“Wise pearls of refractive and cataract surgery revealed in charming style” review of 101 Pearls In Refractive, Cataract and Corneal Surgery. Eurotimes, Jan 2007

PDF of the original is here. I was always billed as “MD” by Eurotimes, despite repeated requests to change it on my part. This review is again fairly typical. My musings on evidence based practice and the possible return of clinical wisdom seem germane to the considerations I wrote about here . Credit to the subeditor for the haiku-like title (too many syllables though)

“Wise pearls of refractive and cataract surgery revealed in charming style”

There is something of a tradition in medical publishing of books claiming to provide “pearls” or “clinical gems” or “clinical secrets”.

These are never primary textbooks that could be used for study, but supplement basic knowledge, and mirror a learning technique of definite effectiveness.

We like to think the practice of medicine is a rational exercise, the application of knowledge gleaned from evidence-based sources and from a rigorous training in the basic sciences that underpin medicine.

The fact is, however, that our practice is very often based on the cases that stick in the mind, those that illustrate some point or other much more effectively than, let us be honest, any amount of high-minded praise of evidence-based practice.

After all, a little introspection will reveal that we remember the unusual, the striking, the individual, far more than the great mass of material we are instructed to recall. Of course, properly applied, evidence  basedpractice flows from the individual case to the peer-reviewed paper, and not the other way round.

Melki and Azar have assembled an international cast of contributors to produce this concise, clear, practical volume, which is aimed at practitioners and assumes a certain degree of familiarity with surgical technique, indication and practice. So this is a typical “pearls” book – not one for the student or the beginner but one for the active practitioner, guiding and advising the actual process of clinical medicine. In this case, the surgeon of the anterior chamber.

There is something charming and collegial about this approach, an approach that conjures up old-fashioned images of medical training and education as a body of knowledge handed down, apprenticeship style, from older practitioners to younger ones.The “pearls” book concept presumably began life as a compilation of the sayings of certain eminent clinicians.

Again, the current of medical education and training now – as well as reforms and/or tinkerings (delete according to taste) with medical training  – is towards self-directed,“problem-based” learning. Fashions change in medical training as much as any other field, and there is something to be said for the older approach. No doubt it will return to some degree.The notion of “expertise” of senior clinicians – or even not so senior ones – counting for much is old-fashioned in medicine.Yet have we lost something in the rush to elevate the meta-analysis of a series of double-blind randomised controlled trials as the measure of all things?

Claes H Dohlman, professor of ophthalmology at Harvard Medical School, contributes a foreword to this second edition as he did to the first edition. Dohlman writes of the apparent presumption of the editors in taking on three enormous areas in a single, relatively compact text.“However, instead of trying to grind through the topics in the traditional way, resulting in superficiality, the authors have cleverly singled out a series of discrete key issues along the cutting edge of this surgery.” Thus the “pearls” of the title.

So what are the pearls? Given that there are 101, the reader will forgive the absence of a list of each and every one.There are 25 subsections, aggregations of pearls so to speak, which begin with surgical planning with wavefront tomography and end with posterior keratoplasty. Each “pearl” is essentially a little section of text, with the accent on practical advice and issues, and at the end an “Always Remember” box succinctly summarises the crucial point. In between, every technical area is covered – as explained above and reiterated by Dohlman in his Foreword, this is not and does not claim to be a comprehensive textbook or, indeed, a manual of every single step of surgery, but a supplement to these sources. The pearls very often relate to the use of specific technologies in surgery, and practitioners may need familiarity with and indeed availability of these technologies to fully benefit from the book.

There is no doubt, however, that what is described is cutting edge, if the pun can be excused, and consistently reflects a high standard of practice which all practitioners should aim to emulate.The pearls also cover anaesthetic issues as well as those relating to particular points of surgical technique and preoperative work-up.

Thus, the relatively slim size and portability of the book. It is attractively presented, with good clear fonts on highquality paper, and a range of full-colour photographs and diagrams.The book I reviewed was a soft-cover edition with an attractively colourful cover. It is a snappy cover that reflects the snappy concept contained therein.

Overall, I was impressed with this book, which will complement comprehensive textbooks for the trainee ophthalmologist of the anterior section, with access to the technical innovations mentioned.

Psychiatry and Society blog – 2008-2011

This is far from my first effort at blogging. There was a blog about classical music concerts in Dublin which may still exist out there. There has been a now defunct blog on the University of Warwick site entitled “Philosophy as a Way of Life.” There was a blog called “Taytoman Agonistes” which still exists – it was basically a commonplace book. There has been Scarface Project, , which I tried to get people interested in There has been Alarm Logos of Dublin, which I also have tried to get people interested in

And there was Psychiatry and Society , which was linked with a series of lectures of the same name I organised for UCD undergraduate medical students. The blog was the subject of academic research as you can read here. To quote that abstract in full:

Blogs have achieved immense popularity in recent years. The interactive nature of blogs and other web-based tools seem consonant with contemporary pedagogical theories regarding student engagement, learner-centred teaching and deep learning. The literature on the use of blogs in education and in particular medical education has focused largely on their potential use rather than the practical experience of medical educators.

We designed a series of teaching sessions designed to explore the interface between psychiatry, mental health, and wider social issues.  To complement this course, a blog specifically designed to provide extra information on the material covered was produced, and to act as a forum for discussion. A widely available, free-to-access web based tool was used to create and design the blog. One of the course tutors was the administrator, and invited the other tutors and lecturers from the course to write on the blog. The blog was publicised at the students’ lectures, at which all the students were present, and via the students’ eLearning platform.

To fully assess the effectiveness of the blog in helping students achieve the learning objectives, quantitative measurements are required. A focus group of students was formed to explore medical students’ use of blogs for educational purposes in general, and the use of this blog in particular. These findings, and reflections on the use of the blog from the lecturer’s point of view, are presented

And that’s more or less what we did. The main “reflection” that has stuck with me in the years since was a comment from a participant that she preferred books as they were more interactive than online resources; you can simply underline, highlight and generally write on a book. This has stayed with me as an example of the paradox that “interactive” technology is “interactive” in very specific, designed ways.

The blog is still there in all its Blogspot glory. There isn’t all that much evidence of student interactivity, except here, predictably enough in a post about faith and delusion. I didn’t realise that there have been comments left in more recent years. I am not sure if any make all that much sense, even the ones which aren’t spam (and which are written in the patented Mr Angry YOU ARE JUST WRONG style so common in internet discourse)

Looking through the blog overall, I don’t find much that deserves to survive the inevitable disappearance of blogspot in a few years. I did come across this  amusing story again which reminds me of something else entirely I will (probably) post here. Looking back ,there is a tension between the blog as a sort of electronic notice board (ie lecture A will be on date B) and my attempts to post contact that would evoke comment. This never really panned out. I deliberately kept a lid on prolixity and looked for topics that I thought would be interesting for a diverse group of medical students. Of course, in retrospect, it would have been best to enlist a group of medical students to actually blog themselves. Those days have come and gone, and Web 2.0 is rather old hat now, but it was an interesting experiment.

Review of “Makers of Modern Medicine”, William Dormandy. Endeavour, June 2005

Original here

I wrote a few reviews for this journal of history of science – I think I lost confidence after having to confess a mistake in a review I wrote in the errata. I consulted Dormandy’s book more recently about something and founds it eccentricities a little off putting rather than charming.

Full-size image (13 K)

In recent years, historians in general and historians of science in particular have tended to shy away from approaching their subjects as ‘Great Men’ of history and providing a narrative account of their achievements. The story of science is no longer told as a series of eureka moments, with lone geniuses toiling away in the isolated pursuit of truth. Sociology, feminism and critiques of capitalism and imperialism – all have informed the new approach to scientific history.

Yet there seems to be an inexhaustible public demand for those Great Man (and, occasionally, Great Woman) stories. Books with titles like ‘The Man Who Changed Everything: The Life of James Clerk Maxwell’ and ‘The Man Who Invented the Twentieth Century: Nikola Tesla’ populate the shelves. The hunger that generates the demand for such books might reflect some deep-seated psychological need to believe in brilliant magi transforming the world. Perhaps it reflects a deeper truth: individual human beings do make breakthroughs and change practices, and although the more febrile romanticism of the Great Man school is evidently ridiculous, portraying science as the product of the interplay of impersonal social forces is equally misleading.

The subtitle of William Dormandy’s Moments of Truth: Four Creators of Modern Medicinesuggests that it is firmly of the Great-Man school. However, this is not the case. Dormandy firmly puts the lives of his subjects in their social and historical context, and explicitly states that it is necessary to do so in order to truly understand their achievements. His pithy, jaundiced tone is not one of blind obeisance to the ideas of progress and scientific omniscience, or to Great Men – self-proclaimed or elevated by others – in any sphere. However, Dormandy remains free from any ideological hang-ups and respects the individuality and humanity of his subjects.

The 19th century marked the birth of recognisably modern medicine. Dormandy has written about four medics whose lives spanned that century and, as they comprise a physician, an obstetrician, a surgeon and a pathologist, represent four major branches of medicine. He accepts a certain arbitrariness to his selection, but by covering the century and the fields that are the specialties of his subjects he hopes to achieve some kind of representative sample.

René Laennac was born in Brittany eight years before the fall of the Bastille in 1789 and would die of tuberculosis in 1825, four years after Napoleon. As well as engaging in epic battles with the blood-letters of the day, Laennac belonged to a new school of medical thinking that emphasized physical examination and the careful tabulation of results. He invented what would become the modern Caduceus: the stethoscope, thus earning his place in Dormandy’s quartet.

Ignác Semmelweis’ story is perhaps the best known of the four ‘creators’ among contemporary medical students. The Vienna hospital this Hungarian obstetrician worked in was divided into a section for wealthier women staffed by doctors, and a section for poor women staffed by midwives. There was a much higher rate of fatal puerperal fever among the wealthier women, and Semmelweis eventually proved that this was due to infection from necrotic material brought in to the ward by doctors from dissections they had conducted in the mortuary. This idea met with much resistance, owing to the medical politics of the era as well as Semmelweis’ abrasive nature.

Joseph Lister developed the principles of antisepsis; the careful avoidance of any possible source of infection during surgery that explains the ritual ‘scrubbing in’ of surgeons today. Walter Reed completes the quartet, and was a pathologist with the US Army Medical Corps. He established that yellow fever was spread by mosquitoes while he was working in Cuba, and this discovery helped to establish principles of modern infection control and prevention.

All four of these men were serious minded, and felt that they were in the vanguard of a new kind of medicine blowing away the superstition and stuffiness of the past. Dying young seems to be as beneficial for a posthumous reputation in medicine as in rock’n’roll or the movies. Of the four, only Lister had a long life, and Dormandy describes his evolution into ‘a slightly petulant enemy of many “new fangled” notions’.

As that little sample indicates, Moments of Truth is a pleasure to read. The writing is fresh and stimulating, judicious but unafraid of bracing judgement. The footnotes are as entertaining, if not more so, than the text itself. Indeed, I found myself with one hand wedged firmly in the back of the book to make sure I didn’t miss a trick. Another attractive feature of the book is a certain warmth and sympathy that is infused into the writing. Some medical histories read like the abstract manipulation of official memoranda and minutes, with the intention of proving some ideological or theoretical point or other – Dormandy’s stories are of living, breathing patients and doctors.