A surgical education: Joseph Queally on what surgical training can learning from music

It’s been a while since I posted anything on this blog, a longer while since I posted anything that wasn’t just a link to something else here, and an even while since I posted anything all that medical education related.

So here is Addrenbrookes orthopaedic surgeon Joseph Queally with an excellent piece on the BMJ site on what surgical training can learn from music. :

Anyone who has learnt a musical instrument knows that countless hours of practice are needed to achieve success. As a musician who has performed as an individual and as part of a group, I have spent many hours practicing before competitions and performances. It becomes apparent that how one practices is a skill in itself and the type or quality of practice is often more important than the quantity of practice. Ericsson formally described this phenomenon as deliberate practice after studying violinists in a music academy in Berlin. Rather than monotonous repetition of a skill or task, deliberate practice involves breaking the task up into chunks, identifying which ones need improvement, and performing focused practice on this chunk or task until a goal is achieved.

As a surgical educator, I can also see a role for deliberate practice in surgical training. As in music, complex tasks (e.g. percutaneous screw placement in fracture surgery) can be broken up into basic steps or “chunks,” such as image intensifier positioning, appropriate screw entry point identification, and trajectory planning. Trainees can then practice the steps they are deficient in under supervision. Here trainers provide critical feedback by identifying the troublesome parts of a technique that an individual trainee is struggling with. Simulation in particular can provide a safe environment for deliberate practice where trainees can practice tasks repeatedly without risk to patients.

Read the whole thing, as they say.


#LivingLibrary – College of Psychiatrists of Ireland event for #GreenRibbon month, 31st May 2018

I will be speaking as a living book in this:

The College is delighted to announce our 4th annual event in partnership with See Change for Green Ribbon Month – A Living Library
When it comes to mental health everyone has a story to share and we find comfort, empathy and compassion in shared experiences. Social contact is known to be one of the most effective ways of reducing mental health related stigma and discrimination so with this in mind, and to mark Green Ribbon month, the College is delighted to announce our ‘Living Library’ event, a library come to life in the outdoors!

At our library the ‘books’ are a little different, they are people; people with different experiences and stories to tell related to mental health including those who have experienced mental health issues and illness, their family members and carers, and the psychiatrists who help them towards the path of recovery. Mental health stigma too often creates discrimination and misunderstanding so we want to give members of the public the opportunity to connect and engage with psychiatrists and people they may not normally have the occasion to speak with.

The aim is to better understand the lived experiences of others who have experienced or facilitated recovery from mental illness and distress and to challenge their own assumptions, prejudices and stereotypes. We invite you to ‘read’ the human books through conversation and gain understanding of their experiences.

For Green Ribbon Month Let’s End the Stigma by not judging a book by its cover and develop a greater understanding of each other’s stories.

Thursday 31st May 2018
12.30pm – 2.30pm
St Stephens Green, Dublin

This is a Free Event, but space is limited. Book your place here.

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.



Marcus Aurelius: reflection good enough for an emperor but is it good enough for medicine?

Sati Heer-Stavert very kindly asked my permission to link to the paper I wrote a while back on Marcus Aurelius, stoicism and reflective practice – here is the post that has resulted which I am very impressed by! Certainly Sati has provided an excellent framework to prompt students and learners to reflect on what reflection means and what the obstacles to it are….


Reflection is an important part of training, appraisal and revalidation for doctors based in the UK. However, for many doctors the very thought of reflection can cause feelings of frustration, non-engagement or even rejection. Where did we go wrong?

Learning objectives

1. Consider the definition of reflection used in medicine

2. Understand how reflection can be assessed

3. Encourage you to read Meditations by Marcus Aurelius

Oh no! A patient has complained about your refusal to supply antibiotics for a cold. Wow! This would make a really good entry in your learning portfolio:

“That men of a certain type should behave as they do is inevitable. To wish it otherwise were to wish the fig-tree would not yield its juice. In any case, remember that in a very little while both you and he will be dead, and your very names will quickly be forgotten.”

You have to respond to…

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The curse of the quick fix

I’ve been reading Simon Garfield’s wonderful book Timekeepers: How The World Became Obsessed With Time. It is a fascinating set of narratives on the modern relationship with time. Towards the end, it slightly turns into a series of lists of conceptual art pieces that sound less Deeply Meaningful than Garfield makes out (oddly reminiscent of Evgeny Morozov’s To Solve Everything Click Here in this regard) and occasionally some of his more jokey passages grate, but most of the time (ho ho) it is a book that makes one see the taken-for-granted of the modern world for what it is. There are very funny passages on time management self-help books and on the world of haut horologie, and extremely thought-provoking ones on our time-poor age (or is it a perception? One of the time management gurus is actually wisest on this…)

Anyway a passage which struck me as especially germane to medicine, health care in general, and health IT in particular was the following – which is actually Garfield citing another author, but there you go:

And can any of these books really help us in these decisions? Can even the most cogently aligned bullet point and quadrant matrix transform a hard-wired mind? The notion of saving four hours every ten minutes is challenged by The Slow Fix: Why Quick Fixes Don’t Work by Carl Honoré. The book set its tone with an epigram from Othello: ‘How poor are they who have not patience! What wound did ever heal but by degrees?’6

The quick fix has its place, Honoré argues – the Heimlich manoeuvre, the duct tape and cardboard solution from Houston that gets the astronauts home in Apollo 13 – but the temporal management of one’s life is not one of them. He reasons that too much of our world runs on unrealistic ambitions and shabby behaviour: a bikini body within a fortnight, a TED talk that will change the world, the football manager sacked after two months of bad results.

He cites examples of rushed and dismal failings from manufacturing (Toyota’s failure to deal with a problem with a proper solution that might have prevented the recall of 10 million cars) and from war and diplomacy (military involvement in Iraq). And then there is medicine and healthcare, and the mistaken belief – held too often by the media and initially the Bill and Melinda Gates foundation – that a magic bullet could cure the big diseases if only we worked faster and smarter and pumped in more cash. Honoré mentions malaria, and the vague but quaint story of a phalanx of IT wizards showing up at the Geneva headquarters of the World Health Organisation with a mission to eradicate malaria and other tropical diseases. When he visited he found the offices somewhat at odds with those of Palo Alto (ceiling fans and grey filing cabinets, no one on a Segway). ‘The tech guys arrived with their laptops and said, “Give us the data and the maps and we’ll fix this for you.”’ Honoré quotes one long-term WHO researcher, Pierre Boucher, saying. ‘And I just thought, “Will you now?” Tropical diseases are an immensely complex problem . . . Eventually they left and we never heard from them again.’”

As my own practice has developed over the years, I have come to a realisation that quick fixes tend to unfix themselves over time, and the quick fix mentality carries a huge cost over time.

Here is Honoré’s TED Talk. Garfield has a very entertaining passage in the book where he talks at a rival of TED’s, which has a 17 minute limit (TED has an 18 minute one)

Helmholtz and the ophthalmoscope, Eurotimes, 2008

Recently I rediscovered some articles for Eurotimes, the European Journal of Cataract and Refractive Surgeons that I had forgotten I had written. I have posted here before some of my book reviews for Eurotimes. I also wrote some pieces on historical ophthalmological figures – the first on Goethe and his work in optics, the second on Hermann von Helmholtz who was one of those towering, foundational figures in modern physics but who also invented the ophthalmoscope


In the last article, I considered one of the towering geniuses of world culture, Johann Wolfgang von Goethe. Goethe made enormous contributions to world literature and philosophy, and significant contributions to the nascent sciences of visual perception, linguistics, plant morphology, and felt he would be remembered most of all for his work on optics. Goethe perhaps epitomises the “natural philosopher”, the original term for “scientist” – an individual of boundless curiosity and enthusiasm, a gifted amateur in the true sense. Science owes much to the activities of men and women who operated outside the dynamic of universities and in an age before the research institute or the grant.

Hermann Ludwig Ferdinand von Helmholtz (1821-1894) is a less towering cultural presence than Goethe. His scientific activities have had a more lasting influence. He bridges the worlds of “natural philosophy” and organised, university based science – both in terms of his lifespan (eleven when Goethe died, he lived to directly influence Einstein and Maxwell) and in his professional life (originally training under paternal pressure as a doctor, he was appointed Professor of Physics in Berlin in 1871). Much of his work attacked the speculative tendencies of the natural philosophers, and was grounded firmly in observation and experiment.

Yet such was the breadth of his activity that he reminds one of the multi-talented natural philosopher as much as a contemporary, specialised physicist or physiologist. The Oxford Companion to the History of Modern Science describes him in summary as “physiologist, physicist, philosopher and statesman of science.” This begins to capture the breadth and diversity of his interest and involvement. We will discuss his work on perception, and on ophthalmic optics, below, but it is important to recall he was simultaneously working on conservation of energy, thermodynamics, and electrodynamics, and developed the philosophy of science itself. His writings ranged from the age of the earth to the origin and fate of the solar system.


One of the more humbling characteristics of the scientists of the past was their seeming mastery of measurement. We are so used to highly accurate, precise computerised measuring apparatus that we can forget that until relatively recently, researchers often had to build and calibrate their own equipment. And going back only a little further, they had to invent it as well. Most readers of EuroTimes probably use one of Helmholtz’s inventions every day – the ophthalmoscope.

Invented in 1851, the ophthalmoscope is a perfect illustration of Helmholtz’s combination of experimental and inventive skill. The invention made him world famous overnight. Helmholtz was actually independently reinventing a device of Charles Babbage’s from 1847. As so often in science, it was the reinventor who recognised the usefulness and applicability of the invention, rather than the first inventor (Babbage, of course, also managed to invent but not complete the first computer) The handheld ophthalmoscope was developed by Greek ophthalmolosist Andreas Anagonstakis later in the 1850s, and in 1915 William Noah Allyn and Frederick Welch invented the self illuminating ophthalmoscope (and founded Welch Allyn) that is the direct precursor of the modern device.

Who was Helmholtz, this man of so many talents and interests and such lasting influence? Born in Potsdam on 31st August 1821 into a lower middle class family that emphasised the importance of education and cultural activities, his father Ferdinand was a teacher of philosophy and psychology in the local secondary school. His mother was a descendant of William Penn, the founder of Pennsylvania, and her maiden name was Penne. Ferdinand Helmholtz was also a close friend of the philosopher Fichte. The scientific and philosophical worlds of the nineteenth century often seem amazingly small and parochial.


Helmholtz’s natural inclination as a student was to pursue studies in physics – however his father observed the financial support available for medical students and the lack thereof for physics students, and persuaded him into medical studies. He enrolled in the Friedrich-Wilhelms-Institut in Berlin, the Prussian military’s medical training college. After this, the served as a medical officer in the Prussian military for a time, simultaneously publishing articles on heat and muscle physiology. In 1847 he published his treatise On The Conservation of Force, which was the clearest and ultimately most influential account of what would become known as the principle of the conservation of energy. From his observations of muscles physiology and activity, he tried to demonstrate that there is no energy loss in muscle movement, and no “life force” is necessary to move a muscle.

In 1848 he left military service and embarked on an academic career. In 1849, he became an associate professor of physiology in Konigsberg.. Shortly after he announced the invention of the ophthalmoscope and also made another discovery that would seal his fame – measuring the rate of conduction of signals in nerves. It had been believed that sensory signals arrived at the brain instantaneously, and it was considered beyond the capabilities of experimental science to measure the rate of nerve conduction. Using a new invention, the chronograph, Helmholtz measured the difference between stimulus and reaction times at different parts of the body, and found the speed of neural conduction to be comparable to that of sound, not light.

A full account of all Helmholtz’s discoveries and scientific achievements would take volumes. He had an intense interest in visual perception, especially visual illusions. This interest was based on his philosophical position that we are separate from the world of objects, and isolated from external physical events, except for perceptual signals which, not unlike language, must be learned and read according to various assumptions. These assumptions may or may not be appropriate. This philosophy underlay many of his research activities and interests, and also his idea that perceptions are “unconscious inferences.”

Most of what goes on in the nervous system, according to Helmholtz, is not represented in consciousness. Psychological and physiological experimental findings often surprise us for this reason, because we cannot discover by introspection how we see or how we think. We derive a perception from incomplete data, hence “unconscious inference.” This idea influenced Freud’s idea of the unconscious, and Helmholtz’s student Wilhelm Wundt, who took Helmholtz’s work and ideas further. Another of his students, Heinrich Hertz, further developed Helmholtz’s work on energy and electrodynamics.

Helmholtz had a huge impact on all areas of perceptual science, and many areas of physics. His name lives in a variety of laws and concepts (Helmholtz illusion, Helmholtz free energy, Helmholtz-Kelvin contaction) and that of an association of research institutes in Germany. And of course, for the humble working ophthalmologist, every day, almost without thinking, Helmholtz’s influence as the originator of the modern ophthalmoscope is literally palpable.

What’s Love Got to Do with It? A Longitudinal Study of the Culture of Companionate Love and Employee and Client Outcomes in a Long-term Care Setting, Barsdale and O’Neill 2014

I have blogged before about the relationship between morale and clinical outcomes. From 2014 in Administrative Science Quarterly , a paper which links this with another interest of mine, workplace friendships .

Here is the abstract:

In this longitudinal study, we build a theory of a culture of companionate love—feelings of affection, compassion, caring, and tenderness for others—at work, examining the culture’s influence on outcomes for employees and the clients they serve in a long-term care setting. Using measures derived from outside observers, employees, family members, and cultural artifacts, we find that an emotional culture of companionate love at work positively relates to employees’ satisfaction and teamwork and negatively relates to their absenteeism and emotional exhaustion. Employees’ trait positive affectivity (trait PA)—one’s tendency to have a pleasant emotional engagement with one’s environment—moderates the influence of the culture of companionate love, amplifying its positive influence for employees higher in trait PA. We also find a positive association between a culture of companionate love and clients’ outcomes, specifically, better patient mood, quality of life, satisfaction, and fewer trips to the emergency room. The study finds some association between a culture of love and families’ satisfaction with the long-term care facility. We discuss the implications of a culture of companionate love for both cognitive and emotional theories of organizational culture. We also consider the relevance of a culture of companionate love in other industries and explore its managerial implications for the healthcare industry and beyond.

Few outcomes are as “hard” – or as appealing to a certain strand of management – than “fewer trips to the emergency room.” The authors squarely and unashamedly go beyond the often euphemistic language of this kind of paper to focus on love:

‘‘Love’’ is a word rarely found in the modern management literature, yet for more than half a century, psychologists have studied companionate love— defined as feelings of affection, compassion, caring, and tenderness for others—as a basic emotion fundamental to the human experience (Walster and Walster, 1978; Reis and Aron, 2008). Companionate love is a far less intense emotion than romantic love (Hatfield and Rapson, 1993, 2000); instead of being based on passion, it is based on warmth, connection (Fehr, 1988; Sternberg, 1988), and the ‘‘affection we feel for those with whom our lives are deeply intertwined’’ (Berscheid and Walster, 1978: 177). Unlike self-focused positive emotions (such as pride or joy), which center on independence and self- orientation, companionate love is an other-focused emotion, promoting interdependence and sensitivity toward other people (Markus and Kitayama, 1991; Gonzaga et al., 2001).

Companionate love is therefore distinct from the romantic love which so dominates our thought when we think about love. As is often the case, we moderns are not nearly as new in our thinking as we would like to see ourselves:

Considering the large proportion of our lives we spend with others at work (U.S. Bureau of Labor Statistics, 2011), the influence of companionate love in other varied life domains (Shaver et al., 1987), and the growing field of positive organizational scholarship, which focuses on human connections at work (Rynes et al., 2012), it is reasonable to expect that this basic human emotion will not only exist at work but that it will also influence workplace outcomes. Although the term ‘‘companionate love’’ had not yet been coined, the work of early twentieth-century organizational scholars revealed rich evidence of deep connections between workers involving the feelings of affection, caring, and compassion that comprise companionate love. Hersey’s (1932) daily experi- ence sampling study of Pennsylvania Railroad System employees, for example, recorded the importance of caring, affection, compassion, and tenderness, as well as highlighting the negative effects when these emotions were absent, particularly in relationships with foremen. Similarly, Roethlisberger and Dickson’s (1939) detailed study of factory life provided crisp observations of companionate love in descriptions of workers’ interactions, describing supervisors who showed genuine affection, care, compassion, and tenderness toward their employees.

There is nothing new under the sun. In subsequent decades this kind of research was abandoned.  The authors go on to describe the distinctions between strong and weak cultures of companionate love:

Like the concept of cognitive organizational culture, a culture of companio- nate love can be characterized as strong or weak. To picture a strong culture of companionate love, first imagine a pair of coworkers collaborating side by side, each day expressing caring and affection toward one another, safeguarding each other’s feelings, showing tenderness and compassion when things don’t go well, and supporting each other in work and non-work matters. Then expand this image to an entire network of dyadic and group interactions so that this type of caring, affection, tenderness, and compassion occurs frequently within most of the dyads and groups throughout the entire social unit: a clear picture emerges of a culture of companionate love. Such a culture involves high ‘‘crystallization,’’ that is, pervasiveness or consensus among employees in enacting the culture (Jackson, 1966).

An example of high crystallization appears in a qualitative study of social workers (Kahn, 1993) in which compassion spreads through the network of employees in a ‘‘flow and reverse flow’’ of the emotion from employees to one another and to supervisors and back. This crystallization of companionate love can cross organizational levels; for example, an employee at a medical center described the pervasiveness of companionate love through- out the unit: ‘‘We are a family. When you walk in the door, you can feel it. Everyone cares for each other regardless of whatever level you are in. We all watch out for each other’’ (http://auroramed.dotcms.org/careers/employee_ voices.htm). Words like ‘‘all’’ and ‘‘everyone’’ in conjunction with affection, caring, and compassion are hallmarks of a high crystallization culture of companio- nate love.

Another characteristic of a strong culture of companionate love is a high degree of displayed intensity (Jackson, 1966) of emotional expression of affec- tion, caring, compassion, and tenderness. This can be seen in the example of an employee diagnosed with multiple sclerosis who described a work group whose members treated her with tremendous companionate love during her daily struggles with the condition. ‘‘My coworkers showed me more love and compassion than I would ever have imagined. Do I wish that I didn’t have MS? Of course. But would I give up the opportunity to witness and receive so much love? No way’’ (Lilius et al., 2003: 23).

In weak cultures of companionate love, expressions of affection, caring, compassion, or tenderness among employees are minimal or non-existent, showing both low intensity and low crystallization. Employees in cultures low in companionate love show indifference or even callousness toward each other, do not offer or expect the emotions that companionate love comprises when things are going well, and do not allow room to deal with distress in the workplace when things are not going well. In a recent hospital case study, when a nurse with 30 years of tenure told her supervisor that her mother-in- law had died, her supervisor responded not with compassion or even sympathy, but by saying, ‘‘I have staff that handles this. I don’t want to deal with it’’ (Lilius et al., 2008: 209). Contrast this reaction with one from the billing unit of a health services organization in which an employee described her coworkers’ reactions following the death of her mother: ‘‘I did not expect any of the compassion and sympathy and the love, the actual love that I got from co-workers’’ (Lilius et al., 2011: 880).

This is obviously a paper I could simply post extracts from all day but at this point I will desist. Perhaps rather than “What’s Love Got to Do With It? the authors could have invoked “All You Need is Love?