The Great Unwashed

by reestheskin on 07/08/2020

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Two letters in the LRB on the now settled status of student hygiene.

The first from Otto Saumarez Smith:

Keith Thomas reminisces about his introduction to regular baths when at Oxford in the 1950s (LRB, 16 July). The architectural historian Gavin Stamp once told me that when George Frederick Bodley came to build new student accommodation at King’s College, Cambridge in 1888, he asked the fellows whether he should include a bathroom, but was told not to be ridiculous: as terms were only eight weeks long the undergraduates could bathe after they got home.

The second from Richard J Evans, in conversation with a porter at an Oxford college:

‘What’s the main difference between the old days and now?’ I once asked him. ‘Well, sir,’ he replied, after some thought, ‘in the old days the young gentlemen used to change their shirt every day and take a bath once a week. Nowadays they take a bath every day and change their shirt once a week.’ It was clear from the shaking of his head that he did not regard this as an improvement.

I was delighted to get out of university halls, to the luxury of a toilet and bathroom only shared with five fellow students (and their occasional guests). The downsides included rodents, and ice on the inside of the bathroom windows. My memory is that the rent in 1977 was £1.85 per person for a salubrious🤣 central location on the Westgate road (opposite the Harley-Davidson shop, and a house of dubious repute). I was in hospital for a few weeks (as a patient) during this period and, at discharge, my father picked me up at the hospital, and we drove to the house so that I could collect some more clothes before heading back to my parents home;  he knew better than to come in.

Why Is College So Expensive?

by reestheskin on 06/08/2020

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From an article in the Atlantic a couple of years back (but the song remains the same).

“I used to joke that I could just take all my papers and statistical programs and globally replace hospitals with schools, doctors with teachers and patients with students,” says Dartmouth College’s Douglas Staiger, one of the few U.S. economists who studies both education and health care.

Both systems are more market driven than in just about any other country, which makes them more innovative—but also less coherent and more exploitive.

State cutbacks did not necessarily make colleges more efficient, which was the hope; they made colleges more entrepreneurial.

Why Is College in America So Expensive? – The Atlantic

You can even get a degree in this sort of behaviour, now: ouroboros studies.

Roll Over Beethoven it is not.

At the same time, Vox found ways of reaching groups of voters who were disgruntled by other aspects of modern life that the mainstream parties weren’t addressing. Think about how record companies put together new pop bands: they do market research, they pick the kinds of faces that match, and then they market the band by advertising it to the most favourable demographic. New political parties now operate like that: you can bundle together issues, repackage them, and then market them, using exactly the same kind of targeted messaging – based on exactly the same kind of market research – that you know has worked in other places. The ingredients of Vox were the leftover issues, the ones the others had ignored or underrated, such as opposition to Catalan and Basque separatism; opposition to same-sex marriage; opposition to feminism; opposition to immigration, especially Muslim immigration… It wasn’t an ideology on offer, it was an identity: carefully curated, packaged for easy consumption, queued up and ready to be “boosted” by a viral campaign.

Anne Applebaum in the Twilight of Democracy. Her description of Boris Johnson — her once fellow traveller — is well worth a read; I am glad the lawyers thought so too.

Queerer than I can imagine

by reestheskin on 05/08/2020

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“Although adult beetles were easily eaten by frogs, 90% of swallowed beetles were excreted within 6 h (0.1–6.0 h) after being eaten and, surprisingly, were still alive.” The aquatic beetle Regimbartia attenuata can swim right through a frog, found biologist Shinji Sugiura. ( Current Biology paper) (Watch a video of it happening in The New York Times, if that’s what you’re into.)

Nature Briefing reporting on a story in the New York Times

In the year of the plague 1666

by reestheskin on 03/08/2020

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I procured me a Triangular glass-Prisme, to try therewith the celebrated Phenomena of Colours. And in order thereto having darkened my chamber and made a small hole in my window-shuts, to let in a convenient quantity of the Suns light…but I surprised to see them in an oblong form; which, according to the received laws of Refraction, I expected should have been circular.

Well, Isaac Newton obviously had better functioning shutters than my bedroom blackout blinds. Most summer mornings (which at this latitude last much of the night…) I receive — without choice — lessons in physics 101. Here are some iPhone shots from this morning. The quote says a lot about science: note the terms, convenient quantity, surprised and expected.

No Mercy / No Malice / Killer whales

The killer whales (cash cows) of high-tuition prestige universities are international students. We claim we let them in for diversity. This is bullshit. International students are the least diverse cohort on earth. They are all rich kids who pay full tuition, get jobs at multinational corporations, and often return to the family business. At NYU, they constitute 27% of our student body and likely half our cash flow, as they are ineligible for financial aid. We have a pandemic coupled with an administration committed to the demonization of foreigners, including severely limiting the prospects of highly skilled grad students. This means the whales may just not show up this fall, leaving us with otters and penguins — an enormous fiscal hole.

Post Corona: Higher Ed, Part Deux | No Mercy / No Malice

Straight talking from Scott Galloway of Stern, NYU.

Late night thoughts of a clinical scientist.

by reestheskin on 30/07/2020

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More accurately, late night thoughts from 26 years ago. I have no written record of my Edinburgh inaugural, but my Newcastle inaugural given in 1994 was edited and published by Bruce Charlton in the Northern Review. As I continue to sift through the detritus of a lifetime of work, I have just come across it. I haven’t looked at it for over 20 years, and it is interesting to reread it and muse over some of the (for me) familiar themes. There is plenty to criticise. I am not certain all the metaphors should survive, and I fear some examples I quote from out with my field may not be as sound as I imply. But it is a product of its time, a time when there was some unity of purpose in being a clinical academic, when teaching, research and praxis were of a piece. No more. Feinstein was right. It is probably for the best, but I couldn’t see this at the time.

 

Late night thoughts of a clinical scientist

The practice of medicine is made up of two elements. The first is an ability to identify with the patient: a sense of a common humanity, of compassion. The second is intellectual, and is based on an ethic that states you must make a clear judgement of what is at stake before acting. That, without a trace of deception, you must know the result of your actions. In Leo Szilard’s words, you must “recognise the connections of things and the laws and conduct of men so that you may know what you are doing”.

This is the ethic of science. William Gifford, the 19th century mathematician, described scientific thought as “the guide of action”: “that the truth at which it arrives is not that which we can ideally contemplate without error, but that which we may act upon without fear”.

Late last year when I was starting to think what I wanted to say in my inaugural lecture, the BBC Late Show devoted a few programmes to science. One of these concerned itself with medical practice and the opportunities offered by advances in medical science. On the one side. Professor Lewis Wolpert, a developmental biologist, and Dr Markus Pembrey, a clinical geneticist, described how they went about their work. How, they asked, can you decide whether novel treatments are appropriate for a patient except by a judgement based on your assessment of the patient’s wishes, and imperfect knowledge. Science always comes with confidence limits attached.

On the opposing side were two academic ethicists, including the barrister and former Reith Lecturer Professor Ian Kennedy. You may remember it was Kennedy in his Reith lectures who quoting Ivan Illicit described medicine itself as the biggest threat to people’s health. The debate, or at least the lack of it. clearly showed that we haven’t moved on very far from when C P Snow (in the year I was born) gave his Two cultures lecture. What do I mean by two cultures? Is it that people are not aware of the facts of science or new techniques?… It was recently reported in the journal Science that over half the graduates of Harvard University were unable to explain why it is warmer in summer than winter. A third of the British population still believe that the sun goes round the earth.

But, in a really crucial way, this absence of cultural knowledge is not nearly so depressing as the failure to understand the activity rather the artefacts of science. Kennedy in a memorable phrase described knowledge as a ‘tyranny’1. It is as though he wanted us back with Galen and Aristotle, safe in our dogma, our knowledge fossilised and therefore ethically safe and neutered. There is, however, with any practical knowledge always a sense of uncertainly. When you lift your foot off the ground you never quite know where it is going to come down. And, as in Alice in Wonderland, “it takes all the running you can do to stay in the same place”.

It is this relationship, between practice and knowledge and how if affects my subject that I want to talk about. And in turn, I shall talk about clinical teaching and diagnosis, research and the treatment of skin disease.

 
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Politics as a class of dominant negative mutation

by reestheskin on 29/07/2020

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Today many scientists describe their research as apolitical, but Haldane knew that was impossible: ‘I began to realise that even if the professors leave politics alone, politics won’t leave the professors alone.’

From a review in the Economist of a biography of JBS Haldane by Samanth Subramanian.

Two things to add. Haldane’s paper A Defense of Beanbag Genetics is a personal favourite, but sticking with the genetics theme, I think of politics, and many politicians, as examples of dominant negative mutations.

Not Waiting to be an Actor

At the beginning of his career, an actor is a waiter who goes to auditions. Getting work makes him a successful actor, but he doesn’t only become an actor when he’s successful.

Paul Graham

Peter Green (1946-2020)

by reestheskin on 27/07/2020

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Most of the music I enjoy I came to via my brother (Al of Penglas in West Cork). There are a few exceptions: I discovered Ralph Towner and the whole ECM catalogue after an aside in an interview  with Larry Coryell; and Mahler, and morning music, from my time in Vienna.

I can remember one particular album that Alun bought as something special. It was a compilation and cost 19/11, and not surprisingly had a blue cover: The World of Blues Power. To my ear the music was incredibly varied, such that I couldn’t imagine how this was a coherent genre. Some tracks I disliked intensely whilst others were just magical. Amongst the latter were three tracks featuring John Mayall’s Bluesbreakers. On two, Eric Clapton was the lead: Steppin Out, which I later learned to play (badly), and All the Love, the guitar part of which — still to this day—  makes the hairs on the back of my neck stand up. If you listen 1’22” in you hear what digital amps and gear now refer to as the British Blues sound (or some such similar name). It is slowhand playing slowly. Magical. A giant beneficial  mutation in the history of the blues.

The third track, Greeny, was very different. It was John Mayall again, but this time with the late Peter Green who died just two days ago. The guitar was just so different, a delta of influences. BB King captures both the sound and Green:

He has the sweetest tone I ever heard; he was the only one who gave me the cold sweats.

On truth

by reestheskin on 26/07/2020

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Yes, a big word. From a review by Martin Wolf of Anne Applebaum’s Twilight of Democracy. Just pencil in your favourite organisation or person.

Her theme is not just this split. It is about the role of intellectuals in supporting the would-be despots. In this, she follows Julien Benda, author of a classic book, La trahison des clercs (1927). Benda’s target were the ideologues of his time, whom he accused, in Applebaum’s words, “of betraying the central task of the intellectual, the search for truth, in favor of particular political causes”.

How did people she knew come to support these new authoritarians? One answer, is “resentment, revenge and envy”. Replacing people of talent and principles with mediocrities who will do anything for success has never been difficult. Finding greedy people happy to join a corrupt new business elite is just as simple. She describes perceptively people who have done such things.

Alarm signals of our authoritarian age | Financial Times

Surplus collagen

His younger co-workers, with their zippy metabolisms and surplus collagen, started referring to him as “the elder.”

A New Luxury Retreat Caters to Elderly Workers in Tech (Ages 30 and Up) – The New York Times

The Cognitive load of everyday life

by reestheskin on 25/07/2020

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The Cognitive load of everyday life

I’m struggling. There is this continuous battle to counteract the exaggerations and misinformation that corporations spend so much time creating. Including universities, now. Those seeking to subvert the intention of regulators, have more money, more time, and abuse the externalities that society has allowed them to work within.

Poor Celine

The Economist heaps praise on Ireland’s ability to get its way:

Ireland has a good claim to be the world’s most diplomatically powerful country

We learn that Ireland beat off Canada to win a seat on the UN Security Council but that like Canada Ireland also has ‘a bigger, sometimes boorish, neighbour’.

Alongside more subtle overtures, the push for the Security Council seat [by Ireland] involved free tickets to Riverdance and a U2 gig. The best that Canada could muster was Celine Dion.

Charlemagne – How Ireland gets its way | Europe | The Economist

Crime pays but leave it off the CV

by reestheskin on 23/07/2020

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Whenever I have looked at the CVs of many young doctors or medical students I have often felt saddened at what I take to be the hurdles than many of them have had to jump through to get into medical school. I don’t mean the exams — although there is lots of empty signalling there too — but the enforced attempts to demonstrate you are a caring or committed to the NHS/ charity sector person. I had none of that; nor do I believe it counts for much when you actually become a doctor1. I think it enforces a certain conformity and limits the social breadth of intake to medical school.

However, I did do things   work outside school before going to university,  working in a variety of jobs from the age of 14 upwards: a greengrocer’s shop on Saturdays, a chip shop (4-11pm on Sundays), a pub (living in for a while 😃), a few weeks on a pig-farm (awful) and my favourite, working at a couple of petrol stations (7am-10pm). These jobs were a great introduction to the black economy and how wonderfully inventive humanity — criminal humanity— can be. Naturally, I  was not tempted😇. Those in the know would even tell you about other types of fraud in different industries, and even that people actually got awarded PhDs by studying and documenting the sociology of these structures (Is that why you are going to uni, I was once asked).

On the theme of that newest of crime genres — cybercrime — there is a wonderful podcast reminding you that if much capitalism is criminal, there is criminal and there is criminal. But many of the iconic structures of modern capitalism — specialisation, outsourcing and the importance of the boundaries between firm and non-firm — are there. Well worth a listen.

 

  1. See below  for a long aside on this point.

I think there is a danger in exaggerating the role of caring and compassion in medicine. I am not saying you do not need them, but rather that I think they are less important that the technical (or professional) skills that are essential for modern medical practice. I want to be treated by people who know how to assess a situation and who can judge with cold reason the results of administering or withholding an intervention. If doctors were once labelled priests with stethoscopes, I want less of the priest bit. Where I think there are faults is in the idea that you can contribute most to humanity by ‘just caring’. The Economist awhile back reported on an initiative from the Centre for Effective Altruism in Oxford. The project labelled the 80,000 hours initiative advises people on which careers they should choose in order to maximise their impact on the world. Impact should be judged not on how much a particular profession does, but on how much a person can do as an individual. Here is a quote relating to medicine:

Medicine is another obvious profession for do-gooders. It is not one, however, on which 80,000 Hours is very keen. Rich countries have plenty of doctors, and even the best clinicians can see only one patient at a time. So the impact that a single doctor will have is minimal. Gregory Lewis, a public-health researcher, estimates that adding an additional doctor to America’s labour supply would yield health benefits equivalent to only around four lives saved.

The typical medical student, however, should expect to save closer to no lives at all. Entrance to medical school is competitive. So a student who is accepted would not increase a given country’s total stock of doctors. Instead, she would merely be taking the place of someone who is slightly less qualified. Doctors, though, do make good money, especially in America. A plastic surgeon who donates half of her earnings to charity will probably have much bigger social impact on the margin than an emergency-room doctor who donates none.

Yes, the slightly less qualified  makes me nervous.

Higher education: things have, and will get worse

The next five years will be worse for English universities than the past five years have been. And the five after that could be worse still.

 Alison Wolf quoted  in THE and on this blog in 2015. Still on course.  [direct link to this aside]

How to be remembered

by reestheskin on 20/07/2020

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John le Carré is one of my favourite authors. There is a wonderful sense of rebellion, coupled with both dismay and hope in his fiction (and non-fiction) writings. Here are a few lines from his speech in Stockholm on 30 January 2020 when he received the Olaf Palme award.

How would Palme wish to be remembered? Well, by this for a start. For his life, not his death. For his humanism, courage, and the breadth and completeness of his humanist vision. As the voice of truth in a world hell-bent on distorting it. By the inspiring, inventive enterprises undertaken yearly by young people in his name.

 

Is there anything I would like to add to his epitaph? A line by May Sarton that he would have enjoyed: One must think like a hero to behave like a merely decent human being.

 

And how would I like to be remembered? As the man who won the 2019 Olof Palme prize will do me just fine.

John le Carré on Brexit: ‘It’s breaking my heart’ | Books | The Guardian

It is less easy to forgive ourselves

by reestheskin on 17/07/2020

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Henry Miller died a few months before I started medical school in Newcastle in 1976. At the time of his death he was VC of the university having been Dean of Medicine and Professor of Neurology. By today’s standards he was a larger than life figure. I like reading what he said about medical education, although with hindsight I think he was wrong about many if not most things. But there was a freshness and sense of spirited independence of mind in his writing that we not longer see in those who run our universities (with some notable exceptions such as Louise Richardson). In the time of COVID we should remember the costs of conformity and patronage.

It would be naive to express surprise at the equanimity with which successive governments have regarded the deteriorating hospital service, since it is in the nature of governments to ignore inconvenient situations until they become scandalous enough to excite powerful public pressure. Nor, perhaps, should one expect patients to be more demanding: their uncomplaining stoicism springs from ignorance and fear rather than fortitude; they are mostly grateful for what they receive and do not know how far it falls short of what is possible. It is less easy to forgive ourselves…..Indeed election as president of a college, a vice chancellor, or a member of the University Grants committee usually spells an inevitable preoccupation with the politically practicable, and insidious identification with central authority, and a change of role from informed critic to uncomfortable apologist.

Originally published in the Lancet, 1966,2, 647-54. (This version from ‘Remembering Henry’, edited by Stephen Lock and Heather Windle).

No just in time here

by reestheskin on 16/07/2020

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“I hope the lesson will really be that we can’t afford as a society to create the fire brigade once the house is on fire. We need that fire brigade ready all the time hoping that it never has to be deployed.”

Peter Piot 1

No just in time here. It’s in the statistical tails that dragons lurk and reputations are shattered. Chimes with a quote from Stewart Brand that I posted a short while back.

Education is intellectual infrastructure. So is science. They have very high yield, but delayed payback. Hasty societies that can’t span those delays will lose out over time to societies that can. On the other hand, cultures too hidebound to allow education to advance at infrastructural pace also lose out.

  1. (Virologist Peter Piot,  co-discoverer of  Ebola and who worked on treating and preventing HIV, talking about getting COVID-19 on his institution’s podcast. (London School of Hygiene & Tropical Medicine podcast )

The Dream is Over*

by reestheskin on 12/07/2020

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Britain’s universities increasingly look like the late Soviet economy, running down their social capital behind a glitzy screen of Potemkin imagery and glasnost-era statistics. Bits of it are locking up, alternately insulted and goaded by the gap between central government diktat and the reality on the ground. The result will be the same: a very long slide into mediocrity and mendacity.

Britain’s universities are on the verge of unravelling | Universities | The Guardian.

I don’t have any wise prescriptions to dispense. Stephen Downes gets it right when he says “educational providers will one day face an overnight crisis that was 20 years in the making”. But a clue is surely in his choice of words: ‘educational providers’.

* The Dream Is Over: The Crisis of Clark Kerr’s California Idea of Higher Education. Simon Marginson

A classics business model to die for

by reestheskin on 08/07/2020

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He needed glory and he needed cash. The quickest route to glory was beating up barbarians; stealing their wealth and selling their bodies into slavery got him the cash.

The above is from a stomach-penetrating piece on the life of Julius Caesar (and not Boris Johnson). I do not know whether it is an effect of age, but perhaps the more one is aware of dying —with or without dignity— the more I find such descriptions, such as the one below, are hard to let go of when you close you eyes with the hope that they might open again.

Unlike most ancient swords, the legionary shortsword, or gladius Hispaniensis, was designed for stabbing, not slashing. While longswords and sabres create horrific, often deadly wounds, even an inch of steel can deliver a lethal puncture – especially given the limits of ancient medicine. Yet as combat instructors know, stabbing another human being at close quarters is much harder than cutting them: we have a psychological block against penetrating others’ bodies in that way, a visceral aversion that must be overcome by stern, psychologically brutalising discipline. Roman legionaries were taught to hurl their spears at the enemy line, then advance with shields held close, plunging their gladii in and out of the men arrayed against them. Units that could stomach this gruelling work against heavily armoured fellow citizens were simply killing machines against the less disciplined and lightly armoured Gauls [emphasis added]

Michael Kulikowski · A Very Bad Man: Julius Caesar, Génocidaire · London Review of Books | 18 June 2020

Meliorism certified

In 1947, Hobsbawm had excused his acceptance of the Birkbeck post by explaining that teaching preparations never took him more than two hours a week, and while he was an inspiring classroom presence, he always adroitly ducked administrative jobs. Evans tells a story of Hobsbawm backing the young Roderick Floud for a professorial chair mostly, Floud later realised, so he wouldn’t have to be head of department himself. It will be hard for today’s young academics, groaning under research assessments and short-term contracts at below the living wage, to read these passages.

Susan Pedersen reviews ‘Eric Hobsbawm’ by Richard J. Evans · LRB 18 April 2019

Mathiness, scientism and give me the money.

by reestheskin on 06/07/2020

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Two nice quotes from Paul Romer about his paper Mathiness in the Theory of Economic Growth

The alternative to science is academic politics, where persistent disagreement is encouraged as a way to create distinctive sub-group identities.

The usual way to protect a scientific discussion from the factionalism of academic politics is to exclude people who opt out of the norms of science. The challenge lies in knowing how to identify them.

I can agree go along with both, but it is in the details that the daemons feast. It appears to me that the ‘norms of science’ argument is itself problematic, reminding me of those silly things you learn at school about the scientific method 1. The historical origin of the concept of the scientific method owed more to attempts to brand certain activities in the eyes of those who were not practicing scientists 2. As a rough approximation, the people who talk about the scientific method tend not to do science. Of course, in more recent times, the use of the term ‘science’ itself has been a flag for obtaining funding, status or approval. Dermatology is now dermatological sciences ; pharmacology is now pharmacological sciences. Even more absurd, in the medical literature I see the term delivery science (and I don’t mean Amazon), or reproducibility science. The demarcation of science from non-science is a hard philosophical problem going back way before Popper; I will not solve it. The danger is that we might end up exiling all those meaningful areas of human rationality that we once — rightly — considered outwith science, but still valued. There is indeed a subject that we might reasonably call medical science(s). It is just not synonymous with the principles and practice of medicine. It is also why political economy is a more useful subject than economics (or worse still, economic sciences).

  1. I guess this depends on how you interpret the ‘they’ in Romer’s second quote. It is the people or the norms that are the problem? I tend to think of both.
  2. There is an excellent recent article in the New York Review of Books that touches upon this issue Just Use Your Thinking Pump! by Jessica Riskin.

The secret of how to get rich

Angus Deaton: Many people have said that there are two ways of getting rich: One way is by making things, and the other is by taking things. And one of the ways of taking things is to make the government give you special favors. Those special favors don’t create anything, but they can make you rich, at the expense of everybody else.

What’s Wrong With America?: “The Despair Is Smoldering in Society” – DER SPIEGEL

Advice for graduating doctors…

by reestheskin on 03/07/2020

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I have forgotten who asked me to write the following. I think it was from a couple of years ago and was meant for graduating medics here in Edinburgh. (I am still sifting through the detritus of academic droppings)

As Rudolf Virchow was reported to say: sometimes the young are more right than the old. So, beware. This is my — and not his — triad.

First, when you do not know, ask for help. And sometimes ask for help when you do know (for how else would you check the circumference of your competence?).

Second, much as though science and technology changes, the organisation of care will change faster. Think on this in any quiet moments you have, for it may be the biggest influence on your career — for good and bad (sadly).

Third, look around you and do not be afraid to stray. The future is always on the periphery along a rocky path to nowhere in particular.

My organ is bigger than your organ

by reestheskin on 02/07/2020

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One thing that sticks with me from medical school onwards (both as student and faculty) is the partisan nature of specialties. Most of this is harmless fun: my organ (skin, liver, kidney etc) is bigger than your organ; the brain is more complicated than any other organ and therefore neurologists must be smarter than everybody else (although curiously this doesn’t seem to stretch to neurosurgeons — at least when neurologists are talking). Let’s call it organ imperialism. The humour of little boys judging their vitality by how high they can p*** up the wall. There are more vital things to get angry about.

There are however some darker sides to this professional ethnicity. Doctors indulging in advocacy for particular patient groups can often seem like doctors wishing their own unit or disease of interest receives more resources. A salient example in dermatology is the way that NHS resources for cancer (or children) frequently trump other demands. It is easier to lobby successfully for skin cancer1 than acne or hair loss in the absence of any meaningful attempt to weigh patient suffering (or just to assume it is self-evident)2. The contrast between paediatrics and geriatrics is often informative about underlying values.

One area that does worry me more is the encroachment of politics on medical education. I am thinking in particular on a priori claims about the superiority of certain models of care, or the attempts to subvert student choice of career in the name of what the ‘NHS needs’.

Undergraduate medical education should be both scholarly and intellectually neutral as to how health care is organised. We should of course introduce students to the various systems, and encourage them to criticise them. We should teach them to be analytical, and to understand the various reasons why people have chosen different systems (or how their views are manipulated). But we should be neutral in the sense that judgments need to be based on rational argument rather than slogans, and that students must be able to argue based on evidence.

I would say the same about career choice. Our primary duty in a university is to students. If a university were to demand that their graduates in computing were only to work for a British computing company and confine themselves to topics of ‘national importance’, or that its graduates in economics were only to work for the public rather than the public sector, they would no longer be taken seriously as an educational institution. And rightly so. Medicine should be no different.

  1. And note my clinical interests were focussed on skin cancer.
  2. I am of course neatly sidestepping the existential difficulty of comparing oranges and apples here. Do not tell me that QUALYs are the answer: it is easy to construct a spreadsheet that tells you the area of skin involvement in a patient with psoriasis, but do not confuse this with the human judgment of whether somebody has bad psoriasis.

The search space is always bigger…

by reestheskin on 02/07/2020

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Defining the appropriate probability space is often a non-trivial bit of statistics. It is often where you have to end up leaving statistics and formal reasoning behind. The following quote puts this in a more bracing manner.

There are no lobby groups for companies that do not exist.

The same goes for research and so much of what makes the future captivating.

The man from Cyberspace on the FQ

by reestheskin on 01/07/2020

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Some quotes from William Gibson in an interview with the FT

“we’re looking at the collapse of the only liveable planetary ecosystem we know of anywhere”.

He fears that the world’s FQ — or F***edness Quotient, as he calls it — is rising to a worrying degree.

And this one gets you

If I could learn one thing about the future,” he says, “I would want to know what they think of us because that would tell me everything I’d want to know about them.”

William Gibson — the prophet of cyberspace talks AI and climate collapse | Financial Times

Peter Piot in the Guardian

As with HIV, “an epidemic reveals the fault lines in society. The big one this epidemic has revealed is how we treat the elderly. We often park them in pre-mortuary type institutions and give a bit of money and hope it is OK”.

Make masks compulsory in public in UK, says virus expert | Coronavirus outbreak | The Guardian

When the tide goes out you see who is not wearing bathing costumes…

On the Origin of Species

by reestheskin on 30/06/2020

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Once there was General Practice, medicine in the image of the late and great Julian Tudor-Hart. Then there was Primary Care. The following article from Pulse made me sit up and wonder whether we have got it right.

Under the five-year contract announced last year, networks were to receive 70% of the funding to employ a pharmacist, a paramedic, a physiotherapist and a physician associate, and 100% of the funding for a hiring social prescriber, by 2023/24… Six more roles will now be added to the scheme from April  ‘at the request of PCN clinical directors’ – pharmacy technicians, care co-ordinators, health coaches, dietitians, podiatrists and occupational therapists…PCNs can choose to recruit from the expanded list to ‘make up the workforce they need’…The document added that mental health professionals, including Improving Access to Psychological Therapy (IAPT) therapists, will be added from April 2021 following current pilots…NHS England will also explore the feasibility of adding advanced nurse practitioners (ANPs) to the scheme [emphasis added].

PCNs to get 100% funding for all extra clinical staff as further roles are added | News Article | Pulse Today

Adam Smith among others pointed out the advantages of specialisation. We owe virtually all of the modern capitalist world to the power of this insight. But we also know that there are opposing forces — and not just those of the Luddites. Just think back to Ronald Coase and the Theory of the Firm. Why do companies not outsource everything? Why are there companies at all? Simply because under some circumstances transaction costs and formalisation of roles and contracts limit outsourcing 1. Contra the English approach is that of the Buurtzorg (links here, here and here) in the Netherlands where it is explicit that many of the tasks undertaken by highly skilled staff do not require high level skills. But — so the argument goes — the approach is more successful, robust and rewarding for both patients and staff. This is closer to the Tudor-Hart model. It really does depend on what sort of widgets you are dealing with, and whether fragmentation of activity improves outcomes, or merely diminishes costs in situations where outcomes are hard to define in an Excel spreadsheet.

  1. I realise I am speaking more metaphorically here than literally in terms of Coase’s work. My argument is about transaction costs in domains where much knowledge is not explicit or capable of easy formalisation, and where there is in one sense path dependency between patient and clinician.