A Medical Informatics Education, 1996.

Today I walked to UCD much as I did nearly 20 years ago on 21st September 1996, to begin college. This time I was walking not to Belfield itself, but to UCD Nexus, located a little further on in Belfield Office Park, for a meeting in my new roles as CCIO liaison to ARCH (if that’s too many acronyms, don’t ask)

Various nostalgic impressions mingled. Cyclists seem more aggressive than they were. UCD is a slicker operation and more given to self-promotion than it was. It had been a while since I had actually walked through campus; the last few times I had driven in, found parking near-impossible, gone to a meeting, and left. Belfield seemed to have become a bit like Docklands , a rather alienating landscape dominated by massive buildings without human scale.

 

Walking through, however, I find Belfield reassuringly unchanged at its core. The Science Block has greatly expanded, but the central lecture theatre structure is unchanged. The Arts Block, the fundamental library structure, the lake, the restaurant – all are different only superficially. The cafe that was officially known as “Finnegan’s Break” and was always called “Hilpers” is now gone.

I was also a little taken aback by how much human interaction there was. I expected serried ranks of screen-focused students. In the restaurant, I saw only one person texting while talking to here friends, and while that wouldn’t have happened in 1996, it would have in 2000. A few years ago there were PC terminals all over the place, which seem to have largely disappeared.

Given the nature of of the  meeting I was going to, I thought about one of the academic highlights of that first year of medicine; medical informatics. This was a subject which, frankly, was much derided. Why? Because it seemed irrelevant, I think, somewhat beneath those who knew anything much about computers and somewhat irksome to those who didn’t. Crucially, I can’t recall anything specifically medical about medical informatics.

We had lecturers on what a CPU was and so forth (more of which anon) and workshops on the use of Word, Excel, Access and the other Microsoft biggies at the time. The undoubted highpoint was the lecturer, Mel ´Ó Cinneide, suddently pulling  a mouse out of his pocket with the immortal words “for those who haven’t seen one, this is a mouse.”

Now, the wheel has come full circle; one wonders how many of a laptop and tablet focused cohort of students would have seen a mouse. UCD Netsoc was, for a few years, the only way to get internet access as a student, and the enthusiastic queued up from early morning to get an account.

As with many other pre clinical subjects at the time, Medical Informatices teaching was by academics in their specific discipline who no doubt found the prospect of teaching medical students even less enticing than teaching students who at least were pursuing the subject at more length.

In subsequent years, Medical Informatics was revamped and, I gather, made more clinically relevant. And now as Ireland slouches towards eHealth the relevance of IT to medicine is much more obvious. I am sure that Medical Informatics in UCD and equivalent courses in other medical schools is now taught in a clinically relevant, pedagogically sound manner with defined learning objectives and so forth. Nevertheless, I have my doubts that in twenty years anyone will recall a moment from this teaching as vividly as what would (mostly) be the class of 02 recall Mel whipping out the mouse.

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DUBLIN 1745-1922. Hospitals, spectacle and vice. By Gary A. Boyd. TLS, 30th June 2006

Thanks to Maren Meinhardt of the TLS, I have been getting the published text of pieces I have written for the TLS over the years. As it happens, a lot of these are from 2006, so a decade on, how do they stand up?

As a piece of prose, this is a rather sturdy, workmanlike review, with some clunky phrasing (“will find much of interest”)

The book deploys theory, as they say, in a way I was probably not all that familiar with at the time. It isn’t as effective as Susan Mat’s Homesickness: An American History in marrying a strong theoretical discussion with a readable, engaging narrative. Theory is often alienating, ironically since so much of it seems to be about power differentials and so forth.

Boyd’s work on Dublin reminds me of the previously-linked to posts by Philip Lawton at Ireland After Nama – as the review suggests the book goes well beyond 1922 until the present day – with the construction of a new Chidren’s Hospital and the ongoing closure of city centre hospitals this analysis is ripe for revisiting.

Medicine at the margins
Seamus Sweeney
Published: 30 June 2006
DUBLIN 1745-1922. Hospitals, spectacle and vice. By Gary A. Boyd. 224pp.

Dublin: Four Courts. Pounds 45 (paperback, Pounds 19.95). – 1 85182 960 1.

Georgian Dublin, to most Dubliners and tourists, evokes architectural splendour, an age of elegance and grace. It is often held up as a contrast to architectural and social developments in Dublin since, as an era of enlightenment and progress. Hospitals from the era such as the Rotunda, the first dedicated, purpose-built maternity hospital in the British Isles, and St Patrick’s, the “house for fools and mad”, founded with Jonathan Swift’s bequest, still retain their original function, or rather, still function as hospitals in today’s sense.

For this was an age in which the meaning of “hospital” underwent a change. Its derivation rooted in the Latin hospes, from which also come hospice, hostel and hotel; “hospital” in the medieval sense was not necessarily a place of cure or anything much by way of medical activity. It denoted a place that offered a wide range of possible services, from lodging and victuals to basic forms of care. They usually had an overtly religious mission. Dublin hospitals founded before the period covered by this book, such as the Foundling Hospital and the Royal Hospital Kilmainham, exemplified this older function.

It was also an age when “man midwives”, by stressing the dangers of parturition and the possibilities of a medical approach, were beginning to acquire respectability.
Nevertheless, obstetrics still stood in some disrepute. John Blunt’s evocatively titled treatise Man Midwifery Dissected; or the Obstetric Family Instructor, Containing A Display of the Management of Every Class of Labours by Men and Boy Midwives; also of their cunning, indecent and cruel Practices, proving that Man-Midwifery is a personal, a domestic and a national Evil typified this anxiety.

Homesickness: An American HistoryThis is the background to Gary A. Boyd’s architectural history -part of the Making of Dublin City series -which focuses on the Rotunda, or Lying-in Hospital, but is far from solely concerned with it. The book originated as an investigation of the relationship in the Dublin of today between the “official city” of civic buildings, monuments, museums, shops and galleries and an “unofficial city” of marginalized spaces; “alleyways, vacated buildings, empty lots” and the like. In the course of this, Boyd discovered that in any CCTV network, such as that which monitors the “cultural quarter” Temple Bar, whose culture now largely consists of stag and hen weekends and Sunday morning piles of vomitus, there are “shadow” zones which evade surveillance, due to various features of urban topography. Thus, “even in one of the most tightly controlled public areas of the city, therefore, certain uncontrollable and unpredictable activities existed”.

Boyd was moved to consider the lacunae in architectural histories of Dublin’s more famous and historic public spaces and buildings regarding the “uncontrollable and unpredictable” activities of those marginalized in traditional architectural historiography. This volume is an attempt to reclaim that human element. Boyd begins on June 4, 1751, with the Lord Mayor of Dublin and other dignitaries processing in state to the New Pleasure Gardens in what is now Parnell Street.

There Bartholomew Mosse, founder of the Lying-In Hospital, a man equal parts impresario and medic, supervised the laying of the foundation stone for what would become the Rotunda. Mosse threw an elaborate breakfast and “genteel and liberal entertainments” for the Lord Mayor and assembled gentry. This spectacle masked Mosse’s, and the hospital’s, precarious financial situation, and the New Pleasure Gardens would play an important role in hospital fundraising.

This incident typifies the close relation between spectacle and buildings with a public, ostensibly altruistic function. The new hospital did not simply serve a function as a maternity hospital, but acted as Palladian backdrop to the promenades in the New Pleasure Gardens. These Gardens were not just the site of elegant strolling, but of illicit assignations, what a later age would call “cruising”.

Thus begins a wide-ranging exploration of the tensions within Dublin, and within medicine, between medical function and issues of desire and social control. The dates given in the subtitle are somewhat misleading. The emphasis is very much on the early stages of the chronology. The book ends with a survey of the development of the red light area, Monto -which takes us to the 1940s rather than 1922, with Monto’s demise hastened by the work of Frank Duff’s Legion Of Mary.

Over the course of the book Boyd covers an impressively wide range of ground, from the work of the Wide Streets Commission, the Leeson Street Magdalen Asylum, the Lying-In Hospital’s admission certificate (reproduced in the book, with its rules including “That no Woman great with Child is to be received into the Hospital, if she hath any Contagious Distemper, or the Venereal Disorder”), the memoirs of the demi-mondaine Peg Plunkett aka Mrs Leeson, developments in hospital planning and management, the relationship between the military presence in Dublin and prostitution and many other topics.

Boyd’s analysis is influenced by Foucault’s conception of medicine as a locus of social control of deviancy, and by Murray Fraser’s work on the administration of late eighteenth-century Dublin. Fraser suggests that, rather than a simple expression of the power and pride of an Anglo-Irish elite, many developments in Dublin at the time resulted from the work of three powerful but conflicting bodies: the “Ascendancy” parliamentarians, the mercantile class, and the British administration in Dublin Castle. Fraser suggests that the work of the Wide Streets Commission, for instance, reflected a realignment of Irish interests with those of Britain.

Dublin 1745-1922 is lively and accessible -largely because Boyd quotes contemporary voices at length. His own prose style has enough wit and evident suspicion of the pieties of other ages and our own to keep the reader’s interest.

It is refreshing to read of issues that are often treated as purely medical or sociological from an architectural history perspective, albeit an architectural historiography strongly informed by social and political considerations. Some readers may find the influence of Foucault overbearing, and the occasional lapses into theoretical jargon somewhat off-putting (things are constantly “subverting” other things). Nevertheless, any Dubliner, anyone with an interest in the city’s history and development, or with an interest in the history of medical and obstetric practice, will find much of interest and find their impression of Georgian elegance modified.

Quality of Smartphone Apps Related to Panic Disorder

More discoveries from Planet Embase:

Quality of smartphone apps related to panic: smartphone apps have a growing role in health care. This study assessed the quality of English-language apps for panic disorder (PD) and compared paid and free apps. Keywords related to PD were entered into the Google Play Store search engine. Apps were assessed using the following quality indicators: accountability, interactivity, self-help score (the potential of smartphone apps to help users in daily life), and evidence-based content quality. The Brief DISCERN score and the criteria of the “Health on the Net” label were also used as content quality indicators as well as the number of downloads. Of 247 apps identified, 52 met all inclusion criteria. The content quality and self-help scores of these PD apps were poor. None of the assessed indicators were associated with payment status or number of downloads. Multiple linear regressions showed that the Brief DISCERN score significantly predicted the content quality and self-help scores. Poor content quality and self-help scores of PD smartphone apps highlight the gap between their technological potential and the overall quality of available products.

In this case, the full paper is available here . From the introduction:

 

A number of recent studies have assessed the quality of medically oriented apps in various fields, such as smoking cessation, weight management, sleep, cancer, and diabetes (1436). While acknowledging the potential opportunity offered by apps-related technologies, these studies concluded that the apps available from different stores, with few exceptions, were of overall poor quality. A gap was furthermore found between the considerable number of apps related to medical conditions available in stores and the low number of peer-reviewed papers about them (37). In particular, despite their potential to improve health care, mental health apps currently available in stores lack scientific evidence about their efficacy (38). With few exceptions (3941), preliminary findings reported for health apps were similar to previous findings on the poor quality of health information websites (4246).

Unsurprisingly then, the authors find that the quality of apps “for” Panic Disorder is …. poor.

 Despite expectations about the potential of PD apps to improve treatments (51, 52), the apps available to users from stores to date need to be improved and to include more patterns of evidence-based information, more interactive assessments, such as ecological momentary assessments (67), and more self-help options.

Crowds aren’t always wise:

Factors related to the community success of a given app, such as the number of downloads and whether the app was recommended, as well as factors linked to the economic model, such as payment status or a link to paid content, were not associated with content quality or self-help scores. This is somewhat surprising, particularly in regard to the number of downloads. One might expect better quality for the most downloaded apps. The results are possibly limited by the assessments of apps found only on the Google Play Store as well as by the small number of apps with a high amount of downloads (only three apps with more than 5000 downloads).

Sexual Dimorphism in Temporal Discrimination.

While EMBASE screening, one comes across abstracts of interest. I was a little struck by the following abstract. I am sure all sorts of hilarious one-liners suggest themselves relating to this study, but right now I can’t think of any:

The temporal discrimination threshold (TDT) is the shortest time interval at which two sensory stimuli presented sequentially are detected as asynchronous by the observer. TDTs are known to increase with age. Having previously observed shorter thresholds in young women than in men, in this work we sought to systematically examine the effect of sex and age on temporal discrimination. The aims of this study were to examine, in a large group of men and women aged 20-65 years, the distribution of TDTs with an analysis of the individual participant’s responses, assessing the “point of subjective equality” and the “just noticeable difference” (JND). These respectively assess sensitivity and accuracy of an individual’s response. In 175 participants (88 women) aged 20-65 years, temporal discrimination was faster in women than in men under the age of 40 years by a mean of approximately 13 ms. However, age-related decline in temporal discrimination was three times faster in women so that, in the age group of 40-65 years, the female superiority was reversed. The point of subjective equality showed a similar advantage in younger women and more marked age-related decline in women than men, as the TDT. JND values declined equally in both sexes, showing no sexual dimorphism. This observed sexual dimorphism in temporal discrimination is important for both (a) future clinical research assessing disordered mid-brain covert attention in basal-ganglia disorders, and (b) understanding the biology of this sexual dimorphism which may be genetic or hormonal.

Via the magic of Google ripping off the veil of anonymity which the abstracts are presented with on Embase is simplicity itself, and imagine my surprise when it turns out this paper came from a centre very familiar to me indeed. Go SVUH!

Reflections on this blog

Narcissistic as it is, I am thinking about this blog and its purpose. Originally, this was simply a personal curatorial project (as described in the original “Hello World” post WordPress helpfully sets up)  to try and identify common threads in my writings about medicine. I didn’t really think of any readership or wider dissemination.

It has evolved to be something else. I have tended to use this to post on various meetings, papers, and books I have read, with a medical focus. In particular I have posted on meetings such as the AMEE Hackathon and the CCIO . My CCIO role has developed somewhat and it is possible my blogging here may reflect this.

Blogging has been a more positive experience for me than it was in the past  – I have certainly found it a helpful medium to clarify my thoughts on various topics. It is also interesting that some posts have struck some kind of chord. I did not intend this blog initially to be what it has become. It will be interesting to see where things go.

“This book is dedicated to mental health nurses everywhere -the unsung heroes of psychiatry” – Dylan Evans, “The Utopia Experiment”

“The Utopia Experiment” is the story of Dylan Evans’ attempt to create an 18-month experiment in post apocalyptic living, in a remote part of Scotland. It was only after I finished reading it that I discovered I had heard of Dylan Evans before  (follow the link to find out why). “The Utopia Experiment” was the first time I had been genuinely impressed by an Amazon “You may also like…” recommendation – up to then this much-hyped feature (only Spotify’s “Discover Weekly” had heretofore impressed me) had always seemed to me quite banal, simply recommending books very like what you have already bought.

Anyhow, “The Utopia Experiment” is an interesting and absorbing read, with much to ponder on on the nature of progress and our hidden motivations . A relatively small part of the book deals with his time in a Scottish psychiatric hospital. Evans unravels over the course of the eponymous experiment, ultimately being admitted involuntarily (although, contra the impression gave by the blurb, he returns to the commune for a time after discharge)

Evans writes, early on:

A psychiatric hospital is a blunt instrument for treating mental illness. You take someone whose life has disintegrated and put them in a building with other lunatics. Once or twice a day you give them some medication, and once a week the doctor pays a visit. That’s more or less it.

This matter-of-fact, rather deadpan tone conveys much of the account of his admission. In his early days in the hospital, he found “my imagination conjuring up all sorts of fearful images of evil psychiatrists and brutal nurses”. The reality he describes is more mundane.

“This book is dedicated to mental health nurses everywhere -the unsung heroes of psychiatry” we read on the dedication page. Ironically enough, while there are three named doctors in his account of the hospital, but no nurse is named (even with what would presumably by a pseudonym) The consultant, Dr Satoshi, comes across as a sympathetic character who takes the trouble to read Evans’ online manifesto and steers him towards the work of Kazimierz Dabrowski on “positive disintegration.”

A typical sample of Evans’ account of hospital life follows the description of the hospital as a “blunt instrument” above:

 

It’s probably necessary to have some time for just resting, for not doing the crazy manic stuff that is likely to make things worse. But since mental illness often involves the loss of any daily routine, it is also important to rebuild some kind of structure. The nurses did their best to help me construct a rudimentary timetable, prodding me out of bed in the mornings, and taking me for occasional walks outside the hospital.

One time, a nurse spotted me pacing frantically around the courtyard, and came over the see if she could calm me down.

‘Don’t worry, Dylan. Things aren’t so bad. What’s the worst that can  happen?’

Perhaps the nurse thought I would conclude that the worst wasn’t all that bad after all, and cheer up. But this isn’t a good question to ask someone who has spent the past year worrying about the collapse of civilisation. It immediately prompted a cascade of rich visual images, culminating in a picture of me suffering a particularly horrible death.

For Evans, his focus on civilisational collapse was ultimately a manifestation of a previous depression, and he is strong on the misanthropic narcissism that underlies an awful lot of we-are-doomed rhetoric (from all parts of the political and cultural spectrum). There isn’t – or shouldn’t be – any necessary reason that an appreciation of the natural world (and a sense that our lives are often out of kilter with our true selves) should lead to apocalyptic fantasies of the destruction of (the rest of) humanity. Evans learns, in ways, to accept the mundanity of life and our (flawed) civilisation and (flawed) institutions. His description of life in the psychiatric hospital, a relatively small part of the overall narrative, is in ways a microcosm of his overall journey – from a media-mediated sense of apocalyptic dread to an appreciation of the “unsung heroes” of everyday life.

From “The Gap in The Curtain”, John Buchan (1932)

“The Professor  elicited from the coy Reggie that in his childhood he had been in the habit of seeing abstract things in a concrete form. For Reggie the different days of the week had each a special shape, and each of the Ten Commandments a special colour. Monday was a square and Saturday an oval, and Sunday a circle with a segment bitten out.; The Third Commandment was dark blue, and the Tenth a pale green with spots. Reggie had thought of Sin as a substance like black salt, and the Soul as something in the shape of a kidney bean.”

As well as an allusion to the Pythagorean belief that beans have souls, this is possibly a relatively early literary description of synaethesia – though Galton had discussed it in the 19th Century I wonder how many fictional portrayals of it there were?