BMJ visual summaries and not being wrong

by reestheskin on 23/05/2018

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Maybe it is just me, but I find many of the graphics in the BMJ hard to follow. The image below is from a clinical update on “Depression and anxiety in patients with cancer” (BMJ 28 April 2018, p116-120). It occupies two whole pages. I am not certain what problem the graphic is trying to solve. For me, it just induces a sense of incomprehension. Or nausea.

In dermatology, there was a famous US academic known for producing slides with numerous arrows, many involving feedback. It was professional cargo-cult science (as the BMJ is cargo-cult education). Sam Shuster always cautioned: more than 3 or 4 arrows per slide, usually means bullshit.

That which is simple is wrong; that which is complicated is useless (Paul Valery).

End of the world [refrain]

by reestheskin on 16/05/2018

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But outside in Times Square, the LED news tickers were telling a different story. On Tuesday, Gibson Brands, Inc – with the biggest product line in the guitar business – filed for bankruptcy, succumbing to an estimated $500m debt load and a failed reinvention in 2014 as a “lifestyle brand”.

Now I know things are really bad.

Troubles in the land of the six-string are not restricted to Gibson. Ten years post-recession, the guitar industry in the US continues to bob, with the 2,633,000 units sold in the United States in 2017 about 5% short of where things stood in 2008, according to Music Trades magazine. The heavyweight retailer on the American scene, Guitar Center, carries $1.6bn in debt.

Played out? Gibson’s bankruptcy fuels fears for the guitar’s future | Music | The Guardian

And here, too.

Politicians beware

by reestheskin on 15/05/2018

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Factfulness ( the book)

Factfulness: The stress-reducing habit of only carrying opinions for which you have strong supporting

Hans Rosling

Diagnosing money.

by reestheskin on 14/05/2018

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Science 21 June 2013: 1394-1399.

For most alumni, university fundraising may seem to be uncoordinated and lacking in focus—an assortment of phone calls, solicitous letters, and invitations to a class reunion. But for Steven Rum, it’s a science. And the goal is to carry out more research.

Rum is senior vice president for development and chief fundraiser for Johns Hopkins Medicine in Baltimore, Maryland. Last year, his team had a banner year, raising $318 million. Their approach places the physician scientists at Hopkins on the donor front lines. The goal is to turn the positive feelings of “grateful patients” into support for new research, faculty chairs, academic scholarships, bricks and mortar, or simply defraying the cost of running a multibillion-dollar medical center.

Rum has 65 full-time fundraisers on a staff of 165. Each one is responsible for meeting weekly with physicians—their “caseloads” range from a dozen to more than 30 docs—to discuss which of their patients might be potential donors. The conversation is designed to help them identify what Rum calls a donor’s “qualifying interest” and connect it to their “capacity,” that is, the ability to make a donation.

More often than not, Rum’s team finds that sweet spot…..

”Ideally, I’d like to have one gift officer manage no more than six doctors,” he says.

Link

Facebook, as Big Tobacco for ‘the next billion’

by reestheskin on 11/05/2018

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Exactly in the same way that Big Tobacco has been free to fill the lungs of Asian of African populations, with little interference from local health administrations, Facebook will have a free hand to lock up these markets. (If you find my comparison with the tobacco industry exaggerated, just ask the Rohingyas or people in the Philippines about the toxicity of Facebook to democracy — or read this Bloomberg Business Week piece, “What happens when the government uses Facebook as a weapon?)

Mark Zuckerberg’s long game: the next billion – Monday Note

Closing time

by reestheskin on 10/05/2018

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A beautifully written vignette in the NEJM by Abigail Luger

Moving On | NEJM

Now I’m the one contemplating a permanent departure. My health is fine, but my stamina is pretty much gone. Our health care system is not kind to the chronically ill and marginally insured, and it is not particularly kind to their doctors, either. Our patients are condemned to an unending swim against a hostile tide. Doctors can head for shore.

Max Schrems: the man who took on Facebook — and won

by reestheskin on 09/05/2018

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Great story. Only true.

Schrems sent the complaints to the Irish data protection commissioner in Portarlington, a town with a population of 8,000. From a modest office above a supermarket, the Irish DPC was responsible for regulating all the tech companies that nominated their Dublin-based subsidiaries as “data controllers”. Despite its role protecting millions of EU citizens, the commissioner had just 26 staff at the time.

FT

This all reminds me of that wonderful scene in the film Local Hero when the visitors from the US mega corporation discover that the same person (played by Denis Lawson) runs the bar, hotel, office, professional services etc. in the small Scottish village where it is set.

BTW: instead of the mandatory GDPR corporate training, can we just not watch Local Hero again?

Institutions (and certification) matter

by reestheskin on 07/05/2018

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My third issue is more nuanced. The biggest reason for cataract blindness is the dearth of ophthalmologists. Orthopaedic surgeons in Leicester faced with a backlog of carpal tunnel surgery decided to train intensively one theatre nurse. As a result, our carpal tunnel surgery service is probably the best and most cost effective in the country. Having a person who is not a “fully qualified doctor and surgeon” operating on cataracts could be the best solution.

Quote from, John Sandford-Smith, retired ophthalmologist, Leicester. BMJ 2018;360:k640

This sort of argument is old, and largely correct. But you can only scale such a process with the help of some form of certification, because without it, there is no durable career structure. And without this, there is no investment.

Focus on the kids: they are the vulnerable ones

by reestheskin on 04/05/2018

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I used to think this whole topic was overblown. But then again, I once thought those who foresaw the obesity epidermic were selling something. Wrong on both counts.

Former Google Design Ethicist: Relying on Big Tech in Schools Is a ‘Race to the Bottom’ | EdSurge News

I see this as game over unless we change course,” says Tristan Harris, a former ethicist at Google who founded the Center for Humane Technology. “Supercomputers play chess against your mind to extract the attention out of you. The stock price has to keep going up, so they point it at your kid and start extracting the attention out of them. You don’t want an extraction-based economy powered by AI, playing chess against people’s minds. We cannot win in that world.”

In an interview with EdSurge, Harris noted that the focus of their campaign started with children because they were the most vulnerable population. He says that particularly children in schools had little agency over whether they opted into or out of a technology platform because of pressure from both peers and educators handing out assignments.

Our struggle with Big Tech to protect trust and truth

by reestheskin on 03/05/2018

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Some nice turns of phrase and perspective from this article in the FT

In 1829, the great Scottish historian and essayist Thomas Carlyle wrote: “Were we required to characterise this age of ours by any single epithet, we should be tempted to call it . . . the Mechanical Age. It is the Age of Machinery . . . the age which, with its whole undivided might, forwards, teaches, and practices the greater art of adapting means to ends.”

He continued with a lament for older ways of doing and being: “On every hand, the artisan is driven from his workshop, to make room for a speedier, inanimate one. The shuttle drops from the fingers of the weaver and falls into iron fingers that ply it faster. The sailor furls his sail, and lays down his oar, and bids a strong unwearied servant . . . bear him through the waters.”

It is a measure of just how much speedier our age is that no one today will take the time to write or read such comparatively languorous prose. What is striking about Carlyle’s writing from today’s vantage point is how early in the industrial revolution he mounted a protest against it. By 1829, the steam engine was entering its ­heyday, but the explosion of iron, steel, coal and oil that we associate with the industrial age was visible only on the horizon.

FT

Performance management in the real world

by reestheskin on 02/05/2018

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Stalin, Krushchev and Brezhnev are riding on a train when it suddenly stops. Stalin says “Comrades we must execute the driver to motivate the others”. The poor driver is dragged out into the snow and shot. the train still doesn’t move. Krushchev says “Comrades, we have made a dreadful error. We must set this thing straight and rehabilitate the poor driver.” So the driver is posthumously rehabilitated. Still the train doesn’t move. “Listen”, says Brezhnev, “The solution is obvious. Let’s pull down the curtains, bounce up and down on the seats and pretend the train is moving”.

The breakthrough is just a filing away.

by reestheskin on 01/05/2018

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Article in Nature. I largely agree, although my views are as much based on the hype-upon-hype that characterises so much of medical research, especially cancer. I do not have a reference, but whatever one’s views about the late David Horrobin, his Lancet article about cancer trials — written when he was dying from lymphoma — is worth a read. What a mess!

Key quotes from this article:

In 2017, my colleagues and I completed a study of all 48 cancer drugs approved by the European Medicines Agency between 2009 and 2013 (C. Davis et al. Br. Med. J. 359, j4530; 2017). Of the 68 clinical indications for these drugs (reasons to use a particular drug on a patient), only 24 (35%) demonstrated evidence of a survival benefit at the time of approval. Even fewer provided evidence of an improved quality of life for symptoms such as pain, tiredness and loss of appetite (7 trials; 10%). Most indications (36 of 68) still lacked such evidence three or more years after approval. Other groups in other regions have observed similar trends. For example, a 2015 study demonstrated that only a small proportion of cancer drugs approved by the FDA improved survival or quality of life (C. Kim and V. Prasad JAMA Intern. Med. 175, 1992–1994; 2015).

But the key point he makes is:

I believe that the low bar also undermines innovation and wastes money.

When assessments — whether in medicine or education — are flawed the loss in value is not in short term financial costs, but in what might have happened 10 years down the road.

Ghost teachers at medical school

by reestheskin on 30/04/2018

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The Medical Council of India has asked state councils to investigate the problem of “ghost” teachers in medical colleges following the discovery of more than 400 fake teachers in four colleges in three states.

He said that the Maharishi Markandeshwar College in Ambala, established in 2008, has an annual intake of 150 students.“It needs a minimum of 108 faculty members as per the Medical Council of India norms. On paper it has 145 teachers listed. But that’s on paper. The college would retain a majority of the names adding new ones off and on. During inspections the doctors would appear and then disappear once the inspections were over.”

We learn that:

These “ghost teachers” are registered as faculty members drawing a hefty salary, but have never taken a single class. Most of them run private clinics, and only attend the college when there is an impending medical inspection.

Link

Well, one wit once remarked that the collective noun for a group of professors is “An absence of professors”.

‘Should’ rather than ‘could’

by reestheskin on 29/04/2018

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Günter Blobel (1936–2018) | Science

Günter taught us to distinguish experiments that should be done from those that could be done; he taught us to cherish the paradox over the obvious next thing. Importantly, Günter excelled at standing up firmly for one’s convictions in the face of controversy.

Of the arts

by reestheskin on 24/04/2018

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Born in Buckinghamshire in 1942, Sulston described his young self as a mechanically minded artisan who preferred science to sport

From an obituary of John Sulstan (by Judith Kible), whom I meet only once when some of our red hair work was featured on the Christmas Lectures. But the phrase harks back to a true characterisation of some types of science. Tool makers; and theorists.

What to say?

by reestheskin on 23/04/2018

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As the surgeon reached for a scrub brush, the medical student lingered back, his thumbs incessantly and rhythmically tapping on the screen of his phone. The surgeon peered at him with frustration, annoyed that again his student appeared more interested in his smartphone than the pathology. In an effort to engage him back to the case, the surgeon asked: “Can you tell me what tendons lie in each of the extensor compartments in the hand?” The student’s head snapped up, and he quickly rattled off the answer with ease. Smiling momentarily, he then asked, “Could I get your thoughts on this new video describing nerve transfers rather than tendon transfers for radial nerve injuries that was just uploaded to our educational portal? See, I have it pulled up right here, it was just presented last week at the plenary session…”

JAMA

Defence

by reestheskin on 20/04/2018

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“Why do doctors feel the need to do this? A study in The BMJ in 2015 suggested that there is an association between increased defensive practice and a reduced likelihood of being involved in litigation.2 One might conclude that defensive practice is a logical behaviour in the face of a culture that leads to doctors being fearful of the consequences of making an error or even of a known adverse outcome.

“No doctor sets out to practise defensively, but a system has been created where this is inevitable. The GMC acknowledges that medicine has become more defensive.3 Doctors often lack confidence in the fairness and competence of investigations and continue to see the GMC as threatening.”

Tom Bourne quoted in the BMJ

Risk to patients?

by reestheskin on 19/04/2018

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A “world renowned” consultant radiologist has been suspended from the medical register for six months after being convicted of failing to pay more than £400,000 in tax on his private practice earnings. XXX a professor of cardiovascular imaging, was given a 15 month suspended prison sentence and fined £200,000 in 2015. The GMC argued that he should be erased from the register. But the medical practitioners tribunal concluded that he made a unique contribution to the care of critically ill patients and the development of cutting edge techniques.

Bmj September 30 , 464, 2017

That old cosmic balance

by reestheskin on 18/04/2018

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“he rose because of the widespread but baseless hunch that people with little outward charisma must possess great depth by way of cosmic balance.”

FT

The robots are already here.

by reestheskin on 17/04/2018

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Modern medicine is full of doctors who are already robotic. But good medicine is like any other subject that requires one to make judgements based on prior cases. You can follow rules, or you can think. The first kidney doctor (who I saw multiple times) never bothered to actually think.

Roger Schank

Nail in the coffin

by reestheskin on 16/04/2018

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And third, the internet is disrupting death as it has life. Comparison sites shed light on funeral providers’ services. And though not many bereaved relations yet “bring their own coffin”, a quick browse online gives people a far better idea of what it should cost. Startups are offering more radical disruption: rocket-launches for ashes; QR codes on graves linked to online tributes; new ways of disposing of bodies besides burying or burning.

I like that you can now go ‘direct’. Purgatory is now optional.

Economist.

Go where the messes are

by reestheskin on 13/04/2018

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(Isaiah)Berlin had learned that if you studied them with philosophical intent, certain second-rate minds grappling with first-rate problems could teach you more than first-rate minds lost in the shrubbery. (Another reason, perhaps, that he abandoned analytic philosophy.).

Mark Lilla in the NYRB

Which for some reason reminds me of a quote from the Economist:

Professors fixated on crawling alone the frontiers of knowledge with a magnifying glass.

Nails and plate tectonics

by reestheskin on 12/04/2018

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Despite my professional area of interest, I always forget how fast fingernails grow. But no longer.

Thanks to plate tectonics, America and Europe are moving apart at about the speed that fingernails grow. (Thanks to Bill Bryson)

Its about control, stupid!

by reestheskin on 11/04/2018

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As anyone who has worked in a large organisation knows, people who are put in charge of a complex activity that would be better left alone, never do nothing; they seek to justify their existence by simplifying and restricting that activity so that it can be controlled.

Paul Seabright

Higher education (but not so high after all)

by reestheskin on 10/04/2018

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A Wonke podcast well worth listening to featuring Matt Robb of EY Parthenon on higher education. I think it will all end in tears, but it has the virtue of laying out what is happening and — to use one a phrase I detest — the direction of travel.

Wonkhe podcast here.

Some selective notes below (not necessarily his views): there remains much misery to go around.

  • increasing rate of change
  • the nature of change
  • HE is increasingly commercial and internationalised
  • universities having to be more extroverted
  • HE sector facing segmentation
  • global elite versus high-end Russell and the low-end…..
  • (some) protection by grouping by brand
  • international students to drive research to drive rankings to attract students…
  • your ranking is under threat
  • rise of TEF
  • the TEF proof of ‘value added’ at bottom of rankings is the only defence against the ‘too many going to university’ argument. (Well, too many are going…)
  • the great challenge (for part of this sector) is to explain what teaching looks like if it is not research led teaching (which is not the mass of higher education).
  • contract lecturers ……more ‘financial’ flexibility
  • online / blended allowing……. more ‘financial’ flexibility
  • Segmentation rules!
  • University Leadership does not have the strategic competence or backup to run universities.
  • a nice analogy between spreadsheets, and strategy versus planning.

Never underestimate the ability of the UK to reflect on, and then destroy its own brands, particularly if consultants are involved.  You can make a lot of money as the ship goes down.

Only robots will apply

by reestheskin on 09/04/2018

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This article is about truck drivers in the US, where getting a license requires a big investment. The article states that there is now a shortage of truck drivers and argues that this may be a result of the ‘inevitable’ rise of automated drivers.

Many young people are reluctant to pay $5,000-$10,000 to learn to drive an 18-wheeler at a time when experts are predicting that it is a dead end career.

This is akin to what I wrote about before. When people know that a line of work is ‘unlikely’ to continue, they are prone not to want to invest in it. It is not too fanciful to see this happening in medicine. Start with imaging specialties first; and then look at the use of paramedical staff in restricted clinical domains.

Slow service

by reestheskin on 05/04/2018

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M&S mental health drop ins

by reestheskin on 03/04/2018

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Restaurants have also lagged behind retailers in offering “experiences”, as the trade jargon has it, rather than the usual broccoli. This is how the more innovative retailers now try to differentiate themselves in a crowded market. It also lets them do something with their underused floor space.  ….John Lewis, for instance, opened its 49th store in October with 20% of the space dedicated to eye tests, children’s car-seat fittings and free styling services for men. Selfridges, another big department store, marked the 400th anniversary of Shakespeare’s death in 2016 by performing “Much Ado about Nothing” in store, and last year it staged concerts. Waitrose hosts yoga classes, and Marks & Spencer mental-health drop-ins called Frazzled Cafés.

People say we spend too much on health, but business does not view it this way. As things approach the margin, there is even more to sell.

Economist

Fear of the known

by reestheskin on 02/04/2018

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Universities are certainly putting their courses online. The question is “why?” I talked last week with a University President whom I have known for many years and asked him why he was building online courses. His answer, unsurprisingly, was “fear.”

Roger Schank

This is an old quote, but still redolent.

When the core is peripheral

by reestheskin on 30/03/2018

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Most, if not all, of us, if asked to be cared for by a television doctor if we had a serious medical problem, would select Dr. Gregory House of the TV series House. He would fail most of the core competencies except for knowledge and skill.

Sidney Herman Weissman in Academic Medicine.

There is a parallel argument used in business: about rounding out the edges leading to less hard thinking. I might agree.