Critical Appraisal Turkey Shoot: Linking Critical Appraisal to Clinical Decision Making

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Since the publication of Physicians for the Twenty-First Century — “the GPEP Report” of 1984, medical educators have identified the need for physicians to become lifelong learners.1 Part of the impetus for this conclusion arises from several studies that have demonstrated that knowledge and/or competence of physicians decline as a function of time since graduation; the evidence indicates the cause to be failure to acquire new knowledge rather than a tendency to forget previously learned material.2 Thus, physicians need to be trained to identify the relevant medical literature (i.e., information-seeking skills) and to apply “critical appraisal” techniques to analyze potentially useful articles culled from the literature search.There is little published evidence that educational interventions around critical appraisal teaching in undergraduate or postgraduate medical curricula impact in a sustained way the knowledge of epidemiologic principles or the critical application of current research information for clinical decision making.3 In considering the impact on conceptual knowledge, one could argue that there is a lack of validated tools available for evaluating critical appraisal skills; alternatively, the format of instruction, timing in the curriculum, and duration of instruction may be at fault. More important, studies have not addressed the issue of whether the demonstration of mastery of particular critical appraisal skills can be related to clinical decision making. Ultimately, such mastery becomes largely irrelevant if it does not translate into better judgment.The authors of this study were concerned that, despite the inclusion in the first-year undergraduate curriculum of several focused objectives surrounding critical appraisal in the domain of clinical epidemiology, feedback from clinical faculty suggested that students had only rudimentary knowledge of the application of these principles at the end of the first year. In contrast to this feedback, problem-based learning (PBL) is believed to hold the potential to equip graduates with the skills to learn after graduation. In fact, several studies have shown significant differences between students of PBL and students of conventional curricula in the use of recently published medical literature.4,5,6 With this inconsistency in mind, two experimental questions were asked.Are critical appraisal concepts to which students are “exposed” in PBL in earlier curricular blocks retained sufficiently to allow identification of methodologic errors in formal articles?Does awareness of such methodologic flaws transfer to an appreciation of how these errors might invalidate the conclusions of the journal articles' authors?Ergo, the goal of this study was to investigate the relationship between understanding the concepts of critical appraisal and their application in clinical decision making. Understanding this relationship can potentially improve the teaching of critical appraisal and the evaluation of this teaching.MethodsParticipants. This was a single-blinded experimental design study. The participant pool was composed of two consecutive first-year undergraduate medical school classes (the graduating classes of 1999 and 2000, respectively) in a PBL curriculum at McMaster University. Each class was composed of 18 tutorial groups of five to six students each. The students had some background in critical appraisal, as it had been studied in a readily identifiable manner during the first curricular unit at the beginning of the first academic year. For each class, the study took place during the third curricular unit running during the final three months of their first academic year.Materials. The subunit planners for each month-long subunit in that third curricular unit selected two journal articles from their respective expert domains of gastroenterology, hematology, and endocrinology. These context experts chose articles that met the defined criteria of being (a) methodologically sound and (b) not directly covered within the context of the unit's curricular problems.

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