Twelve tips for running successful junior doctor-led teaching programmes for medical students.

BACKGROUND: Medical students value teaching by junior doctors and find it comparable to consultant-led teaching. Although several junior doctor-led teaching programmes have been developed, there is insufficient information in the literature to guide junior doctors planning on developing such programmes. AIM: This article gives junior doctors 12 practical tips on how they might develop and run successful teaching programmes for medical students. RESULTS: The 12 tips are (1) Clearly define the scope of your programme, (2) Ensure student-defined learning goals are included at an early stage, (3) Inform and involve your fellow junior doctors in teaching, (4) Plan teaching rotas in advance, (5) Learn to teach effectively by attending courses, (6) Promote your programme to medical students as widely as possible, (7) Use varied and interactive teaching methods, (8) Establish rapport with students, (9) Include assessment as part of the teaching programme, (10) Seek feedback from attendees and senior faculty, (11) Establish rules for tutorials and (12) Secure formal recognition for your scheme. CONCLUSIONS: These 12 tips may help junior doctors to develop and manage successful teaching programmes. It may also be a useful guide for senior faculty advising junior doctors who aspire to establish such teaching programmes.

Is home monitoring of international normalised ratio safer than clinic-based monitoring?

A best evidence topic was written according to a structured protocol, to answer the question: 'In patients taking warfarin, is home self-monitoring of international normalized ratio (INR) safer than clinic-based testing in reducing bleeding, thrombotic events and death?' Altogether, 268 papers were found using the reported search. Five papers represented the highest level of evidence to answer the clinical question (four systematic reviews with meta-analysis and one meta-analysis). The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The principal outcomes of interest were death, major haemorrhage, major thromboembolism, and time (or percentage time) spent within the therapeutic range, compared between self-monitoring/self-management and conventional management. Self-monitoring/self-management was associated with a significantly reduced risk of all-cause mortality of 26-42%. All meta-analyses reported on major thromboembolism, finding significant reductions in risk of ~50%. One meta-analysis found a 35% reduction in the risk of major haemorrhage, with the other four studies finding no significant difference. Only one study found self-monitoring/self-management to be associated with a significantly greater proportion of time within range, with another finding no significant difference in either the percentage of therapeutic results or in the time within range. The remaining two could not combine data for meta-analysis owing to methodological heterogeneity. We conclude that self-monitoring/self-management appears to be safer than conventional management. It is associated with consistently lower rates of thromboembolism and may also be associated with reduced risk of bleeding and death. This supports the updated guidance from the American College of Chest Physicians, recommending self-management of INR for patients who are both competent and motivated.

In patients with carcinoid syndrome undergoing valve replacement: will a biological valve have acceptable durability?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'In patients with carcinoid syndrome undergoing valve replacement, will a biological valve have acceptable durability?' Altogether, more than 130 papers were found using the reported search, of which 17 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The pooled data from all papers represent 51 patients with carcinoid right heart disease who underwent tricuspid valve replacement. Two 'outcomes' studies reported a 30-day postoperative mortality of 16.7-18% and 2-year survival rates of 44 and 50%, respectively. Seventeen patients were detailed in case reports. Of these 17 patients, 7 died during the follow-up period. All but one of these patients had a normal bioprosthesis at echocardiography or at post-mortem. One patient with a plaque-covered valve had a functionally normal valve. We conclude that at present, the best available evidence suggests that although 30-day mortality approaches 20%, approximately half of patients with carcinoid syndrome undergoing tricuspid valve replacement can be expected to survive 2 years. Some patients survive considerably longer than this, beyond 10 years in some cases. Importantly, at autopsy, many replacement valves have been shown to be normal, with a few patients reported as having died of cardiac causes. This should be taken as cautious evidence that biological valves have an acceptable lifespan in patients with carcinoid syndrome and that the process of valve destruction seen in carcinoid patients does not continue to a significant level in the bioprosthesis. Caveats to this include the lack of any directly comparative trial and the predominance of case reports as opposed to higher-level evidence.

Are head bandages required post-pinnaplasty?

A best evidence topic in ear, nose and throat surgery was written according to a structured protocol. The question addressed was: In patients who are undergoing pinnaplasty for prominent ears, does the use of post-operative head bandages as compared to not using post-operative head bandages improve clinical outcomes? A total of 121 papers were identified using the reported search protocol, of which five articles represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. All five studies showed that no advantage exists in using head bandages with patients who have undergone pinnaplasty. Four of the five studies concluded that head bandages should not be utilised at all, whereas two of the five studies suggested that there is little reason to use head bandages after the first 24 h post-pinnaplasty. Therefore, the clinical bottom line is that provided the pinnaplasty result is good at time of surgery, there is reasonable evidence to suggest that head bandages have no effect on complications or patient satisfaction, so at best they are unnecessary and at worst, their physical drawbacks may actually outweigh any of their perceived benefits.

Is acupuncture beneficial in the treatment of Bell's palsy?: best evidence topic (BET).

A best evidence topic in facial nerve surgery was written according to a structured protocol. The question addressed was: in [patients with Bell's palsy], does [acupuncture] improve [facial nerve function and/or pain]? A total of 43 papers were identified using the reported search protocol, of which three articles represented the best available evidence to answer the clinical question. Two of these articles were review papers and together encompassed 13 primary articles. Publication details, type of study, patients studied, outcomes and results are tabulated. The two level 1 articles concluded that before firm conclusions can be drawn, better designed trials are required in order to establish whether acupuncture confers any benefit to patients with Bell's palsy. The level 2 randomised controlled trial (RCT) suggested that two methods of acupuncture were associated with significant improvements in pain in Bell's palsy, although the trial was poorly controlled and had risk of bias. Therefore, the clinical bottom line is that until well designed trials are able to clearly demonstrate a role for acupuncture in Bell's palsy, its efficacy should be considered to remain unproven.