MMR & autism - hogwash

Living in the UK in the late 90s (as I did) it was hard to avoid the MMR scandal. I won't go into the details here. This link will tell you what you need to know and concentrates on the part played by the press in the whole palaver. Suffice to say, they did not cover themselves in glory and undoubtedly influenced a large number of parents not to use the triple jab thereby endangering the children of those parents who immunised their kids but for some reason the jab didn't work.

Now that the dust is settling, that the GMC verdict is in and that the Lancet paper retracted, some reflection is appropriate.

Despite the Bad Science link above suggesting that the autism / MMR link is a UK phenomenon, in my young student cohort one person put their hand up in a tutorial to remark on the link when MMR was mentioned. So, the damage has spread globally.

The other entity that comes out of this mess poorly is the magazine Private Eye. Although it is typical for the magazine to take an automatically contrarian view, their lack of understanding of the data disproving the autism link went on for far too long. Even today, there seems to be a reluctance to accept that they were duped by the lobbyists on this one. I sent them a letter post GMC to see if they'd publicise the safety of MMR as thoroughly as they did the imagined dangers, but normally when the letter is accepted you get a "I've passed this on to the editor"... nothing this time. And there's nothing on their website at the moment when you search for 'MMR'.

Oh God, and I forgot about their special report in 2002. 2002! Geez. The BMJ produced an interesting review here.

The problem comes down to the media's lack of understanding of science. Being largely art grads, this is not surprising. Other skills, such as understanding how the biases of sources can bias a piece of work, you would have thought to have been in an experienced journo's tool kit... but in this case the author of the Private Eye report, Heather Mills, even goes so far as to thank these sources on the back cover of the report..!

Following this debacle, a demonstration of little self-awareness of one's limitations amongst the fourth estate is warranted.

Crap sandwiches

Thinking through the last post, I realised I'd put up some received wisdom on the good old hamburger approach to providing feedback without backing it up with facts. In the spirit of evidence based medicine, to discover whether the crap sandwich is as crap as I thought, or not, I did a quick scout around to see what the world's great thinkers in feedback provision are saying. Caveat: very quick scout about.

A group called Success Strategies, who look like they are a group of management consultants of some kind, post an interesting discussion on the method. Their key issues are that:

(i) most people know about this method, brace themselves for the crap in the middle and discount / ignore the rest, and
(ii) it only takes a couple of rides on the crap sandwich rollercoaster to learn exactly how it works and react as for (i).

This page also provides an alternate method which avoids direct criticism and instead kicks the discussion off with suggestions of how to deal with the situation which went awry. Interesting.

Although this approach is grounded in NLP, which some consider pseudoscience (it says here - although it seems to work for Derren Brown), this group have worked with some creditable organisations which provides a degree of weight to their work.

A literature search brings up little on the subject... perhaps a fruitful research topic for someone, who knows. The search did, however, bring up an excellent article from a US Obs&Gynae educational committee of some sort describing in detail how the US is approaching the provision of feedback to medical undergrads. They outline a quite structured, complex process which necessitates a dialogue and a lot of preparation with no input from peers... quite the opposite to what Australian med schools seem be recommending. Given the lack of outcome evidence (from what I can see), who knows which approach is best.

The reference for this, should anyone be interested, is: American Journal of Obstetrics and Gynecology (2007). 196 (6). 508 -513. I think it may be available if you register, but it's an Elsevier journal so perhaps not.

On balance, I would still say the crap sandwich is on the nose. Avoid.

Med Student peer review

As part of a new phalanx of insight-laden medical students, full of reflective goodness, we receive a lot of feedback from our betters / tutors / call them what you will on a broad range of elements of performance.

Further, given all the reflective bits and bobs, we are at the pointy end of plenty of feedback from ourselves too.

All of this is assessed, and, presumably, if it looks like we're lacking in insight or something, steps will be taken remedy matters before graduation.

On top of this, joy of joys, we are subject to feedback from our peers. We are monitored to make sure that we're not too soft on one another, presumably to avoid an eBay-feedbackesque situation where everyone is nice to avoid tit-for-tat retributions and so to ensure that the feedback is honest and, therefore, valuable.

This all sounds fair enough: most jobs in the real world require an annual or semi-annual appraisal which may or may not be 360 degrees in nature. However, normally the blow of receiving this feedback is softened by (i) the medium of delivery and (ii) who is providing the feedback. And perhaps you'll get a pay rise or a promo if the review goes well.

To address the second issue first, it's going to be interesting to see how the feedback from fellow students evolves over the rest of the course given that to date for most people I've spoken to it's been somewhat lacking in positive, actionable steps.

This isn't a huge surprise given that my peers don't have a lot of experience here and have only been taught the largely discredited "crap sandwich" approach to feedback (start with something good about you, then get the meat of the feedback with something crap about you, then finish off with what to do to improve). Still, some of the stuff is useful so I suck it in and take what I can from what I'm given.

The main issue is the first: the medium of delivery. In my colourful pre-med career I received diverse feedback from diverse people in diverse situations. I've had good reviews from balls-out US investment bankers in the backs of a taxis (mental image unintended), terrible pay news from nervous European bankers over telephone lines and woolly, "what was that conversation all about" feedback from fuddled academics in labs who weren't at all keen on this type of thing. I've also had to use a number of electronic systems having nominated a number of colleagues all of whom, and this is important, have been trained in using these systems the output of which is numerical.

However, what I haven't had is an online posting system where you log in and read feedback. I'm not sure about this route to provide feedback to happy recipients: there's not a lot of room for discussion / clarification with the feedbacker, there isn't space for emotional or intonational nuances to be provided: it's rather like getting a very personal SMS from someone you barely know.

Let's see how things progress.

Professionalism

A common thread running through both medical courses is a focus on reflective practice. Indeed, there is a strong similarity between Australia and the UK regarding the emphasis being placed on this aspect of the training. I can appreciate the importance of ensuring that doctors in training have an understanding of the importance of self-awareness, but I suspect I am in the minority among my student peers on that.

One difference, however, is the almost absolute lack of formal "professionalism" lectures and assignments here in Australia. "Professional behaviour" was almost fetishistically followed in the UK. Whether Australia considers professionalism to be a no-brainer, or whether the previously discussed lack of a Shipman means that the importance of teaching this formally is not appreciated, is hard to say. Perhaps later in the course we will get lectures on this but I can't see anything in he course outline so far.

Unlike reflective practice, the case of drumming professionalism into young medics is, I think, rather less clear cut. By formalising the process of ensuring professional behaviours, by providing all and sundry with the "unprofessional" stick with which to beat 18 yr olds, the importance of such behaviours is eroded. Further, certain parties, including peers, have a tendency to conflate "professional behaviour" with "doing as I say and shutting up". Here are a few examples of "unprofessional behaviour" as defined in UK:

• Not putting hand up prior to speaking in a public forum having been requested to ask a question.
• Not wearing a tie for a social work client encounter having been told previously that wearing a tie would intimidate their clients.
• Ditto another student being reported for wearing trainers which turned out to be smart casual leather shoes.
• Not using Vancouver referencing system correctly (that is, missing out on a comma or two).
• Forgetting to hand in a marking guide cover sheet on an assignment.
  

And on it went in all its nit-picking glory.

Cheerfully, currently the Australian course seems rather more relaxed as to whether the cover sheet on your assignment is 12 or 14 point font. Perhaps this is not setting the right standard up front and perhaps this course will turn out terribly slapdash students who will be unable to recite the 12 or so Duties of a Doctor (the number is hard to pin down because the list isn't MECE and is very hard to fit into a mnemonic). Or perhaps it means that sanctions can be saved for less trivial errors and oversights.