PubMed · 10243551
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1979. Coping with the problem practitioner: five experts' advice.. https://pubmed.ncbi.nlm.nih.gov/10243551/
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CONTEXT: Letters to the editor are an important means for ensuring accountability of authors and editors. They form a part of the postpublication peer review process. I studied the critical footprint made in the medical literature by 3 randomized trials (Hypertension Optimal Treatment [HOT], Captopril Prevention Project [CAPPP], and Swedish Trial in Old Patients with Hypertension 2 [STOP-2]) published in The Lancet and investigated the extent to which that footprint was preserved in shaping clinical knowledge. METHODS: Qualitative appraisal of the criticism of each trial, taken from published letters. Agreed weaknesses and unanswered criticisms were identified from the authors' reply. I searched MEDLINE for practice guidelines published after the trial report and sought evidence for incorporation of criticism into these guidelines. RESULTS: From the time of publication to October 2000, HOT was cited in 9 of 36 practice guidelines; CAPPP, in 6 of 36; and STOP-2, not at all. HOT received 14 published criticisms, 5 comments, and 3 questions, of which 15 were responded to. Only 1 criticism, lack of power, was referred to in 1 guideline. CAPPP received 14 criticisms, 9 comments, and 3 questions, of which 8 were responded to. Only 1 criticism, imbalances between groups, was referred to in 1 guideline. STOP-2 received 12 criticisms, 9 comments, and 3 questions, of which only 6 were responded to. CONCLUSIONS: More than half of all criticism made in correspondence went unanswered by authors. Important weaknesses in trials were ignored in subsequently published practice guidelines. Failure to recognize the critical footprint of primary research weakens the validity of guidelines and distorts clinical knowledge.
AIM: To demonstrate face and construct validity of a computer based flexible sigmoidoscopy trainer. METHODS: The PreOp (Immersion Medical, USA) system is a virtual reality based flexible sigmoidoscopy simulator. The system records several performance parameters, such as percentage of colonic mucosa visualized, time taken, and pathlength of endoscope travel. Forty-five subjects were divided into three groups: novice (never performed a lower GI endoscopy), intermediate (5-50 examinations), and trained (greater than 200 examinations). After initial familiarization subjects were assessed three times on a case module. Results showed a nonparametric distribution. RESULTS: There was a significant difference between all three groups with respect to percentage of mucosa visualized (novice 71.0 +/- 3.7%, intermediate 77.3 +/- 5.6%, expert 84.8 +/- 4.6%, Kruskal-Wallis p <0.001) and efficiency ratio (%mucosa/time, novice 0.163 +/- 0.055, intermediate 0.259 +/- 0.07, expert 0.306 +/- 0.058, p <0.001). The novice group was also slower and had a lower pathlength of instrument travel compared to the others. CONCLUSION: PreOp virtual reality simulator is a valid discriminator of flexible sigmoidoscopic experience. Its effect on training needs to be explored.
Clinical governance has, for the first time, placed the quality of healthcare as a direct responsibility of the Chief Executive and therefore the board of all NHS Trusts (Hospital), community providers and primary care trusts (general practitioners). The foundation for clinical governance was set out in the Department of Health Publication 'A first class service-quality in the new NHS' [Department Of Health, A First Class Service: Quality in the New NHS, London, HMSO, 1998]. Much of this had been precipitated by the Bristol cardiac surgery case and other series of medical disasters in the UK relating to cervical screening, breast screening, psychiatric care and pathological misdiagnoses. This new responsibility of clinical governance involves guaranteeing quality through a number of processes, many of which are currently in use and should be familiar to any clinician or manager. They include clinical effectiveness and optimisation of clinical care, clinical risk management, learning from complaints, professional development, good quality clinical data systems and involvement of patients and carers. This duty is equal to the other statutory responsibilities of NHS organisations, which are of financial probity, accountability and ensuring value for public money on behalf of the taxpayer.