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StatsMiniBlog: Will Rogers Phenomenon

21 Nov, 14 | by Bob Phillips

20140205-091454.jpgThe American humorist, Will Rogers, was reported to have said (of the migration of folk from Oklahoma to California):

When the Okies left Oklahoma and moved to California, they raised the average intelligence level in both states

While this is a deeply unkind comment reinforcing geographical stereotypes, it does a neat job of capturing an epidemological paradox. If you re-define group definitions, you can make both groups averages improve (survival, or IQ) without changing one jot the overall truth. Such a phenomenon must be guarded against when re-defining risk groups, for example on the basis of new diagnostic technologies, and seeing ‘group based’ benefits.

To take it pictorially: more…

Deliberation and determination

17 Nov, 14 | by Bob Phillips

What does it mean to have a choice in your care?

It’s an interesting question, I think. And may not be as neatly answered as the pat response to an exam: “for example, let the child choose which book to look at while you do the venipuncture!.

If you can’t influence the final yes / no – can you be involved in the decision?


Guest Blog: Beyond the stereotypes – getting to the heart of medical management

14 Nov, 14 | by Bob Phillips

david-brentWhen you think of a manager, what image springs to mind? For me, earlier in my career, I may have pictured Montgomery Burns, the quintessential evil capitalist manager of Springfield Power Plant in ‘The Simpsons”, or David Brent , the hilariously incompetent regional manager of Wernham Hogg, in “The Office”.. Perhaps our opinions are influenced by the media, where greedy ‘fat-cat’  NHS managers are often criticized and scapegoated for NHS failings.  Could these negative stereotypes be divisive, alienating clinical and managerial components of the NHS team? And could poor relationships between doctors and managers be counterproductive in the effective running of the NHS?

Until recently, I had very little contact with any NHS managers, and thought that they cared more about money, bureaucracy and politics than patients. This opinion was only informed by what I had heard from other doctors, the media, and the frustrating dealings I’d had with medical staffing departments at numerous inefficient hospital inductions. One memorable interaction resulted in doctors losing our only meeting/seminar/break room, as a result of a top-down decision by a ‘faceless’ manager, grand rounds were re-located to a soft play area where latecomers had to sit on an animal beanbag, or even worse the floor. I have also lived through challenging change in the NHS, driven by political agenda and largely facilitated by managers. I perceived a gradual erosion of doctor’s professional autonomy, with us coming under growing scrutiny through revalidation, targets and inspections, implemented mainly by non-clinical figures who seemed to me to have little insight into the realities of ‘front line’ work.

So when an opportunity arose in my latest training post to meet and work with a manager on an NHS Change Day project at Birmingham Children’s Hospital, I was both curious and keen to discover what managers were really like and share my opinions and insight into patient care. more…

Urban Road Speeds – any of our business?

10 Nov, 14 | by Ian Wacogne

There’s a growing movement in the UK – and around the world – to reduce urban speed limits. New York City recently reduced their limit to 25 mph, to quite a lot of chatter. Some UK cities are considering extending small 20 mph pilots to cover larger areas.  Is it something we should be supporting? more…

Should we stand up for parity of esteem wherever we see it?

6 Nov, 14 | by Bob Phillips

We have worried on here about parity of esteem between physical and mental ill health previously, and there’s a generally increasing feel that we health types should be whistleblowers when we see foul play.

So if we see an example of mental ill health being treated poorly in comparable to physical illness, should we be blowing a whistle on that too?


The crumbling of the pyramid of evidence

3 Nov, 14 | by Bob Phillips

The ‘old way’ of thinking about the hierarchy of evidence was classically envisaged as a systematic review at the top, falling through RCT, cohorts and case-control to expert opinion (and below that, in some iterations, case law & legislative decisions).

There’s been a move against this, with the GRADE system as explained recently in our popular Guest blog: The Systematic Review Speaks The Truth- or does it?

Another example has been published in the tricky field of idiopathic scoliosis, where a group have undertaken an overview of systematic reviews. What they demonstrate, using the AMSTAR approach of assessing systematic reviews, is a huge swath of low-quality reviews when assessing non-surgical interventions. The conclusions of these reviews appear to be more likely to be ‘positive’ than the higher quality reviews, much as expected.

While this message is not startlingly new, it does reinforce the need to always, always appraise the evidence you are looking at. You can do it quickly. You can do it extensively. But you need to do it.

– Archi

Always question your question

30 Oct, 14 | by Bob Phillips

I was recently at a wonderful conference in Toronto, where 1900 folk interested in childhood cancer came together to learn, argue, network, present and be merry – #SIOP2014.

There was a particularly interesting debate between two very clever oncologists about whether or not we should use antifungal prophylaxis in children with AML and post-stem-cell-transplant. (Both are at high risk ~10% of developing fungal disease.) Now there are, as you probably know, two main classes of antifungals – the anti-yeast agents, and those with broader, anti-mould activity. Invasive yeast infections can be deadly; about 25% mortality. But invasive mould infections are said to be worse – around 50% mortality.

The debate centred around what class we should be prescribing. One group advised anti-mould, and one anti-yeast. They both had the same evidence to work from. Why the difference?


Guest post: The Systematic Review Speaks The Truth …… Or Does It?

27 Oct, 14 | by Bob Phillips

A good quality systematic review should identify and synthesise all the available evidence, for a particular question, through meta-analysis. Conclusions can then be made about the effect of the intervention on the outcome. As, in theory, all the available evidence is gathered and assessed, surely the conclusions from the meta-analysis must be the truth and we can then apply this to practice?

Well…..not quite. The transition from putting the conclusions of a systematic review into guideline development is not quite as simple. We need to assess the quality of the evidence presented and its application to practice.  more…


23 Oct, 14 | by Bob Phillips

ExplosiveWell, I thought that was a better title than ‘Volatility’ which, to be fair, is closer to what this meandering post is all about.

When we’re struggling our way through medicine, we have to face all sorts of uncertainties. Some of these are the frank face of ignorance (we just don’t know something), some of them are about the degree of chance that plays into our knowledge, some around the edges where we decide which side of an imaginary line things play, and on top of all these, we have situations where Stuff Changes. Not that we don’t currently know where things are going to end up – for example, that we don’t have the diagnosis yet because we haven’t worked it out – but that it actually alters as we go through time.


Guest Blog: Sampling bias and randomisation

20 Oct, 14 | by Bob Phillips

The blog series is expanding! No doubt soley inspired by now running the magnificent @ADC_JC, @davidking83 has taken up the challenge of exploring a critical appraisal nugget/thorn in response to an appraisal session.

You too could be part of our team – tweet @ADC_BMJ or find us on Facebook to get in touch – but for now, let’s settle back, imaging the warm smell of pastries and coffee, switch off our pagers and enter the Journal Club…


We were recently discussing a paper in my local journal club at Sheffield Children’s hospital,which was a double-blind randomised controlled trial (RCT) examining the effect of pulse oximetry on the admission rate of infants with mild or moderate bronchiolitis. This is a fascinating paper and well worth a read if you have not already. Essentially, it showed that in infants with mild to moderate bronchiolitis, clinicians are less likely to admit children if their oxygen saturations are artificially raised by 3%.

However, one of the points raised from the journal club was the possible effect of selection bias on the results of the trial. The authors state that the parents of a large number of eligible infants refused to take part and this may have introduced selection bias.

The question was raised as to if this made the study less valid.


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