This Article  • PDF  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Contact me when this article is cited  Related Content  • Similar articles in JAMA  Topic Collections  • Journalology/ Peer Review/ Authorship  • Alert me on articles by topic  Social Bookmarking   What's this?

Expanding the Horizons

Margaret A. Winker, MD

JAMA. 2006;295:2888.

A decade ago, JAMA launched, with physicians at the (then) Beth Israel Hospital in Boston and initial support from the Robert Wood Johnson Foundation, the section Clinical Crossroads.¹ A patient-focused clinical review, Clinical Crossroads traditionally has been based on Grand Rounds in a variety of clinical departments specifically structured in accordance with the requirements for Clinical Crossroads and presented at Beth Israel Deaconess or other Harvard hospitals.

We now invite Clinical Crossroads submissions from any academic institution, provided the instructions for these conferences and manuscripts are followed (Box). Interested potential authors and conference organizers should contact Margaret A. Winker, MD, at JAMA.

BOX. Clinical Crossroads Guidelines for Submission Clinical Crossroads is a patient-focused evidence-based review and discussion of a diagnostic or treatment decision faced by an actual patient and physician. Clinical Crossroads may address any medical condition relevant for primary care physicians. Identify an appropriate topic that includes a decision point faced by primary care physicians and patients in the course of patient care, and is clinically important, with a sufficient literature base to support a review. Identify a discussant who is a recognized authority on the subject and who has no disqualifying conflicts of interest. Contact JAMA (Margaret Winker, MD; margaret.winker{at}jama-archives.org) to discuss the priority of the topic for JAMA, the potential discussant, and related issues such as any conflicts of interest and funding source. Identify a patient with the condition who is willing to potentially have his or her medical history and interview published as part of an article in JAMA. Personal details are removed, but patients may still be identifiable to themselves and family members. The patient must sign the JAMA patient consent form and informed consent as required by the institution. If the primary care physician is interviewed, the physician also needs to complete the JAMA consent form. For the patient case description, summarize the patient's history and physical examination, including the crossroads the patient faces; the disease status; pertinent physical findings, laboratory values, and diagnostic tests; patient's concerns or issues, including personal, socioeconomic, or environmental; and medications. The description should frame the clinical question to be addressed. Interview the patient regarding the condition and clinical question, including what questions the patient has for the discussant, and provide a transcript of the interview for the discussant. Videotape or audiotape of the interview is useful for the Grand Rounds. The primary care physician may be interviewed and transcript provided as for the patient. Develop the questions for the discussant to address. Provide the materials to the discussant, including these instructions, the patient interview, and the questions, well before the Grand Rounds. If the patient is inclined to do so, the patient should attend the Grand Rounds and ask questions. At the Grand Rounds, the patient case description is presented followed by the edited patient interview. The Grand Rounds question-and-answer session should be recorded and transcribed for the manuscript and provided to the discussant. The discussant should prepare the manuscript including (in order): the title and author (including financial disclosures), word count of text only, an unstructured abstract no longer than 150 words, patient case description, patient interview, questions for the discussant, the review discussion itself, specific recommendations for the patient, the question-and-answer section (with references added as appropriate), references, and any tables and figures. Length of text only should be 3000-4000 words. The Clinical Crossroads organizers and conference date and location should be provided in the Acknowledgment. The discussion should be based on a systematic review of the best available evidence, focusing on randomized controlled trials and meta-analyses whenever possible. Briefly describe search strategy and inclusion criteria. When discussing studies, include (where possible) study design, sample size, and relevant points about the study methodology; point estimates of risk ratios with 95% confidence intervals; absolute as well as relative rates and/or numbers needed to treat; and adverse events. A table of studies summarizing the available evidence is often helpful. When treatments are compared, approximate costs of treatment generally should be provided. Original illustrations may be developed by the JAMA Graphics Department, if appropriate, but JAMA generally does not republish tables or figures from other sources. The discussion should consider the patient's perspective and refer to the patient wherever relevant, including what unique aspects of the patient's situation may affect particular diagnostic or treatment options (such as other medical conditions, allergies, ability to afford medications, or insurance status). The final section of the discussion (before the question-and-answer section) should include specific recommendations for the patient based on the best available evidence. Funding sources for the conference and manuscript may be government, not-for-profit, or private and should be listed in the manuscript. Commercial funding sources are not acceptable. The manuscript should be reviewed by the Clinical Crossroads organizers for completeness and editorial flow and by the patient if requested. If suitable, the discussant should then submit the manuscript to JAMA, along with completed authorship, copyright transfer, and conflict of interest forms; patient consent; any financial support received; and role of the sponsor. The manuscript will undergo internal review and, if considered potentially appropriate for JAMA, sent for external peer review. If review supports pursuit of revision, the author will receive a revision letter from JAMA along with the reviewers' comments. The author is expected to revise the manuscript and provide a cover letter detailing the point-by-point responses to the requests for revision. There is no guarantee that the manuscript will be accepted for publication in JAMA. RETURN TO TEXT

The Grand Rounds begins with the case history of a patient and that patient's firsthand account of the medical decision he or she faced, occasionally along with the patient's primary care physician's perspective. These accounts are followed by questions for the Grand Rounds discussant, which the discussant, usually a well-recognized authority on the clinical topic, addresses based on available evidence in the literature, and, where no evidence exists, clinical experience. Following the presentation, the discussant drafts the manuscript for submission to JAMA, including the case description, the patient's perspective, the discussion (including references and pertinent tables and figures), and the question-and-answer session that occurred at the end of the Grand Rounds. The manuscript then undergoes editorial evaluation, external peer review, and revision. If the manuscript is revised satisfactorily and determined to have a level of quality appropriate for JAMA, the manuscript is accepted and published in JAMA and usually is featured in Clinician's Corner.

Clinical Crossroads addresses what "patients think of the options they face, and what . . . they want to know" because "even after referral [to a specialist], patients look to their primary doctors for objective information and advice regarding choices in their treatment."¹ Furthermore, just as the consultant's recommendations should take "into account the patient's personal preferences, values and quality of life, and financial considerations and insurance,"¹ so the Grand Rounds discussant should address these issues as well. This approach of addressing the clinical problem "through the patient's eyes"² has extended, in many cases, to the patient attending the conference at which his or her case was presented and asking questions directly of the discussant. The question-and-answer session that follows the Grand Rounds has been included in Clinical Crossroads to help preserve the clinical immediacy of the issue and raise points that otherwise might not emerge, particularly those from the patient's perspective. Patient follow-ups are often published.

In the decade since Clinical Crossroads was launched, 106 Clinical Crossroads articles have been published. They represent the breadth of experience of primary care, with topics ranging from "A 72-year-old man with localized prostate cancer"³ to "A 38-year-old woman with fetal loss and hysterectomy"⁴; from "An 85-year-old woman with a history of falls"⁵ to "A 67-year-old man who e-mails his physician."⁶ Because the importance of viewing clinical problems through the patient's perspective has not changed, the format beginning with the patient's description of his or her case has remained essentially the same. However, in the ensuing 10 years, JAMA's approach to review articles has evolved, changing its approach from one of more traditional reviews to addressing the best available evidence in a more systematic way, providing salient aspects of studies for clinicians to use in judging their relevance and limitations. Clinical Crossroads has similarly gradually evolved to reflect this change. In a second change, we are adding an unstructured abstract to facilitate searching.

We look forward to Clinical Crossroads submissions to JAMA, but regardless, physicians developing Grand Rounds presentations not already oriented toward the patient's perspective are encouraged to do so. Bringing the best possible evidence to bear on a particular clinical issue and addressing the issues of fundamental importance to the patient will help link clinical research with patients' hopes, beliefs, and expectations, ultimately improving the patient's care and aligning the goals of the patient and physician.

AUTHOR INFORMATION
Corresponding Author: Margaret A. Winker, MD, JAMA, 515 N State St, Chicago, IL 60610 (margaret.winker{at}jama-archives.org).

Acknowledgment: We thank Drs Steven Schroeder, Tom Delbanco, Jennifer Daley, and George Lundberg for their work in developing Clinical Crossroads.

Editorials represent the opinions of the authors and JAMA and not those of the American Medical Association.

Author Affiliation: Dr Winker is Deputy Editor, JAMA.

REFERENCES
1. Delbanco TL, Daley J, Walzer J, Winker MA. Clinical crossroads: an invitation. JAMA. 1995;274:76-77. FREE FULL TEXT 2. Gerteis M, ed, Edgman-Levitan S, ed, Daley J, ed, Delbanco T, ed. Through the Patient's Eyes: Understanding and Promoting Patient-Centered Care. San Francisco, Calif: Jossey-Bass; 1993.3. Albertsen P. A 72-year-old man with localized prostate cancer JAMA. 1995;274:69-74. FREE FULL TEXT 4. Sachs BP. A 38-year-old woman with fetal loss and hysterectomy. JAMA. 2005;294:833-840. FREE FULL TEXT 5. Lipsitz LA. An 85-year-old woman with a history of falls. JAMA. 1996;276:59-66. FREE FULL TEXT 6. Slack WV. A 67-year-old man who e-mails his physician. JAMA. 2004;292:2255-2261. FREE FULL TEXT

CiteULike    Connotea    Del.icio.us    Digg    Reddit    Technorati    Twitter     What's this?