Before the pandemic, in our occasional series How the Library Helps Me, Dr Rob Galloway, Emergency Medicine Consultant, was interviewed by former Clinical Librarian Tom Roper. This is a transcript of their conversation.
TR: You’re an Emergency Department consultant and a BSMS lecturer.
You lead human factors work, run a successful critical appraisal course, and you’ve co-authored the excellent Critical Appraisal from Papers to Patient: A Practical Guide.
You’re Medical Director of the Brighton Marathon, and you provide medical services for Brighton and Hove Albion. Are there particular areas of your work where having access to the Library and Knowledge Service particularly helps you?
RG: I’ll be totally honest, I have been trained how to look for evidence and do searches, but I’m pretty rubbish at it. The library helps us find that information when we need it, which is great. Take my human factors course. About five years ago there was very little evidence. And I remember coming to the library, getting help, getting some good books, some references and papers, I could get all the evidence to prepare for my teaching.
Then we’ve got the shop floor. There are many questions and, being a doctor, I’m a jack-of-all-trades, master of none (except telling drunks to go away in a polite fashion). I have very broad knowledge, but, unless it’s my area of expertise, not very deep knowledge. We’ll be teaching on the shop floor and there’ll be questions I can’t answer. Junior doctors will look at UpToDate, and it’s really, really useful.
Fifty years ago, the best doctors were the ones who could remember the evidence for how to do things, remember the twenty treatments for the fifteen conditions we could treat. Now it’s about accessing information. The best doctors are no longer the ones who can remember. Now we work in teams and the clinical librarians help us navigate the massive amounts of information out there. How to distil 10,000 papers a day into clinical practice. It’s translational medicine; the library helps us translate the evidence into clinical practice.
To me, there’s five pillars of medicine. Pillar one is compassion: if you’re not compassionate, you’re a poor doctor or nurse. Pillar two is resources. Pillar three, you need technical skills. If you’re an anaesthetist and you can’t intubate, that’s no good. Pillar four is human factors: it doesn’t matter that you know how to take out a gallbladder if your team are scared to speak up and say “I think you’ve clipped the artery”. And pillar five is translational medicine, translating the evidence into clinical practice and understanding critical appraisal.
Those five pillars are absolutely key. That’s what every medical student should get in their teaching. Another thing I say to our students when they leave med school is “50% of what we’ve taught you in the last five years is wrong; I just don’t know which 50%”.
There’s been stuff I’ve done which has harmed people, but I thought was the right thing. I used to get two litres of fluid for every trauma patient. I’ve now seen the evidence and realised I’ve harmed people, because it showed we need blood products, not IV fluids. But that was the guidance then. I remember reading my first paper on hypotensive resuscitation as a registrar ten years ago, and people weren’t doing it. So we need to be at the forefront of reading the evidence and understanding it. Having a library team to help you deliver translational medicine and understand critical appraisal is absolutely key to clinical care.
TR: That’s interesting and given that we have evidence summary tools like UpToDate, why are we teaching people critical appraisal? It’s in the exams, yes, but do we need to be able to assess the evidence ourselves?
RG: Yes, there are many good tools available. But as doctors and nurses and patients we need to own the evidence, we need to understand it. The NHS is a very socialised system where we care about patients. We don’t care about how much they can pay and that’s why I love the NHS. But there’s a lot of people out to make money. Drug companies do not care about the patients in many ways. They function to make a profit. And they do some great stuff, but we need to understand what their evidence says. They might say there’s a 33% reduction in mortality if you take drug X, but if the condition is so rare the number needed to treat is 2,500 then you’re going to give loads of side effects for something that isn’t going to kill many people anyway. Teaching medical students the number needed to treat is absolutely vital.
The other thing we need is to understand how you make a diagnosis. The evidence from diagnostic papers. The problem about critical appraisal teaching is it’s not made relevant to patient care. People learn about diagnostic papers, they learn about sensitivity, specificity, likelihood ratios. They don’t understand what it means. They learn some a/a+b… Who cares? We need to put it into real numbers. You’re a GP. A patient says he’s had intercourse with a sex worker and the condom split. You assess him and think he’s got 1% chance of having HIV. The sensitivity of the test is 99.99%, absolutely brilliant; the specificity is 95%. And it comes back positive. What do you tell the patient is the revised risk? The answer is 16.7%. But we teach it in the wrong way. It’s about pre-test probability. One out of 100 patients will have contracted HIV and the test is highly sensitive, so that person tests positive. But out of 100 people, five will be false positives. So, six positive results in total, one of which is true. Therefore the chance of having HIV is 1 in 6. That’s what critical appraisal doesn’t teach properly.
The way I think about the library is not for research, but for clinical care. Think about critical appraisal as what you do for your patients, not how you get publications. Most people think about the library as somewhere to get CPD tick points but it should be about: “I’ve got Doris at three in the morning. Should I be giving high flow oxygen, or 28%?”
TR: To move on, what about what I might call the extracurricular stuff, the football, the marathon because you have active research interests around marathon medicine? Is there a place for the library and the librarian there?
RG: Absolutely. There’s a great quote, and I don’t know who said it, but you can save 2,000 hours of research time with an hour in the library. Before you do new research you need to assess what the evidence already says. If you’ve got ten good papers and a systematic review that tell us it works don’t waste your time. When you find out there is no answer, that’s when you need to do the research.
We’ve got the marathon research team, looking at three strands: one is from the military, who use our marathon as a research centre looking at heatstroke. What they want is to be able to do blood tests after initial training to see if soldiers are prone to heatstroke. Because if you can detect a soldier who’s going to get heatstroke, you save their life by not putting them through the training, and from a cost point of view, you can save £2 million.
We’ve then got Richard Venn’s team looking at early renal damage markers. Is there any way of predicting damage before it’s happened? Marathon running is a very good analogy to being sick. You put your body through a lot of stress quite quickly. If we can see a blood test which rises quickly in those who’ve collapsed from running could we do that blood test on arrival and say, actually, although their renal function doesn’t look awful, they are going to develop bad renal function in a couple of days’ time. Let’s treat them early.
And then we’ve been looking at troponin. Chest pain in running is difficult – troponin rises for numerous reasons, exercise and inflammation, sepsis, and people worry is it cardiac or not? And the question can be answered by looking at specific troponin rises in marathon running. We’ve done a load of work looking at different cut-off markers for troponin in marathon running. So if somebody has chest pain, what’s significant or not?
Those are the three broad aims of our research at the moment. For anyone who’s interested, we’re always looking for people to get involved. We’re always looking for students. If anyone’s interested in social science, we also looked at public health benefits of marathon running. We’ve looked at what people take before the Brighton marathon to help them run. We know about 5% of runners take cocaine in the 24 hours before the marathon. Yes, it is the Brighton marathon. We’ve done a lot of work with NSAIDS and the number of runners who take NSAIDS before a marathon, which is incredibly dangerous. The correlation between NSAIDS and collapsing is quite strong.
TR: There’s some people in my running club who take NSAIDs before races.
RG: Will you tell them to read my medical advice to runners please? I blame Boris Johnson for a lot of things, but when he did the London Marathon, he went on TV and advised everyone to pop a few ibuprofen beforehand. After that, heatstroke injuries rocketed.
If you’re running more than 5 or 10k, the risks are massive.
TR: It’s made me think, because I provide evidence updates for you, I might tweak the search strategy slightly. At the moment it focuses entirely on marathon runners and might not pick up some of the military experience.
RG: Those emailed evidence updates are very useful, because I don’t have time to read the evidence, or to search for the papers. I spend maybe a minute looking at the updates, and I can say, actually, “that’s useful”, “that’s not useful”, “I’ve read that paper”.
TR: My final question is quite a broad one. You’ve already talked about the changes you’ve seen in medicine since you were a registrar. I came into this game in 1978. And libraries have been transformed so massively in that time. I wonder if you got out the crystal ball, what do you think libraries are going to be like, in 20-30 years’ time?
RG: I think they’ll be embedded into clinical electronic systems. I think if I’m seeing a patient’s electronic record, I’ll say: ?DVT, I’ll input my pre-test probability, the result of the ultrasound or d-dimer, and I’ll get the post-test probability. And the libraries will help us get those evidence for that.
As consultants and senior doctors we also need to know when to deviate from the protocols. A really good example, I got this wonderful thank you letter from a woman who was 24 weeks pregnant. And I deviated from the protocol. She had a massive pulmonary embolism and she needed thrombolysing. The protocol says pregnancy is a contraindication for thrombolysis. But she was dying in front of me. And I said, look, this is off-licence, it’s against protocol, but death is a contraindication to having a healthy child, and so we thrombolysed her. And she survived. And the baby’s due in August. That’s what a consultant does. That’s why I’m proud to be a doctor.
Medicine is 99% perspiration, 1% inspiration, and the library is there to help you with that 99%. Our training is there for the 1%. But the 99% the library can help us with. We shouldn’t think of it as an academic thing, the library, it should be a clinical tool.
TR: And is there one thing we could do right now that would make your life and your team’s lives easier?
RG: Yes, make it easier to access stuff. There are so many great resources, like BMJ Best Practice, UpToDate but I just find I can’t remember my passwords. There are so many blocks to finding stuff. I end up sometimes not using the resources, just because it’s hard to access. It’s frustrating because there’s loads and loads and loads of things, all blocked by passwords. I can pay with my phone by having it look at my face. Why can’t I do that for libraries?
It’s not that you don’t provide the services, you provide brilliant service, it’s just, you’ve got to remember that someone like me, I’m struggling to cope with life in terms of the amount of work. It’s never been harder on the shop floor.
I am utterly exhausted as a doctor. I’ve got so many responsibilities. The population is getting older and older. We need the library to have a role, massively. The library is that fifth pillar of evidence-based medicine, and knowing which 50% of what we teach our students is wrong.
TR: Thanks very much for your time and thoughts, Rob.