Dangerous ideas

Patrick_Kirsten_headshotCrop4Kirsten Patrick is Deputy Editor at CMAJ, recently returned from the Society for Academic Primary Care's annual conference in Oxford, UK


What sort of research would we be doing if medical research were crowdfunded? Sarah Knowles from Manchster believes that too much research money is wasted on studies that don’t deliver. Some don’t even manage to recruit the desired number of participants. Many funded research studies aren’t studying a question that is of importance to patient stakeholders. Sarah, a researcher in primary care mental health (“We compete with disability research for who gets the least funding!”) strongly advocates for crowdfunding of research. Think Kickstarter. She says it’s the way to ensure public engagement and patient voice in medical research; she points out that whenever she mentions it to other researchers they usually balk. She thinks this probably has to do with fear that we don’t possess adequate ability to communicate why our research is important and to make a compelling case for funding.

Sarah was the last of a panel of speakers at a session on day 2 of #sapcasm entitled “Dangerous Ideas”. The session was modeled on the reality show Dragons’ Den. Speakers pitched their ideas at the audience for five minutes and then the audience had five minutes to throw questions and comments at the speakers (to which they could respond).

I first heard about Kickstarter through a crowdfunding campaign started by the developers of the game ‘Exploding Kittens’, one of whom is Matthew Inman, a cartoonist who draws ‘The Oatmeal’. The Oatmeal has a huge social media following. Exploding Kittens is the ‘most backed’ Kickstarter project of all time. So, as Sarah was talking, although I thought her pitch had merit, I was immediately thinking, “This is flawed because it would be about one's ability to run a successful social media marketing campaign and not about clear communication of the importance of a research question; it would be a popularity contest.” You think the current system of obtaining research funding is time-consuming? Try the time-suck that is social media marketing. I think about the importance of researching how to deliver effective treatments for depression, say, and about how depression is the Cinderella disease….how would we sell that important, but unpopular, lead balloon?

Prof Bruce Arroll kicked off the session with an idea that, I think, scares most physicians. He called it ‘self-disclosure’ and he wants us all to do it. He thinks it is important that we share our own experiences with patients…tell them if we’ve had a condition that they may suffer from, or if someone close to us has had it, so that they will know that we really empathise. He does it and has found it to be beneficial to the physician-patient relations. I’ve done it - with mixed reactions. Bruce thinks that at the very least we should research it.

Andrew Moscrop was next, promoting the idea that we should diagnose poverty. We all know that the most disadvantaged in society have poorer health outcomes across a wide range of indicators after controlling for confounders, and that mortality stats can be shocking in some areas. What would be the rationale behind making a formal diagnosis. Andrew argued specifically that we need to be coding for it so that we can study it better – currently we use a myriad proxies for socio-economic disadvantage, which isn’t helpful. But formally diagnosing poverty would also help us to remember to direct and refer patients to services and benefits that may help with poverty relief. Although I have the utmost faith that we would spend much time and resource arguing over the definition, I thought Andrew argued his case well; I firmly believe that we need to do more to highlight the problems we face due to widening financial inequalities, so I liked the idea and I voted for it when we had a show of hands at the end of the session.

Seven-day working is a policy initiative that is apparently being foisted on (already-overworked) primary care doctors in England, with little evidence to support the notion that it will improve access or health outcomes. John Ford argued that general practitioners in the UK should not take it lying down and should instead actively oppose the government directive. Definitely worth considering if you consider that British general practitioners are leaving partnerships in droves and many more plan to leave in the future. Audience members shared many a fear (and experience) that 7/7 general practice opening would not improve access to care for those who struggled to see a GP now and agreed that different (evidence based) solutions should instead be found. The comment, “I have a colleague who opens on Sundays for extended hours and he usually ends up seeing about 2 patients…and often it’s the same two patients!” summed it up well.

Kyle Knox promoted the idea that pharmacists should be in charge of giving out antibiotics for UTI in the community. He pointed out that when the patient has a classic complex of symptoms the probability of UTI is so high as to obviate the need for a physician expert to diagnose the condition; pharmacists could do it. Making a choice of antibiotic might be thought to be the area where the physician’s skill is needed, but Knox argued that this is increasingly guideline driven and there is, essentially, only one choice. The idea still seemed dangerous to the audience. What about resistance; what about losing information about episodes of illness and treatment from the electronic health record? [Knox said that electronic health record systems in the UK could be easily adapted to include information on pharmacist diagnosis and prescribing, making it available to the physician in the future.] What about the pharmacist’s inherent conflict of interest (being salesperson of the antibiotic)….?

And, of course, a session on innovation wouldn't go ahead without a segment that could fall under the heading ‘There’s an app for that’. Oliver van Hecke talked about how physicians might deliver a primary care service in the style of Uber. You feel unwell. You open an app on your smartphone that tells you where you can go see a reliable and thoroughly-checked-out family physician right away in your area. Access is immediate and convenient, treatment is swift and you can also rate your physician right there in the app. The potential for entirely paperless medical care could be realised. The audience weren’t entirely convinced. “Things often get better on their own”, so instant gratification wouldn’t be a good thing. “The NHS is not a private system and the only way this could exist is in a private system, which would exacerbate issues of access and entrench a two-tier system.” There was a general feeling that the GP’s role is partly one of gatekeeper in a publicly funded system. Care should be supplied according to need and not according to demand. Someone said, “I’m sure this exists already.”
van Hecke
  pointed out that while a service does exist in the UK where you can pay £8 per month to have instant access to a physician, this is for advice only – no treatment can be prescribed – and what’s the use of that? You will have to make an appointment to see your doctor anyway.

Here’s a composite video in which the speakers pitch their ideas in one-minute clips.

What would you vote for? I’ve already said that I voted for diagnosing poverty, which came third with 13 votes from the ≈ 120-strong audience. Actively opposing 7-day working for GPs was the second most popular idea with 14 votes. Suprisingly – well, it surprised me – adopting a crowdfunding model to fund medical research won the day with the vast majority of the audience raising their hand for Sarah Knowles’s idea.

SAPCASM2015The 44th #sapcasm ran from Wednesday 8th to Friday 10th July 2015


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