There is sometimes a prejudice in medical education that somehow teaching at the bedside is always best. Of course most medical encounters are not at the bedside (any more) simply because most clinical encounters are not on wards, but in offices, whether the offices are in hospitals or elsewhere. The arguments for the bedside include tradition, but also reflect the fear that medical education will be expropriated from the clinical context. I have a lot of sympathy with the latter view, but it will sometimes lead to error.

Yesterday, I talked about the Dermofit App, to which I contributed. One of the rationales for this whole approach almost a dozen years ago now, was my belated realisation that clinical exposure — however intense — in dermatology might not be as efficient as a learning environment in a virtual world. In dermatology, simulation is over one and a half centuries old, and the history of this simulation, tracks the development of technology. It is just that this simulation relies on something we have got used to because it is all around us: high quality graphics. Pictures of lesions.

Several years later we published a paper, exploring this. We wrote:

“The overwhelming majority of students 82% (n = 41) did not see an example of each of the three major skin cancers (BCC, SCC, melanoma) and only a single student (2%) witnessed two examples of each. The percentage of students witnessing 1, >3 and >5 examples is given for each of the 16 lesions and demonstrates that there was not only a lack of breadth but also of depth to the students’ exposure.”

In one sense this is all very obvious. We know that (perceptual) classification tasks require practice, and that practice requires multiple training examples. The training signal: noise ratio can be higher in the virtual world, and it is easier to manipulate events in the virtual world. If the quip is that technology is everything that gets invented after your teenage years, we don’t recognise the obvious technology here simply because it is has been around so long. It is just that silicon really allows it to be done so much better. The caveat is whether the business model allows this.

Students will prefer the clinic, for reasons I understand. But they will often be to wrong to do so.

The App version of Dermofit is on the App store. Here is a link to a link. I have only just started to play around with it. The App was a commercialisation of some work we did here in Edinburgh, between myself and and Bob Fisher in Informatics. If you search my main site reestheskin.me using the keyword ‘dermofit’ you will find a little more about it and the work that led up to it. It is for iPad only. [Yes, I stand to benefit  from any sales, but I do not think I will be giving up the day job anytime soon]. I will write another time about the ‘why’ and rationale behind this whole approach.

The (medical) future is here, just unevenly distributed

The lessons from Glybera, the first gene therapy to be sold in Europe, still loom large. It cures a genetic condition that causes a dangerously high amount of fat to build up in the blood system. Priced at $1m, the product has only been bought once since 2012 and stands out as a commercial disaster. Economist

Roger Schank is speaking at OEB 2016, and there is a post from him here on the OEB site.

His second sentence is:

Sorry to be a downer, but technology will change nothing if what is meant by technology is that we have new ways of delivering the same old material.

His suggestions include:

• Eliminating all lectures. No one can listen to someone talk for an hour and get much out of it.
• Creating a data base of stories (a minute and a half maximum length) that are the kinds of things people tell each other in natural conversations that produce recognition in the listener about the potential use of that advice.
• Creating virtual experiences where learners get to pursue their interests in a world that reacts to what they do. If you want to be a fireman when you are ten years old, then you should get to be one (virtually) for as long as you like it. If you think you want to become a doctor, practice when you are ten on virtual patients and get advice from real doctors (in the form of video stories told just in time) when you make a mistake or ask for help.
• Understanding that real teaching involves mentoring. When you have an idea or are trying something out, it is always a good idea to have someone available to ask a question. My daughter ran up the stairs to ask me a question when she was five. After I answered she said “I will be back when I need you again.” And she always has come back when she needs me again. Good parents are natural mentors. They never sit their kids down and give them an hour lecture. Teachers cannot be mentors typically because they have too many students to deal with at the same time and these students are typically not pursing goals they have chosen for themselves.

He goes on to argue how AI / tech can help.

I can agree with much, if not all of this (excepting the ten year old bit, if taken too literally). And building simulators of the ‘real world’ is where we need to be. But I still wrestle with what is foundational and how much preloaded material students need in order to allow them to make sense of the real world (‘preloaded material’, yes, I can hear the hackles…)

You might divide learning into ‘just-in-time’ and ‘foundational’. Foundational rightly has a bad name because most foundational learning is not foundational at all, but often reflects the prejudices of those who benefit from selling particular content. Medical degrees are stuffed full of foundational stuff that is nothing of the kind.

In medicine, you learn your craft by doing it, by seeing patients and diagnosing their ailments in the company of experts, and seeing what happens to them (supplemented by learning about what has happened to others); and by going back to the books and foundational concepts continually. But there is a framework that creates the clinical worldview, and that worldview has a language, that requires immersion.

One (and only one)  key goal of medical school is to enable to you to function in a clinical environment such that you can make sense of it, and learn from it. But that is not available to a novice, however bright, without a lot of ‘preloaded’ baggage. The question is about what the balance is between ‘preloaded’ and ‘just-in-time’. I think we obsess over the former and need to shift much more to the latter. But I do not know exactly how it will look in the end, although I know the direction of travel that is needed.

And yes, tech can help this, but not when PowerPoint is involved. He is right there, and has been for a long time.

[Alice Gopnik, in one of the John Brockman edited books (I think), remarked that although  she had spent much of her professional life studying how babies make sense of the world, little of any of these learning insights made it into how she delivered material to her university students or how they learned. Three years of lectures on cracking eggs, and then in the fourth, you get to do it.]

Terminology is a big problem in dermatology, and not just for dermatologists or other doctors. Years ago, many doctors avoided referring to basal cell carcinomas (BCC) as cancers. The reasons are obvious: whilst they are invasive and are carcinomas, their behaviour puts them in a class of their own. Once you say carcinoma to many patients, the baggage is so large, that you must then give a mini lecture explaining the inadequacy of generic terminology. And you then worry whether they believe you entirely. When the newspapers run the summer stories, what sort of cancer are they talking about: BCC or melanoma? Anyway, my point is that diagnosis is both positive and negative. Negative, in the sense that you have to explain what any entity is not.

I was reminded of this when I say a patient from East Asia for whom English was perhaps a second or third language. She had, what was for her, a frightening pigmented lesion. Fortunately it was medically banal and harmless. I gave the ‘positive name’, and then outlined the list of  ‘negatives’: it wasn’t this, it wasn’t that etc. Suddenly, her eyes lit up, and a smile crossed her face. ‘I’m safe’ she said. Yes.

“Being in the hospital is horrible. They woke me up at 4:00 am once to ask whether I was sleeping well.”

Via Philip Greenspun, describing a friend with a terminal disease, and why he wanted to avoid chemo.

A comment which I will repost here, on a superb essay by Bruce Charlton over on the Winnower.

“This is a terrific essay. The keystone of science’s power and the continued survival of a civilisation based on — and at the mercy of — science, is contained in the following:

‘As Jacob Bronowski (1956) said – in science truth is all-of-a-piece: either we are truthful always and about everything; or else the dishonesty ramifies, the rot spreads, and rapidly we are being honest about nothing.’

External audit, as we have seen over the last quarter century in many human domains, does not work. All too often it is merely a tool for rendering deceit invisible. Integrity is not a bolt on for our survival, but a bit of our biological machinery that is struggling against the loss of the ‘personal’.

If we look back to the writings of Merton, Lewis Thomas, Peter Medawar, John Ziman, and the like, it is clear we lack a coherent and deep view of what has happened to modern science and — because science is integral to the modern world — our civilisation. This essay sets the tone for what must follow.”

10 similarities between Higher Education and the Catholic Church on the eve of the Reformation? 

Ivan Illich might be concerned with at least one half of this comparison. But it is difficult to read it without feeling a little twinge of guilt. Short of original sin, of course. Donald Clark, in fine icon smashing form.

“The idea of ranking institutions skews every aspect of the academic marketplace.” [link] Rich DeMillo.

A trio of posts (here, here and here) on university ranking, the TEF and value. Essentially, all about market distortion and misinformation. Or chaos, to be more charitable.

“Johnson deftly states, “the curse of this age of microspecialization and the proliferation of ‘’omics’ is to separate the ridiculome from the relevantome.””

From a review of George Johnson’s ‘The Cancer Chronicles’ in Science.