CTR Guidance

The following guidance is by no means comprehensive or prescriptive, but reflects some of the experiences of trainees, and much is derived from previous written guidance from the college officers. The information on critical appraisal is derived from courses and the resources referenced here - they come highly recommended. In particular the Centre for Evidence Based Medicine is worth bookmarking.

The College of Emergency Medicine have made available the slides and handout from the Critical Appraisal Course organized by Professor Steve Goodacre. The handout - CRITICAL APPRAISAL FOR EMERGENCY MEDICINE TRAINEES - is a  valuable resource of exceptional quality and readily available. It is essential reading during CTR  and exam preparation. 

Most training regions now require each trainee to write one CTR/year. The first is always the hardest, but by the time your examination comes around, you should have the choice of 3-4 to present. If you want to read another trainee's CTR, or have finished your CTR & exam and would like to share it with others, please visit the Shared Resources section of this website.

Topic

The title should be short, punchy and arresting – it does not have to describe the whole content of the CTR

KEEP IT SIMPLE! - Choose a well defined topic, preferably one that does not bring >100 references on your literature search. Aim for 20-30 references. Don't forget that you'll need to critically appraise each of these, and may be quizzed on your sources during your exam. Aim to be an expert in a small defined area in which you have an interest.

The choice of topic is crucial – poor topics give you a disadvantage.

In particular – it is difficult to score well on a “management” or organizational design topic. Topics reviewing health education, implementation of guidelines, or training in softer interpersonal skills often require a higher degree of original work to support what is often a paucity of medical literature to review. In addition you would need to have additional skills and knowledge in areas outside of Emergency Medicine (social sciences, psychology etc) in order to be able to critically review such topics.

Choosing a topic that has an extensive literature base creates problems, but similarly, focusing on a very small topic may mean that related literature is missed. For example, looking at common conditions but only in children will not allow relevant adult literature to be examined.  

Writing

Don't forget the aims of the CTR are:
    – to demonstrate expert knowledge in an area
    – to summarise and critique the evidence
    – to provide some original work /thoughts
    – make recommendations for improving clinical care

The word count should be carefully applied – and excessive tables and appendices should not be added; if it is not in the main text then it is not relevant. The regulations stipulate a maximum count including tables, figures and references, similar to the EMJ stipulations for publications.

Poor spelling and grammar are inexcusable and will drop your marks. Likewise consistent formatting is important, and avoid unnecessary capitalization, italics, and bold type. References should be correctly applied to the text, and formatted in the Vancouver style. It can be well worth investing in a bibliographic manager like Endnote or similar to make this a very straightforward task.

Well performed original work should gain more marks. Poorly conducted questionnaires circulated around your mates will not. Questionnaire design is a complex and special skill.

The written should carry at least 50% if not 60% of the total marks; some areas should be weighted within the evaluation of the written paper.

Start early
            Choose wisely
                        Write clearly
                                    Seek advice

The steps involved in doing a CTR:

1. Decide on a topic
2. Write (and later refine) inclusion and exclusion criteria for papers
3. Performing the search
4. Either:
   • Discover the topic is too broad/too many available articles -> Return to step 1
   • Narrow search down to identify 10-40 papers -> Go to step 5
5. Summarize papers
6. Assess their methodological quality
7. Discuss findings
8. Consider further original research to explore topic further
9. Once complete:
   • Show your CTR to as many people as possible. Everyone will have a different angle on things
   • Get into the habit of talking about your CTR. Arrange plenty of mock vivas
   • Form your opinions on the implications in the real world of your CTR
   • Regularly recheck references and appraise new developments, and again immediately before your FCEM examination

Final recommendations from the College:

Candidates should seek advice on the written CTR submission from a trainer, preferably a member of the Regional Training committee or FCEM examiner. This does not break the “all own work” rule providing the trainer does not rewrite the CTR, but gives an external view on the result of what should be many months of work.

We also recommend that trainees should have chosen the topic by year 2, and completed the CTR at least six months before the exam and have shown it to at least 2 trainers for comment on content, spelling, format and main message.

We believe it is essential for candidates to undergo a mock viva, as the current allocation of marks is only 40% for the written component.

The review panel have made recommendations for changes to the regulations that will be discussed by the Education and Examination committee.

Recommended texts for guidance include:

• Egger, M., Smith, G. D. - Systematic reviews in health care: meta-analysis in context (London: BMJ)
  -excellent book which gives a step by step guide to doing a systematic review.
• Guyatt, G., Rennie, D. - User’s guide to the medical literature: a manual for evidence based clinical practice (Chicago: American medical association)