Saturday, November 15, 2014

My journey into Evidence Based Medicine and Cochrane Reviews

I was a medical librarian in the PD Hinduja National Hospital & Medical Research Centre, Mumbai in the 1990s, when we first subscribed to Medline on CD-ROM. We got the sanction for the subscription in 1994, after two years of proposals, discussions with 'the management' and more.

In 1994-95 I did everything to learn all about searching Medline effectively. At the back of my mind, I always had the query - how would a doctor actually figure out which of the abstracts and articles would be most useful? There were times when the search results were conflicting. Some abstracts would give certain facts and others (from equally reputed journals) would give almost opposite facts (for example about the comparative efficacy of two drugs). Some young doctors even asked me whether there were any criteria to decide. I of course knew nothing about it, and all I could tell them was that maybe we needed to see which journal / author was more reputed, and base the decision on such factors.

In 1996 I was librarian of HELP - a Consumer Health library. Here we had access to the Internet and  I became a member of the Medlib-L mailing list, which had a large number of medical librarians. I first heard of Cochrane Reviews and of course understood exactly nothing about them. Cochrane was then a fairly new concept. There was so much more to learn about online medical information that I did not do much about Cochrane

In 2000, I attended the ICML - the International Congress on Medical Librarianship, in London. This was the first time I attended an international conference. I was super-excited. Looking through the website, I skimmed through the preconference workshops and one called "Critical Appraisal Skills" caught my eye. "Aha" I thought. "Now I will learn how to choose the most relevant of search results I can choose once I do a good Medline search". I registered for the Basic Course and not the Advanced one, because each course cost 50 Pounds :)

It was after I attended this half day workshop, I realised that there WAS a method for searching for Evidence based publications and it was after we retrieved these, that we could actually appraise them. I learned the basics of appraisal in this course. On my return to India, I searched to check if there was any online course on finding evidence. I was thrilled to find one for librarians - "searching the literature for evidence based medicine" I enrolled for it right away (paying $150 then. The same course costs a lot more today) It was conducted by three librarians in the US. It was one we could do at our pace, and if I remember, I completed it in 4 weeks and also got 10 Credit Points (which were really applicable for US librarians). And thus I made my baby steps into searching for evidence.

Soon I started exploring the Cochrane Library. At first it made no real sense to me. (There was no one to explain it, you see). And the only thing that struck me was that majority of the reviews' abstracts had a conclusion that said "there is no clear evidence about......" And so I felt - abstracts in PubMed have stronger conclusions. Maybe it is better to stick to those!!

In 2007, I was introduced to Dr Prathap Tharyan of CMC Vellore. (He had then just set up the South Asian Cochrane Centre). We had a brief discussion and made some random "future plans" of working together. I was added to their mailing list. I used to keep getting emails about "Protocol Writing Workshops for Cochrane Systematic Reviews". And the only line that caught my eye every time was "This workshop is open to those who have registered a title for a Cochrane Review". And I felt - "I am never going to do this one"!

Year 2008 - and there was an Evidence Informed Symposium organized by the SACN. I registered for this one, and was delighted to see one of the sessions was on Navigating the Cochrane Library. I attended this one, conducted by Ruth Foxlee (who I met again years later in 2011 and again this year), and her colleague. This was an eye opener and I finally learned what a Cochrane Review was about, and what the other five databases were about!

2010 - time for another symposium at CMC. This time Dr. Prathap organized a two hour session for UG students on all four days and I had the opportunity to do the session on searching the literature! This event brought me close to a group of students and at the end of the symposium when we all had discussions with Dr. Prathap, he encouraged all to attend the next Protocol Writing workshop. I asked him "Can I attend this, more as an observer"? And he said "Yes". Little did I know what I was in for.
Came February and I went to Vellore with all excitement. The workshop was for five days. On the first day, he made the fundamentals of a Cochrane Review even clearer. Actually crystal clear. But as days progressed, the dreaded statistics and more came in. When we reached the fourth day, I was all ready to quit. However, the psychiatrist in Prathap played up and he did all he could to make out as if I were the bravest soul around and I would definitely make it through, till the end :).

Manu Mathew, Ravi Ranjan (two students of Kasturba Medical College at that time; now qualified doctors) and I registered a title. We worked hard on it for two years and finally had to withdraw the review. At another point, I was invited by another group to be part of a Cochrane Review, and this one too fizzled out. By this time I had also attended the same workshop two more times and almost gave up about every getting through a review. However I did sharpen my searching skills. And I delivered talks on how to navigate the Cochrane Library in three ICMR centres in India. I have also included an introduction to Cochrane Reviews in all my lectures on literature searching.

And then, finally about a year ago, one more title happened and this week (November 2014) it has turned into a published Cochrane Review!

Gene therapy for hemophilia
  1. Akshay Sharma,*
  2. Manu Easow Mathew,
  3. Vasumathi Sriganesh, 
  4. Jessica A Neely,
  5. Sasank Kalipatnapu
What was my role in it? I am not an expert on the topic. But I did play a significant role in the literature searching, and coordinated with librarians in the US to ensure that I did good strategies. I went through the whole text thoroughly and commenting on part of the content. I played a role on how to reference everything right. I also managed to find a couple of technical errors and get them rectified. Slowly the Cochrane Methodology - the nitty gritty of it is sinking in. Psst - I still refused to touch the statistical bits :>.  I have miles to go. This is a beginning!

Thanks Prathap Tharyan for egging me on every time I was ready to give up!  Thank you Akshay for inviting me to be part of this review. Thanks to the other co-authors - I learned bits and pieces from all your work.

Aside from bravely being one of the authors of a Cochrane Review, I have attended two Colloquia - one in Madrid in 2011 and one this year in Hyderabad (2014). The learning escalates with every such event and I hope it continues. This year, Dr Paul Garner of the Effective Health Care Research Consortium asked me if I were supporting more authors and I said "not yet, because I need more mentoring". And he promised to put me in touch with a mentor. As I said - there is lots more to learn - miles to go!

My message to medical librarians  and to the Institutional heads in India is - "Librarians have a huge role to play in helping authors from India, with systematic reviews. We need to find a way of training lots more librarians to learn more and more, step by step.


caregiver7careseeker said...

Very well written Vasu.

Dr Bhavani said...

Very nice:-)

klimas.two said...

Hi Vasumathi,
In an attempt to prove that counseling works for reducing drinking in concurrent problem alcohol and illicit drug users, I ended up on a journey through research and review. Read the full article in the November issue of the Forum Magazine (Volume 31, Issue 10) or in my post here: