Idea factories

by reestheskin on 12/04/2017

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Universities are idea factories. Current corporatization approaches emphasize the factory rather than the ideas.

Ralf Buckley in Nature. I would say— for the short term at least — unless somebody finds a way to create new ‘dissenting academies’ things in UK higher ed will get worse.

Core service training

by reestheskin on 11/04/2017

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“Core surgical training in the UK has been dubbed “core service training” because many trainees believe it does not provide enough surgical experience. At the southern tip of Africa, I felt I was being taught to operate, not to just watch and hold retractors. My commitment and progression were judged on hard work and merit, not on how many courses I had attended.”


Incentives matter, especially the wrong ones

by reestheskin on 10/04/2017

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Given your past views on measuring quality in universities, what do you think of the teaching excellence framework, which the government would like to use to measure teaching quality?

The government needs to think more about the evidence we have showing that measuring performance, and in particular ranking performance, creates strong incentives – but all too often the wrong incentives.

What is the biggest threat facing higher education today?

Too much emphasis on comparative achievement, not enough on the pleasure of learning or the importance of doing at least some things really well.

Amen. Nora O’Neill interviewed in the THE

Software is eating the clinic

by reestheskin on 07/04/2017

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There was an interesting paper published in Nature recently on the topic of automated skin cancer diagnosis. Readers of my online work will know it is a topic close to my heart.

Here is the text of a guest editorial I wrote for Acta about the paper. Acta is a ‘legacy’ journal that made the leap to full OA under Anders Vahlquist’s supervision a few years back — it is therefore my favourite skin journal. This month’s edition, is the first without a paper copy, existing just online. The link to the edited paper and references is here. I think this is the first paper in their first online only edition :-). Software is indeed eating the world.


When I was a medical student close to graduation, Sam Shuster then Professor of Dermatology in Newcastle, drew my attention to a paper that had just been published in Nature. The paper, from the laboratory of Robert Weinberg, described how DNA from human cancers could transform cells in culture (1). I tried reading the paper, but made little headway because the experimental methods were alien to me. Sam did better, because he could distinguish the underlying melody from the supporting orchestration. He told me that whilst there were often good papers in Nature, perhaps only once every ten years or so would you read a paper that would change both a field and the professional careers of many scientists. He was right. The paper by Weinberg was one of perhaps fewer than a dozen that defined an approach to the biology of human cancer that still resonate forty years later.

Revolutionary papers in science have one of two characteristics. They are either conceptual, offering a theory that is generative of future discovery — think DNA, and Watson and Crick. Or they are methodological, allowing what was once impossible to become almost trivial — think DNA sequencing or CRISPR technology. Revolutions in medicine are slightly different, however. Yes, of course, scientific advance changes medical practice, but to fully understand clinical medicine we need to add a third category of revolution. This third category comes from papers that change the everyday lives of what doctors do and how they work. Examples would include fibreoptic instrumentation and modern imaging technology. To date, dermatology has escaped such revolutions, but a paper recently published in Nature suggests that our time may have come (2).

The core clinical skill of the dermatologist is categorising morphological states in a way that informs prognosis with, or without, a therapeutic intervention. Dermatologists are rightly proud of these perceptual skills, although we have little insight as to how this expertise is encoded in the human brain. Nor should we be smug about our abilities as, although the domains are different, the ability to classify objects in the natural world is shared by many animals, and often appears effortless. Formal systems of education may be human specific, but the cortical machinery that allows such learning, is widespread in nature.

There have been two broad approaches to try and imitate these skills in silica. Either particular properties (shape, colour, texture etc.) are first explicitly identified and, much as we might add variables in a linear regression equation, the information used to try and discriminate between lesions in an explicit way. Think of the many papers using rule based strategies such as the ABCD system (3). This is obviously not the way the human brain works: a moment’s reflection about how fast an expert can diagnose skin cancers and how limited we are in being able to handle formal mathematics, tells us that human perceptual skills do not work like this.

There is an alternative approach, one to some extent that almost seems like magic. The underlying metaphor is as follows. When a young child learns to distinguish between cats and dogs, we know the language of explicit rules is not used: children cannot handle multidimensional mathematical space or complicated symbolic logic. But feedback, in terms of what the child thinks, allows the child to build up his or her own model of the two categories (cats versus dogs). With time, and with positive and negative feedback, the accuracy of the perceptual skills increase — but without any formal rules that the child could write down or share. And of course, since it is a human being we are talking about, we know all of this process takes place within and between neurons.

Computing scientists started to model the way that they believed collections of neurons worked over 4 decades ago. In particular, it became clear that groups of in silica neurons could order the world based on positive and negative feedback. The magic is that we do not have to explicitly program their behaviour, rather they just learn, but — since this is not magic after all — we have got much better at building such self-learning machines. (I am skipping any detailed explanation of such ‘deep learning’ strategies, here). What gives this field its current immediacy is a combination of increases in computing power, previously unimaginable large data sets (for training), advances in how to encode such ‘deep learning’, and wide potential applicability — from email spam filtering, terrorist identification, online recommendation systems, to self-driving cars. And medical imaging along the way.

In the Nature paper by Thrun and colleagues (2) such ‘deep learning’ approaches were used to train computers based on over 100,000 medical images of skin cancer or mimics of skin cancer. The inputs were therefore ‘pixels’ and the diagnostic category (only). If this last sentence does not shock you, you are either an expert in machine learning, or you are not paying attention. The ‘machine’ was then tested on a new sample of images and — since modesty is not a characteristic of a young science — the performance of the ‘machine’ compared with over twenty board certified dermatologists. If we use standard receiver operating curves (ROC) to assess performance the machine equalled if not out-performed the humans.

There are of course some caveats. The dermatologists were only looking at single photographic images, not the patients (4); the images are possibly not representative of the real world; and some of us would like to know more about the exact comparisons used. However, I would argue that there are also many reasons for imagining that the paper may underestimate the power of this approach: it is striking that the machine was learning from images that were relatively unstandardised and perhaps noisy in many ways. And if 100,000 seems large, it is still only a fraction of the digital images that are acquired daily in clinical practice.

It is no surprise that the authors mention the possibilities of their approach when coupled with the most ubiquitous computing device on this planet — the mobile phone. Thinking about the impact this will have on dermatology and dermatologists would require a different sort of paper from the present one but, as Marc Andreessen once said (4), ‘software is eating the world’. Dermatology will survive, but dermatologists may be on the menu.


Full paper with references on Acta is  here.

On not dropping your anchor.

by reestheskin on 06/04/2017

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From the Obit of Derek Walcott.

He would cup a breast as he fondled a white stone from the beach. These propensities, noted when he was teaching in America in the 1980s and 1990s, cost him the chance to be, in 1999, Britain’s poet laureate and, ten years later, professor of poetry at Oxford. He was not concerned, for he did not want to drop his anchor long on any northern shore.


No RAE/REF. The view from Ireland

by reestheskin on 05/04/2017

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‘I think we’re seeing the benefits of a good funding environment, and – to be frank – no research excellence framework’

Brexit and the Emerald Isle. Your mileage may vary. Here.

It is odd to live in a country whose very name—the United Kingdom—sounds increasingly sarcastic.

FT. Obvious, but puzzled as I haven’t see it everywhere.

Writing by candlelight

by reestheskin on 03/04/2017

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last month (, for example, when) the University of Copenhagen fired seismologist Hans Thybo, president of the European Geosciences Union. The official explanation for Thybo’s dismissal — his alleged use of private e-mail for work, and telling a postdoc that it is legitimate to openly criticize university management — seems petty in the extreme.

Nature December 2016. Little hygge on show here, then.

Worst thing about being a medical student? Feeling like a spare part

by reestheskin on 31/03/2017

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A little awhile back after a teaching session, I asked — as I often do — a googly: ‘What is the worst thing about being a medical student?’ The response: ‘Feeling like a spare part’.

My quick and facetious response was to argue that at least spare parts were useful, whereas students were (usually) not. The humour was appreciated 🙂

But if you think this through, it is possible to argue that students are indeed less useful than they once were. At one time, final year students were a key component of clinical service. They clerked people, they could insert iv lines, write up drugs, and they were around long enough in one environment for people to make meaningful judgments of their abilities and remember them. And to be able to trust them. They could do paid locums, and even when they were not being paid, they could not be absent, nor did you need to formalise start and finish times. One of my colleagues  reported that he used to be able to ‘prescribe anything apart from diamorphine’ as a final year student.

This all raises some interesting questions

  1. Medical education may be getting worse. This is not to attach blame, merely a speculation based on what I see. There are indeed more educationalists, but making things explicit is easily confused with competence that is implicit.  It is even conceivable that those who ran medical schools were once more thoughtful, possibly because they were  not juggling so many roles, and because the environment was less cluttered by regulators.
  2. Engagement with clinical service helps learning, but the opportunities for this may be diminishing. Again, this is in part a change in the environment. The inpatient service is not where most medicine occurs: the office is (whether in the OPD or in primary care)
  3. I wonder if we are sequencing medical education incorrectly. The pressure is for more and more training and less and less education, but the facilities for training are diminishing all the time and are largely outwith the control of the universities. In a health service that is falling to bits, medical students are not a priority (and expect things to get worse). The NHS has never taught doctors: doctors have taught doctors. If culture eats strategy — as the saying goes —the toxic nature of much NHS provision, will negate all those lectures on ethics, fairness and sense of vocation. And don’t mention resilience.
  4. Never promise ‘engagement’ when you cannot deliver it, otherwise disenchantment grows. We overpromise, and universities increasingly advertise with exaggerated claims. Scholarship, and advertising are opposing world belief systems.
  5. Comparisons with some other EU countries makes me wonder if we should revisit the boundary between ‘student’ and ‘practice’.
  6. Our ideas of medical education owe much to a time when most people did not go to university. 

Medical education is indeed always advancing: but many of us think it is increasingly out of phase with the world we live in. Magnitudes matter.

Enduring lectures

by reestheskin on 30/03/2017

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We deal with children as individuals when we “teach” them as children. What is wrong with MOOCs is the “massive” part. Education cannot be both massive and actual education. Learning starts with a goal followed by questions when you have trouble reaching your goal. We each have our own questions and our own goals.


Clark is wrong about MOOCs because the very concept of massive education is oxymoronic. Education is only massive because we have created a world of schools that include classrooms and not enough teachers to do one on one education. MOOCs are an extension of a vary bad educational idea called lecturing. We have come to accept lecturing because it is everywhere and we all had to endure it.

Roger Schank. Worth reading in full.

Realistic medicine: NHS 2017

by reestheskin on 29/03/2017

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“We have a policy to help each ward—not just the acute admissions wards, but each ward in the hospital—decide who is the ‘least bad’ patient to approach to ask to sleep on a bed in the corridor. We have a plan for which nurse takes responsibility for taking observations—they are recorded in ‘the corridor folder.’”

Other realistic medicine comments on the same BMJ page here collated from a RCP report.

Surgeons should not look like surgeons

by reestheskin on 28/03/2017

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For a flavour:

Now if I had to pick, I would overcome my suckerproneness and take the butcher any minute.

Incerto here. Deadly serious.

The pleasures of arithmetic and arachnophilia

by reestheskin on 27/03/2017

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Their conclusion was that there are 25m tonnes of spiders around the world and that, collectively, these arachnids consume between 400m and 800m tonnes of animal prey every year. This puts spiders in the same predatory league as humans as a species, and whales as a group. Each of these consumes, on an annual basis, in the region of 400m tonnes of other animals.

Martin Nyffeler of the University of Basel and Klaus Birkhofer of Lund University, quoted in the Economist.

“An estimated 400–800 million tons of prey are annually killed by the global spider community” Link

“Get ‘em out by Friday”

by reestheskin on 24/03/2017

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“When an older person dies, it’s harder to know that they died because of poor care,” but he added that the “families know”.

This is an article about the entirely predictable crisis in care for vulnerable people. We used to do it better, but decided cheating was more profitable. “Most local authorities buy care piecemeal via an auction system where contractors bid to provide a care package for each elderly or disabled person.” You cannot run a service on this basis; you might or might not make money. I remember being told as a young medical student: the local authority homes are the best, they have professional standards their staff have pensions, and unions etc . Avoid private providers.


The lyrics are about a cognate issue but on this topic I am always reminded of Peter Gabriel’s words  and sense of disgust.


Addicted to pharma

by reestheskin on 23/03/2017

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More Americans now die from drug overdoses than from car crashes or gun violence, and more than 26m are being treated for addiction, according to CDC figures.


Economics professor turns to crowdfunding to pay salary

by reestheskin on 22/03/2017

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If you want to pick at the cracks of modern medicine, you look at psychiatry. This is not a criticism of psychiatry or psychiatrists (some of my best friends are….). If you want to do similar things with the academy, look at economics first.

When it works……

by reestheskin on 21/03/2017

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For my studies I moved to Berlin and later to Innsbruck in the Tyrolean Alps. Innsbruck was a great place to study: The teaching in both philosophy and economics happened in small groups and the professors were fantastic teachers. Geoscience was a very broad course and had the advantage that we traveled a lot and spend quite some time out in the field.

Max Rosen

Student life: Not the muse, but the masseuse

by reestheskin on 20/03/2017

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This weekend, my wife and oldest daughter visited her first-choice college, the University of Tennessee. There was one curious moment in an otherwise wonderful weekend. The tour guide noted that the university was there to help students get through the trauma of exams. It brought in masseuses to massage away the stress. It rolls out a sheet of paper, passes out crayons, and lets the students express their rage against algebra. Oh, and it vowed to bring in puppies, so students could cuddle something cute to take the edge off their anxiety.

Quote on Memex from Tyler Cowen’s new book, ‘The Complacent Class’.

Show drugs work before selling them

by reestheskin on 17/03/2017

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This is the title of a piece in Nature, discussing how much evidence is needed before you bring a drug to market, and how much information you should gather after the drug is available. The reality is possibly more nuanced that is made out here, and knowing how regulation has changed and was different between countries is worth factoring in. But I think the key issue is that many people do not trust drug companies, and they are right not to do so. It was in the FT of all places, that the comparison between public perceptions of pharma and ‘the bankers’ was made. Trust has a value, a value to both parties in any exchange. And really, why do you need advertisers to get involved?

Those Ivory Towers (again)

by reestheskin on 16/03/2017

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Refreshing to read an article in which I can find something to disagree with in almost every sentence. And the title — in the print edition only —‘Taking your research to the real world” was probably the work of the subeditor. But the tired trope of academia versus the real world is like a red rag to a bull (self-reference intended). Most of all, I find the belief that unless you are changing health care in the short term is some distant country, you are somehow deficient as an academic, conceited.

Capitalism has helped lift more people out of poverty than most public health researchers; economists basic work on how societies work may do the same; and I am not certain how Watson and Crick would have fared under this self-congratulatory humbug. The real danger is that we are forgetting that universities are some of the few places left to do genuinely transformative and generative work. There are plenty of alternatives for much other ‘close to market work’: private corporations; NGOs; national health agencies; consultancies. Delivery and revolutionary science belong to different scales and cultures (mostly).

Online and out of time

by reestheskin on 15/03/2017

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One of my mantras is that unless we do the online better, we cannot make use of the offline opportunities. Online, should allow us to make better use of the bedside. The following are some quotes from an FT article on MBA degrees.

The great thing about a virtual classroom is that your students are already in a digital format, which means you can run algorithms that recognise patterns in facial expressions to assess understanding and identify students’ emotional state and levels of attention in your class,” says Prof Boehm. Analytics can be used in real time to address students whose attention is wandering or later to improve teaching plans or faculty performance, he adds.

Teaching staff also find students to be more engaged in the virtual classroom. “Because of the way students are positioned on the wall, a headshot from the chest up, it’s very difficult for them to text on their phones or work on their PCs,” says LizHess, managing director of HBX. “It’s very easy for faculty to see if people are distracted — they joke that there’s no back row any more.”

The technology looks terrific in the images shown. But there are other factors at play. Note the group sizes are small in comparison with what many undergraduates receive, and the investment in technology is focussed on those who pay most (upfront). If you look at the money apparently going into medical education, this should be the norm for most undergraduate medical students.

‘Some diversity training-programs, for example, are like blistering — they are somewhat painful to endure and have no beneficial effects.’

Timothy Wilson in Redirect, the book that nobody from HR seems to have read.


Discuss: aristocratic versus state support (of science)

by reestheskin on 13/03/2017

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As if by a miracle, once up and running, the Mark 1 telescope was the only instrument that could both detect the first Soviet and American satellites and transmit instructions to them. Amazing as it now seems, the need for such a telescope had escaped both the telecommunications industry and the military leaders of both superpowers.

Despite its spectacular success, which included tracking the Sputnik 1 satellite mission in 1957, the government did nothing to alter the remaining debt, being bound by the iron restraint of Treasury rules. It was Lord Nuffield who did so, thereby demonstrating the superiority of aristocratic, rather than state support, to science – and indeed to all intellectual activity, a view which Lovell expressed frequently and forcefully to the end of his life.

Sir Fred Hoyle’ obituary of Sir Bernard Lovell. I fear Hoyle is right — at least if we realise we need more Fred Hoyles. Now, they are not aristocrats, but US philanthropists.


Not a literal quote, but an impressionism.

You are a participant in whatever happens… and there is chaos.

You are not stuck in traffic, you are the traffic

Optimism and pessimism all together. Joi Ito here.

On our arrogant universities etc

by reestheskin on 09/03/2017

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Take your pick. Article in the Observer, a response, and Martin Wolf of the FT here(paywall) and here. Some sense in all of them. But the ‘our (i.e. tax payers) money’ argument (from the Observer) always galls me, and should inform any bright graduate about where they want to build a career. As in any tragedy, the players walk on stage, and you know how it will turn out.

It’s not the money stupid

by reestheskin on 08/03/2017

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The report’s authors wanted to know what drove nurses and doctors to join agencies, presuming it was simply a case of higher pay. But the researchers found that agency workers in the NHS had similar pay. What they found interesting was that agency workers felt better off because they had escaped the internal politics, the bureaucracy and the stricture of rotas that rarely matched the demands of home. As agency workers they believed they had more control over their lives and put up with less bullying from their employer.

A report by the National Institute for Economic & Social Research (NIESR) quoted here.

Saying you’ve seen a procedure was never a part of surgical training..

by reestheskin on 07/03/2017

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I have a secret admiration for some aspects of surgical training. We all know the bad ones, so I do not need to talk about them. When Lisa was doing her Mohs’ fellowship, it was the following vector: you watch X procedures, you perform Y procedures under supervision and you then perform Z procedures ‘independently’, with help on hand. After that, you keep learning. Sensible, and has the essential character of what has been known about craft apprenticeships for over one thousand years: apprentice; journeyman; master. This BMJ piece by a urologist asks:

If you were applying for a certificate of completion of training (CCT) in urology in 2015 you had to have seen or assisted in at least 20 radical prostatectomies before being signed off as competent. A year later, for no apparent reason, it appears that 10 will do.

He then goes on:

Standing in a theatre, unscrubbed, so you can say you’ve seen a procedure was never a part of surgical training, nor should it be now. It has no value. Unless you are very good at the procedure already and you are learning nuanced techniques from a master surgeon, watching a procedure will never make you a better surgeon.

Now, I despair of this sort of thing even when we ask medical students to do it. Why, is the question? What value is there, in watching? That this is considered meaningful at this level of training is even more worrying. And of course the figures will be pushed down, over time. This is the NHS, after all; never let expert judgment get in the way of a political imperative or somebody paid by the government: “we have to revise the speed of light for operational reasons….”

There is a more subtle point which makes thinking about the article even more worth while.

Trainees should spend their training doing the things that they’ll be spending their lives doing, not watching procedures they will never perform.

Now, it is clear that the current bull coming out from HEE, NHS, Deans etc is that we don’t need experts anymore, just people to cope with whatever disease is the flavour of the month (that there are demographic changes — pace the lectures I received from John Grimey Evans in 1976— was apparently not obvious to NHS managers or Jeremy Hunt till late 2016). Here is a problem.

When people finish formal training they are not as expert as they will be in 10 or 20 years. I do want an experienced dermatopathologist to be reading the samples I sent him. Wisdom is not the sole preserve of the old, but in many craft or perceptual disciplines I know about, the old guys and women do it better. So, problem one, is that when people come off a training scheme they are not the doctor they want to be. They are not qualified, they are just setting out, able to work without immediate supervision — as they choose and judge. This is the ticket.

The second problem, as the author makes clear, is that the training schemes are wasteful and not geared to excellence. Again, in a world of ‘pull’ (John Seely Brown’s phrase) the NHS is still trapped within the metaphors of the same industrial age that Donald Trump thinks is going to bring all those jobs back.

We have lost our way in much of what is important in medicine. It’s time that we focused on what really makes a surgeon better and stopped the pointless processes that surround training

Amen. But the surgeons have got some things going for them. IMHO many other branches of medicine are much, much worse.

Nature gets real about the bubble that is science

by reestheskin on 06/03/2017

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Interesting editorial in Nature. And unexpected. The issue is support for science and the state of politics in the US.

Just telling the same old stories won’t cut it. The most seductive of these stories — and certainly the one that scientists like to tell themselves and each other — is the simple narrative that investment in research feeds innovation and promotes economic growth. ‘It’s the economy, stupid’, so the saying goes, and as nations become a little less stupid by pushing against the frontiers of knowledge, so the benefits of all this new insight spread from the laboratory to the wider population, as improvements in the standard of living and quality of life. This comfortable story has all the hallmarks of a bubble waiting to pop.

The article goes on:

It is right that more scientists should tell stories of the good their research can do. But it is more important and urgent than ever that researchers should question how these stories really end — and whether too many of the people they claim to act for don’t really get to live happily ever after.

Much science is in a vacuous bubble, and arguments for more funding from its practitioners is increasingly viewed as self serving. Universities share some or much of this blame, all too happy to ‘shift more units’. This lack of intellectual honesty will harm academia in the long term. The one uniting feature that justifies higher education is the pursuit of truth in whichever direction enquiry moves. Universities are not businesses, profit centres, or corporations. They have a different set of norms that are distinct from those advertised by much of the rest of the corporate world (or government). STEM has never been enough, and truthfulness is not something you can opt in or out of, like you can some undergraduate modules. The role for universities — and science — is greater than ever: the issue is whether the universities have the necessary leadership. Even with the right leaders, it is a tough ask.

There is only one way to ensure that assessment is light-touch. Universities should rebrand themselves as banks.

Comment (Mintaka) on an article on the TEF from one of the HE commissars (Nick Hillman).

A defence of the beanbag geneticist, it is then.

by reestheskin on 02/03/2017

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In 1924, a 30-year old journalist on the Daily Express came to Cambridge aiming to interview Haldane. She was Charlotte Burghes, née Franken, and she had a young son, Ronnie. Haldane and Charlotte became lovers, but before they could marry she had to seek a divorce, a procedure that carried substantial social stigma at that time. A university committee resolved to strip Haldane of his readership, which was only restored by successful legal action.

From a review of a new biography of JBS Haldane. The article referred to in the title of this post is here.  I know of no other branch of biology that can build so much, on so few assumptions.