Evidence based medicine

When I came across the phrase “evidence based medicine” for the first time many years ago, I was somewhat bewildered. Was medicine we had learned in the college and practiced since not based on evidence?! Are there two types of medicine, one evidence based and one not?! Shouldn’t all medicine be evidence based?!

The key to the answer to these questions lies in the word “evidence”. Like almost any word in the language (any language), evidence can mean different things to different people or in different contexts. In the field of medicine, evidence can come through reasoning from known (thought to be known) pathophysiological facts. For example, in heart failure the heart does not pump blood to the tissues efficiently. Digitalis increases the force of myocardial contraction. So digitalis should be useful to patients with heart failure. Evidence can be the result of opinions of experienced doctors who obtained it from their practice. It may come from opinions of patients who expressed their satisfaction or dissatisfaction of a certain medical intervention. Evidence can also come from planned scientific experimentation.

During the last century and especially in the latter half of it, a trend towards examining medical interventions (drugs, surgical operations, diagnostic tests, life style changes etc) in a planned scientific way following the steps of the scientific method appeared and evolved. It aimed at properly evaluating the benefits and harms of various medical interventions. The trend became more powerful with the evolution and increasing use of clinical trials (including controlled clinical trials). Doctors, and increasingly the public, are not any more satisfied with the results of mere reasoning or opinions of experts. Reasoning that an intervention should be useful because it sounds logical according to our knowledge of medical facts is not enough. Our knowledge is not necessarily complete or perfect and usually, if not always, it is not. Opinions of experts and patients can be, and usually are, biased. The intervention should be tried on people under strictly controlled conditions and the results interpreted in a proper scientific way to find out if the intervention is really useful. And even if it is, we should make sure that it has no adverse effects that outweigh its benefits.

Medicine based on this kind of evidence is what is called evidence based medicine. This should not mean that the rest of medicine is not based on evidence but it means that the evidence for it is not satisfactory. The phrase does not express this in a clear unambiguous way. But that is language, however meticulous and careful one tries to be, language remains liable to be interpreted in various ways!

Should we conclude that evidence obtained from properly controlled clinical trials is infallible? Certainly not. We regularly hear of drugs withdrawn from the market and processes abandoned after being properly and scientifically evaluated and after years of use. Nothing in life is infallible.

Why Iraqi doctors should be interested in research

In spite of the various research difficulties described in the previous article (Why Iraqi doctors are not interested in research), Iraqi doctors should, in my opinion, be interested in research for the following reasons:

1.     Answers to local problems:

Local research even if it is a simple survey sheds light and may produce answers to some local problems. It does not have to produce important discoveries on a worldwide scale. After all, among the huge amount of research published in thousands of medical journals worldwide, very few constitute really important discoveries.

2.     Experience for the future:

With time, research experience accumulates and results are likely to improve.

3.     Education:

Research is highly educating. Knowledge is gained by reading and discussing the subject of research and related subjects. The researcher also learns the ways of obtaining knowledge like searching the internet and using the library.

4.     Promotion of scientific and critical thinking:

By following the scientific method of making a hypothesis, collecting data and modifying the hypothesis, research promotes scientific thinking. The researcher learns how scientific knowledge is obtained and realizes that so called scientific facts are in fact hypotheses with various degrees of convincing power. They are not certainties and that is why they keep changing. This develops in him a skeptical and questioning mind which is important not only in research but also in practice and in life in general. Knowing how various workers frequently differ about the same subject is a warning that one should not take everything he reads in a book or a journal or hears in a lecture as established facts.

5.     Reflection on practice

a.     The scientific method is not confined to research. It should be the basis of practice too. In fact the clinician is involved in research daily by trying to make a diagnosis of his patient’s illness and find solutions for his problems. Fever in a patient, for example, is a scientific problem. A hypothesis about its cause should be made after the initial information. Data is then collected through history taking, physical examination and various tests to strengthen or modify the hypothesis once or more times. Actions are then taken on the basis of the final hypothesis. This is what the scientific method is all about.

b.     Awareness of observer error and observer bias, common precautions in research, is reflected on interpretation of clinical findings and various tests made during daily work.

c.      Awareness that association is not necessarily causation, a common precaution in research, reflects on clinical work. Jaundice in a patient with a positive hepatitis virus BsAg is not necessarily caused by hepatitis B virus.

d.     Knowing how reference values are obtained makes interpretation of patients’ figures more intelligent. You may e.g. accept a figure slightly outside the reference range because you know that 5% of normal people are so.

e.      Research improves logic and shows its limitations. Treatment of various illnesses is based on trials done on a number of patients somewhere in the world and the results are generalized to include all patients all over the world (induction in logical terms). Why should your patient behaves in the same way as those patients?! In fact induction is the logical basis of most medical knowledge, not only treatment. One should therefore not be surprised to find so many differences between practice and the book. What should be surprising is the presence of so many similarities!

Why Iraqi doctors are not interested in research

Iraqi doctors are generally not interested in doing research. Many have a negative attitude towards it and argue that:

1.  Time spent in research is better spent in patient care.
2.  In our poorly developed situation, research is unlikely to produce significant results. Important discoveries have been made and can only be made in developed countries that have the facilities and the expertise.

These are some possible reasons for the lack of interest and the negative attitude:

1.      Lack of experience:
Most doctors lack the necessary experience:

a.       They were not involved in research during their training, unlike doctors in developed countries who get involved in research done by those who supervise their training.

b.      Most professional postgraduate degrees in clinical branches, including those from developed countries, do not include research in their requirements. (There are exceptions like the certificate of the Iraqi Board of Medical Specialties.)

c.       Earlier education in Iraq in primary and secondary schools is generally based on memorizing (one of the Arabic words commonly used to mean study is “istithkar أستذكار” which means remembering). Thinking and reasoning do not have prominent roles. The student becomes used to accepting what he is told rather than developing a skeptical exploring mind which is the basis for research.

2.      Lack of time:
Doctors are usually busy people. Their time is occupied by care of patients in government institutions and in private practice.

3.      Lack of incentive:

a.       Research is not financially rewarding.

b.      Except in universities, it does not promote the position of the doctor in the place where he or she works.

c.       Most of the problems in medical practice in the country are not medical. They are administrative, political, cultural and financial. These are less likely to be solved by medical research.

4.      Difficulties in research:

a.       Research is time consuming and mentally demanding.

b.      Technical facilities (laboratories, radiology etc.) in our hospitals and medical institutions are not satisfactory.

c.       There is no good medical record keeping and good follow up of patients.

d.      Good libraries and references are not widely available.

e.       There is no sufficient funding for research.

f.       Cooperation of patients and non medical people is generally poor. Importance of research is not widely recognized in our culture.

g.        Animal research is not generally available except on a very limited scale in universities.

h.      Ethical and legal restrictions on research on humans are not well defined and properly legislated and not carefully observed. This can create problems which may sometimes be serious.

Readers may be able to add other reasons that I may have missed.

عون في الشدة أم شدة فوق الشدة؟

من الأحبة والاصدقاء من يكون عونأ في الشدائد، يساعد اذا استطاع وينصح برفق اذا استدعى الموقف النصح ويتعاطف او يتفهم اذا لم يستطع غير ذلك وفي هذا أيضا عون كبير. ومنهم من لا يفعل شيئا من هذا وإنما يلوم ويؤنب دون مبرر مقنع ومعرفة دقيقة ويجدها فرصة لإظهار حذقه ومعرفته بإعطاء صاحبه موعظة في كيفية التصرف التي كان عليه اتباعها وإذا كانت العلاقة بينهما قريبة جدا فقد يفعل ذلك بانفعال يؤدي الى انفعال مقابل ومشادة كلامية هي آخر ما يحتاجه شخص مكروب.

فكم من الاحبة والاصدقاء من هو عون في الشدة؟ وكم منهم من هو في الشدة شدة فوق الشدة؟

Right and wrong, good and bad

This is not an article in the philosophy of ethics and not meant to discuss the controversies in the meaning of the terms. It is about the attitude of people towards them in everyday life.

Most opinions, plans, solutions or actions are compound and have several aspects: good, bad and all grades in between. Good or right and bad or wrong are also relative. Good to somebody may not be so good or even bad for another. The same opinion may be praised by those who look at its positive aspects and deemed wrong by others who look at the negative aspects. The ultimate value of the opinion depends on the sum, the net result, of its various aspects. We generally label it good when the positive aspects prevail and bad when the negative aspects prevail. There are grades of goodness and badness or rightness and wrongness. Two opinions may be different. Nevertheless both may be right with an equal or a different degree of rightness. The good or the right in any matter is not necessarily one. You can go up the hill via different routes. You can move from point A to point B by more than one way and all may be right.

The problem is that many people think and behave according to a concept that any opinion is either right or wrong and if an opinion or plan is right then any one that differs from it is by necessity wrong. They do not conceive of the presence of grades of rightness or wrongness. They have duality of thinking: white and black, no shades of greyness in between. For them there is one right opinion about a specific subject, one right solution for a specific problem. I sometimes hear two people arguing violently, every one claiming his opponent is wrong when, to me as an observer, both opinions seem of similar value each having some positive and some negative aspects.

If these facts are realized and accepted many differences of opinion may be better tolerated.

Defeating the purpose

 When anyone of us does anything, he or she usually has a purpose for doing it. Whether the action succeeds in achieving the purpose or not is another matter. But sometimes the action not only fails to achieve the purpose but be the means of actively defeating and destroying it! I say this having in mind many doctors who work so hard in their clinics in pursuit of money which supposedly will bring them happiness. If they are enjoying their intensive work, that is fine. But many of them are not. They spend most of their lives overworked, tired, tense and miserable. They seek happiness by being miserable!! It is an outstanding example of actions that defeat the purpose.

Approaching the patient with oedema

مناقشة بحوث الطلبة

في مناقشات بحوث الطلبة في العلوم الطبية كبحوث طلبة المجلس العراقي للاختصاصات الطبية او طلبة الماجستير او الدكتوراه في كليات الطب يلاحظ المرء ان بعض المناقشين لا يملك رؤية واضحة لهدف المناقشة وكيفية الوصول اليه فتراه يصرف الوقت في تبيان ما يعتبره أخطاء في البحث وقد يقضي كل الوقت او جله في تصحيح اخطاء لغوية أومطبعية أوما يعتبره نقصا في المعلومات المستقاة من الأدبيات (literature) فيضيف ويصحح ويأخذ دور المتكلم ويترك للطالب دور المستمع أي انه يمارس دور المحاضر الذي اعتاد عليه وينسى انه الان ممتحن وليس محاضرا وعليه ان يسمع اكثر مما يتكلم. ومنهم من يهاجم الطالب ويوبخه أو يستهزء مما كتبه او يقوله. وهو في كل ذلك لا يمس جوهر البحث كحسن اختيار المشكلة موضوع البحث واتباع المنهج العلمي السليم في جمع البيانات وتحليلها واستنباط النتائج ولا يختبر فهم الطالب للاطروحة وقدرته على البحث العلمي.

أن الغاية من مناقشة بحوث الطلبة هي تقويم البحث والطالب (والتقويم هو تقدير القيمة)  واعطاؤهما الدرجة التي يستحقانها باعدل ما يمكن. وبيان اخطاء البحث ونقاط ضعفه ليس غاية وأنما هدفه سماع رد الطالب عليها من اجل تحقيق غاية التقويم.

أن البحث الجيد هو البحث الذي احسن اختيار المشكلة فيه وحددت بصورة واضحة (والمشكلة في البحث العلمي تعني السؤال الذي يجرى البحث للاجابة عليه وتحديدها هو الخطوة الأولى في المنهج العلمي السليم) والبحث الجيد كذلك هوالذي وضعت له خطة صحيحة تجنبه الاخطاء التي قد تنجم عن اختيار العينة (sample selection) او اختلاف المراقبين (observer variability) أو انحيازالمراقب (observer bias) نتيجة معرفته وميوله الشخصية ثم حللت نتائج البحث بصورة صحيحة وتوصل الباحث الى استنتاجات منطقية مستخلصة من عمله وليس مما هو معروف من المصادر ومن عمل الاخرين. ولا يحكم على البحث بكثرة ما فيه من بيانات او فحوص معقدة ومتطورة فهذه قد تكون ذات قيمة كبيرة اذا احسن اختيارها وجاءت في مكانها المناسب وقد تكون عديمة النفع وربما ضارة ومشوشة اذا لم يحسن استخدامها او لم تكن ذات علاقة بهدف البحث. والبساطة والوضوح وتحديد الموضوع وتجنب كثرة الاهداف ليس منقصة وانما هو من عناصر الجودة.

ان من صفات الكتابة الجيدة الاختصار والتقيد بالموضوع المحدد والكلام البليغ هو الكلام الذي لا تستطيع ان تحذف شيئا منه دون ان يختل المعنى ولا يقاس البحث بطوله وكثرة الصفحات التي كتب بها.

ان تأنيب الطالب وتقريعه اثناء المناقشة لا يخدم التقويم العادل بل يعيقه نتيجة تأثيره السلبي على نفسية الطالب وخفض معنويته وارباكه واشاعة جو من التوتر يؤثر على التقويم الموضوعي الهادئ غير المنحاز. وليس من صفات المناقش الجيد التهجم على البحث او الاستخفاف به واحتقاره. ان عمل وكتابة بحث جيد ليس بالامر الهين ومن يشك في ذلك يكفيه ان يلقي نظرة على ما ينشر.

يجب ان لا تقتصر المناقشة على اظهار نقاط الضعف في البحث وانما يناقش الطالب في مواضع مختلفة من البحث لمعرفة مدى فهمه لما هو مكتوب وقدرته على الدفاع عنه والتاكد انه لا يجهل اجزاء مهمة من البحث كانت قد اعدت له من قبل المشرف أو المختص بالاحصاء ولم يكلف نفسه عناء دراستها وفهمها.

وثمة مسألة اخرى. ان المبدأ الذي يتبعه بعض المناقشين في شجب تكرار بحث مشكلة ما أذا كانت قد بحثت سابقا من قبل باحث اخر مبدأ يجب اعادة النظر فيه فالبحوث في العالم تكرر وقد تكرر مرات كثيرة من قبل باحثين مختلفين وفي اماكن مختلفة وقيام باحث ما او مركز ما ببحث مسألة معينة لا يعني ان على الاخرين ان لا يبحثوا فيها وقد يكون العكس هو الصحيح اي انه دعوة للاخرين لتكرار البحث فيها لتأكيد نتائج الباحث الاول أو تغييرها أو نقضها خصوصا اذا بحثت في اماكن مختلفة وعلى مرضى اخرين. وتعتمد قيمة البحث الجديد على رصانته وجودة أنجازه وما قدمه من اضافه او تغيير في تحديد المشكلة والهدف واسلوب البحث ونتائجه وعلى الباحث الجديد ان يشير الى من سبقه في بحث ذلك الموضوع ولا يدعي لنفسه الاسبقية فيه ضمنا او تصريحا. ولهذا الامرأهمية استثنائية بالنسبة للبحوث التي اجريت في بلادنا فيجب ان لا يغفل ذكرها الا انه ينبغي كذلك ان نتذكر صعوبة العثور على البحث العراقي لعدم توفر فهارس سهلة المنال بالبحوث التي أجريت وتجرى هنا.

وكالة

اردت عمل وكالة الى شخص ما. وبما انني قد عملت ذلك سابقا في هذه المدينة فقد كنت مطمئنا انني سانجز المهمة بكفاءة! في تجربتي السابقة وجدت ان الزحام عند الكاتب العدل المسائي اقل من الصباحي مما يجعل أنجاز الوكالة أسهل ولذلك أنطلقت بعد ظهر يوم شديد الحرارة من ايام صيف العراق المشهودة الى مكان الكاتب العدل. فوجئت بعدم وجود زحام بل لم ار شخصا واحدا على الباب مما اثار الشك في نفسي. دخلت المكان وتنقلت بين الغرف حتى قابلت شخصا يرتدي بجامة اخبرني ان الكاتب العدل قد انتقل الى مكان اخر. وبعد تحر واستفسار وانتقال من مكان الى اخر عرفت المكان الجديد واوقات العمل التي اختيرت بعناية لتكون في احر ساعات النهار (الواحدة الى الرابعة بعد الظهر). ذهبت بعد ظهر يوم اخر شديد الحرارة مثل سابقه فوجدت زحاما عرفت منه اننى اهتديت الى المكان الصحيح! لم ار كتاب العرائض الذين (لمن لا يعرف اجراءات العمل في دوائر الدولة العراقية) يخبرونك بما تحتاجه المهمة ويهيئون لك الأستمارة الخاصة والوثائق اللازمة لتأخذها الى الموظف المختص وتبدأ سلسلة التنقل من شباك الى شباك حتى تنجز المهمة (اذا لم تصادفك عقبة غير متوقعة توقف كل الاجراءات). سالت عن كتاب العرائض فدلوني على غرفة في الجانب الاخر من الشارع. ذهبت اليها فوجدتها غرفة ابعادها حوالي اربعة امتار في اربعة فيها شباك صغير واحد وليس فيها وسيلة للتبريد. يجلس داخلها ثلاثة كتاب عرائض وراء مناضدهم يحيط بهم حشد من المراجعين يملؤون الغرفة  الى بابها وكل منهم يستعمل اوراقه كمروحة يدوية يهزها امام وجهه الذي يتصبب عرقا. حشرت نفسي داخل الغرفة وبعد دقائق شعرت انني اوشك ان يغمى علي فخرجت. وبما انني أعرف من خبرتي السابقة ان كتاب العرائض عند الكاتب العدل الصباحي يعملون في مكان واسع مفتوح ومغطى وعددهم كبير حتى ان كل واحد منهم يحاول اغراءك بالمجيء عنده حالهم في ذلك حال كتاب العرائض في مختلف دوائر الدولة العراقية فقد قررت ان أذهب صباحا الى الكاتب العدل الصباحي لأهيأ الاوراق اللازمة عند أحد كتاب العرائض هناك ثم اتي بها مساء الى الكاتب العدل المسائي! وفي صباح اخر خرجت متوجها الى دائرة الكاتب العدل الصباحي وعند وصولى ألى المكان تفاجأت مرة اخرى بعدم وجود ازدحام وعدم وجود كتاب العرائض. وعندما سألت اخبروني ان الكاتب العدل انتقل الى مكان اخر! ولم استطع معرفة المكان الجديد بعد. في بلدنا تجاربك السابقة لا تفيدك! عدت الى البيت خائبا مرة اخرى وفي طريقى شاهدت بائع رقي (بطيخ في لغة بعض البلدان العربية الاخرى) ولكي اشعر نفسي بان خروجي لم يكن فاشلا تماما وقفت واشتريت رقية. وعندما وصلت البيت سألوني مثل كل مرة: هل أنجزت شيئا؟ قلت: نعم. اشتريت رقية! 

Are we copies of our previous selves?

On the same theme of the previous post (the dynamic steady state of our bodies), another thought may be entertained.

Our bodies are changing all the time and are in a tightly controlled balance with the environment. Every substance in the body is continuously lost and replenished. The input equals the output and the body remains in a steady state. Water which composes more than 60% of our bodies is lost through the kidneys, skin, lungs and intestine. It is replaced by the water we drink, water in our food and water produced in our bodies as a result of food metabolism. The water in our bodies today is not the same water that was in them days or weeks ago. The same thing applies to other elements and compounds that compose our bodies. Everything is lost and replaced by a new thing continuously. After a time the whole body has been replaced keeping the same design; the same architecture imposed and governed by our genes. Slow and gradual changes in design occur as a result of aging. Rapid changes occur sometimes as a result of disease and accidents. In other words every one of us is not exactly the same person he was sometime ago. He is a copy of his previous self. If you see a friend that you have not seen for a year you are in fact not seeing him but seeing a copy of him! To be more precise a copy of you is seeing a copy of him!! A somewhat disturbing idea to sleep on if you are reading this article late at night.

Kidney failure and the steady state of our bodies

When I told a group of students that the kidneys of a patient with kidney failure whose condition is stable excrete normal amounts of waste products and other substances like normal kidneys, they responded with a kind of disbelief: why then does the patient develop manifestations of kidney failure and why do we call it kidney failure?!

The answer is this.

If a patient or a person is in a steady state i.e. he or she is the same and his plasma urea and creatinine are the same today, tomorrow or after a week, then the input of any substance (entering or produced in his body) must be equal to the output. In the case of urea and creatinine the production in the body by tissues must be equal to the amount excreted by the kidneys. In other words if the blood urea and creatinine are constant over a period of time (regardless of whether they are in the normal level or elevated) then his kidneys must be excreting all that is produced, otherwise the level must rise. The critical point here is that the failing kidneys excrete normal amounts in spite of their reduced glomerular filtration because the level of the substance in the blood, and consequently in the filtrate, is high; so a reduced volume of glomerular filtrate contains the same amount of urea or creatinine as a larger volume with a lower concentration. If for some reason kidney function deteriorates and filtration drops further then the balance between production and excretion is disturbed. Urea and creatinine start to rise. The patient now is not in a steady state. The level goes on rising resulting in increased excretion until the amount excreted in the reduced volume of filtrate becomes equal to the production. The rise in the serum level stops and the patient reaches a new steady state at a higher level of plasma urea and creatinine. In other words failing kidneys excrete normal amounts of various substances on the expense of a higher plasma concentration of these substances.

To make an analogy, think of a tank with a hole in the bottom and water flowing into it from a tap. The level of water in the tank depends on the balance between the water flowing in and that flowing out. If the hole in the bottom is made smaller the balance is disturbed, the inflow exceeds the outflow causing the level in the tank to rise. The rising level increases the pressure driving the water out from the smaller hole. The water outflow starts increasing. The change goes on until the outflow becomes equal to the inflow. The level of water in the tank then stops rising and stabilizes at a new higher level assuming a new steady state.

The ability of our bodies to keep their composition and various characteristics constant (i.e. in steady states) is remarkable. Think of body temperature, body weight, the number of various blood cells, skin cells, intestinal cells, the amount of water in our bodies, the amount and concentration of various chemical substances in our tissues etc. etc. Everything is kept in a steady state; a dynamic, not static, steady state. The essence of it is to equalize the input and output.

Inverse epidemiology

It is a common knowledge that high body weight, high blood pressure, high blood sugar and high blood cholesterol are detrimental to health. In epidemiological studies (studies of disease in the community) the higher these are the higher the illness (morbidity) rate and death (mortality) rate. Put in a different way the lower they are the lower the illness and death rates. The relationship is a direct relationship. But is that always the case? Do illness and death rates go on decreasing with decreases in these variables without limits? Is a body weight of 40 kg. better than a body weight of 60 kg. or a blood pressure of 70/30 better than 100/60? Obviously not. A decrease in these variables is associated with a decrease in illness and death rates within certain limits. After reaching optimum levels the relationship becomes inverted and lower figures are associated with higher illness and death rates. The epidemiology is now inverse (so called).

I must say I came across the term “inverse epidemiology” for the first time when reading about the relationship between blood pressure and cardiovascular outcome in patients with end stage renal disease on maintenance hemodialysis. I am not sure of the use of the term in the general sense I described earlier. But it seems to me it applies just the same outside the situation of patients on dialysis and outside the subject of blood pressure.

In fact it also applies to aspects of life outside the field of medicine. Direct relationship becomes inverse after certain limits. Too rich, too powerful, too beautiful etc. may become a curse rather than a blessing!!

Yemen uprising. Who represent the people?

The ability of the Yemeni president to launch massive demonstrations in his support struck many people. It made the simple minded wonders; if so many people want him to stay then what is the evidence that the majority of people want him to go?

In politics the majority of people are silent. A minority speaks.  One of the ways in which they speak is demonstration. The size of the demonstration gives an idea about the proportion of people the demonstrators represent. But is it an accurate representation??

The question reminds me of the wisdom of random sampling in statistics! For a sample (the demonstrators) to be representative of the whole (the people) it should be a random sample. So in an ideal theoretical situation we should ask expert statisticians to choose a proportion of the community using random tables or whatever method of proper random sampling they suggest and we then ask the opinion of the individuals in the sample about the matter at stake. Their opinions will then represent the opinions of the nation. Of course this is all imagination but it helps to clarify the fact that demonstrators are not accurate representatives of the people. They are, in statistical terms, selected (not random) samples. The man in power has got a clear advantage in recruiting people to his demonstration. He can intimidate, threatens and bribes. His followers can demonstrate without fear of being jailed or killed. On the opposition side, demonstrators risk being jailed or killed and those who recruit them have not got the power to defend them and cannot offer them material advantages. So although the majority of people who want the Yemeni president to stay and the majority of those who want him to depart are silent, the proportions who speak are quite different in the two sides. It is much larger on the side who is in power. A thousand on the opposition side may represent a larger section of the community than ten thousand on the regime side.

I wish random sampling of statisticians can be applied in politics. That is of course a day dream or, if you like, a mental exercise!

تقكير علمي ام حقظ معلومات؟

   من فضلك انقر على المقالة وان لم تفتح انقر على اليمين وافتحها في شباك منفصل.

الاصيل والقيم والمفيد في الترقيات العلمية في الجامعات العراقية

الاصيل والقيم والمفيد كلمات مالوفة لاعضاء الهيئة التدريسية في الجامعات العراقية الذين يقدمون طلبات للترقية العلمية. انها من المفترض ان تمثل درجات في سلم تقويم البحوث التي يقدمها طالب الترقية. ترسل البحوث الى مقومين يطلب منهم اعطاء كل بحث الدرجة التي يستحقها في هذا السلم وتكون نتيجة التقويم في العادة اهم اساس في الترقية.

فهل تمثل هذه الاوصاف سلما من درجات متسلسلة؟؟

اذا اردت ان ترتب اشياء او اشخاصا في رتب متدرجة فان المنطق يقتضي ان ترتبهم حسب صفة واحدة  حتى يمكن ان تعطي كل واحد درجة في تلك الصفة ولا يقع واحد في اكثر من درجة. فلو اردت مثلا ان ترتب اشخاصا حسب الطول فيمكن ان تكون الدرجات: طويل، ومتوسط الطول وقصير (وتضع حدودا لكل درجة) فلا يمكن عندئذ ان يقع شخص ما في درجتين او اكثر ويكون طويلا ومتوسط الطول او قصيرا في نفس الوقت او ترتبهم حسب الثروة مثلا الى غني ومتوسط الغنى وفقير او حسب الذكاء الى ذكي ومتوسط الذكاء وغبي وهكذا ولا يصح ان يتكون السلم الواحد من درجات من اوصاف مختلفة كان تكون درجات السلم: طويل ومتوسط الذكاء وفقير لان شخصا ما قد يقع في الدرجات كلها ويصبح السلم عديم الفائدة لا يحقق غايته في المفاضلة والمقارنة.

فهل الاصيل والقيم والمفيد درجات من صفة واحدة؟ ان الاصالة شيء والقيمة شيء اخر والافادة شيء ثالث. وان بحثا ما يمكن ان يكون اصيلا وقيما ومفيدا في الوقت نفسه وان اعطاءه ايا من هذه الصفات لا يجعله ارفع او ادنى من بحث اعطي صفة اخرى منها. واذا كان المقوم غير عراقي لا يعرف تأثير كل وصف في انجاز الترقية فانه سيحتار اين يضع البحث؟ أن واضعي تعليمات الترقية العلمية والعاملين فيها اعتبروا ان الاصيل اعلى من القيم والقيم اعلى من المفيد وان القيم ليس اصيلا ! والمفيد ليس اصيلا ولا قيما ولا يصلح للترقية! كل ذلك بحكم تفاهم غير مكتوب ناتج عن طريق الاستنتاج مما رتبه القانون والتعليمات من نتائج على كل وصف من هذه الاوصاف بغض النظر عما تعنيه كل كلمة من الناحية اللغوية وكيف سيفهمها المقوم والاخرون وكأن ذلك لا يهم!!

هذا السلم موجود منذ عشرات السنين وقد تم تغييره لفترة ما في الثمانينيات فاصبح البحث يصنف الى اصيل وغير اصيل ويصنف كل منهما الى جيد جدا وجيد ومقبول أو نحو ذلك لا اذكر بالضبط. وهذا تصنيف افضل فهو يصنفها حسب الاصالة اولا ثم يدرج كل صنف حسب الجودة ثانيا. ولكن هذا التصنيف لم يدم لا اعرف لماذا واعيد الوضع الى الاصيل والقيم والمفيد. اتمنى ان يتغير هذا السلم الى سلم اخر يقبله المنطق السليم او يعاد الى التغيير المذكور الذي حصل في الثمانينيات.

تبقى اسئلة اخرى في موضوع الترقيات العلمية الشائك. ما هي المعايير التي تحدد ان يكون البحث اصيلا او قيما او مفيدا؟ وكيف يتم اختيار المقومين؟ وكيف يضمن عدم معرفتهم والتاثير عليهم من قبل طالب الترقية او غيره؟ وهل من العدالة ان نطبق في ترقيات التدريسيين في جامعاتنا نفس المعايير المطبقة في الجامعات الغربية المتقدمة وان نتوقع منهم ان ينتجوا بحوثا في مستوى نظرائهم في تلك الجامعات رغم الاختلاف الكبير في الامكانات البشرية والمادية خصوصا في الحقول العلمية؟ واسئلة اخرى لا يتسع المجال لذكرها او الخوض فيها في هذه العجالة وتحتاج الى بحث ونقاش وتبادل اراء بين الخبراء بالموضوع. أنه حقل شائك حقأ!!

Approaching hyponatremia

Our concept of disease entities

There is no sharp line between health and disease. (See a previous post in this blog “The concept of health and disease” please). Deviations from what we consider as “normal” that are detrimental to the individual are labeled as illnesses or diseases. The ways in which a person’s condition deviates from normality take innumerable forms and shapes. Every patient’s disease is in fact unique. There are similarities and differences between diseases of different individuals. Because we think that similar diseases may progress in similar ways and respond to our intervention in similar ways we try to group them into one disease entity and give it a name. There are grades of similarity between the individuals in the same disease entity. We might see patients whose diseases fit very well with the classical description of that entity and patients whose diseases differ from the classical description to various degrees. There are no sharp lines of separation between disease entities. Some diseases may not fit well into any of the artificial entities that we create or fall in the boundary between two entities or more.  We then either force them into one of the entities that we consider the nearest possible or include them into more than one entity or create a new entity with a different name to accommodate them.

These facts explain at least partly the differences between doctors about the diagnosis of a patient’s disease and why in many instances a patient’s disease does not behave in the way we expect it to.

Much of the controversy in medical discussions is about language rather than fact. It is semantics. Nevertheless it is important because language dictates our acquisition of knowledge. It is the language, the names, that makes it possible for us to learn about diseases and to get the help of the book or the literature to guide our prediction of prognosis and our management. It is not an ideal situation but that is the case with almost everything in life.

MS & Ph.D debates in our universities

Two phenomena are commonly observed during MS and PhD debates in our universities.

1. The student usually prepares a food and drink party in front of or beside the debate room to celebrate, with friends and relatives, his distinguished success before the start of the debate!! The psychological pressure of this on the examiners needs no comment.
2. Most of these debates end with granting the candidate an (excellent) grade! One candidate became furious because he was given a (very good) grade!!

Isn’t it time to stop these shameful practices to give our postgraduate degrees some recognition and respect?  

Judging doctors’ competence!

People frequently judge doctors by the progress of the patient following their intervention. If the patient improves the doctor is competent. If the patient does not improve or deteriorates the doctor is incompetent.

Many illnesses especially acute ones like viral infections are self limiting and not affected significantly by treatment. The condition starts and gradually worsens over days until it reaches a climax, then it starts to improve until it recovers. If the patient sees a doctor in the beginning of the illness he is likely to deteriorate in the following days irrespective of what the doctor does. The doctor may be blamed for the deterioration. If he then sees another doctor when he is at the climax of his illness he will start improving irrespective of what the doctor does. The improvement may then be attributed to the second doctor. The same thing applies to many chronic illnesses because they have a fluctuant course with spontaneous exacerbations and remissions. Justice is rare in this world. It is a sad fact of life.

Restart is the answer

I have learned through my primitive experience with the computer that when I face a problem that I cannot solve, which is the usual, I restart my computer before asking for help. Fortunately it works most of the time. A similar thing applies to several other instruments. If your mobile or even desk telephone stops obeying your commands, switch it off then on again. If the router stops sending signals, disconnect from power then reconnect. Even the car engine, when it stumbles, sometimes returns to a smooth running when you switch it off then on.

I wish it was the same with human beings. If you get an illness that doctors cannot help much with, you just push a button and restart! If you face problems that you cannot solve and life becomes intolerable, you just restart! If you make a disastrous mistake and you cannot correct it, you just restart. If you become old and suffer the physical, mental and psychological ailments of advanced age you just restart!

غياب المثكلة في بعض رسائل الماجستير

كتبت هذه المقالة قبل سنين طويلة ولكنها تنطبق الان كما كانت في حينها! واعتذر عن الاخطاء اللغوية التي حدثت أثناء طباعتها

من فضلك انقر على المقالة لاظهارها

Notes on treatment of hypertension

Notes on diagnosis of hypertension

Medical consultation between doctors in our hospitals

Consultation between colleagues of different specialties about patients in our hospitals frequently ignores proper ethical principles and may therefore create problems and bad feelings.

Examples:

1.     A junior resident doctor may send a consultation about a patient directly to a consultant in another department sometimes before the patient was seen by the consultant in charge. The proper way is that the consultant in charge of the patient should send the consultation. This ensures that he has seen the patient and that the consultation is needed. Not infrequently, the consultant in charge can solve the problem when he sees the patient or decides that it is not a priority and not needed at that time. It also avoids the possible feeling by the consulted doctor of being treated without due respect because the consultant in charge has not taken the trouble of writing the consultation himself. There may be an excuse for the junior doctor to do so in a case of emergency when time is vital and delay may harm the patient but this is not frequent and should be explained in the consultation letter.

2.     A consultant doctor may ask one of his juniors to respond to a consultation directed to him by a consultant colleague. This deprives the patient of receiving the best available opinion and is not good manners as it does not show respect to the doctor who consulted him. The proper way is that the consultant should respond himself if the letter of consultation has been written by a consultant colleague.

Time, the Enemy

A conference call for papers attracted my attention. The conference is the 33^rd of the “International Association for Time Use Research” to be held in the University of Oxford (England) on 1-3 August 2011. The subject is time use. I entered “time use” in the search engine of Google which responded by showing 1,790,000 results including innumerable articles on time use research in different countries, sites of institutes of time use research and articles about how to manage your time properly because there is not enough time in the day for all you want to do. That brought to my mind the familiar sight in many cities of people reading in their pocket book while sitting in the train or the bus or waiting in a doctor’s room or even standing in a queue.

It also reminded me of the familiar sight in our country (and in others) of people spending most or all of their time sitting on street curbs or in street cafes doing nothing or indulging in some useless games. I remember once I was driving with a visiting professor in my car when we passed by a number of these cafes. Many of those sitting in the café were just rolling the beads of their rosaries (misbaha) and staring at the unknown. I said: it is a pity they are spending their time without a useful activity. The professor corrected: They are breathing! If you ask these people and many others doing all sorts of useless things about what they are doing many will give the familiar answer: we want to kill time. I do not know what made ‘time’ that hated enemy that deserves to be killed!

هل تقاس صحة القرار بنتيجته؟

من الشائع ان يحكم على القرار بنتيجته فان كانت جيدة اعتبر صائبا ونال صاحبه الثناء وان كانت سيئة اعتبر خاطئا وتعرض صاحبه للنقد. وهذا حكم غير منصف لانه يستند على المعلومات التي توفرت بعد اتخاذ القرار ولم تكن متوفرة حين اتخاذه. ان الحكم على صواب القرار يجب ان يعتمد على مدى حسن التقدير بناء على المعلومات المتوفرة حين اتخاذ القرار فان متخذ القرار لا يعلم الغيب وانما يبني قراره على الاحتمالات التي يتوقع حدوثها في كل حالة. ويتضح الامر بضرب مثال. فلو فرضنا ان شخصا اراد السفر من مدينة الى أخرى وكان هناك طريقان احدهما خطير نسبة الحوادث فيه 95% والاخر أمين نسبة الحوادث فيه 5% فاختار الطريق الامين ولكنه تعرض لحادث وان شخصا اخر اختار الطريق الخطر ولكنه نجى ولم يتعرض لحادث فهل نقول ان الاول اخطأ باختياره الطريق الامين وان الثاني اصاب باختياره الطريق الخطر؟

ان الحكم على صواب قرار ما يجب ان لا يعتمد على النتيجة وانما على صحة التقدير بناء على المعلومات المتوفرة حين اتخاذ القرار. ولو عمل الناس بهذا لقل بينهم الخلاف واللوم والتأنيب.

( ولو كنت أعلم الغيب لأستكثرت من الخير وما مسني السوء) – قران كريم (الأعراف 188)

The use of ‘normal’ values

To judge a finding in a patient, be it body weight or height, a blood test like white cell count or serum potassium etc. we usually compare it with so called ‘normal’ values (better called reference values or range). These values are obtained by studying the frequency distribution of the finding (variable) in question in a sample of healthy people and determining its mean and standard deviation (SD). The normal range is taken as the range between + 2 standard deviations and -2 standard deviations.

(Normal frequency distribution curve with number of standard deviations on the horizontal axis)

We know from statistics that this will include 95% of people which means that 5% of healthy people have values outside the normal range. We have to remember then that if a patient’s measurement is slightly outside the normal range it still can be normal. Conversely if it is within the normal range it still can be abnormal for that particular patient because it is significantly different from his usual figure. For example a patient whose white cells count is 4000/c.mm. in normal circumstances the number may rise to 8000/c.mm. when he develops an infection. It is still in the normal range though it is raised compared to his count during health.

Like every thing else in medical practice data have not to be taken blindly and in isolation but have to be interpreted with caution taking all other findings to form an overall picture of the situation.

Changing medicine

Doctors who practice medicine for many years are struck between now and then by changes that turn their previous beliefs upside down. I say this with two examples in mind:

1. The use of antibiotics in the treatment of peptic ulcer: Before the discovery of Helicobacter pylori and then establishing its relationship to the development of peptic ulcer no one would have been stupid enough to consider antibiotics when confronted with a patient with peptic ulcer. In fact mentioning it in an examination would have been a sufficient reason to fail the candidate in the opinion of many examiners.
2. The use of beta blockers in the treatment of heart failure: Not many years ago we considered these drugs contraindicated in the presence of heart failure because they depress myocardial contractility. Now they are considered an essential part of the treatment of heart failure due to systolic dysfunction except when there is some strong contraindication like bronchial asthma.

 It makes one wonder which of the ideas that we consider now established facts will turn to be fallacies in the future and which of the forbidden practices nowadays will become established practices tomorrow. As they say, change is the only constant in medicine!

محاورة بين سقراط وافلاطون

المحاورة خيالية للدلالة على واقع وقد نشرت قبل سنين ولكنها تنطبق الان كما كانت عندئذ

Thoughts on Examination of Medical Students

Examining med. students.pdf - Google Docs

(If clicking the title does not open the article, please right click and open in a new tab or window)

The border between health and disease

The concept of health and disease, in the minds of most people and many doctors, is simple and clear cut. A person is healthy if he has no disease. Diseases are well defined and clearly recognizable conditions.

The reality is not so. Health is not the same in all so called healthy people. It covers a wide spectrum of conditions physically, mentally, and socially. Some people are physically robust, happy, psychologically satisfied, and socially integrated and active. Others are frail, easily tired, worried, frequently unhappy and socially isolated. And there are all grades in between. That is why the aim of medicine is not only to prevent or treat disease but also to promote health.

Apart from acute conditions like acute infections and trauma, the transition between health and disease is gradual and ill defined. Most symptoms of disease are present to some degree in so called normal people. All people become short of breath if they exercise sufficiently and "sufficiently" varies in various people. Some may need to climb fifty stairs to become short of breath. Others may become so after climbing thirty or twenty stairs and so on. People with heart or lung disease may become short of breath on climbing ten stairs or one or two depending on the severity of their illness. What is the number of stairs that makes shortness of breath pathological? Can we put a definite figure? You can say the same about poor appetite, headache, anxiety, numbness, poor memory, readiness to fall asleep on going to bed, muscle and joint pains and so on. Recognizing a symptom as abnormal or pathological varies widely between people. That is one of the reasons why some people go to the doctor frequently and sometimes for no good reason, while others do not go unless they become severely ill.

A similar thing can be said about laboratory tests, but in this case artificial, statistically derived, boundaries have been created by putting a reference range for every test. These reference ranges have come to be generally conceived as the boundaries between normal and abnormal test results. According to these boundaries, a test result can deviate from the average of normal people to a large extent and still be considered normal. Then when it crosses the artificially drawn boundary it suddenly comes to be regarded abnormal!! The transfer from health to disease is not that sharp in real life.

The spectrum of health is wide and so is that of disease and the border between the two is frequently blurred and difficult to discern.

Classification and probability

Classification is the process of putting people, animals or things into groups or classes according to certain characteristics. So we classify people into children and adults according to age or men and women according to sex. We may subdivide adults into young, middle aged and old according to certain limits of age that we allocate for each group. We may classify diseases according to the organ they primarily involve into e.g. heart diseases, lung diseases, kidney diseases and so on.

Sharing a certain characteristic may indicate sharing other characteristics e.g. old people may be more prone to certain diseases than younger adults or children. These classifications which deal with groups have important effects on our dealing with individuals. In medicine we usually translate the occurrence (incidence or prevalence) of a disease in the group into a probability in the individual. For example, if 50% of old people have osteoporosis, when we have an elderly patient we say he has a 50% chance (probability) of having osteoporosis. If 80% of heart failure in elderly people is caused by atherosclerosis and we have an elderly patient with heart failure we think that the cause of his heart failure is atherosclerosis with a probability of 80% and so on. This translation of occurrence into probability is logical. However it may lead to an erroneous conclusion if done blindly. The following example explains this.

Students are taught that in children nephrotic syndrome is caused by minimal change glomerulonephritis in 80% of cases while only 20% of cases in adults are caused by minimal change disease. The most common cause of nephrotic syndrome in adults, they are taught, is membranous glomerulonephritis. Consequently when they see an 18 or 20 year old man with nephrotic syndrome and you ask them what the most likely cause of his nephrotic syndrome is, many will answer membranous glomerulonephritis because he is an adult. The answer is the effect of classifying adults who represent a very large and heterogeneous collection as one group or class. When adults are taken together membranous glomerulonephritis is the most common cause because the group includes many middle aged and elderly people in whom this disease is the commonest cause. That is not the case in young adults. The 80% likelihood of a minimal change disease being the cause of nephrotic syndrome in a child does not dramatically drop to 20% when the child reaches an age that puts him in the adult category. Nature does not change its behavior according to the limits we use in our classification. The 80% chance in say a 5 year old child may become 75 in a 10 year old, 65 in a 15 year old and 60 in a 20 year old. The probability may drop to 20% in a 40 or 50 year old and to less than that in a 60 or 70 year old man (these imaginary figures are only to explain the idea and are not claimed to be real). In other words minimal change is still the most likely cause of nephrotic syndrome in the very young adult and its probability decreases gradually as the age advances. Classification helps us to understand and remember various scientific facts but we have to keep in mind that the sharp boundaries between classes or subclasses are frequently artificial. They are created by us and not necessarily present in nature.

Relative risk and absolute risk

Statistics can be deceiving if one is not careful. We learn of things that double our risk of developing this or that disease or increase it by say 25 or 50%. We also learn of things that decrease our risk of developing a disease by a certain percentage. It may sound very important to have a risk doubled or reduced to half but unless we know how much it originally was, can we really tell how much the change is? If you get a job and your boss tells you that your salary will be double the salary of Mohammed you immediately ask: How much is the salary of Mohammed? We do not do the same when we learn about doubling or halving the risk of a certain condition.  We do not bother to know how much the original risk was. Unless we translate a relative risk (i.e. a risk expressed as a ratio of another risk) into an absolute risk (i.e. the chance of developing an event regardless of how it compares with another risk) we cannot judge its magnitude and importance. For example, if you know that smoking increases your risk of developing a cardiovascular event in the next 10 years by say 50% and your absolute risk is already 20%, the increase is 10% which is important and worth avoiding smoking (leaving aside other harms of smoking). On the other hand if someone tells you that using your mobile phone increases your chance of developing an acoustic nerve tumour by 100% and your statistical chance of developing this disease (i.e. your absolute risk) is 1/100,000 then using the mobile phone will increase it to 2/100,000 i.e. an increase of 1/100,000. Most people will consider this increase, even if it is true, insufficient to make them stop using mobile phones. I can mention other examples of things that decrease the risk and the same thing applies.

We should always remember that it is the absolute risk that counts.

Our maintenance dialysis policy

Because of the poor dialysis situation in our country (and in similar so called developing countries) we do not usually start our patients on maintenance dialysis early. Most patients have obvious uraemic manifestations when they are started (Creatinine clearance usually 5ml/min or less). Some in fact start their dialysis as an emergency life saving procedure. In contrast most patients with chronic renal failure in developed countries start dialysis as a carefully planned procedure before they develop obvious uraemic manifestations (creatinine clearance of 10 ml/min or more). We have been told that early dialysis improves survival and quality of life.

In a recent randomized controlled trial (called Initiating Dialysis Early and Late –IDEAL) conducted at 32 centers in Australia and New Zealand and reported in the August 12 issue of the New England Journal of Medicine(1); Bruce A. Cooper from Royal North Shore Hospital and Sydney Medical School in Sydney (Australia) and Colleagues examined whether the timing of the initiation of maintenance dialysis influenced survival among patients with chronic kidney disease. Between July 2000 and November 2008, eight hundred twenty eight adults (542 men and 286 women) with progressive chronic kidney disease were randomly assigned to an early start group (creatinine clearance between 10 and 14 ml/min) and a late start group (creatinine clearance between 5 and 7 ml/min or the development of obvious uraemic manifestations). At the end of study the authors concluded that planned early initiation of dialysis in patients with stage V chronic kidney disease was not associated with an improvement in survival or clinical outcomes. In an accompanying editorial, Norbert Lameire and Wim Van Biesen from the University Hospital Ghent in Ghent, Belgium commented : "In our view, the IDEAL trial supports the currently recommended practice, in which most nephrologists start patients on renal-replacement therapy on the basis of clinical factors rather than numerical criteria such as the estimated GFR alone,"

Our dialysis policy may after all not be as bad as we think!!??

(1) Cooper BA, Branley P, Bulfone L, Collins JF, Craig JC, Fraenkel MB, Harris A, Johnson DW, Kesselhut J, Li JJ, Luxton G, Pilmore A, Tiller DJ, Harris DC, Pollock CA, A randomized controlled trial of early versus late initiation of dialysis, N Engl J Med, 2010,363(7):609-19.