Category: Writing

Posts on writing by a writer Jano Klimas, primarily on books, poetry, slams and science writing.

Tantalizing exhibition: A night when I was a doctor, an artist and a winning writer

On the night of July 3rd, 2014, I was a doctor, an artist and a winning writer.

An artist

After 30 weeks of laborious drawing and preparing our final show, a group of 16 illustrators and picture book makers exhibited their work in the Culture box, Dublin. We were led by Adrienne Geoghegan. The night before, we hanged our show as illustrated by the photos at the bottom of this post. An illustrator Mr. Clarke opened the night with a story about a British writer who once told him that people talk shite at the openings of exhibitions; it’s such an Irish thing. Wine was pouring, but it was just enough to not make people drunk. The DJ Doolittle played hits from the 60’s.

A Doctor

When Mr. Clarke attended to his keynote duties, he chatted with the artists. I told him that I was one of the people that he mentioned in his opening address. I had great difficulties in fitting the drawing into my day as a scientist. “Are you the doctor, then?” he asked. “Well, I’m a psychologist by background, but I work with doctors.” He wished me well in trying to integrate both careers. Combining Art& Science in one life is like churning 2 things at the same time. And yet, I felt a sense of worth, success at the exhibition. I realized that I have an impact on people, they like me and my work. I’ve never fully realized this until that night. “Are you one of the artists?” Somebody asked me at the end of the night. “Yes,” I replied proudly.

The 2014 Aindreas McEntee awarding ceremony: Dr Coughland and Dr Klimas. Photo source: irishmedicalwriters.com

A winning writer

The 2014 Aindreas McEntee prize, is open to members of Irish Medical Writers, a group of doctors and journalists specialising in healthcare. I’ve submitted my entry on the day of the deadline, expecting little more than introducing myself to the arena of Irish medical writing. The third place came as a surprise. The award ceremony was on the same night as the tantalizing illustrations exhibition. Thankfully, they gave me the prize at the beginning and release me to go for the exhibition. At the end of the night, everybody has won and we all got prizes (dodo bird effect).

76th Annual Conference of College on Problems of Drug Dependence: Decide to be fearless& fabulous

Not one, but two conferences in Puerto Rico made my trip fantastic. As usual, the NIDA International forum happened for the 15th time on the weekend before the Conference of the College on Problems of Drug Dependence. The lines below offer some insights from these meetings.

Integration of addiction treatment into primary care: the portals of entry

Is abstinence related with good health? Is decreased drug use related with good health?
Tae Woo Park and Richard Saitz asked these questions in a secondary analysis of data from a clinical trial of 589 patients using cocaine or cannabis with very low dependence proportion among the sample (ASSIST score >27). To answer their questions, they used clinical measures of good health, such as, SIP-D, PHQ-9, and EUROQoL. Health outcomes were associated with decreases in illicit drug use in primary. However, abstinence and decreased use may represent very different magnitudes. Self-reports related dysphoria could also play a role in the differences. It takes a long time to make improvement in those consequences? 6 months of follow up observations may not be enough. Patient-preferred outcomes are paramount: do they want to have a score lower than XY on PHQ-9? What outcomes are important for them?
The TOPCARE (www.mytopcare.org) project implemented guidelines for potential opioid misuse (Jan Liebschutz). Her slides blew up half-way through the presentation but she delivered the talk excellently. Nurse care management was a component of the guideline implementation trial. Academic detailing (45min, with opioid prescribing expert) included principles of prescribing brochure and difficult case discussion. Is academic detailing effective? The Cochranesystematic review of literature found small-to-medium variable effects. The preliminary results of the project show that the nurse manager programme is a no brainer.
Rich Saitz commented on the sad state of affairs in the addiction treatment, where only 10% of people with addiction are in treatment. Integrated care is the best thing since the sliced bread, but where’s the evidence? His research showed no added benefit of integrated versus care as usual. Why? Maybe, addiction is not a one thing, but we treat it like one thing. Dr Tai provoked the audience with a question: “Do our patients with addiction have the capability to participate in the treatment planning and referral?” If they seek medical care for their broken leg and we refer them to an addiction specialist, will they go? most likely not.
But it is the same with hypertension. Referral is a process and not a once-off thing. Although they may not follow our advice at the first visit, a rapport built by a skilled professional over a series of discussions can help them get the most appropriate care.

Does the efficacy of medications for addiction decrease over time?

An old saying among doctors states “One should prescribe a new medication quickly before it loses its efficacy”. Elias Klemperer pooled the data from several Cochrane systematic reviews on addiction medicines, such as, NIRT gum, Acamprosate, or Buproprion. Their effectiveness decreased over time. The changes in methodologies might have caused the decline; also the sponsorship of trials, target populations or publication bias.

Write, wrote, written

Primary author is in the driver’s seat, others are passengers. Primary author pulls the train. Dr Adam Carrico(UCSF) asked us “What are you really passionate about?” Find it and use your passion for those themes to drive your writing habit. Decide to be fearless& fabulous. Develop a writing routine. Put together a queue of writing projects and don’t churn out 2 products at the same time, one of them will suffer. Schedule writing retreats with colleagues. Set Timelines for writing grant and programme time for reviews by trusted people, give people a warning that this is what you’re planning to do. The JAMA June 2014 issue offers useful tips on how to write an editorial.

Dr Knudsen reported on the editorial internship of the Journal of Substance Abuse Treatment – JSAT, which started in 2006, with Dr McGovern (current editor) and Knudsen as the 1stfellows. Success rate of the fellowship applications is 2/30-45, prior involvement is appreciated (peer reviewer, submission). The new 2014 fellows are: Drs Madson and Rash. In the one year of the fellowship, the fellows typically review 12-15 manuscripts, some years, as a managing editor of a special issue. The Drug and Alcohol Dependence journal has a similar scheme.

Check out the http://www.cpddblog.com/

HORIZON 2020 Marie Skłodowska-Curie Actions Information Day: Mobility is part of their job description

Being able, ready and happy to move for work enhances academic career. On 4th June 2014, in the Gibson Hotel, Dublin, Ireland, the Irish Marie Skłodowska-Curie Office hosted an information day on the individual fellowships. Guest speaker on the day was Alessandra Luchetti, Head of the EU Marie Skłodowska-Curie Actions Unit (Figure 1). The event, co-organised with InterTradeIreland introduced the new opportunities for researchers in the Marie Skłodowska-Curie Actions under Horizon 2020.
In the past, the Marie Curie Actions programme was one of the big success stories of Irish participation in FP7 funding programme, representing almost €100 million of the €600 million drawn-down by Ireland from FP7. The Actions have funded researchers from industry, community and academia to build their research capacity, with a strong focus on international mobility and strengthening careers for researchers.
 

Figure 1 Guest Speaker: Alessandra Luchetti, Head of Unit, Marie Skłodowska-Curie Actions, European Commission: – you are lucky that I do not have to talk in Italian, I’m talkative, so I am genetically modified
More than 25 years ago, it was only the EU mobility scheme; it is the oldest and the most famous. Today, the cutoff for a successful application is 92%. The focus of the fellowship is on career development. UK and USA are the most preferred countries for the European and for the Global schemes, respectively. Ireland has funded identical twins in the FP7 programme (one of them through reserved list).
The fellowship has many benefits. Researchers have the opportunity to go to a centre that is top of their field. The social capital increases, you meet politicians, high-level academics. The fellowship gives leverage to link in with community. The label of MC fellow at the end of the email opens many doors. The postdoctoral researchers, who are normally stuck in Limbo – because they can’t apply for solo-funding – can use this first individual fellowship grant to demonstrate capability of attaining further funding. For the principal investigators, the fellowship offers to do more research with bigger teams. For example, an Irish-EU funding stream – Inspire – funded 21 experienced researchers in 2 calls at the UCD Energy Institute.

Presenting with impact: WII.fm

Research presentations have a terrible reputation. People think they’re boring, content-heavy and poorly delivered. This presentation skills refresher, facilitated by Paula Mullin, was designed to change the way we think about science presentations and how we deliver them.

What’s in it for them?

In another words, why would they care about that? People listen to presentations because of 3 reasons: interest, benefit and fear. Keep them in mind when preparing your presentation.

Hook them

Hook can be a rhetorical question, or a “What if” question, or a prompt to Imagine “this”, or a story. Most people start with an introduction: we’re used to say our names first. But, we have only 30 seconds to hook the audience up. Audiences are very quick to decide whether they want to listen to you or not.
Ted talks are a useful way to observe hooks. Jamie Oliver, in his Longbeach, California (2010) talk, hooks the audience with a statement that People are going to day: “Sadly…” If this way of starting doesn’t feel comfortable, then stick to your learned style. I’ve started my last two presentations by saying my name and asking the audience: “Do we have an alcohol problem in Ireland?”

The rule of 3 key messages

The audience cannot take in more than 3 messages in one presentation. These messages can be made stickier by using stories because they are easier to remember than examples. Sheryl Sandberg, Chief of operations of Facebook, uses a story about a bathroom in her Ted talk (Ted Women, Dec 2010)

Road map

You can just say it. The old school of presenting preached the dogma – tell them, tell them what you told them and tell them what you told them again. The new school pushes the following structure for presentations:
  1. Hook
  2. Roadmap/ Intro
  3. 3 key messages
  4. Hook

Longer presentations should be structured in the same way, but you can have more time for stories and more time for stats in clear form. Using this new structure, I could go back to my opening question by saying: “So, back to my 1st question – Yes, there is an alcohol problem, but what we do about it is in our hands. Our doctor education can help you address that problem.”

No need to be scared

Presentation anxiety is normal, accept it. If you are not feeling a little bit nervous, don’t bother. Believe in yourself: “I’m the best person to be up here talking.” Know your stuff. Practice your talk at least 3 times and record yourself. Breathe into your stomach. It sends the breath where the body needs it.

Executive presence

Meaning is transmitted in face, body and voice. Support your message with hands. Don’t panic if you lose someone’s attention. They’re just humans, they’ll switch off. They need verity in the tone and pace. Think about coming closer to the audience. Make the audience your default. You are your best visual aid.

Celebrate communication in June

June is my month of communication. My June blogs will embrace communication by reporting from the Research support and supervisor development programme at the University College Dublin, Ireland, the Marie Skłodowska-Curie Actions Information Day, and the College on Problems of Drugs Dependence conference in San Juan, Puerto Rico.

European Working Group on Drugs Oriented Research Conference: One size does not fit all

“We all need something to help us unwind at the end of the day. You might have a glass of wine, or a joint, or a big delicious blob of heroin, to silence your silly brainbox of its witterings, but there has to be some form of punctuation, or life just seems utterly relentless.”

― Russell Brand, My Booky Wook 
The 15thInternational EWODOR Symposium, on May 22-23, 2014, was hosted by Coolmine therapeutic community (T.C.) at Trinity College Dublin, Ireland. The conference was capped to 100 attendees, 20 more than usual. This post brings a flavour of four key notes (out of 14).

Irish Addiction Treatment vs MacDonald’s

Was Coolmine TC like McDonald’s? Did it stifle it’s openness to change? Did it hinder adaptation to change? 

Through archival sources, meetings, correspondence, interviews with clients, current and former staff, past staff, Prof Butler researched sociological history of the first therapeutic community in Ireland – the Coolmine. The driving force behind Coolmine was Paddy Rossmore who had 2 recovering users from UK to start Coolmine. A complete reordering of Coolmine happened when Sam Anglin from Daytop, New York rejigged Coolmine, quite like a cult. No one opposed it openly – How do you like if your students were critical with you? But the question is “Was it the Daytop-isation or MacDonalds-isation?”
Sociologist, George Ritzer coined the fast food metaphor which has been researched for the past 20 years. It has been used for many problems since then. “Eat it and beat it” philosophy captures the main dimensions of MacDonaldisation – efficiency, calculability, predictability and control. Is this system dehumanising? To answer this question, we would have to answer a bigger question “Are people predictable, controllable, efficient and calculable?” No, but the answers divide helping professionals into 2 camps: one which clearly says “No”, and the second that says “No, but some behaviours can be predicted, controlled, calculated and changed.” Similar to the dichotomy of the left and right side of brain,  the true answer lies probably somewhere in the middle. No one wants to eat like McDonald’s, but addiction treatment can learn a lot from its business model.
What Prof Butler’s presentation showed us was that sticking rigidly to a foreign TC model may be worse than adapting flexibly to changes in society. Universal approach – one-size-fits-all – does not fit the addiction treatment. His presentation, however, did not answer the Gawande’s question modified for the drugs field: “Food chains have managed to combine quality control, cost control, and innovation. Can addiction treatment?” 
 

L-R: Butler, Yates and Pearce

Drug relationships: I love you and heroin

What is a drug relationship? 

DrMayock answered this question through narratives and interviews with women – drug users. It’s a struggle – Suffering on one hand and intimacy on the other hand. Exchange, power and control are the key characters in such relationship. Half of the interviewed women started using drugs in the relationship. Women were often reliant on the partner to administer heroin. They used threats and rewards – leave temporarily or sex for drugs and protection. Women in drugs economies played a supportive role. However, drugs were not the only connection between partners: “but I love him”, said one of the interviewees. Significance of the relationship beyond drugs was clear even after the end of the relationship. What is the true identity of a female drug user – an abused victim or a tender lover? They are both true.

There’s too much morals around women’s drug use, creating stigma and dismissal. Simmons writes that we need a more complex and nuanced understanding of drug-using couples – “drug treatment providers should:
  • establish policies which recognize the existence and importance of interpersonal dynamics between drug users, and
  • work with them to coordinate detoxification and treatment for both partners, and
  • provide additional integrated couples-oriented services”(Simmons& Singer, 2006).  

Can we do clinical trials of TCs? Or why there is a lack of robust evidence on TCs

What is a TC? What are the critical components and active ingredients?

On a practical level, Dr Pearce summarised the scientific literature on TCs. Therapeutic communities are a popular treatment for the rehabilitation of drug users. This Cochrane systematic review showed that “there is little evidence that TCs offer significant benefits in comparison with other residential treatment, or that one type of TC is better than another”, while another review concluded that “TCs can promote change regarding various outcome categories”. The critics of the Cochrane review for only including randomized trials, “while random group allocation appeared to be either not feasible (i.e., significantly higher drop-out among controls), or advisable (i.e., motivation and self-selection are considered to be crucial ingredients of the treatment process), in several studies.”
Pearce’s TACIT trial, unlike many other TCs, studies a day (outpatient) TC for personality disorders in Britain. Its Primary outcome measure is the Number of days in outpatient psychiatric treatment – total hospital days. TACIT faced typical technical problems: you can’t blind people; you can’t conceal people, difficult to standardize the treatment. Blinding is an issue for all psychosocial treatments. There’s a lack of standardisation and quality control in TCs. The staff is not bothered about clinical trials – they really believe in what they are doing. The TC is a complex intervention – all of the technical problems were taken from, and addressed in, the MRC framework, same like diabetes management or parenting. The logical positivist approach is embedded in the RCT approach – control is central. However, TC can be seen as a safe container for other therapeutic interventions. To respect the principles of safety and deep consent, TACIT asked the TCs themselves whether they want to opt out from the study – none of them did so. Inadequate treatment standardisation can be overcome by using a Model for adherence – Community of Communities – peer-opinion-based accreditation. All in all, it’s possible to do it [RCT] and we should do it.
Opposing the RCT evaluations, Dr Yates argued that we know TCs work, “we’ve done them for 50 years and we know it”. The time is now to study how they work and what the basic principles are. Study TCs for new groups: young runaways, trafficked women and children, self-harmers, recidivist, asylum-seekers, survivors of child abuse, etc. In seeing TCs as learning environments – we could use that stuff in other “schools” for other “students”. For better learning, he helped to setup a Drugslibrary.stir.ac.uk.

On a more fundamental level, Dr Yates asserted that TC is one of the few interventions that systematically address all of the components of Zinberg’s “drug, set and setting” model. The main principles: community as method and whole person disorder. Retention in TCs is poor, but that’s the same for all chronic diseases – you find very poor retention, same as addiction treatment. An audience questioned TC as a very safe environment for recovery – does that necessitate residential? It requires level of intensity: You can’t fund a 6 month programme and expect 12 months outcomes.

Cited work:
Gawande, A. (2013) Big Med. New Yorker, August 13th
Smith LA, Gates S, Foxcroft D. Therapeutic communities for substance related disorder. Cochrane Database of Systematic Reviews 2006, Issue 1. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005338.pub2/full
Wouter Vanderplasschen, Kathy Colpaert, Mieke Autrique, et al., “Therapeutic Communities for Addictions: A Review of Their Effectiveness from a Recovery-Oriented Perspective,” The Scientific World Journal, vol. 2013, Article ID 427817 
Simmons, J., & Singer, M. (2006). I love you… and heroin: care and collusion among drug-using couples. Substance abuse treatment, prevention, and policy, 1, 7. doi: 1747-597X-1-7 
Zinberg, N. E. (1986). Drug, Set and Setting: The Basis for Controlled Intoxicant Use. New Haven, CT: Yale University Press.