A large number of taxonomies are used to rate the quality of an individual study and the strength of a recommendation based on a body of evidence. We have developed a new grading scale that will be used by several family medicine and primary care journals (required or optional), with the goal of allowing readers to learn one taxonomy that will apply to many sources of evidence. Our scale is called the Strength of Recommendation Taxonomy. It addresses the quality, quantity, and consistency of evidence and allows authors to rate individual studies or bodies of evidence. The taxonomy is built around the information mastery framework, which emphasizes the use of patient-oriented outcomes that measure changes in morbidity or mortality. An A-level recommendation is based on consistent and good quality patient-oriented evidence; a B-level recommendation is based on inconsistent or limited quality patientoriented evidence; and a C-level recommendation is based on consensus, usual practice, opinion, disease-oriented evidence, or case series for studies of diagnosis, treatment, prevention, or screening. Levels of evidence from 1 to 3 for individual studies also are defined. We hope that consistent use of this taxonomy will improve the ability of authors and readers to communicate about the translation of research into practice. Review articles (or overviews) are highly valued by physicians as a way to keep up to date with the medical literature. Sometimes, though, these articles are based more on the authors' personal experience, or anecdotes, or incomplete surveys of the literature than on a comprehensive collection of the best available evidence. As a result, there is an ongoing effort in the medical publishing field to improve the quality of review articles through the use of more explicit grading of the strength of evidence on which recommendations are based.

Practical recommendations for timely, accurate diagnosis of symptomatic Alzheimer's disease (MCI and dementia) in primary care: a review and synthesis (Review).

PURPOSE The purpose of this study was to explore the responses of primary care clinicians to patients who complain of symptoms that might indicate depression, to examine the clinical strategies used by clinicians to recognize depression, and to identify the conditions that infl uence their ability to do so. METHODSThe grounded theory method was used for data collection and analysis. In-depth, in-person interviews were conducted with a purposeful sample of 8 clinicians. All interviews were audiotaped and transcribed.RESULTS This study identifi ed 3 processes clinicians engage in to recognize depression-ruling out, opening the door, and recognizing the person-and 3 conditions-familiarity with the patient, general clinical experience, and time availability-that infl uence how each of the processes is used. CONCLUSIONSThe likelihood of accurately diagnosing depression and the timeliness of the diagnosis are highly infl uenced by the conditions within which clinicians practice. Productivity expectations in primary care will continue to undermine the identifi cation and treatment of depression if they fail to take into consideration the factors that infl uence such care.

Metaphors offer exciting opportunities to identify and explore tacit knowledge and behavior that are embedded in complex organizations and shape health care practices. In this article, the authors explore the theoretical rationale, background, and advantages of using metaphor as an analytic strategy in qualitative health research. They used an analysis of 18 practices in a comparative case study designed to explore office practice strategies for delivering cancer prevention services for illustrations. During the individual and comparative stages of the analysis process, researchers heeded the metaphors that they used in their descriptive language of practices. The authors explore examples showing how metaphors clarify unwritten assumptions, values, and motivators that shape variations in practice behavior.