Monthly Archives: May 2014

“Improvement in post secondary education will require converting teaching from a solo sport to a community based research activity.”


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Doctors: We are simply the bridge between nature and our clients.

by reestheskin on 28/05/2014

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Hospitality sciences?























I am fascinated with finding the best metaphors to describe what doctors do, and exactly what sorts of activities allow students to learn to ‘think and behave’ like doctors. Doctors as scientists, doctors as scholars etc., I find dull and too PC. Science is important, rationality more so, but the practice of medicine is called ‘practice’ for a reason. The increasing trend to attempt to redefine medicine as ‘medical science’, dermatology as ‘dermatological sciences’, even nursing as ‘nursing science’, is all about kudos and branding. I have even seen ‘hospitality sciences’, although not on a hospital menu. I think there is a rich mine to explore, looking at comparisons with the acquisition of musical expertise, with the traditional crafts and of course with the traditional professions. This quote from the chef Alain Ducasse captures something important (and avoids the ‘hospitality sciencies’ claptrap).

No geniuses have ever come from the kitchen. The world has had Pierre and Marie Curie, and Leonardo da Vinci. The former couple started a revolution against disease, advancing humanity, and the latter was a man whose genius we’re are still trying to understand. Chefs, on the other hand, are just artisans. If nature doesn’t give us vegetables, if the fisherman didn’t supply us with fish and the farmer with meat, we wouldn’t exist. We are simply the bridge between nature and our clients.

We are simply the bridge between nature and our patients. 

First there are the university fees, then the tuition fees…

by reestheskin on 27/05/2014

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exam testing companies


I always thought it was disheartening (understated, I know, but polite) that parents pay say 10K per year for private schooling, and then sometimes pay for tutors for their children after school. It is not irrational—if you want to pay 10K , why not pay 12K and spread the cost between two types of coaches. But it somehow seemed to say something about the value of the first 10K.

Now I see that some medical students are effectively doing the same. They pay fees to the University, and then feel the need to pay additional monies to various commercial companies who provide them with either  clinical practice or MCQs. I don’t know how many students pay for this sort of additional tuition, nor how valuable it is. But when medical student education is running at 20K/40K per year, I am, as I say, disheartened. Anybody know more than me in terms of numbers and value?

Students told to steer clear of medicine amid excess of applicants

by reestheskin on 26/05/2014

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I haven’t read the full article, as I do not subscribe. The Wellcome Trust newsletter, SPIN, quoted as follows:

The science and universities minister, David Willetts, has expressed concerns over the numbers of students pursuing medical degrees, pointing to the fact that “the number of young people – and it does tend to be more girls than boys – with an aspiration to do medicine way exceeds the number of places that the NHS is likely to have.” With a need for more engineering students, Willetts bemoaned a university application system which saw good candidates unable to switch courses because they had not taken a physics A-level.

The Times article begins:

Bright students, particularly girls, are being encouraged to become engineers rather than doctors because of a “gross excess” of applicants for medical degrees.
Medical schools across the country received more than 11 applications for every place last year compared with fewer than nine applications in 2008, new figures have revealed. David Willetts, the universities minister, said the level of competition to pursue a career in medicine was “one of the most dysfunctional features” of the education system.

It is the first time I have seen the issue raised in the mainstream press of how sensible medicine is as a future career, specifically in relation to the number of jobs that there may be. I am not convinced that the need for doctors, is the same as the needs of the NHS. Nor am I clear whether the article is suggesting that engineering and medicine are ‘close’ to one another in terms of professional activity. People fail to understand that the need for scientific underpinning in various professions, is far less important than the ‘professional activities’ and learned habits needed. How often do we need our quadratic equations, or Newton’s law of motion. Arithmetic and writing, yes. The rest is up for grabs.

Why having fun stops students overturning the teaching barricades

by reestheskin on 23/05/2014

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I posted a few days back about economics students rebelling against much of what they are taught. I wonder what the equivalent grounds for dissent for medical students would be. Possibly the confusion between being trained to work in the NHS, and being educated to practice medicine. Perhaps.

John Kay, as ever, has an article full of insights about the issue, and he thinks the students have a point (as I do). Part of the issue is that the academy always prefers formal methods over informal or tacit knowledge. This, to me at least, was one of the key insights Herb Simon made in his book the Sciences of the Artificial. Serious engagement with students is difficult because as Kay states:

In no other subject [other than economics] do students express such organised dissatisfaction with their teaching. It seems, however, to little lasting effect. Impermanence is inherent in student life: they don suits, collect their first salary and leave their complaints behind until the same gripes are rediscovered by a new group of 19-year-olds with similar naive hopes of changing the world.

He is right. But his most important point is the broader one:

One cause of the problem is not specific to economics. Modern universities prize research above teaching, to a degree that would astonish people outside the system, who imagine its primary purpose is to educate the young. In reality, teaching ability plays a negligible role in university hiring, tenure and promotion decisions. Many academic staff regard teaching as a nuisance that gets in the way of their “own” work. If most students were not having such a good time outside the classroom, they would be angrier than they are. They should be.

So, if they have a duller social life, we might yet see some barricades to education overturned.

And the other ten?

by reestheskin on 21/05/2014

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Zombie lectures and lecture zombies

by reestheskin on 20/05/2014

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Referring to a paper in PNAS:

To weigh the evidence, Freeman and a group of colleagues analyzed 225 studies of undergraduate STEM teaching methods. The meta-analysis, published online today in theProceedings of the National Academy of Sciences, concluded that teaching approaches that turned students into active participants rather than passive listeners reduced failure rates and boosted scores on exams by almost one-half a standard deviation. “The change in the failure rates is whopping,” Freeman says. And the exam improvement—about 6%—could, for example, “bump [a student’s] grades from a B– to a B.”

“This is a really important article—the impression I get is that it’s almost unethical to be lecturing if you have this data,” says Eric Mazur, a physicist at Harvard University who has campaigned against stale lecturing techniques for 27 years and was not involved in the work. “It’s good to see such a cohesive picture emerge from their meta-analysis—an abundance of proof that lecturing is outmoded, outdated, and inefficient.”


Doctors need to know how to drive the car, not build it.

by reestheskin on 19/05/2014

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We understand the world through metaphor, and the ones we choose have a deep impact on how we manipulate our thoughts and the world. In medicine, many parallels have been drawn between aviation and health care. I am thinking of checklists, protocols and the like. On the other hand regulators talk about doctors as ‘scholars’ and ‘teachers’ and so on.
An article by Ha-Joon Chang and Jonathan Aldred, caught my eye. The topic is what to do about economics teaching, post 2008. As far as I can see, despite students being aware the academy is behind the times, little has changed.

There is no doubt that these models, and related research in “econophysics”, represent a promising new research direction in macroeconomics. But that does not make them, even in simplified form, candidates for a new undergraduate curriculum. Most graduate economists will have no contact with these models in their careers; a few of them may need, at most, to understand their broad insights. A civil servant in the Government Economic Service expressed the requirements for the latter group pithily: government economists need to know how to drive the car, not build it.

I think this goes for medicine too. “Government economists need to know how to drive the car, not build it.” Doctors are not the people who design or build planes: we fly them. Less physics, not even too much applied engineering. More like bus drivers in the sky, or taxi drivers of the ward.

Who earns what in US health care

by reestheskin on 18/05/2014

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who earns what in health care

Source: New York Times

Musings on MOOCs, and writing with a stick on the ground

by reestheskin on 18/05/2014

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Gregory Hays shares some nuanced thoughts on MOOCs, on reviewing a book and MOOC by Gregory Nagy.

Will the MOOC revolutionize education in a few short years, as the Virginia conspirators persuaded themselves? Will it remain a marginal though useful supplement to conventional college, like the Open University or the correspondence courses of the 1920s? Will it be merely a playground for retirees and intellectual hobbyists, the digital successor to “great lectures on tape”? Or will it prove an evolutionary cul-de-sac, like the fifth-grade filmstrip of the 1970s?

None of these questions really seems answerable as yet. In its current version, in fact, Nagy’s MOOC feels a lot like a conventional large lecture class: there’s a textbook, a professor who does most of the talking (sometimes alone, sometimes in obviously staged “dialogues”), a virtual discussion section, and tests in multiple choice and short-answer formats. As one browses the website one is struck by the ordinariness of the whole thing—even the classroom dynamics. Some participants are being lectured about courtesy on the bulletin boards, modern Greek students are insisting that only they can really understand Homer, and still others are—well, perhaps “disconnected” is the right word.3

None of this should surprise. It’s typical for new technologies initially to mimic an existing one; Gutenberg’s forty-two-line Bible is not easy to distinguish from a manuscript copy. It takes time to figure out what a new medium can do besides the same thing bigger, faster, or cheaper, and for its particular strengths and weaknesses to emerge. Fifty years after Gutenberg, printing had shown itself vastly superior for Bibles and legal texts, a cheap substitute for deluxe books of hours, and no replacement at all for wills, inventories, and personal letters.

His final sentence:

It is, after all, a medium, not a message. And as the typographer Alvin Doyle Moore observed, “if you’re really good, you can do it anywhere—even on the ground with a stick.”

Correlation is not causation, but…..

by reestheskin on 17/05/2014

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Nice graph, via John Naughton.  Well, indeed correlation is not proof of causation, but a la Judea Pearl and others, correlation may tell you a bit about causal structures.


Dermatology or photoshop?

by reestheskin on 16/05/2014

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Via a great article on the canons of computer software by Paul Ford

‘What a superb medical education we received. It enthused us about every branch of medicine’ …..Now that would be a learning outcome to shout about.


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Statistics, reliable knowledge and medical education (‘crisis’ 1 of 2)

by reestheskin on 14/05/2014

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It is not a real crisis, but perhaps not far from it. People have looked upon science as producing ‘reliable knowledge’, and now it seems as though much science is not very reliable at all. If it isn’t about truth, why should we consider it special? Well, a good questions for an interested medical student to think about. But hard to do so. Part of the answer lies with statistical paradigms (or at least the way we like to play within those paradigms), part with the sociology and economics of careers in science, and part with the means by which modern societies seek to control and fund ‘legitimate’ science. Let me start with a few quotes to illustrate some of the issues.

A series of simple experiments were published in June 1947 in the Proceedings of the Royal Society by Lord Rayleigh–a distinguished Fellow of the Society–purporting to show that hydrogen atoms striking a metal wire transmit to it energies up to a hundred electron volts. This, if true, would have been far more revolutionary than the discovery of atomic fission by Otto Hahn. Yet, when I asked physicists what they thought about it, they only shrugged their shoulders. They could not find fault with the experiment yet not one believed in its results, nor thought it worth while to repeat it. They just ignored it. [and they were right to do so]
The Republic of Science, Michael Polanyi

[talking about our understanding of obesity] Here’s another possibility: The 600,000 articles — along with several tens of thousands of diet books — are the noise generated by a dysfunctional research establishment. Gary Taubes.


“We could hardly get excited about an effect so feeble as to require statistics for its demonstration.” David Hubel, Nobel Laureate (quoted in Brain and Visual Perception)

The value of academics’ work is now judged on publication rates, “indicators of esteem,” “impact,” and other allegedly quantitative measures. Every few years in the UK, hundreds of thousands of pieces of academic work, stored in an unused aircraft hangar, are sifted and scored by panels of “experts.” The flow of government funds to academic departments depends on their degree of success in meeting the prescribed KPIs [key performance indicators]. Robert Skidelsky

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What Can Medical Education Learn From Facebook and Netflix?

by reestheskin on 13/05/2014

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Shiv M. Gaglani, BA, and M. Ryan Haynes  in an article in Annals of Internal Medicine.

The title may raise hackles, but they are more right than wrong. One of the problems with the one-to-many lecture dominated undergraduate model, with minimal repeated contact between staff and students, is that feedback both for students and staff is scarce. The importance of feedback to staff  (and I do not mean the silly popularity charts) is often forgotten in the usually justified critiques of lack of (student) feedback.

Many students, in some cases as many as 80% (3), choose re- corded lectures over live ones because they can be paused, rewound, and played at various speeds. This generates data that may be used to create heat maps of individual lectures. Suppose 50 students watch a recorded lecture and 30 of them pause and rewind the video at time point 28:30. It would be statistically possible to infer that the concept being discussed at this point was unclear, and the professor involved could be notified with actionable insights…..

For example, if a student spends more time on average viewing documents in the neurology versus the cardiology block, it can be inferred that she is either more interested in or confused by the former’s subject material.

They also have some useful things to say about the limitations of learning management systems (sic)

universities care about undergraduates just enough to require a thousand of them to fill a lecture hall, now they are doing it online so the numbers can get much bigger. It’s all about money.



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Medical expertise, mashed potatoes and competency indigestion

by reestheskin on 07/05/2014

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One of my favourite papers about medical education was an article Geoff Norman wrote called ‘Medical expertise and mashed Potatoes’. In it he recounts a meeting with the famous chef Albert Roux. Norman uses the encounter to point out the similarities between expertise in what seems like very different domains. Since I have recently  almost lost the will to live  having tried to gorge on an ultimately inedible diet of pseudo-competency based descriptions of what doctors ‘are’ (really, the Danish devote pages to an exegesis of the  CanMEDS, and tweaking of where to put ‘professionalism’ in a schema of what doctors ‘are’!) They all need to get a dose of Wittgenstein to see the folly of their ways..) Anyway I digress.

Medicine was historically an apprenticeship, but our problem (well, actually the students problem) is that in large part this is not mirrored in the way we organise it at the undergraduate level. As Alice Gopnik, the psychologist once remarked, at university we tend to think the way to teach people how to cook, is to lecture then for three years and then, and only then, allow them to crack an egg. Here is a nice video from the NYT of people who understand education much better than we do. The video, and Norman’s article, say more than the ever enlarging girth of the working groups.



Dr Evil goes to medical school

by reestheskin on 06/05/2014

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I have never taught in a school, just been a pupil. I do remember the sparring that goes on between pupils and teacher. The kids push ‘to the limit’. They then improvise just under this limit, causing trouble. My thought was that teachers could either define limits carefully or, to be slightly evil, just behave in an inconsistent manner. For the latter, think: random acts of terror! In this scenario, the kids can never quite work out any rules of engagement, and will sit there terrified in silence. Evil, I know.

I wonder whether this approach might be useful for learning outcomes. Rather than taking part in an evolutionary war between the students on one hand who want ever more explicit statements of what they should know, and on the other, the inevitable ignoring of all aspects of knowledge that cannot be explicitly stated, we should aim for a little more disorganisation. We shouldn’t tell the students what they need to know, and we certainly shouldn’t tell them the format of the exam, or even when it is. What do they need to know? Lots. Pay attention. Evil, I know.

Textbooks (again) and Spotify economics

by reestheskin on 05/05/2014

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Talking the familiar text book as an example,  American researcher David Wiley compares the cost of renting 75,000 movies  ($9.00 a month  fromNetFlicks) or renting  any of 20 million songs from Spotify  ($9.99/month) with the cost of renting a college text book . A single biology text book rents for $12.99 a month from BookRenter.  This cost imbalance is especially vexing in that consumers choose to rent movies or songs, while professors (often in collusion with publisher representatives) choose the textbooks that others (the students) pay for.


Terry Anderson writes

Why medical professionalism doesn’t matter.

by reestheskin on 05/05/2014

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Around 20 years ago my father was admitted to a major teaching hospital in Wales. He was in his early 70’s and had heart failure. He was under the care of the ‘general medics’, on a general medical ward. He became mildly confused after admission, and within a couple of days had fallen in the bathroom, and was developing red areas on pressure points, a harbinger of pressure sores. I remember talking to one of the nurses, who was apologetic that there was no possibility of getting a suitable bed (‘there isn’t the money’), and that he had fallen when he should have been supervised. The poor nurse was literally run off her feet, a couple of nurses trying to cope with a score or more of patients. I was probably fairly cross, and not concealing it well—but so was she, reasonably so. She and I both knew how things could be made better. Both of us found it uncomfortable, because both knew that key decisions about care are usually made by people who don’t see patients, or have first hand knowledge of the ‘front-line’ (remember the Ballad of Reading Jail: prisons have walls, not so that convicts can’t escape, but so that God cannot see what goes on inside).
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Is skin cancer an unhelpful term?

by reestheskin on 04/05/2014

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Is skin cancer an unhelpful term? from jonathan rees on Vimeo.

College and health care costs: A simple graphic a la Baumol

by reestheskin on 01/05/2014

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New York Times

NYT costs for US citizens