The Glasgow Neuro Society in association with SNI & SNI Digital Innovations in learning, present

SNiIDigital's Let's Talk, an intergenerational discussion of the "ethics of new technology and lack of accessibility in impoverished areas" from a meeting held in Glasgow, Scotland, Friday, January, twentieth, two thousand, twenty three,

organized for the Glasgow Neuro  Society, by Mohammad Ashraf, and  Hassan Ishmael , Moderators, of the  University of Glasgow School of Medicine,

The discussion, guests are  Professor Matthew Walters, Head of the School of medicine, dentistry, and veterinary medicine, consultant stroke physician and professor of clinical pharmacology at the University Glasgow,  Emeritus Professor Jorge Lazareff, Department of neurosurgery David Geffen School of Medicine, UCLA and Associate director, SNI Digital,  Professor Samer Hoz, of the  Department of Neurosurgery,  Neurosurgery Teaching hospital, Baghdad, Iraq, Department of Neurosurgery University Of Cincinnati, Cincinnati, Ohio,  and Associate Director, SNI Digital,

Professor James Ausman, Creator, CEO, SNI and SNI Digital. 

The discussion and questions are  sixty minutes,  peer review evaluation is five out of five ranking. Twenty five attendees from three countries  were present during the recording,

Hello everyone. It's my pleasure to welcome you all to the first , Lets Talk Series by Surgical Neurology International and SNI Digital.  This meeting  is in collaboration with Glasgow Neuro society. My name's Mohammad Ashraf and I served as the last immediate past president of Glasgow neuro society. And I'm one of the moderators for today's talk. We are one of the largest student run interest groups for knowledge into surgery in the United Kingdom are located  at the University of Glasgow Medical School and but affiliated, closely supported by the neurosurgical department at the Institute of Neuroscience. The  beginning of this podcast style, candid discussion on important issues pertaining to 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 and lack of accessibility, especially in impoverished areas and in the developing world". I'd like to give over to my colleague, Hassan  who's going to introduce himself and over to our speakers,

Still good evening. Everyone. My name is Hassan. I am this year's presidents of Glasgow Neuro, and as  Mohamed said we are delighted to be hosting what we're hoping to be 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 like fashioned way. You're welcome to ask questions, 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 the SNI Digital website. Keep 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 any suggestions for ourselves 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  a 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, I am JIm Ausman.

I'm a neurosurgeon, also saw trained as a pharmacologist. I didn't tell you that Matthew, but headed two departments of neurosurgery and was the professor at four medical schools around the country. I  started a journal, SNI,  surgical neurology International, and are starting this new format that , Muhammad, and Hassan, and his of his group, actively participating in. It is called as SNI Digital, which is a open forum of discussion of controversial topics.

I'll jump in next. good evening everyone, love to see all and particular thanks to Mo and Hassan, for for pulling this together with a with others who helped with this organizations. My name's Matthew Walters. I'm Dean  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 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 stroke patients unsurprisingly. So that's me; nice to see you all. 

I am Jorge Lazareff.  I participate in in the beginning of this something that will continue to grow, absolutely deserved them. They're my experience. I was a

pediatric neurosurgeon  essentially for twenty years, in the USA  many other countries. Before now, I am interested  in  education or change of information with 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 for being part of this.

I am Samer Hoz. I'm a neurosurgeon and I have a practice, in Iraq, I do vascular neurosurgery both open, and interventional  and I have experience with trauma black Ten years in neurosurgery Now, I'm based in the University of  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, And yeah, let's learn together.

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, 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. Walkabout the stepping stone towards that which is evidence based medicine, and I'd like to direct the very first prompt towards yourself, Professor  Walters, where evidence based medicine has received 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 on it. 

absolutely were British nationals who use of medicines informed by the best available evidence that we that we have, and it is taking that simple 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 offer individual patients, and by applying those patients judiciously thoughtfully and with the. And then with the consent of the patient, and it you're right that I, I think it can lead to a 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 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 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 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 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 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 medicine which was a difficult thing to do in  the early days. The, the alternatives were far less attractive in a scientific sense, though is what was known as evidence based  medicine, Which was the most 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 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 -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.

There were issues and I don't talk too long about this. The current issues with evidence based medicine. It can really only be applied where there is evidence, so there is still room for the arts as well  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 say as a professor of 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 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.

Jorge,  Do you have any thoughts on that subject? Yes, I mean. I certainly I do  want to,  but the one of the issues with evidence based medicine that a created a very high standard that is not always possible to achieve by everybody, so everybody may get responded on dismissive of the evidence base. Because you don't have the means that, then you've got the means to achieve that perfect diagnoses . Bringing down to the core essence independent of the technology that you use,  ....... . there are countries where those saying it's gonna be done because that the patient is far away as Samer may know, and the patient from seven days later after a SAH, then so what you do with a seven days after patient know;  so that an evidence based medicine transformed more into medicine based evidence. In the sense the individual in needs to get a fair treatment. Okay, The  patient does not fit the criteria stated by everything's made in medicine, though so I, 

....... What about yourself and Dr. Samer Any thoughts from your point of view. I know you know evidence based medicine is perceived differently depending on the person and opinions on it.

And yeah, actually, I am listening and have

many thoughts and examples, and I want to share just a situation. ......If you, If you are thinking of ethics and new technology, and I think the on a practice, you will find an an additional point, Which is who decide is that ethical or not, and of the situation behind that ......say that if you have a patient, and you have limited resources, and for example, I can give only from the knowledge  that I have been that I am a neurosurgeon. And I know this is not exactly as is  said  all as as the guideline, but I'm obligated to, maybe because of limited resources. Maybe sometimes because of I, I didn't know cultural limitation that something will be accepted in this part of the world. ..... It's not the same as not even I think the patient consent, but patient understanding of. Let's 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. ..... ....  This is artificial intelligence and I ask .....Chat CPT is new Artificial Intelligence . 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 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 CHAT got 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 that's an interesting point actually unfair for those who are unaware, just so he was gonna say chat Gpt to use this fantastically new ai that was recently released, and whilst it can do practically 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 that in fact this ai is capable of passing us ....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 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  to the Chat gpt

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 law, ..... A neuroscience of social sciences, and I say to that, and at the students that the objective of the of you being here on you'll be an in depth every day, Because you. ..... Not 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.  The best evidence. Yes, It's fantastic. ..... What are the best possible evidence is

collected analyzed...... The Professor Walters that we need to have these like the Gpt, or rather than a benefit Gpt, 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,

and I make two innocent comments

 The question is what is evidence,

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 phenomena that occur that various people interpret. We don't have to interpret  them the same way, and then the question is with the word evidence, while evidence means a lot of different things,

for example, or you can have evidence based medicine their studies, the neurosurgeons know in neurology and neurosurgery, there was a study done some years ago, which was a randomized controlled trial evaluating a surgical procedure, and whether or not it'd be helpful in stroke,

The the problem turned out to be that the people who are running this study came up with a result but . Others disagreed with  with the conclusion from the evidence, and they formed a special committee to go back and investigate that it can be found that the study evidence couldn't could not reproduced 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 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 without being challenged in his, 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 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. We  are brainwashed to believe that randomized controlled trials are the gold standard of medical observation. I don't agree with that

I think randomized controlled studies and I agree with the  professor there. In pharmacology, many other specialties in medicine can be, if conducted properly, very  illuminating, but you've just seen in the Covid virus work and the vaccine work in your country and our country, USA,  that there were a number of studies. Somewhere, not even randomized or controlled were 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 randomized controlled trials were corrupted. So the challenge to you as a physician as a student is to use your mind. Use your brain and question what is the evidence? What is the basis for 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 properly run studies to come to a reasonable proper conclusion.

Absolutely Professor Walters says.  Are you just just a sort of fully endorsed. What what Professor Ausman  just said  thing is actually right. There is

the best that we've got at the moment. I think that we 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 have, but there is a a real caveat there which exactly he said,  we need to be willing to question everything when we're reviewing the literature. We need to identify our own 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 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 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 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 illnesses that 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 of people with in societies. They 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 shocking statistic.

Yes,  ...... 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 gave a series of lectures,  on how to write . .......very good guidelines know if there were published recently in the journal and the New England Journal of medicine, but I say what are your experience  in telling us what to do with the disease. 

........pediatric neurosurgery we close, despite a beefy than the first one before,.... but there are countries where where they have to close a myelomeningocoele  at seven days after ten days after...... What is that the literature from them telling us what they have observed, ...... This thing is encouraging that that the work by. Different clinicians researchers in different countries do ...... What can be done, and that they, that can be incorporated with the professor Walters,  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 seven days after the event ..... ....... So my point . We have to find a way of encouraging those who see those differences to tell us what out of their solutions to those problems

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, it says when it comes to access certain resources some are expensive are large enough that they require so that  they require that moving patients to central sites.   and it's costs hinder accessibility where potentially rural individuals are left out.  Far away from accessing, these might not be able to make use of potentially new technologies

........

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. 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 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 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 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 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 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 one example of how we can mitigate it, but it remains a big challenge for us.

..... I'm thinking that I can give example and to have your thoughts, especially for

that attendees here at, based on our experience with the professor, and I want to share two point. The First point is that I'm practicing in Iraq. I'm doing the  surgery, and just to graduated. At all of a sudden. I found very crucial question. ......Obviously based on, then you go to a surgical basic knowledge that Yeah, you should do. If the aneurysm rupture how patient somebody younger age, you must treat the patient as soon as possible. At that point, I start. We search for any 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. Basically, so I cannot practise this  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. 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 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 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 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 patients of rupture out of control. SAH Hemorrhage died within the 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. 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 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 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, maybe one week to week and fifty cent of people. That's that's the evidence. If you wait one month then fifty per cent. There's a chance of mortality for those patient. So it was. It was a huge 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 that's how let's say the resource limitation may and have extra at like meats.......This might 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, 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 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?

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. 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 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 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 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 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 . It remains a source of immense frustration that we still 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, 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 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 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 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.

Absolutely any thoughts from the rest of our panelists will not sure.

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 inferior to that in the high end countries..  Do you need technology in order to practice good medicine. The answer to both of those questions is No

 The greatest 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 them. They become successful

at first carotid endarterectomy in  Brazil are the first coronary bypass has done in South America, Argentina. So so why I think people have been brainwashed to believe if you have a 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. I'll give you a practical answer is taking care of a patient. Some years ago He was a farmer

 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 chemotherapy. 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 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 for the 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 members or neighbors or friends. What is a practical decision. We want to make sure know this.. We had this meeting with SNI Digital, with some very high powered people from the United States, and elsewhere, talking about the advances they were making and traumatic brain injury. Samer  presented his work from Iraq, and one of the panelists turn to him;  He was from Johns Hopkins, who is a critical care specialists,  said we cannot  get the best results you have. What

is the message you don't need to be in a rich country. to do good work and get good results. You've been brainwashed to believe that that's not true. SO technologically. How much of this is valuable. There are all kinds of technology being promoted for spine surgery. 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 into money,

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 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. 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 the UK is a backward country that. While yes, in some ways we are, also in the USA  we cannot practically provide this care to everybody everywhere. There are many factors that go into he mentioned..........

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 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 don't reach  that, .......you ought to know the results that if you didn't do that at the procedure or follow, they do that. .... You are doing something wrong.  ......... You ought to doing something wrong. No, you're not doing something wrong. Is the dynamic of the evidence based medicine allows or should  allow. What 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 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. 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 reach that that stand them

anymore, questions Muhammad or someone from the audience.

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 taken a more seriously than not from less developed countries. Yes, I think that's actually. It point...... Yes, there is a bias against the LMIC. I wish I had that reference I read it many many years  ......... It did where there was a group of doctors from it, The Mexico. They send a paper to a journal clinical journal from Mexico, . They were rejected, so they added a doctor 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. Lie after know you said to of being day to an astronaut. It was accepted ......

 I do remember talking to Chinese college in China. They have experience. If we have fifty patients. They have five thousand gain acne. 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

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 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 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 which which we need to arrest,

either set a quick comment here and there the answer is resoundingly.

Yes, and a, if I could also make a quick comment about this that obviously, there's a difffeernce  between academia, industry, and clinicians......... You know, obviously industries, all of always going to be motivated by profit by financial interests. So is there a middle 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 to the developing world, to under service status, you know, sort of whom pushed to be charitable of faith for lack of better wording that what do you guys think?

But I, if I may  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 Eastern Europe.

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 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, 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 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 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 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, 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 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 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 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 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 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 shift has also been made towards these altmetrics.

 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 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, and you know all the disciplines that universities do and and I think it's a good thing.

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 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 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 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 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 cited only five times, Yeah, Well Site that five times by the drafter I was proposing. It has been used by thousands of people.

It

 You have any comments on that.

Now,  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. 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 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 extremely well.

I think the drug companies look to make money

People can wear an orientation that from an academic orientation, and you have to be educated in medicine and follow this 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,

and so it basically those things have nothing to do with it. It has to do is common sense the use of your abilities and talents, to do the very best you can wherever you are in the world to come up with solutions to questions you might have. 

 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 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 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 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 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 you're kind of practice on, so that tell him medicine think was was very helpful, and I think game changing.

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 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 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 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 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 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 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 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 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 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.

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 for their patience with what they have and

most of the journals are oriented to people who write papers.

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 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 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 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 whatever it is, you have to use those skills in everyday life.

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 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 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 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 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. 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 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 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, 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 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.

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, 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 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 we close decision

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 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. Thank you,

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,

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? 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 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 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 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 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 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 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 many more thoughtful and interesting discussions from the experts. Thank you everyone for a better day by banking, Provide them and your night

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