DFTB goes global

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. DFTB goes global, Don't Forget the Bubbles, 2021. Available at: https://doi.org/10.31440/DFTB.34526

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This blog post accompanies the talk Andy Tagg gave at the Global Emergency Care Conference on the 10th of September 2021.

Why are we talking about this?

When we started Don’t Forget the Bubbles back in 2013, there were just four of us. Tessa Davis, Ben Lawton, Henry Goldstein and I thought it might be a good idea to start a blog on paediatrics. The FOAMEd movement was just taking off and although there were many great resources out there for Emergency Medicine and Critical Care, there was very little covering our passion, paediatrics.

We wanted to create a place e where we share the answers to some of those questions that we were common only asked at work, and for which it can be hard to find an answer (hence, all those posts about penile problems at the start).

As time passed we started including other authors, mainly from either Australasia or the United Kingdom, who could talk about the things we couldn’t. We had found an audience and were keen to meet them where they were and produce the content they wanted.

We put off running a conference for some time. We didn’t think anyone would come. But after the success of DFTB17 in Brisbane, we realised what. we had been missing. It was that core connection to our community. More conferences followed, in Melbourne and in London. These were fancy affairs with therapy dogs and ice cream stations and giant games of Operation and Kerplunk. People seemed to like them but we recognised that there was a gap between some of what we were talking about and what you need to know.

Back at the beginning of 2020, we decided to launch a new event – DFTB Essentials. This was going to be two days of intense, hands-on education to be held for a small group (say, 50 people) in Birmingham. And then then, just six weeks before, the world changed.

COVID meant we couldn’t all gather in place. It meant we couldn’t;t travel. It meant that face-to-face conferences were cancelled. We had done a lot of work in the background, preparing talks and we had no intention of wasting it so. we flipped to an online model. Instead of offering the course to just 50 people, who happened to live in England, we could now offer it to everyone, everywhere. We were talking basic concepts, not cutting edge science so it was going to be relevant to anyone that looked after ill or injured kids and because of that we wanted to make access open to anyone.

This is what we learned…

1. Make it easy

It is not always a case of “If you build it, they will come“. You need to reduce the barrier to entry as much as possible. Some conferences set up an elaborate scheme that is akin to trying to get a place at Oxbridge. You need to write a letter of application, submit your resume and a list of references that have known you since childhood. It doesn’t need to be that complicated. Asking people to submit for a coveted spot via an opaque system penalizes healthcare providers that may not have the best English language skills. It penalizes those that may have less than impressive CVs (in white colonial circles). And it penalizes those who are not doctors.

We have offered access to our conferences and courses, for free, to all those who are in any of the World Bank Lower or Middle-Income Countries, guided by Andrew Dixon from Radiopaedia. One of the concerns that had been raised was “What if someone who is not in an LMIC tries to take advantage?” We took a more generous view. If someone is so desperate to lie to gain access then that says something about them, not us. We believe in the inherent goodness of our community.

2. Make it free

There are two things that cost a lot of money when you run a conference – the physical space and the food. These costs morph and flex according to the number of attendees. Since COVID has decimated most face-to-face conferences there has been a bit of a backlash against the costs of conferences. Some people argue that they should be free, as you are only sitting in front of your laptop.

When you run an online event the real costs are the technical ones – recording, distributing, hosting. A lot of those costs are fixed. But they are not free, and nor do the people who perform these key duties do so for free. If you run an online conference for one hundred paying delegates though, it costs next to nothing to add on ten delegates who do not have to pay.

Some of you may be young enough to remember dial-up internet, having to wait to connect to Alta Vista or Ask Jeeves, all the while listening to that weird scritching noise. The internet was a new thing when I was finishing medical school (yes, I am I that old) and we still sent actual letters to people. We have become so used to the ubiquity of always-on WiFi that we complain when it takes fifteen seconds for the next episode of Ted Lasso to stream, forgetting that once we had to plan to be in if we wanted to watch something.

Whilst we may use our hospital or home network to stream a conference, most delegates in LMICs will use mobile data if they have a phone that can access the internet. Data from March 2020 revealed that smartphone access is incredibly varied with 51% of South Africans possessing one, compared to 23% in Kenya and 13% in Tanzania (Ngware, 2020).

I then asked a random sample of folk what mobile data cost in their country. At first, it seems as if prices are equivalent. But they are not. You need to consider purchasing power parity. You should really read this blog post by Stevan Bruijns over at St Emlyn’s about equitable access and the impact of purchasing power. In essence, the purchasing power parity (PPP) allows us to compare the prices of a theoretical basket of goods in the local currency with each other.

Cost of 1Gb of mobile data – adapted from cable.co.uk

We have all suffered from a glitching internet connection but it is even more frustrating if you only have limited bandwidth. Shorter talks are easier to stream. and if they have already been recorded and uploaded then they may be easier to view too.

3. Make it relevant

We love to be cutting edge. We love to know what is the latest and greatest treatment for paediatric status epilepticus. And, of course, we couldn’t be a member of the FOAMEd community without declaring a love of ECMO. But just how relevant is it to the audience. Four-fifths of the world’s children live in LMICs. We need to make sure that if we are inviting them to an event that there is content relevant to them.

We all want to be better at looking after children and young people. If the majority of your event is irrelevant then what is the point. How are you going to know if it is relevant? Ask! When we ran the week-long PECC Kenya Intensive course with George Washington University we reached out beforehand to get a better sense of local challenges. There is no point talking about complex trauma care systems if you can’t even access the first link in the chain of care. There is no point talking about ECMO and REBOA if you cannot even access oxygen and fluids.

4. Make it inclusive

Have you ever gone to a part that was hosted by a friend of a friend? You said yes to the invitation because you didn’t have anything better to do that night and you wanted to get out of the house. You turn up, with a bottle of wine in hand, expecting to see your friend there – someone you know – but it turns out you don’t know anyone. How did you feel? The introverted amongst us would probably just turn right around and head home to spend the evening nursing a glass of Pinot Noir and an episode of something gentle. (Of course, the more self-confident might just go up to. the makeshift bar and start mixing cocktails, but you get what I mean).

Going to a conference where you don’t really know anybody can be a bit like that. You can see that people are having fun, mixing and mingling, but it feels uncomfortable. Even now, as we have transitioned to virtual conferencing there are a lot more lurkers and listeners than participants. So as the host, how can you make our new global visitors feel welcome?

Besides some of the things we have already considered then it is important to make them feel welcome, to include them. We make sure at our online events we have at least one of the team keeping an eye on the chatbox, not as the doorman barring entry into our party, but as a greeter. If we see a name we do not know we say hello, or hi or tukusanyukidde. We make sure that we answer their questions, and, if we can, we amplify their voices.

One of the most successful things that we did at our events was introduce speed networking. Self-selected delegates randomly match in a room with another delegate for three minutes. They can chat about whatever they like and then if at the end of that three minutes they want to continue the conversation, they can. It is through these smaller interactions that we get to learn about and from each other. And it is was through one such ‘date’ that I met Jonathan Kajjimu.

5. Make it up

Every week I receive at least five requests to either submit an article to a journal or to review one. I have learned to say no to the former, especially when I have never heard of the journal, but I try to peer-review as many papers as I am able. In no way could I consider myself a content expert in anything, but I know how to appraise a paper, and I know if I would want to read it.

Global distribution of published scientific papers 2016 – from Worldmapper.org

Roughly 1.8 million papers are published each year in peer-reviewed journals but only a sprinkling are from authors in LMICs. Once again, Stevan Bruijns, chief editor of the Africa Journal of Emergency Medicine, dissects the superficial layers of the problem over at St Emlyn’s. Once we take cost out of the equation, reflect upon another one of the problems that researchers and authors in LMICs face. Even here, in Australia, I don’t always understand the nuances of language*, so how can we expect our colleagues to do the same?

Rather than spend my spare evenings reviewing a paper for the EMJ (sorry, Simon), I am more likey=ly to spend my time copyediting. apart from Jonathan’s group in Uganda. My aim, then, is to do something very similar to what we try to do here at DFTB. It is to help translate knowledge into a form that is easy to understand. Is there some secondary gain for me from doing this? Of course – instead of being an anonymous reviewer two, I get the deep satisfaction of seeing a paper from a colleague accepted for publication.

Jonathan Kajjimu is a fourth-year medical student at the Mbarara University of Science and Technology (MUST). He reached out to me after our speed-dating experience and asked for a little help. In our asynchronously connected world, it is easy to review and help revise a paper. And, despite seven hours between Melbourne and Mbarara, it is also easy for us to connect with the MUST Emergency Medicine Interest Group and provide tutorials. At a time when university and formal teaching was closed down by the Ugandan government due to COVID, we could help out the team of the MUST-EMIG.

There are plenty of opportunities to teach if you look for them. How many grand rounds sessions in your hospital are held over Zoom now? How many of them might be relevant to other doctors, or doctors in training, in another part of the world?

Your homework, then, is to reach out and ask. Use Twitter, use e-mail, or even (heaven forbid) pick up the phone and set something up. We can teach, and we can learn from each other. I know, that if see someone with malaria, here in sweltering Melbourne, exactly who I am going to call. It will be the people who deal with it every single day and know more about malaria than I ever will.

*Because a letter from my former headmaster to say that I went to school in England was not enough to prove I spoke English, I had to sit the IELTS test to get permanent residency. In the oral component of the test I was asked which habits from my homeland would I bring to Australia. Without missing a beat, probably because I did the viva just after a night shift, I replied, “I would teach my children not to bastardize the English language by putting -o onto the end of every profession“.

Selected references

Arend, M.E. and Bruijns, S.R., 2019. Disparity in conference registration cost for delegates from low-and middle-income backgrounds. African Journal of Emergency Medicine9(3), pp.156-161.

Deckelbaum, D.L., Tardiff, A.G., Taylor, R., Howard, A., Khwaja, K., Kyamanywa, P. and Razek, T., 2011. Global health conferences: are they truly “global”? The Bethune Round Table paradigm for promoting global surgery. Canadian Journal of Surgery54(6), p.422.

Ghani, M., Hurrell, R., Verceles, A.C., McCurdy, M.T. and Papali, A., 2021. Geographic, subject, and authorship trends among LMIC-based scientific publications in high-impact global health and general medicine journals: a 30-month bibliometric analysis. Journal of Epidemiology and Global Health11(1), p.92.

Moon, S., Page, S., Rodin, B. and Roy, D., 2010. Purchasing power parity measures: Advantages and Limitations. Overseas Development Institute7(I), pp.1-8.

Ngware M (2020) Delivering education online: coronavirus underscores what’s missing in Africa, The Conversation. https://theconversation.com/delivering-education-online-coronavirus-underscores-whats-missing-in-africa-134914. Accessed 2 September 2021

Niner, H.J., Johri, S., Meyer, J. and Wassermann, S.N., 2020. The pandemic push: can COVID-19 reinvent conferences to models rooted in sustainability, equitability and inclusion?. Socio-Ecological Practice Research2(3), pp.253-256.

Velin, L., Lartigue, J.W., Johnson, S.A., Zorigtbaatar, A., Kanmounye, U.S., Truche, P. and Joseph, M.N., 2021. Conference equity in global health: a systematic review of factors impacting LMIC representation at global health conferences. BMJ Global Health6(1), p.e0034

About the authors

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