Square One

“…and nothing is gained by calling it by a nicer name,” says Tony Judt, historian and professor at New York University as conclusion to his reflections on living with a motor neuron disorder which has made him “effectively quadriplegic.”

Here is an excerpt from the last paragraph of the article, Night:

I suppose I should be at least mildly satisfied to know that I have found within myself the sort of survival mechanism that most normal people only read about in accounts of natural disasters or isolation cells. And it is true that this disease has its enabling dimension: thanks to my inability to take notes or prepare them, my memory – already quite good – has improved considerably, with the help of techniques adapted from the “memory palace” so intriguingly depicted by Jonathan Spence. But the satisfactions of compensation are notoriously fleeting. There is no saving grace in being confined to an iron suit, cold and unforgiving. The pleasures of mental agility are much overstated, inevitably – as it now appears to me – by those not exclusively dependent upon them. Much the same can be said of well-meaning encouragements to find nonphysical compensations for physical inadequacy. That way lies futility.

The full text of Night is here (free pdf)

Tony Judt presently writes a series of short reflections for The New York Review of Books. Night is first in the series.

I am presently conducting a systematic review and meta-analysis that involves a detailed and critical quality appraisal of studies which has made me realise all over again how impoverished the narrative of the classical scientific paper really is, and that indeed like Francis Crick wrote in his 1994 book The Astonishing Hypothesis, “There is no form of prose more difficult to understand and more tedious to read than the average scientific paper.”

The average scientific paper is a work of fiction: often seemingly perfect, compact, well cut, crisp and concise and perhaps deceptive and unreal in its seductive perfection, just like a movie or novel.

In an example that illustrates the disjunction of scientific papers from the reality of the scientific process, Richard Dawkins, former Professor of Public Understanding of Science at Oxford University tells the story of his experience in 1974 when he was appointed as UK editor of Animal Behaviour in his contribution to Leaders of Animal Behaviour: The Second Generation (2009), a volume of invited autobiographical chapters by ethologists:

My particular bugbear was the formulaic scientific paper with its standard headings: Introduction, Methods, Results, Discussion. The rubric’s limitations were especially glaring when – as was common – the author had done a series of experiments, each one prompting the next. I tried to persuade authors that that the proper sequence of the paper was: Question 1; Methods 1; Results 1; Discussion 1; leading to Question 2; Methods 2; Results 2; Discussion 2 leading to Question 3…and so on. You’d be amazed about how many people arranged their paper in the following way: Introduction; Methods 1, Methods 2, Methods 3, methods4…Results 1, Results 2, Results 3, Results 4…; Discussion. Could anything be obviously calculated to confuse and bore?

Need I point out that this is true, and taken for granted as normal for many papers in the general scientific literature, including medicine? It also shows how difficult it is to change a status quo.

However, I have a proposal:

For any movie I particularly enjoy or find intriguing for any particular reason, I want to see a second screening, just like reading a novel the second time. I also want to see the making or listen to an audio commentary by directors and possibly the actors. I want to observe, even if partly, the creative process.

Seeing the process of making the movie or listening to the directors and actors almost demystify the process however doesn’t quite undo it; rather, for me, it deepens and enriches understanding and appreciation of the work.

Just like the movie commentary, I imagine fellow researchers and the lay public would benefit from having a behind the curtain exposure to the workings of the mind of the scientist in action, the process of arriving at the research question, what each author did, how each person became an author, the moments of revelation, the debates, of choice between this analysis or that, this mode of presentation of results or the other: an exposure of science without much of its makeup.

For every publication, every analysis, there should be some sort of author commentary, chatty maybe, contemplative or argumentative, published separately, or recorded as an audio or video podcast, not necessarily for the public, but understandable by an intelligent non-scientific audience without compromising the scientific message.

The internet has revolutionised the amount of space available for publication and so we can’t make the same excuse again about limited space. The limits imposed by space might have been the reason for the present state and structure of the scientific paper, but we can begin to undo its sterile style and language.

It may even be an opportunity for journals that publish these commentaries online to make some revenue from them, and also a very good avenue through which scientists can begin to engage with the public in a more direct way, without the influence of the non-scientific media. I reckon it would also further enhance the standing of scientists, and a more honest engagement with peers and the public.

I imagine something like this:

We couldn’t have done it otherwise. It wouldn’t have made much sense if we did. Most other groups have used a Cox proportional hazards model to assess predictors of time to remission but we decided on deeper reflection and after much argument, mostly between SJG and RD – the two clinicians in the group – that what really matters to patients is not how long it takes for them to achieve seizure remission but how long they spend in remission. So we divided the patients into those who had spent the more than 1 year in continuous remission and those with less than one year in continuous remission and decided to look at the factors that may predict each outcome in a logistic model. The result, apart from being less equivocal than in previous studies is apparently also more useful although we doubt that we have contributed any much further to what was already known.

This post also appears on BMJ Blogs here

Richard Dawkins lends his well recognised voice to the homeopathy debate presently going on in the UK by proposing a study:

1. Take a large, predetermined number of patients, preferably who have presented themselves to homeopathic clinics and been rated suitable for treatment by homeopathic practitioners. They needn’t all be suffering from the same complaint, although it will increase the resolving power of the experiment if they are. Every patient should be examined before the experiment begins, by homeopathic practitioners, the best the profession can come up with, who should write a report on the patient. For every patient, the practitioners should agree upon a prescription of what they consider the ideal homeopathic treatment. The prescriptions for the different patients need not be the same. Every patient is written a prescription of an ideal homeopathic remedy, personally chosen, individually tailored to that individual and for the relevant complain – so nobody can come along afterwards and allege that the treatment was not sufficiently ‘holistic’, or did not take sufficient account of individual requirements.

2. Randomly assign half the patients to the experimental group, and half to the control group. It is vitally important that nobody involved in the experiment should have any way of discovering which patients are experimental and which control: not the homeopathic practitioners, nor the patients, nor the nurses taking care of them, nor anybody involved in writing down the data. The choice should be determined at random by a computer, unknown to any human, and stored securely in the computer.

3. For every one of the prescriptions written down for individual patients, professional homeopathic technicians (the best in the business) should make up the medication identically for the experimental and control cases, with an identical regime of succussion (successive dilution and shaking) with the single exception that the procedure for preparing the experimental doses begins with the purported active ingredient, while the control doses begin with the same volume of water. Apart from that, both must be made by the same regime of successive dilution and shaking. At all stages, the procedures should be carried out by fully trained and experienced homeopathic technicians, exactly as they normally would, but without knowledge of whether they are shaking the experimental or control dose on any one occasion.

4. At the end of the succussion regime, the technicians bottle up the medications, and make them into pills or whatever would be the normal procedure. Then, as determined by the randomising procedure above, each patient is given either the experimental version of his/her own personal prescription or the control version of his/her own personal prescription. Still neither the patient nor anybody else knows which dose is experimental and which control. Treatment proceeds for as long as the homeopathic practitioner has prescribed.

5. At the end of this time, all patients are re-examined by the same practitioners who examined them before the experiment, and judgment is written down as to whether the patient has improved, got worse, or stayed the same. That judgment, once written down, is securely sealed so that it cannot be tampered with after the codes are broken.

6. The computer codes are now broken, and the results analysed by statisticians who are told only that this set of patients belong to ‘Group A’, and that set of patients belong to ‘Group B’. If there is any statistically significant difference between the groups, the identities of ‘Group A’ and ‘Group B’ may now be divulged. My shirt is on there being no difference. Indeed, if there is a significant difference, and it is a repeatably verifiable effect, I will eat my shirt.

It’s just another Double-Blind placebo-Controlled Randomised Trial (DBCRT). That’s what we need to prove the evidence for as many medical interventions as are amenable to this design, and homeopathy absolutely is. The full article is here.

Daniel Sokol, medical ethicist and BMJ columnist writes in this week’s BMJ about doctors deceiving doctors. Not many of us can claim that we are not guilty of some subtle form of deception, mostly to advance the cause of patient care. But is it justified? It brings to mind again, performing the futile CPR, a kind of deception to put the mind of a patient’s family at rest in the conviction that we did our best.

Here are excerpts:

A doctor needs a computed tomography scan for his patient. To obtain the scan in good time he feigns concern about a possible pulmonary embolus on the radiology request form. He is also aware that, in the eyes of his consultant, a measure of his competence is how promptly and reliably he can obtain scans. Under interrogation by the radiologist, the doctor embellishes the truth to justify the urgency.

A doctor on a general ward calls the intensive treatment registrar and lies about the patient’s previous quality of life to boost the probability of admission. It is only when the patient arrives on the ward that the truth emerges. Another doctor uses the same tactic to persuade surgeons to operate on a desperate patient.

In anaesthesia, an occasional deception occurs when the surgeon, struggling to operate during a difficult case, asks the anaesthetist to administer more muscle relaxant. The anaesthetist, whose monitoring tells him that paralysis is adequate, acquiesces and injects a dose of saline.

The full discussion is here.

I have done the futile CPR a number of times for the same reason that intensive care physician Robert Turog advocates in this NEJM article – the family:

Several years ago, I cared for a 2-year-old boy who had been born with a large frontal encephalocele. He survived surgical excision but was left neurologically devastated. The clinical team consistently counseled his parents that he would never have any meaningful neurologic development. We recommended redirecting his care toward comfort and palliation. The parents rejected all these suggestions. I came to know the family fairly well through the boy’s multiple admissions to the intensive care unit (ICU) where I am a physician. Despite extensive and continual efforts by everyone involved to support the family and reach an agreement to limit aggressive treatment, the parents continued to insist that everything be done.

I vividly recall the evening when, a few minutes after a “code blue” was called over the hospital intercom, I watched this little boy being rolled in through the doors of the ICU. He appeared chalky and lifeless; I remember thinking that he might already be dead. Still, mindful of his father’s unyielding refusal to consider a “do not resuscitate” order, I instructed the staff to attempt resuscitation. We ventilated the boy through his tracheostomy and made multiple unsuccessful attempts to place central venous and intraosseous lines. After perhaps 15 minutes, I asked the team to stop. I pronounced the boy dead. None of us felt good about what had just happened. One of the nurses later told me that it had been so upsetting she had had to fight back the urge to vomit.

I went to talk to the parents. They had arrived at the hospital a short time after the code blue was called and were holding their little boy. I fully expected to be on the receiving end of an angry tirade full of accusations about our failure to keep their son alive. Instead, the mood was remarkably quiet and somber, as they began the universal grieving of parents for a lost child. But what surprised me the most was when the father gently opened his son’s shirt, revealing all the puncture wounds and bruises from our failed attempts to place a subclavian catheter. He looked up at me and said, “I want to thank you. I can see from this that you really tried; you didn’t just give up and let him die.”

The full text of the article is here.

Futurology is at best systematic guesswork, and at worst facile hubris. “Prediction is very difficult, especially about the future,” Niels Bohr (1885-1962) once quipped, but if you think about how successful science-fiction has been, you might be tempted to take Bohr’s piece of wisdom with a grain of salt. Is it really so difficult to predict the future?

HG Wells (1866–1946), one of the earliest writers of science-fiction, most popular of which were The Time Machine (1895) and The War of the Worlds (1898) made many predictions in his life time. He wrote his  most clearly and decidedly futuristic work, “Anticipations: An Experiment in Prophecy” (1901), where he predicted what the world would be like in the year 2000.

He got it right that trains and cars would result in population dispersal, that there would be much greater sexual freedom, that Germany will be defeated, and there would be a European Union. Expectedly, there were many misses: he said there wouldn’t be a successful aircraft before 1950, and that there would never be a successful submarine. For one of the fathers of the science-fiction genre, you expect it would be the other way round.

There was one more thing, partly scientific, he did get right though, which I think he is not being given enough credit for: the Internet, and the eventual creation of Wikipedia. Of course, he didn’t use the Wiki word, but his accuracy was stunning. The following are excerpts from his contribution to the new Encyclopédie Française in 1937, titled “World Brain: The Idea of a Permanent World Encyclopaedia,” reissued in a separate volume World Brain:

A microfilm, coloured where necessary, occupying an inch or so of space and weighing little more than a letter, can be duplicated from the records and sent anywhere, and thrown enlarged upon the screen so that the student may study it in every detail.

This in itself is a fact of tremendous significance. It foreshadows a real intellectual unification of our race. The whole human memory can be, and probably in a short time will be, made accessible to every individual.

Its uses will be multiple and many of them will be fairly obvious. Special sections of it, historical, technical, scientific, artistic, e.g. will easily be reproduced for specific professional use. Based upon it, a series of summaries of greater or less fullness and simplicity, for the homes and studies of ordinary people, for the college and the school, can be continually issued and revised.

In the hands of competent editors, educational directors and teachers, these condensations and abstracts incorporated in the world educational system, will supply the humanity of the days before us, with a common understanding and the conception of a common purpose and of a commonweal such as now we hardly dare dream of.

This concisely is the sober, practical but essentially colossal objective of those who are seeking to synthesize human mentality today, through this natural and reasonable development of encyclopaedism into a Permanent World Encyclopaedia.

If you substitute ‘computer’ for ‘microfilm’, what you have is the internet, and the makings of Wikipedia. There is however another of Wells’ scientific predictions, published in World Brain where he predicted that for an educated citizenship in a modern democracy, statistical thinking would be as indispensable as reading and writing.

Unfortunately, here is another HG Wells prediction failure, one that I would wish above all other scientific predictions was successful. Prediction has always been hubris.

Two weeks ago, it was reported that Arsenal FC (Competing Interest: I am a committed Gunner!) striker Robin van Persie would be traveling to Serbia to see Belgrade-based healer Marijana Kovacevic (Marianna the Therapist) for the horse placenta treatment of his ankle injury that has pretty much, amongst other things, destroyed the season for Arsenal. Frank Lampard, Yossi Benayoun, Albert Riera, Fabio Aurelio and Glen Johnson have also tried her out following reports that Serbia forward Danko Lazovic had been cured faster than expected by the massage that involves fluid from horse placenta.

Kamran Abbasi begins his editorial in this month’s issue of the  Journal of the Royal Society of Medicine titled “The Year of the Horse Placenta” by writing, “We are in the Chinese year of the ox but in the UK this could end up being the year of the horse placenta,” and later says, “This fashion for horse placenta therapy shows how the world of medical science is quickly marginalized by more powerful arguments of politics and money. Here the concern is league position and money, money and television rights deals.”

He ends by reminding us that Bertrand Russell once asked whether it was possible for a scientific society to exist, or if such a society must inevitably bring itself to destruction. In Kamran’s words: “Perhaps he should have asked a simpler question: ‘Is it possible to create a scientific society?’”

Jo Stephenson writes in this week’s BMJ about different approaches to equipping doctors for management and leadership roles. This is how we need to start thinking in Nigeria now. We cannot continue to leave the management of our hospitals and health care institutions and system in the hands of those who are not trained to manage them, no matter how senior or clinically experienced.

I sent this article to Dayo Osholowu, a sports physician in Nigeria who replied by saying: “We have to embrace the responsibility that is falling on us or someone else will. The ownership and management of health service insitutions will fall on an elite corp of financially sophisticated management experts. Lets join this corp with open arms and the venture will reward the few.”

He went ahead to paraphrase a quote from Dr Strangeglove, where General Jack D. Ripper says: “Clemenceau (himself a medical doctor who later became French PM) once said that war is too important to be left to the generals. When he said that, 50 years ago, he may have been right, but now, war is too important to be left to the politicians. They have neither the time, the training, nor the inclination for strategic thought.”

Health care management indeed in the same vein, is too important to be left to doctors/clincians. Here are excerpts from the BMJ article:

However, many people would like to see management skills introduced earlier in doctors’ training. In America there are a growing number of dual MD/MBA courses on offer. Harvard set out to create a truly integrated programme, explains Richard Bohmer, medical professor at Harvard Business School.

Students concentrate on medicine for the first two years but do a management internship in a hospital or healthcare firm between the two years. In their third year they continue medical training as well as doing several management courses, including looking at management problems on the wards.

“Students are getting clinical experience. At the same time we’re teaching them about some of the organisational issues they’re seeing,” says Professor Bohmer.
During the fourth year they do an MBA with a clinical rotation and in the fifth and final year they complete their MBA and clinical rotations.

………………..
Meanwhile other US medical schools are introducing leadership elements into graduate medical education, such as Dartmouth Medical School’s leadership preventive medicine residency. It is a two year programme on top of a traditional three year clinical residency, offering the chance to earn a masters degree in public health and gain skills to lead change and improvement in health care.

The programme includes clinical leadership rotations and a major practical assignment in which trainees are expected to apply what they have learnt to a real health service situation.

………………..
Many doctors combine management with clinical work, but in Australia and New Zealand it is possible to be a registered specialist in medical administration by becoming a fellow of the Royal Australasian College of Medical Administrators. Doctors with three years’ postgraduate clinical experience can go straight into a three year training programme providing supervised medical management experience in posts such as deputy medical director.

Alternatively, senior doctors trained in other specialties can gain fellowships in a minimum of 18 months depending on previous experience.
This approach has boosted the status of medical managers. Fellows can command higher salaries, and in some states fellowship is a requirement for directors of medical services.

“There is that feeling that a doctor who has gone into administration has gone over to the dark side. Making it a recognised vocational skill certainly goes a long way to dispelling that myth,” says college president David Rankin

The full article is here.