Nice letter in Academic Medicine. Not convinced by the exact details, but the author is on to something important. The first victim of insincerity is language (Orwell, if I remember correctly).

Medical professionalism is espoused as a necessity in health care, setting an important precedent of excellence and respect towards peers and patients. In many medical schools, a portion of the curriculum is dedicated to the intricacies of medical professionalism. Though typically taught through specific tenets and case studies, professionalism is still a general principle, resulting in varied definitions across institutions. This is, in fact, part of the beauty of professionalism—the lack of definition makes it a flexible concept, applicable in a wide variety of situations. However, the downside to this vagary is that it allows for the weaponization of professionalism, leaving space for “professionals” to reject certain approaches to health care.

I always recommend people to read David Healy’s Psychopharmacology 1, 2, and 3, together with Jack Scannell’s articles (here and here) to get a feel for exactly what drug discovery means. What is beyond doubt is that we are not as efficient at it as we once were. There is lots of blame to go around. The following gives a flavour of some of the issues ( or at least one take on the core issues).

From a review in ‘Health Affairs’ of A Prescription For Change: The Looming Crisis In Drug Development by Michael S. Kinch Chapel Hill (NC): University of North Carolina Press, 2016, by Christopher-Paul Milne.

He chronicles these industries’ long, strange trip from being the darling of the investor world and beneficiary of munificent government funding to standing on the brink of extinction, and he details the “slow-motion dismantlement” of their R&D capacity with cold, hard numbers because “the data will lead us to the truth.” There are many smaller truths, too: Overall, National Institutes of Health (NIH) funding has fallen by 25 percent in relative terms since a funding surge ended in 2003; venture capital is no longer willing to invest in product cycles that are eleven or twelve years long; and biotech companies may have to pay licensing fees on as many as forty patents for a decade before they even get to the point of animal testing and human trials….

In an effort to survive in such a costly and competitive environment, pharmaceutical companies have shed their high-maintenance R&D infrastructure, maintaining their pipelines instead by acquiring smaller (mostly biotech) companies, focusing on the less expensive development of me-too drugs, and buying the rights to promising products in late-stage development. As a consequence, biotech companies are disappearing (down from a peak of 140 in 2000 to about 60 in 2017), and the survivors must expend an increasing proportion of their resources on animal and human testing instead of the more innovative (and less costly) identification of promising leads and platform technologies. Similarly, some of academia’s R&D capacity, overbuilt in response to the NIH funding surge, now lies fallow, while seasoned experts and their promising protégés have moved on to other fields.

Higher education is an industry of the future — one in which the UK is a world-class player. Foreign universities are out to eat Britain’s lunch, and Mrs May’s obdurate stand is one of the best things that has ever happened to them.

Indeed, an industry of the future… “but not as you know it Jim”. FT

My first publication was on eccrine sweating. I was known (for a while) as the ‘sweat guy’, too. Only at work, I note.

 

With many powerful academicians, lobbyists, professional societies, funding agencies, and perhaps even regulators shifting away from trials to observational data, even for licensing purposes, clinical medicine may be marching headlong to a massive suicide of its scientific evidence basis. We may experience a return to the 18th century, before the first controlled trial on scurvy. Yet, there is also a major difference compared with the 18th century: now we have more observational data, which means mostly that we can have many more misleading results.

John P.A. Ioannidis

I think the situation is even worse. Indeed, we can only grasp the nature of reality with action, not with contemplation (pace Ioannidis). But experiments (sic) as in RCT are also part of the problem: we only understand the world by testing of ideas that appear to bring coherency to the natural world. A/B testing is inadequate for this task — although it may well be all we have left.

G4S, the outsourcing company, has sold its US juvenile detention centres business for $57m. It said it had sold the business to BHSB, a US a “behavioural health care services company” that provides services to troubled young people. FT.

We know where this ends up.

Interesting interview in the FT with the African guitarist Lionel Loueke, if you like to think about learning and certification, a couple of truths. The first is how technology can help. ‘Slow it down’ has helped many of us. Being able to record yourself, and then listen ( a point Eric Clapton talks about) is an interesting example of how you blur the gap between private practice and the external ear provided by a teacher.

He first heard jazz when a friend played him cassettes by Wes Montgomery and George Benson. At first, Loueke didn’t even know that jazz was an improvised music. ‘I approached it like I was playing Afropop, and learnt it by ear,’ he says. ‘I slowed down the cassette by putting in weak batteries, then back to electricity to get the speed. That’s how I started jazz”.

And of course, certification has its limits, and the ‘place to learn’ in not always in the classroom. Papert’s ‘mathland’, revisited.

When guitarist Lionel Loueke was a teenager in Benin, boiling precious guitar strings in vinegar to make them last, he didn’t think that one day he’d be auditioning in Los Angeles for a place at the Thelonious Monk Institute of Jazz Performance. Or that the panel of jazz professors would include Wayne Shorter, Terence Blanchard and Herbie Hancock. And certainly not that Hancock would exclaim, ‘How about we just forget about the school and I take you on the road right now?’

Emma Morano’s singular achievement in life may have been perseverance. She lived for 117 years, crediting her longevity to raw eggs and her lack of a husband. She died on April 15.

NYT

“Anyone who tries to make a distinction between education and entertainment doesn’t know the first thing about either.” — Marshall McLuhan

Comment on an FT article. How things have changed. Even I can remember a colleague — a few years my senior — who went for a Wellcome Training Fellowship, only to be interviewed by one person, with the opening question being, ‘Imagine I am an intelligent layperson: tell me what you want to do!’

McRae

I was a war baby, a small farmer’s son and in 1960, at 17, I had a chat with my most trusted teacher about what I should do to apply to become a doctor for which I had just acquired a good group of Scottish highers. He advised me that because I should have applied a number of months before, to write a letter to the University enclosing my qualifications. I was asked to come and have a chat with the Bursar and the only thing I remember him saying was that my qualifications were good but did I realise that I might be preventing somebody else from getting in. I am ashamed to say that I replied that I was not really too troubled about that. I was accepted, and was fine.