Critical reading of the medical literature. Professor HP Redmond Department of Surgery NUL, Cork, Doctors and health care professionals tend to react either with frustration or guilt to the topic of critical reading or appraisal of the medical literature, The term conjures up an image of bundles of unread medical journals. The problems most often cited by anaesthetists are: “I’m too busy”, “there's too much to choose from”, “it’s all jargor/statistics/lab rats which won't improve my practice”, “there are better ways to ‘keep myself up to date ¢.g scientific meetings and workshops”, and “I don’t get CME points for reading the journals”. Although they do not all apply to one’s ability to critically appraise an individual published article, each of these represents an obstacle (real or perceived) to professional self improvement. The most informed and astute reader will not benefit from the medical literature if he or she does not have the opportunity to read or chooses to read articles that are irrelevant or of poor quality Why read the medical literature? ‘A popular concept is that we will derive information from the medical literature which will improve our practice of medicine. This, loosely, refers to evidence based medicine If this is the motivation for reading, then it is necessary to recognise the steps, other than reading, necessary to achieve the desired end result. These have been summarised by Professor David Sackett in first edition of Evidence Based Medicine 1. Convert our information needs into answerable questions. 2. Track down, with maximum efficiency, the best evidence with which to answer these questions. 3. Appraise the evidence critically, assess its validity and usefulness (clinical applicability) 4, To implement the results of this appraisal into our clinical practice. 5, To evaluate our performance. ‘Although this unit will refer only to the number 3, the effort entailed is only justified (using this paradigm) if all five steps occur. Of course, the desire to practice evidence based medicine is only one reason to read medical articles - others include the academic desire to understand a concept more clearly, the need to access existing evidence to produce a new research protocol or grant, or to participate in teaching of doctors or medical students. In each of these cases, the patient will be, presumably, the indirect beneficiary A system for reading an original article.Let us assume that, using the advice offered in Unit 6 “Searching the Medical Literature”, you have identified an original research article which addresses a question which is interesting to you and relevant to your practice. First, “scan” the article, A brief review of the length, headings, key and concluding sentences of each section is worthwhile, It will give some idea of how much time it will take to read the article carefully. It may provide enough information to suggest that, despite the title, the article will not be of interest or be accessible to you. An article entitled , “Predictors of poor outcome in septic patients” may be mainly about genetic testing, an area about which you do not know enough to understand the content. A textbook or review article will be more useful if you are entering previously uncharted ‘waters! The “scan” will also provoke questions or the need for clarification which will direct your focus during a second detailed reading. What exactly do the authors mean by poor outcome? One thousand patients were studied but the data in Table 3 refers to only 400 — what happened to the others? In general, original articles will comprise: i Atitle ii, An abstract or summary iii, A methods (and materials) section iv. — Results vy, Discussion vi References ‘Mach of the information needed to read each of these sections critically is the same as, that required to write them. This will be presented in Unit 11 and the Manuscript Preparation Workshop. What follows will provide a structure or checklist for applying this information to critical appraisal of published original articles. It refers primarily to prospective randomised clinical trials. The title will normally contain three elements : i. setting (types of patients and circumstances under which the study is performed) , ii, intervention (in prospective randomised controlled trials) or study factor, and iii. outcome measure. It can take the form ofa statement, question, clause or phrase. E.g. Effect of carbon dioxide pneumoperitoneum { intervention] on development of atlectasis [ outcome] during anaesthesia [setting]. ‘The abstract or summary should express succinctly the question addressed , the design and methods employed, the results obtained apd some interpretation of them (a conclusion). Many journals now use a structured abstract under these four headings. It is important that the results and conclusion refer to the primary objective of the study. ‘However interesting an incidental finding is, the authors are required to provide a clear answer to the principal question they have addressed (even if that answer is equivocal). Because of its brevity, an abstract may tend to select either positive findings or thosewhich are consistent with the authors’ beliefs. This may represent a form of selection bias to which both author and “abstract only” reader can fall prey. As a slightly exaggerated example Study objective. To compare propofol (3 mg/kg) and thiopentone (8 mg/kg) in terms of quality of intubating conditions achieved without muscle relaxant administration in adults undergoing elective surgery. Results: Eight of forty patients who received propofol (3 mg/kg) developed systemic hypotension (MAP < 50 mm Hg) compared to only three (of 39 patients) who received thiopentone. It was possible to intubate the tracheas of all 79 patients studied. Conclusion: Propofol (3 me/kg) administration is more likely to result in systemic hypotension than thiopentone (8 mg/kg) in adults undergoing elective surgery. Obviously the conclusion refers exclusively to an outcome other than that referred to by the authors in their objective. This does not invalidate the “unexpected” finding. But a titical reader will ask: Was this study powered to examine a difference in the incidence (or proportion of patients who exhibit) systemic hypotension? Was account taken of the potential confounding factors for hypotension when the study was designed. This may have meant excluding patients with a history of heart failure or those taking beta blockers or at least reporting these data for the two groups. Introduction. ‘A good introduction will explain what research question the investigators have addressed and why. It will also describe briefly the study design that the authors have selected to attempt to answer their question. In general, four questions which readers would instinctively ask, should be answered by the time they have finished the Introduction i, What problem is the author attempting to solve? Of course, this need not be a major clinical problem such as the occurrence of myocardial infarction after major vasular surgery. It may be the validation of a novel biomarker which can be used to study and predict myocardial ischemia, Although this does not directly benefit any patient, it is clear that it could be used to design and test clinical strategies which would. The importance of a study might be judged on the basis of its, potential for improving clinical outcome. This might be estimated (a very rough approximation) as the product of the number of patients who will eventually benefit by some measure of the magnitude of the benefit to any one of them. ii, To what extent has this problem already bekn solved? ‘This should not be a mini-review of the area under investigation. A reader should look for the establishment of the limits of our current knowledge in particular those which apply to the present investigation, Perioperative beta blockade decreases mortality in