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Friern Hospital in 2017 (Philafrenzy)

The case of Bolam v Friern Hospital Management Committee (1957)

When we consider clinical negligence we often talk of the Bolam Test, but just who was Mr Bolam and what was the legal case that changed medical practice?

Introduction

In August 1954 Mr Bolam was running out of treatment options. He had been suffering from depression for over a decade and now voluntarily admitted himself to the Friern Psychiatric Hospital in London. What happened to him there would have consequences for medical practice both in the UK and around the world and would define the law on negligence for decades to come.

Bolam and Friern Hospital

John Hector Bolam was born in County Durham at the very start of the 20th century. Unfortunately, this meant that he was a member of the generation that found itself of age to fight in both World Wars.

During the Second World War, he had been commissioned in the Royal Engineers, but because of his depression was invalided out of service in 1942. His mental health did not improve, and in 1954 he attempted suicide after which he was admitted for the first time to Friern Hospital. He is reported to have made a good recovery with rest, was discharged and returned to work as a car salesman in London. However, only six weeks later he relapsed and found himself again in need of in-patient care at Friern. On this admission, he was examined by a consultant psychiatrist attached to the hospital and a course of electro-convulsive therapy (ECT) was recommended.

Mr Bolam was asked to sign a consent form for the procedure, which he duly did and his first treatment was uneventful. However, during his second treatment, which was administered on August 23, by Dr C. Allfrey, a Senior Registrar in the hospital, Bolam suffered serious injuries. ECT is designed to induce a seizure in the hope that this will provide relief from major psychiatric illness. During the procedure, Mr Bolam was supine with a pillow placed under his back, his chin was supported and a gag was used. Otherwise, he was unrestrained, although a male nurse stood on each side in case he should fall from the couch. Importantly, no anaesthesia or muscle relaxants were administered prior to his treatment. This form of ECT is known as unmodified and even in the 1950s was falling out of favour.

During this second course of ECT, Mr Bolam sustained severe physical injuries as a result of the induced seizure.   He dislocated both hip joints with bilateral fractures of the pelvis, which were caused by the head of the femur on each side being driven through the acetabula of the pelvis.

As a result of his injuries Mr Bolam took legal action and sued the hospital management for damages. He claimed that the hospital had been negligent in allowing Dr Allfrey to perform ECT without first administering a muscle relaxant or providing appropriate restraints. He further contended that the doctor had failed to warn him of the risk of fractures during the procedure, which although small (around 1:10,000) was well-recognized, especially as there had been six other cases of unilateral fracture following ECT in the same hospital.

The Court Case

The case came to court in February 1957 and was heard by Mr Justice McNair.   A variety of medical opinion was sought by both sides and what was revealed in court were marked differences in practice. Mr Bolam called a distinguished psychiatrist who remarked that the decision not to provide manual restraint was ‘foolhardy’, and stated that it was his practice always to warn patients of the hazards of ECT. Other expert witnesses offered contrary views and several concurred that it was unnecessary to inform patients of the risk of fracture and agreed that Dr Allfrey had acted appropriately. One consultant psychiatrist said, ‘I have to use my judgment. Giving the full details may drive a patient away. I would not say that a practitioner fell below the proper standard of medical practice when failing to point out all the risks involved.’

Some argued that the use of muscle relaxants and any form of general anaesthesia (so-called modified ECT) rather than being desirable was in fact potentially dangerous, and may even be fatal.

In the course of his summing up to the jury, Mr Justice McNair, made the following remarks on the standard of proof in a negligence suit.

‘How do you test whether this act or failure is negligent? In an ordinary case it is generally said, that you judge that by the action of the man in the street. He is the ordinary man. In one case it has been said that you judge it by the conduct of the man on the top of a Clapham omnibus. He is the ordinary man. But where you get a situation which involves the use of some special skill or competence, then the test whether there has been negligence or not is not the test of the man on the top of a Clapham omnibus, because he has not got this special skill. The test is the standard of the ordinary skilled man exercising and professing to have that special skill.’

He went on to enunciate the principle, which is at the heart of the now so-called Bolam Test:

‘A doctor is not guilty of negligence if he has acted in accordance with a practice accepted as proper by a responsible body of medical men skilled in that particular art. … Putting it the other way round, a doctor is not negligent if he is acting in accordance with such a practice, merely because there is a body of opinion that takes a contrary view.’

Applying this principle, the jury, while expressing their sympathy for Mr Bolam, found for the defendants.

Criticisms of the Bolam Test

The principle that underpinned the definition of clinical negligence would be used for the next 50 years and would be upheld by the House of Lords in several important test cases. However, it has not been without criticism. To pass the Bolam Test an alleged clinical negligence must be compared with what is done in standard practice, rather than what should be done. Thus, if bad practice is the norm, no negligence can be proved.

Some feel that this approach stacks the odds against any patient who claims clinical negligence. In 1997, a House of Lords ruling on another case (Bolitho v. City and Hackney Health Authority) applied the Bolam Test but sought to clarify it by offering a modification. Where there are conflicting bodies of expert medical opinion, if the actions proposed by a body of responsible doctors is not demonstrably reasonable and cannot withstand logical analysis in the court, it will not necessarily constitute a defence. In other words, you cannot defend against negligence on the basis of a practice just because it is current—it also has to be reasonable or logical.

Many countries, whose legal systems are derived from English law, have also used the Bolam Test, but some have developed different approaches to the assessment of clinical negligence. In Australia, for example, there has been a rejection of the Bolam Principle in favour of greater patients’ rights.

Conclusion

In that courtroom in 1957 medico-legal history was made, but one man, the unfortunate patient at the centre of it all, hobbled out despondent. The judge, who had described Mr Bolam as being in a ‘hopeless condition’ in the witness box, where he ‘told the tragic story of [his] sufferings and his experience’ could offer him no damages. What he did offer him, however, was a form of immortality. Mr Bolam has now been dead for several decades, but the principle that bears his name, and which deprived him of any compensation for his injuries, lives on.

 

© Allan Gaw 2017

Now available in paperback…

Testing the Waters: Lessons from the History of Drug Research

What can we learn from the past that may be relevant to modern drug research?

Screen Shot 2015-10-14 at 21.22.11

“I cannot recommend it highly enough: even if you read nothing else about the origins of drug research and what it can (should?) teach us, read this….This is a ‘buy’.”  Madhu Davis review in Pharmaceutical Physician May 2016.

My other books currently available on kindle:

Screen Shot 2015-01-18 at 17.19.43Screen Shot 2015-01-18 at 17.19.00BIS Cover copyScreen Shot 2015-01-18 at 17.19.29Screen Shot 2015-01-18 at 17.18.54Screen Shot 2015-01-18 at 17.19.37Screen Shot 2015-01-18 at 17.19.16Screen Shot 2015-01-18 at 17.19.58Screen Shot 2015-01-18 at 17.20.06

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The case of Victoria Gillick v West Norfolk and Wisbech Area Health Authority
(1985)

When thinking of consent in children and young people, we may talk of Gillick Competence, but who was Mrs Gillick and what is the story behind this landmark ruling more than 30 years ago?

Introduction

To say that Mrs Gillick was angry is an understatement. She felt her rights as a parent had been undermined by a set of government guidelines issued to doctors and endorsed by her Local Area Health Authority. Furthermore, she believed that this guidance amounted to condoning and even encouraging under-age sex. Mrs Gillick, a mother of four daughters at the time, all under 16, took legal action and what happened in the court and at subsequent hearings of her case would fundamentally change the way we view and assess the competence of children to make treatment decisions.

Background

In December 1980, the Department of Health and Social Security (DHSS) issued guidance on family
 planning services for young people, which stated, or implied, that at least in certain cases which were described as 
‘exceptional,’ a doctor could lawfully prescribe contraception for a 
girl under 16 without her parents’ consent. Mrs Victoria Gillick regarded this stance as illegal and objected in the strongest terms to her Local Area Health Authority — West Norfolk and Wisbech — and sought their assurance that her children would not be given advice or prescribed contraceptives without her knowledge or consent. She wrote in March 1981, “I formally FORBID any medical staff employed by Norfolk
 A.H.A. to give any contraceptive or abortion advice or treatment whatsoever to my four daughters whilst they are under 16 years without my consent.” She received no satisfactory assurance that this would be the case and took legal action against both the Area Health Authority and the DHSS in August 1982.

The Court Cases

The case went initially to the High Court in 1984 where Mr Justice Woolf who presided turned down Mrs Gillick’s claim and dismissed the action.

He noted:

“…whether or not a child is capable of giving the necessary consent will depend on the child’s maturity and understanding and the nature of the consent required. The child must be capable of making a reasonable assessment of the advantages and disadvantages of the treatment proposed, so the consent, if given, can be properly and fairly described as true consent.”

However, Mrs Gillick appealed and the following year was successful in having this decision overturned. Against that decision, the DHSS appealed to the House of Lords in October 1985 and the case was examined by the Law Lords — Scarman, Fraser and Bridge.

Mrs Gillick’s case was centred on her loss of parental rights and the legality of the DHSS’s position, and the judges reviewed these in turn.

The Law Lords examined the issue of ‘parental rights’ and concluded that these only really exist for the benefit of the child and effectively dwindle as the child grows in age and maturity. Lord Scarman stated that this ‘parental right yields to the child’s right’ when she acquires ‘sufficient understanding and 
intelligence.’

The judges also firmly concluded that any doctor who exercised his or her clinical judgement in offering contraceptive advice to a girl under 16 without her parent’s consent would not be guilty of an offence.

With these rulings the decision of the Court of Appeal, which had overturned the original ruling, was itself quashed, and Mrs Gillick had lost.

This case will be remembered, however, not for what it said about the legality of offering contraceptive advice to minors, but for its more general rulings on child consent. The case afforded the judges the opportunity to address the issue of competence in those under 16 more generally, and in so doing to create the concept of ‘Gillick competence.’

Lord Scarman ruled,

“I would hold that as a matter of law the parental right to determine whether or not their minor 
child below the age of 16 will have medical treatment terminates


 
if and when the child achieves a sufficient understanding and intelligence to enable him or her to understand fully what is proposed.”

Thus, Gillick competence allows a child under 16 to consent to or refuse medical treatment, and it is up to a doctor to decide whether a child has the maturity and intelligence to fully understand the nature of the treatment, the options, the risks involved and the benefits. That competence is deemed also to be ‘situation dependent’—that is, it applies only to the treatment in question. A child may be deemed Gillick competent to understand one treatment, but not another. If a competent child consents to treatment, no one can override that decision. However, a competent child who refuses treatment may, in some circumstances, be overruled by those with parental responsibility or by a Court.

Gillick competence vs Fraser Guidelines

There has been much confusion regarding the terminology used in this area. In the 1990s there was a widely held belief that Mrs Gillick, who had lost the appeal, objected to her name being attached to the concept of adolescent competence. As such, an alternative term ‘Fraser competence’ was introduced and widely recommended. This referred to the guidelines proposed by Lord Fraser in the same 1985 House of Lords judgement that defined Gillick competence. Unlike Lord Scarman’s ruling, these guidelines were very specifically concerned with contraceptive advice and treatment.

Lord Fraser stated, “the doctor will, in my opinion, be justified in proceeding without the parents’ consent or even knowledge provided he is satisfied on the following matters:

  1. that the girl (although under 16 years of age) will understand his advice;
  2. that he cannot persuade her to inform her parents or to allow him to inform the parents that she is 
seeking contraceptive advice;
  3. that she is very likely to begin or to continue having sexual intercourse with or without contraceptive treatment;
  4. that unless she receives contraceptive advice or treatment her physical or mental health or both are 
likely to suffer;
  5. that her best interests require him to give her
 contraceptive advice, treatment or both without the 
parental consent.
”

These guidelines do not have any general application, and the term ‘Fraser competence’ should be completely avoided as it is not, and never has been, a synonym for ‘Gillick competence’. But, what of Mrs Gillick’s feelings on the matter? In 2006, the author of a BMJ editorial took the entirely reasonable step of writing to ask her if she objected. Mrs Gillick replied saying that she “has never suggested to anyone, publicly or privately, that [she] disliked being associated with the term ‘Gillick competent’”.

Conclusion

When treating children and young people, we have an overriding duty to act at all times in their best interests. The Gillick rulings have served to clarify what can and cannot be done in this area, but they have also brought into focus the importance of involving competent children in medical decisions that will affect them. The NSPCC reminds us that all professionals working with children must ‘balance children’s rights and wishes with our responsibility to keep children safe from harm.’

And what of Victoria Gillick? She remains active — a mother of ten children and now with 42 grandchildren, she has continued to work and campaign against under-age sex and abortion. In 2002, she won an apology and damages in a libel case against a teenage sexual health advice charity. She claimed they had alleged that her challenge against the legality of contraception guidelines was one of the reasons for a rise in teenage pregnancies during the 1980s. More recently, she has spoken out on matters of immigration, and is supportive of her husband, who is a former Ukip member of the Cambridgeshire County Council.

© Allan Gaw 2017

 

Now available in paperback…

Testing the Waters: Lessons from the History of Drug Research

What can we learn from the past that may be relevant to modern drug research?

Screen Shot 2015-10-14 at 21.22.11

“I cannot recommend it highly enough: even if you read nothing else about the origins of drug research and what it can (should?) teach us, read this….This is a ‘buy’.”  Madhu Davis review in Pharmaceutical Physician May 2016.

My other books currently available on kindle:

Screen Shot 2015-01-18 at 17.19.43Screen Shot 2015-01-18 at 17.19.00BIS Cover copyScreen Shot 2015-01-18 at 17.19.29Screen Shot 2015-01-18 at 17.18.54Screen Shot 2015-01-18 at 17.19.37Screen Shot 2015-01-18 at 17.19.16Screen Shot 2015-01-18 at 17.19.58Screen Shot 2015-01-18 at 17.20.06

 

The first church you reach as you drive out of the village is not the one you’re looking for. Go a little further on and down the hill, and you will find it, the larger of the two. Walk up past the row of 17th century Alms Houses, past the mass grave marker for those who died in the plague, past the old Gumbie cat that sits and sits upon the wall, and there it is—the Parish Church of St Michael’s in the Somerset village of East Coker.

For those who know their poetry, the name East Coker will be instantly recognisable as the title for one of TS Eliot’s Four Quartets, but just why I should have spent my afternoon trying to find this village church may be less obvious. But, it is all about Eliot and my attempt to make his acquaintance, albeit more than fifty years after his death.

Go through the heavy studded oak door—a door that by the look of it could bear witness to several centuries of comings and goings—and you will find yourself in a simple church like so many others in Somerset. There are pews and kneelers, occasional Victorian stained glass in medieval traceries and memories of those who came and went, etched in plaques upon the walls. But at the West end of this church, below the window in the corner, there is one oval plaque that carries the opening line of “East Coker”—”In my beginning is my end” — and the name of the man whose ashes lie interred below, Thomas Stearns Eliot, Poet.

For an American poet who changed the world of poetry, who won the Nobel Prize for Literature, and whose work still astonishes and baffles readers, this seems an unlikely resting place. Today there is no pomp, just a simple vase of white lilies and the silence of an empty church. Eliot chose this spot. He had visited the village and the church because his forefathers had left for the States from this Somerset village in the 17th century and perhaps like many descendants of émigrés he felt the need for a homecoming.

Why I should be drawn to sit in silence before the grave of one I have never met is, I admit, puzzling. Eliot’s poetry is difficult and in places impossible, but it is rhythmic and almost primordial in others. Perhaps I am here to pay homage and kiss the hem of a great man. Or perhaps I am here to question, hoping for answers. Eliot’s silence is, however, thunderous. The finality and completeness of death, his death, is underlined by that silence in the church. But, even silent thunder can be eloquent. What is not said—the negative space around our words—is as important as the wit and depth of our sounds. A line from the end of The Waste Land came to me, perhaps was offered to me: “Then spoke the thunder.” His thunder, I thought, a clamour that rattled around the globe. A grumble, a rumble, long drawn out and wrapped in obscure language and startling imagery that holds and humbles the reader.

I reached out and touched his plaque tracing the T for Tom, mouthed a childish prayer and left. Outside the August sun was still shining and any rain clouds that had threatened were now flying to the east of East Coker. A verdant nature had taken the place of the cold church stone and cornflowers swayed blue in the breeze.

Eliot was gone, but that he had been here at all was the point. Here, in his East Coker church, out of sight, he rests for his eternity—a thunder passed, but still heard from afar.

© Allan Gaw 2017

Now available in paperback…

Testing the Waters: Lessons from the History of Drug Research

What can we learn from the past that may be relevant to modern drug research?

Screen Shot 2015-10-14 at 21.22.11

“I cannot recommend it highly enough: even if you read nothing else about the origins of drug research and what it can (should?) teach us, read this….This is a ‘buy’.”  Madhu Davis review in Pharmaceutical Physician May 2016.

My other books currently available on kindle:

Screen Shot 2015-01-18 at 17.19.43Screen Shot 2015-01-18 at 17.19.00BIS Cover copyScreen Shot 2015-01-18 at 17.19.29Screen Shot 2015-01-18 at 17.18.54Screen Shot 2015-01-18 at 17.19.37Screen Shot 2015-01-18 at 17.19.16Screen Shot 2015-01-18 at 17.19.58Screen Shot 2015-01-18 at 17.20.06

 

To be accused of something that you have not done, indeed would never do, is unsettling.   That my accuser is someone I have never met and who does not even know me seems to make the experience all the more chilling. Indeed, I have been left quite literally feeling cold. My temperature lowered, my temperament questioned, my reputation casually trashed and all by a simple email sent to everyone.

In recent years, we have lived through troubling times and just what we can and what we cannot say on the Internet, in a tweet or in an email has been brought front and centre. Although Lord Justice Leveson devoted only one of his 2,000 pages of report to the Internet he did correct the often-held notion that it was a place akin to the “Wild West”—that is, a glamorous place peopled by pioneers, where vigour is celebrated and questions take second place to action. Rather, he described it as an “ethical vacuum”. I would perhaps add that it is, in my experience, particularly my recent experience, a place simply devoid of civility, where those who can type, manage to forget the good manners their mothers taught them.

The details of my particular case are unimportant, but they do prompt me to muse upon the nature of community when we think of the Internet. As humans, we have evolved not just physically, but also socially. We inhabit a socially constructed world sharing our values and holding much in common that constitutes the reality in which we find ourselves. We are wired to live in community and to thrive there, but what if that community is virtual and devoid of eye contact and touch?

This is an important question because, whether we like it or not, we all inhabit virtual communities the moment we log on. Our lives, lived through social media, are one thing, while the communities of purpose in which we work as part of our professional lives are another. The former we choose; the latter we often have foisted upon us.

Technology offers us unprecedented opportunities for connection. Distance is no object and geographical spread unimportant. Time zones hardly matter and we do not even need to be plugged in. We sit at our desks, or on the train or even in the park and by logging on through some wireless magic we are suddenly in a meeting, joining a seminar or gate crashing a conversation. Sometimes, too suddenly, perhaps, to realise that we are no longer in the park.

I can, for example, seek the opinions of everyone I work with at the touch of a button. Whether I receive those opinions is, however, dependent on a number of factors not least of all the degree of engagement my colleagues have with this virtual world. That level of engagement varies in accordance with the level of contribution we are willing to make to our work in general, and with our degree of buy-in to the notion that there is any worth in a virtual working environment at all. Are the communities we create with the help of the Internet artificial? Undoubtedly so, but only in the sense that we were never meant to function without face-to-face contact. I, like you, am the product of a hundred thousand generations of evolution that have honed my people skills. I can read your face and your hands, study your pupils and even scent your feelings. But, of course, I can only do all this if we are in the same room (or perhaps, more appropriately, the same cave). Connected by an email discussion group or Internet forum, I have to develop a whole new suite of skills and, it seems, I have to relearn my manners.

Our ability to offend is not new. It started with the written word, and telegraphs and telephones took it to a new level. The instantaneous nature of our current communication, through email, facebook and twitter, although still at a distance, has brought it into sharper focus.

People would, I suspect, never say many of the things to our faces that they are happy to write and post at the press of a button. I would wager that the casual slurs that appear in emails sent to hundreds of work colleagues would be seriously tempered if they had to be delivered face-to-face, either out of a more obvious need for civility or perhaps just simple fear.   Good manners rein us in, not least of all, for our self-preservation. Perhaps, at a very basic level that’s why we have manners; to avoid being hit.

I don’t want to hit anyone, but I also don’t want to be a victim of consequences that the ill-mannered are unable to foresee while typing their unedited thoughts for all to read. Of course, there is nothing to be gained by responding, for a dialogue would only feed the fire and lead to deeper burns. No, all I can do is lose some sleep and blog about it before moving on. No, please, after you.

© Allan Gaw 2017

 

Now available in paperback…

Testing the Waters: Lessons from the History of Drug Research

What can we learn from the past that may be relevant to modern drug research?

Screen Shot 2015-10-14 at 21.22.11

“I cannot recommend it highly enough: even if you read nothing else about the origins of drug research and what it can (should?) teach us, read this….This is a ‘buy’.”  Madhu Davis review in Pharmaceutical Physician May 2016.

My other books currently available on kindle:

Screen Shot 2015-01-18 at 17.19.43Screen Shot 2015-01-18 at 17.19.00BIS Cover copyScreen Shot 2015-01-18 at 17.19.29Screen Shot 2015-01-18 at 17.18.54Screen Shot 2015-01-18 at 17.19.37Screen Shot 2015-01-18 at 17.19.16Screen Shot 2015-01-18 at 17.19.58Screen Shot 2015-01-18 at 17.20.06

Every day we make hundreds of decisions – many are small and apparently insignificant, some seem to have more recognisable consequences and very occasionally we find ourselves confronted by the momentous. Our ability to make all these decisions easily and fluently often means the difference between a stressful, unfulfilling day and one where we can go home with our to-do list ticked off.

But how do we make those decisions? Are you the logical kind of decision maker who carefully tallies up the pros and cons and after a little mental arithmetic computes the “best” decision? Are you the type that goes with their gut, not really knowing how the decision has been reached but feeling that this is the “right” choice? Or are you the kind of person who, before making a decision, asks questions such as: is this the way we should do things, is this what I ought to do? Rather than trying to pigeon-hole yourself into one of these categories you should realise that we are all a complex mixture of different decision-making styles. And, moreover, we tend to use different approaches for different kinds of decisions.

Some decisions benefit from the logical approach: for example, choosing a new bank account where you can readily access all the features of the different options and work out which is the best for you. But, while a pros and cons list might be good for making a financial decision, it rarely works for choosing whom to fall in love with. There our guts, or should it be our hearts, have the upper hand. The same is true of buying a new house. The average Briton takes just 21 minutes to choose a new home, while it takes us 284 minutes to decide on which new TV to buy. We use our guts to “just know” whether the house is right, while we use our heads to calculate the best television.

The reason it takes more than ten times longer to pick the TV is, however, largely due to the overload of information we have to deal with, and there is a lesson to be learned here. We tend to regard important life decisions as difficult decisions – and one important consequence of this is that we have the unfortunate habit of also inferring that difficult decisions must be important. That’s where it all goes wrong: just because a decision is difficult does not mean it’s important.

Ironically, this seems to happen when we are confronted with a decision that is unexpectedly difficult – one that we thought should have been easy. It’s almost as if we think: “Oh, I thought this was going to be simple, but it’s not, so that must mean I’ve misunderstood its importance. I’d better work at this. It needs more time, more effort.”

And if you don’t believe this happens, think back to the last time you were standing in a supermarket aisle buying toothpaste. A “simple” task but now you see there are fifty different varieties to choose from. Some have fluoride, some don’t; some whiten your teeth, some don’t; some are for sensitive teeth, others aren’t. Suddenly, what should have potentially been a trivial decision is elevated by its apparent complexity into a difficult and therefore an important one, worthy of time and attention. But it isn’t. They’re all toothpastes after all; they all clean your teeth and in the big picture of your life it really doesn’t matter which you choose.

And in life there are many toothpaste decisions like that, where we agonise over the trivial, thinking that the very complexity of the decision means that it’s important. Once you realise that this is not the case, indeed is hardly ever the case, you can turn your attention to those decisions that do matter.

Our ability to make effective decisions is undoubtedly important. Indeed Napoleon said, “Nothing is more difficult, and therefore more precious, than to be able to decide.” But he was talking about deciding whether to invade a country and not which brand to buy in Tesco.

Beware of the trivia and beware of the procrastination that can sometimes occur as a result of our inability to decide. “In any moment of decision,” said Teddy Roosevelt, “the best thing you can do is the right thing, the next best thing is the wrong thing, and the worst thing you can do is nothing.”

Sources

  • Roberts L. The Daily Telegraph, 2 July 2010.
  • Sela A, Berger J. Journal of Consumer Research, August 2012

© Allan Gaw 2017

This article was originally published in the Spring issue of Practice Manager, and you can view it as this website:

https://www.mddus.com/resources/publications-library/practice-manager/issue-16-spring-2017/practice-matters-decision-making

 

Now available in paperback…

Testing the Waters: Lessons from the History of Drug Research

What can we learn from the past that may be relevant to modern drug research?

Screen Shot 2015-10-14 at 21.22.11

“I cannot recommend it highly enough: even if you read nothing else about the origins of drug research and what it can (should?) teach us, read this….This is a ‘buy’.”  Madhu Davis review in Pharmaceutical Physician May 2016.

My other books currently available on kindle:

Screen Shot 2015-01-18 at 17.19.43Screen Shot 2015-01-18 at 17.19.00BIS Cover copyScreen Shot 2015-01-18 at 17.19.29Screen Shot 2015-01-18 at 17.18.54Screen Shot 2015-01-18 at 17.19.37Screen Shot 2015-01-18 at 17.19.16Screen Shot 2015-01-18 at 17.19.58Screen Shot 2015-01-18 at 17.20.06

 

If our understanding of medicine was perfect, there would be no need for research. If no new diseases, like Ebola or Zika, emerged, we could dispense with the need for discovery. If we could prevent or cure all cancers, all infections, all diseases such as diabetes, arthritis and dementia we could consign science to the history books. But everyone knows that this is a dream as yet unfulfilled.

The simple fact is, that although we have come a very long way in improving healthcare, there is still much to be done and understood, and there always will be. Diseases change, the characteristics and susceptibilities of the population alter and even treatments that once could be relied upon, no longer work.

For healthcare to be better tomorrow, or even just as good as it is today, we need to keep moving forward and I believe the engine that powers that momentum is clinical research — the process of finding new knowledge and understanding about health and disease that involves people.

Research involving people is thus at the very heart of modern medicine. For this to happen, however, we continually need new, committed researchers and new willing research participants. There are many misconceptions about how modern clinical research is conducted and any serious attempt to grow and develop this aspect of medicine, and to allow it to achieve its full potential must address these through the provision of high quality and accessible educational and training opportunities.

Those in healthcare or contemplating such a career need to be informed and inspired to take part in research, while those we hope will volunteer to take part in research studies need to be fully research aware and to understand the vital importance of their role and how they fit in to the research process.

Thus, the challenge is one of communication and education, and it is a challenge on a grand scale. While there have been many attempts to address this issue most are relatively small and limited, and they are largely designed to deal with local concerns and to take advantage of statutory training needs.

In order to explore new educational possibilities in this area, a team at the National Institute for Health Research Clinical Research Network (NIHR-CRN) decided to tackle this challenge by harnessing the power of modern educational technology to offer a Massive Open Online Course or MOOC. The aim of this enterprise was to educate and inform the public, patients and healthcare professionals about clinical research.

 

The result, ‘Improving Healthcare through Clinical Research’ is a four week online course offered via the NIHR-CRN and their host organisation the University of Leeds on the FutureLearn platform. It consists of short tailor-made videos and animations, structured and directed readings and a series of external links. The MOOC also contains short self-assessment exercises and an end of course test for those interested in gaining evidence of their satisfactory completion of the course. But, a large part of the educational value in the course comes from the discussion boards where learners are encouraged to post questions and comments and to interact and learn from each other. The boards are moderated throughout the four weeks of the course by the presenters and any specific questions on course content are answered.

As I reflect on my involvement with the MOOC, a number of themes emerge.  Most education is local and contained — 10 people in a tutorial group, 30 in a classroom, 200 in a lecture theatre. When we step on to a global platform to deliver education in this or in any field a number of new opportunities present themselves for the first time, along with equally new challenges. We have the opportunity to speak to a diverse and truly international audience and to influence their thinking about clinical research. But we also have a responsibility especially when talking directly to patients — dealing with their fears, prejudices, misunderstandings and in some cases managing their overriding search for hope.  The international community of learners from a wide range of backgrounds also adds a special dimension to this kind of education for we are all able to learn from those living and working in completely different healthcare landscapes.

It is a privilege to be part of something on such a global scale. It is humbling to hear first hand the stories of those involved in research, either as an investigator or as a participant. And, it is a remarkable medium for education because the MOOC has allowed me to teach more people in a few weeks than I have taught in a lifetime in academia.

Indeed, we are about to deliver this course for the fourth time, starting on May 22, 2017, and over these runs we have reached around 20,000 learners from more than 80 countries. Some are interested members of the public, some are patients, some former research participants, some school children and students and some research professionals already working in healthcare.

If you would like to join that community, why not sign up to take part at https://www.futurelearn.com/courses/clinical-research — it’s free and the feedback so far has been excellent.

 

 

© Allan Gaw 2017

 

Now available in paperback…

Testing the Waters: Lessons from the History of Drug Research

What can we learn from the past that may be relevant to modern drug research?

Screen Shot 2015-10-14 at 21.22.11

“I cannot recommend it highly enough: even if you read nothing else about the origins of drug research and what it can (should?) teach us, read this….This is a ‘buy’.”  Madhu Davis review in Pharmaceutical Physician May 2016.

My other books currently available on kindle:

Screen Shot 2015-01-18 at 17.19.43Screen Shot 2015-01-18 at 17.19.00BIS Cover copyScreen Shot 2015-01-18 at 17.19.29Screen Shot 2015-01-18 at 17.18.54Screen Shot 2015-01-18 at 17.19.37Screen Shot 2015-01-18 at 17.19.16Screen Shot 2015-01-18 at 17.19.58Screen Shot 2015-01-18 at 17.20.06

 

For those who believe in a god, the world must seem to be a wonderful evocation of his mind and will. From the golden dawn to the setting scarlet sun; from the blue teaming oceans to the sparkling canopy of stars; from the majesty of the rain-forest to the rainbow over the waterfall — these are all taken as ample evidence of their god’s artistry.

For those of who us who have no such belief, let me assure you the world is just as colourful and just as dazzling, and perhaps even more wondrous. We see a universe fashioned by the forces of nature rather than the hand of a deity, and humanity as the smallest speck in it all. We strive to understand the workings of this remarkable machine called the Earth and this fragile thing we call life.   And, perhaps, most importantly of all, we recognise that this world and this life are our greatest treasures, for there are no others.

I was recently pitied by a friend for my ‘atheism’. A word, I must admit I detest, as I do not see why I should be defined by something I don’t believe in. There are many things I don’t believe in or subscribe to, like ghosts and day-time television, but I’m not sure that’s how I should be described. “If I didn’t believe in God,” he went on, “I would just do what I liked. I mean, how does anyone who has no god in their life behave morally?” I think the question was genuine, as was the arrant stupidity of the sentiment. The idea that morality has anything to do with religious belief is surely put to rest after even a cursory viewing of the evening news. Now, as in the past, men and women have used their belief in one god or another to justify the most despicable of acts imaginable. Abuse, torture, enslavement, mutilation and murder are all carried out by those doing their particular god’s will. No, belief is not a prerequisite for decency, nor is it a necessity for caring about other people, other animals or the planet we call home itself.

The soaring complexity of creation — and yes I do believe it was created, just not by a god — leave me, just like everyone else, in awe. My way into and through this feeling has been science. The artist may attempt to replicate the wonder of it all, even to harness it, but it is the scientist that seeks an explanation. Through our observations we find patterns and by the careful joining of the dots we craft meaningful pictures that help us understand what we are seeing, hearing, feeling. However, the process of finding out how and why does not destroy the wonder; it is still there and perhaps even increased by the business of discovery.

And those observations can lead us to unexpected conclusions. As the evidence piles up we are forced to accept the possibility, however unpalatable, that we are not the centre of the universe, or even the solar system. We are compelled to accept that we are one species amongst many on this rather average small, blue planet and that the level of our insignificance in the universal scheme of things is simply unfathomable to our finite minds. But while science reveals our limitations, it simultaneously offers us a view of a further horizon, a more distant shore.

When the biologist JBS Haldane was asked what the study of the works of creation could teach us about the mind of the Creator, he pondered and replied that He must have “an inordinate fondness for beetles”. I rather like the idea of a god tirelessly trying out new designs, until quite suddenly he finds himself overrun by prototypes and embarrassed by the time he has spent at the workbench. Indeed, there are more than 350,000 species of beetle; that’s around one in five of all species of living things, animals and plants. However, the reason there are so many different species of beetle currently on Earth, and who know how many more since the dawn of life, is not because of an over zealous God, but because there are thousands of different habitats and niches to occupy. No single design can make a living in every environment, so rich diversity is the key to success. Life is there for one reason and one reason only, to thrive and create more life. At least in my opinion, the purpose, even the meaning of life, is life itself.

But what of god — did he weave the strand of DNA that defines you and differentiates you from the microbe, the banana, the haddock or the chimpanzee? Did he craft the molecules from which you as well as the stars are made? Did he shackle the clouds to the sky and the wind to the waves? Did he craft joy as he was etching pain, happiness as he was distilling agony? I think not. For me, the universe, or the vanishingly small portion of it we know about, is quite wondrous enough to comprehend without resorting to a god. Indeed, it was Mervyn Peake who said, ‘To live at all is miracle enough.’ And I think he was right.

© Allan Gaw 2017

 

 

Now available in paperback…

Testing the Waters: Lessons from the History of Drug Research

What can we learn from the past that may be relevant to modern drug research?

Screen Shot 2015-10-14 at 21.22.11

“I cannot recommend it highly enough: even if you read nothing else about the origins of drug research and what it can (should?) teach us, read this….This is a ‘buy’.”  Madhu Davis review in Pharmaceutical Physician May 2016.

My other books currently available on kindle:

Screen Shot 2015-01-18 at 17.19.43Screen Shot 2015-01-18 at 17.19.00BIS Cover copyScreen Shot 2015-01-18 at 17.19.29Screen Shot 2015-01-18 at 17.18.54Screen Shot 2015-01-18 at 17.19.37Screen Shot 2015-01-18 at 17.19.16Screen Shot 2015-01-18 at 17.19.58Screen Shot 2015-01-18 at 17.20.06

 

Is it the little things that matter — small kindnesses, inconspicuous acts of generosity and moments of undivided attention? We were all famously told years back, ‘Not to sweat the small stuff,’ but I’m not so sure that’s true. Keeping the bigger picture in mind and engineering our lives to ensure that we have the major themes in place is undoubtedly important, but so is the realisation that the big stuff is comprised of the detail.

It is in the detail that excellence lies, and inattention to the finer points of anything we do leads us inevitably down the road toward mediocrity. Let me give you an unexpected example.

Whether you are a Harry Potter fan or not, I would defy you not to be impressed by a visit to the original film sets at the Leavesden Studios, north of London. There, as you walk through the great hall and peer into Dumbledore’s Study, the Gryffindor Common Room and the Potions Laboratory you will of course see immediately recognisable spaces, but you will also see much more. Look closely and you will spy details that could never have been seen on film. The care and attention with which the rooms are dressed and the level of intricate detail is simply breathtaking. On the Common Room notice board every hand written flyer tells you exactly what to expect of the forthcoming quidditch practices and where to report any lost toads. In the Potions Laboratory, you can see the benches and the cauldrons and you can almost hear the swish of Professor Snape’s robes, but look on the shelves and there you can start to marvel. Lining shelf upon shelf there are literally hundreds of glass jars and vials of the purported magical ingredients all with intricately handwritten labels. These would never have been visible in the final films, so why bother?

The production crew on the Potter films strove to create a convincing world and part of that was to ensure that every detail was consistent and believable. The actors and the film crew could see these details even if the cinema-goers could not, and doubtless that was the intention. The detail matters and getting the detail right is a hallmark of excellence. By taking the effort to make these sets as convincing as possible, the production teams were declaring unequivocally the standards required by everyone involved in the project, and the bar was firmly set at high.

 

 

Large scale projects are an enormous challenge, not because they present single big problems, but, rather, because they demand us to do tens of thousands of small things well, and consistently well. This is just as true in the world of clinical research as it is in filmmaking. The quality of our work in clinical research has to be of the highest standards possible, because the stakes are so high. Our findings influence and shape healthcare not just for those involved in the study, but also for countless others across the globe in the years and decades ahead. And the way we ensure this quality standard is to make sure we think about the quality of the detail in our work. Like those British filmmakers, just because something will not be obvious, does not mean that it can be skimped or done half-heartedly. It is about creating a culture of excellence and attention to detail that pervades the work and which ultimately shapes the finished product.

In our work, we need to have a zero-tolerance for the mediocre and we should find the merely ‘good enough’ unacceptable. Instead, we need to replace these approaches with a desire for the best we can do. It may require more effort, sometimes more resources, but always a different attitude.   When we understand that excellence is indeed in the detail, we may also come to realise that it is the small things that really do matter.

© Allan Gaw 2017

 

Now available in paperback…

Testing the Waters: Lessons from the History of Drug Research

What can we learn from the past that may be relevant to modern drug research?

Screen Shot 2015-10-14 at 21.22.11

“I cannot recommend it highly enough: even if you read nothing else about the origins of drug research and what it can (should?) teach us, read this….This is a ‘buy’.”  Madhu Davis review in Pharmaceutical Physician May 2016.

My other books currently available on kindle:

Screen Shot 2015-01-18 at 17.19.43Screen Shot 2015-01-18 at 17.19.00BIS Cover copyScreen Shot 2015-01-18 at 17.19.29Screen Shot 2015-01-18 at 17.18.54Screen Shot 2015-01-18 at 17.19.37Screen Shot 2015-01-18 at 17.19.16Screen Shot 2015-01-18 at 17.19.58Screen Shot 2015-01-18 at 17.20.06

 

whitby-abbey

Approaching Whitby along the coastal path there is drama in the air. The ruined Abbey appears like a piece of charred lace against a grey February sky. There is talk of vampires here, and jet — the black fossilised wood found in the nearby cliffs — is carved into expensive jewellery for those who wish to take a little of the gothic home.

As far as the gothic goes, Bram Stoker, the author of Dracula, has a lot to answer for. Setting part of his masterwork in this North Yorkshire port, he forever branded the town as a heaven (or a hell) for goths and others of darker predilections. It’s all good for the tourist trade though and adds another layer, albeit imagined, on to this town, already busy with history. There are Georgian houses and Victorian lighthouses; tales of Viking raiders and smugglers; the legacies of whaling and fossil hunting; and of course civic pride in the young apprentice sailor James Cook who learned his naval ropes here long before he would land on Botany Bay.

Perhaps Whitby is a popular destination because it can cater to your tastes, whatever they may be. Adaptable, it becomes the town you wish of it. Like a skilled courtesan, it pleases without seeming to try too hard, leaving each visitor feeling satisfied and vowing to return to re-experience the best or to try whatever was left undone through lack of time.

So what was I doing looking out across the harbour from my room in the Pier Inn at dawn one winter morning? Unable to sleep, or perhaps awoken by the bells from the church on the cliff, I pulled back the curtains to see a fishing port coming gently to life. In truth, there are few fishing boats now in what was once one of the busiest and most important ports in England, but there are dog walkers, beachcombers and hooded figures scuffling through the cold morning air to their jobs in hotels and guest houses. And there are delivery vans navigating narrow streets wholly unsuitable for the internal combustion engine. Fresh bread, seafood and newspapers are delivered as well as another commodity that caught my eye — Exotic Fruit for the Catering Trade. For some reason this seemed a little incongruous. The seafood yes, the bread naturally and the papers of course — but exotic fruit?

Whitby, with all its delights is not really an exotic fruit sort of place. Solid Yorkshire sandstone has been used to build the town and its inhabitants. Lobster pots and tales of angling success are both piled improbably high on the dock sides. There are medieval streets and alleyways, listed buildings that even list and a sense of its own longevity almost as old as the fossils in its rocks.   But there is little, if any, need to gild this particular lily with the exotic— it is already special and already golden.

We should take pleasure in the unique and even in the merely unusual, without attempting to smooth its corners and make it fit our ideas. The out of the ordinary may be disconcerting, but it is always interesting, and nowhere more so than in science. ‘Treasure your exceptions,’ counselled the early 20th century Cambridge biologist William Bateson, for he recognised just what could be learned from the unusual. We ignore outliers at our peril for it is in the apparently aberrant that the true story of our data may lie, or at least one complicated aspect of it.

But, worse than discarding the unusual are our often botched attempts at improving upon it. To do so is not only a fruitless task but also a foolhardy one. By taking what is unique and therefore already special and attempting to make it better — to improve upon it — all we end up doing is making it like everything else. In short, making it ordinary. The unique is as special as it gets and that’s the important point.

Whitby this winter’s dawn is special and has no need of exotic fruit — by being unique, it is already quite exotic enough.

© Allan Gaw 2017

Now available in paperback…

Testing the Waters: Lessons from the History of Drug Research

What can we learn from the past that may be relevant to modern drug research?

Screen Shot 2015-10-14 at 21.22.11

 

“I cannot recommend it highly enough: even if you read nothing else about the origins of drug research and what it can (should?) teach us, read this….This is a ‘buy’.”  Madhu Davis review in Pharmaceutical Physician May 2016.

 

My other books currently available on kindle:

Screen Shot 2015-01-18 at 17.19.43Screen Shot 2015-01-18 at 17.19.00BIS Cover copyScreen Shot 2015-01-18 at 17.19.29Screen Shot 2015-01-18 at 17.18.54Screen Shot 2015-01-18 at 17.19.37Screen Shot 2015-01-18 at 17.19.16Screen Shot 2015-01-18 at 17.19.58Screen Shot 2015-01-18 at 17.20.06

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Stand and look down into the stairwell of the Baltic Arts Centre and your heart will skip a beat. Look up and you will be confronted with an equally breathless sense of the infinite, as mirrors below and above you extend the winding stair down into the abyss and up into paradise. This permanent installation by the artist Mark Wallinger, is entitled Heaven and Hell and its simplicity is impressive.

Indeed, there is nothing about this converted flour mill on the banks of the Tyne that does not impress. Remodelled and repurposed into a centre for contemporary art, it stands like an industrial monolith now with panoramic views of Newcastle and Gateshead. Inside, there are large uninterrupted spaces, glass elevators and of course that vertigo inducing stairwell.

‘You’re alright with heights?’ the gallery guide gently probed who greeted me at the door. ‘People usually start at the top and work their way down.’  How different from life, I thought.

I rode the glass elevator to the top floor and wandered through the building, working my way down as directed and marvelled at the place — the setting for the art on show. While filled with an eclectic mixture of modern art, it is the building that is the real masterpiece. Albeit transitory, the set of contemporary installations that were on show the day I visited bewildered and bothered in equal measure, but failed I’m afraid to bewitch. Or at least, I should say, they failed me. Yes, it is all art; I just thought some of it wasn’t very good art.

Because I had spent more than £20 in the gallery gift shop — it was one of those gift shops in which it was very easy to spend more than £20 — I was rewarded with a free tea voucher for the café. The Baltic Kitchen café like the rest of the building is rather lovely with wonderful views of the Sage Gateshead and the Tyne Bridge through huge plate glass walls. But, like the rest of the gallery, I felt its contents did not quite live up to the container. Languid teenage staff who seemed to find it an especial inconvenience to take an order and tea that came with the teabag still in the cup. I mean, really.

But, I was in a forgiving mood — art does that, even bad art. And so does working your way back down to the start from the heights. Most of the time we are scrambling up the increasingly greasy pole of life to get a better view. Here the view was freely given and the journey on offer was a descent, down a winding and infinite stairway, in order to get your feet back firmly on the ground. And, from that ground, the view up into the building was just as exciting as the view down from the top — soaring white spaces just made to be filled with art.

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But glass elevators were not the only means of scaling the heights of the Baltic, and artistic spaces were not all that soared. Outside the building an inland colony of kittiwakes still nest on its brick ledges just under the stark lettering high on its river facade. They are unaffected by the art on show or the heights to which they have flown. On high is where they dwell. They have no aspiration to climb any higher or indeed to swoop any lower. All they need is here. And they are enjoying the view, unawares that there is any other to be had.

People, however, have a broader perspective on their world and their possibilities. A perspective that leads to ambition and either disappointment or success — or more usually a little of both. We worry about our level, and we waste time on our concerns about the climb. While we usually equate height with status and altitude with success, in the Baltic Arts Centre there was wonder to be had on all levels. Having enjoyed both extremes from the highest heights looking down and from the ground staring up, it was clear that this building might have a lesson to teach.

In this building, as in life, enjoy whatever stage you are at, whatever floor you have reached, and don’t spoil the moment by constantly looking upwards or worrying about the fall.

© Allan Gaw 2017

 

Now available in paperback…

Testing the Waters: Lessons from the History of Drug Research

What can we learn from the past that may be relevant to modern drug research?

Screen Shot 2015-10-14 at 21.22.11

My other books currently available on kindle:

Screen Shot 2015-01-18 at 17.19.43Screen Shot 2015-01-18 at 17.19.00BIS Cover copyScreen Shot 2015-01-18 at 17.19.29Screen Shot 2015-01-18 at 17.18.54Screen Shot 2015-01-18 at 17.19.37Screen Shot 2015-01-18 at 17.19.16Screen Shot 2015-01-18 at 17.19.58Screen Shot 2015-01-18 at 17.20.06

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