Hello everyone, and welcome to the Quorum podcast.
This is where academic medicine meets remote, austere and
resource limited areas. Welcome back to the podcast.
This is April Kelly. This week we're with Doctor
Michael Clapper from South Africa.
Michael's been on faculty with the college for well, I decade
or so. He first came to Malta and ages
ago, but and he just earned his doctorate.
He got his DHS through core one of our first graduates.
Michael, welcome to the podcast. Thank you a brick.
It's always a pleasure to do these with you.
So tell us a bit about yourself and what's keeping you busy.
So at the moment I just successfully defended my
dissertation 2 weeks ago. So up until then, the DHS was
pretty much keeping me the busiest.
And alongside my other day job, which is working in AI, just
helping organisations navigate that that ecosystem.
But it's also really working, helping the college set up
various programmes, getting systems to work and just, yeah,
just generally trying to bridge the gap between the world of
software and the world of Austria and remote medicine.
And now that the the DHS is finally behind me, I'd like to
say it's less work, but I'm quickly realising it's even more
work ahead of me. But we'll, we'll get to your
doctoral thesis on AI. But let's let's start way back.
So what? That was your first connection
with the college. Well, interestingly, it all
started with an e-mail I received from you, probably way
back hazard a guess, E 13 E 14. You at the time were visiting
Johannesburg to set up clinical placements, I think with ER 24
and you and I connected through the WMS form register and we
thought, hey, I'm in Johannesburg, you're in
Johannesburg, let's just have a pint together.
And from there I think I was sort of very taken in the bar.
Your vision for remotes and Austria Mits and in general, I
mean, from the that's when the the roller coaster ride started
working with you getting those clinical placements up, you
know, helping look after the medics when they came here.
At the time I was also doing my national registry paramedic
through Percom and at the time you had just receive permission.
I think you were the first organisation to be able to offer
the psychometric evaluation outside of the continental USI.
Then came across to Malta for a couple of weeks, I think it was
the AEMT evaluation. So I completed that with you and
I think there were a few other students at the time.
Then after that came back for a month just to sit in on your
industry paramedic course. So just helped out there and got
a bit more familiar with how the college operates and teachers
and what it was all about. Then carried on pretty much with
my own mission, which was getting my Fellowship of the
Academy, Waters meds and finishing up my national
registry paramedic, and also working or quite heavily
involved in modern search and rescue in South Africa.
And really at the time just bolstering my buildings
education wherever I could. Then one of the more ambitious
projects that worked on with Korum was setting up the field
guide or the digital field guide.
And that was just in such a way that it would really work in
these very limited connectivity environments.
And I'm pleased to say that project has been going for quite
some time. Then as the college grew, just
was always happy to sort of help out, try to get a few programmes
running in South Africa. Yeah, I was just generally, I
would say along for the ride with Koram as it grew to what it
is today. So you have been part of the
family for over a decade now. Yes, if I had to count exactly,
I'd probably say 1314 years. Right.
And I think that we were talking before I even left Ireland with
Remote medicine Ireland moving down to Malta.
I think we had shouted before that.
And then we first met in Johannesburg when I flew down in
2014, I believe it was. And we set up clinical
placements for the R-24. They had asked us for a critical
care class which we we ran a class for them.
I don't remember if you were on that one or not.
Yeah. Do you remember I think that was
the first ever critical K paramedic proctored exam in
South Africa? That's right.
That one I just sat in just helped.
Just a bit of the facilitation of that.
But I think that was only the first trip where you and I met
is getting that all set up. Yeah, back then we're doing
quite a few trips. We we ran a full paramedic
programme out of East London there in the southern coast of
of South Africa. Yeah, that's right.
I do remember doing a couple of trips with you and also a few on
my own. That was a very underserved area
in terms of EMS. And I do remember working on quite a few
interesting calls while working with the Koram students.
Yeah. So we had the clinical
placements going down there, then setting up some of the
clinical placements in Johannesburg at the TMH in the
hospital there. And yeah, also try to, I'm
trying to think of the names of these, some of the other
courses, they escape me at the moment.
But yes, a lot of time spent setting up clinical placements,
going around and just doing as much networking as possible in
South Africa. Right.
I'm trying to, I'm trying to remember what are the courses
where we just ran the paramedic and then the critical care
paramedic in South Africa, if I remember right.
Yeah. And then the clinical
placements, I mean right back in the beginning with your remote
Nets in Ireland, I did run one or two wilderness first aid
courses, but not too many of those.
So Michael, you also have your your farm, you're a fellow of
Academy Wilderness Medicine through the Wilderness Medical
Society, and you've had it now for over 5 years.
Have you thought about getting your M?
Farm Heavens once I have the the form and if you have the
calendar, I think I've had it for over 10 years.
To my belief, I think it was the first person in Africa to get
the award. I do stand to be corrected on
that. The inform was not a high
priority for me. Obviously I had to focus on the
things like my national registry paramedic.
Then we went on to the wilderness paramedic
certification and then on to the DHS.
But now that I had that behind me, it's being the eternal
students. That's something that's
definitely on my radar just to really could be anything that
just helps with my by not just my own knowledge and experience
of our about an osteo medicine, but that anything that just
helps me help my students. So how do you see the form
helping your students? So the form was one of my main
foundational wilderness myths and qualifications.
The one thing I like about the form is just the diversity of
the topics that you have or the, or the diversity of topics in or
particularly in, in modern medicine or wildness medicine.
That's one thing I do my best to try and install in my students
is when you're out in whatever deployment that you're on, you
just need this massive breadth of knowledge and understanding.
You don't necessarily need the exact answer, but you do need to
know that things exists, way to get help, who to speak to and so
on. And that's just something that I
found. The form really helped me
initially is getting that breadth of knowledge.
I found that the form, the form was difficult for me.
I'll be honest, I started in what, 2007 I think it was, and
it took me almost seven years to get it.
No, it took me 5 years. But what I missed was a lot of
the the paediatric stuff are the things that we just didn't get
in the army and I wound up with 160 points, of which only 100 of
the points counted to get me past the finish line and earn my
form. Was that similar with yourself?
Yes. And I've actually had a few
colleagues who've expressed the same.
And I think that is by design. The form is one of those
qualifications which to my understanding, the DMS doesn't
want form candidates to be able to RIP the proverbial bandit off
and get the qualification. I think it is designed to.
I don't mean to use the word force in a negative way, but to
encourage candidates to get that breadth of knowledge.
And oftentimes I did find you'd get these elusive credits that
were very hard to get to. But it was actually the tipping
scale for me on the form was when I went and actually
participated in one of the conferences.
And there that's just a treasure trove of training information,
both practical and theoretical. And I mean, I walked away from
that conference and not just with a couple of the the elusive
form credits in hand, but just a much more robust level of
experience level training and this understanding of of the
wilderness myths and environments.
It is something that I, I push for.
So our, our college is one of the largest providers of farm
credits outside the US and we have four of our courses that
give farm credits and we have our student interest group
because every month we, we hold the ES SIG.
So people who get foam credit there.
Well, because of COVID, one, one of the few things that was
beneficial from that fiasco was WMS has allowed virtual
attendance for, that's one of the requirements for your farm
for your fellowship is you must attend one of the conferences.
And I, I totally understand that, but it was just unbearably
painful to pay 3 grand to fly somewhere in the US.
And they always hold it in resorts that are 200 a night.
And, and it's just that the costs were prohibited and now
you can attend virtually. And they've, they've not dropped
that. They've kept the virtual option
even now that COVID is over. So there is no reason why
someone living here and Europe or in Africa or Asia to not get
their fellowship. Absolutely.
It's living in South Africa where essentially you would take
a dollar or euro and multiply it by 20.
That's one of the common complaints about getting the
form. It just doesn't equate into the
local currency. There is a huge demand in South
Africa among physicians who would like to get the form as
well as the diploma Martin Medicine.
And I think now that we have the MUM and the virtual conferences
available, I think the uptake is increasing because as you
mentioned, travel to anywhere from South Africa that holds his
conferences. We'll easily set you back a few
grand. So, Michael, let's talk about
AI. So you have been studying AI
long before you started the DHS. Now you have a doctorate and AI
in medicine, and you have been helpful with the college getting
in the digital field you created.
You invented a field guide app just for the college, and you've
now updated it again. But tell us about your thesis
about AI in medicine. It's interestingly, when I
started the The Doctor about four years ago, I think at the
beginning of 2022, initially I was not planning on doing AI.
And so interesting. I remember having a
conversation, I think with yourself and one of the founders
of the programme. The advice you gave to me is
whatever you think your final project is today.
So this is four years in the past.
It will not be the case when you actually end up defending your
dissertation. And that was very true when I
started out. I was just really going to do a
bit of work around how the journals operates, what the data
inside all of those journals mean.
But it was only when we had that AI boom.
So the introduction of ChatGPT and basically what most people
think of as AI is I started thinking is what is this
incredible invention called? A large language model?
What impact is that going to have?
I'm sure anyone who's listening, they have probably tried either
a ChatGPT, Gemini, Claude and so on.
They've asked it medical questions, possibly even
research questions and the answers have come back are
always very plausible and very convincing.
That's oftentimes, and I'm sure you've experienced this
yourself, a brick is the answer is completely or seemingly
fabricated or just hallucinating.
So what I did for or started out with my dissertation and what I
started out with was I received a lot of help from the
supervisors and the the head of the programme and, and sort of
forming what my dissertation was going to be is a let me back up
one second. So when, whenever a medical
person is doing research, typically you will go to Google
Scholar, you'll go to pub Med or whichever journal or repository
that you you'd like to use. You will go in and you'll type
in the keywords. Say, for example, you want to
search for the topic of middle area or any other tropical
disease or anything you want in the medical sphere.
Pub meds for example will return you specific results based on
that search. So my thinking for the
dissertation was these databases are all built on technology that
is 1020, even more sort of decades older.
What is it going to look like if AI gets involved in the search
method? So my research question was
quite simple is I wanted to see how the current way of searching
would compare against the call it the new AI way of searching
these databases. And what does that mean in terms
of complying to the evidence based medicine standards?
I'm talking things like Prisma, things like the the Nas
framework, which chats about or framework for adopting new
technology. So it wasn't just a technical
question, it was a sociotechnical question as what
is going to be the overall impact A on performance?
Will the AI search do better or worse than their current search
methods? And what does it mean in terms
of adoption and governance and what impact will that have on
healthcare? So when I started off with this
and the first time I sat with my supervisors, Dr Von Reckling
Housing and Doctor Zuba, they immediately cut the scope of my
dissertation. I was planning on doing an AI
search of hundreds of thousands, if not millions of documents,
and being a lone researcher, we actually set that set and cut
that corpus down to just 439 documents, but specifically in
the ACLS domain. And the reason they did that was
very simple. So if I got into trouble or
wasn't sure about what a lexical search was returning or what a
semantic search was returning, I could very easily sit with those
400 odd documents and work it out myself.
Or A, it's a very small amount for one person to work through
and B, understood the material. And that would basically help me
sort of pull in the reins and just help me understand my own
research. So what we ended up finding or
what I ended up finding was although the AI search
understood my query a lot better, increased the recall or
the amount of articles that are relevant to my query.
The AI search brought back a very different set of documents
than the lexical search. And that is a problem because
one of the things that are surfaced in that research is
with a fixed corpus of information is you could run the
exact queries or two researchers, they could ask the
exact same question and depending on which search
mechanism they used, they get back very different results.
Often in research, we talk about the the smoking gun article, and
that is that elusive article where they could potentially
either derail or significantly shift the outcomes of your
research. And if you have this mismatch
between your traditional search methods, your lexical search and
your AI search, that is going to create a real problem if you're
going to miss very relevant articles.
So my research basically did quite a deep introduction into
how these AI or LLM search mechanisms worked.
We took a a bit of a tour of how the current lexical systems
were. Too often people will take the
underlying mechanisms for pubmitting Google Scholar for
granted. So we went into that.
They did a comparison did did quite deep into the statistical
side of things, but did a very clear comparison of the results
of the AI search. The traditional search wrote up
what that all meant. And the bottom line or the
conclusion of either research is that it's not about the
technology, it's that it's about the the evidence itself.
And that search, whether it's traditional search, IR search,
is an epistemic gatekeeper. So whenever you conduct
research, you have to pay real attention to the search
mechanism you're using, understand how it's going to
bring up the results relative to your research.
And that itself needs to be discussed and disclosed in
whichever research paper you're working on.
So what is your comment to a academic researcher who just
refuses to accept anything coming out of generative AI?
So interestingly, I would agree with that is if you're using a
general purpose generative AI like check GPT or Gemini is
fantastic. Of those products are is I would
agree with them. Don't use those for your
research, however. They are the AI search
mechanisms that are very powerful in helping surface
information from very large bodies of data.
The one is conducting the research.
You really have to be a master of the tools that you're using,
or at least understand where you should use something and where
you shouldn't. And I have found that when
discussing with AI, it's always more useful to discuss
specifically which part of AI you're using because the term AI
encompasses probably at the moment, hundreds of thousands,
if not millions of different tools.
So it helps be very specific. At this moment, I still
discourage the use of generative AI for research, but I do
encourage the other AI search mechanisms for just helping
trawl through these millions of documents, part of the results
of my dissertation. So looking forward to the future
is that hybrid use of the traditional way and the AI way
are very effective in surfacing additional results and just
helping you understand what you have.
So throughout my DHS I've gone through to almost 14,000
documents, mostly at the abstract level, but without some
of these more sophisticated AR tools it would have been very
difficult to get any sort of understanding out of that sheer
volume of data. So what is your suggestion since
you've done all the work to the the medic, the nurse, the doc
out there who is using AI? What platform do you suggest?
I've been looking at perplexity as an option.
Obviously the big ones like ChatGPT, everything that it
comes up with is bollocks. That's my assumption, but what
about some of these? That are specifically aimed at
academia. I had to chocolate that comments
a brick. So I heard another comment from
a conference I was watching where the speaker said if you
want ChatGPT on LLM to give you an answer, you have to tell it
what the answer is. And that's obviously I think
call out some of your frustrations with the tool.
What I would suggest on the research side is again, do your
research. There are more and more
medically rated or research or medical research rated tools
coming out. I'm sure that the, the bigger
platforms, your pub meds, your Google scholars, many of the
journals are starting to augment the AI or augment the existing
searches with AI. When you are embarking on your
research is take the tools that you're used to go and have a
look to see have they augmented that with any sort of Arkansas
tooling and then try and understand how do I leverage
that to help my research. The big take away is if you
don't fully understand the consequences of using Arkansas
in your research, you'll probably sort of best to either
reach out to someone who does understand how to use the tools
or just proceed slowly on a very sandboxed environment.
But definitely don't go in pedal to the middle.
Start bringing AI in different flavours into your research.
You all get to start getting things like semantic drift,
model drift and stuff which can really mess up your results.
I. Am I'm a poor viewer for a few
academic journals. And the first thing that I
always do is I look up all of their their journals that
they've cited and look for DOI numbers.
And that is a very quick way to see if one of our students or
artist, whoever submitted the journal or article created
bollocks using AI. And, and I have at least six
Times Now have immediately kicked back a paper because
their DOI numbers were fake or the research that they're
quoting is fake. And that's before I even start
looking line by line at what they road.
Yeah, that's a real problem, not just in research is part of our
work. I do a lot of medical education
developments in the US and the exact problem you describe is
rearing its head in that environment where the issue is.
If you use something like chat TPT to generate training
material, the issue is that particular system is designed
for generalised day-to-day use, the layperson, so not
specifically medical professionals.
The one thing with AI is the output depends on how it's been
trained. So if you are going to use it to
develop very specialised medical material like we do at Coram in
our environments, you do really need to, if you are going to use
it, use a system that supports that particular medical medical
knowledge. There are systems out there that
will only generate specific or accurate citations, But even
then, the researcher or the author of that paper, I must go
off, not just take the AI, this word for it and go off read the
DRI, make sure it actually correctly supports your your
claim in your paper. But I think you and I take the
similar approach. My approach is a just read the
abstract, then go and check the citations.
I like to make sure that we're checking a citation is, is it
just a random citation put there to support effect and you will
have a 200 page citation article and all you're doing is
surfacing 1 fact. And that's where I find AI can
actually help. If you have a citation again to
our 200 page article to take that article, put it through an
LLM and just help me understand how does the spec relate to the
material that's talking about? Because often it's not clear if
the article is not cited correctly that this is something
we are working on at the college, slowly but surely.
In fact, there's one of my tasks is actually developping a
training module to guide our students on how to use AI safely
and correctly to produce research material.
And it's, it's a pretty complicated field, but ChatGPT,
it's a blessing and a curse because it's so easy to use.
And those results are very plausible.
But if you don't do the work to go and check every little word
that comes out of it, you're going to end up in academic
trouble, unfortunately. It's interesting to see how
quick that AOI is taking off. So 12 months ago I couldn't
spell ChatGPT and now I'm using it every day and, and making
sure that everything that I see come out of it is is verified on
on some way. So from 12 months ago, having
very limited AI capability to the point where now you can type
in create a PhD for me in this and then it would be a 75 page
dissertation. What's going to happen in 12
months? Yes, definitely on a exponential
trend ever. There is a fair amount of
research coming out that LLMS are not going to keep growing
exponentially. It's just physically impossible.
In terms of the the processing power.
The one thing that is evolving very quickly is the tooling
around the LLMS. And specifically there's a term
called RAG or retrieval of meta generation.
Say for example, you wanted to write that 75 page dissertation
on a tropical disease. That's a malaria for example.
It's simply a case of you provide the LLM with as much
valid material as possible and just use the tool to generate
material based on that and you sort of read it for accuracy.
And I found this during my own dissertation chat.
TPT and Gemma were a great help. Taking the material I had
created and checked helped me improve the flow and
occasionally would throw something else ahead.
Did you consider this? But then it's a case of do not
take his word for it. Take that suggestion, go and
research it yourself and if it's valid, bring it back into your
whatever paper you're working on.
But if you take all your work, bundle it up, throw it over the
fence into AI's backyard is you are going to get back something
that is just not of an acceptable standard and
potentially even dangerous. Good advice.
So, Doctor Clapper, what advice do you have for the new medic,
the new nurse, the new doc who is just starting out on the
career in austere medicine? So my advice for that is
whatever environments you're going to, whether that's the,
the mountains, the deserts or the jungle is before you pick up
the the books that understand all the diseases, the complex
medical stuff that we have to deal with that environment is
make sure that you are personally or physically fit and
capable of being in that environments.
Whether it's the physical or the the mental rigour that you're
going into is an issue that I've encountered time and time again.
Whether it's just a lack of physical fitness is if you get
deployed into one of these environments, those deployments,
first of all, are very expensive to get you into that
environment. A huge amount of money has been
spent to transport you the set up, whatever living environment
you need, whatever clinics and so on.
If you arrive there and decide physically you can't handle it,
this is not for you and so on, that can become a problem.
And I do understand there's an acclimatisation to any
deployment that you might do. But my advice, and this is the
advice I gave to my your rescuers this morning is before
you go into the difficult rescue stuff in the wilderness, get
yourself out there, take a backpack, go and spend a few
nights ago and pivot in one of the the safer sort of wilderness
environments. Go hiking, go climbing, be a
Mountaineer, be a hiker, go on a lightweight expedition.
So don't just build up your medical knowledge, just build up
your personal experience in those environments.
And without that, you do risk potentially either injuring
yourself or becoming a liability to the mission that you're
trying to so nobly help. That's a challenge.
From deployment to deployment, you're going to different areas,
aren't you? Yeah, it's as much as you can
try prepare for everything. It's there's always something
new, whether it's just the severity of the patients you
might deal with, if you're not used to altitude, if you're not
used to the humidity. So whatever environment you're
going into is just to make sure that you understand what the
environment is going to be like. And again, do whatever you can
to prepare yourself physically for operating in that
environment. And before we started recording,
you mentioned something about your local Air Force.
What was that about? So this morning I actually was
asked just to go and help the local mouse and search and
rescue and some of the other teams was to just help them with
a dry run for helicopter rescue. And I dispense the same advice
to them. Is that before you decide to get
on the helicopter and one of the biggest risks to the aircraft or
is the rescuer themselves if they don't have all the kits
squared away, if they aren't very familiar with all the
equipment that they are using there, It's a Caribbean safety
lanyard. If they're not comfortable with
their helmets, they're not comfortable with the PPE, the
harness doesn't fit right. They're not quite sure how to
dress for whether to lay a property.
The second you step into the aviation environmental onto a
helicopter, all of those seemingly small nitpicky issues
immediately get compounded. And I demonstrated the several
times where we had over 20 rescuers and the capacity of the
aircraft to 16. If I'm trying to get 16 rescuers
out the aircraft, but if there's even a 32nd delay where someone
is tumbling a Caribbean can't get the air pro on need to
adjust the goggles, that's times 20.
You're looking at now potentially a 10/20 even a
longer minute delay in getting everybody safely deployed and at
the circles in back to my original point is just to make
sure that you are very comfortable in that environment
and that you can deal with the the task load.
And the way you do that is take care of the small stuff first
yourself. And I even gave the advice is
right next to the TV remote in your lounge, put a carabiner to
sit there, get it to a subconscious level, click it
open, you know, and get a feel for exactly how it works.
So when it comes time to use any of that equipment and anger, it
is basically instinctual and second nature.
It's the same advice I give to my students with A10 mil syringe
in class. They should just have it in
their hand and learn how to manipulate it with right hand,
left hand, a whole bunch of different, different ways.
It's it's the hand knowledge, isn't it?
Yeah. It's a muscle memory.
The when I first started out in in Martin Rescue took the same
advice I'm giving now. I joined the Master Club of
South Africa and every single weekend, every single
opportunity I got, I was out there hiking, mining, technical
Rd equipment and that pays huge dividends to this day in the
rescue environment. That's good advice.
So Michael, thank you for being on our podcast again and thank
you for the 10 years that you've given to the college and you've
gotten a doctorate out of it. I understand is reciprocal, but
you are a valued member of our faculty.
Thank you. Thank you every and I look
forward to the next 10 years. Has been a presentation from the
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