The next thing is that they suck and I'm delighted to do so then.
Probably doesn't make any sense at all. I'd have to call the director for the Centre and the Space Medicine and he's going to talk tonight.
Ten components of effective calculus aetiology. So thankfully.
Thanks. Hi, everybody. I put this slide out just because what I do now is to make your life easier.
If you go to the CBN site, you go to the top blog. Now you can pick this up.
It's got the PDF of the talk and then I also have the podcast of the talk when we process it.
So it's a way and it's just got a summary there. So you can get all of the components of this talk available there.
Okay. So I've changed it to ten components because it's still not finished talking.
Let's start with it. And now it's components and I'll probably change again in some way.
But it's a talk about clinical epidemiology, which some of you on the intro to research methods about.
One of the hardest components is about how do you get started?
And I'm going to go through ten components. Feel free to interrupt.
Say what? You think I'm okay with disagreement, but remember, you're being recorded.
Well, I'm being recorded. Okay. So, number one, you've got to start with a problem, Avenue.
You've got to start somewhere.
So I'm taking you on a journey back to 2004 on a little bit of information about a project that we've now been working on for ten years.
And it's around chronic diseases. And this is a slide I looked through about ten or 12 years ago about a problem that interested me.
And this is the rise in noncommunicable diseases, if you like, chronic disease.
If you go from 1972, look at the proportion of people reporting a chronic disease from 21% right up to 35%.
And only that when you look at that, you see that actually people of all ages, across all ages, it's not just the elderly.
You can go down here and pick out children nought for four years old and look at the line.
And as you go up, in fact, it's pretty much across the board.
We've had an increase in chronic diseases. And then I saw this slide and this is a supply that comes from the Department of Health.
And when you think of chronic diseases, you think of the management and each corp represents a day in the management of somebody's chronic disease.
The little white ones represent the clock with some interaction with the health
service may occur and the red one represents the interaction with the doctor.
And when you think of it that way, you start thinking, well, that's ridiculous, isn't it?
Actually, that is a component where you think,
how can anybody have an impact in that smaller time on all of that time period when somebody has a chronic disease?
And that's the problem that started to make me think, oh, what's the issue here?
So the first but you've got to focus on when you're all starting it,
you have to start on a problem that really interests you and shakes you up in a way.
And this is a fundamental issue because most ineffective people in applied health research in clinical epidemiology start out in a problem,
but they don't quite believe it and don't quite understand why they're doing it. And about two years into the project,
the drift off and then start to do something else and go to a new project because at some point in the middle of this project,
it will get hard work, there may be no funding, and I'll show you examples of that.
People might tell you what you're doing is reject your work and you'll feel completely dejected and miserable and then you have to revisit,
well, I thought this was a good idea at the beginning, and it's still a good idea ten years later and it's still important.
So the number one is you have to think about the problem more than you think, and it has to be important and relevant at the outset.
So going back to 2004.
I started or we started with a very simple little grant from the Scientific Foundation Board of the Royal College of General Practitioner,
about £70,000.
And at that point, we decided to do what is the impact of self-monitoring in chronic disease management, a systematic overview of the field.
And so that's my point to in fact, systematic overviews of the field, whatever you're doing.
You have to be in the place where you understand what's going on and what's happened already.
And if you don't do that, then at some point you're going to come into a project about halfway through and you think,
Oh, somebody had already done that, or We already knew that.
In effect, any project starts with what we know and what we don't know.
And so if you don't have some overview of the field in some systematic way, it's not a systematic review.
It's an overview in some systematic way. How are you going to know what's been going on?
So in doing that, we developed this is going back just ten or 11 years.
This is an extraction sheet that I still got in Excel, which details all of the studies and details, all of the components, what them components were.
This is an extraction sheet that tries to pull out which studies had the components.
And then over here it picks out green and red. What's positive, what's not?
And this is me going systematically through every study, extracting the components through Q&A,
extracting the components, trying to say what actually is happening in this field and trying to get an understanding.
And in doing that, one of the things we noticed, we found you find gaps in the research and in the literature,
you find studies and you think, well, we were randomised trials here, nobody's doing a systematic review.
So having some way of systematic overview is an important step.
And I put that number to and if you don't consider that this is a Dphil student and got a dphil last year called Martha McCall Bowen,
who did use complex intervention theory from the MRC to develop a yoga intervention in cancer patient.
And she published a systematic overview, an overview of systematic reviews.
And in doing that I emailed a recently This is what you can look at on Google Scholar and you can see it's been cited about 25 times already.
If you had a heat index of 25 that you've got 25 publications with 25 citations, you'd be on your way to be an associate professor.
You know, most university to be a professor. So by having a systematic overview, people think it's really relevant.
And so we do this all the time. Here's one. Another student of mine who's working with Nick Popovich has just published the protocol
for an overview of systematic reviews of interventions to reduce hospital admissions.
Because when I ask anybody, they say, we're going to reduce hospital admissions.
I'll go, okay, what are you going to do? What's your top four interventions?
Then they go blank on me and I, and if you asked me that question, I don't know the answer to that.
That's why we do in this piece of work. So number two is an overview of the field.
Now, remember, you went back to you and some of your on your intro to research study.
If you're in the IBM world, you get drilled into you about the PICO.
And in doing the PICO, defining the question, this is the fundamental hardest bit of any research project.
This is the intellectual property that defines you as an academic or as an effective clinical epidemiology researcher.
It is not straightforward to define a good research question, it might seem that,
but actually the people who make you feel really anxious are the ones who are always going to you just go over that question a bit more.
You don't quite understand it. Why is it important? So you've got to learn the skills of defining the question.
So here you go,
full grown question that we have that systematic overview in patients on oral anticoagulation do self-test testing compared to usual care,
we do thrombosis. That's the speaker.
Now there are seven types of questions that really apply and they all can fit the PCO if you like, by taking bits in and out of the Pico.
How common is the problem is the prevalence actually. But the really important question is early detection worthwhile enough?
The screening is the diagnostic test accurate diagnostic, and then you move into what will happen if we do nothing.
Believe it or not, we've had some really impact questions from saying what will happen if we do nothing.
Most of the world of clinicians know very little if oh, you've got a sprained ankle and if I go,
well, how long will you have to wait until that actually gets better?
Most people will have some figure between about two and two months that fair enough to note in your head that.
Does that matter? Well, it does matter. Why does it matter?
Because if you say two weeks and somebody is not better, they're going to represent an explanation going, I'm not better.
Then what do we do? We start to intervene and we try and give them treatments.
I have no evidence. So actually we've had lots of interest about doing studies, just about prognosis.
What's the prognosis of acute cough? What's the prognosis of influenza?
What's the prognosis? So for instance, great questions.
And then you get into the interventions to the intervention help. What is the common harm for the intervention?
What are the rare harms? But one of the key bits about your question is how do you make it relevant and important?
And this is helpful. This is called define a criteria.
And I like the final criteria because you just think about the question, is it feasible?
So anybody can have a great question. But if you need £100 million to answer it,
you're on the wrong programme and you're going to have to weigh about 20 years
till we really know what you're doing and then somebody will invest in you. So it has to be feasible.
Happy with that then? Second, it has to be interesting.
It has to be interesting to you, to the population you're interested in, to policy, to practice.
It can be a wealth of people, but it has to be interesting in some way.
It has to be novel. Going back to the overview, if it's been done before, you can answer the same question in some way,
but you have to find some different way of looking at that question.
Ethical. You have to think of that in the issue. But then also, is it relevant and being relevant to policy, to health care is how you develop impact.
So the question I always get with students here with me, if we sat down again in five years time, what would be different?
And if you can't define something's going to be different about the question you're going to ask, then why bother?
Go back to the drawing board because that means it's not feasible.
It means it's likely to not be interesting and it's not going to be relevant.
So the final criteria is quite a nice way of thinking about the question you're looking at and thinking, How do I get around and think about this?
Okay. Number four, then moving on from the overview said, I've got a question.
All research should start and end with a systematic review, which is a bit old really, isn't it?
If you're ending where you started, it's a circular.
But actually if you're going to make a difference at some point,
it's going to get into policy where somebody is going to want to say, we're going to look for the systematic reviews.
Now, when we started with the systematic review and through the Cochrane Library in 2006, which we found a protocol, let's go back to this.
When we were doing our search,
we noticed on the Cochrane Library there was a protocol there that had been sat there for four years and nobody doing anything about it.
And there were about seven or eight trials, randomised trials of self monitoring and from both.
So I wrote to the office and said, are you going to do this because we think we could do it?
And they thought of theft around a bit and said, Well, we've been trying for many years, we'd like some help.
So I said, Well, alright, we'll help you.
And it turns out that chap who I contacted is now a dphil student of mine on the part time Dphil programme with Rafael PEREIRA as well,
and is doing that dphil about optimal information science.
But he still works on this with us and it's been a great collaboration and I'll come back to collaboration,
but if you go to any of the big major funders, any of the major funders like the Natural, the MRC, we'll always have this statement.
We will only fund primary research where the proposed research is informed by review of the existing evidence.
That's the same for the MRC. If you publish a randomised trial in The Lancet, they will say to you,
could you integrate this with the findings of the systematic review that exists?
And we want you to talk about the findings in terms of the review.
So wherever you go, you have to have the skills or know about the systematic review that have been done.
And so this is what we published in 2006. We published the first ever self-monitoring of oral anticoagulation,
a systematic review and meta analysis in The Lancet, one of the top journals in the world.
So obviously we got some bits of it right in terms of impact, and this is what we found.
This is a systematic review of thrombotic events showing a 55% reduction in the endpoint from about 14 trials.
In addition to that, what was also important, why they really liked it.
We had this significant effect in death at the time, although it was a small number of events, it was just very significant.
So by self-monitoring, you could halve the rates of thrombotic events and you could reduce your rates of death by about 59%.
That's impact. That's important. That's ten, nine years ago now.
Well, ten years ago, 2016. And I'll come back to this.
Okay. Now, in doing this and I've left this here, you can take a copy of this exists on the on the website as well.
And I'll be doing this tomorrow with another group of students. But you can do this on yourself.
It's important to know to know about you still gets, isn't it?
How can you start on embarking on a journey if you don't recognise what skills you require at the outset?
And one of the things I talk about in skills, I get people to write themselves and you can write themselves here for a systematic review.
For instance, in a systematic review, I'll start with protocol, development, literature,
search, development of inclusion criteria, data, abstraction, grade analysis.
Redmon uses data for optional analysis. You go on and on, but there are about 15 or 20 core skills for every study methods and all in their quality.
So you can take a copy of that then. But no, but what I want you to think about is when are you doing a skill?
You've either got a one. When somebody said something in the room like Stator, you go, Oh my God, I've got no idea.
If you rate yourself with a one and you're doing a project, you're in trouble.
But what you can't do is rate yourself with a five and everyone can teach the skill, but that would be unfeasible and it can't teach everything.
So when you do in a project, what do you think we do?
I try and accumulate a team of people who have skills for free four or five, where they can undertake the skill but require considerable help.
That's okay. And I met somebody today who came to me for systematic review called I'm a five.
I can teach about systematic reviews and no more or less most of what's going on.
And they come with a three and go. But I need some help.
So if you want to be involved in clinical epidemiology, you really have to think about your skills and some of the skills you have to take to five.
Because when you're teaching and able to teach these skills and people will come to you to collaborate
based on your skill level and you end up involved in all sorts of publications and impact projects,
and you can make a decision about the important ones. Okay, this is important.
So when I think about that, last night when I was doing this talk, I pulled out this book just one generic skill with generic skills in there.
And let's just talk about one skill. So I'm going to come to you guys now.
I want you to think about one of the most important skills in the generic
skills is being able to communicate your research findings to write about them.
There's no usually you're doing a great project and then putting it down in paper and somebody looks at me,
looks at it and puts a big red pen through it going, This is terrible.
All right. So I pulled out. This is one of my books, Stephen King on writing.
Great book. Anybody on it? Okay. How many how many people in the room would rate yourself with being able to teach on writing five?
Let me go back. Alright. How many would you rate yourself with?
Require an input only on the most difficult task.
Four Oak could undertake the scale but require considerable help.
Okay says about half of you heard of the scale and would be able to undertake the basics of writing.
I never heard of writing. You're. Right.
Okay. That's good. You're not. You're pretty about right.
Actually, most people now ask yourself this question, right?
How many books do you own on the scale of writing?
Right. I want you to put your hands up. What?
Zero. Okay. It's about.
Yeah, about 20%. One book. Okay, two books.
Keep your hands up if you've got two. Three. That's it.
So we've got about 25% of, you know, one of them, the mode of view and the median is one and the outliers are two.
Okay. This is not the books in my room.
This is just in my office, downstairs in our basement, where I sit, work, and while away.
They've got Stephen King on writing fantastic book. I really do like it.
The New Oxford Guide to Writing by Thomas Cain. Very good book.
Lot flowing from it from Not How to Write for You. If I had that one, I did my dphil thesis borrowing the money.
Queen's Grammar. Very good. I like that one. Writing of good English really liked this book.
Elements of Eloquence How to Turn the Perfect English Praise. It's really interesting.
Talks about things like alliteration, all sorts of things that great writers use and crap writers never use.
And all the people with known in one book never use and probably to every day.
Grammar by Oxford. Very good for just revisiting the thought basic Colin's improve your writing skills.
Successful fine writing by Matthew the Matthew That's a great book really like that book what's a good structure in that?
And finally the book that tell everybody that you must have a copy of is strong and want the elements and style.
And that's what my list looks like. And I think I could probably teach writing the five when I was in your position,
I would have been too, because I recognise it's a really important skill.
I write about 100 articles a year. About 40 of them are papers with people, about 40 blogs a year.
I just write news articles, all sorts of articles, but it's such a skill and that's a great example of where you can highlight to people and go well
over your bloody brilliant or you're missing out on some opportunity where you've got to think of,
I've really got to upskill myself, okay, knowledge, skills, gap, really important.
Okay. Fix okay. When we did the project, when did you one project it's really interesting to me.
Some people do a project and then they flip to something else completely over there.
They don't think about, Well, I've just done this question, I've just done this systematic review.
What are the further questions that relate to my project?
And in doing that, if you sit around as a group of people,
you can really start to have a dynamic interaction with people where you can go, Hey, hold on a minute.
This is really interesting. What research questions. So just from our systematic review, we had four important questions.
Which subgroups benefit from self-monitoring? Can you replicate trial results in practice?
How useful is timing range of the predictor of adverse events? One of the methodological issues within measuring warfarin and anticoagulation,
and therefore can we predict successful self-monitoring of anticoagulation at the outset?
And we decided to do something about that. So we did this piece.
This is a subgroup benefit from self monitoring and two reports were made from Oxford, UK providing data on a meta analysis of published data.
We presented out published data and then we called trials to collaborate in an individual patient data analysis.
So we moved the field on and that allowed us to answer more questions within the piece of work.
We looked for methodological issues and his good example, I did this with a colleague who was in Oxford at the time, Paul Glazier.
This is going back to 208. What is missing from description of treatment in trials and review?
It became obvious to us over a period of time that when you read a published article,
even if it showed something positive that actually you read the journal publication,
you couldn't actually do it, particularly if it was a non-drug or same for drug intervention.
You look at and go, I want to do this tomorrow in practice, can't do it.
So we took a bunch of trials over a year and systematic reviews and looked at them and said, How often can you replicate this in practice?
And actually it was pretty miserable is about one in ten, about 10% of the time.
Interestingly, even the systematic review that I did that had been included in the cohort couldn't be replicated in practice.
And this item, this paper has led and is now in the consort statement.
Statement, if you go to consort there will be one of the statements, can't remember the number.
It might be about seven or eight about the intervention is directly from this paper.
Can you replicate either a sufficient information in the reported paper to be able to replicate?
The intervention is another one we're doing right now.
I just put this one up. This is a bit from methods. This is about methods.
This is Ben Goldacre is leading this. It's called the Compare Project.
What happened is just three or four months ago, we had some medical student turn up and say it quite like to do something with you.
And I said, Well, is it more than one of you? And he said, Yeah, there is actually.
I said if you can mobilise about five people will do some are interested and Ben Goldacre
we met and what he's doing is a consecutive trial published in the top five journals.
You take the publication and compare it to the Trial Edge Injury Registry or the protocol probably be published before the trial starts.
And notice the changes and when the changes are discrepant between the paper and the trial.
If we wrote a letter to the Journal and you've got to do that within two weeks, we won't get published.
So this has been a right pain in the backside. And you can see we've tracked 66 trials today.
None of them were perfect. 355 pre-specified outcomes were not reported, and 336 new outcomes have been added to the papers.
Quite interesting as an find and you think about this will be big news when we write this up and think about it.
It's just because it's an important issue. It's an important question.
Again, it's a pain in the backyard because it's a lot of work. Why we're involved in it is because we think it's an important question.
And it point one right at the outset we went for that.
Do come in right at the outset we thought this is a priority that people have been writing on Twitter who's funding this?
And we've got well, actually, nobody's funding these five medical students, three doctors, and nobody gives a penny to it.
And there's no funding whatsoever for anybody's time. And it's just something we think is important.
So methods are important. There's another one. So here's an interesting looking at this.
Another of the questions we looked at how useful is timing range of the predictor of adverse events?
When you take warfarin, you have a measure called iron ore that measures a therapeutic window of you being in the right window,
which is an iron hour for atrial fibrillation of, say, 2 to 3.
So you can have a percentage time over a year in range.
That can be 50%, 60%, 70%, 80%.
Nobody had ever said to me, Well, why do we bother? Because we've got a therapeutic range of 70%.
And we're like, So what? So there's always a third factor, like I said at the beginning, where you start your research.
So looking at simple questions like this and again, this has been we're right over there.
This was a Chinese student who was with at the time he won.
And it's been cited about 240 times, which we're now getting into the big world for a very simple question,
because I couldn't understand why we measure it if there's no relationship to an outcome.
We showed that for about every 10% change in the time in therapeutic range, that equates to about one stroke.
If you go from 60 to 70%, you can get rid of about one stroke per patient.
Most organisations in the UK have a suboptimal, tiny therapeutic range and at some point we're going to do something about it.
Okay, so we've got seven now and I'm going to come back and recap and then we can have
a bit of a chat about the number we look for effects in real world populations.
Okay. And what's happening in DC is across the board is we started here and the number of pieces of work this is a program grant that went in,
got funded, more paper has being published here and there. The amount of work is growing and over time that's what you really want to do.
If you get this right here, this should mushroom out your net.
If you get it wrong, it just go right. So again, we're going to come back to beginning.
This is the most important hardest bit getting this right now.
Most people spend so little time on this, but it's amazing.
They tend to do this bit where they feel there's a there's a research grant.
Next week, I'm going to do something and I'm like, well, I've been thinking about some of these questions for eight years now,
seven or eight years, and we're still not sure what to do.
I've got some great research questions, but in the final criteria they're just not feasible.
I'm looking for a feasible way to do it. Going back to the compare study wasn't feasible until we could find five or six people.
Now, I can't fund we can't fund the. Five or six people because suddenly that makes it a £300,000 project coming back.
And what we did is a study called The Chasm Study, a cohort of antiquities going from origin.
And I'm about to show out the back there is Alex Thompson, who published these papers.
We started these in 2009, I remember started at the beginning and said, there's going to come a point where you feel like giving up.
We put this into the NIH, our patient benefit scheme, and the review has come back and said, I can't see the point of this study whatsoever.
And I was outraged at that point, which is not unusual for me.
I want to get angry, email myself back with the email I would have sent and then review it when it calmed down.
But I do not because I still think it's important we do not go away.
So we could have had the whole project thrown away because so many nature
reviewers have no understanding about the importance of health care projects.
And that's okay. You just have to accept some people out there don't know what they're doing and are in important positions.
That's the way it is. But what we did and if get that funded in 2009 and here's the paper there and the lead author is in the room at the back,
Alex Thompson And this is the cohort study of anticoagulation self-monitoring estimate,
the current levels of control of adverse events in patient and explore the factors that predict success.
This is because you've got people in randomised trials who may be different to the real world and that's always an interesting question to me.
Will we get the same effects outside of the trial setting?
Well, this is an interesting topic because the meet is not available on the NHS, but the test strips are.
So there's no real way you can study health care where people can just make it
at the beginning and then decide whether they want to come to the NHS or not.
And that seems a slightly absurd situation that we've developed.
But there are no other areas normally same blood glucose, you can buy the machines, all the prescribed.
There are about five or £6 where here the food and your pound.
So we also thought there would be an issue of inequity that would occur.
We did a speculative cohort study in the U.K. and we included adults over 18 and they had to be registered with the GP.
And as I say, the main outcomes were still self-monitoring. Could actually what proportion could achieve self monitoring,
had not experienced adverse events and had achieved great in 82% of the time in therapeutic range, which is better than the trials in effect.
So we were now outside of it, we want a better outcome than child and here's what the results were.
But we follow 300 patients for a year. They you can see there's a problem immediately.
That's what health care looks like if you make people pay for it. So we've got another question that could be important.
A lot of people were still self-monitoring, 90%, which is pretty good figure.
Means with 75%. So pretty good. Only a small number of minor adverse events.
But again, this is really interesting. Only half the patients received any in-person patient training at the outset.
So half the people just going by themselves. The machines start testing for INR, which is a really important test.
The consequences are dire from both this or a major bleed, and they'll do it without the GP or the doctors involved about half the time.
And what the findings show that even with little training,
people on oral anticoagulation therapy can successfully self monitor and even self manage their own home.
So that's the cohort of anticoagulation, the real world population, and we presented the results a few weeks and they're having an impact.
Point nine, I put this down nine if my nine if I think this is difficult when you don't realise the importance of this but I just typed in this is
I just put into these are all the papers we've done in our anticoagulation and this is for Port Hanigan and Alex and Ward in in Ward,
the director of graduate studies in our department. And we've worked together at the scene since 2006.
We've worked on all these papers in Applied Research and Clinical Epidemiology.
It's very difficult to do anything on your own. It's not like being in a lab or a bench work, even if you're doing a systematic review,
if you're going to publish that systematic review, at some point, you're going to need a second person to check your data.
And people think, I've got people in my back pocket that we can just produce any moment.
It's a collaboration. If I help somebody out over here, you're going to help me out.
If a student you've only coached students helps you out, you help you back,
you increase your publication output while you're helping each other out and you learn skills.
And if you really want to get ahead, then you make your friend a statistician.
And this is Rafael PEREIRA. You are published over 53 papers on PubMed with we published 53 papers in the last ten years together because as a
statistician in an applied to bits he's got from four and five skills that I've not got and I'm okay with that.
I could spend a year with the stats team and become a four or five in these skills, but I choose not to.
But that's okay. But in doing that,
we have lots of great conversations where I'm thinking about the issues all the time and we're discussing them very often in the pub,
but we discuss them because we're really interested in some of the issues.
And in doing that, you have an ally or a colleague who you want to work with, who you feel comfortable with,
particularly is not going to run off and nick your ideas or we don't care about who the first or last author.
We care about the importance of the project all the time.
If there's an interest in all the other stuff, take care of itself.
Apart from a small proportion of time, when you work with people who are run a nightmare and I can't help you with that,
you just have to experience that and think I'm never going to go there again. But I think this this this is an important in the top ten.
This is crucial. Because if you're in a position as well that you've got some good ideas or questions, you have to have somebody.
You're going to bounce them off, don't you? I told you, it takes it the hardest, but is a question where do you go to?
Who do you talk to? I just want to talk to you about this latest piece of research.
What do you think? And if they don't get it boring, why bother?
You've got to go back to the drawing board and thinking. I am my final.
He's got to get organised. Yeah. And I think I put this in.
I like this one, too. McCain. This is McCain. You can use whatever strategy when there are no right or wrong strategies to get in organised it.
But it takes two things interpersonal skills and a Ford Focus and you can think about whatever you want,
but in being organised you have to be able to get on with people. You have to talk to people.
And I know you're not wanting to walk. You do know what that is, but you have to be able to talk.
My job in a team is to be able to work with people, assist. We have to motivate each other.
We have to keep going when it's tough, when it's falling apart. But we do this focus frame, organise,
collect on the stand and sympathise with one way of thinking about there are no tips that work for everybody in getting organised.
So what does it look like ten years into it? What does impact look like?
And this is an Archer Signal published on all 21st of August 2015 that the NHS noise technology assessment has
finally said at ten years this is a cost effective intervention at around about £7,000 willingness to pay.
New oral anticoagulants come in and around about £25,000 for willingness to pay,
and the estimated number of blood clots would be 2.4% lower at ten years using self-monitoring compared with standard care.
25 people per thousand. That's not insubstantial.
But actually we have a lot of interest in the whole idea of self-monitoring and self-care because the current model of the care unsustainable.
No, we can't afford a general practice, so the world can't afford a general practice system where you decide to say every time you need a measurement,
you're going to come in and talk to us. It's actually this completely wrong way to structure a health care,
but we're sort of bound into it now and we've got to undo ourselves so we know what future we have about
10,000 people who use anticoagulation and only a handful of youth self-monitoring with self-care.
This could be pretty cost effective way of getting driving people out.
Carbon footprints pretty good. All sorts of downstream interventions and issues.
So I wrote expert commentary, so that's what it looks like.
I talked about the other research we've done and said, What did I say?
This technology assessment adds to substantial evidence base that supports self-monitoring and self-management oral anticoagulation.
I could have said we knew this ten years ago. However.
If you're going to show something beneficial, you have to keep going down.
I said that right at the outset. There come points where you're going to drop off to show benefit and change.
Practice takes at least five years. This takes it took ten years.
And we still know that it's a bit harder or easier if it's something harmful.
And. Yes, and it's led to this as well. Now we have a collaboration centre with the work show.
They want us to help them understand and interpret how we can have a model of self care for chronic these in low
resource setting because there's no doubt 60% of the global morbidity and mortality is caused by four diseases cancer,
respiratory disease, cardiovascular disease and diabetes.
You put them forward together, you've got a huge amount of catastrophe.
Yet everybody in this room has read about Ebola, knows how disastrous that is for you, because actually it's minuscule compared to and feeds.
But how do you deliver something as simple as hypertension care in somewhere like Tibet or Gaza or an African country where there's no infrastructure?
Infection's a lot easier to do. But you talking about treating people for ten, 20 years.
But the benefits are potentially huge. So this is really interesting in its own right.
Okay. Recap. All right. And then we'll take some questions.
Well, the problem that interest you undertake some systematic overview of the field.
Define the question. Remember I talked to you about the final criteria feasible, interesting novel, ethical, relevant.
Start and end with a systematic review. If it's been done, that's okay.
But if you're doing a project and you have a common book somewhere and we left where that systematic review identified the gaps in your skills,
you can take this on the website as well, but think about the skills.
What are you good at? What do you want to be really good at? To the point you might want to teach it.
Develop in anything you do. Think about all the time. What are the further research questions here in this research?
Look for some methodological issues and look for effects in real world populations.
Yeah. And finally, the bit that's really important that you might want of it, you've got to develop collaborations probably in about ten years.
I'll probably say it takes at least three people, but at the moment it's two. Yeah, you can do it with two.
Yeah. And then my final bit, and this is the most important bit which are to everybody.
You have to get organised. And every year I say to myself,
I work with a lot of smart people and I think I'm going to have to get a bit
more organised to keep ahead of the game because we're all getting smarter.
They know the technology better than me. They have new ways of doing things.
They can build a website in 5 minutes. They can do all this data scraping.
And I have to think, gosh, I'm going to get better at this. I'm going to get more organised.
And we have to think about how we do that as a strategy. Each of us are different in how we do that.
There's no one way that works. You just have to think about it.
And on that basis, thank you very much. Thank.
Thank you very much indeed. You make it sound very simple, persuasive.
But the truth is what you're saying is blindingly obvious, that there is nothing disparagingly to.
Of course, I'm asking is why is it why is it so difficult to have such an obvious, simple impact from from straightforward thing to talk about it?
Why do you think people when you said that you keep it and everybody thought it left a little bit in a nervous life, don't they?
It's really interesting. I go into lots of organisations now and I sit there and I'm there.
I'm going, God, I don't really understand what's going on here.
Everybody in the room is talking and it's very complex and I'm just like, Oh my God, and I now realise what's really happening.
I used to think at one point everybody in the room is far more knowledgeable. Me. What I've realised now is we're all primed to not admit.
We have no idea what's going on.
And actually in the room everybody is basically making it so complicated that actually they're hoping they won't be found out.
But the great thing for me now is I can sit in a massive organisation like the FDA now I still BHO sit there and go,
can we just start at the beginning? I don't quite understand the question.
I don't understand the outcomes here. We're interested and when we've got that then we can move on.
I don't understand. And people will try and derail projects because they'll come in with something they've read and they'll go, Well,
I was looking at this and I'm doing a project to see at the moment where we're evaluating a health care intervention
and people have tried to make it so complex that it seems like their whole mission is to derail the project,
and I'll be able to go, Well, how does that what you want to do help us answer the question discourse.
And when you go to that, keep it simple. That's where it derailed.
Now, I'm going to come back to the thought process that it's really interesting.
The whole crux of great academia is to keep it simple.
And the best example I can get of that is Einstein equals empathy squared that with it.
And by bringing all that into very much simplification, everybody could go,
we can understand this and apply it, but it's so complicated that it's over here.
It might be of interest to mathematicians or to statisticians, but it will be irrelevant to changing everything.
And it's exactly the same in health care. I work in a lot of projects where what we want to see is a big difference, don't we all?
We want to see a straight line that goes like that, very simple.
And if you do that, so and come back to the thinking, if it's too difficult or it's too labour intensive or it's too complex,
it might make a difference in your research today, but it won't make a difference to practice.
And often people are doing research that's so complicated. It's of no value.
Does that help? In a way, and I do think a lot about keeping it simple. It's the same in writing.
If you read Strontium Y, it's actually the most omit needless word.
You write about 1500 words and then you realise you have to chop it down to 600 words.
It's heartbreaking because you think I've spent all this time writing and then somebody comes along and said,
Oh, it's only 400 relevant words that chop it, get rid of it all.
That's keeping it simple to the point, and I think it's difficult to keep it simple.
After about 20 years, I can predict the four questions and how you might answer them in a room to help us move forward.
That's the problem. When you think, Oh, God is bamboozling, you have no idea what the math might be.
Yeah, important point. I mean, just to take that one step further, I think I see the big problem,
the geriatrician and I see big problem in what you describing and in practice where.
Particularly that minor changes, minor adjustment can have a big impact on a person's life.
And then you see maybe the next maybe the ability to make a suggestion.
Yeah. And keeping it patient. Very practical.
Well, scientific or technical and. Yeah.
And geriatrics is a huge area because we showed you the population is getting older, we're increasing.
We have a process which I consider is therapeutic inertia sets in where people do something
to give people treatment and then nobody changes anything because they're all too scared.
They're on 18 drugs. I'm not going to simplify this regime. And you're right.
And then this process is what we've got to do is develop interventions that are simple,
make a difference to somebody's life without being labour intensive.
Because I get intervention.
Sometimes they say we're spending £600,000 on a new geriatric intervention to improve the quality of life of people who are in nursing homes.
It's going to be an exercise based intervention on people, on the elderly people.
And I go, And how many people are going to go to 600?
And I go, Well, why don't give the people in the control group of thousand pound, I'll improve the quality of their life on it.
And people go, You can't do that. And I go, Well, look, what are you going to design so complex it's going to fail.
And we would just say we're wasting money all the time. And these interventions and if you get that test, which is this is not feasible, ditch it.
You have to talk to people. It's quite being critical in that way though.
I've realised you have to do it in a thoughtful way, otherwise people just go, Whoa, yeah, yeah, of course I'm looking at the future.
Yeah, yeah. How much of your time did you take and how you go back to the future?
Because. Yeah, yeah, yeah, that's correct.
I think that's been. Yeah, correct. So there are two I mean, in fact it's getting worse, isn't it, getting harder?
It's really interesting.
It's more difficult to be relevant and impactful now than it was probably 15 years ago, because actually there's more and more published each day.
But there are two bits. There is a component for practice where it's a skill.
You have to be asking lots of questions and searching for evidence all the time, and you can do it pretty quick.
Two minute you can get the relevant information really quickly. That's one skill.
The second bit, though, is if you come to do a systematic review, what you do, if you think, Well, I can't teach you about searching.
So what we do and I've done is work.
Now, if I put Nic Robertson there, you'll see we've published about ten papers one year because sometimes time go,
that's just going to get ourselves a relevant person who knows more about searching the me can actually put it together deliver in a file.
The key though is I still have to be at three or four because I've got to be able to look at the search we develop and go, That's not quite right.
Or She'll come to me sometimes and go, I'm doing this search with Jack over here and it's not quite working.
Have you got any ideas about how we can improve it? So you have to develop your skills.
But he's not somebody you can go from. I'm going to do a course tomorrow, and by the end of that I'll be right.
You can make yourself proficient very quickly. So within about five days of a course, you can make yourself proficient.
But then it's a lifelong skill, isn't it, of upskilling yourself?
So the first bit is quite a big jump, but then the next bit is just a slow progress of practice.
Practice, keep involved in collaboration with which I found very helpful talking to my son.
And he he asked me questions. But in terms of a dphil project, not a five on particular points, but you get to a point in, say,
a statistical analysis where you need somebody who is in five to help you crack that piece.
Yeah. How do you deal with that in terms of a dphil, which is something you do yourself?
Yes. So that's fine knowledge. Yeah. So there are two different things.
Tomorrow I'm doing a thumbprint on the MSI in International Health.
I don't know if you do this in the course, what we're going to do them is make them and we might do that.
We only for this we're going to make them right. Lay summary So you do them now because I think that's cool.
So what we do is I make the of this module then that's why we're doing it.
The reason that's helpful is because of just what you've identified.
If you can write a really good lay somewhere and give it to people who know nothing about the area,
then they can have a conversation with them, can't they? Do you think this is important?
Is it interesting you can go and give it to some people in the disease area?
You know, we've all got people we know you might go, oh, you've got diabetes, you could have a look at this.
What do you think? So actually, number one would be writing a lay summary,
and I think you could do that for every little bit of your project because it helps
you understand what you're really doing as opposed to the scientific abstract,
which is a bit like, Oh, just out. Why is it in that late summer you would say, this is the background, this is why it's important.
These are the outcomes in a lethal merry way and this is how we're going to interpret it and what we might do with this information.
So once you've done that, you could do that for every chapter. But you're right, you cannot.
The key is in any good. And this is the same for a thesis that. Masters level.
It's you just have to be clear about what you did and what you didn't do.
And I think most people would expect you to be able to go.
So what you can't do is turn to a statistician and go, I've got some data.
I'm here to give it you. And could you tell me about what it means?
They'll be really pissed off with you. But you do need to come up and say, Well, I've got some data, I've got it in data, which I've done of course,
and I've got it organised and I want to ask these types of questions of this data and could have a discussion about
you about whether I'm doing the right things and what impact and what should it be or what am I missing out on?
And that would be okay. Would you agree that we okay in the statistics world, that's how I've done it.
And over time, the more times you do that with somebody, then at some point start going,
I can do that bit myself now I can do my bit, but there always still come something.
I think there sometimes and we're doing stuff and I think, well, yeah,
this would take me at least four or five days to get my head around this and I just think I haven't got five days unfortunately anymore.
In the beginning I did, so I used to really enjoy get my head around how to use SPSS, how to use our how to use data, how to use all these products.
And actually, I spend more of my time now,
get my head around programming for websites and blogs for some reason because I'm really interested in how we put
the information and spend my time there probably more now in programming than actually in terms of the databases,
but it's a really important point. So you must go. I've identified a gap.
I'm going to go and do some of the UK's courses to get orientated and then from there go and direct from one.
But what happens in the project where it goes badly wrong?
So every year we see quite a few theses or a few bits of work where we look at it and we have our examiners meeting and we go,
you know, this person's rushed it, you can tell. And because they left everything to the end and suddenly they realise they had a problem,
like a skill gap or a knowledge gap and they tried to forge it in some way.
You can just see it in the work as opposed to people who go, I should be working on this and I've still got four or five month,
but I've got actually an ability to go to this course over here or this over here, fill the knowledge gap and come back and do a better piece of work.
And that's where the get organised come from. And in doing that, being able to fill in gaps early, it gives you a much better piece of work.
So for instance,
writing would be the one where you think I've done all the three years work and I come to the end and I'm writing over 50,000 word piece.
And this is the first or second article I wrote in the last two years.
You're in deep trouble if you take that approach where they should be going. Actually, I'm going to write something.
I'm going to write a blog for Kellogg or for a while, some piece or some commentary.
I'm going to try and publish my background.
So you get in the skill, you developing the core competencies so that when you come to actually do it, you can do a great piece of work.
I saw a presentation for from Cambridge University and they recommend to start writing.
And when we carry out the research, I mean, at the same time.
So according to your thinking points, what is the best moment to start?
Right. Yeah. So day one. Yeah, it's, it's, it's a very interesting, uh, jets during the start of the year, it was just when they,
they used to start writing something that they went, what did we did and we did it one of 2000 where that's yeah.
First time it came in with all these ideas. We sat for about 2 hours in a boat, gone with a load of ideas to go get em down on paper.
There's only so much in a discussion I can take in, isn't there?
And so you got to get it down in paper, and then you got to going, okay, let's get rid of some stuff and get it.
And so and as we write in, you starting to build ideas with the people talking.
If you're managing your supervisor, well, you go, I'm going to give him some written and then I'm going to go and discuss it.
And in there I'm going to go. And the way we do it, you go, well, I had when I was writing this I realised it was an important question.
What do you think? I don't think this has been done before, but this isn't what you think.
You're building up the relationship of being able to go through relevant thought feasibility.
Now you take that to the next level. When you get to a certain point, I go, Well, let's publish something.
If you go to this book by the day, [INAUDIBLE] Brian Haynes called Basics of Clinical Epidemiology.
It's a bit about that which I've read, could have put that in that about how to write and communicate your research.
Finding Brian Haynes right there a good bit and I know Brian Haynes, he writes, Actually, I sent a number of pieces to newspapers.
I used to write for newspapers for about a year because it's a really good skill, because you have to simplify your language, keep it simple.
You have to get it down five, something like 12 words, a sentence, five sense into the paragraph.
They've gone. You can build up your own. That's 60 words a paragraph, ten paragraph.
You've got an editorial structure. Writing is about structure.
So when somebody rings me up and said, I want a piece for The Guardian, or could you write an editorial ten or 12 paragraphs?
What's going to be in the paragraph? What's the structure? What would I do right now?
And I've got it. Well, now, when it started, that would have took me probably about a month.
It would now take me a couple of hours to write some a sensible.
But that's not because somehow within that ten year period from I've just gone, oh, now I've been thrown out because of what set them out.
Practice isn't it. It's like a training environment.
So I would get yourself and you know, even having your own blog is good practice, you know, start them off on WordPress.
Now I found an interesting article. What does it mean?
Keep some resource where you even if you're taking your own notes, writing it out, keep it write something similar like Stephen King.
You see, when you write a novel, [INAUDIBLE] write and say, Well, actually, Stephen King's mantra is to write.
I think he write 1500 words a day and then stop on 12, 1500 word,
and he starts in the morning and stops and then comes back the next day and the next day.
And that's how you write a novel in three months. But the thing is, do a little bit each day is better than doing what.
And that's what I'd say. And don't be afraid to have a go, but buy yourself a copy of Strong.
Good morning. Thank you so much. It's been very interesting looking at the start of how to get started.
I have any advice on how to get complete things because there's been so much good research which has never been completed.
Yeah, well, let's say let's note that we can talk about all of the research,
but let's talk about people I see a lot who work in the field of clinical epidemiology or research or on project.
Being busy is not the problem in the modern world. Everybody is doing something.
They're at a computer, obviously doing something.
But what they don't do is people have a discipline around what they're trying to do as a structure and organised.
So if I'm a builder I think of it to of people like being a builder.
If you come to a job as a builder, you know where you're going to be by Friday, don't you?
By Friday the people are arriving with the window. So we've got to get the wall up to this level or indeed trouble.
That's where we're going to be. So that's what I continually do is set priority lists where I continue to say and it's flexible,
but I say by Friday I'm going to have some tangible output on a project that I'm involved in.
And I do that and I talk to people. It's called the I call it the show. You've only got so much on the shelf.
So if you put a load of books on the shelf some point before, won't it?
And the most important thing is to get the ones off the end so you can have a new book on the shelf.
So whatever you've got on the shelf that is near to completion will get off the shelf.
If it's not completed, it stays on there, doesn't it? So whatever you're doing, try and think about where they are being pushed off the shelf of.
So if we've got a project this week that can be submitted to a journal but requires half a day's import,
that's the one that's going to be prioritised because it to get it off the shelf.
The new stuff can come on and we can go next week. So that's one of the things I use all the time.
And in that I have a tangible output each week. If you just wait to the research and this is people able some people, then I will be horrified.
If you wait till the end of a week from a big paper, you could be waiting ten years.
But actually you just say by the end of this week I'm going to write. I've not got any papers coming out or anything exciting.
I'm going to do a 400 word blog on it or I'm going to do Y or we're going to investigate one thing or look up something,
or maybe do the presentation and finish it.
So you just have one tangible output that has a metric that you can see that like the building, then it suddenly becomes a lot more fun.
Now you might want to think of once a month when you start, you know, don't want to wait.
You might go bananas, but after a bit you might say once a month I'm going to have a tangible output that I can see in the world.
And that could be anything.
It could be a letter to a journal, it could be an editorial, could be a commentary, it could be a newspaper piece, could be a presentation.
But some of it you can look at and go, I did some in the world.
Now that's the difference between people being busy and effective, isn't it?
And making things finish. And yet there are loads of people I work with who don't know how to finish things, and I think maybe I'll come back on this.
I think it's a skill gap. There are some people doing research who get anxious that they're going to be found out.
Someone is going to criticise you and said you did a systematic review but you missed that paper.
You don't know what you're on about and you should be thrown in jail right now and you go, Oh,
maybe I'll just go and redo the search for a few more months and I'll go back to the beginning.
You've got to get away from that. What matters most? The science is imperfect.
What matters is you set out a clear method. You enacted that method and you put the results.
And if there's some error in it, you can correct it. But if you didn't make the paper fantastic, and that happens with all the time,
people go and we've never met one yet, but they always say, you've missed one.
Don't be doesn't meet the inclusion criteria, but they do. And you have to.
But if we do make a mistake, it will correct it. That's what science is about. It's self-correcting.
We've got this problem in the modern world that actually nobody can be wrong.
Well, actually, in science, we should argue. So don't be free to be wrong.
But just be in what you've done. Acknowledge the limitations of what you're doing and what you can do.
Which comes back to the beginning and the final criteria, which is the feasibility.
You haven't got enough money to make it perfect. And I think that's all right.
Yeah.
Consider this, we might have limited time for research to buy food and pyjamas or whatever, and another service which might be too much time for you.
So how do we get the research around all the time?
So is it wrong to take that phrase go which bit in the research around which time.
The, around the time that you have been.
Yeah. So nobody. So that's a common thing. People always say to me, I've got no time.
Yeah, that's a common one, I hear. And I say, Well, number one is you have to re-evaluate whether you're in the right game.
The number one criteria for me is I'm fortunate. I just enjoy everything in this game because it's so interesting to me.
It's insatiable. People come all the time with these great questions and I'm like, Oh my God, this is it's happened twice again today.
And I always say, yes, and I should say no, and I've got no time.
And the busiest people are always the one people who go you.
So you have to really enjoy it and be insatiable about that and enjoying it.
You have to think about, Well, what is it I enjoy in this? For me, I just really like working with people.
I like it when we have a question that's a problem and we have to solve it in some way.
And in doing the solution, stuff happens where we find something out, which is really interesting.
And then we go for a pint and we talk about it and we say, What's next?
The end product for me is never as good as the bit in the middle.
This is a crucial element. Success is never defined by the 250 papers, the whatever here and here and here.
It's always about the bits where you're going. Bloody [INAUDIBLE], this is really interesting.
Aren't we having a fun time? That's one thing.
You have to find the bits within your projects that a research probably people think, Well, I'm going to publish a paper in three years time.
We're always thinking about what can we publish by the end of the week?
And so there's so much issue here that's really important for me or in this project, or is it a method that I can get more out of what I'm doing?
So it's not about creating more time, and this is a crucial element.
You have to be more effective with the time you've got available. Yeah.
So you do. And this is a barrier for of all we don't prepare to invest time at the front end for a downstream benefit.
So if it turns out you could learn theta for instance, as opposed to doing an analysis in Excel, you probably take out doing Excel on a carry on.
And then you put actually if you put that two days effort into learning this, you could probably save yourself ten days downstream.
That's the sort of thinking you should be doing all the time.
The writing skills I can write now for an article that took me one month in about 2 hours because of the amount of time I've invested on the journey.
So wherever you are, you can't do all this. It's a long journey for ten, 12 years.
You have to enjoy yourself. You have to enjoy the process. But whatever you do, you have to be more effective in that area.
So if you are all coming into postgraduate students, in effect, what say to people you are professional students, aren't you really?
You've gone from being an amateur to an undergraduate where you drink lots of beer.
You know, what's the fun? But actually, when we're on The Graduate or at school, we realise we have to get better.
Our skill sets you that get better, more effective, and then think about the bit you really enjoy and go to them.
If you enjoy presenting, do it. If you don't enjoy presenting, do some more writing.
If you don't enjoy any of that, what are you going to do at some point?
But if you go down the high street is a flat on the on the high street where it's got a hook and boil.
Has anybody seen it? You know, cookies and boil, boil, flow, chemistry, flow.
Remember all that? Well, hope with the first ever fellow of the Royal Society.
And he was paid to do an experiment every Friday that he had to do to the public.
For every week. You're like, What we're going to do on a Friday, I'm going to present it.
And then you've got the have to be a priest there to verify the findings were true.
And then they write it up and then they go again.
And in doing that, had all these amazing laws like flow, which is still today, pressure is inversely volume and all that stuff.
But that's a classic example of your job is to be a communicator.
It's not to do research, it's to communicate the findings of the research.
That's the job. If you understand that principle, then you understand, why bother?
And if you don't like the communication aspect of it, then there are service bits of the job which are okay, but actually real job.
I mean, whether that's teaching, presenting, writing, doing radio, talking to a heathen,
if you haven't got anybody communicating to, then you're not actually thinking about it.
So but enjoy that and don't, don't ask for more time.
Be effective with the time you've got available. That's one key component there.
Until somebody can slow the speed of the earth down. We only have 24 hours a day.
Don't. You have to ask if that would actually have been effective.
Yeah, yeah, I'll do the one how to get finished. Yeah, well, no, I think you're welcome.