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.

Tory island doctoring

A while back I featured Elizabeth Shane’s poem  “The Doctor” with its heroic depiction of a doctor bravely taking to the waves to bring succor to a Tory Islander. From Jim Hunter’s “The Waves Of Tory / Tonnta Thoraí“, a rather less flattering portrayal:

 

“For long period in Tory’s history there was not even a nurse on the island. In an emergency a boat would have to go to mainland to fetch a doctor. Many doctors refused to venture across the seas to Tory and often quoted an exaggerated fee to make their services prohibitive to the island community. One doctor demanded a a fee of £2 in advance before travelling to Tory; after he had performed his duties the islanders refused to take him back until he had paid £5 for the return boat trip. More frequently doctors required sick persons to travel to the mainland for attention. Such trips, often in raging seas, did little to improve the condition of patients.”

Hunter describes a more positive experience of nursing:

“Island nurses were held in greater esteem by the islanders. A whole series of Public Health nurses such as Nurse McVeagh, Nurse Savage and Nurse Rodgers are remembered with great affection. Nurse McVeagh, who served on the island from 1936 to 1953, seems to have placed more emphasis on local cures and remedies than on orthodox medication. She would arrive for the delivery of a child with a black bag in which she carried a pair of shoes and a pair of rubber gloves; the gloves were placed aside, but the shoes were thrown under the bed for luck.”

Hunter later informs us (the book was published in 2006):

“A helicopter service now brings a doctor from Falcarragh at regular intervals to check on the health of the islanders. The helicopter service can also be called in an emergency to bring a doctor to the island or transport a sick person to hospital. The islanders are conscious of their dependence on the good medical services provied by the Letterkenny Hospital, and they have been most generous in raising funds for the purchase of medical equipment. It is not unknown for cheques amounting to £10,000 to be handed over the medical authorities by the Tory community.”

Sophistry, the Sophists and modern medical education. Medical Teacher Volume 32, Issue 1, 2010. Part 2.

THE SOPHISTS AND THE PROFESSIONALISATION OF MEDICAL EDUCATION

One of the direct ways in which the Sophists are relevant to today is that they were the first to put a monetary value on education; they were the first professional educators. In Plato’s Hippias Major Socrates remarks that Gorgias ‘by giving exhibitions and associating with the young, he earned and received a great deal of money from the city’ and that Prodicus ‘in his private capacity, by giving exhibitions and associating with the young … received a marvellous sum of money.’
The Sophists’ innovation of seeking payment for tuition is the first appearance of an idea now all pervasive. Today it is taken almost entirely for granted that teachers require payment, and with it in the modern age come sick leave, maternity leave, pensions and other payments.
The professionalisation of education in general is therefore a legacy of the Sophists. The whole apparatus of modern university teaching, for good and ill, has its root in this idea. Despite a long gestation, it is only in recent years that a professionalisation of medical education has taken root, and it still faces cynicism and opposition today even in recent times (Peterson 1999). There has been concern at the standard of clinical teaching in medicine internationally for a number of years (Wall and McAleer 2000). In the United Kingdom, partly under the influence of the National Committee of Inquiry into Higher Education (Dearing 1997), in the number of departments of medical education attached to medical schools has grown, and a proliferation of masters level programmes and postgraduate certificates in medical education (Pugsley et al. 2008). The whole apparatus of modern academic discourse — peer-reviewed journals, associations, national and international conferences and other scholarly paraphernalia — has grown up around the subject. The subtitle of Peterson’s article cited above — Tomorrow’s doctors need informed educators not amateur tutors — gives a flavour of this new emphasis on professionalisation in medical education.

THE SOPHISTS AND TEACHING VIRTUE

The second great sense in which the Sophists are still relevant is their case that virtue was not inborn or innate, but could be taught. Their ‘most revolutionary innovation was, precisely, that, faced with nature, they set up teaching to counteract it and considered that virtue could be learned by attending their classes’ (de Romilly 2002), and the problem of nature versus nurture, as it is invariably dubbed today, is a very old one that troubled the Athenians with a peculiar intensity. We see it in Thucydides, in the comparison between the courage of the Athenians — described by the historian as deriving from reason, from expertise and from experience — and that of the Spartans, portrayed as ‘natural’ and traditional. We see it in Euripides’ play, Hecabe, when Hecabe (wife of King Priam of Troy) learns of the slaughter of her daughter. After a few rather perfunctory expressions of grief she launches into a meditation on this very question:
How strange, that bad soil, if the gods send rain and sun,
Bear a rich crop, while good soil, starved of what it needs,
Is barren, but man’s nature is ingrained—the bad
Is never anything but bad, and the good man
Is good: misfortune cannot warp his character,
His goodness will endure.
          Where lies the difference?
In heredity or upbringing? Being nobly bred
At least instructs a child in goodness; and this lesson,
If well learnt, shows him by that measure what evil is.
(Vellacott 1963, lines 593–603)

Plato’s dialogue Protagoras is devoted to the dispute between Socrates and Protagoras on this particular issue, the teaching of virtue. Although both agree that virtue can be taught, Socrates doubts Protagoras’ self-confidence on the issue. This is an issue that has huge implications not only for education but also for wider political economy. Improved knowledge of genetics in the last hundred years has given the problem a new acuity. Nevertheless, in this as in many fields one can get the impression from contemporary media coverage that all this is a new problem, which only our time has had to face. Nothing could be further from the truth, as the example of the Sophists illustrates.

Whatever ones own beliefs on the issue of nature-nurture, and whatever science may or may not tell us about it, one must concede that the Sophists have, from a practical point of view, won the argument. That education should be available for all is such a commonplace in Western society that to suggest otherwise would be social and (for an elected official) political suicide. Prior to the Sophists, the idea that arete was inborn and therefore unteachable was widely held. Therefore aristocratic birth alone qualified one for rule. If Protagoras’ self-confidence in his ability to teach virtue seemed dubious to Socrates, who was after all sympathetic to the essential point, imagine how shocking it must have been to Athenians more in thrall to notions of aristocratic virtue.
This parallels the reaction medical educators often receive from colleagues. While it is often not directly articulated, the claim that communication skills, for instance, or attitudinal aspects of medical practice, cannot be taught but are innate is frequently encountered. With the exception of ethics teaching (discussed below), medical educators may not consider themselves as teaching ‘virtue’, per se, but overall professionalism and attitudinal aspects of medical practice are explicitly incorporated into curricular design and structure. For instance Harden et al. (1999) describe a concentric circle model of learning outcomes, with an inner core of task focused outcomes defining the technical competency of a doctor, a middle section of ‘approach to practice’ outcomes defining understanding of the context of illness and evidence-based and ethics-based approaches to clinical work, and finally an outer circle of outcomes focused on the overall role of the doctor and ongoing personal development. The term ‘personal development’ itself implies that character can be changed by training.
This debate is particularly relevant to ethics training. A tension has been described (Eckles et al. 2005) between proponents of the view that ethics training should be aimed at the formation of virtuous physicians (for instance, Pellegrino and Thomasina,1993) while others have argued that the moral character of medical students is formed at arrival in medical school (Glick1994). This latter viewpoint is expressed as a belief that the goal of ethics training is to impart of body of ethical knowledge and provide a set of skills for application by medical graduates, whose underlying virtue has been established prior to admission to medical school. Eckles et al. identify this dichotomy as making it ‘difficult to find a consensus regarding the goals of medical ethics education’ and suggest that further theoretical work is needed to delineate the core content, processes and skills relevant to the ethical practice of medicine. The antiquity of this debate is not acknowledged.

INTERLUDE – PROTAGORAS AND EDUCATION

A theme of this article is that what the Sophists really thought, and what their influence on Western thought really was, is very different from the broad caricature often presented. Before discussing the final trend in medical education which is prefigured in Sophist thought, I wish to examine the thought of a specific Sophist figure and link with modern medical education theory. The thought of Protagoras (circa 490-420 BC) described as ‘the first and greatest of the Sophists’ (Waterfield2000) is known from a seven fragments and the reports of others, especially his appearance in the Platonic dialogue Protagoras. Both Socrates and Protagoras believe that virtue can be taught, although to differing degrees (and Plato will later have Socrates definitively oppose this view in the dialogue Meno), but Socrates is sceptical of Protagoras’ confidence on this issue.
The surviving fragments of Protagoras’ thought indicates the seriousness with which he thought about education (Lavery2008). The most famous, ‘man is the measure of all things’, is often cited as a key motif of relativist thought. Debate continues as to whether this was an example of ‘strong’ or ‘weak’ relativism – in other words whether this is a general statement about humanity or is about the individual human being’s ability to accurate perceive the world. However the underlying relativist thrust of this aphorism is not in doubt. Constructivist theories of learning, which are influential in medical education today, are clearly influenced by this approach.
Other Protagorian mottos directly related to education are ‘teaching needs endowment and practice. Learning must begin in youth’ (cited as Fragment 2 in Lavery, 2008). ‘Art without practice, and practice without art, are nothing’ (Fragment in Lavery,2008) and ‘education does not take root in the soul unless one goes deep’ (Fragment 8 in Lavery, 2008). All of these are relevant to medical education – the emphasis on practice and on deep learning, and on lasting attitudinal and behavioural change particularly so. As can be seen, these aphorisms are far in spirit from the caricature of the Sophists as promoting a superficial, purely rhetorical education.

THE SOPHISTS AND BEST EVIDENCE MEDICAL EDUCATION

Another characteristic of contemporary medical education theory prefigured in the thought of the Sophists is an evidence-based approach. The Sophists championed empirical knowledge and direct enquiry, which as well as marking them out as early pioneers of the scientific method, also suggests their place as exemplars of evidence-based practice.
The pre-Socratic philosophers of the centuries before both Socrates and the Sophists are often called both the first philosophers and the first scientists. This, of course, is due to their inquiring minds, and readiness to challenge explanations that depended solely on divine action — thus we have the atomic theory of Democritus, or the postulate of Thales that all matter is water (Waterfield 2000). Nevertheless, a modern reader often finds the Sophists more familiarly ‘scientific’ than the pre-Socratics. This is due to the pre-Socratics’ tendency to expand speculation into explanation, and to engage in metaphysics. The Sophists are more recognisable ancestors of modern scientific method because of their scepticism, their refusal to accept simple explanations, and their pragmatic bent. Defining the scientific method is a hugely problematic enterprise, but an attempt at the unprejudiced search for alternative explanations for any given event or observation is one of its cardinal features.
‘Making the weaker argument the stronger’, a taunt of Aristophanes in The Clouds, is one of the phrases with which the Sophists were most often abused. At first glance, it suggests a sort of confidence trick, a justification for wrongdoing. Yet on reflection, ‘the weaker argument’ may conceal the best answer. The querying approach of the Sophists forces one to examine apparently sound arguments and justifications, and thereby perhaps discover their soundness to be illusory. Richard Feynman described the scientific method as ‘a kind of scientific integrity, a principle of scientific thought that corresponds to a kind of utter honesty–a kind of leaning over backwards. For example, if you’re doing an experiment, you should report everything that you think might make it invalid—not only what you think is right about it: other causes that could possibly explain your results; and things you thought of that you’ve eliminated by some other experiment, and how they worked—to make sure the other fellow can tell they have been eliminated’ (Feynman 1974). So openness to alternative explanations, and a willingness to accept that the ‘weaker argument’ (or initially less persuasive or attractive hypothesis) may be closer to the truth, is a characteristic not of rhetorical chicanery, but of any empirical approach to knowledge and practice.
Best evidence medical education enshrines this empirical approach. Mirroring definitions of evidence-based medical practice, it is defined by Harden and Lilly (2000) as the implementation, by teachers in their practice, of methods and approaches to education based on the best evidence available. This means integrating individual educational expertise with the best available external and internal evidence from systematic research. Best evidence medical education approaches mean that the assumptions of medical educationalists are themselves open to question. Our fondness for a particular innovative means of teaching should be as suspect as the stubborn retention of every aspect of traditional teaching. In Western thought, the Sophists were the great intellectual gadflies, the questioners – pointing out social assumptions and prejudices for what they were. Medical educators owe a debt to these intellectual precursors.
Declaration of interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the article.

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