Schools will undoubtedly still exist, but a good schoolteacher can do no better than to inspire curiosity which an interested student can then satisfy at home at the console of his computer outlet. There will be an opportunity finally for every youngster, and indeed, every person, to learn what he or she wants to learn in his or her own time, at his or her own speed, in his or her own way. Education will become fun because it will bubble up from within and not be forced in from without.
Not in this world, I would add, or at last not yet. Many — possibly most — medical students view university as akin to clearing airport security: a painful necessit if you want to go somehwere. They are no more generous about their schooling.
Bruce Charlton pointed me to this entry in Wikipedia on Seymour Cray
“One story has it that when Cray was asked by management to provide detailed one-year and five-year plans for his next machine, he simply wrote, “Five-year goal: Build the biggest computer in the world. One year goal: One-fifth of the above.” And another time, when expected to write a multi-page detailed status report for the company executives, Cray’s two sentence report read: “Activity is progressing satisfactorily as outlined under the June plan. There have been no significant changes or deviations from the June plan.”
Which brings to mind Sydney Brenner’s comments that eventually requests for research grant funding will eventually resemble flow diagrams recording who reports to who.
His second point, desperately urgent in these early months of Boris Johnson’s administration, is that the law has often stood up for open government and rejected the establishment’s ingrained secrecy. Most people probably assume that when a government decision lands before a court, the judges move to the bench with a bucket of Cabinet Office whitewash ready beside their chairs. This has often been true in the past. Now it is not.
One can but only hope that the whitewash is less scarce than protection.
A query with the catchy expression “global pandemic” or “global pandemic preparedness” in scientific databases, restricted to a 2009–19 range, will return more than 1400 results in JAMA (Journal of the American Medical Association), 30 in-depth papers in ArXiv (Cornell University), and a stunning 17,000 results in Google Scholar, which aggregates multiple repositories. As for the general public, it had the choice between no less than 98 TED Talks on the matter.
We had no excuses.
Just before the H1N1 episode in 2009, France had accumulated an inventory of 1 billion high protection masks (N95 equivalent). It was the consequence of the SARS epidemic. In the same way, the government had stored 20 million doses of vaccine. Later, the Health Ministry responsible for this precaution was blasted for this “excessive” stockpile — which was eventually destroyed as it decayed.
Frederik Filloux makes (and has for a while been making) an argument about journalism and journalism schools that I have not seen advanced by anybody else. The changing economics of the press mean that the modern Fourth Estate lacks expertise across many domains of modern life. He suggests that journalism schools need to regroup and change how they work and take advantage of the fact that most expertise will reside with those who did not go to journalism school in their 20’s. Rather, the press will need to rely on those with professional skills gained in particular domains. He writes:
The shortage of experts is also rooted in a priority shift that plagues major news organizations. All of them became obsessed with not being left in the dust by digital-native organizations riding the wave of social networks. As a consequence, newsroom managers, supported by bean-counters, found it clever to hire bunches of expendable digital “content” serfs who were mandated to keep up with the social frenzy. It was seen as a better investment than keeping a former doctor turned medical correspondent, even if he or she was loaded with decades of expertise, able to lean on a reliable network on practitioners, surgeons, epidemiologists, public health officials, etc. A pure cost vs. benefit choice, and ultimately a bad one.
I do not think there will be any shortage of candidates who possess medical degrees and medical experience.
We are living in dark times, and since I have been sifting through the ashes of a career, it is no surprise that failures signal through like radioactive tracers. Below is one.
Through most of my career I have been interested in the relation between science and medicine. In truth, if what matters is what you think about in the shower, I have been more interested in the relation between science and medicine than I have been interested in either activity in isolation. If I were to use a phrase to describe my focus, although it is a term that I would not have used then, I am interested in the epistemological foundations of medical practice. Pompous, I agree. I could use another phrase: what makes medicine and doctors useful? Thinking about statistical inference is a part of this topic, but there is much more to explore.
These issues became closer to my consciousness soon after I moved to Edinburgh. My ideas about what was going on were not shared by many locally, and I was nervous about going public in person rather than in print at a Symposium hosted by the Royal College of Physicians of Edinburgh. My nervousness was well founded: whilst I liked my abstract, my talk went down badly. Not least because it was truly dreadful (and the evident failure still rankles). Jan Vandenbroucke, one of the other speakers and somebody whose work I greatly admire (his paper in the Lancet, Homoeopathy trials: Going nowhere. [Lancet.1997;350:824], was to me the most important paper published in the Lancet in the 1990s), said some kind words to me afterwards, muttering that I had tried to say far too much to an audience that was ill prepared for my speculations. All true, but he was just being kind. It was worse than that.
Anyway, some tidying up deep in my hard drive surfaced the abstract. I still like it, but it is a shame that at the appropriate time I was unable to explain why.
JAMES LIND SYMPOSIUM: From scurvy to systematic reviews and clinical guidelines: how can clinical research lead to better patient care? (31-10-2003, RCPE Edinburgh)
Guidelines, Automata, Science and Algorithms
There are three great branches of science: theory, experiment, and computation. (Nick Trefethen)
Advance in the mid-third of the twentieth century, the golden age of medical research, was predicated on earlier discoveries in the nineteenth century in both physiology and medicinal chemistry (1). Genetics dominated biology in the latter third of the twentieth century and many believe changes in medical practice will owe much to genetics over the next third-century (1). I disagree, and I will give an alternative view more credence: in 30 years’ time we will look back more to Neumann and Morgenstern than we will to Watson and Crick. What the Nobel laureate Herbert Simon referred to as The Sciences of the Artificial (2), subjects which have largely been peripheral to medicine, will become central.
Over the last 20 years we have seen the first (largely inadequate, I would add) attempts to explicitly demarcate methods of obtaining and promulgating knowledge about clinical practice (3,4). This has usually taken the form of proselytising a particular set of terms – systematic reviews, evidence-based practice, guidelines and the like, terms that have little to commend them or rigour. What is interesting, however, is that they reflect a long overdue renaissance of interest with the practice of medicine and medical epistemology.
The change of emphasis from the natural to the artificial is being driven by a number of forces, mostly extraneous to biomedicine: the increasing instrumental role of science in medicine and society; the increase in corporatisation of knowledge, whether by private corporations or monopsonistic institutions like the NHS (5); the rising costs of healthcare; and a remaining inability to frame questions with broad support about how to chose between alternative disease states at the level of society (6,7).
I will try to illustrate some of these issues by the use of three examples. First, the widespread use of a mode of statistical inference largely ill-suited to medicine, namely Neyman-Pearson hypothesis testing (decision-making), and the way in which this paradigm has been used to undermine expert opinion (8). Second, I will argue that we need to think much harder about clinical practice and fashion a more appropriate theoretical underpinning for clinical behaviour. Third, I will suggest how UK medical schools, in so far as they remain interested in clinical practice, should look to alternative models, perhaps business and law schools, for ideas of how they should operate (2).
Rees J. Complex disease and the new clinical sciences. Science 2002; 296:698-700.
Simon HA. The sciences of the artificial. Cambridge, Mass. MIT Press; 1969
Rees J. Evidence-based medicine: the epistemology that isn’t. J Am Acad Dermatol 2000; 43:727-9.
Rees J. Two cultures? J Am Acad Dermatol 2002; 46:313-16.
Hacking I. The emergence of probability: a philosophical study of early ideas about probability, induction and statistical inference. Cambridge: Cambridge University Press; 1975.
Ziman J. Real science. Cambridge: Cambridge University
Ziman J. Non-instrumental roles of science. Sci Eng Ethics
Gigerenzer G, Swijtink Z, Porter T et al. The empire of chance: how probability changed science and everyday life. Cambridge: CUP; 1989.
Afterword. The symposium used structured abstracts, a habit that might have a place somewhere in this galaxy, but out of choice I would prefer to live in another one. Anyway, in the published version, it reads:
A majority of people in Britain now in their seventies spent some of their childhood growing up in social housing — almost entirely in council houses. When someone of that generation tells you that they grew up in a council house, they are telling you that they were normal. (Danny Dorling, Times Higher Education, 13-2-2020, p46)
And please don’t get me started on the ‘first in my family to go to uni’ trope so beloved of many in academia.
In one of Paul Graham’s essays, he writes about the relation between a thriving society and how parents behave (he does not use these terms). He argues that whilst it is natural for parents to seek advantage for their (own) children, in the interests of efficiency, society should try to to limit this tendency. I agree but the details matter.
In the LRB there is a review written by Adam Swift of a few books that deal with this topic. And for those who like to sell higher educationhigher education, the review makes uncomfortable reading.
Education, which promised to be the solvent that would lessen the class structure, has become an effective means of preserving it.
That used not to be obvious to me. Swift however pulls out a lovely quote that illuminates much of the smug complacency shown by some of the ‘educated classes’ and how they see the world. Many of our current political troubles have cognate origins.
Robin Cook’s memoir repeats a story told by a journalist to Roy Hattersley. Tony Blair, asked why he had sent his son Euan to the Oratory, despite the inevitable political flak, said: ‘Look at Harold Wilson’s children.’ The journalist demurred: one of Wilson’s sons had become a headmaster, the other a university professor. Blair replied that he certainly hoped his children would do better than that.
People are always demanding that medical students must learn this or that (obesity, psychiatry, dermatology, ID, eating disorders). The result is curriculum overload, a default in favour of rote learning by many students, and the inhibition of curiosity. It was not meant to be like this, but amongst others, the GMC, the NHS, and others have pushed a vision of university medical education that shortchanges both the students and medical practice over the long term. Short-termism rules. Instead of producing graduates who are ready to learn clinical medicine is an area of their choice, we expect them to somehow come out oven-ready at graduation. I do not believe it is possible to do this to a level of safety that many other professions demand, nor is this the primary job of a university. Sadly, universities have given up on arguing, intimidated by the government and their regulatory commissars, and nervous of losing their monopoly on producing doctors.
But I will make a plea that one area really does deserve more attention within a university : the history of how medical advance occurs. No, I do not mean MCQs asking for the date of birth of Robert Koch or Lord Lister, but a feel for the historical interplay of convention and novelty. Without this our students and our graduates are almost confined to living in the present, unaware of the past, and unable to doubt how different the future will be. Below is one example.
”In 1938 Albert Hofmann, a chemist at the Sandoz Laboratories in Basel, created a series of new compounds from lysergic acid. One of them, later marketed as Hydergine, showed great potential for the treatment of cerebral arteriosclerosis. Another salt, the diethylamide (LSD), he put to one side, but he had “a peculiar presentiment,” as he put it in his memoir LSD: My Problem Child (1980), “that this substance could possess properties other than those established in the first investigations.
In 1943 he prepared a fresh batch of LSD. In the final process of its crystallization, he started to experience strange sensations. He described his first inadvertent “trip” in a letter to his supervisor:
At home I lay down and sank into a not unpleasant, intoxicated-like condition, characterized by extremely stimulated imagination. In a dream-like state, with eyes closed (I found the daylight to be unpleasantly glaring), I perceived an uninterrupted stream of fantastic pictures, extraordinary shapes with intense, kaleidoscopic play of colors.
After eliminating chloroform fumes as a possible cause, he concluded that a tiny quantity of LSD absorbed through the skin of his fingertips must have been responsible. Three days later he began a program of unsanctioned research and deliberately ingested 250 micrograms of LSD at 4:20 PM. Forty minutes later, he wrote in his lab journal, “Beginning dizziness, feeling of anxiety, visual distortions, symptoms of paralysis, desire to laugh.” He set off home on his bicycle, accompanied by his laboratory assistant. This formal trial of what Hofmann considered a minute dose of LSD had more distressing effects than his first chance exposure:
Every exertion of my will, every attempt to put an end to the disintegration of the outer world and the dissolution of my ego, seemed to be wasted effort. A demon had invaded me, had taken possession of my body, mind, and soul. I jumped up and screamed, trying to free myself from him, but then sank down again and lay helpless on the sofa…. I was taken to another world, another place, another time.
A doctor was summoned but found nothing amiss apart from a marked dilation of his pupils. A fear of impending death gradually faded as the drug’s effect lessened, and after some hours Hofmann was seeing surreal colors and enjoying the play of shapes before his eyes.
Many editors of learned medical journals now automatically turn down publications describing the sort of scientific investigation that Albert Hofmann carried out on himself. Institutional review boards are often scathing in their criticism of self-experimentation, despite its hallowed tradition in medicine, because they consider it subjective and biased. But the human desire to alter consciousness and enrich self-awareness shows no sign of receding, and someone must always go first. As long as care and diligence accompany the sort of personal research conducted by Pollan and Lin, it has the potential to be as revealing and informative as any work on psychedelic drugs conducted within the rigid confines of universities.
Imagine if the entire edifice of knowledge in medicine was built upon a falsehood. Systematic reviews are said to be the highest standard of evidence-based health care. Regularly updated to ensure that treatment decisions are built on the most up-to-date and reliable science, systematic reviews and meta-analyses are widely used to inform clinical guidelines and decision making. Powerful organisations have emerged to construct a knowledge base in medicine underpinned by the results of systematic reviews. One such organisation is Cochrane, with 11 000 members in over 130 countries. This extraordinary movement of people is justifiably passionate about the idea that it is contributing to better health outcomes for everyone, everywhere. The industry that drives the production of systematic reviews today is financed by some of the most influential agencies in medical research. Cochrane, for example, points to three funders providing over £1 million each—the UK’s National Institute for Health Research (NIHR), the US National Institutes of Health (NIH), and Australia’s National Health and Medical Research Council (NHMRC).
Well, it really is a bit late for all this soul searching. See my earlier post here ‘Mega-silliness’ (commenting on what others had already pointed out); or my Evidence Based Medicine: the Epistemology That Isn’t, written over 20 years ago; and my contribution to the wake (even if I didn’t put my hand in my pocket), Why we should let “evidence-based medicine” rest in peace. The genesis of EBM was as a cult whose foundational myth was that P values could act as a true machine. Those followers who had originally hoped for a place in the promised afterlife, soon settled for paying the bills, and EBM morphed into a career opportunity for those who found accountancy too daring. So, pace John Mayall on Jazz Blues Fusion, don’t come here to listen to an old record. I promise.
Two weeks ago, I swabbed my first positive Covid-19 patient during an A&E Locum shift. I must say back then, I hadn’t fully taken in what we as a country will have to face over the coming months. The reports from colleagues in Italy and China are beyond belief.
The UK has been left to fight Covid-19 with half the Intensive Care beds per capita of Italy. Back in 2014, the trigger for my whistleblowing case was my attempt to try and secure more ICU resources for South East London (see Private Eye).
Instead of spending 5 years and £700k fighting /smearing me and damaging whistleblowing law, the NHS could have just fixed the problem. There has never been a more important time for the public and the politicians to understand Intensive Care resourcing and what is decided on their behalf by NHS leaders.
The world is so big, so complicated, so replete with marvels and surprises that it takes years for most people to begin to notice that it is, also, irretrievably broken. We call this period of research “childhood.”
There follows a program of renewed inquiry, often involuntary, into the nature and effects of mortality, entropy, heartbreak, violence, failure, cowardice, duplicity, cruelty, and grief; the researcher learns their histories, and their bitter lessons, by heart. Along the way, he or she discovers that the world has been broken for as long as anyone can remember, and struggles to reconcile this fact with the ache of cosmic nostalgia that arises, from time to time, in the researcher’s heart: an intimation of vanished glory, of lost wholeness, a memory of the world unbroken. We call the moment at which this ache first arises “adolescence.” The feeling haunts people all their lives.
Everyone, sooner or later, gets a thorough schooling in brokenness. The question becomes: What to do with the pieces? Some people hunker down atop the local pile of ruins and make do, Bedouin tending their goats in the shade of shattered giants. Others set about breaking what remains of the world into bits ever smaller and more jagged, kicking through the rubble like kids running through piles of leaves. And some people, passing among the scattered pieces of that great overturned jigsaw puzzle, start to pick up a piece here, a piece there, with a vague yet irresistible notion that perhaps something might be done about putting the thing back together again.
Statistical significance and clinical evidence
Two letters in Lancet Oncology. This bloody story never ends. We have not invented truth machines: judgement has never been exiled from discovery.
I wish I had said that
In discussing some aspects of Higher Education, Dennis Tourish writes:
On all sides, it seems that long-term loyalty is an idea without a long-term future.
Stanley Cohen has died. A special place for those of us hooked on the ectoderm. Some nice comments about him in the Lancet from Geoff Watts.
A May, 1962, issue of the Journal of Biological Chemistry included a deceptively arcane study on the isolation of a protein that could accelerate incisor eruption and eyelid opening in newborn mice. The author, Stanley Cohen, later to become Professor Emeritus of Biochemistry at Vanderbilt University School of Medicine (VUSM) in Nashville, TN, USA, had named his protein “tooth-lid factor”. Cohen’s subsequent studies would not only lead him to rename the protein epidermal growth factor (EGF), but also mark him out as one of the founders of a new area of biology and eventually win him a Nobel Prize.
[says Lawrence Marnett], “When he came here he began studying some growth factors in animal cell extracts. One was of mouse submaxillary gland…It had peptides in it, and when he injected them into newborn mice their teeth broke though earlier than normal, and their eyelids opened sooner.” Cohen’s subsequent studies revealed that his extract worked by stimulating the growth of epidermal cells. Having consequently renamed the material EGF, he devoted the rest of his career to studying it. “He went on to identify the EGF receptor and define target cells that would respond to EGF”, recalls Graham Carpenter, Emeritus Professor of Biochemistry at VUSM, who joined Cohen’s lab in 1973 and worked with him on EGF as a postdoctoral fellow. The EGF receptor proved to be a useful target for drugs, and Cohen’s discoveries opened the door to research on diseases ranging from dementia to cancer. “He understood EGF’s biological importance”, says Carpenter. “But we did not have any idea that this would extend to cancer biology in a major way.”
And as for that most successful of all biology labs, the style of exploration is familiar.
[Graham Carpenter] “In contrast to today, his research group was very small, seldom more than four people—himself, two technicians, and a postdoc…He was central to whatever was going on in the lab.” [Lawrence] Marnett also recalls that determination: “He was one of those guys that was just driven by his desire to understand how things work…It was a classic example of making an observation and then drilling down to try to understand it, not knowing what you’re going to find.” And at that time there was plenty to be found. Cohen, as Marnett puts it, was basically “mining gold”.
Since he shared every passing observation online, it was not surprising that on December 30th he put up a post about an odd cluster of pneumonia cases at the hospital. They were unexplained, but the patients were in quarantine, and they had all worked in the same place, the pungent litter-strewn warren of stalls that made up the local seafood market. Immediately this looked like person-to-person transmission to him, even if it might have come initially from bats, or some other delicacy. Immediately, too, it raised the spectre of the sars virus of 2002-03 which had killed more than 700 people. He therefore decided to warn his private WeChat group, all fellow alumni from Wuhan University, to take precautions. He headed the post: “Seven cases of sars in the Huanan Wholesale Seafood Market”. That was his mistake.
The trouble was that he did not know whether it was actually sars. He had posted it too fast. In an hour he corrected it, explaining that although it was a coronavirus, like sars, it had not been identified yet. But to his horror he was too late: his first post had already gone viral, with his name and occupation undeleted, so that in the middle of the night he was called in for a dressing down at the hospital, and January 3rd he was summoned to the police station.
But most of Case and Deaton’s ire focuses on the health care industry, which not only underperforms but is also wrecking the US economy. We [USA] spend twice per capita what France spends on health care, but our life expectancy is four years shorter, our rates of maternal and infant death are almost twice as high, and, unlike the French, we leave 30 million people uninsured. The amount Americans spend unnecessarily on health care weighs more heavily on our economy, Case and Deaton write, than the Versailles treaty reparations did on Germany’s in the 1920s. If, decades ago, we’d built a health system like Switzerland’s, which costs 30 percent less per capita than ours does, we’d now have an extra trillion dollars a year to spend, for example, on replacing the pipes in the nearly four thousand US counties where lead levels in drinking water exceed those of Flint, Michigan, and on rebuilding America’s bridges railroads, and highways—now so rundown that FedEx replaces delivery van tires twice as often as it did twenty years ago.
In the US, health insurance accounts for 60 percent of the cost of hiring a low-wage worker. Many employers opt instead to hire contract workers with no benefits, or illegal immigrants with no rights at all.
Terrific article on Covid-19 (Sars-CoV-2). in the LRB by Rupert Beale. He says written in haste but it doesn’t read that way. It contains some memorable lines.
As the US health secretary Michael Leavitt put it in 2006, ‘anything we say in advance of a pandemic happening is alarmist; anything we say afterwards is inadequate.’
And how do you think hard about research funding for the long term (I am old enough to remember when stroke and dementia were virtually non-subjects as far as ‘good research funding’ was concerned).
Virologists need more than clever tricks: we also need cash. Twenty years ago, funding wasn’t available to study coronaviruses. In 1999, avian infectious bronchitis virus was the one known truly nasty coronavirus pathogen. Only poultry farmers really cared about it, as it kills chickens but doesn’t infect people. In humans there are a number of fairly innocuous coronaviruses, such as OC43 and HKU1, which cause the ‘common cold’. Doctors don’t usually bother testing for them – you have a runny nose, so what?
And note the conditional tense:
The global case fatality rate is above 3 per cent at the moment, and if – reasonable worst case scenario – 30-70 per cent of the 7.8 billion people on earth are infected, that means between 70 and 165 million deaths. It would be the worst disaster in human history in terms of total lives lost. Nobody expects this, because everyone expects that people will comply with efficient public health measures put in place by responsible governments.
And to repeat my own mantra (stolen from elsewhere): the opposite of science is not art, but politics:
The situation isn’t helped by a president [Trump] who keeps suggesting that the virus isn’t that bad, it’s a bit like flu, we will have a vaccine soon: stopping flights from China was enough. Tony Fauci, the director of the National Institute of Allergy and Infectious Disease, deftly cut across Trump at a White House press briefing. No, it isn’t only as bad as flu, it’s far more dangerous. Yes, public health measures will have to be put in place and maintained for many months. No, a vaccine isn’t just around the corner, it will take at least 18 months. Fauci was then ordered to clear all his press briefings on Covid-19 with Mike Pence in advance: the vice president’s office is leading the US response to the virus. ‘You don’t want to go to war with a president,’ Fauci remarked.
And Beale ends by quoting an ID colleague.
This is not business as usual. This will be different from what anyone living has ever experienced. The closest comparator is 1918 influenza.
Caution: pace the author, ‘This is a fast-moving situation, and the numbers are constantly changing – certainly the ones I have given here will be out of date by the time you read this.’
Link. (London Review of Books: Vol. 42 No. 5, 5 March 2020: “Wash your Hands”: Rupert Beale)
I have spend a lot of time recently sifting through the detritus of a career. Finally — well, I hope, finally — I have managed to sort out my books. All neatly indexed in Delicious Library, and now for once the virtual location mirrors the physical location. For how long I do not know. Since I often buy books based on reviews, I used to put a copy of the review in with the book (a habit I have dropped but need to restart). I rediscovered this one by David Colquhoun (DC) reviewing ‘The Diet Delusion’ by Gary Taubes in the BMJ (with the unexpurgated text on his own web site).
I am a big fan of DC as he has lived though the rise and decline of much higher education in the UK. And he remains fearless and honest, qualities that are not always at the forefront of the modern university. Quoting the great Robert Merton he writes:
“The organization of science operates as a system of institutionalized vigilance, involving competitive cooperation. In such a system, scientists are at the ready to pick apart and assess each new claim to knowledge. This unending exchange of critical appraisal, of praise and punishment, is developed in science to a degree that makes the monitoring of children’s behavior by their parents seem little more than child’s play”.
“The institutionalized vigilance, “this unending exchange of critical judgment”, is nowhere to be found in the study of nutrition, chronic disease, and obesity, and it hasn’t been for decades.”
On Taubes and his (excellent book):
It took Taubes five years to write this book, and he has nothing to sell apart from his ideas. No wonder it is so much better than a scientist can produce. Such is the corruption of science by the cult of managerialism that no university would allow you to spend five years on a book
(as would be expected the BMJ omitted the punch line — they would, wouldn’t they?)
There is also a neat quote from Taubes in one of the comments on DC’s page from Beth@IDblog, one that I will try hard not to forget:
Taubes makes a point at the end of the Dartmouth medical grand rounds video that I think is important: “I’m not trying to convince you that it’s true, I’m trying to convince you that it should be taken seriously.”
Nice article in the LRB by Wang Xiuying, ‘The Word from Wuhan’.
(Throwing woks: when everyone denies all responsibility and tries to shift the blame back onto the blamer, they are busy ‘throwing woks’).
Throwing woks is an art you need to understand if you want to get things done in China. Whether you’re building an airport, applying for a research grant or inviting a foreign national to give a talk, you have to fill in so many forms, and get approval from so many departments with all their competing demands, that you risk getting trapped somewhere in the middle: whichever way you turn you risk causing upset or offence in one quarter or another. In the workplace too, a step in the wrong direction can provoke a superior and ruin a career, so that sometimes it’s wisest to do nothing at all. Until a virus strikes, that is.
With couples confined together 24/7, ordinary marital friction soon escalates into all-out war. Domestic servants, often migrants, who went out of town over the Chinese New Year, have been unable to return to work – but someone still has to do the household chores. Men slump on the sofa playing video games or hide behind a laptop pretending to work, while still expecting three meals a day and fresh laundry. A joke went around:
Client: My wife and I have been quarantined together for 14 days and we’ve decided to get back together! I don’t want to go ahead with the divorce. Can you refund the fee?
Lawyer: 14 days … hmmmm … Let’s not rush it: I think we’re still in business.
I have lots of thoughts about why and when I retired (from paid employment). And I do not feel able to dismiss them, nor not introspect on them. The following is a from the ‘The Daily Stoic’ (a retirement gift from Caroline M). Apposite.
Is this the life I really want? Every time you get upset, a little bit of life leaves the body. Are these really the things on which you want to spend that precious resource? Don’t be afraid to make a change – a big one.
I titled a recent post musing over my career as ‘The Thrill is Gone’. But I ended on an optimistic note:
‘The baton gets handed on. The thrill goes on. And on’
But there are good reasons to think otherwise. Below is a quote from a recent letter in the Lancet by Gagab Bhatnaga. You can argue all you like about definitions of ‘burnout’, but good young people are leaving medicine. The numbers who leave for ever may not be large but I think some of the best are going. What worries as much is those who stay behind.
The consequences of physician burnout have been clearly observed in the English National Health Service (NHS). F2 doctors (those who are in their second foundation year after medical school) can traditionally go on to apply to higher specialist training. Recent years have seen an astounding drop in F2 doctors willing to continue NHS training4 with just over a third (37·7%) of F2 doctors applying to continue training in 2018, a decrease from 71·3% in 2011. Those taking a career break from medicine increased almost 3-fold from 4·6% to 14·6%. With the NHS already 10 000 doctors short, the consequences of not recruiting and retaining our junior workforce will be devastating.
In 1992, philosopher Karl Popper wrote: “Science may be described as the art of systematic oversimplification — the art of discerning what we may with advantage omit.” What may be omitted depends on the discipline.
You can say this another way: all experiments do violence to the natural world. We always want to cleave at the joints. But doing so may lead to error.
In 1992, philosopher Karl Popper wrote: “Science may be described as the art of systematic oversimplification — the art of discerning what we may with advantage omit.” What may be omitted depends on the discipline. Results that generalize to all universes (or perhaps do not even require a universe) are part of mathematics. Results that generalize to our Universe belong to physics. Results that generalize to all life on Earth underpin molecular biology. Results that generalize to all mice are murine biology. And results that hold only for a particular mouse in a particular lab in a particular experiment are arguably not science.
Science should be ‘show me’, not ‘trust me’; it should be ‘help me if you can’, not ‘catch me if you can’. If I publish an advertisement for my work (that is, a paper long on results but short on methods) and it’s wrong, that makes me untrustworthy. If I say: “here’s my work” and it’s wrong, I might have erred, but at least I am honest.
In medicine we have particular problems. Repeating experiments in model organisms is often possible whereas in man things are much harder. There is an awful lot of published medical research that is not a reliable guide to action.
Today is my last day of (paid) work, and of course a day that will be infamous for many more people for other more important reasons. Europe and my professional life have been intertwined for near on 40 years. In the mid 1980s I went to start my dermatological career in Vienna. I had been a student at Newcastle and done junior jobs there, as well as some research on skin physiology with Sam Shuster as an undergraduate student. Sam rightly thought I should now move somewhere else — see how others did things before returning — and he suggested Paris, or Vienna under Klaus Wolff. Vienna was, and perhaps still is, the centre of the dermatological universe, and has been since the mid 19th century. Now, even if I haven’t got very far into this post — it is a day for nostalgia — so allow me an aside: The German literature Problem.
The German Literature
As I have hinted at above, in many ways there have only been two schools of dermatology: the French school, and the German school. The latter has been dominant. Throughout the second half of the 19th century dermatology was a ‘German speaking’ subject. To follow it you would be wise to know German, and better still to have visited the big centres in Germany, Switzerland or Austria. And like most of the modern research university, German medicine and science was the blueprint for the US and then belatedly — and with typos— for England (Scotland, reasonably, had taken a slightly different path).
All of the above I knew, but when I returned to Newcastle after my first sojourn away (a later one was to Strasbourg), I naturally picked up on all these allusions to the German literature, but they were accompanied by sniggering by those who had been around longer than me. Indeed there seemed to be a ‘German Literature Problem’. Unbeknown to me, Sam had written “das problem ” up in ‘World Medicine’, but World Medicine had been killed off by those from Mordor, so here is a synopsis.
The German literature seemed so vast that whenever somebody described a patient with what they were convinced must be a ‘new syndrome’, some bright spark would say that it had already been described, and that it was to be found in the German literature. Now the synoptic Handbuch der Hautkrankheiten on our shelves in the library in Newcastle ran to over 10 weighty volumes. And that was just the start. But of course only German speaking dermatologists (and we had one) could meaningfully engage in this conversation. Dermatology is enough of a a nightmare even in your own mother tongue. Up to the middle of the 20th century however, there were indeed separate literatures in German, French and English (in the 1960’s the newly formed ESDR had to sort out what language was going to be used for its presentations).
Sam’s sense of play now took over (with apologies to Shaw: nothing succeeds like excess). It appeared that all of dermatology had already been previously described, but more worryingly for the researchers, the same might be true of skin science. In his article in World Medicine he set out to describe his meta-science investigation into this strange phenomenon. Sam has an unrivalled ability to take simple abstract objects — a few straight lines, a circle, a square — and meld them into an argument in the form of an Escher print. A print that you know is both real, unreal and illegal. Imagine a dastardly difficult 5 x 5 Rubik’s cube (such as the one my colleagues recently bought me for my retirement). You move and move and move the individual facets, then check each whole face in turn. All aligned, problem solved. But then you look in the mirror: whilst the faces are all perfect in your own hands, that is not what is apparent in the mirror. This is my metaphor for Sam’s explanation. Make it anymore explicit, and the German literature problem rears its head. It’s real — of a sort. Anyway, this was all in the future (which didn’t exist at that time), so lets get back to Vienna.
Night train to Wien
Having left general medical jobs behind in Newcastle, armed with my BBC language tapes and guides, I spent a month travelling through Germany from north to south. I stayed with a handful of German medical students who I had taught in Newcastle when I was a medical registrar (a small number of such students used to spend a year with us in Newcastle). Our roles were now reversed: they were now my teachers. At the end of the month I caught the night train in Ulm, arriving in Vienna early one morning.
Vienna was majestic — stiff collared, yes — but you felt in the heart of Europe. A bit of Paris, some of Berlin and the feel of what lay further east: “Wien ist die erste Balkanstadt”. For me, it was unmistakably and wonderfully foreign.
It was of course great for music, too. No, I couldn’t afford the New Year’s Day Concerts, but there were cheap seats at the Staatsoper, more modest prices at the Volksoper, and more to my taste, some European jazz and rock music. I saw Ultravox sing — yes, what else— “Vienna” in Vienna. I saw some people from the ECM label (eg Eberhard Weber), a style of European jazz music that has stayed with me since my mid teens. And then there was the man (for me) behind ‘The Thrill is Gone’.
I saw BB King on a double bill with Miles Davies at the Stadthalle. Two very different styles of musician. I was more into Miles Davies then, but he was not then at his best (as medics in Vienna found out). I was, however, very familiar with the ‘Kings’ (BB, Freddie, Albert etc) after being introduced to them via their English interpreters. Clapton’s blue’s tone on ‘All Your Love’ with John Mayall’s Bluesbreakers still makes the hairs on my neck stand up (fraternal thanks to ‘Big Al’ for the introduction).
The YouTube video at the top of the page is wonderful (Montreux 1993), but there is a later one below, taken from Crossroads in 2010 which moves me even more. He is older, playing with a bunch of craftsmen, but all still pupils before the master.
But — I am getting there — germane to my melancholia on this day is a video featuring BB King and John Mayer. Now there is a trope that there are two groups of people who like John Mayer: girlfriends; and guitarists who understand just how bloody good he is. As EC pointed out, the problem with John Mayer is that he realises just how good he is. True.
But the banter at the beginning of the video speaks some eternal truths about craft, expertise, and the onward march of all culture — including science. Mayer plays a few BB King licks, teasing King that he is ‘stealing’ them. He continues, it was as though he was ‘stealing silverware from somebody’s house right in front of them’. King replies: ”You keep that up and I’m going to get up and go”. Both know it doesn’t work that way. Whatever the provenance of the phrase ‘great artists steal, not copy’, except in the most trivial way you cannot steal or copy culture: people discover it in themselves by stealing what masters show them might be there in their pupils. Teachers just help people find what they suspect or hope is there. The baton gets handed on. The thrill goes on. And on.
Well, I doubt if any readers of these scribblings will be shocked. After all TIJABP. But this piece by the editor of PNAS wonders if the day of meaningful editing is over. I hope not. Looking backwards over my several hundred papers, the American Journal of Human Genetics was the most rigorous and did the most to improve our manuscript.
“Communication” remains in the vocabulary of scientific publishing—for example, as a category of manuscript (“Rapid Communications”) and as an element of a journal name (Nature Communications)—not as a vestigial remnant but as a vital part of the enterprise. The goal of communicating effectively is also why grammar, with its arcane, baffling, or even irritating “rules,” continues to matter. With the rise of digital publishing, attendant demands for economy and immediacy have diminished the role of copyeditor. The demands are particularly acute in journalism. As The New York Times editorial board member Lawrence Downs (4) lamented, “…in that world of the perpetual present tense—post it now, fix it later, update constantly—old-time, persnickety editing may be a luxury…. It will be an artisanal product, like monastery honey and wooden yachts.” Scientific publishing is catching up to journalism in this regard.
Being a renowned scientist doesn’t ensure success. On the same day that molecular biologist Carol Greider won a Nobel prize in 2009, she learnt that her recently submitted grant proposal had been rejected. “Even on the day when you win the Nobel prize,” she said in a 2017 graduation speech at Cold Spring Harbor Laboratory in New York, “sceptics may question whether you really know what you’re doing.”
CEO Page surprised a convocation of developers in 2013 by responding to questions from the audience, commenting on the “negativity” that hampered the firm’s freedom to “build really great things” and create “interoperable” technologies with other companies: “Old institutions like the law and so on aren’t keeping up with the rate of change that we’ve caused through technology. . . . The laws when we went public were 50 years old. A law can’t be right if it’s 50 years old, like it’s before the internet.” When asked his thoughts on how to limit “negativity” and increase “positivity,” Page reflected, “Maybe we should set aside a small part of the world . . . as technologists we should have some safe places where we can try out some new things and figure out what is the effect on society, what’s the effect on people, without having to deploy kind of into the normal world.
As for his comments on safe spaces, I agree. There are plenty of empty planets left.
I wish I had said that..
A comment on an article:
With reference to Janan Ganesh’s column (“What the US lost when the Berlin Wall fell”, November 7). This is such a clever line.
“It is as though hatred obeys the first law of thermodynamics. Like energy, it can be transferred but never destroyed.
This apropos the US right’s shifting from the Soviet Union to immigration and climate. I’m trying to figure out how to work it into my own stuff. Full credit, of course.