When I was an academic I used to interview candidates for professorships at other universities and I always asked them what they thought their research activities would be in the next ten years, and the only correct answer was, ‘I don’t know’. Roger Needham
I have always defined (my) research as what interests me. Funders have often not agreed. I am attracted to Francis Crick’s gossip test: you should always do what you find yourself gossiping about, and remember that tastes change. Research is what you think about in the shower.
The Long Now: Zombie medical schools
When we started the dermagineering work (see below) it was natural to think harder about how we teach and more importantly how students learn. Initially, I read a lot of the non-medical literature on expertise acquisition and the psychology of learning. This approach is interesting and important but as I argue below it only gets you so far. By contrast with the non-medical literature, if much of the medical education research literature were to be destroyed it would be no great loss to womankind (there are a few giant exceptions to this
hostile generalisation — Geoff Norman and Kathyrn Montgomery to mention two).
Alan Kay has a phrase that seem apposite in this context: “You can fix a clock, but you have to negotiate with a system.” The elephant in the room is the system rather than the individual student or teacher. It was clear to me that there are a lot of what the economists refer to as institutional factors that diminish the quality of medical education (and research). There were some simple things I could achieve. For instance, it is clear that there is market failure in much medical publishing — which was why I wrote the online textbook skincancer909 and tried to use short videos to complement text. But there are bigger problems. One is scale: Individual medical school staffing levels are simply not large or diverse enough to produce much content (compare and contrast with postgraduate training). Second, the business model of medical schools makes no sense from the point of view of students. Medical schools organise and timetable teaching but then outsource most of it to full-time clinicians. They then use most of their own staff to undertake research — so that they can score well in the REF — rather than to develop real expertise in teaching and help drive the costs of medical education down as well as expand it. This trend is longstanding but has accelerated as a side-effect of REF funding. We are left with, at worst, zombie medical schools and, at best, amateur organisations that think 50K per year from each student represents good value. You should never outsource your raison d’être and, if you do, you should not be surprised when you are left with no customers and no business. A few tame papers: here, here and here — better still read my blog where I am trying ideas out. A paper dealing with broader issues still is here. Remember the TIJABP acronym (for the moment anyway).
For most of my career years I was interested in using genetic approaches to understand skin disease and skin biology. Initially, this involved collaborative work on the mapping and gene identification of a number of disorders (Monilethrix, Darier’s disease, Pachyonychia Congenita). My own laboratory concentrated on skin cancer and the underlying mechanisms of sun sensitivity. We published early papers on the effects of UVR on skin p53 expression, and the somatic genetic change in various types of skin cancer or dysplasia. Most notably, my laboratory (in collaboration with Tony Thody and Ian Jackson) identified the ‘gene for red hair’ (MC1R) and published on its relation with non-melanoma skin cancer and melanoma. Over the course of a dozen or so years we studied its clinical relevance (and here), its genetic epidemiology and evolution (with Rosalind Harding). My earlier contributions are summarised in single author reviews in the Annual Review of Genetics (37 | 67 | 2003) and the American Journal of Human Genetics (75 | 739 | 2004), and a premature farewell to much of this field, coauthored with Rosalind Harding, was published in the J Invest Dermatol in 2012. I played a small part in a paper on the genetics of hair colour published in 2018 from the groups of Ian Jackson and Albert Tenesa here in Edinburgh using UK Biobank data. If you are interested in the genetics of red hair written for the non-expert here is a (dated) blog post on the topic.
Although the experimental elegance of genetics still enchants me, in the early and mid-noughties I took the view that the subject’s impact on medicine (as compared with biology) would turn out be more modest than many then imagined. Genetics is a wonderful way to do biology but biology is not synonymous with medicine; getting this relation wrong is one of the reasons why much medical research is so dysfunctional (see an article I wrote in Science in 2002). In truth, I was really fed up with the
money hype surrounding complex disease genetics and gene-therapy, as well as the widespread ignorance about the nature of clinical practice by some scientists. I needed to do something different, and I wanted to start work on a clinical problem. At the same time as I was having these thoughts I chanced upon the obituary of the Nobel Laureate Herbert Simon in Science. I had never heard of him before and I subsequently picked up a copy of ‘Sciences of the Artificial’ and read some of his other work. It was an epiphany and I have never been able to see medicine or medical research in the way I used to.
The central skill of a dermatologist is in the recognition of morphology. This, of course, is not all there is to clinical practise but, just as for the radiologist or the pathologist, the ability to recognise form is critical. The research problem —and it is non-trivial — is how to attach semantics to images. Books have word indexes, as does the Web, but to find out more about a rash you have to be able to first name it. I think we will only make real progress when we build machines to rival, augment or supplant our own skills. Medicine is therefore a branch of engineering: we build systems on the basis of our knowledge of the natural world. This is what I used to call dermagineering.
Most of this work was in collaboration with Prof Bob Fisher in Edinburgh Informatics. We have pursued two approaches: use of 3D image capture, and the development of a content based image retrieval (CBIR) system. The work was funded by Wellcome (and others) and whilst scientifically very productive we were unable to commercialise it to the level we needed. Eventually, we ran out of steam. There are now complementary approaches that have made use of our databases that are extremely promising (for an editorial on this topic written by me see here). In a parallel stream of research we also published experimental work on clinical skills and how they might be improved; and the dangers of using untested assumptions about how you can empower (sic) non-experts / educate the public (example papers: here and here).
A spin off of the informatics and diagnostic research was my present mania: a rekindled fascination with teaching and learning in medicine; and the role of universities in medical education (see top of page).
Itch & scratch
I have published a few papers on itch in man, guinea pigs and mice, all concerned with how we could assay the sensation of itch as observable scratch. The idea was not original, but the development of accelerometers allowed more refined experiments than had been previously carried out contrasting objective and subjective states.
Evidence, statistics and medicine
The evidence based medicine cult has been a disaster for medicine. It is even more galling to find that some of those who made their careers out of it are now enjoying an academic second wind slagging it off: Vicars of Bray. It was always an epistemology that wasn’t. Many others spotted this long before me (Petr Skrabanek and Bruce G Charlton to name two), but I tried in vain to use reason, too. Some papers on this topic: here, here, here, here and here.
If we hadn’t identified the gene for red hair somebody else would have, probably within six months of our paper appearing. For this reason, I am perhaps most proud of some of the essay papers I have written with medicine itself as the subject, simply because they have more individuality about them. This of course does not mean I am always talking sense. Some examples: here, here, here, here, here and here.
How I got started
My research career started the day I stumbled into Sam Shuster’s office in Newcastle as a third year medical student fed up with the tedium of medical school. It was not so much that he changed my life (he did), but that I now recognised what I had been looking for. Sam was wonderfully and creatively dissatisfied with the state of the world; believed in the academic ideal; and was electric to be around (and lots of fun things seemed to happen when he was around). He also believed you could make both the world and clinical medicine better by thinking hard about things and by ridiculing pomp and cant wherever you found it. Klaus Wolff, my other teacher, would describe him as the enfant terrible of British dermatology. Sam would, I suspect, take some pride in the comment coming from Klaus, but I will quote Sam’s own words in another context:
clichés are written by writers who don’t think about what they write, for readers who can’t think about what they read
Klaus would no doubt smile back with equanimity, as befits the Vorstand of the Mecca of dermatology. For Sam, for all the high-table bullshit of academia, there was always a link between being an intellectual and being a protector of integrity. Truth was never an optional bolt-on. And he loathed Margaret Thatcher.