Matt Morgan: Life and how to live it

I still remember the first time I heard the haunting American sound of Michael Stipe, the lead singer of the band R.E.M. I was 10 years old when my dad tried to sing their confusing lyrics from “The Sidewinder Sleeps Tonight.” R.E.M.’s bittersweet combination of melancholy notes with lyrical storytelling spoke to me and has left me helpless ever since. Twenty-five years later, as I was driving back from the hospital, their song “Life and How to Live It” spoke to me again.

This 1985 song describes the bizarre life Brev Mekis, a resident from R.E.M.’s hometown Atlanta, Georgia. Brev lived in a large house divided in two by an internal wall with a single door allowing him to move from one side to the other. He would spend a few weeks living on one side of the wall, wearing certain clothes, reading certain books and eating certain food. He would then move to the other side, eat different food, wear different clothes and watch the television. He flip-flopped back and forth every few weeks until he died. After he died, the housing department cleared out his house and found hundreds of identical books, all neatly stacked in a large, tall cupboard. None of these had been read or even opened. Brev had written and published these books himself. The book was called ‘Life and How to Live it’.

Every time I step through the automatic sliding doors at my hospital entrance, I walk between two sides of my life. I wear different clothes, I eat different food, I read different books. I even wear different aftershave. Unlike Brev, each time I move back to the other side, I take a little baggage with me. When I started as a junior doctor, the two sides of my house were very different. The small amount of baggage I have been bringing back with me ever since has now left the two sides of my life more similar than different. Sometimes this is a good thing, sometimes not. How thick are the walls between your lives?

Matt Morgan is honorary senior research fellow at Cardiff University, consultant in intensive care medicine, Research and Development lead for Critical Care at University Hospital of Wales, and an editor of BMJ OnExamination. He is on twitter: @dr_mattmorgan

Competing interests: None declared 

Read more in Matt’s first book, “Critical – science and stories from the brink of life.” Available to order now www.drmattmorgan.com.

 

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The robot needs a human heart—why AI in medicine brings moral choices into focus

In a crisp, white building deep in the heart of California’s Silicon Valley, teams of people make moral choices on your behalf. The development of self-driving cars may improve global road safety and efficiency, but for individuals, they also transform purely philosophical questions of the past into a harsh reality of today. When self-driving cars need to choose between a head-on collision into a child or swerving into an adult, what should they do? What impact will these dilemmas have for artificial intelligence in medicine?

Described as the “Trolley problem,” a modern version can be traced back to the British philosopher Philippa Foot. [1] She described a runaway trolley heading toward five people who will be killed by the collision. The trolley could be steered onto a different track on which there is only one person by pulling a lever. Intuitively, it seems permissible to turn the trolley to kill one person compared with five. Yet it also doesn’t seem permissible to kill one person to save five in other cases such as organ donation.

Fast forward to 2018, with the first self-driving car fatality, AI collision avoidance systems need a steer on how they should react. Vehicles cannot escape from moral value judgements implicit in their pre-programmed decision rules. What should the humans with hearts tell these inanimate machines to do? Maybe these robots need a human heart?

One way to inform these decisions is to simply ask people. The Massachusetts Institute of Technology ran an online global experiment called the “Moral Machine” where millions of people from over 200 countries took a quiz, resulting in 40 million ethical decisions. The study’s authors describe consistent global preferences in collision avoidance for sparing humans over animals, saving more lives rather than fewer and saving children over adults.

While variation is expected, they also described large shifts in choices made across social, geographic, and demographic groups. In China, Japan, and Saudi Arabia for example, the preference to spare younger rather than older people was far less pronounced.

With AI in medicine consistently described as one of the most important advances in healthcare, the “Trolley problem” is soon coming to a hospital near you. AI models are increasingly promoted for use in diagnostic imaging, risk prediction, and even treating sepsis. Up-front ethical decisions may need to be an integral part of AI modules in healthcare.

When providing care for critically ill patients, predictive AI may help guide who should be admitted to the last critical care bed. This is a close comparator to whether healthcare professionals should “pull the trolley lever” to admit the sick child with leukaemia or else the elderly adult with pneumonia. What should we do?

The first step in managing this problem is appreciating that it exists. Although the hype around AI suggests it is a panacea for improving healthcare, equal focus now needs to be placed on the inherent challenges to humanity as well as the challenges in computing. Social scientists need to be let back into the room, sharing a table with computer scientists, healthcare professionals, politicians and, importantly, patients. Perhaps a medical version of the “Moral Machine” may help gauge the public’s attitude to these ethical dilemmas. We should also consider if healthcare decisions should echo views of people from different geographical areas or simply act as a universal moral compass. Finally, perhaps we should give the owners of self-driving cars the autonomy to make difficult ethical choices themselves in advance as individuals. Some may choose to swerve, some may not. If so, AI in medicine could also be uniquely tuned by individuals to best suit their personal choices and values around health and disease. These decisions could be made in advance before mental capacity was lost as is done through systems of opt-in and opt-out to organ donation. This way, silicone derived artificial intelligence could adjust to the needs of complex organic life.

Matt Morgan, Honorary Senior Research Fellow at Cardiff University, Consultant in Intensive Care Medicine, Research & Development lead for Critical Care at University Hospital of Wales, and an editor of BMJ OnExamination. He is on twitter: @Matrix_Mania His first book Critical will be published in May 2019.

Paul Dark,Consultant in Critical Care Medicine, NIHR Clinical Research Network National Specialty Lead for Critical Care and Chair in Critical Care Medicine, University of Manchester. He is on twitter: @DarkNatter

Competing interests: none declared.

References:

1] Philippa Foot, The Problem of Abortion and the Doctrine of the Double Effect in Virtues and Vices Oxford: Basil Blackwell, 1978, originally appeared in the Oxford Review, Number 5, 1967.

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Is TED dead?—a return to good-old fashioned conversation

We two authors used to attend medical conferences that felt more like pathetic gladiator battles. Weapons included poison-tipped USB sticks, monotone delivery, and a complete lack of eye-contact. The audience’s ritualized beating often also included an entirely pointless ten-minute speaker biography, followed by a bludgeoning from 120 slides. The cruellest speakers went further still: “there’s too much information on this slide but let me try anyway;” “I know my time is up but I’ll just go overtime.” In brief, we were tired of the “sage on the stage.”

We paid good money to live (and die) through blurry images and the entire front page of their manuscript stating the blindingly obvious. We endured the speaker delivering the same tedious joke as last year—and it wasn’t funny the first time. For reasons we could never deduce this death-via-powerpoint often included a picture of the presenter’s children. A big question mark on the final slide then indicated that it was time for the chairperson to contrive a gratuitous question. He or she had to, after all the audience was now comatose. Sometimes, we would leave with a morsel of medical insight. More often we would depart with a sore arse, indecipherable notes, and a useless rucksack. That, and during the break there was never enough tea and biscuits!

However, empires crumble and time marches on. In the educational ring, this has meant the explosion of what naysayers call “infotainment” and what we choose to call “about bloody time”. Thanks to the hard graft of @ffolliet, SMACC and the other people’s champions, we believe that the medical conference has changed and will never be the same again. Admittedly, some of these newer events feel like rock concerts, and have ticket prices to match. Faculty may still be a little too pleased with themselves, and likely still trade invites to the next conference. However, increasingly the presentation is geared to the audience’s needs and not the presenter’s ego.

The goal is to disrupt and to inspire via an engaging story that “sticks.” Multimedia is widely applied and no useful emotion is spared. Some presenters have been known to loosen their ties and some to shed a tear. Regardless, we are big fans and occasional contributors. These talks are both celebrated or derided by calling them “TED-style.” This is after the organization that launched conferences around Technology Entertainment and Design in 1984. At the time these talks really were revolutionary, and were eagerly shared via that other wonder of the modern world—the internet.

Importantly, TED has subsequently worked hard to stay current and user-friendly. They understand that a speaker riding a unicycle while performing beat-poetry (we made that up) might be oodles of fun, but not necessarily fit-for-task. Moreover, for everything gained, something may be lost. Bite-sized inspiration is easy to digest, but doesn’t always offer nutritional balance. Before we overdo this dietary analogy, the point is that we still need nuance, detail, thought, and debate. Above all, we need a conversation.

TED releases long form interview podcasts from speakers where the backstory can be further dissected. These complement rather than compete with the flash-bang of the big stage performance. Long-form conversational podcasts include three hour offerings from celebrity-atheist Sam Harris, the polymath Joe Rogan and Canada’s most unapologetic man, Jordan Petersen. Of note, these are hugely popular, and assuming that most-downloaded equals most-influential. Regardless, the popularity of long-form argues that learners do not have the attention span of a goldfish. Moving back to our more comfortable dietary analogy: we all enjoy tapas, but we will also order an entire meal: it just needs to be tasty.

The value of a medical conferences will always be in its unscripted conversations and the discussion afterwards that matters most. It’s that lightbulb moment when we realize we need international coordination and collaborative research. Importantly, these disruptive discussions often occur away from the stage’s twinkling lights. Accordingly, the best conference makes time for breaks, encourages the hoisting of pints, and emphasizes that debate long outlive the event. Notably, the disruptive and marvellous EMCrit Conference no longer promotes speakers, but rather people to speak with. The organisers provide a platform, a relaxing setting, along with time and space to simply talk. Like us they seem eager to celebrate the long-lost art of conversation. After all, some things should never get old.

Matt Morgan is Honorary Senior Research Fellow at Cardiff University, Consultant in Intensive Care Medicine, R&D lead for Critical Care at University Hospital of Wales, and an editor of BMJ OnExamination. He is on twitter: @Matrix_Mania 

Peter Brindley, Professor of Critical Care Medicine, Medical Ethics, Anesthesiology at University of Alberta, Canada. He is on twitter @docpgb

Competing interests: None declared.

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Matt Morgan and Peter Brindley: Some Christmas words of wisdom for today’s medical students

In the seasonal spirit of giving, Matt Morgan and Peter Brindley share what they’ve learnt from their time in medicine

When these authors were medical students—several millennia ago—we faced the difficult challenge of finding a quote to accompany our graduation photos. On the one hand, we had received a marvelous state subsidised education. We had learnt from the best informed teachers and we were truly thankful and humbled and excited for more. But medical school had also been a multi-year arse kicking that included some moody supervisors, persnickety colleagues, and patients who didn’t make it. Accordingly, we were exhausted and bruised and scared.

One of these authors eventually landed on the first line of a Tale of Two Cities as his quote: “It was the best of times, it was the worst of times.” Given that he didn’t have a “Dickens” what to write, it seemed as good—or as bad—as any one liner. Twenty years on, that quote still causes a wince. It was trite, self-congratulatory, and pretentious. Fortunately, that same doctor had no “great expectations” of being anything else.

As these aging medics move from Christmas past to Christmas present, we still struggle to dispense wisdom to the latest recruits. This is a problem as our trainees are just as bewildered as us. Likely it is selective memory, but, as junior doctors, we recall being given a hard time left and right. The instructors are gentler now but the students are no less hard on themselves. Their hours are less sadistic but the world sure is. We were unsure what kind of  doctors we wanted to be but this rarely found purchase in our sleep deprived brains. We simply assumed that “when we grew up” people would tire of reprimanding us, and we would emerge somewhat clinically competent and moderately valued. Contrast this with today’s medical student: up to their necks in worry.

Instead of focusing on teaching young doctors life saving clinical pearls of wisdom, academic instruction seems to veer more and more into “how you can maximise your future.” Students feel pressured to regard university as little more than time to buff the CV and outflank the competition. In this solipsistic pursuit they are robbed of the opportunity to expand horizons, nourish neurons, meet soulmates, quaff pints, and cut parental cords. Both because it’s the holiday season, and because it truly sucks, we want to say “sorry.” We still have time, and so do you.

The talk that welcomed our classes to medical school focused less on “you are the chosen ones,” and more on “I hope you weren’t a mistake.” Just in case we weren’t “motivated” enough, we were introduced to classmates who had won Olympic medals, sung in major choirs, and run successful companies. However, as a coda, we later learnt that if we hadn’t been singled out that they still saw something in us: our job was to discover it and nourish it. We graduated bruised but ready to go.

We fell into intensive care—or maybe it chose us instead—because we wanted to think and to do. More latterly, we understand that above all we wanted to communicate. We (wrongly?) felt confident that regardless of our hours or the cash, we would never work more than our parents or earn less. We didn’t know that workaholism would likely increase our risk of premature death, and that our dark humour could reach a point of no return. Hopefully, today’s graduates will navigate this better.

We now know that we want our days to include not only “head and hands” but also “hearts.” For these two doctors, true happiness has become about “making connections” whether with patients, colleagues, or even academic ideas. It means that we stop to talk and listen far more than we used to. We just wish we had known and believed this years ago.

Back to Charlie Dickens for a sec. He also wrote that we should maintain “a heart that never hardens, a temper that never tires, and a touch that never hurts.” A much more useful quote for doctors, but equally likely to make eyes roll in this best and worst of times. Fortunately, it’s Christmas so we don’t have to worry how corny it sounds: “God bless us all, everyone.”

Matt Morgan, honorary senior research fellow at Cardiff University, consultant in intensive care medicine and head of research and development at University Hospital of Wales, and an editor of BMJ OnExamination. He is on Twitter: @Matrix_Mania

Peter Brindley, professor in the department of critical care medicine, Department of Anesthesiology and Pain Medicine, and the Dosseter Ethics Centre, University of Alberta, Edmonton, Canada. He is on Twitter @docpgb

Competing interests: None declared. 

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Matt Morgan: What can Bridget Jones can do for medicine?

As we enter Christmas party season, solving the mystery of an unconscious patient will be repeated across emergency departments around the country on countless occasions. The Holy Trinity of legal drug excess, illicit drug use, or organic disease will be explored through endless scans and blood tests.

When looking after critically ill patients, the most effective diagnostic aid is often stolen from right underneath our noses. The Greeks first encouraged taking a “medical history” 300 BC and as Jesus turns over two thousands years old, it is surprising how little has changed. The Hippocratic ancient text would not feel out of place in the paper notes found in my hospital today:

“One should pay attention to the first day the patient felt weak; one should inquire why and when it began. These are the key points to keep in mind. After these questions have been cautiously considered, one should ask the patient how his head feels, or if he has any pain or if he feels heavy.”

— Littre’s Translation of Hippocrates, 2, 436–40: Regimen in Acute Disease. Appendix #9 quoted by Siegel, RE. Clinical observation in Hippocrates: an essay on the evolution of the diagnostic art. J Mount Sinai Hosp 1964;31, 285–86.

What has changed is our insight that even a primary source of information can be mistaken. This can be true when asking patients about their symptom timeline as it can when asking a witness to describe the perpetrator of a crime. A wealth of research now suggests that even eyewitness identification can be unreliable, with the American Psychological Association issuing a warning to courts and juries to be cautious evaluating eyewitness testimony.

When even this primary source is incapacitated, we extend our investigation to family and friends who try their best to fill in the gaps. However, wouldn’t it be fantastic to have a contemporaneous record of events written by the very patient who is now unconscious? There are surprising benefits to regular journal keeping including reduced anxiety and even improved cardiovascular variables. The explosion of social media has silenced the paper-based Bridget Jones inside some of us, although 1 in 4 adults still keep a diary of their life. Peering inside the pages of a patent’s inner Adrian Mole while they have crushing chest pain is unlikely to instil confidence in the medical profession and the personal nature of journalising means it is unlikely to be acceptable to patients to share their diaries.

But would a palatable alternative be to look at the public outpourings found across the social media world? Open access “journals” including Twitter and Instagram may be an acceptable alternative, allowing health professionals to expand their envelopes of history taking, especially in cases where patients are unable to contribute themselves. A colleague recently told me how an unconscious patient’s diagnosis was only revealed after a family member showed them the patient’s Twitter timeline. Should we therefore adapt the “Social History” section of our medical clerking into “Social Media History”? Would this be acceptable to patients, the profession, and how would it affect the doctor-patient relationship?

Thanks to Dr Nick Stallard for inspiration.

Matt Morgan, Honorary Senior Research Fellow at Cardiff University, Consultant in Intensive Care Medicine and Head of Research and Development at University Hospital of Wales, and an editor of BMJ OnExamination. He is on twitter: @Matrix_Mania

Competing interests: None declared

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