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The Art of Science
Last fortnight’s News Blog featured an article on inter-disciplinary research. The CLAHRC WM Director opined that collaboration was most likely to be successful when the topics were closely related cognitively – statistics and epidemiology say – rather than only distantly connected – fine art and nanotechnology say.
It is important, however, to correct any impression that disparate subjects, such as nanotechnology and art, should ‘pass like ships in the night’. It is certainly not the case that art and science are hermetically sealed in distant intellectual boxes. One obvious point of connection lies in the portrayal of science in drama. The CLAHRC WM Director recently accompanied his daughter, Nicola, to Nicole Kidman’s portrayal of Rosalind Franklin in “Photograph 51” at the Noel Coward Theatre in London. Marvellous production, where Kidman gave a vivid, but subtle, portrayal of Franklin’s inner terror of fallibility disguised in a rebarbative outward demeanour. She kept worrying that there was some problem with her data or interpretation, and pusillanimous about publishing her remarkable findings. This reticence created the opening for Watson and Crick to make a scoop – abetted by Birmingham-born Maurice Wilkins. The portrayal of the science was lucid and interesting and seamlessly woven into the plot.
This show made the CLAHRC WM Director reflect on other famous dramatic portrayals of scientific discoveries – here are some examples:
News Blog readers are invited to comment and submit other examples of the genre!
-- Richard Lilford, CLAHRC WM Director
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Winners of the Nobel Prize are awarded a medal, a diploma, 8 million Swedish krona, and are offered a chance to visit a place in Sweden usually reserved for visiting heads of state. What is this place?
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Answer to our previous quiz: The Miller-Urey experiment was a chemical experiment to simulate the (supposed) conditions of the early Earth and the chemical origin of life. It is considered the classic experiment investigating abiogenesis and showed that simple organic compounds could be formed from gases with the addition of energy. A recent study, however, has suggested a potential role for meteoritic phosphorus in the origin and development of early life.
Congratulations to Nathalie Maillard who was first to answer correctly.
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The CLAHRC WM Director's Tale
The CLAHRC WM Director waxed lyrical about the deep satisfaction that comes from treating patients at a recent question and answer session at the University of Warwick’s “Festival of the Imagination”. Prof Richard Smith, the ebullient host of the event, gently chided the CLAHRC WM Director on the grounds that he is now a public health doctor and no longer sees patients. Yet the CLAHRC WM Director believed every word he said – how did it come about then, that a dedicated doctor came to give up clinical practice?
The CLAHRC WM Director built up a large referral practice in feto-maternal medicine after assuming the Chair of Obstetrics and Gynaecology in Leeds in 1984. He established the first feto-maternal training centre in the North of England and two brilliant young clinicians, Jim Thornton (now Professor of Obstetrics and Gynaecology in Nottingham) and Gerald Mason (now retired) became his protégés. The CLAHRC WM Director worked hard to ensure that they both became consultants in his hospital. This allowed him to take on other roles. He was elected to the Council of the Royal College, and became chairman of one of its committees; he was on the management committee of the medical school and chairman of the Institute of Epidemiology at the University of Leeds; and he was an executive director of the United Leeds Teaching Hospitals. The upshot of all of this was that Thornton and Mason gradually took over the future CLAHRC WM Director’s carefully nurtured referral practice so that he became increasingly supernumerary. So the poor old CLAHRC WM Director had become a victim of his success. However, he had also been elected to a full membership of the Faculty of Public Health. This meant that he was in a position to apply when head-hunters called to tell him about a job in the newly expanded R&D Department of Health under Sir Michael Peckham.
The rest, as they say, is history. He languished in the civil service for five years and then returned to academia where he has worked happily for the last 15 years. At dinner parties and elsewhere the question most often asked is “Don’t you miss seeing patients?” And his answer is always simple: “Yes”.
-- Richard Lilford, CLAHRC WM Director
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Raison d'être for the CLAHRC News Blog
People sometimes ask the CLAHRC WM director why he writes his fortnightly News Blog. “Isn’t it an awful lot of work?”, “People already have enough to read,” and from his spouse “Anyway, who wants to know what you think?” So here are some of the reasons for doing it:
- It is a dissemination vehicle for the CLAHRC WM. CLAHRCs have to engage with people and get their message out. This is one way of doing so. It is a way of reaching our patient representatives and the management community who may not access the formal academic literature. People are interested to read what our CLAHRC is doing and how that relates to “issues of the day.”
- It is a way of keeping the score – the News Blog keeps account of the intellectual and practical achievements chronologically – it is a sort of living history of our CLAHRC.
- Writing for the News Blog makes me organise my thoughts, form a view and reflect on the implications of articles I summarise for my work. In other words it is good Continuing Professional Development.
- It is actually quite fun to write.
- I find it acts as a useful repository of references when I am writing research papers and grant applications.
- It is a place where I can publish ideas so outlandish, controversial, perspicuous or ineffable that, while they may entertain and amuse, they would never make it into a ‘serious’ academic journal.
-- Richard Lilford, CLAHRC WM Director
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Director's Choice - From the Journals
More on 'P-Hacking'
News Blog readers know that the CLAHRC WM has a large interest in dissemination biases of various kinds. We recently featured an article on ‘p-hacking’, which can be unmasked by detecting a peak of findings with P values just below the fabled 0.05 threshold, as represented below.
Possible distribution of p-values around the null hypothesis.
Well, Ginsel, et al. analysed 2,000 abstracts selected at random from over 80,000 papers in medical journals.[1] Sure enough, there was an overrepresentation between P values 0.05 and 0.049. The P value in this study was <0.001!
-- Richard Lilford, CLAHRC WM Director
The Obesity Challenge is Very Real, but What About Extreme Low Weight?
A body mass index under 16 in women is associated with anorexia in rich countries, but with malnutrition in low- and middle-income countries. It is associated with reduced life span, but the effects of energy supplementation in people who were seriously malnourished as children are uncertain. A recent cross-sectional study of over 40 countries using Demographic and Health Surveys shows a pooled incidence of extreme underweight of 1.8% (standardised for age). The prevalence is highest in India at over 6% and Bangladesh at over 3%.[1] Rates are declining quite rapidly in these countries, but overall at a very low rate and in some countries they are actually increasing.
-- Richard Lilford, CLAHRC WM Director
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Poverty and Cognitive Function
It would appear that people who are chronically poor have lower cognitive functioning than the well-off.[1] Of course, which way round causality is working is not clear from this finding alone. However, even temporary poverty appears to affect cognitive reasoning, even if nutrition, time to complete the cognitive test, and work-effects do not vary. This latter study was based on Indian farmers tested at various points as their wealth changed across the seasons.[2] The authors postulate that the stress associated with poverty consumes mental resources that are not available for other concerns. These results provide a further argument for focussing resources on the poorest of the poor. For instance, people in registered slums in India have many amenities that are denied those in unregistered slums.[2] It would be better to spread meagre resources even more thinly in order to provide at least some help those who are poorly equipped to help themselves.
-- Richard Lilford, CLAHRC WM Director
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Reference
Q. When Can Evidence-Based Care do More Harm than Good?
A. When People Mistake no Evidence of Effect for Evidence of no Effect
Imagine that you have malignant melanoma on your forearm. You can select wide margin excision or a narrow margin. The latter is obviously less disfiguring.
Results from six RCTs (n=4,233) have been consolidated in a meta-analysis.[1] In keeping with individual trials and with previous meta-analyses, the result is null for numerous outcomes. However, the point estimates all favour wider margins and the confidence limits are close to the (arbitrary) 0.5% significance level. For example, the hazard ratio for overall survival favouring wide margins is 1.09 (0.98-1.22). The authors state that the study shows “a 33% probability that [overall survival] is more than 10% worse” when a narrow margin excision is used. It should be added that this assumes an uninformative prior. If the prior probability estimate favoured better survival with wider excision margins, then the evidence in favour of a wider margin excision is stronger still. Moreover, the authors quote results showing that patients do not trade even small survival gains for improved cosmetic outcome. Despite loose statistical language (conflating the probability of survival given the data with the probability of the data if there was no difference in outcome), the authors have done science and practice a great service. This paper should be quoted in the context of surgical treatment of cancer, not just melanoma excision. For example, is sentinel biopsy really preferred to axillary dissection in breast cancer surgery?
-- Richard Lilford, CLAHRC WM Director
A Standardised Patient's Story
The CLAHRC WM Director loves beautifully written articles about the doctor-patient relationship – a beautiful and precious thing that must be defended against all emotionally shallow attempts to downgrade it. The New England Journal of Medicine recently carried a moving story from a Standardised Patient (SP) (‘fake’ patient).[1] She recounts, in a tender way, her interaction with a generation of medical students who she taught and examined, then describes her own severe illness, bone marrow transplant, and recovery, before concluding with an account of her experience of resuming her SP role. May I entice you to read it by closing, for this year, with her closing words, “If I can help aspiring caregivers learn how to reach through the quagmire of dread and pain to help patients get through their most trying times, it will have been worth every awkward encounter and psychosomatic symptom I've suffered along the way.”
-- Richard Lilford, CLAHRC WM Director
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Patient and Public Involvement
An Update on INVOLVE
A recent email bulletin from Simon Denegri, Chair of INVOLVE and National Director for Public Participation and Engagement in Research, outlined the upcoming changes and future strategy for INVOLVE to align with the outcome of the spending review and NIHR Strategy. The key points are summarised below:
The new INVOLVE contract will be held by the University of Southampton from 1st February 2016. An important element of the new contract is the proposed partnership with the NIHR's Research Design Services (RDS). The RDS is a network of ten offices around the country, where researchers can get help and support, including PPI advice. This partnership has the potential to provide many benefits, by enabling INVOLVE to disseminate information to researchers at the right stage to influence their activities.
The NIHR Strategy Board agreed four cross-cutting priorities for the NIHR over the next 18 months. The first two - 'Growth' and 'Push the pace' - are about maximising the NIHR's impact on the health and wealth of the nation. The others are new priorities to which growing importance will be ascribed in the coming months - 'Health and social care engagement' (strengthening our engagement with the health and social care system); and 'Digital research eco-system' (making greater use of digital technologies).
The NIHR 'PPI' Senior Leadership Team identified the NIHR organisations that will provide strategic leadership on implementing each of the 'Going the Extra Mile' recommendations. They also asked the 'One NIHR Group' to help put together a tool to help others understand what happens in public involvement, engagement and participation across the NIHR.
The NIHR, Great Ormond Street Hospital, the Nuffield Council on Bioethics, and our Generation R 'Young Persons Advisory Group's' came together at the end of October to co-host a discussion on how to take forward the involvement of young people in research. It was agreed to establish the 'Generation R Alliance' to share good practice and further the agenda in the coming months and years. A blog, written by Kate Harvey from Nuffield, features more information.
The 'Factors affecting public engagement by researchers' study was recently published by the Wellcome Trust and a consortium of other research funders (including the NIHR) and Universities UK. If you have read Simon’s blog (http://simondenegri.com/) then you will know he is anxious to use this sort of evidence to push on and make further strides in what we do by persuading institutions that public involvement, engagement and participation are integral to how we should define 'research excellence' in the future.
Hannah Dodd – Programme Officer, CLAHRC WM
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New Health Foundation Grant for Hand Hygeine Compliance
CLAHRC WM researchers have been awarded a new £98,000 grant from the Health Foundation to investigate Environmental Engineering to Increase Hand Hygiene Compliance. The project will be led by Prof Ivo Vlaev of Warwick Business School, in partnership with Prof Tom Marshall of University of Birmingham and Kelly Schmidke (also of WBS), along with other colleagues from the two universities.
Funding Opportunities in Public Health Research Programme
The NIHR Public Health Research Programme are accepting applications to their commissioned workstream for the following topics:
- 15/189 - Interventions to build resilience in children and young people.
- 15/193 - Preventing uptake of smoking by children and young people.
- 15/129 - Local interventions to reduce intake and harm from alcohol.
For more information, and to apply, please click here. Application deadline is 26 April 2016.
They are also accepting outline and full applications to their researcher-led workstream - more information.
Donate Rice for Free
If you have some spare time over the Christmas break and fancy expanding your vocabulary or learning a new language, then take a look at freerice.com. For every question you get right they donate 10 grains of rice through the World Food Programme to help end hunger, using the ad revenue generated by the website to buy the rice from the local economy. There are plenty of different categories of questions, so hopefully there is something for everyone!
Fellowship of the Academy of Translational Medicine Professionals (FAcadTM)
Fellowship applications are open to highly experienced professionals who have a record of significant achievements in benchside, bedside, or community health fields and have demonstrated significant efforts to advance the translational medicine and mission of ATMP.
Clinicians and graduates holding degrees with at least five years of experience in disciplines encompassing benchside, bedside, or community healthcare fields are eligible (see online for eligible disciplines). Successful applicants are typically department heads/chairs and senior academics (full, associate, and assistant professors), directors, and senior executives with relevant experience.
Applicants must submit a completed Application Form along with their CV to: atmp@eutranslationalmedicine.org
Further information can be found at: http://eutranslationalmedicine.org/facadtm/.
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Brian Litchfield-Cant
Dr Brian Litchfield-Cant is a Research Fellow at Warwick Business School. He joined CLAHRC WM Theme 5, Implementation and Organisational Studies after completing a PhD at Nottingham University Business School, exploring how to formulate strategies that are ‘owned’ across diverse and, often disputing, healthcare stakeholders. Brian’s current research focuses on how to support knowledge mobilisation, with specific projects including the mobilisation of safety evidence (Birmingham Children’s Hospital), triage evidence about infections (Coventry), and trauma for elderly patients (Heart of England NHS Foundation Trust). Whist Brian only recently completed his PhD, his interest in strategic planning has longer practice roots. As a public policy adviser and political speech-writer, Brian became frustrated with top-down planning that seemed to identify strong technical positions but gained little traction with practice. Re-training at the London School of Economics (MSc) supported his move into management consultancy where he specialised in facilitating strategic change. After a decade of supporting management teams across the world, the appeal of exploring strategic management more robustly proved too strong to resist, so he joined the CLAHRC WM team. Brian now has the most adorable baby so is no longer able to list any hobbies he enjoys!
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Re: An Intervention So Big you Can See it From Space
That 1 million CHWs should be trained and deployed in sub-Saharan Africa by the end of 2015 is an important goal. But I fear the goal will not be achieved as you have suggested Richard. Of course, counting CHWs is a phenomenally difficult task; so much so that there is a defined operation that aims to do so (see http://1millionhealthworkers.org/operations-room-map/). The current total of CHWs reported by this operation is 141,987 – suggesting either that most cannot be seen from space or that they are yet to come into existence.
-- Celia Taylor, University of Warwick
Re: Diabetes - a Lens for Our Health Woes
Dr Hamnett makes some excellent points. However, I think in addition to reducing overall portion size, shift in food groups needs to be individually tailored. Many people can cut their fat intake without being left feeling hungry. However, if they reduce the amount of complex carbohydrate at meal times, the resulting dip in blood sugar levels makes them hungry between meals. The food available to us between meals is usually high fat and high sugar. I don’t dispute that cutting carbohydrate intake leads to weight loss for some people. But I would also like to point out that weight maintenance and weight loss may require a different dietary balance in one individual.
-- Eleanor McGee, Birmingham Community Healthcare Community Trust
I think it is worth highlighting the biased and inaccurate nature of the information around diet and diabetes in this blog.
Firstly, the references selected around carbohydrate are all from low-carb, high-fat diet proponents and don’t represent a balanced, systematic approach to appraising the evidence.
Secondly, several systematic reviews, including the latest one by van Wyk et al 2015,[Link] conclude weight loss as the key factor in improving blood glucose control in Type 2 diabetes rather than the differences in carbohydrate intake.
Current guidelines do NOT recommend a diet consisting of 50% from carbohydrates. Instead, an individualised approach is recommended.[Link]
Finally, the most recent policy statement from Diabetes UK and The British Dietetic Association’s Diabetes Specialist Group still recommends reducing saturated fat and replacing this with unsaturated fats.[Link]
The evidence for exercising in diabetes suggests an improvement in HbA1c (a measure of long-term diabetes control) can be obtained irrespective of any associated weight loss…
-- Paul McArdle, Clinical Dietician
I am afraid that whole field of diet advice is filled by unfounded statements and the historical record of the diet advice is a total failure. You did not mention the recent (well, recent on my scale) advice to eat more orange\red fruits, not to eat the cholesterol-rich food, not to eat animal fat, the promotion of margarines as low-cholesterol, non-animal fat, etc. 100 years ago the fresh cucumbers were considered unhealthy thanks to medical advice, and so on.
I am not trying to repeat the verdict by J P Ioannidis to the field, but I invite to think more about how quick we have to be in promoting our research based knowledge to the action in population?
-- Vasiliy Vlassov, Professor of Medicine
Author's Reply
Thank you all for taking the time to respond to my guest blog. I am not a scientist but a recently retired GP who was slightly anomalous in so far as I worked full-time right up to retirement with around 200,000 consultations under my belt. There are clearly different takes on whether the big enemy is carbohydrates, but I think it is worth making the broader point on where our epidemic of inactivity, obesity and, dare I say it, unhappiness is leading. Whatever the arguments over science, one thing is for sure, the current trajectory of this triad is driving our NHS rapidly towards the buffers. We currently have a government, and indeed an opposition, who are determined to spend £100 billion on weapons of mass destruction and £65 billion to get me to London 10 minutes faster, but are also happy to cut health and council budgets. The mantra that is chanted is that by merely getting people into work they will resource their own well-being. A sizeable dent in this argument is made by a recent report from Merrill Lynch and Andy Haldane, the Chief Economist at the Bank of England, who point out our there will be 15 million fewer jobs in the UK in 20 years because of the advance of robotics. These will be skewed towards the bottom end of the job market. I can see no other solution to this dichotomy than to create a population that has what is known as 'psychological capital' - hope, optimism, resilience and self-efficacy.
In my opinion being active and thin are two vital components but being happy is probably the most important!
-- Ewan Hamnett
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Events
9 Feb 2016
NIHR Clinical Research Event
Congress Centre, London
The NIHR are hosting a Clinical Research Careers event for non-medical healthcare professionals aimed at aspiring clinical academic nurses, midwives, allied health professionals, pharmacists, health care scientists, and those curious about a clinical research / academic career who want to know more about NIHR funding opportunities. The NIHR Guide for Aspiring Academics and Their Managers will also be launched at this meeting.
For more information, and to book a place, please click here.
24 Feb 2016
ePrescribing: Looking to the Future
Royal College of General Practitioners, London
The Centre for Research on Families and Relationships (CRFR) are holding an event on ePrescribing, from implementation and adoption to organisational transformation and patient benefits, which will look forward from 5 years of ePrescribing research. There will be discussions focussing on lessons learned and implications for the NHS, and maximising benefits and realising returns on investment through technologies. International experts include Prof David Bates (Harvard Medical School), and Prof Denis Protti (University of Victoria).
For more information, and to book a place, please click here.
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Funding available for #NIHR Senior Investigators to host #SystematicReview Fellowships. Find out more and apply: http://ow.ly/VQeDr
@OfficialNIHR, 14 Dec 2015
#NIHR Themed Call now open. Funding research into the prevention and treatment of obesity. Find out more: http://ow.ly/VR1Q0 #ObesityTC
@OfficialNIHR, 15 Dec 2015
A recording of the Fellowship Programme webinar is now avalaible: http://www.workcast.com/?pak=5369731334376955 …
@NIHR_Trainees, 15 Dec 2015
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Receptionist rECognition and rEferral of Patients with Stroke (RECEPTS)
Improving receptionists' knowledge of lesser-known stroke symptoms is required for optimum management of acute stroke. The RECEPTS study used simulated calls and a questionnaire to examine knowledge of symptoms and found that calls with fewer/no FAST symptoms were less likely to be immediately referred to emergency medical services, compared to those with three. Further while 96% of receptionists could name at least one symptom of anterior stroke, only 29% reported a common symptom of posterior stroke and 40% reported incorrect symptoms. There is a need for new interventions to assist receptionists to recognise possible stroke and to reinforce the need for urgent action, even when only one symptom is present.
More information can be found here.
CLAHRC BITEs (Brokering Innovation Through Evidence) are accessible bite-sized pieces of research that aim to summarise findings from our published work and make recommendations for practice for health and social staff locally and beyond. Previously published BITEs can be found here.
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