Wednesday, January 21, 2015

Classroom observation

I get to take my younger son to school three mornings a week, not something every parent gets to do.  On the way home recently I found myself thinking about levels of understanding and evidence based practice.    As you do.

The children enter the classroom ten minutes before registration.  On the whiteboard (electronic) is a piece of work.  They do that work on individual whiteboards (the sort that need pens).   It might be writing down the nouns they can see in a picture, or adding adjectives to a sentence.  When ten minutes is up, the bell goes, and grown ups, who are allowed to stay and help with this work, have to go.

For some grown ups, "help" is writing the questions on the whiteboard for their child (the teacher would rather they didn't), for others (including me, sometimes), it is frustration when their child does not engage with the task.

Sometimes the whiteboard work is numbers, and recently it was partitioning numbers - 25 is 2 tens and 5 units, 123 is 1 hundred, 2 tens and 3 units, for example.

My son could not remember what to do.  He had done the work before, and at the time had understood it well enough to explain it to me.  On this occasion, everyone else on his table had made columns, one for hundreds, one for tens and one for units, and then filled them in.  Reading the question on the class whiteboard made me think this was a possible way to do it, but I could not remember how he had done it before.

I suggested he try the table and columns method.  Just before I left for home, though, the teacher mentioned to me that the column way of doing it was what one parent had done, and then everyone on that table had copied it.  I am not sure who copied it - parents or children - but it was not the method they had been shown in class.  That might explain why my lad was reluctant to do it that way, even though he could not remember how he had done it in class.  I wonder where the parent had come across the method?

The child next to him offered to help, but his help was to allow my lad to copy his table of columns.  My lad obviously did not understand what he was seeing but copied it anyway.

Several things occurred to me on the way home.

First, my lad had understood partitioning when he did it the first time, and had explained it to me.  When they had partitioning to do on whiteboards at that time, he had been able to do it.  And now not.  Why not?   Had he forgotten?   Lack of practice since?  What form did his understanding at the time take? The fact that I could not remember what he had explained to me is telling, too!

Then, he did not feel able to use the method that those around him were using.  I could see it made sense, but did he remember that it was not the method they had used before, even though he could not remember that method?

Then, what did the parents see as "help"?  Completion of the task?  Doing it for their child?   However, I am not sure I saw that - even if a parent writes down the questions, they don't write the answer.   Even if it was a parent who thought of the table and columns method of partitioning, it was the child who was filling in the numbers.

As someone involved in higher education, I then started to think about medical students.   They have learnt to do something in a particular way, and they might remember that way.  For example, they have learnt to search Medline in a particular way and might remember it for an exam.  But do they remember why that way is the "best" way, or a good way, at least?  Have I covered that in my teaching?  Can they apply those skills in another context?  They learn to search to complete an exercise, and again to pass an exam, but can they use it to find information for assignments or even, in due course, for patient care?   Do they see that those skills apply in those other contexts?   Can they remember those skills for long enough to use them in another context?  Or if they can't remember those skills, do they at least remember they need them, and go and learn them again?

What do they see as the aim of learning a particular thing?  Just to pass a test or click a box?  What application does it have?  And what happens when they have spent time learning other things, do they still remember it?

Then there is the "see one, do one, teach one" model - that is copying what you have seen.  Can you teach it if you don't understand it?   If you keep up to date and find out about a new way to do it, then do you need to understand what you did before in order to be able to change your practice? 

And having thought of all that, I got home.

Saturday, January 17, 2015

Finding your way

Driving somewhere?  Satnav or map reading, that is the question.

Satnav, pluses and minuses:
  • - Risk that you will just follow instructions (copy what you are told);
  • - You may have no idea how the route is generated;
  • - You may not not know where you are in relation to your destination;
  • + You don't need to make a choice over route;
  • + If you go wrong, the satnav will work out what to do;
  • + You can drive solo with a satnav;
  • + It is easy to get started with a satnav;
  •  - But better if you take time to work out how it functions.

Maps, pluses and minuses:
  • + You know where you are in relation to your destination;
  •  +/- You have to work out how to get there
  • +/- You need to decide which route, if there is a choice to be made;
  • - The map won't tell you where the potential bottlenecks are, although it will tell you which is the most major road if you know the symbol;
  • - You can't read a map and drive at the same time;
  • - If you go wrong, you need to work out yourself what to do.

Our family car recently gained a satnav, a birthday present for one of its drivers.  We have named it Sally Satnav, as it has a female voice. It (she?) has navigated one or other of us around areas we did not know, and worried for us about the correct junction to take off the motorway and what to do next.  And when we missed a turning, Sally recalculated for us.  Our youngest is amused when Sally does not know the name of a road and tells us to "turn left on road", rather than something like "turn left on Leppings Lane".  And we know what time we are likely to arrive.

I remember testing Sally Satnav on a familiar route in the town where we lived at the time.  She wanted to go a different way to the way I had always gone.  It would have worked.

We have had to learn about how Sally works in order to get the most benefit.  How much notice do you get of junctions?  How do you know if that side road is the one?  Can she tell you what lane to be in at large junctions?  Does she know about roadworks or traffic jams?

But, we have had left turns that are almost too sharp to get round, and more than one road that is only just wider than the car.  And cases where the lane markings and the signs at a roundabout say to go one way, and Sally says to go a different way.  Was it a shortcut?   These things, I imagine, are because of the way Sally calculates your route. 

I am much happier with a route if I have done it before, and not that confident at map reading, so a satnav seems ideal for me.  But to find my way around Sheffield, I have decided I prefer maps.  I want to know where I am in the city (north, south, east or west) and if I am near an area I know, and those things are easier with a map.  I begin to build up a picture of the city in my head.   And on longer trips to unfamiliar places with the satnav, I have not enjoyed the feeling of not knowing where I am on a map, not knowing where I am in relation to where I want to be.

Recently, an academic colleague used the image of satnav and map in discussions about levels of understanding of our medical students.   I have been unpacking the image since.

They learn something and can repeat it in an exam, and perhaps explain it to someone, but if they have to apply that thing in a new context, they are less sure.

With a satnav, I know when I have arrived, but don't always understand how I got there.  I am just copying what Sally Satnav is telling me to do.  Some parts of the route might have been difficult (narrow, sharp turns) and I may not know why.   If I go wrong, I can follow new directions, but I don't have to work them out. With a map, I understand how I got there, and where I went on the way, and I also know how near I am to the destination. If I go wrong, it is easier to see where and how it happened, and I have to work out what to do about it.  Both satnav and map require learning - how does Sally Satnav choose a route? - but you can use a satnav without needing to know that sort of thing, whereas maps are not a lot of good if you don't know how to read them and don't study them in advance.

So, I can follow the images in Netanatomy and know the anatomy of the collarbone.  I can answer a question about the anatomy of the collarbone, and tell you about the anatomy of the collarbone. But faced with a patient who has broken their collarbone, how am I going to use that knowledge to help it mend?   I might learn about the mechanism of fracture healing from a YouTube video, but can I use that basic science to advise the patient what they can do while the bone is mending?   And what if it doesn't mend, or they decide to ignore my advice?   How does the science help me decide what to do next?

Final thought in this ramble.  If I know the route, or have done it before, how about using the satnav as a way to follow it?  If I know I apply that basic science, watching the video or looking at the image may enable me to check my basic knowledge before proceeding.

H1N1 influenza in Aosta, Italy

I am off to Italy for a short break later this year, lucky me, so am trying to resuscitate my holiday Italian.   And so I have downloaded the Android app for La Stampa (I tried two others but the full text wasn't free to read - cheapskate!).  And I spotted this piece about cases of H1N1 influenza in Aosta, northern Italy.

Other Italian sources (like ANSA) are reporting the same, and today (18th January) I have found this in FluTrackers, linking to a local site.

It seems that one man has died, although he may have been in hospital with other conditions (the sentence in ANSA with "pluripatologie", but not sure), and a woman is ill.

FluTrackers also lists other cases in Italy here, some of them also this year.

I hope that's right - or I have just caused panic!   If you know it isn't right, or spot something in English, please add a comment! 

Thursday, January 15, 2015

A and E crisis - amended 20th January

Much in the media in recent weeks about the crisis in Accident and Emergency, with articles comparing A and E unfavourably to military hospitals in the Iraq War, and about the longer and longer wait until you are seen.  Here are some things I have come across in the last few days:

Surviving a night in A and E: a doctor's story - an anonymous diary of one doctor's night duty in A and E, giving an insight into the patients and the staff.  Several patients who ought to be somewhere else, some who are there because they are drunk, and some who are in the right place.

A & E crisis: understanding health at a systems level could drive a better NHS - by Terry Young, Professor of Healthcare Systems at Brunel University, arguing that it is the complexity of the system that needs to be tackled, and arguing that it is time to use the tools that have been developed in other complex areas of life, referring to Atul Gawande's recent Reith Lectures.  This article is part of a series - go to the end of this page to see links to others.

A report in the BMJ about a recent report from the Health Foundation and the Nuffield Trust, which finds that most reasons for the problems do not explain the whole story.  You will need a subscription to read this article.

Rather older, dating from July 2013, a Lancet article by John House (I know, I thought that, but not him!), asking experts about the causes of the crisis.  You will need a subscription to read this too.

An Observer article about operations being cancelled because of the crisis.

The work of the King's Fund on urgent and emergency care. This site includes statistics, publications, and an "alternative guide" which examines the myths.

A new "finally", added 20th January - the BBC's A and E Tracker, which indicates how many patients in the four home nations were seen within 4 hours (England is hiding under "How is your local hospital doing?", at least for me, in England).   You can search by postcode to see how your local hospital is faring.

Saturday, January 10, 2015

Search filters

I have been invited to do the literature searching for a research project looking at care of older people in hospital.  The first part of the project is a literature review.  It's fascinating, and very instructive - I have spent a lot of time working to support others who are doing this, and it is quite eye opening to do it for myself!

The literature review is of systematic reviews (SRs) and meta analyses.  I first of all had to devise the strategy, and that was very interesting.  And then decide how to locate the SRs.  And so is that ...

I could:

1.  Use the standard Medline search limits.  There never used to be a limit for systematic reviews, and meta analysis was the nearest fit, although it is not the same thing.  Publication type limits in Medline are not without issue.  There may be references indexed as meta analyses which are not (but which say they are), and there may be things that are meta analyses, but which are not so indexed.  Now there is a SR limit, but in PubMed anyway it is a filter, not a straightforward limit.  Certainly a search in Medline for systematic finds zero.

2.  This leads us to the second possibility.  As a way to address the shortcomings of the standard limits, and as a way to get reproducible searches, there are search filters, not part of Medline, strategies which can be bolted on to your subject search.  But there are several SR filters.  Which one to choose?   Some have high sensitivity ("the number of relevant reports identified divided by the total number of relevant reports in existence") and others have high precision ("the number of relevant reports identified divided by the total number of reports identified" - this, and the definition of sensitivity are taken from the Cochrane Handbook). 

 The ISSG Search Filters Resource lists many filters, and evaluates many of them.  I wanted it to recommend one, but of course because it depends what you are aiming for in terms of sensitivity and precision, no one can say "this one is the best".

3.  The third option is not to use a filter or limit at all, but include or exclude things yourself.   If you do this, you know exactly what you have kept.  But, there is a practical consideration, which is that if you get 2000 results, do you have time to scan them all?  This is interesting, as I have certainly said to students I have been helping that they may end up with this sort of number of results!

So, what to do.  I think I will be running all the filters (and the "limit") separately, and merging the results.  I suspect, but don't know, that these separate result sets will overlap but that none will completely include any of the others.  We shall see.  I then plan to remove this merged set from the unlimited/unfiltered results, and then we can sample the remainder and see if any of the sample are an SR or a meta analysis.

I put out a request for experience and expertise on two Jiscmail lists, and the results (I shall summarise for the lists) have informed the above.

Friday, January 09, 2015

(Auto)biography as health literature

When I started out in health librarianship, I am sure there was a book called "At the end of all our work is a patient".  I can't find it at the moment, but I can find an article by Shane Godbolt with that title (1).  And as she was my first boss, that is an excellent thing to find, and perhaps that is what I was thinking of.   That fact attracted me to this field of work, and still does. 

Watching the excellent History Boys recently (excellent, and to some extent familiar, as I was at school then, though not in Sheffield and not looking to go to Oxbridge or do history), I was reminded of Alan Bennett's memoir Untold stories (included in a volume with the same name) (2).  In it he writes about his mother's experience of mental health problems, and his discovery that his grandfather had also had them and had in fact committed suicide.

Perhaps there is material in that memoir that didn't make it into textbooks or research papers, perhaps, I am tempted to say, particularly at the time.  And so this sort of literature adds something to the evidence that informs practice and research.

I was recently in hospital for a week following an accident.  I remember what I was doing in the moments before but not what actually happened at the moment of the accident, as I had a head injury.  I don't remember anything till the end of the following day, when some family members came to visit me.  I remember them being there, but not what we talked about - apparently I repeated myself and was not able to sustain any sort of conversation.  I remember my wife coming back to visit me the following day with a friend, and remember realising that this was not a dream, but again I don't remember what we talked about.  On one visit, family members brought a photo album and apparently I couldn't remember the holiday (in one of my favourite places).  I actually don't remember the photo album being brought, either.  My younger son remembers me talking to him on the phone, but I don't.

My experience as a patient is surely valuable to practitioners, although I cannot know if it is typical (surely it is not as we are all individuals), so therefore the experience of other patients is valuable too.   But so is the experience of families and loved ones.  My family remember things about the visits that I don't, and of course my wife had the dreaded phone call from the paramedics to say what had happened, and would she get there as soon as she could.  They have feelings about the whole thing that I do not, and could not have.  I don't remember ever wondering how I ended up in hospital, or whether I would be ok, although I know my wife wondered that last thing, particularly after that phone call.  Also, I came to realise that it could have been so very much worse. 
So, do I as a health librarian buy (or buy access to) biography and autobiography? I read Untold stories while off work recovering.  And fiction, like Ian McEwan's Enduring Love (3), which I read then too (elder son doing it at A level) - plenty of mental health related issues in there.  Do you as a health practitioner or student read (auto)biography and fiction to inform your work or studies?   What can we do with this sort of material as evidence?   Does it end up in reviews?  Patient experience of head injury as related in biography and fiction, that sort of thing.

Let me say that I had the most excellent care at the Northern General Hospital, Sheffield.  And very good follow up care - for an accident that took minutes, I have had a week as an inpatient, and five outpatient visits (two for physiotherapy, two to the fracture clinic and one to the maxillofacial clinic), and one more outpatient visit (to the head injury rehabilitation clinic) to come.  And two GP visits (I chose to have those, although one was for symptoms).   What a lot of health service time for one short accident, and I am grateful it is there. 

References (well, I am a librarian)

(1) Godbolt S. At the end of all our work is a patient.  LA Record, 79(2): 86-9, quoted in Carmel M. (1986). Impact and image: improving the library's contribution. Health Libraries Review, 3: 94-10.  Available from  (Accessed 9th January 2015).
(2) Bennett, A. (2005). Untold stories, in Untold stories.  London: Profile Books, p.1-125
(3) McEwan, I. (1998). Enduring love. London: Vintage.