Enrico Fermi was big on back-of-the-envelope calculations. I cannot match his brain, but I like playing with simple arithmetic. Here are some notes I made several years ago after reading a paper from Mistry et al in the British Journal of Cancer on cancer incidence projections for the UK.
For melanoma we will see a doubling between now (then) and 2030, half of this is increase in age specific incidence and half due to age change. Numbers of cases for the UK:
If we assume we see 15 non-melanomas (mimics) for every melanoma, the number of OP visits with or without surgery is as follows.
This is for melanoma. The exponent for non-melanoma skin cancer is higher, so these numbers are an underestimate of the challenge we face. Once you add in ‘awareness campaigns’, things look even worse.
At present perhaps 25% of consultant dermatology posts are empty (no applicants), and training numbers and future staffing allowing for working patterns, reducing. Waiting times to see a dermatologist in parts of Wales are over a year. The only formal training many receive in dermatology as an undergraduate can be measured in days. Things are worse than at any time in my career. It is with relief, that I say I am married to a dermatologist.
Neurophobia’, a term first coined by Jozefowicz in 1994, describes medical students’ fear of neurology 2. It is a chronic illness that begins early in medical school 4. Physicians and medical students alike often state that neurology is the most difficult subject in the medical school curriculum, and that their knowledge about the subject matter is limited, leading to a lack of confidence in managing neurology patients 5, 6, 7. [link]
There are lots of other phobias, too. Pick one up as you check out of med school.
Abraham Flexner is of course famous in clinical medicine, for his report and influence on medical schools in the USA (and indirectly, the rest of the world). But I did not know of this book. A message I would strongly recommend to those regulators and their ilk who are shorting the future with ‘reforms’ and ‘competency’.
Nevertheless, recent reviews find little evidence that cancer patients benefit after clinicians are taught communication.9, 14-16 Although training can change clinicians’ communication, for instance by increasing open questions or empathic statements, effects on patients’ satisfaction, well-being or clinical outcomes have proved elusive. The reviews’ authors recommend improved research designs in a continued effort to show that training does help patients. However, there are concerns that expert guidance on communication is often unrealistic,17-21 and many clinicians and students remain sceptical of it.11, 20, 22-31 Moreover, social scientists have challenged assumptions on which communication education and guidance in cancer and across health care are based.32-34
Geoff Norman has — as usual — a thoughtful editorial here. My clickbait version of it is:
As anyone who has engaged in the culture wars between qualitative and quantitative researchers will attest, the debate between the two groups are unlikely to resolve anytime soon. …….To put it bluntly, at the risk of offending some, constructivists are going around the world making sweeping generalizations about how you can’t make sweeping generalizations.
And I am glad he gives space to the Gigerenzer critique of some of the “heuristics and biases” school that has become so popular:
While the definitions of the heuristics in Kahneman’s hands appear unequivocal, Zwaan et al. (2017) showed that purported experts are completely unable to agree on the presence or absence of specific biases, and conversely are themselves strongly influenced by hindsight knowledge of the outcome
The foundations of research in medical education are not nearly as secure as many people wish to maintain. Plenty of physics envy to go around, and jobs to match.
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.
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”.
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.
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?
“Physical exam skills are eroding fairly significantly. We see that year after year. The masters who taught us are gone, and we’re not teaching the people below us well enough, for all the reasons we talked about.
At the same time, we grossly overestimated the average clinician’s ability to do an extremely good physical exam and to make all of the relevant physical findings. It has been documented over and over again that the average person’s ability to use a stethoscope and document a murmur accurately is a coin flip. The ability of the average house officer to do volume assessment based on a physical exam is terribly low.”
So, you are interested in medical education? Discuss.
The survey found that UK medical schools employed 3041 full time equivalent clinical academic staff employed by UK medical schools, with a headcount of 3361. This is a 2.1% decline since 2015 and a 4.2% decline since 2010. By comparison, since 2010 the number of NHS consultants has risen by 20.6%.
Reform of, and improving how we educate medical students requires a rethink of medical school staffing, and how clinical academics work. There are plenty of heads in the sand. I think you can improve education and drastically cut costs at the same time. Just stop accelerating into the rose tinted image in the rear view mirror.
This can be read as typical Silicon Valley hype, but I think it is more right than wrong. Just as government thought computer education in schools was about using MS Office, too many in higher education think it is about copies of dismal Powerpoints online, lecture capture, or online surveillance of students and staff. The computer revolution hasn’t happened yet. Medical education is a good place to start.
What can we do to accelerate the revolution? From our observation, the computer revolution is intertwined with the education revolution(and vice versa). The next steps in both are also highly overlapped: the computer revolution needs a revolution in education, and the education revolution needs a revolution in computing.
We think that, for any topic, a good teacher and good books can provide an above threshold education. For computing, one problem is that there aren’t enough teachers who understand the subject deeply enough to teach effectively and to guide children. Perhaps we can utilize the power of the computer itself to make education better? We don’t hope to be able to replace good teachers, but can the computer be a better teacher than a bad teacher?
How to select medical students…………..
On the topic of quotations, though, a longer recent discussion about Hanlon’s Razor on the Farnam Street blog includes this rather nice one from the German general Kurt von Hammerstein-Equord:
I divide my officers into four groups. There are clever, diligent, stupid, and lazy officers. Usually two characteristics are combined. Some are clever and diligent – their place is the General Staff. The next lot are stupid and lazy – they make up 90 percent of every army and are suited to routine duties. Anyone who is both clever and lazy is qualified for the highest leadership duties, because he possesses the intellectual clarity and the composure necessary for difficult decisions. One must beware of anyone who is stupid and diligent – he must not be entrusted with any responsibility because he will always cause only mischief.
Jed Mecurio was on Desert Island Discs. He of ‘Cardiac Arrest’ fame. (ITU: they used to call it the ICU — intensive care unit — till they realised, nobody did). Something he said chimed with a conversation I had with somebody who knows a lot more about junior doctor training in the modern NHS than I do.
Mercurio, was the son of working class Italian immigrants. And, as is true of many immigrants, a child moving into the stable world of the professions is encouraged. Mercurio pointed out that the popular representation of medicine often does not match the reality. Those with family members already in medicine know this, whereas those without this, have to discover it (at least, I hope they discover it).
When I was trying to get a handle on some of the issues surrounding junior doctor training with my source, the very same point came up. Many junior docs idea of what medicine was like, he / she argued, was based on TV programs — and more Eastenders than West Wing. And this is a problem, he commented.
Cardiac Arrest may be showing its age, but for me it was more accurate than all the sanitised bumph that medical schools and the GMC produce. Fiction is sometimes more real than reality.
One of the important things I learned from reading Herb Simon’s ‘Models of my life’ was his view that seldom did reading the academic literature feed him with new ideas on what to work on. I do not mean to imply that reading the literature is irrelevant, but that in some domains of enquiry the formal literature is often unhelpful when it comes to not so much thinking outside the the box, but realising the box needs throwing out and you need a chair instead. For instance, in med ed, I find most of the formal literature akin to chewing sawdust. It is dull and often the main motivation seems to be to advance one’s career rather than change the world. All of this came to my mind when I read the following:
It tells the remarkable tale of Athletic Bilbao, one of three clubs never to have been relegated from La Liga, the Spanish top division, despite having a policy of selecting only Basque players. Bilbao’s story emphasises a recurring theme of the book: the importance of development programmes for young players and the lengths that clubs go to in order to nurture footballers. Benfica, a Portuguese club, uses a 360-degree “football room”, walled by LED lights, to train players in over 100 scenarios. Targets appear for the players to hit with the ball; sensors measure the players’ effectiveness.
( a review in the Economist of The European Game: The Secrets of European Football Success. By Daniel Fieldsend. Arena Sport; 255 pages; £14.99.)
Now, readers will know that given the genes, I am more rugby than soccer, although I marvel at the skill modern footballers show. But what interests me and has interested me for a while is the relation between structured unnatural performance and fluency at performance. Now my phrasing may be a little ugly, and I do not think there is anything deep or new about what I am saying. Just take how we know you learn a musical instrument. How breaking up and sequencing of mini skills is necessary before you put it all together. People do not pay to listen to people play scales (although I will ignore, shred guitar aficionados), but rather they like songs or sonatas etc.
I would push this is the following direction. A real danger in undergraduate medicine is that we have become inured to the idea that learning situated in the clinic is the best way to learn medicine. At one time, I might have agreed. But out clinics have changed, but our ideas have not. One of the benefits of coaching and online learning is that we can make the offline — the clinic — work better. But also need it less, because it is not working well.
There are some interesting apparent paradoxes here. We need (pace the above quote) more ‘football rooms’, but as Seymour Papert argued, if you want to learn to speak French go to France and if you want to learn maths go to mathland. But are these real or virtual?
There are two models. Sage on the stage. Or building structures than scale. Individual brilliance and interpretation; or Hollywood. There are not not enough sages; but people deny we can build structures that scale.
I see this dialectic everywhere in education. When do we need n=1; and what can do at scale. It is not just education however. All over the creative world we can see this battle play out. As Paul Simon put it:
“I’m sittin’ in the railway station, got a ticket for my destination
On a tour of one-night-stands, my suitcase and guitar at hand
And every stop is neatly planned for a poet and a one-man band”
On the other hand look at this. The song maker (Max Martin) few have heard of.
Woodie Flowers in a devastating critique of MITx said it well.
I believe the “sweet spot” for expensive universities like MIT is:
1) access to highly-produced training systems accompanied by
2) a rich on-campus opportunity to become educated.
MITx seems aimed at neither.
Medicine gets this confused big time. There is training and education. If we did the former better, we could offer a real education. But to do the training better, we need scale. And that means content. We could do things better and cheaper.
Institutions with histories matter. It is just that in many instances innovation often comes from the periphery. I think this is often true in many fields: science, music, even medical education. It is not always this way, but often enough to make me suspicious of the ‘centre’. The centre of course gets to write the history books.
An article by Mark Mazower in the NYRB, praising Richard Evans, the historian of the Third Reich, caught my attention. It seems that nobody in the centre was too excited about understanding the event that changed much of the world forever. Mazower writes:
If you wanted to do research on Saint Anselm or Cromwell, there were numerous supervisors to choose from at leading universities; if you wanted to write about Erich Ludendorff or Hitler, there was almost no one. The study of modern Europe was a backwater, dominated by historians with good wartime records and helpful Whitehall connections—old Bletchley Park hands and former intelligence officials, some of whom had broken off university careers to take part in the war and then returned.
Forward-looking, encouraging of the social sciences, open to international scholarship from the moment of its establishment, St. Antony’s is the college famously written off by the snobbish Roddy Martindale in John le Carré’s Tinker, Tailor, Soldier, Spy as “redbrick.” The truth is that it was indeed the redbrick universities, the creations of the 1950s and 1960s, that gave Evans and others their chance and shaped historical consciousness as a result. The Evans generation, if we can call them that, men (and only a very few women) born between 1943 and 1950, came mostly from the English provinces and usually got their first jobs in the provinces, too.
It is interesting how academics who had had career breaks were important. And how you often will need new institutions to change accepted practice. All those boffins whose careers were interrupted by the war led to the flowering of invention we saw after the second world war. You have to continually recreate new types of ivory towers. But I see little of this today. Instead, we live in an age of optimisation, rather than of optimism that things can be different. The future is being captured by the present ever more than it once was. At least in much of the academy.
Some nice memes in this letter from an MD student in Australia. Please discuss. Pharma might be interested
Considering this, if we thought about the pervasive attitudes that inform our definition of a “good” medical student as a disease, it’s hard to believe that we would not try to treat it.
This is from a book review on the ‘birth of cool’, by Robert Eaglestone in the THE.
Despite laying out some principles (“cool is…”), the book focuses on honed case studies of “the saints of cool” (as Hannah Arendt argues, we learn more from examples than from principles).
This little gem was new to me —but not the concept, or the principle…..
Academia tends to love rules, and formal systems, but for some domains of competence, they are grossly overrated. Formal logic is often not what is need, and we may seem more with a metaphor. Alan Kay’s aphorism: a different perspective may be as valuable as 80 IQ points.
I saw this giant problem in my education, and I actually designed a course called, “Physician Heal Thyself, Evidence-based lifestyle.” I brought in all these doctors who are experts in sleep medicine, sleep, fitness nutrition, food as medicine, functional medicine, integrative medicine, osteopathy and acupuncture. I got them all in a room and said I want you to teach students what we’re missing. We need to make this medical school education and have to implement this into the board certification programs as well as board exams. If it’s not required, it’s not going to be taught.
No, I am not taking this too seriously. Awhile back, I compiled a list of all the things we needed to
inflict on / ask medical students to know : I had to buy a larger hard drive. And as for this ‘new medicine’ George Bernard Shaw described it a long time ago.
I began as a university student after two years of military service. My brain was like an empty sponge. University was fantastic, a world full of knowledge and very interesting people. I studied medicine and went to philosophy lectures as much as I could, and then mathematics until my medical exams came up.
Wolfram Schultz in the THE
senility vanity, but I remember being taught by an ‘ancient’ GP in my first year of med school, in 1976. His name was Andrew Smith, and most of us thought him amazing in many ways. One of the stories that made a deep impression on me, was how— the day after he graduated — he was delivering a baby using forceps in the mother’s own house at 3am. I would have been 18 or so and he in his early sixties —not far from where I am now. So, he would have been a medical student in the late 1930s, and I will probably stop practising medicine in the early 2020s. When I add the two professional lifetimes together at the extremes (med student to final year of practice) I am always amazed how big the number is — a span of 80 years or so. And one of our problems in undergraduate education is that we have to be concerned with these extremes: I am teaching students who will practice for another 40 years, but I have inherited a set of code written as many years in the past.
Now the above reminisce was set off by some words from Benedict Evans. He is talking about much shorter timeframes and is concerned with the commercial world. But my question for medical students (and others) is how is medicine really going to look in a few more score years, and how do we imagine all the system wide interactions that will make the future so different? This is surely more meaningful that memorising biochemical pathways.
“Everything bad that the internet did to media is probably going to happen to retailers. The tipping point might now be approaching, particularly in the US, where the situation is worsened by the fact that there is far more retail square footage per capita than in any other developed market. And when the store closes and you turn to shopping online (or are simply forced to, if enough physical retail goes away), you don’t buy all the same things, any more than you read all the same things when you took your media consumption online. When we went from a corner store to a department store, and then from a department store to big box retail, we didn’t all buy exactly the same things but in different places – we bought different things. If you go from buying soap powder in Wal-Mart based on brand and eye-level placement to telling Alexa ‘I need more soap’, some of your buying will look different….In parallel to this, TV, which so far has not really been touched by the internet, is also starting to look unstable.”
Nice letter in Academic Medicine. Not convinced by the exact details, but the author is on to something important. The first victim of insincerity is language (Orwell, if I remember correctly).
Medical professionalism is espoused as a necessity in health care, setting an important precedent of excellence and respect towards peers and patients. In many medical schools, a portion of the curriculum is dedicated to the intricacies of medical professionalism. Though typically taught through specific tenets and case studies, professionalism is still a general principle, resulting in varied definitions across institutions. This is, in fact, part of the beauty of professionalism—the lack of definition makes it a flexible concept, applicable in a wide variety of situations. However, the downside to this vagary is that it allows for the weaponization of professionalism, leaving space for “professionals” to reject certain approaches to health care.
Comment on an FT article. How things have changed. Even I can remember a colleague — a few years my senior — who went for a Wellcome Training Fellowship, only to be interviewed by one person, with the opening question being, ‘Imagine I am an intelligent layperson: tell me what you want to do!’
I was a war baby, a small farmer’s son and in 1960, at 17, I had a chat with my most trusted teacher about what I should do to apply to become a doctor for which I had just acquired a good group of Scottish highers. He advised me that because I should have applied a number of months before, to write a letter to the University enclosing my qualifications. I was asked to come and have a chat with the Bursar and the only thing I remember him saying was that my qualifications were good but did I realise that I might be preventing somebody else from getting in. I am ashamed to say that I replied that I was not really too troubled about that. I was accepted, and was fine.
When you want to find your way around a city, you might memorise key streets or more likely use a simplified map as a guide as you travel. But when you know a city, you navigate by being able to recall how you get from A to B. In fact you may have difficulty drawing a map — certainly to scale — but your memory is made up of lots of instances of what lies around a particular corner. Much of what you learn about diseases is the map in this analogy. By contrast, what the experienced clinician knows are lots of instances of what lies round particular corners. Those instances have a name: they are called patients.
You cannot change or reform undergraduate medical education in a significant way without changing the way doctors work and behave.
I keep coming back to a few central insights that have — in the best sense of the word — disturbed my world view. These are from a wonderful article in a journal I had never heard of, written by Frank Davidoff. (But I do not buy the term ‘revolution’)
Competence, in contrast, is like “dark matter” in astronomy: although it makes up most of the universe of working knowledge, we understand relatively little about it. What does it really consist of? Which of its components are most important? How do people acquire it? What’s the best way to measure it? And how can you tell when they have enough of it?
Most importantly, it is increasingly clear that competence is acquired primarily through experiential learning – a four-element cycle (or spiral) in which learners move from direct personal involvement in experiences, to reflection on those experiences, integration of their observations with sense-making concepts and mental models, and finally back to more experiences. Formal training for all high-performance (applied) professions, for example, music, architecture, theater, and athletics, is grounded in the unique requirements of experiential learning: case-based coaching, rather than lectures by content experts; hands-on, practicum experiences (including simulations, if necessary) in addition to written end-objectives; repeated experiences and outcome evaluations over time rather than initial, one- shot exercises; and, ultimately, acquisition of the advanced skills of “reflection-in-action,” which is required for high-level performance and “reflection-on-action,” which is required for continued self-evaluation and self- instruction (Schon, 1987).
Mens Sana Monographs:2008 | Volume:6 | Issue:1 | Page:29–40
Focus on Performance: The 21 st Century Revolution in Medical Education
Bruce Alberts talks a lot of sense about science education and education in general. And of course he produced a book that ‘educated’ a whole generation (or more) of people like me. But in this recent Science piece he is taking on some of the big questions, questions that have been asked before, but for which few have managed to follow through on. As ever, the emphases are mine.
In previous commentaries on this page, I have argued that “less is more” in science education, and that learning how to think like a scientist—with an insistence on using evidence and logic for decision-making—should become the central goal of all science educators. I have also pointed out that, because introductory science courses taught at universities define what is meant by “science education,” college science faculty are the rate-limiting factor for dramatically improving science education at lower levels.
For example, there is a long-standing belief that every introductory college biology course must “cover” a staggering amount of knowledge. There is no time to focus on a much more important goal—insisting that every student understand exactly how scientific knowledge is generated. Science is not a belief system; it is, instead, a very special way of learning about the true nature of the observable world.
His phrase, “college science faculty are the rate-limiting factor for dramatically improving science education at lower levels”, could equally apply to medicine and medical teachers. It is not hyperbole to say these are some of the central problems of our time. And it is not just science education that is the issue.