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Evidence-Based Mental Health: Yale Psychiatry Residency Program: 6. Keeping Up in Psychiatry

Resources for the Evidence-Based Mental Health Curriculum Yale Psychiatry residency program

Acknowledgement

"Keeping up in Psychiatry" content and handout created by Vinod Srihari. update May 3, 2024

Keeping up in Psychiatry: Accessing evidence from the clinical research literature for application at the bedside

‘The job of the human being [in the digital age] is to become skilled at locating relevant valid data for their needs. In the sphere of medicine, the required skill is to be able to relate the knowledge generated by the study of groups of patients or populations to that lonely and anxious individual who has come to seek help’  (Muir Gray, 2001)

The Problem: Usefulness of medical information = (Relevance) (Validity) (Size of effect)  / Work to find 
-Slawson and Shaughnessy , 2005

  • Large volume of clinical literature >> 2000 new entries into MEDLINE / day
  • Unclear relevance - <10% in core medical journals is of both high quality and relevance for practice
  • Opaque databases (MEDLINE, Embase, PsycInfo are not organized for ease of clinical use)

Figure 1. Continuous Professional Development: Channeling Sisyphus!

Keeping up in Psychiatry image

Solutions or strategies for keeping up in the real world:

  1. Browsing or foraging (‘Just in case’ learning):  Standard sources are colleagues, textbooks, traditional reviews, journals of interest.  Also, consider supplementing/refining this with:
    1. Browsing ‘secondary’ sources: (e.g. EBM Verdict;  BMJ Rapid Recommendations)  
    2. Signing up for e-mail (and high quality) alerting services such as EvidenceAlerts which is based on an explicit, evidence-savvy scanning service
    3. Signing up to be a MORE (McMaster Online Rating of Evidence) sentinel reader in your area of expertise
    4. Sign up for e-Table of Contents for journals of highest relevance to your clinical practice, or use an aggregator like feedly to cover several journals.
    5. NEJM Watch offers brief, expert driven summaries that include a mix of clinically applicable articles and research that is not-yet ready for application.
  1. Problem-solving or hunting (‘Just in time’ learning): 
    1. Do you need Background Knowledge (‘what are the signs and symptoms of major depression?’) or Foreground Knowledge (‘in adults with severe MDD refractory to SSRI treatment what is the efficacy of an MAO-Is vs. a TCA in producing remission over at least 6 months of follow-up?’)?
    2. For Background questions, consult a supervisor, textbook or review article.
    3. For Foreground questions, consider whether you are asking about Prevalence, Etiology/Harm, Prognosis or Treatment. This will inform the kind of study design to look for.
    4. For Treatment questions, consider secondary/processed sources (e.g. a systematic review) before plunging into the primary literature (unless this is an area of established expertise). Consult a librarian and see handout on "Searching for Treatment Questions".
    5. Consult librarians frequently to get familiar with secondary sources and also to get supervised practice at primary database (e.g. MEDLINE, Embase) searches for areas of recurrent relevance to your clinical work: use of specific MeSH terms in MEDLINE, Clinical Query function in PubMed etc. Look also at Scopus and Web of Science. Consider setting up auto-searches for questions of persistent relevance in your practice.
       
  2. ‘Synching’ mode: for conditions you commonly see (early in your career as a clinician) and conditions you rarely see (later in your career as a clinician).

Aside from foraging and hunting, it is helpful to periodically (e.g. annually) update yourself on available and relevant national practice guidelines (e.g. the US, UKCanada, ANZ)  for the conditions you treat most commonly in your practice. The NICE (U.K.) sets the standard for transparency (about levels of evidence) and currency for guidelines.

Consider adapting the approach taken by this GP: I spend up to an hour most weeks reviewing summaries of evidence produced by trusted, public sector organizations covering just the conditions I see commonly. I do not spend longer than that on CPD [continuous professional development]—like most GPs, I do not have the time. My patients expect me to be right up to date with what actually is the best evidence for the management of asthma, diabetes, depression, common infections and so on—not what I think is the evidence based on brief, random reading and talking to colleagues. So, I ‘hot-synch*’ my brain with the best evidence on those topics once or twice a year, in the same way that I hot-synch my iPod* with my music playlists or my Blackberry* continuously hot-synchs* my e-mails, contacts and calendar with my desktop e-mails, contacts and calendar.” (See Maskrey Neal, Getting a Grip on Research, 2010) [*yes, this is dated but still useful advice!]

Other Specific information needs:

  1. For drug interactions consider: The Medical Letter or Lexidrug. The first is also offers an excellent (monthly) update on new approved medications, and regular reviews of medication classes.
  2. For alternative/natural/herbal remedies consult NatMedPro.
  3. For good sources of background information on general medical disorders, the following are (i) well-referenced, (ii) transparent (reference evidence for recommendations), (iii) available online and (iv) succinct enough for workplace-based learning:
    1. Primary Care Medicine: Office Evaluation and Management of the Adult Patient [2014] (Ed. Allan H. Goroll M.D. and Albert G. Mulley JR. M.D., M.P.P.
    2. UpToDate (variably referenced, and sometimes reads like an expert review that is open to selective reporting of the literature, but has great width of coverage and ease of searching for bedside background information)
  4. If this has increased your appetite for more information on the topic of how to keep current, I recommend a series of 5 articles by Neal Maskrey and others: ‘Getting a better grip on research’ InnovAiT, Vol. 2, No. 10, pp. 619–625, 2009.  Here is an approach to learning and improving practice that summarizes –in a very readable way – relevant background knowledge from information management, cognitive psychology and complex organizations that can help you think about how to keep up and then effectively apply your knowledge to improve outcomes for the population of patients under your care.
  5. As you develop other sources for your information diet, and discover new resources for workplace based learning, please let us know! If you are not affiliated with an academic institution, cost may become a limitation in accessing several of these resources. Consider exploring many of these while at Yale to determine which are worth investing in for your ongoing information needs.