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

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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.

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Focus on what you what to focus on.

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One point per slide.

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

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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.

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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.

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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.

The Seven Deadly Sins of MedTwitter

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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

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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.

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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.

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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. 

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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.

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Envy

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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. 

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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.

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Gluttony

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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.

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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.

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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.”

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. 

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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.

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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.

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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.  

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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. 

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…

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.

Mad, Bad and Dangerous: Answering COVID-19 Conspiracies

Spoke to these absolute headcases protesting lockdown today, about 4 brain cells between them pic.twitter.com/GJJN92zxX0

— Josh Kaplan (@JNkappers) May 2, 2020

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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”.  

Using evidence based education to design a teaching session

This sketch by Mitchell and Webb is funny but also has an important message behind it: evidence based medicine (EBM) is the centre of clinical practice. The reason we don’t reach for quartz crystals or start diluting down poisons is because we want to follow the evidence base. Yet while we want to practice evidence based healthcare do we always practice evidence based education? Do we route our education practices in the evidence base as much as we do in healthcare? Or do debunked educational theories such as learning styles still survive and spread? If we wouldn’t try and treat a trauma patient with crystals why try and teach with the educational equivalent of homeopathy?

This blog will take a look at the evidence base of how we learn and use that to form an approach to a teaching session that will make it easy for your audience. Whenever we teach our audience need to be our sole priority. Understanding how they think and learn should be central to how we design a teaching session.

What did you have to eat for lunch three weeks ago? What was the name of your first childhood pet? Chances are you won’t remember the former but will the latter even though your childhood pet may have been years ago. The reason is because of how human beings store information and form memories.

There’s essentially two types of information: the here and now and the long term. There here and now is dealt with by our working memory. Working memory is a cognitive system with a limited capacity. It temporarily holds information available to us to use immediately. Working memory is made of the phonological loop, which deals with sound information, the visual-spatial sketch pad, which deals with visual information and spatial awareness, and the central executive which controls information within the different areas. We therefore use our working memory for tasks such as reading, problem solving and navigation.

Working memory can hold a maximum of nine items (the seven plus or minus two principle) at any one time for fifteen to thirty seconds. That includes sensory information. This is why we have neural adaptation; after a while we no longer feel the clothes we’re wearing or smell the aftershave or perfume we’re wearing. If there’s a constant stimulus eventually our brain will start to ignore it in order to free up working memory.

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Working memory becomes long term memory by categorising information into knowledge structures called ‘schema’. Through integrating these schema with existing knowledge and then repeated retrieval of the knowledge it becomes embedded in our long term memory. The lunch you ate three weeks ago would have been processed in your working memory, the here and now. But once eaten unless you repeated retrieving the memory it quickly became lost. However, your childhood pet, central to so many experiences over a long time, will be part of your long term memory and easily recalled.

The effort of turning working memory into long term memory is called cognitive load. As with physical effort it has its limits; just as if you try and lift too much weight you need to put it down and rest so too if your audience’s cognitive load is too much then they won’t learn.

We can see this outside of the classroom. Say you’re driving to work.  A route you use every working day.  The radio is on and you’re singing along word for word.  Suddenly you see there’s road works and you have to go down a different route you’re not familiar with.  There’s a tight parking spot and you need to do a three point turn.  What about the song?  Now it’s no longer pleasant but a distraction.  It’s like you don’t have the head space to listen and perform your tasks.  You turn the radio down.  Now it all feels easier. That is due to cognitive load. What we think of as multi-tasking is actually us moving attention between information and tasks. The more information and tasks going on the harder it is to manage.

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There are three types of cognitive load which make up the total effort: the Good, the Bad and the Ugly. It’s a zero sum process so if there is too much negative load the less space there is for learning. We have to simplify the ugly, reduce the bad and maximise the good. This is cognitive load theory.

THE (CAN BE) UGLY

Intrinsic cognitive load is the amount of cognitive resources the person would need to use to transfer new information to long term memory. This basically how complex the material being taught is. Therefore it can be ugly. Too much complexity and there is too much of a cognitive load on our audience. An educator needs to manage this part and simplify their message as much as possible. This minimises intrinsic cognitive load and prevents it getting ugly. How can we find the right level for our message?

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Bloom’s cognitive taxonomy

Benjamin Bloom (1913-1999) was an American education psychologist who chaired a committee of educators which devised three hierarchical models for education in the domains of cognition (knowledge), affection (emotion) and psychomotor (action).  These models classify learning into increasing levels of complexity and are used to devise learning objectives and design a teaching session.  

The cognitive domain is used as the basis of traditional curricula.  A student must first be able to achieve the basics before they can be expected to achieve the highest levels.  First they must remember facts, understand them, apply that knowledge before analysing and evaluating material before finally creating it themselves.  

• Before you can understand a concept, you must remember it.

• To apply a concept you must first understand it.

• In order to evaluate a process, you must have analysed it.

• To create an accurate conclusion, you must have completed a thorough evaluation.

We can use the cognitive domain to design a teaching session.  For instance, if you’re designing a session on sepsis and you’re audience have never heard the term before you would want to focus your session on remembering and understanding and so reduce intrinsic load.  Higher level skills should only be attempted once the basics are covered.  

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I was lucky enough to see Professor Brian Cox, one of my role models as a teacher, live on tour. Was he covering everything? Did we leave knowing everything he knew? Did we know everything there is to know about space and time and quantum mechanics? No. He knew his audience and he tailored his message for us. We were only on the lowest levels of Bloom’s cognitive taxonomy but the level was perfect.

Find the right level for your talk.  Find the right message. Your message should be one sentence, one breath.  This is what I am going to talk to you about.  It should be made clear right at the beginning of your talk. Your message is not a punchline for the end.  It should be there at the beginning.  For all we complain if someone ‘spoils the ending’ of something the opposite is true.

In 2011 a series of experiments explored the effect of spoilers on the enjoyment of a story. Subjects were given twelve stories from a variety of genres. One group were told the plot twist as part of a separate introduction. In the second the outcome was given away in the opening paragraph and the third group had no spoilers. The groups receiving the spoilers reported enjoying the story more than the group without spoilers. The group where the spoiler was a separate introduction actually enjoyed the story the most. This is known as the spoiler paradox.

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Understanding the spoiler paradox is to understand how human beings find meaning. This is known as ‘theory of mind’. This means we like giving meaning and intentions to other people and even inanimate objects. As a result we love stories. A lot. Therefore we find stories a better way of sharing a message. The message “don’t tell lies” is an important one we’ve tried to teach others for generations. But one of the best ways to teach it was to give it a story: ‘The Boy Who Cried Wolf’. Consider Aesop’s fables or the parables of Jesus. Stories have a power.

Therefore, if we know where the story is going it becomes easier for us to follow. We don’t have to waste cognitive energy wondering where the story is taking us. Instead we can focus on the information as it comes. Knowing the final point makes the ‘journey’ easier. We use this principle in healthcare when we make a handover:

“Hi, is that the surgical registrar on call? My name is Jamie I’m one of the doctors in the Emergency Department. I’ve got a 20 year old man called John Smith down here who’s got lower right abdominal pain. He’s normally well and takes no medications. The pain started yesterday near his belly button and has moved to his right lower abdomen. He’s been vomiting and has a fever. His inflammatory markers are raised. I think he has appendicitis and would like to refer him to you for assessment.”

OR

“Hi, is that the surgical registrar on call? My name is Jamie I’m one of the doctors in the Emergency Department. I’d like to refer a patient for assessment who I think has appendicitis. He’s a 20 year old man called John Smith who’s got lower right abdominal pain. He’s normally well and takes no medications. The pain started yesterday near his belly button and has moved to his right lower abdomen. He’s been vomiting and has a fever. His inflammatory markers are raised. Could I please send him for assessment?”

Both are the same story with the same intended message - I’ve got a patient with appendicitis I’d like to refer. But which one would be easier for a tired, stressed surgeon on call to follow? In the last one the reason for the phone call is right there at the beginning and so the person at the other end knows exactly what they’re listening out for. Teaching sessions should be the same.

“Hello my name is Jamie. I’m going to talk about diabetic ketoacidosis which affects 4% of our patients with Type 1 Diabetes. In particular I’m going to focus on three key points: what causes DKA, the three features we need to make a diagnosis and how the treatment for DKA is different from other diabetic emergencies and why we that it is important.”

Your audience immediately knows what is coming and what to look out for without any ambiguity.

Brevity is beautiful.  Brevity is also hard.  It goes against our instincts as we want to show everything we know and all about the work we’ve done.  The less time you hard the harder it is.  The hardest talk I’ve ever had to give was a three minute talk on a project.  The project involved me designing a smartphone application for use in simulation sessions and to support my students during their week in the department.  This work had taken over eight months and I was supposed to boil this down to three minutes?  It seemed impossible.

This is why you need to go away and write out everything.  Write a blog or a report or make a handout.  Record a podcast.  Something where everything is.  In that act you’ll spot the key bits to take out and put into your presentation.  The rest your audience can find out afterwards from your blog or your report or your podcast.  This bit has to be done.

Having written out the blog containing all the information I identified the three key parts of the process and with that my message.  My message was how a custom made application could maximise the short time students had with me.  This was right at the beginning.  I then highlighted the three key points at the beginning and went through those.  I signposted to the blog for them to find out more.

Ethos comes from the speaker themselves.  This is you, your background and standing and how you come across.  Logos is using logic during your talk.  An example would be, “my project has shown we can save X amount of money by not needing to do pointless blood tests”.  It is also about how clear and easy to follow your message is and how logical it seems. Finally, pathos appeals to the emotions of the audience, their desire to do good and prevent suffering.  You can combine all three to be an effective speaker. 

THE BAD

Extraneous cognitive load creates distractions and prevents working memory from processing new information. It stops us learning. Distractions in the room and badly chosen media increase extraneous cognitive load and makes it harder to turn working memory into long term memory. As a result extraneous cognitive load must be reduced as much as is possible.

Remember the seven plus two principle of working memory from before. That’s a very small space which can be taken up very quickly by distractions. Once again we can turn to psychology to help us identify potential distractions with Maslow’s Hierarchy of Needs.

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Maslow’s Hierarchy of Needs

Abraham Maslow (1908-1970) was an American psychologist.  His hierarchy of needs is a model for human psychological wellbeing with the most basic and fundamental needs at the bottom and more complex processes at the top.  Just as with Bloom’s taxonomy an individual can’t achieve the highest levels without those at the bottom.  This means that we can’t self-actualise (achieving our full potential) without meeting our physiological needs, feeling safe, relationships and feeling a sense of self-esteem.  While educators can’t cater for all of our audience needs we can think of Maslow’s hierarchy to reduce extraneous load.  Think about room design, background noise, temperature, time of the day and physiological needs such as hunger or needing the toilet.  If those basic needs are met then your audience working memory is being taken up with thoughts of hunger, their bladder or feeling cold.  

Once we’ve thought about our learning environment we need to then think about our learning materials and minimising extraneous load by using words and images correctly. History gives us an important lesson of the potential consequences of this…

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In January 2003 the Space Shuttle Columbia launched. During launch a piece of foam fell from the external fuel tank and hit Columbia’s left wing.

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Foam falling during launch was nothing new. It had happened on four previous missions and was one of the reasons why the camera was there in the first place. But the tile the foam had struck was on the edge of the wing designed to protect the shuttle from the heat of Earth’s atmosphere during launch and re-entry. In space the shuttle was safe but NASA didn’t know how it would respond to re-entry. There were a number of options. The astronauts could perform a spacewalk and visually inspect the hull. NASA could launch another Space Shuttle to pick the crew up. Or they could risk re-entry.

NASA officials sat down with Boeing Corporation engineers who took them through three reports; a total of 28 slides. The salient point was whilst there was data showing that the tiles on the shuttle wing could tolerate being hit by the foam this was based on test conditions using foam more than 600 times smaller than that that had struck Columbia. This is the slide the engineers chose to illustrate this point:

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NASA managers listened to the engineers and read their PowerPoint and thought this was learning. Boeing read out their slides and thought this was teaching. NASA decided to go for re-entry.

Columbia was scheduled to land at 0916 (EST) on February 1st 2003. At 0912, as Columbia should have been approaching the runway, ground control heard reports from residents near Dallas that the shuttle had been seen disintegrating. Columbia was lost and with it her crew of seven. The oldest crew member was 48.

Edward Tufte, a Professor at Yale University and expert in communication reviewed the slideshow the Boeing engineers had given NASA, in particular the above slide. His findings were tragically profound.

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Firstly, the slide had a misleadingly reassuring title claiming that test data pointed to the tile being able to withstand the foam strike. This was not the case but the presence of the title, centred in the largest font makes this seem the salient, summary point of this slide. This helped Boeing’s message be lost almost immediately.

Secondly, the slide contains four different bullet points with no explanation of what they mean. This means that interpretation is left up to the reader. Is number 1 the main bullet point? Do the bullet points become less important or more? It’s not helped that there’s a change in font sizes as well. In all with bullet points and indents six levels of hierarchy were created. This allowed NASA managers to imply a hierarchy of importance in their head: the writing lower down and in smaller font was ignored. Actually, this had been where the contradictory (and most important) information was placed.

Thirdly, there is a huge amount of text, more than 100 words or figures on one screen. Two words, ‘SOFI’ and ‘ramp’ both mean the same thing: the foam. Vague terms are used. Sufficient is used once, significant or significantly, five times with little or no quantifiable data. As a result this left a lot open to audience interpretation. How much is significant? Is it statistical significance you mean or something else?

Finally the single most important fact, that the foam strike had occurred at forces massively out of test conditions, is hidden at the very bottom. Twelve little words which the audience would have had to wade through more than 100 to get to. If they even managed to keep reading to that point. In the middle it does say that it is possible for the foam to damage the tile. This is in the smallest font, lost.

NASA’s subsequent report criticised technical aspects along with human factors. Their report mentioned an over-reliance on PowerPoint:

“The Board views the endemic use of PowerPoint briefing slides instead of technical papers as an illustration of the problematic methods of technical communication at NASA.”

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It’s not the audience’s fault though. Human beings love patterns. And words are a lovely pattern of letters together with meaning. Put them in front of an audience and it doesn’t matter whether it’s a mobile phone contract (left) or even if it’s telling you not to read (right) chances are people will get to the bottom.

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Human beings are addicted to words. Words are a controlled drug. And just like a controlled drug whilst they have a use they have to be used with caution.

Yet when we open up PowerPoint or Keynote we are presented with a host of templates with obscure backgrounds and hard to read text, making it very easy to fall into the same traps:

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One common mistake, which Boeing used when they presented to NASA, is to write lists of data on the slide. This is easy to do yet simply doesn’t work. I could write down the first twenty elements of the periodic table. The audience could read along with me. Yet that is not teaching. Read the twenty elements. Which one is the eighth? Chances are you’ll have to look back.

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There’s another problem, as Edward Tufte pointed out, that bullet pointed lists imply a hierarchy. Those at the top are the most important and those at the bottom are the least. Look at this poster for the ‘Sepsis Six’. Obviously an important campaign and message yet by numbering the points it implies that the higher up steps are more prominent than those at the bottom. From a communication point of view this is a problem.

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You only need one point per slide. That point is then the focus of that slide and your audience. As it’s one point you don't need a heading. Limit the number of words and make your point clear.

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There. The eighth element is oxygen. A clear and memorable point.

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However, just as words can be used badly so too can images. They can be distracting, misleading or just sheer pointless.

In order to minimise extraneous load we have to be careful about how we use images.

“A picture is worth a thousand words.” It’s a cliche but it’s true. Look at cave paintings. Despite the millennia that separate us from our ancestors there is a still a message that cuts through in a way which would be lost with the written word.

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These slides contain some lovely images but also some mistakes. In the slide on the left there are four smalls on one slide. If you were talking about the heart this means there are three other distracting images for your audience to look at. It also means the image is too small. In the slide in the middle there’s pointless and patronising heading and annotation. The slide on the right contains one single, large, clear image. Perfect for use while you talk about the heart.

Pictures also have emotive power. Pictures can change the world. In 1990 HIV/AIDS had been public knowledge for seven years. There has probably never been a disease as stigmatising for its victims. For most it was a disease of gays, of drug users or immigrants. It wasn’t a disease that would affect us. It wasn’t a disease we could empathise with. The red ribbon campaign was still to come. The US didn’t even have a national AIDS policy. Then in 1990 a photograph was published.

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Think how many thousands, how many millions of words had been written about HIV/AIDS by 1990. This photograph made more impact than all of them together. It shows David Kirby, a young man dying of AIDS, surrounded by his family. A patient with AIDS dying with a father, mother and sister grieving him. This photograph, known as ‘The Face of AIDS’, is credited with changing public opinion immediately. In 1992 it was used as part of a provocative campaign from Benetton, a clothing company. It was taken by Therese Frare, a photographer who befriended David Kirby in the final stages of his illness and was allowed to capture his final moments. Almost biblical, it humanised AIDS. These patients were not outcasts, they were people with loved ones just like everyone else.

Remember the photograph of Alan Kurdi, the three year Syrian refugee who drowned in the Mediterranean Sea. Within 24 hours of its publication the charity Migrant Offshore Aid Station reported a fifteen fold increase in donations.

it is possible to read words and be detached. Unless you are a psychopath it is impossible to look at a photograph like ‘The Face of AIDS’ and not feel something. If there’s a face on the screen we’ll find it and we’ll interpret it. Our neural pathways fire and we’ll empathise with that face. We’ll feel what they feel. This is pathos in action. Using an image like ‘The Face of AIDS’ in your slides cuts through far more than a slide of text.

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Data presentation is often a part, or even the reason, for presenting. Just as with words and images we need to present data in a clear way to reduce extraneous load. These graphs all show the same data. The one on the left and in the middle are both pie charts. To interpret them you need to look back at the label, find the colour and work out which looks biggest. Even with labels showing the percentage you still need to compare with others. This takes time and increases extraneous load. The bar chart on the right is much clearer. E immediately looks bigger than the others. This reduces load.

Another way of reducing extraneous load is to find the message in your data. A common mistake is to show all of the data in one slide. The slide on the left here shows data for a made up drug. There’s a table and a bar chart comparing this new drug to existing treatment. “Sorry for the busy slide, I’ll talk you through it” we’ll say and maybe even use a red box to highlight the key point: that the new treatment reduces mortality by a half.

Firstly, never use a slide you have to apologise for. Secondly if there’s a key point of your data then make that the single point of your slide. An easy to repeat and understand key point. If your audience want more data you can signpost them to a blog, report, podcast. Dropbox, Google Drive wherever. But they’ll take away a very simple message. Your brand new wonder drug halves mortality compared to previous treatment.

THE GOOD

Germane cognitive load is a deep process. It describes the organisation of information by integrating and connecting it with exiting knowledge. This is how our audience takes what’s been presented to them there and then and turns it into long term memory. Germane cognitive load needs to be maximised as much as possible.

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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.

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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.

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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. This also goes back to intrinsic load and the importance of a clear, simple message. No subject can be completely covered in a presentation and if you try to do so you’ll fail.  Your presentation should be like an iceberg. You can only show so much.  Present your message and inspire your audience to find out more.  

You should also try to encourage germane cognitive load through deep linkage to previous knowledge. This is difficult and goes against traditional learning. It also goes against that desire to cram.

The traditional model for curricula is to cover a topic in its entirety before moving onto the next which is covered in its entirety before moving onto the next and so on and so on. This is called blocking.

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Blocked learning. Each topic is covered in its entirety and then the learning moves on. Assessment is separate and at the end.

In order to avoid blocking and the forgetting curve there are a number of potential solutions: interleaving, spaced practice and retrieval practice.

Interleaving

Rather than finishing a topic and moving on, never to return to look back in interleaving learners move between topics and ideas. he benefits of interleaving were first studied in rifle shooters in 1979 before also being found to benefit mathematics and music students when compared to blocked learning. The focus is on making connections with otherwise disparate topics.

Further research has shown that interleaving helps students distinguish between similar but different topics, a point not covered by blocked learning. The key seems to be that the topics have some inherent similarity; a paper from Indonesia in 2014 didn’t find any benefit from interleaving compared to blocked learning when learning anatomical words and translations. There is also a problem in terms of methodology. The paper looking at mathematics tested over a 3 month period, the paper looking at music skills tested a day after interleaving whilst the paper from Indonesia tested its subjects at 48 hours and one week. A lack of a coherent approach makes it hard to find a best practice. This is the challenge for educators to take on and find the best way to interleave learning.

Spaced Practice

Spaced practice is the opposite of cramming. The same amount of teaching is spaced out over time. Rather than five hours in one day you learn for one hour for five days. This takes us back to intrinsic load and the iceberg. We can’t cover everything in one session, we have to break a topic up and spread it around.

Retrieval practice

Retrieval practice involves recreating something you’ve been taught from your memory and thinking about it now. This is the basis of the shifting the forgetting curve as we looked at above. The idea is that some time must pass from the teaching session and the retrieval. Different tactics can be used such as quizzes, mock exams or flashcards.

For more information The Learning Scientists have excellent blogs on interleaving, spaced practice and retrieval practice.

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This is how our month might look with interleaving and spaced practice. It’s the same number of teaching sessions as during the example of blocking but there’s a swapping between topics and spacing. Assessment could be in the form of retrieval practice covering what’s previously been taught. The idea is to overcome the forgetting curve.

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This shows that the single presentation can’t be seen in isolation. It’s impossible to cover everything in one talk as it means too much intrinsic load and it prevents germane load. The focus must be on forming connections with previous learning and signposting to further resources or future sessions.

This should shape how we plan the session. Start with your clear message. Recall previous learning through discussion or activity. Introduce the new material. Show the connections between the new material and previous and future learning. Signpost.

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TED talks have an 18 minute limit on their talks. This is to focus speakers and ensure they keep their audience’s attention. We can use something similar in our sessions, aim for no more than 18 minutes on a section of your talk, use exercises to break between sections and keep focus.

We gave up trying to resuscitate patients with smoke up their bottom because there wasn’t an evidence base. We can’t keep trying to educate without an evidence base either. Shape your sessions with the evidence.

Simplify intrinsic load

One simple message. Remember the spoiler paradox. Simplify the complex.

Reduce extraneous load

Remember Columbia. One point per slide. Use images and data correctly.

Maximise germane load

Beat the forgetting curve. Interleave. Use spaced and retrieval practice.

Thanks for reading

- Jamie

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#FOAMPUBMED 6: Type II Error

In a previous blog we looked at how Type I error means we wrongly reject our null hypothesis

TYPE II ERROR COMES ABOUT WHEN WE WRONGLY ACCEPT OUR NULL HYPOTHESIS. 

Say you’re developed a new drug. You give it to one patient and they don’t get better. One of two conclusions can be made at this point. Either the drug genuinely doesn’t work and so this is true negative. Or the drug does work but unfortunately not in this patient’s case and so this would be a false negative.

Type II Error is about too many false negatives in our results and not finding a relationship when there is one. This will mean that we will find our new drug isn’t better than the standard treatment (or placebo) when it actually is.

TYPE II ERROR IS ALSO CALLED BETA

In the above example you can see with one patient you can’t tell the difference between a true negative and a false positive.

This means we need to design our study with enough patients to ensure we can tell true and false negatives apart.

This brings us on to the next blog and Power…

Syncope: A FOAMed Review

This blog has been written to support a recent session I delivered for ACCS trainees on ‘Syncope’. This is not exhaustive but aims to explore some of the more interesting snippets of information I found on various FOAM resources.

What is syncope?

Syncope is a loss of consciousness due to temporary cerebral hypoperfusion. Therefore syncope is not the same as transient loss of consciousness (TLoC) which is a much broader term for any blackout. 

A key feature of syncope is that it is transient; a short period of collapse with a short recovery.  30% of patients with syncope will have more than one episode. 

Syncope by itself makes up 3-5% of Emergency Department presentations.     

In 50% of these cases we don’t find a cause.  Investigating a patient costs about £2000. 

In those patients where we find a cause neurocardiogenic syncope or vasovagal syncope is the most common form of syncope.  This is caused by an initial increase in sympathetic outflow followed by a rebound reduction in sympathetic activity leaving unopposed parasympathetic activity.  Vasovagal syncope makes up 35% of causes. 

Pathophysiology of vasovagal syncope from RCEMLearning, 2018

Key Point: Remember the 3Ps of vasovagal syncope: Prodrome, Posture and Provoked. Don’t try and shoehorn a diagnosis!

Orthostatic syncope is due to an orthostatic drop >20mmHg systolic or >10mmHg diastolic.  This could be due to a reduction in circulating volume (haemorrhage or dehydration) or vasodilatation due to medications or autonomic dysfunction (such as Parkinson’s).  Orthostatic syncope makes up 10% of cases. 

Cardiac syncope makes up 10-30% of cases.  This includes arrhythmias, heart failure and structural and valve problems. 

Neurological/psychiatric syncope is the rarest cause at 5% of cases.  Neurological causes include basilar artery migraine, vestibular dysfunction and vertebrobasilar ischaemia.  Psychiatric syncope is a recognised syndrome found in patients with anxiety, depression and conversion disorder that resolve with treatment of the psychiatric disorder.

Classification of syncope from RCEMLearning, 2018

Whilst cardiac syncope is not the most common causes of syncope it is associated with the highest mortality.

Mortality of the various aetiologies of syncope from Salim Rezaie, 2018

Key point: Syncope is common, most of the time we don’t find a cause but there are some very serious causes with high mortality

Because of how common syncope is and the potentially severity there are a few risk stratification scores designed to help us with the assessment of patients presenting with syncope. 

One such score is the San Francisco Syncope Rule which tries to identify high risk patients at risk of a serious outcome (death, MI, arrhythmia, PE, stroke, subarachnoid haemorrhage, significant haemorrhage or any other condition causing a return ED visit or hospitalisation for a related event) in the next 30 days.  It uses the mnemonic ‘CHESS’:

C ongestive heart failure

H aematocrit <30%

E CG abnormal (changed or any non-sinus rhythm)

S hortness of breath

S ystolic BP <90mmHg at triage

If ‘Yes’ is answered for any of these then the patient can’t be considered ‘Low Risk’. 

If you think about these are all very sensible criteria covering pump failure, potential bleeding, arrhythmia, PE and hypotension.

So far so good but what about the evidence?  MdCalc tells us that The San Francisco Syncope Rule has 96% sensitivity (not surprising given how broad the criteria are) but only 62% specificity so we’d still be scoring about a third of patients without a serious cause as a high risk patient.  If a patient is deemed low risk the NPV is 99.2% but PPV for those deemed high risk is only 24.8%.  According to MdCalc then it will pick up most people with a serious cause (96%) but there are a lot of false positives (75.2%) and whilst it delivers few false negatives (0.8%) it will also fail to rule out about a third of people without a serious cause.  Plus, whilst it is good that it gets us thinking about certain ‘never miss’ diagnoses like PE we already have the Well’s Score for that anyway for more constructive risk stratification.

Academic Life in Emergency Medicine (ALIEM) from Australia has different data but shows similar issues with the San Francisco Syncope Rule and other scoring systems:

Summary of syncope risk stratification scores from Salim Rezaie, 2018

Key point: Syncope risk scores are useful but not enough. Clinical assessment should always override 

So we can’t escape a good history and examination. Ask about before, during and after with all collapses.

Before  –  what were they doing? Were they lying down, standing up, exerting themselves, on the toilet, coughing or swallowing? Were they stood up in a hot, crowded place or had they just eaten? Was there a prodrome?  What medications are they on?  Have they been changed?  Is there a family history of sudden death including unexplained drownings or accidents?  Any chest pain, headache, abdominal pain or shortness of breath? Any recent illness? Anything like this before?

 During  –  do they remember what happened? Get a collateral history of what they were doing while collapsed.  How did they look?  What was the duration?

After – How quick was the recovery?  Are they back to normal? Any deficits?  Any injuries?  Did they bite their tongue or were they incontinent?  Any nausea or vomiting? Any confusion? 

A thorough cardiovascular examination is essential checking ECG, JVP and murmurs.

Specific findings in the cardiovascular examination from RCEMLearning, 2018

RCEM advise that tachycardia and hypotension point toward volume depletion and so should make us concerned.  Lying and standing BP should be sought. 

Neurological examination isn’t so useful; abnormalities found may not point to the pathology and a normal examination does not rule out a neurological cause.

Whilst tongue biting suggests seizure it is not sensitive and its absent does not exclude seizure.

Elderly patients are likely to have two or more reasons for their collapse.  Finding one cause does not preclude from their being others.

Increasing frequency of collapse suggests cardiac causes of syncope.  If the patient is known to have cardiac pathology this is an ominous sign.

Simple syncope during exercise is rare.  The presence of exertional syncope is strongly suggestive of either an arrhythmia or a structural cardiac abnormality.

Differential diagnoses of TLoC from RCEMLearning, 2018

Key Point: Your patient with syncope is a ‘WOBBLER’

WOBBLER’ is a great mnemonic for remembering key ECG findings to look for in any case of syncope. If I hear that the ECG is from a patient with syncope I usually write ‘WOBBLER’ and tick off each one as I’ve checked for them. It also goes through the order of the P, QRS and T waves.

ECGs and diagrams from Life in the Fast Lane

Wolff-Parkinson-White

Wolff-Parkinson-White is a pre-excitation syndrome caused an accessory pathway called the Bundle of Kent which bypasses the AV node.  The classic features are of a short PR interval and the delta wave.  There are two types of WPW.  In Type A WPW the accessory pathway is left-sided and produces a positive delta wave:

Type A Wolff-Parkinson-White

In Type B WPW the accessory pathway is right sided and produces a negative delta wave:

Type B Wolff-Parkinson-White, the negative delta wave is in III and aVF

Because of this bypassing of the AV node the patient is at risk of going into a tachyarrhythmia.  There is a small risk of sudden death.  Electrophysiology studies confirm the presence of the accessory pathway which is then ablated.

For more on Wolff-Parkinson-White check out our blog here.

Obstruction of AV Node

Mobitz II and Third Degree Heart Block are both linked to sudden cardiac death.

Mobitz II 

Unlike Mobitz I which is usually a functional suppression of AV conduction through drugs or reversible ischaemia Mobitz II is more likely due to structural damage to the conducting system through infarction, fibrosis or infection.  Mobitz I is progressive fatigue of the AV nodal cells but Mobitz II is an ‘all or nothing’ phenomenon where the Purkinje cells suddenly and unexpectedly fail to conduct a supraventricular response. 

Third Degree/Complete Heart Block

There is complete absence of AV conduction.  The patient relies on junctional or ventricular escape rhythm.  The patient is at risk of ventricular standstill causing syncope if self-limiting or death if prolonged.

Brugada

Brugada syndrome is due to a sodium channel gene mutation.  There is a familial link and autosomal dominant inheritance has been shown.  Type 1 Brugada, the only definitive ECG change which is potentially diagnostic, is this coved ST segment elevation in V1-3 followed by the negative T wave.    This is Brugada sign.  ECG changes can be unmasked by fever, ischaemia, drugs such as sodium channel blockers, calcium channel blockers, beta blockers, alcohol and cocaine, hypokalaemia and hypothermia. 

Type 2 Brugada has a saddleback ST elevation >2mm.  Type 3 can look like either 1 or 2 but the elevation is <2mm.  2 and 3 are not diagnostic but warrant further investigation. 

The only proven therapy is an implantable cardioverter-defibrillator. Untreated Brugada is estimated to have a mortality of 10% every year.  Risk stratification and management of asymptomatic patients is controversial. 

 Bifasicular block

The conducting system is divided into a right bundle branch and a left bundle branch which is then further divided into an anterior and a posterior fascicle. 

In bifascicular block the right bundle and one of the left anterior or posterior bundles are blocked. This creates a RBBB with either a left (LAFB) or right axis deviation (LPFB). This shows there is a serious problem with conduction although progression to complete block seems to be rare.

Bifascicular block showing RBBB and LAFB

Causes of bifascicular block include ischaemic heart disease (most common), hypertension and aortic stenosis. 

Trifascicular block refers to blocking of the right bundle and both left fascicles.  This can be incomplete or complete.  Incomplete refers to bifascicular block with either a 1st or 2nd degree heart block:

Complete trifascicular block looks like bifascicular block with 3rd degree AV block:

Again there is a risk of complete heart block.  Causes for trifascicular block are similar to bifascicular.  Hyperkalaemia also causes it – this resolved with treatment – as does digoxin toxicity. 

Left Ventricular Hypertrophy

On this ECG you can see the markedly increased LV voltages: huge precordial R and S waves that overlap with the adjacent leads. This is classic for LVH.

Hypertension is the most common cause of left ventricular hypertrophy.  Other causes include aortic stenosis and regurgitation and structural problems such as coarctation of the aorta and hypertrophic cardiomyopathy.  It’s worth remembering that voltage criteria alone is not diagnostic and ECG changes are insensitive for left ventricular hypertrophy. 

Epsilon wave

The epsilon wave is a small positive ‘blip’ buried at the end of the QRS complex.  It is characteristic of arrhythmogenic right ventricular dysplasia (ARVD).

ARVD is an inherited myocardial disease associated with paroxysmal ventricular arrhythmias and sudden cardiac death. The right ventricular myocardium is replaced by fibro-fatty material. After HCM it is the second most common cause of sudden cardiac death in young people (20% < 35 years). The epsilon wave is seen in 30% of patients with ARVD. You may also see anterior T wave inversion. Echocardiography is the first-line investigation but MRI is often the imaging modality of choice.

Repolarisation

Short QT syndrome is a recently discovered (2000) arrhythmogenic disease associated with AF, VF, syncope and sudden cardiac death.  It is an inherited channelopathy.  It is a possible cause of sudden infant death. 

Short QT

There are no diagnostic criteria for short QT syndrome but the ECG features are a short QT interval, short ST segments and peaked T waves especially in the precordial leads:

Long QT syndrome is a congenital disorder causing a prolongation of the QT interval with a propensity to ventricular tachyarrhythmias. Hypomagnesaemia, hypocalcaemia and hypokalaemia can cause long QT. Many drugs can also be responsible such as amiodarone, many antibiotics, TCAs, ondansetron, SSRIs and haloperidol.

Long QT

Key Point: Who’s gonna drive them home?

For a nice PDF table regarding DVLA regulations and certain conditions have a look at here

For simple vasovagal syncope there are no driving restrictions for either Group 1 or Group 2 drivers.  The DVLA does not need to be notified for either group.

In cases of unexplained syncope but the likelihood is vasovagal syncope again there are no restrictions for Group 1 drivers.  Group 2 drivers can’t drive for 3 months.

In unexplained loss of consciousness with high risk factors (or more than one episode in 6 months) Group 1 drivers can’t drive for 6 months if no cause is identified (can drive after 4 weeks if a cause is found).  For Group 2 drivers they can drive 3 months after if a cause is found, 12 months if no cause is found. 

In cough syncope Group 1 drivers must stop for 6 months for a single episode and 12 months for multiple.  Group 2 drivers cannot drive for 5 years from the last attack. 

In arrhythmia Group 1 drivers must cease if it has caused or is likely to cause incapacity.  If the cause is found and controlled they may drive after 4 weeks.  The DVLA doesn’t need to be told unless there are distracting/distracting symptoms.  Group 2 drivers are disqualified. 

Syncope is a common and sometimes challenging presentation. Hopefully this review has shown you a few tips and key snippets to help you when you assess your next patient with syncope. Syncope? Cope.

- Jamie

References:

Marjorie Lazoff, M., Marjorie Lazoff, M., Davies, A., Cadogan, D. and Marjorie Lazoff, M. (2018). LITFL Life in the FastLane. [online] Life in the Fast Lane • LITFL • Medical Blog. Available at: https://lifeinthefastlane.com/ [Accessed 12 Sep. 2018].

Mdcalc.com. (2018). San Francisco Syncope Rule - MDCalc. [online] Available at: https://www.mdcalc.com/san-francisco-syncope-rule#evidence [Accessed 12 Sep. 2018].

Rcem.ac.uk. (2018). [online] Available at: https://www.rcem.ac.uk/docs/College%20Guidelines/5z33.%20RCEM%20summary%20of%20DVLA%20fitness%20to%20drive%20medical%20standards.pdf [Accessed 12 Sep. 2018].

RCEMLearning. (2018). Syncope - RCEMLearning. [online] Available at: https://www.rcemlearning.co.uk/references/syncope/ [Accessed 12 Sep. 2018].

Salim Rezaie, M. (2018). Management of Syncope. [online] ALiEM. Available at: https://www.aliem.com/2013/04/management-of-syncope-aka-done-fell-out/ [Accessed 12 Sep. 2018].

Are medical errors really the third most common cause of death?

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You can guarantee that during any discussion about human factors in Medicine the statistic that medical errors are the third most common cause of patient death will be thrown up. A figure of 250,000 to 400,000 deaths a year is often quoted in the media. It provokes passionate exhortations to action, of new initiatives to reduce error, for patients to speak up against negligent medical workers.

It’s essential that everyone working in healthcare does their best to reduce error. This blog is not looking to argue that human factors aren’t important. However, that statistic seems rather large. Does evidence really show that medical errors kill nearly half a million people every year? The short answer is no. Here’s why.

It’s safe to say that this statistic has been pervasive amongst people working in human factors and the medico-legal sphere.

Where did the figure come from?

The statistic came from a BMJ article in 2016. The authors Martin Makary and Michael Daniel from John Hopkins University in Baltimore, USA used previous studies to extrapolate an estimate of the number of deaths in the US every year due to medical error. This created the statistic of 250,000 to 400,000 deaths a year. They petitioned the CDC to allow physicians to list ‘medical error’ on death certificates. This figure, if correct, would make medical error the third most common cause of death in the US after heart disease (610,000 deaths a year) and cancer (609, 640 deaths a year.) If correct it would mean that medical error kills ten times the number of Americans that automobile accidents do. Every single year.

Problems with the research

Delving deeper Makary and Daniel didn’t look at the total number of deaths every year in the US, which is 2,813,503. Instead they looked at the number of patients dying in US hospitals every year, which has been reported at 715,000. So if Makary and Daniel are correct with the 250,000 to 400,000 figure that would mean that 35-58% of hospital deaths in the US every year are due to medical error. This seems implausible to put it mildly.

It needs to be said that this was not an original piece of research. As I said earlier this was an analysis and extrapolation of previous studies all with flaws in their design. In doing their research Makary and Daniel used a very broad and vague definition of ‘medical error’:

“Medical error has been defined as an unintended act (either of omission or commission) or one that does not achieve its intended outcome, the failure of a planned action to be completed as intended (an error of execution), the use of a wrong plan to achieve an aim (an error of planning), or a deviation from the process of care that may or may not cause harm to the patient.”

It’s worth highlighting a few points here:

Let’s look at the bit about “does not achieve its intended outcome”. Let’s say a surgery is planned to remove a cancerous bowel tumour. The surgeon may well plan to remove the whole tumour. Let’s say that during the surgery they realise the cancer is too advanced and abort the surgery for palliation. That’s not the intended outcome of the surgery. But is it medical error? If that patient then died of their cancer was their death due to that unintended outcome of surgery? Probably not. Makary and Daniel didn’t make that distinction though. They would have recorded that a medical error took place and the patient died.

There was no distinction as to whether deaths were avoidable or not. They used data designed for insurance billing not for clinical research. They also didn’t look at whether errors “may or may not cause harm to the patient”. Just that they occurred. They also applied value judgements when reporting cases such as this:

“A young woman recovered well after a successful transplant operation. However, she was readmitted for non-specific complaints that were evaluated with extensive tests, some of which were unnecessary, including a pericardiocentesis. She was discharged but came back to the hospital days later with intra-abdominal hemorrhage and cardiopulmonary arrest. An autopsy revealed that the needle inserted during the pericardiocentesis grazed the liver causing a pseudoaneurysm that resulted in subsequent rupture and death. The death certificate listed the cause of death as cardiovascular.”

Notice the phrase “extensive tests, some of which were unnecessary”. Says who? We can’t tell how they made that judgement. It is unfortunate that this patient died. Less than 1% of patients having a pericardiocentesis will die due to injury due to the procedure. However, bleeding is a known complication of pericardiocentesis for which the patient would have been consented. Even the most skilled technician cannot avoid all complications. Therefore it is a stretch to put this death down to medical error.

This great blog by oncologist David Gorksi goes into much more detail about the flaws of Makary and Daniel’s work.

So what is the real figure?

A study published earlier this year (which received much less fanfare it has to be said) explored the impact of error on patient mortality. They studied the impact of all adverse events (medical and otherwise) on mortality rates in the US between 1990 and 2016. They found that the number of deaths in that whole 26 year period due to adverse events was 123,603. That’s 4754 deaths a year. Roughly one hundredth the figure banded around following Makary and Daniel (2016). Based on 2,813,503 total deaths in the US every year that makes adverse events responsible for 0.17% of deaths in the US. Not a third. 0.17%.

Of course, 4754 deaths every year due to adverse events is 4754 too many. One death due to adverse events would be one too many. We have to study and change processes to prevent these avoidable deaths. But we don’t do those patients any favours by propagating false figures.

Thanks for reading.

- Jamie

#FOAMPubMed 5: Significance

SIGNIFICANCE MEANS SOMETHING DIFFERENT IN RESEARCH THAN IN LAY LANGUAGE

Often in the media we hear the results of a new trial showing a ‘significant’ result. A company may market a new drug or product that ‘significantly lowers your cholesterol’ for example. Or ‘such and such significantly increases your risk’ of something.

The trouble is for most of us that means that the effect must be large. The drug or product will make your cholesterol drop by a lot. That’s what ‘significantly lowering’ means to us.

SIGNIFICANCE IN RESEARCH MEANS YOU’VE REDUCED THE CHANCE OF FALSELY REJECTING YOUR NULL HYPOTHESIS

It means you’ve designed your study and recruited enough subjects to reduce the effect of chance. Usually the more significant we want our results to be the larger our sample size needs to be.

In a previous blog we looked at how Type I Error means falsely rejecting the null hypothesis through too many false positives. We looked at how we show we’ve minimised that chance with a p value. The gold standard is p<0.05 which means there is a less than 5% chance of falsely rejecting the null hypothesis.

p<0.05 MEANS OUR RESULTS ARE SIGNIFICANT

That’s what statistical significant means. It’s fairly arbitrary. In reality there’s very little between a p value of 0.049 and a p value of 0.051. Except the former allows you to use the magic words “my results are significant” and the latter does not.

SIGNIFICANCE DOES NOT DESCRIBE THE SIZE OF THE EFFECT

I could study a new drug for blood pressure and find the average reduction in my volunteers is only 1mmHg. That doesn’t sound a lot. But if the p-value is p<0.05 that is statistically significant. I could therefore describe my drug as statistically significantly reducing blood pressure.

The Good, The Bad and The (Can Be) Ugly: The Three Parts of Cognitive Load

You’re driving to work.  A route you use every working day.  The radio is on and you’re singing along word for word.  You really love this song.  Suddenly you see there’s road works and you have to go down a different route you’re not familiar with.  There’s a tight parking spot and you need to do a three point turn.  What about the song?  Now it’s no longer pleasant but a distraction.  It’s like you don’t have the head space to listen and perform your tasks.  You turn the radio down.  Now it all feels easier.

This is cognitive overload.  It’s not just an everyday phenomenon but instead an important concept we have to appreciate when we design and present a teaching session.  Cognitive overload explains why some teaching sessions don’t work.  In order to understand this we have to look at how we form memories. 

Working memory is a cognitive system with a limited capacity. It temporarily holds information available to us to use immediately. Working memory is made of the phonological loop, which deals with sound information, the visual-spatial sketch pad, which deals with visual information and spatial awareness, and the central executive which controls information within the different areas. We therefore use our working memory for tasks such as reading, problem solving and navigation.

Working memory becomes long term memory by categorising information into knowledge structures called ‘schema’. Through integrating these schema with existing knowledge and then repeated retrieval of the knowledge it becomes embedded in our long term memory. Working memory can hold a maximum of nine items at any one time.

Cognitive Load

Cognitive load is the amount of mental resources used in working memory used to perform various tasks. In education cognitive load is essentially the amount of effort a student’s brain is having to make in order to learn new information. It is made up of three parts.  One can be ugly, one which is bad and one which is good.  We have to simplify the ugly, reduce the bad and maximise the good to make our presentation work. 

The (can be) ugly

Intrinsic cognitive load is the amount of cognitive resources the person would need to use to transfer new information to long term memory. This basically how complex the material being taught is. Therefore it can be ugly. Too much complexity and there is too much of a cognitive load on our audience. An educator needs to manage this part and simplify their message as much as possible. This minimises intrinsic cognitive load and prevents it getting ugly.

The bad

Extraneous cognitive load creates distractions and prevents working memory from processing new information. It stops us learning. Distractions in the room and badly chosen media increase extraneous cognitive load and makes it harder to turn working memory into long term memory. As a result extraneous cognitive load must be reduced as much as is possible.

The good

Germane cognitive load is a deep process. It describes the organisation of information by integrating and connecting it with exiting knowledge. This is how our audience takes what’s been presented to them there and then and turns it into long term memory. Germane cognitive load needs to be maximised as much as possible.

In order to manage intrinsic load, minimise extraneous load and maximise germane load requires planning. A simple message delivered in a clear way without distractions building on previous knowledge.

Thanks for reading.

- Jamie

The evidence doesn't lie: The case of the Phantom of Heilbronn and the importance of pre-test probability

“Evidence doesn’t lie” - Gil Grissom, CSI

Ten years ago police were on the hunt for an unusual serial killer. There were several factors that made this suspect unique. Firstly; she was female, a rarity amongst serial killers. Secondly; there seemed to be no pattern to her crimes. Her DNA was found at crime scenes in France, Germany and Austria dating back to 1993. On a cup at the scene of the murder of a 62 year old woman. A knife at the house of a murdered 61 year old man. A syringe containing heroin. Altogether she was linked to forty separate crimes including six murders. Her accomplices included Slovaks, Iraqis, Serbs, Romanians and Albanians. This was an unprecedented case. A modern day Moriarty. She was called ‘The Phantom of Heilbronn’ or ‘The Woman Without a Face’.

Then in 2009 the police found her. After a case lasting eight years, 16,000 man hours and a cost of €2 million the police had their suspect. She was a technician working at the factory which made the cotton swabs the forensics team used to collect samples. As she had gone about her work moving and speaking her saliva and skin had got on the swabs and contaminated them. Police confirmed that every sample of the Phantom’s DNA had been collected with swabs from the same factory. The Phantom of Heilbronn did not exist.

If you think about it, it was incredibly unlikely that one woman was involved in so many different crimes across so many countries over so many years. It actually makes much more sense that it was error. And yet the investigators were blinded by the result in black and white on a screen.

This can happen in Medicine. A result from a blood test or imaging comes back positive or negative and we just accept it. We have use our brains and think about the tests we’re ordering and what the results mean.

Sensitivity

If you have a certain disease we want a test that will detect if you have it and come back positive. That is a test’s sensitivity. We don’t want false negatives: people with a disease not testing positive. A sensitivity of 100% means that the test will always come back positive if you have the disease. A sensitivity of 50% means that the test will correctly detect disease in 50% of patients with the disease. The other 50% get a false negative. Sensitivity is very important if you’re testing for a serious disease. For example, if you’re testing for cancer you don’t want many false negatives.

Specificity

As well as detecting disease you also want the test to accurately rule out a disease if the patient doesn’t have it. This is its specificity. We don’t want false positives: people who don’t have the disease testing positive. A specificity of 100% means that the test will always come back negative if you don’t have the disease. A specificity of 50% means that 50% of people who don’t have a disease will correctly test negative. The other 50% will be given a false positive result. Specificity is very important if there’s a potentially hazardous treatment or further investigation following a positive result. If a positive result means your patient has to undergo a surgical procedure or be exposed to radiation by a CT scan you’re going to want as few false positives as possible.

The trouble is that no test is 100% sensitive or 100% specific. This has to be understood. No result can be interpreted properly without understanding the clinical context.

For example, the sensitivity of a chest x-ray for picking up lung cancer is about 75%. That means it gives a true positive for 3 out of 4 patients with the other patient getting a false negative. If your patient is in their twenties, a non-smoker with no family history and no symptoms other than a cough you’d probably accept that 1/4 chance of a false negative and be happy you’ve ruled out a malignancy unless the situation changes. However, in a patient in their seventies with a smoking history of over 50 years who’s coughing up blood and had unexplained weight loss suddenly that 75% chance of detecting cancer on a chest x-ray doesn’t sound so comforting. Even if you can’t see a mass on their chest x-ray you’d still refer them for more sensitive imaging. That’s because the second patient has a much higher probability of having lung cancer based on their history. So high in fact that choosing a test with such poor sensitivity as a chest x-ray might not be the right decision to make. This is where pre-test probability comes in.

Pre-test probability

This principle of understanding the clinical context is called the pre-test probability. Basically it is the likelihood the individual patient in front of you has a particular condition before you’ve even done the test for that condition.

The probability of the condition or target disorder, usually abbreviated P(D+), can be calculated as the proportion of patients with the target disorder, out of all the patients with the symptoms(s), both those with and without the disorder:

P(D+) = D+ / (D+ + D-)

(where D+ indicates the number of patients with target disorder, D- indicates the number of patients without target disorder, and P(D+) is the probability of the target disorder.)

Pre-test probability depends on the circumstances at that time. For example, the pre-test probability of a particular patient attending their GP with a headache having a brain tumour is 0.09%. Absolutely tiny. However, with every re-attendance with the same symptom or developing new symptoms or even then attending an Emergency Department, that pre-test probability goes up.

Pre-test probability helps us interpret results. It also helps us pick the right test to do in the first place.

Pulmonary embolism: a difficult diagnosis

Pulmonary embolism (blood clot on the lung) affects people of all ages, killing up to 15% of patients hospitalised with a PE. This is reduced by 20% if the condition is identified and treated correctly with anticoagulation. PE doesn’t play fair though and has very non-specific symptoms such as shortness of breath or chest pain. The gold standard for detecting or ruling out a PE is with a computerised tomography pulmonary angiogram (CTPA) scan. However, a CTPA scan involves exposing the chest and breasts to a lot of radiation. For instance, a 35 year old woman who has one CTPA scan has her overall risk of breast cancer increased by 14%. There’s also the logistical impossibility of scanning every patient we have. So we need a way of ensuring we don’t scan needlessly.

We do have a blood test, checking for D-Dimers which are the products of the body’s attempts to break down a clot. The trouble is other conditions such as infection or cancer can increase our D-Dimer as well. The D-Dimer test has a sensitivity of 95% and a specificity of 60%. That means that it will fail to detect PE in 5% of patients meaning we miss a potentially fatal disease in 1/20 patients with a PE. It also means it will fail to rule out PE in 40% of patients and so risk exposing patients without a PE to a scan which increases their risk of cancer. Not to mention starting anticoagulation treatment (and so increasing risk of bleeding such as as a brain haemorrhage) needlessly. So we have to be careful to only do the D-Dimer test in the right patients. This is why we need to work out our patient’s risk.

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Luckily there is a risk score for PE called the Well’s Score. This uses signs, symptoms, the patient’s history and clinical suspicion and can stratify the patient as low or high risk for a PE. We then know the chances of whether the patient will turn out to have a PE based on whether they are low or high risk.

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Only 12.1% of low risk patients will have a PE. At such a low chance of PE we accept the D-Dimer’s 5% probability of a false negative and are keen to avoid the radiation exposure of a scan and so do the blood test. If it is negative we accept that and consider PE ruled out unless the facts change. If it is positive we can proceed to imaging.

However, 37.1% of high risk patients will have a PE. Now it’s a different ballgame. The pre-test probability has changed. A high risk patient has a more than 1/3 chance of having a PE. Suddenly the 95% sensitivity of a D-Dimer doesn’t seem enough knowing there’s a 1/20 chance of missing a potentially fatal diagnosis. The patient is likely to deem the scan worth the radiation risk knowing they’re high risk. So in these patients we don’t do the D-Dimer. We go straight to imaging. If a D-Dimer has been done for some reason and is negative we ignore it and go to scan. We interpret the evidence based on circumstances and probability.

This is basis of the NICE guidance for suspected pulmonary embolism.

Grissom is wrong; the evidence can lie. Some of the results we get will be phantoms. Not only must we pick the right test we must also think: will I accept the result I might get?

Thanks for reading.

- Jamie

#FOAMPubMed 4: p values

In the previous blog we looked at how Type I Error is the false rejection of a null hypothesis.

THE MAXIMUM CHANCE WE WANT OF FALSELY REJECTING OUR NULL HYPOTHESIS IS 5%

This is a gold standard.

WE THEREFORE DESIGN STUDIES TO HAVE A LESS THAN 5% CHANCE OF FALSELY REJECTING OUR NULL HYPOTHESIS

A p value is a decimal showing the probability of falsely rejecting the null hypothesis. It will usually be given in a paper along with the results.

As we want a chance of less than 5% of falsely rejecting our null hypothesis the p value we want is p<0.05

Some studies want an even smaller chance of Type I Error and so design their study for p=0.01 (1% chance of falsely rejecting the null hypothesis) for example.

The p value we want will help shape our study, including sample size.

With p<0.05 we will have significant results - more of that in the next blog

#FOAMPubMed 3: Type I Error

First things first, no piece of research is perfect.  Every study will have its limitations. 

One way we try to make research better is through understanding error.  

If we find that the new drug works when it doesn’t that’s called a false positive.  We can’t eliminate false positives; some patients will get better even if given placebo.  But too many false positives and we will find an effect when one doesn’t actually exist. We will wrongly reject our null hypothesis.  

Type I Error comes about when we wrongly reject our null hypothesis. 

This will mean that we will find our new drug is better than the standard treatment (or placebo) when it actually isn't.

Type I Error is also called alpha

A way I like to look at Type I Error is the influence of chance on your study. Some patients will get better just through chance. You need to reduce the impact of chance on your study.

For instance, I may want to investigate how psychic I am. My null hypothesis would be ‘I am not psychic.’

I toss a coin once. I guess tails. I’m right. I therefore reject my null hypothesis and conclude I’m psychic.

You don’t need to be an expert in research to see how open to chance that study is and how one coin toss can’t be enough proof. We’d need at least hundreds of coin tosses to see if I could predict each one.

You see how understanding Type I Error influences how you design your study, including your sample size

More of that later. The next blog will look at how we actually statistically show that we’ve reduced Type I Error in our study.

#FOAMPubMed 2: The null hypothesis

When we do research in Medicine it’s usually to test whether a new treatment works (by testing it against placebo) or better than the established treatment we’re already using.

At the beginning of our study we have to come up with a null hypothesis (denoted as H0).

The null hypothesis is a statement that assumes no measurable difference between whatever you’re studying.  

The null hypothesis is therefore usually something along the lines of: 

‘Drug A won’t be better than Drug B at treating this condition.’  

We then set out to test this null hypothesis.  If we find Drug A is better than B then we reject the null hypothesis and conclude Drug A is the superior treatment. If Drug A is found to be no better (i.e. the same or worse) than Drug B then we accept our null hypothesis and conclude that Drug A is non-superior (or inferior).

Error comes when we either wrongly reject or wrongly accept the null hypothesis.

Error means we come to the wrong conclusion. There are two types of error, the next blog will look at the first, Type I Error.

Going Mobile: A review of mobile learning in medical education

Next month will mark the 50th anniversary of mankind’s greatest accomplishment; landing human beings on the Moon. Yet today the vast majority of our learners each carry in their bag or packet a device with millions of times the computing power than the machines we used to meet this achievement. This is why one of my passions as an educator is mobile learning and the opportunities our unprecedented age now offers. I’ve enjoyed learning how to create resources such as a podcast and a smartphone application and how these have innovated the way I teach.

The Higher Education Academy defines mobile learning as “the use of mobile devices to enhance personal learning across multiple contexts.” Mobile learning itself is a subset of TEL or ‘Technology Enhanced Learning.’ There’s repetition of a key word: enhance/enhanced. We’ll come back to that word later.

This musing looks at some of the current evidence of mobile learning use in medical education and tries to pinpoint some themes and things we still need to iron out if we’re going to make the most out of mobile learning.

From Del Boy to Web 2.0

It’s safe to safe that mobile phones have come a long way since being used as a cumbersome prop in Only Fools and Horses. They are now a key part of everyday life.

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.  By 2020 66% of new global connections between people will occur via a smartphone. We are now in the era of the internet of things such as touchscreen phones and tablets as well as smart wearables such as glasses or watches. Humans have been described 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.”  It’s been argued 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.

A key development in the potential of mobile learning was the development of Web 2.0. The first iterations of the internet were themselves as clunky as Del Boy’s mobile, fixed, un-editable and open to a select few. Web 2.0 is known as the ‘participatory web’; blogs, podcasts and wikis. It is now possible for people with no computing background whatsoever to produce and share learning resources with massive success such as Geeky Medics.

Another aspect interlinked with these social and technological changes has been the shortening of the half-life of knowledge. 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. It’s therefore fairly easy to envisage a world where libraries of books will be out of date. Students will instead be their own librarian accessing knowledge on the go via their mobile device.

In education when we look at professionals collaborating we think of a community of practice. Thanks to Web 2.0 the collaboration of professionals, patients and students in medicine has been given the epithet of ‘Medicine 2.0’. This represents a new community of practice and how technology links all of us in healthcare. Health Education England argue that digital skills and knowledge should be “a core component” of healthcare staff education. In order to reflect the new world of Medicine 2.0 medical schools in the US and Hungary have set up courses aimed at familiarising students with social media. A Best Evidence Medical Education review showed that mobile resources help with the transition from student to professional.

Towards collaboration

The general movement in mobile learning is towards collaboration. 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. 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. The focus is on bringing people together via their mobile devices to share learning and practice.

Perhaps the extreme of mobile learning and collaboration has been the advent of massive open online courses (MOOCs) since 2008.  These are courses without any fees or prerequisites beyond technological access. Some MOOCs are delivered to tens of thousands of learners. As a result along with mobile learning in general MOOCs have been credited with democratising education.  MOOCs have been suggested as best augmenting traditional teaching methods in the ‘flipped classroom’ approach. In the flipped classroom students are introduced to learning material before the classroom session with that time being used to deepen understanding.  In general the HEA credits mobile and online resources as providing an accessible toolkit for delivering flipped learning.

Medical students and mobile learning

The tradition has been to divide students into digital natives (those who grew up with technology) and digital immigrants (those for whom technology arrived later on in life). This distinction assumes that younger people have innate skills with and a preference of technology. However, more recent evidence suggests that this distinction doesn’t exist and is unhelpful. Learners whose age falls within the category of being a digital native still need and benefit from teaching aimed at digital literacy. The notion of digital natives belongs in the same file as learning styles; they just don’t exist.

Research into medical students use of mobile learning focuses on evaluating a specific intervention. These include Facebook, a novel Wiki platform, a MOOC and a tailor made smartphone application. While that has a use I’d argue that most students will appreciate any new learning intervention. As a result we’re still in the early days of understanding how students use mobile resources. That said, the evidence suggests that students quickly find a preferred way of using Web 2.0 resources. Whilst it’s been suggested that male students are less likely to ask questions via a Web 2.0 resource students overall seem to find them a safe environment and more comfortable than clinical teaching. It’s been suggested that mobile learning resource usage is linked to a student’s intrinsic motivation. The more motivated a student is the more likely they are to use a mobile resource. Medical students themselves report concerns regarding privacy and professional behaviour when using social media in education.

A 2013 systematic review of social media use in medical education 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 systemic review the following year however reviewed only publications that included randomisation, reviews and meta-analyses and concluded despite the wide use of social media there were no significant improvements in the learning process and that some novel mobile learning resources don’t result in better student outcomes.   

A recent review of literature on 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. There’s that word enhance again. Is this is limit of mobile learning in medical education? To enhance more traditional teaching and not replace?

There’s also the issue of whether students want more mobile resources. The most recent student survey by the Higher Education Policy Institute 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.  Only tuition fees and teaching quality were reported more often as a reason for rating their course as poor or very poor value for money. More students (19%) were dissatisfied with their contact time than neutral (17%); an increase on 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. 62% of Medicine and Dentistry students reported that they felt they had value for money for their tuition fees; this was the highest reported value for money of any subject.

According to the HEPI students in the UK are conservative in their preferred learning methods and this means any innovation takes time to become embedded in a curriculum. The HEPI recommend engaging with students and involving them in the development of any resource as well as building technology into curriculum design and for a nationwide evidence and knowledge base to be developed on what works.

This is being done. 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.  But there’s no evidence of this being done in UK medical schools. 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 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.

An example from a European medical school was found from 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.

The HEPI have also recommended that the UK higher education sector develop an:

“evidence and knowledge base on what works in technology-enhanced learning to help universities, faculties and course teams make informed decisions. Mechanisms to share, discuss and disseminate these insights to the rest of the sector will also be required.”

Medical educators and mobile learning

Teachers’ attitudes toward and ability with mobile resources are a major influence on students deciding to use them. It’s been suggested that Web 2.0 offers 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.

I’ve not been able to find any research in the literature looking at the perceptions of UK medical educators toward mobile learning. 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.

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It’s obvious that mobile learning offers great opportunities for medical students and educators. I hope this review has shown some of the trends in our current understanding of mobile learning in medical education: that the future seems to be collaboration, digital natives don’t exist and students need tuition in how to use mobile resources, research is currently limited to studying interventions, students value contact time and need to be included to make the most of resources and need to know more about what teachers think.

This is a time for leadership, for educators to start to fill these gaps in knowledge and expand on these trends. In September 1962 President Kennedy challenged his country to go to the Moon by the end of the decade. To say this was ambitious is an understatement; Americans had only got into space barely a year earlier. Yet the country rose to the challenge and on 20th July 1969 man walked on the Moon. I like how he said it. “We CHOOSE to go to the Moon.” Challenges are there to be met. We can meet the challenges of mobile learning in medical education if we choose to. We can choose to use mobile learning and help shape it. Or not. That choice is ours.

Don't Just Sit There: Audience Participation in Simulation

In my last blog I talked a bit about setting the audience up for a simulation. In this blog I wanted to explore this more. Students who volunteer first to simulate are often in the minority but it’s important that the audience don’t feel like it’s an easy ride and just sit there.

The standard lay out when I run a simulation session is like this:

One of the audience members becomes the scribe, recording the clinical history and the story as in unfolds. This provides a point of reference for the students in the simulation as well as helping discussion during debrief. As these example show it also lets students be a bit creative:

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We’ve often given students in the audience a checklist and asked them to record proceedings as well as part of student to student feedback.

If you’re giving the students in the simulation information such as an ECG or blood gas, make sure the audience can either see it or get a copy too to involve them. Later on reflect on their conclusions: are they different from those in the simulation?

In the previous blog I mentioned lifelines such as ‘Ask the Audience’. I find reminding the audience that at any moment the students in the simulation might turn round and ask your opinion inspires them to keep paying attention!"

‘Tag Team Simulation’ is something I’ve thought about but not done yet but would be another way to keep the audience engaged - I’d be interested to hear how this works if anyone has done it.

Managing audience members is a key part of the simulation session. If nothing else their engagement is a sign of respect for the students actually doing the simulation and helps create a positive learning atmosphere for everyone.

Thanks for reading

- Jamie

Setting the Stage: The Pre-Brief

Simulation is an indelible part of medical education as well as the training of other healthcare professionals. At DREEAM I’m lucky to be able to work with the great cohort of simulated patients trained by my colleague Ali Whitfield. Working with real human beings rather than mannequins adds another layer of realism and has become a firm fixture in the training we offer at DREEAM.

However, being ‘on stage’ in a simulation remains a very divisive issue for learners. From my experience half of students will feed back how much they love simulation and want more with the other half hating every moment. That’s usually due to previous bad experiences or pre-conceived notions.

As I’ve worked more with simulation as a facilitator I’ve put more emphasis at the beginning; the pre-brief or ‘setting the stage’ partly due to these pre-conceived notions but also as not every student has the same experiences with simulation. Much as an actor wouldn’t expect to just walk onto a stage so a novice student shouldn’t be expected to just perform without some clear guidance.

My pre-briefs usually follow the same pattern:

• Introduce the session and why we are using simulation - it’s not being arbitrarily used to scare but instead with very clear objectives with definite relevance

• The setting (ward, A&E, GP practice whatever) their role (you’re a student/doctor/nurse) and the expectations of the behaviours expected - act as you would as a doctor, treat the simulated patient as a real patient etc. How do referrals work in this scenario? Also, what is expected from the audience? I regularly get one member to act as a scribe on a flip-chart for the learners in the simulation to refer to. Encourage the audience to be active observers

• Orientate the students around the environment and the equipment. Highlight any potential sources of confusion such as differences between the patient’s palpable pulse rate and what is on the monitor. Will there be blood results available? Are we running in real time? This helps keep the scenarios running later on

• Acknowledge simulation can be challenging and where possible allay fears - if you’ve set the scenario up so that any mistakes made will be corrected and death is not an outcome then tell them! In my experience the biggest apprehension toward simulation from students is that we’re trying to catch them out and they’ll kill the patient. If that won’t happen let them know. If it might happen then also let them know and reassure that it’s a safe environment allowing for these mistakes

• Lifelines - the timeout is a common theme in any simulation and it’s important to reassure students about this. I go further and add lifelines similar to ‘Who Wants to be a Millionaire?’ Students can ‘Ask the Audience’ - turn to the learner watching and ask their opinion or ‘Phone a Friend’ - ask the facilitator a closed, focused question; “I think it’s aortic dissection what’s the best imaging for this?” If it’s not going great we can always time-out and take a break; this is fine and should be used if needed

• Is there a specific aspect of simulation they’d like you to look out for? Giving useful feedback can be challenging. Students may have apprehensions about one particular skill or part of simulation such as cannulation or delivering a useful referral based on previous experiences. If they can tell you this beforehand it helps observation and providing feedback the student can use

• Give them appropriate information beforehand. Most of the simulations I do with students are based in the Emergency Department. One is with a patient presenting with chest pain who turns out to have a pulmonary embolus. In real life there would be an ECG. I provide this ECG and give them a moment to read it. I ask what the students are thinking and why. They usually say Acute Coronary Syndrome. At the end after diagnosing PE during the feedback I then ask them to take us through the process of how they ended up changing their mind from ACS to PE (usually because the patient complains of calf pain). I reinforce how important it is to always consider ACS but also what aspects should make us think PE (yes calf pain is important but the patient had oxygen saturations of 90% with no lung history, a clear chest and her ECG shows AF.) - this shows the nature of a true ‘working diagnosis’ as well as helping us understanding each others thought processes

Ultimately the pre-brief is about you and your learners finding out about each other. Standardise as much as you can. Students who go first may resent being ‘the example’ so think about making a video to show everyone what is expected at the beginning. This is then easier for you later on. I think pre-brief is an investment in your simulation sessions. The more and better you do at the beginning the bigger and more rewarding your session will be.

Thanks for reading

Jamie