Even the human world is queerer than I can imagine

The world is indeed very strange and common sense not much of a guide. Facts, my dear boy, facts…

link

Fiction, apparently.

“…what he read was clear proof of an Anglo-American covert operation already in the planning stage with the dual aim of undermining the social democratic institutions of the European Union and dismantling our international trading tariffs…In the post-Brexit era Britain will be desperate for increased trade with America. America will accommodate Britain’s needs, but only on terms. One such term will be a joint covert operation to obtain by persuasion — bribery and blackmail not excluded — officials, parliamentarians and opinionmakers of the European Establishment. Also to disseminate fake news on a large scale in order to aggravate existing differences between member states of the Union”

Agent Running in the Field, John le Carré

Knowing more than we can see

by reestheskin on 05/12/2019

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I spent near on ten years thinking about automated skin cancer detection. There are various approaches you might use — cyborg human/machine hybrids were my personal favourite — but we settled on more standard machine learning approaches. Conceptually what you need is straightforward: data to learn from, and ways to lever the historical data to the future examples. The following quote is apposite.

One is that, for all the advances in machine learning, machines are still not very good at learning. Most humans need a few dozen hours to master driving. Waymo’s cars have had over 10m miles of practice, and still fall short. And once humans have learned to drive, even on the easy streets of Phoenix, they can, with a little effort, apply that knowledge anywhere, rapidly learning to adapt their skills to rush-hour Bangkok or a gravel-track in rural Greece.

Driverless cars are stuck in a jam – Autonomous vehicles

You see exactly the same thing with skin cancer. With a relatively small number of examples, you can train (human) novices to be much better than most doctors. By contrast, with the machines you need literally hundreds and thousands of examples. Even when you start with large databases, as you parse the diagnostic groups, you quickly find out that for many ‘types’ you have only a few examples to learn from. The rate limiting factor becomes acquiring mega-databases cheaply. The best way to do this is to change data acquisition from a ‘research task’ to a matter of grabbing data that was collected routinely for other purposes (there is a lot of money in digital waste — ask Google).

Noam Chomsky had a few statements germane to this and much else that gets in the way of such goals (1).

Plato’s problem: How can we know so much when the evidence is do slight.

Orwell’s problem: How do we remain so ignorant when the evidence is so overwhelming.

(1): Noam Chomsky: Ideas and Ideals, Cambridge University Press, (1999). Neil Smith.

Books

We commonly think of books as containers of ideas or wrapping for literature, but they can be understood in other ways—as if they were blood cells carrying oxygen through a body politic or data points as infinite as stars in the sky. Books lead lives of their own, and they intersect with our lives in ways we have only begun to understand.

Best Sellers by the Bargeload | by Robert Darnton | The New York Review of Books

A job for life

In the essay “Telling,” he describes the upsetting case of the director of a hospital who, struck down by Alzheimer’s, is admitted to his own hospital. He behaves as if he were still running it, until one day by chance he picks up his own chart. “That’s me,” he says, recognizing his name on the cover. Inside, he reads “Alzheimer’s disease” and weeps. In the same hospital a former janitor is admitted; he too is convinced that he is still working there. He is given harmless tasks to perform; one day he dies of a sudden heart attack “without perhaps ever realising that he had been anything but a janitor with a lifetime of loyal work behind him.”

Truth, Beauty, and Oliver Sacks | by Simon Callow | The New York Review of Books

My mother, a nurse, took on such imagined roles when she too was demented and in a care home.

Downward mobility for all!

by reestheskin on 02/12/2019

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Obituaries are a source of much joy and enlightenment. None more so than those in the Economist. Last week’s was devoted to the ’60’s photographer Terry O’Neill (you can see some of his iconic images here.

Stars had been his subject since 1962, when he was sent to photograph a new band at the Abbey Road Studios. The older blokes at the Sketch scorned that kind of work, but the young were clearly on the rise, and he was by far the youngest photographer in Fleet Street at the time. At the studios, to get a better light, he took the group outside to snap them holding their guitars a bit defensively: John, Paul, George and Ringo. Next day’s Sketch was sold out, and he suddenly found himself with the run of London and all the coming bands, free to be as creative as he liked. A working-class kid from Romford whose prospects had been either the priesthood or a job in the Dagenham car plant, like his dad, had the world at his feet. He wouldn’t have had a prayer, he thought, in any other era.

And obviously it couldn’t last. In a couple of years he would find a proper job, as both the Beatles and the Stones told him they were going to. For it was hardly serious work to point your Leica at someone and go snap, snap.

Obituary: Terry O’Neill died on November 16th – Catching the moment

The reason I found this particularly interesting is the way social mobility appeared to work and the way it was tied to genuine innovation and social change. I have always loved the trope that when jobs are plentiful, and your committments minimal, you can literally tell the boss to FO on a Friday and start another job on the Monday. Best of all you can experiment and experiment lifts all. This to me is one of the best 1960’s rock n’ roll stories.

If you lift your head above the parapet in universities you come across various conventional wisdoms. One relates to ‘mental wellbeing’ or ‘mental issues’, and another is the value of education in increasing social mobility. My problem is that in both cases there seem (to me at least) many important questions that remain unanswered. For the former, are we talking about mental illness (as in disease) or something else? How robust is the data — aside from self-reporting? The widely reported comments from the former President of the Royal College of Pyschiatrists receive no answer (at last not in my institution). An example: I have sat in a meeting in which one justification for ‘lecture capture’ (recording of live lectures) was to assist students with ‘mental health issues’. But do they help in this context? Do we trust self-reflection in this area? Under what conditions do we think they help or harm?

Enhancing life chances and social mobility is yet another area that I find difficult. I picked up on a comment from Martin Wolf in the FT

We also believe that changing individual characteristics, principally via education, will increase social mobility. But this is largely untrue. We need to be far more honest.

He was referring to the work of John Goldthorpe in Oxford. Digging just a little beneath the surface made me realise that much of what I had believed may not true. Goldthorope writes:

However, a significant change has occurred in that while earlier, in what has become known as the golden age of mobility, social ascent predominated over social descent, the experience of upward mobility is now becoming less common and that of downward mobility more common. In this sense, young people today face less favourable mobility prospects than did their parents or their grandparents.

This research indicates that the only recent change of note is that the rising rates of upward, absolute mobility of the middle decades of the last century have levelled out. Relative rates have remained more or less constant back to the interwar years. According to this alternative view, what can be achieved through education, whether in regard to absolute or relative mobility, appears limited.

[Jnl Soc. Pol. (2013), 42, 3, 431–450 Cambridge University Press 2013 doi:10.1017/S004727941300024X]

There is a witty exchange in Propect between the journalist (JD) and Goldthorpe (JG).

JD: Would you say that this is something that politicians, in particular, tend not to grasp?

JG: Yes. Tony Blair, for instance, was totally confused about this distinction [between absolute and relative rates of mobility]. He couldnʼt see that the only way you can have more upward mobility in a relative perspective is if you have more downward mobility at the same time. I remember being in a discussion in the Cabinet Office when Geoff Mulgan was one of Blairʼs leading advisors. It took a long time to get across to Mulgan the distinction between absolute and relative rates, but in the end he got it. His response was: “The Prime Minister canʼt go to the country on the promise of downward mobility!”

On both these topics I am conflicted. And on both these topics there are the tools that characterize scholarly inquiry to help guide action: this is what universities should be about. I am however left with a strong suspicion that few are interested in digging deep, rather we choose sound bites over understanding. Working in a university often feels like the university must be somewhere else. That is the optimistic version.

Not only God plays dice

There is an article this week in Nature about how some funders are explicitly funding grant proposals randomly (lotteries). The cynic might say they have been doing this for a longtime.

Pharma: business as usual

by reestheskin on 29/11/2019

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The article is about pharma and the way its interests flit because of perceived commercial rather than clinical value. There are two phrases that should make you sit up.

  1. ‘Scientists were given incentives to meet milestones in the clinical trials,’
  2. ‘One precondition for success is a large salesforce’.

The first phrase, is scary. We already know how dishonest much of pharma is. We can manage well without more perverse incentives. Short term shareholder value wins over morality every time.

The second begs the question: if the evidence is good, why do you need to flog your medicine with advertising? A collection of data sheets — with citations — is all you need. And since most pharma spends more on advertising than research, here is a simple way to reduce drug costs. (The answer is of course, that advertising sells more than research — shame on us all).

Novartis cholesterol deal highlights mass-market opportunity | Financial Times

Writings from the margins

by reestheskin on 28/11/2019

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I was back in Dublin a few weeks ago for a family celebration. Then last night — on C4 I think— I was listening to an interview with Fintan O’Toole. Something stirred and below are two quotes from Brian Friel: the context may be Brexit, the reality is something much more.

As a character in Translations says, describing his own fading Gaelic world, “a civilisation can be imprisoned in a linguistic contour which no longer matches the landscape of fact”.

 

To remember everything is a form of madness,” warns one of Friel’s characters.

(1) Brexit, the UK and Ireland: a dialogue of the deaf | Financial Times

Costs of business

by reestheskin on 26/11/2019

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This is from the Guardian. The background is serious allergic reactions to food components, and allowing accessible information about what purchased food contains. In her phrase, ‘high-profile casualties on the high street’ she is referring to businesses; I am sure others may have read it differently.

But Kate Nicholls, the chief executive of UKHospitality, said a law change could have a serious impact on the viability of some of the 100,000 restaurants her organisation represents. “Hospitality and particularly high street restaurants are under intense cost pressures and are struggling,” she said. We’ve had a number of high-profile casualties on the high street. Those businesses operate on tight net profit margins. And there’s no doubt some would not be able to cope with any significant change in their cost structure.”

(BTW: she thinks ‘training’ is the solution. Training and education are offered as the answer to everything…”education, education, education”. If only.)

Grieving family’s call for allergy law gets cool response | Society | The Guardian

Indulging our future(s)

by reestheskin on 25/11/2019

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Carbon offsetting is shaping up to be the greatest mis-selling scandal since the Dominican friar Johann Tetzel sold pardons to redeem the dead. Martin Luther attacked this practice in 1517, in his 95 theses.

Five hundred years later, those of us who seek planetary redemption should reduce our carbon footprint in ways that we control — rather than relying on middlemen who may or may not plant trees. The road to hell, I seem to remember, was paved with good intentions.

Well, the Catholic church usually got there first.

Carbon offset gold rush is distracting us from climate change | Financial Times

Dark matters.

by reestheskin on 21/11/2019

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Frank Davidoff had a telling phrase about clinical expertise. He likened it to “Dark Matter”. Dark Matter makes up most of the universe, but we know very little about it. In the clinical arena I have spent a lot of time reading and thinking about ‘expertise’,  without developing any grand unifying themes of my own worth sharing. But we live in a world where ‘expertise’ in many domains is under assault, and I have no wise thoughts to pull together what is happening. I do however like (as ever) some nice phrases from Paul Graham. I can’t see any roadmap here just perspectives and shadows.

When experts are wrong, it’s often because they’re experts on an earlier version of the world.

any

Instead of trying to point yourself in the right direction, admit you have no idea what the right direction is, and try instead to be super sensitive to the winds of change.

How to Be an Expert in a Changing World

Dublin

by reestheskin on 18/11/2019

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These bronze statues at Custom House Quay are even more haunting face to face. As they say, the English never remember, and the Irish never forget. At a celebration of an aunt’s 90th last night, those events were still not ghosts. 

Out of time

by reestheskin on 13/11/2019

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The following is from Janan Ganesh of the FT. The title of the article was “The agony of returning to work in September”.

A personal ambition is to reach the end of my career without having managed a single person.

It seems to me a very sensible ambition, one which used to be the lot of many academics — usually the better ones. He goes on:

Friends who have been less lucky, who have whole teams under their watch, report a quirk among their younger charges. It is not laziness or obstreperousness or those other millennial slanders. It is an air of disappointment with the reality of working life. They will be among the people described in Bullshit Jobs by the anthropologist David Graeber….

A generation of in-demand graduates came to expect not just these material incentives but a sort of credal alignment with their employer’s “values”. The next recession will retard this trend but it is unlikely to kill it.

At one time the words ‘manager’, ‘management’, or worst of all, ‘line-manager’ were alien to much of medicine or academia. Things still got done, in many ways more efficiently than now. It is just that our theories of action and praxis have been ransacked by Excel spreadsheet models of human motivation and culture. It is the final line from the quote that those controllers of ‘managers’ should be scared of:

The next recession will retard this trend but it is unlikely to kill it.

Bullshit (of the world-class variety)

by reestheskin on 12/11/2019

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Andrew Wathey its chairman [of the UK Standing Committee for Quality Assessment] and vice-chancellor of Northumbria University, said: “The UK delivers world-class education to students from all nations. It is therefore right that the sector commits to ensuring that the value of these world-class qualifications is maintained over time in line with the expectations of the UK Quality Code for Higher Education.”

Universities agree more openness on degree marking guidelines | Financial Times

The language betrays all you need to know: spoken by somebody who clearly has no idea what UK higher education once stood for, or who has any sympathy or understanding of the academic ideal. Will the last person who leaves please turn off the ….

Thought of the day

by reestheskin on 11/11/2019

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That, across human experience, in all places and at all times, only one or two societies have unwound concentrations of income and wealth as great as [those that] plague the US today without losing in war to a foreign foe or succumbing to a domestic revolution.

Interview with Daniel Markovits

THE, 31-10-2019

Medicine is just one technology

by reestheskin on 08/11/2019

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From Wikipedia.

Putt’s Law: “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.

Putt’s Law and the Successful Technocrat – Wikipedia

Windows 95: a fate worse than….

by reestheskin on 07/11/2019

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This is from a recent article in Nature describing how its new custom typeface got its name.

A custom typeface, Harding, has been created for Nature’s new logo and much else: you’re reading it right now [you are not]. Harding is named after the late neurologist Anita Harding. Brilliant and generous, she published in Nature before she died in 1995 at age 42. According to colleagues, she was known for taking questions from the clinic back into the laboratory, and for her wry sense of humour. When she learnt that she had a terminal illness, she apparently joked that at least she wouldn’t have to buy Windows 95.

The design decisions behind Nature’s new look

Just not a business anymore….

by reestheskin on 06/11/2019

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From the Economist

Dean Whiteboard writes…

Going forward, we need three priorities. First, to get costs under control. The soup-to-nuts cost for an MBA at Stanford is $232,000—out of our ballpark. The five-star accommodation, gourmet cuisine and other perks on our campus are way over the top. So are some of our packages, even if we haven’t got quite as carried away as Columbia Business School, which, it was recently revealed, paid over $420,000 a year to a professor teaching three classes a year and $330,000 to untenured junior faculty.

The future of management education – The MBA disrupted

Sensing the future.

by reestheskin on 05/11/2019

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We are not a great power and never will be again. We are a great nation but if we continue to behave like a great power we shall soon cease to be a great nation.

Sir Henry Tizard, 1949.

Quoted in the LRB by Ian Gilmore (reprinted 7-11-2019)

Strangers to ourselves (and student learning).

by reestheskin on 04/11/2019

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The quote below is from a paper in PNAS on how students misjudge their learning and what strategies maximise learning. The findings are not surprising (IMHO) but will, I guess, continue to be overlooked (NSS anybody?). As I mention below, it is the general point that concerns me.

Measuring actual learning versus feeling of learning in response to being actively engaged in the classroom.

In this report, we identify an inherent student bias against active learning that can limit its effectiveness and may hinder the wide adoption of these methods. Compared with students in traditional lectures, students in active classes perceived that they learned less, while in reality they learned more. Students rated the quality of instruction in passive lectures more highly, and they expressed a preference to have “all of their physics classes taught this way,” even though their scores on independent tests of learning were lower than those in actively taught classrooms. These findings are consistent with the observations that novices in a subject are poor judges of their own competence (27⇓–29), and the cognitive fluency of lectures can be misleading (30, 31). Our findings also suggest that novice students may not accurately assess the changes in their own learning that follow from their experience in a class.

Measuring actual learning versus feeling of learning in response to being actively engaged in the classroom | PNAS

The authors go on:

These results also suggest that student evaluations of teaching should be used with caution as they rely on students’ perceptions of learning and could inadvertently favor inferior passive teaching methods over research-based active pedagogical approaches….

As I say above, it is the general rather than the particular that concerns me. Experience and feeling are often poor guides to action. We are, after all, creatures that represent biology’s attempt to see whether contemplation can triumph over reflex. There remains a fundamental asymmetry between expert and novice, and if there isn’t, there is little worth learning (or indeed worth paying for).

  • The title is from Timothy Wilson’s book, Strangers to Ourselves, a good place to start on this topic. However, this whole topic is of much more importance than just how we teach students. Lessons for medicine too.

The art of the insoluble

by reestheskin on 30/10/2019

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The following is from an advert for a clinical academic in a surgical specialty, one with significant on call responsibilities. (It is not from Edinburgh).

‘you will be able to define, develop, and establish a high quality patient-centred research programme’

‘in addition to the above, you will be expected to raise substantial research income and deliver excellent research outputs’

Leaving aside the debasement of language, I simply cannot believe such jobs are viable long term. Many years ago, I was looked after by a surgical academic. A few years later he/she moved to another centre, and I was puzzled as to why he/she had made this career move. I queried a NHS surgeon in the same hospital about this career path. “Bad outcomes”, was the response. She/He needed a clean start somewhere else…

Traditional non-clinical academic careers include research, teaching and administration. Increasingly it is recognised that it is rarely possible to all three well. For clinical academics the situation is worse, as 50% of your time is supposed to be devoted to providing patient care. Over time the NHS workload has become more onerous in that consultants enjoy less support from junior doctors and NHS hospitals have become much less efficient.

All sorts of legitimate questions can be asked about the relation between expertise and how much of your time is devoted to that particular role. For craft specialities — and I would include dermatology, pathology, radiology in this category — there may be ways to stay competent. Subspecialisation is one approach (my choice) but even this may be inadequate. In many areas of medicine I simply do not believe it is possible to maintain acceptable clinical skills and be active in meaningful research.

Sam Shuster always drilled in to me that there were only two reasons academics should see patients: to teach on them, and to foster their research. Academics are not there to provide ‘service’. Some juniors recognise this issue but are reticent about speaking openly about it. But chase the footfall, or lack of it, into clinical academic careers.

Depersonalisation and deprofessionalisation

by reestheskin on 28/10/2019

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I am generally nervous about doctors or academics working for the government. Not that I think the roles are unnecessary, far from it. But what worries me is when instead of resigning from their academic role, they end up working for more than one master. So, I tire of the use of university titles when the principle employer does not subscribe to the academic ideal. I think if you have been at Stanford and you go to Washington it should be as a regular civil service post. I think the Americans get it right.

But the retiring CMO, Dame Sally Davies, in an interview in the RCP in-house journal ‘Commentary’ speaks some truths (Commentary | October 2019, p10).

I hear non-stop stories from unhappy juniors. In my day, we (consultants) made up the rotas for the juniors, but now administrators do it without understanding all of the issues. I’m told you can’t go back to the ‘firm’ structure because there are so many doctors in the system, but whenever I meet a roomful of young doctors I ask: ‘Does your consultant know your name?’ It’s rare that a hand goes up. We have depersonalised the relationships between doctors and that can’t help the workings of the medial team, or with the patients.

Your mileage may vary, but when I was a junior doctor it was us — not the consultants — who came up with the rotas. But the point she makes is important, and everybody knows this (already). At one time junior doctors didn’t work for the NHS, rather they worked within the NHS for other doctors, for good and bad. I find it hard to imagine that the current system can deliver genuine apprenticeship learning. Training and service may often have resembled a bickering couple, but there was a broader professional context that was shared. I am not certain that this is the case anymore. Whenever people keep pushing words such as ‘reflection’ or ‘professionalism’, you know — pace Orwell — that the opposite is going on. Politics is a dominant-negative mutation.

What every (good) fly half knows

by reestheskin on 24/10/2019

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“If I can predict what you are going to think of pretty much any problem, it is likely that you will be wrong on stuff. [speaking of certain other economists]….they are very predictable

Lunch with the FT: Esther Duflo | Financial Times

When capitalisms collide

by reestheskin on 22/10/2019

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The future of capitalism is out of the hands of those who spend their time thinking about it.

Not too dissimilar to medicine, either: discuss…..

When capitalisms collide

A time for everything

by reestheskin on 22/10/2019

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Terrific interview with Sydney Brenner about the second greatest scientific revolution of the 20th century.

I think it’s really hard to communicate that because I lived through the entire period from its very beginning, and it took on different forms as matters progressed. So it was, of course, wonderful. That’s what I tell students. The way to succeed is to get born at the right time and in the right place. If you can do that then you are bound to succeed. You have to be receptive and have some talent as well…

To have seen the development of a subject, which was looked upon with disdain by the establishment from the very start, actually become the basis of our whole approach to biology today. That is something that was worth living for.

This goes for more than science and stretches out into far more mundane aspects of life. Is there any alternative?

Kings Review

That was then

by reestheskin on 22/10/2019

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The world has problems, as the old saying puts it, but universities have departments.

Well not any more, I would add.

The Puzzle of Economic Progress by Diane Coyle – Project Syndicate

Invention: good and bad

by reestheskin on 21/10/2019

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The history of innovation is littered with examples of new technologies causing unintended harm. As cultural theorist Paul Virilio said, “When you invent the ship, you also invent the shipwreck.”

Of Reliability and validity

by reestheskin on 16/10/2019

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One of the mantras of psychometrics 101 is that you cannot have validity without reliability. People expel this phrase, like others equilibrate after eating curry and nan-breads with too much gassy beer. In truth, the Platonic obsession with reliability diminishes validity. The world of science and much professional practice, remains messy, and vague until it is ‘done’. The search space for those diamonds of sense and order remains infinite.

Many years in the making, DSM-5 appeared in 2013, to a chorus of criticism; Harrington summarises this crisply (Gary Greenberg’s 2013 Book of Woe gives a painful blow-by-blow account). Harrington suggests that the proliferating symptom categories ceased to carry conviction; in the USA, the leadership of the US National Institutes of Health pivoted away from the DSM approach—“100% reliability 0% validity”, as Harrington writes—stating they would only fund projects with clearly defined biological hypotheses. The big players in the pharmaceutical industry folded their tents and withdrew from the field, turning to more tractable targets, notably cancer. For some mental health problems, psychological therapies, such as cognitive behaviour therapy (CBT), are becoming more popular, sometimes in combination with pharmacotherapy; as Harrington points out, even as far back as the 1970s, trials had shown that CBT outperformed imipramine as a treatment for depression.

Biological psychiatry’s decline and fall | Anne Harrington, Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness, W W Norton (2019), p. 384, US$ 27·95, ISBN: 9780393071221 – ScienceDirect

Big Tobacco, war and politics

by reestheskin on 11/10/2019

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Tobacco killed an estimated 100 million people in the twentieth century. Without radical action, it is projected to kill around one billion in the twenty-first.

Big Tobacco, war and politics