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).
In Britain, an Epipen — a simple device that saves lives in the case of severe allergic reactions — costs $70. In France and Germany, roughly the same. In America, it costs $600. But in 2007, it cost in America what it did in Britain, France, and Germany. What happened? A drug company called Mylan bought the rights to it — and then it didn’t just send prices soaring, it uses all kinds of shady tactics to maximize profits from insurance companies and healthcare systems both. How?
Well, what does it cost to “make” an Epipen? Not a whole lot. It’s just a device for delivering a dose of epinephrine. The dose used in it “costs” maybe $1. I put “cost” in quotes because even those numbers are mostly fictional — the marginal cost of producing a basic chemical like this is pennies. In fact, the real problem is that epinpehrine became too cheap to manufacture — so cheap that many producers stopped making it altogether. And so a company like Mylan swooped in, put two and two together: corner the supply, gain a monopoly on the demand side, and hey presto — mega profits.
That’s predatory capitalism — a drug that should cost pennies, if the economy were run a little more sanely, costs hundreds, without any regard for the human possibility that is destroyed. Mylan didn’t create any real value whatsoever, only extracted it, siphoned it off.
Yep. Wealth creators, and wealth aggregators. Profit harvesting mode.
Well, this was the modest description of a ‘new’ way to test blood. Except it wasn’t. The reality distortion field in hyperspace. If you don’t know the Theranos story — or doubt the importance of real journalism — have a look.
Science 21 June 2013: 1394-1399.
For most alumni, university fundraising may seem to be uncoordinated and lacking in focus—an assortment of phone calls, solicitous letters, and invitations to a class reunion. But for Steven Rum, it’s a science. And the goal is to carry out more research.
Rum is senior vice president for development and chief fundraiser for Johns Hopkins Medicine in Baltimore, Maryland. Last year, his team had a banner year, raising $318 million. Their approach places the physician scientists at Hopkins on the donor front lines. The goal is to turn the positive feelings of “grateful patients” into support for new research, faculty chairs, academic scholarships, bricks and mortar, or simply defraying the cost of running a multibillion-dollar medical center.
Rum has 65 full-time fundraisers on a staff of 165. Each one is responsible for meeting weekly with physicians—their “caseloads” range from a dozen to more than 30 docs—to discuss which of their patients might be potential donors. The conversation is designed to help them identify what Rum calls a donor’s “qualifying interest” and connect it to their “capacity,” that is, the ability to make a donation.
More often than not, Rum’s team finds that sweet spot…..
”Ideally, I’d like to have one gift officer manage no more than six doctors,” he says.
A beautifully written vignette in the NEJM by Abigail Luger
Now I’m the one contemplating a permanent departure. My health is fine, but my stamina is pretty much gone. Our health care system is not kind to the chronically ill and marginally insured, and it is not particularly kind to their doctors, either. Our patients are condemned to an unending swim against a hostile tide. Doctors can head for shore.
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.
Article in Nature. I largely agree, although my views are as much based on the hype-upon-hype that characterises so much of medical research, especially cancer. I do not have a reference, but whatever one’s views about the late David Horrobin, his Lancet article about cancer trials — written when he was dying from lymphoma — is worth a read. What a mess!
Key quotes from this article:
In 2017, my colleagues and I completed a study of all 48 cancer drugs approved by the European Medicines Agency between 2009 and 2013 (C. Davis et al. Br. Med. J. 359, j4530; 2017). Of the 68 clinical indications for these drugs (reasons to use a particular drug on a patient), only 24 (35%) demonstrated evidence of a survival benefit at the time of approval. Even fewer provided evidence of an improved quality of life for symptoms such as pain, tiredness and loss of appetite (7 trials; 10%). Most indications (36 of 68) still lacked such evidence three or more years after approval. Other groups in other regions have observed similar trends. For example, a 2015 study demonstrated that only a small proportion of cancer drugs approved by the FDA improved survival or quality of life (C. Kim and V. Prasad JAMA Intern. Med. 175, 1992–1994; 2015).
But the key point he makes is:
I believe that the low bar also undermines innovation and wastes money.
When assessments — whether in medicine or education — are flawed the loss in value is not in short term financial costs, but in what might have happened 10 years down the road.
“Why do doctors feel the need to do this? A study in The BMJ in 2015 suggested that there is an association between increased defensive practice and a reduced likelihood of being involved in litigation.2 One might conclude that defensive practice is a logical behaviour in the face of a culture that leads to doctors being fearful of the consequences of making an error or even of a known adverse outcome.
“No doctor sets out to practise defensively, but a system has been created where this is inevitable. The GMC acknowledges that medicine has become more defensive.3 Doctors often lack confidence in the fairness and competence of investigations and continue to see the GMC as threatening.”
Tom Bourne quoted in the BMJ
A “world renowned” consultant radiologist has been suspended from the medical register for six months after being convicted of failing to pay more than £400,000 in tax on his private practice earnings. XXX a professor of cardiovascular imaging, was given a 15 month suspended prison sentence and fined £200,000 in 2015. The GMC argued that he should be erased from the register. But the medical practitioners tribunal concluded that he made a unique contribution to the care of critically ill patients and the development of cutting edge techniques.
Bmj September 30 , 464, 2017
Modern medicine is full of doctors who are already robotic. But good medicine is like any other subject that requires one to make judgements based on prior cases. You can follow rules, or you can think. The first kidney doctor (who I saw multiple times) never bothered to actually think.
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.
Restaurants have also lagged behind retailers in offering “experiences”, as the trade jargon has it, rather than the usual broccoli. This is how the more innovative retailers now try to differentiate themselves in a crowded market. It also lets them do something with their underused floor space. ….John Lewis, for instance, opened its 49th store in October with 20% of the space dedicated to eye tests, children’s car-seat fittings and free styling services for men. Selfridges, another big department store, marked the 400th anniversary of Shakespeare’s death in 2016 by performing “Much Ado about Nothing” in store, and last year it staged concerts. Waitrose hosts yoga classes, and Marks & Spencer mental-health drop-ins called Frazzled Cafés.
People say we spend too much on health, but business does not view it this way. As things approach the margin, there is even more to sell.
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.
So, where it this from?
At the peak of the crisis, the hospital had the equivalent of eight full-time pharmacy employees battling the shortage. Technicians worked through the night to mix saline by hand, while nurses injected the solution of salt in water into patients using syringes — a task normally done by the metal stands and plastic bags used for intravenous drips. “Sometimes we’ve had over 20 nurses at a time doing that,” ..
Yes, in the US, at the Cleveland Clinic. FT
I love statistics, but I am just not very good at it, and find much of it extremely counter intuitive (which is why it is ‘fun’). The Monty Hall problem floored me, but then Paul Erdos got it wrong too (I am told), so I am in good — and numerate — company. During my intercalated degree in addition to a research methods tutorials (class size, n=2), we had one three hour stats practical each week (class size, n=10). We each used a Texas calculator, and working out a SD demanded concentration. Never mind, that during the rest of the week we were learning how to use FORTRAN and SPSS on a mainframe, ‘slowing’ down the process was useful.
Medicine has big problems with statistics although it is often not so much to do with ‘mathematical’ statistics but evidence in a broader sense. IMHO the biggest abusers are the epidemiologists and the EBM merchants with their clickbait NNT and the like. But I do think this whole field deserves much greater attention in undergraduate education, and cannot help but feel that you need much more small group teaching over a considerable period of time. Otherwise, it just degenerates into ‘What is this test for?’ exam fodder style of learning.
The problems we have within both medicine and medical research have been talked about for a long while. Perhaps things are improving, but it is only more recently that this topic has been acknowledged as a problem amongst practising scientists (rather than medics). This topic certainly resurfaces with increased frequency, and there have been letters on it in Nature recently. I like this one:
Too many practitioners who discuss the misuse of statistics in science propose technical remedies to a problem that is essentially social, cultural and ethical (see J. Leek et al. Nature 551, 557–559; 2017). In our view, technical fixes are doomed. As Steven Goodman writes in the article, there is nothing technically wrong with P values. But even when they are correct and appropriate, they can be misunderstood, misrepresented and misused — often in the haste to serve publication and career. P values should instead serve as a check on the quality of evidence.
I think you could argue with the final sentence of this (selected) quote, but they are right about the big picture: narrow technical solutions are not the problem here. Instead, we are looking at a predictable outcome of the corruption of what being a scientist means.
The Osborne effect is described in Wikipedia as follows:
The Osborne effect is a term referring to the unintended consequences of a company announcing a future product, unaware of the risks involved or when the timing is misjudged, which ends up having a negative impact on the sales of the current product. This is often the case when a product is announced too long before its actual availability. This has the immediate effect of customers canceling or deferring orders for the current product, knowing that it will soon be obsolete, and any unexpected delays often means the new product comes to be perceived as vaporware, damaging the company’s credibility and profitability.
AI and associated technologies will have major effects in some areas of medicine. Think skin cancer diagnosis, for certain; or this weekend story in the FT on eye disease; and radiology and pathology. This then begs the question, whether these skills are so central to expertise within a clinical domain, that students should think hard about these areas as a career. Of course, diagnosis of skin lesions is not all a clinical expert in this domain does. Ditto, ophthalmologists do more than look at retinas. Automated ECG readers have not put cardiologists out of work, after all. And many technical advances increase — not reduce — workloads.
But at some stage, people might want to start wondering if some areas of medicine are (not) going to be secure as long term careers. The Osborne metaphor should be a warning about how messy all this could be. Hype, has costs.
After earning his medical degree in 1951 he trained in hospitals in Montreal. “To my surprise I also found I enjoyed clinical medicine,” he wrote in his Nobel prize biography. Then he quipped, “It took three years of hospital training after graduation, a year of internship and two of residency in neurology, before that interest finally wore off.”
This article in the NEJM gets to the kernel of one of the major problems in medicine: the increasing dysfunction of doctor-patient interaction fuelled — in part — by awful IT, and a systematic ability to admit that it is no longer possible to actually do what is required within the ‘allocated’ time. In many industries the goal is to match task with skill and, wherever possible, to reduce costs by allocating low skill tasks to those who cost less: ‘right person at the right time’. There is a variation of this in medicine: those charged with ‘support’ or undertaking ‘low skill tasks’ have just been removed, meaning all tasks — both high and low — are done by the same practitioner, but without any change in time allocated. This is akin to asking the pilot of a plane to serve you snacks and check you in, but keep the schedules the same.
In terms of medicine, that this happens is not so much a manifestation of a managerial view that places little value on ‘care’ (true), nor where business innovation (sic) is viewed as synonymous with sacking people (true), but a complete failure to understand their own business and what their own product is. In an ideal world businesses like this should go bust. The problems are when: they are run by the government; there are third party payers; or there is actively created informational asymmetry. Sometimes all three apply.
‘On December 16, 2017, the staff of the Centers for Disease Control and Prevention (CDC) were instructed not to use 7 words in its 2019 budget appropriation request: diversity, transgender, vulnerable, fetus, entitlement, evidence-based, and science-based. These basic phrases are intrinsic to public health. The US Department of Health and Human Services (HHS) offered alternative word choices, such as by modifying “evidence-based” with “community standards and wishes” and using “unborn child” instead of “fetus.”’
Yan Lecun of Facebook wrote:
In the history of science and technology, the engineering artefacts have almost always preceded the theoretical understanding: the lens and the telescope preceded optics theory, the steam engine preceded thermodynamics, the airplane preceded flight aerodynamics, radio and data communication preceded information theory, the computer preceded computer science.
This is so true for (much) medicine, too. The journal comes after the discovery.
Recent years have seen a major drive by government, the NHS, and mental health charities to change attitudes towards mental health and to raise its profile in line with physical health. In a crescendo of media coverage, royals and celebrities have opened up about their own struggles.
Despite having welcomed Prince Harry’s interview about his mental health in April, Wessely believes we can have too much of a good thing: too much awareness. He particularly questions surveys in which most students report mental health problems. “We should stop the awareness now. In fact, if anything we might be getting too aware. One wonders what’s happening when you have 78% of students telling their union they have mental health problems-you have to think, ‘Well, this seems unlikely.'”
Simon Wessely quoted in the BMJ 23 September 2017 p433
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.
The growth of medical tourism in Poland has been mirrored in other central European countries. Hungary also has a reputation for specialising in dental services for foreigners, while Czech Republic has developed a market in cataract surgery. Poland is well known for its plastic surgeons as well as dentists.
“The NHS will have a workforce plan for the first time since 2000, England’s secretary of state for health has announced.”
The concept of continuity of care is important and with winter approaching rapidly in the UK, clinicians should lead the way in ensuring patients are looked after by the right specialist team, in the right place first time and avoid the ‘martini’ principle of hospital care – any time, any bed, anywhere. If we can reduce the number of boarded or outlying patients we will improve their care and also reduce overcrowding in the hospitals.
I like computers (see previous post), but despair of them in the clinical context of keeping medical records. By contrast nobody sane doubts that computers are advantageous in other medical contexts: imaging, radiotherapy, or even using an insulin pump. We don’t have problems with the latter instances, because self-evidently computers work, and they are the result of a culture of improvement. Not so with electronic medical records, where a neutral observer might thing that the purpose is to save money in one budget at the expense of diminishing clinical care in another. The economists might talk about externalities, but essentially many electronic record keeping systems are a form of pollution of the clinical workspace.
The following quote caught my eye because, whilst in Scandinavia recently, a dermatologist from Denmark was expressing frustration with how bad their computer systems are; and how older physicians choose to ignore them by retiring early. I heard a similar tale from the US in the summer, from a dermatologist who takes a financial hit because he has not implemented electronic records. He says he can either manage patients or do IT (and yes, he is planning to get out early).
Electronic medical records (EMRs) have resulted in increased documentation burden, with physicians spending up to 2 hours on EMR-related tasks for every 1 patient-care hour. Although EMRs offer care delivery integration, they have decreased physician job satisfaction and increased physician burnout across multiple fields, including dermatology.
I would add, that I have read that the average ER doc on a shift in the US presses his mouse 4000 times.
A long time ago, Richard Doll wrote an article pointing out that hospital record systems such as hospital activity analysis were perhaps useful to managers, but not much use for doctors or researchers. He was right, and I even published a paper saying similar things. My experience of electronic records in hospitals is that they are designed for the purpose of ‘management’ not clinical care. Contrary to what many say, these two activities have little in common, and share few goals. Our care system is not designed for care or caring, and our software is not designed for clinicians or patients. As for EMR, we are still waiting for our VisiCalc or Photoshop. If somebody can pull it off, it would be worth a Nobel.
Allergan has been particularly aggressive in trying to skirt the IPR system. In September, it took the unprecedented step of transferring patents protecting its prescription eyedrop, Restasis, to the Saint Regis Mohawks. The tribe — which received a $13.5m fee and up to $15m in annual royalties — then claimed it had sovereign immunity from intellectual property challenges launched through IPR.
As I fond of repeating, Martin Wolf of the FT argued that Pharma may soon be shown the same contempt that many now feel towards the Banks.
Marriage, however, proved to be a towering practical problem — Princeton, where Feynman was now pursuing a Ph.D., threatened to withdraw the fellowships funding his graduate studies if he were to wed, for the university considered the emotional and pragmatic responsibilities of marriage a grave threat to academic discipline. [Here]
The above is about Richard Feynman, but reminds me of a story closer to home, told to me by a consultant dermatologist (who I will call CS) and former academic. CS, then a senior registrar, on entering the departmental library, was pleased to see the elderly professor reaching for books on the top shelf. CS, with evident pride, told the professor that he had good news: he was engaged to be married. The professor replied: ‘Sorry to hear that CS, I had high hopes for you’.
I was sent links to both these videos together.
The first is reasonable, but not grounded in reality. As AJP Taylor once said: 90% right and 100% wrong. It is what happens when all the context of a thesis has been stripped away. The second is both more grounded in reality and philosophically sound.