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November 11, 2010

Too scared

Follow-up to Windows 7 "Upgrade" for a MacBook Pro without windows. from Musings on Medical Student Education

I got scared after reading the boot camp installation. Unless someone can reassure me I think I'll have to give it a miss....

Windows 7 "Upgrade" for a MacBook Pro without windows.

I'm just in the process of trying to install windows 7 on a MacBook Pro. Here's the chain of events so far.

  1. I bought the software from "Software4students", as a student thinking it was the bonafide software. Its not.
  2. On arrival of the software it was an upgrade disk. The software came in an unmarked, loose, nonsealed plastic wallet.
  3. I sent it back because I thought I wouldnt be able ot install it on my mac, although i do own genuine windows 7 on my desktop.
  4. "Software4students" refused to give me a refund, and sent the software back to me, stating it was in thier T's and C's. I was pretty annoyed by this, but essentially there was nothing that could be done other than trying to take them to court.
  5. They sent the disc back to me.
  6. I have just read on a blog that I may be able to install it directly on a Mac.

So here goes, installing Windows 7 'Upgrade' on a mac with no windows, although I do own Windows, albeit its on another PC.

windows 7

  • Is it just me or is the 'upgrade' bit on the picture above just a little bit too small?
  • Am I pretty amazed that its pretty unclear as to weather or not this works or not? Yes.
  • Are there lots of students who will by the Windows7 student edition? Yes.
  • Do I think I should be able to get a refund for software that I haven't used or entered a licence key for? Yes.

As it turns out I think Im just going to give it a go and hope for the best.

Will it work? I will find out.... Hopefully in less than under 2 hours!

PS... if you are reading this and you know that its not going to work, feel smug now...

August 16, 2010

New student webmail… seems to work!

I am quite amazed that the university's switchover to live@edu service from Microsoft seems to have gone very smoothly. In fact I had a problem this morning.

  1. I used  the web to find the contact number
  2. Rang the contact number
  3. Received helpful advice
  4. Now my email address seems to work perfectly...

If only everything was this simple... I do have some concerns about the listings of the 5 digit login codes on the address book, and I have emailed the IT service desk to flag this with them (I assume ti is an error?).

August 09, 2010

The PhD trail begins here…

So I'm delighted to say my PhD in virtual patients is beginning her, supported in full by an arthritis research UK educational research fellowship. I feel very privileged to be sponsored by a charity to perform educational research, and hopefully I will be using this blog as a record of my journey through the PhD application Arthritis Research UKprocess (which started on Friday following my last submission of my MMedEd project to Warwick Medical School. Onwards and upwards...

Arthritis Research UK can be contacted via their website. I hope to  be organising my own fund raising for the charity, which provides excellent research funding both for clinical and educational research into the management of arthritis.

July 08, 2010

Sativex: Cannabis extract comes to the UK without a whimper?

Writing about web page http://www.ncbi.nlm.nih.gov/pubmed/

Its been a while since those "cannabis to be grown in the UK for medical research" stories in 2002, but it has finally come onto the UK market in the form of Sativex, a cannabinoid spray marketed by Bayer, for use by  Neurologists in the treatment of the spasticity associated with multiple sclerosis. So a friend tells me.

So far this week in the news on my drive to work I have been told that:

I nearly choked on my weetabix when ICannabiods make Sativex what it is, but the image of cannabis leaves is not going to make Middle England rest easy for the new sub lingual preparation found out that doctors could be dishing out "cannabis" (well its actually cannabinoids) to anyone (or at least people with Multiple Sclerosis) by my non medical friend. He was told so 'by another friend'. So I investigated, and yes its true. But worry not, I am not a crazed physician on a war against medication, but I'm just a little surprised by the absence of any significant media attention for this.

So a cannabis based medicine is licenced in the UK. Do you have an opinion on this? Well I certainly did before I went to medical school. But lets consider the evidence for this for a minute. If you're not a health professional why not have a quick glance through why. You may not know that you can browse abstracts of virtually all medical research of any quality on the US site PubMed, for free. This is quick, simple, and available to anybody on the internet.

The two main studies are linked below.

Randomised controlled trial of cannabis-based medicine in spasticity caused by multiple sclerosis.
Published in the European Journal of Neurology link here.


A double-blind randomized placebo-controlled parallel-group study of Sativex in subjects with symptoms of spasticity due to multiple sclerosis.
Published in Neurology Research, link here.

So. I've read them. Here are my thoughts. Essentially the first study seems to show that about 40% of the patients given the medicine had at least a 30% improvement in their spasticity, measured on an objective spasticity scale.

Seems to work. I am just a little surprised that it hasnt made it into any of the main newspapers or mainstream media from what I have seen. So if you heard it here first, you heard it here first!

Cannabiods make Sativex what it is, but the image of cannabis leaves is not going to make Middle England rest easy for the new sub lingual preparation. What about the potential for abuse? Could it become a street drug with a value to other recreational drug users? A quick scan through PubMed reveals no case reports of illicit drug use. But as compounds as common as co-codamol find their way into recreational use, it will be surprising if there is not some misuse of the drug, albeit perhaps in small amounts.

What about if you really want to know more? A good place to start is often an established charity. With a quick Internet search, the MS Trust has a well written patient information leaflet on the drug, listing the indications, and the likely responses from the medicine. I found it quite informative as a (non neurology) Healthcare professional.

For a bit of light hearted relief, lets look at the side effect profile of the drug, from the pharmaceutical company. Any of these sound familiar? They compare fairly well with what a leading UK drugs charity says about the side effects of the street drug. 

Thoughts or comments (in particular on the media reaction) to this introduction anyone?

Side effect profile of Sativex, cannabinoid extract(1 in 10 to 1 in 100people) [source patient information leaflet, direct quotations] Common side effects of Cannabis [Source: "Talk to Frank" a leading UK drug infromation website for teenagers]

Feeling depressed or confused.

Feeling over-excited or losing touch with reality.

Problems with your memory or having trouble concentrating.

Feeling sleepy or giddy.

Blurred vision.

Difficulty speaking.

Eating more or less than usual.

Changed sense of taste or a dry mouth.

Constipation or diarrhoea.

Feeling or being sick.

Mouth problems, including burning, pain or mouth ulcers

Lack of energy or feeling weak or generally unwell.

Feeling abnormal or drunk.

Loss of balance or falling over.



'Panic attack'



perhaps 'Talk to Frank' need to update thier list!

May 03, 2010

Twitter for Medical Student Lectures?

Writing about web page http://www.medbiq.org/events/conferences/2010/index.html

I had a great time at the International Conference on Virtual Patients in London last week. One of the real positives to come out of the web2.0 discussions was how to hear how students can get engaged with elearning technologies. I personally took one idea as being a really helpful one.Twitter in action

The concept of using twitter and the use of hash-tags (like #lecture) to allow students to post up comments on a running board during the process of a teaching session sounded to me really attractive.

I wonder if anyone else is using a similar technique to help teach, and what their experiences have been. It can be a little daunting teaching groups of 150+, and I guess things could get out of hand, but it sounds like quite an engaging thing to get the students to do. I think Ill roll it out the next time I get to teach a few medical students.

There were quite a few other comments from people attending the conference, I hope to put some of them in a more formal form here.

There is also a great clip on YouTube which really summed up the buzz or the vibe that I'd like to create trying to deliver these new things, from a chap from the University of Arizona. It was interesting to hear the opinions of some of his previous peers on his teaching style, he certainly gets my vote for the high quality production and the messages you get from the video.

April 15, 2010

Health plays key part of UK's first televised election debate: leaders clash on cancer waits

The future of the NHS and service provision formed a central part of this evenings national election debate from Manchester screened live on ITV with concurrent audio on BBC Radio 4. Health care as expected did play an important role this evening. Here are a few quotes from the chief protagonists, Brown and Cameron:

Gordon Brown on the leader of the opposition, and on health care in general.

He [Cameron] couldn't give the same personal guarantees that we're giving about specialist cancer care

Fair to our National Health Service

Protect our helath service

David Cameron: rhetoric, with some serious points.

Choose hope over fear

Stop labours 'job tax' which could destroy our economy

If you work had 'll be behind you

If you're old and you become ill we will always be there for you.

Gordon Brown attacked the leader of the opposition about their plans and possible changes to the two week wait.But what is this two week wait? If you work as a doctor in the NHS, you'll already know, but for those that may not be so well informed, what does the two week wait actually mean in practice?

Essentially the 2WW (as its popular abbreviation) is the target that a patient with suspected cancer should be seen within two weeks of the referral being received. A good system? It seems so. Actually the targets go further, with the first 'definitive treatment' being delivered within the first 62 days from referral. This essentially means if you need an operation to have your cancer out, it is the responsibility of the doctors to diagnose it and treat it definitively. This means the necessary scans, biopsies pre-op checks and the like to achieve things. Lots of NHS initiatives have been criticised. The four hour wait has long been criticised by doctors (including this one) in Accident and Emergency departments, however it does seem to have driven up standards and efficiency in our hospitals. In principle, the two week wait is a good thing. So why would it be cut by the conservatives?


The answer is complex, and not explained in the media writ large. There has been much focus on labours mailshot to potential cancer sufferers, but what politician in their right mind would cut such progress? (Guardian coverage here). The answer lies in policy and procedure, and represents why health is such a sensitive topic. ON the basis of Browns comments above, who without health insurance would not vote Labour? Unless the plans are presented clearly and simply (tonight they were not) it is difficult for those even inside healthcare to make informed voting decisions on such issues.

The conservative leader did consistently focus on the fact that Labour has had 13 years to fix things: how is Labour currently planning to fix things? By saving money, lets look at if its going to hit the workers in the health service (me) or the patients (me). Are there tough choices that have really been outlined for the NHS to date in terms of cuts?

Efficiency Savings: What is the level of 'pain' the NHS can expect?

These points come from the Department of Healths own press release hereI cant help but provide my own bottom line opinion for what it means to staff and patients.

The Department of Health and the NHS will meet this target through a range of activities including:

  • "Up to £1.5bn will be saved by driving down the costs of procurement through securing best prices for goods and services"
    • The bottom line: no pain for the workers or the patients
  • "£100m will be saved by taking a new approach to the National Programme for IT that offers greater choice to local hospitals"
    • The bottom line: no pain for the workers or the patients (unless you're in IT!)
  • "£60m will be saved by reducing the amount of energy the NHS uses, to deliver a 10 per cent cut in carbon emissions"
    • No pain for the workers or the patients, lots of energy saving light bulbs on the shopping list
  • "Up to £70m will be saved from more efficient use of NHS estates"
    • No pain for the workers or the patients, don't expect to buy the local hydrotherapy pool at a cut price
  • "Up to £555m by reducing staff sickness absence in the NHS."
    • No pain for the workers or the patients, unless you're doing things you shouldn't be.

Andy Burnham the health secretary had the following to say on the 4.5billion saved in the budget.

The NHS budget is in a strong position after a decade of record  investment. I am pleased that today’s Budget locks in that growth, guaranteeing that frontline NHS funding will rise with inflation in 2011-12 and 2012-13.  As a result of this funding, the NHS is today more resilient, has more capacity and provides better care than ever before.

Healthcare, two week waits, cancer services, provision of care for the elderly, the payment of this care, and taxation of those receiving it will continue to play a key part in the election leading up to May 2010. As you can see how these policies, and changes to current policy are presented is likely to influence the publics next choice of government.

Missed it? You can catch up on ITV here on what went on. Id be interested to hear comments from anyone and everyone on the above musings...

February 03, 2010

Web Based Learning in Rheumatology, where are we now, and where do we need to be?

We all know about the potential of the web, but how should it be best put to use? Here are some of my musings frommy own thoughts on web based learning and rheumatology as it stands today.internal rotation of the shoulder


When considering web based learning (WBL), extensive research has been conducted to compare e-learning against more traditional teaching methods. Up until recent years, the majority of educational research studies into WBL were non inferiority studies, or comparisons of additional e-learning resources ‘added into’ standard curricula (Cook, 2005, 2008). The largest meta-analysis of WBL learning in healthcare conducted to date has concluded that it is not if, but how we deliver web based learning that is the most critical question facing educators (Cook, 2008). It was confirmed by Wong (2003) that delivery of web based teaching is not simply a case of ‘putting your course on the web’. Robust evidence does not exist on exactly how the delivery of this material influences learning. Few studies attempt to directly compare two different approaches, with almost no data on an ‘interactive video’ based approach compared to a standard online presentation of material.

WBL in Rheumatology
Education in musculoskeletal medicine provides some evidence for some forms of WBL when added to traditional methods (Wilson, 2006); however I have identified no trials that compare different online strategies to teach a clinical skill. Various e-learning techniques have been tried, but they are often not web based. The Arthritis Research Campaign (ARC) have produced a more traditional CD ROM based e-learning package has been evaluated, and been shown to improve OSCE scores post intervention and improve self reported confidence (Vivekananda-Schmidt, 2005), however WBL has not been studied extensively studied by the ARC, or other research groups.

How is WBL Delivered
Web based learning (WBL) is commonly delivered in the form of a Virtual Learning Environment (VLE). A VLE can be thought of as a navigational menu driven system by which a student directs his or her educational pathway through a series of resources or activities. Any accessory materials such as pre/ post teaching evaluation can be delivered, with the results often being automatically collated by the VLE. This structure allows the delivery of educational material to trainees, in a reproducible, secure way. Each VLE can be accessed by students and teachers, with different priorities and user privileges available to users depending on a pre determined level of access.

Online material can be presented I a number of formats inside a VLE, namely via traditional text and pictures with associated connections between topics (hyperlinks), or via more detailed methods incorporating video and audio based aids to assist in their development. There is evidence to support that the more sophisticated the technology or advanced the delivery method, there is an increased associated cost. Furthermore this has been shown as one factor to dissuade medical schools in the United States to sharing online e-learning material, or producing open access medical resources (Huang, 2007).

In summary there is a large amount that is still to be studied relating to web based learning in  Rheumatology. Where do we go from here?

Selected References and Further Reading, if you're interested...

Badcock LJ, Raj N, Gadsby K, Deighton CM. Meeting the needs of increasing numbers of medical students--a best practise approach. Rheumatology  2006;45(7):799-803.

Cook DA, Levinson AJ, Garside MD et al. Internet-Based Learning in the Health Professions, A Meta-analysis. JAMA. 2008;300(10):1181-1196.

Cook DA. The research we still are not doing: an agenda for the study of computer-based learning. Acad Med 2005;80:541-8.

Cook DA. Where are we with Web-based learning in medical education? Med Teach. 2006;28(7):594-8.

Downing SM. Reliability: on the reproducibility of assessment data. Med Educ. 2004;38(9):1006-12.   

Huang G, Reynolds R, Candler C. Virtual Patient Simulation at U.S. and Canadian Medical Schools. Acad Med. 2007;82:446-451

Kay LJ, Deighton CM, Walker DJ, Hay EM. Undergraduate rheumatology teaching in the UK: a survey of current practice and changes since 1990. Arthritis Research Campaign Undergraduate Working Party of the ARC Education Sub-committee. Rheumatology. 2000;39(7):800-3

Norman G Eva KW. Quantitative Research methods in medical education. AMSE. Edinburgh 2008.

Vivekananda-Schmidt P, Lewis M, Hassell AB.Cluster randomized controlled trial of the impact of a computer-assisted learning package on the learning of musculoskeletal examination skills by undergraduate medical students. Arthritis Rheum. 2005 15;53(5):764-71.

Wilson AS, Goodall JE, Ambrosini G, Carruthers DM, Chan H, Ong SG, Gordon C, Young SP. Development of an interactive learning tool for teaching rheumatology- a simulated clinical case studies program. Rheumatology (Oxford). 2006 Sep;45(9):1158-61.

Wong G, Greenhalgh T, Russell J, Boynton P, Toon P. Putting your course on the Web: lessons from a case study and systematic literature review. Med Educ. 2003;37(11):1020-3.

January 22, 2010

Use of Smartphones: an example of the Resuscitation Council UK's App for Advanced Life Support

Its always The Resuscitation Council UK, which provides guidelines for advanced life support in the United Kingdom for adults and childrennice to see how technology can help a budding doctor or nurse. There's lots of free tools available, often increasingly to those with smartphones. Via Twitter and other blogs I saw the coverage of apps for the iphone in Haiti,  including offers from companies such as Epocrates to give out free apps to healthcare workers following the earthquake.

I have three thoughts on this having just bought an iPhone

  1. It sounds like a very good idea
  2. Its a bit of the shame that the battery life of about 24 hours will potentially limit their use in the absence of an adequate power supply
  3. The biggest challenge facing healthcare workers out in Haiti is unlikely to be a case of not knowing what to do, and more likely to be a case of not having the right kit to do it

For those people who are unfamiliar with apps, and their use on the iPhone, lets take a look at a free iPhone application that's now available from the Resuscitation Council UK.

As a relatively new iPhone user, and owner previously of a Blackberry Curve I'm impressed at apples latest offering in terms of the simple ease of use.

Lets try out the iPhone app from the Resuscitation Council Uk, called iResus.

    • The download from the iPhone app store: just select iResus- so far so goodiphone
    • the download proceeds quickly, and does appear to be 'free' just as it says on the tin. For the purpose of this user, I haven't registered my details, but would do under normal circumstances
    • I'm prompted to download what I want. I pick the adult advanced guidelines.
    • I'm taken to the iResus home screen after the 60+ guidelines have completed their download
    • I can now freely browse guidelines using a simple menu interface, which is intuitive like most iPhone apps. It allows me to browse management, and pictorial algorithms, although does not have anything like the detail of the formal guidelines produced by the Resuscitation Council (understandably in the 100+ page A4 book)

    So the very simple iPhone interface that guides me through the algorithms, including a helpful signposting of whats going on.

    I cant help by being a little worried by the fact the iPhone seems to offer you options as if it was the real thing: i.e. real time information for bradycardia management. I have visions of junior doctors pulling out their iPhone to check the management of the next medical emergency they face.

    In conclusion overall the app is an excellent introduction by the Resuscitation Council UK into the world of iPhone apps, and hopefully they will follow suit for other handheld devices. The market for the use of these phones in routine and emergency clinical work is just emerging. Looking at other high quality free apps, perhaps 2010 will be the year of the medical app on the iPhone.

    Finally: a test for any armchair TV medics who have watched enough ER or House. What is the rhythm on the strip identified below with a patient hooked up to a defibrillator?*

    *if you do not have a medical degree then if you get this right you should  be seriously impressed with yourself!

    Rhythm strip

    December 23, 2009

    Merry Christmas to all and sundry at Warwick

    Christmas approaches quick! the last few weeks have been busy with my PhD application, lots of work at my current hospital and discussions around my professional project for my MMedEd. This year I have amongst other things...Festive greetings

    • managed to update my Twitter (jamesbateman) at least once every two months
    • submitted a decent PhD application to the arc which will hopefully have been funded
    • adjudicated our hosptial christmas quiz
    • attended the BMA careers fair
    • totted up a record breaking number of car parking tickets
    • fought numerous car milage claim applications
    • battled against unfair hospital IT access policies
    • regretted buying an Italian car
    • been hacked by russian cyber criminals (and won)
    • unsuccessfully tried to use SPSS
    • managed to finish the majority of my key MMedEd modules
    • tracked santa on NORAD
    • worked hard on my other elearning interests
    • failed to get any medical education bursaries (again!)
    • thought lots about how to reduce my gas bill

    That's all folks for 2009.... Lets hope 2010 brings more smooth running educational research projects, good medical training and mince pies.

    Merry Christmas

    November 30, 2009

    Google SideWiki– Any opinions on a concept I have some concerns about…

    Hello tech experts? Google Sidewiki has justGooglke Sidewiki appeared helpfully in my google toolbar. I didn't select this option, and it it seems to have default installed itself, which to be honest is a bit of a concern.

    But there does seem to be a catch: people can create Google accounts and then 'sidewiki' about essentially any web page they like? That seems to be the idea. So anything you dont like about something, you can just whack it up there, and its all controlled by google?

    Is that really a good idea? Take for example this blog, or any other site that I could write about, or design. Essentially there is a space, out of my control, which people can then edit and post on. Not really a great idea in my opinion, especially given the concerns ofver freedom of speech and informaiton on the internet.

    Look at googles image (right)- this sounds like such a helpful piece of kit. But is it really going to be used like this (just read the comments).

    To quote the venerable Techcrunch:

    Will this work? It’s unlikely that websites will have the same visceral reaction today that they did to Third Voice a decade ago. And Google solves the chicken-and-egg problem nicely by building this into Toolbar. The real question is whether they can control spam, which has plagued SearchWiki. And I guess the other real question is, how long until they put ads in it?

    I wonder what implication this has for things like university websites, and subscription sites etc. I'm sure its fine if you a large multinational, but I have serious concerns about something that someone can post over my own site.

    Take this blog for example: someone could post my personal details alongside the blog. A disgruntled colleague or patient could use it for destructive purposes. Im not comfortable with it, I don't like it, and Im not sure I have the option of refusing it for this or any other website that I currenly have. Perhaps this is an over reaction. Perhaps it isn't. As per techcrunch: spam, spam, spam, abuse, and advertising! What is to stop a large organisation spamming a competitor?

    What is to stop unscrupulous organisations spamming patient information sites about what the best drug is for a condition? I'm not convinced that a reputable site (like the World Health Organisation) should have Google sponsoring some form of sidewiki on it. I just dont agree with it in principle, and it is a gut reaction.

    Not a great day for democracy? What are the opinions of anyone else out there. I would be particularly pleased to hear comments from industry insiders, medical professionals, and anyone who hosts their own website or blog.

    November 16, 2009

    That is the worst drug/ medical device/ MRI scanner.. Can I have one of your cornflakes please?

    Writing about web page http://business.timesonline.co.uk/tol/business/law/article6917365.ece

    I nearly choked on my cornflakes this morning (please don't sue, they were generic cornflakes and the cornflakes were not at fault). This seems to be the order of the day for British libel laws which seem to be putting the UK at the centre of at least one aspect of healthcare.generic cornflakes

    The Times writes on 16.11.09:

    Scientists and specialists who question medical treatments and alternative therapies are being gagged by firms using Britain’s draconian libel laws.

    Researchers who have raised concerns about osteopathy, heart implants and homeopathy have been forced to withdraw or water down scientific papers and websites for fear of being sued.

    It seems to me that there is an increasingly fine line between honest criticism of a product, sharing your opinions and an action that can be considered libel in a country where the writer or blogger is not even at fault.

    While htis initially has started with celebreties (the Independent reporting here) it now seems that healthcare is fair game too.

    In an article that I personally consider deeply worrying, theheart.org report in more detail about a cardiologist and his dispute following comments made regarding an implantable cardiac device. Whilst people may not agree with any number of medical opinions or research data, does this action then become libellous if a person is giving an honest critique? It gives me concerns for my other blog, given the volume of material that wil end up on there!

    Something here has clearly gone very, very wrong.

    No cornflakes were harmed during the wiritng of this blog. I do not even like cornflakes. Any suggestion these cornflakes are not british cornflakes will be stringently denied, unless it is proven they are not cornflakes. Cornflakes may be good for your health, they may also be found to be bad for your health. I reccomend only consuming cornflakes after discussion with an appropriate healthcare provider. People who are allergic to corn, flakes, or cornflakes should not eat cornflakes.

    November 08, 2009

    Medical careers get sexy in the West Midlands….

    The BMJ Careers Group and the West Midlands Deanery Lay on the day for trainees

    If its not the BMJ Careers group putting  on a glitzy presentation, its another organisation wowing junior doctors up and down the UK with promises of a glittering career in Rheumatology/ genitourinary medicine / some other exciting specility.

    Hats off to the deanery who again laid on an excellent careers day for all concerned.

    I was pleased to represent my own speciaility at the annual BMA careers evening hosted in Birmingham at the ThinkTank and had a good time chatting to would be medical students and budding practitioners.

    Rheumatology was enviously split between the less glamorous specialities of Geriatrics (wHich I think is now termed the more politically correct care of the elderly) and Dermatology. My own efferot on why students should choose rheumatology....

    Increasingly each individual speciality is encouraged to wax lyrical about the benefit of studying. In the UK this means recruiting enough (and the best) doctors to your own speciality, something that is becoming increasingly difficult with the perception of an 'easier life' and 'better working conditions' in primary care.

    This is something extending into the day to day life of a medical trainee, being required to promote your own speciality, which can only be seen asd a good thing. Expect more fact sheets like the one to the right to be created by trainees up and down the country.

    I spoke to one anaesthetics trainee for his view on representing the deanery at the Thinktank:

    This can only be good for my CV! I have spoken to quite a few trainees though, and they were all pretty interested, which was nice.

    Well it seems that not everyone's intentions was truly alturistic, but as long as the trainees get their advice, who cares?

    Anyone who wants to know more about any general medical career in the uk should try heading here to the JCRPTB website at http://www.jrcptb.org.uk/Pages/default.aspx or click the link here.

    August 11, 2009

    Politics and the NHS, Productivity, Targets and Numbers

    The NHS is coming under increasing scrutiny, and the issues around its funding once again making front page news. There are some recurring statistics: productivity in the NHS has fallen by 4% despite a large cash injection from 1997 onwards.

    But what does this mean? There is an increasing drive for doctors in training to have formal management qualifications. With this in mind, what does a 4% increase in productivity actually mean? Does every doctor do 4% less work? Are patients likely to get only 96% of the treatment that’s should be given to them? More importantly if a trainee inside the organisation, with an interest in management has little idea of how the numbers are derived, and what they mean to the average medical clinic, A&E department or on call surgical list, then there is a problem.

    The most telling argument was a rule mentioned in passing to me by a colleague. It doubles follows a principle which despite my ‘intelligent’ Google searching, I cannot find…It goes like this: once you turn a marker of performance into a target, that marker of performance ceases to accurately reflect performance.

    When applying this to the NHS you get a simple, understandable concept. Consider the Emergency department 4 hour wait. It is likely that departments that were seeing, treating, discharging or transferring patients within 4 hours of their arrival in that department were good A&E departments, better than the ‘norm’. Where is the evidence for this? Common sense and expert opinion!

    Once the 4 hours becomes a target, then hospitals managers will be ‘forced’ to hit those targets. If that means renaming a bay in A&E as an inpatient observation ward then so be it. If it means treatments being delayed, then so be it. Its increasingly common for junior doctors to be faced with management policies at their inductions, and the potential repercussions of not fulfilling specific targets set. Its more likely that they will be turning away from the NEJM to the other publications (for example form the Medical Defence Organisations like the Medical Protection Society) that produce survival advice for newly qualified doctors in changing times.

    The difficulty is introducing the kind of lean management principles reported in the late 1990s by the American Academics that sought to find out why Japanese Car manufacturers like Toyota could produce and import cars to the US for less money than their American counterparts.

    It is the challenge of meaningfully measuring and quantifying management performance in the NHS that is the challenge. Getting from line staff (like myself) to understand the concepts of productivity is critical, as is giving departments this sort of information.

    If the focus shifts to lean and efficient management processes, then the numbers behind the targets will follow. The measurement of markers of productivity needs to be more transparent to staff, patients, and contributors to the NHS budget (British taxpayers) to allow them as voters to make informed decisions surrounding healthcare policy.

    July 07, 2009

    Virtual Patients

    Writing about web page http://www.virtualpatients.eu/

    I've been enjoying working with a number of different software packages for virtual patients over the past few

    Labrynth is one of a number of educational developments to improve education based on simulated clincal cases

    weeks including Labyrinth, vpSim and a number of offerings from a number of organisations.

    What I can say is the beauty and speed of whats been evolving really does put these developments into really new areas of research.

    The real point is that its not clear exactly how to educate undergraduates, doctors or patients using these forms of software, but  research is now being dedicated towards this area including a European Body eViP, which held the first International Conference dedicated to Virtual patients earlier last month (June 09) in in Krakow.

    Numerous e-learning developments are blogged daily by practitioners interested in the Web2.0, and virtual patients really offers the opportunity to practising physicians and educationalists to work together, each generating significant content.

    Im looking forward to developing some elearning content here at Warwick for undergraduates. But how is this actually done? A diagram below (created using vpSim from the University of Pittsburgh) will help to explain things. Depending on which system is in use, a series of interconnecting pathways with options for questions/ interventions and branches along with multimedia gives students the opportunity to work their way through different clinical cases.

    An example of the pathway followed when creating a vritual patient case

    Each of the nodes contains detailed clinical information as well as patient resources.


    Obviously there are a number of concerns that go along with generating such content. material published on the world wide web can be copied and is difficult to withdraw once consent for publication has been given. Fortunately detailed consent forms and information given to patients whose clinical images may be used in such cases helps minimise the impact of such problems.


    hopefully the open access nature of the Web 2.0 revolution, the creative commons licence and other initiatives will bring virtual patients to an international audience and overall improve the quality of patient care. Important research questions remain to be asked about how these tools can be used to teach doctors, nurses, physiotherapists and other allied health care workers.

    For more information on eViP, watch a video, from them, embedded below.

    June 03, 2009

    Powerpoint to Flash which is SCORM Compatible?

    Spending the last year working on a number of different elearning projects along with the up keep of a large VLE with >2000 registered users has been complex. The most frustrating aspect of elearning is the difficulty in transferring presented material from a common presentation format used by most teachers (in my experience, PowerPoint) to a web based environment.

    Searching the web as I did for "PowerPoint to flash" seemed to be the answer, with the 'flash' platform being well used.


    After using a couple of commercial products as a trial, we have come round to using the Ispring model. this allows the user to create a PowerPoint to flash file at the click of a button. without being an expert in IT, this seems to offer the perfect answer, with simple menu driven functions for zip file/ different presentation flash styles, presenters, layers and other models.Ispring

    SCORM-Taking things a step further

    Being interested in elearning research, what about patterns of use when you're using these sorts of things? SCORM (I believe developed by the US military) seems to be the solution. I gather Ispring now have a tool which is SOCRM friendly to allow users to analyse how students have performed suring custom designed quiz packages.

    We're yet to try this version, but it seems to offer a simple solution to a difficult problem.

    HTML- you will...

    Its still unfortunate that without a simple grasp of HTML, you will still not be able to utilise flash from different sources, no matter how good the software is at creating it. However with the embedded codes that are standard, this isn't too much of a problem.

    Problem Solved?

    All our problems solved?Maybe maybe not. Anecdotally we have had reports that bits of our flash (not generated through Ispring) do not play on peoples Iphones. This is a disappointment.

    We'd like to use the SCORM content with Moodle to try it out.

    Overall we give Ispring a 5/5 rating. I hope to put their software to the test further having already presented it at the British Society of Rheumatology.

    An example of the free hosting that comes with slideboom (handy if you're using a mega file with video and your university webspace is running low)-a site a bit like youtube for flash- can be seen below. This is the ultra basic, free trial version of Ispring. I intend to publish the more complex players on the blog shortly.

    May 05, 2009

    "Dr Death" Visits the UK: Weighing up his 'right to speak'

    We often get to pass judgement on others based on short stories in the media. Consider the news today. A doctor from Australia has been lecturing today on assisted suicide in Bournemouth, England.  I thought I'd utilise my simple ABCDE approach of ethics and see where my own morals lie in the case, as presented to me by the media in various guises on the way home from work today.

    Consider the reporting of Dr Paul Nitschke's arrival in the United Kingdom today. My own perspectives from the media taken from an interview on BBC radio 4 was as follows.

    • He's a doctor (but what sort?- internal medicine? anaesthetics? Doctor of music?)
    • He's here speaking in the UK on assisted suicide (which remains illegal in the United Kingdom)
    • He's an eloquent speaker
    • On the surface the arguments he puts forward seem to be rational with an explanation
    • He was detained by the UK immigration authorities and then released.
    • He apparently appraises forms of assisted suicide, and provides information on them to members of the public
    • He has been much criticised
    • He presents the activities he's undertaking in the UK as legal

    I know nothing more of the man other than from this brief summary. So can I still apply the ethics? Yes, as I in common with other people will initially form an opinion  based on the available evidence


    B= Beneficence

    C= Consent/ Confidentiality

    D= Do no harm

    E= Equality

    Based on my assessment of the media on his arrival I asked myself two questions. In my opinion

    1. Should he be refused entry to the UK?
    2. Should he be allowed to lecture in the UK?



    Consent/ Confidentiality

    Do No Harm


    Should he have been refused entry to the UK




    No (Possibly)


    Should he be allowed to lecture to the general public in the UK


    No (possibly)


    No (possibly)


    This argument could be replayed with any number of questions. Look at the issues in bold, which I consider up for debate on the web.

    Entry to the UK: I don't think this should be refused based on his opinions from the interview however this depends and is inextricably linked to my second question. This therefore becomes a bit of a 'cop out' however it reveals that this is not the central issue. This is made clear when Nitschke himself who said on the BBC:

    In terms of keeping your borders closed so we can have a free and open debate thats a bit of an oxymoron

    Conclusion: I think he should be allowed to enter the UK based on the evidence I've heard.

    To take the second point, should he be allowed to lecture: the fact that this is such a sensitive and emotive medical, psychological and social issue, the best way forward is probably not to have an unregulated speaker who may (unintentionally) have an adverse effect on a patient or individuals decision to harm himself without due cause.

    But... Will we be having the debate if he doesn't first begin to make a stand? Possibly, but not I think probably. It certainly is a topic which needs discussion, but the ethical arguments are in this instance a minefield. So on the grounds of beneficence and Do no harm, my opinion from the basis of what I have heard is that he should not be allowed to lecture to the general public in the UK.

    Now the research: Searching the web this evening brings me to a number of links.

    • Sky news covering the story along with other various media outlets (The Times, The Independent to name a few).The BBC also covers the story and an audio interview can be heard online here.

    I think I'll let you draw you're own conclusions, but I'd be more interested to hear people's views on these sorts of ethical issues that get discussed in a 3 minute slot on the radio. Please post comments if you

    1. disagree with the above
    2. have any thoughts on a simple one minute ethical approach like the one above
    3. have strong opinions on anything thats discussed here.

    Remember this is the viewpoint on discussing a persons right to speak based on a media interview, nothing more.

    April 15, 2009

    Teaching the Teachers?: US vs the UK (andTwitter? )

    I'm set to interview medical students from the US and the UK to try and identify differences in attitudes, beliefs and assessment systems from perspectives from each side of the Atlantic.

    Im quite excited about htis for a number of reasons. It will hopefully back up research that I'm currently carrying out at warwick into the attitudes of medical students to teaching the teachers. This is run from a site I've set up specifically  for NHS research. This study (foillowing ethical approval) is ongoing.

    Although we have >1000 registered students to my sister medical education site, the majority are from the UK. More importantly, the first US based student to be interviewed does not come from this fraternity, but in fact via my twitter page , after following my comments on medical education there.

    There's been alot of discussion on Twitter on the WB site from a number of different perspectives, I think this is where it really gets interesting. No sign of linkedin here!

    I have a reason to be a fan of international medical students, as I owe a lot of the success of Medical Educator to the free, unsolicited assistance of a number fo the Web2.0 personalities.

    I really am a fan of Twitter and have made some useful acquaintances from Finland, Bulgaria, and the US, probably most importantly Berci Mesco, who runs a blog (google page rank of 7/10, which is on a par with some universities (Warwicks intranet page rank is currently 7/10) about medical education and has featured in  Nature Medicine and a number of other high profile interviews (mine not included). As a 'friend' i cite him for a major exposure of our own site- having featured us for no reason.

    If any medical students would like to feature in the article (from Warwick or other universities in the UK or Europe), please email me at james.bateman@warwick.ac.uk.

    Dies anyone else feel that theres any point in doing this, or is it just me? Id love to survey medical student's in the US with the same questions, and I believe the best chance of finding a contact in the US is either through Twitter, or my blog here.

    March 22, 2009

    Google street view comes to Warwick?

    IMagine my surprise when I found out that no, my parents street is not on google streetview and no, neither is Warwick Medical School.


    I wasn't surprised to hear the reports on BBC about infringement of peoples privacy, e.g. being snapped coming out of a sex shop in Soho probably wouldn't go down too well.

    Nevertheless, plaudits to Google for having the balls for coming up with such a comprehensive package.

    And how many advertisers are fitted onto the main page?

    Count them

    1. Tate

    2. Fancy a pint? (encouraging underage drinking?)

    3. Visit Britain ( fair enough)

    4. Mayor of London (Boris do you have nothing better to spent the capitals hard earned cash on? Better save some for Barclay's)

    5. Find a Property (I guess they need all the help they can get in these times, maybe they should ask Boris)

    Wait till they come to Warwick...

    March 17, 2009

    Streaming video for your website: practical points

    I run a Website through a web hosting company which is said to offer "unlimited bandwidth". The bottom line is however that this essentially is meaningless! To host large medical examination videos (i.e. 80megabytes plus) without a dedicated server to 750 plus users is virtually impossible.

    Having now negotiated new hosting, our customers will  hopefully be much happier, however it does seem to be a bit misleading as a non IT professional when you look at whats on offer from some hosting firms. However, apart from the download issue, our hosting providers have been first class, and initially ewe did not specifically ask about video hosting.

    Not withstanding our wonderful VLE (see Robert OToole's site for his perspectives!), having high quality video material is essential.

    You can watch a video here, which was that was first hosted on YouTube.

    Now our speeds are pretty similar to that found on YouTube.

    My Masters in Medical Education is continuing apace and I hope to be able to accredit some of the experiential learning from the site towards my future qualifications.

    At the site, on the quesitons and videos and also on our blog our videos now run quite seamlessly. Hopefully when we encourage feedback from our use base, we'll be able to concentrate more on the content than providing a high quality service.

    If you have any comments I'd love to hear them.