A bit of Prokofiev after an afternoon walk

Sergei Prokofiev’s:

Symphony No.1 in D ‘Classical’, Op.25 performed by Efrem Kurtz and the Philharmonia Orchestra.

The Cello Concerto in E minor, Op.58 performed by Janos Starker and Walter Sussking with the Philharmonia Orchestra.

Sinfonietta in A Major, Op.48 performed by Riccardo Muti and the Philharmonia Orchestra.

Where is the ‘classical’ music dedicated to the Anzacs?

It is interesting to observe that there isn’t much of a tradition of patriotic and memorial classical music in Australia. Looking around I came across very little so I’d be happy to hear from anybody who knows of any, particularly if it related to the Anzacs. The only specific piece I came across was by Miriam Hyde: Anzac Threnody for voice and piano.

I would however like to nominate a piece as a candidate. Symphony No.1 or Da Pacem Domine by Ross Edwards was not specifically written about the Anzac experience but it was at least in part a reflection on war, in this case the Gulf War, in addition to being dedicated to Stuart Challender. David Porcelijn has conducted a recording by the Sydney Symphony Orchestra.

Edwards Symphony No.1 Da Pacem Domine

Towards the minimally disrupted quantified self

One of the emerging movements in healthcare is the quantified self movements. Led by a bunch of tech-savvy self-confessed geeks the quantified self movement is all about collecting personal data and using it to inform life decisions, health care decisions and behaviour change to improve overall well-being. These life-loggers are measuring their habits, food intake, activity levels, mood, heart-rate, blood pressure, blood sugar and a host of other person-reported outcomes and physiological measures and charting them on paper or in spread sheets. Whilst this seems like a small sub-culture most people with smart phones have downloaded at least one health related app that can be used for life-logging. Persistent use is not always durable and perhaps it is because life-logging, like much other healthcare activity is burdensome. You have to spend a lot of time entering data yourself. Well maybe this is all starting to change and being a quantified self is becoming less burdensome.

Victor Montori has been advocating for minimally disruptive medicine, the aim being to reduce the overall burden of healthcare (not just the burden of disease) for patients, particularly those with chronic medical conditions like diabetes. Many chronic medical conditions actually already require individuals to include some form of life-logging as part of their healthcare routines e.g. recording blood sugar levels or blood pressure.

Smartphones and other smartphone facilitated devices are starting to enable data collection in a minimally disruptive way. For example accelerator and GPS-enabled smartphones, or smartphones linked wirelessly to other small devices like a Fitbit or a Nike Fuelband, can track exercise and other activity levels. Calorie consumption can be inferred and flights of stair counter. The same phone or added devices can be used to measure sleep patterns. Increasingly attachments to the phones can measure various physiological parameters in a non-invasive way. Apart from the occasional re-charge (they aren’t solar or movement powered yet) they are pretty much plug & play, set & forget. All you need to do is make an effort to check out the data in the form of customised reports and decide how you will act on them.

To take it a step further companies such as Soma Analytics have apps that move beyond you recording your mood directly to actually inferring your mood by analyzing your voice patterns during phone conversations. This in turn allows a calculation of your stress levels and can give you feedback and advice about stress management.

Another variation is to use the phone using the GPS tracking facility to record activity levels as a marker of a patients’ “social pulse”. For example, if an older person changes their activity patterns based on monitoring of the phone movements then this might be a sign of decline in functional status. Deborah Speaking at @TEDMED Deborah Estrin has referred to this as our “small data” and is encouraging processes to obtain this data from telecommunications providers.

All of this data can be used for personal use but uploaded to the cloud and given the right permission your medical practitioner could access the data remotely and in return provide analysis, interpretation and clinical advice on the basis of your data. Automated alerts flowing to healthcare provider or patients could be a form of minimally present telemetry.

Looking at these existing and emerging technologies one can see that having a data-driven life doesn’t need to be a full-time job even if you are collecting data 24/7/365. Even the activities which might require an effort at data entry, like recording diet or medication use, might become more automated through image recognition software or barcode/QR-code scanning. This could be continuous and uninterrupted for individuals using google glass. I think we can call this the minimally disrupted quantified self.

Minimally Disruptive Medicine

Quantified Self

Small Data

Soma Analytics

fitbit

Things they didn’t teach in medical school: Part 24 Innovation

This is a brief post that needs some more thought and input. This week I’ve been attending @TEDMED at the Kennedy Centre in Washington. Naturally a major theme is innovation. Start-ups, entrepreneurship, thinking out of the box and radical re-thinking is being showcased. Successful entrepreneurs were asked to speak about innovation: interestingly it is common that they can’t explain how it is done (or they are modestly protecting the secret). So if innovation can’t be taught then why include it in the ‘Things they didn’t teach in medical school’ series?

Innovation is a fancy name for making things better. This is perhaps beyond quality improvement and extends to recognising there is problem that requires fixing and then identifying a solution. There is no shortage of problems that innovative ideas could fix in hospitals.

When I attend medical conferences one thing I frequently observe is that people (doctors, nurses and other members of the healthcare team) often have great ideas for solving problems. What the real problem for innovation in healthcare seems to be is a large number of artificial barriers, sustainability, reduction of duplication and dissemination of the big ideas.

An example of the barriers is the IT department. When my colleagues first suggest using Moodle (a learning management system) for the purposes of orienting and training our registrars they were blocked. IT wouldn’t let the external site be accessed through the firewall. Later on the hospital actually adopted Moodle for its’ organisational learning program. Another example is new forms required for safety projects might take months to approve though the ‘forms’ committee.

Ofter innovations are led by a champion who has a short term grant to undertake an improvement project. There is short term success and then when funding runs out the champion, by necessity moves on. In the same way you might find exactly the same project undertaken at another hospital.

The other important barrier is a lack of parties willing to provide opportunity. Start-up companies go and look for venture capital. In hospitals, especially in the public sector, there is no equivalent of venture capital. Convincing administrators to invest in your idea is not easy.

Dissemination of innovations has all sorts of barriers put up by organisations – more often than not these objections are based on money, however, one of the problems is doctors and other healthcare professionals have never been trained how to best undertake organisation and behavioural change: perhaps this is the real skill that hasn’t been taught in medical school – and this will be discussed in the next post.

Things they didn’t teach in medical school: Part 23 Saying goodbye to patients

One of the things I haven’t quite got the knack of is saying goodbye to patients. I’ve recently looked after two young women the same age as myself. Both with children similar ages

In my job as an oncologist I often establish long-term relationships with patients. These relationships can span years and involve periods of fortnightly visits, stays in hospitals, and the roller-coaster ride of good and bad news. Some of these patients genuinely considered to be friends.

Unfortunately, as is the case for cancer and a lot of other diseases, the inevitable end comes. With years of experience doctors becoming increasingly good at predicting the time to end-of-life. The reality is that I know that sometimes when I am consulting with a patient, either in the rooms or on a ward, it will be the last time I see them alive or in some cases the last time I will be able to talk to them. In some cases I know they are going to hospice and won’t return.

I’m sure that the patients often know as well but nonetheless we do the dance, “I’ll see you tomorrow” or “make an appointment for two weeks”. It is an opportunity for imparting hope but a lost opportunity for saying goodbye.

In Annals of Internal Medicine (2005: 148(8), p. 682) Anthony Back offers a list of tips around saying goodbye:

(1) Choose an apropriate time and place
(2) Acknowledge the end of routine contact and the uncertainty about future contact
(3) Invite a response and use it as data about the patient’s state of mind
(4) Frame as an appreciation
(5) Give space for the patient to reciprocate and respond empathetically to the patient’s emotion
(6) Articulate ongoing commitment to care

Like most of these communication experiences it is important to practise and to remember to remember that communication is jazz – you will have to improvise.

Things they didn’t teach in medical school: Part 22 Project Management #TEDMED

Something not taught in medical school is project management. Although at medical school you might undertake assignments and similar activities, unless you are allocated a research project it is unlikely you will have any formal instruction in project management. I, in fact, don’t consider myself to be especially good at hands-on project management and work better as a collaborator on projects rather than running them directly. Project management is related to time management. You an think of time management as about managing your time to do projects and visa versa project management is a about completing tasks on time.

It is important first of all to recognise a project when it is either handed to you or you come up with the idea.

For me the simplest definition of a project is any activity that can be broken down into smaller tasks to produce an outcome which is more than the sum of the individual parts. Using this definition a project may be small e.g. preparing the meeting roster for a year or large e.g. designing a new medical school curriculum.

There are some tips for managing a project:
– really identify what the purpose and aim of the project is and visualise how the finished project will look – what are the deliverables
– estimate the resources you will need and the time you will need
– identify who is critical to your project – for example, if you need statistics advice for a research project get it early
– break the project down into the smallest tasks possible and work out what in what order they should be completed (and which tasks depend on another tasks being completed – a dependency)
– identify what will stop the project from being finished
– based on the above decide if your project is feasible or not
– identify stakeholders and collaborators
– once the project has started have a regular review process to check progress

Last night at the opening session of TEDMED 2013 Professor Rafael Yuste spoke about the relationship between pursuing big science and his passion for mountaineering. He broke them both down to 3 steps: assemble the team, map the course and keep the summit in sight. The scientific summit he plans to climb is the Brain Activity Map now known as the Brain Inititiative which was announced by Barack Obama 2 weeks ago. This is the moon project or human genome project of the decade. You can see him talk @TEDMED