Alickadoo

Well, a new word for me. Nice turn of phrase from Alun Wyn Jones about the decision to allow the opposition to decide on whether the roof is open or closed at Cardiff Arms Park, Millennium Stadium, Principality stadium.

“I don’t know,” he said. “That’s for the alickadoos, isn’t it? I don’t wear a shirt and tie long enough to make those decisions.”

Definition here

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Voting with the epidermis

Skin gets mentions (of course), but rarely do I see the ‘epidermis’ feature outwith the professional literature. But here — with the late Christopher Hitchens’ phrase — it does.

Identity politics can bring a more thoroughgoing fragmentation. In a country as diverse as the US, the number of ethnic groups — to take just that form of identity — will always exceed the number of social classes. To vote, as Christopher Hitchens once put it, “with the epidermis”, is to invite an endless subdivision of the electorate. And this does not even reckon with the criss-crossing variables of sex, sexual preference, religion and language.

Time for America to embrace the class struggle | Financial Times

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Why Is Medicine So Expensive?

Not often I spot typos in the New York Review of Books, but here is one that matters. The article dealt with the price of prescription drugs, and there are of course plenty of villains to go around: crony capitalists; advertising spending being larger than research spending —because it works!; and sloppy thinking with regard to IPR and patents. The article on paper read:

In late October, however, just before the congressional elections, Azar declared to reporters that high prices constituted “the greatest possible barrier to patent access.” Democratic strategists gave prescription drug prices high priority in congressional campaigns. Yet leaders in both parties understood that curbing prices would be no easy task. The pharmaceutical industry, which has long deployed one of the most powerful lobbies in Washington, was increasing its representation in the capital.

Yes, should have read patient not patent, although no doubt pharma might not have agreed.

Why Is Medicine So Expensive? | by Daniel J. Kevles | The New York Review of Books

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Lambs to the slaughter.

by reestheskin on 13/03/2019

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“It’s not that easy to make money out of emptying anal glands.”

Interesting article in the Economist on what is happening to vet practice in the UK. The march of the corporates and private equity firms buying up vet practices from vets who want to get out (recognise the cry of the professional?). The plans are “rationalisation”, and then resale at a higher multiple of income in a few years time (well, to be correct, EBITDA which is earnings before interest, taxes, depreciation and amortization — Wikipedia has more on it here). This is essentially capital doing what capital always does in a world driven by financialisation. The caveat is that for this Ponzi scheme speculation to work, there has to be an end buyer. The Economist, as ever fills in any gaps in logic with the usual magic variables:

As private-equity firms support the consolidation of smaller vet practices, the latter’s productivity should improve. Bigger firms can provide better salaries and more support to vets.

Well, that’s all right then — you just insert the bullshit variable. We are told:

Partly this is because young vets have high student debts; many drop out of the profession because the pay is not good enough. They are also demoralised; suicide rates among vets in America are at least twice the national average, and in Britain, almost four times.

The problem is that the money has to come from somewhere: the animal owners; or the vets (as in salaries); and also accommodate the capitalists’ profit. Downward pressures all round I guess — and wait and see what happens to productivity when you are an employee rather than running your own business. I doubt animal ownership is going to get cheaper.

The Susskinds have written elsewhere on the ‘Future of the Professions” but everywhere I look — dentistry, law, medicine — you see some common themes (no sunlit uplands). Lambs to the slaughter.

Late night thoughts #2

by reestheskin on 12/03/2019

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Late night thoughts on medical education #2: Apprenticeship

We have a very clear idea of how apprenticeship has worked over the last nine hundred years or so within Europe. The core ideas are of course much older, and the geography wider. But we have written records of the creation of the various social structures that led to the rapid changes in society that led in turn via the Renaissance to the Enlightenment and modern capitalism. We can trace so many of the norms that have guided my professional life: Royal Colleges, corporations, guilds, “masters and apprentices”, universities, certification and the granting of monopoly, and ‘professionalism’, to name but a few.

Apprenticeship is a powerful pedagogical model, but one that can only take place when a number of conditions are met. In medicine the ‘apprentice’ model is widely discussed, assumed, and contrasted with the ‘bums on seats’ lecture, the latter, the now signature pedagogy of the modern ‘massified’ university. It is also used to justify the high costs of training of education in medicine and some craft university courses.

At the level of higher professional training in medicine (or in the training of research academics) apprenticeship still can work well. There is an asymmetry between master and pupil (the master does know best, but cannot always justify why he knows best); long term interaction between both parties is required; and, at its best the pupils will model their behaviours on the master. Apprenticeship is not passive — it is not ‘shadowing’ (although a period of shadowing may be required); it will require the pupil to undertake tasks that can be observed and critiqued — you cannot learn complicated tasks based on passive observation. Chimps are highly intelligent, and yet learning to crack nuts using stones takes years and years, not because the young chimps do not watch their mothers, but because the mothers never watch (and hence correct) the young chimps. This requirement is not just required for motor tasks but for any complicated set of ‘thinking’ procedures that require accuracy and fluency. In medicine, surgeons are ahead of physicians on this, and have been for a long time.

In medieval times, becoming a master meant more than being a ‘journeyman’ — the level of professional expertise was greater, and it was recognised that teaching required another level of competence, and breadth. The master is not one step ahead on the way to perfection, but several. We prefer those teaching ‘A’ level physics, to have more than an ‘A’ level in physics themselves. And whatever domain expertise a master possesses, we know that experience of the problems or difficulties learners face, is important.

Still, in comparison with say school teaching the demands on the master (with regard to being a ‘professional’ educator) are modest. They know the job — they do not need to check out the syllabus — as they are effectively training people to do the same job they do day-to-day. They probably also have little need of theory and, in a sensible system, their reputation may be accurate.

In higher professional training in medicine, apprenticeship is still possible — it is just that it is harder than it once was (as to why, that is for another day). Similarly, at one time higher education was in large part viewed as a type of apprenticeship. Students were not staff, but they were not treated as schoolchildren, rather they were —at best— viewed as co-producers of knowledge within a university. If you were studying physics, the goal was to get you to approach the world like a physicist might. This may persist in a few institutions for a minority of students, but it is not the norm anymore.

In undergraduate medicine apprenticeship died a long time ago, although its previous health may well have been exaggerated. There is little long term personal interaction, with students passed around from one attachment to another, with many of the students feeling unwanted (‘burden of teaching’, ‘teaching load‘ etc). Staff and students can walk past each other in the street, none the wiser. Apprentices are — by definition — useful. It is this utility that underpinned the business model that formalised training and acceptance or rejection into the guild. But sadly — through no fault of their own – medical students are rarely useful. If they were useful they would be paid: they are not. Historically, students might have got paid to cover house officer absences (I did), but that world no longer exists. Nor are we able to return to it.

Whereas the master has an implicit model of the goals of training, that is no longer the case in undergraduate education, in which literally 500 or individuals are engaged in educating students for roles that they individually have little knowledge of. Instead of personal interaction, over a long time period, based on a common world view, medical schools create complicated management systems to process students, with the predictable lack of buy-in from those who are doing the educating.

There is a deeper point here. Much though a lot of UK postgraduate medical training is poor, it is possible to improve it within a framework that is known to work. Many doctors know how to do it (although the same cannot be said of the NHS). Undergraduate medical education is in a different place (like much of university education). At graduation, you step form one world into another, but just as with caterpillars and butterflies, the structures and environment we need to create are very different.

‘Joy’

Not the word I usually associate with student descriptions of their emotional state on being taught (except after the exam). Sadly. But the word featured in a teaching management meeting today. Made me smile.

Contrast this with the quote from a book on reforming engineering education, “A Whole New Engineer

Go into the bathrooms at the Massachusetts Institute ofTechnology (MIT) and you will see an acronym scrawled on the walls of the stalls: IHTFP. It means “I Hate This F** king Place.” (IHTFP is also found in the service academies and other elite engineering programs.) Whether this remains the true sentiment of MIT students today or merely a tradition handed down from generation to generation isn’t clear….

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I’m not staying long.

by reestheskin on 06/03/2019

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The parallels between being a school teacher and being a doctor interest me. It is difficult to think of any job more important and potentially more rewarding than teaching schoolchildren. But in the UK (and many others countries) teachers are  — with good reason —  deeply unhappy. Much, if not most of the dissatisfaction reflects politics, the New Public Management dogmas, and the resulting deprofessionalisation of teaching and teachers. Teaching in many UK schools is hard in a way few appreciate. If you doubt me check out Lucy Kellaway’s articles in the FT, where she has documented the stories of a group of people who went into teaching late in life, after very successful  careers in other domains. The graph below tells a story. I wonder if we might imagine similar trends in medicine.

 

Late night thoughts #1

by reestheskin on 05/03/2019

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Late night thoughts on medical education #1: we have no doctors

Today’s (Scottish) Daily Telegraph ran with a story about the shortage of paediatricians in Scotland. The Herald had a similar story, too. It is not just paediatrics that has major shortages. The same can be said about dermatology, radiology and a host of other areas of medicine. And that is not to mention GP land, which normally seems to attract most ‘government’ attention.

I find none of this surprising. The NHS has long been in subsistence mode, eating the seed corn (or to use that other phrase, ‘eating its young’), spending its moral and cultural capital at an alarming rate. Management is notable by its absence, whereas the administrators think they are ‘managers’, in part, because they can’t administrate and stay sane. By lack of management I meant those functions of management we see in most corporations or freestanding institutions. Changes in demography have not happened suddenly; the relation between age and health care provision, has been well known for a century or more; the impact of family structure and geography on care provision of elderly relatives evident since the early 1960s; changes in work force have been growing  for at least 40 years; and UK medicine has a long history of ignoring why people wish to leave either the UK (or want to leave the NHS). The attempt to run health care as a Taylor-like post-industrial service industry using staff who value their autonomy and professionalism, may not end well for doctors — or patients.

All the above, management should have been grappling with over the last quarter century: instead they have been AWOL. Meanwhile, politicians engage in speculative future-selling, where electoral vapourware is often a vehicle for the maintenance of political power. Given the state of UK politics (as in the BxxxxT word), it seems reasonable not to give politicians the benefit of the doubt any more. As individuals, no doubt, most of them mean well, and love their kids etc, but the system they have helped co-create, cannot command respect (that is now electorally obvious).

There are however some aspects of this that bear on what keeps me awake at night: how we educate — and to a lesser extent—how we train doctors.

  • The UK has not been self-sufficient in physicians since the birth of the NHS, rather choosing to import staff from the rest of the world. Despite this, doctor numbers are low in comparison with many other advanced economies. More dermatologists in the city of Vienna than in the UK……
  • Manpower estimates AFAIK, seem to reflect realpolitik rather than be based on bottom up data. Whatever is estimated is decided by the ‘realistic medicine’ availability of cash. Our politicians and the commissars of the medical establishment do not dissect animals in order to learn how the world works, they sacrifice them to the gods of political power, hoping some of the blood runs off on them.
  • The idea that you can plan on the basis that ‘x’ is the number of doctors you need in 10, 20, or40 years seems foolish. Hayek was not wrong about everything, even if Uncle Joe didn’t read him. Dead reckoning usually loses out to a good GPS system.
  • Most importantly of all, you must overproduce doctors. There are various ways you can think about this, but the current system of taking a bunch of 18 year olds into medical school and assuming that attrition will be low, will breed complacency. You cannot build any organisation that is worth working for when the ratio of applicants to vacant posts is less than one. And to miraculously imagine you can get the figure right over a score of years, is well….(and no, the running mean isn’t the right figure, here).
  • Medical education is claimed to be expensive and rate limiting (a Mr Hunt line, I think). There are various comments to make. First, the figures are inflated for political effect and possibly for accounting reasons. Claims that it costs £x to produce a consultant write off all ‘work’ the individual has done on the way to that position. By contrast, the NHS subverts market rates for many jobs done by ‘juniors’. And, as for undergraduate medical education, we know most of the money is an accounting sleight of hand. If you ask could we do it better, for less money, I will tell you for free.
  • The comments in the last point not withstanding, it must be an immediate goal to reduce the cost of medical education; and to think how the workforce of non-physicians can piggyback on what we know about training doctors. These conversations were alive half a century ago, and we have made little progress. The key issue is straightforward enough: without national accreditation, these posts will not encourage candidates to undergo training — you don’t need to read Gary Becker to get this, just talk to those who leave nursing — there are enough of them)
  • Even with more fluidity within professional careers, you need to allow for sideways movement and retraining of many middle aged doctors. You need to encourage staff, and move our focus from competencies(ugh!) to skills.
  • Without funnelling a lot more students into medicine as a career, little of what I have said above will make much difference. There are ways, but that is for another day.

Nothing new under the needle

After needles and morphine were deployed in the American civil war, as many as 100,000 veterans were left addicted. In 1895 scientists at Bayer, a German pharmaceutical firm, began selling a strong morphine compound called diamorphine. To market it, they called it “heroin” from the German word meaning heroic.

Article in the Economist on oxycodone dealing with — well not medicine — but business

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Freiheit und Einsamkeit

by reestheskin on 01/03/2019

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Well, words from the past, to remeasure the future. I am on (a sort of) sabbatical for six months. There is a project, about which I will say more later. My writings here will change, too.

De Selby’s numerical calculations

My experience of Irish government state employees at the ‘border’ is that they aim to be the antithesis of ‘hostile’. It is not a bad USP. Passing through Dublin or Cork is an enjoyable experience: “Welcome home Jonathan’, is not the most formal salute; or, in the case of my wife, “Lisa — from Mulfulira—I remember you”. But this aside in the Economist, brings a little of the Flann O’Brien to the party.

In the 1970s, when contraceptives were still banned in the Irish republic, a family-planning campaigner went south with 40,000 condoms in his station wagon; his insistence that they were all “for personal use” was met with good-humoured banter by an Irish police patrol.

The Border: The Legacy of a Century of Anglo-Irish Politics. By Diarmaid Ferriter. (reviewed in the economist)

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The learned professions

by reestheskin on 19/02/2019

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Quoted in Carel Stolker, ‘Rethinking the Law School’ 

According to a British survey among first‐year law students, the word that best reflects the students’ general attitude is ‘disengaged’. This disengagement is caused particularly by the lack of human connection in almost every educational practice, from teaching methods to our formal assessments. There is extraordinarily little formal human interaction in our first year.

This is a business model. Just not one you would want to emulate. At least Stolker’s home institution, Leiden, has an excuse.

You have to see this stuff…

by reestheskin on 13/02/2019

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This is from an article in the THE. Catherine Heymans is a physicist at the University of Edinburgh, who works on “dark energy”. She is planning to leave the UK to work in Germany (yes, Brexit). But what caught my eye was this quote describing one of those lightbulb moments (pun intended)

QuestionAs a physics undergraduate, how did you feel when the theory of dark energy first emerged?

Heymans: ‘It was 9am, and I was sat in a lecture theatre waiting for our lecturer to turn up – he was late. Eventually he ran into the room and said: “We’re not going to be studying high-energy astrophysics today, because the most amazing paper has just been published – you have to see this stuff.” It was new data that showed that the expansion of the universe was getting faster and faster, which could only be explained by extra, unseen “dark energy” in the universe.

It is an interesting test for whether you believe in the ‘research led teaching’ trope. Or is it: will this be in the exam?

Noting that 1,500 people had travelled to Davos by private jet to hear David Attenborough talk about climate change, he said he was bewildered that no one was talking about raising taxes on the rich.

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Scale matters

by reestheskin on 12/02/2019

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No, not that sort of (dermatological scale). Adam Tooze quoted in FT Alphachat (or another link).

In three years China used more cement that the USA in the whole of the 20th century.

Imagine.. well I am not the only one

by reestheskin on 31/01/2019

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And when they say you are a dreamer, a fool, and deluded, I will use a nice inversion by Lincoln Allison:

Of course, you’re assuming that none of this will ever happen. But you assumed that Brexit and Trump would never happen, didn’t you? 

(Smashing things is however easier than building things).

 

Econ101

by reestheskin on 30/01/2019

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Seen in George Square. I get the Econ101 bit, the 1984 reference, but… And no, I can’t manage crosswords either — although I shared a flat with somebody who, as a student, refused to leave his bed until he had completed the Telegraph crossword. There were studies, and then those other studies.

Skin centre

by reestheskin on 30/01/2019

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Not that sort of….

Deep problems

by reestheskin on 23/01/2019

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News Feature: What are the limits of deep learning? | PNAS

 In addition to its vulnerability to spoofing, for example, there is its gross inefficiency. “For a child to learn to recognize a cow,” says Hinton, “it’s not like their mother needs to say ‘cow’ 10,000 times”—a number that’s often required for deep-learning systems. Humans generally learn new concepts from just one or two examples.

There is a nice review on Deep Learning in PNAS. The spoofing referred to, is an ‘adversarial patch’ — a patch comprising an image of something else. In the example here, a mini-image of a toaster confuses the AI such that a very large banana is seen as a toaster (the  paper is here on arXiv — an image is worth more than a thousand of my words).

Hinton, one of the giants of this field, is of course referring to Plato’s problem: how can we know so much given so little (input). From the dermatology perspective, the humans may still be smarter than the current machines in the real world, but pace Hinton our training sets need not be so large. But they do need to be a lot larger than n=2. The great achievement of the 19th century clinician masters was to be able to create concepts that gathered together disparate appearances, under one ‘concept’. Remember the mantra: there is no one-to-one correspondence between diagnosis and appearance. The second problem with humans is that they need continued (and structured) practice: the natural state of clinical skills is to get worse in the absence of continued reinforcement. Entropy rules.

Will things change? Yes, but radiology will fall first, then ‘lesions’ (tumours), and then rashes — the latter I suspect after entropy has had its way with me.

Talking 22nd Century Skills: All Steamed Up.

by reestheskin on 17/01/2019

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Talking 22nd Century Skills with @realpbanksley – Rick Hess Straight Up – Education Week

I noted that he seems to be one of the leading thinkers in the push to rebrand STEM as STEAMED (Science, Technology, Engineering, Arts, Math, and Everything Delightful).

Annual Review of the ‘business’ that is ed-tech  by Audrey Watters.

Getting too deeply into statistics is like trying to quench a thirst with salty water. The angst of facing mortality has no remedy in probability. Paul Kalanithi, ‘When Breath Becomes Air’

The abusive debt

by reestheskin on 09/01/2019

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A beginner’s guide to student loans in the public accounts | Wonkhe | Analysis 

Bluntly, the main motive for replacing the teaching grant by loans is an accounting trick. There is an apparent decline in public spending, but at the cost of distorting higher education policy … Thus the changes look like a dodgy [Private] Finance Initiative” – Barr, 2012

Well written piece on the loan scandal in Wonkhe by Nicholas Barr. In the language of the laymen, the government is fiddling the books, and dumping the costs on future taxpayers. It fiddles because it wants to mislead, for gain.

He goes on:

higher education finance has elements of a bubble. If I were a Vice-Chancellor, this aspect would give me sleepless nights.

Guarded language — fair enough — but it is not just a financial bubble. Let us just see how this year pans out.

“as long as they keep asking the wrong questions, the answers really don’t matter”.

Thomas Pynchon

A well argued and evidence based article like this will get you nowhere. This is Britain. Better to put some bollox on a bus.

A comment from theSwedish Chef’ on the FT.

The last desperate stand of virility….

by reestheskin on 06/01/2019

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She crossed to his desk and shook his hand. Noticed the telltale transplant plugs dotting his scalp, sprouting hair like little tufts of yellow grass in a last desperate stand of virility. That’s what you deserved for marrying a trophy wife.

[from Body Double; Tess Gerritsen]

“In 1968, each candidate could be heard without interruption on network news for 42.3 seconds. By 2000, the length of a sound bite was 7 seconds.” Lawrence Freedman, Strategy: a history. (via John Naughton)

Talk with the students:whatever next?

by reestheskin on 04/01/2019

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Mary Midgley a Newcastle based philosopher died a fews ago. An obituary in the FT is here. I remember once attending a debate between her and Sam Shuster on the use of animals in medical research. I thought her both strange, and awe inspiring. I am probably now more sympathetic to her views expressed then, than I was at the time,

I then found a “Lunch with the FT” with her, which referred to her husband academic philosopher, Geoffrey Midgley.

While at Oxford, she met her husband Geoffrey, who also lectured in philosophy, and she followed him to Newcastle in 1950. She has lived there since. (Geoffrey Midgley died in 1997.) “I know academics are supposed to be buzzing off to America and all that sort of thing but Geoffrey wasn’t at all interested in that. He just wanted to sit in the common room and talk to his students. It’s so important to do that, colossally educational.”

’Once you have a shiny building, decline follows’

by reestheskin on 03/01/2019

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The quotes below are from an article in the FT (awhile back). They echo one of my rules, a rule that is more of the exception that proves the rule. Just as “no good lab has space” (because the bench space will always be taken up because many will want to work there), so when the grand new building arrives, the quality of work will already be past its peak (because how else would you have justified your future except by looking back). It is all about edge people, and just as social change usually starts at the edge, so do good ideas.

The principle of benign neglect may well operate on a larger scale. Consider Building 20, one of the most celebrated structures at Massachusetts Institute of Technology. The product of wartime urgency, it was designed one afternoon in the spring of 1943, then hurriedly assembled out of plywood, breeze-blocks and asbestos. Fire regulations were waived in exchange for a promise that it would be pulled down within six months of the war’s end; in fact the building endured, dusty and uncomfortable, until 1998.

During that time, it played host not only to the radar researchers of Rad Lab (nine of whom won Nobel Prizes) but one of the first atomic clocks, one of the first particle accelerators, and one of the first anechoic chambers — possibly the one in which composer John Cage conceived 4’33. Noam Chomsky revolutionised linguistics there. Harold Edgerton took his high-speed photographs of bullets hitting apples. The Bose Corporation emerged from Building 20; so did computing powerhouse DEC; so did the hacker movement, via the Tech Model Railroad Club.

Building 20 was a success because it was cheap, ugly and confusing. Researchers and departments with status would be placed in sparkling new buildings or grand old ones — places where people would protest if you nailed something to a door. In Building 20, all the grimy start-ups were thrown in to jostle each other, and they didn’t think twice about nailing something to a door — or, for that matter, for taking out a couple of floors, as Jerrold Zacharias did when installing the atomic clock.

Somewhat reminiscent of Stewart Brand’s ‘How Buildings Learn

[FT Link]

The not so quiet revolution

by reestheskin on 02/01/2019

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General practice has been undergoing a quiet revolution in recent years that has had little fanfare: it is now an overwhelmingly part-time profession.

Official figures suggest almost 70% of the workforce work less than full time in general practice – the highest proportion ever.

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