Review of “Oestrogen Matters” Avram Bluming and Carol Tavris, TLS 29th January 2019

In the current TLS I have a brief review of Bluming and Tavris’ book on HRT. The full text is available to subscribers; here is the first paragraph:

Few medical treatments have seen as stark a rise and fall as hormone replacement therapy (HRT). In the early 1940s, methods were developed to extract oestrogen from pregnant mares’ urine, and the resulting medication was named Premarin. Marketed from the 1950s for menopausal symptoms, HRT was catapulted into the public consciousness by the New York gynaecologist Robert Wilson’s bestseller Feminine Forever (1966), and made Ayerst Laboratories, who had developed Premarin and paid Wilson’s expenses for writing the book, extremely rich. HRT was hyped as a wonder drug adding years to life and life to years

The world of Policy and the Salzburg Statement

With his recent elevation to Taoiseach, something Leo Varadkar (who was supposed to work with me when I did a locum in Tallaght in May 2007… but he was occupied with some election or other) said in the late 1990s got a fair bit of coverage. This was to the effect that as a doctor you can help a few people, but as Minister for Health you can help millions. While at first glance this seems like a truism, it has for some reason got under my skin. There are various reasons for this, not all of which I will get into. Perhaps I am jealous of a road not travelled! (I am pretty confident I am not)

In a way it sums up a particular seduction – the seduction of the World of Policy. Get interested in any field – from the natural world to technology to medicine indeed – and sooner or later the siren song of policy will be heard. Wouldn’t it be great to Make A Difference not just on the piecemeal, day-to-day way, but on a grander scale? Increasingly I think not. Clearly someone needs to formulate policy and to think about things on a broad scale – but they should do so without illusions and with a certain humility. People have a habit of behaving in a way that the enlightened policy makers don’t foresee.  The circuit of conferences and “networking” can become an echo chamber of self congratulation. Doing good, perhaps, is best done on a smaller scale.

These thoughts are occasioned by reading about the Salzburg Statement. This is something I heartily approve of – a call for action to ensure all children enjoy the right to play in a nature rich space within ten minutes of their home.  The statement is made up of eight key actions:

Eight actions to transform cities for children

  1. Ensure children of all ages, backgrounds, income, and abilities have equitable access to nature and play regularly and in meaningful ways to promote good health and wellbeing.

  2. Embed nature in everyday places used by children, such as schools, backyards, parks, playgrounds and city streets, to make the city into a natural outdoor classroom.

  3. Involve children in designing and planning natural spaces for recreation, education, inspiration and health, to give them ownership and pride in their local communities, schools and parks

  4. Build curiosity, wonder, and care for nature in children (for example by greening school grounds and involving children with community gardens).

  5. Protect natural features across cityscapes and create an equitably distributed network of accessible green and nature-rich spaces that all generations can reach on foot.

  6. Connect cities with the broader ecosystems in which they are embedded, creating corridors for people, plants and animals to move safely across the city and into its surroundings.

  7. Establish more urban conservation areas to increase access to nature and connect cities to the broader protected area network.

  8. Work together through cross sectoral and multi-level partnerships to build an inclusive culture of health in cities.

 

There’s nothing there I would disagree with, though as with all these kind of interventions I would like more robust dissection of what, say, Item 3 would mean in practice.

I am always a little wary of dressing up worthy activity in the mantle of Health. What Resting a case for nature on the vagaries of purported health benefits can be a dangerous and debunkable game – especially with the media. This visual  handily shows how media can seize on single studies to generate headlines:statins.png

One can easily imagine a Katie Hopkins-ish journalist seizing on the inevitable ambiguities of research to “debunk” the claims for health benefits of nature.

I should state very clearly I have no reason to think that the Salzburg Statement is a wonderful initiative I look forward to hearing more of. But I am a little wary of the siren call of the World of Policy.

Review of “Casebook of Psychosomatic Medicine”, Bourgeois et al, IJPM 2011

The above review from the Irish Journal of Psychological Medicine follows on from my review of The Physician As Patient in the same journal. Both books were excellently written, and as time has gone by I appreciate their approach more deeply. As I say in the first paragraph, evidence based medicine and what could be called experience based medicine are often driven into a false dichotomy. Both these books possess wisdom in abundance, and wisdom based medicine is perhaps what we should all be aspiring to practice.  

“The slaves of some defunct economist”

“… the ideas of economists and political philosophers, both when they are right and when they are wrong, are more powerful than is commonly understood. Indeed the world is ruled by little else. Practical men, who believe themselves to be quite exempt from any intellectual influence, are usually the slaves of some defunct economist. Madmen in authority, who hear voices in the air, are distilling their frenzy from some academic scribbler of a few years back. I am sure that the power of vested interests is vastly exaggerated compared with the gradual encroachment of ideas. Not, indeed, immediately, but after a certain interval; for in the field of economic and political philosophy there are not many who are influenced by new theories after they are twenty-five or thirty years of age, so that the ideas which civil servants and politicians and even agitators apply to current events are not likely to be the newest. But, soon or late, it is ideas, not vested interests, which are dangerous for good or evil.” John Maynard Keynes, The General Theory of Employment, Interest and Money (pp. 383–4))

This famous quote from Keynes used to baffle me a bit (or rather, the sentence “Practical men, who believe themselves to be quite exempt from any intellectual influence, are usually the slaves of some defunct economist” which is the bit I had come across)

Medicine and healthcare are the domain of pragmatism.This has always been the case, but is heightened in a wider intellectual world which often sees itself as “post ideological” (although political events on  both sides of the Atlantic, not to mention everywhere else, tend to show that actual populations don’t necessarily believe that) Evidence-based medicine elevates “what works” far above what is physiologically plausible. Models of illness such as Bill Fulford’s “full field” model of mental illness increasingly integrate disparate theoretical approaches with a main emphasis on lived experience. These approaches have an awful lot to be said for them; and I personally have always seen myself as a pragmatic practitioner, not wedded to any particular dogma.

Keynes quote, especially considered in full, extends far beyond economics. Pragmatic practice is always located in some kind of intellectual framework. Medical models in psychiatry, for instance, may seem focused on pragmatic approaches but are rooted in a philosophical approach of great complexity. Mental health policy, it often seems, cam be driven by responses to anti-psychiatry writings from the late 1960s, the formative years of many of those now in positions of power and influence.

Ideas which seem simple and uncontroversial – such as the idea that health care should be less and less delivered by large institutions and more and more “in the community” – are themselves located amidst a massive array of beliefs and assumptions which are rarely unpacked.

“The Wild West of Health” care: mental health Apps, evidence, and clinical credibility

We read and hear much about the promise of mobile health. Crucial in the acceptance of mobile health by the clinical community is clinical credibility. And now, clinical credibility is synonymous with evidence, and just “evidence” but reliable, solid evidence. I’ve blogged before about studies of the quality of mental health smartphone apps. I missed this piece from Nature which, slightly predictably, is titled “Mental Health: There’s an app for that.” (isn’t “there’s an App for that a little 2011-ish though?) It begins by surveying the immense range of mental health-focused apps out there:

 

Type ‘depression’ into the Apple App Store and a list of at least a hundred programs will pop up on the screen. There are apps that diagnose depression (Depression Test), track moods (Optimism) and help people to “think more positive” (Affirmations!). There’s Depression Cure Hypnosis (“The #1 Depression Cure Hypnosis App in the App Store”), Gratitude Journal (“the easiest and most effective way to rewire your brain in just five minutes a day”), and dozens more. And that’s just for depression. There are apps pitched at people struggling with anxiety, schizophrenia, post-traumatic stress disorder (PTSD), eating disorders and addiction.

The article also has a snazzy  infographic illustrating both the lack of mental health services and the size of the market:

naturegraph

The meat of the article, however, focuses on the lack of evidence and evaluation of these apps. There is a cultural narrative which states that Technology = Good and Efficient, Healthcare = Bad and Broken and which can give the invocation of Tech the status of a godterm, pre-empting critical thought. The Nature piece, however, starkly illustrates the evidence gap:

But the technology is moving a lot faster than the science. Although there is some evidence that empirically based, well-designed mental-health apps can improve outcomes for patients, the vast majority remain unstudied. They may or may not be effective, and some may even be harmful. Scientists and health officials are now beginning to investigate their potential benefits and pitfalls more thoroughly, but there is still a lot left to learn and little guidance for consumers.

“If you type in ‘depression’, its hard to know if the apps that you get back are high quality, if they work, if they’re even safe to use,” says John Torous, a psychiatrist at Harvard Medical School in Boston, Massachusetts, who chairs the American Psychiatric Association’s Smartphone App Evaluation Task Force. “Right now it almost feels like the Wild West of health care.”

There isn’t an absolute lack of evidence, but there are issues with  much of the evidence that is out there:

Much of the research has been limited to pilot studies, and randomized trials tend to be small and unreplicated. Many studies have been conducted by the apps’ own developers, rather than by independent researchers. Placebo-controlled trials are rare, raising the possibility that a ‘digital placebo effect’ may explain some of the positive outcomes that researchers have documented, says Torous. “We know that people have very strong relationships with their smartphones,” and receiving messages and advice through a familiar, personal device may be enough to make some people feel better, he explains.

And even saying that (and, in passing, I would note that in branch of medical practice, a placebo effect is something to be harnessed, not denigrated – but in evaluation and study, rigorously minimising it is crucial) there is a considerable lack of evidence:

But the bare fact is that most apps haven’t been tested at all. A 2013 review8 identified more than 1,500 depression-related apps in commercial app stores but just 32 published research papers on the subject. In another study published that year9, Australian researchers applied even more stringent criteria, searching the scientific literature for papers that assessed how commercially available apps affected mental-health symptoms or disorders. They found eight papers on five different apps.

The same year, the NHS launched a library of “safe and trusted” health apps that included 14 devoted to treating depression or anxiety. But when two researchers took a close look at these apps last year, they found that only 4 of the 14 provided any evidence to support their claims10. Simon Leigh, a health economist at Lifecode Solutions in Liverpool, UK, who conducted the analysis, says he wasn’t shocked by the finding because efficacy research is costly and may mean that app developers have less to spend on marketing their products.

Like any healthcare intervention, an App can have adverse effects:

When a team of Australian researchers reviewed 82 commercially available smartphone apps for people with bipolar disorder12, they found that some presented information that was “critically wrong”. One, called iBipolar, advised people in the middle of a manic episode to drink hard liquor to help them to sleep, and another, called What is Biopolar Disorder, suggested that bipolar disorder could be contagious. Neither app seems to be available any more.

And even more fundamentally, in some situations the App concept itself and the close relationship with gamification can backfire:

Even well-intentioned apps can produce unpredictable outcomes. Take Promillekoll, a smartphone app created by Sweden’s government-owned liquor retailer, designed to help curb risky drinking. While out at a pub or a party, users enter each drink they consume and the app spits out an approximate blood-alcohol concentration.

When Swedish researchers tested the app on college students, they found that men who were randomly assigned to use the app ended up drinking more frequently than before, although their total alcohol consumption did not increase. “We can only speculate that app users may have felt more confident that they could rely on the app to reduce negative effects of drinking and therefore felt able to drink more often,” the researchers wrote in their 2014 paper13.

It’s also possible, the scientists say, that the app spurred male students to turn drinking into a game. “I think that these apps are kind of playthings,” says Anne Berman, a clinical psychologist at the Karolinska Institute in Stockholm and one of the study’s authors. There are other risks too. In early trials of ClinTouch, researchers found that the symptom-monitoring app actually exacerbated symptoms for a small number of patients with psychotic disorders, says John Ainsworth at the University of Manchester, who helped to develop the app. “We need to very carefully manage the initial phases of somebody using this kind of technology and make sure they’re well monitored,” he says.

I am very glad to read that one of the mHealth apps which is a model of evidence based practice is one that I have both used and recommended myself – Sleepio:

sleepio-logo

One digital health company that has earned praise from experts is Big Health, co-founded by Colin Espie, a sleep scientist at the University of Oxford, UK, and entrepreneur Peter Hames. The London-based company’s first product is Sleepio, a digital treatment for insomnia that can be accessed online or as a smartphone app. The app teaches users a variety of evidence-based strategies for tackling insomnia, including techniques for managing anxious and intrusive thoughts, boosting relaxation, and establishing a sleep-friendly environment and routine.

Before putting Sleepio to the test, Espie insisted on creating a placebo version of the app, which had the same look and feel as the real app, but led users through a set of sham visualization exercises with no known clinical benefits. In a randomized trial, published in 2012, Espie and his colleagues found that insomniacs using Sleepio reported greater gains in sleep efficiency — the percentage of time someone is asleep, out of the total time he or she spends in bed — and slightly larger improvements in daytime functioning than those using the placebo app15. In a follow-up 2014 paper16, they reported that Sleepio also reduced the racing, intrusive thoughts that can often interfere with sleep.

The Sleepio team is currently recruiting participants for a large, international trial and has provided vouchers for the app to several groups of independent researchers so that patients who enrol in their studies can access Sleepio for free.

sleepioprog

This is extremely heartening – and as stated above, clinical credibility is key in the success of any eHealth / mHealth approach. And what does clinical credibility really mean? That something works, and works well.

 

 

Evidence based medicine and evidence based policy

There was a fair bit of media coverage of the finding that teenage-pregnancy-prevention programmes using simulated babies are associated with an increased rather than decreased teenage pregnancy rate. Some of the media discussion focused on the role of evidence in public policy.

Via Twitter, I came across this article on evidence-based policy by Howard White in The Independent

Evidence-based medicine has transformed medical practice. TheCochrane Library has published more than 6,000 studies summarising high quality evidence for health interventions. Notable cases include breast screening, which used to be recommended for women from the age of 40 until the evidence showed that the number of false positives recorded was in fact doing more harm than good. The risks from unnecessary surgery were greater than the often small benefits from early treatment forbreast cancer.

Hormone replacement therapy (HRT) is another example. It was routinely used to reduce heart disease, but then became far less common when evidence showed adverse effects. There is now a more nuanced understanding of which women will benefit from HRT and which will not.

Prior to Cochrane, doctors based their advice on out-of-date knowledge, personal experience and the influence of drug reps. Today, doctors have access to evidence-based guidelines. Decisions on what the NHS can and should fund are informed by the advice of the National Institute for Health Clinical Excellence after a review of the evidence.

So why can’t we do the same for social and economic policy?

For those who are interested, I engaged (or am engaging) in a twitter exchange on this with Howard White, whose replies have been very gracious. As in so many of these exchanges I suspect that we agree on more than we disagree on (and possibly agree on everything with a difference in emphasis)

Of course policy should be based on evidence, where available. This not only seems extremely reasonable and  rational – it is eminently reasonable and rational. I also write as an admirer of the Cochrane Collaboration.

However, I always feel a sense of caution when clinical concepts are introduced into political discourse. The best definitions of EBM always include the word “judicious”, as here

“Evidence-based medicine is the conscientious explicit and judicious use of current best evidence in making decisions about the care of individual patients.”

Judicious is key – judgment and reflection are required. Does this body of evidence apply to my patient, this individual person in front of me, or does it not? As I wrote on another point:

it is one thing to have an evidence base for a specific therapy in medical practice, quite another for a specific intervention in society itself.

My review of Helen Pearson’s The Life Project is still to be published, when it does I will perhaps write a little more on “evidence-based policy”, a concept which began to enjoy great vogue in the 1990s.What Pearson’s book shows, however, is that the devil can cite evidence for his own purpose; “evidence” can be wielded with agendas.

Obviously the Campbell Collaboration aims to address this, by being transparent about the evidence used and the methodology used to synthesise it.

A further point is that evidence-based policy tends to presuppose consensus on the ends of policy  – and emphasise technocratic means of getting there. Thereby the focus on specific interventions, rather than any wider sense of not merely social goals but of social meaning. Of course, this very much in keeping with a time in which we are all supposed to be beyond “grand narratives” – which is of course itself a “grand narrative.” I would suggest that many recent events in politics around the world are best understood as testing this notion to destruction.

Bringing it all back to a question I asked a while ago about the best kind of evidence for health informatics innovations, perhaps what this illustrates is that the way we do evidence now tends to be to focus on specific interventions and, as far as possible, measure their effects as specific interventions and without reference to an overall system. Indeed, this is obviously necessary for assessing therapies and treatments. But is it necessarily missing something when it comes to a system?

Engaging clinicians and the evidence for informatics innovations

A few weeks ago Richard Gibson from Gartner spoke to members of the CCIO group. It was a fascinating, wide-ranging talk – managing the time effectively was a challenge. Dr Gibson talked about the implications for acute care and long term care of technological innovations – as might be obvious from my previous post here, I have a concern that much of the focus on empowerment via wearables and consumer technology misses the point that the vast bulk of healthcare is acute care and long term care. As Dr Gibson pointed out, at the rate things are going healthcare will be the only economic, social, indeed human activity in years to go

One long term concern I have about connected health approaches is engaging the wide group of clinicians. Groups like the CCIO do a good job (in my experience!) of engaging the already interested, more than likely unabashedly enthusiastic. At the other extreme, there always going to be some resistance to innovation almost on principle. In between, there is a larger group interested but perhaps sceptical.

One occasional response from peers to what I will call “informatics innovations” (to emphasise that this not about ICT but also about care planning and various other approaches that do not depend on “tech” for implementation) is to ask “where is the evidence?” And often this is not a call for empirical studies as such, but for an impossible standard – RCTs!

Now, I advocate for empirical studies of any innovation, and a willingness to admit when things are going wrong based on actual experience rather than theoretical evidence. In education, I strongly support the concept of Best Evidence Medical Education and indeed in following public debates and media coverage about education I personally find it frustrating that there is a sense that educational practice is purely opinion-based.

With innovation, the demand for the kind of RCT based evidence is something of a category error. There is also a wider issue of how “evidence-based” has migrated from healthcare to politics. In Helen Pearson’s Life Project we read how birth cohorts went from ignored, chronically underfunded studies ran by a few eccentrics to celebrated, slightly less underfunded, flagship projects of British epidemiology and sociology. Since the 1990s, they have enjoyed a policy vogue in tandem with a political emphasis on “evidence-based policy.” My own thought on this is that it is one thing to have an evidence base for a specific therapy in medical practice, quite another for a specific intervention in society itself.

I am also reminded of a passage in the closing chapters of Donald Berwick’s Escape Fire (I don’t have a copy of the book to hand so bear with me) which essentially consists of a dialogue between a younger, reforming doctor and an older, traditionally focused doctor. Somewhat in the manner of the Socratic dialogues in which (despite the meaning ascribed now to “Socratic”) Socrates turns out to be correct and his interlocutors wrong, the younger doctor has ready counters for the grumpy arguments of the older one. That is until towards the very end, when in a heartfelt speech the older doctor reveals his concerns not only about the changes of practice but what they mean for their own patients. It is easy to get into a false dichotomy between doctors open to change and those closed to change; often what can be perceived by eager reformers as resistance to change is based on legitimate concern about patient care. There are also concerns about an impersonal approach to medicine. Perhaps ensuring that colleagues know, to as robust a level as innovation allows, that patient care will be improved, is one way through this impasse.