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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That was yesterday

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.

GlaxoSmithKline revamps incentives for sales representatives | Financial Times

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Late night thoughts #8

by reestheskin on 31/05/2019

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Late night thoughts on medical education #8: Where to draw the line?

In the previous post, I talked about some of the details of how undergraduate clinical teaching is organised. It is not an apprenticeship, but rather an alienating series of short attachments characterised by a lack of continuity of teacher-pupil contact. This is not something easily fixed because the structure is geared around the needs of the NHS staff who deliver the bulk of student teaching, rather than what we know makes sense pedagogically. I likened it to the need to put up with getting through security when you travel by plane: you want to get somewhere, but just have to grin and bear the humiliation. This is not a university education. I am not saying that individual teachers are to blame — far from it — as many enjoy teaching students. It is a system problem.

The interdependence of undergraduate education and postgraduate medical training

It is not possible to make sense of either undergraduate medical education or postgraduate training without looking at the forces that act on the other. It is also far too easy to assume that ‘the system’ in the UK is the only way to organise things, or indeed, to think it is anywhere near optimal. A damning critique of medicine (and much else in society) in the UK is our inability to learn from what others do.

The formative influences on (undergraduate) medical education are those conditions that were operating over half a century ago. At that time, a medical degree qualified you to enter clinical practice with — for many students — no further formal study. And much clinical practice was in a group size of n=1.

In the 1950s the house year (usually 6 months surgery and 6 months medicine) was introduced. Theoretically this was under the supervision of the university, but in practice this supervision was poor, and the reality was that this was never going to work in the ‘modern NHS’. How can the University of Edinburgh supervise its graduates who work at the other end of the country? In any case, as has been remarked on many occasions, although the rationale for the house year was ‘education’, the NHS has never taken this seriously. Instead, housepersons became general dogsbodies, working under conditions that could have come from a Dickens novel. In my own health board, the link between master and pupil has been entirely broken: apprenticeship is not only absent from the undergraduate course, but has been exiled from a lot of postgraduate training (sic). House doctors are referred to as ‘ward resources’, not tied to any group of supervising doctors. Like toilet cisterns, or worse…

Nonetheless, the changes in the 1950 and other reforms in the 1960s established the conventional wisdom that the aim of undergraduate medical education was not to produce a ‘final product’ fit to travel the world with their duffel-shaped leather satchel in hand. Rather, there would be a period of postgraduate training leading to specialist certification.

Training versus education

This change should have been momentous. The goal was to refashion the undergraduate component; and allow the postgraduate period to produce the finished product (either in a specialty, or in what was once called general practice). It is worth emphasising what this should have meant.

From the point of view of the public, the key time for certification for medial practice was not graduation, but being placed on the specialist register. The ability to practice independently was something granted to those with higher medical qualification (MRCP, MRCPysch etc) and who were appointed to a consultant post. All other posts were training posts, and practice within such roles was not independent but under supervision. Within an apprenticeship system — which higher professional training largely should be — supervision comes with lots of constraints, constraints that are implicit in the relation between master and pupil, and which have stayed largely unchanged across many guilds and crafts for near on a thousand years.

What went wrong was no surprise. The hospitals needed a cadre of generic dogbodies to staff them given the 24 hour working conditions necessary in health care. Rather than new graduates choosing their final career destination (to keep with my airport metaphor) they were consigned to a holding pattern for 2-7 years of their life. In this service mode, the main function was ‘service’ not supervised training. As one of my former tutees in Edinburgh correctly told me at graduation: (of course!)he was returning to Singapore, because if he stayed in the NHS he would just be exploited until he could start higher professional training. The UK remains an outlier worldwide in this pattern of enforced servitude[1].

What has all this to do with undergraduate education?

The driving force in virtually all decision making with the UK health systems is getting through to the year-end. The systems live hand-to-mouth. They share a subsistence culture, in which it almost appears that their primary role is not to deliver health care, but to reflect an ideology that might prove attractive to voters. As with much UK capitalism, the long term always loses out to the short term. What happened after the realisation that a graduating medical students was neither beast nor fowl, was predictable.

The pressure to produce generic trainees with little meaningful supervision in their day-to-day job, meant that more and more of undergraduate education was sacrificed to the goal of producing ‘safe and competent’ FY (foundation years 1 & 2) doctors, doctors who again work as dogsbodies and cannot learn within a genuine apprenticeship model. The mantra became that you needed five years at medical school, to adopt a transitory role, that you would willingly escape from as soon as possible. Furthermore the undergraduate course was a sitting duck for any failings of the NHS: students should know more about eating disorders, resilience, primary care, terminal care, obesity, drug use… the list is infinite, and the students sitting ducks, and the medical schools politically ineffective.

What we now see is an undergraduate degree effectively trying to emulate a hospital (as learning outside an inpatient setting is rare). The problem is simply stated: it is not possible to do this within a university that does not — and I apologise if I sound like an unreconstructed Marxist — control the means of production. Nor is it sensible to try and meld the whole of a university education in order to produce doctors suitable for a particular time-limited period of medical practice, that all will gladly leave within a few years of vassalage.

 Medical exceptionalism

Medicine is an old profession, (I will pass on GBS’ comments about the oldest profession). In medicine the traditional status of both ‘profession’ and ‘this profession’ in particular has been used to imagine that medicine can stand aloof from other changes in society. There are three points I want to make on this issue: two are germane to my argument, whilst the other, I will return to in another post.

The first is that in the immediate post-Flexner period to the changes in medical education in the 1950s and 1960s, few people in the UK went to university. Doctors did go to university even if the course was deemed heavily vocational, with a guaranteed job at the end of it. Learning lots of senseless anatomy may not have compared well with a liberal arts eduction but there was time for maturing, and exposure to the culture of higher learning. Grand phrases indeed, but many of us have been spoiled by their ubiquity. Our current medical students are bright and mostly capable of hard work, but many lack the breadth and ability to think abstractly of the better students in some other faculties. (It would for instance, be interesting to look at secular changes in degree awards of medical students who have intercalated.) No doubt, medical students are still sought after by non-medical employers, but I suspect this is a highly self-selected group and, in any case, reflects intrinsic abilities and characteristics as much as what the university has provided them with.

The second point, is that all the professions are undergoing change. The specialist roles that were formalised and developed in the 19th century, are under attack from the forces that Max Weber identified a century ago. The ‘terminally differentiated’ individual is treated less kindly in the modern corporate state. Anybody who has practiced medicine in the last half century is aware of the increasing industrialisation of medical practice, in which the battle between professional judgment and the impersonal corporate bureaucracy is being won by the latter [2][3]

My third point is more positive. Although there have been lots of different models of ‘professional training’ the most prevalent today is a degree in a relevant domain (which can be interpreted widely) following by selection for on the job training. Not all those who do a particular degree go onto the same career, and nor have the employers expected the university to make their graduates ‘fit for practice’ on day 1 of their employment. Medicine has shunned this approach, still pretending that universities can deliver apprenticeship training, whilst the GMC and hospitals have assumed that you can deliver a safe level of care by offloading core training that has to be learned in the workplace, to others. No professional services firm that relies on return custom and is subject to the market would behave in this cavalier way. Patients should not be so trusting.

In the next post, I will expand on how — what was said of Newton — we should cleave nature at the joints in order to reorganise medical education (and training).

[1] Re; the enforced servitude. I am not saying this work is not necessary, nor that those within a discipline do not need to know what goes on on the shop floor. But to put it bluntly, the budding dermatologist should not be wasting time admitting patients with IHD or COPD, or inserting central lines or doing lumbar punctures. Nor do I think you can ethically defend a ‘learning curve’ on patients given that the learner has committed not to pursue a career using that procedure. The solution is obvious, and has been discussed for over half a century: most health care workers need not be medically qualified.

[2] Which of course raises the issue of whether certification at an individual rather than an organisational level makes sense. In the UK the government pressure will be to emphasise the former at the expense of the latter: as they say, the beatings will continue until moral improves.

[3] Rewards in modern corporations like the NHS or many universities are directed at generic management skills, not domain expertise. University vice-chancellors get paid more than Nobel prize winners at the LMB. In the NHS there is a real misalignment of rewards for those clinicians who their peers recognise as outstanding, versus those who are medical managers (sic). If we think of some of the traditional crafts — say painting or sculpture – I doubt we can match the technical mastery expertise of Florence. Leonardo would no doubt now by handling Excel spreadsheets as a manager (see this piece on Brian Randell’s homepage on this very topic).

Too old, too fat, too lazy and too rich

by reestheskin on 31/05/2019

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Quite a motto to live by, but David Hume saw things more clearly than the rest of us.

Hume’s ironic wit and humour make him a biographer’s dream. After his History of England proved to be a tremendous critical and popular success, his publisher entreated him for another volume, only to receive the memorable rebuff:

 

“I have four reasons for not writing: I am too old, too fat, too lazy and too rich.”

 

When at a last dinner before Hume’s death in 1776, Smith complained of the cruelty of the world in taking him from them, Hume said: “No, no. Here am I, who have written on all sorts of subjects calculated to excite hostility, moral, political, and religious, and yet I have no enemies; except, indeed, all the Whigs, all the Tories, and all the Christians.” There are many other such stories.

 

How Adam Smith would fix capitalism | Financial Times

“It appears to me, the doing what little one can to encrease [sic] the general stock of knowledge is as respectable an object of life as one can in any likelihood pursue.”

Darwin. Letter to his sisters from the Beagle. Quoted in the London Review of Books 23-May-2019, Rosemary Hill.

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The information society

by reestheskin on 27/05/2019

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This is a little old, but I snapped it as I was passing through a hospital. It speaks volumes about the state of learning and engagement in the NHS.

Late night thoughts #7

by reestheskin on 24/05/2019

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Late night thoughts on medical education #7: Carousels

In the previous post I laid out some of the basic structures of the ‘clinical years’ of undergraduate medical degrees. In this post I want to delve a little deeper and highlight how things have gone wrong. I do not imagine it was ever wonderful, but it is certainly possible to argue that things have got a lot worse. I think things are indeed bad.

When I was a medical student in Newcastle in 1976-1982 the structure of the first two clinical years (years 3 and 4) were similar, whereas the final year (year 5) was distinct. The final year was made up of several long attachments — say ten weeks medicine and 10 weeks surgery — and there were no lectures or any demands on your time except that you effectively worked as an unpaid houseman, attached to a firm of two or three consultants. The apprenticeship system could work well during these attachments. The reasons for this partly reflected the fact that all parties had something to gain. Many if not most students chose where they did their attachments (‘if you like fellwalking, choose Carlisle etc), and had an eye on these units as a place to do your house jobs the following year. The consultants also had skin in the game. Instead of relying on interviews, or just exam results, they and all their staff (junior docs, nurses etc) got a chance to see close up what an individual student was like, and they could use this as a basis for appointing their houseperson the following year. If a houseman was away, you acted up, and got paid a small amount for this. At any time if you didn’t turn up, all hell would break out. You were essential to the functioning of the unit. No doubt there was some variation between units and centres, but this is how it was for me. So, for at least half of final year, you were on trial, immersed in learning by doing / learning on the job / workplace learning etc. All the right buzzwords were in place.

Carousels

As I have said, years 3 and 4 were different from final year, but similar to each other. The mornings would be spent on the ward and the afternoons — apart from Wednesdays — were for lectures. I didn’t like lectures (or at least those sort of lectures) so I skipped them apart from making sure that I collected any handouts which were provided on the first day (see some comments from Henry Miller on lectures below [1]).

The mornings were ‘on the wards’. Four year 3 students might be attached to two 30 bedded wards (one female, one male), and for most of the longer attachments you would be given a patient to go and see, starting at 9:30, breaking for coffee at 10:30 and returning for an hour or more in which one or more of you had to present you findings before visiting the bedside and being taught how to examine the patient. The number of students was small, and there was nowhere to hide, if you didn’t know anything.

For the longer attachments (10 weeks for each of paediatrics, medicine and surgery) this clinical exposure could work well. But the shorter attachments especially in year 4 were a problem, chiefly because you were not there long enough to get to know anybody.

The design problem was of course that the lectures were completely out of synchrony with the clinical attachments. You might be doing surgery in the morning, but listening to lectures on cardiology in the afternoon. Given my lack of love for lectures, I used the afternoons to read about patients I had seen in the morning, and to cover the subject of the afternoon lectures, by reading books.

I don’t want to pretend that all was well. It wasn’t. You might turn up to find that nobody was available to teach you, in which case we would retreat to the nurses canteen to eat the most bacon-rich bacon sandwiches I have ever had the pleasure of meeting (the women in the canteen thought all these young people needed building up with motherly love and food 🙂 ).

The knowledge of what you were supposed to learn was, to say the least, ‘informal’; at worst, anarchic. Some staff were amazingly helpful, but others — how shall I say — not so.

Year 5 envy

In reality, everybody knew that years 3 and 4 were pale imitations of year 5. The students wanted to be in year 5, because year 5 students — or at last most year 5 students — were useful. The problem was that the numbers (students and patients) and the staffing were not available. It was something to get through, but with occasional moments of hope and pleasure. Like going through security at airports: the holiday might be good, but you pay a price.

Present day

The easiest way to summarise what happens now is to provide a snapshot of teaching in my own subject at Edinburgh.

Year 4 (called year 5 now, but the penultimate year of undergraduate medicine) students spend two weeks in dermatology. Each group is made up of 12-15 students. At the beginning of a block of rotations lasting say 18 weeks in total, the students will have 2.5 hours of lectures on dermatology. During the two week dermatology rotation, most teaching will take place in the mornings. On the first morning the students have an orientation session, have to work in groups to answer some questions based on videos they have had to watch along with bespoke reading matter, and then there is an interactive ‘seminar’ going through some of the preparatory work in the videos and text material.

For the rest of the attachment students will attend a daily ‘teaching clinic’, in which they are taught on ‘index’ patients who attend the dermatology outpatients. These patients are selected from those attending the clinic and, if they agree, they pass through to the ‘teaching clinic’. The ‘teacher’ will be a consultant or registrar, and this person is there to teach — not to provide clinical care during this session.

Students will also sit in one ‘normal’ outpatient clinic as a ‘fly on the wall’, and attend one surgical session. At the end of the attachment, there is a quiz in which students attempt to answer questions in small groups of two or three. They also get an opportunity to provide oral feedback as well as anonymous written feedback. Our students rate dermatology highly in comparison with most other disciplines, and our NHS staff are motivated and like teaching.

The problems

When I read through the above it all sounds sort of reasonable, except that…

Students will pass though lots of these individual attachments. Some are four weeks long but many are only 1 or 2 weeks in duration. It is demanding to organise such timetables, and stressful for both students and staff

  • each day a different staff member will teach the students
  • it is unlikely that staff will know the names of most of the students. Students will usually not remember the name of the staff member who taught them in a previous week
  • most teaching is delivered by non-university employed staff. Most of these staff have little detailed knowledge of what students are (now) expected to know. The majority will not be involved in any formal assessments, and reasonably view the teaching as a break from doing clinic after clinic.
  • there is little opportunity to provide meaningful feedback on student performance, or to see student knowledge grow. Students find it easy to ‘hide’, and absenteeism is high and the rate of ‘illness’ seems higher than amongst hospital doctors.
  • teaching the students plays second fiddle to service delivery. The terminology within NHS job plans is telling. When you see a patient it is called ‘direct clinical care (DCC)’. For maybe the remaining 10-20% of your time you have sessions allocated as ‘supporting professional activities (SPA)’. SPA time will include work relating to revalidation, CPD, hospital admin, teaching of registrars, and delivery of undergraduate teaching. Our overseas students pay in excess of 50K per year in fees, and each UK student attracts perhaps 50K from fees and government monies. Teaching undergraduates is merely a ‘supporting activity’ even when 50K is changing hands. Fettes or Winchester might be more careful with their terminology.

My critique is not concerned with the individuals, but the system. It is simply hard to believe that this whole edifice is coherent or designed in the students’ interest. It is, as Flexner described UK medical school teaching a century ago, wonderfully amateur. Pedagogically it makes little sense. Nor in all truthfulness is it enjoyable for many staff or many students. Each two weeks a new batch will arrive and groundhog days begins. Again. And again. And if you believe the figures bandied about for the cost of medical education, the value proposition seems poor. We could do better: we should do better.

[1] Lectures. Henry Miller, who was successively Dean of Medicine and Vice Chancellor at Newcastle described how…

“Afternoon lectures were often avoided in favour of the cinema. The medical school was conveniently placed for at least three large cinemas….in one particularly dull week of lectures we saw the Marx brothers in ‘A Day at the Races’ three times.”

Where’s the next frontier?

In a 1963 letter to molecular biologist Max Perutz, he wrote, “It is now widely realized that nearly all the ‘classical’ problems of molecular biology have either been solved or will be solved in the next decade…The future of molecular biology lies in the extension of research to other fields of biology, notably development and the nervous system.”

Sydney observed, and predicted, the flow of science: “Progress depends on the interplay of techniques, discoveries, and ideas, probably in that order of decreasing importance,” he said.

Man, the toolmaker. In this particularly case, a very special one.

Sydney Brenner (1927–2019) | Science [Obit of Sydney Brenner]

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We will need even bigger prisons

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”.

Insys founder convicted in opioid bribery case | Financial Times

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A diagnosis not to miss: email apnea

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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You need a wallet biopsy

“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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Late night thoughts #6

by reestheskin on 09/05/2019

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Late night thoughts on medical education #6: Structures

In the previous post in this series (Late night thoughts #5: Foundations) I wrote about the content or material of medical education, hinting at some of the foundational problems (pardon the meta). We have problems distinguishing between knowledge that is essential for some particular domain of medical practice, and knowledge that is genuinely foundational. The latter is largely speciality independent, less immediate than essential knowledge, and is rightly situated within the university. The expertise necessary to teach foundational knowledge lies within universities.

What I have not made explicit so far in this essay is also important. The best place to learn much essential knowledge is within the hospital, and during a genuine apprenticeship. There are various ways we can hone a meaningful definition or description of apprenticeship but key is that you are an employee, that you get paid, and you are useful to your employer. Our current structures do not meet any of these criteria.

How we got here

Kenneth Calman in the introduction to his book ‘Medical Education’ points out that medical education varies enormously between countries, and that there is little evidence showing the superiority of any particular form or system of organisation. It is one of the facts that encourages scepticism about any particular form, and furthermore — especially in the UK — leads to questioning about the exorbitant costs of medical education. It also provides some support for the aphorism that most medical students turn into excellent doctors despite the best attempts of their medical schools.

Across Europe there have been two main models of clinical training (I am referring to undergraduate medical student training, not graduate / junior doctor training). One model relies on large lectures with occasional clinical demonstrations, whereas the UK system — more particularly the traditional English system — relies on ‘ clerkships’ on the wards.

At Newcastle when I was a junior doctor we used to receive a handful of German medical students who studied with us for a year. They were astonished to find that the ‘real clinical material’ was available for them to learn from, with few barriers. They could go and see patients at any time, the patients were willing, and — key point— the clinical material was germane to what they wanted to learn. The shock of discovering this veritable sweetshop put some of our students to shame.

The English (and now UK) system reflects the original guiding influence of the teaching hospitals that were, as the name suggests, hospitals where teaching took place. These hospitals for good and bad were proud of their arms length relationship with the universities and medical schools. The signature pedagogy was the same as for junior doctors. These doctors were paid (poorly), were essential (the place collapsed if they were ill), and of course they were employees. Such doctors learned by doing, supplemented by private study using textbooks, or informal teaching provide locally within the hospital or via the ‘Colleges’ or other medical organisations. Whatever the fees, most learning was within a not-for-profit culture.

 Scale and specialisation

It was natural to imagine or pretend that what worked at the postgraduate level would work at the undergraduate level, too. After all, until the 1950s, medical education for most doctors ended at graduation where, as the phrase goes, a surgeon with his bag full of instruments ventured forth to the four corners of the world.

This system may have worked well at one stage, but I think it fair to say it has been failing for nearer a century than half a century. At present, it is not a system of education that should be accepted. There are two reasons for this.

First, medicine has (rightly) splintered into multiple domains of practice. Most of the advances we have seen over the last century in clinical medicine reflect specialisation, specialisation as a response to the growth of explicit knowledge, and the realisation that high level performance in any craft relies not solely on initial certification, but daily practice (as in the ‘practice of medicine’). Second, what might have worked well when students and teachers were members of one small community, fails within the modern environment. As one physician at Harvard / Mass General Hospital commented a few years back in the New England Journal of Medicine: things started to go awry when the staff and students no longer ate lunch together.

Unpicking the ‘how’ of what has happened (rather than the ‘why’ which is, I think obvious), I will leave to the next post. But here is a warning. I first came across the word meliorism in Peter Medawar’s writing. How could it not be so, I naively thought? But of course, historians or political scientists would lecture me otherwise. It is possible for human affairs to get worse, even when all the humans are ‘good’ or at least have good intentions. The dismal science sees reality even more clearly: we need to only rely on institutions that we have designed to work well — even with bad actors.

Biology is just messy

Some traits, such as adult height, are readily measured. The heritability of this trait is ∼60 to 80%. Attempts to characterize “height genes” have resulted in the identification of tens of thousands of genes, each of which contributes a small amount to this heritability. The plethora of factors is almost inevitable, given the vast number of cellular and physiological steps involved in the development of an adult human being. A model that accounts for ∼40% of height variability predicts individual heights to within 4 cm for 50% of people, but with errors of more than 10 cm for 5%. Thus, a sophisticated genomic analysis can predict height to some extent, but not well enough for use in ordering tailored clothing. Most direct-to-consumer genomic results are based on much less detailed analyses and many involve complex traits, so considerable skepticism is appropriate.

But such sensible comments, will not stem the hype — or the investors.

Consuming personal genomics | Science

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It’s not all physics

This is why I have doubts about mechanical theories such as disruptive innovation. Too often, they’re presented as a type of physical law: You drop a glass of wine, it always falls to the ground with an acceleration of 32.17405 ft/s2. This truth is indisputable…but it ignores the drunken clumsiness of the oaf who knocked the glass over, and discounts the quick reflexes and imaginative solutions you only get when there’s a human nearby.

Jean-Louis Gassée. A nice summary of why human agency matters, and also why companies fail.

First Winning Wars, Only To Lose Them Later – Monday Note

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Late night thoughts #5

by reestheskin on 02/05/2019

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Late night thoughts on medical education #5: Foundations

We sought out an examiner who would understand that anatomy was being taught as an educational subject and not simply for the practice of surgery. I thought I had found such a man in an old colleague. I listened while he asked the student to name the successive branches emerging from the abdominal aorta in a cadaver. When we got to the inferior mesenteric he asked what viscera were supplied by that vessel. The student gave a complete and correct answer but did not know the exact amount of the rectum supplied. The examiner asked me what I thought and I said that I thought he was very good, that the only question he had missed was the last one, which in my opinion, was trivial. No, said the anatomist, by no means trivial. You have to know that before you can excis the rectum safely.

My mind still boggles at the thought of a newly graduated doctor undertaking the total excision of the rectum on the faint remembrance of the anatomy he learned as a student.

George Pickering, “Quest for Excellence in Medical Education: A Personal Survey

When I was a medical student I read this book by Sir George Pickering. It was published in 1978, and I suspect I read it soon after the Newcastle university library acquired it. Why I came across it I do not know, but at the time ‘new volumes’ were placed for a week or two on a shelf adjacent to the entrance, before being assigned their proper home (or ‘final resting place’). It was a way to find things you didn’t know you might enjoy. I liked this book greatly, and have returned it on many occasions. Parts of it are wonderfully dated (and charming), but it remains a wonderful young man’s book written by an old man. Now I am an old man, who read it first as a young man.

Roger Schank summarise the problems of education this way:

There are only two things wrong with the education system:

  1. What we teach, and
  2. How we teach it

George Pickering’s quote relates to ‘what we teach’ — or at least what we expect students to know — but in clinical medicine ‘what we teach’ and ‘how we teach’ are intimately bound together. This may be true for much  education, but the nature of clinical exposure and tuition in clinical medicine imposes a boundary on what options we can explore. The other limit is the nature of what we expect of graduates. People may think this is a given, but it is not. If you look worldwide, what roles a newly qualified doctor is asked to fill vary enormously (something I discovered when I worked in Vienna).

Here is another quote, this time from the philosopher, Ian Hacking, who has written widely on epistemology, the nature of causality and the basis of statistics (and much else).

Syphilis is signed by the market place where it is caught; the planet Mercury has signed the market place; the metal mercury, which bears the same name, is therefore the cure for syphilis.

Ian Hacking | The Emergence of Probability

Well, of course, this makes absolutely no sense to the modern mind. We simply do not accept the validity of the concept of entities being ‘signed‘ as a legitimate form of evidence. But no doubt medical students of the time would have been taught this stuff. Please note, those priests of Evidence Based Medicine (EBM), that doctors have always practiced Evidence Based Medicine, it is just that opinions on what constitutes evidence change. Hacking adds:

He [Paracelsus] had established medical practice for three centuries. And his colleagues carried on killing patients.

I am using these quotes to make two points. The first, is that there is content that is correct, relevant to some clinical practice and which medical students do not need to know. This may seem so obvious that it is not necessary to say it. But it is necessary to say it. Pickering’s example has lots of modern counterparts. We could say this knowledge is foundational for some medical practice, but foundational is a loaded term, although to be fair I do not know a better one. The problem with ‘foundational’ is that it is widely used by academic rent seekers and future employers. Students must know this, students ‘must’ know X,Y and Z. I once started to keep a list of such demands, but Excel spreadsheets have limits. You know the sort of thing: ethics, resilience, obesity, child abuse, climate change, oral health, team building, management, leadership, research, EBM, professionalism, heuristics and biases etc. Indeed, there is open season on the poor undergraduate, much of which we can lay blame for at the doors of the specialist societies and the General Medical Council (GMC).

My second point, stemming from the second quote, is to remind that much of what we teach or at least ask students to know is wrong. There is a feigned ignorance on this issue, as though people in the past were stupid, whereas we are smart. Yes, anatomy has not changed much, and I am not chucking out all the biochemistry, but pace Hacking, our understanding of the relation between ‘how doctors work’ and ‘what underpins that knowledge’ is opaque. We can — and do — tell lots of ‘just-so’ stories that we think explain clinical behaviour, that have little rational or experimental foundation. Clinicians often hold strong opinions on how they arrive at particularly decisions: there is a lot of data to suggest that whilst you can objectively demonstrate clinical expertise, clinicians often have little insight into how they actually arrive at the (correct) diagnosis (beyond dustbin concepts such as ‘pattern recognition’ or ‘clinical reasoning’).

What is foundational knowledge?

If you are a dermatologist, and you wish to excise a basal cell carcinoma (BCC, a common skin cancer) from the temple, you need to be aware of certain important anatomical structures (specifically the superficial temporal artery, and the temporal branch of the facial nerve). This knowledge is essential for clinical practice. It is simple to demonstrate this: ask any surgeon who operates in this area. Of course, if you are a lower GI surgeon, this knowledge may not be at your finger tips. Looked at the other way, this knowledge is in large part specialty specific (or at least necessary for a subset of all medical specialties). What happens if you damage these structures is important to know, but the level of explanation is not very deep (pardon the pun). If you cut any nerve, you may get a motor or sensory defect, and in this example, you may therefore get a failure in frontalis muscle action.

This knowledge is not foundational because it is local to certain areas of practice, and it does not form the basis or foundation of any higher level concepts (more on this below). The Pickering example, tells us about what a GI surgeon might need to know, but not the dermatologist. Their world views remains unrelated, although the I prefer the view of the latter. There is however another point. We should be very careful about asking medical students to know such things. So what do we expect of them?

Beyond essential

I find the example of anatomical knowledge as being essential compelling. But only in terms of particular domains of activity. Now, you may say you want students to know about ‘joints’ in general, and there may well be merit in this (Pickering, I suspect, thought so), but knowing the names of all the bones in the hand or foot is not essential for most doctors. If we move beyond ‘essential’ what is left?

At one time anatomy was both essential and foundational. And I am using the term foundational here to mean those concepts that underpin not just specialty specific medicine, but medicine in the round. A few examples may help.

Whatever branch of medicine you practice, it is hard to do so without some knowledge of pharmacology. How deep you venture , is subject to debate, but we do not think knowing the doses and the drug names in the BNF is the same as knowing some pharmacology. 

Another example. I would find it very hard to converse with a dermatologist colleague without a (somewhat) shared view of immunology or carcinogenesis. Every sentence we use to discuss a patient, will refer and make use of concepts that we use to argue and cast light on clinical decisions. If you want to explain to a patient with a squamous cell carcinoma (SCC) who has had an organ transplant why they are at such increased risk of tumours, it is simply not possible to have a meaningful conversation without immunology or carcinogenesis (and in turn, genetics, virology, and histopathology). And for brevity, I am putting to one side, other key domains such as behaviour and behaviour modification, ethics, economics and statistics etc.

To return to my simple anatomical example of the excision of the BCC. The local anatomy is essential knowledge, but it is not foundational. What is foundational is knowing what might happen if you cut any nerve.

Sequencing of learning

Let me try and put the above in the context of how we might think about medical education and medical training.

Foundational knowledge is specialty (and hence career) independent. Its function is to provide the conceptual framework that underpin much clinical practice. This not to say that the exact mix of such knowledge applies to all clinical domains, but we might expect most of it to be familiar to most doctors. But none of it will, years later, have the same day-to-day immediacy of ‘essential knowledge’ — think of my example of the temporal branch of the facial nerve for the dermatologist excising facial tumours on a weekly basis.

In this formulation, the core purpose of undergraduate medical education is to educate students in such knowledge. The purpose is not therefore to produce doctors at graduation who are ‘just not very good doctors’ but graduates who are able to pursue specialty training and make sense of the clinical world around them. The job of a medical school is to produce graduates who can start clinical training in an area of their choice. They are now in a position to — literally — understand the language of the practising doctors that surround them. They are not mini-doctors, but graduates, embarking on a professional career.

By contrast most specialty knowledge is not foundational, but essential for those within that specialty — not medical students. If you learn dermatology, you might come across things that help you learn respiratory medicine or cardiology but to be blunt, not very often. Specialties are not foundational domains of knowledge. You do not need to know dermatology to understand cardiology or vice versa.

Place of learning

The best place to learn the ‘foundations’ are universities. Anatomy, again may be an exception, but if you want to learn immunology, genetics, statistics or psychology you have, I think, no alternative. Hospitals simply cannot provide this.

On the other hand, using Seymour Papert’s metaphor, if you to want learn French you should go to Frenchland, if you want to learn maths, you should go to Mathland and if you want to learn doctoring, you need to go to doctorland. Medical schools are not the place to learn how to find you way around doctorland — how could they be?

NB: I will use the epithet TIJABP, but as subsequent posts will confirm, I am serious.

WD (Bill) Hamilton

Scope for recognizing and accommodating exceptional individuals has been diminishing in British universities ever since. Hamilton published relatively few papers, in generally low status journals, and gained only a handful of grants much later in life. Bureaucratic measures of performance are increasingly important and judge the impact of an article only by the journal it is published in. This seriously undervalues radical originality, which although extremely rare is utterly vital to science. It is disturbing that a young Bill Hamilton today would probably find an academic career even more difficult to pursue.

Alan Grafen, in his obituary of Bill Hamilton (Biogr. Mems Fell. R. Soc. Lond. 50, 109–132 (2004)).

I post this excerpt following a discussion with somebody who had never heard of him. Hamilton’s enormous contributions to biology are not well known. You also have to wonder if the lack of a Nobel for biology diminishes medicine in the long run. Some things do indeed get worse.

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Why wait so long?

Apparently, on average, doctors interrupt patients within eighteen seconds of beginning their story. When we tell lawyers about this, they wonder why their medical friends wait so long.

Quoted in the ‘The Future of the Professions

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Arrogance before men; humility before your subject.

by reestheskin on 29/04/2019

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Sydney Brenner has died. Not quite the last of the handful of scientists who made one of the two scientific revolutions of the 20th century. The first half belonged to physics, the second to the biology that he co-created.

A precocious boy—a student at the University of the Witwatersrand by the time he was 15—and bullied for it, reading was his connection to the wider world. Courses, he said, never taught him anything. The way to learn was to get a book that told you how to do things, and then to start doing them, whether it was making dyes or, later in life, programming computers. If he thought more deeply than the other great biologists of his age, which he did, it was surely because he read further, too.

Reading Brenner was a staccato of insights. I hadn’t come across the ‘courses’ quote before, but no surprises there.

Obituary: Sydney Brenner died on April 5th – Irrepressible

The Economist | The AI will see you now

by reestheskin on 19/04/2019

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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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