17 December 2016

Photos from our Galilee bike ride

Here are some photos from our epic journey around The Galilee in Northern Israel. Enjoy, and feel free to add your comments.
Bikers gonna bike bike bike bike bike...
(PS. We had an amazing time and are well on our way to raising £50K for the Nazareth Hospital Paediatric Ward Appeal - thanks everyone!)

22 November 2016

Socratic debate, Union Theological College Belfast, 21 Nov 2016

Last night in Belfast we had a debate, as part of the CS Lewis Festival. Just the usual for this part of the world: "This house believes that God is about as real as Narnia". Proposing the motion were Jennifer Sturgeon and me; opposing us were Chris Hudson and David Capener. Our moderator was William Crawley. For the record, here is the text of my opening statement...

CS Lewis was a master story-teller. When he created the Narnia series, he told an engrossing story of interactions between a world somewhat similar to ours and the fantasy world of Narnia.

Many people have pointed out close parallels between the Narnia fantasies and Christianity, and indeed some go so far as to suggest that Lewis consciously created Narnia as a Christian allegory.

The character of Aslan the lion, who dies and resurrects, is a very close parallel to that other fantasy, the risen Christ. And not everyone is a fan of Narnia - there are elements that are pretty questionable on ethical and intellectual grounds. However, we all agree that Narnia, whatever its merits or demerits, reflects the outworking of a human mind, and is not something that “exists” in a real sense.

And that is OK. Because we humans are story telling creatures. We don’t understand things through lists of facts and figures - we use NARRATIVE. Even scientific theories (and the word theory is much misunderstood, especially by creationists, but that’s another narrative) are in essence *stories* that we use to pull the facts and figures and hypotheses together. We create as coherent a narrative as we can muster, and we try to communicate with that.

So if we use stories to help evolved human brains understand reality, what about the story of God? I maintain that we do know enough about the world to answer that question. God is about as real as Narnia.

Now in saying that I am saying two very specific things:
  1. God in general, whether we are talking about the “God of Classical Theism” or a more localised form of god with intentions, emotions, desires etc, is a human construct that does NOT comport with whatever is really out there, and
  2. The Christian story of Jesus Christ as the Son of God is a story that is not “true” in the deep and meaningful sense that many Christians make it out to be. The same applies of course to other religions based on supernatural beings, but since Northern Ireland seems overly fond of Christianity, perhaps we’ll focus there for now.

I’m also making an ancillary point - the notion that the stories in the bible are the Word of God and point unerringly towards a correct understanding of the divine is manifestly NOT TRUE.

The Bible contains many wonderful stories that incorporate errors, contradictions, propaganda, fiction, embellishments, lies, truths, fabrications, fairy tales, history and pseudo-history. The bible is a human product, but whereas Narnia had a single author, the bible - and the religious fantasies woven around it - had many.

I was a believer in the truth of the Christian God story until I was in my 20s. Then I went to spend some time studying in a hospital in Nazareth, Jesus’s home town. I came across people who were Jewish, Muslim, Christian and Druze – all people with different stories about God. But they all experienced the same joys, pains, worries, hopes. Maybe my view was too narrow?

Indeed, maybe Jesus didn’t actually rise from the dead, and like Paul said in the first letter to the Corinthians, my faith was in vain. And when I studied the bible stories, the protestations of the apologists that the resurrection was historically well attested completely fell away. It was a fantasy too.

For example, the story in the Gospel of Matthew has dead people rising from their graves when Jesus is crucified. This is not reported ANYWHERE else in the bible, or by any ANY contemporary source. The author of Matthew (who was certainly not Matthew the disciple) made it up.

When Jesus rode into Jerusalem on a donkey on Palm Sunday, Matthew, who didn’t know Hebrew, misinterpreted a passage in the Old Testament, and fabricated an EXTRA donkey (the foal) in order to fix what he saw as an error in the gospel of Mark (also not written by an eye witness).

When Jesus allegedly rose from the dead we have separate yarns in the gospels and Acts that are completely at odds with each other, indicating that these were MADE UP. It’s now very clear to me that the stories of the risen Jesus are based on visions dreams, false memories and peer pressure, not actual appearances.

It’s an interesting experiment to get four bibles and read the gospels side by side, and I encourage you to do this. It’s like JRR Tolkien and Bertrand Russell were all having a hack at correcting CS Lewis’s mistakes in Narnia, while Arthur C Clarke was off writing something else.

We don’t have four eyewitness perspectives – we have four people telling stories about something they have never seen, except in their imaginations working on what they’ve been told.

The central story of Christianity is a fantasy. Jesus was just a man about whom stories were written, and we should take them with a BIG pinch of salt.

The omniscient omnipresent omnipotent omnibenevolent God that made the universe is likewise just a story. We don’t know exactly how the universe began. We don’t know the fabric of reality. But we do know that surprises are in store, and EVERY time we’ve thought that God has intervened in the history of our universe, we’ve been wrong. The God of classical theism is a philosophical toy God, and frankly we don’t need it - science has given us BETTER stories.

I sometimes identify as a Christian Atheist. Many aspects of the Christian story still appeal to me, because I love stories too. They have helped form my outlook on the world and life.

But we are the product of the laws of physics working in a universe that also produces supernovae, black holes, ice fountains on Enceladus, nitrogen oceans on Pluto, coral atolls on Earth and joy and pain for human beings.

It’s a marvellous Universe, but it doesn’t really care about whether or not we’re here. But WE care, and we invented the gods and God to give us a central place in the cosmos. God is a mirror, not a window.

God is a story, in exactly the same way as the Shire or Hogwarts or Narnia, and it’s a story that gets BETTER – and WE get better - when we realise that it is fantasy.

20 November 2016

Mission Accomplished!

I have been remiss in updating you on my Israel biking adventure - we rolled in to Nazareth on Friday 11 November 2016 after five (well, six) days of incredible biking. A journey together that brought us from the shores of the Mediterranean up to the Upper Galilee, down to the Jordan Valley and the Sea of Galilee and finally to Nazareth itself.

As a group of old friends and new, we explored the terrain, meeting local people and viewing the splendours of the countryside. We passed through villages populated by Jews, Christians, Muslims and Druze, as well as barren hills, verdant valleys, agricultural fields and scented forests.

But the purpose of our journey was its final destination - the crazy paradoxical town of Nazareth, home to the largest Christian population in Israel, and the location of its oldest continually functioning hospital - the Scottish Hospital, established under the EMMS (Edinburgh Medical Missionary Society) in 1861 by the remarkable Dr Pacradooni Kaloost Vartan.

The whole rationale for the bike ride was to raise money for refurbishment of the Paediatric Surgical Unit. We still need to hear how much we actually raised, BUT if you want to give more, you still can! My fundraising page is at http://justgiving.com/shanenaz2016 and  remains open. When we arrived at the hospital we were given a tour of the current facilities (closed while the refurbishment gets kicked off), and I can certainly give my approval to the new plans. I think it will make a big difference to the kids coming in for surgical treatment.

But all of this got me to thinking - why should we in the UK be supporting a hospital in Israel? Surely the Israeli government should be working harder on its own healthcare policies, and properly resourcing its hospitals and clinics? The answer to this one is both complex and simple. The complex answer is that Israeli healthcare planning and funding is a bit of a mess, and healthcare organisations have to sort it out themselves while seeking reimbursement from the national insurer. Capital development is really under pressure.

The simpler answer is that in building better healthcare, and especially in building links between countries and healthcare economies, we not only show that we are citizens of the world (sorry, Theresa May, but that's what we are), but that we want to build links and collaborations with people who are often neglected or disadvantaged. And for those who aren't neglected nor disadvantaged, we still want to work with them, because life is not a zero sum game. My gain is not necessarily someone else's loss. A problem in another country is not something I can just turn up my nose at. It's an opportunity to build links of friendship and healthcare. And healthcare in particular is an effective way of building peace and understanding.

Here, in a small hospital in Israel, there's a part of Scotland (and OK for these purposes I'm going to self-designate as an Ulster Scot!) - a place that's all about looking outwards and bringing people together.

24 October 2016

Nazareth Hospital Paediatrics Ward Appeal 2016

I've been meaning to set out some details of the 2016 Appeal for the Nazareth EMMS Hospital. This appeal is to refurbish and rebuild the Paediatrics Department in Nazareth - an absolutely vital service for the people of the Galilee region. The following information has been supplied by the Nazareth Trust. Don't forget to donate at http://justgiving.com/shanenaz2016 and make sure you spread the word on Facebook and Twitter!


The total population in Nazareth is 74,620. In the past, the majority of the population in Nazareth was Christian, but today the majority is Muslim. Over the years life expectancy has increased which has led to an increase in chronic diseases.


The Nazareth Hospital is licensed and accredited by the Israeli Ministry of Health. It follows and abides by all the regulations and standards of the Ministry of Health. The Nazareth Hospital does not receive regular government subsidies for capital investment in buildings, equipment, and other major improvements. Neither do we have foreign donors who regularly contribute large amounts to our efforts. When it comes to capital development and purchase of equipment, Nazareth Hospital relies totally on gifts and grants from friends around the world.

In October 2011, the Nazareth/EMMS Hospital officially took on the role of a teaching hospital and opened its doors for the first group of medical students from the Galilee Faculty of Medicine affiliated with Bar Ilan University. Seven of the Nazareth Hospital EMMS departments are recognised for the school’s residency programme.

The Paediatrics Service in Nazareth

The Nazareth Hospital provides health services to a catchment area of 264,000 in the North. Over 40% of the target population is under 18 years of age.

The paediatrics department at the Nazareth Hospital was established over 40 years ago by a missionary doctor who recognized the importance of developing and expanding services for children, including community-based health outreach to raise the awareness of mothers regarding child health.

Today the Nazareth hospital runs a very dynamic pediatrics department and a Neonatology department. With 18 hospital beds, a very dedicated team and despite the very limited space, the pediatrics department houses multiple services including general pediatrics, surgery, orthopedics, urology and plastic surgery and often times gynecology services for children.

It is also important to mention that the Nazareth hospital provides unique services in the region including treatment of burn patients and is the only hospital in the region that is certified by the Ministry of Health to treat and provide vaccinations for children who suffer from allergies that could compromise their condition when they are vaccinated for childhood diseases and require special attention and treatment.

The paediatrics staff applies the hospital’s biopsychosocial model, considering every aspect of the children and youth who come to them for care. The social worker and other multidisciplinary teams are available to intervene when needed.

Today, in spite of the department’s crowded physical conditions, patients and their families still prefer to come to the Nazareth Hospital because of the positive and supportive environment provided.

The Nazareth Hospital has the only psychiatry department in the area with Palestinian staff who speak Arabic, making it much easier for Arabic speaking patients to express themselves clearly to health professionals.

In cases where children require psychiatric consultation at the emergency room or paediatrics department they are provided with this service in their first language. In addition, children from the West Bank and Gaza are often referred for treatment to the Nazareth Hospital

The final beneficiaries of this project are the children and youth who will be better provided with immediate care. In 2015, 2,162 patients were admitted for hospitalization spending a total of 3,638 days in hospital. This is in addition to our out-patient and ER clincs.

Through this upgrade of the Pediatrics department, Nazareth Hospital will:
  • Be positioned for accreditation as a paediatric training program to support the hospital in its role as center for Family Medicine residency training. This outcome will be measured by the number of resident doctors in pediatrics, measured against baseline data.
  • Improve access to high-quality paediatric medicine. This will be measured by the number of children treated in the new facility, as counted against baseline values for that statistic.
  • Increase available square footage dedicated to the comfort of patients and their families and caregivers. The new department will have a place where children can do homework, play, and receive family visits with some privacy. This can be measured by square footage gained. Additional emotional and psychological comfort, although qualitative in nature, can be evaluated through patient feedback.
  • Increase the number of its staff with advanced technical skills and relevant professional expertise. This will be measured by tracking the number of staff trained in relevant paediatrics update courses as part of this project.


There is a fairly sizeable pricetag on the plans. The overall total to rebuild the entire Paediatric Unit will be in the region of $3.8M in the long term, which is a LOT, and assistance will be sought from elsewhere to help bring the plan forward. However everything you give will help, and you will know that you are helping the kids of Nazareth to move to a brighter future.

23 October 2016

Transformation powered by technology

On Tuesday the Northern Ireland Health Minister Michelle O'Neill will announce her response to the eagerly-anticipated Bengoa Review into the configuration of Health and Social Care Services in Northern Ireland. This will be a BIG DEAL for those of us working in the HSC, and a BIGGER DEAL for our patients (i.e. everybody).
Minister Michelle O'Neill [photo: BBC]

Before anyone counters that this is yet another review of the HSC and the other reviews haven't had any effect, it's worth injecting a little context. Back in 2014 the then Health Minister Edwin Poots asked Professor Sir Liam Donaldson to report on the state of the NI Health Service. That report was called "The Right Time, The Right Place", and pointed out a number of factors that make health and social care difficult in NI, others that make it excellent, and yet more that provide an opportunity to make it even better. I'm talking things up a little - there are major reasons why the status quo for the NI HSC is not sustainable, and transformation is critically important. Everyone knows this.

The Donaldson report made a number of significant recommendations, the first of which was the establishment of an international expert panel to review the Health Service and recommend a redesign that all political parties would be expected to sign up to in advance. I feel this was a pretty big ask, and therefore when a subsequent Health Minister, Simon Hamilton, took office, he reconfigured this recommendation into a combination of local, national and international experts, chaired by Prof Rafael Bengoa, to carry this recommendation forward. There was no political advance buy-in, but I don't think anyone finds that too surprising. This is Northern Ireland, but even if it hadn't been, politicians don't like signing up in advance to something they haven't had a chance to look at.

The important thing however is that the Bengoa Review exists as a direct consequence of the Donaldson Review, and it would be wrong to see it as "yet another report". I've previously blogged a little bit about this, but in advance of the report itself, it would be wrong to get too bogged down in hoped-for details.

That said, the word on everyone's lips is Transformation. We have to transform the HSC to achieve the so-called "Triple Aim" - better healthcare, better health, lower cost per capita. This means getting patients much more involved in their own care, changing how we deliver services, being much more open in how we share information and resources, centralising some services where appropriate, shifting expensive acute services to a small number of specialist sites, slashing clinical errors, reducing medication harm, taking a rigorous evidence-based approach to management, supporting much more care in community settings, etc.

There are a number of ways we will need to do this, but it seems very likely that the Minister will announce digital technology as a key feature. At least that is what I very much hope. We cannot truly transform our HSC by tinkering at the edges and redesigning a few forms and processes. We need to make sure all staff and patients are on the same page with regard to the data, that we are minimising risk due to miscommunication across care domains, that we are saving time and risk by not requesting and re-entering the same data multiple times into multiple disparate systems. We need our patients to be able to contact and communicate with us using video and audio calls. We need them to be able to access their own data and manage their own conditions insofar as that is appropriate.

This can't be done without the technology, but implementing that is a people process more than a tech process. The next few years are going to be challenging, but the clinical/professional community and our patients/clients are definitely up for it.

27 September 2016

Trump outdone by Clinton

Photo source: NYT
The Free World outside America is wondering how long this can go on. A less presidential candidate for President is pretty hard to imagine - we have a reality TV "personality" pretending he can run a country, but it's hard to imagine any country currently run by a less suitable person. His voice croaking with what might be exhaustion - who knows? - he accused Hillary Clinton of lacking the stamina to be President. This has gone beyond farce and is now a train wreck. Beat it, Donald - go somewhere. You're the loser here, and frankly the USA will be better and greater without your sexism, racism, ignorance and rapaciousness even in it.

19 September 2016

Building a new Paediatrics Unit for Nazareth

Shane is cycling the Galilee, 6-10 November 2016

Previously we helped build this modern operating theatre.


I will join friends from the UK and Middle East to raise money for the Nazareth Hospital Paediatric Department by cycling round the north of Israel. This post contains some information about me and my ride – feel free to share and to get in touch. Most important of all, I would love you to donate to our appeal – your support is greatly appreciated, and will help us achieve our dream of a modernised Paeds Unit in this amazing little city!

Who am I?

I’m Dr Shane McKee, a consultant in Genetic Medicine at Belfast City Hospital. My job involves the diagnosis and management of children and adults with rare genetic disorders. Some of the work is very hi-tech, involving the latest DNA techniques and computational analysis, but the most satisfying bit of being a Genetics doctor comes down to listening to patients and their families, putting together the pieces of the puzzle, and applying that knowledge to make life better. Children are disproportionately affected by rare genetic disorders, and when kids are ill, they need the best care, with their families around them.

What is the Nazareth Hospital?

Back in 1861 a young Armenian doctor named Dr P.K. Vartan from Constantinople, capital of the Ottoman Empire, arrived in the Palestinian town of Nazareth. He established the only clinic between Beirut and Jerusalem, catering for people from all around the Galilee and beyond. Although well known as the boyhood home of Jesus, Nazareth in the 1860s was a fairly small town. Over the decades, and through considerable turmoil in the region, the hospital expanded and modernised as best it could, supported by the Edinburgh Medical Missionary Society, the organisation that had originally trained Dr Vartan and which had sent him to Palestine.

Today the Nazareth Hospital (known locally as the English Hospital as well as the Scottish Hospital) is a modern facility, acting as the District General Hospital for the region of the Galilee. Although established by a Christian charity, and drawing many of its staff from the local Christian Arab population, the Hospital also has many Muslim and Jewish staff (and others), and treats patients of all backgrounds. It is a beacon for unity and peace in a region that has been marred by conflict for many years. However, several areas of the hospital are in serious need of upgrading, particularly the Paediatric Department, and that is the focus of the latest appeal by the Nazareth Trust.

What is my connection with Nazareth?

During our training as medical students, we were encouraged to travel from Northern Ireland to another country, somewhere unfamiliar, to see how medicine is practiced in conditions very different to back in Belfast. This was in 1993; I chose Nazareth, since a doctor from my home town of Dungannon, Dr Stephen Crooks, was working out there. I have always been fascinated by the Middle East, and this was an excellent opportunity to get to know a small part of it at first hand. I spent six weeks training in Nazareth itself, and fell in love with this little city and its wonderful inhabitants. Although I was only there for a short time, it now feels like a second home to me.

The local Arab Israeli population are warm generous people with a great sense of humour. They graciously welcomed me into their town and their homes, and that experience has shaped my entire medical career as well as my outlook on the world. As I met these people in the Emergency Department, the wards, the operating theatres, the clinics and maternity unit, I learnt a great deal about the practice of medicine, about cross-cultural communication, and about myself. I am forever in their debt. When I returned to Northern Ireland after my elective was over, I longed to return.

In 2009 I joined a sponsored bike ride along the Jordan Valley, from the Dead Sea up to Nazareth. About twenty of us cycled 250 miles through Jordanian and Israeli territory, seeing the sights and feeling the burn of climbing over 1500 metres up from the valley floor to the Jordanian plateau. The proceeds of our ride went to maintaining and developing the hospital, including the new operating theatres which were a massive improvement on the very old-fashioned theatres I worked in as a student. And of course I made a lot of new friends, all of whom share my love of Nazareth.

The Nazareth Hospital celebrated its 150th Anniversary with a conference in 2012 – this was a chance to catch up with old friends and to see how things have changed. Many of the kids whom I met on my first trip now have children of their own, and the Paediatric Unit does amazing work with very limited resources.

What will I be doing?

From 6-10 November 2016 I am joining another intrepid group of cyclists from the UK and The Galilee (and possibly a few from elsewhere). We will start in Haifa, and over the next five days we will cycle over 200 miles around Northern Israel, before crossing the Sea of Galilee by boat, and then making our way up through the hills to Nazareth Hospital. There are some challenging climbs, scary descents and bumpy tracks, as well as a couple of on-foot sections, and we’ll be overnighting in local kibbutzim at each of our stops. It won’t be easy, but it will be unforgettable (there may still be a few spaces available if anyone wants to join us!). Our objective is to raise as much money as possible to help refurbish the Paediatric Unit in the Hospital.

How can people help?

I have set a fund-raising goal of £3000, but I hope to raise as much as I can. I have set up a Justgiving web page at http://justgiving.com/shanenaz2016 . Using Justgiving significantly reduces the administration costs for the charity (The Nazareth Trust) meaning that more money goes directly to the project. I am really grateful for any donations, no matter how small (or how big!) - they all go to making the Paediatric Unit fit for the kids of the 21st Century, and hopefully building peace for the next generation. I am of course also grateful for any publicity on FaceBook, Twitter, Instagram, media or even good old-fashioned sharing – anything to help raise as much as possible for the Hospital, and to raise awareness what we are trying to do for the children of Nazareth.
Nazareth is a popular quick destination for tourists visiting Israel, but most people pass through very quickly on a whistle-stop tour. I would strongly recommend staying a bit longer, perhaps in one of the fantastic local guest houses in the Old City, exploring the town, and talking to the modern Nazarenes. It’s a complex, fascinating, full-on experience – oh, and the Palestinian food is amazing. Nazareth is famous for the best cooking in Israel, if not the entire Middle East.

- Shane McKee

Twitter: @shanemuk hashtag: #shanenaz

10 September 2016

Belfast in CardBoardCamera Virtual Reality

OK, by now you know I like the Google CardboardCamera app. It turns any Joe Soap with a smartphone into a VR 3D photographer, and as such you can in principle use it to experience 3D VR content from many sources and places. There are two main reasons why it is brilliant:

  1. It is actually stereoscopic. Most YouTube VR movies are actually 2D spherical projections - you don't get a real sensation of depth. CardboardCamera is pretty smart, and stitches together its panoramas to give you separate left and right eye images. Nice. 
  2. It overlays an audio track. Sound really boosts the immersiveness of the experience. It's not just looking at a boring image - even though it's still, there is still something going on. The soundtrack helps to locate you within the scene.
So with all that in mind, here is a small collection of CardboardCamera images I shot in Belfast. I hope you come and visit our great wee city, and have as much fun visiting these places in reality as I did shooting them for VR!

Download the panoramas - right-click, "Save link as", and copy the resultant file into your \DCIM\CardboardCamera folder on your Android phone. Then view in the CardboardCamera app.

Belfast City Hall is a masterpiece of art and architecture, dating from the very early years of the 20th Century. It's well worth a visit, with regular tours of the interior.

This fountain commemorates Daniel Joseph Jaffe, one of the leading members of Belfast's small but influential and illustrious Jewish community at the turn of the 20th Century. It sits in the historic heart of the city, close to the modern Victoria Square shopping centre.

HMS Caroline is the last survivor from the Battle of Jutland in World War One, the largest naval engagement in history. The ship has been restored to tell the story of the battle and life at sea in the early 20th Century. It's absolutely fascinating.

This is where I did my first house jobs as a junior doctor, although it's a lot quieter now than back then! The main action in the RVH takes place in the new sections. This Victorian corridor is a listed building, and contains many memories.

Belfast's flagship conference and concert venue in the evening light, as the traffic rushes by on Oxford Street. The Belfast Bikes are a great way of getting around the city.

Well, every city has its not-so-pretty major arterial routes, yes?


03 September 2016

The first Presbyterian Church in Ireland - #VirtualReality

Google Cardboard Camera Virtual Reality panorama of Templecorran, the ruined church in Ballycarry Co Antrim. It's a fascinating place, and now you can visit in VR. [CLICK HERE for the link]

INSTRUCTIONS: Download the .vr.jpg file and put it in the \DCIM\CardboardCamera folder on your Android device. It should show up automatically when you launch the Cardboard Camera app, and you can view it with your Cardboard Virtual Reality viewer. Have fun!

Virtual Reality: Dalway's Bawn

Here's a Google Cardboard Camera VR pic of Dalway's Bawn, a historical Plantation cattle fortress from the early 17th Century. It can be found just outside Ballycarry, near Carrickfergus Co Antrim. The towers and frontage are spectacularly well preserved, yet this amazing piece of history is hardly known outside the immediate area of Ballycarry and Bellahill.


Some more information on Dalway's Bawn:

INSTRUCTIONS: Download the .vr.jpg file and put it in the \DCIM\CardboardCamera folder on your Android device. It should show up automatically when you launch the Cardboard Camera app, and you can view it with your Cardboard Virtual Reality viewer. Have fun!

21 August 2016

Training for #shanenaz2016: GLENARM

You already know that I'm heading to Nazareth, the largest Arab town in Israel, in November. I'll be joining a fine group of folks cycling to raise money for the Paediatric Unit in Nazareth Hospital.

So today (21/8/2016) I did a training ride up to Glenarm in Co Antrim. The Antrim coastline is one of the most scenic in on the planet, and very accessible. Today's ride was up to Glenarm, the southernmost of the famous Nine Glens of Antrim, with its historic castle and harbour.

Here are a few Virtual Reality images from my trip - same as before - download them to your phone or tablet, and view with Google Cardboard. I think they came out pretty well - what do you think? A truly immersive Antrim Coast experience!

FILE 1: BALLYGALLY VIEW. Yes, Northern Ireland has some pretty variable weather, but it's precisely because of that weather that we can enjoy views like this!

FILE 2: GLENARM HARBOUR. A view over the foot bridge towards the harbour.


FILE 3. GLENARM MARINA 1. Little boats rocking in the gentle breeze.

FILE 4. GLENARM MARINA 2. They're still there and they're still rocking.

Please leave me a comment in the box below - I'd love to know how these make you feel.

Here's the Strava map for my journey - this is a lovely ride - do try it out.

And please sponsor my bike ride for Nazareth! Thanks :-)

17 August 2016

How the Clinical Note has to change

How not to do it.
Everything is wrong about this image of clinical noting in the digital age. White coats are an infection hazard. He's not bare below the elbow, presumably in a clinical area. The device is a big clunky useless piece of crap that's a pain to type on using this stylus. Why is he typing anyway?

So here is the problem. When Electronic Health Records were first designed, their job was to replace and carefully emulate what we had been doing with paper records. The concept was that the paper record was something of a Gold Standard, and our objective was to leverage the benefits of electronic onto this gold standard.

However, as Larry Weed pointed out FORTY FIVE YEARS AGO, there is a deep problem with the way we structure clinical records, and I'll be honest here - in my journeys around hospitals and clinics, and even in my own note-taking (even? Good grief!), our notes are not fit for purpose.

Here's a typical example of a note on a baby on day 3 in the Neonatal Unit (I've made this up, but if anything it's better than most): "Thanks for referral; Hx noted. D3. b38/40 twin 1. Other twin OK. bwt 3.21kg. Meconium at delivery, req resus. Resp now OK; off vent. NG feeds. Dysm features: hypertelorism, small mouth, crumpled ears, clinodactyly V, abn palmar creases, hypospadias. Suggestive of genetic syndrome. DNA for array. Will RV. Pls get clinical images & skel surv."

Now in the context of a busy NICU that's going to get buried in loads more clinical notes very quickly. If do that in an electronic system it's going to take me longer to type in (I could have scribbled that in half the time it took me to type it, even with the abbrevs), BUT again it's going to be lost in the load of other observations, consultations and notes that get added in.

As if that wasn't bad enough, just look at it - there's little structure to it. A computer is going to have to be pretty smart to parse even that highly lucid (in my opinion) text into something it can analyse or search on. It's free text. Furthermore there's a load of duplication there - much of that info is recorded elsewhere, similarly in free text. Maybe I've just jotted it down to persuade some lawyer some day that I've actually read the record (not necessarily understood the clinical case - those are different concepts).

So let's say we ditch the paper (YES!) and go digital - how do we change our practice and train doctors, nurses and AHPs to bring the clinical note up to date?

It's not an impossible task. For one thing, if we can crack the login/ID problem it should become easy to see who has made a note, and when (yes, we're supposed to sign and date/time all notes, but that is often missed, or people miss their IDs eg GMC number). It should also become easy to contact that individual through the secure EHR system. So in that area the clinical note is a good "stamp" to focus at least some clinical care around.

We surely don't need to repeat the basics - that should all be in a summary box every time we open that patient's EHR. But who curates that? How do we turn the mass of data that we generate into a coherent story that outlines the scenario relating to that patient, and that all the professionals AND the patient/family can group around and agree? Moreover, how do we turn that summary into something we can perhaps share with tertiary or supra-regional professionals outside our local (or in Northern Ireland's case, we hope) regional EHR?

And (critically) how do we ensure that electronic notes actually bring benefit, not just to the patient, but to the staff using the system? We need it to free up time. We need it to be a pleasure to use. But I feel that our approach to noting has shackled us to the past in such a way that we have lost sight of the purpose and function of The Clinical Record.

In the digital era we need to actually enter things manually to a computer as LITTLE AS POSSIBLE. Voice recognition is still pretty damn basic, but it's making headway. But my clinical note should be short and to the point. If I need to enter something quantitative I should be able to do that, but I'm not writing a legal document here. I want to construct a digital record that is dynamic and positively contributes to good clinical management and outcomes for my patient.

So like clunky tabs and white coats, perhaps the clinical note itself needs a major overhaul before we start replicating in electronic form the mistakes that Larry Weed pointed out to us all those years ago, but nevertheless persist in our training and practice.

12 August 2016

Virtual Northern Ireland

Have you ever wanted to visit Northern Ireland, but haven't got around to it yet? Now you can get a feel for it in #VR prior to booking your trip(s).

VR panorama: Waterfront Hall & Law Courts, Oxford St, Belfast. *Doesn't lead to Oxford.

I've been playing with Google CardboardCamera - an app that allows you to take 3D Virtual Reality pictures on your smartphone and view them with a Google Cardboard Viewer.

Anyway, the lovely people at VisitBelfast gave me one of their special viewers, produced for the new Belfast Go Explore VR app (check it out on Google Play or Apple Store), so in honour of the occasion, here are some of my own VR shots of Northern Ireland for your Virtual pleasure!

Simply download the file from the link (these are DropBox) - you should get a file ending in .vr.jpg - then add the file into a folder on your Android device called /DCIM/CardboardCamera and then launch the CardboardCamera app. It should automatically detect the files, and if you have a VR viewer such as the one above, you can be magically transported to a mystical world of wonder (i.e. Northern Ireland). Enjoy!

Let me know in the comments what you think of these, and don't forget to sponsor my cycle ride to Nazareth for the Paeds Department in Nazareth Hospital! Spread the word - thanks!

30 July 2016

Sponsor me to Cycle the Galilee for Nazareth Hospital

Stubborn to the last. Jordan Valley, 2009.


Nazareth is the largest Arab town in Israel, and home to its largest Christian community. Its hospital is the oldest in the country, founded by the remarkable Dr P.K. Vartan from Constantinople in the days of Ottoman Palestine. I became an honorary Nazarene when I did my elective there as a medical student back in 1993, and saw at first hand the great work being done, using healthcare to build bridges between people.

The Nazareth Trust is raising money to provide much-needed refurbishment for the Paediatric Department, and a group of us are cycling through the ancient terrain of the Galilee in November 2016. Christians, Atheists, Muslims, Jews and others - all are welcome. So please go over to my Justgiving page and sponsor me! Also share on Facebook and Twitter: #shanenaz2016 - and thanks so much for your support!

19 June 2016

Digital doctoring for #EHR4NI

I'm currently reading Dr Bob Wachter's fantastic book "The Digital Doctor" - a hard-hitting and insightful analysis into the whole field of the computerisation of medicine. Medicine has undergone a profound transformation in the past decades, and computerisation was, in many circles, felt to be the Next Big Thing that would deliver better care at lower cost for a greater number of people. The impact of digital in other industries - and indeed in our social lives - was felt to be translatable across to the messy world of Medicine, and we'd swiftly be on our way to a new and safer healthcare world. Billions were spent on this promise, and the big IT contractors gleefully piled in to address the issue.

And of course the reality was that Healthcare is much more complex than they imagined. Rather than this being a *technical* challenge, that could be sorted by wheeling in the appropriate tech and software, we are faced with an *adaptive* challenge, where the problem lies in the people, processes and indeed culture of the healthcare world. If we want to use IT to help us build better healthcare, we have to start with what is going on at the coal face. It's not enough (indeed it's positively fatal) to engage the CEOs and Medical Directors of healthcare delivery organisations (e.g. Trusts in the UK), and expect adoption and improvement to automatically follow.

I'm still something of a newbie at this, despite blogging about various aspects of our Northern Ireland journey over the past few months (in between digressions into biking and virtual reality). However at a recent meeting to discuss our plans for a unified Electronic Health Record for Northern Ireland (#EHR4NI), I heard a senior decision-maker (not a clinician) actually state that the road to clinical engagement would be to speak to the Chief Executives and Medical Directors of the Trusts; this would be how we would deliver the necessary buy-in from the doctors, nurses, AHPs and others that would make the process a success.

Bob Wachter's findings would very much suggest otherwise.

The good news is that NI has appointed Chief Clinical Information Officers for each hospital Trust, to join established colleagues in the Public Health Agency, the Health and Social Care Board and the NI Ambulance Service. There are five HSC Trusts; Belfast is one, and I have the pleasure of being the CCIO there. However, I and my colleagues also have busy clinical jobs also, and this clearly limits what we can actually deliver.

So what do we need to deliver? The "Clinical Engagement Piece" is one element, but exactly what are we asking our clinical colleagues to engage with? One possibility is that NI will go to market to purchase an all-in-one monolithic computer system on the basis of uniting primary care, community services and hospital based care. I have written about this Standard Model before, and it's one that I have a number of deep concerns about. The principal concern is that if we presuppose that we're looking for a computer system, we'll turn this into an IT project rather than a programme to improve the quality of clinical care. This sort of thing has been done plenty of times worldwide, and the common element seems to be that it generally doesn't work - sometimes spectacularly. The systems are beset by problems, the re-design of processes becomes an exercise in fitting the clinical workflow to the software, rather than reimagining both to actually do a better job. [See this 2-part article from Heather Leslie for some excellent learning.]

Another model might be to continue to purchase multiple "Best of Breed" solutions - software written by subject experts, and tailored as best as possible to the clinical process that we're trying to improve. Whether many of the systems we use would qualify as even mediocre, never mind Best of Breed, is debatable. And we're locked into contracts that are difficult to escape from, while our patients' data remains fossilised in systems that are reluctant to give it up again, much less to interoperate across the silos they were engineered to sit atop. It's pretty clear that this way lies madness; patient care is not markedly improved, but we end up spending a whole lot of money anyway, and digging ourselves into an even deeper hole.

So let's see how we resolve this problem. It turns out that farming these important issues out to IT professionals and consultants (not the clinical type!) is a critical error because these people cannot understand the clinical world. How can they? They're not trained. Nor can we just hand over to clinicians, because without the necessary background in quality improvement, change management and multidisciplinary vision, we just end up consolidating irrational variation (based often on whim) and making decisions that end up reinforcing silos, and indeed multiplying them. We need to find ways to get all these people - clinical, IT, managerial, and (most crucially) the patients - collaborating.

I'm still working my way through Bob's book (reading and re-reading each chapter - it's worth it!), but it's reinforcing some thoughts that I and my CCIO colleagues seem to be rapidly coalescing around. One is that we need to get the Data Interoperability issue highlighted (Bob calls it "baked in") from the outset. I'm going to suggest that we very explicitly and at an early stage in the process - now's good - state that we are NOT going to go down the route of a single electronic system to replace all the systems and functions of a healthcare IT infrastructure. Instead, we must create an ecosystem where the patients' data forms the core resource, and multiple developers and vendors can work on refining the interfaces that serve the clinical, management and analytical needs of the health service.

In effect, this seems to imply (and I am continuing my research, so this represents my current view, which may change according to new evidence and arguments) that we address the data first, then progressively migrate the apps to the data, instead of the old ways of migrating the data to the apps. We need evolution, not revolution. Plenty of Positive Pops rather than Big Bang.

What will this allow us to do? Firstly, it should encourage standardisation around best clinical practice - since we will be collecting the same data, we can assess variation, and analyse processes to see how best we can remap them to the most solid evidence base. Secondly, it will encourage innovation - agile software development will make it easier to quickly adapt interfaces to new clinical developments, without the need to change an entire system. Thirdly (and as a result of these), it will allow frontline staff and patients to get much more involved in refinement of the apps and systems that are being used. Fourthly, since the apps will be using the same data according to agreed definitions, data can be reused across clinical scenarios, reducing duplication, waste and errors.

Now these are very logical benefits, but will they actually pan out in practice? That is the million dollar question (or in the case of the UK's largely-failed National Programme for IT, 16 BILLION dollar question). There is good reason for scepticism that all the advantages that come from magical thinking will actually appear in the short term. They call this the "Productivity Paradox" - computerisation should help, but it usually requires a long time before it actually delivers, if at all. Our budgetary decision-makers in NI need to be aware of this - if we are going to go digital, it will cost money up front that may take years to deliver a return.

But let me get back to the main point - our prime objective here is NOT to computerise Health & Social Care - it is to improve the care of our patients. If we keep that principle front and centre, and build in the absolute requirements for an open and interoperable data platform supporting multiple partners, then we can do something pretty special here.  One model that I am very keen on is #OpenEHR, and we are actively exploring what we can do with this approach (and I think we should be doing more).

Is Northern Ireland up for this challenge? Well, before we head too far up this loanen, (old Ulster Scots term - look it up), I suggest we need to invest a good deal more resource (still cheap!) in freeing up some more of the time of the young (or at least not too senior) doctors, nurses, AHPs etc who will explore these waters and energise their clinical teams. I feel we CCIOs need significantly more time in our job plans to be CCIOs (one day a week? seriously?!), and we need clinical colleagues funded within our organisations who will join clinical informatics groups. We also need the CCIO role beefed up in terms of where it sits in the organisational hierarchy. We need specific specialty and patient focus groups that are structured around actual delivery, rather than merely producing wordy documents. We need a workable governance framework for the data, and we need money to do the groundwork and to experiment with various implementation models. This has to involve links with academia and IT industrial partners. We need to take risks. We need to be prepared for multiple Plan/Do/Study/Act cycles, supported by rapid innovation and rigorous data analysis. And we need to be ready to put our backsides on the line.

We have already had remarkable success with the Northern Ireland Electronic Care Record (NIECR) - that rare beast of an IT system that clinicians love, and that has had a dramatic effect on the practical delivery of patient care. Most hospital doctors now use NIECR as their first port of call when trying to find clinical information (letters, lab reports, radiology, medications) on patients, and it makes a real difference. It has shown us what is possible, and now we have to take things to the next level.

It's going to be a lot of work, but by the time Bob writes the second edition of "The Digital Doctor" (or maybe by the third - let's be realistic!), I want Northern Ireland to be one of his shining examples of what is possible when a country gets things right. So let's make sure we do that, rather than ending up as yet another cautionary tale of what happens when you try to turn a quality improvement process into a large scale IT project.

07 June 2016

Slovenian cycling bliss - again in Virtual Reality

We went cycling in Slovenia. The event was the Single Speed European Championships - mountain bikes specifically modded to have only one gear setting. It's all the rage among the kids these days, and certainly imposes an interesting discipline on one's ride.

Anyway, Slovenia is utterly beautiful. And of course I took my phone and captured some fantastic immersive 360 degree virtual reality images of the scenery. You'll really like this one, from the heights of the idyllic Soca Valley near the fantastic little town of Kobarid.

Click here to download the vr.jpg file. Put it on your Android phone and view in the Google CardboardCamera app.

Oh, and in the race I came 4th. Along with about 300 other people. There is no 5th in this race. In the short video below you'll get a flavour of events, and you'll see my brother Rick, and friends Hugh and Davy - as well as a load of new friends. And stuff.

05 May 2016


A beautiful evening in Greenisland. This is a 3D panorama for @GoogleCardboard Virtual Reality, in the vr.jpg format. It has audio and a true 3D still image. You need an appropriate smartphone (I use a Galaxy S7) and a Google Cardboard viewer (£4 on Amazon - seriously). Get ready for an amazing immersive experience - it's just like being ME beside my BIKE! Beside a ROAD and a FIELD! You'll notice that the software compresses moving vehicles into rather strange abberations, but the immersive virtual reality effect is pretty darned good.

I'm getting quite besotted by Virtual Reality and @GoogleCardboard in general - I think it's potentially a fantastic educational tool. Plus, I want to make sure as many people as possible share in my Nazareth experience, so when I do that, I'll be posting plenty of VR pics too. So make sure you get your Cardboard before then... 

[NB. This photo works in Google Cardboard Camera app on Android smartphones. You need to place the image in the Device Storace \DCIM\CardboardCamera folder, and then view it via the app itself. Have fun!]

01 May 2016

Views over Belfast - in Virtual Reality.

Want to see the #VR view on my morning bike ride up Knockagh in Co Antrim? Well, with Google Cardboard, you can! Click here to download the immersive Virtual Reality file, and view it on your Android phone. (some more instructions here).

And don't forget to follow my Nazareth journey - I'll be taking lots more VR shots there, so you'll get a real taste for what it's like to bike around Israel/Palestine. If you sponsor me, I might even take more... go on - it's for the children of Nazareth :-)

30 April 2016

Nazareth bike ride - come along!

OK, so here's the deal. You EITHER have to sponsor me, or sign up to come along and raise your own sponsorship. It'll be epic, and the cause couldn't be better - refurbishment of the Paediatric Unit in Nazareth Hospital. You in?
Musical greeting on our arrival in Nazareth, 2009
CLICK HERE to learn more and (go on!) sign up...

If you're not able to come along, PLEASE SPONSOR ME! :-)

I'll be posting plenty of cool 3D panoramas that you can view on your smartphone using the amazing GoogleCardboard virtual reality setup (really, everyone should get one of these).

17 April 2016

The Future of Medicine

If we are to drive progress in medicine, perhaps we need to think about the distant(ish) future. If we make our projections too near-term, we allow ourselves to get shackled to the status quo, and dream too small. So, what will medicine look like in 2050? That's far enough away that we don't have to worry about how we get there, yet it's close enough that many of us will either still be practising, or may be the recipients of that healthcare.

So go ahead - in the comments below, DREAM BIG! Tell me some stories (science fiction perhaps) about what medicine in 2050 might hold. And you never know - we might even be able to deliver some of them much sooner than that...

10 April 2016

Electronic Health Record - #EHR4NI - a vehicle for Standardisation?

Prof Rafael Bengoa

As you might have gathered from earlier entries in this blog, we in Northern Ireland are embarking upon a journey which will (hopefully) lead to a unified health data structure across the whole region. There are a number of reasons why we want to get all our health (and social care) data into a structure that is operative across many sectors, that reduces duplication in data entry, that is up-to-date and accurate, and streamlines the whole process of health care. It Makes Sense.

The DHSSPSNI have recently given approval to a Strategic Outline Case (SOC) which proposes developing a detailed business case for procurement of what we're calling the #EHR4NI - Electronic Health Record for Northern Ireland. This is potentially momentous - if all goes according to plan (!), Northern Ireland will have a unified health record for all its citizens, incorporating such items as outpatient records, prescribing information, lab tests, radiology and much more. There is also the prospect of bringing Primary Care (GPs) and Community Services into the mix, but the precise scope and detail have yet to be worked out.

In many ways this work directly assists delivery on the Principles of the Bengoa Review. (This is a major review of Health & Social Care in Northern Ireland, mandated by the Minister Mr Simon Hamilton, and which is taking place at the moment.) I'll be blogging at some point on how the Principles align with the #EHR4NI project, but one element that has been prominent in discussions has been that of standardisation of medical care across NI.

I have to declare that I am a fan of standardisation, so long as we're delivering meaningful outcome measures that we can reflect on in an effort drive improvement. If we are all doing things (largely) the same way, we can analyse the outcomes for our patients, and react quickly if things are not going as well as we would like. That's all well and dandy, but if we're all doing the same stuff, can that limit innovation and hence prevent us discovering other ways of doing things even better? Can standardisation be the enemy of best care? If we end up valuing the cookie cutter more than the cookie, we run the risk of missing important insights, demoralising our inventive and innovative health practitioners, and stalling the progress that our patients rightly expect.

Here's my worry - in the rush for an EHR4NI, we may end up simply doing things the way a Big Vendor decides we should do things. We standardise our processes to the standards of the incoming system. The constraints of the IT solution translate into constraints that we have to apply across patient care, because we have no other option. If we go back to the suppliers to suggest a Different Way of Doing Things, we risk being met with stony gazes and the reply that the process is set in stone (near enough). Or if we go to our Department of Health, they respond with a massive governance ask (submitting things to committees and review bodies etc) that stifles the little shoot of innovation before it even deploys its first leaves.

Standardisation, in other words, can become the engine of conservatism, and prevent the very improvements we're trying to achieve with the EHR.

Now all that sounds very pessimistic. But here's another scenario - we simply don't get the required agreement across multiple Health & Social Care sectors to allow us to move to a unified system, people start fighting with each other, and the whole plan falls apart. That is quite clearly worse than standardisation itself - BUT it's an outcome that many other EHR implementations have experienced grief over. It's a likely scenario, not an unlikely one. That's scary, and we need to avoid that at all costs.

Let's re-state what we want: we want the best evidence-based patient care, we want the right information at the point of care, we want near-real-time analytics to let us know how we're doing and to spot problems early, we want systems to help us do our job, and to help our patients better manage their own healthcare. We also want the data to allow the big decisions about resource allocation to be made in an informed manner.

So how can we make standardisation a force for good, not evil? How can we make sure that innovation is rewarded, creativity is encouraged, and changes are properly evaluated? I think the way around this is to explicitly state that standardisation has to be something that emerges from the bottom-up, rather than being enforced from the top-down. The role of the health managers, civil servants, committees and so-forth must be to curate and cultivate the front-line activity, to facilitate sharing of process data and outcomes, and to assist rapid regional adoption of improvements, using the EHR as a key enabler. If we make sharing an explicit part of the process, we create an evolutionary system where continual improvement can be encouraged - possibly even become inevitable.

This may mean we need to look at the EHR differently. The EHR can't be a single monolithic computer system - although that's how many people think of it, it's not possible to achieve the aims of #EHR4NI using this model. Instead, perhaps a specific core system could carry out a large number of the administrative and core clinical informatics tasks, but other platforms and sandboxes could tap into the underlying data structure to allow new applications to be developed, and new ideas trialled. This can be done without having to subject everything to a slow conservative process where deviation from the Agreed Norm, while not exactly heresy, becomes so mired in procedure, that we can't move forward.

Maybe even these thoughts are themselves heresy. Surely the People At The Top know best? I wouldn't count on it. The history of major ICT projects is littered with tales of projects going belly-up because they were treated as ends in themselves, rather than as vehicles to bring real benefit to patients and staff. Let's make this project one that we can be proud of.

01 April 2016

Dooey Beach, Donegal - virtual reality

Here is another Virtual Reality file for Google Cardboard, this time of Dooey Beach, Co Donegal, Ireland. It's just like being there! Well, not quite, but it's still pretty epic.

  • DOWNLOAD HERE. You will get a file that ends in vr.img
  • You need an Android phone or device plus the GOOGLE CARDBOARD APP
  • You will need a Cardboard Viewer (link provided for info - there are many suppliers). These only cost about £3, so they are dirt cheap.
  • Place the vr.img file into the folder on your Android device called \DCIM\CardboardCamera - this really important! You can find this folder using the File Explorer app, or whatever you use to manage your files on your device.
  • Open up the Cardboard App and go to "Cardboard Camera" (or open Cardboard Camera direct)
  • Select the desired panorama, and view it.
This one contains sound, and real 3D, which is a feature that I like about Cardboard Camera. I'll post some more of these, and any time I'm anywhere interesting, I'll get a panorama. Such as when I'm cycling the Galilee. Please go and sponsor me!