studies/cross-sectional studies might provide the best evidence and might thus score higher).
If high recommendations are based on low evidence, the guideline makers should underpin their decision with references and/or a good motivation.
We agree, though, that evidence is not absolute, guidelines and evidence can change over time, that guideline makers should be prudent in giving high recommendations based on low levels of evidence (for that topic) and guidelines should not be imposed upon clinicians
Laika:
Fortunately, I don’t seek certainty. All clinicians are forced to making decisions using imperfect and incomplete information; and all clinicians have had the experience of a patient suffering because of a recommendation the clinician has made in good faith and after careful consideration of the evidence. All we ask is a *reasonable chance* that the advice we’re offering will help our patients more than it harms them. There are also deep moral instincts that make us want to stick with the status quo until we reach some threshold of evidence at which we will adopt a new intervention. At the level of statistics, that shows up in our (purely conventional) 5% cut-off for false positives; at the life-or-death level, it shows up in the much-discussed distinction in medical ethics between “letting die” (inaction) and “killing” (action).
So clinicians review the evidence, weigh it against their own situation and that of their patients, and will switch to a new intervention in a piecemeal way, varying from clinician to clinician and patient to patient, as the evidence becomes more robust.
Ioannidis and my other references then become important, because they show that early evidence of benefit is simply *not* robust, especially if the results of early studies are generalized beyond their area of application. Generalization from initial good results took place both in the case of tight glycaemic control and perioperative beta-blockade, referenced in my previous reply. And such early promising results are exactly the sort of thing that seems to drive an outbreak of new guidelines: I encountered blanket guidelines recommending tight glycaemic control and widespread perioperative beta-blockade in the mid-2000s, before the usual cycle of optimism-pessimism-realism had had a chance to play itself out as the literature expanded. Such guidelines were not generally well received, because clinicians noted that there was clear danger of harm from both interventions, and unpersuasive evidence of benefit in the enlarged target populations.
So low-level evidence simply doesn’t drive clinicians to “switch”: we wait and we watch. Guidelines based on low-level evidence therefore do not drive change. What then is their use? You’ve said that they provide a repository for evidence, and a means of highlighting gaps in our knowledge – but, as I said in my original article, there are other and (in my view) better ways of getting such information to clinicians’ attention without tagging it as a “guideline”.
On the matter of “level of evidence”, I’m quite content that many questions in medicine are not amenable to randomized control trials. Clinicians simply compare the evidence they’ve got with the evidence they would find persuasive, and they don’t budge if the evidence doesn’t match up to the task at hand. In rare instances, as you say, a case series will be enough to compel change (the efficacy of parachutes has never been tested beyond a case series, but I still advise my patients to use them when jumping out of aircraft). Such fine points of usage don’t in any way undermine the general argument.
“It seems like you consider “adherence to guidelines” and “critical thinking” as mutually exclusive.”
I am not sure you have expressed that idea optimally-They are certainly not mutually exclusive. However, many busy doctors who just want to keep out of trouble are inevitably going to follow the path of least resistance, which means following the guidelines and not sticking your head above the parapet. That sometimes, perhaps too often, means that people will be reluctant to try non-standard recommendations simply because they’re not in the guidelines.
@Ken
From your 1st comment I concluded that you found critical thinking *most* important. I gave some examples that “reasoning” alone may not always lead to good decisions. I also think that guidelines can be an important source of prefiltered evidence.
However, I too see the danger you point out “busy doctors who just want to keep out of trouble are inevitably going to follow the path of least resistance, which means following the guidelines and not sticking your head above the parapet”.
And luckily others deduced the same from my post
:
@mariawolters: An important point from @laikas: don’t criticise evidence-based medicine and guidelines, criticise cookie-cutter use j.mp/JsOvoC
BTW: You don’t consider DSM as EBM-guidelines, do you?
Coincidently @ferrisjabris was tweeting a lot about DSM #APA yesterday . He quoted John Livesley several times, i.e.:
@ferrisjabr: John Livesley: APA decided to create entirely new classification of personality disorders that is NOT evidence based #APA
Thanks for joining the discussion.
Jacqueline
I get endless emails from people with these kinds of sites telling me I am on such and such a list…I even get different messages claiming to be from different people, but actually the same email address. They’re splogs and link bait scams almost always and unfortunately some people get suckered into linking to them, giving them credence and publicity. They’re a pain in the ‘arris.
I am a strong supporter in finding a cure for breast cancer and to help prevent tragedies like this. No woman should ever have to loos her breasts. That’s just sad.