Abraham Vergese, an infectious disease physician, gave a talk here in Edinburgh last week. It was a very mixed audience, but I suspect the many students who were there enjoyed it. I have not read any of this books — nor looked at his TED talk — but his Wikipedia entry gives you a flavour of how interesting he is, and how varied a career can be — when you have courage.

One issue that came up tangentially, was the history of diagnosis, and there were some opinions ventured by the audience in terms of when diagnosis was historically established. I may have missed key points, but I found it hard to accept that the idea of diagnosis was something you could date except in very broad terms, even less that you could associated it with the 1870s or with the idea of stethoscopes being a key marker of when modern ideas of diagnosis were established. For instance — and since the lecturer was an ID physician — my first thoughts turned to scabies. The scabies mite was identified in the 1690s, and it was recognised as the cause of the disease ( I am not quoting primary sources so let me know if……) So here we have a clear linking of symptoms, signs, causality, a causal agent, and a broader theory about pathogenesis and epidemiology. So, this it got me thinking about how I view the topic of diagnosis.

Diagnosis is the mapping of one state with another, with the two states being linked by a network of attributes. Diagnosis is a suitcase term: it may contain lots of different tools, tools suited to various purposes, and tools for which we may find different purposes over time. Diagnosis represents an attempt to classify the world into particular states with often the goal of making some predictions about some other state. Most of the time, we think in terms of prediction, about what might happen to that person with or without some intervention. If you see these physical signs (burrows) and the patient describes particular symptoms (itch), then the ‘state’ is scabies. If the diagnosis is correct, you can say something about what causes the state, what might happen, and what effect a particular intervention (permethrin / malathion etc) might have. If you are lucky, you can feel happy with causal arrows linking much of what you say and think. Prediction is important but it is of course not the only quality we want in a theory. We tend to prefer some theories to others, even when they why make similar predictions. Think of Copernicus. We tend to prefer one of the following, irrespective of whether both allow the same quantitative clinical predictions:

1. Sunbathing causes skin cancer: if you increase exposure by X then incidence goes up by Y
2. Sunbathing increase the dose of UVR, UVR is mutagenic and in particular cause very specific types of mutation, cancer is a result of the accumulation of mutations, and therefore we will see particular mutational spectra in skin cancers

Our suitcase of diagnostic concepts have changed over time, however. For instance, even in modern medicine, causality is often lacking. We may use proxy or associated factors to define particular states. We may use simple heuristics as our guide to action, even though we have little idea of where the causal arrows are going. Think much of psychiatry. This does not mean we are powerless, just that we are more ignorant than we would like. We are of course wedded to particular metaphysical systems.

Diagnosis might have been used in the absence of knowledge about particular interventions to attribute blame, as an explanation. If a patient behaved in this way or suffered some state, it was a divine punishment for some behaviour. Now, I may not agree with this world view, but this too is diagnosis. The theory my seem wrong, it may seem primitive, but then my ideas of physics are primitive too if they are applied to the world of the very small.

Galen thought in terms of the mean, and the treatment by opposites (hot treatments for cold; moist treatment for drying diseases etc). This all sounds slightly crazy to modern ears (although dermatologists among you will point out the latter has definite therapeutic merit within very particular skin states). Or how about the idea of therapeutic ‘signatures’. This is from Ian Hacking [1]:

Syphilis is signed by the market place where it is caught; the planet Mercury has signed the market place; the metal mercury, which bears the same name, is therefore the cure for syphilis.

As Hacking points out this allowed Paracelsus to kill lots of people simply because he knew that mercury worked. But whatever the metaphysical system linking two states, the idea of diagnosis was firmly established. Just as Newton got most things right in his physics, and most of us ignore what came after — except when we use the GPS.

Diagnosis was not limited to medicine. Our ancestors spent their lives making diagnoses about what to eat and what not to eat. Making diagnoses about what particular weather states would do to crops etc. Plumbers make diagnoses, as do any humans trying to make sense of an environment that is not static, and where we value intervention.

What may have been specific to medicine was our hangs up about whether there was something special about humans, and whether the simple rules, experimentations and demonstrations of efficacy that allowed other types of human technological progress or indeed much of everyday life, applied in the domain of disease. Successful interventions or demonstrations will have had an effect on metaphysical beliefs in the long term. And of course much of this story is tied up with the growth of that particular branch of formal knowledge we call science. 1870 is just a little late.

[1] Hacking I. The emergence of probability : A philosophical study of early ideas about probability, induction and statistical inference. Cambridge: Cambridge University Press; 1984.

[2] Jonathan Rees: Why we should let EBM rest in peace. Clinics in Dermatology (2013) 31, 806–810

“Over the past year or two, someone has been probing the defenses of the companies that run critical pieces of the Internet. These probes take the form of precisely calibrated attacks designed to determine exactly how well these companies can defend themselves, and what would be required to take them down. We don’t know who is doing this, but it feels like a large a large nation state.”

Bruce Schneller (the ‘security guru’ in the words of the Economist) at Lawfare. You use it. And it is quite possible. Worth a read in full.

The goal of the new CFF [Cystic Fibrosis Foundation, a US patient charity] Therapeutics Lab, says Preston W. Campbell III, the foundation’s CEO and president, is to generate and share tools, assays, and lead compounds, boosting its partners’ chances of finding treatments. Frustration with academic technology transfer agreements was a key motivation, he notes. University-based researchers funded by the foundation have to seek approval from their institution’s legal department before sharing assays, cells, or any intellectual property, a hurdle that can take a year to negotiate. “This was killing us,” Campbell says, “ but if we created our own laboratory, we could not only focus on the things we wanted to focus on, we could also share them freely.”  Science

Inefficiencies in medical eduction are in part borne by students. They are also borne by patients. As a medical student, I ‘delivered’ around 30 babies; I also did some episiotomies with varying degrees of supervision. As a medical registrar I put 32 pacing wires in, inserted a number of chest drains and took pleural biopsies; and put various central lines in. One of the latter interventions, led to a major complication. Things may have changed since I was a junior, but my argument may also  apply to lesser procedures: taking blood, suturing, and indeed any interaction with patients. Even a clumsy bedside manner or history taking. On the other hand, I was sometimes useful to patients. I did my elective here in Edinburgh in psychiatry on the late Prof Bob Kendell’s unit. I spent three months on PU2, and, both at the time, and looking backward, feel I contributed positively to the care of patients.

The issue about the cost of training — especially in practical matters — to patients is not easy. There is always a learning curve. We also know that in some situations a non-expert is all we can afford — think of the example of a single doctor on an Antarctic research base who might have been instructed how to pull a tooth or release a dental abscess, before they went.

The point I make is about whether procedures are genuinely part of a learning curve — that is, a curve in which the individual aims to get better and better, and will carry on with that technique throughout their professional career. Or whether the organisation of training takes little account of known career trajectories, in which case there is no learning curve, and the moral argument more suspect.

I was never going to be an obstetrician, I was never going to be a cardiologist, nor a chest physician. And I knew all that before I qualified. But I was going to need to take blood; and to do dermatological surgery at an intermediate level. Once somebody has decided on a final destination, the route has to change accordingly.

“Earlier this summer we let you know about a new subset of our HarvardX online courses that feature premium Harvard content, small cohort-based learning, higher touch with Harvard faculty and peers, and a valuable HarvardXPLUS credential. The first HarvardXPLUS courses are set to launch on September 12, and there’s still time for you to register.”

Link. And yes, they cost.

I had seen spray on tans but…

1. How much can you learn on your own, and how much do you need a teacher or coach for.
2. What taxonomy can we use to think about what you can, and what you cannot learn without a teacher or coach.
3. How do we think about ‘just-in-time’ and ‘foundational’ material, knowing that foundational usually isn’t (it is the moral hazard of teachers and institutions — or their business model).
4. There is a literature on ‘transference’ of domain knowledge. But my suspicion is that much knowledge about ‘how hospitals or GPs work’ transfers well. There is a lot of redundancy.
5. Why are we so obsessed with lengthening training, and making students do lots of detours.
6. Sage on the stage, or Hollywood, in terms of production values and strategy
7. The inefficiencies of our medical teaching are now borne by our students’ wallets.
8. Why did anybody ever think postgraduate training had much to do with undergraduate medical education.
9. Strict competency frameworks will destroy medical schools’ business models
10. There should be more than ten things to think about.

This is just a test. And thanks to Roslin design.

Well you really could not make this up. From the EFF:

On August 30, 2016, the Patent Office issued U.S. Patent No. 9,430,468, titled; “Online peer review and method.” The owner of this patent is none other than Elsevier, the giant academic publisher. When it first applied for the patent, Elsevier sought very broad claims that could have covered a wide range of online peer review. Fortunately, by the time the patent actually issued, its claims had been narrowed significantly. So, as a practical matter, the patent will be difficult to enforce. But we still think the patent is stupid, invalid, and an indictment of the system….

Before discussing the patent, it is worth considering why Elsevier might want a government granted monopoly on methods of peer review. Elsevier owns more than 2000 academic journals. It charges huge fees and sometimes imposes bundling requirements whereby universities that want certain high profile journals must buy a package including other publications. Universities, libraries, and researchers are increasingly questioning whether this model makes sense.

Avoid Elsevier. This is a world that should no longer exist.

“And still her life is a relative mess. I like the message in that: that we can tick off the boxes, and yet we still don’t quite have it together. And that’s pretty much the truth of growing up, isn’t it?”  NYT

Well this is from Renée Zellweger talking about her Bridget Jones persona. But everywhere I look now I see the great and the good from HEE and the RCP admitting that all this tick- boxing has been a disaster and has subverted medical education. They were told this years ago. It is an irony of the age that those charged with directing postgraduate medical education, are most in need of it themselves. Worse still, the postgraduate world has been allowed to infect the undergraduate world.