The turtle menace – the peril of ICD-10 code W5922XD

Have you heard of the menace represented by ICD-10 code W5922XD?

If you don’t know what the hell I am on about, check it out here.

There’s also the menace of other species.

There’s fires in perhaps unexpected places.

Injuries can happen anywhere – such as here or here or here,

For those who may be offended by my tone, having survived multiple turtle and macaw attacks while being burnt while watersking in the prison pool en route to the library while singing arias, apologies.

At least you don’t have to face this. Repeatedly.

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Circadian rhythms Nobel Prize for Medicine or Physiology 2017

When I was young, the Oscars had an air of naffness, and the likes of the Golden Globes or Emmys even more so. One of the many many ways internet culture has failed to live up to its utopian hype   is the glorification of these sort of jamborees into moments of Great Cultural Significance, endlessly teased over by scolding columnists determined to weed out wrong think even about a glorified trade awards ceremony.

The Nobel Prizes haven’t quite reached the same point – indeed, as I wrote here before, their cultural impact may be somewhat diminished – but nevertheless, they are also subject to a strained search for important messages. The Nobel Prize in Physiology or Medicine 2017 was awarded jointly to Jeffrey C. Hall, Michael Rosbash and Michael W. Young “for their discoveries of molecular mechanisms controlling the circadian rhythm”

The video illustrates nicely what Circadian Rhythms are. 

 

Here is Robash’s lecture (with 5250 YouTube views) which is a good place to start a consideration of circadian rhythms:

And here is Young’s, which ties it all back to human circadian rhythms (just over 4000 views):

Here is Hall’s Nobel lecture, I note he is wearing a Brawndo hat from the film “Idiocracy”. I also note this video has just over 6000 views on YouTube (the Brawndo ad linked to above has over 3 million) Then again, it is a little hard going – Hall is not as funny as he thinks he is… and while there is some interest in his anecdotal style of various prior Drosophilia researchers it is not that effective an entry into this world (so while it is the first lecture given and includes the overall introduction, I have left it to last):

Slides of Robash’s and Young’s lectures are available on the Nobel site. Rather endearingly, they are basic PowerPoint slides replete with credits for everyone in the lab.

So there you go. 3 Nobel lectures on a subject of direct relevance to all our lives have a grand total of less than 15000 views on YouTube. I could easily find some ephemeral/trashy/obscene video with several multiples, but what is the point?

In the New Yorker, Jerome Groopman identified the “real message” of the prize as a rebuke to those who ignore or underfund basic science (in fairness his piece is also a decent introduction to this research).  While there may be some merit to this, it strikes me as more likely that the Academy recognised scientific work of genuine merit and enduring relevance.

And Groopman’s piece was one of the only ones I could find online that discussed the science and the issues related in some context (even though it was one I found slightly suspect) – most of the others essentially recycled the press releases from the Nobel Foundation and the US National Science Foundation

In my post “Why isn’t William C Campbell more famous in Ireland?” I discussed an excellent piece by Declan Fahy on “the fragile culture of Irish science journalism”. One wonders if this fragility is perhaps not only an Irish phenomenon.

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April 15th 1941: The Belfast Blitz, Brian Moore, and Errol Flynn’s father

Around the time of the 2010 IMF/ECB/EC bailout, I remember hearing it described as “the worst day in Irish history.” This struck me as hyperbolic at the time. Obviously, like best of lists, worsts are subjective. Surely however loss of life must count towards “worst days” than economic events. I am not aware of any day in the last hundred years of Irish history with a greater loss of life than April 15th 1941, the Belfast Blitz when over 900 people died.

Much of what I have heard about this focused on the Southern reaction, with fire brigades crossing the border. This is seen as a positive. To some degree, the sheer human cost of 900 lives lost (about a quarter of those lost in the Troubles in a single night) and thousands injured or made homeless is eclipsed by this. More generally, the narrative of the Second World War as “the good war” can blind a little to the suffering involved.

Here are the recollections of novelist Brian Moore (incidentally this piece captures how Moore’s death in 1999 led to near-invisibility in the digital age), who was working in the Mater Hospital at the time:

“In the stink of human excrement, in the acrid smell of disinfectant these dead were heaped, body on body, flung arms, twisted feet, open mouth, staring eyes, old men on top of young women, a child lying on a policeman’s back, a soldier’s hand resting on a woman’s thigh, a carter still wearing his coal-slacks, on top of a pile of arms and legs, his own arm outstretched, finger pointing, as though he warned of some unseen horror. Forbidding and clumsy, the dead cluttered the morgue room from floor to ceiling”.

One thing I didn’t know was that Theodore Flynn, father of Errol Flynn (and grandfather of Sean Flynn) was based in the Mater Hospital and “head of the casualty service” for Belfast:

“The rescue service felt the want of heavy jacks; in one case the leg and arm of a child had to be amputated before it could be extricated … [But] the greatest want appeared to be the lack of hospital facilities … At 2pm, on the afternoon of the 16th (9 hours after the termination of the raid) it was reported that the street leading to the Mater Hospital was filled with ambulances waiting to set down their casualties … Professor Flynn, [father of his more famous son, Errol], head of the casualty service for the city, informed me that the greater number of casualties was due to shock, blast and secondary missiles, such as glass, stones, pieces of piping, etc … There were many terrible mutilations among both living and dead—heads crushed, ghastly abdominal and face wounds, penetration by beams, mangled and crushed limbs, etc. … In the heavily “blitzed” areas people ran panic-stricken into the streets and made for the open country. As many were caught in the open by blast and secondary missiles, the enormous number of casualties can be readily accounted for. It is perhaps true that many saved their lives running but I am afraid a much greater number lost them or became casualties…During the day, loosened slates and pieces of piping were falling in the streets and as pedestrians were numerous many casualties must have occurred.”

It is evident from Theodore Flynn’s biography he was a zoologist rather than a medical doctor. It would be interesting to know how common this sort of thing was on the Home Front in wartime.

Don’t Take Notes With A Laptop – from @andymcnally

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Original Scientific American article.

Theranos, hype, fraud, solutionism, and eHealth

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Anyone who has had to either give or take a blood sample has surely thought “there must be a better way.” The promise of replacing the pain of the needle and the seeming waste of multiple blood vials has an immediate appeal. If there was a technology that could

Theranos were one of the hottest health teach startups of the last decade. Indeed, their USP – that existing blood testing could be replaced by a pin prick – would have been a genuinely disruptive one.

Theranos was founded in 2003 by Elizabeth Holmes, then 19 years old, who dropped out of studying engineering in Stanford in order to start the company. In 2015 she was named by Forbes magazine as the youngest self-made female billionaire in history, with an estimated worth of $4.5 billion. In June 2016, Forbes revised their estimate to zero. What happened?

At times of writing, Holmes has been charged with “massive fraud” by the US Securities and Exchange Commission, and has agreed to pay a $500,000 fine and accept a ban from serving as a company director or officer for ten years. It is unclear if a criminal investigation is also proceeding.
At its height, Theranos had a seemingly stellar team of advisors. The board of directors has included such figures as Henry Kissinger, current US Secretary of Defence James “Mad Dog” Mattis, various former US Senators and business figure. In early 2016, in response to criticism that, whatever their other qualities, the clinical expertise of Mad Dog Mattis et al was perhaps light, it announced a medical advisory board including four medical doctors and six professors.

 

Elizabeth Holmes’ fall began in October 2015, when the Wall Street Journal’s John Carreyrou published an article detailing discrepancies between Theranos’ claims and the actual performance of their technology. This was in response to a Fortune cover story by Roger Parloff, who subsequently wrote a thoughtful piece on how he had been misled, but also how he missed a hint that all was not what it was.

 

Theranos’ claims to be able to perform over 200 different investigations on a pinprick of blood were not borne out; and it turned out that other companies’ products were used for the analysis of many samples.

 

The fall of Theranos has led to some soul-searching among the health tech stat up community. Bill Rader, an entrepreneur and columnist at Forbes, wrote on What Entrepreneurs Can Learn From Theranos:

 

     I have been watching first in awe of perceived accomplishments, and then feeling burned, then later vindicated, when the actual facts were disclosed. Don’t get me wrong, I really wanted their efforts to have been both real and successful – they would have changed healthcare for the better. Now, that seems unlikely to be the case.

 

By now, almost everyone has heard of Holmes and her company, and how she built Theranos on hype and secrecy, and pushed investors into a huge, $9 billion valuation. Now everyone in the industry is talking about this and lawsuits are flying.

Just a couple months ago, a Silicon Valley venture capitalist appeared on CNBC’s “Closing Bell” and instead of talking about the elephant in the room, he diverted to a defense strategy for the Theranos CEO.

 

He claimed Elizabeth Holmes had been “totally attacked,”and that she is “a great example of maybe why the women are so frustrated.”

He also went on to say, “This is a great entrepreneur who wants to change health care as we know it.”

 

The last statement was the strangest thing he said. Wouldn’t we all like to change things for the better? But “wanting” and “doing” are two different things.

 

 

 

Rader’s piece is worth reading for clinicians and IT professionals involved in health technology. The major lesson he draws is the need for transparency. He describes being put under pressure by his own board; why wasn’t he able to raise as much money as Theranos? It transpires that Theranos’ methods may make life more difficult for start-ups in the future, and Rader fears that legitimate health tech may suffer:

 

Nothing good has come of the mess created by Theronos secrecy, or as some have characterized, deception. The investor has been burned, the patient has been left with unfilled promises (yet again) and life science industry start-ups, like my company, have been left with even more challenges in raising much needed investment. And worse of all, diagnostic start-ups in general are carrying an unearned stigma.

 

In this interesting piece, Christine Farr notes that the biggest biotech and health care venture capital firms did not invest in Theranos, nor did Silicon Valley firms with actual clinical practices attached. As Farr writes, the Theranos story reflects systemic issues in funding of innovation, and the nature of hype. And one unfortunate consequence may be an excessive focus on Elizabeth Holmes; a charismatic figure lauded unrealistically at one point is ripe to become a scapegoat for all the ills of an industry the next.

 

The “stealth mode” in which Theranos operated in for the first ten years of its existence is incompatible with the values of healthcare and of the science on which it is based. Farr points out how unlikely it would be that a biotech firm vetting Theranos would let their lack of peer reviewed studies pass. The process of peer review and building evidence is key to the modern practice of medicine.

Another lesson is simply to beware of what one wants to be true. As written above, the idea of Theranos’ technology is highly appealing. The company, and Holmes, sailed on an ocean of hype and admiring magazine covers. The rhetoric of disruptive and revolutionizing healthcare featured prominently, as the 2014 Fortune magazine cover story reveals:

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Perhaps a healthy scepticism of claims to “revolutionise” health care will be one consequence of the Theranos affair, and a more robustly questioning attitude to the solutionism that plagues technology discourse in general.

Clinicians and health IT professionals should be open to innovation and new ideas, but also hold on to their professional duty to be confident new technologies will actually benefit the patient.

Critical thinking about critical thinking

At Aeon, an interesting piece on “critical thinking”, by Carl Hendrick:

Essentially, “critical thinking” as a skill detached from context is meaningless and illusory:

Of course, critical thinking is an essential part of a student’s mental equipment. However, it cannot be detached from context. Teaching students generic ‘thinking skills’ separate from the rest of their curriculum is meaningless and ineffective. As the American educationalist Daniel Willingham puts it:

[I]f you remind a student to ‘look at an issue from multiple perspectives’ often enough, he will learn that he ought to do so, but if he doesn’t know much about an issue, he can’t think about it from multiple perspectives … critical thinking (as well as scientific thinking and other domain-based thinking) is not a skill. There is not a set of critical thinking skills that can be acquired and deployed regardless of context.

This detachment of cognitive ideals from contextual knowledge is not confined to the learning of critical thinking. Some schools laud themselves for placing ‘21st-century learning skills’ at the heart of their mission. It’s even been suggested that some of these nebulous skills are now as important as literacy and should be afforded the same status. An example of this is brain-training games that claim to help kids become smarter, more alert and able to learn faster. However, recent research has shown that brain-training games are really only good for one thing – getting good at brain-training games.

Hendrick concludes:

Instead of teaching generic critical-thinking skills, we ought to focus on subject-specific critical-thinking skills that seek to broaden a student’s individual subject knowledge and unlock the unique, intricate mysteries of each subject. For example, if a student of literature knows that Mary Shelley’s mother died shortly after Mary was born and that Shelley herself lost a number of children in infancy, that student’s appreciation of Victor Frankenstein’s obsession with creating life from death, and the language used to describe it, is more enhanced than approaching the text without this knowledge. A physics student investigating why two planes behave differently in flight might know how to ‘think critically’ through the scientific method but, without solid knowledge of contingent factors such as outside air temperature and a bank of previous case studies to draw upon, the student will struggle to know which hypothesis to focus on and which variables to discount.

As Willingham writes: ‘Thought processes are intertwined with what is being thought about.’ Students need to be given real and significant things from the world to think with and about, if teachers want to influence how they do that thinking.

Medicine of course has had a vogue for “problem-based” learning for over half a century now. The premise of this is similar to that of critical thinking skills, and both have a laudable root of increasing learner engagement and showing the relevance of what they learn to “the real world.” Yet there are all sorts of assumptions, and wishful thinking involved.

“Mental health apps offer a head start on recovery” – Irish Times, 18/01/18

Here is a piece by Sylvia Thompson on a recent First Fortnight panel discussion I took part in on apps in mental health.

Dr Séamus Mac Suibhne, psychiatrist and member of the Health Service Executive research technology team says that while the task of vetting all apps for their clinical usefulness is virtually impossible, it would be helpful if the Cochrane Collaboration [a global independent network of researchers] had a specific e-health element so it could partner with internet companies to give a meaningful rubber stamp to specific mental health apps.

“There is potential for the use of mental health apps to engage people with diagnosed conditions – particularly younger patients who might stop going to their outpatients appointments,” says Dr Mac Suibhne. However, he cautions their use as a replacement to therapy. “A lot of apps claim to use a psychotherapeutic approach but psychotherapy is about a human encounter and an app can’t replace that,” he says.

Here are some other posts from this blog on these issues:

Here is a post on mental health apps and the military.

Here is a general piece on evidence, clinical credibilty and mental health apps.

Here is my rather sceptical take on a Financial Times piece on smartphones and healthcare.

Here is a piece on the dangers (and dynamics) of hype in health care tech

Here is a post on a paper on the quality of smartphone apps for panic disorder.