‘Every age thinks it’s the modern age, but this one really is.’ [Tom Stoppard]

The saying goes that you can tell something about a person by the company he keeps. If books are your company, then what you read may say something about what makes you tick (although the history of the 20th century provides plenty of examples of the love of high culture by many barbarians and butchers — medical humanists, please note). So, if I look back over the year, what sort of company have I been keeping?

Well, start with the Glenn Greenwald book about Ed Snowden and move onto Laura Poitras’s brilliant film, ‘Citizenfour’. Then look at why governments like surveillance, and why surveillance likes information monopolies, with a book I have been putting off reading for many years, Tim Wu’s magisterial treatise on the history of communication technology, The Master Switch. The latter not only serves as a primer on the relation between the control of communication, the state and the communication corporations, but opened by eyes to the way Bell (Labs/ AT&T) blocked human progress: the Kronos effect, whereby advance is retarded because it threatens those who have had a hand in creating it. If you think the internet really is different, read on and worry. Along the way, for those interested like me in tech and learning, remember:

The invention of film, wrote D. W. Griffith in the 1920s, meant that “children in the public schools will be taught practically everything by moving pictures. Certainly they will never be obliged to read history again.” In 1970, a Sloan Foundation report compared the advent of cable television to that of movable type: “the revolution now in sight may be nothing less … it may conceivably be more.”

I have read lots on education. Alison Wolf (Does Education matter?) demolishes lazy thinking relating education to innovation and wealth creation. I wish the GMC would read a little more on this theme. Rich DeMillo’s most recent book (Revolution in Higher Education) was not such an eye-opener for me as his earlier book, Abelard to Apple, but that is probably because I came to it later. For all the naysayers re MOOCs and tech, HigherEd is in a problem because it no longer represents good value for many of those who have been encouraged to go, and because its business model is falling apart. It does some things well — even very well — in comparison with many organisations, but ‘basic’ higher education — is not one of them. The finances all round are not going to get any better, and as even I got into academic print, many university VCs have a lot in common with the much derided CEOs of record companies when Napster and Steven Jobs and iTunes changed things a little. On this theme, Michael Crow’s ‘Designing the New American University’ is up there, too.

Universities, as well as financial problems, have existential problems. They have become lazy corporations, that have left ‘Donnish Dominion’ behind, and replaced it with a facade of consumerism, whilst pretending that they can still be guardians of integrity (and are worth our support for that reason, alone). Well, this is what was called Kissingeritis, or in anther context, the criticism Robert Oppenheimer received: you can be at the centre of power and ‘influential’, or you can speak the truth, but you can seldom do both within the same time frame. As yet, I haven’t had a chance to dip into my copy of ‘Reshaping the University: the rise of the regulated market in higher education’ by David Palfreyman and Ted Tapper. Lots of our UK universities think they are BMWs or Jaguars, imagining themselves close to Ivy League institutions, but the finances say otherwise, as does any scrutiny of how they have taken to looking after their academic staff or their students. Not Fiat 500s, but with effort and reform, they could be useful Golfs, but leave the rest for the glossy prospectuses.

I have been reading about medicine too, but my take on this is that there is even less serious work out there about medicine and medical education, than about our universities. De Selby got it right: ‘serious work takes over from relevance’ and besides everybody is now just too busy for serious work, let alone relevance. Indeed, the anodyne phrase that seems to end every media story about medical research, ‘more research is needed’ [subtext, please give generously], really has no place in medical education. I for one, would wish people would stop publishing papers, and instead join the dots about what we already know. It is as though we collect yet more and more studies linking smoking with poor health outcomes with smaller and smaller odds ratios, all published in journals that nobody reads, and then continue to dole out the Capstan full strength (untipped, of course) to our students. In any case, as in many walks of life, change in this area is unlikely to come from the academy, but from outside. Follow the money. Many years ago, Sydney Brenner, one of the handful of scientists who made the revolution that is modern genetics, wrote an article in Science. The series theme was the influence of Science on Society, but Brenner, true to form, looked at things differently, writing instead about the (largely pernicious) effects of society on science. Universities take note: our laboratories are not as fecund as Sydney Brenner’s.

If one thing surprises me about what I read and what I want to read — because I think it important — it is the irrelevance of much of the scientific establishment to some of out problems, a statement that I speak with some shame. Kenneth Galbraith commented (from memory) that ‘the denigration of value judgement is one of the way the scientific establishment maintains its irrelevance’. I loved the phrase when I read it but couldn’t quite ‘get it’. I do now. Tim Wu’s account of the communication industry makes no sense without the successive waves of technical advance that underpin that change. On the other hand, we learn that the way society and corporations chose to behave limited advance, and closed off ways to maximise human potential. The institutions we create, or allow to exist, all seem to me more critical than ever — for good or bad. The lesson for anybody brought up of natural science, that somehow it is all like the hero in Arrowsmith, that somehow magical discoveries by disinterested scientists will solve all our problems, is magical itself. Magical, as in mythical, or just plain untrue. Look at Jack Scannell’s work on drug pricing for a start, on why institutions as well as molecules are important.

Which sort of brings me to something else that I think important, and that is Larry Lessig’s work on institutional corruption which I have only just come across, despite having read some of his books:

“Institutional corruption is manifest when there is a systemic and strategic influence which is legal, or even currently ethical, that undermines the institution’s effectiveness by diverting it from its purpose or weakening its ability to achieve its purpose, including, to the extent relevant to its purpose, weakening either the public’s trust in that institution or the institution’s inherent trustworthiness.”

He explains:

The field of “institutional corruption” was launched to help ethics grow up.

‘To help ethics grow up‘. I wish I had said that. GMC please note.

In the final chapter of the ‘Ascent of Man’, titled ‘The long childhood’ Jacob Bronowski after 400 pages on science and the culture of science, returns to a theme he has written about elsewhere, namely the relation between integrity, science and society. Bronowski was an optimist, and yet here he is wondering if Shakespeare and Newton will become historical fossils, in the way that Homer and Euclid are now. I feel less certain in 2016, than I did at the beginning of 2015. Hopeful, but less optimistic.

” His precocious intelligence earned him a scholarship to a teacher training college in Dublin.”

Governments please note. [Fintan O’Toole in the NYRB talking about Mairtin O Cadhain].

Everywhere, it seems to me, in both medicine and education, you cannot avoid the adjective, ‘personalised’. Read on. What follows is from an old post of mine, on a site that has died. I have therefore recycled it [pun intended].  All I remember is that it was from a THE article.

The author is a freelance ghostwriter, writing essays for students. As he points out, now that software can reveal what proportion of text has been lifted from other sources, a bespoke personalised essay (rather than a generic one) is the norm. Prerequisites for employment he says are having graduated from Oxbridge or a Russell group University. He writes— and this is where the first snippet is relevant: “I operate on the assumption that the student I’m working for will have little or no personal interaction with academic staff. This means that there is only a small likelihood that the lecturer who sets and marks the questions will be familiar with the student’s style of writing.”

Orwellian, I think. When the ministry of peace is the ministry of war, a personalised service tells you that not much is personal.

 

I accumulate things to do and write about as the year goes on, and the pile in the corner of my desk gets larger and larger. As does the guilt. So this is is just an attempt at wiping away the sin.

Lovely obituary in the Economist (October 17th,2015) of the Irish playwright, Brien Friel. It ends with his words: ‘Confusion is not an ignoble condition’. Agreed. Fail, fail again……

Kids Company. The story that tells how much political patronage is still alive in corporate UK, and how much professional expertise is frowned upon by the political classes and their hangers-on. But the damage is spread wide. From the Times Higher, 17 December 2015:

However, Dr Maitland Hudson said that many academics commissioned by Kids Company has been placed in a difficult position, particularly when their work was later misrepresented by the media. Academics are encouraged to generate income via grants, so it’s quite hard to turn money down when it is offered”

Well that’s alright then.

University funding in Australia. “The independent senators ‘didn’t understand that there were any financial issues, or that we were so heavily reliant on international student fees to fund research’”. You can work out the context. This story is going to run and run in the UK, where the various cross subsidies within university finance are going to have a hard job staying beneath the radar of students and their parents — and other institutions . As Jeff Bezos would say: ‘your margin is my opportunity’.

Rethinking regulation — might less be more. Nice piece in the BMJ by Christoph Lees and Hilarie Williams. It seems — reading between the lines— that even the PSA (professional standards authority — not your prostate test) is of the view that the GMC is out of control. Wait for the GMC to start wanting to regulate school children who might choose medicine as a career. I haven’t read the report they refer to, but am just surprised that anybody with any sense can still be allowed to voice an opinion ( ‘A dog at the master’s gate predicts the ruin of the state’).

“Every doctor a scientist and a scholar’. Gee, when do these people sleep — or practice medicine. Again, I haven’t read the report but somebody surely has been drinking the kool-aid. Guzzling it more likely. (BMA news 18th April 2015).

On being the right size. Well, in this case, on why eyelashes are the length they are. Wonderful. What natural science is all about. And fun, too. (Economist February 28th, 2015).

You’re here to teach. Save the trainspotting for the weekend. David Oldfield in the Times Higher 12 February, 2015. His argument is more nuanced than the title. I am not a trainspotter, either.

A prescription for change. Article by Alastair Buchan arguing that universities should play a bigger role in postgrad medical education. Universities once did, but serious education and NHS management are uneasy bedfellows. (Times Higher 11 June 2015). Contains the usual flimflam of ‘producing the best doctors in the world’. I wondered if he was after the job (‘National Institute of Health Education’). I always say that I was clinically trained in a university department, but then came Thatcher and Griffiths. Education doesn’t scale easily, let alone when it answers to politicians. Control is the single biggest priority of the NHS and its political masters: if you allow  universities in, it tells you something bad has happened to universities.

National examination would benefit medics. More 1984 stuff from the GMC. You could spend a day or more wondering about the motives behind this short letter. Let me stick to one point. The chair of the GMC says that the ‘public would like to be reassured that, in terms of core knowledge, skills and competencies all doctors meet the same standards’. This is simply wrong, and I assume the public have more sense. Little islanders, despite all the talk of world class. As for an exam, I am open to persuasion. As ever with the GMC, the GMC is concerned about the GMC, not doctors. Doctors are just the substrate. (Times Higher, 14 May, 2015).

Practice is going to kill your creativity. Barbara Oakley in the Times Higher (April 16, 2015).

‘There is this feeling that we should make maths and science [at school] fun, because we want them to go into it. And then what happens is that students hit university and it’s like the math and science death march, and they fall right off’. There is a need in the teaching of STEM, she said to encourage ‘procedural fluency’ — the use of repetition to understand processes. ‘You would never say to someone learning the piano, ‘Practice is going to kill your creativity.’ But when it comes math and science.. it is somehow thought to ne very different, and it’s not.’

I would add that if you want to think hard about the acquisition of medical expertise, look hard at Masterchef or how some of use learned — or didn’t learn —to play a musical instrument (See Geoff Norman’s article on “Mashed potatoes and medical expertise”). We have known the basics for a long time and dare I say it: more research is not needed.

Bowing to pressure. Sad, depressing account of what has happened to teacher training / education, by Anthony Kelly (Times Higher, 12 February, 2015). I have said for a long time, with more intuition than rationality, that the destruction of teaching in the UK is what the government has in store for medicine (nursing went belly up a long time ago). The parallels between the various professions and the role of the universities in being the home for the development of professional expertise is worthy of lots of thought. Think about lawyers, medics, business MBAs and so on. I do not think anybody should be too confident of what will unfold — least of all the universities.

Delightful article by John Kay in the FT on famous quotes that aren’t — or at least nobody can track down the original source of when somebody famous is supposed to have said that they are reported to have said. The Casablanca ‘Play it again, Sam’ is a well known example (Bogart didn’t say it in the film). He also reminds that the context of any particular saying often gets lost. He writes, re that Scottish economist:

Sometimes posterity forgets the context. Adam Smith did describe how a merchant might be “led by an invisible hand to promote an end which was no part of his intention”. But the remark was not the eulogy to untrammelled free markets attributed to him by modern libertarians.

In fact, Smith was explaining that protectionism was often unnecessary because consumers and traders so often preferred to buy goods made in their home country rather than importing them.

But I also like this one, re that famous remark attributed to Nye Bevan.

No one has yet tracked down a source for the reported words of Aneurin Bevan, Shawcross’s colleague and founder of Britain’s National Health Service: “The sound of a dropped bedpan in Tredegar Hospital will reverberate round the Palace of Westminster.”

Well, a comment by Bill Ellison on the article, sheds some light:

The Times

13 March 1948, HEALTH SERVICE COMPLAINTS: MR BEVAN’S FORECAST

Mr Bevan, Minister of Health, forecast some of the the probable consequences of the inception on July 5 of the new health service measures when he spoke in London last evening at the annual meeting of the Institute of Almoners.

A situation would arise, he said, in which echoes would reverberate throughout Whitehall every time a maid kicked over a bucket in a hospital ward. (Laughter.) For a while there would be a cacophony of complaints. He continued:-

“For a while it may appear that everything is going wrong. As a matter of fact, everything will be going right, because people will be able to complain. They complain now, but no one hears about it [emphasis added]. What we will happen after July 5 is that a public megaphone will be put in the mouth of every complainant, so that it can be heard all over the country.”

Now that suddenly makes me even more in awe of Bevan’s political genius — and foresight. But also leads to some end of year blues, because in reality people are still not able to complain in any meaningful sense. The ‘public megaphone’ is drowned out by a cacophony of meaningless statistics, press advisers, commissars paid from the public purse, and the amateurs of the nobility.

“You can fix a clock, but you have to negotiate with a system.”
Alan Kay.

“‘I reviewed this dismal lad again in my rooms,’ the GP wrote. ‘He’s unhappy rather than depressed and spreads his unhappiness like a common cold. I suggest he gets a wife and some hobbies.’”

Pulse. When clinical notes were clinical notes

 

““A core part of what the NHS does” is “to contribute to economic growth…through exporting innovation and expertise internationally”. The NHS is a commercial opportunity. Health is a commodity, patients its unit of production, and the accounting of NHS success or failure will include the extent to which health is monetised globally for revenue and profit. Ken Clarke spoke about UK Trade and Investment (UKTI), a wing of government dedicated to promoting exports, and Healthcare UK, a new unit forged between UKTI and the Department of Health. The first product of Healthcare UK will be a new initiative in the Middle East, to be launched in January next year. This is the NHS today: an ever diminished, fragmented, and unaccountable health service at home, but a luxury brand to be exploited abroad.”

Richard Horton quoting Ken Clarke in the Lancet Dec 1st 2012

I like these from Marc Rosenberg (via Stephen Downes)

1. Great eLearning technology combined with bad content results in more efficiently delivered bad content.
2. eLearning that is compensation for bad documentation, tools, processes, or management will ultimately prove to be a waste of time and money.
3. When great eLearning comes up against a lousy learning culture, the culture wins every time.

Stephen Downes comments: ‘Essentially they are restatements of one of the oldest laws of computing: garbage in, garbage out (GIGO)’.

In time, the smartphone will become the device of choice for knowledge acquisition, news, training, general education, heath and transaction services. In Africa alone, 400 million smartphones will be activated in the next four years — most of those running Android.

frederic.filloux in the Monday Note.

[direct link to this aside]