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1.  No departure to "Pandora"? Using critical phenomenology to differentiate "naive" from "reflective" experience in psychiatry and psychosomatic medicine (A comment on Schwartz and Wiggins, 2010) 
The mind-body problem lies at the heart of the clinical practice of both psychiatry and psychosomatic medicine. In their recent publication, Schwartz and Wiggins address the question of how to understand life as central to the mind-body problem. Drawing on their own use of the phenomenological method, we propose that the mind-body problem is not resolved by a general, evocative appeal to an all encompassing life-concept, but rather falters precisely at the insurmountable difference between "natural" and a "reflective" experience built into phenomenological method itself. Drawing on the works of phenomenologically oriented thinkers, we describe life as inherently "teleological" without collapsing life with our subjective perspective, or stepping over our epistemological limits. From the phenomenology it can be demonstrated that the hypothetical teleological qualities are a reflective reconstruction modelled on human behavioural structure.
doi:10.1186/1747-5341-5-15
PMCID: PMC2984418  PMID: 21040525
2.  Multiple health behavior change: a synopsis and comment on “A review of multiple health behavior change interventions for primary prevention” 
ABSTRACT
The ninth column on Evidence-Based Behavioral Medicine is a synthesis of a recent systematic meta-review of multiple health behavior change (MHBC) interventions published by Prochaska and Prochaska in the American Journal of Lifestyle Medicine (Am J Life Med 5:208–221, 2011). Health risk behaviors are highly prevalent and increase the risk of developing and exacerbating chronic disease. The purpose of the meta-review was to examine the efficacy of MHBC interventions in a variety of populations and settings. The available literature was synthesized into three health behavior domains including energy-balance behaviors (physical activity and nutrition), addictive behaviors, and disease-related prevention. Twelve systematic reviews were identified that summarized more than 150 randomized clinical trials. Findings suggest that: (1) Physical activity and nutrition interventions are effective in producing weight loss among adults and female youth, (2) treating two addictive behaviors produces a higher long-term abstinence rate than treating a single behavior, and (3) although preventive interventions for cardiovascular disease and cancer significantly reduce health risk behaviors, reductions in disease incidence are yet to be demonstrated.
doi:10.1007/s13142-013-0200-9
PMCID: PMC3717998
Multiple risk; Behavior change; Risk behavior; Lifestyle change; Primary prevention
3.  Some Comments on Mapping from Disease-Specific to Generic Health-Related Quality-of-Life Scales 
An article by Lu et al. in this issue of Value in Health addresses the mapping of treatment or group differences in disease-specific measures (DSMs) of health-related quality of life onto differences in generic health-related quality-of-life scores, with special emphasis on how the mapping is affected by the reliability of the DSM. In the proposed mapping, a factor analytic model defines a conversion factor between the scores as the ratio of factor loadings. Hence, the mapping applies to convert true underlying scales and has desirable properties facilitating the alignment of instruments and understanding their relationship in a coherent manner. It is important to note, however, that when DSM means or differences in mean DSMs are estimated, their mapping is still of a measurement error–prone predictor, and the correct conversion coefficient is the true mapping multiplied by the reliability of the DSM in the relevant sample. In addition, the proposed strategy for estimating the factor analytic mapping in practice requires assumptions that may not hold. We discuss these assumptions and how they may be the reason we obtain disparate estimates of the mapping factor in an application of the proposed methods to groups of patients.
doi:10.1016/j.jval.2012.07.009
PMCID: PMC3658313  PMID: 23337233
cross-walk; HRQOL; mapping; reliability
4.  Consent, competency and ECT: a philosopher's comment. 
Journal of Medical Ethics  1983;9(3):144-145.
By way of comment, I suggest: 1) That the definitions of 'competence' and 'rationality' require some modification. 2) That Professor Sherlock is right to argue that a competent but irrational decision to refuse beneficial treatment ought to be overruled; but in practice it is extremely difficult to be sufficiently sure that the decision is really irrational and the treatment really will be beneficial, except when the patient's life is in danger or he is refusing basic necessities. 3) That in practice the issue is further complicated by such questions as whether there are alternative treatments, whether persuasion is possible, what the doctor's or institution's legal obligations are, and what resources are available. 4) That the presumption should be against coercion, and the patient--however irritating this may be to some doctors--should be considered 'rational until proved irrational'.
PMCID: PMC1059321  PMID: 6620318
5.  “Who writes what?” Using written comments in team-based assessment to better understand medical student performance: a mixed-methods study 
BMC Medical Education  2012;12:123.
Background
Observation of the performance of medical students in the clinical environment is a key part of assessment and learning. To date, few authors have examined written comments provided to students and considered what aspects of observed performance they represent. The aim of this study was to examine the quantity and quality of written comments provided to medical students by different assessors using a team-based model of assessment, and to determine the aspects of medical student performance on which different assessors provide comments.
Methods
Medical students on a 7-week General Surgery & Anesthesiology clerkship received written comments on ‘Areas of Excellence’ and ‘Areas for Improvement’ from physicians, residents, nurses, patients, peers and administrators. Mixed-methods were used to analyze the quality and quantity of comments provided and to generate a conceptual framework of observed student performance.
Results
1,068 assessors and 127 peers provided 2,988 written comments for 127 students, a median of 188 words per student divided into 26 “Areas of Excellence” and 5 “Areas for Improvement”. Physicians provided the most comments (918), followed by patients (692) and peers (586); administrators provided the fewest (91). The conceptual framework generated contained four major domains: ‘Student as Physician-in-Training’, ‘Student as Learner’, ‘Student as Team Member’, and ‘Student as Person.’
Conclusions
A wide range of observed medical student performance is recorded in written comments provided by members of the surgical healthcare team. Different groups of assessors provide comments on different aspects of student performance, suggesting that comments provided from a single viewpoint may potentially under-represent or overlook some areas of student performance. We hope that the framework presented here can serve as a basis to better understand what medical students do every day, and how they are perceived by those with whom they work.
doi:10.1186/1472-6920-12-123
PMCID: PMC3558404  PMID: 23249445
Written comments; Undergraduate; Assessment; Medical students; Clerkship; Mixed-methods; Qualitative; Clinical performance; Team
6.  Comment: Applications of robotics in the clinical laboratory 
The implementation of a robotic workstation in the clinical laboratory involves considerations and compromises common to any instrument design and development activity. The trade-off between speed and flexibility not only affects the way the instrument interacts with human operators and other devices (the ‘real-world interface’), but also places limitations on the adaptation of chemistries to the given instrument. Mechanical optimization for speed and reproducibility places restrictions on the imprecision of consumables. Attempts to adapt a robot to a constrained system may entail compromises that either degrades the theoretically-attainable quality of results, or requires human interaction to compensate for physical or mechanical limitations. The general considerations of function and workflow, programming and support, and reliability place practical limits on the implementation of robotic workstations in the clinical laboratory.
doi:10.1155/S1463924690000177
PMCID: PMC2547824  PMID: 18925267
7.  Comment: On the consequences of sexual selection for fisheries-induced evolution 
Evolutionary Applications  2008;1(4):645-649.
It is becoming increasingly recognized that fishing (and other forms of nonrandom harvesting) can have profound evolutionary consequences for life history traits. A recent and welcome publication provided the first description of how sexual selection might influence the outcome of fisheries-induced evolution (FIE). One of the main conclusions was that if sexual selection generates a positive relationship between body size and reproductive success, increased fishing pressure on large individuals causes stronger selection for smaller body size. Here, we re-evaluate the sexual selection interpretation of the relationship between body size and reproductive success, and suggest it may in fact be representative of a more general case of pure natural selection. The consequences of sexual selection on FIE are likely to be complicated and dynamic, and we provide additional perspectives to these new and exciting results. Selection differentials and trait variance are considered, with density-dependent and genetic effects on the strength and the direction of sexual selection given particular attention. We hope that our additional views on the role of sexual selection in FIE will encourage more theoretical and empirical work into this important application of evolutionary biology.
doi:10.1111/j.1752-4571.2008.00041.x
PMCID: PMC3352389
conservation; fisheries-induced evolution; natural selection; selection differentials; sexual selection
8.  Why pharmacokinetic differences among oral triptans have little clinical importance: a comment 
Triptans, selective 5-HT1B/1D receptor agonists, are specific drugs for the acute treatment of migraine that have the same mechanism of action. Here, it is discussed why the differences among kinetic parameters of oral triptans have proved not to be very important in clinical practice. There are three main reasons: (1) the differences among the kinetic parameters of oral triptans are smaller than what appears from their average values; (2) there is a large inter-subject, gender-dependent, and intra-subject (outside/during the attack) variability of kinetic parameters related to the rate and extent of absorption, i.e., those which are considered as critical for the response; (3) no dose-concentration–response curves have been defined and it is, therefore, impossible both to compare the kinetics of triptans, and to verify the objective importance of kinetic differences; (4) the importance of kinetic differences is outweighed by non-kinetic factors of variability of response to triptans. If no oral formulations are found that can allow more predictable pharmacokinetics, the same problems will probably also arise with new classes of drugs for the acute treatment of migraine.
doi:10.1007/s10194-010-0258-4
PMCID: PMC3072488  PMID: 20878535
Acute treatment; Disposition; Headache; Pharmacokinetics; Triptan; Variability
9.  Why pharmacokinetic differences among oral triptans have little clinical importance: a comment 
Triptans, selective 5-HT1B/1D receptor agonists, are specific drugs for the acute treatment of migraine that have the same mechanism of action. Here, it is discussed why the differences among kinetic parameters of oral triptans have proved not to be very important in clinical practice. There are three main reasons: (1) the differences among the kinetic parameters of oral triptans are smaller than what appears from their average values; (2) there is a large inter-subject, gender-dependent, and intra-subject (outside/during the attack) variability of kinetic parameters related to the rate and extent of absorption, i.e., those which are considered as critical for the response; (3) no dose-concentration–response curves have been defined and it is, therefore, impossible both to compare the kinetics of triptans, and to verify the objective importance of kinetic differences; (4) the importance of kinetic differences is outweighed by non-kinetic factors of variability of response to triptans. If no oral formulations are found that can allow more predictable pharmacokinetics, the same problems will probably also arise with new classes of drugs for the acute treatment of migraine.
doi:10.1007/s10194-010-0258-4
PMCID: PMC3072488  PMID: 20878535
Acute treatment; Disposition; Headache; Pharmacokinetics; Triptan; Variability
10.  Paucilymphoid non-keratinizing nasopharyngeal carcinoma with prominent stromal desmoplasia – an unusual case reported with brief comments on uncommon histological variants 
We present a case of de novo non-keratinizing carcinoma of the nasopharynx (NK-NPC) with an unusual combination of histological features; (1) a minimal associated component of reactive lymphoplasmacytic cells and (2) a prominent desmoplastic stromal response. Apart from the unusual histologic features, this case did not display any unusual clinical or radiological features. On immunohistochemistry the tumor cells were strongly positive for cy-tokeratins (AE1-3 and 5/6) and p63 and there was strong and diffuse nuclear positivity for EBV on in situ hybridization. Since no external factor could be attributed to the conspicuous paucity of associated lymphoid cells, we feel that this may be due to inherent features of the neoplasm itself. This case highlights the histomorphological variability of NK-NPC. Awareness of the histological spectrum of NK-NPC is important in clinical practice and this is not always adequately highlighted in currently used standard textbooks of head and neck pathology.
PMCID: PMC3093065  PMID: 21577326
Nasopharynx; carcinoma; fibrosis; fibroplasia; desmoplasia
11.  Is Depression “Evolutionary” or Just “Adaptive”? A Comment 
Some recent explanations of depression have suggested that it may be “evolutionary” in that there are advantages to the depressed individual which arise from some aspects of depressive symptomatology. While the depressive behaviour of withdrawal from the adverse environment may provide some immediate benefits to the depressed individual, thus making it potentially “adaptive” in the short-term, this does not fit the biological definition of “evolutionary”. In fact, depression does not meet two of the three required criteria from natural selection in order to be evolutionary. Therefore, while some depressive behaviour may be advantageous for the depressed individual, and is therefore “adaptive” in an immediate sense, it cannot be accurately described as “evolutionary”. Implications for research and clinical practice are discussed.
doi:10.1155/2010/631502
PMCID: PMC2989690  PMID: 21152220
12.  Measuring Addiction Propensity and Severity: The Need for a New Instrument 
Drug and alcohol dependence  2010;111(1-2):4-12.
Drug addiction research requires but lacks a valid and reliable way to measure both the risk (propensity) to develop addiction and the severity of manifest addiction. This paper argues for a new measurement approach and instrument to quantify propensity to and severity of addiction, based on the testable assumption that these constructs can be mapped onto the same dimension of liability to addiction. The case for this new direction becomes clear from a critical review of empirical data and the current instrumentation. The many assessment instruments in use today have proven utility, reliability, and validity, but they are of limited use for evaluating individual differences in propensity and severity. The conceptual and methodological shortcomings of instruments currently used in research and clinical practice can be overcome through the use of new technologies to develop a reliable, valid, and standardized assessment instrument(s) to measure and distinguish individual variations in expression of the underlying latent trait(s) that comprises propensity to and severity of drug addiction. Such instrumentation would enhance our capacity for drug addiction research on linkages and interactions among familial, genetic, psychosocial, and neurobiological factors associated with variations in propensity and severity. It would lead to new opportunities in substance abuse prevention, treatment, and services research, as well as in interventions and implementation science for drug addiction.
doi:10.1016/j.drugalcdep.2010.03.011
PMCID: PMC2930133  PMID: 20462706
tobacco; cannabis assessment; individual differences; adolescents
13.  Comparison Between Family Function Dimensions and Quality of Life Among Amphetamine Addicts and Non- Addicts 
Background
One of the most important factors in drug abuse and drug avoidance is family and its function.
Objectives
This study aimed to compare family function and quality of life dimensions among Amphetamine addicts and non-addicts.
Materials and Methods
The current study is a case-control, which assessed 95 Iranian addicts and 95 non-addicts. Sampling method in the addicts group was random clustering. The non-addicts were selected from accompanied addicts in other centers with respect to the demographic characteristics. The instruments were Family Assessment and Quality of Life (SF-36) scales. SPSS software version 11.5 was used for statistical analysis and Pearson’s correlation coefficient, stepwise regression analysis, and independent samples t-test were conducted.
Results
The study revealed that some disorders in family function dimensions were higher in the addicts compared to non-addicts. Addicts have a quality of life lower than non-addicts (P < 0.05). There was a relationship between different dimensions of family function and the quality of life in both the addicts and non-addicts (P < 0.05). Regression analysis showed that roles dimensions and family function could roughly account for 17% of the changes in the addicts’ quality of life while in the non-addicts, behavioral control dimension of family function could account for roughly 17% of the changes in their quality of life.
Conclusions
Regarding the study findings, there was a significant difference between family function dimensions and quality of life among addicts and non-addicts.
doi:10.5812/ircmj.9947
PMCID: PMC3785914  PMID: 24083013
Employee Performance Appraisal; Quality of Life; Behavior, Addictive; Amphetamine
14.  ‘I saved a life’: a heroin addict's reflections on managing an overdose using ‘take home naloxone’ 
BMJ Case Reports  2010;2010:bcr0520102986.
Research shows that most heroin addicts, at some point in their drug using careers, accidentally overdose and that accidental overdose is the most common cause of death in this group. As most such overdoses are witnessed by other drug users or their carers, it is argued that providing ‘take home naloxone’ (a fast-acting opiate antagonist) to them (as potential witnesses to an overdose) can save lives. Despite the robust evidence base to support the feasibility and effectiveness of this strategy, its integration into clinical practice in the UK is still very limited. Here, we report the case of a heroin addict who used his take home naloxone to manage an overdose and thereby saved a life.
Through this account, we hope to raise clinicians’ awareness of this simple yet life-saving intervention. We will also briefly discuss the evidence base for take home naloxone with particular reference to the UK and will also give some practical guidance to clinicians on prescribing take home naloxone.
doi:10.1136/bcr.05.2010.2986
PMCID: PMC3027358  PMID: 22778195
15.  Withdrawal of inhaled corticosteroids in individuals with COPD - a systematic review and comment on trial methodology 
Respiratory Research  2011;12(1):107.
Inhaled corticosteroids (ICS) reduce COPD exacerbation frequency and slow decline in health related quality of life but have little effect on lung function, do not reduce mortality, and increase the risk of pneumonia. We systematically reviewed trials in which ICS have been withdrawn from patients with COPD, with the aim of determining the effect of withdrawal, understanding the differing results between trials, and making recommendations for improving methodology in future trials where medication is withdrawn. Trials were identified by two independent reviewers using MEDLINE, EMBASE and CINAHL, citations of identified studies were checked, and experts contacted to identify further studies. Data extraction was completed independently by two reviewers. The methodological quality of each trial was determined by assessing possible sources of systematic bias as recommended by the Cochrane collaboration. We included four trials; the quality of three was adequate. In all trials, outcomes were generally worse for patients who had had ICS withdrawn, but differences between outcomes for these patients and patients who continued with medication were mostly small and not statistically significant. Due to data paucity we performed only one meta-analysis; this indicated that patients who had had medication withdrawn were 1.11 (95% CI 0.84 to 1.46) times more likely to have an exacerbation in the following year, but the definition of exacerbations was not consistent between the three trials, and the impact of withdrawal was smaller in recent trials which were also trials conducted under conditions that reflected routine practice. There is no evidence from this review that withdrawing ICS in routine practice results in important deterioration in patient outcomes. Furthermore, the extent of increase in exacerbations depends on the way exacerbations are defined and managed and may depend on the use of other medication. In trials where medication is withdrawn, investigators should report other medication use, definitions of exacerbations and management of patients clearly. Intention to treat analyses should be used and interpreted appropriately.
doi:10.1186/1465-9921-12-107
PMCID: PMC3185272  PMID: 21838890
16.  Quality care process in the VA: a synopsis and comment on “Comparison of the quality of medical care in veterans affairs and non-veterans affairs settings” 
ABSTRACT
The fourth column on Evidence-Based Behavioral Medicine presents a synopsis of the systematic review by Trivedi et al. (2011) comparing the quality of medical care in veterans affairs (VA) and non-VA settings. Thirty-six studies were included in the synthesis. Each article was given a grade of A, B, or C based on the six elements of high-quality studies. Most studies assessing adherence to recommended processes of care showed that the VA performed better that non-VA sites. Similar rates were found for both groups in studies that assessed risk-adjusted mortality. This implies that a greater adherence to evidence-based processes (e.g., preventive care, medication prescription, and referral) did not result in decreased morbidity and mortality. It is established that engaging in evidence-based practices and processes improves short-term intermediate endpoints (e.g., patient satisfaction). Future research is needed to test whether short-term benefits of evidence-based care processes connect to mortality outcomes.
doi:10.1007/s13142-011-0087-2
PMCID: PMC3717672  PMID: 24073072
Evidence-based practice; Care processes; Quality of care; Outcomes; Research-to-practice translation
17.  GP recruitment and retention: a qualitative analysis of doctors' comments about training for and working in general practice. 
BACKGROUND AND AIMS: General practice in the UK is experiencing difficulty with medical staff recruitment and retention, with reduced numbers choosing careers in general practice or entering principalships, and increases in less-than-full-time working, career breaks, early retirement and locum employment. Information is scarce about the reasons for these changes and factors that could increase recruitment and retention. The UK Medical Careers Research Group (UKMCRG) regularly surveys cohorts of UK medical graduates to determine their career choices and progression. We also invite written comments from respondents about their careers and the factors that influence them. Most respondents report high levels of job satisfaction. A noteworthy minority, however, make critical comments about general practice. Although their views may not represent those of all general practitioners (GPs), they nonetheless indicate a range of concerns that deserve to be understood. This paper reports on respondents' comments about general practice. ANALYSIS OF DOCTORS' COMMENTS: Training Greater exposure to general practice at undergraduate level could help to promote general practice careers and better inform career decisions. Postgraduate general practice training in hospital-based posts was seen as poor quality, irrelevant and run as if it were of secondary importance to service commitments. In contrast, general practice-based postgraduate training was widely praised for good formal teaching that met educational needs. The quality of vocational training was dependent upon the skills and enthusiasm of individual trainers. Recruitment problems Perceived deterrents to choosing general practice were its portrayal, by some hospital-based teachers, as a second class career compared to hospital medicine, and a perception of low morale amongst current GPs. The choice of a career in general practice was commonly made for lifestyle reasons rather than professional aspirations. Some GPs had encountered difficulties in obtaining posts in general practice suited to their needs, while others perceived discrimination. Newly qualified GPs often sought work as non-principals because they felt too inexperienced for partnership or because their domestic situation prevented them from settling in a particular area. Changes to general practice The 1990 National Health Service (NHS) reforms were largely viewed unfavourably, partly because they had led to a substantial increase in GPs' workloads that was compounded by growing public expectations, and partly because the two-tier system of fund-holding was considered unfair. Fund-holding and, more recently, GP commissioning threatened the GP's role as patient advocate by shifting the responsibility for rationing of health care from government to GPs. Some concerns were also expressed about the introduction of primary care groups (PCGs) and trusts (PCTs). Together, increased workload and the continual process of change had, for some, resulted in work-related stress, low morale, reduced job satisfaction and quality of life. These problems had been partially alleviated by the formation of GP co-operatives. Retention difficulties Loss of GPs' time from the NHS workforce occurs in four ways: reduced working hours, temporary career breaks, leaving the NHS to work elsewhere and early retirement. Child rearing and a desire to pursue interests outside medicine were cited as reasons for seeking shorter working hours or career breaks. A desire to reduce pressure of work was a common reason for seeking shorter working hours, taking career breaks, early retirement or leaving NHS general practice. Other reasons for leaving NHS general practice, temporarily or permanently, were difficulty in finding a GP post suited to individual needs and a desire to work abroad. CONCLUSIONS: A cultural change amongst medical educationalists is needed to promote general practice as a career choice that is equally attractive as hospital practice. The introduction of Pre-Registration House Officer (PRHO) placements in general practice and improved flexibility of GP vocational training schemes, together with plans to improve the quality of Senior House Officer (SHO) training in the future, are welcome developments and should address some of the concerns about poor quality GP training raised by our respondents. The reluctance of newly qualified GPs to enter principalships, and the increasing demand from experienced GPs for less-than-full-time work, indicates a need for a greater variety of contractual arrangements to reflect doctors' desires for more flexible patterns of working in general practice.
PMCID: PMC2560447  PMID: 12049026
18.  From knowing to doing—from the academy to practice Comment on “The many meanings of evidence: implications for the translational science agenda in healthcare”  
In this commentary, the idea of closing the gap between knowing and doing through closing the gap between academics and practitioners is explored. The two communities approach to knowledge production and use, has predominated within healthcare, resulting in a separation between the worlds of research and practice, and, therefore, between its producers and users. Meaningful collaborations between the producers and users of research could in theory, create the conditions for more situated knowledge production and use, and result in a potential reduction in the evidence-practice divide within a health service context.
doi:10.15171/ijhpm.2014.08
PMCID: PMC3937942  PMID: 24596897
Knowledge Translation; Co-Production; Implementation; Evidence-Based Healthcare
19.  Making Sense of Intimate Partner Violence in Late Life: Comments From Online News Readers 
The Gerontologist  2012;52(6):792-801.
Purpose:
The purpose of this study was to gain insight into public awareness of intimate partner violence (IPV) in late life by how individuals respond to incidents of IPV reported in the newspaper.
Design and Methods:
Using grounded theory techniques, online news items covering 24 incidents of IPV in late life, and the reader comments posted to them were analyzed. The news items were examined for incident details, story framing, and reporting style. An open coding process (Charmaz, K. [2006]. Constructing grounded theory: A practical guide through qualitative analysis. Thousand Oaks, CA: Sage Publications.) was used to generate a comprehensive understanding of themes and patterns in the comments posted by readers.
Results:
Few posters indicated that incidents were episodes of IPV. As many posters struggled to make sense of incidents, they attempted to remove guilt from the perpetrator by assigning blame elsewhere. Comments were influenced by personal assumptions and perspectives about IPV, relationships, and old age; reporting style of the news items; and comments posted by other posters.
Implications:
Altering public views of IPV in late life requires raising awareness through education, reframing the ways in which information is presented, and placing greater emphasis on the context of the violence. By engaging interactive news media, reporters, participatory journalists, and policymakers can enhance public recognition and understanding of IPV in late life.
doi:10.1093/geront/gns046
PMCID: PMC3495909  PMID: 22547086
Domestic violence; Spousal abuse; News media; Participatory journalism
20.  Can continuous quality improvement be assessed using randomized trials? [see comment] 
Health Services Research  2000;35(3):687-700.
STUDY QUESTION: Continuous quality improvement (CQI) has been implemented at least to some degree in many health care settings, yet randomized controlled trials (RCTs) of CQI are rare. We ask whether, when, and how RCTs of CQI might be designed. STUDY DESIGN: We consider two applications of CQI: as a general philosophy of management and (by analogy with the use of conceptual models from the behavioral sciences) as a conceptual model for developing specific interventions. The example of warfarin therapy for stroke prevention among patients with atrial fibrillation is used throughout. PRINCIPAL FINDINGS: While it is impractical to use RCTs to study CQI as a general management philosophy, RCT methodology is appropriate for studying CQI as a conceptual model for generating interventions. RCTs of CQI might be considered when the process change under consideration is very large, its implications (e.g., in terms of cost, outcomes of care, etc.) are very great, and the best approach is uncertain. When designing RCTs of CQI, critical decisions include (1) the unit of randomization; (2) whether the focus is on CQI as a method for generating interventions or, instead, is on specific interventions in and of themselves; and (3) the flexibility available to local personnel to modify the intervention's operational details. CONCLUSIONS: RCTs of CQI as a conceptual model for generating interventions are feasible.
PMCID: PMC1089142  PMID: 10966090
21.  The impact of team science collaborations in health care: a synopsis and comment on “Interprofessional collaboration: effects of practice-based interventions on professional practice and healthcare outcomes” 
ABSTRACT
The eighth column on evidence-based behavioral medicine is a synthesis of the study of Zwarenstein et al. (1). which examines the effects of practice-based interventions to improve interprofessional collaboration. Poor interprofessional collaboration may have deleterious effects on quality of care. The purpose of the systematic review was to investigate whether interventions aimed at improving interprofessional collaboration affect patient satisfaction and/or the effectiveness and efficiency of care. Five randomized controlled trials were reviewed, examining studies that differed across setting, interventions, and outcomes. Of the five studies reviewed, three showed improvements in patient care, one found no effect, and one had mixed findings. Findings indicate that interventions aimed at improving interprofessional care may improve outcomes, but interpretation of these findings is limited due to the small sample size and heterogeneity across studies reviewed.
doi:10.1007/s13142-012-0169-9
PMCID: PMC3717942  PMID: 24073139
Team science; Interprofessional collaboration; Practice-based Interventions
22.  Comment: ‘The Problem Surgical Colleague’ 
The review of ‘The problem surgical colleague’ by Mr John Mosley is both timely and relevant. All surgeons are naturally concerned about the mechanisms in place, both locally and through the General Medical Council (GMC) to deal with fitness-to-practise issues. It is inevitable that criticisms, often unfounded, are voiced by the profession. Most surgeons welcome a fair and transparent system to deal with such matters whilst maintaining the principle of self-regulation. We must accept that there are a small number of surgeons whose practice is impaired to such a degree that they represent a serious patient-safety risk and they must be dealt with appropriately.
As a GMC medical case examiner since 2003, and having dealt with over 600 fitness-to-practise cases, I wish to comment on some of the important issues raised by Mr Mosley, specifically in relation to the surgeon and his or her practice. In doing so, I will set out the investigative process to be followed when fitness-to-practise concerns are brought to the attention of the GMC.
doi:10.1308/003588407X202191
PMCID: PMC2048590
23.  Responses to Comments of Weis 
A response to Weis and Pasipanodya 'Measuring health-related quality of life in tuberculosis: a systemic review - Response'.
doi:10.1186/1477-7525-8-6
PMCID: PMC2821369  PMID: 20074383
24.  Ignorance isn’t biased: Comments on receiving the Pioneer Award 
Cleveland Clinic journal of medicine  2009;76(Suppl 2):S31-S36.
Researchers ordinarily work by deriving testable hypotheses from theories using a deductive process. Hypothesis testing is inherently biased, however, because of the practical requirements of finding and publishing positive results. In contrast, ignorance isn’t biased. The combination of relevant new technology, sufficient mastery of the topic to know what is not yet known, and access to patients with rare but informative disorders sets the stage for discoveries about disease mechanisms based on induction from observations. Patient-oriented research is a strength of heart-brain medicine. Patients are a unique scientific resource because they tell us the truth. We experience the joy and thrill of a “sparkle of insight” when we realize what they teach.
doi:10.3949/ccjm.76.s2.07
PMCID: PMC2956407  PMID: 19376979
25.  Expert committee to formulate policy and guidelines for approval of new drugs, clinical trials and banning of drugs-comments 
All is not well with the clinical research industry. Instances of scientific misconduct by investigators, cutting corners by sponsors, irregularities by regulators, have brought a bad name to the industry. These however form a small part of the clinical research done in this country. The US FDA has conducted over 40 audits, and not made any major observations, suggesting that the clinical research in India is by and large above board. Regulators have amended trial rules recently which have cost the industry dear. A committee appointed to formulate the policy and guidelines for approval of new drugs, clinical trials and banning of the drugs has made 25 recommendations of which most are either superfluous or not likely produce the desired effect. Clubbing banning of the drugs with approval of new drugs and clinical trials also does not make sense, since the mechanisms involved are totally different. Barring a few, most recommendations are counterproductive and should be rejected outright. It is time we learnt that appointment of a committee is not the best way to solve a problem.
doi:10.4103/2229-3485.134304
PMCID: PMC4073545  PMID: 24987579
Clinical research; drug development; guidelines; policies; regulations

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