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Using Mayer's Multimedia Learning Theory in Presentations: #1 The Coherence Principle

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Richard Mayer is an educational psychologist and Professor of Psychology at the University of California. His areas of research are described on his profile:

Dr. Mayer is concerned with how to present information in ways that help people understand, including how to use words and pictures to explain scientific and mathematical concepts. His research is motivated by the question, "How can we help people learn in ways that allow them to use what they have learned to solve new problems that they have never seen before?"

This led him to develop the multimedia learning theory, with principles designed to shape how information can and should be presented to improve learning. Although these principles were designed for electronic learning they contain lessons in information presentation useful for anyone designing and delivering a presentation: how to present information. This is all about cognitive load so if you’ve not heard that expression before make sure you read my blog on the topic and good, bad and ugly cognitive load.

So let’s start, as is traditional, with the first principle.

Principle No. 1: The Coherence Principle

Mayer’s first principle basically states that human beings (i.e. your audience) learn best when pointless information is removed and they’re only shown the stuff that matters. This is about removing extraneous (the bad) cognitive load

Remember the story of the space shuttle Colombia and the slide that killed seven astronauts.

Pick a message for your presentation.

Dump the data don’t data dump.

Lose the long lists.

Focus on what you what to focus on.

One point per slide.

The Medieval Key Workers

Between 1346 and 1351 the Black Death swept across Europe. First from the east along trade routes to Italy before spreading to northern Europe and Britain.

In all up to 200 million people died, somewhere between one and two thirds of Europe’s population. It was a horrible way to die; victims suffered fevers, bloody coughing, extreme pains and the characteristic ‘buboes’ or swellings full of pus. 

For the people of Europe at the time it must have been like the end of the world. When COVID-19 first struck most people, while scared, had at least some rudimentary knowledge of germs and how disease is spread. This was not the case in the 14th century, some 400 years before germ theory would emerge. Doctors might have their own individual theories but couldn’t offer much hope. As a result people turned to the church. 

This made sense. The Bible speaks of plague as the work of God and so the Catholic church, the dominant religious power in Europe, was expected to provide answers. As people died priests were to become the key workers of the Black Death, providing what comfort they could and, importantly, performing the Last Rites to ensure passage to Heaven. 

Unfortunately, this put the priests at great risk. Without any form of PPE they would often fall victim to the Black Death themselves. It’s estimated that 42-45% of priests died from the Black Death. In 1348 six cardinals would die. 

The head of the Catholic church at the time, Pope Clement VI, therefore faced an unprecedented challenge: how best to provide spiritual leadership and ensure salvation for people. Born Pierre Roger in 1291, he had been Pope since 1342. He was the fourth Avignon Pope - a series of seven popes between 1309 to 1376 whose court sat in the French town of Avignon rather than the Vatican. The wine Châteauneuf-du-Pape (the Pope’s new house) dates from this period and is still made in the region today, its name signifying its papal legacy.

In facing the Black Death Clement VI was pragmatic. As grounds for burial began to run out he consecrated the River Rhône in 1349 so that the bodies of plague victims could be disposed of there. He granted the remission of sins of all of those who died from the plague so even if they couldn’t confess their sins and receive the Last Rites their souls would be safe. As fear mongering led to the blame and persecution of Jews he issued two papal bulls in 1348 denouncing anti-Semitism. On 26th September 1348 he issued Quamvis Perfidiam in which he called on Christians to protect Jews:

“certain Christians, seduced by that liar, the Devil, are imputing the pestilence to poisoning by Jews…“since this pestilence is all but universal everywhere, and by a mysterious decree of God has afflicted, and continues to afflict, both Jews and many other nations throughout the diverse regions of the earth to whom a common existence with Jews is unknown (the charge) that the Jews have provided the cause or the occasion for such a crime is without plausibility.”

Ralph of Shrewsbury, Bishop of Bath of Well’s, would be similarly pragmatic as he faced a shortage of key workers to hear plague victims’ confessions. In the absence of priests to hear confessions now plague sufferers could confess to each other, or a layman or even to a woman. He commanded this in a letter to his priests written in January 1349: 

“The contagious pestilence of the present day, which is spreading far and wide, has left many parish churches and other livings in our diocese without parson or priest to care for their parishioners. Since no priests can be found who are willing, whether out of zeal and devotion or in exchange for a stipend, to take on the pastoral care of these aforesaid places, nor to visit the sick and administer to them the Sacraments of the Church…We, therefore, wishing, as is our duty, to provide for the salvation of souls and to bring back from their paths of error those who have wandered, do strictly enjoin and command..that, either yourselves or through some other person you should at once publicly command and persuade all men, in particular those who are now sick or should fall sick in the future, that, if they are on the point of death and cannot secure the services of a priest, then they should make confession to each other, as is permitted in the teaching of the Apostles, whether to a layman or, if no man is present, then even to a woman.”

History doesn’t necessarily repeat herself but she does like to rhyme. It’s hard not to see the Catholic church’s response to the Black Death in a similar vein to how we in the West approached COVID-19: military involvement, new hospitals, volunteer groups, lockdown, furlough etc.

Two years into the pandemic and many of us might well be questioning our governments and leaders: Boris Johnson’s behaviour during lockdown will probably define his career forever.

In the Middle Ages it was the same. After the Black Death passed there was a shortage of labour leading to the Peasants Revolt of 1381. It could be argued that the Catholic church could never again demand the total power it had once wielded: they had not been able to save people. Questions could be asked and their authority challenged. Within 200 years Lutheranism would rise and Henry VIII would break from Rome. As Europe began to recover the seeds of new discovery had been sown. The Renaissance would see a new era of art and discovery. 

This season was an opportunity for Marcus Rashford which has slipped away

Wayne Rooney was blunt.

“What I hope is that Marcus Rashford f***ing gets his head out of his a*** and goes and breaks that record. He is a Manchester lad.”

Yet the idea that Rashford might stay at Manchester United to take Rooney’s status as record goalscorer is seeming less and less likely. His meteoric rise from a surprise starter against FC Midtjylland in 2016 to borderline national treasure has stalled. It did not have to be this way.

Wembley Stadium. London. 11th July 2021. England vs Italy in the final of Euro 2020. It’s 2–2 on penalties and Marcus Rashford stepped up to take England’s third and put them 3–2 up. His slow run-up sends Gianluigi Donnarumma the wrong way. Yet the ball agonisingly slowly clips the Italian’s right-hand post and ricochets away. Rashford, brought on bizarrely late specifically to take this penalty, holds his head in his hands. You know the rest.

For what it’s worth Rashford’s penalty was not that bad. His technique was much the same as that used 47 days earlier in the Europa League final in Gdansk when he sent Gerónimo Rulli of Villareal the wrong way for Manchester United. Then his kick hit the back of the net, although he still ended up on the losing side.

The fact was, however, that Rashford’s miss against Italy capped a personally disappointing campaign. He played just 84 minutes of England’s journey to the final. He had no shots, no assists and no goals.

Yet, as he dusted himself off Rashford could have looked back at Euro 2020 and forward to Qatar 2022 and seen an opportunity. One of the key lessons from England’s Euro campaign was their reliance on Harry Kane and Raheem Sterling. Only John Stones (679) and Kalvin Phillips (665) played more minutes than Kane (649) and Sterling (641) at Euro 2020. The forwards had the most shots and highest expected goals ratings of any England player with Maguire and Mount coming distant thirds respectively.

Kane and Sterling were not just at the end of movements; they also involved themselves in passing sequences. In total Sterling was involved in 24 passing sequences which finished with a shot and 6 which finished with a goal. Kane was involved in 21 sequences that ended with a shot and 7 which ended with a goal. The total expected goals for movements (total expected goal value of unique open play shot or goal-ending sequences that a player was involved in) involving Sterling was 7.08 and 6.38 for those involving Kane. Kalvin Phillips was a distant third.

However, against Italy neither Kane nor Sterling managed a single shot. By controlling Kane and Sterling Italy was able to nullify most of England’s threat. With the next World Cup coming mid-season the need for a deep squad and alternatives is obvious. Rashford, or at least someone near him, could easily see that this season was his opportunity to push for a spot in Southgate’s plans either alongside Kane and Sterling or as a ready-made alternative to either. Rashford has the ability as both a centre forward or to play from either side. The spot was there for the taking. Get your head down and make it yours.

Yet, in the most recent England squad, Rashford was not called up. Instead, Ollie Watkins of Aston Villa was there, scoring and staking a claim. According to Gareth Southgate, it had been between Watkins or Patrick Bamford for the spot. No mention of Marcus Rashford.

The thing is Rashford hasn’t even made the decision hard for Southgate. He’s played just 974 minutes of football in the league this season, scoring 4 goals and making 2. Fourteen of his United teammates have played more minutes. Neither Kane nor Sterling has had a vintage season yet their numbers dwarf Rashford’s. Kane has played 2509 minutes in the league, scoring 12 and making 6. Sterling has 1651 minutes, 10 goals and 3 assists. Even Mason Greenwood, suspended since 30th January, has more minutes (1305) and goals (5) than Rashford.

It’s hard not to see this as a situation slipping away from Rashford. His last competitive start for England was on 14th October 2020. His last competitive international goal was on 11th October 2020. Recent history is full of promising England forwards who faded without a trace from the international scene: Daniel Sturridge, Danny Welbeck and Theo Walcott being three who spring to mind.

So what to make of reports he is looking for a move elsewhere? He certainly isn’t the only England player to struggle post-Euro 2020 nor is he the only United player who will want this season to have finished yesterday. Whoever replaces Ralf Rangnick will be Rashford’s sixth manager at Old Trafford (including caretakers and interims); one for every year since his debut. It is entirely reasonable for him to look at the hierarchy at United and wonder if he’s best out of it (although why he’d look at PSG for sanity is baffling).

Yet look at who he’s had to work with since his debut. When he first appeared for United one of his fellow forwards was a certain Wayne Rooney, someone surely able to give a young English forward a few pointers. Then came Zlatan Ibrahimović. Then Edinson Cavani. Then Cristiano Ronaldo. For all the chaos at Old Trafford in terms of striking pedigree it’s hard to think of a club anywhere where a young forward could have had a better peer group.

It was an injury crisis involving thirteen players which saw Marcus Rashford included in the United squad to face FC Midtjylland. When Anthony Martial was injured in the warm-up Rashford was told to start. He grabbed the opportunity. Three days later he started against Arsenal in the league. He grabbed the opportunity. Roy Hodgson later gave him his England debut against Australia. He grabbed the opportunity. This is not a player used to not succeeding in his targets. Add in his MBE and the fact that as a black player he still has to face horrific abuse from troglodytes online and it is impossible not to be impressed by Marcus Rashford.

However, it is hard not to agree with Rooney’s assessment of Rashford. England will start their 2022 World Cup campaign on 21st November. Between now and then there are six Nations League matches to play which Southgate will use to plan. Rashford needs to get his head out of his a**e and make sure he gets back in those plans. The opportunities are running out.

Shark Tales: the oldest shark attack, the shark attack survivor who became a lord mayor, and the shark that solved a crime

Shark attack. The very phrase brings a particular fear. At a silent, malevolent force dragging us to our death. Once calm, azure water frothing and turning crimson. Yet these creatures, older than the dinosaurs and unchanged in over 400 million years, also bring fascination. The seas have been there’s about as long as there has been life on land. So as long as humans have ventured to the sea there have been sharks.

Inspired by The Daily Jaws here are three stories of our relationship with sharks: the oldest shark attack, the shark attack survivor who became a lord mayor and the shark that helped solve a crime.

The first shark attack

Three thousand years ago in what would one day be called Japan, a young man died. His death was violent. He had fractured ribs, lost one hand and both feet, and one of his legs was severed clean off. He was buried with some care and with his leg. 

Around 1920 his skeleton was excavated and became known as ​​Tsukumo No. 24. He was part of the Jōmon period of prehistoric Japan, a time of hunter-gatherers and fishermen. In total, his bones had 790 different marks on them across the whole of the skeleton. Tsukumo No. 24 represented a mystery to archaeologists. Clearly, his last moments had been horrific but what had caused them? What kind of prehistoric weaponry could have left these marks? Japan is home to bears and wolves, could they have been responsible?

A paper published earlier this year may have found the answer. Through detailed imaging of the skeleton of Tsukumo No. 24 scientists were stunned at how deep into the bone his injuries went. They were V-shaped and showed lines or striations. This is typical for shark bites. The researchers surmised that Tsukumo No. 24 had been killed by a great white or tiger shark which had had enough time to start feeding. 

Tsukumo No. 24 now represents the world’s oldest shark attack. It’s likely his death was quick, probably through rapid blood loss after his leg was bitten off. Whilst the shark or sharks had started feeding his body and leg were salvaged either through the tide or the intervention of other people. The result was that his body was able to have a ceremonial burial. No one present would have known what this would one day represent.

The Lord Mayor of London, the Artist, and the Shark

Brook Watson was born in Plymouth, Devon on 7th February 1735. In 1741 he was sent to live with his aunt and uncle, a merchant, in Boston, Massachusetts after his parents died. By the time he was a teenager, Watson had been signed up as a crew member on one of his uncle’s ships. 

In 1749 the ship anchored in the harbour of Havana, Cuba. The 14-year-old Watson decided to go for a swim. Whilst the crew prepared a boat to escort their captain ashore Watson stripped and cooled off in the Caribbean. It was then he was attacked. His right leg was grabbed by a shark which stripped the flesh from his calf. He was released but the shark returned and took his foot clean off. By the time the shark came back for a third attack his crewmates had launched their boat and were able to fight off the assailant and haul Watson to safety.

Watson’s naval career was over. His right leg was amputated below the knee and, after 3 months of recuperation, he was discharged. After first returning to America he made his way back to London and was Member of Parliament for the City of London from 1784 to 1793. In 1796 he became Lord Mayor of London. He would later join the Bank of England before being created a baronet. Watson requested that his new coat of arms featured his missing right foot. 

At some point, Watson met the American artist John Singleton Copley (1738-1815) whom he befriended and commissioned. In 1778 Copley painted ‘Watson and the Shark’ capturing the moment of Watson’s rescue; his crewmates grabbing him from the jaws of a shark. The shark is not particularly anatomically correct; it appears to have lips and bellows of air coming from its nostrils.  The painting was exhibited in London’s Royal Academy. Watson himself is believed to have penned a description to accompany the painting:

“after suffering an amputation of the limb, a little below the knee, the youth received a perfect cure in about three months”

In the end, Copley painted three versions. The 1778 version is currently on display in the National Gallery of Art, Washington DC. A second version is in the Museum of Fine Arts, Boston, while a third, smaller, 1782 version is in the Detroit Institute of Art.  

The shark that helped solve a crime

Hugh Whylie was in trouble. It’s 28th August 1799 and Whylie is a commander in the British Navy leading the ship Sparrow in the Caribbean. It’s a time of simmering tensions with the Dutch, especially within the tropical theatre Whylie calls home. He has just intercepted the ship Nancy, captained by Thomas Briggs on suspicion of smuggling. The Nancy has been veering around, porting at Aruba and Haiti. Briggs blames bad weather. Whylie suspects smuggling. 

As Whylie’s men board Nancy Briggs comes up on deck and presents his papers. The Nancy is Dutch-owned and her journey is legitimate so his story says. Everything seems in order. But Whylie is not sure. He arrests Briggs and seizes The Nancy. He must have known how delicate the situation was. Briggs was American. The War of Independence had only finished 16 years earlier. Diplomatic relations between the United Kingdom and the United States of America were only 14 years old. It did not look good for British naval officers to be arresting Americans in the Caribbean. And if he’s intercepted a legitimate Dutch ship this could be an act of war.

Whylie filed a suit against Briggs in Kingston, Jamaica. Briggs immediately countersues for lost revenue. The pressure is on for Whylie. Other than his gut feeling and the fact that The Nancy had been veering off course he has nothing. Briggs has his story about bad weather, which there had been, and his seemingly immaculate papers. This could be a costly mistake by Whylie and after two days he must have been worried about his future.

Then, something incredible happened. Crewmen on the British ship Ferret caught a large shark off the coast of Haiti. Cutting into the shark they made a bizarre discovery in its stomach: a bundle of papers tied with string. Anyone who has seen the film Jaws will remember the scene where Hooper cuts into a tiger shark to see if there are human remains and comments on how slow a shark’s digestion is. The papers are in such good condition the writing on them is still legible. The captain of The Ferret Michael Fitton summons Whylie. Whylie expects breakfast and is bemused to be shown papers drying out on Fitton’s desk. 

Remarkably, they contain letters and papers which belong to The Nancy and show that her Dutch ownership is a cover and that Briggs really was captaining a smuggling operation. Having seen The Sparrow coming Briggs had ordered the papers to be thrown overboard where a passing shark had fancied them for a snack. 

Briggs presents the ‘shark papers’ in court. They are the deciding factor in the case. Briggs is found guilty of both smuggling and piracy. He describes it as an “active and unnatural piece of cruelty” to be “damned and condemned by a bloody sharkfish”. The shark papers remain on display in the National Library of Jamaica. 

What I Wish I'd Known Before Studying Law #1: How to read a case title

All subjects have their own terminology and law is no different. On starting a Postgraduate Diploma in Law last October one of the hardest things I came across was the titles of cases. For example, a famous case in contract law is this one:

Williams v Roffey Bros & Nicholls (Contractors) Ltd [1991] 1 QB 1

There’s a lot of information here. It tells you the two sides of the case, its year and where it was reported. Reading it seems pretty weird. Then you might get asked to read it out loud. It’s important read a case properly. In a moot for example, if you say “Williams v Roffey and Nicholls (Contractors) Ltd 1999 1 QB 1” you will lose moots. It’s important to follow a number of rules:

The first rule is that it’s never ‘versus’. Although there’s a ‘v’ you don’t say “versus”. This will be jumped on immediately by any of your teachers. In civil cases you say “and” and in criminal cases, you say “against”. So ‘Williams v Roffey’ is to be read as “Williams and Roffey”. This is almost rule number 1 of law. It’s never versus.

The second rule is to understand the Oxford University Standard for Citation of Legal Authorities (OSCOLA) way of citing a case. This breaks the case title down into the different parts of the citation:

The third rule is to identify the law report. 

Law reports are the documents where the case was reported. It’s important to cite the law report because that’s the official record of that case. As case law (the stuff decided in court cases) is such an important part of UK law we have to show precisely where that piece of law came from. So when you read the case you want to say the title of the case and what number issue of what law report in what year it was reported.

The law report title will be in abbreviated form. Here is a non-exhaustive list of UK law report abbreviations from Oxford University:

The Law Report Series

AC   Appeal Cases

Ch   Law Reports, Chancery Division

QB  Law Reports, Queen's Bench Division

KB   Law Reports, King's Bench Division

Fam Law Reports, Family Division

P     Law Reports, Probate Division

Other commercial series

All ER All England Reports

BCLC Butterworths Company Law Cases

Cr App R  Criminal Appeal Reports

Cr App R (S) Criminal Appeal Reports Sentencing

FSR  Fleet Street Reports

ICR  Industrial Cases Reports

IRLR  Industrial Relations Law Reports

LLoyd's LR Lloyd's Law Reports

P & CR  Property, Planning and Compensation reports

SC   Session Cases (Scottish)

WLR Weekly Law Reports

So if we look back at Williams v Roffey Bros & Nicholls (Contractors) Ltd [1991] 1 QB 1 this tells us that it was reported in the Law Report, Queen's Bench Division.

We can now break the citation up into its different parts and we can then learn how to read those parts:

So rather than “Williams v Roffey Bros & Nicholls (Contractors) Ltd [1991] 1 QB 1”

You’d say:

“Williams and Roffey Bros & Nicholls (Contractors) Ltd as reported in the first volume of the Law Reports, Queen Bench Division for the year 1991 starting at page 1”

Rule four is about neutral citation. They are independent of a specific report (hence neutral). The letters in the title refer to a court, not a report and the number at the end refers to the case number of that year. A neutral citation would look like this:

Rock Advertising Ltd v MWB Business Exchange Centres Ltd [2018] UKSC 24

UKSC stands for United Kingdom Supreme Court. The year was 2018 and this was the 24th case of that year. 

We can now break the neutral citation up into its different parts:

And we can then learn how to read those parts:

So rather than “Rock Advertising Ltd v MWB Business Exchange Centres Ltd [2018] UKSC 24”

You’d say:

“Rock Advertising Ltd and MWB Business Exchange Centres Ltd, neutral citation, 2018, United Kingdom Supreme Court, number 24”

Rule five is about ‘Re’.

Re is a Latin phrase meaning “in the matter of”. It is used in cases that are non-adversarial (not cases where one person is against another) and refers to the primary matter of a case such as the name of a company. One such case was in 1993 when the Inland Revenue petitioned the courts for a winding-up order of a company called Selectmove who owed tax:

Re Selectmove Ltd  [1993] EWCA Civ 8
You don’t say “Re”. You say “in the matter of”.

So rather than Re Selectmove Ltd  [1993] EWCA Civ 8

You’d say:

“In the matter of Selectmove Ltd, neutral citation, 1993, England and Wales Court of Appeal Civil Division number 8”

And finally:

When reading out numbers whether of the issue, page or case they must be read out as a whole number, not digit by digit. So you’d say “one hundred” not “one, zero, zero”.

It feels a bit clunky but once you’ve got the hang of it it starts to feel easier. Definitely, something I wish I’d known before I started studying law!

AOME 2021 Conference: Perceptions of collaborative mobile learning in medical education: a phenomenological study of medical educators and students at a UK medical school

I was lucky to present at the rearranged AOME Spring Conference on 16th September 2021.

This blog post is about the project I presented.

Below you can find a recording of my presentation, my slide set (complete with navigation) and full details of the project’s background, methodology and findings.

Abstract

As technology has developed so the focus of mobile learning has moved toward collaborative practice.  It has been shown that educator attitude and student engagement in the process of developing mobile resources are key to the success of mobile collaboration.  Best practice will therefore require an understanding of student and educator perceptions toward mobile learning. Yet research into the perceptions of medical students in the UK towards mobile learning is limited to the evaluation of a specific resource.  There has been no study performed in the UK exploring the perceptions of medical educators.  

The COVID-19 pandemic was obviously disruptive to medical education yet has been described as a catalyst for transformation which had been “brewing” for a decade1. There was early recognition that moving to virtual education represented an “alternative way of learning”2. The aim of this study was to explore the perceptions of UK medical educators and students towards mobile learning using the University of Nottingham as a case study.  Perceptions post-pandemic were compared to those beforehand. 

Semi-structured interviews were conducted in 2019 with 9 third-year medical students, 4 clinical teaching fellows with day-to-day teaching duties, and 5 senior medical educators with university roles in curriculum design, e-Learning, and assessment.  A further round of semi-structured interviews was conducted in 2020 with 7 third-year medical students, 3 fellows, and 3 senior medical educators. Three of the educators were in both rounds. Following transcription hermeneutic phenomenological analysis was performed for each participant and then each cohort.

Participants in both rounds viewed mobile resources only as an adjunct to traditional teaching.  It was suggested as being best used for senior students or in postgraduate education.  Educators do not perceive all mobile resources to be of equal value and are particularly mixed regarding social media. Students in the first round were only likely to use resources if recommended by an educator or peer.  Students in the second round self-reported an increased motivation to seek out resources for themselves. Educators were only likely to recommend resources they used themselves. It was felt in both rounds that students require guidance on evaluating resources. This need was felt to have increased since the pandemic.  Participants were concerned about fostering a reliance on mobile resources but this was felt to be unavoidable in the second round. 

References:

1 Lucey CR, Johnston SC. The Transformational Effects of COVID-19 on Medical Education. JAMA. 2020;324(11):1033–1034. doi:10.1001/jama.2020.14136

2 Ahmad Al Samaraee. The impact of the COVID-19 pandemic on medical education. 2020. British Journal of Hospital Medicine. 1-4. 81. 7. 10.12968/hmed.2020.0191.32730144


Background


The Higher Learning Academy (HLA) defines mobile learning as: “the use of mobile devices to enhance personal learning across multiple contexts” (Heacademy.ac.uk, 2018).  Technology-enhanced learning (TEL) is an evolving field building from developments within both learning and technology over decades (Conole, 2017; Parson, 2014).  Mobile learning has become a key component of this with a number of social and technological phenomena behind its rise (Heacademy.ac.uk, 2018).  

One is the increasing access to mobile technology amongst students.  Indeed, since 2000 there has been a significant shift in the literature towards appreciating that no understanding of mobile learning would be possible without viewing it through the prism of social and cultural trends (Kukulska-Hulme, Sharples, Milrad, Arnedillo-Sánchez, & Vavoula, 2011).  More than 4 billion people, over half the world’s population, now have access to the internet, with two-thirds using a mobile phone; more than half of which are smartphones (McDonald, 2018).  By 2020, 66% of new global connections between people will occur via a smartphone (Hollander, 2017).  

Another development is what can actually be achieved with that access.  We are now in the era of the internet of things (He et al, 2016) such as touchscreen phones and tablets as well as smart wearables such as glasses or watches.  Jaldermark et al (2017) therefore described humans as “technology equipped mobile creatures that are using applications, devices, and networks as a platform for enhancing their learning in both formal and informal settings.”  They argued further that as society is now heavily characterised by the widespread use of mobile devices and the connectivity they afford there is a need to re-conceptualise the idea of learning in the digital age. 

The original version of the Internet (so-called Web 1.0) saw a limited number of resources with most users accessing the Internet to browse (Anderson, 2007). Most text was hypertext (electronically linked non-linear text) with a similar approach to learning as a student would use with a book (Kintsch, 1997).  Therefore, the early Internet and its use fitted into previous pedagogy.  Subsequent developments have focused on collaboration and the ability to create and edit resources.  This is Web 2.0 technology or the ‘participatory web’.  Students can now produce resources themselves and share via social media rather than through traditional forms of publication.  A prominent example of this is the website ‘Geeky Medics’ created in 2010 by a then medical student as a forum to share notes and learning.  By 2018 geekymedics.com had grown with over 50 million visits from more than 150 countries accessing material varying from blogs to videos and a smartphone application (Potter, 2018). 

Web 2.0 has been described as “disruptive” (Ntloedibe-Kuswan, 2014) to traditional education. With unprecedented access and resources, mobile learning has been described as ubiquitous learning (Hwang and Tsai, 2011).  The opportunities of Web 2.0 resulted in academic interest; the average annual growth rate of biomedical publications related to Web 2.0 since 2002 was 106.3% and by 2015 Web 2.0 was well integrated into the academic field (Boudry, 2015).  

The era of smart devices includes the emergence of different touchscreen devices with opportunities for instant social and technological networking independent of time and place. Devices such as small portable laptops, smartphones, tablets, and, more recently, various wearable devices have made up a mobile technological platform enabling an online community for students (Moubarak et al, 2010) The emergence of mobility as an essential aspect of everyday life underlines a need to update the conceptualisations of how we learn (Traxler & Kukulska-Hulme, 2016).

Besides awareness of the rapid technological development, it is also important to understand its impact on the learners' context and how learners communicate with each other (Amara, Macedo, Bendella, & Santos, 2016).  As a result, a field of mobile learning has emerged, which focuses on how collaborative learning could be enhanced by applying various mobile technologies (Berge & Muilenburg, 2013; Traxler & Kukulska-Hulme, 2016).   As mobile technology has developed toward increasing connectivity so understanding of mobile learning has trended toward a focus on collaboration.    

Mobile-computer-supported collaborative learning (mCSCL) describes the deliberate use of mobile resources and technology to collaborate with learning (Sung, Yang, and Lee, 2017).  This novel field represents the general trend of mobile learning (Fu and Hwang, 2018).  This trend embraces an understanding of how to enhance mobile technologies through collaboration as well as observing and evaluating collaborative learning activities in everyday informal and formal educational settings. (Jaldemark et al., 2017).  It also informs understanding of how learning is provided in a society characterised by an emerging digitalisation (Duval, Sharples, & Sutherland, 2017; Traxler & Kukulska-Hulme, 2016).

 In Hungary optional (Mesko, Győrffy and Kollár, 2015) and in the USA compulsory (Gomes et al., 2017) courses for medical students on digital literacy and utilising Web 2.0 resources have been developed.  The use of mobile resources has been shown in the UK to help with a student’s transition to clinical practice (Dimond et al., 2016) as it reflects current practice.   

Despite the benefits and challenges of mobile learning within medical education in the United Kingdom, there are no national guidelines for its implementation or strategic use.  Research in the UK focuses on initiating a particular intervention and surveying student opinion (Cole et al., 2017; Pickering and Bickerdike, 2016; Ravindran et al., 2014).  Results have been mixed.  It has been shown that medical students prefer learning with mobile technology (Davies et al., 2017) and they react positively to mobile learning (Chase et al., 2018).  However, in another study when presented with an online course medical students reported a preference for traditional learning (Swinnerton et al., 2016).  This reflects the most recent findings of a student survey published by the Higher Education Policy Institute (Neves and Hillman, 2018) suggesting that students prefer traditional contact time over all other learning events.  Students nationally report dissatisfaction with current levels of contact time with their educators (Neves and Hillman, 2018).  

Students in the UK are conservative in their preferences of learning methods and engagement with them prior to introducing mobile resources is a key step in their success (Davies, Mullan and Feldman, 2018).  There is a growing list of case studies of UK universities utilising some form of the student body to consult their opinions prior to introducing mobile learning in the curriculum  (Davies, Mullan and Feldman, 2018; Ferrell, Smith and Knight, 2018).  Examples of similar student engagement bodies within medical education have been established in the US (Shenson et al., 2015) and Germany (Hempel et al., 2013) but within the UK there is a dearth of work into this area in medical education.

Systematic reviews into Web 2.0 resource use in medical education have shown that educator attitude is also an important step with opportunities to change educator practice (Cheston, Flickinger and Chisolm, 2013; Hollinderbäumer, Hartz & Uckert, 2013).  However, whilst there is evidence from Germany of medical educator negativity toward using certain Web 2.0 resources (Volgelsang et al., 2018) there is limited evidence as to the attitude of medical educators in the UK toward Web 2.0 or mobile learning in general.  However, it has been suggested they are less likely to engage with mobile resources than their students (Cole et al., 2017). 

Literature Review

Towards mobile collaborative learning 

Since the year 2000 literature exploring mobile learning has increasingly focused on the learning process, the preferences of the learner, and collaboration.  Kreijns, Kirschner, and Jochems (2002) proposed that there were five stages to learning through mobile collaboration: copresence, awareness, communication, collaboration, and coordination.  They also identified that attempting online collaboration placed pressure on educators to ensure it took place amongst their learners.  This observation has continued in the literature and it is well recognised that online collaboration is a phenomenon that does not spontaneously occur amongst learners (Zhao, Sullivan, & Mellenius, 2014).  Collaboration is important for building knowledge (Mylläri,  Åhlberg,  &  Dillon,  2010) and finding meaning (Yang, Yeh, & Wong, 2010).

However, the unique features of mobile devices, in particular their portability, social connectivity, and a sense of individuality mean they make online collaboration more likely as opposed to desktop computers that don’t have those features (Chinnery, 2006; Gao, Liu, & Paas, 2016; Lan & Lin, 2016; Song, 2014; Zheng & Yu, 2016). Mobile devices have been credited with making learning movable, real-time, seamless, and collaborative (Kukulska-Hulme, 2009; Wong and Looi, 2011). A meta-analysis of 48 peer-reviewed journal articles and doctoral dissertations from 2000 to 2015 revealed that mobile technology has produced meaningful improvements to collaborative learning (Sung, Yang, and Lee, 2017).

As discussed before the role of mobile learning to foster collaboration between learners has been described as mobile-computer-supported collaborative learning (mCSCL). This distinction arose from developments of mobile technology and how it can be integrated into teaching activities based upon learner cooperation (Zurita & Nussbaum, 2007). This distinction within pedagogy would not have been possible without the empowering nature of mobile devices and resources (Song, 2014).

The majority of literature looking at TEL and mobile learning within medical education focuses on more traditional courses.  Analysis of literature pertaining to TEL use within only problem-based learning (PBL) reveals similar strengths to traditional courses; accessing information, collaboration and reflection, and weaknesses; infrastructure demand and the need for teacher and staff engagement  (Cheston, Flickinger and Chisolm, 2013) (Jin and Bridges, 2014). Meta-analysis of the literature on mobile learning in PBL found that problem-solving is one of the major cognitive skills emphasised and that device and implementation aspects are the main limitations to mobile learning use in PBL (Ismail et al., 2016).

Digital literacy and Medicine 

Health Education England (HEE) defines digital literacy as, “those capabilities that fit someone for living, learning, working, participating and thriving in a digital society" (Health Education England, 2018).  In announcing their Building a Digital Ready Workforce programme HEE argued that, “every single organisation in health and social care has a duty for the learning and development of its own staff and we believe that digital skills and knowledge should be a core component of this.”  It’s been argued that social media helps to provide patient education and so introducing students to social media helps to prepare them for “the world of empowered patients” (Mesko, Győrffy, and Kollár, 2015) as well as reflecting an adaptable curriculum (Gomes et al., 2017).  Professional courses focussing on medical students’ use of social media have been shown to foster continued self-monitoring (Lie et al., 2013).  One example from Hungary was an elective course for students designed to support online behaviour and information management with a special emphasis on social media (Mesko, Győrffy, and Kollár, 2015).  A similar compulsory course has been designed in the United States for first-year medical students based on student usage of social media with discussion with peers and educators (Gomes et al., 2017).  Whilst the course in Hungary focussed on efficient use of mobile resources the US course prioritised students’ professionalism and use of social media to aid their careers.  Both reported positive outcomes.  In the UK a Digital Literacies course was introduced into the medical curriculum at Imperial College London starting in the first year and extending longitudinally throughout the course.  It is claimed that this course, “looks to the future impacts of digital technologies on the medical profession”  (Digitalstudent.jiscinvolve.org, 2014). However, unlike the US and Hungary courses, no publication has resulted from the UK course.   

Another aspect interlinked with these social and technological changes has been the shortening of the half-life of knowledge. In 2008 half of all knowledge learned on a university degree was obsolete within 2 years (Tucker, 2008). By 2017 the half-life of medical knowledge was estimated at 18-24 months.  It is estimated that by 2021 it will be only 73 days (Colacino, 2017).  It’s been argued that with increasing in situ mobile access learners increasingly perceive knowledge as disposable and ephemeral (Pedro, Barbosa, and Santos, 2018). The use of Web 2.0 as part of open-book assessments has been suggested as a potential development in medical education in order to reflect real-world practices and to develop digital literacy (Glasziou et al., 2011).

A Best Evidence Medical Education review of 49 abstracts on mobile learning for health profession students on clinical placement showed powerful education support, especially with transitions from student to professional reflecting the demand for digital literacy within Medicine.  However, there were concerns especially with professionalism, confidentiality, mixed messages, and distractions when using mobile resources (Maudsley et al., 2018).  This theme regarding professionalism was reflected in other studies (Flickinger, O'Hagan, and Chisolm, 2015)


Student perceptions of mobile resources 

The term ‘digital natives’ coined by Prensky (2001) describes students for whom technology has been an indelible part of their development and education.   This led to debate regarding how digital nativism might shape education and the potential differences between those who have been born into technology and those who have adapted to it; termed digital immigrants. However, the latest evidence suggests that this distinction is not as clear as at first believed and this presumption of digital literacy based on youth might hamper education (Kirschner and De Bruyckere, 2017).  An Introduction to e-Learning course delivered to undergraduate students in Australia suggested that ‘digital natives’ are not familiar with education technologies and need to be made aware of and explicitly taught about them (Ng, 2012) whilst subjects aged over 50 can adapt to an unfamiliar mobile resource (Scheibe et al., 2015).   It has been recently shown that students can be taught through learning tasks to improve how they process digital learning resources (Greene et al., 2018).  Through teaching sessions, the digital literacy of digital natives can be improved (Ng, 2012).  Mobile learning can positively affect students’ learning in all three domains of Bloom’s taxonomy (Koohestani et al., 2018).

A common theme across the literature regarding student perceptions towards mobile learning is the research design of implementing a mobile resource and then evaluating perceptions.  For example, in one particular study exploring UK students’ attitudes towards mobile learning (Green et al., 2015) it was suggested that mobile learning enhanced education.  However, this study, whilst focusing on student preferences and barriers to usage, also surveyed students following implementing a specific intervention, in this case providing students with a mobile device with tailored resources.  For the purposes of this study, this made it hard to specifically find literature exploring student attitudes towards mobile learning recorded in isolation.  Therefore, the conclusions of the literature were reviewed but I was mindful these were conclusions following a specific intervention.   

Various interventions are being used in the literature.  Facebook in particular is being increasingly used in medical education as it offers forum and messaging services (Pickering and Bickerdike, 2016, Jaffar, 2013, Ravindran et al., 2014).  Another option is the creation of novel mobile learning resources such as a Wiki platform created for first-year medical student case-based discussion at Cardiff Medical School (Cole et al., 2017).  A MOOC has been used at Leeds Medical School to support first-year medical students with their anatomy teaching (Swinnerton et al., 2016).  Novel applications have been designed and used to supplement traditional teaching (Golenhofen et al., 2019).

In a systematic review of published literature on social media use in medical education Cheston, Flickinger, and Chisolm (2013) found an association with improving knowledge, attitudes, and skills.  The most often reported benefits were in learner engagement, feedback, collaboration, and professional development.  The most commonly cited challenges were technical difficulties, unpredictable learner participation, and privacy/security concerns.  A systematic review from the same year reported a dominance of literature from the US and Great Britain.  (Hollinderbäumer, Hartz and Uckert 2013).  It suggested that learning through Web 2.0 was a form of self-deterministic learning and increases reflection, knowledge construction, and teamwork.  A year later however Arnbjörnsson (2014) reviewed only publications that included randomisation, reviews, and meta-analyses and concluded that despite the wide use of social media no studies reported significant improvements in the learning process and that some novel mobile learning resources don’t result in better student outcomes.   

All of these systematic reviews were limited in the available literature with only 14 studies (Cheston, Flickinger and Chisolm, 2013), 20 studies (Hollinderbäumer, Hartz and Uckert 2013) and 25 studies (Arnbjörnsson, 2014) reviewed.  A later systematic review of 21 studies from 2007 to 2017 (Koohestani et al., 2018) showed three themes: improvement in student clinical confidence and competence, improvements in the acquisition and enhancing theoretical knowledge, and positive attitudes of students toward mobile learning. However, only one of those studies was conducted in the United Kingdom.  This was a study comparing student use of a mobile drug calculator to using the British National Formulary for Children (BNFC).  Utilising the smartphone was significantly more accurate and faster and increased prescriber confidence.  Medical students using the smartphone outperformed consultant paediatricians using the BNFC (Flannigan and McAloon, 2011).

 Students quickly adapt their usage of Web 2.0 resources to fit a preferred way of working (Cole et al., 2017, Ng, 2012).  Female students seem more likely to approach online learning in a more personalised manner (Swinnerton et al., 2016).  Using a familiar social media platform helps increase confidence and decrease anxiety (Pickering and Bickerdike, 2016).  Whilst it’s been suggested male students may be less likely to ask questions via a Web 2.0 resource (Pickering and Bickerdike, 2016) students overall seem to find these a safe environment and feel more comfortable asking questions than in a clinical area (Ravindran et al., 2014).  There is evidence that certain learning resources are more readily engaged with than others with Swinnerton et al., 2016 reporting greater student appreciation toward videos and quizzes than discussion fora.  

There has been some discussion that students are intrinsically motivated by mobile learning due to their experience of mobile devices (Laurillard, 2007 and Roblyer and Doering, 2010). Arnbjörnsson (2014) linked student usage of mobile resources to intrinsic motivation; the higher-achieving the student the more motivated they were and so the more likely they are to use a mobile resource.  

A recent review of literature pertaining to mobile learning use in medical education suggests that it remains a supplement only.  There still is not a consensus on the most efficient use of mobile learning resources in medical education but the ever-changing nature of resources means this is probably inevitable (Klímová, 2018).

It’s been suggested that while mobile learning offers incredible opportunities, it requires students to be motivated and able to self-regulate their learning (Sha, Looi, Chen, and Zhang, 2012).  Terras & Ramsay, (2012) identified a number of psychological challenges for students using mobile learning including oversight of students and the management of information which often comes at disparate moments.  Greene, Yu, and Copeland, (2014) suggested that effective digital literacy relies upon a student being able to effectively plan and monitor their own strategies as well as vetting material found. Medical students themselves report concerns regarding privacy and professional behaviour when using social media in education (Flickinger, O'Hagan, and Chisolm, 2015).

The most recent student survey by The Higher Education Policy Institute (HEPI) found that students prefer direct contact time with educators over other learning events.  44% of students rating their course as poor or very poor value for money included a lack of contact hours as part of their complaint.  More students (19%) were dissatisfied with their contact time than neutral (17%) and had increased in the previous year.  However, the survey did not explore mobile resources either as a contact time alternative or how students viewed their educators creating resources for them.  (Neves and Hillman, 2018).    

Teachers and Institutions 

Whilst evidence points to mobile learning being enjoyable and increasing student engagement (Heath et al, 2018) it is shown that technology-based courses with a low sense of human feedback and collaboration will suffer the highest rates of student attrition (McInnery, 2018).  Students in the UK are conservative in their preferences of learning methods and their university engaging with them prior to introducing mobile resources is a key step in the successful use of that resource.   It, therefore, takes time for any novel teaching practice to become embedded with students needing to experience and reflect on their overall learning practice (Davies, Mullan, and Feldman, 2018). 

 Case studies in the UK show that the success of mobile learning in higher education has involved some degree of student inclusion alongside educators during design (Ferrell, Smith and Knight, 2018).  No evidence of medical student inclusion during mobile resource design in the UK was found in the literature.  One example was published from Vanderbilt University, Nashville; a committee formed of administrators, educators, and selectively recruited students.  This committee serves four functions: to liaise between students and administration; advising the development of institutional educational technologies; developing, piloting, and assessing new student-led educational technologies; and promoting biomedical and educational informatics within the school community. The authors report benefits from rapid improvements to educational technologies that meet students’ needs and enhance learning opportunities as well as fostering a campus culture of awareness and innovation in informatics and medical education (Shenson et al., 2015).

An example from a European medical school was found in the Faculty of Medicine of Universität Leipzig, Germany.  Rather than a physical committee their E-learning and New Media Working Group established an online portal for discussion with students over mobile resources as well as expanding the university’s presence across social media to help disseminate information (Hempel et al., 2013).  

HEPI has recently made seven recommendations for successful provision of mobile learning at UK universities which include building technology into curriculum design and for a nationwide evidence and knowledge base to be developed on what works (Davies, Mullan and Feldman, 2018).  

In 2017 the UK government established the Teaching Excellence Framework since renamed the Teaching Excellence and Student Outcome Framework (TEF), as a national exercise to assess the quality of higher education (Officeforstudents.org.uk, 2019).  This assessment is based on student feedback, outcomes, and drop-out rates.  The TEF results in an institute being awarded a gold, silver, or bronze award.  HEPI argued that “Digital technology should be recognised as a key tool for higher education institutions responding to the TEF. Providers should be expected to include information on how they are improving teaching through the use of digital technology in their submissions to the TEF” (Davies, Mullan, and Feldman, 2018). 

Both Cheston, Flickinger, and Chisolm, (2013) and Hollinderbäumer, Hartz and Uckert, (2013) suggested during their conclusions that Web 2.0 offered opportunities for educator innovation. However, it has been shown that teachers may be less engaged than their students in utilising Web 2.0 resources especially in accessing materials outside of the classroom (Cole et al., 2017).

Both students and teachers need to be trained prior to using Web 2.0 resources (Cole et al., 2017).  Teachers’ attitudes toward and ability with mobile resources are a major influence on students (Kuo, 2005; Demb, Erickson & Hawkins-Wilding, 2004 and MacCallum and Jeffrey, 2009).  Students’ fear of patient and teacher perception is reported as a barrier to using mobile resources but these fears may be due to hearsay rather than actually experience (Davies et al., 2012).

No literature exploring the perceptions of UK medical educators toward mobile learning was found.  However, a recent online survey of 284 medical educators in Germany did show some interesting findings.  Respondents valued interactive patient cases, podcasts, and subject-specific apps as the more constructive teaching tools while Facebook and Twitter were considered unsuitable as platforms for medical education.  There was no relationship found between an educator’s demographics and their use of mobile learning resources (Volgelsang et al., 2018).

COVID-19 pandemic and mobile learning

Due to concerns regarding student safety, the COVID-19 pandemic saw a switch away from face-to-face teaching and clinical experience to mobile learning. This was obviously disruptive to medical education yet has been described as a catalyst for transformation which had been “brewing” for a decade (Lucey and Johnston, 2020).

In a cross-sectional, online national survey of medical students across 39 medical schools, respondents reported a 300% increase in the amount of time spent on online platforms following the pandemic. Flexibility was deemed to be the greatest perceived benefit whilst distractions from family and poor internet connection were the greatest downsides. Further incorporation of mobile learning with traditional methods of teaching was recommended, particularly focused on problem-based learning and teamwork. It was also felt that a move towards mobile learning would reflect the move towards remote clinical consultations as well (Dost et al, 2020). The positive aspect of flexibility, especially in students being able to learn in their own time, has been reported in other studies (Kay and Pasarica, 2020)  as has the negative impact of technological limitations (Hagler, 2019). Concerns regarding the relevance of online medical education have stated that sessions simulating virtual consultations should be used (Wolanskyj-Spinner, 2020).


In the UK the General Medical Council (GMC) sped up the processing of final-year medical students’ applications for professional registration (General Medical Council, 2020). In another online survey of final-year medical students across 33 medical schools respondents felt that while changes to their curricula had been necessary, it had adversely affected their transition from student to doctor with regard to losing their clinical assistantships. Yet students still felt confident about going into their Foundation Year One (Choi et al, 2020). Concerns have been raised about how to meet students’ mental health needs remotely. (Rainbow and Dorji, 2020). 


While it’s been argued that remote learning cannot replace face-to-face teaching in medical education it has proven to be a flexible and inexpensive way of delivering core content (Rainbow and Dorji, 2020). A Best Evidence in Medical Education systematic review found that adoption of remote learning had been rapid in many countries as a “new norm” at many levels but that evaluation had been “limited” (Gordon et al, 2020). Online sessions need to be planned in a similar way to face-to-face teaching (Smith and Bullock, 2020) and tailored to students’ levels of experience (Gishen et al, 2020). It’s also been argued that thanks to the pandemic, “tomorrow’s trainers” will have experienced the “reimagining” of medical education (Emanuel, 2020). 


In summary, the trend of mobile learning is towards increasing collaboration.  Digital literacy is a key skill within Medicine with some suggestions in the literature of an online community of practice being formed.  Several medical schools are implementing modules to prepare their students for working in this new digital literate environment.   Mobile learning has been suggested as working optimally in a flipped classroom blended learning approach.     Evidence of students’ perceptions of mobile learning focuses on the evaluation of a specific resource or intervention rather than in isolation as a concept.  However, there is growing evidence that student engagement early on in the design of a resource leads to better engagement with the resource once developed and released.  Whilst there are examples of these groups in non-medical UK faculties as well as at medical schools in the US and Europe there is no evidence of an equivalent at a UK medical school.  Educators are a major factor in students adopting a mobile resource.  However, there is limited evidence of medical educator perceptions toward mobile learning and none from the UK.  

The COVID-19 pandemic has been called a ‘catalyst’ for transformation and has seen students change their use of online resources. Concerns remain regarding the limitations of mobile learning which include technological and pastoral elements. Yet there is an argument that the changes reflect those seen in clinical practice and could affect the future of medical education.

The purpose of this phenomenological study was to explore how medical students and educators perceive mobile learning. Current literature is void of evidence regarding medical student perceptions toward mobile learning in isolation rather than related to a specific resource and its evaluation. Another void in the research concerns the perceptions of medical educators toward mobile learning. The voices of medical students and educators were at the core of this study as their lived experiences shed light on their perception of the phenomenon of mobile learning. A qualitative strategy was chosen to help navigate the investigatory process.

Phenomenology

Phenomenology is a key interpretivist and anti-positivist branch of social science research.  Phenomenology has its roots in philosophy and is interested in the analysis and descriptive experience of phenomena by individuals in their everyday world; what is called their ‘lifeworld’ (Creswell, 2013).  Therefore, the interest is in the real-world experience of an individual and not why it is that way.  Any human experience is worth studying as phenomenologists perceive the human experience of the everyday world as a valid method of inquiry.  This means that phenomenological research differs from other forms of qualitative research as it attempts to understand a particular phenomenon from the points of view of the participants who have experienced it (Christensen, Johnson, and Turner, 2010). The phenomenon in question for this study is mobile learning in medical education.

A phenomenological inquiry is “an attempt to deal with inner experiences unprobed in everyday life” (Merriam, 2002).  Therefore a phenomenological method was chosen to help identify meaning behind the human experience as it related to a phenomenon or notable collective occurrence (Cresswell, 2009).  The phenomenon of interest was how medical students and educators experience and perceive mobile learning in medical education.  

Phenomenology is used extensively in research in the fields of sociology, psychology, health sciences, and education (Cresswell, 1998).  This methodology was chosen to show “how complex meanings are built out of simple units of direct experience” (Merriam, 2002) and how “general or universal meanings are derived” from lived experience (Cresswell, 1998).  After a phenomenological approach was deemed appropriate for this study its design was based on Moustakas (1994).  

Moustakas described the steps in phenomenological analysis (Moustakas, 1994).  First, he recommends giving each statement in the transcript equal weighting and value.  This is part of the epoch process.  Statements referring to the phenomenon in question are to be lifted out of the transcription and onto a separate sheet.  These are the horizons of the transcription.  This process is known as horizontalisation.  Once the horizons for each participant are lifted the process of reduction and elimination can begin.  Moustakas recommends two questions when analysing the horizons (Moustakas, 1994):

  1. Does it contain a moment of the experience that is a necessary and sufficient constituent for understanding it?

  2. Is it possible to abstract and label it? 

Only if the answer to these questions is yes can the statement be labelled as an ‘invariant constituent’ of the experience and move on for further analysis by clustering and thematising the invariant constituents.  These clustered themes allow textual descriptions to be constructed for each participant which then allows composite descriptions to be created for each category of participant.  

The potential impact of the researcher on the participants’ responses as well as analysis is well established Creswell (2013).  Reflexivity is an attitude of attending systematically to the context of knowledge construction, especially to the effect of the researcher, at every step of the research process so as to avoid bias and skewing analysis.  It’s been recommended that during phenomenological study the researcher should employ regular breaks of time and place from the data as well as reflecting on their own emotions during analysis (Clancy, 2013).  Breaks were taken before and after each stage of the phenomenological process so the researcher could encounter the data anew as much as possible. 

As this study was not interested in generating theory the grounded theory approach was not considered appropriate.  Grounded theory also requires multiple cycles which would not fit with this study’s time frame.  This study was not attempting to create a consensus nor only consider the thoughts of experts and so the Delphi model was not selected.  The mixed-methods approach was considered but early on it was felt any form of quantitative analysis would not offer any benefit compared to interviewing alone. 

Phenomenological Case Study

Phenomenologists aim to examine the lived experiences of a particular group of people to best capture and describe their perceived realities within a certain context (Moustakas, 1994).  Phenomenological research allows understanding of the essence of a human experience in order to gain a rich understanding of a particular experience from the perspective of the participant(s).  These participants’ personal, firsthand knowledge provides descriptive data which provides the researcher a firmer understanding of the “lived experience” for a particular event (Patton, 2002). This phenomenological approach, used with the case study method, allows researchers to understand and/or make sense of intricate human experiences and “the essence and the underlying structure of a phenomenon” (Merriam, 2009).

Case studies are “anchored in real-life situations,” and they result in “…a rich and holistic account” of a particular phenomenon (Merriam, 2009). This design allows researchers to gain a more in-depth understanding of participants’ total experiences.  Unlike quantitative analysis, where patterns in data are examined on a large scale, case studies allow researchers to observe and analyse data on a much smaller, intimate level. Utilising the case study design allows researchers to examine a given uniqueness in order to reveal a phenomenon that otherwise may not be accessible (Merriam, 2009). The researcher is able to come to understand the phenomenon through the participants’ descriptions of their lived experiences as well as search for the cruxes of those experiences (Moustakas, 1994).  The results of case studies facilitate an understanding of real-life complexities that directly relate to readers’ routine, ordinary experiences.

Study Design

This was a qualitative study, which intended to explore the lived experiences of medical students and medical educators of mobile learning through phenomenological inquiry.  Medical students and educators at the University of Nottingham were selected as a case study.  Whilst case studies are often inextricably linked to a particular setting, sometimes the sample of data itself is the unit of interest with the location acting as a backcloth to the collection of data (Bryman, 2012).  With a case study the case is an object of interest in its own right and the researcher aims to provide an in-depth examination of it.  

This was felt to be a representative case.  Representative cases are not extreme or unusual in any way but instead provide a suitable context for research questions to be answered (Bryman, 2012).  They “capture the circumstances and conditions of an everyday or commonplace situation” (Yin, 2009).  To this end, medical students and educators at the University of Nottingham were felt to be a representative case to explore the perceptions of mobile learning in medical education.  A single case cannot be extrapolated to generalise across other settings; the limit of external validity is well known in case studies.  Therefore, the key point is not whether a single case can be generalised but the extent to which the researcher generates conclusions from the data (Yin, 2009).  In that regard, there is an inductive process to interpreting a case study with the opportunity to both generate and test theories (Bryman, 2012).  

Setting

This study was conducted at the Medical School of the University of Nottingham, a Russell Group member since 1994.  As of August 2018, the Medical School is ranked 23rd out of 33 in the Complete Universities Guide ranking of UK Medical Schools (Bhardwa, 2017).   At the time of the study, the main undergraduate course lasts 5 years with 2 years of pre-clinical study before undertaking a bachelor’s dissertation.  Following this undergraduate students start Clinical Phase 1 (CP1) in the latter half of their third year.  They are joined by Graduate Entry Medicine (GEM) students whose course consists of one and a half years of PBL pre-clinical study before they enter CP1 and continue the clinical stage with the undergraduate students.  CP1 consists of 14 weeks with 7 spent in Medicine and 7 in General Surgery.  Students are sited in hospitals across the East Midlands Deanery for CP1.  This study was sited at one of these hospitals, the Queens Medical Centre (QMC) in Nottingham.

Participants and recruitment

Participants were purposively sampled for relevance to the research question. There were three participant groups.    

Medical students placed at the QMC were approached at the beginning of their CP1 attachment with a verbal presentation by the author during their induction sessions.  An invitation was sent via email to students after the halfway point of the CP1 attachment including a description of the study.  Students who replied were placed into focus groups with a suitable date and time for the interview to take place.  It was felt their perspectives at that stage of the course would offer relevant insight as to the most junior group on a clinical attachment with recent experience of the pre-clinical years.  

All medical educators employed by the University of Nottingham as Clinical Teaching Fellows at the QMC were sent an invitation via email along with a description of the study.  Those who replied were offered a suitable date and time for the interview to take place.  It was felt they would offer an experience of day to day teaching and the related practicalities and methods.  

Senior medical educators were purposively sampled due to their experience in assessment, e-Learning, curriculum design and the regulatory requirements of the GMC. A senior medical educator was defined as anyone employed by the University of Nottingham Medical School in a director or lead capacity.  Those purposively sampled were sent an invitation via email along with a description of the study.  Those who replied were offered a suitable date and time for the interview to take place.  Engagement with the project was voluntary for all and participants had the option to withdraw at any time.

As medical educator recruitment became an issue for this study it was felt prudent to keep to the individual interview model for these subjects.  Literature detailing medical educator perceptions of mobile learning is particularly sparse as discussed earlier and it was felt an individual interview model would allow more exploration of each subject’s lived experience.  There was also a concern to avoid any professional friction or seniority hierarchy which may have resulted from a focus group of educators.  Finally, it was also felt that the teaching ethos of an individual educator is a personal matter.  Peer discussion in a focus group may coerce members to offer views they feel cultural appropriate (Bryman, 2012) and not their actual views.  An individual educator’s perception of teaching was therefore felt to be better explored in an anonymous interview.

Data collection

Data collection was through focus groups of students and interviews with educators.  During the initial stages of this project, it was intended to perform interviews with both groups of participants.  However, following the recommendations in the literature of student bodies becoming involved in the formation of mobile resources it was felt to be sensible to seek the perceptions of focus groups of students.  Focus groups allow researchers to study the ways a particular group makes sense of a phenomenon especially if members of the group probe and challenge each other’s opinions (Bryman, 2012).  Focus groups also relinquish a degree of control from the interviewer to the group, allowing them to set the agenda to some extent with regard to priorities.  This was also felt to give a realistic representation of the recommended medical student groups.  

Interviews were conducted in various sites at the Queens Medical Centre between May and June 2018 in the first round and between May and June 2021 in the second.  In the first round, the following interviews were held:

Two student focus groups comprising of 9 third-year medical students in total.  4 medical educators and 5 senior medical educators were interviewed individually. 

In the second round, the following interviews were held:

Two student focus groups comprising of 7 third-year medical students in total. 3 medical educators and 3 senior medical educators were interviewed individually. The three senior educators had been interviewed in the first round as well.

Although the interviews were anonymous participants' basic demographics were recorded (gender, age and whether they had received education outside of the UK).  Both focus groups lasted 60-70 minutes with each educator interview lasting up to 40 minutes and were conducted by the author using Bevan’s format.  Interviews were semi-structured using a question guide based on contextualising, apprehending and clarifying the phenomenon of mobile learning.

Interviews were digitally recorded, anonymised and transcribed verbatim. Audio recordings of interviews and transcripts, once produced, were securely stored on an encrypted USB drive.  No interview was rejected.

It’s been argued that any form of interviewing develops a structure regardless of intent and to allege otherwise is not accurate (Mason, 2002). Therefore a semi-structured questioning style was decided upon ensuring that key themes were explored with the opportunity for elaboration and deviation as necessary.  The right questioning format had to be defined early on.    

Any interview format in phenomenological research must be kept practical (Bevan, 2014). A suggested format for semi-structured interviewing is based on key concepts within phenomenology: the participant’s description of the phenomenon, their natural attitude and their lifeworld view, the modes of the phenomenon appearing in day to day life, reduction and imaginative variance (Bevan, 2014).  These key concepts are divided into three domains of questioning, contextualisation, apprehending the phenomenon and clarifying the phenomenon (Bevan, 2014).  

Question selection 

Through contextualisation the participant reconstructs and describes their experience in a form of narrative.  It is possible to ask for descriptions of places or events, actions and activities (Spradley, 1979). This method fits with previously established processes such as Giorgi’s description and interview (Giorgi, 1989) and Seidman’s focused life history (Seidman, 2006). 

Apprehending the phenomenon focuses attention on the experience in question.  As Bevan argues, different people will experience the same phenomenon in different ways and the interviewer cannot predict how they will choose to express themselves.  Therefore descriptive questions should be supplemented with more structured questions to add depth and quality to the information gathered (Spradley, 1979). 


Clarification of the phenomenon is through imaginative variation.  Usually, imaginative variation is a core part of phenomenological analysis as described by Husserl (Husserl, 1970) and Heidegger (Heidegger, 1962) to imaginatively vary the elements of an experience to clarify it (Husserl, 1960) rather than the interview process.  Bevan argues that by including it during the interview process we can add clarity by explicating experiences.  The format of three domains of questioning allows the interviewer to choose a structure of core questions.  This appears a very practical approach that lends itself easily to this project.  

Data Analysis

Data were analysed by hand as described by Moustakas (1994).  First, all the transcripts were read as part of the initial exploration.  They were then annotated as themes and relevant statements were found.  These themes and statements were lifted for each participant to form the clustering and horizontalisation for that individual.  This was then used to form a textual description for the individual participant in question.  These were then compiled to form a composite description for each group of participants: medical students, medical educators and senior medical educators.  Reflexivity was performed before each stage.  

These composite textual descriptions formed the basis of analysis of the participants’ perspectives of mobile learning.  Further analysis was performed on the thematic grouping of invariant constituents across all the participant groups.  This analysis primarily focused on the invariant constituents as they related to the emergent themes discovered in the literature review regarding mobile learning in medical education as described earlier as well as the specific research voids:

  • Factors influencing students’  use and perception of mobile learning

  • Factors influencing educators’  use and perception of mobile learning

  • Participants’ perceptions of social media in medical education 

  • Digital literacy and experience with mobile learning in clinical practice

  • Experience with collaborative mobile learning

  • Potential of student engagement with mobile resource design

  • Impact of COVID-19 on the above (for second round only)

Any other emergent themes during the study were also to be analysed.  As per the rationale of hermeneutic phenomenology the author’s own reflections were included as part of the analysis.  

Results

Selection Criteria

First round:

Two focus groups and nine interviews were conducted between May and June 2018 and all were identified as suitable for the study.  16 third-year medical students arranged to attend one of the focus groups, ultimately 9 attended.  6 medical educators arranged interviews but 2 pulled out due to work commitments and an alternative time could not be found.  All 5 of the senior educators purposely sampled agreed to interview.  

Second round:

Two focus groups and nine interviews were conducted between May and June 2021 and all were identified as suitable for the study.  21 third-year medical students arranged to attend one of the focus groups, ultimately 7 attended.  3 medical educators arranged interviews and attended.  All 3 of the senior educators purposely sampled agreed to interview.  

Descriptive Data 

First round:

In total 18 participants were included in this study.  For the purposes of anonymous analysis in the transcriptions medical students were labelled Medical Student A-I, medical educators were labelled Medical Educator A-D and Senior Educators were labelled A-E.  

In total 13 participants were included in this study.  For the purposes of anonymous analysis in the transcriptions medical students were labelled Medical Student J-P, medical educators were labelled Medical Educator E-G and Senior Educators were labelled A-C; being the same labelling as for the first round.

Clustering and Horizontalisation

Clustering was performed based on themes in the literature and which may have emerged during the course of the interviews.  Based on this horizontalisation was performed extracting the invariant constituents for each participant.  All invariant constituents were then used to form the textual description for each participant. The textual descriptions for each participant were used to form the composite description for each participant group; medical student, medical educator and senior educator.  

There were six key themes explored amongst the participants’ invariant constituents based on themes in the literature review as well as voids in the research being examined by this study.  These were:

  • Factors influencing students’ use and perception of mobile learning

  • Factors influencing educators’ use and perception of mobile learning

  • Participants’ perceptions of social media in medical education 

  • Digital literacy and experience with mobile learning in clinical practice

  • Experience with collaborative mobile learning

  • Potential of student engagement with mobile resource design

  • The effect of the COVID-19 pandemic on the use of mobile learning (for second round only)

Early on in the analysis process it became apparent that there were a number of emergent themes across the transcriptions.  These were:

  • Mobile learning as perceived as a field of pedagogy

  • The future of medical education

  • Assessment with mobile resources

During horizontalisation the key invariant constituents which were felt by the author to capture the essence of the phenomenon being studied (Moustakas, 1994) were included in the composite descriptions so to allow greater reflection of the life experience of participants.   The composite descriptions are presented with headings for these emergent themes and their key invariant constituents.


Composite Descriptions: First Round

Medical Students


Perception of mobile learning


All of the students considered themselves positive toward mobile learning to varying degrees.  Students felt mobile learning served as a supplement to more traditional teaching.

Medical Student C

“I think it's something that you'd use to supplement your learning, not something that you'd use independently to sort of teach yourself from scratch”

There was agreement amongst the students that they would not engage as well with mobile learning as with more traditional learning and anticipated issues with discipline and motivation.  

Medical Student F

“Personally I could do with like a teacher stood behind me like whipping me to get me to work.”

Factors influencing use of mobile resources and experience of collaboration

Recommendation either from a medical educator or a peer was needed before the students would use mobile learning resources. 

Medical Student B

“ it's pretty much recommendation for me it's like what I've heard from others are good I just used those ones I don't particularly sort of go around looking for new information I just use what's told”

Only one student mentioned themselves recommending a resource to other students.  No student had used mobile learning for collaboration with other students, however, they did see the potential to use mobile learning for collaboration.  There was a preference for face-to-face contact with educators and other students.

Medical Student C


“I don't think the platforms I've seen truly compare with just like being sat around a table with someone” 


Digital literacy


Students agreed that digital literacy was an important skill for doctors.   Students had seen mobile resources and devices being used clinically by doctors of different grades. This helped their confidence when it came to using the same resources and devices.  There had previously been an assumption that using a smartphone in a clinical environment would be unprofessional. Two of the students mentioned smartphones being banned at their school.


Mobile resources and stage of medical school 


It was felt that the clinical phase of the course provided motivation to use mobile resources due to an urge to seek out extra information to avoid negative consequences such as falling behind in knowledge.  As a result it was felt that mobile resources are best used in the clinical phase and would be too advanced for the pre-clinical years. Students were also concerned about more junior learners being anxious without more traditional learning.  

Medical Student I


“I think the one difficulty with online resources is that they are sometimes designed for people at a much higher level than we are. So I think even now sometimes using them I can feel a bit overwhelmed”


They voiced concern regarding objectives and other expected standards which contact time seemed to assuage.  It was felt that mobile learning in comparison might increase anxiety unless standards were explicit or even demonstrated, such as with a video. 

Medical Student I

“I think a really helpful thing would be some kind of consensus on clinical skills”

Current use of mobile learning 

There was a difference in the students between those who felt they had used more mobile resources since starting CP1 and those who were using fewer.  Those who were using more pointed to the opportunistic and practical nature of mobile resources.  

Medical Student G

“it's really easy to find things using your phone basically and it everything has to be accurate so you can just take out your phone and like search up NICE guidelines”

Those who were using fewer did so because there were recommended textbooks for the course they were using instead.  However, it was noticed that some students described using their smartphone in a clinical environment but did not consider this as mobile learning as they were in the environment at the time.

Medical Student D

“it's been a lot more focused on being on the wards and just trying to respond to what you find there and that necessarily is something that has to be done in person. Not at a distance.”

Some students did search for mobile resources such as smartphone applications for revision.  However, use was short lived due to a variety of reasons such as being from the USA or poor usability.  Consistent use of resources was linked to recommendations from educators and repeated use during teaching sessions.  The BNF application being used during Therapeutics sessions was mentioned by several students as an example of this. 

Perceptions of social media in medical education 

Discipline was also considered to be an issue in using social media for education.  Students were generally against using social media in education.  It was felt that any mobile resources would require oversight and facilitation from medical educators.  

Medical Student G

“I can't really imagine using social media for educational purposes”

University mobile resources and access to technology

Students felt competent in their skills using mobile resources and accepted that there was an assumption from the university that they would be able to use mobile technology adequately.  All agreed that digital literacy was an important skill for doctors but it was also felt skills didn’t need to be too advanced and one student had observed a ward round being held up due to technical issues.  One student with prior experience with mobile resources was disappointed in the quality of resources he’d seen in the clinical setting.  

Medical Student D

“coming into this world I was absolutely amazed by how primitive a lot of it is”

Another student said her non-medical friends had been surprised at the degree to which she could progress on her course via online learning rather than through direct contact.       

Medical Student A

“friends and family they were a little pretty shocked that...could've actually just do University from a bedroom just listening for them online if you wanted to. “

They were negative regarding university mobile technology in particular about correct information and reliability.  Students felt any future resources would have the same technical issues.  

Medical Student G

“I’d just be genuinely surprised if the university managed to put out an app that actually worked”

However, it was felt that the university and educators should be creating resources.  Standardised clinical examination examples were seen as one area where resources would be very useful.   

Medical Student B

“the university should definitely be doing more apps and so guides and things I think are clinical skills teaching in first and second year was a bit hit and miss so that other universities have for YouTube videos with exactly what they want online. So you could watch them and know exactly what you need to do but here it's sort of like here's a checklist.”

 It was felt that mobile learning and e-Learning both aided uniform learning across different sites and helped create a universal experience. It was felt that in order for students to fully utilise any mobile resources the university would have to consider equipment and previous experience of a lack of support in this area was reported.  No student suggested or mentioned being consulted by the university prior to any new resources being released.  

None of the students valued university innovation as a consideration during applying and instead looked at reputation, course design and the pass rate.  One student felt that there needed to be a session on available mobile learning resources at the start of CP1 induction.  It was felt that the university needed to be better at signposting resources.  

 Reliance on mobile devices 

There was agreement that basic knowledge is needed as a doctor but beyond that further information could be accessed as needed and this was a skill that needs to be taught.  However, there was concern about becoming too reliant on technology.  

Medical Student A

“if you can't function without having something in your hand like a phone then that's not really going to be sustainable long term”

Medical Student G

“ why do I need to remember the order of drugs to give for like hypertension when I can just search it up?”

Design of learning session based on mobile learning 

It was argued that any course based on mobile learning would not be radically different from other teachings that the students had experienced in particular Anatomy in the pre-clinical years and Pathology and Therapeutics in CP1.  In Anatomy and Pathology, there is central teaching with extra resources for self-directed learning.   Some students felt this model encouraged them to learn whilst others felt they did not have the motivation to make the most of opportunities in this way but still saw the value in it.  In Therapeutics, the sessions are based on problem-solving and using the British National Formulary (BNF) application to access information relevant to the case being discussed. These sessions were mentioned in particular as a reason why students had accessed mobile resources. 

One student had experienced the flipped classroom at school and felt there was a similarity.  Students were mixed in their support for the flipped classroom.  This was linked with trepidation regarding discipline and motivation of self-directed use of mobile resources in general.  However, it was felt that mobile resources might allow closer oversight of progress.  

Medical Student A

“it's just a risk of it all becoming too much online and just, yeah need some kind of interaction at the end of the day like you need to be able to talk to a patient”

Medical Student D

“I certainly don't trust myself... going more mobile doesn’t necessarily less oversight and potentially, possibly an earlier lighting up issues.”

Medical Student F

“the sessions that I take most away from are the ones that I've...I've done all the further reading before.“

Students felt adopting mobile learning was an acceptance of social trends regarding smartphones and other mobile technology.    Students saw it being used in simulation and clinical decision making or to look at cases before then discussing findings in a traditional classroom setting.  Formative assessment was also suggested. It was felt it would be too overwhelming in the pre-clinical course and would work best in small groups.  

In appraising online resources some students did use skills taught to them as part of their course.  Others used common sense and chose resources by reputation.  Students did use resources not approved by the university such as Wikipedia but as a starting point and not as their only resource.  

Medical Educators

Mobile resources in clinical practice and in teaching 

All of the medical educators used either online or mobile resources as part of their clinical practice for quick reference.  The majority (three) of the medical educators used mobile resources as part of their teaching either in a classroom or ward based environment.  They mentioned that this reflects real life practice and prepares students for working as a doctor.  Their attitude towards mobile learning was predicated on their own use.  

Medical Educator A

“anything I’ve used or had experience of I would recommend and I found easy to use, yeah I’ll just recommend to people”

One educator discourages the use of mobile devices in her sessions.

Medical Educator D

“in the classroom, I have to say I'm not a massive fan of mobile phones because I see students on Facebook, Instagram and texting...I do think that it ultimately does distract you from what is going on in front of you”

Educators who didn’t regularly teach using mobile learning described themselves as “old fashioned” in their outlook.

Medical Educator C

“So I would probably say I'm a bit more old-fashioned...I'm still probably more a textbook kind of person”

Medical Educator D

“So, I think I'm probably bit old-fashioned in that no not really I know that some of my other colleagues at induction will recommend certain apps and things and I have to say that I don't. And that's because I don't use them myself”

Practicality, the amount of knowledge available and the rate of change were also factors in choosing to use these resources in both teaching and clinical work.  

Medical Educator B

“I think the best way to learn to use technology is often by necessity”

Factors influencing the use of mobile resources in teaching 

Mobile resources were recommended if they had been used in the educator’s own clinical work and so were trusted and from a validated source.  The mobile resources mentioned were published from renowned books or websites that predated them.   

Medical Educator B

“I tell them to download the BNF on the first day of placement...the reason I recommend those apps is because I use them as a junior doctor and they need to get comfortable using those different modalities of accessing information”

The medical educator who didn’t recommend mobile resources did so because she didn’t use them in her own practice rather than for an educational reason.   One medical educator believes that without technology doctors will struggle to stay relevant.  

Medical Educator C

“I've seen the most senior consultants pull out their smartphones and use it for very specific things. Research changes so quickly...the ones that are slow to change others ones that are slow to stay relevant”

There was a discussion about how mobile learning was impacting students’ relationships with knowledge.  

Medical Educator B

“I think a lot of the students take a lot of knowledge for granted and knowledge is a bit more

disposable...how you get the information becomes the key cornerstone of it rather than the actual information itself.”

Medical Educator C

“think there are some limitations in it that some students would be reluctant to get too deep into the actual knowledge...”

Digital literacy and designing teaching based on mobile learning 

All of the medical educators agreed that digital literacy is a key skill for doctors and that access to and proficiency with mobile technology were expected in medical students.  

Medical Educator B

“we’d be doing our students a disservice if we didn’t improve their computer literacy as well”

It was mentioned that support is needed for medical educators to produce their own resources.  Three of the medical educators had experienced issues with using mobile technology in their teaching, mentioning Wifi failure and difficulties with information governance as reasons sessions hadn’t gone as planned. 

One medical educator felt unsupported by the university when trying to set up a new teaching programme based on mobile learning as they wanted something more tangible and traditional.  One of the medical educators always has a backup plan when a session using technology is planned due to a fear of issues arising.  

Social media in medical education 

One of the medical educators was enthusiastic about using social media in education as the best way to keep up with developments in Medicine.

Medical Educator A 

“Yeah I think it’s a good thing…because advances in medicine and things are changing sorted so rapidly, it seems to be really the best way to sort of keep up with those advancements”

 Other medical educators were hesitant.  It was believed that social media posed the challenge of students being able to vet the information they find.  It was felt that this is not a skill taught well to students.  There was agreement in doctors having some form of social media presence and using it to share information.  The risks of professional behaviour and public image were mentioned, with social media activity as a student having potential repercussions even when graduated.  However, the use of social media as a community was mentioned as a benefit.  

Medical Educator D

“I have very mixed feelings about social media in general, in terms of our lives as doctors. Because I think we are, whatever you put out is exposing you to a certain amount of risk..I do think it's a valuable resource and the other thing that I suppose that Twitter specifically gives you is a sort of a sense of community as well. And medical school can be incredibly isolating, it can be very lonely sometimes.”

One medical educator surmised that that educational and research in the future might change as a result of students now being so accustomed to and experienced with social media. 

Medical Educator C

“the question will come in about five or ten or fifteen years’ time when the people of this current age other people that are making their decisions. When they're consultants and they're the ones that's putting out information are they then going to be susceptible to was kind of sensationalism to get the message out and cut corners on research or discussion or context”

Collaboration using mobile learning

 One medical educator was concerned about him and his colleagues working in silos and needing to collaborate further.  Although there was agreement about using mobile learning to access up to date information there were no further comments about sharing information across mobile resources.

Medical Educator B

“I think if we are to innovate, we need to have a more networked approach between the different educational providers...we’re replicating the same work that’s being done in multiple different hospitals open around the world”

Role of the educator and mobile learning 

All of the medical educators saw themselves in some kind of guide or signposting role when they teach.  

Medical Educator D

“I'm very much there to kind of guide”

All emphasised that they are not the source of all information.  They all bring their own clinical experience to teaching emphasising the nuances and differences from a theory that can happen in real life.  This came out as one of their perceived strengths of the teaching fellow role.  These nuances were felt to be important to clinical medical education.   One medical educator felt that the traditional teacher role didn’t suit modern Medicine.  

Medical Educator C

“I think because actually the unique role that our current role as clinical educators is that we are more, we are closer to them from a teacher learner role than a traditional classroom environment teacher learner role. Whereby they would always look up to the teacher and expect them to know everything , that’s not what Medicine is and again that rose back to what we how we practice clinically”

Perceptions of mobile learning 

Reaction to educators focusing on mobile technology was mixed.  One medical educator felt teaching through mobile learning wasn’t vastly different from situated learning or social learning theory whilst another felt it sounded like PBL.  

Medical Educator B

“situated learning and potentially social learning theory, because we’re using technology to

communicate between people. It's just changing the format of the communication. And then

situational learning we’re just placing the learning activity in a different situation with different technology. But it’s still an information exchange, it just happens since before educational theory were invented”

Medical Educator D

“certainly my understanding of PBL is that you're given a problem and you're asked to solve it and you're shown potentially where you might look for that information. So on the face of it sounds very similar”

There was general agreement that using mobile learning is well established as an educational tool and that it would work best for the more experienced undergraduate students or in the postgraduate sphere.  

Medical Educator B

“For junior undergraduate medical students, they’ve not learnt that level of critical appraisal yet. So, getting them to use resources where it’s not all valid and it’s not over liable information becomes a bit of a dodgy situation in my opinion… It’s not something that we explicitly teach very well in undergraduate medicine for, perhaps using technology is a good way to do it.”

The medical educator who doesn’t use mobile resources felt that her normal approach using real life props such as clerking sheets was similar in principle to using mobile learning just without the technology as it focuses on realism.  

There were concerns that weaker students might not engage with mobile learning and that it would be harder to keep an eye on student progress.  It was felt that mobile learning would require an element of contact time with more traditional teaching to ensure there is a grounding of theoretical knowledge.    One medical educator mentioned her own opinions regarding the cost to students of medical education and the expectation of contact time that comes with this.  

Medical Educator D

“If I’m paying for something I’d quite like that to be delivered to me.”

Designing teaching sessions based on mobile learning 

It was felt that mobile learning would work better in smaller groups of students.  Proposed sessions involved simulation to replicate real world practice or in case based discussions looking up guidelines and treatment algorithms. One medical educator suggested running the session similar to PBL.  

Medical Educator B

“I think like using a PBL type session, would make a lot of sense”

Another proposed session was similar to the flipped classroom which two of the medical educators had used with good results.  One had encountered as a student himself.   

Medical Educator A

“I’ve had experience of it as a learner, quite a long time ago and it was very different then...whereas, now because everything sort of is more to hand, I think you’ve got more ability to make it more interesting and more interactive...some sort of interactive learning, after the teaching and then come back and stop discuss that...then feedback on what they’ve found or they could do it through case based discussions or something”

It was agreed that students usually brought correct information to flipped classroom sessions without much direction needed.  It was also felt that mobile learning activities would follow a more traditional didactic session and would need to be explained to students as a concept.  

Medical Educator C

”would not be the first thing you do, but it may be the third or fourth type of thing you would do. So you would use it to build on top of previous knowledge that you gained from a different aspect or something”

Concerns were voiced about how information could actually be covered in this session with one medical educator feeling it would cover more behavioural activities than knowledge.  

Medical Educator C

“I guess you just have to be careful of how much information from a knowledge one of you are going to try and give in this sort of setting….but I guess it would be more from work from a behavioral point of view that I would try and plan a session. And less on hard cold facts trying to get people thinking in a particular way as opposed to these are the set numbers I was you’re able to learn”

No medical educator saw mobile learning as completely or mostly replacing traditional learning exercises.  No medical educator suggested involving medical students in the creation of resources.  

Senior Educators

Student engagement in designing mobile resources 

One senior educator had noticed a push for resources from students and suggested forming a focus group with them.

Senior Educator E

“I think there is certainly a push for more resources. ..But I think you know I think giving them a choice you know I think is something that we wanted, we've had to find you know to find out and do focus groups and stuff”

Perceptions of mobile learning

All of the senior educators had experienced mobile learning in some capacity although only one had actively used it in their lessons with interactivity and pre-course materials.  One senior educator was sceptical about mobile learning in general, viewing it as similar to reading a book, albeit easier to seek out information. He felt with technology there was a focus on the novel over their actual value and that mobile learning brought unique challenges due to the unpredictable quality of information available. 


Senior Educator C

“learning, is learning, doesn't matter how it's delivered...the fact that it's shiny in technology that makes it seem like it's something special...it brings with it far more problems that any of the other methods because as well as all the good information you've got a lot of dross in there as well”

One senior educator felt her age and preferred approach to learning precluded her from using mobile learning. 

Senior Educator D

“No, I'm very old...I would like to have time to be a bit more reflective about it (reading), which is probably why I haven't used it as a learner...But I guess I'm not, you know, I might not be typical and young people might like to do it.” 

Role of educator

All of the senior educators agreed that medical education had moved from the more traditional models.  There was a general agreement of the role of an educator as either a guide or facilitator.

Senior Educator A

“I do see it very much as a facilitator role rather than a teaching role and I think that something has changed over my period of life as an educator.”

Access to technology

Technological limitations were mentioned as affecting the use of mobile learning; in particular the availability of Wifi. It was felt that modern students all have access to mobile technology and the ability to use it. The University of Nottingham had considered giving students a mobile device as part of their course but this has been rejected in favour of infrastructure investment and it was felt that students would rather use a device they were used to. 

Senior Educator C

“I think part of the argument of not doing that is well actually most students have got their own preferred device and better to try and run systems that can actually work”

Although it was argued that it was possible to study Medicine without mobile technology it was noted that the university only had to loan mobile devices to fewer than ten students a year. 

Digital literacy

It was mentioned that teaching with technology can often focus on the teaching about the technology itself which one senior educator felt was unnecessary due to the students’ abilities growing up in the mobile era. 

Senior Educator B

“kids are doing that all the time they're experts in it.”

Another senior educator felt that current students had been conditioned and protected with modern technology and did not have the experience of his generation with the internet in its earlier imperfect stages and so their technological knowledge was lacking.

Senior Educator D

“we say that students are okay with technology but actually the students who are starting University now aren’t as technically literate as students who were starting five ten years ago…if something goes wrong they don't know how to deal with it...”


Innovation 

Innovation was seen as useful with varying degrees of emphasis. It was agreed that branding was still important to the university at least for now, although one senior medical educator felt this would change quickly without innovation. 

Senior Educator B

“I think in the short term clearing the branding and the names will stand out but I think if universities are clearly left behind that will become apparent very quickly”

Senior Educator C

“Russell Group universities look better on paper and even with fluctuations in league tables...there's a brand behind the universities”

Two of the senior educators pointed out that innovation does not mean technology alone and pointed to curricula as an area for innovation that students appreciate. 


Future of medical education 

One senior medical educator went further and argued that Medicine was moving away from being doctor focused into a more generic medical worker from various backgrounds accessing knowledge as needed. He also felt that a number of medical professions may be made redundant due to technology and that universities would become increasingly redundant with more virtual education. 

Senior Educator B

“I think in the future the concept of a doctor is a kind of a dead duck...we'll be looking at a kind of a more generic healthcare worker...Radiology as it is now probably won't exist... “

Two of the senior educators admitted they did not know what medical education would look like in the future and this was a challenge to the university and medical education. 

Senior Educator C

“(is)a new medical student gonna be prepared to be working in to 2050, which is what they’re going to be doing now, which is very, very scary.”

Collaboration 

It was felt that the university does not collaborate as well with other universities as it could do. There was an understanding that branding and intellectual property were important and to forego these would mean missing out on funding. 

Senior Educator C

“I was quite frustrated...I can see the other side of it...it would be giving away, you know up to 40 percent of income, if it were to relax its intellectual property rights”

However, it was argued that once students are at university and with the forthcoming GMC Medical Licensing Assessment competition more cooperation may be necessary.  Memorandums of understanding were suggested as a way around intellectual property rights.  

Senior Educator D

“we shouldn't really be competitive with (other) medical schools...we're after students who are...all pretty much the same...once we've got them do we need to be competitive...we're all moving towards the central licensing examination, so we should all be singing from the same hymn sheet”

Mobile learning as pedagogy

Only one of the senior educators was enthusiastic about mobile learning due to its benefits with individualised learning and wanted it to be embedded more into the curriculum but only if it was blended.

Senior Educator B

“I'm a great supporter of the concept and I think it's got a massive value...it allows for individualised learning in a way that we don't at the moment tailor it to...I think they have to be part of a blended approach”

 The other senior educators varied from calling it a “tool” to dismissing it as a “21st-century PBL”. 

Senior Educator A

“It’s a tool, one of many”

Senior Educator C

“I think it's just it's just a progression of technology of it is a sort of it is a more up-to-date 21st century PBL really.”

There was agreement that the amount of knowledge and rate of change made retention difficult and necessitated the ability to access information quickly. 


Senior Educator C 

“the actual  sheer amount of knowledge is impossible for any one person to hold”

Senior Educator D 

“there's a lot to be said for that approach I agree that really we shouldn't focus on knowledge, delivery of knowledge as much as being able to find the knowledge out for themselves”

Mobile learning in clinical practice 

Two of the senior educators noted that they were using mobile learning in their clinical work and felt comfortable with this. There was acceptance of doctors admitting the limits of their knowledge although this may go against the current culture in Medicine. 

Senior Educator B

“I think one of the most important things for the medical profession to learn to be able to say is I don't know...goes really against the grain of what its being kind of impaled into them. And that's dangerous for patients”

Senior Educator E

“I will say to them that I just want to check the current guidelines.”

There was discussion about the dangers of being reliant on technology and how useful a doctor with limited knowledge would actually be especially in situations without technology. It was felt that mobile resources are only useful with the foundation knowledge and would need scaffolding with traditional teaching methods. 

Senior Educator D

“you can't go orienteering if you don't have to read a compass.”

Senior Educator E

“I think that would be harder if you'll coming in without baseline knowledge...talking about the novice learner...I think that's harder because the more advanced learning will you'll be able to scaffold that information”

Role of mobile learning in medical education 

All of the senior educators commented on the importance of communication and interpersonal skills and doubted that these could be taught through mobile learning. 

Senior Educator A

“unfortunately that we’re potentially going to miss...one of the things I think people get out of sometimes face-to-face learning as I would class it, is that social interaction as a group. Being there in the room and I don't think whether you could get that (with mobile learning)”

It was argued that students choose optional modules and provide positive feedback based on contact time with educators over other learning opportunities. It was also felt that students are resistant to non-classroom based learning against experiential learning which two of the senior educators felt was the correct model for clinical learning. 


Senior Educator C

“experiential learning for Medicine is really important,,,the more you do that  you see the nuances and things fall into place and that's I guess that's what our current students are perhaps lacking.”

Senior Educator D

“students are very focused on the fact that they're paying for an educational experience..they’re customers and they want face to face time which shows, you know in their preferences for attachments they would prefer to go to attachment that provides lots and lots of classroom teaching”

One of the senior educators admitted choosing courses based on the amount of social interaction. 

Senior Educator A 

“I picked the course that had face-to-face learning education rather than one that was solely based on e-learning as their prime resource.”

It was commented that as technology becomes more prevalent there will be increased importance on medical students to learn and provide non-technical skills such as compassion and empathy. 

Senior Educator B

“they still need to be able to interact at a human level...to impart all the other elements of healthcare which are around communication, kindness. All of the things to help make people physically and spiritually better.”

The Johari window was mentioned in the context of doubting that students would be able to address all their learning needs using mobile learning. 

Senior Educator C

“you don't know what you don't know. Doing that Johari window and you don't know where to look”

There was some feeling that mobile learning would better suit postgraduate students who already have a core knowledge set.

Senior Educator D

“probably more so in the postgraduate sphere where there on any fixed learning objective..the undergraduate course there are boundaries to what we expect them to know and we don't need them to go...when you're in clinical practice anything can present”


Teaching sessions based on mobile learning 

Mobile learning teaching sessions were seen as using mobile devices for engagement in larger groups whilst for smaller groups sessions on situation judgement or similar to PBL or the flipped classroom model were suggested. 

Senior Educator C

“it's more that's a flipped classroom...go away you know look at this subject and then come and then within the class you'll actually then start to work through to the next level.”

Assessment with mobile learning

When it came to assessment with mobile learning different models were suggested including in work assessment or simulation demonstrating information seeking in a real world setting. Open book knowledge exams were suggested as well. It was argued that such assessments would be add-ons only rather than the main mode of assessment. 

Senior Educator E

“assessment is changing all the time and I think we have to align ourselves with the direction of where things are going…”

One senior educator said that mobile learning was not in the university’s plans for future development. It was argued that the GMC would need reassurances from the university that learning had taken place using mobile learning and felt it would be difficult to achieve. An example of compulsory e-Learning modules being left to run in the background was used.


Senior Educator C

“The GMC is a quality assurance body...it would have to have all of the assurances that...your students have actually opened on the message and actually learn it...sometimes you know this compulsory learning...you have a 20 minute podcast... I switch it on sometimes and walk away and make a cup of tea...those sorts of things immediately the GMC quite rightly would not want to endorse”

Social media and medical education 

Senior educators were mixed over social media. It was equated positively with professionals talking as though in the doctors’ mess but was also seen as a barrier to social interaction. Social media was equated to Wikipedia as a potential starting point to find information and there was acceptance of using a variety of sources not necessarily from a university for finding information but it was emphasised how important it is to use quality assured sources and facilitate. 

Senior Educator A

“I think it's great if it's been peer reviewed”

Senior Educator B

“the best learning is done by people just sitting around chatting...the ability to do that virtually in chat rooms and chat forums and stuff like that is again it's the same thing as a social construct”

Senior Educator C

“you know I get pretty angry if I'm trying to teach a group of students and they're actually twittering at the time...I don’t like it in my gut it annoys me....it comes down to...interpersonal relationship skills that I find that...a bit rude to be honest”

Senior Educator D

“if they're using social media as a jumping-off point to find other thing, then that's absolutely fine. It's no no different than having a chat in the doctor's mess”

It was commented upon that the Trust computers block or limit a lot of social media sites that students might use for clinical knowledge.  There was a general agreement that there is no explicit teaching in appraisal skills for medical students. It was hoped they are picked up in their honours year project or through trial and error. 

Composite Descriptions: Second Round

Medical Students

Students openly admitted fear and a desire to help during the pandemic.

Medical Student O

“I was obviously worried...my family was worried too...you just want to be safe, for everyone to be safe”

Medical Student P

“I wanted to help, that’s why we want to be doctors, to help”

All students reported using more online resources since the onset of the pandemic. This seemed to be driven by necessity more than any other reason and due to convenience. Some students noticed a change in their approach to finding information themselves or in asking to be signposted by their educators. 

Medical Student K 

“I’ve definitely used online things more since the pandemic”

Medical Student O 

“It's a necessity isn’t it? It can be that or nothing”

Medical Student P

“Needs must”

Medical Student K 

“Rather than waiting for something to be given to me I had this time, I was at the computer anyway why not have a look at what there is?”

Medical Student L

“I looked at lots of things...I was asking more for guidance to resources than I would have done before when I wouldn’t ask to be pointed to stuff online”

Students had noticed the amount of fake information being spread especially on social media which had fostered a distrust of the medium.

Medical Student J

“I realised how much rubbish is out there”


Medical Student L

“I think I tried to stay off social media anyway let alone for learning”


Students were mostly negative about the change compared to their previous teaching. There was some discussion regarding the lack of contact time and the perceived lack of value for their tuition fees. One student categorically stated that they would not have gone to a medical school taught virtually. Loneliness and boredom were common experiences. One student, however, had seen some benefits to virtual learning, especially the flexibility it afforded. 

Medical Student J 

“I think it made me miss face-to-face teaching more”

Medical Student J

“It’s not what I signed up for...obviously this was unprecedented...but...not what I signed up for at medical school at all...I would never be at a medical school run like this”

Medical Student L

“I hope things get back to normal as soon as possible...it’s not really how to be a doctor is it?”

Medical Student K

“I miss my friends. I miss patients and going out to hospital...I’m fed up of my room”

Medical Student O

“It is a lonely way to study...I know it’s all unprecedented but it’s not exactly value for money is it?”

Medical Student P 

“I’m not saying I’d want this to carry on forever...but some things are better...like why can’t I learn when I want to?...I’d be sad if we didn’t keep some of the changes”

Medical Educators

The medical educators reported a feeling of confusion at the beginning of the pandemic with face-to-face teaching being cancelled as well as the obligations of being a doctor foremost. They reported needing guidance from the university in adapting their teaching and being safe for students. Once again, a necessity as a driving force was mentioned.

Medical Educator E

“It’s been weird...so weird”

Medical Educator F

“There was a time of just thinking ‘what on Earth can I do?’

Medical Educator G

“I’m a doctor first. So I wanted to be there for patients. I’m sorry but teaching wasn’t my priority”

Medical Educator F

“We needed guidance...like...talking to the university...what do you want from us now?”

Medical Educator G

“I had a timetable and everything arranged and I’d planned my teaching. The next thing I’m being told that it’s all cancelled...was a really disconcerting moment...wondering what the heck to do”

Medical Educator E

“Safety had to be the priority”

Medical Educator E

“There’s that saying about necessity being the mother of invention or something. There was definitely a moment of thinking ‘what can I do?’”

Two of the educators stated that they had been forced to try new things in their teaching as well as creating new learning materials. 

Medical Educator F

“It made me try new things. I had never used Teams or made anything for online teaching before”

Medical Educator G

“Definitely a lot of chaos...lot of having to do stuff I had never done before”

Two of the educators had sought the help of other educators in order to meet their teaching obligations.

Medical Educator E

“Principles were the same but still I was asking for help a lot”

Medical Educator G

“I needed help”

All of the medical educators felt that students needed more guidance in the new learning environment than before. There was discussion about students having a responsibility to use the time they had productively as well as whether students could be trusted to find resources themselves. 

Medical Educator E

“Students can’t just go to the ward to practise or you can’t just take them to ward so we had to be better at finding stuff and I think students needed a really clear guidance to resources”

Medical Educator F

“There was a moment of saying to students ‘you have this time, use it to find stuff’ but they definitely needed guidance to resources”

Medical Educator G 

“Students really can’t identify good stuff”

One medical educator felt that the change in teaching reflected broader changes seen at the clinical level.

Medical Educator G

“There was enough change at the clinical level with distant consultations etc we had to show that change in teaching as well”

However, one educator had concerns regarding pastoral support for students online. 

Medical Educator E

“There’s definitely something lacking. In the room you can judge a student’s body language and see if they're struggling. You can’t see that on a screen, even if they had their screen on, or in emails”

Two medical educators were pleased about their experience in making online resources. One felt that all educators would need to make some online materials as a back-up at least while the other felt teaching online was not as good as traditional teaching.

Medical Educator F

“I’d be pleased to go back to ‘normal’ but definitely I think now every educator needs to have some online stuff”

Medical Educator G

“I made online resources and felt proud of that but it didn’t feel anywhere near as good (as face-to-face teaching)”


Senior Medical Educators

In a similar vein to the medical educators, the senior educators recalled the feelings of confusion at the start of the pandemic. There was some discussion about involving students in the changes made and how those changes were communicated. Student safety was again a concern with one senior educator arguing that by keeping students safe there was space to make further decisions later. It was felt that students needed to be patient due to the nature of the disruption. 

Senior Educator A

“Student safety has to be the priority. End of”

Senior Educator B

“I think students understood the changes. It’s not as if this was a foreseeable circumstance. We had to explain to students that we were doing the best at all times but the situation was very, very fluid”

Senior Educator C

“Basically...everything was out of the window”

Senior Educator A

“You’d love to include students in this but, ultimately, you have to make decisions and in the beginning it was very much about...being safe, let’s make the safe decision first and let’s go from there”

Senior Educator B

“It’s not great to be totally top-down but what’s the alternative? There’s a deadly pandemic virus on the one hand and on the other a group of young people we have a duty of care for. It’s a no-brainer to say ‘stop it, be safe and we can look at things in the future’”

Senior Educator C

“Obviously students had concerns but I didn’t feel there was anything wrong in saying ‘give us a bit of time here’...it’s not as if we knew this was coming and we had to...build the plane while flying it”

With regard to moving to online teaching, the senior educators acknowledged that there was a lot of disruption. They disagreed about how ready they felt the university was. There was a discussion about how everyone needed to learn how to switch to online working and how to bring the students along.

Senior Educator A

“There was a model which is very tried and tested, this clinical attachment with students learning through time with patients...almost like an apprenticeship...suddenly we can’t use that anymore”

Senior Educator B

“I was in meetings with other doctors where we couldn’t get Zoom to work and I remember feeling worried. I thought everything was going to go wrong”

Senior Educator C

“Luckily we had a virtual learning platform to share information, slides, podcasts etc and so we had some expertise and something to use as a launchpad for more things”

Senior Educator B

“I think it’s something we all got better at...there were tips all over the place about how to use Teams and how to actually have an online meeting...people really needed to learn this stuff and that includes students...can’t just do the same thing online and that’s learning”

Senior Educator C

“You had to acknowledge ‘this is weird’ and set some rules and guidance because students didn’t know how to do it”

There was also a discussion about how assessment was shaped by the pandemic. Not all of these changes were felt to be negative. 

Senior Educator A

“Basically we had to say what we couldn’t do and then look at what was left, what we could do...we can’t do exams in person so what can we do online?”

Senior Educator C

“Maybe it showed what is actually necessary. Rather than the ‘nice to have’ we were looking at the essential only...we had online vivas without patients but exploring concepts with students. That was obviously a compromise and not ideal but it took a fraction of time and money...not saying this is the future, like I said it wasn’t ideal but it showed an alternative which had merit”

There was also a discussion regarding the future. It was felt that some degree of virtual communication will remain but that it was impossible to jump to telemedicine without the step of patient contact on the way to gain experience. It was felt that any changes toward virtual medical education will follow changes toward virtual medical practice. 

Senior Educator A

“I think we will all want to get back to normal as soon as possible. Maybe in future rather than meet in person we will say ‘let’s chat on the phone’ or on Teams and maybe patients will push for telemedicine as it fits in with them but I think medical education will get back to normal as soon as possible”

Senior Educator B

“I don’t think this is how things will be done. Medical education follows medical practice and so the only way you’ll get it being the future is is medical practice is all virtual”

Senior Educator C

“Patients are the focus of being a doctor and so you’ll always need that patient contact. It’s one thing having the patient contact experience and then moving to virtual consultation but another thing entirely to skip that step...of patient contact...and jump to the virtual”


Summary of findings

This study broadly supports previous literature; that educators do not perceive all mobile resources to be of equal value and are particularly mixed regarding social media.  Participants valued contact time and viewed mobile resources as an adjunct, not a replacement, to traditional methods of teaching.  There was broad agreement that mobile learning would require a foundation of knowledge best achieved through more traditional learning such as seminars with direct contact. It was suggested as being best used for senior students or in postgraduate education.  Suggestions on the best use of mobile learning focused on using it to supplement established teaching or as well signposted stand alone sessions after more traditional learning had taken place.  Students did not perceive university resources to be of high value.  Educators pointed out that mobile resources are just one example of innovation and may distract from work in other areas such as curriculum design.  All three groups of participants were concerned about professionalism and discipline using mobile resources, especially social media. Educators all expect students to have a certain level of digital skills. However, some students are discouraged by mobile resources.  Students were likely to use a mobile learning resource if it was recommended by an educator or peer.  There were concerns from all participants about fostering a reliance on navigation at the expense of knowledge and how this might impact on the standard of clinical acumen.  This reflects similar concerns of dependence reported in the literature (Maudsley et al., 2018).  Only one participant, a senior educator, suggested forming a focus group with students to discuss mobile resources.  No student suggested something similar.  Mobile collaboration experience amongst participants was limited. 

In the second round of interviews, post-pandemic students reported increased motivation to find resources for themselves. Educators believed an increased use of mobile resources in education reflected an increase in clinical practice at that time. It was also felt that online teaching needed a foundation of physical learning to build on. It was still felt that students required guidance on identifying resources of good quality. There was a perception that a feature of the pandemic was a lot of misinformation online. Both educators and senior educators admitted to a lot of improvisation at the start of the pandemic with student safety a priority. Concerns regarding student pastoral support and value for money were voiced. Senior educators had switched to virtual student assessment which had paired back some of the domains being assessed. Some of the changes were not viewed entirely negatively with a major positive being the ability for students to learn independent of the location at a time to suit them. 


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Get Ahead of the (Forgetting) Curve

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It’s the night before your big exam. There you are, hunched over your books, highlighter in hand, caffeine in your bloodstream, flooding your short term memory with as much as you can. You continue doing so even as you wait to be called into the exam hall. You try and remember as much as you can. The next day, as the adrenaline leaves your system and you can finally get your life back you realise you remember very little about what you covered in those final, intense sessions of revision. The following day you remember even less. Eventually, despite having forced yourself to remember all those final bits of knowledge, you realise you remember nothing of it. You’ve passed your exam yet you have actually learnt nothing. We’re all guilty of the learn and burn approach of cramming. Yet we are all living, breathing proof it doesn’t work. This is the story of Hermann Ebbinghaus, the forgetting curve and how interleaving our learning can prevent the loss of knowledge.

Hermann Ebbinghaus (1850 – 1909) was a German psychologist. Contrary to the scholarly fashion of the time he was interesting in studying memory using himself as a test subject. He tried to memorise a collection of nonsense words and plotted how many he could remember a week or so later. He published his work in 1885 as Über das Gedächtnis (later translated into English as Memory: A Contribution to Experimental Psychology). He charted how poor recall was following an isolated learning event was without frequent calls to draw on that knowledge. The more frequently he recalled the nonsense words the longer he could remember them. This is the forgetting curve.

Ebbinghaus gave the process a formula and hypothesised several contributing factors to the ability to recall knowledge: how complex the subject was, how it linked to previous learning, and personal factors such as sleep and stress. Time is unlikely to be the sole factor but the forgetting curve demonstrates a remarkable loss of learning unless that subject is regularly reviewed as shown below.

However, through repeated reviews of the learning material (the stars) we can shift the learning curve and improve retention of knowledge. This shows how it is impossible to cover everything in a talk. Your audience won’t retain it. It shows the importance of frequent recall rather than a single isolated event.

How that *one* thing we all 'know' about Egyptian Mummies might be wrong

Ancient Egypt: land of pyramids, animal-headed gods, pharaohs’ curses, and mummies. It’s fair to say that, perhaps out of any civilisation in history, it’s Egypt that mesmerises us the most. And it’s possibly mummies and mummification which hold the greatest sway over our fascination. The Egyptian belief that preserving the dead body guaranteed eternal life for the deceased’s soul ensured an intricate process of evisceration and embalming. And what’s the one fact about mummification that everyone, from child to adult, can recite with either glee or disgust?

“They pulled the brain out with a hook”

Certain organs would be stored in canopic jars each with a head for a lid. There was Hapi, the baboon-headed god associated with the North whose jar held the lungs. Duametef, the jackal-headed god associated with the East whose jar held the stomach. Qebehsenuef, the falcon-headed god of the West whose jar held the intestines. And Imsety, the god who looked like a human and was associated with the South whose jar held the liver.

Canopic jars. From left: Qebehsenuef (intestines), Imsety (liver), Hapi (lungs) and Duametef (stomach).

But not the brain. No, that was hooked out and thrown away. That’s a fact. The one thing we all know about mummification. Except it might be wrong.

Sculpture of Herodotus in the porch of the Stoa of Attalos building at the Ancient Agora of Athens. Attica region, Greece.

Herodotus (c484 BC - c425 BC) was an Ancient Greek known as the ‘Father of History’. In circa 425BC he travelled to Egypt and documented what he saw there. It is from his Book II of History that we get the following entry regarding the Ancient Egyptian process of mummification:

“They take first a crooked piece of iron, and with it draw out the brain through the nostrils, thus getting rid of a portion, while the skull is cleared of the rest by rinsing with drugs”

Attempts to recreate the mummification process as described by Herodotus suggested that the brain could not be removed using a hook. Then in 2008 CT imaging and then endoscopy of a mummy found an eight centimetre wooden tube had been left inside the skull. This suggested that, rather than hooking the brain out through the nose, the brain was liquified first (maybe using a hook) before the body was laid on its front (prone) and the tube was used to allow the brain to drain out via gravity.

CT scans of a 2,400-year-old female mummy revealed a tubular object embedded in its skull between the brain's left parietal bone and the resin filled back of the skull. Image copyright RSNA RadioGraphics)

The object, which measures 3 inches (8 cm) in length, was cut off from resin that it had gotten stuck to. It was left in the skull by the embalmers by accident, possibly because it broke off.

(Image credit: Photo copyright RSNA RadioGraphics )

Of course. it might well be that different areas of Ancient Egypt used different methods of mummification. It might also be that status and wealth affected how your body was preserved. But this find offers a snapshot that questions what every schoolboy and schoolgirl remembers about Ancient Egypt and mummies.

Maybe they didn’t hook the brain out but used a straw.

Johnson's Gamble: hoping the COVID-19 chain stays broken

There is no gambling like politics. 

Benjamin Disraeli UK Prime Minister 1868 and 1874-1880

The British Government is gambling. Cases of coronavirus are doubling every 10 days in England and hospital admissions have risen over 50% in the past week alone. Yet today the government is set to lift restrictions, from social distancing to mask wearing, in a bid to restore normality to the economy. Prime Minister Boris Johnson has said “if not now, then when?” with regard to lifting restrictions. 

The new UK Health Secretary Sajid Javid has warned that the country is entering “uncharted territory” as the last COVID-19 restrictions are likely to be removed by July 19th and UK daily cases could reach an unprecedented 100,000. Neil Ferguson, a leading epidemiologist at Imperial College London and government modeller on COVID-19 called this a “slight gamble”. This article is not about arguing for perpetual lockdown. It is rather an attempt to explore what that gamble means using the data available. For it is a gamble. And, if it goes wrong, more than a “slight one”.

At the peak of the second wave on 29th December 2020 81,517 people tested positive in one day. Of these 3,249 (3.99%) were admitted to hospital and 1,939 (2.38% of the daily cases) were in hospital requiring mechanical ventilation. 656 people (0.8% of the daily cases) died. This was at the start of the UK vaccination programme. On 3rd July 2021 22,230 tested positive for SARS-CoV-2. 386 (1.74%) were hospitalised, 327 people (1.47%) required mechanical ventilation and 20 (0.09% of the daily cases) died.


A key challenge for the vaccination campaign and a mantra often quoted in the media is to ‘break the chain’ of hospitalisations and death. Whilst a vaccinated person may still fall unwell due to COVID-19 the point is to prevent serious illness which requires hospitalisation. These data suggest that the chain has been broken. Sajid Javid’s gamble is that this stays the same. It may not. 

The Delta variant (previously called B.1.617.2.) was first identified in India in December 2020. It is now the dominant strain in the UK. Delta is 50% more contagious than Alpha (previously called B.1.1.7 or the Kent strain) which emerged in the UK in September 2020 and was itself 50% more contagious than the original SARS-CoV-2 virus. This means that while a patient infected with the original coronavirus strain could be expected to infect about 2.5 other people, someone infected with the Delta variant in the same environment would pass it on to 4.5 or 5 people. 

By 3rd July 63.8% of the UK adult population had had two vaccine doses. Current data suggest that the Pfizer-BioNTech vaccine is 96% effective against hospitalisation after 2 doses and the Oxford-AstraZeneca vaccine is 92% effective against hospitalisation after 2 doses. This is obviously good news and suggests that nearly two-thirds of the UK adult population have >90% protection from hospitalisation due to Delta. However, this may change. 

Viruses, like all life on Earth, use a genetic code. A genetic code is a series of letters. Whenever a genetic code is replicated there may be ‘spelling mistakes’ much as we might make a mistake copying out text and one or more letters may be replaced with another. This is how mutation happens. Sometimes these mutations may result in disease. Sometimes they may convey an advantage. This is how virus variants such as Alpha and Delta emerge. Mutations that convey an advantage (such as greater infectivity) mean that the virus particles with that mutation are more likely to be spread. Although SARS-CoV-2 seems to have a relatively slow rate of mutation compared to other viruses such as influenza, the more chances it has to spread and replicate the more chance it has to mutate. If the government allows a situation where 100,000 people a day in the UK are contracting SARS-CoV-2 they are permitting a fertile environment for new variants. The gamble is that a new variant won’t emerge against which the vaccines aren’t as effective and the chain of hospitalisations becomes unbroken. This is why Pfizer/BioNTech are trialling a version of their vaccine which targets the Delta variant as well as publishing guidance to add a third ‘booster’ vaccine six to twelve months after the two-dose regime. Boosters and new versions may become the norm. There is also the chance that a variant may emerge in other parts of the world with much lower rates of vaccination (currently only 2% of the population of Africa have received two doses of COVID-19 vaccine).

The data for 3rd July projected for 100,000 daily cases suggests 1,740 hospital admissions a day and 90 daily deaths. All less than the data for 29th December. However, if a new variant emerges which pushes us back to the data for 29th December then with 100,000 daily cases the UK would see 3,990 hospitalisations, 2,380 patients on ventilation, and 800 deaths. Nearly ten times the number of deaths based on 3rd July data. This is the government’s gamble: that the current modelling continues and a new variant doesn’t disrupt the benefits of vaccination.

The British Medical Association reports that between March 2020 and April 2021 there were 3.5 million fewer elective procedures and 22.27 million fewer outpatient attendances. The total number of patients waiting over 18 weeks for treatment has increased to 1.8 million.

This clearly is not sustainable. Sajid Javid faces a big challenge to get the NHS back to what President Biden would call normalcy. But even that would not be enough. The COVID-19 pandemic followed the 2018/19 winter when all non-emergency and non-cancer care was cancelled for a month. The NHS needs more than claps if it is going to be able to focus on non-COVID-19 care. The ramifications of Johnson’s government’s gamble are huge. Let’s hope it pays off.

The Seven Deadly Sins of MedTwitter

Welcome to Medical Twitter or MedTwitter. You may have joined to learn or to network. It won’t take long for you to realise it is a strange place.  

It’s an inclusive and diverse world where everyone agrees that Civility Saves.  It’s nice to be important but even more important to be nice.  Tweets are posted in threads going well over double figures spreading education, values, and virtues. There are educators, researchers, and authors.  ‘Celebrities’, quacks and peddlers.  It’s a game of choosing who is worth a follow and who is worth a mute.  It’s saccharine, occasionally sanctimonious, often banal but always nice.  Until it turns.  Gosh, how it can turn.  

You may be going in with the most virtuous of intentions but it’s important to be armed with the knowledge of the vices you might encounter on your way. The seven deadly sins have been part of Christian teaching since about the fourth century and feature the vices to be avoided: Pride, Wrath, Greed, Envy, Lust, Gluttony, and Sloth. Whilst it seems churlish to compare Medical Twitter to an actual religion (although many tweeters would like to be seen as prophets) these vices are similar to those you’ll see on your tweeting journey.

I am by no means the first person to cock a snook at the world of medical Twitter. Having been heavily inspired by @SamuelBS85, @JTweeterson, and @placemat_the I tentatively present for your consideration the seven deadly sins of MedTwitter:

Pride

I’m certain that when Tim Berners-Lee invented the internet in 1989 he did not have education at the forefront of his mind. Or connectivity. Or widening participation in society. No, I am certain he was hopeful that three decades later there would be a website on the internet where doctors would finally be able to debate the correct way of introducing themselves on the telephone.

We start with Pride because this is perhaps the most pervasive of the Deadly Sins of MedTwitter. I’m not talking about a student proudly posting they’ve passed an exam or a doctor announcing they’ve made it as a consultant. Pride in MedTwitter exists in a number of forms.

First, there’s virtue signalling. By no means a phenomenon isolated to MedTwitter but the variant seen amongst doctors on Twitter can be amongst the most virulent. I bow down the aforementioned superior blog of @jtweeterson on this matter and implore you to read their guide to virtue signalling. 

However, Pride in MedTwitter goes further. Pride is what convinces someone that their hot take on whether or not we should call hyperkalaemia ‘hyperkalaemia’ is actually really important and needs to be shared. Of course, it’s nonsense. Of course, it’s a totally pointless endeavour but Pride means that people will reply. And discuss whether we should call something that it is called. And this will dominate MedTwitter for a good day or so. And nothing changes.

It’s difficult to predict what will be the latest hot take. Maybe it’s whether we should write ‘deny’ in our notes. Or what sort of job title we should allow non-doctors to have. Or someone thinks they should be allowed to review the notes for the actual President of the United States. Pride is hard to predict but it will always be there. But it’s not the initial post that is important. It’s the self-aggrandising discussion it prompts as well. 

You may see doctors so full of Pride they refer to themselves as ‘angels’ or ‘heroes’.  Fair enough if this comes from a grateful patient or relative but healthcare workers are not heroes or angels. They are people doing a job. Calling ourselves heroes or angels sets a level of expectation and moral authority that’s impossible to maintain. It also avoids real discussions about the issues in healthcare. But that’s not the point. It’s all about Pride.

Let’s get out our electron microscopes to start splitting the finest of hairs. Just be careful about getting torticollis from all that navel-gazing. Remember, for 99.9% of all human beings none of this matters.

How to spot: 

Virtue signalling is incredibly easy to spot. Remember: it achieves nothing except making the poster look virtuous. The poster gets likes and retweets and gets praised for being an example to us all. It’s not there to share best practice or knowledge or to even promote a trust or hospital. It exists only to make a person look good and therefore is mostly disingenuous. It also implies that anyone not meeting these lofty examples is failing. There won’t be any education or tips or actual, measurable quality improvement. 

There might also be a slogan attached such as “every patient, ‘every time, without fail” or ‘“the standard you walk past is the standard you accept”.

There may be an empty gesture such as a consultant giving their lanyard to their F1 as this ‘flattens the hierarchy’ even though everyone from the cleaner to the matron knows who’s really the boss. This will always be accompanied by a hashtag such as #Leadership or #HumanFactors. 

Nurses are a common target for tactical virtue signalling by doctors in a condescending way of showing your virtuous credentials. Even if the rest of their output suggests they are anything but virtuous. 

Remember: for a lot of people their virtue definitely doesn’t go without saying/tweeting.

A ridiculous hot take will tend to follow these four simple steps:

  1. The original tweet is sent something like “Stop calling potassium ‘potassium’ it’s elitist and wrong”

  2. There’s immediate support praising the tweeter as a visionary for daring to question the status quo, of course, it’s wrong to call potassium ‘potassium’ and everyone who does is basically a fascist

  3. There’s the counterargument pointing out how ridiculous this is all is 

  4. There’s the counter-counter argument telling those in Step 3 to #BeKind

And nothing changes. Plus ça tweets, plus c'est la même chose.

Wrath

You have to worry about the blood pressure of many doctors on social media. The constant, sheer anger. They tweet about their rota, the cafeteria menu, their uniform, their break times, the government, parking, their supervisor, their portfolio…the list goes on and on. And they get their likes and their replies and their validation and so they keep churning out their anger. And nothing gets solved. Because rather than following correct channels in place through which doctors can voice their grievances they emit them into the void.

Because that’s their brand.  No solutions offered or discussions had. Just impotent rage. It is important that nothing actually improves because then they would have nothing to actually post about. 

How to spot:


First and foremost every tweet will be a complaint. Read any random segment of their timeline and you will be left with such a sense of righteous indignation on their behalf; that no-one in the history of Medicine, or perhaps mankind, has ever been so wronged.

You’re right, how dare the consultant be two minutes late for a ward round! You are literally the new Nelson Mandela, you should definitely strike!

Doctors taking a knee outside Downing Street…in the same week as George Floyd was killed…classy…

There may be terrible political gestures: sanctimonious lecturing on public transport or doctors in full scrubs (and stethoscopes) handing out documents at a Labour Party Press Conference. They may take a knee outside Downing Street in the very same week as George Floyd was killed by a policeman in Minnesota. Or threaten to resign unless the Chief Advisor to the actual Prime Minister resigns first. 

Remember: absolutely nothing productive will come from wrath. It may generate some newspaper column inches and the doctor will talk about the intangible benefit of ‘increasing awareness’ but no actual benefit will actually be made.  Ever. In fact, the only tangible impact I’ve ever seen was a few medical students in tears the day after the last election because doctors on social media had convinced them that the Tories ate children.

Greed

This is where we take Pride even further. Of course you’ll still be all about virtue signalling. And there’s Wrath. But that doesn’t pay the rent. It’s time to get some green.

We can’t all get that sweet Furniture Village gig. It’s time to monetise the one thing you’ve got ready access to: patients.

Time to write the definitive pandemic journal. Until the next one. Each journal is more definitive than the last. Let’s get sharing those intimate moments your patients trusted with you. Well, they didn’t say they didn’t want you writing about them did they? Suckers.

Each elderly patient is just the same as the other, after all. You have a point to prove in whatever narrative is in Chapter 8 so let’s get mushing all those lives together to fit it. The patient said they didn’t want resuscitation but they didn’t mention amalgamation did they? Of course changing names and details will definitely not offend any relatives whose opinions you didn’t seek in the first place. Is this a fair way to treat the lives of fellow human beings? La-la-la can’t hear you!

The pandemic has made people want to buy masks. Time to step up. You’re a spokesperson now. Get your ‘brand’ on some knock-off PPE and get people buying so you can keep sharing your truth. Keep saying how “inspiring” and “breathtaking” you’ve found the NHS. In fact, the only thing more breathtaking is your sheer gall but hey, you’re the one getting to make it rain!

How to spot:

They will almost certainly have joined Twitter during the junior doctors’ strikes in 2016. 

They will have been described as “the voice of junior doctors/the NHS” and, while they may not have first called themselves that, they definitely won’t argue. You imagine they spend every evening sticking pins into their doll of Jeremy Hunt. 

They definitely write for The Guardian or HuffPost. Owen Jones and various Labour backbenchers will certainly retweet them. A link to their book at Waterstones or a Just Giving page will never be far away. In fact, it’s probably their pinned tweet. 

Criticism is possible, but you will unleash the full force of fury and accusations of jealousy and heresy. They even have found a lawyer friend to be their ‘Head of Legal’ to hunt you down for your sacrilegious behaviour.

It’s better to mute but not before remembering that every day their first emotion is sheer fury at the fact that they are not Adam Kay before unleashing an Edvard Munch-esque scream to the cosmos.

Envy

You know how it is. You’ve reached a level of achievement in your profession. You’re (probably only technically) a consultant or a professor. You’re probably known for tweeting about a single topic or condition. And, let’s face it, apart from a few notable examples you’re a man. Suddenly, a pandemic has come along and the general public suddenly wants to hear from that dweeb Chris Whitty rather than you. What to do? Only one thing for it. Incessantly tweet. Make it all about you and your favourite topic. Never mind that you know nothing about virology and epidemiology. Remember: you’re a genius and the world needs to hear from you.

Domestic violence against women? Definitely something you should comment on. Is there really a second wave? You should definitely share your gut feeling that PHE is wrong and that lockdown doesn’t work with the world. Evidence-Based Medicine? Leave that to that nerd JVT. You’re here for likes and retweets only, baby. COVID-19 is due to too much processed sugar and you need to get the word out that people can buy your badly written book to make it all go away. Insult if you must. If people ask for evidence you can always block them.


How to spot:

Their timeline is one long circle jerk to their magnificent ego. They’ll make every event about their area of ‘expertise’. After tweeting about how Black Lives Matter is all down to gluten they’ll retweet not only their original post but each and every supportive reply they’ve ever received, even if critical responses are in the majority 10:1. 

They will definitely have appeared on Good Morning Britain or whatever radio programme is hosted by Julia Hartley-Brewer. They may have written for the Daily Mail or Daily Express. They’ll absolutely have quoted ‘data’ from that Statistics Guy Jon. They’ll be retweeted by such luminaries as Allison Pearson, Lawrence Fox and Anthea Turner. 

Once again, there’s no discussion. Dissent is not tolerated. If in doubt they’ll claim to be the sole voice of reason in a profession of idiots. Bringing the profession into disrepute? Do one mate. The GMC doesn't care. Trust me. 

shutterstock_95047852.jpg

Lust

It’s easy to a cock a snook and sneer in Medicine but actually it is pretty amazing. Passion for our job is a good thing and inspires us to do our best. Lust is something else though. Passion is about building and trying to be better. Lust is all about the glory.

Take your passion and tell us EXACTLY what happened.

You’re the on-call doctor and you’ve been called from home by your junior? The simply passionate would merely fulfill their contractual obligation and come in and do their job. Not for the lustful. Over at least 30 tweets you will reveal in painstaking detail exactly how you fulfilled the basic demands of your job. Don’t just tell us what was said, tell us HOW it was said. Make sure you mention exactly how breathless you were. And make sure you take a photo of the junior to stick right at the end of your thread? Why? Lust. That’s why. 

Conflict at work? A private conversation between you and a colleague? A patient’s last moments of life? Definitely share these with your followers. Added points if you can mention when the patient coughed or cried or how breathless you all were. 

Your sycophants will thank you for sharing YOUR story even though it never is your story or yours to share.

How to spot:

Invariably the tweet will have ‘A thread’ someone in it. Or a number. The truly professionally lustful will calculate exactly how long their thread will be and kindly orientate you by putting (1/34) at the end. 

Is it a private moment or conversation? Are they revealing the last words of a patient’s FaceTime with relatives before intubation? Do you get an awkward, voyeuristic feeling as though you’re encroaching on something private? Listen to that.  

It’s fair to say that few tweet formats are as annoying as “that’s the tweet” but brevity is a sweet delight in comparison to the unruly mess of 30+ long thread of nauseous saccharine. The lustful will release a steady stream of intrusive, mawkishness to feed their followers. You can point out how they’re violating confidentiality which won’t go down well with their sycophants. So it’s best to just mute them. After you’ve finished dry heaving.  And checking if it’s possible to develop ocular diabetes just by reading.

Gluttony

This is the one we are all guilty of. Because we are. 

Something mildly funny and relevant comes along. Bernie Sanders at Biden’s inauguration. Jackie Weaver. Oprah’s face. Someone uses the meme in a post which generates some love. You want in on those intoxicating likes and retweets. 

Time to get flooding Twitter with “Bernie as every anaesthetist ever” or “Oprah’s face as the reply when a Group and Save is rejected’. Of course this is a game of diminishing returns because every tweet ruins the joke just a little bit more. So your tweet will never get the response it deserved because you’re destroying the very thing you love.

This led to the wave of TikTok embarrassments last summer as medics ‘challenged’ each other to wear PPE and dance to Mambo No. 5. In the same afternoon as tweeting about how busy the NHS was and people should stay away. Luckily we were spared the insanity when some nurses did the haka and were accused of racism. The lesson: @DGlaucomflecken is the only medic who should be allowed to use TikTok. The rest need blocking immediately. 

How to spot:

This is easy to spot as soon as you log in. Your timeline will be a sea of the same meme over and over again. You will roll your eyes but soon you’ll be their trying to fit Hagrid into your thread of ‘Hogwarts teachers as ODPs’ or finding a fresh angle on ‘Jessica Fletcher as the on-call anaesthetic SHO at a DGH on a Bank Holiday when there’s a fire drill’. 

This is why we can’t have anything nice. We’re sick.

Sloth

Sloth comes from a translation of the Latin term acedia meaning ‘without care’. Sloth in MedTwitter is not about laziness but instead about doctors not taking care with the information they put out.

It might start off innocently enough. You’ve read an article stating that mortality in 2020 was actually lower than previous years. You only casually glance at the methodology and hit the retweet button to broaden the debate. That is the gateway to the sloth-side of MedTwitter.

Before you know it you’re commenting on things you know nothing about. Sure you specialised in Endocrinology but you definitely should be able to discuss complex epidemiology with the BBC. The media has a role in this too of course. The Guardian appeared to have their own sideline in approaching re-deployed F1s for opinion pieces entitled “As an ICU doctor…” They are guilty of sloth too. Such has been the demand for a talking head we’ve been saturated with doctors talking far outside of their lane of expertise with all the inherent risk. 

You read that hats with names on save lives. Boom, that’s a retweet. Medical error is the third biggest cause of death? Boom, that’s a retweet. Blood clots following the AstraZeneca vaccine? Boom, that’s a retweet.

If you feel it you post it.  You think your PPE is ‘flimsy’ despite it being fully PHE and WHO compliant? Make sure the world knows. Never mind that this is the same thought process of every vaccine hesitant patient who looks at the evidence yet feels they know better. Never mind that doctors are trained to use evidence. Felt it? Post it. Somebody else already posted it? Boom, that’s a retweet. 

Sloth is what happens when we don’t take just a moment to question what we’re reading. Sloth is what allows all the other sins to get away with it without being challenged. 

It literally only takes a moment, a few seconds to use our training and ask a question:

Does this statistic really make sense?

Is this opinion being presented as fact?

Is this doctor using confidential information to peddle their latest book?

Am I just being manipulated into buying some masks? 

Is someone whose fame is entirely based on appearing on a reality TV show REALLY the best person to speak for our profession? 

Once again we are all guilty of this. The trick is to recognise it.

How to spot:

The trick is to just take one moment and question what you’ve read:

OK, you’re telling me that medical error is the third biggest cause of death in the US. 

That might seem reasonable but if we think about it would therefore mean that medical error kills more people in the US than road traffic accidents. Does that make sense? Of course not. Just one moment, one question and suddenly that number doesn’t stand up.

We can then have a read about it and realise just how badly that number stands up.  Suddenly other claims being made might be questioned:

You’re telling me now that if I have a hat with my name on it it’s been proven to save lives?

It once again is merely the matter of a moment to assess the evidence and find conclusions such as how names on hats “could improve communication in crisis scenarios and help break down hierarchical barriers on a daily basis, resulting in improved patient safety” and how the results are based on staff responses not patient outcomes and how “there is currently a lack of academic evidence to show that knowing a name and role improves patient outcomes”.

Just a few minutes of thinking and checking and we can spot the arse gravy.

In the words of Take That “it only takes a minute” to identify those peddling utter arse gravy on MedTwitter, mute them and suddenly the whole experience is a better place to be.

Stick to your lane of expertise. Remember the difference between opinion (no matter how considered) and fact. Check your ego. And always keep in mind that there will always be someone who knows more than you about something. And you don’t have to like them for them to be right. And just because you like them it doesn’t mean they’re not wrong.

So there we have it. The Seven Deadly Sins of MedTwitter. I’m aware by writing this I’m guilty myself of quite a few of them. But hopefully you’ve enjoyed this nonetheless.

It’s really important to remember: none of it really matters. If in doubt, mute and put your phone down and so something important.

As the Jewish Book of Sirach said of the original Seven Deadly Sins:

“If you keep adding to them, you will not be without reproach; if you run after them,

you will not succeed nor will you ever be free, although you try to escape.”

Give Me Liberty or Give Me Death: The liberal case for lockdown

Liberty Leading the People by Eugène Delacroix commemorating the July Revolution of 1830 which toppled Charles X of France. A female personification of liberty is shown leading the people. In France, this figure has come to represent the French Republic and is called Marianne. I took this photo in the Louvre in 2017.

“Give me liberty or give me death”

Patrick Henry (1736-1799) American politician


A group of influential backbench Conservative MPs calling themselves the ‘COVID Recovery Group’ have put pressure on Prime Minister Boris Johnson to lift lockdown restrictions by April. They argue that if the vaccination programme continues as planned there would be 

“no justification for legislative restrictions to remain.”

Their leader Mark Harper argued that ‘vaccine = immunity from lockdown and restrictions”. Once again there are arguments about ‘the cure being worse than the disease.’

Mark Harper’s tweet claiming that the vaccine means immunity from lockdown.

The British tabloid media have been predictably considered and reserved when it comes to reporting the end of lockdown.


On an appearance on the BBC’s Andrew Marr Show Harper claimed the CRG was following the science in their announcement. The government instead has pledged to follow the data, not dates in their own planned end to lockdown in England by 21st June 2021. The purpose of this blog is not to judge who is correct between the CRG and the government but instead to have a look at lockdown in the context of liberalism. 




Elections cancelled, emergency legislation, movement restricted, schools closed and jobs furloughed. This has not been a great time for liberty.  But is lockdown completely illiberal? Does being a liberal automatically mean opposing lockdown? If we explore the history of liberalism we find that, actually, following the evidence and placing restrictions to avoid harm is entirely within the scope of liberalism. 

For some, ‘liberal’ is an insult aimed at the ‘woke’ and ‘cancel culture.’  Some wear the label proudly, marking them out as a supporter of ‘free speech’ and ‘common sense’ against the ‘woke cancel culture.’

A radical idea

Liberalism is a radical idea. Ian Dunt, author of ‘How to be a Liberal’ describes liberalism as an idea at the centre of which is the belief that people are individuals with their own freedom and should be treated as such. Therefore, pointing to ‘elites’, ‘us vs them’, class warfare or identity politics are, by definition, illiberal. A liberal would not presume to know you based on where you were born, what you looked like, what body parts you did or didn’t have, to whom you did or didn’t pray or whom you loved.  It does not pretend that human-beings form homogenous blobs. It does not speak about ‘the will of the people’ or about putting one group or one country above another. In short, it is everything that populism is not. Trump, Brexit, Viktor Orbán’s Hungary, Andrzej Duda’s Poland, Modi’s India, China, Jair Bolsonaro’s Brazil and Putin’s Russia are all fine examples of how not to be a liberal.

In the United Kingdom, the torch of liberalism has been carried by several parties over several centuries. In its spirit, UK governments abolished slavery, traded freely, established universal suffrage and free education, introduced the welfare state, decriminalised homosexuality, legislated for reproductive rights for women, statuted against discrimination based on gender or race, removed the death penalty, joined the European Economic Community, devolved power to its member nations, created the minimum wage and brought about first civil ceremonies and then fully equal same-sex marriage. Truly a radical idea. 

Circles to square

Of course, if you take the idea of individual freedom you can go off in many different directions. Classical liberalism in the UK was interested in increasing suffrage, the elimination of corruption in democracy and free trade. Social liberalism was born out of a desire to increase freedom from poverty. Neoliberalism, which for many now means liberalism, dominated from the financial deregulation of the 1980s and increased freedoms for business. There is now green liberalism, to provide freedom from climate change and to the project the environment. 

Under the banner of freedom, Margaret Thatcher and Ronald Reagan felt liberalism meant rolling back the state and freeing up the markets. For John Maynard Keynes liberalism meant the state actively involving itself in the market to steady the boom-bust cycles. The Liberal Party of the United Kingdom would, within a century, encompass laissez-faire economics under William Gladstone, the beginnings of the welfare state under Herbert Asquith and David-Lloyd George and, through the famous report penned by Liberal peer William Beveridge, provide the inspiration for the socialist post-war Labour government of Clement Attlee. 

All political factions are by nature a coalition and liberalism is perhaps the broadest of churches. This means contradictions. The founding fathers of the United States would enshrine the inalienable right to “life, liberty and the pursuit of happiness” yet have no problem with the idea of one human-being owning another. Sir Winston Churchill proclaimed “long live the cause for freedom” yet when it came to the idea of other country’s independence would say “I have not become the King's First Minister in order to preside over the liquidation of the British Empire.” Margaret Thatcher’s government would seek to free people’s ability to make money yet passed Section 28 banning teaching  “the acceptability of homosexuality as a pretended family relationship.”

If we take liberalism to its extreme we reject any form of government. This is where we find anarchism and libertarianism. And yet more contradictions. For the anarchist Pierre-Joseph Proudhon “all property is theft.” For the libertarian Ayn Rand “a free mind and a free market are corollaries."  It is the libertarian wing of the Conservative Party which makes up the CRG.  They campaign for liberty against lockdown. Yet they also were the MPs most willing to support the absolute removal of the rights of UK citizens to live, work and trade without barriers with the European Union. 

Essentially then when it comes to liberty clearly there are a lot of circles to square. 

Liberalism and logic

Liberalism has its roots in the Age of Enlightenment. Also known as the Age of Reason, this period lasted from the late 17th to early 19th century. Following the English Civil War and execution of Charles I in 1649 the restoration of the monarchy in 1660 under Charles II saw a return to absolute rule. This prompted a rethink of how society should work. This was a time of Sir Isaac Newton, of encyclopaedias and the scientific method. This focus on evidence and logic shaped philosophy. 

John Locke.

Thomas Hobbes.

Jean-Jacques Rousseau.

John Locke (1632-1704), considered the father of liberalism, was a physician and empiricist. He believed that human-beings came to decisions based on observation and rationality, just as a scientist like Sir Issac Newton studied the world. In 1689 he published Two Treatises of Government in which he argued against the divine right of kings to rule without question, for religious tolerance and the separation of church and state and for the innate rights of the individual to life, liberty and property. The role of government was to respect those rights at the risk of being replaced if they did not.  

Locke of course was not alone. His publication reflected the 1651 work Leviathan by philosopher Thomas Hobbes (1588-1679) which called for a social contract between the state and the individual to unlock freedom for all. The Genevan Jean-Jacques Rousseau (1712-1778) would similarly point to the role of government to ensure the innate freedoms of its citizens. In England through the Bill of Rights in 1689, the American Revolution of 1765-1783 and the French Revolution of 1789-1799 freedom and the rights of people to have a say in how they were governed were starting to take hold.

But Locke illustrates an important point when it comes to lockdown. For Locke, knowledge was not something divinely dispensed at birth but something gained through experience and, through acquiring knowledge, an individual became happier and freer. I very much doubt he would have any truck with a politician claiming to have ‘had enough of experts’. Locke would have supported looking at the evidence and using reason. 

Freedom and the Harm Principle

Does being free mean having the ability to determine your own future and life? Or does it mean that there are no obstacles being placed in front of you? The first definition describes positive liberty. This is basically the foundation of liberal democracy: individual citizens each avowed with the power to shape their shape. Neither Hobbes and Locke had any problem with a government having power over people. Hobbes argued that if completely free mankind would be cruel to each other with the strong dominating the weak and so a government was needed to prevent this. Locke however felt man was inherently good and that a government, with the consent of the people, should have the right to govern in the common good.

The second definition describes negative liberty. This is the creed of the libertarian: government is the problem and we should all be able to do what we want. If we accept that to be free is to be unconstrained then lockdown has to be illiberal. But let’s try to explore this thought process. Are drink-driving laws illiberal? If we removed that constraint and people had the right to drive whilst under the influence what about the freedom of a pedestrian they might hit? As much as lockdown impairs the right of a young, healthy person to carry on living their life, what about the rights of a vulnerable, older person to whom the younger person might pass on the virus? Liberalism, again, has an answer.

John Stuart Mill.

John Stuart Mill (1806-1873) served as a Member of Parliament for the Liberal Party from 1865-1868. He was a polymath raised from childhood on philosophy and travel. He supported the abolition of slavery in America and the equal rights of women. In 1859 he published On Liberty in which he explored the extent to which a government could restrict the right of the individual. In this essay he articulated a position known as the harm principle:

“The sole end for which mankind are warranted, individually or collectively, in interfering with the liberty of action of any of their number, is self-protection. 

That the only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others. 

His own good, either physical or moral, is not sufficient warrant. 

He cannot rightfully be compelled to do or forbear because it will be better for him to do so,

 because it will make him happier, because, in the opinion of others,

 to do so would be wise, or even right.… 

The only part of the conduct of anyone, for which he is amenable to society, 

is that which concerns others.”

MIll did not see harm as something you do to yourself but to others. If you want to drink excessively, go do it. If, however, you decide to then get behind the wheel of a car and endanger others then the state should step in and intervene. 

But what about a complex system such as the National Health Service where all healthcare is provided via the joint taxation of citizens? It could be argued that it is a form of harm to others if the decisions you made with regard to your health result in requiring healthcare resources that you might not otherwise need to use. 

If, through risky actions, an individual is exposed to COVID-19 and becomes infected we could argue that that is their decision. If that individual then passes the disease to another, more vulnerable person then that is harm. If that individual then requires a hospital admission and thus helps stretch finite resources that will have an impact on others. If hospital capacity is reached what then of the rights of another patient who’s had a heart attack or who needs emergency surgery? This would prevent the positive liberty of others from being realised. 

The UK government has faced criticism over an initial delay in lockdown and then early easing of which led to further restrictions being necessary. Of course political debate and differences of opinions are a cornerstone of a liberal democracy. Liberalism is about the right to differ. But to ignore evidence in favour of political principles at the risk of public health is not liberalism. Listening to evidence and reason and putting aside individual liberty to protect others is entirely within the liberal tradition. 

In other words when it comes to COVID-19 you don’t have to choose between liberty or death. A liberal would tell you that you can have both. 

One leg is better than two: why we don't need two-legged fixtures in the Champions League & Europa League

The times they are a-changing. The last fortnight has seen the return of knock-out European football. Last autumn it was announced that UEFA look set to change the format of the Champions League in favour of a ‘Swiss system’ with four more matches. This will be a mistake. This is not the change needed. We got an idea of the change needed last summer.

* * *

Out of the horror of the COVID-19 pandemic have been glimpses at something different. Some of this has been profound: pollution reduced or the daily commute eliminated. Another change, albeit meaningless in the grand scheme of things but significant in its own way was the single-legged format of the final stage of the Champions League and Europa League held in Portugal and Germany respectively. As Arrigo Sacchi put it: “football is the most important of the least important things in life”.

The first European Cup in 1955–56 consisted of 29 matches from start to finish. The following year’s edition contained a preliminary round and tiebreakers and so consisted of 44 matches from start to finish. The 2018–19 tournament, not including qualifiers, consisted of 125.

In the 2018–19 Champions League, the knockout phase began on February 12th and consisted of twenty-eight matches before the final on 1st June. In the 2019–20 season once the single-legged format began at the quarter-final stage there were only 7 matches including the final between 12th and 23rd August. That was it. None of the coaches or players with one eye on domestic football between two legs of continental football, this was distilled and focused. In a summer where the European Championship was cancelled this was tournament football which, although without fans, was compelling in a way that the traditional format couldn’t achieve.

It seems every season now fixture congestion raises its head. We debate the merits of the League Cup, the need for FA Cup replays and a winter break. Yet every season we continue to play 28 matches over 3 months in the Champions League without question. In an age of great awareness over travel and its environmental impact as well as ever-greater squeezing of the football fan’s wallet could the knockout stages we’ve just seen be a blueprint for the future?

The double-legged format of the knockout stages of European club football has been in place since inception. In many ways, it’s a vestige of the competitions at their genesis, before group stages became entrenched in the 1990s and beyond. Back then it was knockout football from the beginning. Without seeding. In 1978 Nottingham Forest were rewarded for their league win with a first-round draw against defending European champions Liverpool. They won. In 1960 defending European champions and five times consecutive winners Real Madrid were drawn against Spanish champions Barcelona. And lost. You played the team you were drawn against home and away. Add up the aggregate score and whoever has the most goals went through. Simple.

The worth of group stages, wherein the Champions League 96 matches are played so the top-seeded 16 clubs invariably go through and the bottom seeded 16 go out, can be debated but won’t change as it’s UEFA’s concession to their lower-ranked members. With a group stage, even the worst teams are guaranteed 6 matches with all the involved money. That won’t change. Now we have an idea of what is possible with the knockout rounds. UEFA President Aleksander Ceferin has recently announced that the new format could be the future from the 2025 season. Should it be?

Of course, in order to change from two legs to one, we’d have to look at what we might lose. As a Manchester United fan, I think back to that second leg against Roma in 2007 turning a 2–1 first leg deficit around with a 7–1 win at home. Chelsea fans will point to Napoli in 2012 on their way to glory. Liverpool fans to Barcelona in 2019. The 2018–19 Champions League, in particular, was a season of great comebacks in the second leg for Manchester United, Ajax, Tottenham Hotspur and, of course, Liverpool. This is what romance in sport is made of: a team coming from behind to win against the odds.

But how often does it actually happen? The Champions League has been in its current format since 2003. The Europa League since 2009. In the 16 seasons between 2003 and 2019 that meant 448 knockout matches, not including finals for the Champions League. For the Europa League, that’s 600 from 2009 to 2019.

Let’s look at those matches and see which knockout fixtures ‘needed’ a second leg. To do that we’ll look at the number of knockout fixtures where a team lost the first leg but won the second. These are the only fixtures where the second leg ‘mattered’. We’ll then look at how many times that ‘changed’ the outcome of that particular fixture i.e. the team losing the first leg came from behind to go through. We won’t include ties where the first leg was drawn because in a single-leg fixture the match would just go to extra time. This is only the matches where a full second 90 minutes changed the outcome.

Champions League knockout fixtures 2003-2019.

In the Champions League, a team lost the first leg but won the second 42 times between 2003 and 2019. The peak was 7 times in 2011–12 and 2018–19. The lowest number was once in 2005–06 and 2008–09. There was no season where a team didn’t manage to go through despite losing the first leg. The peak of a team changing the outcome was in 2018–19 when the team winning the second leg after losing the first went through 86% of the time (6/7).

Europa League knockout fixtures 2009-2019.

In the Europa League, a team lost the first leg but won the second 76 times. The peak was 11 times in 2017–18. The lowest number was 6 times in 2013–14 and 2017–18. There was no season where a team didn’t manage to go through despite losing the first leg. The peak of a team changing the outcome was also in 2018–19 when the team winning the second leg after losing the first went through 83% of the time (5/6).

In the 64 times in the Champions League where a team won the second leg after losing the first, the outcome was changed 42 times (66%). In the Europa League, it mattered less: 40 times out of 76 (53%). So while it happened more often in the Europa League (not surprising given the greater number of matches played) the effect was larger in the Champions League. The pattern seems to be that if a team can win the second leg after losing the first they are more likely to go through than not, probably due to the psychological impact on their opponent.

In the 224 two-legged knockout Champions League fixtures between 2003 and 2019, a team losing the first leg but going through made up only 18.8% of fixtures

If we include all the fixtures, however, the second leg makes much less sense. In the 224 two-legged knockout Champions League fixtures between 2003 and 2019, a team went through despite losing the first leg in 18.8% of the ties.

In the 300 two-legged knockout Europa League fixtures between 2009 and 2019 a team losing the first leg but still going through made up only 13.3% of fixtures.

In the Europa League, the point of second legs is even less clear. In the 300 two-legged knockout fixtures between 2009 and 2019, a team going through despite losing the first leg made up only 13.3% of the total fixtures.

In all knockout fixtures in the Champions League between 2003 and 2019 and in the Europa League between 2009 and 2019 a team lost the first leg but managed to go through in 16% of two-legged fixtures.

If we add up the knockout matches for the Champions League and the Europa League that’s 1048 matches played when the second leg was actually needed only 16% of the time across the two competitions.

* * *

This is a decision of rationality vs romance. In 2018 after a first-leg defeat to PSG Ole Gunnar Solskjær opined that “mountains are there to be climbed. You can’t lay down and say ‘this is over’.” We then know what followed. A team coming from behind is probably the most powerful image in any sport. That’s why they stick with us. These are moments that define a season. Without a second leg, Real Madrid would have been knocked out by Wolfsburg in 2016 and not won the competition. Same for Liverpool in 2019. But as we’ve seen, they are rare.

There’s also the factor of a self-fulfilling prophecy here. When Barcelona took to the field at Anfield in 2019 how much was the result against Roma in 2018 playing on their mind? How much was that Barcelona result playing on the minds of the PSG players when they faced Manchester United? Surely it isn’t a coincidence that PSG made the final the season when they only had one two-legged fixture? Having come from behind to beat Atalanta 2–1 in the quarter-finals, would the narrative of bottlers have remained if they’d had to play a second leg?

Another benefit of switching to single legs would be removing the away goals rule. No change since abolishing back passes could improve the game as much. Away goals skew football: I remember in 2011 listening to Radio 5 Live and a Spurs fan called in to say he was disappointed his team had ‘only’ won 1–0 away to AC Milan and not 2–1 because then they could lose 1–0 at home and still go through. Bizarre. The away goal rule punishes a home team for playing on the front foot: better to win 2–0 and stop than carry on attacking and win 3–1 or 4–2. This is insanity. Think of the cynicism we’d lose in one fell swoop.

Olympique Lyonnais played above and beyond against Manchester City last summer and won 3–1. Imagine the narrative under the traditional format. City would have another 90 minutes to come from behind. If their goal were an away goal City might even be favourites still. What if Bayern Munich and Barcelona had to play a second leg after the 8–2? A pointless 90 minutes which could only have threatened injury and suspension for Bayern Munich and embarrassment for Barcelona. As it was Bayern Munich and Lyon won and were through. Barcelona and Manchester City lost and were out. Done and finished after 90 minutes as codified in 1897.

The prestige of the Champions League is the jewel in UEFA’s crown. FIFA has looked enviously at Europe’s premier competition which is largely behind its decision to expand the FIFA World Club Cup. To reduce the number of matches would go against the general trend of football: more teams, more games, more money. Yet this summer we’ve had a glimpse of something else. Crisp and succinct. Rather than a bloated competition across countries and months, this was engrossing tournament football. The only thing it was missing was fans. Once they’re back UEFA could be onto something here. One leg is better than two.







It's Official: Liverpool are currently worse than David Moyes's Manchester United

In the pantheon of appalling Premier League titles Chelsea 2015/16 and Leicester City 2016/17 stand front and centre as the worst examples. Following this, however, would have to be David Moyes’s Manchester United 2013/14. Moyes’s nine-month stint went from being handpicked as Sir Alex Ferguson’s ‘chosen one’ to his banner being almost torn down by angry fans. Liverpool fans at the time gloated about the Scotsman’s troubles. Yet, now in the defence of their first Premier League title, the Merseysiders are officially worse in terms of points than Moyes’s Red Devils.

***

On 9th February 2014 Manchester United found themselves, after 25 league matches played, 7th in the league following a 2-2 draw at home with Fulham. This was the match of 81 crosses, 18 of which found a teammate, as Ferguson’s former first -team coach René Meulensteen left Old Trafford with a point. Manchester United had already exited the FA Cup at the third round to Swansea City and, having made the semi-finals, were knocked out of the League Cup on penalties to Sunderland. They had won their Champions League Group and were about to play Olympiacos in the Round of 16 before being knocked out by Bayern Munich in the Quarter-Finals. Their only piece of silverware of the season was the 2013 Community Shield beating Wigan Athletic. 

On 20th February 2020 Liverpool played their 25th league match of the 2020/21 season losing 2-0 at home to Everton. This was their fourth defeat in a row. They are sixth in the league. They already have been knocked out of the FA Cup by Manchester United in the fourth round and out of the League Cup by Arsenal, also in the fourth round. Like Manchester United, they won their Champions League group yet look far from the favourites for the competition. They also lost the 2020 Community Shield to Arsenal. 

Liverpool have won fewer matches and conceded more than Moyes’s United. They have managed more goals and fewer defeats but the end result is 40 points from 25 matches compared to Moyses’s 41 from 25 in 2014.

Looking at the drop in quality from the previous season is startling. Moyes was always going to struggle coming in after Sir Alex yet it was still surprising when his United won 21 fewer points after 25 matches than the 2012/13 champions had managed. Liverpool have managed to drop 33 points from the same position last season.

***

Much has been made of Liverpool’s injuries and the strange circumstances of the pandemic. True, Jurgen Klopp’s choice of a thin squad has backfired yet in many ways this drop in quality was predictable. As I’ve already written Liverpool outperformed their expected points last season by nearly 25. 14 of their 32 wins were by a single goal. After 25 matches last season Liverpool were outperforming their expected points by 20.41 points. 

In comparison, this season they would be expected only 3.99 more points than they’ve achieved. In other words whilst they were overperforming by 20.41 points they are only slightly underperforming this time around. Unfortunately, the data for the 2013/14 season is not available to compare. Regression to the mean was to be expected and we are seeing it now. Their 7–2 defeat to Aston Villa was due to be the biggest away defeat of the season until United beat Southampton 9–0. Regression to the mean was to be expected and we are seeing it now. Their 7-2 defeat to Aston Villa was due to be the biggest away defeat of the season until United beat Southampton 9-0. 

Liverpool are now 19 points from the summit of the Premier League. Their championship defence now ranks along with Moyse. Klopp has already conceded the title. He has experienced tremendous tragedy in recent months which must be putting a lot of his team’s travails into perspective and deserves immense sympathy. Maybe he’ll take a break soon. His Dortmund side of 2014/15 serves as a warning. Whilst it would be fanciful to see his Liverpool fighting relegation it is possible that there is more gas in this explosion. 

,

Lies, Damn Lies and Statistics: The Media's Misuse of Numbers during the Pandemic

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This week the respected German broadsheet Handelsblatt published an article claiming that the German government had leaked that the Oxford University/AstraZeneca vaccine only gave pensioners eight percent protection against COVID-19. They hastily released a clarification: the article resulted from a mishearing of a statistic: that 8% of the subjects in the AstraZeneca efficacy study were between 56 and 69 years of age. From this mishearing came a snowballing and a potentially damaging piece of misinformation. 

Misinformation comes in many forms. It’s easy to spot the obvious lies: that COVID-19 doesn’t exist, that it’s spread by 5G towers, that Bill Gates is trying to fill us with microchips.

Misinformation based on a misreading of statistics may be a simple mistake, as with Handelsblatt, but others may be much more cynical: that we are overreacting to a disease with only 1% mortality, that the NHS occupancy is much lower than normal and that there hasn’t been an increase in deaths compared to previous years. These lies are seductive and often used to justify more myths: that lockdowns don’t work, that lockdown has caused a rise in suicides or that wearing masks doesn’t work.  It’s time to challenge the misuse and misrepresentation of statistics.  

Let’s start with that line about how we are overreacting to a disease with only a 1% mortality rate. This is actually wrong as a statistic. The World Health Organisation COVID-19 Dashboard reports a mortality rate of 2.1%. But for the sake of argument let’s run with that figure of 1%. A  mortality rate of 1% doesn’t sound like much at all. It’s far less than the mortality rate of Ebola (50%) and another disease caused by a coronavirus, MERS (35%). 

But that’s not the point with a proportion. It’s not the percentage itself that’s important it’s what it’s a percentage of.  If you have 100 people infected that means only one person dying - not a big number at all. But if 100,000 people are infected that means 1,000 dying. Not an insignificant number. On the 8th January 1,035 people died in the UK within 28 days of testing positive. To put that in context 67 Britons died during the September 11th terrorist attacks. The right-wing media rightly admonish terriorism and honour those who died in terror atrocities. However, on 8th January COVID-19 killed 1545% the number of Britons murdered on September 11th. In total over 100,000 people in the UK have died from COVID-19. Double that killed by the Blitz.

This focus on 1% mortality also ignores other basic facts of COVID-19. Whilst ‘only’ 1% of patients with COVID-19 will die about 15% will need hospital care. About 5% of those infected will need to come to critical care (ICU). Once again, if 100 people are infected that’s 15 coming to hospital and 5 needing critical care. If 100,000 are infected that’s 15,000 needing a hospital bed and 5,000 needing ICU.  That’s without mentioning the impact of ‘long COVID’. This is not a disease where just 1% of people die and 99% have the sniffles and are fine. Painting it otherwise is a false dichotomy and a lie. 

Of course the impact of the pandemic on non-COVID-19 patients has rightly been brought up. However, this again misses the point. If a hospital’s capacity has been taken up with patients with COVID-19 then that means there is no space for patients who’ve had a heart attack or need emergency surgery. The NHS would cease to function.      

The other lie which is peddled is that because a percentage of ICU beds being used is less than the same time in a previous year this means that critical care is not as busy. 

This once again is a misunderstanding of proportions. It’s not just the percentage of critical care beds being occupied it’s the total of critical care beds available. 25% is less than 50%. But it’s a simple fact that 25% of 200 is the same as 50% of 100. Just looking at the percentage ignores the fact that ICU capacity has been increased in response to the pandemic. For example, in March 2020 Northwick Park Hospital in North West London increased their critical care capacity from 22 to 52 beds, an increase of 236%.  Even if the percentage of beds occupied is lower if the number of beds has gone up this still represents a greater demand on the NHS. 

Northwick Park is part of London North West University Healthcare NHS Trust. A look at the monthly situation report on the number of available and occupied Critical Care beds on the last Thursday of the month for 2020 tells us that at the end of January last year London North West University Healthcare NHS Trust had 33 adult ITU beds in total of which 28 were occupied. That’s 85% occupancy.

If we look at the Urgent and Emergency Care Daily Situation Reports 2020-21 we see that on 11th January 2021 London North West University Healthcare NHS Trust had 102 adult critical care beds of which 78 were occupied. That’s 76% occupancy.

So if we look at occupancy alone London North West University Healthcare NHS Trust had a smaller percentage of their adult critical care beds occupied on January 11th 2021 than at the end of January 2020. But because they had massively increased their critical care capacity the number of beds actually occupied was much larger: 78 compared to 28 or an increase of 279%. Focusing on occupancy alone ignores the true picture of the pandemic.

Another line often taken has been that “we should just use the Nightingale Hospitals”. These are seven hospitals set up in England as well as one each in Scotland, Wales and Northern Ireland  in order to create extra capacity for COVID-19 patients.  

This is misleading again. It’s all well and good to set up a hospital, another thing entirely to run it. Even in April 2020 there were warnings that the NHS could not staff the new hospitals. We could fill the hospitals with patients but without doctors, nurses and other healthcare staff they won’t be looked after. NHS staffing shortfalls pre-exist COVID-19 but the pandemic has exposed how threadbare the situation is. 

Another theme in the misuse of statistics has been to claim that mortality this year has been no higher or even less than in recent years. A rather egregious example of this was a Daily Mail article from 20th November 2020 entitled ‘What they don’t tell you about COVID’ which claimed the number of weekly deaths is currently “barely any higher” than the maximum level from the previous five years. This was wrong and torn apart both on Twitter and by Full Fact.

The figures came from a character called ‘Statistics Guy’ on Twitter who joined in April 2020. He claims to “do uk statistics for ordinary people. cutting (sic) through the waffle on your behalf”. In calculating the figures for the Daily Mail he missed out data which would have changed his conclusions as well as ‘adjusting’ figures for population growth. This was bizarre: as though the basic number of COVID-19 deaths can be negated because there are more people in the UK than in previous years. 

A more recent example on 8th January, the same day that 1,035 people died of COVID-19 in the UK, former pathologist John Lee claimed on Julia Hartley-Brewer’s talkRADIO show that:  

“We're seeing mortality that's well within the envelope of what normally happens this time of year. The last five years have been a below average number of death years if you look at the ONS data anyway compared to the last 27, which is how far their data go back...we’re below the average point of the deaths at this time of year...”

This again was torn apart by Full Fact. The five-year average is standard practice when looking for excess deaths so by not using it seems that Lee was trying to cherry-pick the data. Regardless, even adjusting for population he was wrong on both the 27-year and 5-year average. 

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"Figures often beguile me...in which case the remark attributed to Disraeli would often apply with justice and force: 'There are three kinds of lies: lies, damned lies, and statistics.'"

Mark Twain

Mark Twain has been proved right many times over, especially during the COVID-19 pandemic. Statistics sound good and, superficially at least, given credence to an argument. We should be careful when we hear or read a statistic to think about what’s actually being shown. So too should those of us speaking far outside our arena of expertise. Toby Young, a right-wing journalist of no scientific or medical training, has recently had to apologise for a 'significantly misleading' column for the Daily Telegraph in which he claimed the common cold could provide "natural immunity" to COVID-19. Let’s remember Mr Twain. There is nothing more contagious than a lie. And no more dangerous a lie than a statistic. 

The very simple reason why masks are safe to wear (and everything you've read which says they aren't is wrong)

Masks are safe to wear. Thanks to analytics I’m aware that only about a third of readers of my posts actually read them in their entirety. So before you go I want you to know: masks are safe to wear. Whatever you may have read online, they are safe. If that’s all you take away that’s enough for me. My ego can take it. If you’d like to know more then please read on. It’s really very simple: size matters.

I’ve argued before that if you get 100 scientists in a room, broadly speaking, you’ll get consensus. The fact that scientists agree isn’t some grand Illuminati scheme; it’s because they follow a scientific method in the pursuit of replicable results. Conspiracy theorists do not. Get 100 conspiracy theorists together and you’re likely to get 100 different stories. They’ll agree that there’s a conspiracy but not on which one. It was the Mafia. No, it was the CIA. No, it was the military-industrial complex.

So it is with mask conspiracy theories. On the one hand, you may have seen that masks offer no protection against the SARS-CoV-2 virus because the holes in them are too big to block the virus. On the other, you may have read that the masks stop carbon dioxide from being breathed out by wearers result in the build-up of carbon dioxide, a lack of oxygen being breathed in. You may have heard of a supposed epidemic of people ill with hypercapnia (too much carbon dioxide) or hypoxia (lack of oxygen). Or you may have heard that they are causing dangerous infections due to build-up of bacteria. 

It is nice of them to offer a choice. All are wrong. This is why.

An individual SARS-CoV-2 virus is tiny. Each particle is 100 nanometres across. Outside of the human body, these particles are called virions, biologically inert showing no signs of life. Inside a human body, the particles infect cells, hijacking the cells’ genetic material with their own. It’s this process which is called a virus. So, one conspiracy goes, 100 nanometres is too small for surgical masks to block so what’s the point?

However, SARS-CoV- 2 virions don’t exist in isolation. They are suspended in droplets of respiratory secretions much larger than the virions themselves. It’s these droplets which surgical masks are designed to block. And we know exactly what size droplets they can block thanks to research. 

COVID-19 is not the 21st century’s first pandemic. 

So-called ‘avian flu’ or H5N1 was the focus of the international community at the turn of the century. Here in the UK, this culminated in an outbreak at a turkey farm in early 2007. In the spring of 2009, a novel H1N1 influenza virus caused a pandemic known as ‘swine flu’ killing 151,700–575,400 people worldwide. 

A surgical mark, Source: Shutterstock

It was against this backdrop that the Health and Safety Executive (HSE) in the UK investigated the protection that different masks afforded the wearer against droplets containing airborne virions. This included surgical masks. 

They focused on the size of droplets a surgical mask could stop. The key distinction was droplets greater or less than 5 micrometres, or 5000 nanometres across. Droplets larger than 5000 nanometres tend to drop out of the air quickly due to their weight. Droplets smaller than 5000 nanometres are called aerosols and are more likely to remain airborne and represent a greater infection risk. 

While they found that respirators could block 100% of aerosols they found only a 6 fold reduction by surgical masks. They concluded that surgical masks should provide “adequate protection against large droplets” they “might not sufficiently reduce the likelihood of transmission” from the smaller aerosols. 

In other words, the holes in surgical masks were found to be too big to stop droplets smaller than 5000 nanometres across. This is why surgical masks are not recommended to be worn for aerosol-generating procedures such as intubation which make those smallest droplets. 

Yet conspiracy theorists would have you believe that a mask which can’t stop droplets 5000 nanometres in diameter somehow does stop carbon dioxide molecules which are only 0.334 nanometres across. Or oxygen molecules which are only 0.299 nanometres from end to end. It is a physical impossibility. 

An FFP3 mask, Source: Shutterstock

So that’s surgical masks but what about respirator masks? Surely the FFP3, worn by medical staff during aerosol-generating procedures must be a risk? 

Of course not. True, the pores in respirator masks are smaller than in surgical masks. FFP3 masks are designed to filter 99% of all particles bigger than 600 nanometers. Small enough to stop aerosols, which is why they are worn by health workers for aerosol-generating procedures, but still much bigger than carbon dioxide and oxygen molecules. 

Cloth masks, Source: Shutterstock

And what of cloth masks? The filtration effect of non-medical cloth masks is less than surgical masks or FFP3 masks. Therefore, for the reasons we’ve already looked at it would be impossible for cloth masks to cause hypercapnia or hypoxia. They are safe to wear. 

However, a study in the British Medical Journal in 2015 advised that due to “moisture retention, reuse of cloth masks and poor filtration” cloth masks should not be used by healthcare workers. This is not surprising: cloth masks are not as good at filtering the air as surgical masks or FFP3 masks and so should not be worn by healthcare workers looking after patients in a high-risk environment. 

For non-medical use such as going to the shops or on public transport however, a cloth mask is perfectly fine. The idea is that they trap the droplets spread by the wearer when they talk, cough or sneeze. This means they protect other people from the person wearing the mask. The CDC published a study in November 2020 which recommended cloth masks as suitable for community use. They advised that they should be washed regularly.

So everything you have read about masks causing hypoxia or hypercapnia is wrong. Size matters.

What about the conspiracy theory that masks can cause infections in the wearer through the build-up of bacteria? Again, wrong. There is no evidence of masks causing infections in the people wearing them. Why would there be? You’re wearing a mask. Unless you’re borrowing it (don’t) any saliva etc. on the inside is yours. If you have an infection and then put a mask on you’ll still develop symptoms but, of course, the mask didn’t cause that. 

There is evidence of bacteria build-up on the outside, however. This makes sense. Surgical masks aren’t made up of some special anti-bacterial material. Latex gloves are the same. Although they’re a physical barrier they don’t actually repel bacteria. If you touch a surgical mask you’ll transfer any germs on your hands. It’s been shown that surgical masks can pick up significant bacterial growth on the outside correlating with bacteria in the environment. It’s been recommended that surgical masks should be changed every 2 hours for this reason. If you’re wearing a mask it needs to be regularly changed and any touching reduced to a minimum. Same as if you’re wearing latex gloves: they still need to be changed regularly or washed.

So there you have it. Masks combined with other social distancing measures have been shown to reduce the spread of SARS-CoV-2. As shown here masks are also completely safe. Whatever you may have read online, they are safe. You should wear one.

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Answering Your Questions about the COVID-19 Vaccines

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From Shutterstock

The United Kingdom has approved the BioNTech/Pfizer vaccine and the very first people in the world have received their first jabs against COVID-19. The end should be in sight of this pandemic. Following previous posts, I’ve been asked a lot in person and online about the COVID-19 vaccines and vaccination in general. Here I’ve tried my best to answer them. Hope you find them useful. Please note although I am a doctor I am not involved in any of the trials mentioned.

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How does the immune system work?

The human immune system is divided into two parts: the innate and adaptive. We’re born with the innate immune system whilst the adaptive is something we develop. The innate immune system is broad while the adaptive is specialised. The innate immune system consists of cells (phagocytes) which ‘swallow’ and destroy bacteria, viruses and other disease-causing organisms (pathogens). This happens quickly after being infected. These cells break up the pathogens into smaller parts which they then display on their surface. Cells called helper T cells ‘read’ these smaller parts and start the adaptive immune response. Cells called B lymphocytes are activated and turn into plasma cells which start producing antibodies. These are proteins designed to specifically counteract one particular pathogen. They fit around proteins called antigens on the surface of the pathogen. After doing this they stop the pathogen functioning, in the case of viruses this can stop them being able to invade cells, and helps the phagocytes find and swallow them. The helper T cells also activate killer T cells which find and destroy cells which have been infected by the pathogen. The adaptive immune system as a result is slower. But it lasts. Both B and T cells retain ‘memory’ of that pathogen so if we are infected again they can start working immediately to destroy it. It’s this memory which is the basis of vaccination.

How does a vaccine work and how long do they take to produce?

Even in the early days of what we would recognise as Medicine people noticed that patients who survived some infections, such as smallpox, would never suffer the disease again. The concept of inoculation was based on this. Dried smallpox pustules were scratched into the skin or blown up the nose of patients. The majority of people would develop mild symptoms but then be immune to smallpox. Some patients would develop full-blown smallpox and so a safer alternative was sought. The story of Edward Jenner, the English country physician, is famous. He noticed how dairymaids who contracted cowpox, a mild disease, never suffered from smallpox. He scratched cowpox pustules into the arms of a boy called James Phipps who then developed a fever. Once Phipps recovered Jenner repeatedly injected the boy with smallpox pus. The boy showed no symptoms. The process was called vaccination from the Latin word for cow.

Vaccines usually consist of a weakened, non-infectious version of a pathogen or a part of a pathogen. The idea is to activate our adaptive response (which is why following a vaccine we often feel unwell) and so give us that ‘memory’ ready to fight the pathogen in the future.

But this takes time. Vaccines traditionally take about 10-years to produce.

You can hear me talking to my Pharmacist colleague Kunal Gohil about the immune system and the process of vaccine production here:

COVID-19 Part Four: The search for a cure — Take Aurally
A feature of the COVID-19 pandemic has been the rush to find the magic bullet to defeat it. Under the heading of…www.takeaurally.com

So how did we make the COVID-19 vaccines so quickly?

The Pfizer, Moderna and Oxford vaccines have all been made using new methods.

The Pfizer and Moderna vaccines use messenger RNA. Human beings (like most life on Earth) store our genetic material as DNA. DNA is like a blueprint for making proteins. The blueprint is ‘read’ and something called messenger RNA (mRNA) is made. The mRNA is used by our cells as a code to make the proteins which we use to live.

The Pfizer and Moderna vaccines use mRNA that codes for the spike protein on the COVID-19 virus wrapped in small fatty molecules to stop the mRNA from being destroyed by our enzymes. The mRNA is read by our cells who then make the protein to be detected by helper T cells.

The Oxford vaccine uses a harmless virus which causes the common cold in chimpanzees called an adenovirus. The adenovirus was altered to express the COVID-19 spike protein. The end result is the same: our helper T cells detect the spike protein and kick off our adaptive immune response.

Although these vaccines have been produced in response to a disease we’ve only known about for a year, the technology behind them has been decades in the making. New ways of making vaccines, called platform technology, have been sought for over twenty years as a way of being able to provide new vaccines quickly to fight a new disease. While the vaccines feel like they’ve been produced overnight they’re actually the result of lots of preparation. In January 2020 the SARS-CoV-2 virus was first identified and its genetic sequence was analysed and published by Chinese scientists. This meant work could begin immediately to produce vaccines using the platform technology. It also puts paid to the idea that the virus was a Chinese conspiracy.

The other reasons are due to the huge amounts of money, both public and private, given to fund the trials as well as the number of altruistic volunteer participants. Traditionally, companies would wait until the end of their trials to publish data but instead, they released ‘rolling’ data ‘as it happened’. In the case of BioNTech/Pfizer they were able to publish data in October. Scientists and clinicians at the UK Medicines and Healthcare products Regulatory Agency, (MHRA) were then able to work day and night to scrutinise over 1000 pages of results.

How do we know these vaccines work?

BioNTech/Pfizer enlisted 43,448 people. 21,720 were given their vaccine and 21,728 were given a placebo. 170 participants went on to catch COVID-19. 162 (95%) were in the placebo group. Only 8 (5%) were in the vaccine group. This is where the figure of 95% effectiveness comes from.

Moderna enrolled roughly 30,000 people and again divided participants into those receiving the vaccine and those receiving a placebo. 95 participants in total caught COVID-19, 90 in the placebo group and 5 in the vaccine group. This again gives us a figure of 95% effectiveness. 

Oxford-AstaZeneca enrolled over 11,000 people in the UK and Brazil who were either given the vaccine or a placebo. The vaccine group was further divided between people receiving two full doses and those receiving a half dose followed by a full one. The two full vaccine dose regime was found to be 62% effective in preventing COVID-19 while the 1.5 dose regime was found to be 90% effective. The reason for this difference is not yet understood.

Will the new variant make the vaccine pointless?

Genetic code consists of letters. Whenever genetic material replicates those letters are copied. From that copy, a new genetic code is written. This is called transcription and translation. As when we copy and type out text the odd mistake can happen. Letters can be replaced for another. This can lead to mutations. These can be bad and lead to mistakes which cause cancer. Sometimes the mutation gives the organism a benefit over other organisms, making them more likely to survive and breed and so pass on that advantage. This is the basis of evolution through natural selection. 

Viruses are particularly prone to mutation because of how frequently they replicate. Overall, the SARS-CoV-2 virus has shown a low rate of mutations and been quite stable for a virus. Its genetic code consists of 30,000 ‘letters’ and two other mutations had already been identified: one in Spain and one in Danish mink. The Covid-19 Genomics UK (COG-UK) consortium was set up in April 2020 to genetically sequence random positive samples of COVID-19. Since inception, the consortium has sequenced 140 000 virus genomes from people infected with COVID-19. 

It was this consortium which picked up a variant of SARS-CoV-2 with 23 mutations, 17 of which may affect its behaviour. One of these mutations causes changes to the spike protein on the virus. As the spike protein is used by the virus to infect cells it is possible that this mutation could make the virus more infectious. This ‘variant under investigation’ has been called VUI-202012/01 or B.1.1.7.

The variant was identified in September and as of 15th December accounted for 20% of viruses sequenced in Norfolk, 10% in Essex, and 3% in Suffolk was likely to have arisen in the UK. It accounted for 62% of new infections in London in the week ending December 9th, up from 28% in early November.

Based on computer modelling it’s been suggested that this new variant is 70% more transmissible than non-variant COVID. The R number, the average number of people every person infected can spread the disease to, seems to be 0.4 higher for the new variant.

Fortunately, one mutation in the spike protein is not likely to render the virus resistant to antibodies generated by the virus so far. However, if sufficient changes to the spike protein were to happen then, yes, the vaccine may be ineffective. This is why we need a different influenza vaccine each year as the influenza virus mutates so quickly.

There is some good news though. Thanks to platform technology we now have a way of quickly producing new vaccines. We have the basics sorted; we would just need to change the mRNA used in the Pfizer and Moderna vaccines or the spike protein expressed in the Oxford vaccine.  

Of course, as viruses mutate as they replicate if we reduce cases in the community through vaccination and social distancing we will, as a consequence, reduce the mutation rate.

I’ve seen memes about thalidomide comparing it to these vaccines, how do we know they’re safe?

Just as with any medicine, no vaccine is perfect although as shown above the risks are far outnumbered by those of disease. Thalidomide is not a vaccine, it was marketed in 1957 for morning sickness and discontinued in 1961 due to birth defects. The problem was with the thalidomide molecule and its orientation. The ‘left-handed’ thalidomide was safe, the ‘right-handed’ caused birth defects. This is why it is important to monitor the safety of all medicines.

Medical legislation in this country is incredibly robust; there are 349 individual regulations in 17 parts to make sure any medication, healthcare equipment or vaccine is safe. This includes the reporting of any ill effects. The emergency authorisation is being constantly reviewed and will be rescinded if the vaccine is found to be unsafe.

All of the vaccine trials have been clear when it comes to reporting the rates of adverse reactions to their vaccines. Oxford-AstraZeneca, Moderna and Pfizer/BioNTech have all reported low rates of adverse reactions. The Oxford-AstraZeneca trial was paused due to three adverse reactions: one was in a patient who had not received the COVID-19 vaccine, one had a high fever and it wasn’t known which vaccine they’d received as they were still blinded at that point. One participant who received the COVID-19 vaccine had an inflammation of the spinal cord 14 days after their booster which settled.

The most common ones included pain at the injection site, muscle pains, headache and feeling generally unwell. This is in keeping with any vaccination as those symptoms as a sign of it generating the immune response we want. Last year when I had my influenza vaccine my arm was sore and swelled up at the injection site. This year I felt run down the day after. Both times I took Paracetamol and had a nap. The next day I was fine. Both times were better than having influenza. Having seen the look on patients’ faces struggling to breathe thanks to COVID-19 as they are taken away to be intubated and ventilated I can assure you that the mild side effects of a vaccine are better.

Did we approve this vaccine faster due to Brexit?

In short, no. The UK approved the vaccine before the EU using regulation 174 of the UK’s Human Medicines Regulations, which enables the temporary authorisation of medicine prior to approval by the European Medicines Agency in the case of urgent public need. This Human Medicines Regulations came into effect in 2012, 4 years before the Brexit vote. On top of this EU law allows member states to “temporarily authorise the distribution of an unauthorised medicinal product in response to the suspected or confirmed spread of pathogenic agents, toxins, chemical agents or nuclear radiation any of which could cause harm”. It has nothing to do with Brexit.

I heard this vaccine can’t be stored in most places as it needs to be really cold, is this true?

For long-term storage (about six months) the vaccine has to be kept at -70° C, which requires specialist cooling equipment. But Pfizer has invented a distribution container to keep the vaccine at that temperature for 10 days if unopened. These containers can also be used for temporary storage in a vaccination facility for up to 30 days as long as they are replenished with dry ice every five days. Once thawed, the vaccine can be stored in a regular fridge at 2°C to 8°C for up to five days.

Isn’t natural immunity better? 

As far as our bodies are concerned there is no such thing as ‘natural’ immunity. You either develop antibodies through infection or through vaccination. Your body’s response is the same. With infection, you can be seriously unwell as your body’s adaptive immunity kicks in. With vaccination, you develop antibodies without the risks of infection. For example, 0.0001% of patients will experience an adverse reaction to the measles vaccine as opposed to the 0.2% of patients infected with measles who die. The maths is clear.

Don’t vaccines cause autism?

No. The paper which claimed it did was nonsense. 

On 28th February 1998, an article was published in The Lancet which claimed that the Measles, Mumps and Rubella (MMR) vaccine was linked to the development of development and digestive problems in children. Its lead author was Dr Andrew Wakefield, a gastroenterologist. The paper saw national panic about the safety of vaccination. Prime Minister Tony Blair refused to answer whether his newborn son Leo had been vaccinated.

However, Andrew Wakefield held a lot back from the public and his fellow authors. He was funded by a legal firm seeking to prosecute the companies who produce vaccines. This firm led him to the parents who formed the basis of his ‘research’. The link between children developing developmental and digestive problems was made by the parents of twelve children recalling that their child first showed their symptoms following the MMR vaccine. Their testimony and recall alone were enough for Wakefield to form a link between vaccination and autism. From a research sense, his findings were formed by linking two events that the parents thought happened at the same time. But the damage was done. The paper was retracted in 2010. Andrew Wakefield was struck off as were some of his co-authors who did not practice due diligence. Sadly, this has only helped Wakefield’s ‘legend’ as he tours America spreading his message tapping into the general ‘anti-truth’ populist movement. Tragically unsurprisingly, often in his wake comes measles.

Last year the largest study to date investigating the links between MMR and autism was published. 657,461 children in Denmark were followed up over several years (compare that to Wakefield’s research where he interviewed the parents of 12 children). No link between the vaccine and autism was shown. In fact, no large high-level research has ever backed up Wakefield’s claim. For a more explicit takedown of common anti-vaccine myths click here.

If we can develop a vaccine for COVID-19 so quickly how come we can’t develop one for HIV?

The human immunodeficiency virus (HIV) is very different from the SARS-CoV-2 virus. HIV infects and destroys helper T cells and so leaves a patient unable to mount adaptive immunity. This means they are vulnerable to opportunistic infections: this is Acquired Immune Deficiency Syndrome (AIDS). Although the virus was discovered in 1984 we are still yet to develop a vaccine. This is because although people infected with HIV do form antibodies (this is how we detect infection) those antibodies are not actually able to kill off the virus. HIV has the ability to hide from our immune system by producing a protein which stops cells it infects from being detected and destroyed. HIV is also able to impair the function of killer T cells. So, even if a vaccine were available which produced antibodies it is unlikely to be able to completely prevent infection.

A much greater success story has been anti-HIV medication which is able to grind HIV replication to a halt, although not completely kill it. Successful antiretroviral treatment can make a patient ‘undetectable’ — it is impossible to detect their HIV in a blood test. This means it is impossible for that patient to pass on their HIV to others. The availability of antiretroviral medication to be given to people at risk of HIV exposure (Pre-exposure Prophylaxis or PrEP) or to people within 72 hours of exposure (Post-exposure Prophylaxis or PEP) can greatly reduce infection rates. Both are nearly 100% effective if taken properly. We’ve been able to turn an infection with a nearly 100% mortality to a manageable, chronic disease in less than four decades. A future without HIV/AIDS is possible but probably won’t involve a vaccine.

I heard these vaccines use nanotechnology to control us

Nanotechnology springs to mind visions of tiny robots swimming in our bloodstream like something from science fiction. Although nanotechnology is real, it doesn’t mean that. ‘Nano’ means ‘one billionth’ or 1 x 10−9. So a nanometre is 0.000000001 metres, a nanosecond is 0.000000001 seconds and so on. Nanotechnology basically means technology which creates, uses or manipulates tiny things on the molecular or atomic level. Nanotechnology in Medicine is also called nanomedicine. As these vaccines involve the use of matter nanometres across such as viruses, mRNA and the participles used to wrap around them they are classed as nanotechnology even though not a single tiny robot is involved. 

I heard GPs are being paid to give this vaccine to us

General Practitioners in England are not employed by the NHS. Surgeries are private businesses owned by their partners which the NHS pays to provide services in line with a number of contracts. For providing some services, such as vaccination, the GP surgery charges an ‘item of service’ to the NHS. This fee covers the cost associated with providing the vaccination and is paid by the NHS to practices. It is used to pay for costs associated with providing the treatment.

In a letter sent to GPs on 9 November, NHS England said that it had agreed with the British Medical Association that the “Item of Service fee” for a potential Covid vaccine would be £12.58 per dose (and so £25.16 for a two-dose vaccine such as the one produced by Pfizer and BioNTech). The letter also confirms that the fee for the flu jab will remain £10.06.

So, yes, they are being paid. But it’s not ‘hush money’ or ‘dirty money’ it’s a contracted amount of money for providing a service.

I heard there is aborted fetal tissue in the vaccines

Sigh. This is where a glimmer of fact has been manipulated.

As discussed above the Oxford vaccine uses a chimpanzee virus. In order to propagate the virus, this required what all viruses need to multiply: cells to invade. This meant the study needed cells to use to grow the virus. This is not unique to research involving viruses, a lot of research requires cells. This is when cell lines are used.

Cell lines are mass-produced by taking original tissue and maintained to keep a reliable supply to use in research. Not every cell line lasts. Cells naturally have a ‘senescence’ or ageing process and so will die off. Cell lines are ‘immortalised’ either because they come from tumour cells which through mutation overcome senescence (this is how cancer starts) or because they are altered after being sampled. Each cell line has its own name.

The cell line used to ‘grow’ the chimpanzee virus for the Oxford virus is called HEK293. It is true the original cells for this line came from the kidney of a female fetus which was either lost to miscarriage or medically aborted in the Netherlands in 1973. Researchers used a virus to make the cells immortal and cultured just one bunch of cells. From this bunch of cells came a cell line. This cell line has been maintained ever since as HEK293, as clones of clones of clones of clones of clones etc. over 47 years. The immortalisation process means these cells are not the same as the original sample and the passage of time means those original cells have long gone. The HEK293 cell line was used to ‘farm’ the chimpanzee virus which is then filtered out of the culture. There is no aborted fetal tissue in this vaccine.

It is fair to say that science has a far from innocent record in this area. The first immortalised cell line, HeLa, was taken without consent from an African-American woman called Henrietta Lacks from the cervical cancer which killed her in 1951. As they were tumour cells, they were already immortal and so were cultured to produce a cell line. The HeLa cell line continues to be used in medical research in areas such as cancer treatment and the invention of the polio vaccine. This is the legacy of ‘the immortal Henrietta Lacks’ whose cells continue to live nearly 70 years after she died. However, no consent was sought or compensation given. Her family were not informed of the cell line until 1975. The case of Henrietta Lacks is an example of the need for informed consent in scientific research. It’s also important that scientists follow ethical procedure because, as we’ve seen from Mr (not Dr) Wakefield, they can do a lot of harm.

I heard the vaccines will make you infertile

This just makes me want to…

media.tenor.com-images-54d526fd183bb842780b9df05ebf6af6-tenor.gif

Right, sorry about that.

OK, let’s take a moment to discuss evidence and science. Let’s say we went up to an astronomer and asked them if the Earth was going to be hit by a comet tomorrow:

Us: “Hi astronomer’.

Astronomer: “Hello (insert name)”

Us: “Is a comet going to hit the Earth tomorrow and wipe out all life?”

Astronomer: “There is no evidence of that happening”.

Us: “What do you mean?”.

Astronomer: “Well, we haven’t picked up a comet on a trajectory with the planet Earth which is big enough to wipe out all life on Earth”.

Us: “So it won’t happen?”.

Astronomer: “There is no evidence a comet is going to hit Earth tomorrow and wipe out all life on Earth”.

Us: “I want definite answers. You’re a scientist, come on, is a comet going to hit us?”

Astronomer: “There is no evidence that will happen”.

Us: “So it could happen?”

Astronomer: “There is no evidence it could”.

Us: “But you’re not certain?”

Astronomer: “I’m a scientist, I look for evidence. We have not found a comet due to hit the Earth so at the moment there is no evidence a comet will hit us tomorrow and wipe us all out”.

Us: “So you’re telling me a comet is going to hit Earth?”

Astronomer: “No, I’m telling you there is no evidence”

Us: “I knew it, we’re all going to die. This is as bad as you guys faking the moon landings”.

Astronomer: “Please leave”.

Scientific proof is not what we think it is. Scientists have ideas or theories and test them. This involves experiments or observation through studies. The results are called evidence. There are levels of evidence which correspond to how ‘good’ a study is based on how it was conducted and how the findings can be applied to other settings. This is fairly obvious: a study conducted in one hospital is not as good as a study involving multiple hospitals across different countries.

Scientists can look at the most recent high-level evidence and draw conclusions based on what best explains what they’ve observed. That is scientific ‘proof’. The theory of evolution best explains the evidence gleaned from fossils, genetic inheritance and DNA. The Big Bang theory best explains the evidence from studying the evolution of stars, galaxies and heavy elements and cosmic microwave background. Observing falling objects and planetary motion is best explained by the theory of gravity. And so on. If observed evidence changes then the theory must change or be rejected for a new one. This is how scientists went from believing the Sun went around the Earth based on the evidence of seeing the Sun move across the sky to believe it’s the other way round. As the famous economist John Maynard Keynes put it so brilliantly:

“When the facts change, I change my mind. What do you do, sir?”

It is the same in Medicine. We’ve seen in patients who take Paracetamol that none of them turns purple with yellow spots. We’ve seen patients who take too much Paracetamol develop liver failure. Therefore, there is currently no evidence that taking Paracetamol makes you turn purple with yellow spots but there is evidence that taking too much Paracetamol causes liver failure.

Somewhere along the line as a society, we have started to demand certainty. We also seem to have somehow reached a point where scientific evidence and personal opinion are now one and the same and can be used interchangeably by members of the public and politicians alike. Scientific evidence is not certain. Nor is it an opinion. It is something which follows a constant process of testing, observing, recording and analysis.

And so back to the question. There is no evidence that the vaccines cause infertility. That’s it.

The building blocks of proteins are called amino acids, and it’s sequences of those that make up different proteins. A small part of the COVID-19 spike protein resembles a part of another protein vital for the formation of the placenta, called syncytin-1. But the sequence of amino acids that are similar in syncytin-1 and the SARS-CoV-2 spike protein is quite short and not the whole protein. They are not the same.

Therefore realistically the body’s immune system is not likely to confuse the two, and attack syncytin-1 rather than the spike protein on SARS-CoV-2 and stop a placenta forming.

This claim came from concerns that the COVID-19 spike protein the vaccines make the body produce antibodies against also contain “syncytin-homologous proteins, which are essential for the formation of the placenta in mammals such as humans”. The authors: Dr Mike Yeadon in the UK, who has made a name for himself as a contrarian to the scientific consensus during the pandemic and Dr Wolfgang Wodarg from Germany, who has a history for casting doubt on everything from pandemic definition to vaccine production demanded that it must: 

“be absolutely ruled out that a vaccine against SARS-CoV-2 could trigger an immune reaction against syncytin-1, as otherwise, infertility of indefinite duration could result in vaccinated women”. 

As we’ve just discussed, no one seriously wanting scientific evidence would make such a request for absolute proof. An actual scientist would think about this problem. Infected patients produce antibodies just as vaccinated people do. Is there any evidence that infected women lose their pregnancy?

This study of 225 women in their first trimester found no increase to early pregnancy loss in those infected with COVID-19. This study compared 113 women pregnant in May 2020 to 172 pregnant in May 2019 and found no increase in pregnancy loss. This study looked at 252 pregnant women infected with COVID-19 found no increase in adverse pregnancy outcomes.  

There is no evidence that the vaccine causes infertility or miscarriages. A couple of attention-seeking ‘truth seekers’ have lit a bin fire and left the serious medical profession to put it out. With that in mind, I am fed up with members of my own profession talking far outside of their area of expertise, cynically or otherwise, during the pandemic and helping to fuel mistrust at a time when we should have stood together. But that’s a blog for another day.

I heard that the vaccine companies can’t be sued if things go badly

Wrong. A government consultation document laid out proposals to potentially authorise a vaccine for emergency use. Existing UK law (as informed by EU law) says that if the government decided to do this, manufacturers and healthcare professionals would not take responsibility for most civil liability claims. But, if the vaccine is found to be defective or not meet safety standards then: 

“the immunity does not apply…(and) the UK government believes that sufficiently serious breaches should lead to loss of immunity”

If the vaccines are found to be dangerous or defective you can guarantee that the companies involved will be sued until their pips squeak. 

* * *

There. I hope this has made sense. Thanks to everyone who reached out and asked questions. I appreciate that this will not be enough for the conspiracy theorists who will say everything I’ve put here is a ‘point of view’ as valid as their memes. For the rational majority, I hope it has answered those questions and any lingering doubts. It has been a strange year and it has never been easier to spread lies. Fortunately, it’s never been easier to spread the truth.

 Why trying to ‘live with COVID’ meant another lockdown

So, here we are the end of England’s Lockdown 2. Lockdown, the word of the year, was supposed to be a one-off as we ‘learned to live’ with COVID-19 until the white knight of a vaccine arrived over the nearest hill. Yet the second lockdown was near-inevitable due to the nature of COVID-19 and the attempts in the UK to control it. This is why.

* * *

“So what do you think should be done about COVID-19?”

Chances are you’ve asked, or been asked, this, probably over Zoom, as your region moved up a Tier or as you contemplated a Christmas without being able to see all of your nearest and dearest. Maybe you were worried about your favourite business or wondering what on Earth a substantial meal is. Or perhaps you’re concerned about University students locked in their halls living off food parcels. Then it all seemed for nought as England entered a month-long lockdown.

It doesn’t mean you’re a COVID-19 conspiracist or a mask-debater; you’d have to have your head in the sand to not be confused or worried about the UK’s response to the pandemic. Stay home, protect the NHS, save lives became ‘Eat Out to Help Out’ before it became easier to list the regions not in Tier 3 before Lockdown 2 arrived. 

As U-turns go, the Prime Minister’s has been the screeching, handbrake on kind. Boris Johnson first went against scientific advice and resisted a ‘circuit breaker’ three-week lockdown. Leader of the Opposition Sir Keir Starmer committed his party to pressurise the government to U-turn.

Then other countries, inside and out of the UK acted. The Republic of Ireland, after similar resistance, announced a six-week lockdown. Wales went into a shorter two-week‘ firebreak’. France and Germany announced new lockdown measures. 

Then, Johnson U-turned and announced a month-long lockdown for England from the 5th November. Flanked by Chief Medical Officer, Chris Whitty and Chief Scientific Officer, Sir Patrick Vallance Johnson painted a grim picture on 31st October. Two key slides showed how projected daily deaths exceeded the government’s own reasonable worst-case scenario and how the NHS capacity would be exhausted.

The two slides shown by Chris Whitty which were used to justify a second lockdown, taken from the BBC

Yet the government has its detractors. Some of Johnson’s own MPs have formed a group, the sardonically named COVID Recovery Group, to impose further lockdowns. They allege that the cure of lockdown is “worse than the disease” and advise that we “live with COVID-19” until mass vaccination is a reality. There is talk of a new political party aimed at opposing lockdowns.

The lockdown sceptics have presented their argument. The Great Barrington Declaration, funded by the American Institute for Economic Research, a libertarian think tank, was published on 4th October 2020 and advocates focused protection for those people most at risk of COVID-19 whilst allowing others to live as normal. Included in its list of signatories are ‘Dr Person Fakename’ and ‘Harold Shipman’. It’s been estimated that about half of its supporters on social media are fake bot accounts. Despite this in response, ten days later, came the John Snow Memorandum advocating a continuation, or even extension, of lockdown measures. So, what to believe?

The simple fact is that in one way or another the UK, like the rest of the Western North Hemisphere world, has tried to “live with COVID”. To try and balance ‘business as usual’ with public health measures. New Zealand, on the other hand, went for ‘zero COVID’ or ‘COVID eradication’. This involved a rapid shutdown, closing the borders and a “level 4 lockdown” which meant that people could only interact with people within their home. New Zealand eradicated COVID-19 and, despite some small outbreaks, have achieved a successful economic and public health outcome. This strategy was based on the experiences of Asian countries with the SARS pandemic. The idea was to take COVID-19 cases to zero. In the UK we have tried to suppress COVID-19 to low levels but not tried to eliminate it. We tried to live with it, with a mixture of opening up the economy whilst applying local restrictions. The result was more cases and more restrictions. 

One of the central tenants of Medicine is informed consent: the ability of patients to make decisions regarding their care based on being presented with all available information. This article will try to do just that: present what the information and what ‘living with COVID-19’ means.

The case against lockdown

The first argument against lockdown is economic. The chancellor Rishi Sunak has spoken of his “sacred responsibility” to balance the country’s books. Yet thanks to COVID-19 the UK’s GDP has plummeted to record depths. More on that later. The next arguments come regarding the people most at risk of the disease.

Public Health England broke down the cases of COVID-19 in each age group. For both men and women, the majority of deaths have been in the over 85 age bracket. For women, this age group has also seen the highest excess mortality compared to the 2015–19 average. For men, the highest excess mortality was in those aged 75–84. What is interesting is that in both men aged over 75 and women aged 75–84 the number of deaths due to COVID-19 exceeded the expected mortality. This means that other expected causes of death actually went down.

Breakdown of COVID-19 deaths by age-group in England to week ending 18th September 2020, Source: PHE

This trend is seen across multiple agencies studying the effects of COVID-19. Despite Boris Johnson promising a protective ring around care and nursing homes, the Office of National Statistics (ONS) estimated about 26,500 excess deaths in care homes and 23,500 excess deaths at home in comparison with the 2015–19 average for March to 7th August.

Why should young university students be stuck in halls because of a virus which is a bigger threat to the elderly? Why should we shut down the economy and hit working-age people? We can’t pretend that lockdown is some benign experience. The impacts on mental health, education and other non-COVID healthcare aspects may take years to become fully apparent. 

The NSPCC have reported record calls to its helpline during lockdown. A study from the London School of Hygiene and Tropical Medicine has found an increase in breast, lung, oesophageal and colorectal cancer deaths. The British Heart Foundation have identified 2085 excess deaths in England and Wales due to stroke and heart disease. The National Blood and Transplant Service reported reductions in donor referrals and transplants.

This, sadly, is not an unusual phenomenon seen in the response to a disaster. Following the terrorist attacks of 11th September 2001 it was estimated that there were 1600 extra deaths on American roads due to people avoiding flying. In response to one threat, we can often go willing into the arms of another. Of course, what isn’t apparent is to what extent this ‘collateral damage’ could have been avoided with planning and foresight. We’ll come to that later.


Research from Imperial College London estimates the risk of dying from COVID-19 for someone infected aged between 10 and 20 at 0.006%. For someone aged 40–49 the risk becomes 0.15%. If you’re aged over 80 it’s 9.3%; nearly one in ten. 

Here comes the argument of ‘shielding’ the most vulnerable allowing the young to restart their lives. Others are far blunter: any lockdown only postpones death, it doesn’t prevent them. What’s the point? It’s time to learn to live with COVID-19. To develop herd immunity. To treat coronavirus like influenza; part of the fabric of life. But what does this mean?

We have vaccinations and central heating. Yet influenza and winter still kill a lot of people.

Influenza makes an easy comparison to COVID-19. Donald Trump and his Brazilian counter-part and political soul mate Jair Bolsonaro have both made the comparison in a typically crass fashion. Both diseases affect the upper respiratory tract. Both are spread primarily through droplets of respiratory secretions. Both are of greatest risk in the elderly and those with pre-existing co-morbidities. We don’t shut down for ‘flu so why should we for COVID?

The UK government tracks influenza and each year produces an annual report of that year’s ‘flu season’. They are all free to access here. The data collected tells us that from the winter of 2015/16 to week 9 of 2020 56,461 people died in the UK of influenza.

UK Influenza Deaths, Source: PHE

Influenza is a disease with which we have “learnt to live”. A disease for which we can offer proven vaccinations to those patients most at risk. Yet 56,461 people in the UK have died of influenza in the past 5 years. In the single worst winter, 2017–18, over 20,000 people died. These numbers are likely to be an underestimate given that not every patient with influenza is tested.

England and Wales Excess Winter Deaths, Source: ONS

Something else we have ‘learnt to live with’ is winter itself. Yet winter is associated with an increase in mortality due to factors such as infections and the cold. An increase in mortality for a period of time compared to the historical average is known as excess mortality. The Office of National Statistics (ONS) reports that the winter of 2017/18 saw 49,410 more deaths in England Wales than the five-year average for winter. For the winter of 2018/19, they estimate an extra 23,200 deaths.

Despite modern medicine, heating and knowing full well what winter involves it has killed over 70,000 people more than expected in just two years.

COVID-19 has killed more people in less than a year than influenza has in five

UK Influenza Deaths, Source: PHE compared to UK COVID-19 Deaths, Source: WHO

So, having ‘learnt to live’ with influenza and winter how does COVID-19 compare? At the time of writing the World Health Organisation (WHO) reports that there have been 58,245 deaths in the UK due to COVID-19. This is far greater than the recorded UK deaths due to influenza in any one winter. In fact, it is greater than the total recorded influenza deaths for the past five winters. The WHO figure could be an underestimate. The ONS records COVID-19 deaths if the disease is mentioned on the death certificate not only if there is a confirmed positive result. The ONS estimate that there were 51,935 deaths due to COVID-19 in England and Wales up to 7th August. If correct this is only 4,526 less than the total deaths due to influenza since 2015/16.

England and Wales Excess Winter Deaths compared to England and Wales Excess Deaths March-August 2020, Source: ONS

The ONS estimates excess mortality of 58,000 in England and Wales for early March and 7 August 2020 compared with the 2015–19 average for the same period. This again is far greater than the excess mortality seen for the 2017/18 and 2018/19 winters. Between January and August, 2020 COVID-19 was the underlying cause of death for three times as many patients as influenza and pneumonia in England and Wales.

COVID-19 has a far greater burden on healthcare than influenza

Of course, mortality is just one way to measure the impact of a disease. Another is how poorly is makes patients and the level of care they require. In this regard again COVID-19 has a greater impact. 

Total Influenza ICU Admissions in England and Peak Weekly Admissions for 2018-19, Source: PHE compared to COVID-19 ICU Admissions, Source: Gov.uk

During the 2018–19 influenza season, a total of 2,924 patients in England were admitted to intensive care in England due to the disease. At its peak, 287 patients were admitted in one week to an intensive care unit due to influenza. In comparison at the peak of the first wave of COVID-19 on the 12th April 2020, 2,881 patients in England were in intensive care requiring mechanical ventilation. On 2nd April, ten days after the first lockdown was announced, 1,494 patients were in intensive care in England for mechanical ventilation due to COVID-19. By 1st September this had fallen to 59. By the time Johnson announced a second lockdown, just over eight weeks later, it had risen to 815 patients. It has continued to rise. At the time of writing there are 1,417 patients in England in intensive care for mechanical ventilation due to COVID-19. ‘Living with’ COVID-19 is not the same as ‘living with ‘flu’

Other aspects of COVID-19 also make any attempt to ‘live with it’ very difficult. Asymptomatic patients may unwillingly spread the disease to the vulnerable. It’s also worth pointing out that it is not as if COVID-19 is benign for younger people. The extent of ‘long COVID’ is still becoming apparent. 

Recently work was published looking at results from the COVID Symptom App which gives an idea of the extent to this condition. 88% of Italian patients hospitalised with COVID-19 report symptoms 2 months later. 55% of French patients report fatigue 110 days after being hospitalised with COVID-19. Although younger people are at a reduced risk, cases of multi-organ failure have been seen in children and young people infected with COVID-19. Oxford University performed MRI scans on COVID-19 survivors and found post-infection changes to the lungs and other organs including the brain. We don’t know if in a few decades time long-term consequences may be revealed in younger people infected with COVID-19 today. To this raft of physical symptoms comes news of mental health problems being reported in survivors of COVID-19.

The virus isn’t becoming ‘less deadly’ and herd immunity isn’t happening (without a vaccine)

While SARS-CoV-2 is slowly mutating the implications of this are not clear. There is no evidence that the virus is becoming ‘milder’. The Financial Times global database found that those countries which suffered the most in the spring seem to be becoming hotspots in the autumn again.

Source: Financial Times

The implications of the new ‘mink variant’ remain unclear. If anything, the risk may be greater; the virus mutates to a form untouchable by vaccines in production, rather than becoming ‘milder’. Nor are we becoming immune ‘naturally’.

Herd immunity describes the number of individuals in a population who would need to be immune to a disease (either through vaccination or previous infection) to prevent transmission to vulnerable non-immune people. Each disease has a different proportion needed, 95% in measles, for example. The WHO estimate that about 70% of the population would need to have immunity to COVID-19 to confer herd immunity. There is no evidence we are anywhere close to that target. Even Sweden, held up as an example for lockdown sceptics, has not received that target with one recent study in the Journal of the Royal Society of Medicine finding evidence of immunity in just 15%. Imperial College London has reported that antibody prevalence in England is falling, not rising.

Sweden is an example, but not a good one

Source: The Spectator

A more detailed examination of Sweden’s COVID-19 shows some uncomfortable truths. While they have recorded fewer deaths per million compared to the UK (most countries have) they dwarfed their Nordic neighbours. Once lockdown was first announced in the UK deaths per million actually fell below Sweden’s.

Source: Financial Times

The country’s public health agency has recently admitted that their predictions about a second wave in Sweden were wrong following a surge in cases.

The systems we needed haven’t worked


The story of the Track and Trace programme has not been a happy one. 15,841 positive cases went untraced and had to be retrospectively added to the caseload. Looking at the most recent data on the Track and Trace system tells us that 40.1% of contacts of cases were not being reached. When the ONS launched its COVID-19 survey in May 51% of households signed up. That number has now fallen to 5%. Johnson’s much-vaunted ‘moonshot’ rapid testing trial failed to identify COVID-19 infection in over 50% of cases.

Going into how the government has awarded contracts and positions of responsibilty could be an article in of itself. The bizarre story of Michael Saiger is perhaps the most potent example of how the government has sought to answer the pandemic. Saiger, a Miami- based jewellery designer, earned £200 million in contracts from the UK government before paying £21 million to a Spanish businessman, Gabriel Gonzalez Andersson, to act as a go-between and source PPE. More on the economic response later. 

Shielding would be near impossible


The idea of ‘shielding’ the elderly sounds simple and honourable but in reality, would be deeply impractical. Data from Age UK reveals that a third of households in the UK are headed by someone aged 65 or over, 19% of carers are themselves aged over 65 and one in five people aged 50 to 64 in the UK are a carer. Cutting off the older age group from society would be impossible. This is without mentioning the ethical concerns of sacrificing older people for the sake of the economy, not to mention other issues. Sweden recently lifted restrictions on the over-70s citing the physical and mental consequences of social isolation.

What about at-risk groups? Public Health England’s report, Disparities in the risk and outcomes of COVID-19, makes for sobering reading. People of Chinese, Indian, Pakistani, Other Asian, Black Caribbean and Other Black ethnicity had between 10 and 50% higher risk of death when compared to White British. Should all these people shield? Working-age males diagnosed with COVID-19 were twice as likely to die as females. Should all men shield? It’s a non-starter. 

Economy vs lives is not an argument

Source: Financial Times

Opponents of further lockdowns use the argument of how much economic pain is worth saving lives? It’s a facile argument because the opposite question can easily be posed: how many deaths are worth protecting the economy? This is not a zero-sum game. According to data from the Financial Times economic impact of COVID-19 has been worse the poorer a country has been at controlling the disease. The two go together not as separate strands.

True, the economic impact of COVID-19 has been huge. Some of this has been due to the UK’s poor pandemic preparation. For example, The National Audit Office has revealed the price of sourcing PPE due to an inadequate stockpile. Between February and July this year, the Department of Health and Social Care spent almost £12.5 billion buying PPE that would have cost £2.5 billion before the pandemic.

As the UK’s economy is set shrink by 11.3 per cent in 2020 and the government would need to borrow £394bn to fund a shortfall in taxes and £280bn in public spending the fact is the money hasn’t been well-spent. Compared to other G7 countries the UK is set to spend over 80 per cent more, with a 90 per cent deeper decline in economic output in 2020 and almost 60 per cent more deaths. The reason appears to be delays in both the spring and autumn to impose lockdown with the result being harsher measures undermining the economy.

With the focus on COVID-19 it is easy to forget that in five-or-so weeks time will come the end of the UK’s transition period with the EU and the full impact of Brexit will hit. So easy, that Sunak did not mention it during his spending review statement. Yet for all the pain COVID-19 has wrecked the economy with the London School of Economics and the Office of Budget Responsibility both predict greater harm from the UK leaving its largest trading bloc.

Source: LSE

It is predicted that by the end of 2022 COVID-19 will have resulted in a 1.7% decline in GDP. In other words, the pandemic will cause a nasty, but short impact. However, leaving the EU with a trade deal will cause a 4.9% decline in 15 years time. A no-deal Brexit would cause the economy to shrink by 7.6% in 15 years. One hopes that those MPs pushing against lockdown on economic grounds will be as vigilant in pushing the government to ensure as close a deal as possible to the EU.

What does ‘postponing death’ even mean?

This cuts to the very nature of modern medicine. It is a fact of the human experience that death is ultimately unavoidable. As a doctor should I therefore not stop a patient dying from a heart attack because I’m merely postponing the inevitable? This is a question broader than just COVID-19. The fact is that while life expectancy has improved, the time spent in health has not improved as much. We have added years to life and not life to years.

However, delaying a pandemic is a good thing. It’s not just about saving capacity in a health service it also buys time for research. It buys time to improve care. A meta-analysis and systematic review (the highest level of scientific evidence) of intensive care units in Europe, Asia and America found that mortality amongst their patients with COVID-19 fell by a third from March to May. 

In other words, if the lockdown delayed you contracting COVID-19 by just three months from March to May your chance of survival improved from nearly 40–60 to 60–40. It doesn’t sound like much but it would do if you were the one about to be admitted and wanting to know your chances. It also buys time to trial new initiatives such as mass testing in Liverpool.

Let’s look again at that data from Public Health England which broke deaths from COVID-19 into age groups. 25.4% of deaths due to COVID-19 were recorded in patients aged 0–74. Hardly insignificant. However, life expectancy at birth in the UK in 2017 to 2019 was 79.4 years for males and 83.1 years for females. If we look at deaths in people aged up to 84 we see a different picture: 57.8% of deaths. 

COVID-19 deaths in England in 0-74 age-group compared to 75+, Source: PHE

COVID-19 deaths in England in 0-84 age-group compared to 85+, Source: PHE


In other words, nearly 6 out of every 10 deaths were in people within life expectancy. At what point has someone lived ‘long enough’ and the fact they didn’t reach life expectancy become meaningless? 

The way out


The ultimate step to successfully defeat COVID-19 will be vaccination. Through lockdown and other social distancing measures, the idea is to reduce the number of people infected whilst this key weapon is developed. On Monday 9th November Pfizer and BioNTech announced that initial results for their vaccine: an astonishing 90% efficacy rate. This vaccine was produced in a novel way which could pave the way for faster vaccine production in the future. However, the vaccine currently requires two doses three weeks apart and has to be sorted at about minus 75 degrees Celsius. 

Shortly afterwards Moderna announced the results for their vaccine: 95%. Once again, their vaccine requires two doses but refrigeration at a more manageable, but still extreme, minus 20. Oxford Uni-AstraZeneca then published their data: 62–90% efficacy improved by giving 1.5 doses rather than 2. Their vaccine only needs standard refrigeration at 2 degrees. These announcements are what we have been waiting for.

Source: The Economist

Final approval for vaccines will require time as will planning on how to overcome logistical issues of storage and overcoming vaccine hesitancy. There are also other vaccines in production. This is what the time lockdown gives us can do. There will be people alive to be vaccinated who wouldn’t have been without lockdown.

Lockdown also works. Non-pharmaceutical interventions such as staying at home and closing businesses have proven very effective at limiting the spread of COVID-19. The inverse is also true. Any relaxation means an increase in transmission. Data shows that by cutting long trips in particular lockdown limits transmission. It is a harsh medicine but necessary. All the more bizarre then the government’s Christmas bubble idea. A political decision with little Public Health behind it, it risks a lot. It’s sad that the message with it was that it was the season “to be jolly careful”. Hardly clear.

* * *

Boris Johnson grew up wanting to be ‘world king’. In December 2019 as he won a historic election a few cases of atypical pneumonia in China would have been the last thing on his mind. 2020 wasn’t supposed to be like this. This was supposed to be the year of Brexit finally delivered and of a new levelling up agenda. But this is what leadership is all about. Tony Blair won a second landslide on 7th June 2001 yet his whole premiership would be redefined on September 11th that year. Gordon Brown came to power in 2007 little knowing that the prize he’d lusted after for a decade would be wrecked within a year by the credit crunch. You don’t choose the circumstances. When the inevitable inquiries come into how the UK responded to the COVID-19 pandemic our leaders have to own the decisions they made and explain how and why they came to them. That is leadership.

It might also be wise leadership to explain how the UK went from a leader in pandemic planning in 2008 to the situation we are in now. To explain why we were so poorly prepared for a pandemic that the health service was unable to meet usual demand as well as face COVID-19? It might also be wise to detail the extent the findings of Operation Cygnus, the pandemic planning exercise in 2016, were used to shape policy. What was learnt and what was forgotten?

Finally, in a bid to end on a positive note it is important to look at just what we have achieved this year. When the Black Death hit the British Isles in 1348 it would be another 500 years before the cause was identified and another century before a cure was available. It took 80 years to identify the virus behind ‘Spanish ‘flu’. When HIV/AIDS first appeared in 1981 it was 3 years before the virus behind it was identified and another decade before a reliable treatment was available. In one year we have gone from a new disease to identifying the virus, sequencing its genetic code, finding a reliable treatment for the most severe cases and now have multiple vaccines available. This is astonishing. We should be proud of what we have got right. We should also learn from the things we got wrong. 

Reasons to be Cheerful if You're Not a Liverpool Fan: how the champions overachieved and may not be as good as we think

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30 years of hurt are over.  Blackburn Rovers and Leicester City have been knocked off their effing perches.  Liverpool have their first Premier League title.  In case you were in any doubt: This Matters More and You’ll Never Walk Alone. (Unless you’re the staff they attempted to furlough or Liverpool Women neglected to their fate).

There have been and will continue to be plenty of puff pieces on this subject.  The world according to Steve McManaman or Jim Beglin.  Where Anfield is home to special fans who know football better than others who support a club with history; because no other club has passionate fans or history.  A world where Michael Owen is suddenly a Liverpool fan again and thinks that the highest point of Atletico Madrid’s existence was winning on Merseyside.  A world where a recent BBC programme chronicled Liverpool’s title charge as an almost biblical mission.   

And so with a snort of derision I find myself wondering: are Liverpool actually THAT good? Yes, I’m a Manchester United fan and yes, this is (slightly) tongue in cheek but are they?

There was once a role within the Catholic Church to provide evidence against the canonisation of a candidate.  The advocatus diaboli or ‘Devil’s Advocate’ would seek out holes in the argument to award sainthood.  Consider this playing (red) devil’s advocate against the imperious reputation of Liverpool this season.  Before you accuse me: yes, of course I’m bitter.  Liverpool won the Premier League at a canter and, rightly, won plaudits.  However, I’m going to put their season under some scrutiny and use data to answer the question: Are there reasons to be cheerful if you’re not a Liverpool fan looking ahead to next season?  Is there a chance they won’t retain the title?

A glance at the 2019-20 Premier League table is impressive.  There’s Liverpool on 99 points; 18 clear of Manchester City.  Only once before had a club won the league with more points.  Surely there is no questioning their dominance?  Enter statistics.  

Whilst VAR hogs most discussions regarding recent updates to the world of football, for me Expected Goals (EG) has been a far more interesting and illuminating way of looking at the game.  It’s a simple piece of data with far reaching potential.  Each chance at goal is given a numerical value, or xG, between 0-1.  This value basically reflects how hard or easy that chance is.  A shot with an xG of 0.5 means it would be scored 50% of the time.  A shot with an xG of 0.9 would be scored 90% of the time.  And so on.  This BBC Sport article goes into depth about how each chance is awarded a value but, essentially, the closer you are to the goal and the ‘easier’ the shot the higher the xG.  

If you think about it this has the chance to revolutionise how we look at football.  Rather than simply measuring a striker’s quality by goals scored we can look at their xG: do they match their xG (score as many as they should based on difficulty of the chance) or do they exceed or even fall under it?  The same principle works on a defence.  Say a team concedes a lot of shots on goal, we might be tempted to think their defence was poor.  However, they may be employing a low block and, as a result, concede a lot of long shots which count as a shot on goal but have a low xG.  This would give that team a low EG against and more accurately reflect how well they were defending. 

If we can calculate the EG scored (xGs) and EG against (xGa) for both teams during a match we can calculate the result that statistically ‘should’ have happened.  

For example, Liverpool started the 2019-20 season with a 4-1 thrashing of newly promoted Norwich City.  The EGs for both teams was 2.23 for Liverpool and 0.43 for Norwich City.  So, actually both teams scored more than their EG suggests but the result would still have been a Liverpool win.  

Their next match was a 2-1 win away at Southampton.  A statement of intent.  Looking again at the EG and we are given a score of 2.14 - 1.52 in Southampton’s favour.  According to statistics Liverpool should not have won this match.  Not surprising when you might remember this match contained Danny Ings’s horror miss from a few yards out.  

On September 22nd they racked up their sixth straight win away at Stamford Bridge.  However EG shows that rather than a 2-1 away win the chances created would indicate a score of 1.23 to 1.03 in Chelsea’s favour.  

By November 10th Liverpool looked like champions elect already with a 3-1 win against defending champions Manchester City at Anfield 3-1.  The EG score? 1.33 - 1.48.  Another win that shouldn’t have been.

Through the EGs for each match we can then calculate the Expected Points (EP) that team ‘should’ have acquired based on the chances they were making and conceding during the season.  As you may have guessed, looking at Liverpool’s EP tells an interesting story.

Here’s the final 2019-2020 table as it was:

Here it is based on EP:

Liverpool outperformed their EP by 24.72.  They scored 9.81 goals more and conceded 6.57 fewer than their xGs and xGa would suggest.  Based on EP they should have been second,  12 points behind Manchester City and only 4 above Manchester United in 4th.  

As I said before the game isn’t played on the pitch so there’s obviously going to be some discrepancy and teams will over-perform to some extent.  To see the biggest ‘overachievers’ in the 2019-20 Premier League season I subtracted EP from actual points.  This is the top five:

Liverpool overachieved more than any other club, double the degree of Newcastle United, who came second in this table.  I think we’d all agree that Steve Bruce did good work at Newcastle United but based on EP his team would have been relegated at the rock bottom.  What does that say about Liverpool?  OK, maybe this was a fluke and Liverpool were simply on a roll this season. Let’s look at 2018-19; the season where Liverpool lost only once, won 97 points and finished second.  Here’s the top four as it finished:

Incredibly, Liverpool outperformed their EP by 13.55.  Once again they were the highest overachievers.  In 2017-2018 the highest overachievers were Jose Mourinho’s Manchester United who finished second but should have finished sixth.  And we know how that played out.


So, over the course of 2 seasons, Liverpool have outperformed their EP by a staggering 38.72 points.  This is obviously commendable but is it sustainable? The received wisdom was that Leicester City’s fairy story in 2016 was a one-off and so it came to pass.  However, they only exceeded their EP by 12.06.  By comparison, in winning the Bundesliga Bayern Munich exceeded their EP by only 4.67 in 2020 and actually should have had 4 more points in 2019. Manchester City in their disaster of a season should have won the league this year.


Why the discrepancy?  How did Liverpool finish 18 points ahead of Manchester City when they should have been 12 behind? Of their 32 wins, 14 (44.75%) were by one goal.  In comparison in 2018/19 only 9 (28.125%) of Manchester City’s wins were by one goal.  Manchester City outperformed Liverpool by 17 goals scored and only conceded 2 goals more.  But they lost 9 games to Liverpool’s 3.  5 of those defeats were by only one goal.  These are the margins behind the story of the 2019-20 season.   A compelling story but not one which should make the chasing pack terrified for the new season.

So how have Liverpool been able to exceed EP and beat the model?  There’s been a bit of talk about this and in my opinion, this is the real question which needs answering and isn’t amongst all the plaudits.  Of course, Liverpool played very well but they only have the player of the season if you’ve never heard of Kevin de Bruyne.  The number of one-goal wins and their xGa suggests they own a lot more to Alisson than any other player.  Of course, it’s not a bad thing to have a good goalkeeper: in fact, it’s essential.  We don’t know whether if Liverpool did concede more they wouldn’t have just gone up the other end and scored more rather than seeing a match out.  But we can only look at the data we have.

There is lots of discussion about Liverpool’s style of play and their manager’s tactical acumen.  To my mind as long as Pep Guardiola resides on these shores I’d argue that Klopp could only be second in the list of most interesting tacticians in the Premier League.  Now Marcelo Bielsa will be plying his trade in the top flight Jurgen is third at best. Maybe the over-performance of Liverpool over the past two seasons shows us that this is not where his strengths lie: rather it is about eking out consistency from his players as well as managing situations within a game.  An emotive coach, it was inevitable that he would work at Liverpool: an emotive club.  Perhaps only Diego Simeone embodies the very persona of his team in a greater way than Klopp does.

Klopp has shown how he is the master of managing situations and matches.  His Champions League triumph in 2019 owed much to managing moments: a knockout round place earned thanks to a 1-0 win against a sleepy Napoli with Arkadiusz Milik hitting an injury-time chance straight at Alisson; a buoyant semi-final against a Barcelona so emotionally fragile they were capable of throwing away a 3-0 lead; a final facing a broken Spurs team which lasted all of two minutes until a dubious penalty was awarded.  They managed the match at 1-0 and scored a late second.

In 2019-20 Klopp then brought this to their league form: securing single goal margins and seeing a game out.  This would put him at the pinnacle of the psychological aspect of the game.  Gareth Southgate has done much with England to help them manage high pressure situations as well as using emotions for advantage.  Ole Gunnar Solskjaer at Manchester United, Frank Lampard at Chelsea, Zinedine Zidane at Real Madrid and now Andrea Pirlo at Juventus are all appointments based on emotions. Perhaps their records as players speak more to modern players than tacticians like Jose Mourinho, Rafael Benitez or Maurizio Sarri, coaches with no playing career to speak of.  In a game of high-profile moments with season-defining jeopardy, maybe Jurgen Klopp has turned owning the match into an art.  Maybe that is where his plaudits should actually lie. 

Jurgen Klopp is a fascinating character.  The general image is of him laughing and joking yet some had a certain Portuguese manager screamed at a linesman, run onto a pitch, criticised the tactics of Manchester United in the league and Atlético Madrid, played a youth team in the League Cup and refused to attend a FA Cup match it is tempting to wonder if the press would remain as positive.  He’s winning now and it is easy to be nice when you’re winning.  Yet his final season at Borussia Dortmund should serve as a warning.  At Christmas, the club he had won two titles with and taken to the Champions League final were in the relegation zone.  He took them back up to the Europa League places before resigning. Perhaps when the power to control moments slips so too do the results.  Maybe this is the downside of an emotive coach at an emotive club.  The first match of the 2020-21 season against Leeds United may be instructive.

Of course, in order for Liverpool to lose the title, someone else has to win it.  Arsenal, Chelsea and Manchester United are all in decent places.  Mikel Arteta is showing promise, Chelsea are assembling an intriguing squad and Manchester United have their most entertaining group of attacking players since the days of Sir Alex.  Yet it is hard to see any of them taking the title just yet.  Although based on EP Chelsea and Manchester United were much closer to Liverpool than the table would tell us and should be encouraged. The favourite to stop Liverpool remains Pep Guardiola, though.

Guardiola is entering his first fifth season at a club. This is uncharted territory.  Yet the manager who turns diligence to obsession will want to win back the league.  And it is closer than you think  Turn those 5 single goal defeats to draws and that 18 point gap becomes 8. If 4 of Liverpool’s 14 single goal wins become draws and that 18 point gap is gone.

Finally, this is not an era of eras.  Since 2009 only one club has retained the Premier League. For several of those campaigns such as Manchester United in 2013-14, Manchester City in 2014-15 and 2019-20; Chelsea in 2015-16 and 2017-18 and Leicester in 2016-17 title defences were non-existent.  Jurgen Klopp did retain the Bundesliga once with Borussia Dortmund but then failed to match Bayern Munich.  He would do well to not slip into hubris.  To look at the data and perhaps reflect on how this league title was won.  And how it might be taken off him far easier than we might think.

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Mad, Bad and Dangerous: Answering COVID-19 Conspiracies

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The Electromagnetic Spectrum

“A Lie Can Travel Halfway Around the World While the Truth Is Putting On Its Shoes”

Last Saturday saw a protest in London against the COVID-19 lock down. Its architects were global warming denialist Piers Corbyn and David Icke, a man who alleges that the British Royal Family are actually giant lizards. Cue a deep dive into COVID-10 conspiracy theories. No one can agree which conspiracy is the correct one but there definitely is one. Wake up sheeple! 

The above tweet from Joe Politics showing anti-lock down protesters caught my attention as it nicely displays the general themes these lies have taken: the virus isn’t real, it’s being used as an excuse by governments and that 5G is behind the whole thing. I thought I’d go through each of the claims made by the protesters in the video and look to see if the science backs them up. In summary it doesn’t. For more information, read on.

“I believe that the virus is real, but it’s not as bad as they are saying it is”

“The mortality rate for this is less than the ‘flu. It’s been proven”

I’ve grouped these two claims together as they are on a similar theme and echo sentiments made by people in power such as Brazilian President Jair Bolsonaro.  Is COVID-19 as bad as is made out?  

It depends on which ‘flu you mean.  Influenza is a disease which has been with mankind for a long time.  Hippocrates the Ancient Greek physician described what sounds like ‘flu over 2000 years ago.  It is caused by a virus of which there are three kinds: A, B and C.  The most  common is Influenza A.  Influenza A viruses contain two proteins: haemagglutinin and neuraminidase which are abbreviated to ‘H’ and ‘N’.  Strains of influenza A are distinguished by the type of these proteins, or antigen, they express on their outer surface; H1N1 being one strain, H2N2 being another and so on.  

There’s been a lot of talk of the influenza pandemic of 1918-1919; often called ‘Spanish ‘flu’.  This was caused by H1N1 Influenza A.  It’s estimated that it infected 500 million people worldwide, killing 50 million.  That’s a mortality rate of 10%.  

By comparison as of 1st September 2020 there have been 25,694,471 confirmed cases of COVID-19, including 855,962 deaths, reported to the World Health Organisation (WHO). That’s a mortality rate of 3.33%. So he’s right, COVID-19 has a mortality rate about a third of Spanish ‘flu.  

But hang on.  Because we have lived so long with influenza we have entered into an ‘arms race’: the virus mutates, we develop immunity, the virus becomes less deadly until a new mutation and so on.  This is the difference between seasonal ‘flu we experience every year and pandemic ‘flu.  

Since 1919 we have also developed influenza vaccines not to mention we’ve made vast improvements in public health.  The H1N1 virus was also behind the swine ‘flu pandemic of 2009-2010.  Over 80 years since the Spanish ‘flu.  Same virus, 80 years of medical improvements later.  The WHO reported  491,382 confirmed cases and 18,449 deaths.  That’s a mortality rate of 3.75%.  Only slightly more than COVID-19.  

What about a different Influenza A virus?  The Asian ‘flu pandemic (H2N2) of 1957 to 1958 had a mortality rate of 0.3% in the UK.  Much less than the 12.4% mortality we’ve seen with COVID-19 in the UK at the time of writing.  

Data for the 2019-2020 influenza season is still being collected and, understandably, research has been superseded by the COVID-19 pandemic. When saying one disease is ‘worse’ than another it’s important to try and limit differences as much as possible.  Here in the UK we have a much more sophisticated healthcare infrastructure than a lot of the world with some diseases which cause huge numbers of deaths worldwide such as malaria non-existent here.  

To that end let’s look at numbers as focused and comparable as possible.  

On 3rd June 2020 the Scottish Intensive Care Society Audit Group published a report on COVID-19.  Between 1 March 2020 to 16 May 2020 there were 504 patients with confirmed COVID-19 admitted to intensive care units in Scotland.  Of these patients, 38% died.  

Looking at data available from the 2018-2019 influenza season tells us that from October 1st 2018 to April 8th 2019 only 166 patients with influenza were admitted to an intensive care unit in Scotland.  Of these patients, 19% died.  

In other words, in just 12 weeks over three times the number of patients in Scotland were admitted to intensive care with COVID-19 than those admitted over 27 weeks with influenza.   The mortality rate for COVID-19 was double that of influenza.  

Three times the number of patients. Double the mortality rate.  In less than half the amount of time.  

The CDC in the USA has recorded 34,157 deaths due to influenza in the 2018-19 ‘flu season. This represents 10.4 deaths per 100,000 people in the USA.  As of 11th June 2020, the World Health Organisation has recorded 111,978 deaths in people in the US who tested positive for COVID-19.  This represents 32 deaths per 100,000.  

This disease is bad.  It has a lower mortality rate than the worst influenza pandemic ever but that is hardly a comfort.  Spanish ‘flu’s mortality rate is dwarfed by that of the Black Death where it’s estimated a third of the population of Europe died.  Does this make deaths due to Spanish ‘flu inconsequential?  Of course not.  Once again.  This disease is bad.  It’s much worse than seasonal ‘flu and even some pandemic ‘flu.  

“The test that they use, it has an 80% false positive.  This virus has never been proven to exist”

Let’s start with the bit about the virus not existing.  

Viruses are bizarre.  First, there’s what they actually are.  They are just a collection of genetic material wrapped in an envelope of proteins and sugars.  That’s it.  Then there’s their size.   They are tiny.  You could fit 100,000 of even the largest species of viruses on a full stop.  As a result whilst the existence of an infective agent smaller than bacteria was hypothesised in the 19th century it wasn’t until 1931 when we could actually see them.  This was due to the invention of the electron microscope which used beams of electrons rather than light.  Then there’s how they multiply.  By themselves, viruses appear inert.  It is only when they infect a host they are able to multiply.  They injecting their genetic material into the host’s cells which hijacks their normal functioning.  The cell instead starts producing more virus until it ‘explodes’ releasing the new virus which can infect more cells and so on.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus behind COVID-19 is a member of the coronavirus ‘family’ of viruses.  Coronaviruses were first identified in chickens in the 1930s and in humans in the 1960s.  Their name comes from the Latin for crown because when viewed down an electron microscope spiky proteins on their surface looks like the points of a crown.  They are common and have been found in a variety of animals from bats to camels.  It’s estimated that about a quarter of all cases of the common cold are caused by coronaviruses. Their pandemic potential has also been proven.  The Severe Acute Respiratory Syndrome (SARS) pandemic of 2003 (8096 cases, 774 deaths) and Middle Eastern Respiratory Syndrome (MERS) pandemic of 2012 (2494 cases, 858 deaths) were both caused by a coronavirus.  

The first cases of COVID-19 were identified in an unusual pneumonia in China in December 2019.  Within a month SARS-CoV-2 had been genetically sequenced.  In February the first electron microscopy pictures of the virus were released.  We’re tracking its mutation rate.  We have modelled the structure of the virus’s membrane and the receptors in humans it targets and replicated these in mice.

So to clarify: this virus comes from a family we know a lot about and which has already been shown to cause pandemics.  Within a couple of months of becoming aware of it, we have been able to sequence its genetic material and even take photographs of it.  We know how it targets us and we’re tracking its evolution.  It exists. It has been proven to exist. 

What this illustrates is a fact about conspiracy theories and theorists.  Whilst one of the interviewed protesters was happy to admit the virus is real this gentleman claimed it hasn’t been proven to exist.  If there’s a conspiracy what is it?  You see this with claims about JFK, the moon landings or vaccines.  Everyone has their own ideas: it was the mafia, it was the CIA etc.  Surely if there is a conspiracy only one of them can be right?  But which one?  Maybe the reason there are so many conspiracy theories is that they’re all wrong whereas people following an actual scientific method tend to arrive at the same conclusions: Lee Harvey-Oswald killed JFK, the moon landings happened, vaccines are safe and COVID-19 exists.  That’s not a conspiracy.  It’s just the reason why we have a scientific method in the first place.

Now, what about this claim about 80% false positives?

No test is perfect and there are ways of being able to assess any test used in Medicine.  One is the ability of a test to detect disease in someone who has it.  This is sensitivity.  Another is a test’s ability to rule out disease in people who don’t have it.  This is specificity.  

This chap is alleging that the test for COVID-19 has a false positive rate of 80%.  He’s claiming that 80% of positive results for COVID-19 are wrong; that people without COVID-19 are testing as positive.  Therefore he is alleging that the test for COVID-19 is not specific enough; it is failing to rule out the absence of disease in 80% of cases.  Never mind the fact that if the virus didn’t exist the false positive rate would actually be 100%, let’s explore that figure of 80%.  That doesn’t sound right.  That’s because it isn’t. 

Firstly it’s important to look for a disease in the right place.  The Ebola virus, for example, is spread by direct contact with body fluids.  The blood of a patient with Ebola as well as other fluids such as vomit is therefore full of the virus.  COVID-19, by comparison, is spread by coughing up droplets containing the virus and so it sticks to the respiratory system.   

A study in China looked at different samples taken from patients known to have COVID-19.  In all, they looked at over one thousand samples taken from over two hundred patients.  Only 1% of the blood samples taken showed the virus.  By contrast, the best sample for detecting the virus was bronchoalveolar lavage: a test performed by shooting water in the deep airways of a patient and then collecting it to see what the washing picks up.  93% of these samples found the virus.  But this is a test only performed on sedated patients; it can’t be used in mass testing.  The study also looked at swabs taken from the nose and throat (the tests we use most commonly) and found they detected the virus in 63% and 32% of patients respectively.  This suggested a false negative rate of 37% for nasal swabs and 68% for throat swabs.  According to Dr Jessica Watson; a GP studying the quality of diagnostic tests, who appeared on a recent episode of the BBC Radio 4 show More or Less, the nose and throat swabs being used in the UK currently pick up the virus in about 70% of patients showing symptoms.  

This all indicates that the problem is with false negatives rather than false positives; with sensitivity (finding the disease in people who have it), not specificity (ruling it out in people who don’t).  This makes sense.  The test for the virus looks for its genetic material.  In order to detect it, we run a polymerase chain reaction (PCR) test which takes a small sample of genetic material and makes more of it in order so it can be analysed.  This is the same principle used in forensics.  If a swab is taken too early in the infection or too late there may not be enough virus around to detect.  If the person taking the swab doesn’t use the right technique it won’t pick up enough or any virus to analyse in the first place.  That’s before we even get onto the UK’s policy toward testing and the phenomenon of asymptomatic patients.  

Rather than a false positive rate of 80%, there is, in fact, a false negative rate of about 30%.  Far from over-diagnosis the problem, in fact, is with under-diagnosis.  In both counts this man is wrong.  

“If you look up radiation poisoning, the effects of that and the effects of COVID-19 fit together like a glove”

Ah, the 5G conspiracy.  100 5G masts have been set on fire in the UK due to the belief that the wireless network either created the COVID-19 virus or has weakened our immune system to the point that we’re more susceptible to the virus.  Of course, this is nonsense.  Let’s look at why.

5G is so-called because it is the fifth generation network being used by mobile phones.  The idea being it uses radio waves of a higher frequency (the number of waves in a given period of time) than previously used so a greater amount of information can be transmitted. Waves at a greater frequency can’t travel as far so more towers are needed to transmit.  Radio waves are a form of electromagnetic radiation.  Uh-oh, radiation.  That’s bad, right? Not necessarily. All forms of electromagnetic radiation exist on a spectrum, the electromagnetic spectrum, with waves of shorter frequency on one end and those of higher frequency on the other.  Those waves of a higher frequency are called ‘ionising radiation’; the waves are able to interfere with the structure of atoms.  It is ionising radiation which can damage DNA.  Lower frequency, or non-ionising radiation, can not do this as the waves don’t carry sufficient energy.  You’ll note that even though 5G uses higher frequency radio waves their frequency is still so low they sit comfortably on the non-ionising side of the spectrum.  You’ll also see that as well as nuclear radiation on the ionising side there is also visible light.  This is why sunburn is so serious as light waves have the ability to damage skin and mutate DNA to cause cancer.  But of course, no-one protests against the Sun.  Or light bulbs.

But let’s for one moment break the rules of physics and pretend that 5G is ionising radiation.  Luckily there’s a resource for healthcare workers called Toxbase which gives advice on all things toxicological.  For patients recently exposed to ionising radiation it gives these symptoms:

“Nausea, vomiting, anorexia, mild pyrexia, erythema and diarrhoea developing hours to days following exposure. Earlier onset of clinical features indicates higher absorbed dose. Conjunctivitis may occur if the eyes have been exposed”.

The WHO gives this information on the symptoms of COVID-19:

“The most common symptoms of COVID-19 are fever, dry cough, and tiredness. Other symptoms that are less common and may affect some patients include aches and pains, nasal congestion, headache, conjunctivitis, sore throat, diarrhea, loss of taste or smell or a rash on skin or discoloration of fingers or toes. These symptoms are usually mild and begin gradually. Some people become infected but only have very mild symptoms.”

Hardly fitting like a glove.

Let’s now listen to the laws of physics and look up what non-ionising radiation (what 5G actually is) can do to you:

“Skin burns, which may be more penetrating than burns from a thermal source.

No consistently replicable effects have been found from exposures at levels below those that produce detectable heating, in particular there is no convincing evidence of common symptoms (e.g. headaches), genetic damage or increased likelihood of cells becoming malignant due to acute or chronic radio frequency exposures (PHE)”.

Again not even fitting like a glove (you’ll have to imagine me doing that thing he did with his hands). 

There are only so many symptoms a disease can cause.  Just because different disease processes have similar symptoms it doesn’t mean those diseases are the same.  High blood pressure and brain tumours are two very different things yet both can cause headaches.  The art of Medicine is in exploring a symptom with history and investigations to find the cause.  Not just reading a list online.  

This is not the only myth about 5G.  Another is that 5G weakens our immune system.  Another is that somehow it caused this virus.  Both are biological impossibilities.  The scruples of people peddling these lies can be shown by the peddling of the £339 ‘5GBioShield’ which claimed to provide “protection for your home and family, thanks to the wearable holographic nano-layer catalyser.”  It was found to just be a normal USB stick.  

I can not emphasise this enough: There is no evidence that 5G is bad for you.  It does not cause COVID-19.  

“You don’t lock the world up for a virus that has a mortality rate of less than 1%”

See above.  Its worldwide mortality rate is currently 3.33%. That’s more than 1%.  Not less. 

But anyway, why did we lock the world up?  The reason is not just with the number of people who might die but also the burden placed on healthcare systems.  One way of looking at how infectious a disease is by measuring its basic reproduction number called R nought (R0).

One study in Wuhan, China found that COVID-19 had an R0 of 3.  This means that every patient infected another 3 people and so on. That doesn’t sound much but in just 13 steps:

1 -> 3 -> 9 -> 27 -> 81 -> 243 -> 729 -> 2187 -> 6561 -> 19683 -> 59049 -> 177147 -> 531441 -> 1594323

One case could become more than 1.5 million.  As the disease emerged it became apparent that 5% of patients infected developed critical illness.  That would be 75,000 patients needing critical care.  In the most recent data available before the COVID-19 lock down there were 4,122 intensive care beds in England.  1.5 millions patients, 75,000 of whom needing a critical care bed would easily overwhelm our health service.

This is the reason behind lock down, behind ‘stay home, protect the NHS, save lives’ and flattening the curve.  Through lock down measures in Wuhan the study found that the R0 was reduced from 3 to 0.3  This is the crucial step of beating an infectious disease; reaching the point where each patient is infecting fewer than one other person.  This makes the difference between millions of patients and beating the virus.  In the past week, Professor Neil Ferguson a former senior member of the Scientific Advisory Group for Emergencies (SAGE) has claimed that the UK death toll could have been halved if lock down had been started a week earlier.  A recent systematic review and meta-analysis (the highest level of scientific evidence) of the literature in the Lancet strongly supports the use of physical distancing measures in reducing the risk of infection.

For what it is worth measles does have a mortality rate of less than 1% at 0.2% although the disease carries a risk of serious complications.  Despite its low mortality measles is even more infectious than COVID-19 with an R0 of somewhere between 12 and 18. Last year during an outbreak of measles in New York there was a public health emergency slightly prescient of the lock down declared.   Non-vaccinated children were not allowed in public spaces, legislation allowing vaccine exemption was repealed and some pre-schools were closed.   And that’s for a disease where there is a vaccine. So she is wrong.  Both on the mortality rate of COVID-19 and on the lock down.  

“I think we will be living in a far worse, dystopian version of Nazi Germany”

The Nazis were responsible for the systematic discrimination, persecution and murder of people based on a deranged idea of eugenics.  They sent people to work as slaves and die purely because they didn’t fit the perceived Nazi ideal.  They sought out the most vulnerable: the disabled and the young and made them their own plaything to experiment on.  They murdered six million Jewish men, women and children.  I am genuinely staggered how anyone could think a “far worse, dystopian” version of this possible much less make a casual prediction that a lock down designed to prevent a virus is going to bring it about.  I can’t really say anything else whilst being polite.  

So there we have it.  Five conspiracy theories which don’t stand up to scientific scrutiny. I don’t expect this will change minds of the converted, but maybe, as with vaccination we can ring around ‘outbreaks’ of conspiracy and prevent it being spread further. Misinformation drives public health risks such as vaccine hesitancy.It’s not easy.  I’ve tweeted about the lies of anti-vaxxers and been called everything from a clown to a stooge of big Pharma by people who feel their meme corresponds to a medical degree.  But as US Senator Daniel Patrick Moynihan said, “You are entitled to your opinion. But you are not entitled to your own facts”.  

Ice and a slice (of history): the story of the G&T

shutterstock_169910423.jpg

Last weekend saw World Gin Day; a chance to celebrate a drink which has exploded in popularity in the UK over the past few years. ‘Gin’ describes a liquor which is at least 40% alcohol by volume derived from grain distillation and primarily flavoured with juniper berries. It is the Dutch word for juniper, genever, which gives us the word ‘gin’. With the warm weather, many of us may be reaching for a relaxing beverage in the form of a gin with its most popular mixer: tonic. The story of this drink, with its myriad different garnishes and taste profiles, starts in the most unlikely place: fighting a deadly disease.

Malaria remains one of the biggest global health issues. According to the World Health Organisation in 2018 228 million people were infected worldwide with malaria, with 405,000 dying. Nearly half of the world’s population live in malaria-affected areas. The symptoms are vague; tiredness, muscle pains and periods of fever and shivering. Multi-organ failure can result.

The disease is caused by a single-celled organism called Plasmodium. This parasite has a complex life cycle which begins with a sporozoite stage which infects liver cells where they reproduce once: creating merozoites which are released when the infected liver cells burst. The merozoites in turn infect and reproduce inside red blood cells. The red blood cells burst and release more merozoites which infect yet more red blood cells and the cycle continues. This stage corresponds to the periodic fever the patient feels. At some point gametocytes rather than merozoites are produced. These are sexual (there are male and female forms). If a female Anopheles mosquito bites and drinks the blood of an infected patient it is the gametocytes which are ingested as well. Inside the stomach of the mosquito, they undergo sexual reproduction and form sporozoites. The next time the mosquito feeds it is these sporozoites she’ll inject into that person’s bloodstream and so the circle begins anew and another patient develops malaria.

Dr. Alphonse Laveran, a military doctor in France’s Service de Santé des Armées (Health Service of the Armed Forces).

Illustration drawn by Laveran of various stages of malaria parasites as seen on fresh blood.

Illustration drawn by Laveran of various stages of malaria parasites as seen on fresh blood.

Malaria was endemic in Europe; its name comes from medieval Italian for ‘bad air’ and was associated with swamps and other stagnant water. However, it was colonialism which would represent the biggest battle between imperial powers and malaria. The cause of malaria would first be identified in 1880 by a French army doctor, Alphonse Laveran, spotting the parasite down a microscope in the blood of patients.

As is often the case in medical history, however, a cure was sought long before the cause was identified.  

It’s the early 17th-century in Peru.  The Spanish Countess of Chinchón, Ana de Osorio, the wife of the Viceroy of Peru is ill with malaria.  The locals present her with the bark of a local tree.  The tale was that a local man, ill with malaria, drank from a pool of water contaminated with this bark and was cured.  Although probably apocryphal, the bark had become a reliable cure for the natives.  Ana de Osorio took the bark and was cured.  On her return to Europe, she brought word of this tree.  French scientists were able to isolate the compound responsible for defeating malaria and named it ‘quinine’ after the Inca word for the tree bark.  The tree itself was named ‘cinchona’ in honour of the countess.  

Wellcome Images

Wellcome Images

The Scottish physician George Cleghorn (1716-1789), who had spent years studying fevers in Minorca (now Menorca), would hear of the properties of quinine and recommended that a solution of quinine in water be provided to British soldiers stationed in the Indian subcontinent.  He was listened to and ‘Indian Tonic Water’ became a staple of colonial life.  However, the solution was incredibly bitter.  To make the drink more palatable by the 19th-century soldiers had started mixing it with sugar, lime, and; crucially, gin. The gin and tonic was born.

Portrait. Credit: Wellcome Library

Initially, the Peruvian authorities did all they could to protect their monopoly on cinchona plants and prohibited the exportation of its seeds.  British businessman and alpaca farmer Charles Ledger, with the help of his manservant, was able to smuggle cinchona seeds out of the country.  He sold them to the Dutch government who started growing cinchona in the Dutch East Indies. 

By 1900 at least two-thirds of the world’s supply of quinine was grown in Java.  Indonesia and India remain important cultivators of cinchona; it is also grown throughout Africa.  

Modern tonic water has a quinine content far below the therapeutic dose and is produced for consumption only, not a cure.  Quinine itself has been replaced with other drug treatments for malaria although it remains an option in cases of drug-resistance.  Resistance has been identified in two of the four Plasmodium species which cause malaria and represents a public health challenge.  Mosquito control and sanitation remain staples of attempts to control the disease. Gin and tonic remains a popular drink with its own international day: 19th October.  

Disease has been a part of existence throughout the history of mankind.  It therefore shouldn’t be surprising to find aspects of modern life which appear completely unrelated to healthcare with their roots in the history of medicine.  When it comes to gin and tonic there are hints: the popular tonic water brand ‘Fever Tree’ chose its name in honour of the cinchona plant. Every time you have a ‘G&T’ you’re sampling a taste of that history.

Cheers.