A relative of Nye Bevan, the founder of the NHS, died after serious mistakes by two hospital trusts meant his lung cancer went from treatable to incurable…
(Image courtesy of Alun of Penglas).
Medical students have higher rates of depression, suicidal ideation, and burnout than the general population and greater concerns about the stigma of mental illness. The nature of medical education seems to contribute to this disparity, since students entering medical school score better on indicators of mental health than similarly aged college graduates. Roughly half of students experience burnout, and 10% report suicidal ideation during medical school
This is from the US, and I do not know the comparable figures for the UK. Nor as I really certain what is going on in a way that sheds light on causation or what has changed. By way of comparison, for early postgraduate training in the UK, I am staggered by how many doctors come through it unscathed. I don’t blame those who want to bail out.
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An economist may have strong views on the benefits of vaccination, for example, but is still no expert on the subject. And I often cringe when I hear a doctor trying to prove a point by using statistics.
There were some critical comments about this phrase used by Wolfgang Münchau in a FT article. The article is about how ‘experts’ lose their power as they lose their independence. This is rightly a big story, one that is not going away, and one the universities with their love of mammon and ‘impact’ seem to wish was otherwise. But there is a more specific point too.
Various commentators argued that because medicine took advantage of statistical ideas that doctors talked sense about statistics. The literature is fairly decisive on this point: most doctors tend to be lousy at statistics, whereas the medical literature may or (frequently) may not be sound on various statistical issues.
Whenever I hear people talk up the need for better ‘communication skills’ or ‘communication training’ for our medical students, I question what level of advanced statistical training they are referring to. Blank stares, result. Statistics is hard, communicating statistics even harder. Our students tend to be great at communicating or signalling empathy, but those with an empathy for numbers often end up elsewhere in the university.
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I have removed the name of the institution only because so many queue to sell their vapourware in this manner
Precision Medicine is a revolution in healthcare. Our world-leading biomedical researchers are at the forefront of this revolution, developing new early diagnostics and treatments for chronic diseases including cancer, cardiovascular disease, diabetes, arthritis and stroke. Partnering with XXXXX, the University of XXXX has driven … vision in Precision Medicine, including the development of a shitload of infrastructure to support imaging, molecular pathology and precision medicine clinical trials…… XXXXXX is now one of the foremost locations in a three mile radius to pursue advances in Precision Medicine.
And He declared to them, “It is written: ‘My house will be called a house of prayer. But you are making it ‘a den of robbers.'” Matthew 21:13
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”A lot of patients are still having open surgery when they should be getting minimal access surgery,” said Mr Slack, a surgeon at Addenbrooke’s Hospital in Cambridge. “Robotics will help surgeons who don’t have the hand-eye co-ordination or dexterity to do minimal access surgery.”
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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.
Moving On | NEJM. | Beautifully written piece by retiring US physician, Abigail Zuger, M.D.
Last week I was talking to somebody who was not a doctor, but who had ‘gone off the grid’ and was commenting on how many ‘professionals’ were bailing out, often in their late 30s, looking for something their professional career was not giving them. As they say, fish do not know what water is, but when you head for land, things seem different.
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‘The Socratic slogan- “If you understand it, you can explain it’, should be reversed. Anyone who thinks he can fully explain his skill, does not have expert understanding’.
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GlaxoSmithKline is to reintroduce performance-based bonuses linked to the number of prescriptions written for its medicines, reversing a company ban on the practice following a bribery scandal in the US….
The company was fined $3bn in 2012 after it admitted bribing doctors to write extra prescriptions for some products. As part of the settlement with US authorities, the drugmaker agreed it would no longer pay reps according to the number of prescriptions generated. That agreement has since lapsed.
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Mr Kapoor’s co-defendants were Michael Gurry, Insys’s former vice-president of managed markets, Richard Simon, former national director of sales, and former regional sales directors Sunrise Lee and Joseph Rowan. Michael Babich, former chief executive of the company, and Alec Burklakoff, former vice-president of sales, had already pleaded guilty.
The defendants face up to 20 years in prison. Andrew Lelling, US attorney for Massachusetts, said it was “the first successful prosecution of top pharmaceutical executives for crimes related to the illicit marketing and prescribing of opioids”.
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A phenomenon that occurs when a person opens their email inbox to find many unread messages, inducing a “fight-or-flight” response that causes the person to stop breathing.
James Williams, ‘Stand Out of Our Light’
I wonder when this will be recognised as a bona fide occupational disease.
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“However, if a wallet biopsy – one of the procedures in which American hospitals specialise – discloses that the victims are uninsured, it transfers them to public institutions.”
In Paul Starr, ‘The Social Transformation of American Medicine’.
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I read an earlier book of Eric Topol’s (The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care) and got a lot out of it, although I don’t know to what extent his ideas will come to pass. The Economist reviewed his more recent book, “Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again”.
The Economist reports:
The fear the author harbours [referring to Topol] is that AI will be used to deepen the assembly-line culture of modern medicine. If it confers a “gift of time” on doctors, he argues that this bonus should be used to prolong consultations, rather than simply speeding through them more efficiently.
But then goes on, in true Economist style:
That is a fine idea, but as health swallows an ever-bigger share of national wealth, greater efficiency is exactly what is needed, at least so far as governments and insurers are concerned…. An extra five minutes spent chatting with a patient is costly as well as valuable. The AI revolution will also empower managerial bean-counters, who will increasingly be able to calibrate and appraise every aspect of treatment. The autonomy of the doctor will inevitably be undermined, especially, perhaps, in public-health systems which are duty-bound to trim inessential costs.
Modern medicine — as implied — is already an assembly line culture. And yes, many of us think it will get worse. Staff retention will get worse, too. If you want to see the future of medicine as a career, look at what has happened to school teachers within public systems (or academics in most universities in the UK). Blame it all on poor Max Weber, if you will. Those in charge have very little feel for what ‘doing medicine’ is all about. But there seems to an elision between ‘greater efficiency is needed’ and talking to patients being ‘costly and valuable’. Interesting to note that only the public systems are obliged to trim ‘inessential costs’: Crony Capitalism feasts on the wants rather than the needs.
“There’s a classic medical aphorism,” he recalls. “‘Listen to the patient, they’re telling you the diagnosis.’ Actually, a lot of patients are just telling you a lot of rubbish, and you have to stop them and ask the pertinent questions.”
Jed Mercurio: ‘Facts used to have power. Now stupidity is a virtue’ | The Guardian
The question is when?
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Shortage of GPs will never end, health experts say | Society | The Guardian
OK, maybe the subeditor is to blame, but spare me the cartel of health think tanks and their pamphlets. Enticing people into general practice and keeping them there is not rocket science. When I was a junior doctor getting onto the best GP schemes around Newcastle was harder than getting the ‘professorial house-jobs’. Many people like, and want to be, GPs. If general practice is dying , it is in large part because the NHS is killing real general practice.
A few years back I wrote a personal view in the BMJ, arguing that an alternative model for dermatology in the UK would be to use office dermatologists, as in most of the first world. It is likely cheaper and capable of providing better care as long as you consider skin disease worthy of treatment. The feedback was not good or in some instances, even polite. The more considered views were that my suggestion was simply not possible: how would we train these people? Well jump on a ferry or book Ryanair, and look how the rest of Europe does it.
There are some general discussion points:
Two personal examples:
I received an orthopaedic operation under a GA at a major teaching hospital. I was in the my mid 50’s, and previously fit. At the clerking / pre-op assessment by a nurse, my pulse and BP were recorded, and my urine was tested. I was asked : “Are your heart sounds normal and do you have any heart murmurs?” (There was no physical examination). My quip — that how could you trust a dermatologist on such matters — was met with a total lack of recognition. I recounted the story to the anaesthetist as a line was inserted in my arm. I also mentioned, for effect, that they didn’t ask about my dextrocardia….( I achieved the appropriate response — to this untruth). Subsequent conversations with anaesthetists confirmed that their opinions were in keeping with mine, and this “was management” and ‘new innovative ways of
As a second year medical student, with a strong atopic background (skin, lungs, hay fever etc). I came out in what I now know to be widespread urticaria with angioedema. On going to the university health centre, the receptionist triaged me to the nurse, because it was ‘only skin’. I didn’t receive a diagnosis, just an admonition that this was likely due to not washing enough (which may have been incidentally true or false…). A more senior medical student provided me with the right diagnosis over lunch.
The latter example chimed with me, because DR Laurence in his eclectic student textbook of Clinical Pharmacology lampooned the idea that nurses had ‘innate’ understandings of GI pharmacology, a delusion that remained widespread through my early medical career. Now, sadly, similar prescientific reasoning underpins much UK dermatology. The public are not well served.
A long, long time ago, I published papers on p53 and skin (demonstrating p53 upregulation in a UVR wavelength specific way). But germline mutations are something else. The account below is from a US medical student with Li-Fraumeni syndrome (germline p53 mutations)
The changes to my outlook, my psyche, have been much more profound. It’s impossible to describe the unique panic that comes with imagining that any of your cells could decide to rebel at any moment — to propagate, proliferate, “deranged and ambitious,” as my anatomy professor remarked of cancer. It sounds like a paranoid medical student’s fugue-state nightmare. Any cancer at any time: a recurrence, a new primary, a treatment-related malignancy. Some are more likely than others: brain, colon, leukemia, sarcomas. But the improvisation of my cells and their environment is the only limit. And then there are more practical questions: Should I wear sunscreen every day, or is it better just to stay inside?
I recently saw a college friend I hadn’t seen in 10 years and told her about my mutation. Nonmedical people react badly to such news. Medical people probably would, too, but we have rehearsed emotional distance, so our reactions often stay internal, to be unearthed later. “You must be very careful about what you…eat? Drink? What you…put into your body?” she said.
“No,” I said. “There’s no point to that.”
“Oh,” she said, saddened. “This must have changed you. It must really affect the way that you see…the world?”
I nodded, thinking, You have no idea.
I like statistics and spent most of my intercalated degree ‘using’ medical stats (essentially, writing programs on an IBM 360 mainframe to handle a large dataset, that I could then interrogate using the GLIM package from the NAG). Yes, the days of batch processing and punchcards. I found — and still find — statistics remarkably hard.
I am always very wary of people who say they understand statistics. Let me rephrase that. I am very suspicious of non-professional statisticians who claim that they find statistics intuitive. I remember that it was said that even the great Paul Erdos got the Monty Hall problem wrong.
The following is from a recent article in Nature:
What will retiring statistical significance look like? We hope that methods sections and data tabulation will be more detailed and nuanced. Authors will emphasize their estimates and the uncertainty in them — for example, by explicitly discussing the lower and upper limits of their intervals. They will not rely on significance tests. When P values are reported, they will be given with sensible precision (for example, P = 0.021 or P = 0.13) — without adornments such as stars or letters to denote statistical significance and not as binary inequalities (P < 0.05 or P > 0.05). Decisions to interpret or to publish results will not be based on statistical thresholds. People will spend less time with statistical software, and more time thinking.
There is lots of blame to go around here. Bad teaching and bad supervision, are easy targets (too easy). I think there are (at least) three more fundamental problems.
Science has been thought of as a form of ‘reliable knowledge’. This form of words always sounded almost too modest to me, especially when you think how powerful science has been shown to be. But in medicine we are increasingly aware that much modern science is not a basis for honest action at all. Blake’s words were to the effect that ‘every honest man is a prophet’. I once miswrote this in an article I wrote as ‘every honest man is for profit’. Many an error….
A couple of articles from the two different domains of my professional life made me riff on some old memes. The first, was an article in (I think) the Times Higher about the fraud detection software Turnitin. I do not have any firsthand experience with Turnitin (‘turn-it-in’), as most of our exams use either clinical assessments or MCQs. My understanding is that submitted summative work is uploaded to Turnitin and the text compared with the corpus of text already collected. If strong similarities are present, the the work might be fraudulent. A numerical score is provided, but some interpretation is necessary, because in many domains there will be a lot of ‘stock phrases’ that are part of domain expertise, rather than evidence of cheating. How was the ‘corpus’ of text collected? Well, of course, from earlier student texts that had been uploaded.
Universities need to pay for this service, because in the age of massification, lecturers do not recognise the writing style of the students they teach. (BTW, as Graham Gibbs has pointed out, the move from formal supervised exams to course work has been a key driver of grade inflation in UK universities).
I do not know who owns the rights to the texts students submit, nor whether they are able to assert any property rights. There may be other companies out there apart from Turnitin, but you can see easily see that the more data they collect, the more powerful their software becomes. If the substrate is free, then the costs relate to how powerful their algorithms are. It is easy to imagine how this becomes a monopoly. However, if copies of all the submitted texts are kept by universities then collectively it would make it easier for a challenger to enter the field. But network effects will still operate.
The other example comes from medicine rather than education. The FT ran a story about the use of ‘machine learning’ to diagnose retinal scans. Many groups are working on this, but this report was about Moorfields in London. I think I read that as the work was being commercialised, then the hospital would have access to the commercial software free of charge. There are several issues, here.
Although, I have no expert knowledge in this particular domain, I know a little about skin cancer diagnosis using automated methods. First, the clinical material and annotation of clinical material is absolutely rate limiting. Second, once the system is commercialised, the more any subsequent images can be uploaded the better you would imagine the system will become. This of course requires further image annotation, but if we are interesting in improving diagnosis, we should keep enlarging the database if the costs of annotation are acceptable. As in the Turnitin example, the danger is that the monopoly provider becomes ever more powerful. Again, if the image use remains non-exclusive, then it means there are lower barriers to entry.
Not often I spot typos in the New York Review of Books, but here is one that matters. The article dealt with the price of prescription drugs, and there are of course plenty of villains to go around: crony capitalists; advertising spending being larger than research spending —because it works!; and sloppy thinking with regard to IPR and patents. The article on paper read:
In late October, however, just before the congressional elections, Azar declared to reporters that high prices constituted “the greatest possible barrier to patent access.” Democratic strategists gave prescription drug prices high priority in congressional campaigns. Yet leaders in both parties understood that curbing prices would be no easy task. The pharmaceutical industry, which has long deployed one of the most powerful lobbies in Washington, was increasing its representation in the capital.
Yes, should have read patient not patent, although no doubt pharma might not have agreed.
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“It’s not that easy to make money out of emptying anal glands.”
Interesting article in the Economist on what is happening to vet practice in the UK. The march of the corporates and private equity firms buying up vet practices from vets who want to get out (recognise the cry of the professional?). The plans are “rationalisation”, and then resale at a higher multiple of income in a few years time (well, to be correct, EBITDA which is earnings before interest, taxes, depreciation and amortization — Wikipedia has more on it here). This is essentially capital doing what capital always does in a world driven by financialisation. The caveat is that for this
Ponzi scheme speculation to work, there has to be an end buyer. The Economist, as ever fills in any gaps in logic with the usual magic variables:
As private-equity firms support the consolidation of smaller vet practices, the latter’s productivity should improve. Bigger firms can provide better salaries and more support to vets.
Well, that’s all right then — you just insert the bullshit variable. We are told:
Partly this is because young vets have high student debts; many drop out of the profession because the pay is not good enough. They are also demoralised; suicide rates among vets in America are at least twice the national average, and in Britain, almost four times.
The problem is that the money has to come from somewhere: the animal owners; or the vets (as in salaries); and also accommodate the capitalists’ profit. Downward pressures all round I guess — and wait and see what happens to productivity when you are an employee rather than running your own business. I doubt animal ownership is going to get cheaper.
The Susskinds have written elsewhere on the ‘Future of the Professions” but everywhere I look — dentistry, law, medicine — you see some common themes (no sunlit uplands). Lambs to the slaughter.
The parallels between being a school teacher and being a doctor interest me. It is difficult to think of any job more important and potentially more rewarding than teaching schoolchildren. But in the UK (and many others countries) teachers are — with good reason — deeply unhappy. Much, if not most of the dissatisfaction reflects politics, the New Public Management dogmas, and the resulting deprofessionalisation of teaching and teachers. Teaching in many UK schools is hard in a way few appreciate. If you doubt me check out Lucy Kellaway’s articles in the FT, where she has documented the stories of a group of people who went into teaching late in life, after very successful careers in other domains. The graph below tells a story. I wonder if we might imagine similar trends in medicine.
A slow-motion train-wreck: In England, the rate at which teachers are retained in government-funded schools has declined in each of the last seven years: https://t.co/kDuexCJkFk pic.twitter.com/XqpyYxNFTj
— Dylan Wiliam (@dylanwiliam) February 28, 2019
After needles and morphine were deployed in the American civil war, as many as 100,000 veterans were left addicted. In 1895 scientists at Bayer, a German pharmaceutical firm, began selling a strong morphine compound called diamorphine. To market it, they called it “heroin” from the German word meaning heroic.
Article in the Economist on oxycodone dealing with — well not medicine — but business
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In addition to its vulnerability to spoofing, for example, there is its gross inefficiency. “For a child to learn to recognize a cow,” says Hinton, “it’s not like their mother needs to say ‘cow’ 10,000 times”—a number that’s often required for deep-learning systems. Humans generally learn new concepts from just one or two examples.
There is a nice review on Deep Learning in PNAS. The spoofing referred to, is an ‘adversarial patch’ — a patch comprising an image of something else. In the example here, a mini-image of a toaster confuses the AI such that a very large banana is seen as a toaster (the paper is here on arXiv — an image is worth more than a thousand of my words).
Hinton, one of the giants of this field, is of course referring to Plato’s problem: how can we know so much given so little (input). From the dermatology perspective, the humans may still be smarter than the current machines in the real world, but pace Hinton our training sets need not be so large. But they do need to be a lot larger than n=2. The great achievement of the 19th century clinician masters was to be able to create concepts that gathered together disparate appearances, under one ‘concept’. Remember the mantra: there is no one-to-one correspondence between diagnosis and appearance. The second problem with humans is that they need continued (and structured) practice: the natural state of clinical skills is to get worse in the absence of continued reinforcement. Entropy rules.
Will things change? Yes, but radiology will fall first, then ‘lesions’ (tumours), and then rashes — the latter I suspect after entropy has had its way with me.
General practice has been undergoing a quiet revolution in recent years that has had little fanfare: it is now an overwhelmingly part-time profession.
Official figures suggest almost 70% of the workforce work less than full time in general practice – the highest proportion ever.
This is from an interview with Geoffrey Hinton who — to paraphrase Peter Medawar’s comments about Jim Watson — has something to be clever about. The article is worth reading in full, but here are a few snippets.
Now if you send in a paper that has a radically new idea, there’s no chance in hell it will get accepted, because it’s going to get some junior reviewer who doesn’t understand it. Or it’s going to get a senior reviewer who’s trying to review too many papers and doesn’t understand it first time round and assumes it must be nonsense. Anything that makes the brain hurt is not going to get accepted. And I think that’s really bad…
What we should be going for, particularly in the basic science conferences, is radically new ideas. Because we know a radically new idea in the long run is going to be much more influential than a tiny improvement. That’s I think the main downside of the fact that we’ve got this inversion now, where you’ve got a few senior guys and a gazillion young guys.
I would make a few comments:
All has been said before, I know, but no apology will be forthcoming.
This is from an article by Stephen Senn in Nature. He keeps making this point — for the very good reason that people want to pretend there is no problem. But there is.
Personalized medicine aims to match individuals with the therapy that is best suited to them and their condition. Advocates proclaim the potential of this approach to improve treatment outcomes by pointing to statistics about how most drugs — for conditions ranging from arthritis to heartburn — do not work for most people. That might or might not be true, but the statistics are being misinterpreted. There is no reason to think that a drug that shows itself to be marginally effective in a general population is simply in want of an appropriate subpopulation in which it will perform spectacularly.
When you treat patients with chronic diseases such as psoriasis, it quickly becomes clear that there is considerable within person variation is response to treatments. We do not understand what this variation is due to. What we do know however, is that assuming variation in response between people at single time points may be misleading in that we have no measure of within person variance. This is only one of the problems. But hey, precision, personalised.. whatever: it shifts units (as Frank Zappa once said of Michael Jackson).
This is from a book review in the FT of American Overdose. by Chris McGreal — prescription for carnage.
McGreal has written an interview-based book, with especially vivid reporting from West Virginia, the state hit hardest by the epidemic. In the little town of Williamson, or Pilliamson as people came to call it, pharmacies were dispensing opioids at a staggering rate both to locals and to out-of-state visitors, who clogged its streets with their cars but boosted some local businesses as well as city tax revenues.
When the federal authorities belatedly raided one Williamson clinic in late 2009, they found that an individual doctor had written 355,132 opioid prescriptions over the previous seven years — about 1,000 for every inhabitant of the town. Another wrote 118,443 scrips over the same period. Most were handed out for cash fees without the doctors bothering to see their patients. The investigators estimated that the clinic took in $4.6m cash during 2009 and they found banknotes stuffed into safes and cupboards in the doctors’ homes and offices.
At my old university, we were encouraged to explore our subjects and to love what we were studying. Now, at medical school, the emphasis seems to be don’t burnout, focus on not making mistakes, and understand that life is going to be hard, so develop the resilience to cope.
The above is from a letter to this month’s Academic Medicine [83(12) 1745-1884, 2018] written by a graduate student at Warwick medical school (TC Shortland). The title is what caught my eye: “Enjoying, and Not Just Surviving, Medical School”
He goes on:
At Warwick Medical School, staff and students are trying to build a more positive environment. Staff and students have organized art classes, interstaff/ student sports events, and several baking competitions; the last winner featured cupcakes that could be injected with either a salted caramel or raspberry filling. As positive health care workplaces and positive cultures are associated with better patient outcomes,why shouldn’t medical schools try and create such environments for future medical professionals?
I am not against the various suggestions (…well, I am actually), but what I and others are in despair about is how much (?most) medical education has become so dull, tedious, and brutal, rather than humane. When I have spoken to others, some hold similar views: the students put up with it, because they want to be doctors, but they no not enjoy most of it. If they are obliged to attend, they do; but out of choice, many would skip much of what we offer.
Now this is not a new thought or phenomenon. I didn’t enjoy — in fact I actively hated — the preclinical years (aka: the prescientific years) — but I did get a big kick out of the clinical years, and loved my intercalated degree. What made the clinical years work, was that the opportunity for some kind of personal bond with some teaching staff made up for all the despots and dull souls who should have been destined to be gravediggers. And unless somebody has recently discovered something I have missed, scale and intimacy rarely go together.
Of course, what makes matters worse, is that the ennui and anomie will get worse: for many junior doctors, after the initial high of being qualified, their working jobs are miserable. If they get to higher training, things may improve, but not for all.
George Steiner’s comments in a slightly different context are apposite:
“Bad teaching is, almost literally, murderous and, metaphorically, a sin. It diminishes the student, it reduces to gray inanity the subject being presented. It drips into the child’s or the adult’s sensibility that most corrosive of acids, boredom, the marsh gas of ennui.”
The NHS (for this is the fault of the NHS rather thant the universities) is accumulating a massive moral debt, borrowing on the very market it has rigged (because it can!), forgetting that this is like PFI on steroids. It assumes it is too big to fail: I think otherwise.
How did you go bankrupt: slowly and then suddenly.