Winnowing XXMMI

by reestheskin on 19/01/2021

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KPIs

The crisis within Britain’s care system | Financial Times

From a review of Madeleine Bunting’s Labour of Love in the FT.

Bunting deplores the marketisation of care, in which looking after others is reduced to a commodity requiring specific outputs. (I was reminded of the nurse who, within minutes of my mother’s death, handed us a feedback form on which we were apparently to rate her handling of my mother’s closing moments.)


On Human Remains and NHS management

The Economist | Straight talking

Other changes are required to end the gobbledygook that plagued the previous regime. We will no longer have a “human resources” department: our employees are people, not resources. That section has been renamed personnel.

A few years back I read how the hospital I worked in considered FY1 doctors ward resources. They would not work for and learn from a particular group of more senior doctors (this after all is supposed to be an apprentice system) but be a generic utility for whatever patients were placed on that ward. At once, all we know about learning, security and safety was thrown out the window. As one of my colleagues told me, based on his experience of having to treat a senior hospital manager, many know next to nothing of how medicine works. This form of competence inversion is known as Putt’s law.

Putt’s Law and the Successful Technocrat

“Technology is dominated by two types of people, those who understand what they do not manage and those who manage what they do not understand.” Putt’s Corollary: “Every technical hierarchy, in time, develops a competence inversion.” with incompetence being “flushed out of the lower levels” of a technocratic hierarchy, ensuring that technically competent people remain directly in charge of the actual technology while those without technical competence move into management…”


Bullshit

The Economist | The wisdom of Scrooge

The Christmas Economist was in fine form — at least, better than the state the UK finds itself in.

Today almost everything is the opposite of what it pretends to be. Companies claim that they are devoted to advancing gay rights, promoting multiculturalism or uniting the world in a Kumbaya sing-along, when they are in fact singlemindedly maximising profits. Chief executives claim that they are ever-so-humble “team leaders”—in homage to another great Dickens invention, the unctuous Uriah Heep—when they are actually creaming off an unprecedented share of corporate cash. Private schools such as Eton claim that they are in the business of promoting “diversity” and “inclusivity” even as they charge £42,000 a year. Future historians seeking to sum up our era may well call it “the age of humbug”…

 

Whether the purveyors of this sanctimonious guff actually believe it, or whether it is cynical doublespeak, is immaterial. Either way, spin doctors, sycophants and so-called thought leaders pump noxious quantities of it into the atmosphere. The nation is in desperate need of a modern-day Dickens to clear the air. Until one emerges, Britons should repeat his great creation’s Christmas mantra in every season: “Bah, humbug!”

Pathologies of power

by reestheskin on 16/01/2021

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COVID

UK COVID-19 public inquiry needed to learn lessons and save lives – The Lancet

It is hard not to be moved nor not be angry on reading the editorial in this week’s Lancet, written by three members of the Covid-19 Bereaved Families for Justice group.

The UK Prime Minister Boris Johnson has previously suggested that an immediate public inquiry into the government’s handling of COVID-19 would be a distraction7 or diversion of resources in the fight against COVID-19. We have long proposed that quite the opposite is true: an effective rapid review phase would be an essential element in combating COVID-19.

An independent and judge-led statutory public inquiry with a swift interim review would yield lessons that can be applied immediately and help prevent deaths in this tough winter period in the UK. Such a rapid review would help to minimise further loss of life now and in the event of future pandemics. In the wake of the Hillsborough football stadium disaster on April 15, 1989, for example, the Inquiry of Lord Justice Taylor delivered interim findings within 11 weeks, allowing life-saving measures to be introduced in stadiums ahead of the next football season.

I will quote Max Hastings, a former editor of the Daily Telegraph and Evening Standard, and a distinguished military historian, writing in the Guardian many years ago. He was describing how he had overruled some of his own journalists who had suspected Peter Mandelson of telling lies.

I say this with regret. I am more instinctively supportive of institutions, less iconoclastic, than most of the people who write for the Guardian, never mind read it. I am a small “c” conservative, who started out as a newspaper editor 18 years ago much influenced by a remark Robin Day once made to me: “Even when I am giving politicians a hard time on camera,” he said, “I try to remember that they are trying to do something very difficult – govern the country.” Yet over the years that followed, I came to believe that for working journalists the late Nicholas Tomalin’s words, offered before I took off for Vietnam for the first time back in 1970, are more relevant: “they lie”, he said. “Never forget that they lie, they lie, they lie.” Max Hastings

Two of Hasting’s journalists at the Evening Standard were investigating the funds Peter Mandelson had used to purchase a house.

One morning, Peter Mandelson rang me at the Evening Standard. “Some of your journalists are investigating my house purchase,” he said. “It really is nonsense. There’s no story about where I got the funds. I’m buying the house with family money.”

I knew nothing about any of this, but went out on the newsroom floor and asked some questions. Two of our writers were indeed probing Mandelson’s house purchase. Forget it, I said. Mandelson assures me there is no story. Our journalists remonstrated: I was mad to believe a word Mandelson said. I responded: “Any politician who makes a private call to an editor has a right to be believed until he is proved a liar.” We dropped the story.

Several months later

…when the Mandelson story hit the headlines, I faced a reproachful morning editorial conference. A few minutes later, the secretary of state for industry called. “What do I have to do to convince you I’m not a crook ?” he said.

I answered: “Your problem, Peter, is not to convince me that you are not a crook, but that you are not a liar.”

The default, and most sensible course of action, is to assume that the government and many of those who answer directly to the government have lied and will continue to lie.


Canadian’s tolerance of mediocrity

Where Health Care Is a Human Right | by Nathan Whitlock | The New York Review of Books

An article discussing Canadian health care with echoes of the UK’s own parochial attitude to health care (and don’t mention Holland, Germany, France, Switzerland…).

How do such gaps and problems persist? Part of the problem, ironically, is the system’s high approval ratings: with such enthusiasm for the existing system, and with responsibility for it shared between federal and provincial or territorial governments, it’s easy for officials to avoid making necessary changes. Picard sees our narrowness of perspective as a big obstacle to reform: “Canadians are also incredibly tolerant of mediocrity because they fear that the alternative to what we have is the evil US system.” Philpott agrees that Canadians’ tendency to judge our system solely against that of the United States can be counterproductive. “If you always compare yourself to the people who pay the most per capita and get some of the worst outcomes,” she told me in a recent Zoom call, “then you’re not looking at the fact that there are a dozen other countries that pay less per capita and have far better outcomes than we do.”


The longest lasting health care corpotation in the world

Holy See – Wikipedia

The Holy See is thus viewed as the central government of the Catholic Church. The Catholic Church, in turn, is the largest non-government provider of education and health care in the world.[8] The diplomatic status of the Holy See facilitates the access of its vast international network of charities.[emphasis added]


The antithesis of science, is not art, but politics

There is a famous quote ( I don’t have a primary source) by the great Rudolf Virchow

“Medicine is a social science, and politics is nothing more than medicine on a large scale.”

I know what Virchow was getting at, but if only.

Winnowing MMXXI

by reestheskin on 14/01/2021

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Kieran, Please Come Over For Gay Sex

Excellent summary of recent discoveries in human evolution by John Lanchester in the LRB1. Lucid writing. When I worked on the evolution of skin and hair colour, I was always puzzled about the way a single find of skeletal remains could pivot a whole narrative of how we got here. N-of-1s, are tricky. In recent years many remains have been discovered and, amazingly (because it is amazing), using DNA we can literally spy on the past, not quite in real time, but in a way that when I was a medical student would have seemed like science fiction.

Another thing that I never understood was why these remains were often found in caves. Is that where the action was? John Lanchester put me right — to an extent.

In the case of the Neanderthals, the sense of distance and the sense of strangeness are stronger; empathy seems both more necessary and more remote, harder to access. I have stood at the site of a Neanderthal shelter at Buoux in the South of France and been hit by an overwhelmingly strong feeling of remoteness, the idea that these people, these similar-but-different humans, were so far from anywhere human and place-like that they must have been hiding from something. Their very existence — we now know there were only a few tens of thousands of Neanderthals alive at any one time — seems contingent and marginal. What were they trying to get away from?

But that’s bollocks. That sense of remoteness, of distance from and hiddenness, are a side effect of humanity’s planetary domination: the only places where traces of the deep past remain are places we haven’t built over or crushed underfoot. There could be Neanderthal remains all around where I’m writing this, but I live in London and those traces, if they ever existed, are long and permanently lost. We find evidence mainly in caves because they’re the only places where remains haven’t been washed away by time and the human present. This is the same reason the far past continues to make news: we are constructing knowledge from scraps and fragments, and big new discoveries have the potential to rewrite the story.

Bollocks, as he says. As for my title, well, the best mnemonics at medical school tended to be rude. Lanchester writes

If you’re having trouble remembering the sequence of kingdom, phylum, class, order, family, genus, species, I can recommend the mnemonic ‘Kieran, Please Come Over For Gay Sex.

In truth, mnemonics never did much for me.


‘Fellatio, Masochism, Politics and Love’. And Hwyl

The above was the title of a book by Leo Abse, the Labour MP for Pontypool when I was growing up in Cardiff. I do remember my parents mentioning his name, although I am not certain what their views of him were. As the Economist writes.

A little after 10pm on Monday July 3rd 1967, just as most sensible Britons were turning in for the night, the member for Pontypool was warming up. Leo Abse (pronounced Ab-zee) had been working the tea rooms of the House of Commons all day, charming and cajoling his fellow MPs in his rococo tones—a little flattery here, a white lie there. Now he slipped into the chamber, turning heads as always in spite of his short frame. Settling in his usual perch on the Labour government’s benches, his mischievous eyes darted about the place, searching out both his “stout fellows” and his foes. If his bill were ever to get through, tonight was surely the night.

His bill, printed on the green pages each MP clutched, was plain enough: that, in England and Wales, “a homosexual act in private shall not be an offence provided that the parties consent thereto and have attained the age of twenty-one years”

Abse what a colourful character in all sorts of ways. His WikiP entry gives you some flavour. His second marriage was to Ania Czepulkowska, in 2000, when Abse was 83, and she fifty years younger. A bust of him was unveiled in 2009 at the National Museum of Wales in Cardiff, but his nomination for a seat in the House of Lords had been vetoed by Margaret Thatcher. What would you expect?

  1. The title of the article is Twenty Types of Human: Among the Neanderthals and he is reviewing Kindred: Neanderthal Life, Love, Death and Art by Rebecca Wragg Sykes. Bloomsbury, 400 pp., £20, August, 978 1 4729 3749 0

Academic lives

by reestheskin on 11/01/2021

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Originality is usually off track

How mRNA went from a scientific backwater to a pandemic crusher | WIRED UK

For decades, Katalin Karikó’s work into mRNA therapeutics was overlooked by her colleagues. Now it’s at the heart of the two leading coronavirus vaccines

By the mid 1990s, Karikó’s bosses at UPenn had run out of patience. Frustrated with the lack of funding she was generating for her research, they offered the scientist a bleak choice: leave or be demoted. It was a demeaning prospect for someone who had once been on the path to a full professorship. For Karikó’s dreams of using mRNA to create new vaccines and drugs for many chronic illnesses, it seemed to be the end of the road… ”It was particularly horrible as that same week, I had just been diagnosed with cancer,” said Karikó. “I was facing two operations, and my husband, who had gone back to Hungary to pick up his green card, had got stranded there because of some visa issue, meaning he couldn’t come back for six months. I was really struggling, and then they told me this.”

Karikó has been at the helm of BioNTech’s Covid-19 vaccine development. In 2013, she accepted an offer to become Senior Vice President at BioNTech after UPenn refused to reinstate her to the faculty position she had been demoted from in 1995. “They told me that they’d had a meeting and concluded that I was not of faculty quality,” she said. ”When I told them I was leaving, they laughed at me and said, ‘BioNTech doesn’t even have a website.’”


Being at the bottom of things

Knuth versus Email

Donald Knuth is a legend amongst computer scientists.

I have been a happy man ever since January 1, 1990, when I no longer had an email address. I’d used email since about 1975, and it seems to me that 15 years of email is plenty for one lifetime.Email is a wonderful thing for people whose role in life is to be on top of things. But not for me; my role is to be on the bottom of things. What I do takes long hours of studying and uninterruptible concentration. I try to learn certain areas of computer science exhaustively; then I try to digest that knowledge into a form that is accessible to people who don’t have time for such study. [emphasis added]

On retirement:

I retired early because I realized that I would need at least 20 years of full-time work to complete The Art of Computer Programming (TAOCP), which I have always viewed as the most important project of my life.

Being a retired professor is a lot like being an ordinary professor, except that you don’t have to write research proposals, administer grants, or sit in committee meetings. Also, you don’t get paid.

My full-time writing schedule means that I have to be pretty much a hermit. The only way to gain enough efficiency to complete The Art of Computer Programming is to operate in batch mode, concentrating intensively and uninterruptedly on one subject at a time, rather than swapping a number of topics in and out of my head. I’m unable to schedule appointments with visitors, travel to conferences or accept speaking engagements, or undertake any new responsibilities of any kind.


On Keeping Your Soul

John Baez is indeed a relative of that other famous J(oan) Baez. I used to read his blog avidly

The great challenge at the beginning of ones career in academia is to get tenure at a decent university. Personally I got tenure before I started messing with quantum gravity, and this approach has some real advantages. Before you have tenure, you have to please people. After you have tenure, you can do whatever the hell you want — so long as it’s legal, and you teach well, your department doesn’t put a lot of pressure on you to get grants. (This is one reason I’m happier in a math department than I would be in a physics department. Mathematicians have more trouble getting grants, so there’s a bit less pressure to get them.)

The great thing about tenure is that it means your research can be driven by your actual interests instead of the ever-changing winds of fashion. The problem is, by the time many people get tenure, they’ve become such slaves of fashion that they no longer know what it means to follow their own interests. They’ve spent the best years of their life trying to keep up with the Joneses instead of developing their own personal style! So, bear in mind that getting tenure is only half the battle: getting tenure while keeping your soul is the really hard part. [emphasis added]


On the hazards of Epistemic trespassing

Scientists fear that ‘covidization’ is distorting research

Scientists straying from their field of expertise in this way is an example of what Nathan Ballantyne, a philosopher at Fordham University in New York City, calls “epistemic trespassing”. Although scientists might romanticize the role and occasional genuine insight of an outsider — such as the writings of physicist Erwin Shrödinger on biology — in most cases, he says, such academic off-piste manoeuvrings dump non-experts head-first in deep snow. [emphasis added]

But I do love the language…


On the need for Epistemic trespassing

Haack, Susan, Not One of the Boys: Memoir of an Academic Misfit

Susan Haack is a wonderfully independent English borne philosopher who loves to roam, casting light wherever her interest takes her. 

Better ostracism than ostrichism

Moreover, I have learned over the years that I am temperamentally resistant to bandwagons, philosophical and otherwise; hopeless at “networking,” the tit-for-tat exchange of academic favors, “going along to get along,” and at self-promotion

 

That I have very low tolerance for meetings where nothing I say ever makes any difference to what happens; and that I am unmoved by the kind of institutional loyalty that apparently enables many to believe in the wonderfulness of “our” students or “our” department or “our” school or “our” university simply because they’re ours.

 

Nor do I feel what I think of as gender loyalty, a sense that I must ally myself with other women in my profession simply because they are women—any more than I feel I must ally myself with any and every British philosopher simply because he or she is British. And I am, frankly, repelled by the grubby scrambling after those wretched “rankings” that is now so common in philosophy departments. In short, I’ve never been any good at academic politicking, in any of its myriad forms.

 

And on top of all this, I have the deplorable habit of saying what I mean, with neither talent for nor inclination to fudge over disagreements or muffle criticism with flattering tact, and an infuriating way of seeing the funny side of philosophers’ egregiously absurd or outrageously pretentious claims — that there are no such things as beliefs, that it’s just superstitious to care whether your beliefs are true, that feminism obliges us to “reinvent science and theorizing,” and so forth.

.


Citizens of nowhere trespassing…

The Economist | Citizen of the world

From a wonderful article in the Economist

As Michael Massing shows vividly in “Fatal Discord: Erasmus, Luther and the Fight for the Western Mind” (2018), the growing religious battle destroyed Erasmianism as a movement. Princes had no choice but to choose sides in the 16th-century equivalent of the cold war. Some of Erasmus’s followers reinvented themselves as champions of orthodoxy. The “citizen of the world” could no longer roam across Europe, pouring honeyed words into the ears of kings. He spent his final years holed up in the free city of Basel. The champion of the Middle Way looked like a ditherer who was incapable of making up his mind, or a coward who was unwilling to stand up to Luther (if you were Catholic) or the pope (if you were Protestant).

The test of being a good Christian ceased to be decent behaviour. It became fanaticism: who could shout most loudly? Or persecute heresy most vigorously? Or apply fuel to the flames most enthusiastically?

And in case there is any doubt about what I am talking about.

In Britain, Brexiteers denounce “citizens of the world” as “citizens of nowhere” and cast out moderate politicians with more talent than they possess, while anti-Brexiteers are blind to the excesses of establishment liberalism. In America “woke” extremists try to get people sacked for slips of the tongue or campaign against the thought crimes of “unconscious bias”. Intellectuals who refuse to join one camp or another must stand by, as mediocrities are rewarded with university chairs and editorial thrones. [emphasis added]

As Erasmus might have said: ‘Amen’.

Winnowing MMXXI

by reestheskin on 08/01/2021

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Sunday 27 December, 2020 | Memex 1.1

The following were both posted separately by John Naughton over recent weeks. It may seem bad manners to ‘borrow’ in such a way, but the combination seems apposite, and the necessary conclusion hard to put aside.


There are no credentials. They do not even need a medical certificate. They need not be sound either in body or mind. They only require a certificate of birth — just to prove that they were the first of the litter. You would not choose a spaniel on those principles.

Lloyd George on the House of Lords, 1909.


The privately educated Englishman — and Englishwoman, if you will allow me — is the greatest dissembler on Earth. Was, is now and ever shall be for as long as our disgraceful school system remains intact. Nobody will charm you so glibly, disguise his feelings from you better, cover his tracks more skilfully or find it harder to confess to you that he’s been a damned fool.

George Smiley in John le Carré’s The Secret Pilgrim.

Remind you of anyone?

Winnowing MMXXI

by reestheskin on 05/01/2021

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Vaccine rollout hampered by red tape and lack of back-up stocks | Financial Times

Mr Hancock told the BBC that the amount of bureaucracy would be reduced, including no longer requiring vaccinators to undergo training on the need to tackle terrorism.

No surprise here. Those familiar with the NHS (and many other organisations) will know there is little limit to the crap that those at the top can pass down, chiefly to protect their own hides. I used to chair a student teaching ethics committee (note: an ethics committee, not an ethical committee). We had to ask all applicants whether they were aware of the Home Office’s Prevent Strategy (terrorism!). As for training, the standard of NHS online modules that I used to have to do, was execrable. They were yet another form of subsidy for the parasitism this is much of UK Private Business. Even with retirement, the rage only ebbs away slowly. Wasted days.


So far away

Between now and Easter universities should stop, collaborate and listen | Wonkhe

Academics got good at distance learning — for students who were studying at the distance of half a mile away.

The long-term issue is simply that if the experience is mainly large lecture delivery, then the value of university has been washed away by successive cuts and internal transfers of money to research and ‘impact’. That is what should worry universities now. At one time you could find high street retail with knowledgeable staff. Then rationalisation took over and quality took a nose dive in order to pay the dividends of investors. Then came Amazon.


All I want for 2021

All I want for 2021 is to see Mark Zuckerberg up in court | Internet | The Guardian

It’s always risky making predictions about the tech industry, but this year looks like being different, at least in the sense that there are two safe bets. One is that the attempts to regulate the tech giants that began last year will intensify; the second that we will be increasingly deluged by sanctimonious cant from Facebook & co as they seek to avoid democratic curbing of their unaccountable power.

John Naughton, my first and still my favourite blogger. It was on my list too, but Amazon have failed to deliver.


Innumerate economists.

Blanchflower aiming to counter ‘disastrous’ austerity economics | Times Higher Education (THE)

“I think I said on Bloomberg [the business TV channel] I thought Brexit was the worst decision made by any advanced country in the last thousand years,” he continued. “And I only said a thousand because I’m not very good on the thousand before that.”

Danny (David) Blanchflower.


Bozo et al.

What makes John le Carré a writer of substance | Financial Times

Again, like Orwell — who revealed himself now and then as a poetic limner of deep England — le Carré had a pitch-perfect ear for the disingenuous hypocrisies sustaining those who mistook “Getting Away with It” for national purpose.

Who — or what — cares

by reestheskin on 14/12/2020

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I think the quip was from the series Cardiac Arrest: the ITU used to be called the ICU (intensive care unit) until they realised nobody did.

In March, 2019, a doctor informed 78-year-old Ernest Quintana, an inpatient at a hospital in California, USA, that he was going to die. His ravaged lungs could not survive his latest exacerbation of chronic obstructive pulmonary disease, so he would be placed on a morphine drip until, in the next few days, he would inevitably perish. There was a twist. A robot had delivered the bombshell. There, on a portable machine bearing a video screen, crackled the pixelated image of a distant practitioner who had just used cutting-edge technology to give, of all things, a terminal diagnosis. The hospital insisted that earlier conversations with medical staff had occurred in person, but as Mr Quintana’s daughter put it: “I just don’t think that critically ill patients should see a screen”, she said. “It should be a human being with compassion.”

From Care in crisis – The Lancet

Retirement and the Curse of Lord Acton

by reestheskin on 10/12/2020

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According to a helpful app on my phone that I like to think acts as a brake on my sloth, I retired 313 days ago. One of the reasons I retired was so that I could get some serious work done; I increasingly felt that professional academic life was incompatible with the sort of academic life I signed up for. If you read my previous post, you will see this was not the only reason, but since I have always been more of an academic than clinician, my argument still stands.

Over twenty years ago, my friend and former colleague, Bruce Charlton, observed wryly that academics felt embarrassed — as though they had been caught taking a sly drag round the back of the respiratory ward — if they were surprised in their office and found only to be reading. No grant applications open; no Gantt charts being followed; no QA assessments being written. Whatever next.

I thought about retirement from two frames of reference. The first, was about finding reasons to leave. After all, until I was about 50, I never imagined that I would want to retire. I should therefore be thrilled that I need not be forced out at the old mandatory age of 65. The second, was about finding reasons to stay, or better still, ‘why keep going to work?’. Imagine you had a modest private income (aka a pension), what would belonging to an institution as a paid employee offer beyond that achievable as a private scholar or an emeritus professor? Forget sunk cost, why bother to move from my study?

Many answers straddle both frames of reference, and will be familiar to those within the universities as well as to others outwith them. Indeed, there is a whole new genre of blogging about the problems of academia, and employment prospects within it (see alt-acor quit-lit for examples). Sadly, many posts are from those who are desperate to the point of infatuation to enter the academy, but where the love is not reciprocated. There are plenty more fish in the sea, as my late mother always advised. But looking back, I cannot help but feel some sadness at the changing wheels of fortune for those who seek the cloister. I think it is an honourable profession.

Many, if not most, universities are very different places to work in from those of the 1980s when I started work within the quad. They are much larger, they are more corporatised and hierarchical and, in a really profound sense, they are no longer communities of scholars or places that cherish scholarly reason. I began to feel much more like an employee than I ever used to, and yes, that bloody term, line manager, got ever more common. I began to find it harder and harder to characterise universities as academic institutions, although from my limited knowledge, in the UK at least, Oxbridge still manage better than most 1. Yes, universities deliver teaching (just as Amazon or DHL deliver content), and yes, some great research is undertaken in universities (easy KPIs, there), but their modus operandi is not that of a corpus of scholars and students, but rather increasingly bends to the ethos of many modern corporations that self-evidently are failing society. Succinctly put, universities have lost their faith in the primacy of reason and truth, and failed to wrestle sufficiently with the constraints such a faith places on action — and on the bottom line.

Derek Bok, one of Harvard’s most successful recent Presidents, wrote words to the effect that universities appear to always choose institutional survival over morality. There is an externality to this, which society ends up paying. Wissenschaft als Beruf is no longer in the job descriptions or the mission statements2.

A few years back via a circuitous friendship I attended a graduation ceremony at what is widely considered as one of the UK’s finest city universities3. This friend’s son was graduating with a Masters. All the pomp was rolled out and I, and the others present, were given an example of hawking worthy of an East End barrow boy (‘world-beating’ blah blah…). Pure selling, with the market being overseas students: please spread the word. I felt ashamed for the Pro Vice Chancellor who knew much of what he said was untrue. There is an adage that being an intellectual presupposes a certain attitude to the idea of truth, rather than a contract of employment; that intellectuals should aspire to be protectors of integrity. It is not possible to choose one belief system one day, and act on another, the next.

The charge sheet is long. Universities have fed off cheap money — tax subsidised student loans — with promises about social mobility that their own academics have shown to be untrue. The Russell group, in particular, traducing what Humboldt said about the relation between teaching and research, have sought to diminish teaching in order to subsidise research, or, alternatively, claimed a phoney relation between the two. As for the “student experience”, as one seller of bespoke essays argued4, his business model depended on the fact that in many universities no member of staff could recognise the essay style of a particular student. Compare that with tuition in the sixth form. Universities have grown more and more impersonal, and yet claimed a model of enlightenment that depends on personal tuition. Humboldt did indeed say something about this:

“[the] goals of science and scholarship are worked towards most effectively through the synthesis of the teacher’s and the students’ dispositions”.

As the years have passed by, it has seemed to me that universities are playing intellectual whack-a-mole, rather than re-examining their foundational beliefs in the light of what they offer and what others may offer better. In the age of Trump and mini-Trump, more than ever, we need that which universities once nurtured and protected. It’s just that they don’t need to do everything, nor are they for everybody, nor are they suited to solving all of humankind’s problems. As had been said before, ask any bloody question and the universal answer is ‘education, education, education’. It isn’t.

That is a longer (and more cathartic) answer to my questions than I had intended. I have chosen not to describe the awful position that most UK universities have found themselves in at the hands of hostile politicians, nor the general cultural assault by the media and others on learning, rigour and nuance. The stench of money is the accelerant of what seeks to destroy our once-modern world. And for the record, I have never had any interest in, or facility for, management beyond that required to run a small research group, and teaching in my own discipline. I don’t doubt that if I had been in charge the situation would have been far worse.

 

Reading debt

 

Sydney Brenner, one of the handful of scientists who made the revolution in biology of the second half of the 20th century once said words to the effect that scientists no longer read papers they just Xerox them. The problem he was alluding to, was the ever-increasing size of the scientific literature. I was fairly disciplined in the age of photocopying but with the world of online PDFs I too began to sink. Year after year, this reading debt has increased, and not just with ‘papers’ but with monographs and books too. Many years ago, in parallel with what occupied much of my time — skin cancer biology and the genetics of pigmentation, and computerised skin cancer diagnostic systems — I had started to write about topics related to science and medicine that gradually bugged me more and more. It was an itch I felt compelled to scratch. I wrote a paper in the Lancet   on the nature of patents in clinical medicine and the effect intellectual property rights had on the patterns of clinical discovery; several papers on the nature of clinical discovery and the relations between biology and medicine in Science and elsewhere. I also wrote about why you cannot use “spreadsheets to measure suffering” and why there is no universal calculus of suffering or dis-ease for skin disease ( here and here ); and several papers on the misuse of statistics and evidence by the evidence-based-medicine cult (here and here). Finally, I ventured some thoughts on the industrialisation of medicine, and the relation between teaching and learning, industry, and clinical practice (here), as well as the nature of clinical medicine and clinical academia (here  and here ). I got invited to the NIH and to a couple of AAAS meetings to talk about some of these topics. But there was no interest on this side of the pond. It is fair to say that the world was not overwhelmed with my efforts.

At one level, most academic careers end in failure, or at last they should if we are doing things right. Some colleagues thought I was losing my marbles, some viewed me as a closet philosopher who was now out, and partying wildly, and some, I suspect, expressed pity for my state. Closer to home — with one notable exception — the work was treated with what I call the Petit-mal phenomenon — there is a brief pause or ‘silence’ in the conversation, before normal life returns after this ‘absence’, with no apparent memory of the offending event. After all, nobody would enter such papers for the RAE/REF — they weren’t science with data and results, and since of course they weren’t supported by external funding, they were considered worthless. Pace Brenner, in terms of research assessment you don’t really need to read papers, just look at the impact factor and the amount and source of funding: sexy, or not?5

You have to continually check-in with your own personal lodestar; dead-reckoning over the course of a career is not wise. I thought there was some merit in what I had written, but I didn’t think I had gone deep enough into the problems I kept seeing all around me (an occupational hazard of a skin biologist, you might say). Lack of time was one issue, another was that I had little experience of the sorts of research methods I needed. The two problems are not totally unrelated; the day-job kept getting in the way.

 

 

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The last three patients: dermatology

by reestheskin on 27/11/2020

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Patient 3

He was nearer seventy than sixty, and not from one of Edinburgh’s more salubrious neighbourhoods. He sat on the examination couch unsure what to do next. His right trouser was leg rolled up, exposing a soiled bandage crusted with blood that had clearly been there for more than a few days. He nodded as I walked into the clinic room and I introduced myself with a shake of his hand. This was pre-covid.

I knew his name because that was typed on the clinic list alongside the code that said he was a ‘new’1 patient, but not much else. Not much else because his clinical folder contained sticky labels giving his name, address, date of birth and health care number only. That was it. As has become increasingly the norm in the clinic room, you ask the patient if they know why they are here.

He had phoned the hospital four days earlier, he said, and he was very grateful that he had been given an appointment to see me. He thanked me as though I was his saviour. If true, I didn’t know from what or from whom. If he was a new patient he would have seen his GP and there should be a letter from his GP in his notes. But no, he hadn’t seen his GP for over a year. Had I seen him before? No, he confirmed, but he had seen another doctor in the very same department about eighteen months previously. I enquired further. He said he had something on his leg — at the site of the distinctly un-fresh bandage — that they had done something to. It had now started to bleed spontaneously. He had phoned up on several occasions, left messages and, at least once, spoken to somebody who said they would check what had happened and get back to him. ‘Get back to you’ is often an intention rather than an action in the NHS, so I was not surprised when he said that he had heard nothing back. His leg was now bleeding and staining his trousers and bed clothes, hence the bandage. He thought that whatever it had been had come back.

Finally, four days before this appointment day, after he relayed his story one more time over the phone, he had been given this appointment. He again told me again how grateful he was to me for seeing him. And no, he didn’t know what diagnosis had been made in the past. I asked him had he received any letters from the hospital. No, he replied. Could he remember the name of any of the doctors he had seen over one year previously? Sadly, not. Had he been given an appointment card with a consultant’s name on? No.

There was a time when nursing and medicine were complementary professions. At one time the assistant who ushered him into the clinic room would have removed the bandage from his leg. In my clinical practice, those days ended long ago. I asked him if he would unwrap the bandage while I went in search of our admin staff to see if they knew more than me about why he was here.

He had been seen before, just as he had said, around eighteen months earlier. He had seen an ‘external provider’, one of a group of doctors employed via commercial agencies who are contracted to cope with all the patients that the regular staff employed by the hospital are unable to see. That demand exceeds supply, is the one feature of the NHS that all agree on, whatever their politics. It outlives all reorganisations. Most of these external provider doctors travel up for weekends, staying in a hotel for one or more nights, and then fly back home. They get paid more than the local doctors (per clinic), and the agency takes a substantial arrangement fee in addition. This had been the norm for over ten years, and of course makes little clinical or financial sense — except if the name of the game is to be able to shape waiting lists with electoral or political cycles, turning the tap on and off. Usually more off, than on.

The doctors who undertake this weekend work are a mixed bunch. Most of them are very good, but of course they don’t normally work in Scotland, and medicine varies across the UK and Europe, and even between regions within one country. It is not so much the medicine that is very different, but the way that different components of care fit together organisationally that are not constant. This hints at one fault line.

That the external doctors are more than just competent is important for another reason. The clinic lists of the visiting doctors are much busier than those of the local doctors, and are full of new patients rather than patients brought back for review. The NHS and the government consider review appointments as wasteful, and that is why all the targets relate to ‘new’ patients. It’s a numbers game: stack them high, don’t let the patients sit down for too long, and process them. Meet those government targets and move in phase with the next election cycle. Consequently, the external provider doctors are being asked to provide episodic care under time pressure; speed dating rather than maintaining a relationship. For most of the time, nobody who actually works in Edinburgh knows what is going on with the patient. But the patients do live in Edinburgh.

Old timers like me know that one of the reasons why review appointments are necessary is that they are a security net, a back up system. In modern business parlance, they add resilience. Like stocks of PPE. In the case of my man, a return appointment would have provided the opportunity to tell him what the hell was going on and to ensure that all that had actually been planned had been carried out. There is supposed to be a beginning, a middle and an end. There wasn’t.

An earlier letter from an external provider doctor was found. It was a well-written summary of the consultation. The patient had a lesion on his leg that was thought clinically to be pre-malignant. The letter stated that if a diagnostic biopsy confirmed this clinical diagnosis — it did — then the patient would require definitive treatment, most likely, surgical. The problem was that in this informal episodic model, the original physician was not there to act on the result; nor to observe that the definitive surgical treatment had not taken place because review appointments are invisible in terms of targets. They are wasteful.

Even before returning to the clinic room, without sight of anything but the blood stained bandage, I knew what was going on. His pre-malignant lesion had, over the period of ‘wasteful’ time, transformed into full-blown cancer. He now had a squamous cell carcinoma. His mortality risk had gone from effectively zero to maybe 5%.

I went back to the clinic room, apologised, explained what had gone on and what needed to happen now, and apologised again. The patient picked up on my mixture of frustration, shame and anger, and it embarrasses me to admit that I had somehow allowed him —mistakenly — to imagine that my emotions were a response to something he had said or done. I apologised again. And then he did say something that fired my anger. I cannot remember the whole sentence but a phrase within it stuck: ‘not for the likes of me’. His response to the gross inadequacy of his care was that it was all people like him could expect.

He was not literally the last patient in dermatology I saw, but his story was the one that told me I had to get out. When a pilot or an airline engineer says that an aircraft is safe to fly there is an unspoken bond between passengers and those who dispense a professional judgement. But this promise is also made by one human to another human. I call it the handshake test, which is why I always shook hands when I introduced myself to patients. This judgement that is both professional and personal has to be compartmentalised away from the likes of sales and marketing, the share price — and government targets or propaganda. This is no longer true of the NHS. The NHS is no longer a clinically led organisation, rather, it is a vehicle for ensuring one political gang or another gains ascendancy over the other at the next election.  It is not so much about money, as about control. True, if doctors went down with the plane, in this metaphor, there would be a much better alignment of incentives. Doctors might be yet more awkward. Better still, we might think about where we seat the politicians and their NHS commissars.

Most doctors keep a shortlist of other doctors who they think of as exceptional. These are the ones they would visit themselves or recommend to family. If I had to rank my private shortlist, I know who would come number one. She is not a dermatologist, but a physician of a different sort, and she works far away from Edinburgh. She has been as loyal and tolerant of the NHS as anybody I know — much more than me. Yet she retired  before me, and her reasoning and justification were as insightful and practical as her medical abilities. Simply put, she could no longer admit her patients and feel able to reassure them that the care they would receive would be safe. It’s the handshake test.

I don’t shake hands with patients any more.

  1. A ‘new’ outpatient is usually a patient you are seeing for the first time, after they have been referred by their GP or another consultant. During this ‘illness episode’, if you see them again, they are a ‘review’ patient. Once they have been discharged from hospital review, they may of course re-enter the system — say many years later —as a ‘new’ patient once more with the same or a different condition.

Link to patient 1

Link to patient 2

The last three patients: general medicine

by reestheskin on 25/11/2020

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Patient 2

It hasn’t happened to me often — maybe on only a handful of occasions — but often enough to recognise it, and dread it. I am talking to a patient, trying to second guess the future — how likely is it that their melanoma might stay away for ever, for instance — and I find myself mouthing words that a voice in my head is warning me I will regret saying. And the voice is not so much following my words but anticipating them, so I cannot cite ignorance as an excuse, nor is it a whisper or unclear in any way, and yet I still charge on. A moment later, regret will set in, and this regret I could share with you at that very moment if you were there with me.

The patient was a young man in his early twenties, who lived with his mother, just the two of them at home. He had dark curly hair, was of average height, and he lived for running. This was Newcastle, in the time of Brendan Foster and Steve Cram. He had been admitted with pyrexia, chest pains and a cough. He had bacterial pneumonia, and although he seemed pretty sick, none of us were worried for him.

After a few days, he seemed no better, and we switched antibiotics. Medics reading this will know why. He started to improve within a day or so, and we felt we were in charge, pleased with, and confident of our decisions. This was when I spoke with his mother, updating her on his progress. Yes, he had been very ill; yes, we were certain about his diagnosis; and yes, the change of antibiotics and his response was not unexpected. I then said more. Trying to reassure her, I said that young fit people don’t die from pneumonia any more. That was it. All the demons shuttered.

At this time I was a medical registrar and I supervised a (junior) house officer (HO), and a senior house officer (SHO). In turn, my boss was a consultant physician who looked after ‘general medical’ patients, but his main focus was clinical haematology. In those days the norm was for all of a consultant’s patients to be managed on their own team ward. On our ward, maybe half the patients were general medical, and the others had haematological diseases. Since I was not a haematologist, I was solely tasked with looking after the general medical patients, and mostly acted without the need for close supervision (in a way that was entirely appropriate).

One weekend I was doing a brief ‘business’ ward round on a Sunday morning. Our young man with pneumonia was doing well, his temperature had dropped, and he was laughing and joking. We would have been making plans to let him home soon. The only thing of note was that the houseman reported that the patient had complained of some pain in one calf. I had a look and although the signs were at best minimal I wondered whether he could have had a deep vein thrombosis (DVT). Confirmatory investigations for DVTs in those days were unsatisfactory and not without iatrogenic risk, whilst the risks from anticoagulation in a previously fit young man with no co-morbidities are minimal. We started him on heparin.

A few days later he was reviewed on the consultant’s ward round. I knew that the decision to anti-coagulate would (rightly) come under review. The physical signs once subtle were now non-existent, and the anticoagulation was stopped. A reasonable decision I knew, but one that I disagreed with, perhaps more because of my touchy ego than deep clinical judgement.

Every seven to ten days or so I would be the ‘resident medical officer’ (RMO), meaning I would be on call for unselected medical emergencies. Patients might be referred directly to us by their general practitioner, or as ‘walk-ins’ via casualty (ER). In those days we would usually admit between 10 and 15 patients over a 24-hour period; and we might also see a further handful of patients who we judged did not require hospital admission. Finally, since we were resident, we continued to provide emergency medical care to the whole hospital, including our own preexisting patients.

It was just after 8.30am. The night had been quiet, and I was in high spirits as this was the last time I would act as an RMO. In fact, this was to be the last day of me being a ‘medical registrar’. Shortly after, I would leave Newcastle for Vienna and start a career as an academic dermatologist, a career path that had been planned many years before.

The clinical presentation approaches that of a cliché. A patient with or without various risk factors, but who has been ill from one of a myriad of different conditions, goes to the toilet to move their bowels. They collapse, breathless and go into shock. CPR may or may not help. A clot from their legs has broken free, and blocked the pulmonary trunk. Sufficient blood can no longer circuit from the right side of the heart to the left. The lungs and heart are torn asunder.

When the call went out, as RMO, I was in charge. Nothing we did worked. There is a time to stop, and I ignored it. One of my colleagues took the decision. Often with cardiac arrests, you do not know the patient. That helps. Often the call is about a patient who is old and with multiple preexisting co-morbidities. That is easier, too. But I knew this man or boy; and his mother.

That was the last patient I ever saw in general medicine.

[Link to Patient 1]
[Link to Patient 3]

The last three patients: general practice

by reestheskin on 23/11/2020

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Patient 1 

When I was a medical registrar I did GP locums for a single-handed female GP in Newcastle. Doing them was great fun, and the money — she insisted on BMA rates — was always welcome. Nowadays, without specific training in general practice, you can’t act as a locum as I did then. This is probably for the best but, as ever, regulations always come with externalities, one of which is sometimes a reduction in overall job satisfaction.

I worked as a locum over a three period, usually for one week at a time, once or twice a year, covering some of the GP’s annual leave. Weekdays were made up of a morning surgery (8.30 to 10.30 or later), followed by house-calls through lunchtime to early afternoon, and then an evening surgery from 4.30 to around 6:30. I also ran a short Saturday morning surgery. Within the working day I could usually nip home for an hour or so.

From 7pm till the following morning, the Doctors Deputising Service (DDS) took over for emergency calls. They also covered the weekends. The DDS employed other GPs or full-time freelancers. Junior hospital doctors often referred to the DDS as the Dangerous Doctor Service. Whether this moniker was deserved, I cannot say, but seeing patients you don’t know in unfamiliar surroundings is often tricky. Read on.

Normally, the GP would cover the nights herself, effectively being on call 24 hours per day, week in, week out. Before she took leave, she used to proactively manage her patients, letting some of her surgery ‘specials’ or ‘regulars’ know she would be away, and therefore they might be better served by waiting for her to return. Because she normally did her own night-calls, she was aware of how a small group of patients might request night visits that might be judged to be unnecessary. I think the fee the DDS charged to her was dependent on how often a visit was requested, so, as far as was reasonable, she tried to ensure her patients knew that when she was away they would only get a visit from a ‘stranger’ — home night-time call-outs should be for real emergencies. I got the strong impression that her patients were very fond of her, and she of them. Without exception, they were always very welcoming to me, and I loved the work. Yes I got paid, but it was fun medicine, and offered a freedom that you didn’t feel in hospital medicine as a junior (or senior) doctor.

The last occasion I undertook the locum was eventful. I knew that this was going to be the last occasion, as that summer I was moving on from internal medicine to start training in dermatology — leaving for Vienna in early August. A request for a house-call, from forty-year-old man with a headache, came in just as the Friday evening surgery was finishing, a short while after 6.30pm. My penultimate day. I had been hoping to get off sharpish, knowing I would be doing the Saturday morning surgery, but contractually I was covering to 7pm, so my plan was to call at the patient’s house on the way home.

I took his clinical paper notes with me. There was virtually nothing in them, a fact that doctors recognise as a salient observation. He lived, as did most of the surgery’s patients, on a very respectable council estate that literally encircled the surgery. I could have walked, but chose to drive, knowing that since I had locked up the surgery, I could go straight home afterwards.

When I got to his house, his wife was standing outside, waiting for me. She was most apologetic, informing me that her husband was not at home, but had slipped out to take his dog for a walk. I silently wondered why if this was the case, he couldn’t have taken the dog with him to the surgery, saving me a trip. No matter. Grumbling about patient behaviour is not unnatural, but is often the parent of emotions that can cloud clinical judgement. There lie dragons.

The patient’s wife ran to the local park to find her husband, who, in tow with her and the dog, came running at a fair pace back to the house a few minutes later. The story was of a headache on one side of his head, posterior to the temple, that had started a few hours earlier. The headache was not severe, he told me, and he felt well; he didn’t think he had flu. His concern was simply because he didn’t normally get headaches. There was nothing else remarkable about his history; he was not on any medication, and had no preexisting complaints or diseases beyond the occasional cold. Nor did the actual headache provide any diagnostic clues. On clinical examination, he was apyrexial, with a normal pulse and blood pressure, and a thorough neuro exam (as in that performed by somebody who had recently done a neuro job) was normal. No neck stiffness or photophobia and the fundi were visualised and clear. The best I could do was wonder about a hint of erythema on his tympanic membrane on the side of the headache, but there was no local tenderness, there. I worried I was making the signs fit the story.

I told him I couldn’t find a good explanation for his headache, and that my clinical examination of him was essentially normal. There was a remote possibility that he had a middle ear infection, although I said that since he had no history of previous ear infections, this seemed unlikely. I opted to give him some amoxycillin (from my bag) and said that whilst night-time cover would be provided by the DDS, I would be holding a surgery on the Saturday morning in just over 12 hours time. Should he not feel right, he should pop in to see me, or I could visit him again. He and his wife thanked me for coming round, I went home and, as far as I knew, that was the end of the story of my penultimate day as a locum GP. He did not come to my Saturday morning surgery.

Several weeks later, when I was back doing internal medicine and on call for urgent GP referrals, the same GP phoned me up about another of her patients who she thought merited hospital assessment. This was easily sorted, and I then asked her about some of the patients of hers I had seen when I was her locum. There was one in particular, with abdominal pain, whom I had sent into hospital, and I wanted to know what had happened to him. She then told me that the patient had meningitis. There was a moment of confusion: we were not talking about the same patient.

The story of the man with the headache was as follows. I had seen him just before 7pm, apyrexial, fully conscious, with a normal pulse and blood pressure, and no neuro signs. By 8pm his headache was much more severe and his wife put a call into the DDS who saw him before 9pm, but could not find anything abnormal. By 10.30pm he was barely conscious, and his wife called the DDS who were going to be delayed. Soon after, she dialled 999. He was admitted and diagnosed and treated for bacterial meningitis. The GP told me he had made a prompt and complete recovery.

That was the last patient I ever saw in general practice.

[Link to patient 2]

[Link to patient 3]

Nicely put

Capitalism on the way up, and socialism on the way down is cronyism.

Corona Corps + Biden | No Mercy / No Malice

You would have to be mad…

by reestheskin on 20/11/2020

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“I have been this close to buying a nursing school.” This is not a sentence you expect to hear from a startup founder. Nursing seems a world away from the high-tech whizziness of Silicon Valley. And, to use a venture-capital cliché, it does not scale easily.

This was from an article in the Economist awhile back. As ever, there is a mixture of craziness and novelty. The gist of the article is about Lambda School, a company that matches ‘fast’ training with labour force shortages (hence the nursing angle). When I first read it, I had thought they had already opened a nursing school, but that is not so. Nonetheless, there are aspects that interest me.

We learn that

  1. Full-time students attend for nine months, five days a week from 8am to 5pm. Latecomers risk falling behind, but for most classes, 85% of students who began a course finish. Study is online but ‘live’ (rather than pre-recorded videos). These completion rates are a lot higher than for many community colleges in the US.
  2. Lambda only gets paid after its students have landed a job which pays them more than $50,000 a year. Around 70% of those enrolled do so within six months of graduation. Lambda then receives about a sixth of their income for the next two years, until they have paid about $30,000 (or they could pay £20,000 up front).
  3. One third of the costs are spent on finding jobs for graduates, another third on recruitment and only one third on the actual teaching. Scary.

The Economist chimes in with the standard “Too often students are treated as cash cows to be milked for research funding.” Too true, but to solve this issue we need to massively increase research costings, have meaningful conversations with charities and government (including the NHS) about the way students are forced to involuntarily subsidise research, and cut out a lot of research in universities that is the D of R&D.

But this is not a sensible model for a university. On the other hand it is increasingly evident to me that universities are not suitable places to learn many vocational skills. The obvious immediate problem for Lambda is finding and funding a suitable clinical environment. That is exactly the problem that medical (or dental) schools face. A better model is a sequential one, one which ironically mimics the implicit English model of old: university study, followed by practical hospital clerkships. Just tweak the funding model to allow it.

It’s just business

by reestheskin on 19/11/2020

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I have rich memories of general practice, and I mean general practice rather than primary care 1. My earliest memories centre around a single-handed GP, who looked after my family until we left Wales in the early 1970s. His practice was in his house, just off Whitchurch village in Cardiff. You entered by what once may have been the back gate or tradesman’s entrance. Around the corner and a few steps up, you found the waiting room. Originally, I guess, it might have been a washroom or utility room for a maid or housekeeper. By the standards of the Rees abode the house was large.

The external door to the waiting room was opposite the door into the main part of the doctor’s house, and on the adjacent sides were two long benches. They were fun for a little boy to sit on because since your legs couldn’t touch the floor, you could shuffle along as spaces became available. When you did this adults tended to smile at you; I now know why. If you were immobile for too long your thighs might stick to the faux-leather surface; pulling them away fast resulted in a fart like noise, although in those days I was too polite to think out loud.

Once you were called — whether it was by the doctor or his wife I cannot remember— you entered his ‘rooms’. The consulting rooms was by my preferred unit measure — how far I could kick a ball — large, with higher ceilings than we had at home. The floorboards creaked and the carpet was limited to the centre of the room. If there was a need for privacy there was what seemed like a fairly inadequate freestanding curtained frame. For little boys, obviously, no such cover was deemed necessary.

I can remember many home visits: two stand out in particular, mumps, and an episode of heavily infected eczema where my body was covered in thousands of pustules, and where I remember pulling off sheets of skin that had stuck to the bedclothes. The sick-role was respected in our home: if you were ill and off school you were in bed. Well, almost. Certainly, no kicking the ball against the wall.

Naturally, the same GP would look after any visitors to my home. Although my memories are influenced by what my mother told me, on one occasion my Irish grandmother’s valvular heart failure decompressed when she was staying with us (her home was in Dublin). More precisely, I was turfed out of my bed, so she could occupy it. The GP phoned the Cardiff Royal Infirmary explaining that the patient needed admission, and would they oblige? The GP however took ten years-or-so off her true age. Once he was off the phone, my mother corrected him. He knew better: if I had told them the truth they would have refused to admit her, he said. (This was general practice, not state medicine, after all). The memory of this event stuck with me when I was a medical student on a geriatrics attachment in Sunderland circa 1981. Only those under 60 with an MI were deemed suitable for admission to the CCU, with the rest left in a large Nightingale ward with no cardiac monitoring 2. I thought of my father who was then close to 60.

I was lucky enough to be able to recognise this type of general practice — albeit with many much needed changes — as a medical student in Newcastle, and to be taught by some wonderful GPs, and even do some GP locums when I was a medical registrar. And although I had never met the late and great Julian Tudor-Hart face-to-face, we are linked by a couple of mutual Welsh friends, and we exchanged odd emails over the years.

So, why do I recall all of this? Nostalgia? Yes, I own up to that. But more out of anger that what was unique about UK general practice has been replaced by primary care and “population medicine”, and many patients are worse off because of this shift. Worse still, it now seems all is viewed not through the lens of vocation, but by the egregious ‘its just business’. Continuity of care and “personal doctoring” is, and has been, lost.

I write after being provoked by a comment in the London Review of Books. Responding to a terrific article by John Furse on the NHS, Helen Buckingham of the Nuffield Trust states — as many do — that “The reality is that almost all GP practices are already private businesses, and have been since the founding of the NHS.” (LRB 5/12/2019 page 4).

Well, for me, this is pure sophistry. There are businesses and businesses. If you wish, you might call the Catholic Church a business, or Edinburgh university a business, or even the army a business. You might even refer to each of them as a corporation. But to do so, misses all those human motivations that make up civil society. Particularly the ability to look people in the eye and not feel grimy. There is no way on earth that the GP who looked about me would have called what he did a business. Nor was he part of any corporation. And the reason is simple: like many think tanks, many modern corporations — especially the larger ones — have no sense of morality beyond the dollar of the bottom line3, often spending their undoubted skills wilfully arbitraging the imperfections of regulation and honest motivation. It does not have to be this way.

  1. Here I am echoing the arguments made by Howie, Metcalfe and Walker in the BMJ in 2008: The State of General Practice — not all for the better. Comments on this article effectively said: the halcyon days of general practice were over. Get used to it! I am not convinced. What has happened is that ‘government led population / public health’ has gobbled up ‘personal doctoring’. For the latter, it appears, you will need more than the NHS.
  2. Many epidemiologists argued that there was no need for CCUs as no RCTs had shown their benefit. Ditto for parachutes, renal transplantation , no doubt.
  3. You can insert your own favourite de jour: Pfizer and Flynn for raising the price of an anti-epilepsy drug by up to 2,600 per cent, or GSK, or Crapita, Test and Trace etc. The list goes on, well before we get to the likes of Facebook or the Financial Services Industry

On Idle thoughts and Flexner

by reestheskin on 18/11/2020

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I have previously commented on Abraham Flexner on this site. The Flexner report is the most influential review of US medical education ever published, although some would argue that the changes it recommended were already working their way through the system. For a long time I was unaware of another project of his, an article with the title The Usefulness of Useless Knowledge 1. For me, there are echoes of Bertrand Russell’s In Praise of Idleness and the fact that Flexner’s essay was published at the onset of World War 2 adds anther dimension to the topic.

As for medical education, the ever-growing pressure is to teach so much that many students don’t have time to learn anything. I wish some other comments from Flexner opened any GMC dicta on what a university medical education should be all about.

“Now I sometimes wonder,” he wrote, “whether there would be sufficient opportunity for a full life if the world were emptied of some of the useless things that give it spiritual significance; in other words, whether our conception of what is useful may not have become too narrow to be adequate to the roaming and capricious possibilities of the human spirit.”

  1. The essay originally published in Harper’s Magazine was republished with a companion essay by Robbert Dijkgraaf by Princeton University Press in 2017.

Inside the Leviathan

“I work for a government I despise for ends I think criminal.”

John Maynard Keynes, 1917, in a letter to Duncan Grant.

The above quote via John Naughton who commented

I wonder how many officials in the US and UK governments currently feel the same way.

Sinking ships

by reestheskin on 17/11/2020

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Following on from the previous post, here is a bit more economics, surely germane to Deaton and Case’s work, and which provides yet another example of where the ‘observation’ (‘facts’) may, if not shout for themselves, at least whisper that something important is going on. The graphs are from Saez and Zucman’s The Triumph of Injustice. Note the timeline for each graph.

On rejection by editors and society

by reestheskin on 16/11/2020

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The history of science is the history of rejected ideas (and manuscripts). One example I always come back to is the original work of John Wennberg and colleagues on spatial differences in ‘medical procedures’ and the idea that it is not so much medical need that dictates the number of procedures, but that it is the supply of medical services. Simply put: the more surgeons there are, the more procedures that are carried out1. The deeper implication is that many of these procedures are not medically required — it is just the billing that is needed: surgeons have mortgages and tuition loans to pay off. Wennberg and colleagues at Dartmouth have subsequently shown that a large proportion of the medical procedures or treatments that doctors undertake are unnecessary2.

Wennberg’s original manuscript was rejected by the New England Journal of Medicine (NEJM) but subsequently published in Science. Many of us would rate Science above the NEJM, but there is a lesson here about signal and noise, and how many medical journals in particular obsess over procedure and status at the expense of nurturing originality.

Angus Deaton and Anne Case, two economists, the former with a Nobel Prize to his name, tell a similar story. Their recent work has been on the so-called Deaths of Despair — where mortality rates for subgroups of the US population have increased3. They relate this to educational levels (the effects are largely on those without a college degree) and other social factors. The observation is striking for an advanced economy (although Russia had historically seen increased mortality rates after the collapse of communism).

Coming back to my opening statement, Deaton is quoted in the THE

The work on “deaths of despair” was so important to them that they [Deaton and Case] joined forces again as research collaborators. However, despite their huge excitement about it, their initial paper, sent to medical journals because of its health focus, met with rejections — a tale to warm the heart of any academic whose most cherished research has been knocked back.

When the paper was first submitted it was rejected so quickly that “I thought I had put the wrong email address. You get this ping right back…‘Your paper has been rejected’.” The paper was eventually published in Proceedings of the National Academy of Sciences, to a glowing reception. The editor of the first journal to reject the paper subsequently “took us for a very nice lunch”, adds Deaton.

Another medical journal rejected it within three days with the following justification

The editor, he says, told them: “You’re clearly intrigued by this finding. But you have no causal story for it. And without a causal story this journal has no interest whatsoever.”

(‘no interest whatsoever’ — the arrogance of some editors).

Deaton points out that this is a problem not just for medical journals but in economics journals, too; he thinks the top five economics journals would have rejected the work for the same reason.

“That’s the sort of thing you get in economics all the time,” Deaton goes on, “this sort of causal fetish… I’ve compared that to calling out the fire brigade and saying ‘Our house is on fire, send an engine.’ And they say, ‘Well, what caused the fire? We’re not sending an engine unless you know what caused the fire.’

It is not difficult to see the reasons for the fetish on causality. Science is not just a loose-leaf book of facts about the natural or unnatural world, nor is it just about A/B testing or theory-free RCTs, or even just ‘estimation of effect sizes’. Science is about constructing models of how things work. But sometimes the facts are indeed so bizarre in the light of previous knowledge that you cannot ignore them because without these ‘new facts’ you can’t build subsequent theories. Darwin and much of natural history stands as an example, here, but my personal favourite is that provided by the great biochemist Erwin Chargaff in the late 1940s. Wikipedia describes the first of his ‘rules’.

The first parity rule was that in DNA the number of guanine units is equal to the number of cytosine units, and the number of adenine units is equal to the number of thymine units.

Now, in one sense a simple observation (C=G and A=T), with no causal theory. But run the clock on to Watson and Crick (and others), and see how this ‘fact’ gestated an idea that changed the world.

  1. The original work was on surgical procedures undertaken by surgeons. Medicine has changed, and now physicians undertake many invasive procedures, and I suspect the same trends would be evident.
  2. Yes, you can go a lot deeper on this topic and add in more nuance.
  3. Their book on this topic is Deaths of Despair and the Future of Capitalism published by Princeton Universty Press.

A carry-on of professors

by reestheskin on 11/11/2020

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There was a touching obituary of Peter Sleight in the Lancet. Sleight was a Professor of Cardiovascular Medicine at Oxford and the obituary highlighted both his academic prowess and his clinical skills. Hard modalities of knowledge to combine in one person.

Throughout all this, at Oxford’s Radcliffe Infirmary and John Radcliffe Hospital, Sleight remained an expert bedside clinician, who revelled in distinguishing the subtleties of cardiac murmurs and timing the delays of opening snaps.

And then we learn

An avid traveller, Sleight was a visiting professor in several universities; the Oxford medical students’ Christmas pantomime portrayed him as the British Airways Professor of Cardiology. [emphasis added]

This theme must run and run, and student humour is often insightful (and on occasion, much worse). I worked somewhere where the nickname for the local airport was that of a fellow Gold Card professor. We often wondered what his tax status was.

The pleasure of words(and beer) in the second age of COVID-19

by reestheskin on 10/11/2020

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A letter from Colin Mills (Basel) in last week’s Economist

Milk, beer and sweets were listed as “basic necessities” supplied by corner shops, which are thriving during the pandemic (“Turning a corner”, October 17th). Two of the three can hardly be considered necessities. Sweets are bad for you, and many people live perfectly happily without drinking milk.

Cream rises

by reestheskin on 08/11/2020

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From the obit of the 007 in the Economist.

Sean Connery as James Bond simply is British manhood: good-mannered, patriotic, entitled.
Both went to Fettes College in Edinburgh, Mr Bond after he was reputedly expelled from Eton, Mr Connery to deliver milk from a barrow. He grew up in Fountainbridge, which used to be known as Foulbridge for the open sewer that ran through it.

And why those milky early morning thoughts matter.

In playing Bond, I had to start from scratch,” he pointed out to an interviewer just after “Dr No” opened. “Nobody knows anything about him, after all. Not even Fleming.”

Breaking bad

by reestheskin on 02/11/2020

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From this week’s Economist | Breaking through

Yet nowhere too little capital is being channelled into innovation. Spending on R&D has three main sources: venture capital, governments and energy companies. Their combined annual investment into technology and innovative companies focused on the climate is over $80bn. For comparison, that is a bit more than twice the R&D spending of a single tech firm, Amazon.

Market and state failure may go together. Which brings me back to Stewart Brand’s idea of Pace Layering

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.

Pace Layering: How Complex Systems Learn and Keep Learning

I won’t even mention COVID-19.

Fail. Fail again. Fail better.

by reestheskin on 28/10/2020

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I came across a note in my diary from around fifteen years ago. It was (I assume) after receiving a grant rejection. For once, I sort of agreed with the funder’s decision1. I wrote:

My grant was trivial, at least in one sense. Neils Bohr always said (or words to the effect) that the job of science was to reduce the profound to the trivial. The ‘magical’ would be made the ordinary of the everyday. My problem was that I started with the trivial.

As for the merits of review: It’s the exception that proves the rule.

  1. Bert Vogelstein, who I collaborated with briefly in the 1990s, after seeing our paper initially rejected by the glossy of the day , informed me that the only sensible personal strategy was to believe that reviewers are always wrong.

You can learn but you cannot teach.

by reestheskin on 27/10/2020

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I have posted on this topic before, but the comments below speak to me more now than ever. They are reflections on the philosopher Michael Ignatieff’s failed attempt to run for political office in Canada. He wrote a book about these events which is highly recommended (I haven’t read it, yet). A comment on the article, He brought a syllabus to a gun fight and lost, should be understood by all those who wish to protect the academy from the current gangs of populists.

“One of the things that is extremely challenging to my teaching now is the possibility that there are some things you can learn only from experience and can’t be taught. The pathos of teaching is that some things can’t be taught — and one of them might be political judgement. I don’t think that’s a despairing thought, but it does induce humility in a teacher and make the job much more interesting.”

A comment on this article is below

As someone who spent time with Ignatieff on the hustings and whose baby he has indeed kissed, I can say with some confidence that normatively desirable outcomes never address which end of the sign stake goes in the ground. He brought a syllabus to a gun fight and lost. Canada lost more. Comment from Steven McGannety [emphasis added]

THE

2014:The UK is sleepwalking towards disintegration

by reestheskin on 26/10/2020

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It remains overwhelmingly likely that Scotland will vote in September to remain part of the union. But it is also more likely that the UK is sleepwalking towards disintegration — not in this vote but in the next. Political leaders were wrong to think they would bind the UK together through devolution, and they are probably wrong to believe giving more power to Edinburgh will now have that effect. These moves only strengthen the sense of a distinct Scottish identity. They need instead to make being British something to be proud of.— John Kay writing in the FT in 2014… 

Doesn’t look good, does it?

On this day 1966: Aberfan

by reestheskin on 21/10/2020

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I don’t remember where I was when JFK died; I was too young. And my brother, Alun,  still chastises me for not remembering where we were  when man first landed on the moon (answer: the West Cork hotel in Skibbereen, watching it on TV). I do however remember when my mother told me that Bobby Kennedy has just died after being shot. For some reason she had picked me up from school that day, and some  fragments of our conversation I can still hear. I would have been ten at the time, but an Irish mother and a Catholic school education, meant that the Kennedy clan were not too recondite for even a small boy to not know about.

There is one other ‘event’ from those 1960s days in Cardiff that I do remember well.  It was closer to home.  On this day, in  1966 I can remember the anguish of both my mother, and my Welsh father who had grown up in the Welsh valleys trapped on all sides by slag heaps, both literally and metaphorically.

From Wikipedia

The Aberfan disaster was the catastrophic collapse of a colliery spoil tip at around 9:15 am on 21 October 1966. The tip had been created on a mountain slope above the Welsh village of Aberfan, near Merthyr Tydfil and overlaid a natural spring. A period of heavy rain led to a build-up of water within the tip which caused it to suddenly slide downhill as a slurry, killing 116 children and 28 adults as it engulfed Pantglas Junior School and other buildings.

The Aberfan Disaster Memorial Fund (ADMF) was set up on the day of the disaster. It received nearly 88,000 contributions, totalling £1.75 million. The remaining tips were removed only after a lengthy fight by Aberfan residents, against resistance from the NCB and the government on the grounds of cost. Clearing was paid for by a government grant and a forced contribution of £150,000 taken from the memorial fund. In 1997 the British government paid back the £150,000 to the ADMF, and in 2007 the Welsh Assembly donated £1.5 million to the fund and £500,000 to the Aberfan Education Charity as recompense for the money wrongly taken.[emphasis added]

Some aspects of one’s politics are formed so young, you just forget where they came from.

Grahame Davies, a poet who writes in Welsh and English wrote the following words about another disaster — not Aberfan — but the deaths of 268 men and boys in an explosion at the Prince of Wales Colliery in Abercarn in 1878. They  seem apposite for my purpose.

We do not ask you to remember us:
you have your lives to live as we had ours,
and ours we spent on life, not memory.
We only ask you this – that you live well,
here, in the places that our labour built,
here, beneath the sky we seldom saw,
here, on the green earth whose black vein we mined,
and feel the freedom that we could not find.

The Aberfan disaster featured in the Netflix drama The Crown. In this dramatisation we learn that the Queen was advised to show some emotion — this was South Wales not the Home Counties. There are some heart-wrenching photographs in an article in the Smithsonian 1 — all the more powerful because they are in black and white. A quote from this article is below:

“A tribunal tasked with investigating the Aberfan disaster published its findings on August 3, 1967. Over the course of 76 days, the panel had interviewed 136 witnesses and examined 300 exhibits. Based on this evidence, the tribunal concluded that the sole party responsible for the tragedy was the National Coal Board.”

“The Aberfan disaster is a terrifying tale of bungling ineptitude by many men charged with tasks for which they were totally unfitted, of failure to heed clear warnings, and of total lack of direction from above,” the investigators wrote in their report. “Not villains but decent men, led astray by foolishness or by ignorance or by both in combination, are responsible for what happened at Aberfan.”

Plenty of them still about.

  1. A History of the Aberfan Disaster From “The Crown” | History | Smithsonian Magazine. MEILAN SOLLYSMITHSONIANMAG.COM | Nov. 15, 2019,https://www.smithsonianmag.com/history/true-story-aberfan-disaster-featured-crown-180973565/

Where there is muck, there is…science

by reestheskin on 20/10/2020

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The background is the observation that babies born by Caesarian have different gut flora than those born vaginally. The interest in gut flora is because many believe it relates causally to some diseases. How do you go about investigating such a problem?

Collectively, these seven women gave birth to five girls and two boys, all healthy. Each of the newborns was syringe-fed a dose of breast milk immediately after birth—a dose that had been inoculated with a few grams of faeces collected three weeks earlier from its mother. None of the babies showed any adverse reactions to this procedure. All then had their faeces analysed regularly during the following weeks. For comparison, the researchers collected faecal samples from 47 other infants, 29 of which had been born normally and 18 by Caesarean section. [emphasis added]

Healthy childbirth — How to arm Caesarean babies with the gut bacteria they need | Science & technology | The Economist

They always put me on hold. Thank You for Being Expendable

Years after I first returned from Iraq and started having thoughts and visions of killing myself, I’d call the Department of Veterans Affairs. They always put me on hold. 

NYT

Statisticians and the Colorado beetle

by reestheskin on 19/10/2020

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‘Statisticians have already overrun every branch of science with a rapidity of conquest rivalled only by Attila, Mohammed, and the Colorado beetle’

Maurice Kendall (1942): On the future of statistics. JRSA 105; 69-80.

Yes, that Maurice Kendall.

It seems to me that when it comes to statistics — and the powerful role of statistics in understanding both the natural and the unnatural world — that the old guys thought harder and deeper, understanding the world better than many of their more vocal successors. And that is without mentioning the barking of the medic-would-be-statistician brigade.

Coetzee on the last great man

by reestheskin on 18/10/2020

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“Like the rest of the leadership of the ANC, he was blindsided by the collapse of socialism worldwide; the party had no philosophical resistance to put up against a new, predatory economic rationalism. Mandela’s personal and political authority had its basis in his principled defense of armed resistance to apartheid and in the harsh punishment he suffered for that resistance. It was given further backbone by his aristocratic mien, which was not without a gracious common touch, and his old-fashioned education, which held before him Victorian ideals of personal integrity and devotion to public service…

… He was, and by the time of his death was universally held to be, a great man; he may well be the last of the great men, as the concept of greatness retires into the historical shadows.” 

JM Coetzee on Nelson Mandela in the NYT