Ian Wacogne's posterous page

Just stuff

Breaking in the Brooks Saddle

Well, it was about time.  My lovely wife bought me a gorgeous Brooks saddle nearly two years ago now, for a significant wedding anniversary.  There had always been a reason not to fit it to the bike, and then, suddenly, there was none.  Usual cycling pal @nicebrowncardy was otherwise engaged, and so a shorter than usual Sunday morning ride beckoned.  I marinated the new saddle in Proofide - smells like beeswax and lemon juice - and climbed gingerly aboard.

And what a beautiful ride.  What cycling is about, 100%.  I don't want to go all "Last year at band camp..." here but bicycle rides are filled with the sorts of serendipity that no other form of transport can offer.  Like nearly colliding with the bloke who had been our best man all those years ago, up on the Harborne Walkway.  Then catching up with another family friend, and a cup of coffee at Brindley place, which led me to decide that it was a good day for Urban Archaeology.  Or, to be less poncy about it, getting lost on the canals; you know the sort of thing - taking a left when you'd usually take a right.  Fun for an hour in brilliant sunshine.  This view below takes in the Selfridges building at the Bullring, Millenium Point, some ancient engineering and a bit of post industrial bleakness.  

Then, leaving the canal I decided to zigzag through the inner city to get to Highgate and pick up the Rea Valley way at Cannon Hill Park.  Hearing a little bit of a commotion, which sounded like fun, I was surprised to find a bunch of folk, including some I think I could recognise from @brumcyclist playing cycle polo.  Turns out they're http://birminghambikepolo.com/ - and they were very kind, in that they didn't run me off the grounds shouting "idiot" when I asked about the rules etc.  It was very exciting to watch - and played in tremendous good humour.  A small part of me wondered whether I should have a midlife crisis and take it up myself; however the commitment seems quite a lot and I already feel pretty guilty about my odd leisure pootle without family on the bike.  And of course, being middle aged now my bones wouldn't heal as fast these days...  I was surprised to read that Brooks saddles are big in the world of cycle polo too though.  

And my Brooks?  Well, got me the ten miles or so home, and pretty comfy - but not utterly broken in yet.  That said, me and this saddle are going to cover tens, if not hundreds of thousands of miles together, so there's plenty of time for that.  

What's research? Means a lot of different things to different people...

Right, so first off, I'm not a researcher, and aside from a woeful few weeks in a lab as a medical student I've never done anything that could be properly described as research.  I don't have the aptitude for it, for starters, and then there are a whole bunch of other reasons that I shouldn't be allowed in a lab...

I've been thinking a lot, though, about the use of the word "research" and how its use has shifted. 
A few examples, to illustrate what I mean, and deliberately extreme:

Watson/Crick, in the pub, circa 1953:  "We've been researching the structure of DNA".  Meaning  They've done some fairly serious thinking, mixed in with a bit of genius, playfulness, and come to an extraordinary insight.

Woodward/Bernstein, terrified and excited, circa 1972:  "We've researched the goings on at Watergate and discovered that the president was lying".  Meaning  Dogged hard work, persistence, luck and good use of a source.  

My tutor to me as a student circa 1987, "An afternoon of research in a library can make you a local expert".  Meaning  I'd got the critical facilities to be able to dissect an issue with a bit of reading around it.  

Average anti-vaccine contributor to a website "I've researched vaccines, and they're bad".  Meaning  I've googled it.

I have to say that I get this last one quite a lot from parents in clinic too.

Now, Google is an amazing thing .  For example I can tell you, full of pretension, that only this afternoon I was trying to understand what a platonic solid was, and Wikipedia helped me out in seconds.  And, I reckon if you gave me another half hour with the website I could have a pretty good go at explaining to you what a platonic solid is. But this wasn't research.  Not in any sense of the word.  To go back to the vaccine example, any proper use of the word "research" with respect to vaccines would reveal that they're actually pretty good things.  We should have a word for what I was doing - well, we've got lots, but none are that helpful.  

We need to carve out and reserve the word "research" as a description of a deep understanding of an issue, and the ability to carry out critical thought in that area.  Of course, this also implies that we need to equip many more  people with the ability to carry out critical thoughts, which is perhaps the more important thing.  And given that in the last week, three of the headlines in one of the red tops have been about someone apparently chucked off of the X factor TV show, I suspect that's not what those that sell us a lot of the information want us to develop.  

"Brain Scans Diagnose Autism" - when is a test not a test?

Listening to the radio this morning you'd be forgiven for assuming that there had been some extraordinary breakthrough in the battle to better understand autism.  The Today program - BBC Radio 4's flagship news program - ran it as the third item in each of their headline recaps, and quoted, among other things:
 - "the scan works with 90% accuracy"
 - "researchers think it will work even better on children"
 - "the test should be available for general use within two years"
Parents ask me a lot in clinic if I think their child has autism.  I'm not an expert, because it's pretty difficult to diagnose - which is why I've recently been trying to commission an Interpretations paper in Archives E&P on this subject.  I had visions of parents saying to me "Well, can't you just do that new scan they've been talking about?"  So, I resolved to read a bit about it.  Especially as I've never heard of the statistical term "accuracy".

I started with the BBC.  Then Google news.  What was striking was that there was a lot of similarity between the news articles it threw up.  This isn't unusual; lots of journals have press releases about interesting papers.  But, there didn't seem to be any more depth to any of the articles.  One of them was kind enough to mention that this research was from the Journal of Neuroscience.  I went to their website.  No details, and a search for autism revealed nothing.  I've read enough of BadScience  to not find much about science reporting a real surprise, but I have to admit being a little flabbergasted that perhaps none of the news sources had access to the original paper.  So, nobody was able to examine this critically at the time the headlines were being written.

Finally, this evening, the paper is available.  (thanks to the folk at http://trusttheevidence.net for the hint, via @cebmblog on twitter)  It's here:  http://bit.ly/AutismScan  It's pretty hard to recognise this as the same study that the press furore is about.  I'm going to limit my comments to what I see - as a non-researching reader - are the major flaws; I'll try and ignore the other irritating aspects like the absence of a structured abstract which is, surely, just polite in modern publishing.  
1.  It's about 40 people.  That's 20 subjects and 20 controls. 
2.  This is why the numbers - the sensitivity and specificity are such neat round numbers - quoted as 90% and 80% respectively.  Apparently sensitivity is the "accuracy" quoted
3.  The subjects, as far as I can tell, are people with autistic spectrum disorder (ASD), and as far as I can tell - and sorry, I'm not great at all this particular detail - are pretty high functioning.  The authors do discuss this in their paper.  What's clear, however, is that they are not representative of what clinical practice or personal experience will encounter as a spectrum.  
4.  They then measured a whole bunch of stuff, and found that combining five of these features - they call them dimensions - using a "support vector machine" - I think this was a program - then they were able to identify one group from the other, with the sensitivity and the specificity above.

And that's all they did.

They didn't do what most people would require researchers to do under these circumstances:  Try out the technique on a completely new cohort and see how it has worked.  To see the depth of flaw in this, I'll give you the example I gave my wife just now.  (Yes, I know I should have more interesting conversations).  
"There were two people in our kitchen.  We knew one to be female, and one to be male.  We noted, from various variables, that wearing a red top identified 100% of the females - with 100% sensitivity and specificity.  We tried this test back on the two people in the kitchen.  It still worked.  Therefore red tops predict female gender..."

And what about children? 
I can't see anything in the paper about children.
To extend my "kitchen" example, "We expect that this will work even better if we look for red tops in children".

There's a further extension to this.  Like I say, I'm no researcher, but one of the things you learn very early is to distinguish an association from cause and effect.  So, what if, as one of the many possible hypotheses you could generate here, the ASD behaviour causes your brain to develop in certain ways.  This would mean that you could have ASD, and then after years develop the brain changes.  So why would you postulate - strongly - that the brain changes would be the first thing?  
Back to the "kitchen" example.  It's a bit like saying: "Wearing the red top made the female person a female."  Or, "Because the person was female, the top turned red".    

The final aspect to this is something that Ben Goldacre covers with brilliant economy here:  http://bit.ly/crystalppv  
In brief:  The population you start with - the underlying risk of a condition in that population - is the ultimate arbiter of how good a test is.  If you need to remember this as a shorthand, then just memorise that the lower the prevalence, the less likely that a positive result of you test is a true positive.  (As Ben says, it's a good idea to do the arithmetic yourself with a pencil - it really helps get this into your brain.  Otherwise, just trust me on this.)  That's why you have to be very, very careful with new tests, and understand how to use them.  

So, who is at fault here?  A variety of possibles. 
1.  The media?  It's a slow news day.  I mean, there are only a few million people displaced by floods in Pakistan...  (That's sarcasm, for anyone who can't read it on a computer).  You have to say that it is pretty irresponsible giving this much credence to what is a pretty dense and highly technical research theory paper.  Especially if you've not read the paper.  Which I don't think they can have.
2.  The press office of the journal?  I don't know anything about The Journal of Neuroscience; it seems fairly dry - which is not in itself a criticism; perhaps they had a hack who was really bored of trying to spin their other papers, and this one potentially had a really sexy message.
3.  The researchers?  I've not been interviewed on live national radio, but they didn't seem that keen to play down these findings.  One of the people interviewed - I'm not sure if he was an author or someone wheeled out to give an opinion - stated [quote from memory so apologies for inaccuracy]  "Well, it's hard to diagnose autism; it takes a team of people hours, so this test will really help..."  I'm sorry, but I don't care how hard it is for you to get your Research Grant renewed; that's just irresponsibly put.  

Me?  I'm just assuming that for the next couple of years people will ask me about the scan, and I'll have to grit my teeth, not say what's actually on my mind and reply something like "Um, well, that was all a little optimistic..."

Caveats:  This is a really dense paper, in a journal that I'm not familiar with, and using research methods and terms I don't understand.  If I have made any serious error, then of course I will happily amend and apologise.  

For @EvanHD - Why it is always "Images of Child Abuse" and not "Child Pornography"

I was going to wrap myself in knots trying to keep this in tweets, so I thought I should blog it.  

On the news this morning there were items covering that someone had been charged with possessing "Child Pornography", although the description did vary between calling it this and "Images of Child Abuse".   As a paediatrician, it's something I feel strongly about.  

I follow @EvanHD on twitter, and know that he looks at tweets during the show.  I tweeted him to say: "can you remind John [Humphrys] that it's "images of child abuse" not "child pornography"?   Evan was kind enough to reply, but his reply worried me a little:  he said:  "are you sure? papers running it as child pornography".

It's interesting that the distinction is drawn by many people - and that Evan has a concept that one is worse than the other.  I think they are the same thing, but that the language lessens one of them.  I think that you should always refer to this as "child abuse images".  Pornography, in general, is a transaction between two people, which might be coercive but in general is a two way thing.  If, for example, someone had images of, say, the actual rape of someone we would not refer to it as a pornographic image, we would refer to it as an image of an offence being committed.

When a sexual act is committed with a child it cannot be in any way consensual; the child is being abused.  If images of these acts are collected, it is an equivalent of the rape situation.  It cannot be pornography, and to describe it as such risks partly trivialising the terrible experience the child has been through by placing it in the same spectrum as pornography in consenting adults.

A editorial policy to refer to the abuse of children as "child abuse images", and avoiding the sloppy "child
pornography" abbreviation, would play an important role in the protection of our children.

Well, that's how I feel about it.  Evan, if you've been able to read this, thanks for taking the time.

A reply to @CharlieNeck "Does being a parent make you a better Paediatrician"

Carlos Cuello, aka @CharlieNeck has written here: http://bit.ly/aViRPN about whether or not being a parent makes you a better paediatrician.

It's a hard question, and one I've thought about a lot.  I've struggled with the same thoughts as CharlieNeck - mostly because of the implications of if it is true.  If it is true then it should follow that:
 - as @CharlieNeck has had suggested to him, not having a uterus diminishes your ability to be a gynaecologist
 - my colleagues who have no children are less good at being a paediatrician than I am
 - I was a worse paediatrician before I was a parent
 
To take these in turn.  
The "uterus" argument.   I think this is probably rubbish.  Nobody says that someone who looks after the elderly has to be elderly.  Nobody implies that you have to have sustained a fractured neck of femur to be an orthopaedic surgeon.  If you are stuck in this way of thinking, then you deny any ability to empathise.  You might as well not bother, for example, to read A Tale of Two Cities because you can't begin to think what it might be like for Sydney Carlton to face the guillotine.  If we're only what we've experienced, then our lives are  pretty shallow.

The "Childless make Poor Paediatricians" argument.  Well, that's patently false, and what's more pretty patronising.  I can remember being told "Oh, you'll understand so much more when you're a parent" and thinking, well, I know what you mean, but actually that's a bit patronising.  I know many of my colleagues, who are not parents, are better paediatricians than me.  

The "I was worse before" argument.  Well, that's beguiling.  I hope that I'm a better paediatrician now than I was seven years ago.  But it would be interesting to speculate on what has driven that.  For example, I've been a consultant paediatrician for about that period of time too, which was about the same amount of time that I was in training between qualifying in medicine and becoming a consultant.  Each year I hope I get better at what I do.  It's part of a normal, examined career.  

So, this leads me to two questions.  

The first is:  What does make someone a "better" paediatrician - bearing in mind that the word better here is hugely loaded.  I think that this includes time, patience, learning, time, work, time, learning, reflection, time, patience and more time.  

The second is:  What does being a parent do to you as a paediatrician?  And that for me is a different, and altogether more interesting question.  Because although I'm not a better paediatrician as a sole consequence of being a parent, I am most definitely a Different one.  

And the different paediatrician that I am is probably the subject of a whole series of blogs...

@ian_wac

Rejection slip perfection

Can't remember where I first saw this, but just found it again; perfect:

The standard rejection slip from a Chinese economics journal supposedly went this way (quoted in the Financial Times) : "We have read your manuscript with boundless delight. If we were to publish your paper, it would be impossible for us to publish any work of lower standard. And as it is unthinkable that in the next thousand years we shall see its equal, we are, to our regret, compelled to return your divine composition, and to beg you a thousand times to overlook our short sight and timidity."

Iron and breath holding; now Cochrane adds nothing...

Here's the first time I wrote about iron supplementation;
Now, courtesy of Wiley's alerting system, there's this:

Iron supplementation for breath-holding attacks in children
Cochrane Database of Systematic Reviews
Anthony A Zehetner, Nigel Orr, Adam Buckmaster, Katrina Williams, Danielle M Wheeler
Year: 2010
Record   http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD008132/frame.html

They prefer a different two papers (well, one the same, the other different from the archimedes paper).
Same weak conclusion:
 - if they're anaemic, give iron - fair enough.
 - if they're not anaemic, give iron because it just might help - which isn't supported by the evidence at all, as presented.

Oh dear.

PowerPoint the Enemy?, via @TimHarford

A thought provoking article on the excesses of the use of PowerPoint in the US military.

http://www.nytimes.com/2010/04/27/world/27powerpoint.html

Interesting shades of the whole “servicing the bit of paper/report/target and missing the point”.  Its striking that we’ve gone from the point when I first saw PowerPoint – in about 1998 I think – to astonishing ubiquity; in 1997 I thought it a bit over-glossy if someone used laser printed flimsies on an overhead projector…

I disagree with part of what they say; the concept that reducing things to bullet points doesn’t capture the complexity strikes me as Old School “It’s much more complicated than you could possibly understand without my large brain and decades of experience”.  Of course it doesn’t capture the complexity, but I’m much more at the “if you can’t explain it, then you don’t understand it” end of the spectrum.  And I’ve been struck that whenever I sit in a lecture delivered (usually) by a lawyer who says “Good news.  I’m not going to use PowerPoint” I know two things for certain; firstly they’ve got an overinflated sense of their own presentation skills, and secondly I’m going to feel quite refreshed by the short nap I’m getting in about five minutes.  However, that might be my own ADHD setting in…

What are your brown M&Ms?

I read this recently, and have been thinking about it.  

The important thing is that the Brown M&Ms in this instance are a proxy indicator of quality.  The contract with a venue about to stage a Van Halen concert ran to hundreds of pages, and right down in the small print there was a stipulation that backstage, there should be a large bowl of M&Ms but with all the brown ones removed.  It's easy to dismiss this as rock star egotism, but it's actually a very clever ruse.  The presence of brown M&Ms in the backstage goodies implies that nobody has bothered to read the contract properly, and that perhaps they've done something really dangerous.  And in this situation, the dangerous thing could involve a stage set weighing some hundreds of tonnes collapsing because the stage isn't strong enough.  

So, what are my brown M&Ms?  Well, thinking about it, I've got a lot.  And they're mostly things that tell me that folk aren't paying enough attention to detail.  The child who has been admitted but nobody can tell me the result of the blood tests done.  Or nobody has taken time to file the notes, or plot the growth.  I've probably got too many to list, and I know that each time I bring one up - especially on the ward round - people look at me as if I'm a spoiled rock star.  But I know why I look for the brown M&Ms

So, what are your brown M&Ms?