I have finished Evidence Based Medicine (for a while)

This evening, I logged on to do some Embase screening:

embase

Noting that there were a mere 100 records to screen, I worked away for a while, until:

embaseoneleft

 

With bated breath I screen the one remaining record (naturally enough, a Reject verdict), and after a bit of deliberation clicked on “Save and Exit”, to discover that :

victoryembase

 

Of course, I know that a gigantic batch of records will no doubt be delivered to Embase for screening, if it hasn’t already (and I am probably misunderstanding something even more basic) but, for the moment, there is a pleasing sensation of having reached the ultimate extreme of human knowledge (only mild hyperbole here!)

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Great moments in personality research: Study of the personality of patients with spontaneous pneumothorax

If it wasn’t for EMBASE screening, I would never have come across this gem:

 

Study of the personality of patients with spontaneous pneumothorax

Martín Martín M1, Cuesta Serrahima L, Rami Porta R, Soler Insa P, Mateu Navarro M.

INTRODUCTION:
Medical psychology has contributed to a greater understanding of many diseases that are predominantly medical and has also helped to improve prognosis. This study explores a surgical entity, namely spontaneous pneumothorax.
OBJECTIVES:
The aim was to compare the personality, depression, anxiety and type-A behavior pattern in a group of 34 patients with spontaneous pneumothorax to a group of 33 control patients admitted for a variety of minor surgical procedures.
MATERIAL AND METHODS:
The following objective assessment instruments were used: Trait Anxiety Inventory, Beck Depression Inventory, Jenkins Activity Inventory, Eysenck Personality Questionnaire. The questionnaires were administered before the intervention of the surgeon and after an informative interview.
RESULTS:
The rate of type-A behavior was statistically different in the two groups. No differences were seen for personality, depression or anxiety.
CONCLUSION:
We conclude that type-A behavior patterns should be reduced in patients who suffer spontaneous pneumothorax in order to improve outcome.

I love that sweeping conclusion “type-A behaviour patterns should be reduced” – just like that! – but also admire the researchers choice of an apparently unpromising area to research. I will try, if I have time, to read the original paper.

Information Transforms Medicine For Me: ItsMe2, the “digital me”, the future of health care, Big Big Science and me.

itsme2

My recent musings on visions of future healthcare reminded me of a project I was involved in five years ago. This is a long, involved story, so bear with me.

It began in very early 2010, when I came across a link on a BBC news web page. I have been trying to find the particular BBC story without success; I recall it involving Polish researchers and quantum computing in some way. Anyway, the link lead to the European Commission’s CORDIS portal, and some surfing later I found a page on the Future And Emerging Technologies Flagships project.

FET Flagships are:

 

“ambitious large-scale, science-driven, research initiatives that aim to achieve a visionary goal.
The scientific advance should provide a strong and broad basis for future technological innovation and economic exploitation
in a variety of areas, as well as novel benefits for society.”

The site also mentioned they would have a budget of 100 million euros per year, for ten years.

At the time I had been working on various medical education projects and was coming to the end of my Masters in Medical Education from University of Dundee. I had come to the conclusion that many of the outstanding questions in medical education required a massive, long term, cohort approach. Meaningful work on issues like medical school selection and retention, or the introduction of technology into medical education that truly improved patient outcomes, required long-term studies, rather the short-term surveys and pilots that seemed to dominate the field.

The Flagship call was simply an online form. I used my role with the psychiatry section of RAMI as an institutional cover. At the time, I was a Senior Registrar in St Brigid’s, Ardee, and while I will still quite closely linked with UCD, I had no formal role in any third level institution. I fill out the online form really as a way of getting my own thoughts on the topic together.

I was surprised to get an email, a few days later, inviting me to present at a Flagship workshop in Brussels. At first, I thought this was impossible. Then I realised that it was far from impossible – as it happened the workshop was on my research day. I booked a flight to Brussels and the rest is …. well, not quite history, but nevertheless remains online 

transforming medical education

 

The content of my slides is presented below with some comments after each quote – the headings are those of the Flagship application form:

Idea

TRANSFORM MEDICAL EDUCATION •

ICT in medical teaching – from video‐based Virtual Patient to fully immersive Virtual Clinical Environment

• Long term, multicentre, multidisciplinary assessment of impact of Virtual Clinical Environment on students from pre‐intake to established practice

• assessing every aspect of their acquisition and development of information related to knowledge, skills and attitudes using technology as well as other teaching methods.

This is in some ways the most straightforward part of the story. I was not – and am not – predominantly interested in what technology can do for practice, but what constitutes good practice. I am pro-technology if it helps good practice and good outcomes, and anti-technology if it leads to bad practice and bad outcomes.

Ambition •

2020 – “major societal goal is to live longer in better health, in a secure environment and in prosperous conditions” – ISTAG (ICT Advisory Group), July 2009.

• Developing of plausible, fully interactive, immersive, “presence” ‐laden virtual environments

• Difficulty in assessing behavioural change and positive clinical outcome due to educational interventions – require long term, broad evaluation integrating approaches of social science and humanities

• Applicable to other educational contexts

All very worthy, I’m sure you will agree. The EC Cordis ICT Advisory Group was touted very much as the shaping force of this Flagship idea, so I thought it was good to mention them.

Impact

• Health is now one of the biggest issues affecting competitiveness, ongoing sustainabiltiy, and society overall

• High fiscal cost of medical education

• High fiscal, social and mortality/morbidity cost of medical mistakes and missed health promotion opportunities.

• Importance of medical research – a s well as producing clinicians, producing hypothesis generators and research workers.

• Medical education – training practitioners and researchers. Integrates many disciplines.

• Wider impact on education and training generally

Very much in the motherhood-and-apple-pie camp. I have to say I like the phrase “producing hypothesis generators and research workers.”

Integration

• Medicine is transdisciplinary by nature

• Four proposed strands

—• ICT developing immersive virtual teaching environments & other innovations

—• clinical research into practice outcomes

—• educational – integrating and evaluating ICT and other innovative teaching methods

—• information science /social studies – th e entire process of becoming a doctor in social, anthropological, information ‐management and other contexts

All of this is proof I do not lack for grandiosity (at least in some settings)

Plausibility

• Medicine and medical education are EU Strengths

• Much work already throughout EU on each strand (see next slide)

• Long term approach required to assess clinical outcomes of medical educational innovations

• All students entering the project would be subject, to baseline assessments and follow up of academic performance and clinical performance. Individual institutions will be part of the other strands to differing degrees

• Unified approach relating ICT innovation to educational, clinical and social outcomes

(see next slide) indeed – though this was where things were about to get even more intereste

 

Expected support

• AMEE and other medical educator networks

• Virtual Patient project http://www.virtualpatients.eu

• INMEDEA – virtual clinical environment

• MedBiquitous Europe – technical standards for eLearning

• Focus on clinical outcomes – support of Departments of Health, health insurers • Humanities departments as well as ICT/Medical departments of Universities

Need I say that absolutely none of these stakeholders knew the slightest thing about my Massive Grandiose Plan?

This is what I presented at the workshop in Brussels on January 22nd, 2010. The day featured lots of interesting, and in fairness quite frank, discussion as to whether this whole flagship thing was a good idea or not. CORDIS were upfront that they wanted projects that were man-on-the-moon, Human Genome Project style ones which would grab public attention and media coverage. Someone pointed out that putting a man on the moon was useless, although they wouldn’t sniff at the HGP – someone else immediately pointed out that the moon landings gave the USA a continuing advantage in aerospace technology, while the HGP had yet to yield a single treatment for any illness.

The day also featured one of the most impressive – scratch that, THE most impressive – presentations I have seen, from Henry Markram, then of IBM’s Blue Brain Project . Markram will feature a little further on in our story – suffice it to say that he did not skimp on any of the challenges or philosophical implications of the proposal to simulate the brain in toto.

In any case, the upshot of the Workshop was that no one had come into the room with a big enough idea. I was not at all surprised – after all, I did not expect (except in wilder dreams, perhaps) that funding medical education research was anywhere like as exciting as Neil Armstrong landing on the moon. It was then things got interesting, but also that my own role began to change.

I decided to contact some of the stakeholders I had so blithely included on my slide, particular the European Virtual Patients project. I emailed Terry Poulton and Chara Balasubramaniam of St Georges University of London in semi-apologetic form. One of my worries that I had misread the state of virtual patients badly, and arrogantly, and that my contentions would be laughed out of court.

 

It was flattering to find Terry and Chara seeing this project as a potential opportunity. They also recruited Panagiotis Bamidis , who had been involved in the eLearning standard-setting Meducator Project , and we had a series of fruitful discussions on the phone and via various online meeting platforms. Terry took on the reins of presenting at the next workshop, which was in Barcelona.

At this juncture my own professional situation was asserting itself. I was coming to the end of Higher Specialist Training in Psychiatry. I didn’t have  a job come July 2010. I didn’t have budget to travel to conferences that weren’t specifically training related. I had no real institutional affiliation or position, and nothing much to bring to the table of proposals except a song in my heart and a smile on my face. I emailed various stakeholders in Ireland, and had interesting meetings with Science Foundation Ireland, the National Digital Research Centre, and various other research institutes in Ireland. A billion euro project does tend to attract interest. However, what did I have to offer? Keep in touch was the generally encouraging word. And I was not sure how all this would go down in terms of applying for what were primarily clinical jobs, on a CV that already featured its share of somewhat atypical entries. Perhaps more crucially, I didn’t feel I could take the time out, as I was in the position of needing to get locum work  (this was 2010 – now the power is much more with the locum) in the near future.

 

Things moved apace. Terry found synergies with the Virtual Physiological Human project and Prof Hans Lemke’s Computer Assisted Radiology and Surgery project, both of which had entered proposed FET Flagship ideas. These three arms coalesced into a proposal for a project for a “medical avatar”, a “digital me” that would initially be developed for educational purposes but would gradually become a combination of personal electronic health record and personalised health simulator.

At this point I was in a locum position in Cork. Finally one of my meetings paid off, and Prof George Shorten, the new Dean of the UCC Medical School, was interested in a more tangible way in the project. This involved making me a Visiting Fellow of UCC Medical School. Unfortunately, most of the connections had been made, and I still did not have much specific to “bring to the table.”

Nevertheless the project continued, and that December I found myself in a B& B in Ardee, Co Louth, stranded by the snow, working with a range of random collaborators around Europe on the proposal which became called ItsMe2. A screenshot above shows the first page of the 313-page PDF.  This, from the proposal abstract, gives a flavour of what my medical education project had become:

The ITsMe2 Preparatory Action will meet the most pressing socio-economic challenge of European societies: the sustainability and reform of our health and care systems. It designs a long-term roadmap for a FET-Flagship Initiative that develops radically new, integrative, ICT-facilitated models and solutions for delivering well-being and health services to global citizens. The ICT challenges this poses are far beyond current frontiers in user interfaces, physiological modelling, simulation, computer facilities, data storage, interoperability, educational and training support.

ITsMe2 will realise the most advanced “virtual” entity (or avatar) on Earth, a highly advanced digital representation of every individual that stays with us for life, evolving, ‘learning’, becoming an increasingly personalised description of our anatomy, physiology, emotional and physical-socialenvironment as new data and information becomes available. This requires a novel IT infrastructure to manage and integrate the exploding quantities of data, information, knowledge and wisdom far beyond presently dominating somatic aspects. Health policy experts and business modelling will support transfer towards innovation and exploitation.

Is that too modest a goal? Let’s have another go:

Our aims are the construction of an avatar, a digital representation of each and every individual that stays with us for life, evolving, ‘learning’, becoming an increasingly accurate personalised description of our anatomy, physiology and even emotional make-up as new data and information becomes available to populate these characteristics, and secondly the construction of the new IT infrastructure that will be required to manage and to integrate the exploding quantities of data, information, knowledge and wisdom, to evolve data into wisdom, and to present them to the individual user (citizen, patient, healthcare professional,…) in a manner that is intuitive and usable

I didn’t write this 313 page proposal. I did write a few parts, suggested a few changes, made a few edits. I was one of the people on the 2nd of December working on this as the deadline approached, although really just as a quasi-proof reader. It was a strange experience being in Ardee, collaborating with researchers in Norway and Sheffield and Barcelona

Now I am somewhat allergic to excessive use of the word “revolutionise.” This  may have been a kind of  reaction formation to being associated with the ItsMe2 proposal:

Revolutionise healthcare by extending Evidence-Based Medicine into Explanation-based
Medicine, by deploying these radically innovative technologies into the European industrial and
healthcare system, and assess their efficacies;

– Revolutionise healthcare through Information and Communication Technologies to make possible
a complete digitalisation, a complete integration, and an ubiquitous but secure access to every data,
information, and knowledge relative to the wellness, the prevention, and the healthcare of every citizen
of Europe;

– Revolutionise the vision and the culture of all key stakeholders and of the public opinion on the
role of ICT in wellness, prevention and healthcare, by training and re-training the medical
professionals, and by orienting the policy makers and the public opinion.

– Revolutionise the business model to support research and innovation in wellness, prevention and
health care as is mandatory to overcome the current IT stagnation in healthcare, by leverage
mechanisms
that induce co-investment from the member states paralleling EC investments and
overcome the challenges associated with the scale of ambition of a paradigm shift in healthcare
infrastructures.

We didn’t make the cut for the next stage – the “preparatory action.” The final Flagships were on Graphene and the Human Brain Project. Henry  Markram is leading this, and has had the inevitable troubles with managing a project of this nature . I had looked at the HBP page a while back, hoping for something to do, but my connectome skills aren’t what they were.

ItsMe2 seems to have more or less vanished from the Internet, yet another salutary warning of the dangers of overdependence on the cloud as an outboard memory. The VPH/AMEE link persisted. I sometimes wish i had been able to be more active in the development of this project. Thinking about visions of healthcare, ItsMe2 was certainly a grand vision; personally one I would now modify . And in a way it became something far far different than anything I had thought of, with less of an emphasis on anthropology, social science, philosophy etc.

Nevertheless, now I am involved in the HSE CCIO , I find myself wondering if this grand vision is one that we could usefully learn from again. It is over five years since I sat in a B&B room in Ardee with my laptop and wifi dongle. In some ways the world is very different, but in many it feels similar – the way I work is recognisably that of 2010 (and before) and, for all the pace of change, the ItsMe2 vision does not seem any closer.

 

Technology Symposium at the International Psychogeriatic Association, Berlin, October 14th 2015.

( I  began writing this post just after the meeting but for various reasons didn’t complete it. I have decided to leave the beginning unchanged despite the overlap with a more recent post)

 

Following on from my prior posts from a Hackathon , a CCIO meeting , and a symposium on trial methodology , I am going to continue using this blog as a sort of reflective journal on various meetings I go to. The technology/healthcare interface seems to be the main topic of these meetings.  There also seems to be a certain evolution here – from tech evangelisation at the Hackathon, to more sober tech governance/implementation at the CCIO, to the trial methodology symposium’s more tangential take on technology … and now to a big, grown-up (not that the other meetings weren’t grown up) international meetings.

I went to the International Psychogeriatric Association meeting in Berlin – the main focus of which is clinical factors relating to psychiatry of later life (or old age psychiatry, or psychogeriatrics, or older adult mental  health, or whatever combination of those words suits) – there was however a symposium session on technology in this field. This symposium doesn’t have any kind of microsite I can direct you to – just the general International Psychogeriatric Association page and you can scroll down to see the details of the speakers.

Assistive technology is one of those areas which is subject every so often to breathless pieces in the papers about the latest somewhat sinister developments in Japan. (that is as far as my first draft went! The rest is written some weeks later)

What was impressive about all three speakers was their seeming immunity to some of the more hype-ish aspects of this field. The first speaker was  Josien Shuurmans  of the Dutch-led eCare@home – which involves “Tablet-Based Ambient Assistance for Older Adults with Bipolar Disorder or Recurrent Depressive Episodes” Shuurmans gave a presentation which covered the pitfalls as well as the promise of such a project, particular the multinational ones which the European Union are so fond of funding. She described a very user-focused project – among the learnings she conveyed was the importance of ensuring clinicians bought into the project and were comfortable with the technology as well. Listening to her, eCare@home sounded like something that could be beneficial at any age, so I asked her how age-specific it is. It turns out certain features such as the visual design do take into account eyesight issues and motor skills issues, but these apply to any age group, especially given the general health issues that often accompany psychiatric issues.
Next was Maurice Mulvenna , Professor Computer Science in the University of Ulster. His speech was specifically on  “Monitoring and Analysis of Sleep Patterns of People with Dementia” but was a much more wide ranging and stimulating talk, which included this great image which says so so much about design vs the user experience. Mulvenna discussed the pitfalls (again!) of the apparently straightforward process of monitoring the sleep patterns of people with dementia, touching on a wide range of issues.
Finally Jeffrey Soar of the University of Queensland, with a vast range of experience in healthcare and in evaluation of technology in health care  – his talk was on “Technological Support for Dementia and Ageing” the meat of which was discussing the process of evaluating assisted living technologies, and what works and what doesn’t. This is an area in which the initial hype has been tempered by experience. What doesn’t work is perhaps easier to define than what works – solutions imposed by well meaning family  (or wider society) without consideration of the person’s own wishes or desires, and technology-focused approaches that can do cool things but perhaps aren’t really what the person wants. One of Prof Soar’s observations has already re-shaped my vision of what healthcare could be so I guess that’s a tribute.

 

My struggle against EMBASE Screening addiction

Ok, the headline is a little glib, and I don’t want to make fun of any actual addiction – but since discovering EMBASE screening at a HRB TMRN event on systematic reviews on Thursday last, I’ve been hooked.
EMBASE screening is very simple – as the Cochrane Collaboration Community Page on the project states “The project’s purpose is to identify reports of randomised controlled trials (RCTs) and quasi-RCTs from EMBASE for publication in the Cochrane Central Register of Controlled Trials (CENTRAL)” Put simply , “The EMBASE project provides an opportunity for new and potential contributors to get involved with Cochrane work by diving into a task that needs doing. No prior experience is necessary as the task supports a ‘learn as you do’ approach. ”

 

Basically the screener is presented with a title and abstract (occasionally just a title) and has to decide if this is an RCT/quasi-RCT, definitely not an RCT/quasi-RCT, or impossible to tell. There are lots of checks and balances so one shouldn’t worry about making a mistake. The interface is very simple and a good, clear training module is provided before you get stuck it.

This is a much better way of passing a few minutes with a smart phone than checking news sites again or again, or whatever your poison is…. and along the way I have come across some intriguing abstracts such as this and this (neither of which is a RCT)

 

 

Every sufficiently advanced little thing she does is indistinguishable from magic

This has been the longest hiatus on this blog so far, and  my last post on November 19th wasn’t exactly a deep meditation on anything.

I am hoping to re-invigorate things a little by successively blogging about three events I attended in the recent past – one last week, one the week before that, and one way back in October. Thinking about it I think this blog will increasingly become a platform for me to working out my thoughts on various matters relating to the intersection of technology and healthcare, medical education, and evidence-based practice/methodology questions. More general writing and “curation” of my old writing will appear on my other blog

On November 25th I attended another meeting of the CCIO, following on from the last one in September. The same caveat (“not only are these opinions not those of the CCIO, the HSE, or any other institution I may have links with, they are barely even those of myself.”) applies.

Unfortunately I couldn’t make the entire day so missed some of the morning session. I was fortunate enough to catch the talk by Robert Cooke , IT Delivery Director for Community Health, which encompasses my own professional area of mental health. As Robert said in his presentation infrastructure-wise particularly, mental health is starting from a low base for eHealth – and therefore infrastructure development is an important place to start.

As with pretty much all of the presentations I have seen at the CCIO Robert’s was particularly impressive in its blend of enthusiasm and a tough-minded realism about the size of the challenge. No one at these meetings is getting up and announcing that tech will magically sort out what ails healthcare. Indeed Robert strongly made the point that systems and processes need to be addressed before technology is applied, rather than waiting for it to be a magic bullet.

There were other very interesting presentations but the highlight was the breakaway group. In a relatively small group myself and three other CCIO members were facilitated in addressing  a) our vision for what eHealth could make the healthcare system look like in five years time, b) what barriers and enablers exist relating to this vision, and c) what would need to change. This exercise was part of the work UCD’s Applied Research in Connected Health team are doing on Ireland’s eHealth journey. As often happens, the discussion was so stimulating that we didn’t get to c) (and barely covered b) in time)

During the discussions about “the vision thing”, the famous Arthur C Clarke quote ““Any Sufficiently Advanced Technology Is Indistinguishable From Magic” kept coming into my mind, along with a memory of a point about Assisted Living Technologies made by Jeffrey Soar at the International Psychogeriatric Association congress in Berlin (which I drafted a blog post on and hope to actually complete very shortly) – those assisted living technologies that are successful are unobtrusive, in the background, invisible.

So much was the Arthur C Clarke quote going round my mind I was impelled to tweet it:

It turned out when I tweeted this that an extremely witty twist on the quote has already been minted:

So my vision for the future of healthcare is sitting in a room talking to someone, without a table or a barrier between us, with the appropriate information about that person in front of me (but not a bulky set of notes, or desktop computer, or distracting handheld device) in whatever form is more convivial to communication between us. We discuss whatever it is that has that person with me on that day, what they want from the interaction, what they want in the long term as well as the short term. In conversation we agree on a plan, if a “plan” is what emerges (perhaps, after all, the plan will be no plan) – perhaps referral onto others, perhaps certain investigations, perhaps changes to treatment. At the end, I am presented with a summary of this interaction and of the plan, prepared by a sufficiently advanced technology invisible during the interaction, which myself and the other person can agree on. And if so, the referrals happen, the investigations are ordered, and all the other things that now involve filling out carbon-copy forms and in one healthcare future will involve clicking through drop-down menus, just happen.

 

That’s it.