Journal of Cancer Education
ISSN: 0885-8195 (Print) 1543-0154 (Online) Journal homepage: http://www.tandfonline.com/loi/hjce20
Development of critical appraisal skills in medical students: Opportunities in oncology‐related learning situations Michael P. Thirlwell MD, CM & Henry R. Shibata MD, MSc To cite this article: Michael P. Thirlwell MD, CM & Henry R. Shibata MD, MSc (1991) Development of critical appraisal skills in medical students: Opportunities in oncology‐related learning situations , Journal of Cancer Education, 6:3, 141-144 To link to this article: http://dx.doi.org/10.1080/08858199109528110
Published online: 01 Oct 2009.
Submit your article to this journal
Article views: 2
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=hjce20 Download by: [Australian Catholic University]
Date: 18 August 2017, At: 09:24
J. Cancer Education. Vol. 6 No. 3, pp. 141-144, 1991 Printed in the U.S.A. Pergamon Press pic
0885-8195/91 $3.00 + .00 © 1991 American Association for Cancer Education
• MINISYMPOSIUM ON TEACHING CLINICAL DECISION MAKING
DEVELOPMENT OF CRITICAL APPRAISAL SKILLS IN MEDICAL STUDENTS: OPPORTUNITIES IN ONCOLOGY-RELATED LEARNING SITUATIONS*
Downloaded by [Australian Catholic University] at 09:24 18 August 2017
MICHAEL
P.
THIRLWELL,
MD, CM** and HENRY R.
SHIBATA,
MD, MSc†
Abstract — Considering the increasing need for medical students to acquire critical appraisal skills, we have reviewed the curriculum at McGill as to where and how this subject is taught. It is apparent that critical evaluation is covered formally and informally in the course of the four years of medical school. However, this effort is limited by other demands on curriculum time. It could be extended by practical applications, utilizing opportunities arising in oncology-related learning situations, identifiable during periods of clinical electives, clerkship and options, and laboratory research. The elements of a core curriculum to develop critical appraisal skills and a pertinent bibliography have been identified. This information will be transmitted to oncologists supervising medical students, with the intention of eventually providing it to teachers in other specialties with the hope thereby of reaching all medical students. Concurrently, means of evaluating the method and results need to be formulated.
INTRODUCTION In current medical practice, the need for physicians to have formal skills in clinical decision making is becoming increasingly clear.1 This need relates to the large number of diagnostic and therapeutic options that have been and are being developed, and to the mounting pressures to restrict the cost of medical care. 2 ' 3 A starting point for the process of education in critical evaluation and clinical decision making is in the medical school.4 From this perspective, we noted in a recent review of the oncology curriculum at McGill University that opportunities exist for the development of critical appraisal skills. This article reviews the present status regarding the teaching of critical evaluation to medical students at McGill University and formulates a plan to utilize oncology-related-learning situations to provide this teaching. *Presented in part at the annual meeting of the American Association for Cancer Education, Cincinnati, Ohio, October 5, 1990. **Director, Division of Medical Oncology, Montreal General Hospital and Department of Oncology, McGill University, Montreal, Quebec. †Director, Division of Surgical Oncology, Royal Victoria Hospital and Chairman, Education Committee, Department of Oncology, McGill University, Montreal, Quebec. Reprint requests to: Michael P. Thirlwell, MD, CM, Montreal General Hospital, 1650 Cedar Avenue, Montreal, Quebec, Canada, H3G 1A4.
PRESENT STATUS The current situation concerning oncology teaching at McGill, as gleaned from the recent review of the curriculum, is that the teaching is dispersed throughout the four-year program and is not concentrated into any single bloc. The four years are roughly divided into three phases: 18 months of basic sciences; 12 months of "link," in which knowledge and skills are acquired in physical examination and diagnosis; and then an 18-month clinical ward experience. The last three months of the third phase entail a return to didactic teaching and tutorials, and participation in selected clinical électives (options), to consolidate and correlate previous basic science subjects to the newly gained clinical experience. In the preclinical phase, oncology topics are taught in pathology lectures and in a 21-hour clinical epidemiology course run by the Department of Epidemiology and Biostatistics of the Faculty of Medicine. It is in the latter course that biostatistics and the rudimentary elements of critical appraisal in medicine are introduced to the students. About three hours are devoted to these subjects through lectures and tutorials. Self-learning is available using the course manual and computer video programs, which include knowledge testing exercises. In the link phase, students are allowed to choose électives in clinical areas, which include surgical, radiation, and med-
141
Downloaded by [Australian Catholic University] at 09:24 18 August 2017
142
M. P. THIRLWELL and H. R. SHIBATA
ONCOLOGY-RELATED LEARNING SITUATIONS
ogy, such as the development of anti-cancer drugs and treatment protocols. In the process, they can practice their knowledge on how to evaluate results published in the literature. Fourth, students may have additional exposure to oncology and critical evaluation by engaging in laboratory research during a chosen elective or during the summer holidays, with a bursary-supported job. Because McGill University is a member of several clinical trials groups, there is often the chance for oncology clinician-teachers to consider the state of the art of investigations and treatments in various cancers and the opportunity to critically review with students the current results published in the field. These groups include the National Surgical Adjuvant Breast and Bowel Project, Cancer and Leukemia Group B, National Cancer Institute of Canada, Radiation Treatment and Oncology Group, individual pharmaceutical companies, and the combined McGill hospitals. The clinical studies cover the areas of experimental therapeutics involving phase I and phase II trials, adjuvant treatment, phase DI trials, symptom control and other issues. All the above provide opportunities from the oncology perspective to teach critical evaluation to medical students. What is crucially needed is to identify a core curriculum of material and skills that have to be learned by the students.
We can identify situations in which the students are exposed to oncology teachers and researchers, and these are primarily as follows. First, in their link phase students may choose électives in clinical oncology specialities, as noted. Second, during their clinical clerkship period, students may be assigned to clinical teaching units that have a concentration of patients with cancer. For example, at the Montreal General Hospital, there is a Medical Oncology-Hematology ward where all students spend four weeks of their eight-week medical rotation. This represents about one-third of the total number of students. During that rotation, the students manage oncology patients and attend ward rounds, lectures, and seminars. Third, during the didactic teaching and selected clinical options period of the final year, students may get the opportunity to learn more about specific areas of oncol-
PROPOSED CORE CURRICULUM In attempting to instill the basic principles of critical analysis to students, at least four core topics need to be touched upon.5 These are: the analysis of a study, the assessing of a test, the understanding of a rate and the choosing of a statistic. These topics need not be covered in great depth, and they can be brought up again later as relevant case examples or situations present. Students may then be directed to pertinent textbooks5"7 and articles8"13 to supplement and complete their knowledge base. In particular, students are directed towards using a uniform framework for approaching these topics.5 For appraising a study, key items are assignment (selection of cases), assessment (determination of results), analysis (application of
ical oncology. This can offer opportunities to observe the use of the critical evaluative process. Such occasions arise, for instance, during consultation rounds with the assigned tutor, attendance at multidisciplinary tumor board conferences, and participation in journal clubs. During their clinical clerkship, students are exposed to oncology as they manage patients and participate in ward rounding on the clinical teaching units. In the final three months referred to above, there are further hours devoted to epidemiology and other subjects. During this period, three hours are specifically devoted to issues in critical evaluation with practical exercises being a component of the learning experience. These exercises include case studies constructed to test the student's knowledge and to reinforce the key principles of critical appraisal. From the above, it is evident that there is formal teaching on critical evaluation. However, hours devoted to the subject are few, being limited by other demands on curriculum time. Furthermore, most of this instruction occurs during nonclinical periods. There is informal teaching in critical evaluation as students obtain their clinical experiences, but it is uncoordinated, spotty, and difficult to identify.
Downloaded by [Australian Catholic University] at 09:24 18 August 2017
Development of critical appraisal skills
statistics), interpretation (drawing conclusions), and extrapolation (to cases not in the study). In analyzing a test and its diagnostic discrimination it is important to be aware of the variability of the test, of the disease-free population, and of the diseased population. In this context the concepts of normal range, sensitivity and specificity, predictive value and test performance can be discussed.7 With regards to rates, it is important to understand their selection, sampling, standardization, statistical significance (p values, "type I and Type II errors, and power) and sources of differences or changes.5 This understanding is of relevance in choosing diagnostic tests, defining prognostic factors, designing studies, and analysing results. Last, the role of statistics should be covered. The two common situations in which statistical techniques are used are measuring the difference in outcome between groups and studying associations, such as two or more measurements made on the same individuals. A detailed knowledge is not expected, but the framework to be used involves understanding what questions are being asked, what choices of methods are available for answering the questions, and what the answers mean.5 Printed handouts and a bibliography can be distributed to the students. From the foregoing, we have defined what the curriculum should cover in terms of theory, and that is largely dealt with in the epidemiology teaching periods described earlier. These principles should be reinforced by practical application as students come under the tutelage of oncologists during their clinical work and, in some instances, during their laboratory work. The practical applications of critical appraisal in clinical situations should be particularly directed towards assessing diagnostic tests, prognosis, and clinical trials of therapy in cancer patients. There are myriad opportunities for the oncologist-teacher to initiate discussions of these items during the supervision of students (and housestaff) managing cancer patients. Because of the overriding importance of being able to critically evaluate clinical trials of treatment, it is worth dwelling further on this area. As a start, the key elements in setting up a clinical trial document should be noted.14 Then the basic components for appraising a published report of a clinical trial of treatment can
143
be reviewed.8 Beginning with the question being addressed by the trial, the three components to examine are: the initial state, describing the patient population; the maneuver, describing the treatment; and the subsequent state, describing the outcome events, such as survival, that will determine the usefulness of the treatment. The question is asked as to whether the study complied with méthodologie standards. These features should be assessed as they apply to the initial state (criteria for inclusion/exclusion, prognostic stratification and co-morbid conditions); the maneuver (adequate description, random allocation, contamination, co-intervention, and compliance); and the subsequent state (outcome criteria, total reporting, and statistical assessment).7'8 A printed checklist can be prepared as an aide-mémoire.
PROPOSED ACTION Thus, in our review of the current status of teaching critical appraisal to medical students we have tried to identify the extent of instruction presently occurring. There is coverage of the basic principles but so far no concerted effort to supplement and test that knowledge in clinical situations. Having identified learning opportunities in oncology-related situations, we have the potential to implement a curriculum and learning objectives for the students while exposing them to practical examples in the course of their involvement with patient care. Through the Education Committee of the Oncology Department, oncologists across the McGill system involved in teaching medical students can be informed of the existence of the curriculum and its goals and be sensitized to the need to impart and to test this knowledge in the medical students under their supervision during clinical électives, clinical clerkships, fourth-year option courses, and engagement in laboratory research. Although oncology as a specialty field seems particularly to provide many opportunities for tutors to teach critical appraisal to medical students, it is obvious that other specialties could provide similar opportunities. The same curriculum and objectives outlined above could be utilized. What is appealing about this approach
Downloaded by [Australian Catholic University] at 09:24 18 August 2017
144
M. P. THIRLWELL and H. R. SHIBATA
is that there is no demand for additional time to be taken from the main four-year curriculum. The essential element is that the" teachers be aware of the topics to be covered and the reference sources to which the students can be directed. A brief instructional course could be provided for the teachers. In this manner there is the potential to impart critical appraisal skills to all medical students during their clinical apprenticeship, preceded by lectures in their first year and followed by the supplementation and consolidation of their knowledge in the final periods in clinical epidemiology and clinical options before graduation from medical school. Needless to say, as we push along in these endeavours, we must concurrently develop means to evaluate the method and the results of our efforts. A simple beginning might be to test the knowledge and skills of the post-clerkship students with standard flaw-catching exercises (simulated articles fraught with a variety of errors5) and to correlate the results with prior exposure to oncology-related learning situations. Prospectively, to determine if theory translates into practice, a study might be made of the performance of first-year housestaff, who have had or have not had such learning experiences, in clinical situations requiring critical appraisal skills. In the current climate of economic restraints it would be useful to know if these skills result in reduced costs for patient care. Acknowledgments — The authors wish to thank Dr. D. Danoff, Associate Dean, Faculty of Medicine; Dr. T. Gyorkas, Department of Clinical Epidemiology; and Dr. J. Leclerc, Department of Medicine of McGill University, for the information they provided.
REFERENCES 1. Pauker SG: Comments by the representative of the Society Medical Decision Making. J Am Coll Cardiol
14(suppl):72A-73A, 1989. 2. Flanagin A, Lundberg GD: Clinical decision making: Promoting the jump from theory to practice. JAMA 263:279-280, 1990. 3. Eddy DM: Clinical decision making: From theory to practice. The challenge. JAMA 263:287-290, 1990. 4. Horton J, Silberberg Y: Medical school education in critical evaluation skills. J. Cancer Education 5:5, 1990. 5. Riegelman RK: Studying a Study and Testing a Test. How to Read the Medical Literature. Boston: Little, Brown and Company, 1981. 6. Sackett L, Haynes RB, Tugwell P: Clinical Epidemiology. A Basic Science for Clinical Medicine. Boston: Little, Brown and Company, 1985. 7. Boyd NF: A guide to studies of diagnostic tests, prognosis and treatment. In, Tannock IF, Hill RP (eds): The Basic Science of Oncology. New York: Pergamon Press, 1987, pp 358-373. 8. Feinstein AR: Clinical Epidemiology: The Architecture of Clinical Research. Philadelphia: W. B. Saunders, 1985. 9. Department of Clinical Epidemiology and Biostatistics, McMaster Health Sciences Center: How to read clinical journals: I. Why to read them and how to start reading them critically. Can Med Assoc J 124:555-558, 1981. 10. Department of Clinical Epidemiology and Biostatistics, McMaster Health Sciences Center: How to read clinical journals. II. To learn about a diagnostic test. Can Med Assoc J 124:703-710, 1981. 11. Department of Clinical Epidemiology and Biostatistics, McMaster Health Sciences Center: How to read clinical journals. HI. To learn about the clinical course and prognosis of disease. Can Med Assoc J 124:869-872, 1981. 12. Department of Clinical Epidemiology and Biostatistics, McMaster Health Sciences Center How to read clinical journals. IV. To determine etiology or causation. Can Med Assoc J 124:985-990, 1981. 13. Department of Clinical Epidemiology and Biostatistics, McMaster Health Sciences Center: How to read clinical journals. V. To distinguish useful from useless or even harmful therapy. Can Med Assoc J 124:11561162, 1981. 14. Simon RM: Design and Conduct of Clinical Trials. In, DeVita VT, Hellman S, Rosenberg SA (eds): Cancer. Principles and Practice of Oncology. Philadelphia: J. B. Lippincott, 1985, pp 398-419.
ISSN: 0885-8195 (Print) 1543-0154 (Online) Journal homepage: http://www.tandfonline.com/loi/hjce20
Development of critical appraisal skills in medical students: Opportunities in oncology‐related learning situations Michael P. Thirlwell MD, CM & Henry R. Shibata MD, MSc To cite this article: Michael P. Thirlwell MD, CM & Henry R. Shibata MD, MSc (1991) Development of critical appraisal skills in medical students: Opportunities in oncology‐related learning situations , Journal of Cancer Education, 6:3, 141-144 To link to this article: http://dx.doi.org/10.1080/08858199109528110
Published online: 01 Oct 2009.
Submit your article to this journal
Article views: 2
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=hjce20 Download by: [Australian Catholic University]
Date: 18 August 2017, At: 09:24
J. Cancer Education. Vol. 6 No. 3, pp. 141-144, 1991 Printed in the U.S.A. Pergamon Press pic
0885-8195/91 $3.00 + .00 © 1991 American Association for Cancer Education
• MINISYMPOSIUM ON TEACHING CLINICAL DECISION MAKING
DEVELOPMENT OF CRITICAL APPRAISAL SKILLS IN MEDICAL STUDENTS: OPPORTUNITIES IN ONCOLOGY-RELATED LEARNING SITUATIONS*
Downloaded by [Australian Catholic University] at 09:24 18 August 2017
MICHAEL
P.
THIRLWELL,
MD, CM** and HENRY R.
SHIBATA,
MD, MSc†
Abstract — Considering the increasing need for medical students to acquire critical appraisal skills, we have reviewed the curriculum at McGill as to where and how this subject is taught. It is apparent that critical evaluation is covered formally and informally in the course of the four years of medical school. However, this effort is limited by other demands on curriculum time. It could be extended by practical applications, utilizing opportunities arising in oncology-related learning situations, identifiable during periods of clinical electives, clerkship and options, and laboratory research. The elements of a core curriculum to develop critical appraisal skills and a pertinent bibliography have been identified. This information will be transmitted to oncologists supervising medical students, with the intention of eventually providing it to teachers in other specialties with the hope thereby of reaching all medical students. Concurrently, means of evaluating the method and results need to be formulated.
INTRODUCTION In current medical practice, the need for physicians to have formal skills in clinical decision making is becoming increasingly clear.1 This need relates to the large number of diagnostic and therapeutic options that have been and are being developed, and to the mounting pressures to restrict the cost of medical care. 2 ' 3 A starting point for the process of education in critical evaluation and clinical decision making is in the medical school.4 From this perspective, we noted in a recent review of the oncology curriculum at McGill University that opportunities exist for the development of critical appraisal skills. This article reviews the present status regarding the teaching of critical evaluation to medical students at McGill University and formulates a plan to utilize oncology-related-learning situations to provide this teaching. *Presented in part at the annual meeting of the American Association for Cancer Education, Cincinnati, Ohio, October 5, 1990. **Director, Division of Medical Oncology, Montreal General Hospital and Department of Oncology, McGill University, Montreal, Quebec. †Director, Division of Surgical Oncology, Royal Victoria Hospital and Chairman, Education Committee, Department of Oncology, McGill University, Montreal, Quebec. Reprint requests to: Michael P. Thirlwell, MD, CM, Montreal General Hospital, 1650 Cedar Avenue, Montreal, Quebec, Canada, H3G 1A4.
PRESENT STATUS The current situation concerning oncology teaching at McGill, as gleaned from the recent review of the curriculum, is that the teaching is dispersed throughout the four-year program and is not concentrated into any single bloc. The four years are roughly divided into three phases: 18 months of basic sciences; 12 months of "link," in which knowledge and skills are acquired in physical examination and diagnosis; and then an 18-month clinical ward experience. The last three months of the third phase entail a return to didactic teaching and tutorials, and participation in selected clinical électives (options), to consolidate and correlate previous basic science subjects to the newly gained clinical experience. In the preclinical phase, oncology topics are taught in pathology lectures and in a 21-hour clinical epidemiology course run by the Department of Epidemiology and Biostatistics of the Faculty of Medicine. It is in the latter course that biostatistics and the rudimentary elements of critical appraisal in medicine are introduced to the students. About three hours are devoted to these subjects through lectures and tutorials. Self-learning is available using the course manual and computer video programs, which include knowledge testing exercises. In the link phase, students are allowed to choose électives in clinical areas, which include surgical, radiation, and med-
141
Downloaded by [Australian Catholic University] at 09:24 18 August 2017
142
M. P. THIRLWELL and H. R. SHIBATA
ONCOLOGY-RELATED LEARNING SITUATIONS
ogy, such as the development of anti-cancer drugs and treatment protocols. In the process, they can practice their knowledge on how to evaluate results published in the literature. Fourth, students may have additional exposure to oncology and critical evaluation by engaging in laboratory research during a chosen elective or during the summer holidays, with a bursary-supported job. Because McGill University is a member of several clinical trials groups, there is often the chance for oncology clinician-teachers to consider the state of the art of investigations and treatments in various cancers and the opportunity to critically review with students the current results published in the field. These groups include the National Surgical Adjuvant Breast and Bowel Project, Cancer and Leukemia Group B, National Cancer Institute of Canada, Radiation Treatment and Oncology Group, individual pharmaceutical companies, and the combined McGill hospitals. The clinical studies cover the areas of experimental therapeutics involving phase I and phase II trials, adjuvant treatment, phase DI trials, symptom control and other issues. All the above provide opportunities from the oncology perspective to teach critical evaluation to medical students. What is crucially needed is to identify a core curriculum of material and skills that have to be learned by the students.
We can identify situations in which the students are exposed to oncology teachers and researchers, and these are primarily as follows. First, in their link phase students may choose électives in clinical oncology specialities, as noted. Second, during their clinical clerkship period, students may be assigned to clinical teaching units that have a concentration of patients with cancer. For example, at the Montreal General Hospital, there is a Medical Oncology-Hematology ward where all students spend four weeks of their eight-week medical rotation. This represents about one-third of the total number of students. During that rotation, the students manage oncology patients and attend ward rounds, lectures, and seminars. Third, during the didactic teaching and selected clinical options period of the final year, students may get the opportunity to learn more about specific areas of oncol-
PROPOSED CORE CURRICULUM In attempting to instill the basic principles of critical analysis to students, at least four core topics need to be touched upon.5 These are: the analysis of a study, the assessing of a test, the understanding of a rate and the choosing of a statistic. These topics need not be covered in great depth, and they can be brought up again later as relevant case examples or situations present. Students may then be directed to pertinent textbooks5"7 and articles8"13 to supplement and complete their knowledge base. In particular, students are directed towards using a uniform framework for approaching these topics.5 For appraising a study, key items are assignment (selection of cases), assessment (determination of results), analysis (application of
ical oncology. This can offer opportunities to observe the use of the critical evaluative process. Such occasions arise, for instance, during consultation rounds with the assigned tutor, attendance at multidisciplinary tumor board conferences, and participation in journal clubs. During their clinical clerkship, students are exposed to oncology as they manage patients and participate in ward rounding on the clinical teaching units. In the final three months referred to above, there are further hours devoted to epidemiology and other subjects. During this period, three hours are specifically devoted to issues in critical evaluation with practical exercises being a component of the learning experience. These exercises include case studies constructed to test the student's knowledge and to reinforce the key principles of critical appraisal. From the above, it is evident that there is formal teaching on critical evaluation. However, hours devoted to the subject are few, being limited by other demands on curriculum time. Furthermore, most of this instruction occurs during nonclinical periods. There is informal teaching in critical evaluation as students obtain their clinical experiences, but it is uncoordinated, spotty, and difficult to identify.
Downloaded by [Australian Catholic University] at 09:24 18 August 2017
Development of critical appraisal skills
statistics), interpretation (drawing conclusions), and extrapolation (to cases not in the study). In analyzing a test and its diagnostic discrimination it is important to be aware of the variability of the test, of the disease-free population, and of the diseased population. In this context the concepts of normal range, sensitivity and specificity, predictive value and test performance can be discussed.7 With regards to rates, it is important to understand their selection, sampling, standardization, statistical significance (p values, "type I and Type II errors, and power) and sources of differences or changes.5 This understanding is of relevance in choosing diagnostic tests, defining prognostic factors, designing studies, and analysing results. Last, the role of statistics should be covered. The two common situations in which statistical techniques are used are measuring the difference in outcome between groups and studying associations, such as two or more measurements made on the same individuals. A detailed knowledge is not expected, but the framework to be used involves understanding what questions are being asked, what choices of methods are available for answering the questions, and what the answers mean.5 Printed handouts and a bibliography can be distributed to the students. From the foregoing, we have defined what the curriculum should cover in terms of theory, and that is largely dealt with in the epidemiology teaching periods described earlier. These principles should be reinforced by practical application as students come under the tutelage of oncologists during their clinical work and, in some instances, during their laboratory work. The practical applications of critical appraisal in clinical situations should be particularly directed towards assessing diagnostic tests, prognosis, and clinical trials of therapy in cancer patients. There are myriad opportunities for the oncologist-teacher to initiate discussions of these items during the supervision of students (and housestaff) managing cancer patients. Because of the overriding importance of being able to critically evaluate clinical trials of treatment, it is worth dwelling further on this area. As a start, the key elements in setting up a clinical trial document should be noted.14 Then the basic components for appraising a published report of a clinical trial of treatment can
143
be reviewed.8 Beginning with the question being addressed by the trial, the three components to examine are: the initial state, describing the patient population; the maneuver, describing the treatment; and the subsequent state, describing the outcome events, such as survival, that will determine the usefulness of the treatment. The question is asked as to whether the study complied with méthodologie standards. These features should be assessed as they apply to the initial state (criteria for inclusion/exclusion, prognostic stratification and co-morbid conditions); the maneuver (adequate description, random allocation, contamination, co-intervention, and compliance); and the subsequent state (outcome criteria, total reporting, and statistical assessment).7'8 A printed checklist can be prepared as an aide-mémoire.
PROPOSED ACTION Thus, in our review of the current status of teaching critical appraisal to medical students we have tried to identify the extent of instruction presently occurring. There is coverage of the basic principles but so far no concerted effort to supplement and test that knowledge in clinical situations. Having identified learning opportunities in oncology-related situations, we have the potential to implement a curriculum and learning objectives for the students while exposing them to practical examples in the course of their involvement with patient care. Through the Education Committee of the Oncology Department, oncologists across the McGill system involved in teaching medical students can be informed of the existence of the curriculum and its goals and be sensitized to the need to impart and to test this knowledge in the medical students under their supervision during clinical électives, clinical clerkships, fourth-year option courses, and engagement in laboratory research. Although oncology as a specialty field seems particularly to provide many opportunities for tutors to teach critical appraisal to medical students, it is obvious that other specialties could provide similar opportunities. The same curriculum and objectives outlined above could be utilized. What is appealing about this approach
Downloaded by [Australian Catholic University] at 09:24 18 August 2017
144
M. P. THIRLWELL and H. R. SHIBATA
is that there is no demand for additional time to be taken from the main four-year curriculum. The essential element is that the" teachers be aware of the topics to be covered and the reference sources to which the students can be directed. A brief instructional course could be provided for the teachers. In this manner there is the potential to impart critical appraisal skills to all medical students during their clinical apprenticeship, preceded by lectures in their first year and followed by the supplementation and consolidation of their knowledge in the final periods in clinical epidemiology and clinical options before graduation from medical school. Needless to say, as we push along in these endeavours, we must concurrently develop means to evaluate the method and the results of our efforts. A simple beginning might be to test the knowledge and skills of the post-clerkship students with standard flaw-catching exercises (simulated articles fraught with a variety of errors5) and to correlate the results with prior exposure to oncology-related learning situations. Prospectively, to determine if theory translates into practice, a study might be made of the performance of first-year housestaff, who have had or have not had such learning experiences, in clinical situations requiring critical appraisal skills. In the current climate of economic restraints it would be useful to know if these skills result in reduced costs for patient care. Acknowledgments — The authors wish to thank Dr. D. Danoff, Associate Dean, Faculty of Medicine; Dr. T. Gyorkas, Department of Clinical Epidemiology; and Dr. J. Leclerc, Department of Medicine of McGill University, for the information they provided.
REFERENCES 1. Pauker SG: Comments by the representative of the Society Medical Decision Making. J Am Coll Cardiol
14(suppl):72A-73A, 1989. 2. Flanagin A, Lundberg GD: Clinical decision making: Promoting the jump from theory to practice. JAMA 263:279-280, 1990. 3. Eddy DM: Clinical decision making: From theory to practice. The challenge. JAMA 263:287-290, 1990. 4. Horton J, Silberberg Y: Medical school education in critical evaluation skills. J. Cancer Education 5:5, 1990. 5. Riegelman RK: Studying a Study and Testing a Test. How to Read the Medical Literature. Boston: Little, Brown and Company, 1981. 6. Sackett L, Haynes RB, Tugwell P: Clinical Epidemiology. A Basic Science for Clinical Medicine. Boston: Little, Brown and Company, 1985. 7. Boyd NF: A guide to studies of diagnostic tests, prognosis and treatment. In, Tannock IF, Hill RP (eds): The Basic Science of Oncology. New York: Pergamon Press, 1987, pp 358-373. 8. Feinstein AR: Clinical Epidemiology: The Architecture of Clinical Research. Philadelphia: W. B. Saunders, 1985. 9. Department of Clinical Epidemiology and Biostatistics, McMaster Health Sciences Center: How to read clinical journals: I. Why to read them and how to start reading them critically. Can Med Assoc J 124:555-558, 1981. 10. Department of Clinical Epidemiology and Biostatistics, McMaster Health Sciences Center: How to read clinical journals. II. To learn about a diagnostic test. Can Med Assoc J 124:703-710, 1981. 11. Department of Clinical Epidemiology and Biostatistics, McMaster Health Sciences Center: How to read clinical journals. HI. To learn about the clinical course and prognosis of disease. Can Med Assoc J 124:869-872, 1981. 12. Department of Clinical Epidemiology and Biostatistics, McMaster Health Sciences Center How to read clinical journals. IV. To determine etiology or causation. Can Med Assoc J 124:985-990, 1981. 13. Department of Clinical Epidemiology and Biostatistics, McMaster Health Sciences Center: How to read clinical journals. V. To distinguish useful from useless or even harmful therapy. Can Med Assoc J 124:11561162, 1981. 14. Simon RM: Design and Conduct of Clinical Trials. In, DeVita VT, Hellman S, Rosenberg SA (eds): Cancer. Principles and Practice of Oncology. Philadelphia: J. B. Lippincott, 1985, pp 398-419.
