Kenneth Arrow has died. A real economist. I have a very hard time talking most health economists seriously, especially when they think QUALYs are anything but an almighty sleight of hand over reason (contract work for the NHS). As one economist pointed out to me, one is tempted to imagine that economists who were not very good at economics, become health economists. But that may be a little unkind, and we do need clear thinking about health. Here is a link to a paper published on the economics of the health care industry in 1963. It is both deep, humble, and wonderfully lucid. The econocracy movement should champion it.
Nice paper by Erik Driessen, and much more nuanced that my quotes might suggest. Worth a read. But still a phrase that I use as a bullshit detector.
Many students do not value reflection as a learning strategy, especially not when they are forced to use an artificial and fixed format and they have little opportunity to direct their learning as a result of these reflections.
“Few things seem to irritate doctors and medical students so much as mandatory reflection. (Tomlinson 2015)”
Twenty-five years of portfolio reveal a clear story: without mentoring, portfolios have no future and are nothing short of bureaucratic hurdles in our competency-based education program
But I do prefer the term ‘learner chart’, but why not just say, ‘a record of what you did’, just like handing a lab book in. Once again, school teachers might be our guides.
There is a good piece on Wonke by David Morris, dealing with the issue of how research and teaching are related, and the dearth of empirical support for any positive relation between the two. R & T are related at the highest level — some universities can do doctoral research and teaching well — and although I have little direct experience, the same can apply at Masters level. The problems arise at undergraduate level, the level in which most universities compete, and which accounts for the majority of teaching income. As ever, I think we have to think ecology, variation and the long now. What seems clear to me, is that research is indeed often at the expense of teaching, and that the status quo needs to be changed if universities are to continue to attract public (and political) support. Cross subsidies and the empty rhetoric of ‘research led teaching’ do not address what are structural issues in Higher Ed, issues that have been getting worse, driven by poor leadership over many decades.
For many universities this is a pizza and / or pasta issue: some of us like both. Just because the two show little covariation in ecological data, does not mean that they shouldn’t inform each other much better than they have over the recent past. On the other hand, scale and education are unhappy bedfellows, and staff time and attention matter. Do you really think about teaching the same way you approach research? If T & R do not covary, then are your students in the best place, and why did you admit them? Honest answers please.
People who make predictions of how many doctors or even what specific type of doctor we need in (say) 20 years are IMHO generally deluded. Or they are telling fibs. Or selling something. The following is from the NEJM and is about ‘hospitalists’
Twenty years ago, we described the emergence of a new type of specialist that we called a “hospitalist.”. Since then, the number of hospitalists has grown from a few hundred to more than 50,000 — making this new field substantially larger than any subspecialty of internal medicine (the largest of which is cardiology, with 22,000 physicians), about the same size as pediatrics (55,000), and in fact larger than any specialty except general internal medicine (109,000) and family medicine (107,000). Approximately 75% of U.S. hospitals, including all highly ranked academic health centers, now have hospitalists. The field’s rapid growth has both reflected and contributed to the evolution of clinical practice over the past two decades.
The only way you can play ‘make believe’ like the DoH and all the NHS ‘experts’ so keen to trample all over our medical students’ futures is if you think Stalin is still alive and sorting out the tractor numbers.
Doctors seem to diagnose what they know, so find out what they know before you ask them whats wrong with you.
I have written before about the problems that learning outcomes fail to deal with (Jorge Luis Borges and learning outcomes), but there is another cognate issue that bugs me from time to time. The following is a quote from The Undercover Economist in the FT
Should the rules and targets we set up be precise, clear and sophisticated? Or should they be vague, ambiguous and crude? I used to think that the answer was obvious — who would favour ambiguity over clarity? Now I am not so sure. Ponder the scandal that engulfed Volkswagen in late 2015, when it emerged that the company had been cheating on US emissions tests. What made such cheating possible was the fact that the tests were absurdly predictable — a series of pre-determined manoeuvres on a treadmill.
I think there is a very clear downside to making too precise what it is that students should learn. I actually think we need noise in the system, simply because assessment methods are imperfect and unnatural, and the more you seek particular psychometric qualities the greater the distance between what is important and what and how you test. This is not a popular position to take, and I confess I am one of the worst offenders in terms of producing tightly defined content. But if:
At a lecture following the publication of his book, Sustainable Energy – Without the Hot Air, he was assailed by an angry environmentalist who asked him why he was “so hostile” to wind power. [Prof David] MacKay smiled sweetly and replied: “I’m not hostile to anything. I’m just in favour of arithmetic.”
I remember reading this awhile back, but came across it again on Memex
From an obituary of George Klein in Nature. If you have ever thought about cancer, his thoughts have touched yours.
In 1957, a chair was created for him in tumour biology, a research field that he had helped to establish. The department of tumour biology that ensued was international and influential. Most of today’s leading cancer researchers who are over 50 have had some interaction with George and his department. Seven secretaries wrangled his large correspondence. He invented social media before the technology existed.
A telling phrase:
His last book, Resistance (Albert Bonniers Förlag, 2015; published in Swedish), won the prestigious Gerard Bonnier prize for the best essay collection of that year. It deals with resistance to extremism and to cancer. Throughout his life, George was preoccupied with the thin borders between evil and good, and health and disease.
Here. But your knew this already. This is not about truth, or doing the right thing, but about power and the imposition of an ideology in which the natural world has to be subservient to a dogma. Most of all, this is not about improving education, but of an expansion of power and patronage. And money.
[Or see what Martin Wolf of the FT, has been saying in this week’s Time Higher]
Nice piece in ‘Science’ with the title: ‘No easy answers: What does it mean to ask whether a prekindergarten math program “works”?’ Geoff Norman, many years ago, used the term RCT in the context of medical education to stand for Randomised, Confounded and Trivial. Research into what works and what does not work in education is hard, and most studies (IMHO) fail to inform. Education isn’t a product like a drugs is, and gee it is hard to demonstrate when and where most drugs will work if you do not have an understanding of the biology and large effects to play with and outcomes that need to be measured over the long term.
I think about this a lot, but have no easy rules to guide action. Which is, of course, exactly the problem.
As one Credit Suisse analyst looking at the $35 billion industry put it, “it’s hard not to make a profit” in the for-profit education sector. The stock prices of for-profit colleges and universities (FPCUs) reflected that; they rose more than 460 percent between 2000 and 2003 with much support from public subsidies. Their promotional budgets rose, too—Apollo recently spent more on marketing than Apple, the world’s richest company.
But education, sadly, did not benefit. As A.J. Angulo outlines in his detailed history of the for-profit sector, Diploma Mills, that’s because such schools [for profits] spend a large majority of their budgets not on teaching but on raising money and distributing it to investors. In 2009, for example, thirty leading FPCUs spent 17 percent of their budget on instruction and 42 percent on marketing to new students and paying out existing investors. Is it any wonder, then, that investigations into the industry from 2010 to 2012 found that while it represented only 12 percent of the post-secondary student population, it received a quarter of all federal aid disbursements and was responsible for 44 percent of all loan defaults, many of them by working-class students who either couldn’t afford to graduate or, once they did, found their degrees were largely useless in the marketplace?
Remember the jokes about the only way to run an efficient hospital is to have one without any sick people? Well just read this, from an editorial by Martin McKee and colleagues in the BMJ. The context is what might be involved in any trade deals with the US and what US corporations would require:
They can be expected to look abroad, making the UK, with a struggling NHS, a tempting target. The UK prime minister, Theresa May, has not excluded the possibility of opening the NHS even further to them. At present, US corporations struggle to make a profit in the NHS. They would be unlikely to agree any deal that limited their ability to press for changes that would generate profits, such as excluding poor and ill people.
Not so long ago, at an internal meeting, the message was ‘things are tough for this year, and next, but after that all the tightening and discipline will pay off, and things will get back to normal’. I doubted that at the time, and stick to my conviction that things are going to get a lot worse for much Higher Education in the UK. There is plenty of blame to go around: institutions have preferred their own propaganda to reality; they have allowed their business (sic) to grow fat on subsidies; and they have lost touch with the academic ideal. Most of all, they have failed to keep with up the rate of societal and technological change — ironic, since this is a world that universities, more than any other institutions, created. As we can see so bluntly in medical education (for an egregious example, just read this recent editorial in the BMJ), governments view universities not as meaningful components of a healthy society, but as providers who are required to do contract work for the government. The more the students have to pay for their own training rather than their own education, the better. The independence of many or most universities is illusory. They are like temporary post-docs, jumping from grant to grant, doomed to follow the ideas of others: renters not home owners. The institutional question remains: where do you position yourself? And how.
(Wonke has a little on some vibrations — aka shocks — that will only become bigger)
It was reading Herb Simon’s ‘Sciences of the Artificial’ that woke me up what some professional schools had in common. I even wrote a piece in PLoS Medicine arguing that medicine is more engineering than science (‘The problem with academic medicine: engineering our way into and out of the mess’). And I think I called it right. But the parallels between medicine and many other other traditional professions is large. I am thinking law, architecture, teaching, and engineering. These are all design sciences, or since I sort of object to this use of the word science, design domains. One of the reasons medical education — and to a lesser extent medicine is in such a mess — is the way that we have failed to grasp this distinctions. I wrote last year:
Simon was a genuine — and it is an overused word— polymath, and at that time I was ignorant of his many contributions. His work ranged through business administration, economics (for which he was awarded a ‘Nobel’ prize), cognitive science, computing, and artificial intelligence. But what fascinated me most was the content of his most famous book, ‘sciences of the artificial’. In this work Simon set out to unify and provide a common intellectual framework for many human activities that involve creating artefacts that that realise a purpose of our choosing. Unlike our dissection of the natural world, whether that be identification of a gene for a disease, or a virus that causes a human disease, Simon was concerned with how humans build artefacts. In particular how do we navigate search spaces that are large, and where uncertainty is all around, and where there may be no formal calculus to allow us to fire across boundaries. He was thinking about thinking machines of course, but quite explicitly he was concerned with the professions, architecture, law, and of great interest to me, medicine and teaching and learning. I was hooked.
More and more, business schools were becoming school of operations research, engineering schools were becoming schools of applies physics and math, and medical schools ere becoming schools of biochemistry and molecular biology. Professional skills were disappearing from the faculties.…they did not fit the general norms of what is properly considered academic. As a result, they were gradually squeezed out of professional schools to enhance respectability in the eyes of academic colleagues.
If you want to explore the meme about tech destroying jobs (and value) there are some great quotes in a piece by Steven Levy about John Markoff, of the New York Times, stepping down. Some samples:
I used to tell people that the Times’ loyal readership was both its great strength and weakness. The good news was that they would read the paper until they died. The bad news was that they were dying.
Then when I went back to school one fall, the men were all gone. It was the fall of 1969 and the Union Bulletin had gone to offset type. The men in the aprons had vanished. They had been shipped off with the press to a small paper in Oregon. In their place were women in skirts working at Selectric keyboards.
The next transition happened 15 years later when I got my first job at a daily paper, the San Francisco Examiner. I was part of a new generation of reporters who went to the gym after work instead of the bar.
That’s another irony — that I was one of the first to write about the digital world, but when it really arrived it was pretty clear that I wasn’t going to be a digital native. When blogging began, John Dvorak told me that there was no point in doing it unless you posted at least seven times a day. “Why would I want to do that?” I thought. I had already worked for an afternoon daily and I never wanted to work for a wire service.
Some things won’t change. I’m certain that when the next corrupt president is impeached it will be because of the hard work and persistence of some new Woodward and Bernstein.
I have often quipped that high quality journalism could contribute more to health care in the UK than the Department of Health in London. This was once a daring proposition.
From Audrey Watters excellent round up of the year that was:
I think it’s safe to say, for example, that venture capital investment has fallen off rather precipitously this year. True, 2015 was a record-breaking year for ed-tech funding – over $4 billion by my calculations. But it appears that the massive growth that the sector has experienced since 2010 stopped this year. Funding has shrunk. A lot. The total dollars invested in 2016 are off by about $2 billion from this time last year; the number of deals are down by a third; and the number of acquisitions are off by about 20%.
To the entrepreneur who wrote the Techcrunch op-ed in August that ed-tech is “2017’s big, untapped and safe investor opportunity.” You are a fool. A dangerous, exploitative one at that.
Lots of good reasons for this, but surely the main one is that the products are so awful. It is a big domain of human activity, although whether it is a market I will leave for the moment. But people may prefer to spend their money on something that works. And that is before we mention LMS. Of course we can just sell our students user data….
Lots more good stuff from her here, although a stiff drink may be seasonally appropriate.
I read the book, ‘Ways of Seeing’ soon after it came out, but had never seen the videos. Spellbinding. Via here. It took me a while to appreciate it was the same mind that wrote ‘A fortunate man’ about, not primary care, but General Practice.
More worrying is the role of scoring in these judgments. For decades educationists have tried to assess the output of schools, and largely failed. They have fallen back on anything they can find that is measurable. The outputs are not happy children or well-adjusted or even well-paid ones, let alone a more productive economy or a more stable society. They are merely exam results and test scores, places in a league table. It’s like judging piety by testing the Bible.
Simon Jenkins, awhile back in the Guardian. In the UK, this is the madness that Thatcher set off all across the pubic sector, including health and education (and soon higher education). Teachers matter, it is just that measuring teachers may wreck genuine attempts to improve teaching (pace Dylan Wiliam).
Well, not that I do, and in particular not this one. But, after sitting recently working in a coffee shop across the road from a school playground in Berlin, being both disturbed (“I was working!”) and amazed at the racket from all the frantic school children hurtling around a school playground, I do puzzle why it all changes when you ‘grow up’.
Anyone who rose morning after morning this week for an exhausting and ache-generating exercise class to fulfill a New Year’s resolution will envy the bar-headed goose. The bird has the strength and endurance to fly 3000 kilometers over the Himalayas between its breeding grounds in Mongolia and wintering grounds in India. Yet a new study indicates that it doesn’t do a lick of exercise to prepare.
In at least some species, extra exercise may even be harmful, studies of captive zebra finches reported at the meeting suggest……… birds getting the extra exercise suffered cellular damage, from oxygen radicals and other charged molecules released by active muscle.
Birdbrain I might be, but not of the goose persuasion.
’The average doctor who emerges from this process is usually a basically bright person with a mutilated mind.’
“books of the type written by the current hotshot Op-Ed writer at the New York Times may get some hype at publication time, manufactured or spontaneous, but their five year survival is generally inferior to that of pancreatic cancer.”
There are many worthwhile insights on show in the THE interview with the Nobel physicist Saul Perlmutter, ‘You can’t order up a breakthrough’. But this caught me eye:
“I think for students it’s never too early…to realise that they should be helping…to figure out the world together, not just learning the received facts and the things we already know,” he says. “We find ourselves looking at a world where I don’t think almost any of the problems I see today would worry me, if we knew how to work together and how to think through problems together in a rational way that wove together fears and needs with a rational understanding of the world…Maybe one of the best ways into that is to start teaching.” (emphasis mine)
I think this is the kernel of the problem we face, and the trite “we need more STEM’ or ‘teach all students to code’, is missing the key issue. We are, as has been said before, a ‘civilisation that is face to face with its own implications”.
I am often accused of being too cynical. Events in 2016 have not dissuaded me that my approach was not the right one. But I like this quote, which is new to me:
As George Carlin said: “Scratch any cynic and you will find a disappointed idealist.” Guilty as charged: I was an idealist and remain one, well, sort of. Tim Wu interviewed by John Naughton
Tim Wu’s last book, “The Big Switch: The Rise and Fall of Information Empires”, was magisterial, and of interest to anybody interested in education, tech and the web. His latest, has not been published in the UK yet, but tracks the relation between attention and advertising (‘The Attention Merchants’). In the interview Naughton reprises one of Herb Simon’s great insights:
The cue for his new book, The Attention Merchants, is an observation the Nobel prize-winning economist Herbert Simon made in 1971. “In an information-rich world,” Simon wrote, “the wealth of information means a dearth of something else: a scarcity of whatever it is that information consumes. What information consumes is rather obvious: it consumes the attention of its recipients. Hence a wealth of information creates a poverty of attention and a need to allocate that attention efficiently among the overabundance of information sources that might consume it.”
Anybody who looks at how students want to learn, and the fractured landscape of content and ‘learning behaviour’, needs to think hard about this topic.
“This may upset some of my students at MIT, but one of my concerns is that it’s been a predominantly male gang of kids, mostly white, who are building the core computer science around AI, and they’re more comfortable talking to computers than to human beings. A lot of them feel that if they could just make that science-fiction, generalized AI, we wouldn’t have to worry about all the messy stuff like politics and society. They think machines will just figure it all out for us.”
In June 2016, data released by the UK’s Office for National Statistics revealed that there had been 52,400 more deaths in the year following June 2015 compared with the same period a year before; an annual rise of 9%. These rises in mortality rates are unprecedented in post-war times. In England and Wales, the increase was almost entirely in the population aged over 55 years, predominantly in those aged over 75, and was largely attributed to dementia and Alzheimer’s disease, with influenza being suggested as a minor contributory factor. It was mostly those with long-term care needs who were dying earlier.
In addition, in late 2016, official data was released for Scotland showing no rise in life expectancy for men and women for the first time in 160 years.
These are two quotes from an article in yet another new journal, Nature Human Behaviour. The title of the piece, ‘Policymakers should not act like scientists’, is worth thinking over. There is always a bias built into ‘tests of departure from..’ and those who control the funding, can control what counts as legitimate evidence. And the null hypothesis of the ‘classical statistical paradigm’ is not appropriate for many types of problems. From somewhere, I remember a comment from Paul Jannsen along the lines of, ‘in those days the idea of obviousness still existed’. As we saw last week, in the debate about the NHS, in the mouths of politicians a handful can mean upwards of 10,000. As is often misquoted: the plural of anecdote is data.
I first became ware of the importance of intellectual property law and custom after reading James Boyle’s ‘Shamans, Software and Spleens’. I had been completely unaware of how important the institution of private intellectual property was, and how destructive it frequently was of human advance. Of course, it was not meant to be this way. Boyle’s book is dense but funny, and he lambasts the contradictions in copyright law, the tortured logic in the bizarre attempts to explain why blackmail and insider trading are illegal, and the craziness that surrounded patenting DNA and what you can do with my spleen once you once removed it. As Cory Doctorow commented, about another of Boyle’s books, ‘Bound by Law’, “Copyright, a system that is meant to promote creativity, has been hijacked by a few industrial players and perverted. Today copyright is as likely to suppress new creativity as it is to protect it.” It was reading Boyle that led me to write an essay in the Lancet on how the ease or difficulty of assigning IPR distorted medical advance.
This is a funny story with a surprise inside. The funny part is the artwork: an artist created glass blocks exactly the dimensions of a FedEx box and then shipped them in those boxes, producing unique art out of the cracks and breakage that resulted. The surprise is that it turns out that Fed Ex has corporate ownership over that space. “There’s a copyright designating the design of each FedEx box, but there’s also the corporate ownership over that very shape. It’s a proprietary volume of space, distinct from the design of the box.” Now I’m afraid I might accidentally violate FedEx’s ownership over that specific shape should I decide to, I don’t know, create my own mailing box.
Not so much enclosing the commons, but space itself.