Transition

It’s now a year to the day since my last post on this blog.

One year ago I took a piece of paper to visit a friend,
she signed as witness to a change in my name.
it’s been a long journey, it’s not been easy.
I think it’s fair to say that some were surprised.

I wasn’t surprised because I’ve always known
A splinter in my mind nagging and telling
A question hanging over every relationship
” if you knew who I really was, would you love me still?“

to know that you are impossible, unnatural
to hear “people like that should be locked away“
that “you’ll ruin your life if you go on like that”
means you bury it deep, in a very deep grave

and on the soil of that deep grave
you build a life, full and challenging
you work, you work, you work
as work sets you free, you don’t have to think

you know the part you know the role
You wear the suit, you smile, you laugh
you watch the others and learn to pass
until it’s almost like you’re really there.

But ask any gravedigger and they’ll tell you
That graves collapse as time does pass
And monuments or stones erected
Will lean in chaos or collapse.

The ecosystem of my life was dying
I had tried and almost passed
the clock, my time of life was passing
and I had lost my well worn mask

the songs I’d sung, the hymns and motets
the prayers became the words he’d said
i didn’t know if divine creation or aberrant
psychology was my inmost being

but ex terra lucem is my home town motto
and through the soil rose up my soul
forgiveness for the lies I’d lived
not certain and certainly not my prize

so here I am at last existing
within my life some damage caused
some pride still for the history created
and trepidation at the future course

I have the words, I have the skills
i have the friends and family
i have the knowledge of my existence
but finally, I now have me.

going digital in general practice

There is a recent British Journal of General Practice edition which focuses on the use of health technology to digitise Primary Care.

The edition opens with an editorial which focuses on the challenges of modernising general practice. There are a couple of papers looking at the results of a study in primary care of patients and clinicians thoughts about using video and telephone consultations, followed by an analysis of the content of video and face-to-face consultations.

My problem with this edition is that it is effectively trying to understand whether traditional general practice, based on booked appointments and face-to-face consultations and decades of experience, can pick up the new ways of working to transform into a 21st century process.

Needless to say one of the big drawbacks pointed out is that not everybody has access to the technology which is required for the new models of working.

This is of course the case with any new technology whether it is electric cars or video streaming services, without the infrastructure access is impossible.

However, choosing to avoid the temporary inequity involved in disruptive technology attaches the provider to a population which will become obsolete in time. We saw this occur rapidly with video tapes and video streaming services, we see it slowly with banking services. The transition from cash to cashless is following the growth of digital hand held technology and moves at a generational pace.

The problem when it comes to technology is that very few incumbents can adopt the nee ways of working at scale and pace, for them it will always be an add on.

It's the new entrants who are digital by default who embrace the technology and create the new models of working.

Perhaps there's an argument that the best way to digitise General Practice is by starting primary care again with a blank sheet?

Virtual Consultations - Where to bury the survivors?

You know the old joke, "if a plane crashes on the border of France Holland and Belgium 99 people are killed where do you bury the survivors? " say it quickly and a debate follows on international law.

I feel we're enacting that joke in the real world right now over virtual consultations. This new frontier, like many new frontiers, is moving ahead of the laws meant to govern it.   When you consider an online consult the current default is that same country consults are safest, governed by the law of one land. The inherent lack of geography contained in teleconsultation means that not only is it possible to consult with people in different countries, there are certain times it's preferable and safer than face to face.

Seeking primary care attention or specialist advice whilst on holiday may be facilitated online safer and more effectively than a random visit to local facilities with different languages, drugs and guidelines. 

If I'm ever lucky enough to  pre-retire I'd like to spend some time abroad and have considered teleconsultation as a way of maintaining professional practice whilst outside the UK.

The biggest single barrier is indemnity. 

If I'm in France and consult via servers in the UK with a patient who is on holiday in Dubai where do you handle the claim? 

In other words where does the consultation happen?  

Cyber law currently lacks clarity. Hack a server in the states - the feds want you, but extradition may not happen so you are charged in the UK.

I would suggest that since both patient and doctor choose to use the same online service they are both agreeing to consult in that "location" . So the legalities of the host nation providing the online environment have primacy. The clinician will need accreditation in that country.

The alternative is chaos. The alternative is to suggest that the chair in which I sit as a doctor plays a bigger part in the consultation than the screen I use. The alternative suggests that the nature of a patient doctor consultation is influenced by the sunshine, air temperature and humidity the patient is experiencing.

You could argue that the exchange of information is between the mind of the patient and the medic and that therefore the consultation occurs 50% in that patients country and 50% in the medics and has nothing to do with the location of the servers facilitating the consult. That would be useful if it were then possible to prove the "processing error" happened either in the mind of the doctor or patient. However it still means that the actual consultation occurs in two places at the same time. 

Arguing that the consultation takes place only in either participants head is, I suggest flawed and not worth exploration. 

So, to sum up, when you undertake a consultation I would suggest that the location in which the consultation happens is the location in which the consultation happened,  whether you consult me face to face at Wingate Medical Centre, call my phone number at Wingate Medical Centre or video call me at Wingate Medical Centre  the consultation happens there, at Wingate Medical Centre.

When you call it matters not to you   whether I'm in room 15, the meeting room, at home or abroad- the consultation happens at Wingate Medical Centre.

You see, there's no need to bury the survivors. 

Cherry picking or evolution?

 it's been an interesting  couple of days on Twitter, with concern being voiced in many quarters about the new service launched in London by Babylon Health.  

 Here is my declaration of interest:  I am a sessional GP for Babylon Health,  I also work as a regular NHS GP and in the local out of hours service which is a GP co-operative. 

I'm also a patient, one whose GP offers routine appointments for the next week every Wednesday,  and on the day call up at 8 for the lottery of today's appointments.

My GP was failing before Babylon. 

When I work out of hours I'm supposed to be out in the vehicle, but I spend a huge amount of time on the phone speaking to people looking for advice and support which they can't get from their GP during the day.  

This was happening before Babylon. 

So, we can rail about a systematic underfunding of primary care. We can  cry foul over allegations of cherry picking, but the reality is that patients can make their own minds up about accessing a GP service, Some will choose access over continuity, others will stick with continuity in the face of failing access.

What you can't complain about is a new entrant to the ecosystem who sees a niche and exploits it, because that I'm afraid is evolution.  

The Virtual Locum is here

Right now is a great time to be a GP. 

There are too few of us to continue with the way its always been done, so we now need new ways of working to be actually implemented.  

My solution ( one of many) is the Virtual locum. I'm not talking an AI or online text service, but a human, able to log on to the clinical system, pick up a list of calls, either telephone or video and then work through that list from wherever they are. Supporting practices with specific projects, solutions or activities which are suited to remote working should remove the need to get bodies into the building.

There is sufficient evidence to support the delivery of good clincial assessment by experienced clinicians as a means to reduce inappropriate face to face consultations, improve access, and outcomes.  

It's not rocket science but will enable practices to not divert precious clincial room space to phone calls, to not have to learn the skills of telephone and video consults, to offer patients the possibility of evening and weekend calls without opening the building. 

Obviously the key issue is systems access, which is not difficult , but tends to be guarded by parochial IT services who demand control and ownership of the technology and the process of access. 

Right now if I was a locum agency I'd be seeking clinicians with that skill set, developing the infrastructure and preparing to solve the workforce crisis by removal of travel time and clincial space requirements.  

Interested? Ask me more...lets hangout/FaceTime/ Zoom about it. 

Mr Spock, you have the conn.

It's interesting to think that Star Trek foresees the use of a naval term which dates back to the 1800s. The conn refers to control of the a ship, usually controls these days but previously the rudder control.

This ritual means  it's always clear who is in charge with the handover being unambiguous. 

I thought of this when hearing about the death of of a driver of an automatic car made by tesla.  

The driver apparently only had his hands on the wheel of the self driving car for 27 seconds of his 37 minute journey. However the manufacturer recommends that you keep your hands on the wheel at all times, even when the machine is in charge. 

I'm sorry, but that's not clear enough to be safe. Either I'm driving or you are, either I have the conn or you do.  

That's something we can learn and a mistake we can avoid as we see the growth in Artificial intelligence and Augmented intelligence in medicine.   Either the AI is taking the decision fully and is recognised as such, the best example being warfarin or an econsult which has an outcome and the human will accept the recomendation as reliable, or the human still has the conn and takes the AI or AugI under advisement. 

Effectively this  is a binary representation of the fluid negotiation which occurs between a clinician and their patient during every consultation. However that also fails due to lack of clarity, the number of times patients say they persisted with inadequate or inappropriate treatment because the doctor told them to, is legion. 

Unfortunately we are the designers of the intelligence, we are the users, and we, not the intelligence, will suffer if the lines of responsibility are not clear. 

Mr Spock, you have the conn. 

The fault lies not in our stars but in our cells.

Ok Shakespeare didn't say cells, but selves. The science of genetics would have us believe that the fault does reside in the cells and that as we progress our treatments will become personalised to match our genome.  

The much talked about 23andme service is pretty much the vanguard of the genetic revolution for the fairly well off man/woman in the street, so as a prime example of the man/woman in the street I have completed and received the results of my personal genetic analysis. 

Why did I do it? 

Several reasons, firstly I'm a seeker after knowledge, secondly I'm a technophile, thirdly as a clinician I will be dealing with omics increasingly over the next twenty years and how better to understand and explain than to experience and explore?

What happened? 

The mechanics are simple, spit in a tube, post it off and 6-8 weeks later the results appear as a link in your inbox.  

What did I learn? 

The results are fascinating, there's two parts, the historical evolutionary part, and the health part. 

It turns out my ancestry is European. No surprise, but seeing my maternal lineage arising from Africa and paternal lineage arising in Asia is truly fascinating. 

The health part was more concerning. There are dozens of traits, disorders and diseases that are screened. Some are expressed as associations with disease or characteristics, others are expressed as risks of development of certain conditions. 

Thats where the General Practitioner will have an issue. 

What do you say to someone discovering a risk for HOCM?  

What do you say to somebody who receives a report saying they have a 20% risk of dementia by age 85? 

Think about that for a moment. Imagine opening the report and seeing an "increased risk" of 20% dementia at age 85. How do you feel? Happy that's 80% not likely to have dementia? Determined to not live to 85? Shocked it's so low given your family history? 

There may be a bit of everything. But who will you ask to set this in context?

I'm prepared to answer that question now. I'd say that the prevelance of dementia in the 85 year olds, is between 24 and 50% so having a 20% risk is not necessarily as bad as it may seem, and that an association does not always result in an actual disease. 

However there are lots of conditions that I'm not prepared to answer at present. There's a lot of answers I need to find out to have sufficient knowledge to be an effective resource to my patients.  

There's some fascinating stuff around effectiveness and medication, in my case I'm at an increased risk of statin related myositis, and also unresponsive to clopidogrel. 

Who knows, at some point in the future that knowledge might come in useful.  

So, I've done it, I'm preparing for the population to ask, I've experienced the process, I have knowledge of my cells, now it's time to reach for the stars. 

Saving Face

Have you tried the Face App? 

if you do social media you will have seen the collages produced by the age changing, gender bending app. It recognises the key points of your face then applies the formula values associated with age, youth , male or female genders and even a "good loooking" formula.  

The science behind it is the one which means your passport photo should be without smiling and glare free on the glasses. There's been a lot of money spent on facial recognition.  

There's also been a lot of money on machine learning so what happens if you put the two together? 

In the world of medicine the answer is Face2gene .

This app has learned the typical features of people with multiple genetic defects. Unlike a human geneticist who must study books, recall the details and make a judgement call before ordering genetics, the app compares and produces a likelihood match for hundreds of conditions. 

Clearly there are caveats in using this app.  

Its designed for clinicians. It's designed as a diagnostic aid not a replacement for clinical expertise.  

Here's an example.  

I have a high gestalt match for Gapo syndrome. Never heard of it? Me neither.   The gestalt match means my photo matches the aggregated "deep learning" of the system. 

I do not have Gapo syndrome, I have hair, relatively normal intellligence, and have made it to over 50. 

The system is essentially providing the clinician with a memory which never forgets, never struggles to match the pattern. As the ultimate genetic aide memoire it's got a bright future, as a replacement for a clinical geneticist it's a dodo. 

Happy St George's Day!

Take as read the usual inclusive stuff about us adopting a Turkish soldier or the fictional nature of his task.

Today is a chance to celebrate what it is to be English.

I don't mean flag waving xenophobia, blind insular superiority, or apologists for acts of history.

I don't mean feeling aggreaved by historical slights and injustices now centuries old.

We are a small country colonized many times, whose world impact over centuries has been astounding.

Combined with our Celtic partners, our nation has spread justice and fear in equal measure. Science and exploitation have been partners of ours through history.

However, we do also have the ability to change. We have led the world in establishing law, justice, even charity, we are often regarded as the gold standard of conduct in many walks of life.

As the second Elizabethan age draws to a close we have the chance to leave a mark in history.

On Friday we did a day without coal powering our electrical needs, for the first time since the industrial revolution we did not power our present by burning the past.

Every day is a new start, a chance to define ourselves anew, a chance to be proud of our journey, but not contained by our route to the present.

That's why each day we face our dragons and can only do our best.

That's being English.

Just as real, but different, Dry Brain, Wet Brain

It's fascinating reading about the demise of human doctors, engineers, architects. All made obsolete by the rise of artificial intelligence.  

I'm irked by this talk.  

I don't deny the benefits of instant recall, analysis devoid of emotion and all the powers that come with binary based, self learning systems. 

Neither do I deny the benefits of empathy, soft signals, people based communication.  

i suspect the reality is one of Iain M Banks Culture novels, augmentation not replacement.  

So I've been looking for a way to explain the best of both worlds. 

"Artificial" is an ugly word. It resonates with artifice, despite its honest hand hewn origins.  

Watching Dr Who recently I heard a phrase from my undergrad days "wet brain", of course as a medic this is an out of date name for an alcohol induced brain disease, but through the wit of the writer (Frank Cotterell-Boyce) it was paired with Dry Brain; Human and artificial intelligences placed side by side, neither replacing the other.

Suddenly it seems much easier and more honest to recognise the two different, distinct and possibly equally valuable intelligences. 

For risk analysis, hypothesis generation and decision support a dry brain is clearly the best tool. But for tears, empathy, honest explanation, and nuance a wet brain is essential.  

I have a motto for the registrars, my own "House of God" rule,  

"people don't care how much you know, they need to know how much you care." 

However, accepting the synergy of wet and dry brains means we can offer our patients both knowledge and care.  

If we ever founded a Royal College of Informatics perhaps I can suggest the motto might be:  

Cum Cognitionis, Caritas  

The best of both brains. 

From the ground, up.

Q? What happens when you put corner shops and the post office together?

A. in China you create a retail network which rivals major brands for supremacy. 

Q. What happens when you put a community provider and a bunch of GPs together?

A. Usually nothing, they just "work together" it's like working apart, but you tell people you are working together. 

I know there's a lot riding on the new models of care programme, but I don't think that anywhere has really created the synergy that exists between corner shops and post office in China. 

I say this because fundamentally the organisational structures still remain, cultures still survive, "referrals" are still required and demarcation defines access. 

So, if I had the chance to design primary care from the ground up how would it look?

Firstly, there is no one size fits all. 

Dependant on activation, need (health and care), social segmentation and personal choice our consumer fit will vary greatly.

Recent work in my own practice neatly illustrates that people who use out of hours services are not people who couldn't get access to the day time GP, they are people who access out of hours services. some people choose to make the accident and emergency department their medical home, others choose out of hours GPS, most choose their GP, but even there the choice is a myriad of all alike, none the same complex choices.

Secondly, increasing need creates increasing fragmentation. 

When you are well or have a mild to moderate health need there's a good chance a single provider will manage your care. But with increasing illness and frailty your attendant providers increase in number and each new interface offers a barrier to communication and knowledge. 

So how could it be?  What would the alternative to fragmentation be? I think that the answer is actually pretty clear. The idea that existing General Practictioners can keep up to speed on their populations health, their patients care, their organisational sustainability, their extended team members in different organisations, and the overall responsibilities of cradle to grave care is no longer tenable.

Equally risible is the Dr Informed mentality of abrogating personal, professional responsibility because the GP has been informed. The storm of data flooding the doors of most general practices is clearly beyond the capacity of a decreasing number of practitioners to process, analyse and act upon.

So here's the deal. 

Dismember practices, dismember community trusts, work on the basis that 2000 people, 2 GPs,6 Nurses, 20 paid carers dozens of family and community based carers plus admin constitute a medical team. That all professionals access the same care record, that the record is supported by data mining and social prescribing to promote health and community cohesion.

This team does not work in isolation, they are supported by an infrastructure covering a million patients, the remains of what used to be hospitals, with specialists whose purpose is to intervene when needs arise beyond the medical team. The intervention is not necessarily face to face, or one to one, remote group consultations supported by a clinical facilitator will educate and share knowledge with groups of patients and carers whose shared experience acts as a reservoir of community support and care. Can't remember what the specialist said? - ask Mabel she was writing it down, or play back the recording, it's on your phone. 

Taking  this to its limit the ownership of health resource passes to the community. The custodianship of resource is a shared endeavour.

Is is this too far? Is this too flawed?  I don't know, but it must be worth a new model of care.

Consent- with feeling- Facebook style

Just so you know. If you are one of my patients I can look at your data in the clinical system, but I can't see your hospital record. 

It's ironic because the etymology of consent is from the Latin words for "with feeling" in other words consent means our emotions and motions are aligned. All too often we take consent as meaning "with knowledge"   so accessing a patients record without their knowledge is a bad thing, but what if it's something that you are doing to help them and improve their care?

I know if you work in healthcare these Information Governance silos are commonplace. I also know that there are good reasons why I can't just go browsing the hospital records of patients for whom I don't have a legitimate relationship. 

However, I'm suspicious that in a lot of circumstances the barriers we use to protect data are in fact just protecting the interests of the organisation that supplies the care or the provider that supplies the system. 

Here's an example- If i send a patient to hospital the letter I send is created by me with the amount of data I considered necessary. If the specialist wants more info they can not get it without writing to me and I write back. It's antediluvian.  

It would be much better if the speialist could just dip into the patients record, read the stuff they needed and bingo! Problem sorted. 

We don't do that, we have an industry of governance, a consentual nightmare.  

If I may can i suggest we move to the way our world works in other spheres.  

Right now there's a lot of people on Facebook. They have been trained, prompted and schooled in the art of information sharing.  

"Who do you want to see your posts?" And "Share with friends (except acquaintances)" is not rocket science, but if the NHS were more like Facebook in its consent life would be a whole lot easier.  

Imagine seeing your GP, afterwards you open the app, view the notes of a consultation describing your bad chest and need for time off, then you choose to make it available. Your default is GP and primary care team, but you can choose share with family (careers),  secondary care (named specialists), research (non identifiable), and even your employer! Of course your attendance at the special clinic has a default so not even your GP can see it. 

To establish the choices each of those specialists and wider care team would need to send a "friend request" ad you the human would need to decide or refuse. Simple. 

Just like Facebook.  

Now you'll tell me, just like Donald Trump that Healthcare is complicated, that access to information on which decisions are made is critical, that data is valuable, that breaches are costly, that I clearly fail to grasp the complexity of the situation. 

My response?  

Unless we decide to put the person who we are caring for at the centre of a joined up network of consent to share the NHS will fail. The move to accountable care organisations will require such a model, HIPAA-esque portability of records. We either do this or our cousins from across the water will show us how its done. 

Just like Facebook.  

Not my Future, Not my Monkeys

I recently had the pleasure of attending an event for "Big Minds" to anticipate the future of healthcare.  

It was fascinating as people exchanged ideas that could be part of our healthcare futures. I wont say what the "Big Idea"  was that emerged from the group was - thats somebody else's prize, but I'd like to make a few observations.   

I read a book when I was a child, I can't remember the title, but it was something along the lines of "The future of work with computers". It was brilliant, essentially the exponential growth in machine prowess meant that by the time I reached adulthood my function would be to enjoy leisure. Perhaps to aim for those few jobs that machines were still not able to handle, but only for a few hours a week. 

Taking this advice to heart I became a Sax playing, Haiku writing, Dog Mushing, writer who practices medicine to "give back" to society. At least that was the plan.  

The reality of this future prediction forty years on is that we are not on a three day week enabled by machine intelligence, living in a utopia with food and shelter for all. Instead I work the equivalent of 6 days a week over 7, managing health risk in a system which is on the edge of collapse, at a time when global unification for mutual survival seems an impossibility. 

Unfortunately I can't claim mis-selling of a future like personal insurance product, I wouldn't even want to go back and change my career path, I can say after over 5 decades, I'm happy being me.  

However I can rejet proposals to create a future which, In my opinion, is further mis-selling, further false prophecy, 

I'm still troubled by the fact that 60 people in the world have as much wealth as the bottom 50% - you want the source? its from Wired Magazine earlier this year. 

I'm troubled that in my generation we have gone from biodiversity to extinction with our eyes shut.  

It may trouble you to know that scientists are studying a particular nematode ( thats round worm) which has a mutant variant which lives a life three times longer and more healthy than its non mutant cousins, that those scientists are working out if we too have that gene. The prospect of tripled lifespan may be near for those 60 peoples descendants whose wealth means nothing is impossible, but for my patients whose finances mean that sometimes the choice between medicine or food is a regular one, tripling life expectancy is a horror only Dante could imagine.

So forgive me if I don't embrace utopian far flung ideas of possible futures. I've read them in science fiction, seen them in the movies, and pondered them in my wildest dreams.  

I'm prepared to be entranced by someone who can do something NOW to make a difference to the living, which will in turn enhance the lives of those yet to come. I'm looking at Bromley by Bow and thinking that's my option, I'm looking for the solution to the next twenty years of ageing population. Rather like William Gibson I think the future is already here, just not evenly distributed.  

So forgive me if your future is an appealing challenge, an exciting science based proposition,  but as the Polish people say  Nie mój cyrk, nie moje małpy . I'm interested in the applitivity of existing approaches, the benefits to be gained for the three to four generations alive right now and the one next to arrive. 

Fix today, forge tomorrow, and teach our children to dream the future.   

NHSUX

I recently tried to hire a city bike in Liverpool.  

It didn't go well. 

To be fair its never gone well. I use it infrequently, so each time I do I need to find my log in and password (worryingly described as card number and pin), take out a contract, add credit, then actually get my bike out of the stocks, which last time failed to happen. 

I occasionally take out a "Boris Bike" in London.  

That works. 

There's no app, just use the card, take the bike, ride. That's it.  

The difference is not the technology, the app is arguably more "modern" but arcane in its workings.  
The difference is not the bike, they both work in the same way, indeed you might observe that the Liverpool bikes are pristine clean in the white and green livery. 

The difference is in the user experience, the UX as technologists call it. 

Recently our practice has had some concerns regarding comments on Facebook. Apparently being accessible enough to provide people with a GP contact 3 hours after they decide to come in isn't good enough for some.
In context of course we have over a thousand patients a week generating a contact with us, so one or two a month is small, but we think significant. 

We are still implementing our new model, redesigning and shaping access, long term conditions, self care and data mining to offer a personalised proactive and sustainable healthcare to the residents we serve.  

But those one star and no comment reviews are worrying.  

Currently we offer phone and two apps as means of contacting the surgery.  

Currently we offer phone or face to face as means of appointment booking.  

Currently we use text, letters and app notifications to contact people. 

From the UX perspective we are still fragmented.  

I appreciate we will never be able to meet all demand, two people wanting to see the same GP at the same time, when that GP is not available, are both going to be disappointed, but still we can make it easier, better and more joined up than our current process. 

We just need to partner our IT systems with a UX focussed front end. 

Any takers?  

What would a Clinical Turing Test look like?

I have always been a big fan of the Turing Test. When I first attempted "Computer Studies" O Level, in a school with no computers, the history of computing was actually quite brief. The terminology very basic, as were the languages. However, above all the acronyms and bits soared the principle of the Turing Test. 

A Test so beautiful in its conception that you can explain it to a small child "are you talking to a person or a machine?"  

It now seems likely that we will actually achieve machine intelligence in my lifetime, that the Test will be passed, that we won't be able to tell if our casual conversation is with a human or a machine.

But is the Test good enough for a Medical Artificial Intelligence?

The current Test only requires that the tester remains unable to distinguish between a person or a machine. A clinical Test will also require that the patient can not only not tell if it is consulting a human or machine medic, but also that the intelligence is most likely correct and appropriate for the clinical interaction. 

Our first issue is that sometimes medical problems have no answers, since they are often not problems to be solved, but statements of fact. These quasi philosophical challenges "why am I so unhappy?" Do not have right or wrong answers, but they can be judged as appropriate in the eyes of the questioner. 

Principle One-  The patient should feel understood and that their question answered by the entity.

Our second issue is that with enough questions any fixed answer from a large data set can be reached, play "Akinator the Genie" game to appreciate that, but imagine being the patient on the other end of that algorithm, forced to already identify a single topic and stick to it, fact g endless questions. Humans will always be human and extraneous data will always occur. I remember a case from medical school of a man who was certain that his Lymphoma had been triggered by eating UHT cream.  Would the AI discard that information as quickly as the human?  Would it go on to ask about other food allergies? So the questioning must be person centric, flexible and time bound, this is a judgment by the patient and something a reasonable body of clinicians would feel adequate. 

Principle Two- The patient should feel humanely questioned not interrogated by the entity.

Finally the Clinical Turing Test needs to be   compassionate. One of the joys of the brilliance of Sherlock on the BBC is the dismay shown by clients when their cases are solved by blindingly obvious deductions and they are summarily dismissed. The medical equivalent of "Yes, yes, you have cancer and will die there's nothing I can do- goodbye " is not acceptable. The human questioner will pose the toughest question of all - does this machine/doctor care about me? Before they decide if that machine/doctor can care for them.

Principle Three- The patient should feel cared for by the entity.

Hopefully we're now prepared for the onslaught of Medical AI, but if you're struggling to recall the principles just look at the motto of the Royal Colllege of General Practitioners  

 Cum Scientia Caritas

Compassion (empowered) with Knowledge

Infect Scalability

I was asked how can we scale general practice the other day. 

The person asking was probably one of the most informed people I've met, aware of primary care and all its possibilities, so it wasn't a question I could risk getting wrong.  

I bottled it and did not answer at the time, but rather like the bon mot that arrives too late for a real riposte here is my answer.  

I'm a GP, you can't make me do anything, and it's often said handling GPs is like herding cats. 

If you have owned a cat you know that you get them to do what you want, by getting it to be what they want too. It's usually food with felines and often money with GPs, but the money has gone and we need to deliver high quality, innovative general practice at scale, right now.  

I was chatting to a patient the other day or "docsplaining" as my daughter calls it, you know how it goes, assuming that the patient either knows too little or too much, briefed by Dr Google, you start with the explanation that a virus infects a cell and end up with the reason why a cold doesn't need antibiotics.  

Anyhow, I was explaining infection rates and why some viruses are more deadly than others, at least as far as I could, and a fluorescent tube flickered in the corridors of my brain. 

We can't force any scale into general practice. We need to infect it.  

In my simple medical mind that means people need exposure to the idea, contact with a carrier and allowance for the incubation period to follow.

Sometimes the infection will mutate, an example being the story of Apple engineers visiting Xerox, seeing a screen in which the open windows or tiles were stacked neatly and heading back to apple to write that in their OS. Turns out that Xerox hadn't cracked the problem but Apple thought they had. 

Sometimes the infection is defeated, usually by previous exposures and a rapid response.  

So what does this mean for scalability in General Practice? 

Easy.  

1) support GPs and others getting out from their own practices and encourage visits to others. Advise appraisers to mention intrapractice visits as a means of generating CPD.  

2) Identify the ideas you want to spread and backfill those medics to GO AND SIT AND SWAP with each other. A morning sat with another.  GP who does things differently is such a luxury, but ideas are always better spread with trust. A PowerPoint talk and chalk is not as virulent as a sit and swap surgery, especially with a GP shedding ideas like a monkey with Ebola. 

3) Celebrate the infection. Such a hard thing for the NHS, we love the " this is our bright idea" awards, but never celebrate the "not invented here but we did it anyway" which is essential for adoption. 

4) Do not fix on the original idea. One of the success factors of a good idea, like a virus, is that it should change, ideally as quick as the environment (first principle of sustainability) so for example specifying and contracting for telephone consults will stifle video and virtual consults. 

5) Some hosts will reject the idea. It's tue, some ideas will easily result in some GPs leaving, shutting up shop, taking the  pension pot home. But those that survive will already have adopted, adapted and improved, they will use the next idea to become stronger still. 

I think I've stretched the viral metaphor as far as it will go, the bottom line being you can't force the scale of change required, but you can encourage the close contact required for a good idea to spread. 

Pass me a handkerchief I can feel an idea coming on.  

Time is Money

In the 21st Century it's probably no longer true that  the value of time is equivalent to money. 
I'm pretty sure that for many people the value of time is greater than money. 

However we don't yet bank time or save it or trade it. 

But we can try. 

I'm involved in an initiative the is seeking clinicians from the northwest (Lancashire Cumbria, Cheshire and Merseyside) who are willing to invest- not money- but time in new innovations, now technologies. 

Unlike the BBC Dragons Den its not your cash that's the bait, but your time. 

The Innovation Agency (Northwest Coast AHSN) is looking to find clinicians interested in hearing pitches from providers of new technology and if you wish invest your time in adopting and disseminating your learning, experience and views of the new technology. 

Recent examples include the AliveCor portable ECG and the FNB portable diagnostic pack Dr Go.

If you are a clinician in the Northwest and you want to join our Digital Dragons Den, then look me up on Twitter @chrismimnagh 

My job will never be threatened by machines.

I was watching aTED talk the other day on the jobs which are likely to be "threatened" by machines. 

The very concept seems alien to me. I'm a technophile and have always looked to the machine to help me do a better, faster more accurate job. 

There are tasks I do which are repetitive, structured and quite honestly boring, reading results and letters, tagging incoming data for example. 

If we had a smart machine which could file the normal or unchanged result, generate the recall and urgency of the next test or appointment my life would be significantly improved.   

If the machine improves my job by removing those high volume, repetitive tasks that I deplore then I won't feel threatened - I'll feel liberated.  

The bit of my job as a GP which actually counts is the time speaking to humans, explaining  and exploring their illness and their health, listening to their concerns and acting as an advocate in the health care system of the NHS.  

Even that bit of the job can be enhanced by a machine intervention. My recent experiences with online access systems that attempt to advise or triage humans is that sometimes the humans like telling the machine what is worrying them, they like asking questions that would never pop up in a humans intervention. Just look at the questions we throw at Google for an example of the 21st century's love of bizarre.  

So provide my population with a system that can tell them answers to questions such as "what is the best position for sex during pregnancy?" and  "How often should I clean my belly button?"  which means I won't have to offer my speculation on the matter. 

Simply put, no matter what further technology is introduced to the family physicians role my job will never be "threatened" only enhanced.  

End Discharges Forever.

It's not a secret that humans respond to advertising. We buy in to aspirations and ideas which appeal to our needs to feel good about ourselves.  We also respond to the labels applied to sell concepts. 

"New and improved" is a primer to say "this is better and you want the best". 
 "Cost effective" or "Good value" carries positive connotations whereas "cheap" brings associations of "cheap and tacky" "cheap and nasty". 
Branding is a dark art on its own and fraught with danger, sometimes it works well, no longer a "dodgy Datsun" but a "Nice Nissan", the scandals of Anderson Consulting do not linger around the Accenture brand. 

So look at the health service and tell me what's a discharge?  

Usually unpleasant, better out than in?  

Painful, nauseating, puss filled?  

No actually, they are our customer, our treasure, our reason for being.

We should pass them on like heirlooms, like eggs in baskets. 

Separate responsibility from location. 

one quick and easy way to end discharges would be to only have transfers of care. Six years ago I blogged about discharging from primary care, into hospital. That was wrong, but said as away of shifting a paradigm it can open the door to change. 

Provision of teams who take complex patients home,establish viability BEFORE transfer to primary care offers an end to re- admissions. 

Similarly hospital rounds carried out by hospitalists who collect the inpatient data, enter it on EMIS web, send prescriptions via electronic prescribing to community pharmacy who actually deliver will end discharge letters, avoid waiting for letters and receive the patient back into the arms of primary care, whilst still in hospital. 

Discharge is over if you want it.

When radicalisation is good.

There's a lot in the media at present about radicalisation and the various politicos saying "we must prevent it, remove the causes" 

Usually they blame extremist preachers or internet video recruitment on you tube.

I'm not actually convinced that's the real cause. 

There have been no video pleas from turban wearing clerics, no influx of terrorists hiding as immigrants and yet 76% off our country's junior doctors have become radicals, enough to strike. 

We need to understand that these NHS radicals are not fighting to keep things the same, they are not fighting for money, they are not fighting for job security, they are fighting for a cause. 

They are fighting for the NHS, an idea to which they have dedicated their working lives. 

When you become a medic in the UK you do so knowing that your employer will be the NHS, that you will earn money which is ultimately very good, but delivered by a monopoly supplier who will work you hard.

You take on this deal because you believe it's the right thing to do. 

When the government arrives, lies "there will be no top down reorganisation of the NHS" lies "doctors are coasting" and lies again "more people die on weekends because you are not there" they do not need to be Einstein to work out that "this new contract is not about reducing the wage bill and removing penalties to trusts for working youth long hours" stands as much chance of being truth as I have of being Health Minister. 

So why is their radicalisation good?  

Thanks to their oppression by Mr Hunt, their fatigue in hearing his spin, we now have a cohort of medics who are not prepared to accept that "this is the way it is," or that "you can't change that".

And you know what?- As a practicing GP I think that's exactly what the NHS needs to survive.