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The glass scammed or a society in association with Sai, Digital Innovation in learning, present Sai Digital's let's talk and intergenerational discussion of the ethics of new technology and lack of
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accessibility in impoverished areas from a meeting held in Glasgow, Scotland, Friday, January, twentieth, two thousand, twenty three,
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organized for the Glasgow nourish Society, by Mohammad Ashraf, her son Ishmael Ko, Moderators University of Glasgow School of Medicine,
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discussion, guests of Professor Matthew Walters, Head of the School of medicine, dentistry, and veterinary medicine, consultant stroke physician. And professor of clinical pharmacology at the
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University Glasgow, Emeritus Professor Jorge Laws, Riff, Department of neurosurgery David Geffen School of Medicine, you, Cla Associate director, S N I Digital, Professor Sam or Hof Department
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of Neurosurgery Neurosurgery Teaching hospital, Baghdad, Iraq, Department of Neurosurgery University Of Cincinnati, Cincinnati, Ohio, Associate Director, S N I, Digital, Professor James
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Ousmane, Creator, C E, O, S N I and S N I digital,
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the discussion and questions, sixty minutes, peer review evaluation, five out of five ranking. Twenty five attendees from three countries during the recording,
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so hello everyone. It's my pleasure to welcome you all to the force, Less talk Series by Surgical Neurology International, For the latest initiative, Sai, Digital. The Stalkers is in
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collaboration with Glasgow Nudist society. My name's Mohammad Ashraf and I served as the last immediate past president of Glasgow need into society. And I'm one of the moderators for today's talk.
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We are one of the largest student run interest groups for new knowledge into surgery in the United Kingdom would be used at the University of Glasgow Medical School and but affiliated, closely
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supported by the neurosurgical department at the Institute of Neuroscience and Classical, and really be helped by beginning this podcast style, candid discussion on important issues pertaining to
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the practice of medicine can have an insightful meaningful and worthwhile conversation by sharing our experiences in our pursuit of knowledge, the title for today's talk as ethics of new technology
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and lack of accessibility, especially in impoverished areas and in the developing world. I'd like to give over to my. It was my mortgage and her son who's going to introduce himself and over to our
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speakers,
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yet. Still good evening. Everyone. My name is Hassan. I am this year's presidents of Glasgow Neuro, and just as at my cost, Mohamed said we are delighted to be hosting what we're hoping to be
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the first of many sessions, looking at certain topics that are seldom spoken about in medicine, and really, this is going to be done in a podcast. L fashioned way. You're welcome to ask questions,
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and the whole point is that questions can be forwarded to these you know to to a panel of experts, and things can be openly talked about. The session will also be posted on this and Ice will keep
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your eyes peeled there, and at the end we're also going to be posting a feedback form in the chat. Three questions, just asking about your thoughts about our first session and whether you've got
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any suggestions for Ourself on how to improve, but without further ado, I'm going to hand over to our speakers so they can give a brief introduction to themselves and we have a really tough fight to
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fantastic line up of four powerhouses, and after that, we'll get going with the evening. That's awesome, and if I can handle that you first,
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I'm a neurosurgeon Ben also saw trained as a pharmacologist. I didn't tell you that as, but but
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headed to departments of neurosurgery and the professor and four medical schools are around the country, started a journal, Call this an eye, surgical neurology International, and restarting this
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new format that they are Ma, Muhammad, and Hassan, and his of his group, or his one is actively participating, and called as an Ai, Digital, which is a open forum of discussion of controversial
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topics.
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I'll jump in next. If I'm a good evening. Everyone love to see all and particular thanks to Moa and Hassan, for for pulling this together with a with gyms, or helped with his organizations. Have
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my name's Matthew Walters. I'm practically the hand of the School of medicine, dentistry, Nursing at the University of Glasgow, in the interest of full disclosure. I am not a surgeon, and you
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wouldn't want the operating on you in. In any capacity. I'm a physician and clinical pharmacologist, and I work in the acute stroke unit of the Queen Elizabeth University Hospital where I treat
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stroke patients unsurprisingly. So that's me nice to see will vote to the conversation.
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I am a whore. Her last breath. I openers les day or a cycle that accolade you all that to bravely. I participate in in the beginning of this something that will continue to grow absolutely deserved
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them. They're my experience. I was a tad off the other, yet essentially for twenty years, the cla many other countries. Before now, I am centered on day, education or change of information with
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the low and middle income nations and to one a strong interest in the subject that will bring us all together today, which is the distribution of resources, welcome all, and I am extremely grateful
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for being part of this.
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Amd Adam Sandler has a. I'm a neurosurgeon and I have a practice, and at arc, I do vascular neurosurgery both open, and there was cooler and I have experience with trauma black Ten years in
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neurosurgery Now, I'm based in Paused of Torah and the Cincinnati, Usa, and I am very happy to be part of this well esteemed, and to thank you, Hassan and Mohamed for this invitation for sure,
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And yeah, let's learn together.
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That was fantastic. There we go. I real all star lineup of everybody from the fields of surgery made and stroke, and what we're really hoping for. Like I said, it's some really interesting chats,
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and without further ado, I think we'll get the show on the roads, and before we can begin to talk about the main me of our topic, which is ethics, new technology. We have to briefly first of all.
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Walkabout the stepping stone towards that which is evidence based medicine, and I'd like to direct the very first prompt towards yourself, Press Walters, where evidence based medicine has received
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some criticism from individuals about how potentially it's making medicine a bit too regimented. Could you briefly, just first of all, tell us about evidence based medicine, And what your thoughts
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on it are
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absolutely were British nationals who took my head is the conscious and judicious use of medicines informed by the best available evidence that we that we have, and it is taking that simple
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definition. I think that an entirely rational and certainly the most easily justified method of delivering clinical care by conducting clinical trials by identifying what the best treatment options
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offer individual patients, and by applying those patients judiciously thoughtfully and with the. And then the the consent of the patient, and it you're right that I, I think it can lead to a
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perceived restriction in the freedom of clinicians, and I think we can understand that if we look back at the history of medicine and how decisions were historically made, aerospace medicine is a
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relatively new phenomenon that was certainly empowered by the developments in technology in the eighties and nineties that enabled very rapid searching of databases to extract literature and to make
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sure that you could distill the the key messages from the big clinical trials that have been done, most of the people on the screen of two far too young to remember what I had to do and I suspect my
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fellow panelists when we were trying to do a literature review in advance of starting a study, we would have to go to this enormous wall of the library that was covered in the Index Medicus, and we
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would have to look for each individual year. We would have to search on paper on paper. If the papers that were relevant to our search and I in Africa and find them physically and then pay ten pence
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for each sheet that we photocopied in order to generate our literature. Now you guys at the click of a button can have it all on your screen within a couple of nanoseconds of aerospace medicine was a
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difficult thing to do in in the early days, and it, The, the alternatives were far less attractive in a scientific sense, though is what was known as eminent space medicine, Which was the most
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senior person on the ward round decided what was done at, and that was it there was a sort of consensus based medicine where people would sit round a desirable, the best that the the the best
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treatment would be, and they would do it that way. There was the sort of convention base May as well, we've always done it that way, And why would we want to do it any differently, So evidence
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-based medicine was disruptive and I think people objected to it and to an extent because it did constrain them, and it led to the development to have guidelines.
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There were issues and I don't talk too long about this. The current issues with with within space medicine. It can really only be applied where there is evidence, so there is still room for the
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arts as well as the site as the science of medicine and experienced clinicians can still have to make choices on the basis of a lack of evidence or information to guide those decisions, but I would
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say isn't professor clinical pharmacology, and someone who does clinical trials for living that those clinical trials are good things, and the development of good informed clinical guidelines
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probably serves everybody's interests, and I think advances the development and delivery of healthcare. I've said enough. I think I'll stop at that point.
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Hassan, I think of our hairs is talked about her fixed of people around the world and an evidence based medicine Hurry. Do you have any thoughts on that subject? Yes, I mean. I certainly I do
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what I want. The award was from award was just just say a they brought brought with him on them is no problem, but but but the one of the issues with evidence based medicine that a created a very
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high standard that is not always possible to achieve by everybody, so everybody gets a may get responded on dismissive of the evidence base magazine, Because you don't have the means that, then
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you've got the means to achieve that perfect diagnoses on the benefit,
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if the solution though, and I wonder if if he shouldn't be. And therefore the flow, maybe the base metal scene in it, bringing down to the core essence independent off the technology that you use
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to reach such a, they have mostly snow, and to to be belief in the unit said you can field. The evidence based medicine says that they're neon years. Any support on a hamburger at Jane product. I
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knew these women should be believed in the first forty eight hours. I saying no to the Russell Street journal. I mean the Osman would actually be more detail, but there are countries where those
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saying it's gonna be done because that the patient is far away as Summer may know, and the patient from seven days off, then so what you do with a seven days after patient know so that an evidence
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based medicine transformed more into law, medicine based evidence. In the sense the individual in need got our justice. Okay, he, he's patient does not feel the criteria stated by everything's
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made medicine, though so I, I wonder if he shouldn't be with this attribute finish and evidence based medicine that aims at going to the core of the issue rather than to the details of things that
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you have to do in order to achieve for better diagnostics.
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I'll definitely. What about yourself and Dr. Samir Any thoughts from your point of view. I know you know evidence based medicine is perceived differently depending on the person and Germany
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opinions on it.
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And yeah, actually, I am listening and have many thoughts and examples, and I want to share just a situation. When Adjust to continue the example approved by the Rosa lives out of that. If you,
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If you are thinking of ethics and new technology, and I think the on a practice, you will find an an additional joint, Which is who decide is that ethical or not, and tired of the situation behind
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that and derive the whole process as a pro, settlers, out of say that if you have a patient, and you have limited resources, and for example, I can give only from tuition that I have been that I
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am a neurosurgeon. And I know this is not exactly as the let's say all as as the guideline, but I'm obligated to, maybe because of limited resources. Maybe sometimes because of I, I didn't know
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cultural limitation that something will be accepted in this part of the world. Something something. It's not the same as not even I think the patient consent, but patient understanding off. Let's
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say a potential complication on the outcome. There's a huge difference in that the concept. This is from one side and from either side. I. If I eat. If I'm thinking of a new technology. I. I
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just popped in my mind that then you would technology for for chat to Gdp, and its auto writing of papers within few milliseconds, I. I have just experienced Dad's a few days ago, as just I dunno.
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It's a for for some time before I. I paused and I think Wow. This is artificial intelligence and I ask the G to the Judge Gpg that it can you write about my pussy that patrols the precinct. Lloyd,
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or throw elaborate. I find out approach which I know that very few people understand this and I have like three hundred words within. I think four seconds very well written on that topic, and I
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just wow know what's this. This is an orthodox. I think nature just to share something about that is that there is a huge dilemma on what's the ethics? Be that behind that and and some paper that
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child Gpg which is artificially like a reality, a reality a used at author are included as a co -author on. People is what will be the future, and yeah, that's that's my initial thoughts. That's
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that's an interesting point actually unfair for those who are unaware, just so he was gonna say chat Gp to use this fantastically new ai that was recently released, and whilst it can do practically
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anything, you ask it to an aspect that has been used in the scientific world as help with writing table publication, and as an example of its power and some people have and written papers showed
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that in fact this ai is capable of passing us an elite without any problems, and it's it's just an interesting topic and and quite interesting segue, potentially, maybe even the topic of a future
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talk that that's an interesting thing in its own right, but then, but that'd give us an. I don't want to do that. I mean I, I hope somebody jumps into this as well huguenots to the Gbp Eur, that
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was the best three men or delay, the, The the the analogy of the the best treatment. What a particular condition, and it will come by that best treatment over that is not necessarily applicable
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law, and damn truth, vain, and so are we putting the horse in front of it. God. I did take the course in under polo jacket, At The your A neuroscience of social sciences, and I say to that,
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and at the students that the objective of the of you being here on you'll be an in depth every day, Because you. I didn't the The The The students is to learn something how to face the world. Not
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to get an A and that the T allows you to get an A, but doesn't doesn't teach you how to face The what seemed on A. If we put them at the Djibouti, The best evidence. Yes, It's fantastic. I think
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that has to be a temple. What are the best possible evidence is
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collected analyzed. And thought out a I could eat up all in order to disagree that you are going to eat hundred percent with the air. The professor water that we need to have these like the Gpp, or
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rather than a benefit Gpp, That is everything's based medicine, but we also need to have that understanding how to how to jiggle and wiggle with evidence in the situation that we add on,
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and I make two innocent comments
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I, I shake, and for me, evolution and professional hunters wants to show me, but the question is what is evidence,
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evidence or observations that are made by humans and certain phenomena, and therein lies the problem There are isolated tracks that are proved to be one hundred per cent accurate. There are
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phenomena that occur that various people interpret. We don't have to own jerker them the same way, and then the question is, are labels with the word evidence, while evidence means a lot of
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different things, for example, or you can have evidence based medicine their studies, which fortress or Walter's know, and and and the neurosurgeons know in neurology and neurosurgery, there was
19:45
a study done some years ago, which was a randomized controlled trial evaluating a surgical procedure, and whether or not it'd be helpful and stroke, The the problem turned out to be that the people
19:59
who are running this study came up with a resulted. Others disagreed with a disagreed with the conclusion from the evidence, and they formed a special committee to go back and investigate that it
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can be found that couldn't could not reproduce the same evidence from the primary center on three different visits, which meant they can't produce the same evidence. Which meant that conclusion is
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in question yet everyone because it was backed by the government went ahead and adopted the conclusion of the study which stands today. Some thirty years later have without being challenged in his,
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changed the face of medicine, so the question is when you're talked about evidence based medicine. I think the first thing you have to do is not abandon your brain is to analyze yourself. What is
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the evidence. What are the facts that leads to the conclusion, so you can make that decision yourself rather than accepted necessarily from someone else. Ah where Ruben are brainwashed to believe
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that randomized controlled trials are the gold standard of medical observation. I don't agree with that I think randomized controlled studies and I grew as a professor there. In pharmacology, many
21:20
other specialties in medicine can be, if conducted properly, very very illuminating, but you've just seen in the virus work and the vaccine work in your country and our country that there were a
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number of studies. Somewhere, not even randomized controlled son was adopted on the basis of evidence that no longer seems to be valid in the conclusions are made on on that basis. Some of the
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randomized controlled trials were corrupted. So the challenge to you as a physician as a student is not is to use your mind. Use your brain and question what is the evidence. What is the basis for
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your telling me this is evidence, and maybe you'll disagree there, but I think I agree with Professor. Ideally. Yes, we need to get properly accumulated evidence properly validated tracks and
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properly run studies to come to a reasonable proper conclusion.
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Absolutely Walter Germany, causing Marxian well, Are you just just a sort of fully endorsed. What what pressure Ashman as as just sad thing is actually right. There is the best that we've got at
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the moment. I think that can do that. The consensus view in clinical academia is that meta analysis of randomized controlled trials provides probably about the most reliable evidence that we that we
22:42
have, but there is a a real caveat there which exactly his press announcement has said we need to be willing to question everything when we're reviewing the literature. We need to identify our own
22:53
patients in the literature in order to be sure that what's being said is applicable to us, and then of course as the other question about whether the technology that's being evaluated if it is shown
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to be efficacious is available to us, and that really is the number of. I think, the broader conversation that we're going to have. It might be helpful to spread quickly to put some numbers around
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that because there is to my mind a shameful statistic in clinical medicine and in medical research, which is that. It is said that approximately ten percent of global health research in terms of
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financial support for global health research is devoted to the conditions that account for ninety percent of the global disease burden. So what you find is the The The The the illnesses that
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disproportionately affect those wealthy countries are studied in exhaustive detail and minor increments. Incremental advances have potentially made. Whilst in the background there are large numbers
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of people with in societies. The prompts don't have the money to pay for new treatments whose disease burden is not being as rigorously assessed and alleviated, and that to my mind is a is is a
24:00
shocking statistic. While I'm up, and actually, that's a very important from segue into our next point. I wanted to ask this question. All the panelists. Professor Waters mention that a lot of
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the conditions that make up the global sort of burden of disease are given due priority once as entities. Mighty clean into your head injury management, and just to sort of jump off that I want to
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ask you guys. That medicine had the sort of perception that a lot of research we see being done in the Uk. In the U. S. Is focused on sort of new technology. A lot of expensive technology that's
24:34
inaccessible, but in fact we knew that research can and should be done to look at simpler interventions to design robust, well conducted trials on simple aspects of management from a neurosurgical
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example that could be saved, hinge craniotomy just rang whether you should leave a gap in between the bournemouth. You close it or not, but something that's simple and easy and can make a big
24:54
difference and can be incorporated to a disease that's affecting the entire world. We just don't see that much research going on in those areas, and we sort of wanted to ask you guys were your
25:02
opinion as a bit though, And is there really too much disproportionate emphasis on expensive technology that may or may not prove to be efficacious? Yeah, I that you address an important point
25:13
about it and I'm I am still in this room from the gym. I they, I think is we are still seen in the way that we are talking, and when I say we, I say we know. I don't say we we are talking. Is
25:31
that what we shall do for them That my effort in the last ten years with a tiny tiny bit of of the reasons is allow them to do that own their own research and develop their own, The research. I, I
25:55
gave a series of lectures, Strong mechanism on Saturday on how to write in my gun. He got out why and I say Thanksgiving is a chronic condition, and then they got our particularly in the Atlantic
26:10
Coast by the guidelines for dengate about treatment that they are fall, fallen what region? In Australia, what they also a danger, which is good, and that is a very good guidelines know if there
26:24
were published recently in the journal and the New England Journal of medicine, but I say what are your experience in in telling us what to do with Dendy, I. I. I gave an example of the supposed
26:39
show that Oprah order and assembling pediatric neurosurgery we close, despite a beefy than the first one before, I was quite clearly an order for the Da Da the most, but there are countries where
26:50
they where they have to close at seven days after ten days after, Because the patient time will get. What is that the literature from them telling us what they have observed, Know so do this with
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my eyes It, I think that our other way of perhaps helping grab everything. This This thing is encouraging that that the work by. Different clinicians researchers in different countries do actually
27:21
the lesser fate. What can be done, and that they, that can be incorporated with the professor or the matthews, Alright, Walters, Marty, Who is the? Is that the first name, I just abuse of the
27:34
confidence with it at the Professor Walter, To actually a okay, say yes, We have favorite things are the best think is in twenty four hours, But we also my favorite is that if the patient comes to
27:46
seven days after the Bbc's that or those side of the different sets that are important. A doctor. I was mine, Mention they, they show with it, and if the vaccine, yes, there are controversies
28:01
and issues, or because it, but what out of it they the paper all the suggestions by those who oppose that and
28:14
the golden state of the believe. So my point I going just do it to someone else is this. If we think that that is up at the disparity. We have to find a way of encouraging those who see those
28:29
differences to tell us what out of their solutions to those problems
28:38
I finished
28:40
the young to disease. Is your colleagues in the Have chevrolet question.
28:48
There was a question actually came through to me, and the person was actually asking quite an interesting question. What they wanted to know was basically, and the way the void you to hold on,
28:57
cause it's worded a bit strangely, it says when it comes to access certain resources some are expensive are large enough that they require at, and they require that that moving patients to central
29:09
sites does not know, and it's sales hinder accessibility where potentially rural individuals who left. Far away from accessing, these might not be able to make use of potentially new technologies
29:24
on the one I dunno, I said guns right done, my, so No, I. I leave that to my. The cornerstones are. No,
29:34
I'm happy, just to say a brief word is an excellent point, and it is a very real challenge for us and particularly those of us who deliver clinical care at West's kind of urban sort of high density.
29:47
High population density centers. There are some ways around that that it's much easier for physicians, and then then for surgeons, so, for example, and we have a tele medicine link with some of
29:60
our more remote centres that enable us to deliver thrombolytic therapies have an old fashioned acute treatment for the scheme stroke, and and we do that over five broader area than would it would be
30:11
possible if we had to physically be present in the same room as the patient, when the. It was administered, so we will be able now to use tele medicine, and this has been used in many parts of the
30:20
world, so the doctor can review the patient can review the imaging remotely and make a decision to inform the local teams management of the patient with regard to delivery of samba license, or or or
30:31
not, It's not ideal. By any means There is a you know, it reduces that episode of clinical care tutors at a worn binary decision. When in fact, there's a lot of subsequent management that needs
30:41
to be done. The tele medicine is one way of improving or removing some of the barriers to high quality healthcare provision when delivered across a very, a very large area, as that that. That's
30:55
one example of how we can mitigate it, but it remains a big challenge for us.
31:06
I do you have any questions or thoughts. Yeah a while while waiting for rare that a young and get a questions, and I'm thinking that I can give example and to have your thoughts, especially for
31:22
that attendees here at, based on our experience with the professor, always Manipur of settlers out of, and I want to share two point. The First point is that I'm practicing in Iraq. I'm doing the
31:38
basket on your surgery, and just to graduated. At all of a sudden. I found very crucial question. Do I need to do with the color pink urgent. Obviously based on, then you go to a surgical basic
31:54
knowledge that Yeah, you should do. If the aneurysm rupture how patient somebody younger yardage, you must treat the patient as soon as possible. At that point, I start. We search for any
32:07
evidence that support this particular information. That. If you have such patient, who should treat Director. Okay, Why, because there is nothing about that and there and the guidelines and Iraq.
32:22
Basically, so I cannot practise this app on my patient outpatient emergency. I have nothing to support that I can operated know as an emergent case or urgent case, so I get to the to the guidelines.
32:41
Every every guidelines say that. Yeah, it should be operated as soon as possible, but there is nothing that obligate people that you should operate in their first or second day, And that was very
32:55
huge. Because if I, if I have any evidence that and I, I should operate in the first or second day. I, this will be my evidence. With anesthesia so I kind of operate at night, the surgery may
33:08
may take eight hours or seven hours, or maybe twelve hours, so if I don't have such evidence how I convince people, and that the bottom line of this example is that I see, and I think some of the
33:26
team and we are observing that I want patient dying. At some point. I go to the head of department. I say that I have nine patient of rupture herself out of control. Hemorrhage died within the
33:40
last two months, waiting for surgery, waiting for elective clipping of the aneurysm rupture, cerebral aneurysm rupture, but an aneurysm, but they are actually not elect. Not elective cases.
33:54
They should be operated on the first day. Maximum on the second date is to say that if you have something as an evidence that you should operate. Well, the first or second date bring it to me. I
34:07
couldn't find this was all like the one at like eighty years of people working an aneurism and evidence, because we cannot include everything in the guide dying, and if I tried to call people
34:24
everywhere I found this, this is common sense that I. I have five admitted patient of ruptured aneurysm waiting for surgery, and any neurosurgeon said, what waiting waiting for what I said, Okay,
34:39
maybe one week to week and fifty cent of people. That's that's the evidence. If you wait one month than fifty per cent. There's a chance of mortality for those patient. So it was. It was a huge
34:52
determinant, and I was back and forth between guideline on glocal application, Guideline Look on vacation. I couldn't help help it, so yeah. That that's that's how important the evidence and
35:08
that's how let's say the resource limitation may and have extra at like meats. I've I've just tried to Christian. Come up in the truck from one of your colleagues and I think was waters. This might
35:24
be sort of drifted towards you. Someone has just asked that one given that the Uk is probably one of the most developed Western countries that still doesn't have a thrombectomy service for stroke,
35:35
and there's all these new evidence and fifty papers coming out abode sort of these new endovascular devices, pipeline devices as sort of Florida voters in these new embolization devices, and they
35:46
aren't even established to be efficacious? How does how do you sort of take that into account when diluting the stroke service? It is that kind of a disservice straightener to our patients?
35:56
Oh gosh, and how long do we have twenty minutes? Know that the E right there. I have to say that I mean there are huge frustrations in being a clinician. Generally those are always were optimistic.
36:12
Were were were willful people as a general as a profession. Generally there's an awful lot we want to achieve. To do. We're very driven and we get very frustrated as a community as a profession
36:22
when we are slaughtered in those good intentions by bureaucracy by lack of resource, and so on and so on now clearly it's far worse in other parts of the world, and this is what what we're
36:34
discussing, But yeah, my own personal story and that of my colleagues of frustration with regard to the delivery of a thrombectomy service, and is, it's enormously difficult, and we have windows
36:49
of time during the day when we can deliver the service, but if a patient is admitted at with those windows, then we really struggled to deliver the quality of care that we would that that we would
36:58
hope to do that at what we do about that is. You know we've we've been advocating. We've been pushing as hard as we possibly can and bucks. It remains a source of immense frustration that we still
37:11
as a extensively developed twenty first century for looking healthcare service are still in on many occasions delivering nineteen ninety standard care with systemic administration from politik drug,
37:26
but without the ability to intervene in as many patients as we went, we would like to be to do. We're hearing that things are moving that we're beginning to win the arguments and the will be up in a
37:36
a sustainable service in the near future, but in the meantime it's very difficult to do this job because you are seeing patients whom you feel could potentially benefit who perhaps are not being
37:47
given the treatment that you know would be, would be better for them, and so in many ways that does give something of an insight into how it feels in other parts the well that perhaps I've even
37:57
fewer resources than we do in the Uk. Where they feel that way more often about more conditions, and it's a very uncomfortable place to be as as a physician or so.
38:10
Absolutely any thoughts from the rest of our panelists will not sure.
38:15
I think the fundamental question that's being asked is if you are from a low to middle income country, or you don't have enough money or resources. Are you going to be practicing medicine? That is
38:28
inferior to that in the high end. Non countries. All ethical. By far Do you need technology in order to practice good medicine. The answer to both of those questions is No is no, the greatest
38:43
advances in neurosurgery and I'm sure neurology have come from people outside the high income countries and in developing countries where they have creative people, innovative ideas, and they pursue
38:57
them. They become successful
39:00
at first carotid endarterectomy restaurant, and Brazil are the first to coronary bypass has done in South America, Argentina. So so why I think people have been brainwashed to believe if you have a
39:12
lot money that you're going to come up with a good result and it's better than anybody else and the question that is what is the evidence that proves that, and the answer is there isn't a lot. Now.
39:25
I'll give you a practical answer is taking care of a patient. Some years ago He was a farmer
39:31
league. He has a, He had a glioblastoma a malignant brain tumor we operated on, and we we did. We removed as much as we could, and it, and then the choice came at that time. There wasn't much
39:46
chemotherapy was. Should he have radiotherapy, He lived three hours away. He would have to travel three hours back and forth to the hospital every day of radiation therapy, And that's during the
39:57
best time of his life Because the life expectancy was between a six months in a year, so here's a country that had the most of. The abundantly available technology, but it made no sense to use sir
40:12
for their patient, and so then that gets us out of the idea of of the technology and science, in that. As we have to deal with patients, those patients are our brothers or sisters or family
40:26
members or neighbors or friends. What is a practical decision. We want to make sure you and and and Sam Rosanna up a panel. We had this and I digital, with some very high powered people from the
40:42
United States, and elsewhere, talking about the advances they were making and traumatic brain injury. He presented his work from Iraq, and one of the panelists turn to 'em He was from Johns
40:53
Hopkins, Who is a critical care specialists had said we can get the best results site. You have. What is the message you don't need to be in a rich country. Into do good work and get good results.
41:09
You've been brainwashed to believe that that's not true. So and we don't know technologically. How much of this is valuable. There are all kinds of technology being promoted for spine surgery.
41:23
There's not a shred of proof. Any of those things are valuable. Not a shred of it and they don't want to do randomized controlled study because it would be against the manufacturers, and that gets
41:34
into money,
41:36
so I think it gets back to using your common sense which are born with which your family taught you and looking at things from their point of view. People in high income countries make stupid
41:49
mistakes. They also do good things, but it doesn't mean because you're in a low income or middle income country, we can't do that in the Uk and the Usa. We have very high levels of healthcare.
42:02
You can't tell me and I can tell you that every single person in our country has access to that care. It doesn't exist. While the professor said that rear backward country that. While yes, in some
42:15
ways we are, can we practically provide this care to everybody everywhere. There are many factors that go into he mentioned
42:24
in in in one thing that was a run on on what the husband Hussein is that he has unbundled with with the salmon they are, and thus the job of evidence based medicine, which is of a better job, and I
42:40
think that has to be a repository of all the human analysis that will be constantly changing. Know is not fit right in.
42:52
I keep on saying Matthews, But as Walters when his work is they are is we, we have. I think that has to be constantly changing. It was evidence based medicine last month may have switch and a
43:06
little bit better today. No, and that's that that they, they, but by the idea that many of my college in the so -called developing nations in Africa and Central America and a half is that if you
43:21
don't reach ducks done that, then better hide you ought to know the results that if you didn't do that at the procedure or follow, they do that. The rules. Specifically. Well. You are doing
43:34
something wrong. We are put in that the God of influence of the horse know as the Osbournes was such an insane. If people cannot really say, know your, you ought to a four, be the end or in
43:47
beating your patient to have radiation therapy. You ought to doing something wrong. No, you're not doing something wrong. Is the dynamic of the evidence based medicine allows or shoot allow. What
44:01
all these stretching of the the boundaries know and I transmit to my patients to my to my students that he. No evidence based medicine is not that. If you're gonna do at the conference, you should
44:19
wear two thousand dollar suit to be listened to. No. You just need to have properly organized slides and ideas. You'll need to have a latest Apple computer to write that they would pay Bury you.
44:36
You need to have a computer know to actually type, and that's why small problem I see in developing nations with evidence based medicine that they feel ashamed in quotation marks of not being able to
44:50
reach that that stand them
44:55
anymore, questions Muhammad or someone from the audience.
45:00
Yeah, actually, there's a beautiful one that that that actually details about this and it might be a controversial one or someone's asking. Is there a bias were developed countries. Researchers
45:09
taken a more seriously than not from less developed countries. Yes, I think that's actually. It point. Don't is. Yes, there is a buck. Yes, there is a bias against the bias. Don't that I was
45:21
Monday's fighting with surgical neurology International. We are. I am the editorial board and I wish I had that reference of the baby bit gross. I read it many many years to low, and I say all day,
45:34
I wouldn't I wouldn't find that. Were No, They didn't find it. It did where there was a group of doctors from it, The Mexico. They send a paper to a journal clinical journal from Mexico, Mexico,
45:51
Mexico, Mexico. They were rejected, so they padded with a collared from Johns Hopkins. And they send the same paper with the same date. That. Of course. They have taught me that he was an actor.
46:04
Lie after know you said to of being day to an astronaut. The Naval North Korea was the John Hopkins Hopkinsville, the modern, blah, blah, blah hospital, and the people were subjected.
46:16
Yes, there are maybe less, maybe more, but Betty's a bias. I do remember talking to Chinese college in China. They have experience. If we have fifty patients. They have five thousand gain acne.
46:31
That these themes that you want to actually fine, and I was saying why you don't publish this. Oh, you will not believe us will be nice. It, Yes, that is a bias absolutely
46:47
lap. In a pharmacological context. Is that you know if you don't have the evidence in particular populations? And so, for example, the sign away, Fda wants to see evidence of drugs working in
47:01
it's particular population, because there may be some pharmacological differences in how drugs are handled between different to different populations that can go on to impede the acceptance of new
47:11
drugs, new treatments, and ultimately disadvantage, further disadvantage the countries that are already disadvantaged to begin with, so there are quite significant practical implications, and
47:22
which which we need to arrest,
47:27
either set a quick comment here and there the answer is resoundingly. Yes, went into the meeting of average of journals happened to be narrow, neuroscience, neurosurgery, neuroscience, neurology
47:38
journalist, and that question was brought up by the audience about unanimously on the panel, as if the paper came from outside the developed world, they may read at once, or they may just rejected
47:50
out of hand, the fundamental basis of the the question you're asking. Is is there bias? Inherent bias comes from people who claim to be scientific and objective people in dealing with information
48:07
and the answer you just heard is Yes, for example, there are a number of articles in their prominent journals, Lancet Nature is another New England journal of medicine Jama that refused to publish
48:20
the evidence, said Dr. Ah. Miser, who was talking about a month of an accent, or if you practise in a hospital, you're not allowed to understand this information recently in California, If you
48:32
didn't tell what the government told they told you with the right treatment. You could have your license taken away, so you're entering a world that has in here. There is bias in every different
48:45
way And how do you deal with it? You You have to understand it. You have to know what you have to think about it. You'll have to judge it for yourself.
48:57
Yeah, and a, if I could also make a quick comment about this that obviously, there's a triode between academia industry and clinicians. Uh, How'd you guys propose that those sort of signature of
49:10
the the top of the gene in a position to influence policy Address this, You know, obviously industries, all of always going to be motivated by profit by financial interests. So is there a middle
49:21
way. We're sort of those in academia in clinical practice can sort of push. It almost lobbied them to dedicate some amount of their resources to the dweller Portland's to the developing world, to
49:31
under service status, you know, sort of whom pushed at hand to be charitable of faith for lack of better wording that what do you guys think?
49:40
But I, if I may mot juste un organisers say something provocative because it's a Friday night had waited in Glasgow, that at least if you look at you know fifty years of Soviet rule and across
49:54
Eastern Europe.
49:56
Zero new drugs emerged from that. I don't know about surgical techniques that might not be the case, but in terms of the, the, in the absence of a commercial imperative, it would appear. For
50:07
whatever reason, certainly drug discovery, drug development is an. Is it is very difficult, and it's not an environment that fosters that sort of intellectual endeavour and having having said that,
50:21
I think there are some reasons to be a little more optimistic now within Senate again, in the context of drug development. The relationship between the pharmaceutical industry and the academic
50:30
centers is beginning to change a little bit, and that what what I'm I take some hope from is that there's a much greater focus now on meaningful impact of research done by higher education
50:43
institutions in the Uk. We used to be judged just on the number of citations of papers go, but now it's much more about the actual meaningful difference that is made, and if you're developing a
50:52
fifteenth, similar blood pressure drug. It might confer modest incremental benefit in the morning as ayers in patients who react to the other drugs that, but you know that's pharmacologically,
51:02
have potentially of interest, but the impact is very small, whereas if you're doing something that will make a meaningful difference globally and years investigating a more a technique that could be
51:11
applied worldwide rather than just exclusively in a developed nation. Then you know that the weight Uk policy is shifting at the moment that will attract more funding and more kudos for the
51:22
institution and vice chancellors in the hands of universities in the Uk are encouraging their researchers to think more deeply about the impact of their research before getting stuck into it, so a
51:32
it's a, it's a small ray of light in quite what is still quite a dark tunnel, and I've got a quick question on the point you made about metrics, so as you said, it was Oliver number of
51:43
publications or citations, citations, and a very good metric for say something like basic signs, but the Mac might not be the best metric for clinical practice. You know vast majority of people
51:53
who'd been the clinical lead. Practicing clinical medicine would be in the developing world, so they might cite your research, but they might find your paper incredibly valuable. Do you think the
52:01
shift has also been made towards these altmetrics. He personally vote. Yes, I think it hasn't happened yet, but I think it's on the way. I think increasingly we are being asked to provide. But
52:11
not only that our papers are being cited highly, but also that what we're doing is impactful and the people are benefiting from the work we do. That's not exclusively immense that covers engineering,
52:23
and you know all the disciplines that universities do and and I think it's a good thing.
52:30
Yeah, in a clinical medicine, also Esa sometimes and their clinicians to read that the papers do not publish, but they danced. They change their am and practice based on the paper they read, so
52:44
they not necessarily meant, since you can Hirano J International, and many many many of the journalists when you look at, they are, they are they the paper? It says the number of times that the
52:55
paper was read, or at least don't know that all that'd be there for rent or downloaded an access know, and they that the social saw is a volume about intangible way of that, then I mean in the day
53:08
and a efficacy of blood pressure or controlling drafters. A different something many clinicians in Scotland are using that new evidence, but that is not translated until many many years after, when
53:25
they say, Oh, yeah, really, it made the difference, but by then the Aca they made at the careers of many, perhaps was the range of not properly fuelled know or you hold, I. I, the paper was
53:37
cited only five times, Yeah, Well Site that five times by the drafter I was proposing. It has been used by thousands of people.
53:49
It
53:51
was Rosalind. You have any comments on that.
53:55
Now, dude. I just want to and just tell the audience. Wednesday. You have to sit back and think about what goes on in society, surgeons light new surgery, and and they approach a situation many.
54:12
I'm not saying everybody does looking for a surgical answer. If you go through the papers in the literature today, there's always a new variety of some technique on which you can use to operate on a
54:25
patient. I don't think that's great advance in science because you can probably do a similar operation in a country that doesn't have all those resources get this yet the same as better jobs and do
54:37
extremely well.
54:40
I think the drug companies look to make money and macadamia. I obviously, people can wear an orientation that from an academic orientation, and you have to be educated in medicine and follow this
54:53
principle in order to be intelligence work, and you got to go to college. You will meet many people in your life who don't go to college or extremely smart,
55:03
and so it basically those things have nothing to do with it. It has to do is commonsense the use of your abilities and talents to the very best you can wherever you are in the world to come up with
55:14
solutions to questions you might have. There are reasonable Sam, or what do you think of that?
55:23
Yeah,
55:25
I generally. I. I agree with that practice wise, and I can say I can see even the point already flagged by a process of Walter about the tele medicine on the application, I, I think at some point
55:43
and let's say there is a solution in the middle between the two at extremes, Order the two pushing factor. For example, I don't have a guideline, but one of the solution to them, many a things
56:02
related to endovascular practice at our coaches at some point related to companies, as you know, that is a lot of supplies, and it's very cozy and it's not available on governmental hospital on to
56:14
the tilly proctoring. Actually we get to the Brooklyn. I'm from one of the professor and. So would you Arab? Yeah, He's trained in Canada, and that for us, at least we are, and what we, we
56:30
think that we are no more ethical. We are not practicing based on direct and decision just to a situation of decision, nor we have the official event that let's say the customized guidelines that
56:46
you're kind of practice on, so that tell him medicine think was was very helpful, and I think game changing.
56:58
I actually have a really interesting a question here in the comments or unnaturally festival. This is the interesting one. I think it'll be at least that interesting one I should just for discussion
57:09
sake, and the question is actually. It's an interesting talking point. Do you reckon a potential solution could be to mandate research alongside medicine to ensure medical research is constantly
57:22
being advanced, and that's actually very interesting point, and we want to go further than but everyone's benefit. Personal Hunter's could use either to the audiences. He runs. For sure. I'm
57:31
just really reflecting. My answer is written on the screen, Illinois My own experiences, When are many many years ago when I was a young doctor doing research about time. If you wanted to work in
57:40
a big teaching hospital, you have to do a doctoral degree, and so everyone had to take time out of their clinical training in order to pursue research. What that meant Was it diluted the amount of
57:50
research money that was available because everyone had to do it and. It meant there was a whole bunch of people who aren't particularly bothered about research, but just wanted a nice job in a
57:57
teaching hospital when they finish the training that they were doing it. All of that the hearts went went fully in it. It wasn't the best model to my mind. I do think that we need to make sure that
58:08
all medical graduates, and it's our job as medical educators to inculcate in all of our students an understanding of how research is done and in order as Jim was saying earlier on to really empower
58:19
them to question what they read and to come to their own conclusions as how to do that unless you have an understanding of the scientific method and process, and so that is the way I would prefer to
58:28
do it and leave the research to those who actually really want to do research. We've moved that way in the Uk in the last decade or so, and I think that's a better more.
58:40
Then you have to remember that probably most of the physicians in the world are not in academia. Yeah, you're taking care of patients and they need to wanted. They want to do the very best they can
58:53
for their patience with what they have and
58:58
most of the journals are oriented to people who write papers.
59:04
The journal Surgical neurology International takes papers from all over the world. Probably more than any journal in our field. We don't even know where they come from, so that that doesn't enter
59:14
the do that. When enters into the judgment is the quality of the work. I. I agree with Professor Walters and research. I don't think I would mandate, and for anything particular, I wouldn't have
59:25
the government government mandate anytime bait. Because equally they can't. They have been able to do anything constructive and were in terrible situations because of decisions made by politicians
59:38
so. I think you're just a goal that you should have is to develop your own intelligence. Your own ability or an analytical skills, and no matter what track you take, whether it's a practice or
59:50
whatever it is, you have to use those skills in everyday life.
59:56
I, I ought to professor award the scum and that of that for those willing to tell to do some form of clinical research on this. I saw a story. Tell either story I saw this patient, and I thought
1:00:10
about this and I game like these on a Friday's and an even wider tonight. I read this paper, and that is basically what any any clinical paper is is about is telling a story. Know the mystification
1:00:25
of natural process of instance, and yes, of course the true researcher says Professor want to say. None of those guys know how to do it, but there are stories about patient care about large number
1:00:38
of it. Patients, a patient care situation doesn't need to be told to guide their research. There are within that most of the other grow. Grow from the lab to the bedside. Usually go from the
1:00:55
bedside to the lot. I've seen this. Can you please the biochemist and pharmacologist explained me today, and then they go on Deutsche as such them, But that starts from the bedside to a there.
1:01:10
It's alright A where the research we didn't be taken seriously in a sense where it would end up. You know a person from the neighboring hospital, but like all well, you know this is just a quick
1:01:20
report from someone. There's no point in believing this compared to what's now being established. As. No, No, we have to believe the large things. Yeah, That's right. I'd usually at bedtime on
1:01:30
you studying Are gay, says that Aids Aids for a long time and I do remember was called the. H diseases, as for the ages, know H you on heroin, abuse, a homosexual and the haemophiliac, and the,
1:01:47
and then somebody said well by them and seen women, having, this is probably no, No, and the New England rejected the paper, dunno women are women who do not fail with within the four ages, and
1:01:60
I'm talking about ninety eight to now forty years ago, so on for Da, but they're am. So yes, the that is a dialogue, and that is a stretch, and all the all the boundaries are flexible enough.
1:02:19
Yeah, Yeah, right, it's been an absolute privilege and I'd like to first of all, Thank everyone who points. I'd like to quickly make before we close off one. If everyone could please write to us,
1:02:30
especially those who are being this recording cause it'll be uploaded future topics that anyone would be interested in and how we can improve on the current session. And if everyone can also wish
1:02:39
Chris Walters Happy birthday, because he's about to head off to his birthday dinner, and I'll give it. I'll give our panelists an opportunity to give any closing remarks that they may have before
1:02:47
we close decision
1:02:51
started. Thank you very much for of for a developing this Midi, and I thank those people for coming. We hope it's been invaluable. We're trying this as an experiment to see if we can have
1:03:03
communication across disciplines and between generations, which is not common Know about subjects that are controversial, so we hope it's been helpful. We'd like to know how we can do it better.
1:03:15
Thank you,
1:03:17
Then do on on on on fun to be dug into your living with you. On learning from the questions. As well. It was fun,
1:03:29
and yeah, I've actually. I. I should say that at the last point I want to bring. What are the thank you is that at I along with their point that pumped out by Mohammad about the citation of that?
1:03:46
A research on how it should be considered is that good or bad, or as endpoint about that. That is it, and they take it in account if it's if it's a new thing or not, but I think it depends on your
1:04:00
angle of how you view the subject or your duty. I think some people should do very efficient systematic research, and some other people who are more in the practice. They made Brown the initial
1:04:16
idea, so they should do similar research. Aren't a part of that. I think both of them are evident. I should be done together and Yeah, I'm I'm very honored to be with this said discussion. I
1:04:28
think you and I would just like to say thank you all so much has been thoroughly enjoyable. Perhaps the Jura collective attention to the principle of lifelong learning, which underpins medical
1:04:39
education is a really a really important principle. I think it's worth mentioning before we close. I am getting older. As we speak, I'm old now and am still learning. I've really enjoyed learning
1:04:50
from the conversation we found this evening and thank you all for joining in and you take a very beautiful segue, just as trust Walter says it's absolutely crucial that that lifelong learning, and I
1:05:02
guess that's the idea of doing something like this. Everybody's learning for everybody and again, but like to thank everyone for coming and hopefully and will have many of these to common. That
1:05:11
many more thoughtful and interesting discussions from the experts. Thank you everyone for a better day by banking, Provide them and your night
1:05:23
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1:05:27
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