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A year ago, a friend died.  We had known each other for over four years, but we had only met in person three times.  Most of our friendship had been virtual and what began as part of my research into the ethics of clinical trials was to end one evening in a deep and painful sense of loss.

I had been expecting the email from her husband for some time.  We all knew just how sick Joanna was, but, as is often pointed out by the bereaved, expectation does not forestall the shock when it actually comes.  Her death had at least been peaceful and pain-free, surrounded by family, and I suppose that is all most of us can hope for, but she was only 62.  Her cancer had been particularly exotic and pernicious and the end though slowed by everything modern medicine could muster was, I’m afraid, inevitable.  And, now I feel so deeply saddened that we will never meet again.  There was still so much to do and say and write, but a door was simply closed on our friendship. Slammed.

I had first tentatively contacted Joanna because of my professional interest in her father, Maurice Pappworth, who had in the 1960s been a firebrand in the world of research ethics.  I wanted to write about him and I felt I needed her permission and that of his surviving family.  After explaining what I wanted to do, I think she was quite naturally suspicious.  Her father had been a highly controversial figure who had polarised those he met, and I suspect Joanna was anticipating a hatchet-job that would do nothing to serve her father’s memory.  However, my intention was quite the opposite, feeling that history had been especially unkind to him and that his actions and their motives deserved a fairer analysis.  I felt it was time for his contributions to be brought before a wider public.

Joanna agreed to meet me in London, on the steps outside the V&A, so we could talk about my project in the museum tearoom.  I arrived early, which was a mistake, as the passing time only served to magnify my anxiety.  History is comfortable when it is confined to dusty pages, but here was I about to meet the flesh and blood end of it.  She was colourful when she arrived: red beret and bright purple coat and a lipstick that dazzled.  She was a tiny woman and I towered over her, but she was unfazed for Joanna was only small physically.  We spent a couple of hours in the V&A tearoom talking and eventually laughing about things.  As we parted, I confessed how nervous I had been to meet her and she simply dismissed my silliness but allowed me to kiss her hand in thanks before we went our separate ways.

I wrote my first paper about her father’s work and sent it to Joanna and she in turn shared it with her two sisters.  I honestly did not know what to expect.  It’s easy to write about history in the abstract, where the characters involved might be thought of as nothing more than fictions.  But here I was writing about a very real man, recently deceased, and his three children were reading my words.  I was overwhelmed by the positive responses I received from Joanna and her sisters and my confidence was buoyed to carry on the project. I wrote a further paper and a book chapter and gave a number of talks about his work and I hope in a small way I have brought his name and his contributions back into the ongoing discussion of the ethics of clinical research.

But, I had only written about her father’s role as a whistle-blower, exposing unethical clinical research.  As part of my research, I had also interviewed his former students who held him in nothing short of awe, and his secretary, a remarkable woman called Helen Bamber.  She attributed much of her own later success in the fields of international human rights as having their origins in her conversations with Pappworth. What was emerging was an even more interesting story, only fragments of which were widely known.

I was one of the people to encourage Joanna to write her own memoir of her father, realising that her perspective as his eldest daughter would be unique.  She completed the manuscript in the weeks before her death and kindly sent it to me to read.  My last email to her a couple of days before the end was to tell her just how well she had told the story.

It was a beautifully crafted piece of work,  successfully blending together her family’s personal history with a fiercely objective analysis of her father’s professional life.  As a result, she sculpted a three dimensional portrait of the man.  It might have been easy, as his daughter, to paint either a simple loving or an equally simple hateful portrait, but Joanna offered the reader an unsentimental narrative, that rang true.   His professional story was familiar to me, but most of the back story was not, and the way she wove that into her narrative provided much needed context for the man, his attitudes and his actions.  I found the moments when she offered her own personal reminiscences of her father especially poignant, and one of the biography’s greatest strengths.  No one else could have written such a memoir and I was delighted that she had.  However, it is part of my sadness that I’ll never know if she read my comments on it.

With a death, our thoughts must naturally turn to those left behind, to Joanna’s husband and her children and her sisters.  But, there is also the matter of legacy, especially if we have an eye on history.  Joanna was a daughter, a sister, a wife, a mother, an academic, a teacher, and, for me, a friend and through all those roles she was an inspiration, touching those she met and worked with in many ways and it is our collective memories of her that will abide.

People, of course, only die if they are forgotten, and no one, I expect, who ever met Joanna will forget her. I will never forget her warmth and encouragement, her impeccable manners and her hospitality even when she was gravely ill. And I will never forget the debt I owe to her and her family.

Rest peacefully, Joanna, but in your sleep do not expect to be forgotten.

Joanna Seldon (1954-2016)

 

https://www.amazon.co.uk/Whistle-Blower-Maurice-Pappworth-Establishment/dp/1908684976/ref=sr_1_1?ie=UTF8&qid=1512138313&sr=8-1&keywords=joanna+seldon

 

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The supermarket was small by any standard and tiny compared with what I was used to in Glasgow, but here in Kyle of Lochalsh on the Western edge of Scotland and in sight of the single span of the Skye Bridge, was a shop remarkably well-stocked. But, as well as the obvious, there was also fun to be had as I noticed with curiosity that the aisles and shelves were labelled in Gaelic as well as English.

I already knew that ‘aran’ meant bread, but to see my meagre knowledge of Gaelic validated by the green sign hanging over the bakery section gave me a small but palpable thrill. The feeling reminded me of the first time, as a child, that I overheard a native French speaker casually utter words I had only ever seen in my school books. At that moment, I realised that, after all, the French language was real. It wasn’t all just an academic exercise designed to torment. And now standing in the Co-op in Kyle I was reliving that moment and it felt warm.

I looked around eager for more and was not disappointed. ‘Làgar’ did not present too much of a challenge for the beer shelf; ‘gràn’ for cereals was likewise reasonably clear and of course ‘yogurt’ was self-explanatory. Just when I thought I was getting the hang of the lingo, the vocabulary moved up a notch, along with Gaelic’s delightfully floral approach to spelling. The sign said, ‘croispaichean’ and hung over the shelves of crisps. ‘Tràth ullamh’ signposted the ready meals, while ‘baidh eadar-nàiseanta’ proudly, if cryptically, pronounced international foods, and indeed there was a surprisingly rich selection from around the globe in this little supermarket on the edge.

I did know that the cheerful salutation of ‘Slàinthe’ that traditionally accompanied the clinking of whisky glasses meant health, so the sign ‘slàinthe is maise’ came as no surprise to be hanging over the paracetamol and cough mixtures as well as the cosmetics for this was health and beauty.

And then there was my favourite, ‘fuineadaireachd-dachaigh’ which was one of those Gaelic words that you struggled to get a handhold on, being elusively full of vowels and any obvious meaning. Despite its inaccessibility to my meagre language skills, all I found it meant was home baking. You’ve got to love a culture that can turn flour and sugar and bicarbonate of soda into that.

Translation might be a pleasant game but it is also talked about endlessly these days in science. We are expected to work on so-called translational research, and indeed the Medical Research Council states, ‘Translation is the principle of turning fundamental discoveries into improvements in human health and economic benefit.’ That seems laudable, but there is an underlying difficulty, or at least I think there is. The MRC and indeed many other such funding organisations are powerful advocates of such translational research stating that it drives innovation, speeds up the transfer of the best ideas into new interventions, and improves the return on investment in fundamental research. In other words, fundamental research seems only to have worth today if we can readily see the practical payback from it and in double-quick time at that. And that’s where I think the problem lies.

Fundamental research is by its nature not inherently practical. It’s about studying how fruit flies live and die; it’s about finding new ways to look at molecules down a microscope and it’s about detecting what were once thought only to be theoretical waves in gravity. None of these have obvious benefits; none are going to change our lives for the better in the short term; and of course none are going to make anyone any real money any time soon. But those forays into fundamental research have just earned the scientists who pioneered them the 2017 Nobel Prizes in Medicine, Chemistry and Physics.

Such discoveries may or may not change the world in your lifetime, but they may change your children’s or your grandchildren’s. The point is we don’t know, and our focus today on funding only what can be obviously translated into short term benefit is doing a disservice to the process of scientific discovery, and perhaps depriving us of the most important breakthroughs — the practicalities of which are the stuff of the future.

I like translation. I like the riches to be found when watching one language become another. And I love to learn and appreciate what cannot be readily translated and what might be uniquely expressed in one language and not another. In the same way, sometimes I wonder if a piece of beautiful science, a new understanding, a unique discovery, might be just as beautiful if it cannot be translated, or at least not yet.

© 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

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

 

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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