The html version of this isn’t available, so rather unusually here is an image of my review of this book. I have had reason to return to this topic of late.
The html version of this isn’t available, so rather unusually here is an image of my review of this book. I have had reason to return to this topic of late.
In 2010, Dartmouth University neuroscientist Craig Bennett and his colleagues subjected an experimental subject to functional magnetic resonance imaging. The subject was shown ‘a series of photographs with human individuals in social situations with a specified emotional valence, either socially inclusive or socially exclusive’. The subject was asked to determine which emotion the individual in the photographs were experiencing. The subject was found to have engaged in perspective-taking at p<0.001 level of significance. This is perhaps surprising, as the subject was a dead salmon.
This may sound like a parody, or a debunking of neuroimaging, but in fact it was intended to point out the considerable challenge of neuroimaging research, and more specifically how the vast number of potential variables inherent in this research pushes ‘traditional’ statistical methodology to its limit.
In 2007, Colorado State University’s McCabe and Castel published research indicating that undergraduates, presented with brief articles summarising fictional neuroscience research (and which made claims unsupported by the fictional evidence presented) rated articles that were illustrated by brain imaging as more scientifically credible than those illustrated by bar graphs, a topographical map of brain activation, or no image at all. Taken with the Bennett paper, this illustrates one of the perils of neuroimaging research, especially when it enters the wider media; the social credibility is high, despite the methodological challenges.
The title of this book alone leads one to expect that it is an exploration of one widespread popular notion about neuroimaging; that it is a way of reading thoughts. Some of the essays do explore this theme; but most don’t, at least not that directly. Notwithstanding the inclusion of an essay by the former editor of this journal, the book is something like the proverbial curate’s egg, good in parts (without any partiality, Professor Kelly’s contribution is one of the good parts).
There are four sections to the book. First, an overview of the state of the art of neuroimaging and of the conceptual questions raised. Second, a focus on medical applications of mind reading through brain imaging. Third, a section on criminal justice, and finally one on mind reading and privacy.
Among the contributors, practitioners of neuroimaging-based research alternate with (relative) skeptics of the approach. It is interesting to observe the actual researchers, rather than being zealots, are tentative and provisional in their suggestions; the skeptics are more forthright. For instance, Colin Campbell and Nigel Eastman baldly evoke the ghost of phrenology – evidently a nearby shade for many contemplating this area – in the conclusion of their essay on neuroimaging on the law. Although this is a valid point – and undoubtedly some commercially promoted ‘mind reading’ technologies are pure hokum – it is rather jarring conclusion to their essay.
There is nevertheless much useful and stimulating material here. John-Dylan Haynes provides a useful overview of brain imaging technology itself and some of the possibilities and limits of the field. The second section, rather alarmingly titled ‘Medical applications of mind reading through brain imaging’, is generally comprised of thoughtful, nuanced discussions of the issues in non-responsive patients, pain, and mental health.
However, the essays are overall quite mixed in tone and content. Some bear the hallmarks of generic essays on particular topics with relatively little directly on the topic of the book (for instance, Annabelle Lever’s chapter on ‘Neuroscience versus privacy’ which is rather an extended discussion of privacy with some mentions of neuroscience). Contributors often rehash discussions that are covered at greater length, sometimes rather tediously so, in other essays.
The Hastings Centre Report ‘Interpreting neuroimages: an introduction to the technology and its limits’ – available at http://www.thehastingscenter.org/Publications/SpecialReports/Detail.aspx?id=6841 – covers much of the same ground as this book but more concisely and more accessibly, particularly Martha J. Farah’s essay in the ‘Brain images, babies, and bathwater: critiquing critiques of functional neuroimaging’. With the Hastings Centre Report freely accessible in the public domain it is hard to advise readers to part with their money for this volume.
Another excellent blog post on the ARCH website, this time by Dr Marcella McGovern, on the blame culture of the Irish health system. The trigger for this article was the recent controversy on “hidden waiting lists.” This led to a rather predictable response from the current Minister for Health:
The Minister for Health, Simon Harris, responded to this programme by saying that he “intends to shine a light” on management in the Irish Health Service Executive (HSE) and that if management does not “measure up”, they will be removed from their roles.
Tough talk, but as Dr McGovern writes:
it fails to acknowledge the Government’s responsibility for that problem. Governance, performance oversight and holding the HSE to account for the implementation of national health policy are key functions that the Minister for Health and his Department are responsible for performing on an ongoing basis; not in response to a crisis. The question put to Ministers for Health in a crisis therefore, should be where in your Department’s oversight of the HSE did you fail to detect this problem and what steps are you taking to correct the problem and ensure that it doesn’t happen again?
Of course, this is hardly new:
Paul Cullen highlighted in an analysis piece in the Irish Times (Irish Times, 11th February 2017) that Minister Harris’ predecessor, Leo Varadkar, similarly promised that “heads will roll” over hospital overcrowding. Yet, this winter again saw overcrowded Accident & Emergency Departments resulting in planned inpatient and outpatient appointments being postponed. The back-log of these postponed appointments are now contributing to the current crisis over long waiting lists, illustrating that unjustifiably “blaming the bureaucrats” (Dubnick, 1996) has knock on effects.
Dr McGovern uses the work of Dubnick on “prejudical blame culture” as a framework for her piece:
Three major conditions (for defining prejudical blame culture):
1. It makes no requirement that the blamed person or collection of persons have assumed responsibility for the condition they are blamed for; rather, it targets an ill-defined but inclusive group that everyone knows to exist (e.g. bureaucrats);
2. It doesn’t require any role for the blamed in contributing to the cause of the blameworthy or harmful condition. It is assumed that the vaguely defined ‘they’ are highly influential in shaping the world;
3. [It] eliminates the need for any degree of specificity regarding what the harmful condition entails. It could be the decline of the economy, or the loss of national prestige, or the general malaise of society. (Dubnick, 1996: 22).
Dr McGovern’s work, in the ARCH context, is on the effect on system readiness for innovation. Of course, blame culture has a much wider impact, paralysing innovations beyond the technological sphere:
From a Connected Health perspective, there is a danger that a blame culture demonstrated at the highest levels of the Irish health system will have a trickle-down effect, compromising system readiness for innovation. If the Department of Health blame the HSE for poor management and the HSE blame the Department of Health for inadequate resources, and if clinicians blame managers for excessive bureaucracy and managers blame clinicians for resisting change; organisational trust may be lost in the battles between “us” and “them” (Firth-Cozen, 2004). Within such environments, potentially transformative leaders and early adopters behave cautiously and become reluctant to take “ownership” of innovations (Heitmueller et al. 2016), which by their nature carry the risk of failure and unintended consequences (Ash et al. 2004).
On the ARCH (Applied Research in Connected Health) website, research lead Dr Maria Quinlan has a blog post entitled
“Happy Organisations and Happy Workers – a key factor in implementing digital health”
The whole is worth a read. Of course, having a happy organisation made up of happy workers is inherently important of itself, as well as from the point of view of implementing digital health. As Dr Quinlan writes in the first paragraph:
To paraphrase Tolstoy, “all happy organisations are alike; each unhappy organisation is unhappy in its own way.” The ability for healthcare organisations to innovate is a fundamental requirement for adopting and sustainably scaling digital health solutions. If an organisation is unhappy, for example if it is failing to communicate openly and honestly, if staff feel overworked and that their opinion isn’t valued, it stands to reason that it will have trouble innovating and handling major complex transitions.
Reading this, I am struck by how important it is to make time in a day with an accumulation of pressing demands for reflection:
What these factors combine to achieve is happy, engaged workers – and happy workers are more effective, compassionate, and less likely to suffer burnout . Clear objectives, praise, a sense that your voice matters – these can seem like fluffy ‘soft’ concepts and yet they are found over and over to be central to providing the right context within which new digital health innovations can flourish. Classic ‘high involvement’ management techniques – for example empowering team members to make decisions and not punishing them for every misstep are found to be key . As Don Berwick of the Institute of Healthcare Improvement (IHI) says, people who feel joy in work are “not scared of data”, rather “joy is a resource for excellence” 
Managing what Sigal Barsade, Professor of Management at Wharton calls the ‘emotional’ culture of an organisation is a very important concept – especially in the healthcare environment which expects so much of staff . Healthcare workers face pressures which many of us working in other fields can’t really comprehend, a recent systematic review found that clinicians have higher rates of suicidal ideation than the general population, with a high prevalence of burnout, psychiatric morbidity and depression linked to excessive workload . Attempting to introduce innovative new ways of working within such constrained environments can be challenging to say the least. Exhausted workers, those with little time in their day for reflection, or those who work in organisations which fear failure are less likely to innovate .
Much of the rhetoric around healthcare innovation tends to be messianic in tone. A gap between this rhetoric and the messy, pressured reality of healthcare can diminish the credibility of innovators.
The concept of “adaptive reserve” is an important one, especially in the context of reforms and innovations being introduced into already pressured environments:
Drawing from their work researching healthcare organisations ability to handle complex transitions in the US, Jaen et al (2010) developed a 23-item scale measure for what they term ‘adaptive reserve’. Adaptive reserve is an internal capability for change which includes being agile; capable of continuous learning; and being adept at self-assessment, reflection and improvisation. The Adaptive Reserve questionnaire asks staff to rate their organisation according to a variety of statements which include statements such as; ‘we regularly take time to consider ways to improve how we do things’ and ‘this organisation is a place of joy and hope’.
Overall, this a fascinating blog post on an issue which is close to my heart. I intend to post some more on this topic over the next while.
I previously noted a brief reference in a book on high rise life to the role of aquaria in fighting loneliness. There is a fair amount written about the calming effects of contemplating aquaria. This paper attempts to study the phenomenon empirically in a (very) particular patient group. It is also an example of an abstract selling a result in the way the paper doesn’t support… “trend towards significance” indeed!
This study investigates the effect of an aquarium on pre-treatment anxiety, fear. frustration, and depression in electroconvulsive therapy (ECT) patients. Forty-two patients consecutively referred for ECT were rotated between rooms with and without aquariums. Self report measures of depression, anxiety, fear, and frustration were obtained, along with heart rate and blood pressure measurements. Preliminary mixed-model, repeated measures analysis of variance (ANOVA) revealed no significant differences between the aquarium and control conditions on any of the dependent measures. A trend toward significance was found for self reported anxiety (p=0.08) and further data were collected. Subsequent mixed model, repeated measures ANOVA confirmed the trend toward differences (p=0.08) in anxiety between the aquarium and control conditions. Factoring out demographic factors, the average patient experienced 12% less anxiety in the presence of an aquarium.
The authors describe how ECT is an effective, evidence-based psychiatric treatment, but that pre-treatment anxiety is an issue. Prior interventions have not been found significantly effective:
Educational interventions have been primarily developed to address this fear and anxiety; however, conflicting results have been reported regarding their effectiveness. One study focused on the effect of emotional support, provided by a psychiatric nurse in an educational context, on the anxiety levels of 32 ECT patients (Cohen 1970). The results revealed no significant difference in anxiety levels between patients receiving the intervention and those who did not. Another study involving 37 veteran psychiatric patients reported that while knowledge and behavioral intent showed positive changes following an educational ECT video, there was no reduction in fear (Battersby, Ben-Tovim and Eden 1993). Contrary results were reported using a continuous quality improvement model in which an educational video and written information were found to reduce anxiety. These findings are based on follow-up telephone interviews from15 patients (Harrison and Kaarsemaker 2000).
The authors describe animal-assisted therapy:
One environmental intervention, animal-assisted therapy (AAT), has been found to calm patients in some circum-; the benefits of interacting with companion animals are receiving increased attention in the healthcare industry. Studies have documented an association between pet ownership and reduced cardiovascular risk factors,improved one-year survival rates following myocardial infarction, reduction in minor health problems, and lower physician utilization (Friedmann et al.1980; Siegel 1990; Serpell 1991; Anderson, Reid and Jennings 1992). More recently, randomized controlled studies have shown a positive effect of pet ownership, or the presence of pets, on physiological indicators of reactivestress (Allen et al. 1991; Allen 2000; Allen, Shykoff and Izzo 2001; Allen,Blascovich and Mendes 2002). Interacting with companion animals has also been associated with reduced anxiety levels for non-psychiatric as well as inpatient psychiatric populations (Wilson 1991; Barker and Dawson1998). A significant reduction in anxiety was reported in a study involving 241 hospitalized psychiatric patients with a broad range of diagnoses fol-lowing 30 minutes of animal-assisted therapy (Barker and Dawson 1998).A more recent study found a significant reduction in fear following a 15-minute interaction with a therapy dog and its handler for 35 psychiatric patients waiting for electroconvulsive therapy (Barker, Pandurangi and Best 2003). No significant differences were found for anxiety or depression.
The authors describe the limitations of this study. One strikes me as fairly fundmental – patients were not asked to look at, or engage with the aquarium…. and in fact couldn’t, by and large, actually see it :
Similar to the results reported by Katcher, Segal and Beck (1984),blood pressure and heart rate readings were not significantly different for the patients in the aquarium and control conditions: the presence of an aquarium was not associated with reduced physiological measures of anxiety in patients waiting for ECT. However, unlike the earlier Katcher, Segaland Beck study, patients in this study were not asked to look at, or in anyway attend to, the aquarium, nor was it suggested to them that the aquarium would have a calming effect. Instead, the purpose of this study was to assess the impact of the mere presence of a fish aquarium. Further studies are needed in which patients are instructed to watch the fish.
The lack of significant findings in the present study may also be in part due to the background role of the aquarium. As patients were not seated in front of the aquarium or asked to look at it, they were not intentionally exposed to the potentially calming effect of watching the fish, unless they deliberately chose to do so. Most patients tended to lie down while in the holding rooms. In order to view the fish in this position, they would have to deliberately lie on one side. It may be necessary for patients to focus on the aquarium to derive benefit; a task that may be difficult for severely depressed patients. Also, the aquarium may not represent a powerful enough stimulus to distract patients from thoughts of their upcoming ECT treatment.
As neither study resulted in a significant reduction in anxiety, it maybe that the anxiety related to the ECT procedure is not amenable to the calming effects of animal-assisted activities. Also, the global nature of the visual analog scales used in both studies may not be sensitive to anxiety changes resulting from animal-assisted activities.
It does strike me that, as ECT is now reserved for specific indications and, by definition, those most severely ill, the anxiety and distress associated is likely to be at the more severe end of the spectrum – and less likely to respond to the passive presence of an aquarium.
Cecil Helman was a South African-born GP who died in 2009 of motor neurone disease. He was also an anthropologist whose textbook, Culture, Health and Illness, remains a key reference and teaching text for medical anthropology. His approach to medicine, and life, is summed up in the words of one of his obituaries:
For Cecil literature and art were as important as the science of medicine. He was fascinated by people, their cultural and ethnic backgrounds, the narratives of their illnesses, their interaction with practitioners, and the role of traditional healers in many different societies. As he said, to be an effective healer, a doctor needs to ‘understand the storyteller as well as the story’.
While his academic works have had a major influence on healthcare education and training, his most popular book was 2006’s Suburban Shaman a “mosaic of memories” of storytellers/patients and their stories, informed by his anthropological knowledge and approach. A posthumous sequel, An Amazing Murmur of the Heart, is a sort of sequel, in which Helman discusses the often-dehumanising process of medical education, during which the patient becomes something denatured, disconnected from their narrative. And in this book Helman identifies a new kind of doctor – the “technodoctor”:
Young Dr A, keen and intelligent, is an example of a new breed of doctor – the ones I call ‘techno-doctors’. He is an avid computer fan, as well as a physician. He likes nothing better than to sit in front of his computer screen, hour after hour, peering at it through his horn-rimmed spectacles, tap-tapping away at his keyboard. It’s a magic machine, for it contains within itself its own small, finite, rectangular world, a brightly coloured abstract landscape of signs and symbols. It seems to be a world that is much easier for Dr A to understand , and much easier for him to control, than the real world – one largely without ambiguity and emotion.
Helman further identifies that this attitude marks a further step along the road of reductionism and dehumanising in medical care:
Like many other doctors of his generation – though fortunately still only a minority – Dr A prefers to see people and their diseases mainly as digital data, which can be stored, analysed, and then, if necessary, transmitted – whether by internet, telephone or radio – from one computer to another. He is one of those helping to create a new type of patient, and a new type of patient’s body – one much less human and tangible than those cared for by his medical predecessors. It is one stage further than reducing the body down to a damaged heart valve, an enlarged spleen or a diseased pair of lungs. For this ‘post-human’ body is one that exists mainly in an abstract, immaterial form. It is a body that has become pure information.
I was reminded by Robert Wachter’s speech at the 2016 CCIO Network Summer School in Leeds, on unintended consequences in health IT. He gave the example of hospitals where doctors are no longer to be found on the wards interacting with patients and other staff, but in a room full of doctors on computers, interacting with the EHR. The most stark illustration he used, however, was a child’s picture of a visit to the doctor, showing the doctor’s back turned to the child and her mother, tap-tapping away at the screen.
“A body that has become pure information” is how Helman describes the end process of the dehumanisation he decries. While I think the “technodoctor” is something of a straw man, Helman is certainly pointing to a genuine risk. “An Amazing Murmur of the Heart” is full of wisdom about the importance of connection, of physical touch, of attending to the story the patient brings, and the meaning of their symptoms for them. It would be a pity if this kind of rich, truly humanistic approach to medicine is somehow placed in opposition to the world of the “technodoctor.”
One way of avoiding the development of this false dichotomy into something tangible lies in Helman’s emphasis on the need to “understand the storyteller as well as the story.” What Helman doesn’t discuss in these passages is how paper-based information systems in healthcare can obscure the story and the storyteller in a welter of disjointed confusion. My own experience of paper notes is all too often wading through pages of confusing, if not illegible, notes, searching for something typewritten or printed. In this circumstance, the story the person is bringing to the encounter is utterly lost.
Initiatives like the EHR Personas allow for the conscientious, judicious use of narratives in planning and executing a major health IT change, one that could radically alter not only how healthcare is delivered but also how the personal story that is at the heart of all this activity is told.
Helman is, from the grave, issuing a warning, however, about what could go wrong. It is the same warning as that Bob Wachter gives with the child’s picture. It is fortunate that “narrative medicine” has become an academic subject in its own right, although perhaps this development indicates that something has been lost. In planning health IT interventions, we must ensure that they allow the story to be told and the storyteller to be heard. Let us focus on ensuring that the human stories that are the real stuff of every single clinical encounter are never lost, and that we turn our faces not to the screen but to those human stories.
“As a doctor you can never forget. Over the years you become a palimpsest of thousands of painful, shocking memories, old and new, and they remain with you for as long as you live. Just out of sight, but ready to burst out again at any moment”.
This quote from Cecil Helman’s “An Amazing Murmur of the Heart”, a book I was somewhat tepid when I reviewed, has been resonating with me lately. I have also posted here about Helman’s disparagement of “Technodoctors”:
Like may other doctors of his generation – though fortunately still only a minority – Dr A prefers to see people and their diseases mainly as digital data, which can be stored, analysed, and then, if necessary, transmitted – whether by internet, telephone or radio – from one computer to another. He is one of those helping to create a new type of patient, and a new type of patient’s body – one much less human and tangible than those cared for by his medical predecessors. It is one stage further than reducing the body down to a damaged heart valve, an enlarged spleen or a diseased pair of lungs. For this ‘post-human’ body is one that exists mainly in an abstract, immaterial form. It is a body that has become pure information.
I have been re-reading passages of “An Amazing Murmur of the Heart” lately. While the reservations I have about Helman’s use of medical anthropology being at times, a little glib, and the “technodoctor” something of a straw man, remain, it is a rewarding text. Here he quotes Dr L, one of “six great doctors I have met in my life”, “an old family doctor, battle-weary and cynical after decades in practice. He’s a traditional, no-nonsense type of doctor, stern and impatient, though he has a warm and kindly core.”
Helman has Dr L impart words of genuine wisdom, beyond medical practice:
Every time I see him at work, he reminds that medical practice is about all those tiny, trivial, almost invisible things. They’re the ones that really make a difference. And Dr L is full of advice about them.
“And don’t ever forget about time, ” he says. “Always pay attention to time – and the ways it can affect your patients’ bodies and their minds.” He warns me that time is never linear, and that in emotional terms it can loop and curve back upon itself, at any particular moment. And that some traumatic memories can act like time-bombs, set to go off at some unexpected time in the future.
Helman recalls this in 1994, when the 50th anniversary of D Day sees sudden post traumatic issues, physical and mental, amongst veterans, and again in 1995 with the 50th anniversary of the liberation of the concentration camps.Dr L also impresses on Helman the importance of touch, of human connection.
Of the three books I reviewed for the TLS in 2014, I thought Henry Marsh’s the best as a purely literary work. Heimlich’s memoir was entertainingly grandiose (and, indirectly, led to my discovery that Heimlich’s own son labels him a fraud, a circumstance entirely misses from Heimlich’s book) Helman’s was the book I was most tepid about, and yet it is now the one which has stayed with me most.