Monthly Archives: September 2016

Online or paper

by reestheskin on 30/09/2016

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Nick Carr writes about e-textbooks, quoting research that students don’t like them, or at least they prefer conventional textbooks. Seems reasonable to me. We know a lot more about the design of conventional textbooks, layout, indexing, and interaction and so on. But for dermatology it seems to me e-textbooks offer a way forward. If you want to learn dermatology, you have to look at images, and to do this well, you need access to lots and lots of images. One of the conclusions of a paper we published several years ago was how few instances of a particular disease students are exposed to. Seeing only n of 1 for a particular lesion type is just not enough: imagine your sole idea of what a ‘dog’ is, was based on only seeing one poodle. Current publishing models and norms mean that most dermatology textbooks are short on images — and often the images they contain are poor. E-textbooks are one way round this, and it is difficult to look at an iPad and not wonder what a good dermatology text would like like on it. What will be really interesting is what will happen to the legacy publishers given the price sensitivity of undergraduate students and the lower barriers to entry.

Annotation and memory of position on the page are important issues, but I doubt invention will not improve things. Just look at the way the ‘clunky’ Kindle allows you to highlight text, then retrieve it on the Amazon web site and go back to the text at the various bookmarks. A scholars dream for encouraging accurate referencing and citation.

In the meantime keep reading skincancer909^^ and my online material! Lots of room for improvement however.

^^ Skincancer909 is currently being rewritten and the future version will incorporate video with a new design.

More updates to ed.derm.101 (Part C v1.45)

by reestheskin on 29/09/2016

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I have added some more SoundCloud answers and added and sorted the links in Part C Chapters 5,6,7. Getting there.

Why STEM lobbying misses the point

by reestheskin on 29/09/2016

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First, it maintains a disciplinary focus to education at a time when our disciplinary boundaries are becoming prisons that prevent us from fully understanding the rapidly changing world around us…

Second, it suggests kids should go into disciplines that are particularly vulnerable to automation…

Third, it seems to be driven by the sense that we’ll all need to become “techies” in order to survive in a world increasingly shaped by technology…

Great post from John Hagel. Worth reading in full. I had heard of STEMM but not STEAM —proves the acronyms are more about vested interests than education.

The State we are in

by reestheskin on 28/09/2016

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The University believes the Secretary of State should not have the ability to determine, or even to have significant influence over, which subjects universities can and cannot teach.

Written evidence submitted by the University of Cambridge (HERB 17). Higher Education and Research Bill Committee.

Years ago, we would have said that the state trying to control education would have been a characteristic of societies — Russia, China, spring to mind — that paid little attention to individual liberty or which failed to understand that most expertise — and power — should reside outwith government. No longer. Sadly, medical education is already increasingly subjugated to the state.

‘We are being weighed in the balance at this moment’

by reestheskin on 27/09/2016

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Knowledge is not a looseleaf notebook of facts. Above all, it is a responsibility for the integrity of what we are, primarily of what we are as ethical creatures. You cannot possibly maintain that it informed integrity if you let other people run the world for you what you yourself continue to live out of a rag bag of morals that come from past beliefs. That is really crucial today. You can see it is pointless to advise people to learn differential equations, or to do a course in electronics or in computer programming. And yet, 50 years from now, if an understanding of man’s origins, his evolution, his history, his progress is not the commonplace of the schoolbooks, we shall not exist. The commonplace of the schoolbooks of tomorrow is the adventure of today, and that is what we are engaged in……

It sounds very pessimistic to talk about western civilisation with a sense of retreat. I’ve been so optimistic about the ascent of man; and I going to give up at this moment? Of course not. The ascent of man will go on. But do not assume that it will go on carried by Western civilisation as we know it. We are being weighed in the balance at this moment.

The Ascent of Man, Jacob Bronowksi 1973.

The dissolution of the universities

by reestheskin on 26/09/2016

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What defines a conservative? The answer must include reverence for institutions that have successfully stood the test of time and a deep belief in their autonomy. In the UK, no institutions have more successfully stood the test of time and none better illustrate the value of enduring autonomy than universities. So why does this government propose not only to turn them into the equivalent of purveyors of baked beans, but to seize the power to abolish their independence by administrative fiat? This disaster has to be stopped.

This is from Martin Wolf in the FT

And here is THE

Cambridge says: “The proposal for the OfS to make arrangements for the assessment of standards is an unprecedented extension of powers and contradicts a cornerstone of the UK higher education sector, namely that providers with degree awarding powers are responsible, as autonomous institutions, for the standard of their awards”.

The university also objects to powers for the OfS to revoke an institution’s degree-awarding powers or university title, even when granted by Royal Charter. “These sections effectively grant the OfS the competence to revoke parts of primary legislation and Royal Charters, without full parliamentary scrutiny,” says Cambridge.

Back to another FT article

Finally, this is no time to add to the challenges UK universities face. Legislation that will lower the barriers for new institutions offering degrees and introduce a controversial system to measure the quality of teaching requires caution. Further obligations — linking higher fees to the sponsorship of schools, for example — are an unhelpful distraction. Britain’s universities are a huge national strength — they need protection.

Finally from the recently published book by Anthony King and Ivor Crewe, ‘The Blunders of our Governments’.

In previous generations, foreign observers British politics viewed the British political system with something like awe. Governments in Britain was not only highly democratic: it was also astonishingly competent. It combined effectiveness with efficiency. British governments, unlike the governments of so many other countries, knew what they wanted to do and almost invariably succeeded in doing it. Textbooks in other countries were full of praise, and foreign political leaders often expressed regret that their own system of government could not be modelled on Britain’s. Sadly, the British system is no longer held up as a model, and we suspect one reason is that today’s British governments screw up so often. They screw up more often more most people seem to realise. Our strong impression is that, while a majority of Britons know about this, that or the other cock-up, they are by no means aware of the full range of them.

The worst aspect of all these acts of vandalism, it that they get in the way of the genuine change we need in higher education. Britain used to make great British cars, and if you ever visited Cardiff docks, like I did as a child with my father, you would see thousands of them, row upon row as far as you could see, ready for export.

Knowing more than we can say

by reestheskin on 25/09/2016

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There are hidden rules not just in grammar, but at every level of language production. Take pronunciation. The –s that marks a plural in English is pronounced differently depending on the previous consonants: if the consonant is “voiced” (ie, the vocal cords vibrate, as in “v”, “g” and “d”), then the –s is pronounced like a “z”. If the consonant is “unvoiced” (like “f”, “k” and “t”), then the –s is simply pronounced as an “s”. Every native English-speaker uses this rule every day. Children master it by three or four. But nobody is ever taught it, and almost nobody knows they know it.

From the Economist: Hidden in plain sight.

I am fascinated by linguistics. It never existed in my mind as a subject before I read some Chomsky, and yet I find it fascinating. See the papers in last week’s Nature about human genetic diversity and our history, and linguistic diversity in Australia (there is an article about this in Science).

But one reason why the above amuses and intrigues me, is that it is clear in so many clinical situations that we know more than we can say. We really are very poor at explaining clinical competence, and until we think hard about this issue, our teaching remains worse than it might be.

Some updates to ed.derm.101

by reestheskin on 25/09/2016

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I have posted some new audio SoundCloud answers to questions from the first three chapters of ed.derm.101 Part C.

Unnatural learning

by reestheskin on 22/09/2016

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I can seldom revisit anything Alan Kay has said or written and not find ideas worth exploring. Here is one such quote:

If you take all the anthropological universals and lay them out, those are the things that you can expect children to learn from their environment—and they do. But the point of school is to teach all those things that are inventions and that are hard to learn because we’re not explicitly wired for them. Like reading and writing.

Virtually all learning difficulties that children face are caused by adults’ inability to set up reasonable environments for them. The biggest barrier to improving education for children, with or without computers, is the completely impoverished imaginations of most adults

If we think of medical education, and subjects like mine in particular, it is clear that some of the skills we wish to encourage are ‘natural’. I think children in the right environment could acquire them. Humans are hard wired to learn to be able to classify their environment and divide the world on the basis of form. We can do this even when we have little idea of causality or underlying structure, or of that branch of formal knowledge called science. Feedback is required but the basic tools are there. Think of the way children learn to distinguish between cats and dogs, and even though it is hard to formalize the basis for this expertise, it is easy to demonstrate. Jared Diamond in ‘Guns, Germs and Steel’, tells how he compared his ability to classify the natural world with that of Yali, a native of Papua New Guinea. Diamond is an an expert ornithologist, and natural historian and yet Yali had difficulty understanding how and why Diamond was so poor (relatively) at some classification tasks. Classifying fauna and flora — or at least the machinery that allows expertise in this area— is hard wired. And of course it is not unique to humans or even mammals, but humans have the ability to meld these faculties with cultural transmission and make them very powerful. Of course, varying degrees of formal and informal learning is part of this process.

Not all skills we want students to know are like this. Statistics and insight into probability — key clinical skills — are wonderfully counterintuitive. Worse still, we know that on many occasions our strongly held convictions are mistaken, and hard for us to self-diagnose. But to return to the ‘natural’ skills and related to the points Kay is making, one question is whether beyond childhood, we create the right environment that allows natural learning to take place. Many of us suspect that when we explain why lesion X is diagnosis X because of appearance Y and Z, or worse still some formal rule, we are not seeing the world as it really is. Rather, we should realise that whilst feedback of one form or another is critical, students have to discover and grow their own abilities, even though they too may not know how they do it. So I might change some words:

The biggest barrier to improving medical education is the completely impoverished imaginations of medical schools.

“The NHS has developed a widespread culture more of fear and compliance, than of learning, innovation and enthusiastic participation in improvement.” It also said “Virtually everyone in the system is looking up (to satisfy an inspector or manager) rather than looking out (to satisfy patients and families)” and “managers ‘look up, not out.’”

The Institute for Healthcare Improvement (IHI), a US organisation, report on the NHS ( quoted by Brian Jarman in the BMJ. BMJ 2012;345:e8239 doi: 10.1136/bmj.e8239 (Published 19 December 2012)).


The NHS could then become a threadbare charity, available to avoid the embarrassment of visible untreated illness. Julian Tudor Hart  BMJ 2016:354;i4934

On diagnosis

by reestheskin on 19/09/2016

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Abraham Vergese, an infectious disease physician, gave a talk here in Edinburgh last week. It was a very mixed audience, but I suspect the many students who were there enjoyed it. I have not read any of this books — nor looked at his TED talk — but his Wikipedia entry gives you a flavour of how interesting he is, and how varied a career can be — when you have courage.

One issue that came up tangentially, was the history of diagnosis, and there were some opinions ventured by the audience in terms of when diagnosis was historically established. I may have missed key points, but I found it hard to accept that the idea of diagnosis was something you could date except in very broad terms, even less that you could associated it with the 1870s or with the idea of stethoscopes being a key marker of when modern ideas of diagnosis were established. For instance — and since the lecturer was an ID physician — my first thoughts turned to scabies. The scabies mite was identified in the 1690s, and it was recognised as the cause of the disease ( I am not quoting primary sources so let me know if……) So here we have a clear linking of symptoms, signs, causality, a causal agent, and a broader theory about pathogenesis and epidemiology. So, this it got me thinking about how I view the topic of diagnosis.

Diagnosis is the mapping of one state with another, with the two states being linked by a network of attributes. Diagnosis is a suitcase term: it may contain lots of different tools, tools suited to various purposes, and tools for which we may find different purposes over time. Diagnosis represents an attempt to classify the world into particular states with often the goal of making some predictions about some other state. Most of the time, we think in terms of prediction, about what might happen to that person with or without some intervention. If you see these physical signs (burrows) and the patient describes particular symptoms (itch), then the ‘state’ is scabies. If the diagnosis is correct, you can say something about what causes the state, what might happen, and what effect a particular intervention (permethrin / malathion etc) might have. If you are lucky, you can feel happy with causal arrows linking much of what you say and think. Prediction is important but it is of course not the only quality we want in a theory. We tend to prefer some theories to others, even when they why make similar predictions. Think of Copernicus. We tend to prefer one of the following, irrespective of whether both allow the same quantitative clinical predictions:

  1. Sunbathing causes skin cancer: if you increase exposure by X then incidence goes up by Y
  2. Sunbathing increase the dose of UVR, UVR is mutagenic and in particular cause very specific types of mutation, cancer is a result of the accumulation of mutations, and therefore we will see particular mutational spectra in skin cancers

Our suitcase of diagnostic concepts have changed over time, however. For instance, even in modern medicine, causality is often lacking. We may use proxy or associated factors to define particular states. We may use simple heuristics as our guide to action, even though we have little idea of where the causal arrows are going. Think much of psychiatry. This does not mean we are powerless, just that we are more ignorant than we would like. We are of course wedded to particular metaphysical systems.

Diagnosis might have been used in the absence of knowledge about particular interventions to attribute blame, as an explanation. If a patient behaved in this way or suffered some state, it was a divine punishment for some behaviour. Now, I may not agree with this world view, but this too is diagnosis. The theory my seem wrong, it may seem primitive, but then my ideas of physics are primitive too if they are applied to the world of the very small.

Galen thought in terms of the mean, and the treatment by opposites (hot treatments for cold; moist treatment for drying diseases etc). This all sounds slightly crazy to modern ears (although dermatologists among you will point out the latter has definite therapeutic merit within very particular skin states). Or how about the idea of therapeutic ‘signatures’. This is from Ian Hacking [1]:

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.

As Hacking points out this allowed Paracelsus to kill lots of people simply because he knew that mercury worked. But whatever the metaphysical system linking two states, the idea of diagnosis was firmly established. Just as Newton got most things right in his physics, and most of us ignore what came after — except when we use the GPS.

Diagnosis was not limited to medicine. Our ancestors spent their lives making diagnoses about what to eat and what not to eat. Making diagnoses about what particular weather states would do to crops etc. Plumbers make diagnoses, as do any humans trying to make sense of an environment that is not static, and where we value intervention.

What may have been specific to medicine was our hangs up about whether there was something special about humans, and whether the simple rules, experimentations and demonstrations of efficacy that allowed other types of human technological progress or indeed much of everyday life, applied in the domain of disease. Successful interventions or demonstrations will have had an effect on metaphysical beliefs in the long term. And of course much of this story is tied up with the growth of that particular branch of formal knowledge we call science. 1870 is just a little late.

[1] Hacking I. The emergence of probability : A philosophical study of early ideas about probability, induction and statistical inference. Cambridge: Cambridge University Press; 1984.

[2] Jonathan Rees: Why we should let EBM rest in peace. Clinics in Dermatology (2013) 31, 806–810

Someone Is Learning How to Take Down the Internet

by reestheskin on 18/09/2016

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“Over the past year or two, someone has been probing the defenses of the companies that run critical pieces of the Internet. These probes take the form of precisely calibrated attacks designed to determine exactly how well these companies can defend themselves, and what would be required to take them down. We don’t know who is doing this, but it feels like a large a large nation state.”

Bruce Schneller (the ‘security guru’ in the words of the Economist) at Lawfare. You use it. And it is quite possible. Worth a read in full.

Intellectual friction and remix: ‘this was killing us’

by reestheskin on 17/09/2016

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The goal of the new CFF [Cystic Fibrosis Foundation, a US patient charity] Therapeutics Lab, says Preston W. Campbell III, the foundation’s CEO and president, is to generate and share tools, assays, and lead compounds, boosting its partners’ chances of finding treatments. Frustration with academic technology transfer agreements was a key motivation, he notes. University-based researchers funded by the foundation have to seek approval from their institution’s legal department before sharing assays, cells, or any intellectual property, a hurdle that can take a year to negotiate. “This was killing us,” Campbell says, “ but if we created our own laboratory, we could not only focus on the things we wanted to focus on, we could also share them freely.”  Science

Inefficiencies in medical education

by reestheskin on 16/09/2016

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Inefficiencies in medical eduction are in part borne by students. They are also borne by patients. As a medical student, I ‘delivered’ around 30 babies; I also did some episiotomies with varying degrees of supervision. As a medical registrar I put 32 pacing wires in, inserted a number of chest drains and took pleural biopsies; and put various central lines in. One of the latter interventions, led to a major complication. Things may have changed since I was a junior, but my argument may also  apply to lesser procedures: taking blood, suturing, and indeed any interaction with patients. Even a clumsy bedside manner or history taking. On the other hand, I was sometimes useful to patients. I did my elective here in Edinburgh in psychiatry on the late Prof Bob Kendell’s unit. I spent three months on PU2, and, both at the time, and looking backward, feel I contributed positively to the care of patients.

The issue about the cost of training — especially in practical matters — to patients is not easy. There is always a learning curve. We also know that in some situations a non-expert is all we can afford — think of the example of a single doctor on an Antarctic research base who might have been instructed how to pull a tooth or release a dental abscess, before they went.

The point I make is about whether procedures are genuinely part of a learning curve — that is, a curve in which the individual aims to get better and better, and will carry on with that technique throughout their professional career. Or whether the organisation of training takes little account of known career trajectories, in which case there is no learning curve, and the moral argument more suspect.

I was never going to be an obstetrician, I was never going to be a cardiologist, nor a chest physician. And I knew all that before I qualified. But I was going to need to take blood; and to do dermatological surgery at an intermediate level. Once somebody has decided on a final destination, the route has to change accordingly.

MOOCs not dead yet, just winding their way around the roots of the bigger bushes

by reestheskin on 15/09/2016

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“Earlier this summer we let you know about a new subset of our HarvardX online courses that feature premium Harvard content, small cohort-based learning, higher touch with Harvard faculty and peers, and a valuable HarvardXPLUS credential. The first HarvardXPLUS courses are set to launch on September 12, and there’s still time for you to register.”

LinkAnd yes, they cost.

Spray on blocking

by reestheskin on 14/09/2016

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I had seen spray on tans but…

spray on sunblock

Things I think about in the shower

by reestheskin on 14/09/2016

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  1. How much can you learn on your own, and how much do you need a teacher or coach for.
  2. What taxonomy can we use to think about what you can, and what you cannot learn without a teacher or coach.
  3. How do we think about ‘just-in-time’ and ‘foundational’ material, knowing that foundational usually isn’t (it is the moral hazard of teachers and institutions — or their business model).
  4. There is a literature on ‘transference’ of domain knowledge. But my suspicion is that much knowledge about ‘how hospitals or GPs work’ transfers well. There is a lot of redundancy.
  5. Why are we so obsessed with lengthening training, and making students do lots of detours.
  6. Sage on the stage, or Hollywood, in terms of production values and strategy
  7. The inefficiencies of our medical teaching are now borne by our students’ wallets.
  8. Why did anybody ever think postgraduate training had much to do with undergraduate medical education.
  9. Strict competency frameworks will destroy medical schools’ business models
  10. There should be more than ten things to think about.

just a test

by reestheskin on 13/09/2016

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This is just a test. And thanks to Roslin design.

Stupid patent of the month

by reestheskin on 13/09/2016

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Well you really could not make this up. From the EFF:

On August 30, 2016, the Patent Office issued U.S. Patent No. 9,430,468, titled; “Online peer review and method.” The owner of this patent is none other than Elsevier, the giant academic publisher. When it first applied for the patent, Elsevier sought very broad claims that could have covered a wide range of online peer review. Fortunately, by the time the patent actually issued, its claims had been narrowed significantly. So, as a practical matter, the patent will be difficult to enforce. But we still think the patent is stupid, invalid, and an indictment of the system….

Before discussing the patent, it is worth considering why Elsevier might want a government granted monopoly on methods of peer review. Elsevier owns more than 2000 academic journals. It charges huge fees and sometimes imposes bundling requirements whereby universities that want certain high profile journals must buy a package including other publications. Universities, libraries, and researchers are increasingly questioning whether this model makes sense.

Avoid Elsevier. This is a world that should no longer exist.

Bridget Jones on medical education

by reestheskin on 12/09/2016

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“And still her life is a relative mess. I like the message in that: that we can tick off the boxes, and yet we still don’t quite have it together. And that’s pretty much the truth of growing up, isn’t it?”  NYT

Well this is from Renée Zellweger talking about her Bridget Jones persona. But everywhere I look now I see the great and the good from HEE and the RCP admitting that all this tick- boxing has been a disaster and has subverted medical education. They were told this years ago. It is an irony of the age that those charged with directing postgraduate medical education, are most in need of it themselves. Worse still, the postgraduate world has been allowed to infect the undergraduate world.

Faculty do not have the time to teach..

by reestheskin on 11/09/2016

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Interesting article about US medical students complaining about their national licensing exams. I think the students have  some very valid points. Some quotes:

Dr. Peter Katsufrakis, the senior vice president of the National Board of Medical Examiners, agreed that the exam isn’t difficult, but pointed out that 871 students did fail it in the 2013-14 academic year. Besides, he said, most medical school faculty don’t have time to observe third- and fourth-year students doing a complete physical exam, so it’s important to test those skills as part of the licensing process. [emphasis added]


The National Board of Medical Examiners doesn’t give feedback to test takers — in part because that would be expensive and in part because it would make it too easy for students to cheat by sharing their feedback forms, which would likely contain hints about the specific scenarios being tested, Katsufrakis said.

Well, we have a new angle on Shaw’s ‘conspiracy against the laity’.