A Bunch of Good New Articles

Every now and again, I like t0 provide readers of this blog with the abstracts of new articles germane in some way to the chiropractic profession. Herewith are a few of the latest I have found, which I hope you will find equally interesting.

1. Murphy D. Current understanding of the relationship between cervical manipulation and stroke: what does it mean for the chiropractic profession? Chiropr Osteop 2010;18:22 doi:10.1186/1746-1340-18-22

ABSTRACT
The understanding of the relationship between cervical manipulative therapy (CMT) and vertebral artery dissection and stroke (VADS) has evolved considerably over the years. In the beginning the relationship was seen as simple cause-effect, in which CMT was seen to cause VADS in certain susceptible individuals. This was perceived as extremely rare by chiropractic physicians, but as far more common by neurologists and others. Recent evidence has clarified the relationship considerably, and suggests that the relationship is not causal, but that patients with VADS often have initial symptoms which cause them to seek care from a chiropractic physician and have a stroke some time after, independent of the chiropractic visit.
This new understanding has shifted the focus for the chiropractic physician from one of attempting to "screen" for "risk of complication to manipulation" to one of recognizing the patient who may be having VADS so that early diagnosis and intervention can be pursued. In addition, this new understanding presents the chiropractic profession with an opportunity to change the conversation about CMT and VADS by taking a proactive, public health approach to this uncommon but potentially devastating disorder.

2. From Palmer faculty and staff: Pohlman KA, Hondras MA, Long CR, Haan AG. Practice patterns of doctors of chiropractic with a pediatric diplomate: a cross-sectional survey. J Comple Altern Med 2010;10:26 doi:10.1186/1472-6882-10-26

ABSTRACT
Background: Complementary and alternative medicine (CAM) is growing in popularity, especially within the pediatric population. Research on CAM practitioners and their specialties, such as pediatrics, is lacking. Within the chiropractic profession, pediatrics is one of the most recently established post-graduate specialty programs. This paper describes the demographic and practice characteristics of doctors of chiropractic with a pediatric diplomate.
Methods: 218 chiropractors with a pediatric diplomate were invited to complete our survey using either web-based or mailed paper survey methods. Practitioner demographics, practice characteristics, treatment procedures, referral patterns, and patient characteristics were queried with a survey created with the online survey tool, SurveyMonkey©®.
Results: A total of 135 chiropractors responded (62.2% response rate); they were predominantly female (74%) and white (93%). Techniques most commonly used were Diversified, Activator ®, and Thompson with the addition of cranial and extremity manipulation to their chiropractic treatments. Adjunctive therapies commonly provided to patients included recommendations for activities of daily living, corrective or therapeutic exercise, ice pack\cryotherapy, and nutritional counseling. Thirty eight percent of respondents' patients were private pay and 23% had private insurance that was not managed care. Pediatrics represented 31% of the survey respondents' patients. Chiropractors also reported 63% of their work time devoted to direct patient care. Health conditions reportedly treated within the pediatric population included back or neck pain, asthma, birth trauma, colic, constipation, ear infection, head or chest cold, and upper respiratory infections. Referrals made to or from these chiropractors were uncommon.
Conclusions: This mixed mode survey identified similarities and differences between doctors of chiropractic with a pediatric diplomate to other surveys of doctors of chiropractic, CAM professionals, and pediatric healthcare providers. The pediatric diplomate certificate was established in 1993 and provides didactic education over a 2 to 3 year span. The results of this study can be used for historical information as this specialty continues to grow.

3. Ilic D, Forbes K. Undergraduate medical student perceptions and use of Evidence Based Medicine: A qualitative study. BMC Med Educ 2010;10:58 doi:10.1186/1472-6920-10-58

ABSTRACT
Background: Many medical schools teach the principles of Evidence Based Medicine (EBM) as a subject within their medical curriculum. Few studies have explored the barriers and enablers that students experience when studying medicine and attempting to integrate EBM in their clinical experience. The aim of this study was to identify undergraduate medical student perceptions of EBM, including their current use of its principles as students and perceived future use as clinicians.
Methods: Third year medical students were recruited via email to participate in focus group discussions. Four focus groups were conducted separately across four hospital sites. All focus groups were conducted by the same facilitator. All discussions were transcribed verbatim, and analysed independently by the two authors according to the principles of thematic analysis.
Results: Focus group discussions were conducted with 23 third-year medical students, representing three metropolitan and one rural hospital sites. Five key themes emerged from the analysis of the transcripts: (1) Rationale and observed use of EBM in practice, (2) Current use of EBM as students, (3) Perceived use of EBM as future clinicians, (4) Barriers to practicing EBM, and (5) Enablers to facilitate the integration of EBM into clinical practice. Key facilitators for promoting EBM to students include competency in EBM, mentorship and application to clinical disciplines. Barriers to EBM implementation include lack of visible application by senior clinicians and constraints by poor resourcing.
Conclusions: The principles and application of EBM is perceived by medical students to be important in both their current clinical training and perceived future work as clinicians. Future research is needed to identify how medical students incorporate EBM concepts into their clinical practice as they gain greater clinical exposure and competence.

4. Hill TE. How clinicians make (or avoid) moral judgments of patients: implications of the evidence for relationships and research. Phil Ethics Humanities Med 2010;5:11 doi:10.1186/1747-5341-5-11

ABSTRACT
Physicians, nurses, and other clinicians readily acknowledge being troubled by encounters with patients who trigger moral judgments. For decades social scientists have noted that moral judgment of patients is pervasive, occurring not only in egregious and criminal cases but also in everyday situations in which appraisals of patients' social worth and culpability are routine. There is scant literature, however, on the actual prevalence and dynamics of moral judgment in healthcare. The indirect evidence available suggests that moral appraisals function via a complex calculus that reflects variation in patient characteristics, clinician characteristics, task, and organizational factors. The full impact of moral judgment on healthcare relationships, patient outcomes, and clinicians' own well-being is yet unknown. The paucity of attention to moral judgment, despite its significance for patient-centered care, communication, empathy, professionalism, healthcare education, stereotyping, and outcome disparities, represents a blind spot that merits explanation and repair. New methodologies in social psychology and neuroscience have yielded models for how moral judgment operates in healthcare and how research in this area should proceed. Clinicians, educators, and researchers would do well to recognize both the legitimate and illegitimate moral appraisals that are apt to occur in healthcare settings.

Really Cool Websites for Faculty

Herewith a list of interesting, informative and unusal websites for your viewing pleasure:

1. Presentation Zen: http://www.presentationzen.com/
I’ve spoken often of this website, which was created by Garr Reynolds, a designer who is also associate professor of management at Kansai Gaidai University in Japan. This is the key website about presentation design and delivery on the internet. His goal is to change how we see and use slide technology, notably PowerPoint and Keynote. His focus is upon harmony of design, and is built around the basic ideas of Zen Buddhism. His ideas are simple yet profound and can be used to help remodel how you use slides in class, moving you away from heavily text-based slides to simpler and more illustrative slides. A visit to this site is like a visit to a peaceful garden; you have to think and consider issues here.

2. Seth’s Blog: http://sethgodin.typepad.com/
This is the website of noted business author Seth Godin, author of many books of which “Linchpin” is but the latest. He offers words of counterintuitive business wisdom that resonate in our academic culture and setting. He might suggest that not being in synch with your various digital technologies (Facebook, Twitter, and so on) is the sign of a leader, not a follower; maybe you would invite a passionate amateur to accomplish a task rather than an experienced professional, and so on. He is always engaging and will certainly get you thinking.

3. Pecha Kucha: http://pecha-kucha.org/
You will likely be unaware of the pecha kucha movement, but the basic goal of pecha kucha is to develop a slide presentation that uses 20 slides, each lasting 20 seconds. Why do so? Here, it is so that the presenter is forced to hone his or her ideas into its basic components and its most essential information. The wesite provides you examples of such presentations, drawn from actual pecha kucha night activities, and it also provides you a link of locations for upcoming pecha kucha. By the way, pecha kucha is a Japanese transliteration of the term “chit chat.”

4. Tom Peters: http://www.tompeters.com/
Most of us know of Mr. Peters from his earlier works on excellence, such as A Search for Excellence. His blog is dedicated to this as well, and it covers many aspects of management related to becoming excellent at what we do. He provides free slides for you to use, and offers a series of, well, excellent video clips one can view.

5. Center for Evidence-Based Medicine: http://www.cebm.net/?o=1011
Switching gears here, this site is dedicated to promoting EBM in healthcare education and it gives you a series of superb links to information and tools. For example, if you click on the “EBM Tools” at the top of the home page, it will then link you to a page that discusses the basic EBM approach known as the 5 A’s (which was the basis of a recent in-service at PCCD), and to online calculators for likelihood ratios, numbers needed to treat and more.

6. The Integrator Blog: http://theintegratorblog.com/site/
This site is maintained by John Weeks and is a leading site for information related to the business, policies and education of Cam and integrative medicine. Palmer’s own Dr. Christine Goertz is on their editorial board, and the blog does a great job at keeping up with news affecting the entire spectrum of the CAM community.

7. Slayage: http://www.slayageonline.com/
Of course, we all know of my love for Buffy the Vampire Slayer, but how many people know that there is an online academic journal dedicated to the show. Well, now you do and here it is, and I dare you to make sense of most of what you read. But hey, this is all about really cool websites, and this one surely is.

Enjoy the reading!

PowerPoint Use and Misuse

One of the more humorous things I have read lately was from a message board dedicated to, of all things, distance running (my older sons are talented distance runners, so I live vicariously through them). The actual thread had nothing to do with running; instead, it was about a man who had broken up with his girlfriend using PowerPoint to do so. This is not the best use of the technology.

So keeping in mind modern readings on the use of slide technology, I went to visit the Presentation Zen website. I’ve spoken of this in the past; this is a site maintained by Garr Reynolds and dedicated to helping the reader develop successful presentations. His focus is on the harmony of presentation- which is why he has entitled his blog Presentation Zen- and he uses modern understanding of design, harmony and even psychology to craft meaningful presentations.

As a result, he stresses the need to move away from text-based and text-heavy slides. His point is made quite well in his August 21 entry on his blog, at http://www.presentationzen.com. In this entry, he shows how General Dodonna, in Star War IV (“A New Hope”), uses a full wide-screen display to show his fighters the schematics of the Death Star- a picture here being worth many thousands of words. He then duplicates the scene but this time shows the presentation as a text slide in typical PowerPoint format. Of course, there is this caveat: “You can't see this well on this Micro Galactic ProjectionPoint, but an analysis of the plans provided by Princess Leia has demonstrated a weakness in the battle station. Follow this link at the bottom of the screen for more info if needed." There is a difference here in how we understand the information.

He closes his entry by suggesting we push back against the Imperial template propaganda and its conventional usage patterns. He recommends that when you use PowerPoint, it is far better to use visuals rather than to use lines of text which remind you what to say. See, the real issue here is what your audience learns; this technology is not a simple convenience for you to help you lecture, but is instead a powerful tool to help others learn. When it used correctly. Your visual information will help amplify the words you speak to your audience; use the Force wisely here when you do so. Otherwise, problems in learning occur will they (says Yoda, wise in all things).

The Five Dysfunctions of a Team

There is an entire genre of business books which I refer to as “business fables.” Perhaps the most well-known among them is “The One-Minute Manager,” by Spencer Johnson (1), but not far behind is Patrick Lencioni’s “The Five Dysfunctions of a Team.” (2) I always approach these types of book with my skeptical eye well open, but each time I am confronted with a book that offers me insights into working in a collegial environment, and in the case of Lencioni’s book, I took some heart in the message his book extends.

Lencioni’s book relates the story of the appointment of Kathryn Peterson as new CEO for Decision Tech. Ms. Peterson does not come from the industry in which Decision Tech competes, and she was in semi-retirement when she was recruited for the position by the Chairman of the Board for the company. Her main action during her first year on the job is to attempt to unite her senior executive team, all highly competent individuals who are unable to work together effectively. Her decision and actions are described as she moves her company forward against some very real odds. These actions are placed into the context of resolving known dysfunctions, the five of which are indicated by the title. They are not obvious.

Dysfunction 1: Absence of trust. Lencioni notes that trust is at the heart of a functioning team, but trust is not simply believing that others mean to do well. Rather, trust here centers on the idea that given that we know others mean to do well, we need not be careful around members of our team. We must become vulnerable when around each other and be confident that our vulnerabilities will not be used against us- for we each have such vulnerabilities. In such fashion we stop being political with one another, stop subtley seeking position, and work together for the common good. Otherwise, behaviors too often will influence the actions that are taken and the discussions that occur.

Dysfunction 2: Fear of conflict. We need productive conflict to be able to grow. But, too often conflict is seen as undesirable in work settings, and therefore deep discussions on issues are avoided- a “go along to get along” kind of thinking. Now, conflict here does not refer to destructive fighting or personal politics; it refers to productive ideological debate. Sometimes conflict is avoided in order to avoid hurting others’ feelings, but if we note the first dysfunction, that of trust, this problem disappears.

Dysfunction 3: Lack of commitment. Lencioni notes that commitment is a function of clarity and buy-in. If we achieve buy-in from all members, clear and timely decisions will be made. And Lencioni further notes that the two main causes of lack of commitment are (surprisingly), a desire for consensus and a need for certainty. Consensus is, to me, often a way of reducing an issue to the least-common denominator- we all agree, but no one gets what they really want. It is better that we make a decision, even one that we might not all agree with, knowing that our thoughts have been heard, appreciated and considered. And once a decision is made- where we now have certainty, at least with regard to direction, we can unite behind that certainty. We never have full information and often make decisions without knowing the best direction in which to move, but once a decision is made, we move with it.

Dysfunction 4: Avoidance of accountability. This refers to the willingness of team members to call their peers on performance or behaviors that can hurt the team. We don’t like to do this; all too often we want to be liked rather than respected, so we allow behaviors from people that we know are damaging because it is never fun to call them to account for those behaviors. We don’t hold others accountable, because conflict avoidance is easier. But peer pressure can exert such influence as well.

Dysfunction 5: Inattention to results. This refers to the tendency of team members to care about something other than the collective goals of the group: their own personal advancement, rewards, etc., and not the objective for which the team exists. Lencioni notes the influence of these factors: (1) Team status: for some, being on the team is a status reward in and of itself, and therefore the actual results may not be important to some people, since being on the team is the reward. (2) Individual status: where people focus on advancing their own positions in the organization at the expense of the team goal. We need to focus on the team results, for that is what will take the organization forward.

It is an interesting and informative group and one that has led me to think over its message. For that reason, I do recommend it, and it is a text that can be read in a brief period of time, but that has a message I think will resonate with you.

References
1. Johnson S. The one-minute manager. New York, William Morrow and Company, 1981
2. Lencioni P. The five dysfunctions of a team. San Francisco, CA; Jossey-Bass, 2002

The Genius Bar

I grew up with Macintosh computers. I got my first Apple, a IIe, in 1984, and I have upgraded every few years with new Mac computers at my home, with my current computer, an iMac with a 17” screen, sitting on my desk. In fact, not until I came to Palmer College had I ever worked with a Windows-based computer. When I first started, I did not know how to do even the most basic functions, for most of them were not similar in any fashion to how the interface worked on a Mac. This is just history. I do know that it would have been nice to have someone to walk me through the initial intricacies of working in a Windows environment.

Which brings me to the point of this post. Last week, during the Palmer Davenport Homecoming celebration I met with Dr. Tammi Clark, a faculty member and president of the Faculty Senate from our West campus. She related a story to me about her purchase of a Mac computer, and how she had both some problems and questions about working with her new platform. She noted that she learned about Apple’s Genius Bar, sort of by a serendipitous mistake; she was visiting an Apple Store and simply saw the Genius Bar inside. This led her to make an appointment with an Apple Genius, and that provided her skills and answers to her questions and needs.

Let me step back a moment and clarify. The Genius Bar is part of every Apple store. It is a tech support station that provides users with help and answers for their Mac-related questions. You make an appointment to visit the Genius Bar, and when you do you obtain the help of an Apple Genius, a person extensively trained in the use of Mac technology. This person will work with you to answer your questions, problem solve and offer repairs. But more than this, this person will do more than simply help you figure out what is wrong; he or she is as likely to say to you “well, let me ask you, what do you want to do with your computer?” And from that, they will help you learn how to use your computer to do what you want it to.

For me, this is sort of a powerful metaphor for how I see the Center for Teaching Learning working. There are challenges in working across three campuses when you are based at one of them, and can visit the other two only infrequently. And keeping the CTL in the front of faculty can be difficult as well. But the CTL exists to help faculty become more productive at what they already do so well. And I can work with you to meet your needs, if I only know what they are. I continue to gather information from as many sources as possible; in fact, my meeting with Dr. Clark generated a number of possible general interest topics for future in-service sessions. But beyond that, if you, the reader, can but contact me and let me know your needs, I can work with you to meet them. What is you want to do? I can provide resources, training, advice, ideas and more. Consider, for example, this simple list of possible ideas: how to effectively use PowerPoint in the classroom (and the corollary of how to use it at all, for those who may not have yet made the switch to this technology), Generation Y learning styles, classroom engagement techniques (already in discussion, so I understand), website development, test writing workshops, how to use rubrics, team-based learning, etc. This is all related to teaching, not to research or publication, making us better at our primary assignment and responsibility.

So I urge you to feel free to contact me (x5302 or dana.lawrence@palmer.edu) and let me know your needs. I promise to help all I can. I am no genius, but I am pretty tenacious and I will certainly do what I can to help.

Causality

I wish to turn attention to an area of epidemiological research that is increasingly important, the concept of causality. In epidemiology, an intervention or public health action is based on the presumption that associations seen in various studies are causal, not due to bias or some other spurious research. When we say causal, we mean that the cause of, say, a disease is “an event, condition, characteristic, or combination of factors that plays an important role in the development of disease or health condition." (1) Of course, we realize that demonstrating causality can be exceedingly difficult; how do we definitively know that an association is causal?

Initial descriptions of causality were developed by Henle and Koch (2), relating more to identifying infectious agents in disease outbreaks. Here, the agent had to present in each case of the disease when cultured, could not be found in other diseases, could reproduce the disease in question when isolated and injected into animals, and must then be recovered from the infected animal. But this approach does not work as well for modern public health, where exposures to environmental factors may take years to occur. Thus, Bradford Hill (3) came up with his criteria for causality, which have been modernized into these 6 key factors:

1. Consistency: the association is seen in different settings and populations. Thus, the likelihood of a causal relation increases as the number of studies with similar findings occurs.

2. Strength: This is defined by the size of the relative risk estimate; thus, the likelihood of a causal relation increases as the summary relative risk estimate increases (bringing in a concept we have previously explored in the context of evidence-based care). The larger the effect estimate, the less likely it is due to bias or chance.

3. Temporality: that is, there has to be demonstrated an exposure to the risk prior to the development of the condition of interest. This is a critically important aspect of causality.

4. Dose-response relationship: This is defined as the observed relationship between the dose of the exposure and the magnitude of the relative risk estimate. Put another way, what this means, is that the larger the exposure (intensity or time), the greater the chance (risk) of developing the condition of interest.

5. Biological plausibility: What we know about the mechanism of action for a given risk factor and the disease outcome. What do we know about why smoking leads to cancer, for example? If we can develop a biological rationale for why the exposure leads to the condition of interest, it strengthens the likelihood that a causal relation is present.

6. Experimental evidence: This is a bit more technically sophisticated; here, defined as the presence of findings from a prevention trial in which we remove the exposure from randomly assigned individuals. If we see a reduction in the condition of interest, it strengthens the likelihood that a causal relation exists.

Our challenge becomes removing all potential confounders from consideration, and given this one can se why developing causal relations can be so difficult. An example was a study showing that coffee drinkers had a higher risk of cancer. Of course, it was not the coffee drinking which was involved; it turned out that there were more smokers among the coffee drinkers and that was what led to higher cancer rates. Another challenge is to apply this to chiropractic theory and methods, including subluxation research.

References
1. Brownson RC, Baker EA, Leet TL, Gillespie KN. Evidence-based public health. New York; Oxford University press, 2003:30
2. Last JM, ed. A dictionary of epidemiology, 4th edition. New York; Oxford University Press, 2001
3. Hill AB. The environment and disease: association or causation? Proc Royal Soc Med 1965;58:295-300

Plagiarism Anew

A recent article in the New York Times (1) discusses how today’s students seem to misunderstand the nature of plagiarism in the digital age. The article first describes several incidents of student plagiarism where the students simply did not understand they had done anything wrong; for example, one student copied material directly from Wikipedia and then claimed that since it was a collective work it was common knowledge to be freely used by anyone. Since we live in a world where illegal downloading is commonplace, it seems that this is beginning to extend into areas of scholarship as well. On the one hand, the internet is a freewheeling locus of activity and information exchange and discovery; on the other, there are mechanisms in place to protect copyright and limit plagiarism.

What appears obvious is that the concept of authorship is not well understood, nor is the concept of intellectual property. So much information is available on the web that we forget it was produced by someone, who made an effort and who created a work product. I suspect that if we were to query our students as to how many have at some time cut and pasted material without attribution, the number would be quite high. And why not? I recall a story involving a German teenager who had written a novel that was receiving good reviews but who had been criticized for copying material from another existing source. Her argument was that her work was a pastiche or “remix” and she saw no problem with using others’ words in her work since her work represented a new creative product (2). Authorship is changing, and this is evident even in scientific publication, where one can be an author without actually writing any of the text that is later published; for this reason, the idea of “contributorship” is emerging.

The concern is that real scholarship goes wanting. Students are more concerned about finishing an assignment and getting their grade than they are the material the assignment is supposed to teach. As Susan Blum (3) notes, "it’s O.K. if you write the papers you couldn’t care less about because they accomplish the task, which is turning something in and getting a grade.”
So we have two tasks to counter this. First is to build in ethics training in our work, focusing not just on an understanding of copyright and plagiarism, but on appropriate ethical behavior for physicians. Second is to develop assignments which have meaning to our students. Both are not easy, but both are necessary. Our world is changing and we need to be ahead of the changes before they happen.

References
1. Gabriel T. Plagiarism lines blur for students in digital age. http://www.nytimes.com/2010/08/02/education/02cheat.html?_r=1&partner=rss&emc=rss, accessed August 2, 2010
2. Meadows C. Plagiarism or “remix”? 17-year-old author’s borrowing creates controversy. http://www.teleread.com/2010/02/13/plagiarism-or-remix-17-year-old-german-authors-borrowing-creates-controversy/, accessed August 2, 2010
3. Blum S. My word!: plagiarism and college culture. Cornell, MY: Cornell University Press 2009