With recent-ish news of the reinvention of space race with front runner Elon Musk, interest in the world beyond our blue planet has made a come back. The paradigm traveling alongside is no longer tinted with Cold War and atomic annihilation of human life , but rather environmental apocalypse and annihilation of human life. To a certain extent, colonizing another planet is a way to prepare for the collapse of society and in that regard, Elon Musk is the ultimate prepper!
I recently gave a presentation to doctors of the Hospital de Los Valles, Universidad San Francisco de Quito USFQ, Ecuador about Delphi panels and I thought I’d translate it into a blog post to keep a trace, but also because I am sure some have asked themselves the question. Indeed, many have encountered the term “Delphi” without really digging into what it means. This post aims to be brief and straight to the point and answer the following questions:
– What is a Delphi panel?
– What are Delphi panels applications in health?
– What is the position of Delphi panels within health evidence?
Several times, prospective PhD students have asked my opinion about whether they should start a PhD or not. I’d like to share one aspect – among many other – which supports commitment into a PHD: improved productivity.
Why am I writing a PhD? Throughout my now fairly long life as a PhD candidate (I am now five and a half years into it), I gave the answers I thought best: it teaches me to be responsible of a large scale project all by myself, I learn how to use new research methods and, among many other reasons, I learn about how I function as a human being – Oh, and I contribute to research, I was going to forget that one!
While they are true, these responses only answers part of the question. Why do I write a PhD? Not the part about motivations, but rather the so what part.
Here is something about me – about most of us: I procrastinate, i.e. I postpone to tomorrow what could be done today. And since primary school, we are taught that procrastination is evil. Just look up online the thousand pseudo solutions to fight procrastination.
Imagine sitting in the chair of a venture capitalist: you have two candidates, one with an average idea with strong evidence that there is a need for the product and another with a very innovative project but who did not give too much thought into the evidence. It is likely that the candidate with strong evidence will get the funding. What could the innovative project candidate have done to more effectively make their case?
Working in health and more precisely around pharmaceutical products is a complex situation due to the highly controversial actions of the pharmaceutical industry. To sketch things in a slightly over simplistic manner, researchers have to choose side: either you are a pure academic sociologist and generally oppose the capitalist pharmaceutical industry or you collaborate with the industry and take for granted a certain number of assumptions.
I feel I sit between both chairs. On the one hand my research lab displays a sociological orientation working independently from the pharmaceutical industry and my supervisors are not known for their support to the pharma world. On the other hand, my sponsoring institution is a consultancy working directly for the industry. This potential issue had not arisen so far, but since I have started working on theoretical concepts of medicalisation and pharmaceuticalisation, I see the topic has become hotter.
The efficacy of pharmaceutical treatments is in many ways the centre of disagreement. In his book ‘Limits to Medicine, Medical nemesis: the Expropriation of Health, Illich unwillingly exposed the dilemma. (Illich I. 1976) He argued that many treatments, especially newer ones harm society more than they help. However, he admitted that a number of pharmaceutical discoveries were in fact fundamentally positive, citing infections like malaria or syphilis for which medical treatments were found to be efficacious. To me, by entering the field of comparative health research he puts his argumentation at risk of being falsified due to advancing knowledge and contradictory evidence.
After having worked in health economics for over three years I understand that measuring efficacy of medical treatments is not a straight forward black or white science. It is necessarily embedded in theoretical assumptions, methodological biases and limitations of a number of sorts. Treatments initially appearing as efficacious in a particular indication can be demonstrated harmful ten years down the line and/or can be proven efficacious later in another indication following complementary investigations. Because of the pharmaceutical industry’s financial interests, the controversy will remain between those defending the product and those opposing it.
When I first entered the medical field of osteoporosis and knew only very partially the existing literature, I started with the reading of pro-pharmaceutical industry publications (including the report I mentioned in a previous post, Hernlund et al. 2013). As most observers, I was sensitive to the argument of a tremendous treatment gap: older people were denied efficacious treatments. So my initial research question was formulated as follow: there are fully recognised efficacious treatments available to treat a well known harmful and costly disease: why are treatment uptake rates low and now declining? This was the argumentation I supported at one of my first conference presentations, the SMi Safe Geriatric Medicine Summit in 2013 in London.
As I went on reading I understood the other side of the controversy alongside the limitations associated with the efficacious characteristics of treatments against osteoporosis as well as the concepts of disease mongering (pejorative way of describing the role of the pharmaceutical industry in the increasing place of health in life). I also acknowledge that I don’t have the knowledge nor the willpower to engage in this endless and highly technical debate. It is for this reason that I have decided to take an almost anthropological stand at the situation and avoid the question of efficacy.
When anthropologists study the role of shamans or sorcerers in societies (technological or traditional societies – yes there are still such practices in Western countries nowadays!), they do not argue the effectiveness of the spiritual procedure; either because the researcher considers in a slightly cynic way that such beliefs are kinda retarded or because he/she voluntarily chooses a neutral position. Adopting such a position in our modern societies on the topic of pharmaceuticals suggests that I put medicines at the same level as an exorcist procedure. Because I work in an environment completely devoted to the assessment of pharmaceuticals’ effectiveness, it makes it delicate to adopt an external position. Sorry for the comparison, it is as if I was anthropologically questioning the usage of exorcism as I simultaneously worked as priest assistant! It is complex, yet surely not impossible.
Since the mid 1990’s, awareness around the risks and burden of osteoporosis has climbed up the ladder of public agendas. It came alongside the discovery of pharmaceutical medicines preventing the loss of bone mass (bisphosphonates). As soon as drugs were made available on Western markets, uptake rates built up. The most renown bisphonsphonate, Fosamax (alendronate) participated in the success of the pharmaceutical company Merck & Co.
The following graph, computed from Hernlund et al (1) describes in DDDs (defined daily dosage) the evolution of the osteoporosis medications uptake rates in France between 2001 and 2011. The increasing trend was very clear between 2011 and 2007. However, 2008 appeared to be a turning point, whereby consumption started declining. Investigating and explaining this trend is the main aim of my PhD.
The number of osteoporotic people does not seem to have declined, drug prices have very significantly fallen and scanners for diagnostic have never been has widely available as they are now. So I wonder about the phenomenon occurring since 2008. Is the way osteoporotic drugs are perceived changing? Is there a profound change in the way we apprehend care for older people? Were the benefits associated with these treatments overdone (and adverse events underestimated?)? Were too many people being unnecessarily treated?
(1) Hernlund, E., Svedbom, A., Ivergard, M., & Compston, J. (2013). Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden. Archives of Osteoporosis, 8(136). Retrieved from http://www.iofbonehealth.org/osteoporosis-european-union-medical-management-epidemiology-and-economic-burden
Half of the work of writing a PhD is around redefining, reorienting and remodelling the research question. I am learning this the hard way. But this is a lesson that I find useful in many other situations.
On a day-to-day basis, we continually find simple solutions to simple problems. A water leak needs proper care. If not too handy, one call to the plumber. An indecent bill later, the problem is solved. In research, we spend so much time and energy on the methods, the research, the reading, the thinking that we often find ourselves wandering and suddenly asking an imaginary friend: “What is it that I am researching? What is the problem? What is my research question?
There are loads of posts on LinkedIn about making the best decisions in your life, about happiness at work and so on. These posts often offer solutions to a number of problems and the reader question whether or not it applies to him/her. Many solutions are proposed, but few posts suggest to properly assess the problem. There are numerous reasons to be unsatisfied/unhappy about work, research family or else, but are we capable of identifying exactly what it is that troubles us, what the exact problem is?
The risk of not taking the time to identify the problem is to jump into solutions that don’t actually respond to the problem. Resources of all kinds will have been thrown into this solution and once quiet has come back, the same uncomfortable feeling comes back with it. All that for nothing: back to square one.