My wonderful moustachioed man at Heathrow.

 

My moustachioed man at Heathrow.

 

When I was 16 years old my big brother went off on a gap year, backpacking around Australia. I was jealous and wanted to go too but there was a problem – I was only 16. Eventually my parents compromised, I could go, but to visit my Uncle and Aunt in Brisbane and be back soon to start A levels.

 

I waved goodbye at departures, got through security (explaining that the cricket bat in a box was a gift for my cousin and was not a dangerous weapon, pre-9/11) and off I went on my own. I found a seat and as I sat down, tears started to form. I was emotional. I was 16.

 

There was another passenger already seated on the benches in front of me. Until that moment he had been hidden behind a large broadsheet. He slowly lowered his Financial Times and peered out at me over his glasses. Revealed was a tall, skinny man, larger than life. He was dressed in tweed with a remarkable moustache, a big bushy beard large enough to hide Basil Brush and Roland Rat and to top it all, he was wearing a wonderfully bright red turban.

 

“What are you crying for young lady?” he asked me, not accusingly, not aggressively, not patronisingly, just quietly.

 

“I’m going to Australia.” I sobbed.

 

“Mmmm, well that just sounds like there’s a wonderful adventure to be had and no reason to cry. You’re going to love it” and with that he was hidden again behind his newspaper.

 

I couldn’t help but stop crying and start laughing about at how silly I was being.

 

I never saw him again, not in person anyway. I think of him all the time though, when things start to get a little hairy and I feel like a 16 year old heading off alone to the other side of the world.

 

What a chap.

 

It is easy to fixate on the shit comments people have said to us, the ones that really stick in us like knives and do us so much harm. For some reason, remembering the helpful stuff is harder. There are plenty of chances to see the positive and be helpful and kind to those around us. If you are in a position of authority and even if you can’t match the remarkable facial hair of my wonderful moustachioed man at Heathrow, please offer up a good comment, you never know who might remember it, with fondness, 22 years from now.

 

 

Part 2: Creative Commons: the best medicine?

commons1x

 

In Part 1: A rising tide floats all boats, I took my position on the side of Us v Them – free open access sharing v the old established order. Naive you may think but that’s led me to more discussions (and ranting) about Copyright and Creative Commons (which is healthy isn’t it?).

 

As a former commercial photographer I took part in numerous debates around copyright and protecting our work from the thieves who would use us to make their own money. I didn’t ever really flatter myself to be honest, but I have seen others being taken advantage of by big and small businesses. I would get grumpy when clients used their phones to shoot my printed proofs in order to stick them on Facebook. One day though, I had a call from a client’s friend who had seen such posted pictures and wanted their own. It led to work, directly to work, passing Go and collecting way more than two hundred pounds. That’s what happens when, as a creative, you share.

 

Medical research though, is not a photograph. Yes, OK, let’s get dreamy eyed for a second: a picture can say a thousand words, we all love a good image but photographs are not medical research. Dare I say it, they aren’t quite as important (in this context of course). Preventing access to important research by making it inaccessible to those who can’t pay should not be the future of healthcare in any economy.

The far reaching consequences of keeping research behind paywalls, using scarcity and inaccessibility in order to profit, is I would say, questionable.

 

Sure, photographers, creatives, medics, publishers, we all have to put food on the table. I understand that. Be that as it may, I want my work to be seen and shared as far and wide as possible, shared and discussed…that’s what leads to new work and in medicine, that is what could lead to better outcomes. If you want the best of both worlds, of sharing and protection, you could always turn to a Creative Commons license.

 

Creative Commons was the brainchild of Lawrence Lessig – a prof at Harvard Law School. The idea was actually to protect the laws of copyright. You can use Creative Commons licenses for your work and set conditions of your choosing. You could say…Sure, I am happy for you to use my work, just say where you got it from, make sure you acknowledge the source. Seems reasonable. Again, does this accessibility make it less worthy? Not solely on the grounds of being free it doesn’t. Does a CC license then infer some credibility? Maybe not.

creative-commons_logo

 

If you are splashing the creative commons logo on everything and feeling good about it, well done. Forgive me a second for getting all idealistic but you are still slapping rules and caveats on it that are there solely to protect yourself…if you’re a photographer that is. If you are a researcher, I would disagree. It seems a good start in a move towards open access and I suppose it does make everything feel a bit more legit, for now. It’s a start.

Having been shared and having been acknowledged, that’s when your discussions, your collaborations, the joining forces, the arguments, the further sharing can get going. That’s when the magic can start to happen that leads to better outcomes for patients. That is after all, why you did the research isn’t it?  Mmmm?

Copyright laws are about the protection of original material for the creator, to keep on feeding their family and that’s fair enough. Copyright and access though are different things. I’m not talking about profiteering from the hard work of others. I’m talking about access for decision making directly for treating patients. If that material is incorporated into education resources which are sold as courses then yes, we have a different problem, whatever your intentions.

 

It’s a tricky one.

 

We all might agree that it is all kinds of moral badness to deny treatment to people (or whole countries of people) on the grounds that they can’t afford it. Yet we are happy for this to continue in medical research and education. I would argue that it is just as unjust.

Keeping information behind paywalls is leading directly to the pirates, the copyright rule breakers, the ones who think it is right they should have all the information to make decisions for their patients. It is making criminals of those wanting to do right by their patients. Is it worse to be the one breaking copyright or to be the one denying access to people who could potentially benefit – and easily so in this new economy of easy sharing? Simon Carley answered my comment in his recent post about pirate platforms by saying you are distinguishing only between two evils. I strongly believe which one is the greater of those two evils and it is not the one breaking somebody else’s copyright rules in an age of world wide access and new economy publishing.

We need to put an end to journals who use scarcity in order to increase their own wealth – to the detriment of those who can’t join in. I haven’t yet quite figured out how (believe me, I’m working on it) but creative commons licenses and copyleft ideas might be a good place to start. A compromise on the way to Open Season.

 

So we should choose wisely how our research is shared and what can be done with it…or question why we did it in the first place.

 

Suz

 

I have just been challenged on all this though and here’s a new question I have been asked…

If you are so outspoken about free/open access to everything, what about your medical data? Should that be freely accessible?

Now there’s a question…and one for part three.

 

Some linked interesting-ness…

 

Creative Commons

Open Educational Resources Commons

EMJ Blog: What’s the future of medical journals?

Richard Smith: What will the post journal world look like?

Link tax is a thing? Seriously?

 

Please add your thoughts to the comments section below….

 

 

 

 

A rising tide floats all boats.

threex

 

I was having a discussion about disruptive technology in medical education (as you do) and in a reply one particular line stood out for me…

I think the world is now mature enough to be sceptical about what we see and hear on the internet.

Sure, that is true for those of us who happily embrace the internet and internet 2.0 but there are still many who are not happy that we are out there, sharing our thoughts and having free open discussions with a global audience. We can’t be trusted, you see, to think for ourselves.

I still feel like the world is split into us and them – those who want to share and collaborate openly and freely and those who see value only in what they have to pay for and what they are told to read. As a commercial photographer, I spoke at numerous business group meetings and events about the beauty of collaboration and sharing using social media – only to split rooms in two. It is the same in the world of medicine.

I’m baffled that we still need articles like that in the BMJ this week bemoaning the tweet-dodgers at conferences, complaining that their data will be stolen or misinterpreted if anyone tweets from such private gatherings. It goes on to the suggest guidelines for conference tweeting…yawn…still needed in 2016? Clearly so. I have a colleague studying for a Masters in Medical Education to whom I recently had to explain the term FOAMed. His response was an eye-roll and a “whatever”. I think he and others are massively underestimating the power that online sharing and teaching will have in the future (and even now). Imagine a world where we no longer have to make sacrificial offerings to the gods of publications, to the gatekeepers of the journals who decide whether or not our careers are worthy of their ink. Judging academics by where they are published is just a ludicrous idea isn’t it? Yet my portfolio and my job applications would have it otherwise.

Until we can break free from the current outdated system, there will always be us and them. For many, what is seen as cheap will be seen as worthless. Anything that is hidden behind paywalls must therefore be far better? I disagree. Data/information/anything that we create – it can all be copied and shared on a massive scale on the internet – but that doesn’t make it worthless.

What we need to move towards appreciating is that the value comes not from what can be easily copied but from what comes with it, those things that can’t be easily copied or stolen – what is instant or timely; what is personal; analysis based on the experience and the validity and the accessibility of the authors. I’m talking about our ideas, our conviction, our experience and excellence – essentially, ourselves and what we bring with our data.

“I don’t have enough followers to bother” is a false predicament – you only need one or two followers who share your interest, who see something in your work and who will engage – this is all you need to get your work and ideas out there because there will be people who care enough about your vision to join in and to share. Maybe if there is one person reading my blog today who feels strongly enough they will share and discuss – that may be all I need. There is a phrase I have stolen (from someone who shared it with me) and I believe it strongly: a rising tide floats all boats. Information should be free to be shared in order to raise the collective up together and further. If you are on your way up, take others with you.

Open access for freely available research, data and even opinion undermines the established order – but we don’t want to do it to piss people off (maybe) we do it because we don’t need the established order anymore. It wasn’t working for us. It only ever worked for itself.

For research and education in the world of medicine, it is such an exciting time and it is time to accept that there is another way.

 

Part 2: Creative Commons : the best medicine? (watch this space)

It is your reaction that is the problem.

reaction2

 

I’ve been feeling a little uneasy about Scott Weingart’s opening talk from SMACC. It was an extraordinary talk, recorded live on stage for the EMCRIT podcast and it took quite a few people by surprise. He talked about meditation and negative contemplation….all good things, if they work for you, but still I am uneasy and here is why…

 

A few years ago I started a year-long job that was a bit of a distance from home. Far enough that I wasn’t going to be driving home after 13 hours at work only to come back again the next day. So I rented a hospital flat and was away from home for that year. On the first day, during induction, I was asked how I was going to cope being away from Mr Edge and our girls.

 

At the time, my answer was very clear. They are safe, they are well looked after, they are happy.
I was pretty chilled about it all because, and I can recall it so clearly, it was a time of horrendous fighting in Gaza and I had been watching online the devastation happening in the Middle East. The hashtag that stuck out for me was a chilling call for the International Criminal Court to deal with Israel. Now this is not a political blog post and I have nothing to say about that. Whatever the circumstances, as a human being, it was harrowing. In particular I saw a series of traumatic photographs of a broken man, walking a broken street with a plastic bag. He was picking up the pieces of his child, who had been torn apart by a bomb. The final image was shocking, it was a close-up of the contents of that bag. I think about that image often.

.
Scott was getting at this… Imagining the worst case scenario will always set you free to make a leap, because it will make you realise the unlikeliness of that scenario coming true. It will give you the strength and courage to face the difficulties of your day. But do we really need to be so graphic? I think about that image a lot. Perhaps that is my own personal negative contemplation. My children are safe, they are well looked after, they are happy but it is a painful way to remind myself that this is so.

.

I play along with the rhetoric and philosophy of the Stoics. I keep Marcus Aurelius at arm’s reach in my school bag. In fact the Meditations of Marcus Aurelius was the book I took with me to Dublin (did I think I was going to get a chance to read it?). Like Seneca himself I could probably be considered slightly less than stoic at times…but that’s OK, I am after all a work in progress. For a start I do not join in deliberately with any Negative Contemplation. I don’t ever deliberately visualise my girls dead in my arms. I don’t feel the need to go that far. This is something that Scott brought up in his talk, he says he does this, deliberately, daily. Understandably he was met with stunned silence in the large auditorium. He went on to explain how this and meditation helps him get through the tough stuff and how you too could make a start yourself on the path to inner peace.

In this arena full of high achievers, we all want this to work for us too. Since SMACC I have heard a few people say that they are going to start meditating. They are rushing home to give it a go. But this is a bit of a word of warning…beware that it may not bring what you’re looking for and that’s OK.

I am not being a #meditationwanker and I am not having a go at Scott Weingart, VERY far from it. We are looking now to a future where our wellbeing is considered much more important and we can discuss mental health issues more openly. This can only be a good thing. In the past this would have been unconscionable. We need people like Scott, with the reach and influence he has, to say that it is OK to seek out help like this and to suggest tools that could help. I’m just saying, personally, I struggle with the meditation that he suggests and negative contemplation feels to me like the sort of self flagellation I accidentally achieve daily anyway. As long as I channel it to positive outcomes then that’s fine and it doesn’t necessarily have to be quite so traumatic.

 

So what CAN I do?

For me it is writing. I write a lot. Only a tiny portion ever reaches publication – the rest is all shit (you might argue the published bits are shit too). I am guilty more than anyone of trying something only a couple of times before moving on when I am not suddenly representing my country or winning awards but

My point?
Do what floats your boat.

I have friends and colleagues who meditate and boy do they do go on about it. I spent a lot of time punishing myself for not finding it helpful. I did this too when I couldn’t find what I was looking for in Tai Chi…I gave it a chance but after I while I went back to kickboxing because really I just needed to punch and kick people to help me feel peaceful.

It doesn’t matter if you can’t do what Scott Weingart says. Give it a try. If you try (and like anything, you need to give it time) and it doesn’t work for you, recognise that you didn’t fail and you don’t have commitment issues. It just wasn’t your thing. Stoics see it like this – it is not the problem that’s the problem, it is your reaction to the problem that is the problem. If this doesn’t work, don’t go beating yourself up…and it is not Scott Weingart’s fault either. So,

 

Meditate
Don’t meditate
Imagine the worst case scenario
or don’t.
Write
Watch Football
Read
Run
Study

It is in the deliberate and in the mindfulness that you find your thing.

Strike your own match against whatever is going to set you on fire.

Just make sure you strike it somewhere and remember it is unlikely to be your last match and that’s OK.

Small town excellence

Sometimes you have to turn things on their head and look at them in another way. I was made to recently by the boss…who had a slightly different (and of course far more experienced) point of view.

crackinthewall

I was grumbling to some colleagues about a subject that seems to be becoming my thing…the fact that where you live really shouldn’t determine if you live.

But it does.

Time and again I read and hear examples of this being so.

Scotland’s aeromedical service (@EMRScotland) only this evening pointed out on Twitter that London Air Ambulance (@LDNairamb) has 2 dedicated trauma teams on tonight, and Scotland has none. Northern Ireland has none. Dr John Hinds (@DocJohnHinds) regularly points out such inequalities and that trauma care in Northern Ireland is something of a lottery.

Where we live has consequences when things go wrong.

When my husband and I bought our beautiful cottage amongst the mountains we could not have been happier. For our youngest daughter, things were not so great. The day we moved in she became unwell. The bad nausea, vomiting, fever, photophobia, stiff-as-a-board type of unwell. I phoned the out of hours GP service and they sent an emergency ambulance. As Mr Edge went out into the dark to guide them to the house, I contemplated the longest time it would take to get us to hospital. I couldn’t help but question our decision to move so far from the big city.

But we chose to be rural and I know what you’re thinking. Scotland isn’t quite the outback…we aren’t relying on @ketaminh to fly us miles and miles across the land to definitive care, but none the less, where we live could have a huge part to play in whether  or not we live, should disaster strike. Distance to a local hospital might not be that great, but next stage distance to a teaching centre with ICU, neurosurgery, interventional radiology and dermatology (OK maybe not dermatology so much) being available on site must have an impact on the local population? Doesn’t it? Are there any studies?

Sure, we should strive to be centres of excellence in big cities, but we should be striving for even more than that if we are far away.

We have a brilliant District General Hospital. It is staffed by many talented,  enthusiastic and slightly eccentric but reliable and committed generalists. We are sometimes viewed by the specialists in the big city as being another ward of the Trust in which we all belong. Most of the time though we feel like the crazy Aunty that nobody wants to sit next to at a family wedding because she smells of mothballs.

Things are different here.

REBOA carried out on a London street to save the life of a young trauma victim is science fiction to us. If you suffer a traumatic cardiac arrest on the roads around here, you’ve had it. Sorry, did I use the word if? This is happening on local roads every single day just now. But I’m not just talking about the sexy trauma stuff. I’m talking about the other every day life changers: the tumours, the brain haemorrhages, the clots, the STEMIs and the time it could take to get you through the DGH system and on to definitive treatment.
Having a STEMI? The cath lab is quite far away, will thrombolysis do?
Emergency neurosurgery? Good luck with that.
Abdominal pain at night? Hi, I’m a new FY2 (seriously, that could be me you’re getting first).  I’m not really sure if DGH populations understand that? I didn’t before I came here.

The boss stepped in at that point…she stopped me in my tracks. She put it like this…

Of course it’s obvious that where we choose to live determines our chances….but our chances of what exactly?
Because of the geographical gap between us, it can make life harder to get people to the end result they might need but we do get people out the door and down the road when we need to. 
I believe that it is because we DON’T have all of their snazzy potential interventions and “things to try” at ANY cost, that we are far better at discussing and considering all the options, including death. Good old-fashioned end-of-life, death. We do palliation really bloody well. Sometimes, that’s what people really need and packing them off the big city might not be for the best. Providing a good death, with family nearby and consideration of comfort, dignity and DNACPR are as important when needed as ICU when it’s appropriate. I think we do that really well here.

She’s got a point.

The local population might not appreciate how different their care can be far from big teaching hospitals but maybe like me, they choose to live (and die) here anyway and for other reasons.

As for my daughter, after what seemed like a vey long trip, she jumped out of the ambulance, shone the pen-torch in her own eye and giggled on the long journey home with the packet of biscuits the nurses had given her. We didn’t sell up and move back to the big city. Not yet.

****

I posted this blog post about 24 hours ago. Since then I have learned the sad news that Dr John Hinds died today in a crash doing what he loved…risking his life to save others. Northern Ireland deserves the same care services as the rest of the UK.

Where you live shouldn’t determine if you live…but it does. RIP Dr Hinds.

 

 

We’ve always done it this way

castles2

There is not a phrase in existence that I could despise more.

Please don’t get me wrong, as a junior doctor it is a phrase that has helped me out of a few sticky situations when uttered by an experienced nurse who’s watching my back. I’m talking about the other context though, the one where we’re trying to improve, innovate or are daring to hope to make things better and when we are met by this giant, immovable, smug, grinning brick wall of “always”.

I can remember, in all detail, the very moment this intense hatred began. In the summer of 2001 I had just graduated with an Honours degree in Medical Molecular Biology and was waiting to start Med School. I got a job in the University bookshop. Perhaps I should have realised beforehand that my exuberance was not suited to such an endeavour but at least it taught me so, and quite quickly. I worked in the back office, selling books to libraries (not a tough job as it turned out, as books were all libraries seemed to buy).
The shop’s systems were laborious and complicated and there wasn’t a computer in sight. For the student who had started the first tentative websites for the University clubs and sports societies, this was hard going.

I arrived at work one day to find a new batch of deliveries. It was periodicals day. The publishers sent them out to us and it was my job to sort them out, figure out who they were destined for and make arrangements for delivery.

After an age of time-wasting I couldn’t take the system any longer. I made a suggestion to the boss— Margaret. I didn’t whine, I simply made what I thought was a useful suggestion. I gave a solution to this time-wasting problem and I set out an argument for implementing it. Margaret, who glared at me over the top of her glasses, was not impressed. She lifted the tatty old notebook marked “periodicals” from the shelf, opened it up and handed it to me across her desk.

“This is how we have always done it” she said

and that was the end of that.

As I turned to leave I looked down at the notebook, to the page that she had handed me. What I saw stopped me in my tracks. The very first entry in the book was dated 14th December 1978. The day that I was born. Even more striking was that it was written in Margaret’s own distinctive handwriting and she had written in it, the same way, every month since.

She was happy with that. Some people just are. This was a battle I wasn’t going to win. I didn’t stay long in the back office selling books to libraries.

That bookshop is no longer there. Those periodicals are online now.

So here’s how it makes me feel when you utter those words. You take all creativity, innovation, excitement and hope and you stamp on them, kick them, punch them in the face and bury them in a box. You draw a line in the sand and you take your place on the wrong side of it.  There are two types of people on that sandy beach of yours. Those that proclaim we’ve always done it this way and those who move with the dunes.

 

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