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.
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.”