Take your pick. Article in the Observer, a response, and Martin Wolf of the FT here(paywall) and here. Some sense in all of them. But the ‘our (i.e. tax payers) money’ argument (from the Observer) always galls me, and should inform any bright graduate about where they want to build a career. As in any tragedy, the players walk on stage, and you know how it will turn out.

The report’s authors wanted to know what drove nurses and doctors to join agencies, presuming it was simply a case of higher pay. But the researchers found that agency workers in the NHS had similar pay. What they found interesting was that agency workers felt better off because they had escaped the internal politics, the bureaucracy and the stricture of rotas that rarely matched the demands of home. As agency workers they believed they had more control over their lives and put up with less bullying from their employer.

A report by the National Institute for Economic & Social Research (NIESR) quoted here.

I have a secret admiration for some aspects of surgical training. We all know the bad ones, so I do not need to talk about them. When Lisa was doing her Mohs’ fellowship, it was the following vector: you watch X procedures, you perform Y procedures under supervision and you then perform Z procedures ‘independently’, with help on hand. After that, you keep learning. Sensible, and has the essential character of what has been known about craft apprenticeships for over one thousand years: apprentice; journeyman; master. This BMJ piece by a urologist asks:

If you were applying for a certificate of completion of training (CCT) in urology in 2015 you had to have seen or assisted in at least 20 radical prostatectomies before being signed off as competent. A year later, for no apparent reason, it appears that 10 will do.

He then goes on:

Standing in a theatre, unscrubbed, so you can say you’ve seen a procedure was never a part of surgical training, nor should it be now. It has no value. Unless you are very good at the procedure already and you are learning nuanced techniques from a master surgeon, watching a procedure will never make you a better surgeon.

Now, I despair of this sort of thing even when we ask medical students to do it. Why, is the question? What value is there, in watching? That this is considered meaningful at this level of training is even more worrying. And of course the figures will be pushed down, over time. This is the NHS, after all; never let expert judgment get in the way of a political imperative or somebody paid by the government: “we have to revise the speed of light for operational reasons….”

There is a more subtle point which makes thinking about the article even more worth while.

Trainees should spend their training doing the things that they’ll be spending their lives doing, not watching procedures they will never perform.

Now, it is clear that the current bull coming out from HEE, NHS, Deans etc is that we don’t need experts anymore, just people to cope with whatever disease is the flavour of the month (that there are demographic changes — pace the lectures I received from John Grimey Evans in 1976— was apparently not obvious to NHS managers or Jeremy Hunt till late 2016). Here is a problem.

When people finish formal training they are not as expert as they will be in 10 or 20 years. I do want an experienced dermatopathologist to be reading the samples I sent him. Wisdom is not the sole preserve of the old, but in many craft or perceptual disciplines I know about, the old guys and women do it better. So, problem one, is that when people come off a training scheme they are not the doctor they want to be. They are not qualified, they are just setting out, able to work without immediate supervision — as they choose and judge. This is the ticket.

The second problem, as the author makes clear, is that the training schemes are wasteful and not geared to excellence. Again, in a world of ‘pull’ (John Seely Brown’s phrase) the NHS is still trapped within the metaphors of the same industrial age that Donald Trump thinks is going to bring all those jobs back.

We have lost our way in much of what is important in medicine. It’s time that we focused on what really makes a surgeon better and stopped the pointless processes that surround training

Amen. But the surgeons have got some things going for them. IMHO many other branches of medicine are much, much worse.

Interesting editorial in Nature. And unexpected. The issue is support for science and the state of politics in the US.

Just telling the same old stories won’t cut it. The most seductive of these stories — and certainly the one that scientists like to tell themselves and each other — is the simple narrative that investment in research feeds innovation and promotes economic growth. ‘It’s the economy, stupid’, so the saying goes, and as nations become a little less stupid by pushing against the frontiers of knowledge, so the benefits of all this new insight spread from the laboratory to the wider population, as improvements in the standard of living and quality of life. This comfortable story has all the hallmarks of a bubble waiting to pop.

The article goes on:

It is right that more scientists should tell stories of the good their research can do. But it is more important and urgent than ever that researchers should question how these stories really end — and whether too many of the people they claim to act for don’t really get to live happily ever after.

Much science is in a vacuous bubble, and arguments for more funding from its practitioners is increasingly viewed as self serving. Universities share some or much of this blame, all too happy to ‘shift more units’. This lack of intellectual honesty will harm academia in the long term. The one uniting feature that justifies higher education is the pursuit of truth in whichever direction enquiry moves. Universities are not businesses, profit centres, or corporations. They have a different set of norms that are distinct from those advertised by much of the rest of the corporate world (or government). STEM has never been enough, and truthfulness is not something you can opt in or out of, like you can some undergraduate modules. The role for universities — and science — is greater than ever: the issue is whether the universities have the necessary leadership. Even with the right leaders, it is a tough ask.

There is only one way to ensure that assessment is light-touch. Universities should rebrand themselves as banks.

Comment (Mintaka) on an article on the TEF from one of the HE commissars (Nick Hillman).

In 1924, a 30-year old journalist on the Daily Express came to Cambridge aiming to interview Haldane. She was Charlotte Burghes, née Franken, and she had a young son, Ronnie. Haldane and Charlotte became lovers, but before they could marry she had to seek a divorce, a procedure that carried substantial social stigma at that time. A university committee resolved to strip Haldane of his readership, which was only restored by successful legal action.

From a review of a new biography of JBS Haldane. The article referred to in the title of this post is here.  I know of no other branch of biology that can build so much, on so few assumptions.

Kenneth Arrow has died. A real economist. I have a very hard time talking most health economists seriously, especially when they think QUALYs are anything but an almighty sleight of hand over reason (contract work for the NHS). As one economist pointed out to me, one is tempted to imagine that economists who were not very good at economics, become health economists. But that may be a little unkind, and we do need clear thinking about health. Here is a link to a paper published on the economics of the health care industry in 1963. It is both deep, humble, and wonderfully lucid. The econocracy movement should champion it. 

Nice paper by Erik Driessen, and much more nuanced that my quotes might suggest. Worth a read. But still a phrase that I use as a bullshit detector.

Many students do not value reflection as a learning strategy, especially not when they are forced to use an artificial and fixed format and they have little opportunity to direct their learning as a result of these reflections.

“Few things seem to irritate doctors and medical students so much as mandatory reflection. (Tomlinson 2015)”

Twenty-five years of portfolio reveal a clear story: without mentoring, portfolios have no future and are nothing short of bureaucratic hurdles in our competency-based education program

But I do  prefer the term ‘learner chart’, but why not just say, ‘a record of what you did’, just like handing a lab book in. Once again, school teachers might be our guides.

There is a good piece on Wonke by David Morris, dealing with the issue of how research and teaching are related, and the dearth of empirical support for any positive relation between the two. R & T are related at the highest level — some universities can do doctoral research and teaching well — and although I have little direct experience, the same can apply at Masters level. The problems arise at undergraduate level, the level in which most universities compete, and which accounts for the majority of teaching income. As ever, I think we have to think ecology, variation and the long now. What seems clear to me, is that research is indeed often at the expense of teaching, and that the status quo needs to be changed if universities are to continue to attract public (and political) support. Cross subsidies and the empty rhetoric of ‘research led teaching’ do not address what are structural issues in Higher Ed, issues that have been getting worse, driven by poor leadership over many decades.

For many universities this is a pizza and / or pasta issue: some of us like both. Just because the two show little covariation in ecological data, does not mean that they shouldn’t inform each other much better than they have over the recent past. On the other hand, scale and education are unhappy bedfellows, and staff time and attention matter. Do you really think about teaching the same way you approach research? If T & R do not covary, then are your students in the best place, and why did you admit them? Honest answers please.

People who make predictions of how many doctors or even what specific type of doctor we need in (say) 20 years are IMHO generally deluded. Or they are telling fibs. Or selling something. The following is from the NEJM and is about ‘hospitalists’

Twenty years ago, we described the emergence of a new type of specialist that we called a “hospitalist.”. Since then, the number of hospitalists has grown from a few hundred to more than 50,000 — making this new field substantially larger than any subspecialty of internal medicine (the largest of which is cardiology, with 22,000 physicians), about the same size as pediatrics (55,000), and in fact larger than any specialty except general internal medicine (109,000) and family medicine (107,000). Approximately 75% of U.S. hospitals, including all highly ranked academic health centers, now have hospitalists. The field’s rapid growth has both reflected and contributed to the evolution of clinical practice over the past two decades.

The only way you can play ‘make believe’ like the DoH and all the NHS ‘experts’ so keen to trample all over our medical students’ futures is if you think Stalin is still alive and sorting out the tractor numbers.