NHS founder’s relative died after ‘neglect’.

by reestheskin on 26/07/2019

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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… 

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(Image courtesy of Alun of Penglas).

Summer flight

by reestheskin on 26/07/2019

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Not so much a jet plane, but I don’t know  exactly when I will be back either.

 

Smombies everywhere

My youngest daughter lived in South Korea for a while and I visited on a couple of occasions. It was a lot of fun in all sorts of ways. The following rings(!) true

The government initially tried to fight the “smombie” (a portmanteau of “smartphone” and “zombie”) epidemic by distributing hundreds of stickers around cities imploring people to “be safe” and look up. This seems to have had little effect even though, in Seoul at least, it recently replaced the stickers with sturdier plastic boards.

Instead of appealing to people’s good sense, the authorities have therefore resorted to trying to save them from being run over. Early last year, they began to trial floor-level traffic lights in smombie hotspots in central Seoul. Since then, the experiment has been extended around and beyond the capital. For the moment, the government is retaining old-fashioned eye-level pedestrian lights as well. But in future, the way to look at a South Korean crossroads may be down.

A dangerous creature is haunting South Korean crossroads – Smombie apocalypse

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Software is eating..

Comparison of the accuracy of human readers versus machine-learning algorithms for pigmented skin lesion classification: an open, web-based, international, diagnostic study.

You can dice the results in various ways, but software is indeed eating the world — and the clinic. The (slow) transition to this new world will be interesting and eventful. A good spectator sport for some of us. (Interesting to note that this study in Lancet Oncology received no specific funding. Hmmm).

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What is science for: dangerous thoughts.

The quote below was from a piece in the Lancet by Richard Horton.

Reading [Bertrand]Russell today is a resonant experience. Existential fears surround us. Yet today seems a long way from the dream of Enlightenment. Modern science is a brutally competitive affair. It is driven by incentives to acquire money (research funding), priority (journal publication), and glory (prizes and honours). Science’s metrics of success embed these motivations deep in transnational scientific cultures. At The Lancet, while we resist the idea that Impact Factors measure our achievements, we are not naive enough to believe that authors do not judge us by those same numbers. It is hard not to capitulate to a narrow range of indicators that has come to define success and failure. Science, once a powerful force to overturn orthodoxy, has created its own orthodoxies that diminish the possibility of creative thought and experiment. At this moment of planetary jeopardy, perhaps it is time to rethink and restate the purpose of science.

Offline: What is science for? – The Lancet

I am just musing on this. We like to think that ‘freedom’ was necessary for a modern wealthy state. We are not so certain, now. We used to think that certain freedoms of expression underpinned the scientific revolution. We are having doubts about this, too. Maybe it is possible to have atom bombs and live in a cesspool of immorality. Oops…

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Living in Scot itchland

Genital scabies was, to the English, “Scotch itch,” and Scotland was “Itch-land.” The pox was the Spanish or Neapolitan Disease to the French; the French Disease to the Spanish, English, and Germans; the Polish Disease to the Russians; the Portuguese Disease to the Japanese. Captain Cook was chagrined to learn that it was called the British Disease in Tahiti as, in so many words, it was in Ireland: in Ulysses the Citizen, a rabid Irish nationalist, mocks Leopold Bloom’s reference to British civilization: “Their syphilisation you mean.”

Vile Bodies | by Fintan O’Toole | The New York Review of Books

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Wigged out!

“There is no urgent need to go discarding something which has been out of date for at least a century.”

The Economist | Wigged out

This quote refers to the wigs judges in the UK wear. But it seems apposite for much of the way we think about medical education.

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Mental Health Services for Medical Students

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

NEJM

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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Statistics and empathy

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.

Age of the expert as policymaker is coming to an end | Financial Times

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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It’s the economy stupid!

The main story is about an ‘anti-vaxxer’ who had informed the university that he/she was opposed to receiving any vaccinations, but the university had not noticed or acted upon this advice till after the student had started univeristy. Cardiff university were ordered to pay £9K to the anti-vaxxer healthcare student.

Cardiff ordered to pay £9K to anti-vaxxer healthcare student | Times Higher Education (THE)

But this caught my eye even more.

In a separate case summary, also published on 1 July, the OIA said that it had told Wrexham Glyndwr University to compensate eight students who had complained about the quality of a healthcare-related course.

The watchdog said that the students had complained that a key part of the course had not been taught as promised, meaning that they were not given the necessary skills to practise safely. Some teaching hours were cancelled for some modules, and the group also complained about the behaviour of a staff member, who they said was “unapproachable and aggressive”.

The OIA, which ruled that the complaint was partly justified, said that Glyndwr should refund tuition fees of £2,140 to each student, and pay an additional £1,500 compensation to each of them for the inconvenience caused.

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The digital skin web

On some Swedish trains, passengers carry their e-tickets in their hands—literally. About 3,000 Swedes have opted to insert grain-of-rice-sized microchips beneath the skin between their thumbs and index fingers. The chips, which cost around $150, can hold personal details, credit-card numbers and medical records. They rely on Radio Frequency ID (RFID), a technology already used in payment cards, tickets and passports.

Why Swedes are inserting microchips into their bodies – Bjorn Cyborg

One of these is going to end up being sectioned as some time….waiting for the first case-report. Not often I can get two puns in a three word title.

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Sunday in Lisbon

“Catholicism imbued a spirit of rebellion and the ghost of faith.”

Well, I get that, too. In a review of Bruce Springsteen’s biography in the Economist.

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Did you enjoy Uni?

“The job prospects outweigh three years of misery.”

The Economist | The glum ones

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On  ratio scales and the spirits of invention

It is said that much of the foundations of 20th century physics was done in coffee houses (or in the case of Richard Feynman in strip bars), but things were once done differently in the UK

With neither institutional nor government masters to answer to, the British cyberneticians were free to concentrate on what interested them. In 1949, in an attempt to develop a broader intellectual base, many of them formed an informal dining society called the Ratio Club. Pickering documents that the money spent on alcohol at the first meeting dwarfed that spent on food by nearly six to one — another indication of the cultural differences between the UK and US cyberneticians.

The work of the British pioneers was forgotten until the late 1980s when it was rediscovered by a new generation of researchers… A company that I cofounded has now sold more than five million domestic floor-cleaning robots, whose workings were inspired by Walter’s tortoises. It is a good example of how unsupported research, carried out by unconventional characters in spite of their institutions, can have a huge impact.

A review from 2010 by Rodney Brooks of MIT of “The Cybernetic Brain: Sketches of Another Future” in Nature (For more on Donald Michie and “in spite of their institutions” see here).

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Chadgrind lives on

I have had of all people a historian tell me that science is a collection of facts, and his voice had not even the ironic rasp of one filing-cabinet reproving another.

Jacob Bronowski | Science and Human Values

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Precision medicine and a den of robbers

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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The pleasures of tenure

Mr Sammallahti is not a recluse, nor lacking in ambition. He travels the world taking photographs; a book, “Here Far Away”, was published in 2012; another, of bird pictures, comes out later this year. But he shuns the art scene, believing that commercial pressures undermine quality. He does not lecture and rarely gives interviews. In 1991 he received an unprecedented 20-year grant from the Finnish government. Its sole condition was that he should concentrate on photography, so he gave up teaching. “I want to work in peace,” he explains, “to be free to fail.”

Economist

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TEF or REF?

Smith was supported by earnings from his professorship at Glasgow, where a university teacher’s earnings depended on fees collected directly from students in the class. This contrasted with Oxford, where Smith had spent six unhappy years, and where, he observed, the dons had mostly given up even the pretence of teaching.

But Smith relinquished his professorship in 1763, and the writing of ‘Wealth…’ and the remainder of his career was financed by the Duke of Buccleuch, who as a young man employed Smith as a tutor.

Is there more to Adam Smith than free markets? | Financial Times

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On statistics

Statistics — to paraphrase Homer Simpson’s thoughts on alcohol — is the cause of, and solution to, all of science’s problems.

Andrew Gelman

Of chaos, storms and forking paths: the principles of uncertainty

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Blasts from the past

Digging deep into some of my old notes, I came across this obituary of John Ziman written by Jerry Ravetz. I know both through their written work and was lucky enough to meet and chat briefly with John Ziman not long before he died. Ziman’s book “Real Science” is for me the classic account of what has happened to science as it moved from a ‘way of life’ to a job.

Jerry Ravetz writes:

I first became aware of him through his 1960 radio talk Scientists – Gentlemen Or Players?, where he observed how a career in science was starting to change, from being a vocation to being a job.

There was a paradox running through his later career, to which he must have been sensitive. He was a “Renaissance man” in a way highly desirable for a scientist, but he did not exert the influence that he might have hoped to. This was due less to the passion he deployed in argument than the times in which he found himself. The age of such eminent scientist-savants as JBS Haldane, JD Bernal and Joseph Needham was passing, while a new generation of socially responsible scientists had yet to establish itself. Those who reminded scientists of their social responsibilities were viewed with suspicion; and those who had stopped doing research were treated as defectors.

Obituary: John Ziman | Education | The Guardian

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Use it for lose it

The following was from a “Lunch with the FT” article with Armen Sarkissian, the President of Armenia, a former physicist. Both quotes respect their fact that expertise is time limited. One big downside of certification at a fixed time point is that it pretends otherwise.

On the collapse of the Soviet Union in 1991, Sarkissian was asked to become independent Armenia’s first ambassador to London, a post he filled again on two later occasions — a record, he believes, at the Court of St James’s. For good measure, he also opened embassies and missions in Belgium, the Netherlands, Luxembourg, the EU, Nato and the Vatican. “I dreamt that I could do both science and diplomacy. But being a research physicist is like being a concert pianist. Unless you practise every day, it is gone. It becomes a hobby,” he says, regretfully.

Those people who know how to listen are also people who learn,” he says. “The moment you stop learning, you die. Age is not the number of years that you have been living. Age is the condition of your soul.”

Armen Sarkissian: ‘The moment you stop learning, you die’ | Financial Times

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Take that, capitalism !

There are, of course, reasons why tattooing is different from other fine arts. First is the medium: human skin. Then there is the fact that a tattoo, unlike a painting or sculpture, cannot be sold on. “To a degree, the fine art world has jumped on it. But a tattoo has no resale value. That is crucial,” said London-based tattoo artist Alex Binnie.

Link

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How the Nobel are fallen

As John Hammerbacher, Facebook’s first research scientist, remarked: “the best minds of my generation are thinking about how to make people click ads… And it sucks.”

Quoted in Stand Out of Our Light, James Williams

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Surgeons?

”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.”

Trial of new generation of surgical robots claims success | Financial Times

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Transfer

A not wildly unsurprising comment to anybody in the ‘modern’ university.  A comment Russ Roberts made in an interview with David Epstein.

I want to share my favourite course evaluation when I used to teach in the classroom. So, I got a 1 from this student, on a scale of 1 to 5 (where 5 is good and 1 is bad)…. a 1 is really demoralising. So, I look at it:

What does the student say? “This course was very unfair. Professor Roberts expected us to apply the material to things we had never seen before.”

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Late night thoughts #9

by reestheskin on 06/06/2019

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Late night thoughts on medical education #9: The Great Schism

Our present pattern of medical education is only one of several that are operating more or less successfully at the present time: good medicine can be taught and practised under widely varying conditions.

Henry Miller. ‘Fifty Years after Flexner’, 1966.

In my last post, I used a familiar Newton quote: ‘the job of science is to cleave nature at the joints’. We can never understand the entirety of the universe, all we can do is to fragment it, in order to make it amenable to experimentation or rational scrutiny. Before you can build anything you have to have taken other familiar things apart. Understanding always does violence to the natural world.

In this series of posts I have already listed some of the many things that confound attempts to improve medical education. But I don’t think we now need just a series of bug fixes. On the contrary, we need radical change — as in a new operating system — but radical change we have had before, and there are plenty of examples that we can use to model what we want. And as I hinted at in my last post, medical exceptionalism (and in truth pride) blind medical educationalists to how other domains of professional life operate. This soul searching about professional schools is not confined to medicine. There are debates taking place about law schools [1] and engineering schools [2], and corresponding debates about the role of the professions in society more generally (have the professions a future — professional work has, but who is going to do it?) [3][4].

Where to wield the scalpel

The conventional medical degree has two components: the preclinical years (which I used to to call the prescientific years, simply because rote learning is so favoured in them); and the clinical years. This divide has been blurred a little, but does not seriously alter my argument — the blurring has in any case been a mistake IMHO. The preclinical years have some similarities with other university courses, for good and bad. The clinical years are simply a mess. They aspire to a model of apprenticeship learning that is impossible to deliver on.

A positive

All is not lost, however. We know we can do some things well. Let me consider the ‘clinical’ first, before moving back to the ‘preclinical’.

Registrar training day in any speciality can work well. We know how to do it. There is a combination of private study, formal courses, and day-to-day supervised and graded practice. Classic apprenticeship. This doesn’t mean it is always done well — it isn’t — but in practice we know how to put it together. Let me use dermatology as an example.

In the UK and a few other countries, you enter dermatology after having done FY (foundation years 1 & 2) and a few years of internal medicine, having passed the MRCP exams along the way (the College tax). I refer to this as pre-dermatology training. At this stage, you compete nationally for training slots in dermatology.

This pre-dermatology training is unnecessary. We know this to be the case because most of the world does not follow this pattern, and seems to manage OK in terms of quality of their dermatologists. (This ‘wasted years’ period was painfully pointed out to me when I started dermatology training in Vienna: ‘you have wasted four years of your life’, I was told. I wasn’t pleased, but they were right and I was wrong)[5]. Why you ask, does the UK persist? Three explanations come to mind. First, the need for cheap labour to staff hospitals. Second, the failure to understand that staff on a training path need to supplement those who provide ‘core service’: much as senior registrars were supernumerary in some parts of the UK at one time. Finally, an inability to realise that we might learn from others.

Providing good apprenticeship training in dermatology is (in theory) very straightforward. Book learning is required, formal courses online can supplement this book learning, and since trainees are grouped in centres, interpersonal learning and discussion is easy to organise. Most importantly, trainees work with consultants, over extended periods of time, who know what they are trying to achieve: the purpose of the apprenticeship is to produce somebody who can replace them in a few years time. You do not need to be deep into educational theory to work well within this sort of environment, indeed you should keep any ‘educationalists’ at arms length.

Where this model does not work well, is in the ‘predermatology’ training. The obvious point is that much of this pre-dermatology work is not necessary and where it is, it should be carried out by those who are embarking on a particular career or by non-training staff (who may or may not be doctors). In the UK, if you have a FY doctor attached to a dermatology ward, they will rotate every few months through a range of specialties, and it is likely that they will have no affinity for most of them. Such jobs are educationally worthless as dermatology is an outpatient specialty. Ironically the only value of such jobs, is for those who have already committed to a career in dermatology. I will return to the all too familiar objections of what I propose in another blog post, but for training in many areas of medicine, including GP, radiology, pathology, psychiatry, what I have said of dermatology, holds.

We could frame my argument in another way. If you cannot hold onto the tenets of apprenticeship learning — extended periods of graded practice under the close supervision of a small group of masters and novices, it is not a training post.

University and the function of medical schools

I am now going to jump to the other end of medical education: what are medical schools for?

Current undergraduate medical education is a hybrid of ‘education’ and ‘training’. Universities can deliver high class education (I said can, not do), but they cannot deliver high class clinical training. They do not have the staff to do it, and they do not own the ‘means of production’. Apprenticeship learning does not work given the number of students, and in any case, teaching of medical students is a low priority for NHS hospitals who have been in a ‘subsistence’ mode for decades. Things will only get worse.

Other professions

Some (but not all) other professional schools or professions organise things differently. A degree may be necessary, but the bond between degree and subsequent training is loose. Unlike medicine, it is not the job of the university to produce somebody who is ‘safe’ and ‘certified’ on the day of graduation.

What I propose is that virtually all the non-foundational learning is shifted into the early years of apprenticeship learning where the individuals are paid employees of the NHS (or other employer). I talked about what foundational learning is in an earlier post, and here I am arguing that it is the foundational learning which universities should deliver. Just as professional service firms, law firms or engineering schools may prefer graduates with particular degrees, they know that they need to train their apprentices in a work environment, an environment in which they are paid (as with all apprenticeships the training salary reflects the market value to the individual of the professional training they receive). What becomes of medical schools?

Schools of health

The corpus of knowledge of the determinants of health and how to promote health, as well as how to diagnose and care for those who are sick is vast. Looked at in financial terms, or numbers of workers, it is a large part of the modern economy, and is of interest way beyond the narrow craft of clinical medicine. The fundamental knowledge underpinning ‘health’ includes sciences and arts. Although modern medicine likes to ride on the coat-tails of science, it is in terms of practice, a professional domain that draws eclectically from a broad scholarship and habits of mind. Medical science has indeed grown, but as a proportion of the domains of knowledge that make up ‘health’ it has shrunk.

Simply put, we might expect many students to study ‘health’, and for the subset of those who want to become doctors we need to think about the domains that are most suitable for ‘practising doctors’. Not all who study ‘health’, will want to be ‘practising doctors’, but of those who do, there may be constraints on what modules they should take. The goal is to produce individuals who can be admitted into a medical apprenticeship when they leave university.

Wrap up

I will write more about ‘health’ in the next post, and contrast it with what we currently teach (and how we teach it). The later part of training (genuine apprenticeship), as in the dermatology example, I would leave alone. But what I am suggesting is that we totally change the demands put on medical schools, and place apprenticeship learning back where it belongs.

[1] Stolker C. Rethinking the Law School. Cambridge University Press; 2014

[2] Goldberg DE, Somerville M, Whitney C. A Whole New Engineer: The Coming Revolution in Engineering Education. Threejoy Associates; 2014

[3] Susskind RE. The end of lawyers? : rethinking the nature of legal services. Oxford; New York: Oxford University Press; 2010

[4] Susskind R, Susskind D. The Future of the Professions. Oxford University Press, USA; 2015

[5] Rees J. The UK needs office dermatologists. BMJ. 2012;345:35.

Moving on

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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On Expertise

‘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’.

Hubert Dreyfus.

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Manchester is the clearest portrait of this new educational-industrial complex.

The Manchester model: universities lead urban revival | Financial Times

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Changing your mind — and how to avoid

The economist J.K. Galbraith once suggested that when people are “faced with the choice between changing one’s mind and proving that there is no need to do so, almost everyone gets busy on the proof”

The market is dead: long live the market | Wonkhe | Comment

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