The inspirational imperative

“Inspirational” and its derivatives has replaced “passionate” as a CV-staple. “Inspirational” has also become a clickbait-staple. My Twitter feed seems to sag under the burden of just so many “inspirational” and “inspiring” links. “Inspiration”, “inspiring”, “inspirational” – all join “disruptive”, “revolutionary”, “transformational” in the Overused Lexicon.

Recently a video circulated online (OK, “went viral”) of a woman with terminal illness being interviewed by Ryan Tubridy on The Late Late Show. While her own determination to live every moment is entirely admirable, I do wonder if the cult of Inspiration can put pressure on people in this situation (and many others) to Be An Inspiration. Winston Churchill’s battles with the “black dog” of depression are often held up as inspiring – look what he achieved despite his depression! – but this can be demoralising – look what he achieved despite his depression, so why can’t I? Cue guilty spiral…

Currently Sir Bradley Wiggins is facing serious questions about his use of Therapeutic Use Exemptions. Cycling seems a sport that, even more than others, is bound up with a culture of Being Inspirational (perhaps this is because cycling does seem to small-i inspire many adults to take up the bike themselves, in a way watching professional football, for example, doesn’t) . One of the reasons Lance Armstrong got away with his drug cheating was the Inspirational Story he was able to wrap himself in, and a natural reluctance on the part of many to burst an Inspirational bubble.

Much of the discourse online about eHealth can take a similarly  Inspirational Above All turn. Perhaps this is another example of how the can-do, market-focused, startup culture of tech conflicts with the more restrained, evidence-focused, small-c conservative world of healthcare.

 

 

#flicishere, the #IoT and invisible health IT

 

#Hereisflic! Flic is a wireless smart button “for your smartphone, smarthome and smartlife” as the website puts it. While I am rather deficient in the smarthome and smartlife departments, I do have a smartphone and had an enjoyable evening playing around with Flics. A Flic is a little button – the pack above contained 4:

 

Each is a pleasingly solid little artefact. Put very simply, there are three ways of pressing the Flic – single click, double click, and hold. Each of these can be linked with an action of your smartphone (or smarthome devices/system) or using If This, Then That a whole range of other apps and devices:

Playing around with Flic was great fun and had that you-can-do-that? factor which I don’t get all that much with technology any more. Indeed, messing around with Flic got me thinking of grandiose, utopian vision of healthcare (I suspect some of my aversion to grandiose, utopian visions of technology and healthcare is pure reaction formation. And obviously my grandiose, utopian vision is better than everyone else’s grandiose, utopian vision) – which to recap was:

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.

I suppose putting flesh on those bones would involve a speech to text system that would convert the clinical encounter into a summary form “for the notes” (and for a summary letter for the person themselves, and the GP letter, and for the referrals) – perhaps some key phrases would be linked with certain formulations and phrases (to a great degree medical notes, even in psychiatry, are rather formulaic) – with of course capacity or editing and adding in free text. While clicking Flic-type devices during a consultation would be distracting, a set of different Flic type buttons with different clinical actions – ie contact psychologist to request a discussion on this patient, make provisional referral to dietitian, text community nurse to arrange a phone call – would certainly smoothen things much more than the carbon-copy world I currently live in.

When I wrote the above vision I was not familiar with the illustration Bob Wachter uses in his talks of a young girls picture of her trip to the doctor:

Turned away, tapping at a keyboard, disengaged from the family. That is what technology should not facilitate. Perhaps the internet of things could be a way of realising my particular grandiose vision of invisible Health IT.

Random thoughts on the media and healthcare

Every so often some one wonders aloud where there isn’t more good news reported. The BBC host Martyn Lewis , for instance, has been prominent in this, no doubt tired of having to read out news scripts full of doom and gloom during his career. Indeed, I discovered when looking up Martyn Lewis’ stance the site Positive News, which is all about Positive News.

And yet, the Daily Mail – which whatever else one can say, does not exactly put a positive, shiny, happy spin on the news – is the world’s most popular news website. We may say otherwise when asked, but we are drawn to the disastrous and doomy, or at least what can be portrayed as disastrous and doomy.

 

Someone – maybe Neil Postman – once observed that trust in media tends to erode dramatically when one considers the media coverage of something one actually knows about. If the media doesn’t get My Area right, why should I trust them on economics, or politics, or healthcare? This is even more pronounced in the current age where high-quality information on any technical topic is easily accessible with a little effort; the oft-lazy, unnuanced approach of much media. This is the other side of the clickbait we are drowning in.

In health care, there are a vast amount of interactions the vast majority of which are unremarkable or positive. Yet these don’t – and probably will never – get reported. Positive initiatives will get some media coverage  but this will be drowned out by controversy and scandal. This is the way of the world, and clearly has a role in ensuring good practice. One must also recognise, however, that this can distort our view not only of healthcare practice but of what we want to achieve. “Staying out of the papers” becomes an aim in itself, and leads to a reluctance to engage in any positive discourse for fear of being portrayed as pollyannaish or indifferent.

Interestingly, as a coda to these brief thoughts, consistently polls in Ireland find that doctors are the most trusted profession – in 2016 and in 2011. The comparative figures for other professions – especially the media and TDs – are interesting!

 

 

 

“The slaves of some defunct economist”

“… the ideas of economists and political philosophers, both when they are right and when they are wrong, are more powerful than is commonly understood. Indeed the world is ruled by little else. Practical men, who believe themselves to be quite exempt from any intellectual influence, are usually the slaves of some defunct economist. Madmen in authority, who hear voices in the air, are distilling their frenzy from some academic scribbler of a few years back. I am sure that the power of vested interests is vastly exaggerated compared with the gradual encroachment of ideas. Not, indeed, immediately, but after a certain interval; for in the field of economic and political philosophy there are not many who are influenced by new theories after they are twenty-five or thirty years of age, so that the ideas which civil servants and politicians and even agitators apply to current events are not likely to be the newest. But, soon or late, it is ideas, not vested interests, which are dangerous for good or evil.” John Maynard Keynes, The General Theory of Employment, Interest and Money (pp. 383–4))

This famous quote from Keynes used to baffle me a bit (or rather, the sentence “Practical men, who believe themselves to be quite exempt from any intellectual influence, are usually the slaves of some defunct economist” which is the bit I had come across)

Medicine and healthcare are the domain of pragmatism.This has always been the case, but is heightened in a wider intellectual world which often sees itself as “post ideological” (although political events on  both sides of the Atlantic, not to mention everywhere else, tend to show that actual populations don’t necessarily believe that) Evidence-based medicine elevates “what works” far above what is physiologically plausible. Models of illness such as Bill Fulford’s “full field” model of mental illness increasingly integrate disparate theoretical approaches with a main emphasis on lived experience. These approaches have an awful lot to be said for them; and I personally have always seen myself as a pragmatic practitioner, not wedded to any particular dogma.

Keynes quote, especially considered in full, extends far beyond economics. Pragmatic practice is always located in some kind of intellectual framework. Medical models in psychiatry, for instance, may seem focused on pragmatic approaches but are rooted in a philosophical approach of great complexity. Mental health policy, it often seems, cam be driven by responses to anti-psychiatry writings from the late 1960s, the formative years of many of those now in positions of power and influence.

Ideas which seem simple and uncontroversial – such as the idea that health care should be less and less delivered by large institutions and more and more “in the community” – are themselves located amidst a massive array of beliefs and assumptions which are rarely unpacked.

Brief thoughts on biases

Cognitive biases are all the rage in intellectual discourse, especially since the publication of Thinking, Fast And Slow.

Recent on Twitter I came across this tweet:

Beautiful if terrifying graphic by @jm3 of 175 cognitive biases from @buster https://t.co/pE1iqsJJyC #humanfactors pic.twitter.com/wbL6do6UU3

— Ross Scrivener (@Scr1v) September 9, 2016

(the image isn’t with the embedded tweet so you will have to follow the link)

Not only is the diagram “beautiful if terrifying”, but the accompanying article at the link is a terrific overview of biases. It also makes the point very clearly that biases are tools – and are responses to problems. Much of the discourse around bias makes them sound like unmixed evils and realising they are in fact approaches to the world that help up survive and (possibly) thrive, with the potential to mislead also, is important.

I have been contemplating a longer piece on bias, and the role of bias-discourse in contemporary debates (especially online) Bias-hunting has become a bit like the Popperian view of Marxism and Freudianism – an approach that explains everything. There are so many biases that everyone and every assertion can be accused of possessing at least one.

This is something I wish to expand on at some point. Bias discourse is very prevalent in the medical literature – this is broadly to be welcomed. Yet I am suspicious (this is perhaps a bias of some kind) that bias discourse can be misused to shut down debates and dialogues, and that some of the proposed solutions – “metacognition”, the scientific method (reified to an uncomfortable degree) – are themselves prone to bias.

 

Deer ears – more on forest bathing

Continuing my exploration of “forest bathing”, which I am not as sceptical about as my prior post may have indicated. Or rather, my scepticism is in its proper place. Here I write about a particular sensory-enhancement technique that is absurdly simple and yet very effective….

Séamus Sweeney

My post on forest bathing on A Medical Education may have seemed a little sceptical in tone. That’s because it was in terms of the claims made for forest bathing as a therapy – as any initial response to a claimed novel therapy should be. The tone, however, hopefully didn’t conceal the interest and indeed enthusiasm I have in this activity.

One online resource Shinrin-Yoku.org which has a wealth of information on the practice. If you sign up at their site they send a starter email, including a link to a PDF of 10 “starter nature connection invitations.”

They are all interesting and, in my personal experience, quite effective tools for approaching the natural environment (and applicable beyond the forest – I used some on a trip to Slievenamon.

It would be wrong to reproduce the 10 moments here – the reader can go to the effort of signing…

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“The Wild West of Health” care: mental health Apps, evidence, and clinical credibility

We read and hear much about the promise of mobile health. Crucial in the acceptance of mobile health by the clinical community is clinical credibility. And now, clinical credibility is synonymous with evidence, and just “evidence” but reliable, solid evidence. I’ve blogged before about studies of the quality of mental health smartphone apps. I missed this piece from Nature which, slightly predictably, is titled “Mental Health: There’s an app for that.” (isn’t “there’s an App for that a little 2011-ish though?) It begins by surveying the immense range of mental health-focused apps out there:

 

Type ‘depression’ into the Apple App Store and a list of at least a hundred programs will pop up on the screen. There are apps that diagnose depression (Depression Test), track moods (Optimism) and help people to “think more positive” (Affirmations!). There’s Depression Cure Hypnosis (“The #1 Depression Cure Hypnosis App in the App Store”), Gratitude Journal (“the easiest and most effective way to rewire your brain in just five minutes a day”), and dozens more. And that’s just for depression. There are apps pitched at people struggling with anxiety, schizophrenia, post-traumatic stress disorder (PTSD), eating disorders and addiction.

The article also has a snazzy  infographic illustrating both the lack of mental health services and the size of the market:

The meat of the article, however, focuses on the lack of evidence and evaluation of these apps. There is a cultural narrative which states that Technology = Good and Efficient, Healthcare = Bad and Broken and which can give the invocation of Tech the status of a godterm, pre-empting critical thought. The Nature piece, however, starkly illustrates the evidence gap:

But the technology is moving a lot faster than the science. Although there is some evidence that empirically based, well-designed mental-health apps can improve outcomes for patients, the vast majority remain unstudied. They may or may not be effective, and some may even be harmful. Scientists and health officials are now beginning to investigate their potential benefits and pitfalls more thoroughly, but there is still a lot left to learn and little guidance for consumers.

“If you type in ‘depression’, its hard to know if the apps that you get back are high quality, if they work, if they’re even safe to use,” says John Torous, a psychiatrist at Harvard Medical School in Boston, Massachusetts, who chairs the American Psychiatric Association’s Smartphone App Evaluation Task Force. “Right now it almost feels like the Wild West of health care.”

There isn’t an absolute lack of evidence, but there are issues with  much of the evidence that is out there:

Much of the research has been limited to pilot studies, and randomized trials tend to be small and unreplicated. Many studies have been conducted by the apps’ own developers, rather than by independent researchers. Placebo-controlled trials are rare, raising the possibility that a ‘digital placebo effect’ may explain some of the positive outcomes that researchers have documented, says Torous. “We know that people have very strong relationships with their smartphones,” and receiving messages and advice through a familiar, personal device may be enough to make some people feel better, he explains.

And even saying that (and, in passing, I would note that in branch of medical practice, a placebo effect is something to be harnessed, not denigrated – but in evaluation and study, rigorously minimising it is crucial) there is a considerable lack of evidence:

But the bare fact is that most apps haven’t been tested at all. A 2013 review⁸ identified more than 1,500 depression-related apps in commercial app stores but just 32 published research papers on the subject. In another study published that year⁹, Australian researchers applied even more stringent criteria, searching the scientific literature for papers that assessed how commercially available apps affected mental-health symptoms or disorders. They found eight papers on five different apps.

The same year, the NHS launched a library of “safe and trusted” health apps that included 14 devoted to treating depression or anxiety. But when two researchers took a close look at these apps last year, they found that only 4 of the 14 provided any evidence to support their claims¹⁰. Simon Leigh, a health economist at Lifecode Solutions in Liverpool, UK, who conducted the analysis, says he wasn’t shocked by the finding because efficacy research is costly and may mean that app developers have less to spend on marketing their products.

Like any healthcare intervention, an App can have adverse effects:

When a team of Australian researchers reviewed 82 commercially available smartphone apps for people with bipolar disorder¹², they found that some presented information that was “critically wrong”. One, called iBipolar, advised people in the middle of a manic episode to drink hard liquor to help them to sleep, and another, called What is Biopolar Disorder, suggested that bipolar disorder could be contagious. Neither app seems to be available any more.

And even more fundamentally, in some situations the App concept itself and the close relationship with gamification can backfire:

Even well-intentioned apps can produce unpredictable outcomes. Take Promillekoll, a smartphone app created by Sweden’s government-owned liquor retailer, designed to help curb risky drinking. While out at a pub or a party, users enter each drink they consume and the app spits out an approximate blood-alcohol concentration.

When Swedish researchers tested the app on college students, they found that men who were randomly assigned to use the app ended up drinking more frequently than before, although their total alcohol consumption did not increase. “We can only speculate that app users may have felt more confident that they could rely on the app to reduce negative effects of drinking and therefore felt able to drink more often,” the researchers wrote in their 2014 paper¹³.

It’s also possible, the scientists say, that the app spurred male students to turn drinking into a game. “I think that these apps are kind of playthings,” says Anne Berman, a clinical psychologist at the Karolinska Institute in Stockholm and one of the study’s authors. There are other risks too. In early trials of ClinTouch, researchers found that the symptom-monitoring app actually exacerbated symptoms for a small number of patients with psychotic disorders, says John Ainsworth at the University of Manchester, who helped to develop the app. “We need to very carefully manage the initial phases of somebody using this kind of technology and make sure they’re well monitored,” he says.

I am very glad to read that one of the mHealth apps which is a model of evidence based practice is one that I have both used and recommended myself – Sleepio:

One digital health company that has earned praise from experts is Big Health, co-founded by Colin Espie, a sleep scientist at the University of Oxford, UK, and entrepreneur Peter Hames. The London-based company’s first product is Sleepio, a digital treatment for insomnia that can be accessed online or as a smartphone app. The app teaches users a variety of evidence-based strategies for tackling insomnia, including techniques for managing anxious and intrusive thoughts, boosting relaxation, and establishing a sleep-friendly environment and routine.

Before putting Sleepio to the test, Espie insisted on creating a placebo version of the app, which had the same look and feel as the real app, but led users through a set of sham visualization exercises with no known clinical benefits. In a randomized trial, published in 2012, Espie and his colleagues found that insomniacs using Sleepio reported greater gains in sleep efficiency — the percentage of time someone is asleep, out of the total time he or she spends in bed — and slightly larger improvements in daytime functioning than those using the placebo app¹⁵. In a follow-up 2014 paper¹⁶, they reported that Sleepio also reduced the racing, intrusive thoughts that can often interfere with sleep.

The Sleepio team is currently recruiting participants for a large, international trial and has provided vouchers for the app to several groups of independent researchers so that patients who enrol in their studies can access Sleepio for free.

This is extremely heartening – and as stated above, clinical credibility is key in the success of any eHealth / mHealth approach. And what does clinical credibility really mean? That something works, and works well.

 

 

The Twenty-Four Hour Mind – Rosalind D. Cartwright (8/10)

I came across this book as a recommended reading on the Edinburgh Sleep Course in March 2015 – hadn’t been able to find it so far so very interested in this lucid (no pun intended!) review!

Orchid's Lantern

Rosalind Cartwright is a leading sleep researcher, with expertise in behaviour and neuroscience. Her work has led to her becoming known as the ‘queen of dreams’ in her field. In this book she shares some of her theories and findings from laboratory tests and experiments with sleep patients.

Dreaming is a big area of interest for me, and although I largely subscribe to Jungian analysis I am always interested to keep up to date with new research on the subject. It is an area which, according to Cartwright, it is fairly difficult to obtain funding for, due to the application of knowledge about dreams in general being unproven, and being costly in terms of time and resources. The Twenty-Four Hour Mind describes why it is so important, and how furthering our understanding could be beneficial in the treatment of mental illness, behavioural problems, and even in law.

One of the…

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“Godterms”

Yesterday I came across the following tweet:

Godterm of ‘patient-centredness’ called into service to rationalize #CBME – how convincing so you find this rhetoric? #AMEE2016

— Lorelei Lingard (@LingardLorelei) August 31, 2016

I had never come across the coinage “Godterm” before – and the meaning I ascribed to it was simply this: something that is, as the saying goes, like motherhood and apple pie; no-one wants to be seen to be arguing against it. This usually reflects that it is indeed a Good Thing, maybe even a Very Good Thing, maybe an Extremely Good Thing. However the term becomes something of a rhetorical blunderbuss – this is Patient-Centered, and YOU AREN’T AGAINST PATIENT-CENTEREDNESS, ARE YOU?

I tweeted Lorelei Lingard expressing that “godterm” was a useful find and she replied:

@JamesMcQueen78 yes, useful! godterms lurk everywhere and shape what we think and do in powerful ways. Valuable to excavate them. #AMEE2016

— Lorelei Lingard (@LingardLorelei) August 31, 2016

There are indeed godterms lurking everywhere – “innovation” is another. Note that pointing out that X is a godterm does not mean one is criticising X, but rather the use of X as a shield to deflect scrutiny.

Thanks again to Lorelei Lingard for introducing me to this term! I look forward to happy godterm excavation.