Helen Pearson, “The Life Project”, Review in TLS 29/03/17

I have a review of Helen Pearson’s “The Life Project” on the UK birth cohort studies in the current TLS. The full article is behind a paywall so here is the preview:

Born to fail

SÉAMUS SWEENEY

To a non-Briton, the oft-repeated assertion that the NHS is “the envy of the world” can grate. If imitation is the sincerest form of envy, the world’s laggardly adoption of free-at-point-of-use health care is perhaps the truest mark of how much emotional investment the rest of the world really has in the UK’s health system. Early in The Life Project, her book on the British birth cohort studies, Helen Pearson describes them as “the envy of scientists all over the world”. In this case, envy is easier to precisely pinpoint; birth cohort studies have become all the epidemiological and social scientific rage in recent decades, especially around the turn of the millennium. My own daughter, born in 2008, is a member of the Economic and Social Research Institute’s “Growing Up in Ireland” birth cohort.

1946 is the Year Zero of birth cohorts. The low interwar birth rate had caused much…

 

 

Hickam’s Dictum

While researching the medical saying “When you hear hoofbeats, think of horses not zebras”, I came across Hickam’s dictum – “patients can have as many illnesses as they damn well please.”

It is described as a counter-saying to Occam’s Razor, which has always struck as a a heuristic saying which has been misused many times to suggest that the “simplest” explanation MUST be true. Occam’s Razor can be a valuable tool for cognitive discipline, but it is NOT a normative statement about The Way The World Is

Hickam’s Dictum was a new one on me, but has a reasonable presence in the medical literature. And it is very far from an abstract notion.

There is a whole world of medical sayings and proverbs (a lot of which are new ones on me) out there. On the one hand, they represent a sort of hidden curriculum of heuristic tools. On the other hand, how influential are they really? As I said, I have never come across Hickam’s dictum before – but I think I will end up quoting it quite a bit.

Why Our Connection with Nature Matters

More from the Finding Nature blog – a very interesting post on nature and human well-being, which obviously relates to themes I have blogged about here. I am always a bit leery of overly therapeutising (sic) nature but admire how the author has managed this dynamic here….

Finding Nature

Nature is good for us, but why? There’s plenty of evidence that exposure to nature is good for people’s health, well-being and happiness – with green spaces even promoting pro-social behaviours. However, less is known about why nature is good for us. Simply put, nature is good for us, because we are part of nature. We are human animals evolved to make sense of the natural world. This embeddedness in the natural world can often be forgotten and overlooked, mentally we can become disconnected from nature because we’re now deeply embedded in a human-made world. Emerging research is showing that knowing and feeling this connection with nature is also good for us, and it helps bring about the wider health benefits of exposure to nature. Knowing your place in nature brings meaning and joy!

My research is focussed on understanding and increasing this connection with nature, an interest that…

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Nature Connections 2017 – Call for Papers

Have posted here before about “forest bathing” – which I do find a somewhat clunky term. This conference sounds very interesting and perhaps a chance to explore the theme more.

Finding Nature

The Nature Connections conferences are now into their third year and this years event takes place at the University of Derby, Tuesday 27 June 2017. The headline theme this year is, ‘Beyond Contact with Nature to Connection’.

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Morale, adaptive reserve and innovation

I have another blog post on the CCIO website – the contents of which may remind readers here of this and this and also this – so here is the Greatest Hits version:

 

POSTED BY SEAMUS MACSUIBHNE ON 8TH MARCH 2017 POSTED IN INNOVATION

On the ARCH (Applied Research in Connected Health) website, research lead Dr Maria Quinlan recently wrote a post called Happy Organisations and Happy Workers – a key factor in implementing digital health.

In the opening paragraph, Dr Quinlan invokes Anna Karenina:

 

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.

The whole post is a fascinating read, with implications for team functioning beyond the implementation of digital health and indeed beyond healthcare itself. Dr Quinlan cites research on what makes a happy worker;

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” 

Dr Quinlan goes on to describe the high rates of burnout and emotional exhaustion among healthcare workers. Unfortunately this is a phenomenon that has been consistent in survey after survey. Not only does poor morale compromise the introduction of innovation, it also causes direct human suffering and compromises what an organisation is trying to achieve.

The concept of “adaptive reserve” is an important one, especially in the context of reforms and innovations being introduced into already pressured environments:

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’.

There is sometimes an urge to reform or innovate our way out of the situation healthcare finds itself in, and yet the concept of Adaptive Reserve suggests that this is inverting how reform and innovation work; there needs to be not just systematic space and infrastructure for it to happen, but psychological space among staff.

A related blog post on the ARCH website by Dr Marcella McGovern on the blame culturethat exists within many organisations, and particularly in the Irish health care context is worth reading. Dr McGovern uses Melvin Dubnick’s framework of “prejudicial blame culture” to describe how systems focused on blame stifle initiative and responsibility.

Google recently completed Project Aristotle, a study of what makes a successful team. Far and away the most important factor is “psychological safety” – “Can we take risks on this team without feeling insecure or embarrassed?”  Focusing on technological fixes in the absence of a sense of psychological safety is a recipe for innovations to fail and for morale to decrease further. Can technology, in and of itself, foster psychological safety? My inclination is to say no, that psychological safety is much more about interpersonal relationships within a team and a system. What technology may be able to do – in a positive sense – is help facilitate team communication.

Of course, this also has to be carefully thought through. Evgeny Morozov’s “To Solve Everything, Click Here”  is a fascinating and at times rather frustrating book which takes a searching look at technology in the modern world. Morozov is against both the excessive hype of technological utopians and the excessive gloom of technological pessimists. He strongly decries what he calls “solutionism”:

“solutionism.” … has come to refer to an unhealthy preoccupation with sexy, monumental and narrow-minded solutions – the kind of stuff that wows audiences at TED Conferences – to problems that are extremely complex, fluid and contentious. These are the kind of problems that, on careful examination, do not have to be defined in the singular and all-encompassing ways that “solutionists” have defined them; what’s contentious then, is not their proposed solution but their very definition of the problem itself. Design theorist Michael Dobbins has it right: solutionism presumes rather than investigates the problems that it is trying to solve, reaching “for the answer before the questions have been fully asked.” How problems are composed matters every bit as much as how problems are resolved.

The problems of healthcare are truly “extremely complex, fluid and contentious” and any honest attempt to solve them must engage with this complexity.  Can judicious innovation help foster psychological safety within a team, and thereby not only create happiness among health workers but also help them achieve the organisational goals they are engaged in meeting?

 

Dept. of Unfortunate Acronyms

Via #revScreen comes the following:

J Hum Hypertens. 1996 Feb;10 Suppl 1:S69-72.
Interactive electronic teaching (ISIS): has the future started?
Consoli SM1, Ben Said M, Jean J, Menard J, Plouin PF, Chatelier G.
Author information
Abstract
Medical education of hypertensives as well as of other asymptomatic cardiovascular risk patients requires individualized, interactive and attractive strategies. Electronic teaching set up in hospital or clinic settings opens the way of the future, saving time and allowing more advantageous use of caretakers. ISIS (Initiation Sanitaire Informatisee et Scenarisee), a French computer assisted program for cardiovascular risk patients, combines a scientific information, divided in 12 sequential but independent modules, with a recreative imaginary trip in the world of ancient Egypt. To test the impact of this tool on patient health information retention, 158 hypertensives hospitalized in a day-hospital clinic were randomized into an intervention or ISIS group (IG, n = 79) and a control group (CG, n = 79). Both groups received cardiovascular education through standard means. In addition, IG patients underwent a 30 to 60 min session on the computer. Cardiovascular knowledge was tested by a nurse administering a standardized 28-item questionnaire before and two months after education. Retesting was done by telephone interview. A total of 138 completed questionnaires (69 from each group) were analyzed. Overall mean cardiovascular knowledge score before education (14.3 +/- 4.2, range 4-25) improved significantly after education (3.7 +/- 3.5, p = 0.0001). This improvement was more important in the IG than the CG (3.8 +/- 3.6 vs 2.4 +/- 3.2 respectively, p = 0.02), especially in hypertensives having a known disease for more than six months. Isis is now available in two languages: French and English. Patients’ satisfaction and the conclusion of this comparative trial encourage confirmation of these first results in other French or English speaking populations, in order to test the long term effects of structured electronic teaching sessions on health behaviour, and to promote a wide use of computers and multimedia communication in hypertension control programs.

#revScreen – Cochrane Crowd Challenges on home visiting and medical education

Previously I blogged about the addictive nature of EMBASE Screening. This is now rebranded as Cochrane Crowd, but the overall approach is unchanged – the user assesses abtracts to see if they are RCTs/CCTs or not. It it surprisingly addictive.

 

Anyhow, there are two new Cochrane tasks – screening for RCTs for two specific reviews Home visiting for socially disadvantaged mothers, and  Interventions for improving medical students’ interpersonal communication in medical consultation. 

If any readers are interested in these areas, the Cochrane Crowd process exposes one to a wide range of (at times rather tenuously related) studies and papers on the topic… I tend to get sidetracked easily.

Anyhow, here is the email:

Dear all,

 

We need your help!

 

When you next log into Cochrane Crowd you will be able to see two new ‘tasks’ in your dashboard area. One is for an update of a review entitled: Home visiting for socially disadvantaged mothers, and the other is for a new review, called: Interventions for improving medical students’ interpersonal communication in medical consultations.

 

The searches for each of these reviews has identified between 3000-5000 records. The core author team for each review has come toCochrane Crowd asking if this community can help. I think we can.

 

Before you dive in, here are some questions you might have:

 

What do I need to do that is different from the usual RCT screening task?

Absolutely nothing. The task is exactly the same making you very well qualified to help! We want all the randomized or quasi-randomized trials to be identified even if the trial has nothing to do with the topic of the review.

 

What’s in it for me?

For those who screen 250 or more records, your contribution will be acknowledged in the review for which you contributed. In addition, on one of the reviews, the home visiting review, the review team will reward authorship to the top screener. This will be based not just on the amount you screen but the accuracy of your screening.

 

How long will these tasks be posted for?

We’ve set the deadline for 31^st March. It would be fantastic to have both sets of records screened by that date.

 

Who can I contact if I have any questions or queries?

You can either contact me, Anna, (anna.noel-storr@rdm.ox.ac.uk) or my brilliant colleague, Emily (crowd@cochrane.org) and we’ll try and get back to you as quickly as possible.

 

Do I need to let anyone know if I plan to contribute or not?

No, you don’t need to let us know either way. If you want to contribute to either or both reviews, just log into Crowd and get cracking! We’ll know who has taken part. Likewise, if this just isn’t for you or you don’t think you’ll have the time, that’s absolutely fine; you don’t need to let us know.

 

When can I start?

Right now! Go and make a nice cup of tea and hop over to Cochrane Crowd (http://crowd.cochrane.org). Log in as usual and you should see the two new tasks. I think I’ll head there now myself.

If you’re a twitterer, we’ll be using #RevScreen for these two exciting pilots!

 

With best wishes to all and happy citation screening,

 

 

Anna and Emily

 

Cochrane Crowd

 

A Spoonful of Medicine, Owen Gallagher

Published in 2004 in The Irish Catholic, my only publication there – the literary editor, Peter Costello, is the father of a friend. This is a somewhat sturdy review of an entertainingly straightforward little memoir. Perhaps this piece presaged more recent writings on medical memoirs.

Owen Gallagher
A Spoonful of Medicine: Tales of an Irish Doctor
(Barny Books, Hough On the Hill, Grantham, Lincolshire, £5.99)
Reviewed by Seamus Sweeney

The public have a seemingly inexhaustible appetite for medicine, as can be seen in the TV schedules and the bookshops. There are two definite strains in medical drama. One is the hard-nosed likes of ER, or Samuel Shem’s House of God. These revel in the gory, the seamy, the adrenaline-fuelled, the sleep-deprived and the dramatic. The other sorts, as exemplified by The Royal, are exercises in gentle nostalgia and anecdote. A Spoonful of Medicine, Dr Owen Gallagher’s memoir of his time as a junior doctor, tends more towards the latter school, although it avoids sentimentality and cheap nostalgia.

This book is a collection of stories from Dr Gallagher’s years as a recent medical graduate in the late 60s and early 70s, particularly in accident and emergency, in paediatrics and in psychiatry.
Some anecdotes bear the hallmarks of much polishing over the years, and certainly some of the dialogue is rather unbelievable, with the characters coming out with perfectly grammatical paragraphs and overly pat witty repartee. There are several lapses on the part of the sub-editors, which lead to distracting typos and occasional confusion as to what precisely is happening on occasion.

However, these seem rather churlish caveats about what is a warm-hearted, entertaining book. The stories, while comic and sharply observed, are never cruel and Gallagher’s compassion comes through without ever becoming sanctimonious. Particularly in the final series of stories from his time in psychiatry, we sense his admiration and respect for certain of his patients’ bravery and approach to life.

It was a far different Ireland then, and it was also a far different medical practice. Certainly its impossible to conceive a character like Dr Moore, protagonist of one of the most memorable sections, being produced by today’s medical schools. Dr Moore was a GP whose practice revolved around the schedules of the racetrack rather than any notion of patient convenience. Moore had honed his system until the least possible amount of time was spent with the patients, with anything at all worrying referred to accident and emergency post haste. Dr Gallagher, working in the nearby A&E, bore the brunt of this extra work.

One patient recalled Moore completely ignoring his complaints, preferring to listen to the radio broadcast of a horse race, and then telling him to get himself down to the pub for a couple of pints and a few cigarettes, as “your complaint is mainly in your head, anyway.” Moore never asked a patient to undress, and would listen with his stethoscope over even the heaviest clothing. It may come as no surprise that his patients were all very fond of Dr Moore, who never kept case notes as he knew all the patients from living in the same community as them. Dr. Gallagher too came to appreciate his more endearing qualities.

It certainly is a long way from that to the obsession with targets and mission statements that marks modern health services. This book is not a sociological tract and it would be unfair to expect a deep analysis of the relative pros and cons of the health system, or indeed society as a whole, then and now. There is however a sense of loss at the passing of a certain pace of life and a certain approach to social interaction. Modern practice seems much more rushed and impersonal.

The book could also have been subtitled “what they don’t teach you in medical school.” If the book has a “moral”, it is that much of the education in human nature that makes a good doctor takes place far from the lecture hall or library. It is an enjoyable account of how one doctor acquired that education.

Unintended consquences and league tables

I have just finished Simon Westaby’s memoir Fragile Lives: A Heart Surgeon’s Stories of Life and Death on the Operating Table . This is for a review which will follow in due course. The main focus of the book is on the stories of the patients and the surgeries themselves, some passages have a (literal) heart-stopping intensity.

One recurrent theme, towards the end of the book especially, is the deleterious effect of blame culture and league tables on surgical practice. Prof Westaby, it turns out, wrote a recent paper on surgeon’s perception of this:

National Survey of UK Consultant Surgeons’ Opinions on Surgeon-Specific Mortality Data in Cardiothoracic Surgery

Abstract

Background—In the United Kingdom, cardiothoracic surgeons have led the outcome reporting revolution seen over the last 20 years. The objective of this survey was to assess cardiothoracic surgeons’ opinions on the topic, with the aim of guiding future debate and policy making for all subspecialties.

Methods and Results—A questionnaire was developed using interviews with experts in the field. In January 2015, the survey was sent out to all consultant cardiothoracic surgeons in the United Kingdom (n=361). Logistic regression, bivariate correlation, and the χ² test were used to assess whether there was a relationship between answers and demographic variables. Free-text responses were analyzed using the grounded theory approach. The response rate was 73% (n=264). The majority of respondents (58.1% oppose, 34.1% favor, and 7.8% neither) oppose the public release of surgeon-specific mortality data and associate it with several adverse consequences. These include risk-averse behavior, gaming of data, and misinterpretation of data by the public. Despite this, the majority overwhelmingly supports publication of team-based measures of outcome. The free-text responses suggest that this is because most believe that quality of care is multifactorial and not represented by an individual’s mortality rate.

Conclusions—There is evident opposition to surgeon-specific mortality data among UK cardiothoracic surgeons who associate this with several unintended consequences. Policy makers should refine their strategy behind publication of surgeon-specific mortality data and possibly consider shift toward team-based results for which there will be the required support. Stakeholder feedback and inclusive strategy should be completed before introducing major initiatives to avoid unforeseen consequences and disagreements

This was reported in the Daily Telegraph as follows:

Patients are dying because heart surgeons are too worried about their mortality ratings to operate on critically ill people, a major study has found.

One surgeon claimed he had a watched a three-year-old child die waiting for a valve replacement because a doctor was “too chicken” to operate because of the potential risk to his reputation.

Another warned that surgeons had “become experts in running away from difficult cases”.

 Patients have been able to see league tables showing how well doctors perform on an NHS website since 2014, while information about individual heart surgeons has been available for a decade.

But nine in 10 heart surgeons claim that publishing individual data has led to blame culture where the sickest patients are denied treatment for fear it will lead to an investigation if they die in theatre.

Research carried out by doctors including Stephen Westaby, of the John Radcliffe Hospital in Oxford, and Professor Lord Darzi, chair of surgery at Imperial College and a government adviser, found nearly 60 per cent of surgeons said they were opposed to the current system.

Some 87 per cent of the 264 heart surgeons who replied to a survey said that publication of surgeon specific mortality data had caused a “risk averse” culture in the NHS.

Report author Dr Westaby said: “We have been trying to establish what has been happening among colleagues for some time now. It’s so damning you can hardly believe [it].

“Doctors won’t see a patient if they think it will be a risk to their reputation.

“And it’s often the guys that are doing the sickest patients who end up with the worst scores, because their patients are more likely to die.”

One wrote: “Decisions have become about protecting me, not about what is best for the patient. This is a terrible form of medicine to practice. There is no dignity at the end of life, with surgeons delaying inevitable adverse outcomes in the hope of a miracle or transferring patients to other units so that they don’t count in the figures.”

Another said: “When previously surgeons would have been willing to give it a go on a patient who was certain to die, as there as nothing to lose, now they will be concerned that there is quite a lot to lose.”