Red, white and blue

by reestheskin on 18/02/2021

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Winnowing MMXXI

by reestheskin on 13/02/2021

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Canada pushes abundant PhD graduates towards industry needs | Times Higher Education (THE)

Canada’s universities need to adjust their doctoral degree programmes to help make their swelling surplus of PhD graduates more attractive to industry, a government-chartered assessment has concluded.

Perhaps they need fewer PhDs. And as for how to make a bad situation worse:

Universities, meanwhile, should keep adjusting the content of their doctoral degree programmes to include skills in management, teamwork and communication that are valued by companies, the experts say.

David Hubel, a Canadian by birth, and a Nobel Laureate, wrote that one of the advantages of having an MD was that — in those days, but not now — you didn’t need to do a PhD. Like many so many of his ideas about doing science, he was spot-on. I was delighted to have got through in the wonderful bad-old days, managing to avoid this credential.

Its just business

Australian universities in ‘deep trouble’ as borders stay closed | Times Higher Education (THE)

Simon Marginson, professor of higher education at the University of Oxford, said in 2018 that Australia was poised to overtake the UK as the second most popular global destination for international students in 2019. However, speaking to Times Higher Education, he said it was now “impossible to see that position being restored.…in fact, Australia may not recover market share in the longer run”.

He goes on:

My sense is that international education in Australia is in deep, deep trouble. That means higher education is in deep trouble and scientific research is in equally deep trouble because this is heavily financed from international student fees.

One commentator on this report states:

Australian Universities are at a cross-roads and along with them the huge international education market (our 3rd biggest export industry), yet our politicians are doing nothing… It is unimaginable that any other large export industry would be so conscientiously ignored. [emphasis added].

Rich DeMillo describes higher education as a multisided marketplace. It is a feature of our age that cross-subsidies within such marketplaces will come under strain. If you want to do research, you need to fund it; if you want high-quality teaching, you have to fund it on its merit. No free lunch.


Precisely what?

Precision medicine in rheumatology: are we getting closer? — The Lancet

One of the things that led me to become disenchanted with much of modern medical genetics was the hype that was necessary to secure funding. Genetics is a great way to do biology, but biology is not synonymous with medicine; advance in one does not necessarily follow from the other.

And personally speaking, the best reason for the study of modern human genetics was to tell the story of humanity — how we got here, and what is our story. It is sad that there is no Nobel for biology.

Precision medicine is another (IMHO) bullshit phrase. Read this recent Lancet article (link above):

The overarching aim of precision (also referred to as personalised) medicine is to identify the best possible management approach for an individual with a certain disease. The main prerequisite for such an approach is the identification of characteristics linked to a favourable outcome of a certain treatment. The characteristics of interests might be clinical or molecular biomarkers or identified through imaging, allowing for stratification of patients and prediction of response. The size of the strata might range from big subgroups covering a substantial proportion of patients to individual patients.

But medicine has always worked this way. You don’t give children the same dose of drugs as adults; you don’t treat all cases of psoriasis the same way. And as for biomarkers, well, over a century ago there was the H&E project (H&E standing for the two most common dyes used in diagnostic histopathology), a discovery that still predicts outcomes better than all those wonderful machines in the Sanger centre (and they are wonderful).

And then in Science I read:

A genome to celebrate | Science

The completion of the draft sequence laid the foundation for a new precision medicine paradigm that aims to use a person’s unique genetic profile to guide decisions about the treatment and prevention of disease. We have already seen some signs that precision medicine is possible, and although off to a slow start, the promise of this approach may ultimately be realized.…. Given the pace at which breakthroughs based on the human genome sequence are happening, when we next commemorate the publication of the draft human genome sequence, be it at 25, 30, or 50 years, we may look back again, realize that this accomplishment was a watershed for the biological sciences, and marvel at how far we have come in such a short period of time. [emphasis added].

We might indeed, but the phrasing reminds me of the celebrations that used to surround a grant being awarded, rather a discovery made. I, too, should confess on this point.

Please, oh please, a little modesty and perspective. We are not in sales.

That Welshman

Here is something more solid and sustaining; something where the purpose of language is to communicate and not to shill.

I have been reading Nye Bevan’s biography by Nicklaus Thomas-Symonds. Here is an excerpt from a speech Bevan made in 1959.

I have enough faith in my fellow creatures in Great Britain to believe that when they have got over the delirium of the television, when they realize that their new homes that they have been put into are mortgaged to the hilt, when they realize that the moneylender has been elevated to the highest position in the land, when they realize that the refinements for which they should look are not there, that it is a vulgar society of which no person could be proud, when they realize all those things, when the years go by and they see the challenge of modern society not being met by the Tories who can consolidate their political powers only on the basis of national mediocrity, who are unable to exploit the resources of their scientists because they are prevented by the greed of their capitalism from doing so, when they realize that the flower of our youth goes abroad today because they are not being given opportunities of using their skill and their knowledge properly at home, when they realize that all the tides of history are flowing in our direction, that we are not beaten, that we represent the future: then, when we say it and mean it, then we shall lead our people to where they deserve to be led.

Winnowing XXMMI

by reestheskin on 12/02/2021

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More evidence in the case against Luxembourg | Financial Times

Luxembourg sometimes resembles a criminal enterprise with a country attached.

Via The Tax Justice Network and Cory Doctorow

666 trademarks and all that

Mark of the Devil: The University as Brand Bully by James Boyle, Jennifer Jenkins :: SSRN

James Boyle is a Scottish law professor at Duke. He is one of the leading academics in the field of IPR. His book Shamans, Software and Spleens: Law and Construction of the Information Society opened my eyes to a world that I literally did not know existed. It is hard to live a game when you fail to understand not just the nature of the rules, but the idea that there are rules. I would also plug his graphic book on IPR and music Theft: A History of Music.

He has now obviously been studying things closer to his own academic home.

In recent years, universities have been accused in news stories of becoming “trademark bullies,” entities that use their trademarks to harass and intimidate beyond what the law can reasonably be interpreted to allow. Universities have also intensified efforts to gain expansive new marks. The Ohio State University’s attempt to trademark the word “the” is probably the most notorious.

I don’t have a reference, but one of the delivery companies (DHL, Fed Express etc.) tried to get IPR — wait for it — not for their package design but over the dimensions of air that the package encompassed.

On being human

Academic jailed in Iran pulls off daring escape back to Britain | Iran | The Guardian

“They started on me in a very, very small room, it’s almost like a grave. You have three army blankets, one as a cover, one to sleep on and one as a pillow. For 24 hours there is a bright shining light on top of your head, a Qur’an, a mohr on which Shias pray, and a phone to contact the guards to take you to the toilet. There is no natural light, and a window in the prison door opens through which they put your food. That is your only communication with the outside world. It is incredibly quiet, and you just become crazy. You don’t know what time it is, and you don’t know what will happen next.

“When you are taken out to go to the toilet, or half an hour’s fresh air or to be interrogated you are blindfolded. And then your interrogation becomes your lifeline, it’s so sad that you want to be interrogated more because that is the only way you can communicate with a fellow human being. [emphasis added]

The Irish pol is a revenant from a dead era.

Can Joe Biden make America great again? | Books | The Guardian

Probably not…but some nice words (again from Fintan O’Toole)

In normal times, this rhetoric would seem ludicrously over the top, all the more so coming from a garrulous, glad-handing old Irish pol, who spent 36 years in the Senate and eight as vice-president. Biden is not obvious casting for the role of apocalyptic warrior.

The impulse comes with the territory of Biden’s Irish Catholicism, its fatalistic view of this earthly existence as, in the words of the rosary, a “valley of tears”. This is, as Biden sees it, “the Irishness of life”.

Biden the Irish pol is a revenant from a dead era. His skills as an operator, a fixer, a problem-solver, are finely honed — but they are redundant. He is a horse whisperer who has to deal with mad dogs. He is a nifty tango dancer with no possible partners. There is no reasonable, civilised Republican opposition with which he can compromise. There can be no such thing as a unilateral declaration of amity and concord.

The great problem of American political discourse has always been — strangely for such a Biblical culture — a refusal to accept the idea of original sin.

Surprise, surprise

No confidence vote in Leicester v-c as 145 at risk of redundancy | Times Higher Education (THE)

Union members at the University of Leicester have voted in favour of a motion of no confidence in the vice-chancellor in response to the threat of redundancies across the university.

A Leicester spokeswoman said the university was “naturally disappointed to learn about [the] vote of no confidence”.

A graph

by reestheskin on 10/02/2021

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Winnowing MMXX1

by reestheskin on 07/02/2021

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Britain Alone: the Path from Suez to Brexit, by Philip Stephens

I know little about Paul A Myers except that he is one of the sharpest commentators on the online FT comments forum.

Britain made a bad choice with Brexit. The coming years will probably reveal just how much. It failed the one test it had to make as an international strategist in the opening decades of the 21st century. It is inevitably going to wind up with something smaller and less influential — and probably less prosperous. But then it has been making bad choices for a long, long time.

When London is able to imagine itself as a bigger and similarly successful Copenhagen, then new geopolitical success will await. Apparently just some such thinking is taking hold in Edinburgh.

As for Edinburgh, I truly wish that to be the case.

The Capitalist Case for Overhauling Twitter

This next quote is via Scott Galloway in the New York Magazine.

The political philosopher Hannah Arendt, analyzing the fall of democratic Germany to the Nazis, observed that totalitarianism comes to power through a “temporary alliance between the elite and the mob.”

Forget Zuckerberg and Cook’s hypocrisy – it’s their companies that are the real problem | Facebook | The Guardian

The following is from John Naughton, one-time TV critic of the Listener, and who effectively introduced me to the world of blogs and tech a long, long, time ago.

A few years ago, during a period when there was much heated anxiety about “superintelligence” and the prospects for humanity in a world dominated by machines, the political theorist David Runciman gently pointed out that we have been living under superintelligent AIs for a couple of centuries. They’re called corporations: sociopathic, socio-technical machines that remorselessly try to achieve whatever purpose has been set for them, which in our day is to “maximise shareholder value”. Or, as Milton Friedman succinctly put it: “The only corporate social responsibility a company has is to maximise its profits.”

The paradox of human nature, our obsession with the skies, and the realities of transplant surgery: Books in brief

Desmond Morris in one of his popular ethology books pointed out the logical flaw in the arguments that posits that war is a function of individual violence, whether the origins of the latter are inherited or acquired. The propensity to cooperation over dissent is problematic.

The following is from a review of The Goodness Paradox by Richard Wrangham. The subtitle is: How Evolution Made Us More and Less Violent.

Homo sapiens see-saws endlessly between tolerance and aggression. To parse our paradoxical nature, primatologist Richard Wrangham marshals gripping research in genetics, neuroscience, history and beyond. His lucid, measured study ranges over types of aggression, the evolution of moral values, the age-old problem of tyrants, and war’s “coalitional impunity”. The propensity for proactive violence, he argues — forged by self-domestication, language and genetic selection — marks out our primarily peaceful species. We uniquely bend cooperation to ends both cruel and compassionate. [emphasis added].

That was then and this is now

by reestheskin on 05/02/2021

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This is a slide from a John Kay talk. It is a few years old but the message resonates more than ever.

Life on the margins

There are two gangs of people you tend to see loitering in or close to hospitals. Groups of smokers (staff or patients) trying to find a safe-space close to, but outwith, the official perimeter. And medical students, forlornly waiting for the teacher to arrive.

Writers start early:

by reestheskin on 04/02/2021

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Richard Flanagan: ‘Art was something that happened elsewhere’ | Financial Times

No, this is not the advice about getting 500 words in by sunrise, but rather a fun Lunch with the FT column.

FT: By the time I sit down with Richard Flanagan, he is armed with a glass of champagne. Technically speaking, it is a sparkling white wine from a vineyard in Tasmania, the remote Australian island state that the Booker Prize-winning novelist has lived in for all but three and a bit years of his life. Everyone calls it champagne in Australia but either way, Flanagan is not just drinking it but knocking back hefty swigs of the stuff.

“I’ve also got an Armagnac, just to help me along,” he says.

FT: I laugh uncertainly. Each to his own and all that, but it is barely 7 o’clock in the morning in Hobart and I had been expecting to see him with at least a slice of toast.

Whether it is the booze or not, Oxford doesn’t come out of it too well.

“Well,” he says, staring into the distance for so long that I think my screen must have frozen. “What can I say?” he eventually says, 28 long seconds later. “I found it a place of sublime emptiness.” 

FT: He was, he says, surrounded by people from whom he felt utterly alienated. One don told him Australia had no culture. Another routinely addressed him as “Convict”. The whole place left him cold.

“These were people who thought women were slime. These were people who thought black people were apes. These were people who didn’t think they were the master race, they knew it.” Another pause. “I went from a universe of wonder to a storied place and I discovered to my astonishment it was small,” he says. “Oxford above all else is a bit dull.”

On his books not been viewed favourably closer to home, in Australia, and his decision to not enter them for the Miles Franklin Award, one of Australia’s oldest and most important literary prizes.

“I just decided I wouldn’t enter it any more,” he says quietly. “Prizes need writers but writers don’t need prizes.” [emphasis added]

What’s in a name?

by reestheskin on 03/02/2021

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Metabolic surgery versus conventional therapy in type 2 diabetes – The Lancet

I like the parlour game of inventing collective nouns for doctors — a ganglion of neurologists, a scab of dermatologists, and so on— and I also cannot help but smile when Mr Butcher turns out to be, well, a surgeon, and Lord Brain is a…. You get it.

I saw this article when I was skimming through the Lancet the other week, and something tweaked in my mind from long-back.

Metabolic surgery versus conventional therapy in type 2 diabetes. Alexander D Miras & Carel W le Roux

A few more details:… “report their trial in which they randomly assigned patients to metabolic surgery or medical therapy for type 2 diabetes.1 60 white European patients (32 [53%] women) were evaluated 10 years after Roux-en-Y gastric bypass (RYGB), biliopancreatic diversion (BPD), or conventional medical therapy.

Now, I suspect the name Roux is not rare but of course checking with Wikipedia, I can remind you:

César Roux – Wikipedia

César Roux (23 March 1857, in Mont-la-Ville – 21 December 1934, in Lausanne) was a Swiss surgeon, who described the Roux-en-Y procedure.

No relation to Ross-on-Wye.

To err is human

by reestheskin on 01/02/2021

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What my retraction taught me

In the middle of the pandemic, I got an e-mail asking whether I had access to data from the experiments behind a paper I’d published in 2014. Three months later, I requested that the paper be retracted. The experience has not left me bitter: if anything, it brought me back to my original motivation for doing research.

This is a disarmingly honest piece (in the journal Nature) about how mistakes in the analysis of complicated data sets caused inappropriate conclusions, leading, in this case, to a retraction of a manuscript.

As a student, I was even told never to attempt to replicate before I publish. That is not a career I would want — luckily, my PhD adviser taught me the opposite.

John Ziman warned over 20 years ago in Real Science that we were entering post-academic science. Here are some words of his from an article in Nature.

What is more, science is no longer what it was when [Robert] Merton first wrote about it. The bureaucratic engine of policy is shattering the traditional normative frame. Big science has become a novel way of life, with its own conventions and practices. What price now those noble norms? Tied without tenure into a system of projects and proposals, budgets and assessments, how open, how disinterested, how self-critical, how riskily original can one afford to be?

As the economists are fond of saying: institutions matter. As do incentives. Precious metals can be corrupted, and money — in the short term — made.

Can Medicine be Cured?

by reestheskin on 29/01/2021

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I am probably biased as my mother was Irish, one of a large O’Mahony clan who were born in or around Cork. She moved to Dublin in her early teens, crossed the water in 1941, and, a few years later, after meeting a Welshman from Neath, set up home together in Cardiff. Cardiff had a long-established Irish community, one that was good at replenishing itself with fresh blood from the motherland, in tune with the rhythms of economic cycles. I was sent to a Christian Brothers’ school where many of the brothers were Irish exports. In junior school, at least, I can remember having some green plant pinned to my lapels on March 17. I didn’t stand out, many of the other kids were similarly tattooed. If I count my extended family — including my brother — they mainly reside across the water.

Without any grand theory at hand I have always thought there must be something special about schooling in Ireland, even if the supposed benefits are not intentional, nor shared equally. Historically, there are many bad things; this is well known. But if I cast an eye over medics who I judge to write deeply about medicine, there is a disproportionate number of Irish doctors.

Anthony Clare was the first example I came across. I was a wannabe psychiatrist when I was a medical student in Newcastle, and I spent undoubtedly the most enjoyable three months of my undergraduate medical course, in Edinburgh, on an elective on the unit headed by Prof Bob Kendell. For most of this time, since it was summer, there were no Edinburgh students, and so I was viewed by the staff as useful. One of the tragedies of being a medical student nowadays is that you don’t feel useful simply because for most of the time you are not useful. The thousand-year-old laws that guide apprenticeship learning have not so much been forgotten but well and truly trashed.

Clare wrote a wonderful book Psychiatry in Dissent when he was still a Senior Registrar at the Maudsley. Despite the title, it was a calm and measured critique of medicine and psychiatry. Reading it felt dangerous, but more than that, it was the voice of quiet reason and a call to arms. It stands as an example of the difference between a medical education and a medical training. The GMC don’t do the former, nor does the NHS.

Another Irish psychiatrist whose writings I have admired is David Healy. Healy is now in Canada and, as far as I can see, has been blackballed by the UK medical and psychiatric establishment. His three-volume history of Psychopharmacology (The Psychopharmacologists) is a masterpiece. Sam Shuster was the first person to introduce me — over coffee— to how many of the revolutionary drugs that changed medicine in the middle of the last century were developed, but Healy’s scholarship cast it in a larger and richer framework. Healy has done lots of other things, too, and possesses a well of moral courage that puts to shame most of the so-called leaders of the profession.

James McCormick was a professor of general practice at Trinity, in Dublin. I first came across him when he contributed a chapter to Bruce Charlton’s and Robert Downie’s book on Medical Education (The Making of a Doctor: Medical Education in Theory and Practice). I have only recently returned to this book, but reading his chapter is disturbing because it makes you shocked that you can ever have been taken in by the pabulum of the modern world of ‘primary care’ and its apologists. The late and singular Petr Skrabenek found his academic home with McCormick in Trinity. Petr was on holiday in Ireland when the Russian tanks rolled into his hometown of Prague n 1968. Yes, not Irish, but if you read his writings about medicine (check out Wikipedia), and have dipped into Havel and Flann O’Brien, you see he is of that place.

Seamus O’Mahony, a ‘Cork-man’, who used to work in Edinburgh before returning to Ireland, has published two books about medicine. The first — which I haven’t read — is named The Way We Die Now. His more recent book, published in 2019, is titled Can Medicine Be Cured? The full title is Can Medicine Be Cured?: The Corruption of a Profession. You get the message, and the jury didn’t take long to realise which clause required an affirmative verdict.

The book covers a lot of ground, yet the pages fly by. There are chapters on how much medical research is dysfunctional — when it is not criminal; on the corruption of the academy; and the oft hidden problems of combining the practice of science and medicine. He talks about pharma (of course), the invention of disease (there isn’t enough money in treating the sick, we need to treat the non-sick), the McNamara fallacy (data, just data, dear boy), and the never-ending bloody ‘War on Cancer’. He picks apart the lazy confusion between needs, wants, and consumerism, and highlights the fact that the directionless NHS is run by politicians who want to do everything— except politics: they just want to be loved. Meanwhile, the medics tired of the ever faddish evidence-based medicine turned to sentimentality-based medicine allowing ‘empathy’ and superstition to ride roughshod over the ability to reason about the natural world, and their patients. Among doctors and medical students, a facile sense of feeling good about yourself has overtaken technical mastery, allowing all to wallow in kumbaya around the campfire they now pretend to share with their charges. Not so. If doctors were once labelled as priests with a stethoscope, we have cast our tool away.

O’Mahony writes well. I particularly liked his metaphors that are familiar to anybody brought up in Catholicism even if they left the bus before it (and they) returned to the terminus. A few examples:

The decadence of contemporary biomedical science has a historic parallel in the mediaeval pre-Reformation papacy. Both began with high ideals. Both were taken over by careerists who corrupted these ideals, while simultaneously paid lip-service to them. Both saw the trappings of worldly success as more important than the original ideal. Both created a self-serving high priesthood. The agenda for the profession is set by an academic elite (the hierarchy of bishops and cardinals), all the day-to-day work is done by low status GPs and hospital doctors (curates, monks). This elite, despite having little to do with actual patient care, is immensely powerful in the appointment of doctors.”

The Czech polymath and contrarian Peter Skrabanek (1940–94) taught these skills at Trinity College Dublin medical school during the 1980s and early 1990s, and lamented that “my course on the critical appraisal evidence for medical students can be compared to a course on miracles by a Humean sceptic for prospective priests in a theological seminary”.

And on attending a consensus conference of medical experts in Salerno (you only have a consensus when there bloody-well isn’t any…).

I found a picture online of the experts gathered at Salermo, and was reminded of a fresco in the Sistine chapel depicting the first Council of Nicea in A.D. 325. The council was convened by the Emperor Constantine to establish doctrinal orthodoxy within the early Christian Church. The industry-sponsored get-together in Salerno had similar aims.… The aim is expansionist: the establishment of a new disease by consensus statement, the Big Science equivalent of a papal bull. Non-coeliac gluten sensitivity has been decreed by this edict, just as papal infallibility was decreed by the first Vatican Council in 1870.

As for the sick and needy

Meanwhile, the sick languish. The population are subjected to more and more screening programs (for breast cancer, cervical cancer, colon cancer, high blood pressure, cholesterol levels etc.), but if they become acutely ill and need to go to hospital, it is likely that they will spend hours on a trolley in an emergency department. When they are finally admitted to a ward, it is often chaotic, squalid and understaffed. Hospices have to rely on charity just to keep going, and have so few beds that ten times as many people die in general hospitals than hospices.

And, as for David Cameron (lol!) and his plans to fund cancer drugs that were rejected by NICE, well, he was a nice (not NICE) guy, and he was on the side of the people. O’Mahony points out that this money alone would have funded all UK hospices for over a year.

Populism doesn’t cure cancer, but it trumps justice, evidence and fairness every time.

Along with Henry Marsh’s Do No Harm, O’Mahony’s book deserves to become a classic. Buy it and read it. Just don’t turn it into a multiple-choice exam. A brave medical school might even add it to the freshers’ pack — well, I can still dream.

The photo, facing towards Kerry, is from Penglas, a mainly Welsh hamlet in West Cork.

Winnowing MMXXI

by reestheskin on 26/01/2021

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Machines #1: A crisis of connoisseurship

The Economist | Computer says no

Conventional scholarship involves the study of aesthetics, style and historical records. The oeuvre of a great painter has traditionally been defined by a scholarly panel that maintains a definitive catalogue of the artist’s authentic works. The Corpus Rubenianum, for instance, is an Antwerp-based body that adjudicates the work of Peter Paul Rubens; it reveres the legacy of Ludwig Burchard, a German-born expert who died in 1960. Yet such scholarly deference can be excessive: many of Burchard’s attributions have turned out to be mistaken, as the Rubenianum has quietly acknowledged. “There is no question that more scientific examination is needed” to clean up the Flemish master’s oeuvre, says Kasia Pisarek, a Polish-born British art scholar, whose doctoral thesis traces what she calls a crisis of connoisseurship.

Machines #2: A crisis for pollers

Facial recognition technology can expose political orientation from naturalistic facial images | Scientific Reports

Ubiquitous facial recognition technology can expose individuals’ political orientation, as faces of liberals and conservatives consistently differ… Accuracy remained high (69%) even when controlling for age, gender, and ethnicity. Given the widespread use of facial recognition, our findings have critical implications for the protection of privacy and civil liberties.

Machines #3: A crisis in a company

Paul Taylor · Insanely Complicated, Hopelessly Inadequate · LRB 21 January 2021

Last year, Google’s work on natural language processing was the subject of a piece co-written by Timnit Gebru, one of the leaders of its ‘ethical AI’ team. The article expressed concerns about the work’s carbon footprint — the extraordinary scale of computation involved means that the carbon dioxide emitted in training Transformer is equivalent to 288 transatlantic flights — and about the way it looks at language. Because it is trained on text that Google harvests from the internet, its calculations reflect the way language has been used in the past or is used now. The problem isn’t just that its outputs therefore reflect our biases and prejudices, but that they crystallise them and, because the programs are inscrutable, conceal them. The paper also discusses the opportunity cost involved in pursuing this approach …

Google’s response was to shoot the messenger, sacking Gebru and then claiming she had resigned. Given that one very dangerous aspect of AI is that it amplifies the already extraordinary power of a very small number of massive corporations, this authoritarian behaviour is alarming. On the other hand, one of its immediate effects has been to galvanise workers at Google into forming a trade union.

Celtic feelings… I know thee well.

The ‘Ulysses’ trial still resonates 100 years on

When Ulysses eventually found a publisher — in Sylvia Beach, proprietor of Shakespeare & Co in Paris — in 1922, it was promptly banned in the UK until 1936. In the US, its publication was finally legalised in 1933, after a long campaign by Morris Ernst, legal counsel of the American Civil Liberties Union, against efforts by the Society for the Suppression of Vice, and others. Judge Woolsey, delivering his opinion on United States vs One Book Called Ulysses, stated his defence of Joyce: “In respect of the recurrent emergence of the theme of sex in the minds of his characters, it must always be remembered that his locale was Celtic and his season spring.”

Celtic words

Cartographers of Stone and Air | by Colin Thubron | The New York Review of Books

Tim Robinson, an English writer, died from Covid-19 in April at the age of eighty-five. For more than forty years he made an intensive study of the region that many conceive as Ireland’s heart: Connemara.

His words:

History has rhythms, tunes and even harmonies; but the sound of the past is an agonistic multiplicity. Sometimes, rarely, a scrap of a voice can be caught from the universal damage, but it may only be an artefact of the imagination, a confection of rumours. Chance decides what is obliterated and what survives if only to be distorted and misheard.

Irish placenames dry out when anglicized, like twigs snapped off from a tree. And frequently the places too are degraded, left open to exploitation, for lack of a comprehensible name to point out their natures or recall their histories.

No free lunch

Arianne Shahvisi | No such thing as a free lunch · LRB 12 January 2021

The UK’s free school meals programme ensures that children from deprived households get at least one meal a day and costs the government £600 million a year. (‘Eat Out to Help Out’, which ran for just a month and subsidised restaurant meals, cost £849 million.) According to the Sustainable Food Trust, malnutrition costs the UK £17 billion a year, as well as leaving people desperate, miserable, reduced to bellies with a few accessory organs.

Winnowing MMXXI

by reestheskin on 21/01/2021

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STEM stupidity

Stupid | No Mercy / No Malice

Mark Zuckerberg is what happens when you replace civics with computer science.

Eureka… if not the bath

New Year Monday Note. | Jean-Louis Gassée | Jan, 2021

In the shower, all ideas look good.


Universities challenged: critical theory and culture wars | Financial Times

A comment about the above article:

As a full professor in a similar situation, a humanities department in a British teaching factory (sorry major research university) I completely agree with Musidorus.


The Economist | Awesome, weird and everything else

Ironically, some old gender stereotypes may now be helping girls. When girls are toddlers they are read to more than boys. Their fathers are five times more likely to sing or whistle to them and are more likely to speak to them about emotions, including sadness. Their mothers are more likely to use complex vocabulary with them. Most of this gives girls a leg up in a world that increasingly prizes “soft skills”. Girls still have less leisure time than boys, but nowadays that is primarily because they spend more time on homework and grooming, rather than an unfair division of chores. And in the time left for themselves they have far more freedom.

The one good thing about COVID-19 is that it’s good for nature and the environment and dolphins,” says Sarah, “but I wish it wouldn’t kill so many people in the process.”

COVID-19 aware

David Hume — Wikipedia

He had little respect for the professors of his time, telling a friend in 1735 that “there is nothing to be learnt from a Professor, which is not to be met with in Books”. He did not graduate.

Nor did I ever submit my PhD. As David Hubel once said, the great advantage of an MD degree was (then) being able to avoid having to gain a PhD credential.

Winnowing XXMMI

by reestheskin on 19/01/2021

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The crisis within Britain’s care system | Financial Times

From a review of Madeleine Bunting’s Labour of Love in the FT.

Bunting deplores the marketisation of care, in which looking after others is reduced to a commodity requiring specific outputs. (I was reminded of the nurse who, within minutes of my mother’s death, handed us a feedback form on which we were apparently to rate her handling of my mother’s closing moments.)

On Human Remains and NHS management

The Economist | Straight talking

Other changes are required to end the gobbledygook that plagued the previous regime. We will no longer have a “human resources” department: our employees are people, not resources. That section has been renamed personnel.

A few years back I read how the hospital I worked in considered FY1 doctors ward resources. They would not work for and learn from a particular group of more senior doctors (this after all is supposed to be an apprentice system) but be a generic utility for whatever patients were placed on that ward. At once, all we know about learning, security and safety was thrown out the window. As one of my colleagues told me, based on his experience of having to treat a senior hospital manager, many know next to nothing of how medicine works. This form of competence inversion is known as Putt’s law.

Putt’s Law and the Successful Technocrat

“Technology is dominated by two types of people, those who understand what they do not manage and those who manage what they do not understand.” Putt’s Corollary: “Every technical hierarchy, in time, develops a competence inversion.” with incompetence being “flushed out of the lower levels” of a technocratic hierarchy, ensuring that technically competent people remain directly in charge of the actual technology while those without technical competence move into management…”


The Economist | The wisdom of Scrooge

The Christmas Economist was in fine form — at least, better than the state the UK finds itself in.

Today almost everything is the opposite of what it pretends to be. Companies claim that they are devoted to advancing gay rights, promoting multiculturalism or uniting the world in a Kumbaya sing-along, when they are in fact singlemindedly maximising profits. Chief executives claim that they are ever-so-humble “team leaders”—in homage to another great Dickens invention, the unctuous Uriah Heep—when they are actually creaming off an unprecedented share of corporate cash. Private schools such as Eton claim that they are in the business of promoting “diversity” and “inclusivity” even as they charge £42,000 a year. Future historians seeking to sum up our era may well call it “the age of humbug”…


Whether the purveyors of this sanctimonious guff actually believe it, or whether it is cynical doublespeak, is immaterial. Either way, spin doctors, sycophants and so-called thought leaders pump noxious quantities of it into the atmosphere. The nation is in desperate need of a modern-day Dickens to clear the air. Until one emerges, Britons should repeat his great creation’s Christmas mantra in every season: “Bah, humbug!”

Pathologies of power

by reestheskin on 16/01/2021

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UK COVID-19 public inquiry needed to learn lessons and save lives – The Lancet

It is hard not to be moved nor not be angry on reading the editorial in this week’s Lancet, written by three members of the Covid-19 Bereaved Families for Justice group.

The UK Prime Minister Boris Johnson has previously suggested that an immediate public inquiry into the government’s handling of COVID-19 would be a distraction7 or diversion of resources in the fight against COVID-19. We have long proposed that quite the opposite is true: an effective rapid review phase would be an essential element in combating COVID-19.

An independent and judge-led statutory public inquiry with a swift interim review would yield lessons that can be applied immediately and help prevent deaths in this tough winter period in the UK. Such a rapid review would help to minimise further loss of life now and in the event of future pandemics. In the wake of the Hillsborough football stadium disaster on April 15, 1989, for example, the Inquiry of Lord Justice Taylor delivered interim findings within 11 weeks, allowing life-saving measures to be introduced in stadiums ahead of the next football season.

I will quote Max Hastings, a former editor of the Daily Telegraph and Evening Standard, and a distinguished military historian, writing in the Guardian many years ago. He was describing how he had overruled some of his own journalists who had suspected Peter Mandelson of telling lies.

I say this with regret. I am more instinctively supportive of institutions, less iconoclastic, than most of the people who write for the Guardian, never mind read it. I am a small “c” conservative, who started out as a newspaper editor 18 years ago much influenced by a remark Robin Day once made to me: “Even when I am giving politicians a hard time on camera,” he said, “I try to remember that they are trying to do something very difficult – govern the country.” Yet over the years that followed, I came to believe that for working journalists the late Nicholas Tomalin’s words, offered before I took off for Vietnam for the first time back in 1970, are more relevant: “they lie”, he said. “Never forget that they lie, they lie, they lie.” Max Hastings

Two of Hasting’s journalists at the Evening Standard were investigating the funds Peter Mandelson had used to purchase a house.

One morning, Peter Mandelson rang me at the Evening Standard. “Some of your journalists are investigating my house purchase,” he said. “It really is nonsense. There’s no story about where I got the funds. I’m buying the house with family money.”

I knew nothing about any of this, but went out on the newsroom floor and asked some questions. Two of our writers were indeed probing Mandelson’s house purchase. Forget it, I said. Mandelson assures me there is no story. Our journalists remonstrated: I was mad to believe a word Mandelson said. I responded: “Any politician who makes a private call to an editor has a right to be believed until he is proved a liar.” We dropped the story.

Several months later

…when the Mandelson story hit the headlines, I faced a reproachful morning editorial conference. A few minutes later, the secretary of state for industry called. “What do I have to do to convince you I’m not a crook ?” he said.

I answered: “Your problem, Peter, is not to convince me that you are not a crook, but that you are not a liar.”

The default, and most sensible course of action, is to assume that the government and many of those who answer directly to the government have lied and will continue to lie.

Canadian’s tolerance of mediocrity

Where Health Care Is a Human Right | by Nathan Whitlock | The New York Review of Books

An article discussing Canadian health care with echoes of the UK’s own parochial attitude to health care (and don’t mention Holland, Germany, France, Switzerland…).

How do such gaps and problems persist? Part of the problem, ironically, is the system’s high approval ratings: with such enthusiasm for the existing system, and with responsibility for it shared between federal and provincial or territorial governments, it’s easy for officials to avoid making necessary changes. Picard sees our narrowness of perspective as a big obstacle to reform: “Canadians are also incredibly tolerant of mediocrity because they fear that the alternative to what we have is the evil US system.” Philpott agrees that Canadians’ tendency to judge our system solely against that of the United States can be counterproductive. “If you always compare yourself to the people who pay the most per capita and get some of the worst outcomes,” she told me in a recent Zoom call, “then you’re not looking at the fact that there are a dozen other countries that pay less per capita and have far better outcomes than we do.”

The longest lasting health care corpotation in the world

Holy See – Wikipedia

The Holy See is thus viewed as the central government of the Catholic Church. The Catholic Church, in turn, is the largest non-government provider of education and health care in the world.[8] The diplomatic status of the Holy See facilitates the access of its vast international network of charities.[emphasis added]

The antithesis of science, is not art, but politics

There is a famous quote ( I don’t have a primary source) by the great Rudolf Virchow

“Medicine is a social science, and politics is nothing more than medicine on a large scale.”

I know what Virchow was getting at, but if only.

Winnowing MMXXI

by reestheskin on 14/01/2021

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Kieran, Please Come Over For Gay Sex

Excellent summary of recent discoveries in human evolution by John Lanchester in the LRB1. Lucid writing. When I worked on the evolution of skin and hair colour, I was always puzzled about the way a single find of skeletal remains could pivot a whole narrative of how we got here. N-of-1s, are tricky. In recent years many remains have been discovered and, amazingly (because it is amazing), using DNA we can literally spy on the past, not quite in real time, but in a way that when I was a medical student would have seemed like science fiction.

Another thing that I never understood was why these remains were often found in caves. Is that where the action was? John Lanchester put me right — to an extent.

In the case of the Neanderthals, the sense of distance and the sense of strangeness are stronger; empathy seems both more necessary and more remote, harder to access. I have stood at the site of a Neanderthal shelter at Buoux in the South of France and been hit by an overwhelmingly strong feeling of remoteness, the idea that these people, these similar-but-different humans, were so far from anywhere human and place-like that they must have been hiding from something. Their very existence — we now know there were only a few tens of thousands of Neanderthals alive at any one time — seems contingent and marginal. What were they trying to get away from?

But that’s bollocks. That sense of remoteness, of distance from and hiddenness, are a side effect of humanity’s planetary domination: the only places where traces of the deep past remain are places we haven’t built over or crushed underfoot. There could be Neanderthal remains all around where I’m writing this, but I live in London and those traces, if they ever existed, are long and permanently lost. We find evidence mainly in caves because they’re the only places where remains haven’t been washed away by time and the human present. This is the same reason the far past continues to make news: we are constructing knowledge from scraps and fragments, and big new discoveries have the potential to rewrite the story.

Bollocks, as he says. As for my title, well, the best mnemonics at medical school tended to be rude. Lanchester writes

If you’re having trouble remembering the sequence of kingdom, phylum, class, order, family, genus, species, I can recommend the mnemonic ‘Kieran, Please Come Over For Gay Sex.

In truth, mnemonics never did much for me.

‘Fellatio, Masochism, Politics and Love’. And Hwyl

The above was the title of a book by Leo Abse, the Labour MP for Pontypool when I was growing up in Cardiff. I do remember my parents mentioning his name, although I am not certain what their views of him were. As the Economist writes.

A little after 10pm on Monday July 3rd 1967, just as most sensible Britons were turning in for the night, the member for Pontypool was warming up. Leo Abse (pronounced Ab-zee) had been working the tea rooms of the House of Commons all day, charming and cajoling his fellow MPs in his rococo tones—a little flattery here, a white lie there. Now he slipped into the chamber, turning heads as always in spite of his short frame. Settling in his usual perch on the Labour government’s benches, his mischievous eyes darted about the place, searching out both his “stout fellows” and his foes. If his bill were ever to get through, tonight was surely the night.

His bill, printed on the green pages each MP clutched, was plain enough: that, in England and Wales, “a homosexual act in private shall not be an offence provided that the parties consent thereto and have attained the age of twenty-one years”

Abse what a colourful character in all sorts of ways. His WikiP entry gives you some flavour. His second marriage was to Ania Czepulkowska, in 2000, when Abse was 83, and she fifty years younger. A bust of him was unveiled in 2009 at the National Museum of Wales in Cardiff, but his nomination for a seat in the House of Lords had been vetoed by Margaret Thatcher. What would you expect?

  1. The title of the article is Twenty Types of Human: Among the Neanderthals and he is reviewing Kindred: Neanderthal Life, Love, Death and Art by Rebecca Wragg Sykes. Bloomsbury, 400 pp., £20, August, 978 1 4729 3749 0

Academic lives

by reestheskin on 11/01/2021

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Originality is usually off track

How mRNA went from a scientific backwater to a pandemic crusher | WIRED UK

For decades, Katalin Karikó’s work into mRNA therapeutics was overlooked by her colleagues. Now it’s at the heart of the two leading coronavirus vaccines

By the mid 1990s, Karikó’s bosses at UPenn had run out of patience. Frustrated with the lack of funding she was generating for her research, they offered the scientist a bleak choice: leave or be demoted. It was a demeaning prospect for someone who had once been on the path to a full professorship. For Karikó’s dreams of using mRNA to create new vaccines and drugs for many chronic illnesses, it seemed to be the end of the road… ”It was particularly horrible as that same week, I had just been diagnosed with cancer,” said Karikó. “I was facing two operations, and my husband, who had gone back to Hungary to pick up his green card, had got stranded there because of some visa issue, meaning he couldn’t come back for six months. I was really struggling, and then they told me this.”

Karikó has been at the helm of BioNTech’s Covid-19 vaccine development. In 2013, she accepted an offer to become Senior Vice President at BioNTech after UPenn refused to reinstate her to the faculty position she had been demoted from in 1995. “They told me that they’d had a meeting and concluded that I was not of faculty quality,” she said. ”When I told them I was leaving, they laughed at me and said, ‘BioNTech doesn’t even have a website.’”

Being at the bottom of things

Knuth versus Email

Donald Knuth is a legend amongst computer scientists.

I have been a happy man ever since January 1, 1990, when I no longer had an email address. I’d used email since about 1975, and it seems to me that 15 years of email is plenty for one lifetime.Email is a wonderful thing for people whose role in life is to be on top of things. But not for me; my role is to be on the bottom of things. What I do takes long hours of studying and uninterruptible concentration. I try to learn certain areas of computer science exhaustively; then I try to digest that knowledge into a form that is accessible to people who don’t have time for such study. [emphasis added]

On retirement:

I retired early because I realized that I would need at least 20 years of full-time work to complete The Art of Computer Programming (TAOCP), which I have always viewed as the most important project of my life.

Being a retired professor is a lot like being an ordinary professor, except that you don’t have to write research proposals, administer grants, or sit in committee meetings. Also, you don’t get paid.

My full-time writing schedule means that I have to be pretty much a hermit. The only way to gain enough efficiency to complete The Art of Computer Programming is to operate in batch mode, concentrating intensively and uninterruptedly on one subject at a time, rather than swapping a number of topics in and out of my head. I’m unable to schedule appointments with visitors, travel to conferences or accept speaking engagements, or undertake any new responsibilities of any kind.

On Keeping Your Soul

John Baez is indeed a relative of that other famous J(oan) Baez. I used to read his blog avidly

The great challenge at the beginning of ones career in academia is to get tenure at a decent university. Personally I got tenure before I started messing with quantum gravity, and this approach has some real advantages. Before you have tenure, you have to please people. After you have tenure, you can do whatever the hell you want — so long as it’s legal, and you teach well, your department doesn’t put a lot of pressure on you to get grants. (This is one reason I’m happier in a math department than I would be in a physics department. Mathematicians have more trouble getting grants, so there’s a bit less pressure to get them.)

The great thing about tenure is that it means your research can be driven by your actual interests instead of the ever-changing winds of fashion. The problem is, by the time many people get tenure, they’ve become such slaves of fashion that they no longer know what it means to follow their own interests. They’ve spent the best years of their life trying to keep up with the Joneses instead of developing their own personal style! So, bear in mind that getting tenure is only half the battle: getting tenure while keeping your soul is the really hard part. [emphasis added]

On the hazards of Epistemic trespassing

Scientists fear that ‘covidization’ is distorting research

Scientists straying from their field of expertise in this way is an example of what Nathan Ballantyne, a philosopher at Fordham University in New York City, calls “epistemic trespassing”. Although scientists might romanticize the role and occasional genuine insight of an outsider — such as the writings of physicist Erwin Shrödinger on biology — in most cases, he says, such academic off-piste manoeuvrings dump non-experts head-first in deep snow. [emphasis added]

But I do love the language…

On the need for Epistemic trespassing

Haack, Susan, Not One of the Boys: Memoir of an Academic Misfit

Susan Haack is a wonderfully independent English borne philosopher who loves to roam, casting light wherever her interest takes her. 

Better ostracism than ostrichism

Moreover, I have learned over the years that I am temperamentally resistant to bandwagons, philosophical and otherwise; hopeless at “networking,” the tit-for-tat exchange of academic favors, “going along to get along,” and at self-promotion


That I have very low tolerance for meetings where nothing I say ever makes any difference to what happens; and that I am unmoved by the kind of institutional loyalty that apparently enables many to believe in the wonderfulness of “our” students or “our” department or “our” school or “our” university simply because they’re ours.


Nor do I feel what I think of as gender loyalty, a sense that I must ally myself with other women in my profession simply because they are women—any more than I feel I must ally myself with any and every British philosopher simply because he or she is British. And I am, frankly, repelled by the grubby scrambling after those wretched “rankings” that is now so common in philosophy departments. In short, I’ve never been any good at academic politicking, in any of its myriad forms.


And on top of all this, I have the deplorable habit of saying what I mean, with neither talent for nor inclination to fudge over disagreements or muffle criticism with flattering tact, and an infuriating way of seeing the funny side of philosophers’ egregiously absurd or outrageously pretentious claims — that there are no such things as beliefs, that it’s just superstitious to care whether your beliefs are true, that feminism obliges us to “reinvent science and theorizing,” and so forth.


Citizens of nowhere trespassing…

The Economist | Citizen of the world

From a wonderful article in the Economist

As Michael Massing shows vividly in “Fatal Discord: Erasmus, Luther and the Fight for the Western Mind” (2018), the growing religious battle destroyed Erasmianism as a movement. Princes had no choice but to choose sides in the 16th-century equivalent of the cold war. Some of Erasmus’s followers reinvented themselves as champions of orthodoxy. The “citizen of the world” could no longer roam across Europe, pouring honeyed words into the ears of kings. He spent his final years holed up in the free city of Basel. The champion of the Middle Way looked like a ditherer who was incapable of making up his mind, or a coward who was unwilling to stand up to Luther (if you were Catholic) or the pope (if you were Protestant).

The test of being a good Christian ceased to be decent behaviour. It became fanaticism: who could shout most loudly? Or persecute heresy most vigorously? Or apply fuel to the flames most enthusiastically?

And in case there is any doubt about what I am talking about.

In Britain, Brexiteers denounce “citizens of the world” as “citizens of nowhere” and cast out moderate politicians with more talent than they possess, while anti-Brexiteers are blind to the excesses of establishment liberalism. In America “woke” extremists try to get people sacked for slips of the tongue or campaign against the thought crimes of “unconscious bias”. Intellectuals who refuse to join one camp or another must stand by, as mediocrities are rewarded with university chairs and editorial thrones. [emphasis added]

As Erasmus might have said: ‘Amen’.

Winnowing MMXXI

by reestheskin on 08/01/2021

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Sunday 27 December, 2020 | Memex 1.1

The following were both posted separately by John Naughton over recent weeks. It may seem bad manners to ‘borrow’ in such a way, but the combination seems apposite, and the necessary conclusion hard to put aside.

There are no credentials. They do not even need a medical certificate. They need not be sound either in body or mind. They only require a certificate of birth — just to prove that they were the first of the litter. You would not choose a spaniel on those principles.

Lloyd George on the House of Lords, 1909.

The privately educated Englishman — and Englishwoman, if you will allow me — is the greatest dissembler on Earth. Was, is now and ever shall be for as long as our disgraceful school system remains intact. Nobody will charm you so glibly, disguise his feelings from you better, cover his tracks more skilfully or find it harder to confess to you that he’s been a damned fool.

George Smiley in John le Carré’s The Secret Pilgrim.

Remind you of anyone?

Winnowing MMXXI

by reestheskin on 05/01/2021

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Vaccine rollout hampered by red tape and lack of back-up stocks | Financial Times

Mr Hancock told the BBC that the amount of bureaucracy would be reduced, including no longer requiring vaccinators to undergo training on the need to tackle terrorism.

No surprise here. Those familiar with the NHS (and many other organisations) will know there is little limit to the crap that those at the top can pass down, chiefly to protect their own hides. I used to chair a student teaching ethics committee (note: an ethics committee, not an ethical committee). We had to ask all applicants whether they were aware of the Home Office’s Prevent Strategy (terrorism!). As for training, the standard of NHS online modules that I used to have to do, was execrable. They were yet another form of subsidy for the parasitism this is much of UK Private Business. Even with retirement, the rage only ebbs away slowly. Wasted days.

So far away

Between now and Easter universities should stop, collaborate and listen | Wonkhe

Academics got good at distance learning — for students who were studying at the distance of half a mile away.

The long-term issue is simply that if the experience is mainly large lecture delivery, then the value of university has been washed away by successive cuts and internal transfers of money to research and ‘impact’. That is what should worry universities now. At one time you could find high street retail with knowledgeable staff. Then rationalisation took over and quality took a nose dive in order to pay the dividends of investors. Then came Amazon.

All I want for 2021

All I want for 2021 is to see Mark Zuckerberg up in court | Internet | The Guardian

It’s always risky making predictions about the tech industry, but this year looks like being different, at least in the sense that there are two safe bets. One is that the attempts to regulate the tech giants that began last year will intensify; the second that we will be increasingly deluged by sanctimonious cant from Facebook & co as they seek to avoid democratic curbing of their unaccountable power.

John Naughton, my first and still my favourite blogger. It was on my list too, but Amazon have failed to deliver.

Innumerate economists.

Blanchflower aiming to counter ‘disastrous’ austerity economics | Times Higher Education (THE)

“I think I said on Bloomberg [the business TV channel] I thought Brexit was the worst decision made by any advanced country in the last thousand years,” he continued. “And I only said a thousand because I’m not very good on the thousand before that.”

Danny (David) Blanchflower.

Bozo et al.

What makes John le Carré a writer of substance | Financial Times

Again, like Orwell — who revealed himself now and then as a poetic limner of deep England — le Carré had a pitch-perfect ear for the disingenuous hypocrisies sustaining those who mistook “Getting Away with It” for national purpose.

Who — or what — cares

by reestheskin on 14/12/2020

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I think the quip was from the series Cardiac Arrest: the ITU used to be called the ICU (intensive care unit) until they realised nobody did.

In March, 2019, a doctor informed 78-year-old Ernest Quintana, an inpatient at a hospital in California, USA, that he was going to die. His ravaged lungs could not survive his latest exacerbation of chronic obstructive pulmonary disease, so he would be placed on a morphine drip until, in the next few days, he would inevitably perish. There was a twist. A robot had delivered the bombshell. There, on a portable machine bearing a video screen, crackled the pixelated image of a distant practitioner who had just used cutting-edge technology to give, of all things, a terminal diagnosis. The hospital insisted that earlier conversations with medical staff had occurred in person, but as Mr Quintana’s daughter put it: “I just don’t think that critically ill patients should see a screen”, she said. “It should be a human being with compassion.”

From Care in crisis – The Lancet

Retirement and the Curse of Lord Acton

by reestheskin on 10/12/2020

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According to a helpful app on my phone that I like to think acts as a brake on my sloth, I retired 313 days ago. One of the reasons I retired was so that I could get some serious work done; I increasingly felt that professional academic life was incompatible with the sort of academic life I signed up for. If you read my previous post, you will see this was not the only reason, but since I have always been more of an academic than clinician, my argument still stands.

Over twenty years ago, my friend and former colleague, Bruce Charlton, observed wryly that academics felt embarrassed — as though they had been caught taking a sly drag round the back of the respiratory ward — if they were surprised in their office and found only to be reading. No grant applications open; no Gantt charts being followed; no QA assessments being written. Whatever next.

I thought about retirement from two frames of reference. The first, was about finding reasons to leave. After all, until I was about 50, I never imagined that I would want to retire. I should therefore be thrilled that I need not be forced out at the old mandatory age of 65. The second, was about finding reasons to stay, or better still, ‘why keep going to work?’. Imagine you had a modest private income (aka a pension), what would belonging to an institution as a paid employee offer beyond that achievable as a private scholar or an emeritus professor? Forget sunk cost, why bother to move from my study?

Many answers straddle both frames of reference, and will be familiar to those within the universities as well as to others outwith them. Indeed, there is a whole new genre of blogging about the problems of academia, and employment prospects within it (see alt-acor quit-lit for examples). Sadly, many posts are from those who are desperate to the point of infatuation to enter the academy, but where the love is not reciprocated. There are plenty more fish in the sea, as my late mother always advised. But looking back, I cannot help but feel some sadness at the changing wheels of fortune for those who seek the cloister. I think it is an honourable profession.

Many, if not most, universities are very different places to work in from those of the 1980s when I started work within the quad. They are much larger, they are more corporatised and hierarchical and, in a really profound sense, they are no longer communities of scholars or places that cherish scholarly reason. I began to feel much more like an employee than I ever used to, and yes, that bloody term, line manager, got ever more common. I began to find it harder and harder to characterise universities as academic institutions, although from my limited knowledge, in the UK at least, Oxbridge still manage better than most 1. Yes, universities deliver teaching (just as Amazon or DHL deliver content), and yes, some great research is undertaken in universities (easy KPIs, there), but their modus operandi is not that of a corpus of scholars and students, but rather increasingly bends to the ethos of many modern corporations that self-evidently are failing society. Succinctly put, universities have lost their faith in the primacy of reason and truth, and failed to wrestle sufficiently with the constraints such a faith places on action — and on the bottom line.

Derek Bok, one of Harvard’s most successful recent Presidents, wrote words to the effect that universities appear to always choose institutional survival over morality. There is an externality to this, which society ends up paying. Wissenschaft als Beruf is no longer in the job descriptions or the mission statements2.

A few years back via a circuitous friendship I attended a graduation ceremony at what is widely considered as one of the UK’s finest city universities3. This friend’s son was graduating with a Masters. All the pomp was rolled out and I, and the others present, were given an example of hawking worthy of an East End barrow boy (‘world-beating’ blah blah…). Pure selling, with the market being overseas students: please spread the word. I felt ashamed for the Pro Vice Chancellor who knew much of what he said was untrue. There is an adage that being an intellectual presupposes a certain attitude to the idea of truth, rather than a contract of employment; that intellectuals should aspire to be protectors of integrity. It is not possible to choose one belief system one day, and act on another, the next.

The charge sheet is long. Universities have fed off cheap money — tax subsidised student loans — with promises about social mobility that their own academics have shown to be untrue. The Russell group, in particular, traducing what Humboldt said about the relation between teaching and research, have sought to diminish teaching in order to subsidise research, or, alternatively, claimed a phoney relation between the two. As for the “student experience”, as one seller of bespoke essays argued4, his business model depended on the fact that in many universities no member of staff could recognise the essay style of a particular student. Compare that with tuition in the sixth form. Universities have grown more and more impersonal, and yet claimed a model of enlightenment that depends on personal tuition. Humboldt did indeed say something about this:

“[the] goals of science and scholarship are worked towards most effectively through the synthesis of the teacher’s and the students’ dispositions”.

As the years have passed by, it has seemed to me that universities are playing intellectual whack-a-mole, rather than re-examining their foundational beliefs in the light of what they offer and what others may offer better. In the age of Trump and mini-Trump, more than ever, we need that which universities once nurtured and protected. It’s just that they don’t need to do everything, nor are they for everybody, nor are they suited to solving all of humankind’s problems. As had been said before, ask any bloody question and the universal answer is ‘education, education, education’. It isn’t.

That is a longer (and more cathartic) answer to my questions than I had intended. I have chosen not to describe the awful position that most UK universities have found themselves in at the hands of hostile politicians, nor the general cultural assault by the media and others on learning, rigour and nuance. The stench of money is the accelerant of what seeks to destroy our once-modern world. And for the record, I have never had any interest in, or facility for, management beyond that required to run a small research group, and teaching in my own discipline. I don’t doubt that if I had been in charge the situation would have been far worse.


Reading debt


Sydney Brenner, one of the handful of scientists who made the revolution in biology of the second half of the 20th century once said words to the effect that scientists no longer read papers they just Xerox them. The problem he was alluding to, was the ever-increasing size of the scientific literature. I was fairly disciplined in the age of photocopying but with the world of online PDFs I too began to sink. Year after year, this reading debt has increased, and not just with ‘papers’ but with monographs and books too. Many years ago, in parallel with what occupied much of my time — skin cancer biology and the genetics of pigmentation, and computerised skin cancer diagnostic systems — I had started to write about topics related to science and medicine that gradually bugged me more and more. It was an itch I felt compelled to scratch. I wrote a paper in the Lancet   on the nature of patents in clinical medicine and the effect intellectual property rights had on the patterns of clinical discovery; several papers on the nature of clinical discovery and the relations between biology and medicine in Science and elsewhere. I also wrote about why you cannot use “spreadsheets to measure suffering” and why there is no universal calculus of suffering or dis-ease for skin disease ( here and here ); and several papers on the misuse of statistics and evidence by the evidence-based-medicine cult (here and here). Finally, I ventured some thoughts on the industrialisation of medicine, and the relation between teaching and learning, industry, and clinical practice (here), as well as the nature of clinical medicine and clinical academia (here  and here ). I got invited to the NIH and to a couple of AAAS meetings to talk about some of these topics. But there was no interest on this side of the pond. It is fair to say that the world was not overwhelmed with my efforts.

At one level, most academic careers end in failure, or at last they should if we are doing things right. Some colleagues thought I was losing my marbles, some viewed me as a closet philosopher who was now out, and partying wildly, and some, I suspect, expressed pity for my state. Closer to home — with one notable exception — the work was treated with what I call the Petit-mal phenomenon — there is a brief pause or ‘silence’ in the conversation, before normal life returns after this ‘absence’, with no apparent memory of the offending event. After all, nobody would enter such papers for the RAE/REF — they weren’t science with data and results, and since of course they weren’t supported by external funding, they were considered worthless. Pace Brenner, in terms of research assessment you don’t really need to read papers, just look at the impact factor and the amount and source of funding: sexy, or not?5

You have to continually check-in with your own personal lodestar; dead-reckoning over the course of a career is not wise. I thought there was some merit in what I had written, but I didn’t think I had gone deep enough into the problems I kept seeing all around me (an occupational hazard of a skin biologist, you might say). Lack of time was one issue, another was that I had little experience of the sorts of research methods I needed. The two problems are not totally unrelated; the day-job kept getting in the way.



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The last three patients: dermatology

by reestheskin on 27/11/2020

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Patient 3

He was nearer seventy than sixty, and not from one of Edinburgh’s more salubrious neighbourhoods. He sat on the examination couch unsure what to do next. His right trouser was leg rolled up, exposing a soiled bandage crusted with blood that had clearly been there for more than a few days. He nodded as I walked into the clinic room and I introduced myself with a shake of his hand. This was pre-covid.

I knew his name because that was typed on the clinic list alongside the code that said he was a ‘new’1 patient, but not much else. Not much else because his clinical folder contained sticky labels giving his name, address, date of birth and health care number only. That was it. As has become increasingly the norm in the clinic room, you ask the patient if they know why they are here.

He had phoned the hospital four days earlier, he said, and he was very grateful that he had been given an appointment to see me. He thanked me as though I was his saviour. If true, I didn’t know from what or from whom. If he was a new patient he would have seen his GP and there should be a letter from his GP in his notes. But no, he hadn’t seen his GP for over a year. Had I seen him before? No, he confirmed, but he had seen another doctor in the very same department about eighteen months previously. I enquired further. He said he had something on his leg — at the site of the distinctly un-fresh bandage — that they had done something to. It had now started to bleed spontaneously. He had phoned up on several occasions, left messages and, at least once, spoken to somebody who said they would check what had happened and get back to him. ‘Get back to you’ is often an intention rather than an action in the NHS, so I was not surprised when he said that he had heard nothing back. His leg was now bleeding and staining his trousers and bed clothes, hence the bandage. He thought that whatever it had been had come back.

Finally, four days before this appointment day, after he relayed his story one more time over the phone, he had been given this appointment. He again told me again how grateful he was to me for seeing him. And no, he didn’t know what diagnosis had been made in the past. I asked him had he received any letters from the hospital. No, he replied. Could he remember the name of any of the doctors he had seen over one year previously? Sadly, not. Had he been given an appointment card with a consultant’s name on? No.

There was a time when nursing and medicine were complementary professions. At one time the assistant who ushered him into the clinic room would have removed the bandage from his leg. In my clinical practice, those days ended long ago. I asked him if he would unwrap the bandage while I went in search of our admin staff to see if they knew more than me about why he was here.

He had been seen before, just as he had said, around eighteen months earlier. He had seen an ‘external provider’, one of a group of doctors employed via commercial agencies who are contracted to cope with all the patients that the regular staff employed by the hospital are unable to see. That demand exceeds supply, is the one feature of the NHS that all agree on, whatever their politics. It outlives all reorganisations. Most of these external provider doctors travel up for weekends, staying in a hotel for one or more nights, and then fly back home. They get paid more than the local doctors (per clinic), and the agency takes a substantial arrangement fee in addition. This had been the norm for over ten years, and of course makes little clinical or financial sense — except if the name of the game is to be able to shape waiting lists with electoral or political cycles, turning the tap on and off. Usually more off, than on.

The doctors who undertake this weekend work are a mixed bunch. Most of them are very good, but of course they don’t normally work in Scotland, and medicine varies across the UK and Europe, and even between regions within one country. It is not so much the medicine that is very different, but the way that different components of care fit together organisationally that are not constant. This hints at one fault line.

That the external doctors are more than just competent is important for another reason. The clinic lists of the visiting doctors are much busier than those of the local doctors, and are full of new patients rather than patients brought back for review. The NHS and the government consider review appointments as wasteful, and that is why all the targets relate to ‘new’ patients. It’s a numbers game: stack them high, don’t let the patients sit down for too long, and process them. Meet those government targets and move in phase with the next election cycle. Consequently, the external provider doctors are being asked to provide episodic care under time pressure; speed dating rather than maintaining a relationship. For most of the time, nobody who actually works in Edinburgh knows what is going on with the patient. But the patients do live in Edinburgh.

Old timers like me know that one of the reasons why review appointments are necessary is that they are a security net, a back up system. In modern business parlance, they add resilience. Like stocks of PPE. In the case of my man, a return appointment would have provided the opportunity to tell him what the hell was going on and to ensure that all that had actually been planned had been carried out. There is supposed to be a beginning, a middle and an end. There wasn’t.

An earlier letter from an external provider doctor was found. It was a well-written summary of the consultation. The patient had a lesion on his leg that was thought clinically to be pre-malignant. The letter stated that if a diagnostic biopsy confirmed this clinical diagnosis — it did — then the patient would require definitive treatment, most likely, surgical. The problem was that in this informal episodic model, the original physician was not there to act on the result; nor to observe that the definitive surgical treatment had not taken place because review appointments are invisible in terms of targets. They are wasteful.

Even before returning to the clinic room, without sight of anything but the blood stained bandage, I knew what was going on. His pre-malignant lesion had, over the period of ‘wasteful’ time, transformed into full-blown cancer. He now had a squamous cell carcinoma. His mortality risk had gone from effectively zero to maybe 5%.

I went back to the clinic room, apologised, explained what had gone on and what needed to happen now, and apologised again. The patient picked up on my mixture of frustration, shame and anger, and it embarrasses me to admit that I had somehow allowed him —mistakenly — to imagine that my emotions were a response to something he had said or done. I apologised again. And then he did say something that fired my anger. I cannot remember the whole sentence but a phrase within it stuck: ‘not for the likes of me’. His response to the gross inadequacy of his care was that it was all people like him could expect.

He was not literally the last patient in dermatology I saw, but his story was the one that told me I had to get out. When a pilot or an airline engineer says that an aircraft is safe to fly there is an unspoken bond between passengers and those who dispense a professional judgement. But this promise is also made by one human to another human. I call it the handshake test, which is why I always shook hands when I introduced myself to patients. This judgement that is both professional and personal has to be compartmentalised away from the likes of sales and marketing, the share price — and government targets or propaganda. This is no longer true of the NHS. The NHS is no longer a clinically led organisation, rather, it is a vehicle for ensuring one political gang or another gains ascendancy over the other at the next election.  It is not so much about money, as about control. True, if doctors went down with the plane, in this metaphor, there would be a much better alignment of incentives. Doctors might be yet more awkward. Better still, we might think about where we seat the politicians and their NHS commissars.

Most doctors keep a shortlist of other doctors who they think of as exceptional. These are the ones they would visit themselves or recommend to family. If I had to rank my private shortlist, I know who would come number one. She is not a dermatologist, but a physician of a different sort, and she works far away from Edinburgh. She has been as loyal and tolerant of the NHS as anybody I know — much more than me. Yet she retired  before me, and her reasoning and justification were as insightful and practical as her medical abilities. Simply put, she could no longer admit her patients and feel able to reassure them that the care they would receive would be safe. It’s the handshake test.

I don’t shake hands with patients any more.

  1. A ‘new’ outpatient is usually a patient you are seeing for the first time, after they have been referred by their GP or another consultant. During this ‘illness episode’, if you see them again, they are a ‘review’ patient. Once they have been discharged from hospital review, they may of course re-enter the system — say many years later —as a ‘new’ patient once more with the same or a different condition.

Link to patient 1

Link to patient 2

The last three patients: general medicine

by reestheskin on 25/11/2020

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Patient 2

It hasn’t happened to me often — maybe on only a handful of occasions — but often enough to recognise it, and dread it. I am talking to a patient, trying to second guess the future — how likely is it that their melanoma might stay away for ever, for instance — and I find myself mouthing words that a voice in my head is warning me I will regret saying. And the voice is not so much following my words but anticipating them, so I cannot cite ignorance as an excuse, nor is it a whisper or unclear in any way, and yet I still charge on. A moment later, regret will set in, and this regret I could share with you at that very moment if you were there with me.

The patient was a young man in his early twenties, who lived with his mother, just the two of them at home. He had dark curly hair, was of average height, and he lived for running. This was Newcastle, in the time of Brendan Foster and Steve Cram. He had been admitted with pyrexia, chest pains and a cough. He had bacterial pneumonia, and although he seemed pretty sick, none of us were worried for him.

After a few days, he seemed no better, and we switched antibiotics. Medics reading this will know why. He started to improve within a day or so, and we felt we were in charge, pleased with, and confident of our decisions. This was when I spoke with his mother, updating her on his progress. Yes, he had been very ill; yes, we were certain about his diagnosis; and yes, the change of antibiotics and his response was not unexpected. I then said more. Trying to reassure her, I said that young fit people don’t die from pneumonia any more. That was it. All the demons shuttered.

At this time I was a medical registrar and I supervised a (junior) house officer (HO), and a senior house officer (SHO). In turn, my boss was a consultant physician who looked after ‘general medical’ patients, but his main focus was clinical haematology. In those days the norm was for all of a consultant’s patients to be managed on their own team ward. On our ward, maybe half the patients were general medical, and the others had haematological diseases. Since I was not a haematologist, I was solely tasked with looking after the general medical patients, and mostly acted without the need for close supervision (in a way that was entirely appropriate).

One weekend I was doing a brief ‘business’ ward round on a Sunday morning. Our young man with pneumonia was doing well, his temperature had dropped, and he was laughing and joking. We would have been making plans to let him home soon. The only thing of note was that the houseman reported that the patient had complained of some pain in one calf. I had a look and although the signs were at best minimal I wondered whether he could have had a deep vein thrombosis (DVT). Confirmatory investigations for DVTs in those days were unsatisfactory and not without iatrogenic risk, whilst the risks from anticoagulation in a previously fit young man with no co-morbidities are minimal. We started him on heparin.

A few days later he was reviewed on the consultant’s ward round. I knew that the decision to anti-coagulate would (rightly) come under review. The physical signs once subtle were now non-existent, and the anticoagulation was stopped. A reasonable decision I knew, but one that I disagreed with, perhaps more because of my touchy ego than deep clinical judgement.

Every seven to ten days or so I would be the ‘resident medical officer’ (RMO), meaning I would be on call for unselected medical emergencies. Patients might be referred directly to us by their general practitioner, or as ‘walk-ins’ via casualty (ER). In those days we would usually admit between 10 and 15 patients over a 24-hour period; and we might also see a further handful of patients who we judged did not require hospital admission. Finally, since we were resident, we continued to provide emergency medical care to the whole hospital, including our own preexisting patients.

It was just after 8.30am. The night had been quiet, and I was in high spirits as this was the last time I would act as an RMO. In fact, this was to be the last day of me being a ‘medical registrar’. Shortly after, I would leave Newcastle for Vienna and start a career as an academic dermatologist, a career path that had been planned many years before.

The clinical presentation approaches that of a cliché. A patient with or without various risk factors, but who has been ill from one of a myriad of different conditions, goes to the toilet to move their bowels. They collapse, breathless and go into shock. CPR may or may not help. A clot from their legs has broken free, and blocked the pulmonary trunk. Sufficient blood can no longer circuit from the right side of the heart to the left. The lungs and heart are torn asunder.

When the call went out, as RMO, I was in charge. Nothing we did worked. There is a time to stop, and I ignored it. One of my colleagues took the decision. Often with cardiac arrests, you do not know the patient. That helps. Often the call is about a patient who is old and with multiple preexisting co-morbidities. That is easier, too. But I knew this man or boy; and his mother.

That was the last patient I ever saw in general medicine.

[Link to Patient 1]
[Link to Patient 3]

The last three patients: general practice

by reestheskin on 23/11/2020

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Patient 1 

When I was a medical registrar I did GP locums for a single-handed female GP in Newcastle. Doing them was great fun, and the money — she insisted on BMA rates — was always welcome. Nowadays, without specific training in general practice, you can’t act as a locum as I did then. This is probably for the best but, as ever, regulations always come with externalities, one of which is sometimes a reduction in overall job satisfaction.

I worked as a locum over a three period, usually for one week at a time, once or twice a year, covering some of the GP’s annual leave. Weekdays were made up of a morning surgery (8.30 to 10.30 or later), followed by house-calls through lunchtime to early afternoon, and then an evening surgery from 4.30 to around 6:30. I also ran a short Saturday morning surgery. Within the working day I could usually nip home for an hour or so.

From 7pm till the following morning, the Doctors Deputising Service (DDS) took over for emergency calls. They also covered the weekends. The DDS employed other GPs or full-time freelancers. Junior hospital doctors often referred to the DDS as the Dangerous Doctor Service. Whether this moniker was deserved, I cannot say, but seeing patients you don’t know in unfamiliar surroundings is often tricky. Read on.

Normally, the GP would cover the nights herself, effectively being on call 24 hours per day, week in, week out. Before she took leave, she used to proactively manage her patients, letting some of her surgery ‘specials’ or ‘regulars’ know she would be away, and therefore they might be better served by waiting for her to return. Because she normally did her own night-calls, she was aware of how a small group of patients might request night visits that might be judged to be unnecessary. I think the fee the DDS charged to her was dependent on how often a visit was requested, so, as far as was reasonable, she tried to ensure her patients knew that when she was away they would only get a visit from a ‘stranger’ — home night-time call-outs should be for real emergencies. I got the strong impression that her patients were very fond of her, and she of them. Without exception, they were always very welcoming to me, and I loved the work. Yes I got paid, but it was fun medicine, and offered a freedom that you didn’t feel in hospital medicine as a junior (or senior) doctor.

The last occasion I undertook the locum was eventful. I knew that this was going to be the last occasion, as that summer I was moving on from internal medicine to start training in dermatology — leaving for Vienna in early August. A request for a house-call, from forty-year-old man with a headache, came in just as the Friday evening surgery was finishing, a short while after 6.30pm. My penultimate day. I had been hoping to get off sharpish, knowing I would be doing the Saturday morning surgery, but contractually I was covering to 7pm, so my plan was to call at the patient’s house on the way home.

I took his clinical paper notes with me. There was virtually nothing in them, a fact that doctors recognise as a salient observation. He lived, as did most of the surgery’s patients, on a very respectable council estate that literally encircled the surgery. I could have walked, but chose to drive, knowing that since I had locked up the surgery, I could go straight home afterwards.

When I got to his house, his wife was standing outside, waiting for me. She was most apologetic, informing me that her husband was not at home, but had slipped out to take his dog for a walk. I silently wondered why if this was the case, he couldn’t have taken the dog with him to the surgery, saving me a trip. No matter. Grumbling about patient behaviour is not unnatural, but is often the parent of emotions that can cloud clinical judgement. There lie dragons.

The patient’s wife ran to the local park to find her husband, who, in tow with her and the dog, came running at a fair pace back to the house a few minutes later. The story was of a headache on one side of his head, posterior to the temple, that had started a few hours earlier. The headache was not severe, he told me, and he felt well; he didn’t think he had flu. His concern was simply because he didn’t normally get headaches. There was nothing else remarkable about his history; he was not on any medication, and had no preexisting complaints or diseases beyond the occasional cold. Nor did the actual headache provide any diagnostic clues. On clinical examination, he was apyrexial, with a normal pulse and blood pressure, and a thorough neuro exam (as in that performed by somebody who had recently done a neuro job) was normal. No neck stiffness or photophobia and the fundi were visualised and clear. The best I could do was wonder about a hint of erythema on his tympanic membrane on the side of the headache, but there was no local tenderness, there. I worried I was making the signs fit the story.

I told him I couldn’t find a good explanation for his headache, and that my clinical examination of him was essentially normal. There was a remote possibility that he had a middle ear infection, although I said that since he had no history of previous ear infections, this seemed unlikely. I opted to give him some amoxycillin (from my bag) and said that whilst night-time cover would be provided by the DDS, I would be holding a surgery on the Saturday morning in just over 12 hours time. Should he not feel right, he should pop in to see me, or I could visit him again. He and his wife thanked me for coming round, I went home and, as far as I knew, that was the end of the story of my penultimate day as a locum GP. He did not come to my Saturday morning surgery.

Several weeks later, when I was back doing internal medicine and on call for urgent GP referrals, the same GP phoned me up about another of her patients who she thought merited hospital assessment. This was easily sorted, and I then asked her about some of the patients of hers I had seen when I was her locum. There was one in particular, with abdominal pain, whom I had sent into hospital, and I wanted to know what had happened to him. She then told me that the patient had meningitis. There was a moment of confusion: we were not talking about the same patient.

The story of the man with the headache was as follows. I had seen him just before 7pm, apyrexial, fully conscious, with a normal pulse and blood pressure, and no neuro signs. By 8pm his headache was much more severe and his wife put a call into the DDS who saw him before 9pm, but could not find anything abnormal. By 10.30pm he was barely conscious, and his wife called the DDS who were going to be delayed. Soon after, she dialled 999. He was admitted and diagnosed and treated for bacterial meningitis. The GP told me he had made a prompt and complete recovery.

That was the last patient I ever saw in general practice.

[Link to patient 2]

[Link to patient 3]

Nicely put

Capitalism on the way up, and socialism on the way down is cronyism.

Corona Corps + Biden | No Mercy / No Malice

You would have to be mad…

by reestheskin on 20/11/2020

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“I have been this close to buying a nursing school.” This is not a sentence you expect to hear from a startup founder. Nursing seems a world away from the high-tech whizziness of Silicon Valley. And, to use a venture-capital cliché, it does not scale easily.

This was from an article in the Economist awhile back. As ever, there is a mixture of craziness and novelty. The gist of the article is about Lambda School, a company that matches ‘fast’ training with labour force shortages (hence the nursing angle). When I first read it, I had thought they had already opened a nursing school, but that is not so. Nonetheless, there are aspects that interest me.

We learn that

  1. Full-time students attend for nine months, five days a week from 8am to 5pm. Latecomers risk falling behind, but for most classes, 85% of students who began a course finish. Study is online but ‘live’ (rather than pre-recorded videos). These completion rates are a lot higher than for many community colleges in the US.
  2. Lambda only gets paid after its students have landed a job which pays them more than $50,000 a year. Around 70% of those enrolled do so within six months of graduation. Lambda then receives about a sixth of their income for the next two years, until they have paid about $30,000 (or they could pay £20,000 up front).
  3. One third of the costs are spent on finding jobs for graduates, another third on recruitment and only one third on the actual teaching. Scary.

The Economist chimes in with the standard “Too often students are treated as cash cows to be milked for research funding.” Too true, but to solve this issue we need to massively increase research costings, have meaningful conversations with charities and government (including the NHS) about the way students are forced to involuntarily subsidise research, and cut out a lot of research in universities that is the D of R&D.

But this is not a sensible model for a university. On the other hand it is increasingly evident to me that universities are not suitable places to learn many vocational skills. The obvious immediate problem for Lambda is finding and funding a suitable clinical environment. That is exactly the problem that medical (or dental) schools face. A better model is a sequential one, one which ironically mimics the implicit English model of old: university study, followed by practical hospital clerkships. Just tweak the funding model to allow it.

It’s just business

by reestheskin on 19/11/2020

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I have rich memories of general practice, and I mean general practice rather than primary care 1. My earliest memories centre around a single-handed GP, who looked after my family until we left Wales in the early 1970s. His practice was in his house, just off Whitchurch village in Cardiff. You entered by what once may have been the back gate or tradesman’s entrance. Around the corner and a few steps up, you found the waiting room. Originally, I guess, it might have been a washroom or utility room for a maid or housekeeper. By the standards of the Rees abode the house was large.

The external door to the waiting room was opposite the door into the main part of the doctor’s house, and on the adjacent sides were two long benches. They were fun for a little boy to sit on because since your legs couldn’t touch the floor, you could shuffle along as spaces became available. When you did this adults tended to smile at you; I now know why. If you were immobile for too long your thighs might stick to the faux-leather surface; pulling them away fast resulted in a fart like noise, although in those days I was too polite to think out loud.

Once you were called — whether it was by the doctor or his wife I cannot remember— you entered his ‘rooms’. The consulting rooms was by my preferred unit measure — how far I could kick a ball — large, with higher ceilings than we had at home. The floorboards creaked and the carpet was limited to the centre of the room. If there was a need for privacy there was what seemed like a fairly inadequate freestanding curtained frame. For little boys, obviously, no such cover was deemed necessary.

I can remember many home visits: two stand out in particular, mumps, and an episode of heavily infected eczema where my body was covered in thousands of pustules, and where I remember pulling off sheets of skin that had stuck to the bedclothes. The sick-role was respected in our home: if you were ill and off school you were in bed. Well, almost. Certainly, no kicking the ball against the wall.

Naturally, the same GP would look after any visitors to my home. Although my memories are influenced by what my mother told me, on one occasion my Irish grandmother’s valvular heart failure decompressed when she was staying with us (her home was in Dublin). More precisely, I was turfed out of my bed, so she could occupy it. The GP phoned the Cardiff Royal Infirmary explaining that the patient needed admission, and would they oblige? The GP however took ten years-or-so off her true age. Once he was off the phone, my mother corrected him. He knew better: if I had told them the truth they would have refused to admit her, he said. (This was general practice, not state medicine, after all). The memory of this event stuck with me when I was a medical student on a geriatrics attachment in Sunderland circa 1981. Only those under 60 with an MI were deemed suitable for admission to the CCU, with the rest left in a large Nightingale ward with no cardiac monitoring 2. I thought of my father who was then close to 60.

I was lucky enough to be able to recognise this type of general practice — albeit with many much needed changes — as a medical student in Newcastle, and to be taught by some wonderful GPs, and even do some GP locums when I was a medical registrar. And although I had never met the late and great Julian Tudor-Hart face-to-face, we are linked by a couple of mutual Welsh friends, and we exchanged odd emails over the years.

So, why do I recall all of this? Nostalgia? Yes, I own up to that. But more out of anger that what was unique about UK general practice has been replaced by primary care and “population medicine”, and many patients are worse off because of this shift. Worse still, it now seems all is viewed not through the lens of vocation, but by the egregious ‘its just business’. Continuity of care and “personal doctoring” is, and has been, lost.

I write after being provoked by a comment in the London Review of Books. Responding to a terrific article by John Furse on the NHS, Helen Buckingham of the Nuffield Trust states — as many do — that “The reality is that almost all GP practices are already private businesses, and have been since the founding of the NHS.” (LRB 5/12/2019 page 4).

Well, for me, this is pure sophistry. There are businesses and businesses. If you wish, you might call the Catholic Church a business, or Edinburgh university a business, or even the army a business. You might even refer to each of them as a corporation. But to do so, misses all those human motivations that make up civil society. Particularly the ability to look people in the eye and not feel grimy. There is no way on earth that the GP who looked about me would have called what he did a business. Nor was he part of any corporation. And the reason is simple: like many think tanks, many modern corporations — especially the larger ones — have no sense of morality beyond the dollar of the bottom line3, often spending their undoubted skills wilfully arbitraging the imperfections of regulation and honest motivation. It does not have to be this way.

  1. Here I am echoing the arguments made by Howie, Metcalfe and Walker in the BMJ in 2008: The State of General Practice — not all for the better. Comments on this article effectively said: the halcyon days of general practice were over. Get used to it! I am not convinced. What has happened is that ‘government led population / public health’ has gobbled up ‘personal doctoring’. For the latter, it appears, you will need more than the NHS.
  2. Many epidemiologists argued that there was no need for CCUs as no RCTs had shown their benefit. Ditto for parachutes, renal transplantation , no doubt.
  3. You can insert your own favourite de jour: Pfizer and Flynn for raising the price of an anti-epilepsy drug by up to 2,600 per cent, or GSK, or Crapita, Test and Trace etc. The list goes on, well before we get to the likes of Facebook or the Financial Services Industry

On Idle thoughts and Flexner

by reestheskin on 18/11/2020

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I have previously commented on Abraham Flexner on this site. The Flexner report is the most influential review of US medical education ever published, although some would argue that the changes it recommended were already working their way through the system. For a long time I was unaware of another project of his, an article with the title The Usefulness of Useless Knowledge 1. For me, there are echoes of Bertrand Russell’s In Praise of Idleness and the fact that Flexner’s essay was published at the onset of World War 2 adds anther dimension to the topic.

As for medical education, the ever-growing pressure is to teach so much that many students don’t have time to learn anything. I wish some other comments from Flexner opened any GMC dicta on what a university medical education should be all about.

“Now I sometimes wonder,” he wrote, “whether there would be sufficient opportunity for a full life if the world were emptied of some of the useless things that give it spiritual significance; in other words, whether our conception of what is useful may not have become too narrow to be adequate to the roaming and capricious possibilities of the human spirit.”

  1. The essay originally published in Harper’s Magazine was republished with a companion essay by Robbert Dijkgraaf by Princeton University Press in 2017.

Inside the Leviathan

“I work for a government I despise for ends I think criminal.”

John Maynard Keynes, 1917, in a letter to Duncan Grant.

The above quote via John Naughton who commented

I wonder how many officials in the US and UK governments currently feel the same way.

Sinking ships

by reestheskin on 17/11/2020

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Following on from the previous post, here is a bit more economics, surely germane to Deaton and Case’s work, and which provides yet another example of where the ‘observation’ (‘facts’) may, if not shout for themselves, at least whisper that something important is going on. The graphs are from Saez and Zucman’s The Triumph of Injustice. Note the timeline for each graph.