Doorstep For Evidence Based Medicine: Traditional Narrative Review

Evidence Based medicine is One of Rapidly adopting model in clinical practice and Heath Governance. Though introduced in late nineteen century, Clinical Practitioners and Institutions are reluctant to adopt this model. One of the major reason behind Massive Leap Approach and Models of New guidelines for clinical practice and Health regulation is Increasing access to the technological platform for Practitioners. Even before Evidence Based Medicine became frontier of Clinical Guidance Literatures were being published and reviewed by scholars and subject matter experts. 

Here,  I'm going to discuss about one of the traditional ( still relevant ) method of evidence synthesis, Traditional Narrative Review,  which led the Academicians and practitioners  to get updated with Research work in their field and New anticipated changes that needs to be adopted by practitioners. Though it is not as rigid as systematic review and Meta-analysis, Gold standard of Evidence Based Medicine, Narrative review writing is still significant for Academicians and Researchers to get Comprehensive knowledge and critical appraisal made by subject matter experts. For this reason I Considered Traditional Narrative Review as doorstep to enter into Evidence Based Medicine. 

         Key features of Narrative Review writings 

1. One of the various Research Design which has significant strength on Decision Making since Findings of  Various literatures are Combined in one  article. 
2. A Comprehensive source of Information as educational purpose for Students and Researchers, since all the Research findings from past to present on that particular topics are Included 
3. Since, narratives are written by Subject matter exports of that particular topics, It gives broader prospective of information. Personal Insights and narration of authors can help to make outlines for Significant changes in the particular fields. 
4. Findings and conclusion has ability to becomes the major Backbone of information and references for future Researchers and Readers
5. Since Only peer reviewed Journals and Valid database searches are considered as the source of information, Rectification  of Common mistakes, misconceptions and ambiguities can be  done in the current state of knowledge and practices. 
6. Beside providing new perspective in pitfall of previous research, Literatures Narrative also provides the basis of Validating Hypothesis and  Assumptions providing dynamic insight on findings or other research. 
7. Philosophical as well as Theoretical aspects  of subjects Matters are Included in the Review, which gives the origin of new debates, discussions and huddles for the betterment in contemporary scenarios.  
8.  Cost effective, since there is scant or no field work 

Steps of Literature Narrative Writings

Pre-requisites

1. Author Selection: Writers of Narrative reviews should be experts in the field of study and Previous experience of conducting study on her/his own should be there.  Multiple authors are  more preferential than single for the sake of Reducing Biases. 
2. Selection of study topic: Topic should be accurate, scientific and should be able to address contemporary needs in the field. Author's experience and preliminary work plays significant role in this aspect. 
3.  Preliminary Literature Search : Helps Author to refine the study topic, find out trend of information and help to reduce overall time of study. 

Format and Layout

Like any research article or thesis work, Narrative review also follow the standard pattern of Literature. Those layout with headings are as follows

Title:  should denote somewhere that This is Narrative Review. Ambiguous title confuse readers.

Abstract: Includes the summery of the Journals referred, electronic databases searched, keywords and MESH terms used and cumulative findings. Abstract should be written in a way that readers get chance to explore their Topic of interest with brief knowledge of all the content.

Introduction: Here author should be able to justify the need of his/her review in the  light of available information along with Lacking in previous work. Introduction should include aims of writing Narrative and  scenario of cases where findings of this study can be applied as an Example.

Method: Sources of information, Search term and delimiting, selection Criteria,

Discussion: Synthesis of Information, interpretation and presentation of findings are covered in this segment. 

Limitations of the study: This section is way of confessing that their work itself is not perfect and to shows where the study might have failed to acknowledge some findings. Rigidly defined Limitation not only binds readers but also gives the extra strength and Validity of the Work. 

Conclusions: Here, Author can make his own suggestions / preferences based upon concrete analysis previous research findings, own experience as well as expertise and finally, contemporary needs. 

Acknowledgements: Throughout the process, Author might have ask help with different people with different expertise, which they can mention in this particular section. 

References: All the literature taken into consideration for source of information as well as data synthesis are cited here following any of the standard format. 

Lists of tables and figures: This is quite common in all the research work. 

              Sources of Information

It should be covered in Method section of the Narrative, where all the sources of data synthesis are included. gold standard method is Electronic databases.

• Mostly used Electronic platforms are MEDLINE, PUBMED, EMBASE, and Other Field specific Indexed journals. At least two database search is considered as high quality data retrieval. Author should keep track of all the terms used for database search and the terms used. 
• A tracking sheet can be maintained throughout the time in order to track back numbers of literature found with each search. Example of a tracker is attached here
• The 'Search Terms'  used should be appropriate to the Research topic. for example term 'Diarrhoea' gives thousands of article whereas ' Acute Gastroenteritis of Bacterial Origin' gives the specific articles of each terms used, such as : Acute, Gastroenteritis and Bacterial. The later is much more specific and preferential too. Read more about literature search by clicking below: https://researchsapling.blogspot.com/2019/08/how-to-find-appropriate-literatue-in.html)
• While synthesizing information, various forms of primary, secondary and tertiary sources  can be taken into consideration. These may include: Conference proceedings, Unpublished manuscripts, Governmental publications, Company reports, indexes, Books, catalogue, bibliographic, Newspaper etc. Here again, choice of source is completely dependent on Author considering his/ her objective and intentions of Narrative. 

                  Selection of the Study 

• While defining the exclusion criteria, author should be astringent enough so that His / Her personal judgements are not taken into considerations. At the same time, Those studies which are not relevant, Old enough to provide new insight and Which does not aid the quality of work should not be included. 
• Similarly Inclusion criterial should include Title of Work, study designs employed,  population / Demographics considered , disease and major findings of the studies, so that Your Question get answered with the data derived from those studies. 

                       Data synthesis

•  Discussion section of the Narrative is majorly covered by data synthesis where readers find exactly what they are searching for. 
• Either paragraph with Comprehensive discussions or Tables of different data structures are used to demonstrate the data retrieved from the various sources of literature reviewed. There is no any Gold standard for writing this section, hence author can do it own his/ her own way keeping target readers in Mind. 
•  Mostly In Writing review of Findings of Different Clinical trials with various Interventions, number of participants, numbers of cases / Control and numbers with different outcomes are presented in graphical representation ( table, graphs etc. ) whereas findings are discussed in authors own terms. Here, authors should go through each and every study that are considered as inclusion criteria, derive the major study outcome and put it in perspective of his perspective justifying objectives of the Narrative. 
•  Chances of bias is Very High in this section while interpreting the findings of previous research work. Hence, author should be as Neutral as possible. All the interpretation, critical appraisals and appreciations should be trailed by specific reference of the article or previous work. 
• Personal Suggestions or advices are Not entertained in this section. 

                    Limitations of Narrative reviews

Though Narrative reviews are  great source of information, scientific communities argue that findings of Narrative reviews should be limited to educational purpose only. For Evidence synthesis, Narrative writing can be misleading. Likely reasons are pointed out below. 

1. The major pitfall lies in the process of making conclusions based upon limited sources. Most of the  time, reviewer only chose those studies which are likely to support his topic of interest. Hence, Drawing conclusions based upon Incomplete literature sources Leads to Bias. 
2. Since the Narrative review is non-systematic approach, Process  of extracting the information from original articles is always subjective and lacks the explicit Inclusion and exclusion criteria, which further aids Biasness. 
3. Generalizing the outcome is difficult if Patient populations involved in studies taken into consideration varies significantly in terms of demographics, Clinical Manifestations and outcome analysis. 
4. Since, Narratives are mainly descriptive, there is relatively general way of interpretation instead of quantitative analysis of results. 
   
5.  In case of Commentary writing, Authors opinion is likely to override the Actual data. This faulty conclusions can be carried out to next generations of researchers and can also influence the overall clinical practice if  the author is Influential enough. 

Should we still endorse Traditional Narrative Approach ? 

Straight forward answer for this question is "Yes",  we should make use of this approach specially while designing health policies. In most of the countries, their indigenous and traditional practices lack that level of competency to be included within rigid criteria of systematic review. As for example Ayurveda, Unani, Homeopathy and other allied heath practices are being effective since time but still lacks Researches like Randomized Controlled Trials Comparing with Placebo or conventional Medicines. In such scenario, Even small scale of Researches such as: Case studies, Case series, Observational studies, RCTs with small sample size, single armed clinical trials, Academic thesis works by postgraduates, Single molecular study conducted by Clinical pharmacist, Botanist, KAP ( knowledge, attitude and Practice) studies etc. can be taken into considerations to demonstrate efficacy of the practice and major Lacuna in these Approaches. Findings of such Narratives can be guidance in future to conduct Randomized controlled trial and other large scale research; on the other hand, Policy makers can also take into consideration while prioritizing National Health system based upon public and scientific impact. 

                                                                                                         Thank You !!!