Marvin Minsky once quipped “Every educational reform is doomed to succeed”. He meant “with some students”.

Alan Kay

“If I had to reduce all of educational psychology to just one principle, I would say this: The most important single factor influencing learning is what the learner already knows. Ascertain this and teach him accordingly.”(Ausubel, 1968 p. vi). Via Dylan Wiliam.

When I was a child, growing up in Wales, my father would express puzzlement that I didn’t seem to know how to pronounce certain words. He didn’t get that since Welsh was his equal first tongue — but not mine— knowing how you pronounce Welsh words was obvious to him, but not to me. For my part, it was only scores of years later that I realised some of his verbal mannerisms were not just odd idiosyncratic English or slang, but Welsh, although the meaning was clear to me. I  had just not realised these were Welsh words or phrases, and of course I too would use them.

I have noted in the past, that when students mispronounce some of these dreadful dermatological terms, it was a signal that they had read about a disease, but had never been taught on that disease. It signalled to me how much they were acquiring on their own. English is like that, certainly in comparison with German: until you hear the word spoken, guessing how you say it, is tricky. More so, when you chuck in the various languages that contribute to the dermatological lexicon — and when they are then spoken / bastardised by English speakers.

But today, a student today pointed out that it would be helpful to include how words are pronounced in our course material. I am not certain how to do this yet, but I can believe that not knowing how to pronounce a term might ‘inhibit’ thinking and ‘silent talking’ about the topic (I do not know whether there is any research to back this opinion up).

I wrote a post on this topic awhile back trying to map out the territory of funds going in and out of undergraduate medical education. It was a bit too rambling but more thought out I feel than Jeremy Hunt’s latest slant on statistics that the Guardian (and others) reported. So here are some bullet like points on this issue, together with some questions. The backdrop is the article I wrote before, and the issue of ‘we paid for their training so we can seize their passports’ (Phil Hammond’s, ‘Hotel California clause’: ‘you can check in but you can never leave’.) And because, somebody asked me to spell things out a little more.

In England medical students pay 9K fees. HEFCE (Higher education funding) add another 10K. Lets round up and call it 20K. HEFCE also adds money beyond fees for other expensive degrees (engineering, for example) although I do not know if it is 10K or less. This 20K goes through the universities

Medical students do not pay their final year fees in England, but must meet all their living costs, and 9K fees for the other 4 or 5 years. Government loans attract interest and, as others have commented, the government alters the conditions in a way that would be illegal for any bank (Gee! The government makes even the bankers look like saints). So say 40-45K fees, plus living costs. I doubt much change from a 100-120K. The money attracts interest and will be much larger by the time it is paid back, and will also feed into the debt of students who do not earn enough to pay back their fees.

The other funding stream is via the NHS. In England this is called SIFT, in Scotland it is called ACT. This is probably in the region of 20K per student per clinical year, and is designed to meet the costs of the ‘students on the wards’ and pay for all the NHS staff time for those involved in teaching. This money stays within the NHS, and the universities have essentially no access to it.

If you add there two streams together you are talking about close to 30K of ‘state funding’ plus 10K from the students. Living expenses are on top, and I will ignore opportunity costs of what students defer from earning.

The problem with the 30K state funding figure is it fails the reality test. These sums add up to a figure (40K) close to what Stanford charges its small medical student cohort, and yet it is clear that our UK medical students get a much worse deal. Or just compare what this sort of money buys you at an expensive private school. There is a (fat) rabbit off somewhere. Nobody with any knowledge of medical education, and who isn’t playing politics, believes that is what we spend on each of our students.

Above, I said 20K goes through the universities, but I did not say that universities spend that 20K on delivering undergraduate teaching. The obvious issue is that medical research is big business, and most research in general loses an institution money — this is especially true of charity funded research, the main funder of medical research in the UK (although there is an attempt to make up this deficit from QR funds but it is grossly inadequate). Peacocks tail, and all that. So, teaching fees are used to subsidise this loss. There are good costings for this in some US schools, but they use endowments to meet the costs; in the UK we get students to pay for this. To what extent? I do not know. Do not ask, is the mantra. This will run and run. And then unwind.

What about the NHS money. Well, nothing is transparent in the NHS, but we know most of the this money is not used to support teaching, but siphoned off to pay for clinical care. What proportion? I would start at saying 70% (i.e. only 30% goes for what it is intended for). So I think 18K over the whole course. But I know of no convincing data in this area, just the sort of bumph Hansard repeats, which is not reality based. Do not ask, is again the mantra.

My previous post added in come complexities. And there are more, that I have not mentioned.

The key points are:

1. We do not know how much undergraduate medical education costs, just that the available figures are not credible.
2. Much of the money said to support medical education is used for other purposes (this is a generally accepted argument across many research universities throughout the world).
3. Costing is opaque and multiple parties have little interest in transparency.
4. Money (as in staff) is a key determinant of teaching and learning. Until you follow the money, you cannot seriously think about improving medical education. Some of us even think it is possible to reduce costs and improve learning at the same time. This is why all this  matters — and not just to students.
5. Institutional and student interests are not completely aligned.
6. Certification is a monopoly business. To paraphrase Derek Bok, a distinguished former President of Harvard, if institutional survival (money)and morality conflict, morality goes out the window.
7. Current models of medical education are based on what made sense in the immediate post-war world. It really should be done so much better.
8. People often ridicule arts students, saying how little contact time they have. Meaningful contact time in medicine not what it was, nor what it should be — talk to medical students across the UK.
9. Hospitals perform worse than GPs in delivering teaching. There is a moral here.

Anyway you can still listen….

Short video  on the above topic. There will be supporting material on my teaching page soon under the Skin Biology series (video 8). The Vimeo file is here.

I have always thought two Irish writers great guides to life: Samuel Becket, and Brian O’Nolan (aka Brian Ó Nualláin, Flann O’Brien, Myles na gCopaleen ). Becket’s line, in a postcard of the lithograph by Tom Phillips of him, hangs on my wall: “No matter. Try again. Fail again. Fail better.” But now I have come across something more fitting for my state, and with optimism:

“I work on, with failing mind, in other words, improved possibilities.”

Review of The Letters of Samuel Beckett, Volume IV, in the FT.

‘Innovative’ educational practice is more fashion-driven than those who attend the catwalks are.

Interesting post from Tony Bates on the history of distance learning, and the University of London External Programme, which started in 1828.

Unfortunately I have no knowledge of the individuals who originally created the University of London External Programme back in 1828. It’s a worthy research project for anyone interested in the history of distance education.

I was once (mid-1960s) a correspondence tutor for students taking undergraduate psychology courses in the External Programme. In those days, the university would publish a curriculum (a list of topics) and provide a reading list. Students could sit an exam when they felt they were ready. Students paid tutors such as myself to help them with their studies. I would find old exam papers for the course, and set questions for individual students, and they would send me their answers and I would mark them. Many students were in British Commonwealth countries and it could take weeks after students sent in their essays before my feedback eventually got back to them. Not surprisingly, in those days completion rates in the programme were very low…

But I am fascinated by (and was ignorant of) the following:

Note though that teaching and examining in the original External Programme were disaggregated (those teaching it were different from those examining it), contract tutors were separate from the main faculty were used, and students studied individually and took exams when ready. So many of the ‘new’ developments in distance education such as disaggregation, self-directed learning, and many of the elements of competency-based learning are in fact over 150 years old.

“The original Apple Watch has 450 nits of brightness. The new one has 1,000 nits. That’s a lot of nits. In case you were wondering, a “nit” is a unit of luminance equal to one candela per square meter.”

My father used to call me a nit on a daily basis. Now I know he was being flattering. Tricky for us dermatologists, too

David Sparks

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

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

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

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