We have a very clear idea of how apprenticeship has worked over the last nine hundred years or so within Europe. The core ideas are of course much older, and the geography wider. But we have written records of the creation of the various social structures that led to the rapid changes in society that led in turn via the Renaissance to the Enlightenment and modern capitalism. We can trace so many of the norms that have guided my professional life: Royal Colleges, corporations, guilds, “masters and apprentices”, universities, certification and the granting of monopoly, and ‘professionalism’, to name but a few.
Apprenticeship is a powerful pedagogical model, but one that can only take place when a number of conditions are met. In medicine the ‘apprentice’ model is widely discussed, assumed, and contrasted with the ‘bums on seats’ lecture, the latter, the now signature pedagogy of the modern ‘massified’ university. It is also used to justify the high costs of training of education in medicine and some craft university courses.
At the level of higher professional training in medicine (or in the training of research academics) apprenticeship still can work well. There is an asymmetry between master and pupil (the master does know best, but cannot always justify why he knows best); long term interaction between both parties is required; and, at its best the pupils will model their behaviours on the master. Apprenticeship is not passive — it is not ‘shadowing’ (although a period of shadowing may be required); it will require the pupil to undertake tasks that can be observed and critiqued — you cannot learn complicated tasks based on passive observation. Chimps are highly intelligent, and yet learning to crack nuts using stones takes years and years, not because the young chimps do not watch their mothers, but because the mothers never watch (and hence correct) the young chimps. This requirement is not just required for motor tasks but for any complicated set of ‘thinking’ procedures that require accuracy and fluency. In medicine, surgeons are ahead of physicians on this, and have been for a long time.
In medieval times, becoming a master meant more than being a ‘journeyman’ — the level of professional expertise was greater, and it was recognised that teaching required another level of competence, and breadth. The master is not one step ahead on the way to perfection, but several. We prefer those teaching ‘A’ level physics, to have more than an ‘A’ level in physics themselves. And whatever domain expertise a master possesses, we know that experience of the problems or difficulties learners face, is important.
Still, in comparison with say school teaching the demands on the master (with regard to being a ‘professional’ educator) are modest. They know the job — they do not need to check out the syllabus — as they are effectively training people to do the same job they do day-to-day. They probably also have little need of theory and, in a sensible system, their reputation may be accurate.
In higher professional training in medicine, apprenticeship is still possible — it is just that it is harder than it once was (as to why, that is for another day). Similarly, at one time higher education was in large part viewed as a type of apprenticeship. Students were not staff, but they were not treated as schoolchildren, rather they were —at best— viewed as co-producers of knowledge within a university. If you were studying physics, the goal was to get you to approach the world like a physicist might. This may persist in a few institutions for a minority of students, but it is not the norm anymore.
In undergraduate medicine apprenticeship died a long time ago, although its previous health may well have been exaggerated. There is little long term personal interaction, with students passed around from one attachment to another, with many of the students feeling unwanted (‘burden of teaching’, ‘teaching load‘ etc). Staff and students can walk past each other in the street, none the wiser. Apprentices are — by definition — useful. It is this utility that underpinned the business model that formalised training and acceptance or rejection into the guild. But sadly — through no fault of their own – medical students are rarely useful. If they were useful they would be paid: they are not. Historically, students might have got paid to cover house officer absences (I did), but that world no longer exists. Nor are we able to return to it.
Whereas the master has an implicit model of the goals of training, that is no longer the case in undergraduate education, in which literally 500 or individuals are engaged in educating students for roles that they individually have little knowledge of. Instead of personal interaction, over a long time period, based on a common world view, medical schools create complicated management systems to process students, with the predictable lack of buy-in from those who are doing the educating.
There is a deeper point here. Much though a lot of UK postgraduate medical training is poor, it is possible to improve it within a framework that is known to work. Many doctors know how to do it (although the same cannot be said of the NHS). Undergraduate medical education is in a different place (like much of university education). At graduation, you step form one world into another, but just as with caterpillars and butterflies, the structures and environment we need to create are very different.
Not the word I usually associate with student descriptions of their emotional state on being taught (except after the exam). Sadly. But the word featured in a teaching management meeting today. Made me smile.
Contrast this with the quote from a book on reforming engineering education, “A Whole New Engineer”
Go into the bathrooms at the Massachusetts Institute ofTechnology (MIT) and you will see an acronym scrawled on the walls of the stalls: IHTFP. It means “I Hate This F** king Place.” (IHTFP is also found in the service academies and other elite engineering programs.) Whether this remains the true sentiment of MIT students today or merely a tradition handed down from generation to generation isn’t clear….
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Today’s (Scottish) Daily Telegraph ran with a story about the shortage of paediatricians in Scotland. The Herald had a similar story, too. It is not just paediatrics that has major shortages. The same can be said about dermatology, radiology and a host of other areas of medicine. And that is not to mention GP land, which normally seems to attract most ‘government’ attention.
I find none of this surprising. The NHS has long been in subsistence mode, eating the seed corn (or to use that other phrase, ‘eating its young’), spending its moral and cultural capital at an alarming rate. Management is notable by its absence, whereas the administrators think they are ‘managers’, in part, because they can’t administrate and stay sane. By lack of management I meant those functions of management we see in most corporations or freestanding institutions. Changes in demography have not happened suddenly; the relation between age and health care provision, has been well known for a century or more; the impact of family structure and geography on care provision of elderly relatives evident since the early 1960s; changes in work force have been growing for at least 40 years; and UK medicine has a long history of ignoring why people wish to leave either the UK (or want to leave the NHS). The attempt to run health care as a Taylor-like post-industrial service industry using staff who value their autonomy and professionalism, may not end well for doctors — or patients.
All the above, management should have been grappling with over the last quarter century: instead they have been AWOL. Meanwhile, politicians engage in speculative future-selling, where electoral vapourware is often a vehicle for the maintenance of political power. Given the state of UK politics (as in the BxxxxT word), it seems reasonable not to give politicians the benefit of the doubt any more. As individuals, no doubt, most of them mean well, and love their kids etc, but the system they have helped co-create, cannot command respect (that is now electorally obvious).
There are however some aspects of this that bear on what keeps me awake at night: how we educate — and to a lesser extent—how we train doctors.
Well, words from the past, to remeasure the future. I am on (a sort of) sabbatical for six months. There is a project, about which I will say more later. My writings here will change, too.
My “Beginner’s Guide” to the messy world of medical education over at Wonkhe.
N.Y.U. said that it had raised more than $450 million of the $600 million that it anticipates will be necessary to finance the tuition plan. About $100 million of that has been contributed by Kenneth G. Langone, the founder of Home Depot, and his wife, Elaine, for whom the medical school is named.
To date, only a handful of institutions have tried to make medical education tuition-free, according to Julie Fresne, senior director of student financial services of the Association of American Medical Colleges, a nonprofit organization that represents medical schools.
Those who rent seek on biomedical knowledge wish to seek to define the norms of what is foundational. What is foundational for the practice of medicine should be contested more. Anatomy for surgeons is an easy case to make. But for most non-surgeons, the case for much anatomy is far from simple.
In any historical account of the ascent of modern medicine, Versalius looms large. But this Nature article (Sex, religion and a towering treatise on anatomy) intrigues me for a not so obvious reason: the counterpoint between how such knowledge was represented and understood.
Even Vesalius realized that his images could be confusing, and devised an ingenious method to explain them. A letter or number was printed onto the image of each body part, with a separate key. Unfortunately, the characters were often too small to pick out against the swirling background….
Faced by such challenges, many medics might have given up on the images. Indeed, when we reconstructed what early modern readers and scholars found fascinating about the Fabrica, it was evidently the text. The clear majority of sixteenth- and seventeenth-century readers who annotated the book focused on that and left no traces of having engaged with the illustrations. Sixteenth-century reviews of the Fabrica confirm this impression, because they tended to discuss only the text.
This is no surprise. The Fabrica’s scholarly readership was trained in the traditions of Renaissance humanism, which put a strong emphasis on textual analysis. Even if they found it difficult to interpret visual information, medical practitioners were expert at making sense of long Latin texts.
Here are the figures for skincancer909 my online textbook of skin cancer for medical students. The site was rewritten and updated in the final quarter of last year (with videos). Usage is 80% from search, with the rest from direct links. In June about 4,600 sessions. Local usage (Edinburgh) is around 5%. I am pleased, but financially poorer.
A revered teacher, Seldin was known for his pithy expressions, including: “A good medical education leaves much to be desired”; “One of the dangers of a medical education is that it leads to graduation from medical school”; and “The greatest crime is to do the right thing for the wrong reason.”
An obit of Donald W Seldin – The Lancet. I do not know the source of my favourite cognate aphorism:
most students turn into good doctors despite the earnest attempts of medical educationalists
I posted this awhile back, but it still makes me smile. I wrote:
Well my knowledge of Neanderthals is rather limited to the work showing that some of them would likely had red hair. But now a reviewer (Clive Gamble) in Nature of a book on Neanderthals states that
Wynn and Coolidge conclude that today, Neanderthals would be commercial fishermen or mechanics, based on their enormous strength and ability to learn the motor procedures needed. Their capacity for empathy might even have made them competent physicians, the authors say, although a lack of mathematical ability means that they would never have been able to graduate from medical school. Neanderthals would also make excellent army grunts, with their high levels of pain tolerance, and would be good tacticians in small combat units. They would never rewrite the tactical manual — although tearing it up, however thick, would not be a problem.
“It’s quite obvious that we should stop training radiologists,” said Geoffrey Hinton, an AI luminary, in 2016. In November Andrew Ng, another superstar researcher, when discussing AI’s ability to diagnose pneumonia from chest X-rays, wondered whether “radiologists should be worried about their jobs”. Given how widely applicable machine learning seems to be, such pronouncements are bound to alarm white-collar workers, from engineers to lawyers.
The Economist’s view is (rightly) more nuanced than Hinton’s statement on this topic might suggest, but this is real. For my own branch of clinical medicine, too. The interesting thing for those concerned with medical education is whether we will see the equivalent of the Osborne effect (and I don’t mean that Osborne effect).
Discussing the shortage of GPs, a locus GP writes:
As so often, there are several factors. Many GPs have retired early – the causes are often quoted as falling GP work earnings, disenchantment with CCGs, the CQC, and revalidation. I think more significant is the sense that we have suffered a loss of control of our work, with QOF making us ask pointless questions about emergency contraception to 45-year-olds, prescribing software pop-ups that order us around for petty savings, warnings about FGM on computers of doctors in areas with no ethnic minorities. These are very harmful to our sense of doing a worthwhile job.
And we have failed to recruit new GPs. Quite an achievement when one considers that the training is three years rather than seven, salaries are good, and there is no out-of-hours work if you don’t want it. How have the deaneries managed that? I have talked to many young doctors and most of the ones who have done F2 in general practice have felt exploited and hated it. They feel that have been chucked in at the deep end. There seems to have been lots of investment in the system for training registrars who often work at the practices of the doctors in the training hierarchy, but very little in F2 practices – who are after all the shop window that we need to perform well if we are to attract new GPs.
Maybe it is just me, but I find many of the graphics in the BMJ hard to follow. The image below is from a clinical update on “Depression and anxiety in patients with cancer” (BMJ 28 April 2018, p116-120). It occupies two whole pages. I am not certain what problem the graphic is trying to solve. For me, it just induces a sense of incomprehension. Or nausea.
In dermatology, there was a famous US academic known for producing slides with numerous arrows, many involving feedback. It was professional cargo-cult science (as the BMJ is cargo-cult education). Sam Shuster always cautioned: more than 3 or 4 arrows per slide, usually means bullshit.
That which is simple is wrong; that which is complicated is useless (Paul Valery).
My third issue is more nuanced. The biggest reason for cataract blindness is the dearth of ophthalmologists. Orthopaedic surgeons in Leicester faced with a backlog of carpal tunnel surgery decided to train intensively one theatre nurse. As a result, our carpal tunnel surgery service is probably the best and most cost effective in the country. Having a person who is not a “fully qualified doctor and surgeon” operating on cataracts could be the best solution.
Quote from, John Sandford-Smith, retired ophthalmologist, Leicester. BMJ 2018;360:k640
This sort of argument is old, and largely correct. But you can only scale such a process with the help of some form of certification, because without it, there is no durable career structure. And without this, there is no investment.
The Medical Council of India has asked state councils to investigate the problem of “ghost” teachers in medical colleges following the discovery of more than 400 fake teachers in four colleges in three states.
He said that the Maharishi Markandeshwar College in Ambala, established in 2008, has an annual intake of 150 students.“It needs a minimum of 108 faculty members as per the Medical Council of India norms. On paper it has 145 teachers listed. But that’s on paper. The college would retain a majority of the names adding new ones off and on. During inspections the doctors would appear and then disappear once the inspections were over.”
We learn that:
These “ghost teachers” are registered as faculty members drawing a hefty salary, but have never taken a single class. Most of them run private clinics, and only attend the college when there is an impending medical inspection.
Well, one wit once remarked that the collective noun for a group of professors is “An absence of professors”.
As the surgeon reached for a scrub brush, the medical student lingered back, his thumbs incessantly and rhythmically tapping on the screen of his phone. The surgeon peered at him with frustration, annoyed that again his student appeared more interested in his smartphone than the pathology. In an effort to engage him back to the case, the surgeon asked: “Can you tell me what tendons lie in each of the extensor compartments in the hand?” The student’s head snapped up, and he quickly rattled off the answer with ease. Smiling momentarily, he then asked, “Could I get your thoughts on this new video describing nerve transfers rather than tendon transfers for radial nerve injuries that was just uploaded to our educational portal? See, I have it pulled up right here, it was just presented last week at the plenary session…”
This article is about truck drivers in the US, where getting a license requires a big investment. The article states that there is now a shortage of truck drivers and argues that this may be a result of the ‘inevitable’ rise of automated drivers.
Many young people are reluctant to pay $5,000-$10,000 to learn to drive an 18-wheeler at a time when experts are predicting that it is a dead end career.
This is akin to what I wrote about before. When people know that a line of work is ‘unlikely’ to continue, they are prone not to want to invest in it. It is not too fanciful to see this happening in medicine. Start with imaging specialties first; and then look at the use of paramedical staff in restricted clinical domains.
Most, if not all, of us, if asked to be cared for by a television doctor if we had a serious medical problem, would select Dr. Gregory House of the TV series House. He would fail most of the core competencies except for knowledge and skill.
Sidney Herman Weissman in Academic Medicine.
There is a parallel argument used in business: about rounding out the edges leading to less hard thinking. I might agree.
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.