Information Transforms Medicine For Me: ItsMe2, the “digital me”, the future of health care, Big Big Science and me.

itsme2

My recent musings on visions of future healthcare reminded me of a project I was involved in five years ago. This is a long, involved story, so bear with me.

It began in very early 2010, when I came across a link on a BBC news web page. I have been trying to find the particular BBC story without success; I recall it involving Polish researchers and quantum computing in some way. Anyway, the link lead to the European Commission’s CORDIS portal, and some surfing later I found a page on the Future And Emerging Technologies Flagships project.

FET Flagships are:

 

“ambitious large-scale, science-driven, research initiatives that aim to achieve a visionary goal.
The scientific advance should provide a strong and broad basis for future technological innovation and economic exploitation
in a variety of areas, as well as novel benefits for society.”

The site also mentioned they would have a budget of 100 million euros per year, for ten years.

At the time I had been working on various medical education projects and was coming to the end of my Masters in Medical Education from University of Dundee. I had come to the conclusion that many of the outstanding questions in medical education required a massive, long term, cohort approach. Meaningful work on issues like medical school selection and retention, or the introduction of technology into medical education that truly improved patient outcomes, required long-term studies, rather the short-term surveys and pilots that seemed to dominate the field.

The Flagship call was simply an online form. I used my role with the psychiatry section of RAMI as an institutional cover. At the time, I was a Senior Registrar in St Brigid’s, Ardee, and while I will still quite closely linked with UCD, I had no formal role in any third level institution. I fill out the online form really as a way of getting my own thoughts on the topic together.

I was surprised to get an email, a few days later, inviting me to present at a Flagship workshop in Brussels. At first, I thought this was impossible. Then I realised that it was far from impossible – as it happened the workshop was on my research day. I booked a flight to Brussels and the rest is …. well, not quite history, but nevertheless remains online 

transforming medical education

 

The content of my slides is presented below with some comments after each quote – the headings are those of the Flagship application form:

Idea

TRANSFORM MEDICAL EDUCATION •

ICT in medical teaching – from video‐based Virtual Patient to fully immersive Virtual Clinical Environment

• Long term, multicentre, multidisciplinary assessment of impact of Virtual Clinical Environment on students from pre‐intake to established practice

• assessing every aspect of their acquisition and development of information related to knowledge, skills and attitudes using technology as well as other teaching methods.

This is in some ways the most straightforward part of the story. I was not – and am not – predominantly interested in what technology can do for practice, but what constitutes good practice. I am pro-technology if it helps good practice and good outcomes, and anti-technology if it leads to bad practice and bad outcomes.

Ambition •

2020 – “major societal goal is to live longer in better health, in a secure environment and in prosperous conditions” – ISTAG (ICT Advisory Group), July 2009.

• Developing of plausible, fully interactive, immersive, “presence” ‐laden virtual environments

• Difficulty in assessing behavioural change and positive clinical outcome due to educational interventions – require long term, broad evaluation integrating approaches of social science and humanities

• Applicable to other educational contexts

All very worthy, I’m sure you will agree. The EC Cordis ICT Advisory Group was touted very much as the shaping force of this Flagship idea, so I thought it was good to mention them.

Impact

• Health is now one of the biggest issues affecting competitiveness, ongoing sustainabiltiy, and society overall

• High fiscal cost of medical education

• High fiscal, social and mortality/morbidity cost of medical mistakes and missed health promotion opportunities.

• Importance of medical research – a s well as producing clinicians, producing hypothesis generators and research workers.

• Medical education – training practitioners and researchers. Integrates many disciplines.

• Wider impact on education and training generally

Very much in the motherhood-and-apple-pie camp. I have to say I like the phrase “producing hypothesis generators and research workers.”

Integration

• Medicine is transdisciplinary by nature

• Four proposed strands

—• ICT developing immersive virtual teaching environments & other innovations

—• clinical research into practice outcomes

—• educational – integrating and evaluating ICT and other innovative teaching methods

—• information science /social studies – th e entire process of becoming a doctor in social, anthropological, information ‐management and other contexts

All of this is proof I do not lack for grandiosity (at least in some settings)

Plausibility

• Medicine and medical education are EU Strengths

• Much work already throughout EU on each strand (see next slide)

• Long term approach required to assess clinical outcomes of medical educational innovations

• All students entering the project would be subject, to baseline assessments and follow up of academic performance and clinical performance. Individual institutions will be part of the other strands to differing degrees

• Unified approach relating ICT innovation to educational, clinical and social outcomes

(see next slide) indeed – though this was where things were about to get even more intereste

 

Expected support

• AMEE and other medical educator networks

• Virtual Patient project http://www.virtualpatients.eu

• INMEDEA – virtual clinical environment

• MedBiquitous Europe – technical standards for eLearning

• Focus on clinical outcomes – support of Departments of Health, health insurers • Humanities departments as well as ICT/Medical departments of Universities

Need I say that absolutely none of these stakeholders knew the slightest thing about my Massive Grandiose Plan?

This is what I presented at the workshop in Brussels on January 22nd, 2010. The day featured lots of interesting, and in fairness quite frank, discussion as to whether this whole flagship thing was a good idea or not. CORDIS were upfront that they wanted projects that were man-on-the-moon, Human Genome Project style ones which would grab public attention and media coverage. Someone pointed out that putting a man on the moon was useless, although they wouldn’t sniff at the HGP – someone else immediately pointed out that the moon landings gave the USA a continuing advantage in aerospace technology, while the HGP had yet to yield a single treatment for any illness.

The day also featured one of the most impressive – scratch that, THE most impressive – presentations I have seen, from Henry Markram, then of IBM’s Blue Brain Project . Markram will feature a little further on in our story – suffice it to say that he did not skimp on any of the challenges or philosophical implications of the proposal to simulate the brain in toto.

In any case, the upshot of the Workshop was that no one had come into the room with a big enough idea. I was not at all surprised – after all, I did not expect (except in wilder dreams, perhaps) that funding medical education research was anywhere like as exciting as Neil Armstrong landing on the moon. It was then things got interesting, but also that my own role began to change.

I decided to contact some of the stakeholders I had so blithely included on my slide, particular the European Virtual Patients project. I emailed Terry Poulton and Chara Balasubramaniam of St Georges University of London in semi-apologetic form. One of my worries that I had misread the state of virtual patients badly, and arrogantly, and that my contentions would be laughed out of court.

 

It was flattering to find Terry and Chara seeing this project as a potential opportunity. They also recruited Panagiotis Bamidis , who had been involved in the eLearning standard-setting Meducator Project , and we had a series of fruitful discussions on the phone and via various online meeting platforms. Terry took on the reins of presenting at the next workshop, which was in Barcelona.

At this juncture my own professional situation was asserting itself. I was coming to the end of Higher Specialist Training in Psychiatry. I didn’t have  a job come July 2010. I didn’t have budget to travel to conferences that weren’t specifically training related. I had no real institutional affiliation or position, and nothing much to bring to the table of proposals except a song in my heart and a smile on my face. I emailed various stakeholders in Ireland, and had interesting meetings with Science Foundation Ireland, the National Digital Research Centre, and various other research institutes in Ireland. A billion euro project does tend to attract interest. However, what did I have to offer? Keep in touch was the generally encouraging word. And I was not sure how all this would go down in terms of applying for what were primarily clinical jobs, on a CV that already featured its share of somewhat atypical entries. Perhaps more crucially, I didn’t feel I could take the time out, as I was in the position of needing to get locum work  (this was 2010 – now the power is much more with the locum) in the near future.

 

Things moved apace. Terry found synergies with the Virtual Physiological Human project and Prof Hans Lemke’s Computer Assisted Radiology and Surgery project, both of which had entered proposed FET Flagship ideas. These three arms coalesced into a proposal for a project for a “medical avatar”, a “digital me” that would initially be developed for educational purposes but would gradually become a combination of personal electronic health record and personalised health simulator.

At this point I was in a locum position in Cork. Finally one of my meetings paid off, and Prof George Shorten, the new Dean of the UCC Medical School, was interested in a more tangible way in the project. This involved making me a Visiting Fellow of UCC Medical School. Unfortunately, most of the connections had been made, and I still did not have much specific to “bring to the table.”

Nevertheless the project continued, and that December I found myself in a B& B in Ardee, Co Louth, stranded by the snow, working with a range of random collaborators around Europe on the proposal which became called ItsMe2. A screenshot above shows the first page of the 313-page PDF.  This, from the proposal abstract, gives a flavour of what my medical education project had become:

The ITsMe2 Preparatory Action will meet the most pressing socio-economic challenge of European societies: the sustainability and reform of our health and care systems. It designs a long-term roadmap for a FET-Flagship Initiative that develops radically new, integrative, ICT-facilitated models and solutions for delivering well-being and health services to global citizens. The ICT challenges this poses are far beyond current frontiers in user interfaces, physiological modelling, simulation, computer facilities, data storage, interoperability, educational and training support.

ITsMe2 will realise the most advanced “virtual” entity (or avatar) on Earth, a highly advanced digital representation of every individual that stays with us for life, evolving, ‘learning’, becoming an increasingly personalised description of our anatomy, physiology, emotional and physical-socialenvironment as new data and information becomes available. This requires a novel IT infrastructure to manage and integrate the exploding quantities of data, information, knowledge and wisdom far beyond presently dominating somatic aspects. Health policy experts and business modelling will support transfer towards innovation and exploitation.

Is that too modest a goal? Let’s have another go:

Our aims are the construction of an avatar, a digital representation of each and every individual that stays with us for life, evolving, ‘learning’, becoming an increasingly accurate personalised description of our anatomy, physiology and even emotional make-up as new data and information becomes available to populate these characteristics, and secondly the construction of the new IT infrastructure that will be required to manage and to integrate the exploding quantities of data, information, knowledge and wisdom, to evolve data into wisdom, and to present them to the individual user (citizen, patient, healthcare professional,…) in a manner that is intuitive and usable

I didn’t write this 313 page proposal. I did write a few parts, suggested a few changes, made a few edits. I was one of the people on the 2nd of December working on this as the deadline approached, although really just as a quasi-proof reader. It was a strange experience being in Ardee, collaborating with researchers in Norway and Sheffield and Barcelona

Now I am somewhat allergic to excessive use of the word “revolutionise.” This  may have been a kind of  reaction formation to being associated with the ItsMe2 proposal:

Revolutionise healthcare by extending Evidence-Based Medicine into Explanation-based
Medicine, by deploying these radically innovative technologies into the European industrial and
healthcare system, and assess their efficacies;

– Revolutionise healthcare through Information and Communication Technologies to make possible
a complete digitalisation, a complete integration, and an ubiquitous but secure access to every data,
information, and knowledge relative to the wellness, the prevention, and the healthcare of every citizen
of Europe;

– Revolutionise the vision and the culture of all key stakeholders and of the public opinion on the
role of ICT in wellness, prevention and healthcare, by training and re-training the medical
professionals, and by orienting the policy makers and the public opinion.

– Revolutionise the business model to support research and innovation in wellness, prevention and
health care as is mandatory to overcome the current IT stagnation in healthcare, by leverage
mechanisms
that induce co-investment from the member states paralleling EC investments and
overcome the challenges associated with the scale of ambition of a paradigm shift in healthcare
infrastructures.

We didn’t make the cut for the next stage – the “preparatory action.” The final Flagships were on Graphene and the Human Brain Project. Henry  Markram is leading this, and has had the inevitable troubles with managing a project of this nature . I had looked at the HBP page a while back, hoping for something to do, but my connectome skills aren’t what they were.

ItsMe2 seems to have more or less vanished from the Internet, yet another salutary warning of the dangers of overdependence on the cloud as an outboard memory. The VPH/AMEE link persisted. I sometimes wish i had been able to be more active in the development of this project. Thinking about visions of healthcare, ItsMe2 was certainly a grand vision; personally one I would now modify . And in a way it became something far far different than anything I had thought of, with less of an emphasis on anthropology, social science, philosophy etc.

Nevertheless, now I am involved in the HSE CCIO , I find myself wondering if this grand vision is one that we could usefully learn from again. It is over five years since I sat in a B&B room in Ardee with my laptop and wifi dongle. In some ways the world is very different, but in many it feels similar – the way I work is recognisably that of 2010 (and before) and, for all the pace of change, the ItsMe2 vision does not seem any closer.

 

My struggle against EMBASE Screening addiction

Ok, the headline is a little glib, and I don’t want to make fun of any actual addiction – but since discovering EMBASE screening at a HRB TMRN event on systematic reviews on Thursday last, I’ve been hooked.
EMBASE screening is very simple – as the Cochrane Collaboration Community Page on the project states “The project’s purpose is to identify reports of randomised controlled trials (RCTs) and quasi-RCTs from EMBASE for publication in the Cochrane Central Register of Controlled Trials (CENTRAL)” Put simply , “The EMBASE project provides an opportunity for new and potential contributors to get involved with Cochrane work by diving into a task that needs doing. No prior experience is necessary as the task supports a ‘learn as you do’ approach. ”

 

Basically the screener is presented with a title and abstract (occasionally just a title) and has to decide if this is an RCT/quasi-RCT, definitely not an RCT/quasi-RCT, or impossible to tell. There are lots of checks and balances so one shouldn’t worry about making a mistake. The interface is very simple and a good, clear training module is provided before you get stuck it.

This is a much better way of passing a few minutes with a smart phone than checking news sites again or again, or whatever your poison is…. and along the way I have come across some intriguing abstracts such as this and this (neither of which is a RCT)

 

 

CCIO thoughts

Again I find myself deviating from the original purpose of this blog and writing an original post. It is a companion piece of sorts to my previous thoughts on the AMEE Hackathon in Glasgow and continues its ruminations on technology and health. It is also very much a reflective piece and not only are these opinions not those of the CCIO, the HSE, or any other institution I may have links with, they are barely even those of myself.

On Wednesday 16th September I attended my first full CCIO meeting. What is a CCIO? Put simply, it is a Council of Chief Information Officers and its role is summarised by the HSE (Health Services Executive, for non-Irish readers the body that manages public health care in the Republic of Ireland) thus:

A Council of Clinical Information Officers has been established to provide clinical governance to the delivery of eHealth solutions and in particular the Electronic Health Record (EHR) Programme. Its role is primarily as an advisory group, supporting the primary governance and oversight provided by the Office of the CIO and the eHealth Ireland committee

I won’t get too much into the content of the CCIO meeting – essentially discussing the question of governance of eHealth.  Essentially presentations alternated with small group discussions that focused on specific questions on the governance issue. In our group there was a great depth of expertise and experience and the discussions grew somewhat beyond the specific questions.

It was an interesting contrast with the Hackathon which I previously blogged about. By comparison with the tech-evangelisation of the Hackathon, the CCIO’s level of discussion was impressively realistic, and open to the pitfalls of technology as much as the promise. Indeed, there was clearly a high level of experience and expertise in the room. As a clinician with a (sometimes quite sceptical) interest in technology, rather than hands on experience of eHealth and with pretty much no actual IT experience,  it is interesting and a little challenging to be in that room. I am not involved personally in any local IT project and indeed my clinical work is very much paper-and-pen based.

In one of the groups I did try and make a point about expertise in information management that currently exists. Sometimes pen and paper files are talked about as if they are beneath contempt as a solution. Of course, if they are available at the right time, are legible, and reliably contain the relevant information, paper files are a reasonable and effective solution. The problem is that they are not reliably any of those things.

However, the information ecosystem of paper files has developed in a way that may reflect local practices, may reflect workflow issues, may reflect industrial relations practices (ie which staff member gets the file) but also may reflect something about the overall system that is worth knowing, and perhaps worth retaining. I am still working out my thoughts on this.

I am a very sporadic tweeter, but have begun following the  CCIO twitter feed. As so often, Twitter tends towards a certain slightly overcaffieneated enthusiasm. eHealth has become one of those motherhood and apple pie things that almost no-one objects to and tends to attract social media enthusiasm that I suspect can be rather frothy (I may also blog at some point about the recent OECD report on technology in education, and the rather dismaying social media reactions exhibiting a bad case of confirmation bias). It is interesting to contrast this with the nuts and bolts of the actual discussions. Richard Corbridge, the CIO , gave a closing peroration which combined enthusiasm with a sense of the challenges that lie ahead, and also a reflection that from the feedback given by the small groups, a lot of what the HSE Is currently doing isn’t getting through to the staff on the ground.

I am quite sceptical of terms like “transformation” and “revolutionise” in general, and particularly when applied to technology’s impact on healthcare (and education) I was interested to read Richard Corbridge’s blog post on transition, transformation and continued development. The distinctions between the three are well made, and Corbridge particularly focuses on the “enthusiasm” element of transformation.

This has got me thinking that perhaps my resistance to the discourse “transforming” and “revolutionising” health/education/whatever may (almost certainly does) reflect my own beliefs about and reaction to those words – that perhaps my own expectations of “transformation” are too high, and somewhat utopian. Therefore I resist the transformation concept as setting an impossibly high standard, one which dooms one to disappointment.

I was also struck in the CCIO groups discussions how many (nearly all?) of the challenges are cultural and involve managing people. Ultimately it all comes down to relationship management. I have been involved in other change management situations in which cultural factors are acknowledged, but often in a very superficial way that implies changing culture is simply a matter of people deciding one day to believe something totally contrary to what they believed before. I am glad that Richard Corbridge and the CCIO team are more aware of the challenge.

Finally, in my Glasgow/AMEE blogpost I wrote that the pitfall of the tech driving the process, rather than the clinical need, is perhaps a trickier problem than it first appears. The dynamic of technology being “in the driving seat” is more complex and more difficult to manage than a simple case of telling everyone to in some way think differently (clearly there is an overlap with my thoughts on culture above) The CCIO somewhat modulated my thoughts on this. The CCIO members are, by definition, interested and enthused by this area, and are also very aware that the tech does NOT come first.

Review for TLS of Rose Shapiro’s “Suckers: How Alternative Medicine is Making Fools of Us All” , 2008

Original text of review for TLS of Rose Shapiro’s “Suckers: How Alternative Medicine is Making Fools of Us All”

The TLS published this with slight tweaks, I will try and use Lexis/Nexis to get the final text.  I suppose my view on “alternative medicine” comes across here. Wellness and health are ultimately subjective, and experienced at an irreducibly individual level. This doesn’t mean every wild claim should be taken at face value.  Books like Suckers are exercises in shooting fish in a barrel. What is really interesting about alternative medicine is why so many people are drawn to it. This may be because of failings of mainstream medicine, but ultimately I believe says more about society in general. Increasingly life expectancies and an increasing  expectancy of an active older age do not necessarily mean that our expectations of what it means to be healthy are realistic, or even achievable. The WHO’s grandiose definition of health doesn’t help. Ultimately the popularity of alternative medicine is an attempt to sate a need that mainstream medicine doesn’t even begin to address – nor should it.

Suckers: How Alternative Medicine Makes Fools Of Us All by Rose Shapiro – Harvill Secker 2008

In the UK, £4.5 billion is spent each year on Complementary and Alternative Medicine (often usefully abbreviated to CAM). CAM is a broad term. As Rose Shapiro observes towards the end of this astringent book, these treatments are on a continuum, with some herbal remedies and relaxation techniques being incorporated into the mainstream. Somewhere beyond these therapies are the likes of acupuncture – with some possible efficacy for pain and nausea – and further along we get to the bulk of CAM “therapies”, of which Shapiro gives many lengthy and non-exhaustive lists – from ear candling to Bach flower remedies and from homeopathy to cranial osteopathy – all of which are unproven and with a theoretical basis positively antithetical to physiological, biochemical, chemical and anatomical knowledge.

CAM therapies and have recurrent features, and their pioneers and proponents have recurrent tendencies. Emblematic is the life of Daniel David Palmer, inventor-prophet of chiropractic. Canadian-born, in the 1890s Palmer had established a magnetic healing practice in Iowa and styled himself “Doctor” (despite their disdain for the medical establishment, CAM practitioners seem keen to claim the title and trappings of the profession) and decided that there must a single cure for all diseases, another familiar theme.

In the world of CAM, anecdotal experience trumps repeatable scientific study. Palmer claimed to have restored a local janitor’s hearing by manipulating his spine (a claim disputed by the janitor’s family) thereby discovering “subluxations”- a borrowing from orthodox medicine which in chiropractic refers to any spinal deviation, the supposed cause of 95% of disease. Palmer lost control of chiropractic, the idea for which had been revealed to him during a séance, to his less mystical and savvier son B J Palmer, who realised that the real money was in training further chiropractors. Much entertaining brouhaha ensued, with the elder Palmer dying after being hit by a car whilst protesting at the annual jamboree held by his son’s school of chiropractic (internecine feuding, no surprise with so many “discovering” the cure to all disease , seems another feature of the CAM landscape).

Shapiro wittily illustrates other CAM traits, the misuse of scientific-sounding words like “quantum” and “paradigm”, the paranoid stance towards conventional medicine which is in conspiratorial cahoots to suppress the hugely profitable CAM, the paradox that CAM practitioners stress the timeless, ancient qualities of their remedies while often trying to cloak it in the terminology of state-of-the-art technology. She has read widely, yet there is little evidence of original research or observation. There is not much here that not covered in more depth in other popular books, or even more pertinently websites such as Stephen Barrett’s quackwatch.com. Shapiro takes Barrett’s impatient, take-no-prisoners approach, which plays well with fellow sceptics but does little to convert the undecided. There is more of a UK focus than in other books on the subject, with issues such as availability on the NHS and should B.Sc. degrees in CAM practices (Bachelor of Science without the science, as one critic points out) be offered discussed.

The “therapies” are so many fish in a barrel, and Shapiro does her debunking work with glee. And yet there is a sameness to it all, a sense of missing the wider point. The post-industrial West is a world with unprecedently high life expectancy and freedom from serious life-shortening disease. This is also s world where “Dr” Gillian McKeith markets a snack bar listing “Unconditional Love” as an ingredient. Why are the legions of educated, high-disposable-income middle-aged, middle-class women– identified by Shapiro as the key consumers of complementary/alternative medicine – so keen to abandon critical thinking when it comes to their health? Shapiro makes some unexceptional observations about CAM offering these women some control and power over their lives, but does not explore these issues in depth.

Why do the majority of the headaches, back aches, fatigue and non-specific pain that comes the way of general practitioners have no physically identifiable cause? Why has having an illness become somehow desirable; why for instance are the “ME lobby” so vehement in their insistence that the condition has a purely physical cause? The World Health Organisation has defined health as “a stage of complete physical, social and mental well being and not merely the absence of disease or infirmity”, a statement of awesome fatuity which renders health unattainable in this world. And if health is considered a right, and not a blessing or or what the Stoics would have called a “preferred indifferent” (to be desired, but out of one’s control and therefore not should try and view with indifference) – its unattainability becomes unbearable.

We are often told that CAM is a reaction to authoritarian, impersonal mainstream medicine. The irony is that there are few graduates from medical schools nowadays who fit the paternalistic stereotype. Medical students are taught to beware personal authority and experience and to follow the impersonal calculus of evidence-based medicine. As Shapiro writes, it is mainstream medicine that suggests a holistic, biopsychosocial approach to ME, and it is the alternative medical world that promotes a unitary physical cause. The cult of personality of the trust-me-I’m-a-doctor archetype is more likely to be found in the world of CAM

Shapiro quotes Richard Dawkins’ observation “either it is true that a medicine works or it isn’t – it cannot be false in the ordinary sense but true in some ‘alternative’ sense.” The contemporary sense of what health is renders this commonsensical statement – which perhaps could be the epigraph of Shapiro’s book – unworkable. What does it mean anymore for a medicine to “work”? CAM promises panaceas where mainstream medicine is humble and promises palliation. If health is promoted as complete well-being, we should not be surprised if the public falls for the deceptive and unlimited promises of completely unproven therapies

Ancient Medicine by Vivian Nutton – review from Nthposition.com, between July and November 2004

Unfortunately the link to the original review is broken (at time of writing)

I wrote somewhere else (I thought it was here, but revisiting it I don’t see this point) that while we don’t look to the Ancient Greeks or Romans for medical advice, we do for philosophical advice. Re-reading this piece, I wonder if the ideal of the four humours being “in balance” continues to have a strong lay influence, and indeed an influence on us all. Certainly I aspire to be “in balance” and tend to feel bad about it if I don’t.

I heard Nutton speak at a symposium on Vesalius last year in Cork – a fascinating talk, and I was lucky enough to have a chat with him afterwards.

Re-reading this review, I feel awkward about the passages which are pretty obvious paraphrases of Nutton himself, ie the third, fourth and fifth paragraphs. I am not sure how equipped I really was (or am) to properly judge this as a scholarly work. That doesn’t scupper the review, but perhaps I should have avoided throwing around terms such as “magisterial.” The reference to “The Simpsons” also dates this piece  a little – even in 2004 I doubt I kept up with “The Simpsons” that much anymore.

Ancient medicine – Vivian Nutton

Think “ancient medicine”, and for most, Hippocrates comes to mind. The famous oath, which Hippocrates himself almost certainly had nothing to do with, has preserved the name into the age of mass pop culture; one recalls Homer Simpson begging Dr Hibbert to “remember your hippopotamus oath.” Perhaps some have dimly heard of Galen or other medical figures of classical antiquity, but Hippocrates is undoubtedly number one. Many would have also some awareness of the theory of the four humours, the four fluids which ancient doctors felt went “out of balance” in illness.

Professor Vivian Nutton, in his magisterial study that is, apparently, “the first large-scale history of ancient medicine in a single volume for almost 100 years”, looks beyond the Hippocratic method and tradition to the other medical practices of the Ancient Greeks and Romans. He acknowledges that much, and in particular much of the folk tradition and the role of female healers and midwives, is out of our reach because of the nature of the sources that have survived, and avoids making the book a dry account of the famous names and competing theories.

The history of medicine, Nutton writes, is the history of “men and women striving to come to terms with illness, whether as sufferer or as healer.” Hippocrates and the Hippocratics are dealt with fully, but Nutton is keen to bring us the full range of ancient medical thought. He pays especial attention to Galen of Pergamum, a figure much of his academic work has been concerned with and one whom he evidently feels a special affinity. But Galen tended to present himself as a lone fighter for truth amidst ignorance; Nutton introduces other schools of thought, less of whose works have survived (almost three million of Galen’s words are with us still), such as the Methodists, Pneumatists and the various groups of Hippocratics.

Medical thinking inevitably informs and is informed by the wider culture. The detailed description of wounds and their treatment in the Iliad lead some fanciful commentators to postulate that Homer was a medical officer attached to the Argives during the Trojan War. And Thucydides’ famously dispassionate description of the plague that befell Athens during the Peloponnesian War bears the influence of the Hippocratic method and has also inspired speculation that the author has had medical training.

Nutton discusses the interplay between medicine and religion. It comes as a surprise to discover how pliable the Ancient Greek Pantheon was. The cult of Ascelpius, god of healing, only emerged in the fifth century BC. Nutton suggests that there was not competition between medical and magical models of healing in the Greece of this time. It is easy to write of where ancient doctors got things wrong; certainly the four humours (blood, phlegm, bile and black bile) do not feature much in contemporary biology. However, their major insight, that illness was not necessarily a supernatural judgement from above, but something that could be understood and alleviated, was perhaps the most significant breakthrough in thinking about disease in history.

Most commentators have tended to be rather dismissive of Roman medicine. At least some of this is due to an equation of Roman with Latin and a more limited, insular culture than the Greeks; as Nutton writes, this was certainly true of the Republic but not of the multilingual Empire. Galen was a man of the second century AD. The book is strong on the medicine of the later Empire, with the rise of Christianity occasionally clashing with medical thinking but on the whole complementing it. The new religion, with its emphasis on the New Testament injunction to love one’s neighbour, oversaw the creation of the modern hospital in the early fourth century AD.

Nutton’s main focus is an attempt to reconstruct the individual lives of patients and doctors. He writes that he wants to “give a sense of ancient medicine, what it must have been like to have seen Hippocrates at the bedside of a patient, Erasistratus experimenting, Asclepiades or Thessalus holding forth, or Galen dissecting a pig.” Ancient doctors were independent spirits, and Nutton’s attempt to reconstruction the contention of different ideas of healing and illness is entirely admirable. The traditional, heroic account of ancient medicine as the gradual accumulation of skills and knowledge from early Greece to Galen is not abandoned, but balanced.

For a scholarly work, Ancient Medicine is a readable story of the ordinary lives of history. Nutton is a patient, fair-minded and wise guide to the array of medical practices of the classical past. The book acts as a corrective to misconceptions about the classical past, without indulging in revisionism for the sake of it.

Operation Ouch! Medical Milestones and Crazy Cures, Inis Childrens Magazine/Childrens Books Ireland, November 2014

From Childrens Books Ireland, a capsule review of a childrens book about medicine. The van Tulleken brothers strike me as quite admirable in their enthusiastic multimedia presence. Again, perhaps a wry scepticism about history-from-below is evident. I didn’t have space to note that while the entries on Fleming, Nightingale and most other figures in the book are irreverent, that on Seacole is very sober and straight-laced:

Operation Ouch! Medical Milestones and Crazy Cures
by
Chris van Tulleken and Xand van Tulleken

History traditionally focused on what were deemed great events – sometimes caricatured as the ‘maps and chaps’ approach. In recent decades, ‘history from below’ has gained in academic prestige, with everyday life and consideration of marginalised, under-documented groups being the focus. The huge popularity of the Horrible Histories series has shown the appeal of history-from-below in a perhaps more literal sense – their focus on bodily functions and gross-out humour may not be to everyone’s taste, but they do provide a gateway into reading about the everyday life of the past.

The van Tulleken twins are Oxford medical graduates who have carved a niche for themselves as presenters of the CBBC series Operation Ouch! This book is the second tie-in volume; the first, Your Brilliant Body, won the 9-11 Best Fact Book award at the Booktrust Best Book Awards in 2014. Medical Milestones and Crazy Cures is formatted as a series of dialogues between the brothers on various parts of the body, interspersed with short profiles of medical notables and some quirky activities that will get the target readership’s attention.

The history-from-below emphasis is even apparent in the vignettes on pioneers of healthcare, with the Jamacian-born Mary Seacole, about whom very little is reliably known, given equal prominence with Florence Nightingale, Alexander Fleming and the rest. The brothers’ dialogues don’t entirely work on the printed page, but that aside this is a handsomely produced tie-in that combines medical history with bodily functions in a way that will appeal to the target readership.