Not wishing to choose sides, this thread reminded me of a classical story regarding scientific debate and shifting paradigms. Unfortunately, for the philosophically naive (and I include myself in that category), a bit of background information is required first...
Zeno of Elea sought to explain that only permanence is reality, because change is impossible. That does not mean to say that we cannot experience change, it is just that any attempt to explain change would lead to contradictions, therefore only that which is permanent exists, that which is not permanent just a product of our deranged imaginations. In order to illustrate this, he used a series of paradoxes, the most famous of which is Achilles and the Tortoise (in a race between the two, Achilles runs ten times faster than the tortoise, but the tortoise has a ten metre head start. By the time Achilles has run ten metres, the tortoise has moved on one metre. By the time Achilles has run this further metre, the tortoise has moved on 10cm... Achilles will therefore never catch up). Another paradox is about an arrow flying through the air. To do this, it must either move where it is, or move where it is not. If it moves where it is, then it is standing still. If it moves where it is not, it cannot be there. Therefore the arrow does not move.
Which leads onto the story...
Once upon a time, in ancient Athens, our hero, an adherent of Zeno, was relating his argument to the listening throng on the (scientific?) nature of permanence and the non-nature of change, when in the course of some wild and passionate gesticulations, he managed to dislocate his shoulder. A physician in the crowd examined him, and gave him the diagnosis that his pathology was impossible, for he had either dislocated his shoulder where it was, or where it was not. If he had dislocated his shoulder where it was, then it had not moved and was therefore not dislocated at all. If he had dislocated his shoulder where it was not, then it could not have been there to be dislocated in the first place. At this point, our hero chose the pragmatic(?) solution, and demanded the physician fix his shoulder, no matter how it got there.
Regards,
Steve
Steve Coward
Operational Manager, Automation
Clinical Biochemistry
Belfast Trust
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From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of Reynolds Tim
Sent: 23 May 2011 17:43
To: [log in to unmask]
Subject: Re: Core beliefs
My point exactly!
The man in the street simply wants a result. They don't care what the units are. On holiday you know roughly the conversion rates between dollars and pounds and euros etc. In your head you convert those numbers back to 'how much can I afford'. The same applies to HbA1c. Patients are used to %, and we get mmol/mol simply by applying a different fudge factor to the result that the analyser produces. It makes not one jot of difference to the patient what the number is reported as - but they cannot understand the new number and need a conversion factor to make sense of it [like Granny with the new-fangled decimal currency in 1971]. The only thing that changing the units does is give the illusion that the method is now 'more scientific' because it uses a 'scientific' unit, even though all that has changed is the factor we use in the calculation.
Even without changing the units that a test is reported in, It is possible to improve assays by using international standards and reference methods. So, all changing units does is add another fudge factor.
TIM
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-----Original Message-----
From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of Mainwaring-Burton Richard (SOUTH LONDON HEALTHCARE NHS TRUST)
Sent: 23 May 2011 14:48
To: [log in to unmask]
Subject: Re: Core beliefs
Dear fellow sceptics, metrologists, purists, pedants, pragmatists (and Tim)
How may of our analyser suppliers are calibrating and producing results in new money ? I cannot believe that all these years they have been generating "truly scrumptious scientific" mmol/mol results and converting them to % for our consumption. In the short to medium term, I am sure that they are simply going to do the mathematical conversion into new money for us, while leaving the % figures in the background for our US colleagues.
I have to declare my cards as a supporter of glycated HbA principally on the grounds that it represents a closer approximation to the in vivo glycation process than an ion exchange or immunoassay based mechanism.
The analytical processes used to separate, detect and measure HbA1c are so varied, there has to be some levelling of the playing field between measurement and reporting.
I think it's currently called harmonisation.
I think it used to be called fudge-factorisation.
with best wishes
Richard
Richard Mainwaring-Burton
Consultant Biochemist
South London Healthcare Trust
Queen Mary's Hospital
Sidcup, Kent, DA14 6LT
020-8308-3084
020-8863-5724
mob: 07831-739876
________________________________
From: Clinical biochemistry discussion list [[log in to unmask]] On Behalf Of Mohammad Al-Jubouri [[log in to unmask]]
Sent: 23 May 2011 12:09
To: [log in to unmask]
Subject: Re: Core beliefs
Surely exactologists have to be pragmatic some times for the sake of practicality, risk reduction and clarity to our clinical users and patients. I may be (definitely) missing the point here, but what is wrong with using HbA1c method that utilises IFCC standards to generate a HbA1c result in mmo/mol but then use LIS to transform it/interpret it to %HbA1c language that our users/patients are familiar with?
Best regards
Mohammad
Dr. M A Al-Jubouri, MB ChB, MSc, FRCP Edin, FRCPath
Consultant Chemical Pathologist
________________________________
From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of Jonathan Middle
Sent: 23 May 2011 10:54
To: [log in to unmask]
Subject: Core beliefs
Hello again
I understand that my postings are not everyone's cup of tea, but I don't think I quite deserved Mike Hallworth's comments, although I perfectly respect his right to make them and have not taken offence. I actually think my 'high horse' is a little Shetland compared with the Shires of some I have encountered after 30 years in NHS lab medicine, but we'll let that go for now! We all have our faults and quirks which make us human, and there is a well known New Testament quotation which is applicable here! But just to explain a little more of why I say what I do, for those that might be interested, I would like to add the following.
Health Warning! - if you think you might be irritated or patronised - look away now!
My obsession with good measurement science began many years ago, but didn't reach maturity until I started working with Linda Thienpont and Lothar Siekmann, and after reading articles by and talking with Roger Ekins and attending his lectures. 23 years of steroid EQA work showed that even when there exists an extremely well-characterised reference measurement system, there can persist for decades huge differences in results between methods, which doctors, laboratories and manufacturers seem content to tolerate. (I have never understood this and find it truly perplexing.)
When I became involved in the HbA1c story, I tried to apply the same concepts of metrological traceability, which is why I have been fiercely critical of the NGSP approach and fully supportive of the IFCC approach. I make no apology for my postings, which I believe are factually correct. I am prepared to accept being wrong, but I assert the right to express my beliefs and be respected and tolerated for this, especially by people who disagree. All they have to do is show why I am wrong and why they are right. Simples!
My other obsession is the total commitment to the primary QA concept of 'meeting customer requirements'. Our ultimate customers are patients, who have an absolute and unswerving belief that the results we provide are true, that the same result would be obtained wherever their sample was tested, and that their result would have the same meaning and be interpreted the same way by all doctors. Every lay person and many frontline hospital staff that I have spoken to over the years when I have discussed my EQA work with them, have confirmed this view, and I always indicate this as a primary driver for analytical quality in the lectures I give.
If our customers (and paymasters) believe this, then we are under strong moral and professional imperatives to meet their requirements, or at least explain why we cannot and what this means in terms of result uncertainty (in its broadest sense), and method and interpretation differences. I believe we have perhaps unwittingly encouraged this belief in our omnipotrence, but it will come back to bite us when the real situation becomes publicly known and politicians give us a short timescale to put the situation right. This is why I abhor attemps to 'pragmatise' and 'fudge' the underpinning science of the measurements we make for patients, and will remain an irritation for those who promote such practices when the correct science is known. (I fully understand that it may sometimes be necessary to use fudge factors and slopes, but this should only be a temporary situation to avoid potential harm to patients, be fully explained to users and corrected as soon as possible by the application of appropriate measurement science.)
Working hard to promote these core beliefs for the benefit of patients is my mission in life, through my work with CLSI, IFCC C-TLM and AQMLM. I don't think this is being patronising in any sense of the word, but if it is, then so be it, that's what I am. I will shut up eventually, but not for a few years yet I hope!
However, as a parting shot, consider this:
You issue a result to a patient : X = 283.5 ng/L. But, you know the result uncertainty is 10%, NEQAS tells you that other methods may give results 100 more or less, and since X is an ill-defined mixture and there is no proper reference measurerement system, there is no way to find out which is correct. And you know you shouldn't be using SI mass units anyway because there is no SI definition of X in your calibrant! So who is being patronising now?
I'll be at Focus later on today and tomorrow and would be happy to continue this conversation face to face!
Cheers
Jonathan
PS - I have just seen Tim's comment to my Berlin Blog, but am happy with Ian's reply, so won't be responding to Tim on this occasion, even though I desperately want to - and at great length! (Tim - you owe Ian a beer now!) J
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