“De Correspondent is ambitious in its ideals, yet modest in its claims”.

by reestheskin on 18/12/2017

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Seems a nice term of phrase for what the academy might once have been (and still should be). But I guess the the definition of the Fourth Estate in a networked world is broad.

“De Correspondent” and the blueprint for a successful membership model

Too much awareness

by reestheskin on 15/12/2017

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Recent years have seen a major drive by government, the NHS, and mental health charities to change attitudes towards mental health and to raise its profile in line with physical health. In a crescendo of media coverage, royals and celebrities have opened up about their own struggles.

Despite having welcomed Prince Harry’s interview about his mental health in April, Wessely believes we can have too much of a good thing: too much awareness. He particularly questions surveys in which most students report mental health problems. “We should stop the awareness now. In fact, if anything we might be getting too aware. One wonders what’s happening when you have 78% of students telling their union they have mental health problems-you have to think, ‘Well, this seems unlikely.'”

Simon Wessely quoted in the BMJ 23 September 2017 p433

Skin cancer on the back of the envelope

by reestheskin on 14/12/2017

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Enrico Fermi was big on back-of-the-envelope calculations. I cannot match his brain, but I like playing with simple arithmetic. Here are some notes I made several years ago after reading a paper from Mistry et al in the British Journal of Cancer on cancer incidence projections for the UK.

For melanoma we will see a doubling between now (then) and 2030, half of this is increase in age specific incidence and half due to age change. Numbers of cases for the UK:

  • 1984: 3,000 cases
  • 2007: 11,000
  • 2030: 22,000

If we assume we see 15 non-melanomas (mimics) for every melanoma, the number of OP visits with or without surgery is as follows.

  • 1984: 45,000 cases
  • 2007: 165,000 cases
  • 2030: 330,000 cases

This is for melanoma. The exponent for non-melanoma skin cancer is higher, so these numbers are an underestimate of the challenge we face. Once you add in ‘awareness campaigns’, things look even worse.

At present perhaps 25% of consultant dermatology posts are empty (no applicants), and training numbers and future staffing allowing for working patterns, reducing. Waiting times to see a dermatologist in parts of Wales are over a year. The only formal training many receive in dermatology as an undergraduate can be measured in days. Things are worse than at any time in my career. It is with relief, that I say I am married to a dermatologist.

Just waive the tuition fees

by reestheskin on 13/12/2017

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For example, graduate stipends at the US National Institutes of Health (NIH) are capped at $23,844 and are not adjusted for cost of living. To help out, universities often waive tuition fees, which can sometimes be more than a student’s income.

Editorial in Nature.

Work experience

by reestheskin on 12/12/2017

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Many of us held down a summer job during our school days to earn a bit of cash. Some, such as those who attended the fictional Scumbag College, did everything they could to avoid work. Things look a bit more draconian over in Zhengzhou where, as my colleague Yuan Yang has revealed, thousands of students have been working 11-hour shifts to assemble the iPhone X. There is nothing wrong with a bit of hard work but this situation constitutes illegal overtime for student interns under Chinese law. Six students told the Financial Times that they were among a group of 3,000 from Zhengzhou Urban Rail Transit School sent in September to work at the local facility run by Apple supplier Hon Hai Precision Industry, better known as Foxconn. The mandatory three-month stint was called “work experience”.

FT

Ricardo

by reestheskin on 11/12/2017

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The growth of medical tourism in Poland has been mirrored in other central European countries. Hungary also has a reputation for specialising in dental services for foreigners, while Czech Republic has developed a market in cataract surgery. Poland is well known for its plastic surgeons as well as dentists.

Medical tourism on the rise in central and eastern Europe

Neurophobia

by reestheskin on 08/12/2017

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Neurophobia’, a term first coined by Jozefowicz in 1994, describes medical students’ fear of neurology 2. It is a chronic illness that begins early in medical school 4. Physicians and medical students alike often state that neurology is the most difficult subject in the medical school curriculum, and that their knowledge about the subject matter is limited, leading to a lack of confidence in managing neurology patients 5, 6, 7. [link]

There are lots of other phobias, too. Pick one up as you check out of med school.

Five years

by reestheskin on 07/12/2017

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This is from John Naughton, although I haven’t the URL to hand. I read it five years ago.

Like democracy, public universities are also ‘inefficient’ — often, in my experience, woefully so. And only some of that inefficiency can be defended in terms of academic freedoms; much of it is down to the way university culture has evolved, the expectations of academic staff, poor management (rather than enlightened administration), and so on — things that could be fixed without undermining the really important values embodied by the idea of a university. The advent of serious tuition fees in English universities will have the effect of highlighting some of the more egregious deficiencies — poor (or at best uneven) teaching quality, little pastoral care, archaic pedagogical methods, etc. But any attempt to remedy these problems is likely to be seen as interference with cherished academic freedoms, and resisted accordingly. Already, however, students are beginning to ask questions: why, for example, should they pay £9,000 a year for crowded lectures, ‘tutorial groups’ of 50 or more, zero pastoral care and — in some cases — lousy social facilities? Why should complaints about the crass incompetence of a particular lecturer be ignored by the Head of his department? (These are gripes I’ve heard from students recently, though not at my university.)

Universities engage in different activities, with different norms and timeframes. You have to ’ship’ teaching, at least the ‘low-level’ teaching that makes up most of the bums on seats. Advanced teaching and research should march to a different pace, and the last thing you should be doing is ‘shipping product’. But John’s comments are spot on.

 

Multiple births and close birthdates, and university costs

by reestheskin on 06/12/2017

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This is from the FT, pointing out that the means testing of parental contribution to students maintenance, has some perverse side effects.

The UK’s hidden one-child-per-family university policy. Supporting two children studying at university could cost much more than you think.

And even when parents do cough up the parental contribution, that doesn’t mean the full maintenance loan amount is enough. For a good chunk, it doesn’t cover basic costs. Students on courses with long hours who can’t secure a part-time job are in trouble, but most won’t hear about this until they get to university as the debate is so skewed towards focusing on the ‘debt’.

I am still shocked at how many of our medical students work part time. That may say as much as about me, as them.

Poetry in motion

by reestheskin on 05/12/2017

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Wikipedia has some (quoted) beautiful lines about the greatest fly half that I had the pleasure to watch on so many occasions at the old Arms Park.

[Barry] John ran in another dimension of time and space. His opponents ran into the glass walls which covered his escape routes from their bewildered clutches

Ed tech: For all of eternity

by reestheskin on 04/12/2017

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“The field of educational technology, largely ignorant of its own history, seems eternally condemned to repeat itself.”

Nature review of a book on the PLATO project. The internet that wasn’t

Skincancer909 and skin cancer prevention

by reestheskin on 30/11/2017

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I hae been updating skincancer909. I am way behind schedule, but at last sorting out some of the typos and creating some more videos. Here is one of the ‘in one minute’ efforts. Enjoy. It will be finished soon. Honest.

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Prevention in one minute from jonathan rees on Vimeo.

Compound interest, USS and all that

by reestheskin on 29/11/2017

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Take salary: as Mrs. Neal told us during her crash course, you’ll carry your whole life the compound price of an un-negotiated first salary.

From Frederic Filloux in the Monday Note. A great article which, whilst focussed on the topic of journalism schools, has bags of relevance to future and therefore present day medical schools. The professional schools have a lot in common.

 

Multiple births and close birthdates, and university costs

by reestheskin on 28/11/2017

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This is from the FT, pointing out that means testing of parental contribution to student maintenance, has some perverse side effects.

“The UK’s hidden one-child-per-family university policy. Supporting two children studying at university could cost much more than you think.

And even when parents do cough up the parental contribution, that doesn’t mean the full maintenance loan amount is enough. For a good chunk, it doesn’t cover basic costs. Students on courses with long hours who can’t secure a part-time job are in trouble, but most won’t hear about this until they get to university as the debate is so skewed towards focusing on the ‘debt’.”

I am still shocked by how many of our medical students work part time. That says as much about me, as them.

Ed tech: For all of eternity

by reestheskin on 27/11/2017

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“The field of educational technology, largely ignorant of its own history, seems eternally condemned to repeat itself.”

Nature review of a book on the PLATO project: The Internet that wasn’t.

Seeing things differently

by reestheskin on 24/11/2017

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This is from a review of Jaron Lanier’s new book, in Nature. I think these comments give a flavour of one arm of the pincer movement that will hit higher education over the next decade.

What struck me most was the originality of Lanier’s trajectory as a research pioneer. His technological trailblazing and vision have led to him sitting on the faculties and boards of big universities. But the book shows that a conventional academic career might have hindered him considerably. As he reveals with tales of his development of VR programming languages and the VPL experience, he carved out the freedom to follow his scientific curiosity, unlike many a postdoc or tenure-track faculty member. That is a useful insight at a time when technology research is thriving outside academia, as Google’s DeepMind and other technology companies lead the way in quantum computing, artificial intelligence, autonomous vehicles and, of course, VR.

Nature

Pockmarked people?

by reestheskin on 23/11/2017

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He is one of 10 case studies in Black Tudors, an enlightening and constantly surprising book about the men and women of African origin who found themselves on a cold island on the fringe of Europe amid a pale and pockmarked people.

Black Tudors by Miranda Kaufmann — a hidden history

You could not make this stuff up

by reestheskin on 22/11/2017

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“The NHS will have a workforce plan for the first time since 2000, England’s secretary of state for health has announced.”

BMJ

In a minute

by reestheskin on 21/11/2017

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I have been (very!) busy updating skincancer909, sorting out typos and more egregious sins, and adding some short ‘in this chapter’ videos. Here is one, ‘The Clinician’s approach’. More will follow.

 

The clinicians approach from jonathan rees on Vimeo.

Make mine a Vesper

by reestheskin on 20/11/2017

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The concept of continuity of care is important and with winter approaching rapidly in the UK, clinicians should lead the way in ensuring patients are looked after by the right specialist team, in the right place first time and avoid the ‘martini’ principle of hospital care – any time, any bed, anywhere. If we can reduce the number of boarded or outlying patients we will improve their care and also reduce overcrowding in the hospitals.

Link

 

Flexner: the flip side

by reestheskin on 17/11/2017

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Abraham Flexner is of course famous in clinical medicine, for his report and influence on medical schools in the USA (and indirectly, the rest of the world). But I did not know of this book. A message I would strongly recommend to those regulators and their ilk who are shorting the future with ‘reforms’ and ‘competency’.

 

No dwarf tossing here!

by reestheskin on 16/11/2017

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Economics is perfectly capable of incorporating questions of morality, says Mr Tirole. It simply imposes structure on debate where otherwise indignation would rule. It might make sense to ban some markets, like dwarf-tossing,

and before you get alarmed:

 [of dwarf-tossing] ….its existence diminishes the dignity of an entire group. But a market in organs or blood, for example, should not be rejected on the basis of instinctive moral repugnance alone. Policymakers should consider whether payment would raise the supply of donated blood or kidneys, improving or even saving lives. (It might not, if the motivation of money makes generous people afraid of looking greedy.) Whatever the answer, policymakers should make decisions from “behind the veil of ignorance”: without knowing whether any one person, including the policymakers themselves, would be a winner or loser from a particular policy, which society would they choose?

From a review of “Economics for the Common Good”, by Jean Tirol in the Economist [link]. I assume the ‘veil’ reference is from John Rawls, an approach that I always like, but worry that I am missing something deeper.

EMRs as polluters of the clinical workspace

by reestheskin on 15/11/2017

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I like computers (see previous post), but despair of them in the clinical context of keeping medical records. By contrast nobody sane doubts that computers are advantageous in other medical contexts: imaging, radiotherapy, or even using an insulin pump. We don’t have problems with the latter instances, because self-evidently computers work, and they are the result of a culture of improvement. Not so with electronic medical records, where a neutral observer might thing that the purpose is to save money in one budget at the expense of diminishing clinical care in another. The economists might talk about externalities, but essentially many electronic record keeping systems are a form of pollution of the clinical workspace.

The following quote caught my eye because, whilst in Scandinavia recently, a dermatologist from Denmark was expressing frustration with how bad their computer systems are; and how older physicians choose to ignore them by retiring early. I heard a similar tale from the US in the summer, from a dermatologist who takes a financial hit because he has not implemented electronic records. He says he can either manage patients or do IT (and yes, he is planning to get out early).

Electronic medical records (EMRs) have resulted in increased documentation burden, with physicians spending up to 2 hours on EMR-related tasks for every 1 patient-care hour. Although EMRs offer care delivery integration, they have decreased physician job satisfaction and increased physician burnout across multiple fields, including dermatology.

Here

I would add, that I have read that the average ER doc on a shift in the US presses his mouse 4000 times.

A long time ago, Richard Doll wrote an article pointing out that hospital record systems such as hospital activity analysis were perhaps useful to managers, but not much use for doctors or researchers. He was right, and I even published a paper saying similar things. My experience of electronic records in hospitals is that they are designed for the purpose of ‘management’ not clinical care. Contrary to what many say, these two activities have little in common, and share few goals. Our care system is not designed for care or caring, and our software is not designed for clinicians or patients. As for EMR, we are still waiting for our VisiCalc or Photoshop. If somebody  can pull it off, it would be worth  a Nobel.

Of spreadsheets and the end of the world

by reestheskin on 14/11/2017

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Today (Oct. 17) was International Spreadsheet Day, marking the day back in 1979 that VisiCalc first shipped for the Apple II. Creator Dan Bricklin devised the program originally to help him crunch numbers for an assignment at Harvard Business School. [Link]

I dislike spreadsheets, and think the world will end not in fire, but in one giant bloody spreadsheet (or as a result of one). I also think they are a great metaphor for what is often wrong in medicine: an Excel spreadsheet can calculate a PASI (pissing awful psoriasis index, in lay terms) but it cannot tell you when somebody has bad psoriasis. People get confused about the epistemology here.

But these comments are a little sour. I have never really had to use spreadsheets, instead preferring to use something like R for when I have need of matrices, or when I was really young, FORTRAN. And to be fair even then, I would (now) need to go via a spreadsheet / csv file to enter the data. And this ignores the fact that mostly spreadsheets are used as static tools to present multicoloured tables rather than do calculations. But spreadsheets were, and are, revolutionary. I knew of Dan Bricklin, their inventor, but not all of the following story about how he invented then because he needed them to carry out a set assignment at Harvard Business School

Bricklin knew all this, but he also knew that spreadsheets were needed for the exercise; he wanted an easier way to do them. It occurred to him: why not create the spreadsheets on a microcomputer? Why not design a program that would produce on a computer screen a green, glowing ledger, so that the calculations, as well as the final tabulations, would be visible to the person “crunching” the numbers?

Why not make an electronic spreadsheet, a word processor for figures?

Bricklin’s teachers at Harvard thought he was wasting his time: why would a manager want to do a spreadsheet on one of those “toy” computers? What were secretaries and accountants and the people down in DP for? But Bricklin could not be dissuaded. With a computer programmer friend from MIT named Bob Frankston, he set to work developing the first electronic spreadsheet program. It would be contained on a floppy disk and run on the then brand-new Apple personal computer. Bricklin and Frankson released VisiCalc (the name was derived from Visible Calculation) in late 1979.

There are some general points. Advances are often made by tool makers; and the best fillip for great software is a problem you personally need to solve (a point Paul Graham makes repeatedly). And of course, people who know better, will not think your efforts worthwhile. Little of this is true of hospital information systems.

Here

Communication breakdown

by reestheskin on 13/11/2017

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Nevertheless, recent reviews find little evidence that cancer patients benefit after clinicians are taught communication.9, 14-16 Although training can change clinicians’ communication, for instance by increasing open questions or empathic statements, effects on patients’ satisfaction, well-being or clinical outcomes have proved elusive. The reviews’ authors recommend improved research designs in a continued effort to show that training does help patients. However, there are concerns that expert guidance on communication is often unrealistic,17-21 and many clinicians and students remain sceptical of it.11, 20, 22-31 Moreover, social scientists have challenged assumptions on which communication education and guidance in cancer and across health care are based.32-34

Here And letters too here. Musical appreciation below (Page starts at 1’16”):

 

IPR matters

by reestheskin on 10/11/2017

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Allergan has been particularly aggressive in trying to skirt the IPR system. In September, it took the unprecedented step of transferring patents protecting its prescription eyedrop, Restasis, to the Saint Regis Mohawks. The tribe — which received a $13.5m fee and up to $15m in annual royalties — then claimed it had sovereign immunity from intellectual property challenges launched through IPR. 

Pharma industry faces hypocrisy charge over patents

As I fond of repeating, Martin Wolf of the FT argued that Pharma may soon be shown the same contempt that many now feel towards the Banks.

Screwing people as the social norm

by reestheskin on 09/11/2017

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“Whenever a company decides it’s ok to screw its suppliers, its customers, or its employees, it is only a matter of time until it gets around to screwing all 3 groups. That is because the idea that screwing people is ok becomes the corporate mindset.”

Comment by Howard on I, Cringely

Marriage

by reestheskin on 08/11/2017

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Marriage, however, proved to be a towering practical problem — Princeton, where Feynman was now pursuing a Ph.D., threatened to withdraw the fellowships funding his graduate studies if he were to wed, for the university considered the emotional and pragmatic responsibilities of marriage a grave threat to academic discipline. [Here]

The above is about Richard Feynman, but reminds me of a story closer to home, told to me by a consultant dermatologist (who I will call CS) and former academic. CS, then a senior registrar, on entering the departmental library, was pleased to see the elderly professor reaching for books on the top shelf. CS, with evident pride, told the professor that he had good news: he was engaged to be married. The professor replied: ‘Sorry to hear that CS, I had high hopes for you’.

Android epistemology

by reestheskin on 07/11/2017

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Geoff Norman has — as usual — a thoughtful editorial here. My clickbait version of it is:

As anyone who has engaged in the culture wars between qualitative and quantitative researchers will attest, the debate between the two groups are unlikely to resolve anytime soon. …….To put it bluntly, at the risk of offending some, constructivists are going around the world making sweeping generalizations about how you can’t make sweeping generalizations.

And I am glad he gives space to the Gigerenzer critique of some of the “heuristics and biases” school that has become so popular:

While the definitions of the heuristics in Kahneman’s hands appear unequivocal, Zwaan et al. (2017) showed that purported experts are completely unable to agree on the presence or absence of specific biases, and conversely are themselves strongly influenced by hindsight knowledge of the outcome

The foundations of research in medical education are not nearly as secure as many people wish to maintain. Plenty of physics envy to go around, and jobs to match.

Childhood lost?

by reestheskin on 06/11/2017

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Childhood, which is supposed to be the province of spontaneous play, has become highly administered, with parents and schools priming their human capital investments — children — for a merciless jobs market: “Between 1981 and 1997, elementary schoolers . . . recorded a whopping 146 per cent gain in time spent studying.”

FT link here