Uncertainty and information management
At graduation, the student should be able to:
- a) describe the importance of evidence based medical practice
- b) demonstrate an understanding of the need to be able to critically appraise evidence
- c) appraise information from patients and other subjective sources critically, and record in a way that allows the information to be retrieved and communicated effectively for optimal management
- d) critically appraise the available information guiding the management of common cancers and be able to distinguish different levels of evidence
- e) locate published high quality evidence and guidelines for practitioners and patients using electronic literature searches, both locally and from overseas
- f) adapt and apply information to the management of individual cases and to the formulation of management options in the absence of definitive information (tolerating uncertainty)
- g) demonstrate an understanding of clinical trials and their importance; explain their value to patients and encourage patients to participate in trials
- h) describe basic elements of clinical trials, cohort studies and case control studies
- i) appraise studies of treatment, prevention, diagnosis, prognosis, causation and harm, systematic reviews, clinical practice guidelines and cost-effectiveness studies
- j) demonstrate an understanding of the limits of evidence, its broad application and its advancement over time
- k) discuss unproven or alternative/complementary cancer therapies in a way that encourages patients to appraise their claimed benefits and their costs in a critical manner.
- Basic understanding of clinical epidemiology.
- Ability to describe and utilise clinical epidemiological terms such as sensitivity and specificity
- Understanding of processes of critical appraisal
- Ability to locate available evidence based medicine and guideline information by manual and electronic literature searches, including the internet and Cochrane collaboration databases
- Ability to describe basic elements of research methods: randomised control trials; cohort and case control studies
- Understanding the relative value of evidence provided by such different research methods and how they are quantified
- Understanding the role of qualitative research findings in guiding clinical decision making
- Understanding the principles of evidence based medicine and levels of evidence
- Understanding the strengths and weaknesses of different study designs
Representative questions that suggest the required depth of knowledge
1. Mr Cathari, a 58 year old man with metastatic colon cancer, visits you in your general practice. He has some mild lethargy but is otherwise well. He wants advice about alternative/complementary treatments for his cancer. What do you tell him?
Essential in answer:
- Concept of unproven as opposed to alternative therapy
- Critical appraisal of cost benefits
- Knowledge of guidelines
2. A patient who has breast cancer comes to you with some information on breast cancer from the internet. She is very worried and has a lot of difficulty knowing what to believe. What do you tell her about retrieving useful information from the internet?
Essential in answer:
- Critical appraisal
- Knowledge of useful websites
- Encouragement of use of well written evidence based literature in addition to web-based information
- Awareness of other sources of information such as breast cancer support services and the Australasian Lymphology Association
3. “Clinical practice guidelines are a waste of time” – discuss.
Essential in answer:
- Levels of evidence
- Variation in practice
- Limits to knowledge
- Individualising care
4. A randomised phase III was performed between drug X and Docetaxel as second line therapy for metastatic non-small cell lung cancer. Fifty patients were randomised to each arm and when comparing objective response rates no significant difference was found between the two arms p>0.05. Discuss the possible meanings of this result.
Essential in answer: The numbers may not provide sufficient power to detect a clinically meaningful difference so it is not necessarily a negative study, but an indeterminate result. Is objective response rate the best endpoint in this situation?