26 Jul, 16 | by Bob Phillips
It’s one of the delights of my professional clinical practice that (nearly) all the time, the diagnosis of a malignancy is hard & sound, reproducible, based on good data showing discrimination from other settings and with minimal interpersonal variation. Take a chunk of a particular renal tumour and show it to half a dozen paeds pathologists, and nearly all the time the Wilm’s tumour will be recognised and identified as such.
People who deal with the un-biopsiable, the disorders without a test and with a requirement for artistic flair, both overwhelm me with their skill and terrify me with the Emperors New Clothes potential. Things like interpreting chest radiographs, or diagnosing Kawasaki disease and ADHD spring to mind. The methods used to guard against the off-piste clinician: regular group review; diagnostic criteria, checklists and the like; analysis of yes/no cohorts to detect changes in proposed outcomes, are all essential and undertaken regularly.
One area which has been subject to huge scrutiny because of the challenging implications of making/unmaking a ‘diagnosis’ is child abuse and neglect. The CORE-INFO group in Cardiff who have collected and reviewed thousands of studies have piled up the evidence for us, and these have been used to help guidelines for reproducible practice become established, yet there remains some difficulty in the finding of unexplained bruising.
19 Jul, 16 | by Bob Phillips
It’s become fairly clear that most people don’t really know how articles get from the pen into the ‘accepted’ queue at a journal.
At the most wonderful paediatric / child health journal on the planet (*) the process works like this:
* ADC of course!
12 Jul, 16 | by Bob Phillips
Trials and tribulations we all have. The not-knowing of the future can create anxiety, distress and an unhealthy desire for chocolate. Some days, knowing what’s for tea can provide the only concrete grounding in an otherwise fluctuant universe.
And along with that, the naming of things can sometimes be enlightening.
So, for un-knowing, you could consider using the following sorts of words:
Imprecision. The sort of not-knowing that is generated by small sample sizes with wide confidence intervals.Uncertainty in a mathematical sense.
Vagueness. Uncertainty about something because it has been poorly defined or described, the ambiguity of the written “How’re you doing?” – which may differ if from the melting voice of Joey Tribbiani or the concerned and serious tones of your Aunt Ethel.
Volatility. Uncertainty through a potentiality of futures that may be sweepingly different depending on as yet undetermined features … if only we’d had a referendum recently in the UK that might provide an example …
5 Jul, 16 | by Bob Phillips
If there was a chance that you missed a diagnosis about which you would be able to intervene 2:1,000 times, and that the test which could diagnose it cost about £3 and was minimally invasive – wouldn’t you be daft not to use it?
Or would you think “what a waste of time!” and wonder about the £3,000 you had spent to make £6 of a diagnosis?
The dilemma is common – there are a whole list of things that are traditionally associated with a differential diagnosis which may be exceptionally rare and sometimes coincidental rather than causative.
Take urinary tract infection in jaundiced babies.
28 Jun, 16 | by Bob Phillips
There are some times when it seems that no decision can be the right decision but doing nothing is as much as a decision as doing something.
Admittedly, it’s rare you’re faced with shooting a killer in cold blood to prevent him murdering a not-so-innocent man.
But sometimes the triadic nature of paediatric & adolescent medicine causes us trouble. more…
21 Jun, 16 | by Bob Phillips
My mum insists that we, at home, always cut off the green bit & splice the strawberry in case it had a slug in it.
For Ian Wacogne it’s sitting with his back against a radiator.
Well, in my case it’s so that you can’t eat a slug … that’s managed to get into the strawberry without having left a hole / magic taped it together afterward .. garbage, yup?
I asked my mum about it. She said that my grandma had told her she had eaten a slug in a strawberry when she was little, but that no, she didn’t remember eating the slug, and actually, on recollection, it was that she had nearly eaten a slug in a strawberry …
Such ‘strawberry stories’ are prevalent and problematic. They exist in clinical medicine, research and publishing. Some we’ve heard recently:
“You can’t publish fetal or animal papers in ADC F&N” … You can
“You need NHS Ethics to involve patients in developing research studies & protocols” … You don’t
“Multi-disciplinary research is never worth the effort” … Nope
Identifying these strawberry stories, and overcoming them should probably be one of the tasks we take on every day. I wish I could point you at high quality evidence of how to do it, but sadly, I can’t.
17 Jun, 16 | by Bob Phillips
We’ve started to publish a fair few quality improvement reports in the Archives recently, aiming for 1200 words, 5 references and a readable SQUIRE-compliant paper that gets across the key messages about how a #QI project was undertaken.
These aren’t trials, don’t have control arms, and may suffer from significant publication bias. (It’s not surprising to anyone that in my role as an Associate Editor, I’ve not seen a Report that shows how the QI intervention was completely bloody useless.)
So what on earth are we – EBM centric academic ivory towerists – doing promoting these things?
14 Jun, 16 | by Guest Post
Dr Jess Morgan, working in the University of York, has taken time out from writing up a massive mixed-methods study to splurge on why you might like to use focus groups in your research study. You see, they aren’t just a way of getting a tonne of interviews done without having to do all the driving between coffee shops.
There are loads of different reasons that you might choose to use focus group discussions instead of individual interviews when carrying out qualitative health research. I’m going to outline my top six (there are more but six seems just about enough)….
10 Jun, 16 | by Bob Phillips
It’s been a while since a little burst of statistical fun hit the blogosphere but summer is sort of here, and you may be faced with a choice of tracks in a forest and unsure which one to take …
Path analysis will not aid you.
Path analysis (aka ‘structural equation modelling’ … sort of …) is a type of regression analysis, where you try to predict one thing that you don’t know (for example, final hight of a child) using stuff you do know (like the height of the parents, current age, height & pubertal status). more…
7 Jun, 16 | by Bob Phillips
You’re sure to remember the ethical dilemma in ADCE1 – the overheard conversation of information that may have done more harm than good – and you’re likely to have spend hours awake, wondering about the next dilemma to come your way.
Will it be, as posed by Emma Neumann in the “Tea & Jeopardy” podcast
“If you were to be approached by someone holding two cocktails & wearing nothing but a winning smile, who would it be?”