Monday, 29 August 2011

Going with the grain in this world of change

An extract from an Eric Schmidt lecture was published in the Guardian on Saturday ( As chairman of Google, I imagine he has become used to being listened to, but he also makes some points that are worth listening to.

He got me onside straight away by bemoaning the demise of the polymath, and actually went as far as criticising the British educational for polarising us in to two camps - the boffins and the luvvies. This struck a chord with me, because although I am no Renaissance man, I would have liked to study English, history and Latin at A-levels, but decided on Maths, Chemistry and Biology for two reasons: firstly I wanted to become a doctor, and secondly the school that I was act required all of its students to continue to study literature, history, art and a bit of philosophy regardless of what they had decided to specialise in. This latter fact made giving up subjects I enjoyed a lot easier.

These days, my preference for the arts and the humanities usually manifests itself with me wibbling away on a ward-round, in a rather supercilious manner to disinterested colleagues, who would really rather focus on the much more important matter of getting patients better. I also have a policy of requiring medical students attached to the firm I work on not to be in the hospital on Wednesday afternoons: for many students this is the day they play university sports matches, but for those who don’t, I tell them that Wednesday afternoon is their chance to do something else. It doesn’t have to be sport, but it should be unrelated to medicine.

Much of this emphasis on learning outside medicine, is I think, actually underpinned by certain amount of intellectual snobbery and personal preference. Having spent some time over the last couple of days mulling the matter over, I think that I have a tendency to over-emphasise the value of a good knowledge of the arts and humanities in doctors, simply because they are subjects that I enjoy. It is nice to think that your doctor is urbance and debonair, but it is far more important to have a doctor with a good technical knowledge, and a healthy amount of humanity about him. A desire for a cultured or artistic doctor has something of the James Bond illusion about it: for someone to be that well read or talented at something else means that they must have found medicine so easy that they had lots of time left over for their extra-curricular activities. Of course, it would be equally valid to assume that they only had time to practice the guitar or karate precisely because they spent too little time studying medicine.

The only way to tell if your doctor is any good is to establish what investigations and treatment he recommends, and to weigh him on the way he communicates this information to you. What he gets up to in his free time should be irrelevant, as long as it doesn’t prevent him from being up-to-date.

But this brings me on to another point one often hears uttered in the corridors of hospital, usually under the exasperated breath of be-suited, middle-aged consultants, who exclaim that modern medical students learn how to communicate, but do not actually take the time to learn any medical knowledge worth communicating. This of course is nonsense - medical graduates have always needed supervision and support, the only difference is that today they are able to ask for it and expect to be given it.

Future consultants will probably have a narrower field of expertise than previous ones, because of the increasing technical complexity of medical practice, and also because young doctors do spend less time in hospital than they used to. This is not a bad thing - we used to be a profession in which it was acceptable to allow junior doctors to practice unsupported, exposing both those doctors and their patients to unnecessary risks. Junior doctors can now look forward to a training programme in which their educational requirements are set out before them, and they are supported and assessed as they go along. This will result in doctors who will be better trained in the skills that they use everyday, and will be able to demonstrate how this competency was achieved. This should be reassuring to both patients and doctors; the price we pay for better training will be the requirement that each doctor (particularly surgeons)  will have a narrower range of skills and procedures that they are trained to do.

The way we train doctors, and the way we interact with patients makes for a different world of medical practice. This is reality. We cannot change this, and we must work out the best ways to offer the best quality and best value healthcare within the confines of the world that exists. Many of the factors underlying these changes are in themselves positive - we should applaud ourselves for arriving at a place where junior doctors are no longer working 100 hour weeks, and we should be congratulated for adapting medical education to be more accountable and thorough. There were a number of cock-ups along the way, and there are a great many issues that need to be ironed out, but that should not distract from the idea that we have ended up in a better place than we used to be. And this brings me back to Eric Scmidt - in the new world of on-line media, he argues that policy makers should go ‘with the grain’, and find new ways to offer the protection that is needed in a way that does not stifle innovation. Exactly the same is true of healthcare - we should not be dismayed at what has changed, but rather embrace it, and see it as the opportunity to improve education and patient care that it is.

Thursday, 25 August 2011

The camouflage of numbers

Often in my blog I ask a question about the way we do things in medicine, and reflect on how honest we are being with both ourselves and others. My blog is sometimes my way of asking myself how I really do things. But you knew that already, didn’t you? This week, I have been thinking about how we as doctors use data, both with patients and among ourselves.

For a little while, I have known that we are often guilty of the pitfalls of ecological fallacy. This is when we take data that we know applies across whole populations, and inappropriately apply it to individual circumstances; we are guilty of this when every time we resort to stereotypes (and we know how much all doctors like to stereotype.....), but we are also guilty of it in the way that we use data and information, and in the way that we relay that information to patients and colleagues.

When a patient asks me what the chances of recovery/complication/dying is, I can refer to the data available and say that there is a 75% of full recovery, a 10% chance they will develop a complication and a 5 year survival of 76%. I rarely do this, for a number of reasons, but there are two main ones. Firstly, even when such information is available to me, and it often is not, I do not really know how it applies to the particular patient in front of me. The epidemiological data we have is based on populations of people, and the figures we derive from such data are applicable to the average person within that population, and who really knows what average looks like? I'm pretty sure that whatever average is, it is rarely the elderly patient I am looking after – the elderly tend to be excluded from the major trials, so application of the evidence to the elderly usually requires extrapolation outside of the data set.

But although what I have just said about evidence in the elderly is entirely true, I have taken an intellectual shortcut, in the full knowledge that the sort of argument I have just given tends to be more acceptable than the argument that I am just about to give.

The use of clinical data in conversation is an obfuscation, driven not by a desire to inform the conversation, but rather driven by a desire to assert one's intellectual authority or to avoid the real question.

The epidemiology of disease rarely informs one's clinical practice, or what one actually does for an individual patient, but it can give the appearance of competence, and give weight to credibility. This often plays out between competing professionals, and in the interesting interpersonal dynamics in the work place.

Furthermore, blinding patients with numbers can be a way of putting up a barrier between you and them. One of the definitions of a profession is that it a trade with a syndicalist mode of representation, with a knowledge monopoly in a particular field, and using the kind of data that we have access to can be a way of emphasising that fact: I have the information, I am a professional, and therefore, my views and opinions are important.

I am not suggesting that that attitude is commonly expressed, but I think that it is subconsciously implied.

When a patient asks about their chances, are they really asking for the numbers, or are they asking you to help them know what to expect? The judicious use of relevant information can be a great way of making a point, but we should not forget what is often the subtext: being a patient can be daunting and bewildering, and it can be very difficult for patients to put this feeling into words. They therefore resort to socially validated ways of seeking the kind of information on to which they might be able to hang their hopes. 'Doctor, what are the risks of …...?' is often the way that patients say, 'Actually, doctor, I'm a bit bewildered, and confused, and actually, what I would really like is for someone to talk me again through what is happening.'

Sunday, 21 August 2011

The frontiers of knowledge - the unspoken truth

Something is afoot in the world of chronic fatigue syndrome - an article in today’s Observer highlights new levels of intimidation by activists who disagree with some of the recent evidence that has been published on the causes and the treatment of Chronic Fatigue Syndrome (see What particularly struck me was the story of abuse suffered by the authors of a Lancet article which suggested that Cognitive Behavioural Therapy could help relieve the symptoms of ME. It turns out that rather than being reassured at the availability of effective treatment, some ME sufferers were enraged that someone could have the gall to suggest that there might be a psychological component to their illness.

Such a reaction belies the social view of illness that prevails: we live in a world that is addicted to a scientific model of health and illness, and when explanations fall outside of this model, they tend to rebuffed or accepted with reluctance. This is well captured by the French - go to a French pharmacy, and you will see people queuing up to buy bucket loads of drugs for all sorts of ailments. Until fairly recently, French citizens could go and see as many doctors they liked for a particular problem (presumably so that they could find the doctor that gives them the answer they are looking for). This has led to a health care system in which the patients have created a tendency to over investigate, over prescribe and over operate. In America, the demand is driven by doctors being paid for on a fee-for-service basis, but the outcome is the same.

And I don’t think we are much different in the UK: empricism and evidence-based medicine are our watch words, and yet I am not sure that we are as honest as we should be about how uncertain our knowledge often is. For example, when dealing with acute strokes, we still have no really clear idea about how blood pressure should be controlled - we continue to fly blind, without the kind of evidence that we really need to inform our decisions. And the flip side is also true - there are many examples of failure to implement evidence that we know makes a difference: for example, we have known for years that prophylaxis for thrombo-embolism can save thousands of lives a year, and yet it takes a government target to actually get us to focus on doing it right.

Clearly, there have been massive improvements in the quality of diagnostics and treatments available to us, but often I feel that the fact that we have a better understanding of some things persuades us that we have a better understanding of everything. I have met a few renal physicians who make out that there is nothing about the human body that they do not understand, and the only way that I can explain such breathtaking levels of arrogance is to say that they must have allowed the fact that they have a good understanding of the workings of the kidneys to mean that they must also have a good understanding of how all the organs work, through some process of physiological extrapolation.

I know that the social views of health and illness are influenced by a great many factors, but surely doctors are important opinion formers, and perhaps there is greater scope for us to admit that our knowledge is limited, particularly when it comes to psychological and psychiatric illness. I have often wondered whether the limits of our knowledge in this field are due to imperfect data and the absence of the right hypothesis, or due to a more fundamental limitation of our scientific model to allow us to understand. It will be interesting to find out.

Saturday, 13 August 2011

Social norms and your field of influence

I've just finished reading 'The Help' by Kathryn Stockett. Set in Jackson, Mississippi, it tells a story about race segregation in the context of white families who have 'colored help'. It's really a story about cross-racial sisterhood, but it’s one that makes you smile benignly about the behaviours of others in the past, where you judge their actions as uninformed and bigoted. Underpinned by the assumption that you would never be guilty of such actions today, you assume that you would not have been guilty of those actions then.

At one point, while I was reading it, the Tracy Chapman song, ' Across the lines' came on the radio. I've known that album since the late 80s, when I used to spend my summers in Chicago, and the image that it portrays of racial segregation in the USA is one of the constant truths of modern life. Recently, Louis Theroux made a documentary about black men in prison in Miami (I think it was Miami). During the programme he offered us the startling statistic that there are more black men currently in prison now that were ever slaves in the USA. I haven't validated that fact, but it makes a powerful point – there are a lot of black men in prison in the USA.

Putting these things together then, it seems to me that the language and the precise form of racial segregation has definitely changed, but can one really argue that the situation is qualitatively better, if whole generations of Americans still experience the paucity of opportunities of their predecessors, and the guarantee of social immobility?

But I do not want to lecture about American social history – what I would like to question is how able are we all as individuals to resist the social norms of the times we live in. In Mississippi in the 1960s, it was normal for 'coloreds' to have separate schools, stores, toilets, and it took some bravery not just to be different, but to challenge these norms. The language of segregation may have changed from colour to education and affluence, but it is still the same people who are affected, and this is what Tracy Chapman sings about so well. Louis Theroux captured the inevitability of crime for young black Americans poignantly – for these men, the revolving door of prison is their inherited legacy in the aftermath of the civil rights movement. And this is not just an American phenomenon.

Consider society today, and consider all the things that you could challenge, but don't. Consider all the wrongs that you see going on around you, and ask yourself why you don't. We can offer ourselves many satisfying explanations, about how we like to pick our fights, about how we don't have enough time, about how there are so many different issues that require our attention, and I bet for a lot of us, this results in us doing very little at all. For doctors there is the added risk of quoting some form of moral surplus in our defence: I spend all day helping the sick, surely nothing more is expected of me in our spare time?

While it undoubtedly takes a lot of courage and energy to lead a charge against something like racism or discrimination, we must also recognise that it takes an equal amount of courage to follow that charge. Venturing into the unknown may yield huge rewards, but it may also expose one to significant risk. It is perhaps, therefore, the norm for people to turn the other cheek, I think it was Malcolm X who preached to his followers that 'if a white man puts his hand on you, I expect you to ensure he does not put his hand on anyone else.' This combative cry was perhaps born out of the realisation that black Americans had been yoked for many years, but no one had really tested how strongly they were bound to that yoke.

In day to day life, we tend to be risk averse and self-protecting. Examples of people allowing discrimination abound, with tolerance of racism being a common theme. What we know, therefore, is that we are reluctant to stand up to the headline issues, and that we will suffer a great deal of wrong before we are urged to do right.

But perhaps there is another way – is it intellectually valid to assume that a society that tolerates discrimination is more tolerant of more minor intellectual misdemeanours? For example, does the fact that the UK has the highest per capita prison population of Western Europe seed any underling trends about the assumptions that individuals make about criminality, its origins and it solutions? Are our views and attitudes shaped and influenced by the operating framework of the society we live in? If society tells us that all criminals should be sent to prison, does that influence our views on who these criminals are, and what has led them to crime? I suspect the answer to most of these questions is yes, and if it is, is not a solution to the prejudices we make as a society about how to deal with crime to challenge, at an interpersonal level, the manifestations of those prejudices?

Do you see my point? What I am saying is that we are all responsible for the impact we create on other people, even though what we say and what they interpret may go through serial phases of miscomprehension and misrepresentation. Therefore, we can each take responsibility for trying to achieve some justice in our actions at work and in our home lives. This can take any form you choose, and the only requirement of you is that your actions and statements hold up to the kind of scrutiny that you would subject other s to.

I'm freewheeling a bit here, but it amounts to the realisation that very few of us are pioneers, and few of us are brave first followers. I'm very unlikely to be a Frodo Baggins, and probably won't even be a Samwise Gamgee. But we all have a sphere of influence, we all have the chance to create an impression on the people we deal with; perhaps,we can choose to be masters of that impression, and can create our own little zones of tolerance, so when people step into the our circles they are held to the standard we would like to see everywhere. This is not just about racial discrimination, this is about fairness and kindness at all levels, in all its manifestations, and about the actions we can take to make life just a little more fair. We can't change the whole world in one go, but we can exert a positive influence on the people around us. This isn't even about perfection, this is about being kinder, more tolerant and more forgiving, and realising that there is no finishing line, but rather there are things we can all do a bit better.

Post script

I asked my wife to read this. She warned me about trying to be messianic.