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Critical Appraisal Module

Module Leader:
Dr John-Paul Taylor

February 2013-Jun 2013




Overall aims
The aim of this module is to support your learning in Critical Appraisal for the relevant parts of the
MRCPsych exam. Critical Appraisal is specifically tested within Paper 3 but aspects of epidemiology and
critical examination of key journal articles are spread throughout the exam papers. In addition this module
does not restrict itself exclusively to material necessary for the exam and the intention is to provide a more
general introduction to critical appraisal as well as support a life-long learning approach to the use and
application of evidence based medicine. Involvement in local journal clubs or evidence based medicine
groups will also strongly complement this course.
MRCPsych curriculum
The module is based around the MRCPsych curriculum, specifically the critical appraisal curriculum which
is available at http://rcpsych.ac.uk/traininpsychiatry/examinations/about/mrcpsychpaper3.aspx. The
programme of seminars adheres closely to this curriculum and aims and learning objectives match this
curriculum. However clearly the lesson plans cannot comprehensively cover everything. Nevertheless there
is a strong emphasis on basic biostatistics as this is often an area that trainees find most difficult
particularly if they do not have much prior statistical experience.
Module objectives
These state the aims of each part of the module and the learning outcomes expected. You will have the
opportunity to evaluate this module in terms of these learning outcomes at the end of the module.
Reading lists
Reading lists are divided into essential and other reading. We recommend that the essential reading be
done prior to and during that weeks teaching for you to get the most out of the teaching.
Lesson plans
The lesson plan details the material to be covered in each session and the teaching methods to be used.
For sessions which require participation and discussion please be prepared to actively partake in this. Not
only will this be needed for the session to be successful but the more you participate, the more you will
gain from the course.
Local hospital teaching
As with other parts of the course, the critical appraisal module in the MRCPsych course is not intended as
a comprehensive programme of teaching within the specialty. It is designed to supplement education
experience gained from evidence based medicine or journal clubs in your local hospital.
There will be an assessment afternoon on the last day of the module. This is intended to be formative in
nature and help prepare you for the exam. Teachers for each session have been asked to submit
questions in advance for this final session which will be facilitated by the module lead. We will review the
answers once the assessment is over. It would help considerably if you prepare for this morning by revising
the taught material in advance as you would for an examination. A register will be taken and unless
previously agreed the expectation is that you will attend this important final part of the module. Remember
the more you put in for the assessment session the more you will get out.


Venue: Education Centre, Lanchester Road Hospital, Durham



27th February 2013

9.30 11.00 (1.5 hr)

11.15 12.45 (1.5 hr)

Introduction and a revision of critical appraisal

(Part 1)
Evidence based medicine a revision
Different types of clinical questions a revision
Understanding the evidence

Retrieving the evidence (Part 2)

Niraj Ahuja

Sheena Hanes & Clare



1.30 4.30 (3 hr)

13th March 2013

Basic biostatistics Part 1

Different types of data
Summary measures
Simple tabular presentations
Graphical presentations
Diagnostic accuracy
Receiver Operating Characteristic Curves

Matt Linsley

Basic biostatistics Part 2

Prevalence, Cumulative incidence, Incidence rates
Survival curves
Mortality statistics
Measures of treatment impact
Sampling variability and standard error

Matt Linsley

Basic biostatistics Part 3

Hypothesis testing
Parametric and non-parametric data
Confidence Intervals
Type I error and Type II error
Power and Sample Size
Correlation coefficients
Regression analysis

Matt Linsley

9.30 12.30 (3 hr)

10th April 2013

9.30 12.30 (3 hr)




24th April 2013

9.30 11.00 (1.5 hr)
11.15 12.45 (1.5 hr)

Basic Health Economics

An introduction to qualitative methods

Joanne Gray
Rachael Lawson

8th May 2013

9.30 12.30 (3 hr)

Basic biostatistics Part 4

Intention to Treat Analysis
Missing data
Fixed and random effect models
Statistical heterogeneity
Sensitivity analysis

Matt Linsley

Basic epidemiology

Liz Lingard

22nd May 2013

9.30 12.30 (3 hr)

5th June 2013

9.30 11.00 (1.5 hr)
11.15 -12.45 (1.5 hr)

How to critical appraise the evidence

Assessment and Multiple choice questions

Niraj Ahuja
John-Paul Taylor

All trainees must apply for study leave to attend this course. All enquiries regarding course programme to
Adam Goddard (Tel: 0191 275 4744; e-mail: adam.goddard@northeast.nhs.uk).
Please inform Adam Goddard of any absence or change of post or address.


Introduction and a revision of critical appraisal



Provide overview of critical appraisal and its use in psychiatry
Make the optimal use of current best evidence in making decisions about the care of patients
Discussion of basic principles of Evidence based medicine, its limitations and uses

Learning outcomes
The Trainee should be able to:
Formulate clinical questions using the PECO(t) formula (Patient, exposure/intervention, comparison, outcome,
Recognise and formulate different types of clinical questions for understanding: therapy, harm, aetiology,
prognosis, diagnosis, economic and qualitative
Be able to systematic retrieve the best available evidence and understand the hierarchy of evidence


Reading List

Essential reading
Critical Appraisal for Psychiatrists (MRCPSY Study Guides) Stephen M. Lawrie, Andrew McIntosh, and Sanjay Rao
ISBN-13: 978-0443070174

Other reading
The Pocket Guide to Critical Appraisal. Iain Crombie. ISBN-13: 978-0727910998
Evidence-Based Medicine: How to Practice and Teach it. 4E. Sharon Strauss, Paul Glasziou. 2010. ISBN-13-9780702031274
How to Read a Paper: The Basics of Evidence-Based Medicine. Trisha Greenhalgh. 4E. 2010. ISBN-13-1444334364

2. Basic epidemiology

Module objectives

To understand different forms of bias in research
How data is sampled in epidemiological studies
How to deal with confounding data in epidemiological studies
Understanding causality in epidemiological studies
Describe different epidemiological study designs
Learning Outcomes
Describe different types of errors (systematic, random etc.)
Understand the concept of validity in terms of internal vs. external; as well as construct, content, face and
criterion validity
Know how different types of data are sampled e.g. cluster, random, stratified etc.
Understand the purpose of randomisation, blinding and methods of randomisation/concealment
Understand how cause and effect can be implied (Koch, Hill criteria etc.)
Know the strengths and weaknesses of different epidemiological study designs


Reading List

Essential reading
Charles Hennekens & Julie Buring. Epidemiology in Medicine, Lippincott Williams and Wilkins, 1987

Miquel Porta & John M Last. A Dictionary of Epidemiology, 5 Edition, Oxford University Press, 2008
David Streiner & Geoffrey Norman. Health Measurement Scales: A Practical Guide to Their Development and
Use, Oxford University Press, 4 Edition, 2008.
Please note: The E-learning module Epidemiology for Practitioners available on the Health Knowledge website
summarises material from the textbooks and may be an easier way to review the basic epidemiology concepts that
will be covered in this teaching session.
(Available at: http://www.healthknowledge.org.uk/e-learning/epidemiology/practitioners)
Please prioritise the following pages on this E-learning module:
Errors in epidemiological measurements
Introduction to study designs geographical studies, cross-sectional studies, case-control studies, cohort
studies, intervention studies and randomised controlled trials
Causation in epidemiology: association and causation
Role of chance, bias and confounding in epidemiological studies
Chapter 2 of Streiner & Norman provides an easy to read overview of the criteria that should be used to assess any
health measurement instrument cited in the literature. This is a particularly good resource for understanding the
concept of validity and reliability. (Available via google books at http://tinyurl.com/azyfono)


Lesson Plan

Basic epidemiology
Subject matter
Error in epidemiological measurements
Chance, bias and confounding
Validity and reliability
Strategies to limit bias and confounding
Association and causation
Epidemiological study designs

Teaching methods


Pre-reading as suggested above to

facilitate learning in seminar

Liz Lingard

Interactive seminar
Exercises to abstract & appraise
epidemiological information from
journal articles

StR in Public Health

North East Quality
Observatory System,

3. Basic biostatistics
Note: This component of the critical appraisal module is spread over 4 sessions



Provide an grounding and working knowledge of biostatistics

Learning outcomes
Understand different types of data e.g. categorical, continuous, nominal etc.
Describe summary measures of the average: mean, mode, median
Describe measures of spread: standard deviation, range, and interquartile range
Able to use contingency tables and understand frequency distributions
Able to interpret graphic presentations of data
Understand in studies examining diagnostic accuracy, characteristics including prevalence, sensitivity,
specificity, PPV, NPV, and likelihood ratios as well as nomograms
Able to interpret receiver operator curves
Describe and calculate prevalence, incidence and cumulative incidence
Understand survival curves and Kaplan-Meier plots
Calculate mortality statistics
Understand and calculate odds ratios, absolute risk reduction, absolute benefit increase, numbers need to
Understand what is meant by sampling variability and the use of the standard error in statistical inference
Understand and describe (not required to calculate) different hypothesis tests e.g. chi-square, t-test
Understand how to carry out hypothesis tests in three or more groups (ANOVA/ANCOVA) and with nonparametric data
Interpret and describe confidence intervals and compare and contrast to t-tests
Know what type I and type II error means and by association power and sample size
Interpret correlation co-efficients and results from regression analyses
Be able to explain intention to treat, last observation carried forward as well as trial analyses such as worst
case analysis, multiple imputation etc.
Be confident in understanding meta-analysis approaches including the difference between fixed and random
effect models and how to recognise statistical heterogeneity

3.2 Essential reading

Medical Statistics at a Glance by Ava Petrie and Caroline Sabin
Publisher: Wiley-Blackwell; 3rd edition (10 July 2009) ISBN-10: 140518051X; ISBN-13: 978-1405180511

3.3 Other reading

Medical Statistics: A Textbook for the Health Sciences by Michael J. Campbell, David Machin and Stephen J. Walters
Publisher: Wiley-Blackwell; 4th edition (29 Jun 2007) ISBN-10: 0470025190; ISBN-13: 978-0470025192
Statistics Explained by Perry R. Hinton Publisher: Routledge; 2nd edition (15 July 2004) ISBN-10: 0415332850;
ISBN-13: 978-0415332859

4a. Basic Health Economics



Have a broad understanding of health economic analyses and their impact upon the broader health service and the
design and delivery of clinical services

Learning Outcomes
The Trainee should be able to:
Describe the basic differences between direct and indirect costs and the ways in which they can be estimated
Know what is meant by cost-effectiveness, cost-utility analysis, cost-benefit analysis and cost-minimisation
Be able to define what is meant by a quality or disability adjusted life year and the rational for using these
Describe opportunity cost and different approaches to discounting
Explain what is meant by the term sensitivity analysis in the context of an economic evaluation


Reading list

Guiness, l & Wiseman, V. 2nd ed Introduction to Health Economics. Understanding Public
Health. Open University Press, Maidenhead, 2005. Section 5: Economic Evaluation
Fox Rushby J & Cairns J (eds) Economic Evaluation. Understanding Public Health. Open
University Press, Maidenhead, 2005.

Torrance GW. (1986) Measurement of health state utilities for economic appraisal. Journal of
Health Economics, 5: 1-30.
Gerard K. and Mooney G. (1993). QALY league tables: handle with care. Health Economics, 2:
Contingent valuation:
Donaldson C. and Shackley P. (2002). Willingness to pay for health care. In A Scott, A Maynard
and Elliot R (Eds) Advances in Health Economics. Wiley, Chichester.
Bayoumi, AM. (2004). The measurement of contingent evaluation for health economics.
Pharmacoeconomics, 22, 11: 691-700.


Monetary Value of QALYs:

Brouwer W, van Exel J, Baker R, Donaldson C (2008) The new myth: The social value of the QALY.
PharmacoEconomics 26, 1: 1-4


Lesson Plan

Basic Health Economics

Subject matter
Introduction to health economics principles,
methods of economic evaluation, costs and
outcomes for economic evaluation

Teaching methods
Didactic, discussion



4b. An introduction to qualitative methods

4b.1 Objectives
Cover a range of qualitative research methodologies
Learning outcomes
The trainee should be able to:
Know when to apply grounded theory, phenomenological and ethnographic qualitative research methods
Describe approaches to data gathering and sampling in qualitative studies
Describe the role of qualitative research in shaping instrument design (screening, diagnostic, and outcome
Describe methods for validating qualitative data and methods for minimizing bias
Broadly describe how qualitative data is analysed and understand the meaning of data saturation

Essential reading
Green J & Thorogood N (2009) Qualitative Methods for Health Research London: Sage
Other reading
Silverman D (Ed) (2011) Qualitative research London: Sage
Pope C and Mays N (2007) Qualitative Research in Health Care Blackwell: London
Barbour R (2007) Introducing Qualitative Research London, Sage

Lesson Plan

An introduction to qualitative methods

Subject matter
Introduction to qualitative
Conducting qualitative

Teaching methods
Participatory exercise

RL 1 hours


5a. How to critical appraise the evidence


Module objectives

Complementary session to module 1.
Opportunity to address gaps not covered in critical appraisal module
Opportunity for trainee presentations on their critically appraised paper

Learning outcomes
The trainee should be able to:
Explore methods for critical appraisal of diagnostic questions, prognostic questions, as well as therapy/harm
and aetiology questions
How to critically appraisal economic evaluations, qualitative studies, systematic reviews and meta-analyses
as well as clinical practice guidelines
Able to describe audit, change planning, feedback, and other elements of PDSA (Plan, Do, Study, Act) cycles,
and their implications for clinical governance


5b. Assessment and reflection

5b.1 Module objectives
Complementary session to module 1
Opportunity to address gaps not covered in critical appraisal module
Confidence in dealing with MRCPsych critical appraisal MCQs

Learning outcomes
The trainee should be able to:
Confidently deal with MRCPsych critical appraisal MCQs

Other reading
The Bedford Murder: An Evidence-Based Clinical Mystery. Marshall Godwin and Geoffrey Hodgetts. 2003. ISBN-13: