Psychotherapy research: new findings and implications for training and practice.
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The last decade has seen progress in psychotherapy research, despite the methodological complexity in this field. However, empirical research has influenced training and clinical practice to only a limited extent. This article is a brief evaluation of trends and some findings in modern psychotherapy research that may influence professional psychotherapy training and practice. (+info)
Clinical interventions and outcomes of One-to-One midwifery practice.
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BACKGROUND: Changing Childbirth became policy for the maternity services in England in 1994 and remains policy. One-to-One midwifery was implemented to achieve the targets set. It was the first time such a service had been implemented in the Health Service. An evaluation was undertaken to compare its performance with conventional maternity care. METHODS: This was a prospective comparative study of women receiving One-to-One care and women receiving the system of care that One-to-One replaced (conventional care) to compare achievement of continuity of carer and clinical outcomes. The evaluation took place in The Hammersmith Hospitals NHS Trust, the Queen Charlotte's and Hammersmith Hospitals. This was part of a larger study, which included the evaluation of women's responses, cost implications, and clinical standards and staff reactions. The participants were all those receiving One-to-One midwifery practice (728 women), which was confined to two postal districts, and all women receiving care in the system that One-to-One replaced, in two adjacent postal districts (675 women), and expecting to give birth between 15 August 1994 and 14 August 1995. Main outcome measures were achievement of continuity of care, rates of interventions in labour, length of labour, maternal and infant morbidity, and breastfeeding rates. RESULTS: A high degree of continuity was achieved through the whole process of maternity care. One-to-One women saw fewer staff at each stage of their care, knew more of the staff who they did see, and had a high level of constant support in labour. One-to-One practice was associated with a significant reduction in the use of epidural anaesthesia (odds ratio (OR) 95 per cent confidence interval (CI) = 0.59 (0.44, 0.80)), with lower rates of episiotomy and perineal lacerations (OR 95 per cent CI = 0.70 (0.50, 0.98)), and with shorter second stage labour (median 40 min vs 48 min). There were no statistically significant differences in operative and assisted delivery or breastfeeding rates. CONCLUSIONS: This study confirms that One-to-One midwifery practice can provide a high degree of continuity of carer, and is associated with a reduction in the rate of a number of interventions, without compromising safety of care. It should be extended locally and replicated in other services under continuing evaluation. (+info)
Did Osler suffer from "paranoia antitherapeuticum baltimorensis"? A comparative content analysis of The Principles and Practice of Medicine and Harrison's Principles of Internal Medicine, 11th edition.
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One of the most important legacies of Sir William Osler was his textbook The Principles and Practice of Medicine. A common criticism of the book when it was first published was its deficiency in the area of therapeutics. In this article, the 1st edition of The Principles and Practice of Medicine is compared with the 11th edition of Harrison's Principles of Internal Medicine. The analysis focuses on the treatment recommendations for 4 conditions that were covered in both books (diabetes mellitus, ischemic heart disease, pneumonia and typhoid fever). Osler's textbook dealt with typhoid fever and pneumonia at greater length, whereas Harrison's placed more emphasis on diabetes mellitus and ischemic heart disease. Notwithstanding Osler's reputation as a therapeutic nihilist, the 2 books devoted equivalent space to treatment (in terms of proportion of total sentences for the conditions). For all conditions except ischemic heart disease, Osler concentrated on general measures and symptomatic care. Throughout Osler's textbook numerous negative comments are made about the medicinal treatment of various conditions. A more accurate statement about Osler's therapeutic approach was that he was a "medicinal nihilist." His demand for proof of efficacy before use of a medication remains relevant. (+info)
Decision analysis and the implementation of evidence-based medicine.
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The evidence-based medicine movement has received enthusiastic endorsement from editors of major medical journals. Hardly anyone can disagree with the aim of helping clinicians to make judicious use of the best scientific evidence for decisions in patient care. Evidence-based medicine, however, because of its dependence on randomized trials, cannot be applied to all individuals seen in daily practice. Specifically, patients may differ in age, severity of illness, presence of comorbidity and myriad of other clinical nuances. In response to these limitations, decision analysis, a technique which allows to consider multiple health outcomes, such as the patient's preferences for different states of health, and to measure the consequences of many strategies for which randomized trials are not feasible, provides a rational means of allowing health professionals to move from finding evidence to implementing it. Such formal approach may reconcile evidence-based medicine with 'real life' and patient's preference. It should therefore be considered complementary to evidence-based medicine. (+info)
Circular epidemiology.
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Circular epidemiology can be defined as the continuation of specific types of epidemiologic studies beyond the point of reasonable doubt of the true existence of an important association or the absence of such an association. Circular epidemiology is an extreme example of studies of the consistency of associations. A basic problem for epidemiology is the lack of a systematic approach to acquiring new knowledge to reach a goal of improving public health and preventive medicine. For epidemiologists, research support unfortunately is biased toward the continued study of already proven hypotheses. Circular epidemiology, however, freezes at one point in the evolution of epidemiologic studies, failing to move from descriptive to analytical case-control and longitudinal studies, for example, to experimental, clinical trials. Good epidemiology journals are filled with very well-conducted epidemiologic studies that primarily repeat the obvious or are variations on the theme. (+info)
Librarians, clinicians, evidence-based medicine, and the division of labor.
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Have librarians promoted end user searching to the detriment of the profession and promoted clinical inefficiency from causally trained health practitioners? Issues related to the complexity of bibliographic retrieval in the networked environment are explored within the context of evidence-based medicine and the division of labor. (+info)
Problem Knowledge Couplers: reengineering evidence-based medicine through interdisciplinary development, decision support, and research.
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The rapid growth of medical knowledge is creating a demand for new ways of providing information in support of evidence-based medical practice. Problem Knowledge Couplers are a clinical decision support software tool that offer a new approach to this growing problem. Couplers are developed through a collaboration among clinicians, informaticians, and librarians. They recognize that functionality must be predicated upon combining unique patient information, gleaned through relevant structured question sets, with the appropriate knowledge found in the world's peer-reviewed medical literature. Two pilot studies indicate that couplers can meet the gold standards of decision making within both a primary care and a specialty practice. Issues remain about how to best integrate Problem Knowledge Couplers into clinical practice and whether large-scale outcomes research will support the findings of pilot studies. However, Problem Knowledge Couplers represent a promising approach that might portend a new model for health care delivery in the next millennium. (+info)
Evaluating medical student searches of MEDLINE for evidence-based information: process and application of results.
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OBJECTIVE: To evaluate the adequacy of the MEDLINE instruction routinely given to all entering medical students at the University of Miami School of Medicine and the ability of students to search effectively for and retrieve evidence-based information for clinical decision making by the end of their third-year. METHODOLOGY: The authors developed and implemented a strategy for evaluating the search strategies and articles selected by third-year students, who participated in the Objective Structured Clinical Examination (OSCE) in June 1996, 1997, and 1998, and reviewed the literature on evidence-based medicine and evaluation of medical student searches. RESULTS: A mean of 5% of the students' search strategies and a mean of 26% of articles selected were ranked "excellent" or "good"; a mean of 26% of search strategies were ranked "fair" and a mean of 69% were ranked "poor"; and a mean of 22% of articles selected were ranked "fair" and a mean of 52% were ranked "poor" based on the strategy developed to evaluate student searches. CONCLUSIONS: Evaluating medical student searches for evidence-based information is an effective way of evaluating students' searching proficiency, and, in turn, the adequacy of the instruction they receive. Based on the results of the OSCE test, the school of medicine expanded the library's educational role and the library implemented major changes in the training program. Information on evidence-based medicine is now incorporated into the MEDLINE instruction. Library faculty evaluate the required searches performed by students for evidence-based information during their first and second years; 30% of students are identified for follow-up, individualized instruction based on the evaluation; and a new case-based curriculum has been proposed with a fourteen-week problem-based learning (PBL) block. These developments are timely in light of the evidence-based competencies recently published by the Association of American Medical Colleges. (+info)