Twenty years of schoolin’ and they put you on the day shift

by reestheskin on 20/10/2017

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Is it medical education or medical training? This is almost an age-old question, one that I am not going to resolve here. But every generation has to ask it anew. Not least because the sands of time keep moving.

In undergraduate medicine, in 2017, I fear we have got this wrong in a big way. Just when the future looks ever more uncertain, when we have to consider how much traditional ideas of medical careers — and even how we conceptualise doctors — is up for grabs, we are ever more focussed on short term goals: not medical education, but short term training (‘produce FY1 doctors’). But of course, the purpose of medical eduction is not to produce FY1 doctors — that is like saying that passing tests is the purpose of education. The purpose of medical education is to equip students to work (usually) in medicine for a lifetime. Graduates must be able to start learning safely in a clinical environment, but the purpose is not to be FY1’s or core medical trainees.

But the other reason that this problem needs revisiting, is that medical education was framed in time when few people went to university, and when spending five years at university seemed unusual. No matter that much of it was ‘training’ rather than education: by comparison with ‘average’ there was some education in there. But what I fear now is that many medical students are being left behind, increasingly ‘trained’ for one employer and one niche, at the cost of their education. A niche that is threatened by ecological change. And to echo a theme of the day, young people are being made to pay (via debt) for what many other corporations rightly accept is their ‘training’ responsibility.

Now, I do not see the solution in making medicine a postgraduate degree (for most), but I think we can start meaningfully thinking about what I would call ‘medicine plus’ degrees. Doing this, means we have to start unpicking ‘training’ and ‘education’ in ways that do not increase costs, and with an eye on the student’s future, not that of the NHS.

MIT’s WoodyFlowers has some interesting things to say in a completely different context (that of the failure of the MOOC movement), but which I think we can meld to our purpose .

The missed opportunity, I argued, involved recognition that education and training are different and that training could be dramatically improved through use of well structured, high quality modules that would help students train themself so person-to-person time could be used for education. Essentially the strategy would outsource training and nonjudgmental grading to digital systems, and thereby free instructors to serve as mentors.

Woodie Flowers

Title: borrowed from “Subterranean Homesick Blues”. There are lots of lines that students of the fees era would do well to reflect on, including: “Don’t follow leaders, Watch the parkin’ meters”.

No HR solution available

by reestheskin on 19/10/2017

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This was a comment on on the political question of our time by Janesh Ganash in the FT, but to me it has a wider relevance, including how we think about higher education. Of course, people will keep perseverating, believing the contrary.

There is no human resources solution to an ideological problem.

Strong and stable: the importance of neither

by reestheskin on 18/10/2017

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Writing was invented to support taxation. Elites’ insatiable appetite for fully domesticated workers boosted forced labour and slavery. It almost comes as a relief to be reminded that the oppressive character of the state was leavened by its own brittleness: rather than precipitating a calamitous slide into chaos, periodic collapse would simply have disassembled larger states into their constituent communities. Plenty of fetters were loosened in the process.

This is not too far from the antifragility, of Taleb

Review of ‘Against the Grain’, by James C Scott in the FT.

Most lawyers don’t make anything except hours.

by reestheskin on 17/10/2017

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This was a quote from an article by an ex-lawyer who got into tech and writing about tech. Now some of by best friends are lawyers, but this chimed with something I came across by Benedict Evans on ‘why you must pay sales people commissions’. The article is here (the video no longer plays for me).

The opening quote poses a question:

I felt a little odd writing that title [ why you must pay sales people commissions]. It’s a little like asking “Why should you give engineers big monitors?” If you have to ask the question, then you probably won’t understand the answer. The short answer is: don’t, if you don’t want good engineers to work for you; and if they still do, they’ll be less productive. The same is true for sales people and commissions.

The argument is as follows:

Imagine that you are a great sales person who knows you can sell $10M worth of product in a year. Company A pays commissions and, if you do what you know you can do, you will earn $1M/year. Company B refuses to pay commissions for “cultural reasons” and offers $200K/year. Which job would you take? Now imagine that you are a horrible sales person who would be lucky to sell anything and will get fired in a performance-based commission culture, but may survive in a low-pressure, non-commission culture. Which job would you take?

But the key message for me is:

Speaking of culture, why should the sales culture be different from the engineering culture? To understand that, ask yourself the following: Do your engineers like programming? Might they even do a little programming on the side sometimes for fun? Great. I guarantee your sales people never sell enterprise software for fun. [emphasis mine].

Now why does all this matter? Well personally, it still matters a bit, but it matters less and less. I am towards the end of my career, and for the most part I have loved what I have done. Sure, the NHS is increasingly a nightmare place to work, but it has been in decline most of my life:  I would not recommend it unreservedly to anybody. But I have loved my work in a university. Research was so much fun for so long, and the ability to think about how we teach and how we should teach still gives me enormous pleasure: it is, to use the cliche, still what I think about in the shower. The very idea of work-life balance was — when I was young and middle-aged at least — anathema. I viewed my job as a creative one, and building things and making things brought great pleasure. This did not mean that you had to work all the hours God made, although I often did. But it did mean that work brought so much pleasure that the boundary between my inner life and what I got paid to do was more apparent to others than to me. And in large part that is still true.

Now in one sense, this whole question matters less and less to me personally. In the clinical area, many if not most clinicians I know now feel that they resemble those on commission more than the engineers. Only they don’t get commission. Most of my med school year who became GPs will have bailed out. And I do not envy the working lives of those who follow me in many other medical specialties in hospital. Similarly, universities were once full of academics who you almost didn’t need to pay, such was their love for the job. But modern universities have become more closed and centrally managed, and less tolerant of independence of mind.

In one sense, this might go with the turf — I was 60 last week. Some introspection, perhaps. But I think there really is more going on. I think we will see more and more people bailing out as early as possible (no personal plans, here), and we will need to think and plan for the fact that many of our students will bail out of the front line of medical practice earlier than we are used to. I think you see the early stirrings of this all over: people want to work less than full-time; people limit their NHS work vis a vis private work; some seek administrative roles in order to minimise their face-to-face practice; and even young medics soon after graduation are looking for portfolio careers. And we need to think about how to educate our graduates for this: our obligations are to our students first and foremost.

I do not think any of these responses are necessarily bad. But working primarily in higher education, has one advantage: there are lost of different institutions, and whilst in the UK there is a large degree of groupthink, there is still some diversity of approach. And if you are smart and you fall outwith the clinical guilds / extortion rackets, there is no reason to stay in the UK. For medics, recent graduates, need to think more strategically. The central dilemma is that depending on your specialty, your only choice might appear to be to work for a monopolist, one which seeks to control not so much the patients cradle-to-grave, but those staff who fall under its spell, cradle-to-grave. But there are those making other choices — just not enough, so far.

An aside. Of course, even those who have achieved the most in research do not alway want to work for nothing, post retirement. I heard the following account first hand from one of Fred Sanger’s previous post-docs. The onetime post-doc was now a senior Professor, charged with opening and celebrating a new research institution. Sanger — a double Laureate — would be a great catch as a speaker. All seemed will until the man who personally created much of modern biology realised the date chosen was a couple of days after he was due to retire from the LMB. He could not oblige: the [garden] roses need me more!

Left and right: where is the difference?

by reestheskin on 16/10/2017

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There are now more demands and requirements placed on higher education institutions than ever before. It’s an unlikely truism, but Conservative governments generally tend to seek to centralise and control universities – in Michael Barber’s language of how policy is made: It’s the difference between “Trust and Altruism” and “Choice and Competition” drifting into “Command and Control.”

Wonke newsletter 16 October 2017

Surpluses from teaching

by reestheskin on 12/10/2017

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Phil McNaull, director of finance at the University of Edinburgh and chair of the British Universities Finance Directors Group, says that “it has been clear for some time” that direct income for research “does not cover the full economic cost of conducting it, and the net deficit is subsidised by other sources”, such as surpluses from teaching.

Quoted in THE, (emphasis mine). Factually, this is true. It is a mistake to believe that the price of things, equates to how much they cost to produce. Look at the differential pricing of home and non-EU students, for instance. Or the gap between the component parts of an iPhone and the retail price. Or why most successful drugs only cost a fraction of what pharma claims is the cost of development. But the possibilities for some sort of arbitrage are there. And in an area in which agents make up their own standards (i.e. higher education), I think a lot more scrutiny is required.

Patents or graduates? I guess the latter are worth more.

Education is an admirable thing,” wrote Oscar Wilde, “but it is well to remember from time to time that nothing that is worth knowing can be taught.

Foundational knowledge

by reestheskin on 11/10/2017

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You don’t learn to draw by knowing how pencils are made

These sort of aphorisms always make me to want to think harder about what exactly is foundational in medical education. The suspicion is that it is far less than we think. Schooling is full of wasted time spent learning things that are of little use, but easy to test, meaning there is little time for students to learn things that are useful.

The case for anatomy in surgery is robust and self-evident. If you remove tumours in the preauricular area or on the temple, you have to know what structures to avoid or which ones may have become compromised. If you ask any competent surgeon they will of course know what these structures are. But when you move into many areas of clinical medicine, I am always amazed by how much competent physicians have forgotten about all these things that were labelled ‘foundational’, and formed the basis of high-stakes exams. It is of course possible to be aware of schema, that structure your behaviour, and be unable to recall them — schema that experts implicitly know and novices don’t. But I suspect we need some sort of minimalism project, to work out how far we can go.

What Toy Story got wrong. And more.

by reestheskin on 10/10/2017

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If we go back to the traditional kindergarten, kindergarten was first invented about 200 years ago. It was explicitly designed to be different than the traditional school, where it was primarily about delivering instruction, delivering information that students who then dutifully wrote down on paper and recited it back. The early kindergartens recognized that something very different was needed for five-year-olds.

And yet:

There’s a real challenge today because even kindergartens are starting to become more like the rest of school with children filling out phonics worksheets and looking at arithmetic flashcards

Interview with Mitch Resnick

Why don’t dentists work privately?

by reestheskin on 09/10/2017

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To some extent, many UK governments have trialled their plans for much of medicine on dentists and dentistry. To some extent, fear of what the ballot box may say, has limited their wishes. But here is a well written piece about dentists and dentistry that should be read by many medics, both as a warning, and a guide to action. Dermatology and dentistry share many genes.

Textbooks and curriculums

by reestheskin on 06/10/2017

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Students pay $300 or more for textbooks explaining that in competitive markets the price of a good should fall to the cost of producing an additional unit, and unsurprisingly regurgitate the expected answers. A study of 170 economics modules taught at seven universities found that marks in exams favoured the ability to “operate a model” over proofs of independent judgment.

The teaching of economics gets an overdue overhaul

So-called norms of so-called reality.

by reestheskin on 05/10/2017

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Just last week, when faced with a report that its advertising numbers promised an American audience that, in certain demographics, well exceeded the number of such humans in existence, judging by U.S. Census Bureau numbers, Facebook told the Wall Street Journal that its numbers “are not designed to match population or census estimates. We are always working to improve our estimates.” Facebook’s intercourse with the public need not adhere to the so-called norms of so-called reality.

Make Mark Zuckerberg Testify

Unrealistic medicine

by reestheskin on 04/10/2017

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There is perhaps too much Machine learning/AI hype in this article — or at least for my taste, but it is well worth a read. The problem the authors are grappling with is perhaps the central intellectual problem modern medicine faces: how formal can our methods become? And how can we use a variety of cognitive prostheses to guide clinical behaviour.

Asking doctors to work harder or get smarter won’t help. Calls to reduce “unnecessary” care fall flat: we all know how difficult it’s become to identify what care is necessary. Changing incentives is an appealing lever for policymakers, but that alone will not make decisions any easier: we can reward physicians for delivering less care, but the end result may simply be less care, not better care.

Informatics — using the term in the broadest possible sense — and the management of expertise, is the central challenge facing medicine and medical care. It is where the action should be. The authors are right about this, but their caution is also true: “The state of our health care system offers little reason for optimism.” Amen. And spare me ‘realistic medicine’.

NEJM

That sort of Celtic lilt

by reestheskin on 03/10/2017

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It was 40 years ago when Carwyn James warned of the dangers of what he called crash-ball centres, players who were being encouraged to feel rather than think. “The boring, unthinking coach continually preaches about mistakes,” he once said. “The creative coach invites his players to make mistakes. This new midfield ‘crash-ball’ is a disaster – hunks of manhood with madness in their eyes, battering-ram bulldozers happy to be picked off on the gain-line by just-as-large hunks from the opposing side. For what? Just to do it all over again.”

Which just shows that Welsh fly-halves (Carwyn James) can be as majestic with their words as their feet. But then if you look at his Wikipedia page, you see he was special in all sorts of ways.

Quoted in the Guardian.

LMS, and what the monks got right.

by reestheskin on 02/10/2017

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KellsFol200rGeneolgyOfChrist.jpg
Public Domain, Link

I dislike LMS (learning management systems). There are lots of reasons for this, but chief is that the ones I have seen are ugly and don’t entice. Universities are increasingly employee facing, rather than student facing (they claim the opposite). LMS are ‘management’ tools, not tools to help you learn. Fit for widgets, not humans. When you go back and look at Gutenberg’s bible or the great illuminated manuscripts you feel the power and pleasure of what the authors intended transmitted via the scribe. The monks understood this — they shared the passion. The web and nascent industry of informal learning for autodidacts is also full of great design (here is an example from Highbrow), even if it usually designed as part of a ‘pop culture’. But not the dismal corporate LMS.

More Big data, rather than Big ideas

by reestheskin on 29/09/2017

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No, I could not run, lead or guide a pharma company. Tough business. But I just hope their executives do not really believe most of what they say. So, in a FT article about the new CE of Novartis, Vas Narasimhan, has vowed to slash drug development costs; there will be a productivity revolution; 10-25 per cent could be cut from the cost of trials if digital technology were used to carry them out more efficiently.

And of course:

(he) plans to partner with, or acquire, artificial intelligence and data analytics companies, to supplement Novartis’s strong but “scattered” data science capability.

I really think of our future as a medicines and data science company, centred on innovation and access (read that again, parenthesis mine)

And to add insult to injury:

Dr Narasimhan cites one inspiration as a visit to Disney World with his young children where he saw how efficiently people were moved around the park, constantly monitored by “an army of Massachusetts Institute of Technology-trained data scientists”.

And not that I am a lover of Excel…

No longer rely on Excel spreadsheets and PowerPoint slides, but instead “bring up a screen that has a predictive algorithm that in real time is recalculating what is the likelihood our trials enrol, what is the quality of our clinical trials”

Just recall that in  2000 it would have been genes / genetics / genomics rather than data / analytics / AI / ML etc

So, looks to me like lots of cost cutting and optimisation. No place for a James Black, then.

Two cultures revisited

by reestheskin on 28/09/2017

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I now add the phrase “learning outcomes” to the list of words and phrases that should never be used, along with “stakeholders,” “imbricate,” “aporia” and “performative.”)

Here.

Of low salaries and high tables

by reestheskin on 27/09/2017

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It was not deliberate policy; it simply seemed to be only men who applied, usually refugees from the twin miseries of academia: low salaries and high tables.

Ah, those were the days…

The Fear Index, Robert Harris

Market failure

by reestheskin on 26/09/2017

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If you don’t like how careless Equifax was with your data, don’t waste
your breath complaining to Equifax. Complain to your government.

Surveillance capitalism fuels the Internet, and sometimes it seems that everyone is spying on you. You’re secretly tracked on pretty much every commercial website you visit. Facebook is the largest surveillance
organization mankind has created; collecting data on you is its business model. I don’t have a Facebook account, but Facebook still keeps a surprisingly complete dossier on me and my associations — just in case
I ever decide to join. I also don’t have a Gmail account, because I don’t want Google storing my e-mail. But my guess is that it has about half of my e-mail anyway, because so many people I correspond with have accounts. I can’t even avoid it by choosing not to write to gmail.com addresses, because I have no way of knowing if newperson@company.com is hosted at Gmail.

Bruce Schneier

Incarceration as the educational business model. Medium

Staying sharp

by reestheskin on 25/09/2017

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For obvious reasons, it’s difficult for researchers to know just how common the “smart drug” or “neuro-enhancing” lifestyle is. However, a few recent studies suggest cognition hacking is appealing to a growing number of people. A survey conducted in 2016 found that 15% of University of Oxford students were popping pills to stay competitive, a rate that mirrored findings from other national surveys of UK university students. In the US, a 2014 study found that 18% of sophomores, juniors, and seniors at Ivy League colleges had knowingly used a stimulant at least once during their academic career, and among those who had ever used uppers, 24% said they had popped a little helper on eight or more occasions.

The 15 most common smart drugs, and the science behind them — Quartz

Last day

by reestheskin on 22/09/2017

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Like arguing with a table

by reestheskin on 21/09/2017

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When you ask me that question I am gonna revert to my ethnic heritage and answer your question with a question: On what planet do you spend most of your time? As you stand there with a picture of the President defaced to look like Hitler, and compare the effort to increase health care to the Nazis, my answer to you is, as I said before, it is a tribute to the First Amendment that this kind of vile, contemptible nonsense is so freely propagated. Ma’am, trying to have a conversation with you would be like arguing with a dining room table: I have no interest in doing it.

Barney Frank, in response to questioner at a town-meeting in Dartmouth, Massachusetts, broadcast on CNN (18 August 2009).

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So-called norms of so-called reality.

by reestheskin on 20/09/2017

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Just last week, when faced with a report that its advertising numbers promised an American audience that, in certain demographics, well exceeded the number of such humans in existence, judging by U.S. Census Bureau numbers, Facebook told the Wall Street Journal that its numbers “are not designed to match population or census estimates. We are always working to improve our estimates.” Facebook’s intercourse with the public need not adhere to the so-called norms of so-called reality.

Make Mark Zuckerberg Testify

Equal opportunities for all adipocytes

by reestheskin on 19/09/2017

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For some companies, that can mean specifically focusing on young people, as Ahmet Bozer, president of Coca-Cola International, described to investors in 2014. “Half the world’s population has not had a Coke in the last 30 days,” he said. “There’s 600 million teenagers who have not had a Coke in the last week. So the opportunity for that is huge.”

How Big Business Got Brazil Hooked on Junk Food – The New York Times

Somewhere else, for a few days

by reestheskin on 18/09/2017

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Its housing, but not as we know it.

by reestheskin on 13/09/2017

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The developers can get away with such things, because student housing doesn’t officially classify as housing. It falls into the murky category of “sui generis” (Latin for “of its own kind”). As it falls outside a specific use class, it doesn’t have to adhere to the usual standards associated with dwellings (class C3). Local authorities differ in the their approaches, but student accommodation is usually either treated as a hotel (C1) or residential institution (C2), the same category as care homes, hospitals and boarding schools. Due to their limited occupation, these building types are immune from many of the codes that govern residential dwellings – from space standards to daylight and acoustics. At the same time, crucially, the developer is exempt from providing any contribution towards affordable housing.

Guardian

In praise of idle thoughts

by reestheskin on 12/09/2017

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I was browsing through some old noes and came across this:

Third, we’re convinced that medical education and training must be reinvented to adapt to the changing health care paradigm. We think that AHCs should reexamine traditional beliefs and approaches to medical education, questioning its cost and duration. Should education shift toward using dedicated instructors, increased online instruction, simulation, even gaming? Can AHCs shorten training time by streamlining the educational continuum — for example, providing a focused 3-year medical school curriculum in primary care, plus a 2-to-3-year residency?

NEJM

Got the fags; got the phone…

by reestheskin on 11/09/2017

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It’s almost vanishingly rare that we pick a new device that we always have with us,” the historian of mobile technology Jon Agar says. “Clothes—a Paleolithic thing? Glasses? And a phone. The list is tiny.

In 2014, Wall Street analysts attempted to identify the world’s most profitable product, and the iPhone landed in the top slot—right above Marlboro cigarettes. The iPhone is more profitable than a relentlessly marketed drug that physically addicts its customers.

The One Device, Brian Merchant

The vandals in the cathedrals

by reestheskin on 08/09/2017

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“It’s not that the undergraduate education is better at Ivies than at other private universities. (In fact, Ivies almost certainly provide a worse education than many obscure liberal arts colleges that may have loose admissions standards but provide very intensive and personal instruction.) It does mean that, in the current budget situation, pretty much any private college will provide a much, much better education in the liberal arts and social sciences than any public university — except the rare ones that operate like liberal arts colleges, like William & Mary or SUNY-New Paltz.

This wasn’t always true. (In 1970, Berkeley spent 70 percent as much per student, from all funding sources, as Stanford. As of a few years ago the figure was 30 percent and now I bet it’s more like 20 percent. With those numbers, there’s no way that the private-public distinction is a matter of fancy gyms and climbing walls.) I wish it weren’t true now. And none of this necessarily means you’re wrong about how to fund higher education: subsidizing students to attend the Ivies in some ways may widen the gap I’ve just mentioned.”

Public vs. Private Universities: A Reply From the Trenches – Mother Jones