“A full 14 minutes into the 20-minute appointment, I realized that the patient sitting in front of me in the exam room was softly crying, her hands cradling the box of tissues that she had searched out herself. I had spent the majority of the appointment engaged in a frantic search through her extensive electronic medical record, and I cursed myself for being so buried in the computer screen that I had hardly glanced in her direction. Mrs. S had end-stage cancer, and my misguided chart review had revealed countless studies, medical therapies, and procedures that had done little to change her very poor prognosis. I turned the computer monitor off, wheeled my chair over, and gently took her hand. With five minutes left in the appointment, I discovered the real reason she had come to see me.”
William Bynum in Academic Medicine [Issue: Volume 89(2), February 2014, p 212–214]
Scary concept of the day: “Global Governance”.
Former PM Gordon Brown hammered this home. The last thing we need is a European-style bureaucracy to act as a gate-keeper for higher education. Rich DeMillo at the World Economic Forum
The situation was a familiar one. Some time back, I was gossiping to a medical student, and he began to to talk about some research he had done, supervised by another faculty member of staff. I asked what he had found out: what did his data show? What followed, I have seen if not hundreds of times, then at least on several score occasions. A look of trouble and consternation, a shrug of embarrassment, and the predictable word-salad of ‘significance’, t values, p values, statistics and ‘dunno’. Such is the norm. There are exceptions, but even amongst postgraduates who have undertaken research, the picture is not wildly different. Rarely, without directed questioning, can I get the student to tell me about averages, or proportions, using simple arithmetic. A reasonable starting point surely. ‘What does it look like if you draw it?’ is met with a puzzled look. And yet, if I ask the same student, how they would manage psoriasis, or why skin cancers are more common in some people than others, I get —to varying degrees—a reasoned response. I asked the student how much tuition in statistics they had received. A few lectures was the response, followed by a silence, and then, “They told us to buy a book”. More silence. So this is what you pay >30K a year for? The student just smiled in agreement. This was a good student.
Statistics is difficult. Much statistics is counter-intuitive and, like certain other domains of expertise, learning the correct basics often results in a temporary —or in some cases a permanent —drop in objective performance.** That is, you can make people’s ability to interpret numerical data worse after trying to teach them statistics. On the other hand, statistics is beautiful, hard, and full of wonderful insights that debunk the often sloppy thinking that passes for everyday ‘common sense’. I am a big fan, but have always found the subject anything but easy. But, like a lot of formal disciplines, the pleasure comes from the struggle to achieve mastery. I also think the subject important, and for the medical ecosystem at least, it is critical that there is high level expertise within the community. On the other hand, in my experience many of the very best clinicians are (relatively) statistically illiterate. The converse is also seen.
Sometimes we try to make ourselves smarter. We call that research. Sometimes we try to make our peers smarter. We call that publishing. Sometimes we try to make our students smarter. We call that teaching. And that’s it. That’s all there is. These are important jobs for sure, and they are hard jobs at times, but they’re not magic. And neither are we.
It is hard to find anything in the Scotsman worth writing about. Newspapers and good journalism are victims of the medium I am writing in. But here is something. Sir Harry Burns, is stepping down from his role as Chief Medical Officer for Scotland, and taking up a position in Global Public Health at the University of Strathclyde. I am a little bit cynical about the academic bandwagon of ‘Global Public Health’. Much of it seems to miss the point that Sydney Brenner with characteristic insight made many years ago: the most common disease on this planet is MDD. Otherwise known as money-deficiency-disease. Correcting this is not straightforward— and medicine has an important, but limited role— but, as Bruce Charlton pointed out, industrialisation and capitalism has lifted more people out of poverty in the last quarter century (and hence cured more people with MDD) than public health research funding. Too often I am suspicious academics are trying to mine away at a newly exposed seam of research funding, rather that solve problems. Exceptions all around; Paul Farmer and the like, I accept. What however is worthy of mededed.me, is that Burns takes a broadside at the way we train doctors.
Looking back on his time as CMO, Sir Harry said there were still issues needing addressed. “I am not happy with the way we train young doctors now,” he said. “As I look at young people training in medicine now, I think their opportunity to do the kind of things that I have done, which has been a very varied career, I think those opportunities are harder to deliver now. “How they are trained now is very rigid. What I did in moving from surgery to public health would be really difficult now. “There’s an over-emphasis on ticking boxes, as opposed to encouragement of innovation and new ways of looking at your career.”
Well, I couldn’t agree more. But walk down any hospital corridor in Scotland and many doctors will tell you postgraduate training is a mess, and has been getting worse. Yet, each year, another report will spew forth from one of the various Bunkers in London, and yet more tick-boxing will be enforced, alongside more debasement of the English language. And the position in Scotland, under Burns’ watch, is arguably worse than in other parts of the UK. I used to wonder how people in the former eastern bloc melded official doctrine, with their private thoughts. How did they reconcile their inner beliefs with all the bullshit. I now know— as do a lot of doctors. Too much of medical education is about producing widgets for the NHS, wrapped up in an unwholesome diet of newspeak and doublethink. The problems are that we do not know what sort of widgets we might want, and second, many of us do not think medical education should be in the widget business. There is plenty left to do in the UK.
Citation classics tend to be cited more often than read
Think of our current institutions as powerful chisels, relentlessly chipping away at our edges until we fit neatly into the tightly defined roles that our institutions have created. (John Hagel)
“Simply put, for the majority of students, the value of higher education is a function of its immediate employment prospects as opposed to long-term developmental and intangible benefits. This quest for value is especially prevalent in developed economies, where slow economic growth and scarcity of employment prospects fuel scepticism.”
Not certain how much of this article I agree with, as it is a bit policy wonk-ish. But the issues are real, and it is a useful summary. At least, it is what lots of people think. An unravelling is in place.
“All of education is fad-driven.”
All or just most?
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I didn’t understand what the word design meant until I read Herb Simon’s ‘Sciences of the Artificial’. I don’t mean this literally of course. I knew architects designed buildings, and graphic artists coloured the world I lived in. Painters painted. Musicians composed. Quavers got ordered. Colour got rearranged. But mainly I saw the world in terms of taking it apart. I lived in a largely man-made world, but was invisible to how it was done. When my eyes opened in the morning, it was all there,just like the birds. I remember, when I was a student at Newcastle University, a friend from school, who was supposed to be studying fine art, taking advantage of cheap student rates to go to the cinema on a Wednesday afternoon. He would watch the same film again and again. Over and over. I didn’t really understand what was going on. The only film I had watched repeatedly in one sitting was “Let it be’ by the Beatles ( in the Cardiff Odeon I think). Now to anybody of my generation watching the Beatles time and time again, does not appear so strange. But why watch film X again and again? Surely you knew the plot and, unless the film fulfilled some sort of comfort role, what was the point. You knew what was going to happen. (But music?).