Revisiting Grit

In an earlier blog I wrote about grit. The interpretation I had was one that associates grit with perserverence at all costs. So I didn’t speak about grit as always being a good thing. Because it’s good to know when to quit. I’ve since learned about a broader interpretation that’s made me rethink the concept.

Perserverence is one of the factors that makes up grit, and apparently it’s common to think of them as synonyms. But there are other factors as well. Angela Duckworth wrote a whole book on it. She talks about 5 characteristics: courage, conscientiousness, long-term goals and endurance, resilience and excellence.

But I like the way Seth Godin talks about it. He talks about grit being the stuff that gets stuck in machines and stops them from working. This fits well within his overarching metaphor of aspiring to be anything but a faceless cog in the industrial machine. In his book The Icarus Deception is the following passage:

Grit includes perseverance, but it comes before the need for perseverance arrives, because grit includes goals and a passion for those goals. Some people will persevere merely because they are instructed to do so. Those with grit will persevere because they believe they have no choice, not if they wish to be who they are.

Squishy Pharmacy

Yesterday I was watching YouTube videos with my daughter of someone giving makeovers to squishy toys. Her name is Moriah Elizabeth and she is one hell of an entrepreneur.

Moriah takes these beat up toys with chunks out of them, faded colours and rips, and she converts them into fresh new pieces to be enjoyed. She doesn’t just restore them, she reinvents them. And people love watching her do it. She has 3.5 million subscribers!

This is a great example of being able to take a fairly generic product that’s available to anyone and add value to it to turn it into something special that makes money. Not because she sells the finished product. Because of the experience she’s created around it.

Through these videos in which she shares her makeover process she inspires others to pursue their own creative projects. Or at least she makes them think that it’s something they could do. She has published two books to help. Oh, and she sells the products she uses on her website. She sells merchandise too. Moriah Elizabeth is a savvy young business woman.

What’s in it for her once she’s sick of squishies? I’m guessing that she’ll have developed some pretty transferable skills in video production. Not to mention the experience she’ll have gained in setting up and running a small business. I’m not worried for the future monetary position of Moriah Elizabeth.

The lesson in this for me is not to find a niche YouTube opportunity that exploits the interests of children. It’s about taking something generic and transforming it into something special by adding value to it. Because that is the very essence of quality community pharmacy.

Anyone can take a prescription medicine, put a label on it and provide some basic information to a patient. But that’s like an off the shelf squishy, it’s not special. It’s as generic and forgettable as it comes. It doesn’t earn you customer loyalty. Or customers that tell their friends how good the service is. No, that only comes from providing them with an experience that makes them feel special. Where the Pharmacist takes the opportunity to connect with and provide people with a service that responds to their needs. That’s the quality stuff. That’s the stuff that people will keep coming back for.

Revisiting Comparison

In an earlier blog I wrote about avoiding comparison as it rarely has a positive effect. But I read something recently that made me revisit that. This passage was in the weekly email update from James Clear, who each week shares 3 ideas, 2 quotes and 1 question:

To improve, compare little things.

-marketing strategies
-exercise technique
-writing tactics

To be miserable, compare big things.

-career path
-marriage
-net worth

Comparison is the thief of joy when applied broadly, but the teacher of skills when applied narrowly.

Playing in White Spaces

This morning I was listening to the story of Steve Martin in his stand up days. His name is one that comes up repeatedly in any book I’ve read or podcast I’ve listened to when the topic of art as a learned practice comes up. His book Born Standing Up has been on my ‘to read’ list for some time so maybe I’ll move it to nearer the top.

The angle of the story this morning was about him finding his audience and recognising his role. His hugely successful stand-up career wasn’t long, only a few years. He quit at the height of his success when he was performing at stadiums in front of 40,000 people. Not because he burnt out, but because he recognised that the material couldn’t keep evolving in the way the audience needed it to. But he was far from an overnight success. He worked devotedly for years before that without commercial success.

So what changed to turn things around from playing to a crowd of 100 to 40,000? It wasn’t so much his material. It was how he delivered it. He paid extreme attention to what his audience responded to positively. He began to deeply understand his audience and tried to understand their world view. He didn’t just focus on the content, he focused on the spaces in between. The nuances of his movements. “He realised he was the ringleader of the party, not the provider of funny”.

You look at his work now and it doesn’t seem all that special. But if you watch his episode on Comedians in Cars Getting Coffee with Jerry Seinfeld, you get a sense of just how well revered he is in the comedy community. The type of reverence that Jerry Seinfeld reserves for the true kings of comedy, the people he learned from and admires. Because Steve Martin created a new genre of comedy. He was so committed to creating original content that he rarely borrowed lines from other comedians, and when he did he always asked permission first.  Not only did he worked really hard at creating something that nobody else was doing, he paid close attention to tailoring it to what his audience wanted. He acted in service of them.

Why do we look down upon servitude so often? Being in service of people is a privileged position. I think sometimes we buy into the power stuff too much. We get so caught up in the need to be clever and look like the expert that maybe we miss opportunities to please the audience we serve. I’m using the term audience loosely here. I don’t mean it in the passive, receiver of performance kind of way. I’m speaking about it as the people you’re trying to connect with. As a pharmacist, it’s patients, their families, the care providers, our colleagues. We hope to contribute to better use of medicines, so the audience we seek to serve is anyone that plays a role in that medication management cycle really. Our service is to assist them in playing their role the best they can.

If I think about my research on cancer and chronic conditions as an example, I think it’s easy for pharmacists to get fixated on issues concerning chemotherapy because that’s the bit that cures the cancer and that’s the bit that makes people sick. That’s kind of the equivalent of developing a good ‘bit’ in a comedy routine. But that’s not necessarily where our value lies. That’s not what makes us special. Just as there are plenty of people producing funny content, there are also plenty of people who know stuff about chemotherapy and it’s side effects who are providing information to patients and care providers. But it doesn’t always lead to better outcomes. It only leads to a better outcome if it connects with that person and influences their behaviour in some way.

I wonder what would happen if more of us started paying more attention to the white spaces. The stuff other people aren’t paying attention to. The questions that patients don’t feel comfortable asking their doctor. The niggling side effects they’ve just accepted as their new normal. The challenges they have in popping the tablets out of the blister pack since they developed peripheral neuropathy. Started listening more closely to their stories. Started paying much more attention to the work we do and the responses we get. What happens when we use less complicated language? Do people open up more when I ask the question this way, instead of that? If I sit like this, does that make it better or worse?

It’s completely natural to focus on developing expertise in our domain knowledge, but I think we need to be realistic about it. Helping most people does not require supreme mastery of domain knowledge. More than competent, surely, but B grade is probably good enough for most people. Just in time deeper knowledge will probably get you by for most of the other times. But just as it is with Steve Martin and his comedy routine, if the content of the bits is good, it’s the delivery that makes it great. If we want to build better connections with the audience we wish to serve, if we wanted to truly optimise our impact, then we maybe we should start paying closer attention and play around in those white spaces.

 

Tall Puppies

My husband is Canadian. His family will tell you that he now has an Australian accent. Strangers often tell him he has an Irish accent. Communication isn’t really a problem between us. But every now and then we find a word or a phrase that is comically misunderstood. Macramé and aluminium/aluminum foil have become popular riffs among our group of Aussie/Canadian/English friends (I mean, how does macramé even come up in conversation?). Bowl/ball has led to a prolonged and confused conversation more than once. And “tall puppy syndrome” had him thinking that Australians were kind of a bit cruel by nature.

I don’t think I realised just how much the tall poppy syndrome was ingrained into my being until I met Chris and I started to realise how uncomfortable I was with pursuing success in a way that may be recognised by others. Americans and Canadians seem much more comfortable with owning their successes. For a long time I have been self-deprecating to the core. And while I’m not advocating to take the Liam Gallagher route of self-appreciation, I do think my avoidance of being seen as a tall poppy has resulted in me selling myself short at times.

Seth Godin talks about this in The Icarus Deception, which I’m listening to at the moment. (side note, as audiobooks go I find it enjoyable, but I still want to see the words on the page to allow it to really sink in and process. I don’t find audiobooks fulfilling in the same way as reading it). The premise of the book is that the commonly told myth of Icarus only tells one part of the story, the don’t fly too close to the sun or you’ll get burnt bit. Apparently there’s another, equally important bit about not flying too low because the sea water would ruin the lift in his wings. Godin argues that flying too low is even more dangerous than flying high because it is deceptively safe.

We need people to self-actualise if we want to tackle some of the societal problems that continue to be placed in the too hard basket. If we want to encourage this then I think we not only have to accept within ourselves that it’s ok to pursue quality, but we need to recognise how much we reinforce the opposite within our culture.

What do I mean by this? I’ll use myself as an example, because I’ve got plenty of material to work with. Now my upbringing instilled in me some pretty strong values about being an active citizen and caring for others etc, but it didn’t exactly teach me to celebrate the success of others. To say I’m critical by nature is probably a gross understatement. For a very long time it’s been my natural tendency to poke holes in things first, and if they continue to remain then maybe there’s something of value there. I am very sceptical. I convinced myself that this was ok because I gave myself the same treatment. I was treating others as I was being treated, it didn’t clash with my values.  But I’ve come to realise recently that while that may be true, it doesn’t help me to get the best out of things. In fact, I think sometimes it means that I miss out on realising the value that is on offer.

I’m not saying that we should lower our standards to the lowest common denominator (I think that’s my most hated phrase in the world!). I think what I’m saying is if you go into something looking for the holes, the weaknesses, then you are going to find them and then you may get stuck on them. There are always holes. But if we focus on them first then we may be less receptive to the rest of the offering, and there might be some real value in there.

I’m trying to retrain myself to do things the other way round. First look at things assuming the best, see where the value might be. Only then do I think about assessing the validity of it, and only in relation to what it means to me. How does it fit with the purpose of the interaction. Because half of the time, if I’m honest, my criticisms say more about me than they do about the recipient.

I think this is one of the things I find challenging about my literature review at the moment. It’s really easy to look at these small studies and rip them to shreds with critique. Design flaws, poorly written up, not generalisable. But what value does that add, really? Doing literature reviews like that are kind of a zero sum game. I make the authors look bad, I try to make myself look smart, but in the end there isn’t any new knowledge produced that is of any value. And isn’t the whole purpose of a literature review, of any research to contribute new knowledge?

It makes me think about when Brené Brown talks about choosing to make the assumption that people are doing the best with the tools they have. And her favourite quote from Theodore Roosevelt

It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better.The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, who comes short again and again,because there is no effort without error and shortcoming; but who does actually strive to do the deeds; who knows great enthusiasms, the great devotions; who spends himself in a worthy cause;who at the best knows in the end the triumph of high achievement, and who at the worst, if he fails, at least fails while daring greatly.

If we want to build a culture of innovation and risk taking, then we need to keep our tendency to immediately cut people down and criticise in check. This is going to mean different things for different people. And for people like me it is hard work! I have to actively train myself to try and see the good before the bad. And to value those who are out there and giving it a go, even when I can think of ten ways they could’ve done it better. Because they’re out there doing it and that’s a start.

 

Creative Problem Solving

Bluey has got to be one of the best kids tv shows ever created. Big call I know, but valid. I have watched every episode multiple times and I don’t even mind (definitely not the case for Paw Patrol). It’s like the kid version of Seinfeld. Seriously, the writing is that good. And the music and art direction are also quality. I don’t even get sick of the theme tune. In fact, it never fails to make me smile.

Being a kids show of course there’s always a decent life lesson in each of the episodes. Not that this is a feature of every kids show I guess, there are a fair few based around narcissists out there (I’m looking at you Peppa).

This morning we watched Bike. Bluey is at the park with her dad learning to ride her bike without training wheels and gives up out of frustration. She sits on the bench in protest and watches her little sister and friends. Each of them are dealing with their own problems. They’re all struggling and they’re all getting frustrated. One by one we witness their breakthroughs. The music crescendos as they each achieve their individual goals. But they don’t do this through sheer determination, or by suddenly gain a new skill or attribute, or having someone step in and fix things for them. They are able to achieve their goals because they each changed the way they were looking at the problem.  By stepping back and taking a moment to think about the bigger picture, each were able to approach the problem from a different angle. They got creative in their problem solving and it was effective.

 

Prices We Pay for Free Stuff

Since I started earning money, each year I buy myself a birthday present. Something a bit more luxurious or expensive than I would normally buy. Like nice sunglasses or a bag. Something unnecessary. This year I took a different tact and gifted myself participation in the Akimbo Bootstrapper’s Workshop which started with its first lesson Wednesday. I’ve been growing increasingly interested in the intersection of commercial and service industries and I figured it would put me so far out of my comfort zone that I’d be bound to learn something of value.

The first lesson prompted me to think about the things I spend money on that I could’ve made or sourced myself, and why I choose to do so. For me, I seem to be happy to spend money on things if they make me feel good in the moment, help build better relationships, allow me to spend more time on the things I prioritise, or are investments in the long-game.

But I’ve also been thinking a lot lately about the stuff that we don’t pay for. Well, not in money anyway. Because the reality is, if it’s a product or service that’s free then we’re paying for it somehow. I’m talking things like Facebook, Google services, etc. I use these services, and I’ve always known that I was paying for this through advertising and been happy enough to accept that. And I am still happy enough to accept that, for some things.

After watching documentaries like The Great Hack on Netflix it is hard not to be a little bit concerned about how Cambridge Analytica were able to influence outcomes in the 2016 US election, Brexit and more, with basically no backlash. You might think documentaries can’t be trusted, they are a narrative, not necessarily the whole story. I agree you can’t just gobble it all up. But then you listen to something like this podcast, an interview with a guy called Roger McNamee who was a mentor to Mark Zuckerburg and even introduced him to Sheryl Sandberg, and you start to understand it a little bit more. What’s most scary about is the lack of transparency, and the failure of companies such as Facebook to live up to their civic responsibility.

I want to share one of the things I learned. I’m not being condescending here. I genuinely am a bit aghast that I’ve only just learned about this stuff. I’m willingly making myself look stupid here (maybe I’m the only one who didn’t know this?) because I think it needs to be talked about and acted on.

I’ve always been pretty willfully naive regarding my use of apps and the internet. When I use things like Facebook, or Google products (which I use a lot, even my nearly 2 year old can say something that sounds like “hey Google”) I would take it on face value that while the advertising may be targeted to me, the content was the content. And I don’t really mind advertising being targeted to me. I love online shopping. Sure, I thought maybe someone else might see it in a different order or something, but I figured they essentially see the same thing. But this isn’t what happens at all. What we see depends on our filter bubble.

A filter bubble is an algorithmic bias that skews or limits the information an individual user sees on the internet. The bias is caused by the weighted algorithms that search engines, social media sites and marketers use to personalize user experience”

This filter bubble thing is really important to get your head around. There’s a really good Ted talk by Eli Pariser from 2011 (note, 5 years before the 2016 election!) about the invisible algorithmic editing that happens on the web. Watch this! He explains it way better than I can, and it’s only 8 minutes. This isn’t some tinfoil conspiracy theorist kind of thing. According to Mark Zuckerburg himself at any given time Facebook has something like 10,000 different versions deployed depending on what the engineers want to try out.

A quick summary is that if I type something into a Google search, then I get the results they want me to see. Perhaps more importantly, I don’t know what they edit out. My search results are going to be very different to yours, based on our search history, use of Google maps, what I’ve clicked on in Chrome, my Gmail…

Similarly, when I see my newsfeed or go into a group in Facebook, I see a selection of posts they have decided are most relevant to me. Same goes with most news sites, or big shopping sites, etc. This might not matter if I’m searching for something frivilous, or if my Facebook feed is mainly just a bunch of photos from people’s kids during Book Week. It may even be useful. But it’s the lack of transparency that’s a problem. Particularly if you’re using these products as your source of news and information. There’s a chance that your perspective will be skewed and you won’t even realise. In the case of Cambridge Analytica, they identified people who met the profile for swing voters and filled their newsfeeds with content that would influence their vote. And it worked. Multiple times. In different countries.

Now think about how this might affect you if you’re using these products for professional purposes. Many professional groups host their communities in groups on Facebook or LinkedIn. The PSA’s Early Career Pharmacists group is a large, very active group of over 9,000 members on Facebook. GPs Down Under is another closed Facebook group with an active community of more than 6,000 members. But while these groups may be private in terms of not being visible to outsiders, it certainly does not mean that the information shared remains between the members of the group.

The data that we offer these platforms is what their business is all about. We aren’t the customers of these platforms, we’re the commodity. The customers are the people that pay. They pay for the opportunity for direct marketing, they pay for the rich data that is found in our posts, they pay for the opportunity to recruit people for employment. It doesn’t necessarily mean that professional groups shouldn’t use these free platforms, but it’s something that should be seriously considered and the membership can decide if it’s a trade off they’re comfortable with. If something is free, then we have to think about how they are getting their money.

In the US there are a few products that offer social network type products that are especially for healthcare professionals, usually doctors. The biggest one is Sermo which is marketed as a place where “doctors can candidly share their true feelings about their profession and lives, and talk ‘real world’ medicine”. They claim to have nearly 400,000 members in the US and is available in seven countries. It started as a pharmacovigilence tool set up after the Vioxx recall. Sound pretty good, right?

Good except for the fact that they too are listening into the conversation and providing that data to pharmaceutical companies and whoever else wants to pay for it. It’s hidden in the terms and conditions. It may be presented as though it’s just like sitting and chatting in a doctors lounge, but in real life if you discovered microphones hidden in potplants or behind pictures you probably wouldn’t feel all that good about it. You might think it doesn’t really matter all that much if they use this data to inform sponsored posts on medications, that you know how to evaluate information sources. But it gets back to the whole filter bubble thing. In environments like this, how do you really know what you know to be true is true? In my mind, the trade off of free platform to data mining is doesn’t pass the sniff test. I don’t trust it. (I’m not the only one, you can read more about this here).

Another similar product in the US is Doximity. Another free platform without advertising, but they openly disclose that they make their money through providing recruitment opportunities. The US is a big market, so that sounds pretty reasonable to me. And they offer some useful tools for collaborative practice too. That might be a trade off that I’d be comfortable with. It’s less likely to be viable in Australia though. We need another option.

I think social networks are a valuable resource for healthcare professionals and I think we need a more independent, secure platform to facilitate this. And it’s not just me. In their 2012 systematic review, Frances Cunningham and colleagues at Australian Institute of Health Innovation argue

“networks can represent not just the social glue of the professional interaction but the sociological building blocks of effective organisations”.

This is the problem that I want to help solve. I am going to provide an independent, secure online platform to host communities of healthcare providers. More than that, this platform is also going to offer a place for members of different communities (and disciplines) to connect with each another. So that we can all work together to build a more sustainable and well functioning healthcare system. Anyone want to help me make it happen? Let me know on Twitter @laurencortis.

 

 

Grit

Last night was the finale of Australian Survivor. I’m not even going to pretend to be embarrassed about my love of Survivor, because I unashamedly love it. I love watching the relationships and the scheming and strategizing.

As is Survivor tradition, the last immunity challenge is about enduring discomfort. Last night they lasted six and a half hours! Staying up there took serious grit. But does that mean that Harry and Pia we’re quitters when they asked to get down? Were they being soft by not staying until their bodies convulsed uncontrollably?

Some people would probably say yes, they gave up. Winners never quit. Grit is what it takes to be successful in life. That’s the David Goggins approach for sure. “You got to callous your mind”. And I think there are circumstances where this is worthwhile. But not all the time.

Just over 10 years ago, I somehow found myself taking on the role of being project manager to implement an oncology clinical information system at the hospital where I was working. I was in no way qualified to do this, but no-one else would even try. Unlike other people I was open to whatever opportunities came my way to see what I might learn. And learn I did.

There was a bit of political pressure to make this work, because the project had been funded by a charitable grant, there had been a recent error which ended up in bad publicity and it was already behind schedule and over budget by the time I took it on. But it was very obvious to me very early on that there was little to no chance it was going to be successful. As is the case with most software implementation, there’s no such thing as a plug in off the shelf solution. Managing the change of workflows and all the human and governance stuff is a lot of work and it’s really important. So if you can’t get the key players engaged in working on it, it’s just not going to happen.

It’s not like I just passively accepted this. I worked really hard to try and get things happening. But no-one wanted to do the actual work and I couldn’t do it for them. So at the end of the day I had to be brave and tell the executive sponsor and all the powers that be that even though they’d spent a lot of money (the project had been going for some time before I took over it) it was my advice that the best thing to do was pull the plug on it. I have to tell you, it was not an easy thing to do. It took quite a few repetitions of this message escalating over time for it to be heard. Nobody was happy with me. But it was definitely the right thing to do.

I wonder how often this happens, that people are willing to admit defeat even if it makes them look bad? I suspect it’s more common to hold on to your pride and keep pushing until someone else tells you to stop. Maybe that’s one of the reasons why projects blow out their budgets so often, because we’re not accustomed to taking pause and checking in that everything is going ok. Instead we just react and adjust our timeline, move the targets out further and further.

I don’t agree that winners never quit. I think knowing when to quit shows intelligence, and sometimes it may even be the braver thing to do.

Fake it til you make it

I have not been disciplined in my work today. It is 1:22pm and I haven’t started what I am supposed to be working on. I got sucked into shinier things that are much more appealing. I don’t want to work on what I’m supposed to be working on.

I know, once I get started momentum will kick in. So that’s what I’m doing here. I’m procrastinating, kind of, but in a fake it til I make it kind of way by talking about the bits of the work I find interesting. I’m hoping I trick myself into getting fired up about doing the work. Here goes…

I’m writing a literature review looking at the empiric research on patient-directed medication management services that have been implemented in cancer populations. One of the things that struck me (which is becoming a bit of a recurring theme) is how segmented the literature is. Research is reported as adherence interventions, symptom management interventions (e.g. pain), or pharmacist-led interventions and systematic reviews typically look at one segment in isolation. This seems a bit silly to me. If you only look at interventions claiming to be ‘adherence’ interventions, then you’ll likely miss the more comprehensive services that address adherence as well as everything else, like medication review. If you only look at pharmacist-led interventions, then you’ll miss all the interventions delivered by nurses, or designated research assistants. Sure, they might be more simple, but they’re probably also less resource intensive and may suffice for some people depending on their level of need. If you want to know about what interventions improve medication outcomes, surely you need to look at the whole lot, don’t you?

Another thing that I find interesting short sighted, is how often we exclude the very people who would have the most to benefit from the intervention. I mean, if you’re investigating an intervention that is designed to positively impact the medication taking behaviour of a person who is self-administering medication, then it shouldn’t matter if they speak another language, or they have some cognitive impairment, or psychiatric illness. They’re probably the ones who need the most help, no? Sure, it’ll be harder to implement the intervention, but it might give more meaningful results that are actually relevant to the real world. Wouldn’t it be better to explicitly state that self-administration of medicines is an inclusion criteria, than to list things like cognitive impairment and psychiatric illness as exclusions? I’m pretty sure people with stable psychiatric illness are relied upon to self-administer medicines all the time. And if someone’s got such cognitive impairment that you can’t obtain informed consent, then they probably shouldn’t be administering their own medication.

And one more thing, while I’m thinking out loud. Is it really accurate to call something an adherence intervention if the decision to prescribe has already been made? I don’t want to get all pedantic about the semantics, but they are distinctly different terms. If an intervention is about how much a person’s medication taking behaviour matches what was prescribed, then it’s really talking about compliance. Adherence implies there was some sort of agreement between patient and the prescriber about what the plan should be. I suppose you could argue that if an intervention identified that the patient had an issue with the prescribed medication and then took steps to resolve the problem with the prescriber to something that was mutually agreeable, then that could be considered an adherence intervention.

This is why I don’t like writing literature reviews. It’s too bloody hard to do it well. It’s so easy to gloss over stuff and generalise, and not pay attention to the details like the terms they’re using etc. But the details matter. If you lump a whole bunch of interventions together because they all measure ‘how many doses were taken’ as an outcome, then it’s pretty much guaranteed that you’re not going to get any meaningful results. Studies will be too heterogeneous and of low quality to draw any meaningful conclusions. What’s the point of that? How does that add value to the existing knowledge base? I don’t want to do that. So better get back to it I guess.

Thick Data

I’ve been running regularly each week since my daughter started school in February. Well, jogging as best I can. And I was reminded this morning of what converted me after never having the slightest bit of interest before. In fact, I was probably anti-running, and definitely very judgemental. But that’s all changed now and I’ve flipped to being a running evangelist. Like yoga, it really is active meditation.

This morning I could have used many excuses not to do it. Spring has brought beautiful weather in Adelaide, but just as it does every year, it also brings hayfever. This morning I feel as though I’ve been hit in the face by Rocky Balboa (I don’t really know much about real life boxing). I had a bit of a mental breakthrough yesterday and I’m really keen to get working on my literature review, running would delay that (side note, why do mental breakthroughs always come at the end of the days work?). And it’s my birthday, who wants to run on their birthday? But to be honest, birthdays kind of lost their shine for me when I woke up to the news on my 20th birthday. Day and night news coverage of 9-11, followed by annual reminders is pretty sobering. But I digress…it’s a beautiful day today and my daughter was happy to ride her scooter to school so I thought I might as well make the most of it and jog home.

I usually run along the river, but I got swooped by a magpie the other week and now I’m scared. So today I took the easier flatter option of running around the streets. As I usually do, I listened to a podcast, only to be interrupted part way by flat batteries in my headphones. So the rest of the way home was just me and my thoughts. And that’s when I was reminded of the meditative nature of running. I’ve been so caught up in trying to make the most of every opportunity to learn lately that all of my exercise time has been spent consuming and interpreting other people’s content. Giving your mind space to breathe is also really important.

This isn’t one of the outcomes I had in mind when I started couch to 5K. When I started my goal was to be able to run for at least 30 minutes without stopping. Then it was to run for 5K without stopping (I’m slow!), 45 minutes, etc. But in May, once I was running regularly enough to justify buying gadgets, I got myself a Garmin running watch. Then I started getting more interested in the numbers. Particularly pace and VO2 max. I didn’t even know what VO2 max was before that (and truthfully, I still don’t have a solid understanding).

For a time those numbers were looking pretty good. Until winter hit, and then the numbers started going backward. And the numbers are still going backward.

Just looking at the numbers can be pretty disheartening to be honest. I mean, it’s not like I was training specifically to improve them, but to decline has been a bit annoying. But what I need to remember is, those outcomes aren’t really indicative of whether or not I’ve been successful in my running. The reason they don’t indicate success because they don’t reflect my goal.

My goal is to exercise for at least 30 minutes, three times a week regularly, and to get at least two runs in a week as part of that. And I have been successful in achieving that goal all but one week since May. That’s despite all the snotty viruses we’ve had and my recent war with pollen.

Now, if I were to focus on the numbers instead, I might feel like it’s all a waste of time. That I might as well wait until spring has passed, I can breathe clearly again, and things will be good again. Take an all or nothing approach. This would obviously be stupid, but it’s actually a pretty common way to react to situations like this. If you think the outcome data outweighs the impact on lived experience then there’s a very real risk this will happen.

This is where the thick data bit comes in. Yesterday I had a meeting with an experienced researcher who is known for her strong opinions to talk about my research. And I was really nervous, because even though I feel like I’m starting to be credible in what I’m talking about I still have self doubt. Especially in the world of Pharmacy where everyone seems to be obsessed with quantitative research. But she reminded me that I should never apologise for doing qualitative work. Good quantitative data is important, yes, but qualitative data is thick data. It helps you to gain a deep understanding of what’s going on. Where the problems lie. To tell a story that’s meaningful. Its important and difficult work to understand and interpret lived experiences. It is essential to making sense of the numbers.

There’s a really great example of this in the book Range, by David Epstein. It’s been written about other places too, but I’ll use any opportunity to plug this book that I can because it’s so good. He tells the story of the Challenger disaster, which I’ve mentioned briefly in an earlier post but I want to explore it again from a slightly different angle.

The Challenger decision was not a failure of quantitative analysis. NASA’s real mistake was to rely on quantitative analysis too much.

How often do we do this in relation to medicines? All the bloody time! If we’re talking with patients, our obsession about our clinical indicators and our assumptions around them often means we neglect to explore the actual lived experience of the person themselves and encourage them on the steps they’ve taken toward reaching their goals. We almost reinforce the all or nothing approach. In my running example, sure my numbers suck, but I’ve been putting in consistent effort over time and there has been multiple positive impacts on my lived experience. I can think of many examples of dealing with patients when I haven’t been considerate to their effort. We have a tendency to thing of patient behaviour as dichotomous, compliant or non-compliant. But reality is far more complex than that, far more dynamic, and it can’t be reduced to numbers or singular outcomes.

We do it on broader scales as well. Our obsession with systematic reviews is the perfect example of this. Yet, how many systematic reviews are conducted to reach the same cliche conclusion of “studies were too heterogenous and of low quality to draw conclusions”? Ok, fair enough, but that’s not terribly helpful. Last year Trisha Greenhalgh and colleagues challenged this in their perspective piece Time to challenge the spurious hierarchy of systematic over narrative reviews? It’s a really thought provoking piece about the assumption that systematic is better. They basically call bullshit on this. Choose the review methodology that best suits your research question and conduct a robust review.

The first time I realised this to be true, that quantitative RCTs weren’t the be all and end all, was when I heard David Currow speak in 2011. He is a professor in palliative care who heads up the Palliative Care Clinical Studies Collaborative (PsCCSC). They are a national research network who are working to build a high quality evidence base for palliative care, facilitate RCTs in palliative care etc. I remember attending a talk he was giving sharing their latest studies findings on ketamine and he talked about study design. I distinctly recall him saying that the question defines the methods. It’s the essence of high quality research and it has stuck with me.

The worst thing about the challenger disaster was that they had the other data available, it just didn’t pass their threshold of what was deemed credible. They had photographs that concerned the engineers. The engineer later testified to the commission investigating the disaster about being reluctant to insist on the decision makers paying attention to their concerns:

“I was asked to quantify my concerns, and I said I couldn’t”…”I had no data to quantify it, but I did say I knew that it was away from goodness”

It was a cultural issue at NASA that led to them ignoring key information that resulted in the deaths of seven people. Cultural issues are just as important to acknowledge and address as determining the number needed to treat, or effect size. It might be difficult to do, but we’ve got to start somewhere right?