Far transfer through music? This longitudinal study suggests it works!

A post on the potential “far transfer” of music education – ie the longer term impact on cognitive ability. I like the way that Pedro restrains his enthusiasm here! “Far transfer” is tricky to study, but also is a factor in education that needs to be considered when subjects/disciplines are accused of lacking “relevance”

From experience to meaning...

I’m a musician as some of you might know and very much in favor of music and music lessons, but I’m a bit hesitant about this new study. It sounds like great news: cognitive skills developed from music lessons appear to transfer to unrelated subjects, leading to improved academic performance.

Why I’m not so sure? Well, this kind of far transfer is not something easy to achieve and I don’t want to get my hopes up too high. So, let’s have a look at the press release:

Structured music lessons significantly enhance children’s cognitive abilities — including language-based reasoning, short-term memory, planning and inhibition — which lead to improved academic performance. Published in Frontiers in Neuroscience, the research is the first large-scale, longitudinal study to be adapted into the regular school curriculum. Visual arts lessons were also found to significantly improve children’s visual and spatial memory.

Music education has…

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Stephen Westaby, “community focus”, and medical education

Not so long ago, surgery and (internal) medicine were the pinnacles of medical school, the final subjects before graduation. Surgery in particular possessed a dark, elitist glamour, its notoriously long hours and intensity attracting rather than repelling many. Of course, being attracted by a perceived mystique is different from having a sustainable career (and life)

In recent years, medical curricula have been reshaped by many factors, including the realisation that most doctors will practice not as surgeons but as general practitioners, and that the bulk of healthcare need is perhaps more mundane than what goes on in the operating theatre. While there is justice to this “community orientation” of medical education, there is also a certain sense of taking the surgeons and physicians down a peg or twenty. Perhaps there is also a certain anti-intellectualism at work – focusing on the behavioural acts that a doctor performs, rather than the academic disciplines (which include clinical disciplines)

Recently I have been reading Simon Westaby’s memoir of his surgical career, Fragile Lives: A Heart Surgeon’s Stories of Life and Death on the Operating Table. Indeed, the above paragraphs are taken from a first draft of my review (both paragraphs cut for reasons of space and general narrative flow of the review). Westaby’s book is a good read (there, that’s the review bit out of the way) and full of exciting surgical action, described deftly but dramatically. It is also something of an elegy for a certain time of medical and surgical training – an era of overwork and monomaniacal dedication, but also one of intellectual and moral curiosity and rigour, often absent from a modern practice subservient to bureaucratic imperatives. I have already blogged about Westaby’s thoughts (and research) on the impact of league tables on surgical practice. I do wonder whether, for all its manifold faults, “traditional” medical education created a breed of doctor with an espirit de corps to whom a resistance to bureaucratic imperatives came easier?

 

 

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

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

cochrane crowd logo

 

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

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

Anyhow, here is the email:

Dear all,

 

We need your help!

 

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

 

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

 

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

 

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

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

 

What’s in it for me?

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

 

How long will these tasks be posted for?

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

 

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

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

 

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

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

 

When can I start?

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

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

 

With best wishes to all and happy citation screening,

 

 

Anna and Emily

 

Cochrane Crowd

 

The imperative voice in medical journal editorials

I’ve long wanted to do a little study – though in my experience no study is ever “little” – which is available to anyone in the entire world to do if they have the time and inclination (and resources)

Essentially I wished take a year or so of editorials from various medical journals and assess how much imperative language used. The seemingly endless “musts” and “shoulds” and “needs” that tend to be as inescapable a feature as the words “more research is needed.” I would like to assess exactly who “must” do this-or-that, and what the this-or-that tends to be. Often the subjects of this imperative language are those old standbys “stakeholders” or “policymakers”, adding to their holding of stakes and making of policy duties. Often it is rather specific bodies, often it is more generalised groups (“doctors”, “consultants”, “junior doctors”) It would be interesting to have the benefit of some kind of empirical study of this phenomenon.

For all the status of the medical profession, doctors do not seem to be a terribly happy bunch.   In the piece I just linked to I originally had a section in the opening paragraphs more explicitly exploring how much of this was contextual – related to working patterns, social attitudes, etc. – and how much was something inherent in the profession of medicine itself, either in the practitioners or in the practice. As I wrote in that review:

Lewis Terman’s classic study of “gifted” individuals, published in 1954, found that physicians tended to feel inferior relative to those of comparable attainment in other fields, and the Grant Study, George Vaillant’s epic survey of adult development, following the Harvard Class of 1944, identified self-doubt as the feature distinguishing physicians from control subjects.

In Myers and Gabbard’s highly readable The Physician as Patient we read of the physicians ultimate impotence in the face of death and much disease, and discussion of the defence mechanisms used to manage this. There is also a tendency to conscientiousness that can easily tip over into obsessionality.

Of course, there are non-conscientious doctors, and no doubt plenty of very happy doctors, and doctors who lack of the feelings of inferiority identified by Terman and Valliant (although Myers and Gabbard write that to a certain degree the oft-purported medical narcissism is a defence against the unknown and uncontrollable)

The essential point remains however. It has always struck me that – admirable as it is – the culture of audit and of quality improvement can all too easily tip into a kind of self-flagellation. There is no end to the potential improvements would could  make to one’s own practice. It can be difficult to separate out the individual from the role, especially the role of the individual within a system, and to over-personalise the findings of an audit.

I wonder too about the endless imperative language of editorials feeding into this tendency. With a certain amount of irony, a recent Lancet editorial “When the doctor is sick too” illustrates the style perfectly in its closing paragraph:

The Academy, the RCP, NHS England, NHS Employers, and Health Education England need to work together to provide solutions without stifling individual actions. Junior doctors need to lead on actions, supported by their organisations. But overall, family structures and small groups work better than huge multidisciplinary teams in supporting the health of junior doctors. Consultants and managers, please take note.

I am not disputing anything that is being said – indeed (perhaps more than most editorials) I would fully support what is being said, especially about the relative benefit of “family structures and small groups.” Yet it is more the tone of the imperative language used that struck me as typical of a certain kind of editorial.
It can be easy to spot the point in an editorial where the author switches from descriptive or evaluative language into something-must-be-done mode.

I find the issue most acute in papers with an educational bent. Surveys of the degree to which topic A is taught in medical schools will almost always find that topic A isn’t taught enough, or taught properly, or taught in a way that students feel emboldened to fill out a Likert scale self-assessing their competence with “Very Competent.” Topic A therefore needs to be, must be, or should be more integrated or even included in the curriculum. In papers on medical education published outside the specialist medical educational literature, rarely if ever is there much discussion beyond a few cursory words on that fact that curricula are already quite overloaded as it is, and while Topic A is no doubt wonderful if not life-saving, not all goods are reconcilable.

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.

 

The perils of trying to do too much: data, the Life Study, and Mission Overload

One interesting moment at the CCIO Network Summer School came in a panel discussion. A speaker was talking about the vast amount of data that can be collected and how impractical this can be. He gave the example of – while acknowledging that he completely understood why this particular data might be interesting – the postcode of  the patients most frequent visitor. As someone pointed out from the audience, the person in the best position to collect this data is probably the patient themselves.

When I heard this discussion, the part of my that still harbours research ambitions thought “that is a very interesting data point.” And working in a mixed urban/rural catchment area, in a service which has experienced unit closures and admission bed centralisation, I thought of how illustrative that would be of the personal experience behind these decisions.

However, the principle that was being stated – that clinical data is that which is generated in clinical activity – seems to be one of the only ways of keeping the potential vast amount of data that could go into an EHR manageable. Recently I have been reading Helen Pearson’s “The Life Project” , a review of which will shortly enough appear. Pearson tells the story of the UK Birth Cohort Studies. Most of this story is an account of these studies surviving against the institutional odds and becoming key cornerstones of British research. Pearson explicitly tries to create a sense of civic pride about these studies, akin to that felt about the NHS and BBC. However, in late 2015 the most recent birth cohort study, the Life Study, was cancelled for sheer lack of volunteers. The reasons for this are complex, and to my mind suggest something changing in British society in general (in the 1946 study it was assumed that mothers would simply comply with the request to participate as a sort of extension of wartime duty) – but one factor was surely the amount of questions to be answered and samples to be given:

But the Life Study aims to distinguish itself, in particular by collecting detailed information on pregnancy and the first year of the children’s lives — a period that is considered crucial in shaping later development.

The scientists plan to squirrel away freezer-fulls of tissue samples, including urine, blood, faeces and pieces of placenta, as well as reams of data, ranging from parents’ income to records of their mobile-phone use and videos of the babies interacting with their parents. (from Feb 2015 article in Nature by Pearson)

All very worthy, but it seems to me that the birth cohort studies were victims of their own success. Pearson describes that, almost from the start, they were torn between a more medical outlook and a more sociological outlook. Often this tension was fruitful, but in the case of Life Study it seems to have led to a Mission Overload.

I have often felt that there is a commonality of interest between the Health IT community, the research methodology community, and the medical education community and the potential of EHRs for epidemiology research, dissemination of best evidence at point of care  and realistic “virtual patient” construction is vast. I will come back to these areas of commonality again. However, there is also a need to remember the different ways a clinician, an IT professional, an epidemiologist, an administrator, and an educationalist might look at data. The Life Study perhaps serves as a warning.

A Medical Informatics Education, 1996.

Today I walked to UCD much as I did nearly 20 years ago on 21st September 1996, to begin college. This time I was walking not to Belfield itself, but to UCD Nexus, located a little further on in Belfield Office Park, for a meeting in my new roles as CCIO liaison to ARCH (if that’s too many acronyms, don’t ask)

Various nostalgic impressions mingled. Cyclists seem more aggressive than they were. UCD is a slicker operation and more given to self-promotion than it was. It had been a while since I had actually walked through campus; the last few times I had driven in, found parking near-impossible, gone to a meeting, and left. Belfield seemed to have become a bit like Docklands , a rather alienating landscape dominated by massive buildings without human scale.

 

Walking through, however, I find Belfield reassuringly unchanged at its core. The Science Block has greatly expanded, but the central lecture theatre structure is unchanged. The Arts Block, the fundamental library structure, the lake, the restaurant – all are different only superficially. The cafe that was officially known as “Finnegan’s Break” and was always called “Hilpers” is now gone.

I was also a little taken aback by how much human interaction there was. I expected serried ranks of screen-focused students. In the restaurant, I saw only one person texting while talking to here friends, and while that wouldn’t have happened in 1996, it would have in 2000. A few years ago there were PC terminals all over the place, which seem to have largely disappeared.

Given the nature of of the  meeting I was going to, I thought about one of the academic highlights of that first year of medicine; medical informatics. This was a subject which, frankly, was much derided. Why? Because it seemed irrelevant, I think, somewhat beneath those who knew anything much about computers and somewhat irksome to those who didn’t. Crucially, I can’t recall anything specifically medical about medical informatics.

We had lecturers on what a CPU was and so forth (more of which anon) and workshops on the use of Word, Excel, Access and the other Microsoft biggies at the time. The undoubted highpoint was the lecturer, Mel ´Ó Cinneide, suddently pulling  a mouse out of his pocket with the immortal words “for those who haven’t seen one, this is a mouse.”

Now, the wheel has come full circle; one wonders how many of a laptop and tablet focused cohort of students would have seen a mouse. UCD Netsoc was, for a few years, the only way to get internet access as a student, and the enthusiastic queued up from early morning to get an account.

As with many other pre clinical subjects at the time, Medical Informatices teaching was by academics in their specific discipline who no doubt found the prospect of teaching medical students even less enticing than teaching students who at least were pursuing the subject at more length.

In subsequent years, Medical Informatics was revamped and, I gather, made more clinically relevant. And now as Ireland slouches towards eHealth the relevance of IT to medicine is much more obvious. I am sure that Medical Informatics in UCD and equivalent courses in other medical schools is now taught in a clinically relevant, pedagogically sound manner with defined learning objectives and so forth. Nevertheless, I have my doubts that in twenty years anyone will recall a moment from this teaching as vividly as what would (mostly) be the class of 02 recall Mel whipping out the mouse.