Brittany Bronson is an English instructor at the University of Nevada, Las Vegas, a restaurant server and a contributing opinion writer.

A byline from an article in the NYT on the value and job prospects of those with a degree.

[direct link to this aside] 

 

John Nash has died. The NYT says:

Dr. Nash was widely regarded as one of the great mathematicians of the 20th century, known for the originality of his thinking and for his fearlessness in wrestling down problems so difficult few others dared tackle them. A one-sentence letter written in support of his application to Princeton’s doctoral program in math said simply, “This man is a genius.”

Well, thank God he got through before the current tick-boxing charade crippled much of higher ed and the NHS.

[direct link to this aside] 

Reviewed in the NYT, a quote I should never have forgotten. The book, ‘Do No Harm’, by Henry Marsh, remains the book all medical students should read. (And I will only say that once every five years).

Clinical practice is becoming a theater of the absurd for patients as well. Hospital charts are filled with N.H.S. forms detailing irrelevant aspects of care. Searching for a patient’s operative note, Marsh finds documentation she passed a “Type 4 turd.” He shows her an elaborate stool chart “colored a somber and appropriate brown, each sheet with a graphically illustrated guide to the seven different types of turd. . . . She looked at the document with disbelief and burst out laughing.”

And as to what medicine is:

He dismisses the popular notion that surgery is a mix of art and science. “I have always found this rather pretentious, and prefer to see what I do as a practical craft. Clipping aneurysms is a skill, and one that takes years to learn.” This is the journeyman nature of operating, an iterative process that ultimately results in earned expertise

Well, for me the crisis in modern medicine is to do with this very topic: expertise and how well distributed it is in professional practice. To paraphrase Keynes wanting economists to be as useful as dentists, I too wish doctors were always as expert as the travelling  journeyman. Too much reflection, and lofty verbiage, serves us—and out patients— ill.

[direct link to this aside]

Lisa Rosenbaum, in a well argued article (NEJM) about financial and industry bias and physicians, recalls:

I would like to say I was just following the guidelines, that I’d read the many trials addressing the optimal approach to reperfusion under these circumstances and was thinking only about the patient. But deep down, I know my assessment may have been clouded by a secondary interest, and it wasn’t stock in the manufacturer of a fibrinolytic agent. Rather, it was sleep — an area where my own best interests were clear. If the patient received fibrinolytics and reperfusion was successful, I could admit him when he arrived and then go to bed; catheterization could wait until the next day. If, instead, he was transferred for PCI, by the time he was reperfused, settled in the coronary care unit, and I had pulled the catheter sheath as required a few hours after the procedure, the night would be over.

Sleep. This rings true to me. Much as I am suspicious of pharma advertising, doctors own motivations may be a bigger problem — and in any case, doctors are downstream of pharma, and therefore in a position to correct any wrong. Large amounts of health care expenditure reflect variations in practice linked — not to sleep, as in this example — but money.

The $2.6 Billion Pill — Methodologic and Policy Considerations. Jerry Avorn in the NEJM. Understated article pointing out the figures often used to justify drug prices are hidden, and tricky to accept at face value. And that help of the cost relates to capital costs, figured at over 10% per year, whereas bonds issued by drug companies only pay 1–5%. As has been said before, Pharma is doing its very best to enjoy the same reputation as Banks now have. It was not always this way, and they were profitable too, then.

I do hate agreeing with Richard Smith, but I think he is right when he says “I spoke at the centenary meeting of the MJA last year, and my core argument was that the time of journals as conduits for publishing science is coming to an end”. The context is that the Australian Medical Association keeps sacking its editors, and the reasoning appears to be about money (or at least morality versus money). Journals are major sources on income for many clinical societies, together with annual meetings. They need to plan for when both sources of income dry up. I argued this over 15 years ago and — you will point out — it hasn’t happened yet. But it will ( if only in large part). Of course, what will not want to accept the end of journals, will be the vast audit culture of UK Higher Ed.

Is the ‘closed’ mindset of the Open Educational Resources community its own worst enemy? Donald Clark makes lots of great points. A few quotes: “ I still encounter fierce resistance and an almost visceral dislike of Wikipedia by professional educators, yet universal acclaim by learners and users; Rather than celebrate the existence MOOCs, many educatiors immediately engaged in a guerrilla war against either the quality of the content or the ‘privatisation’ of education; More focus on saving costs would not be ‘managerialism’ but an honest attempt to lower the cost of education, which we know is spiralling out of control. Education (not information) wants to be free. “ Finally, a new one on me: CAVE dwellers (colleagues against virtually everything)

Message to My Freshman Students. Keith M Parsons. “However, things are very different for a university professor. It is no part of my job to make you learn. At university, learning is your job — and yours alone. My job is to lead you to the fountain of knowledge. Whether you drink deeply or only gargle is entirely up to you.”

Adjunct teaching: For love of the lecture. Nature. “Before and after her classes, Finley advises and tutors students, a commitment for which she receives no compensation. “I’m one of the first professors these students have, and I love it,” she says. “But I’m not paid for those hours, even though those are the hours I remember the most. Financially, it’s not easy.” Welcome to Baumol’s law, and the business model that now underpins most service industries.

U.S. Will Pay Med Schools To Reduce Glut of Doctors. Well this is from 1997, but made me smile. No doctors, no patients. Think of the savings.

 There is a review of Oliver Sack’s memoirs here. I  haven’t read his later books, but loved his earlier ones. And for me, the best ( and best, as in outrageously good) recent book about medicine was Henry Marsh’s, Do No Harm. I find it hard to imagine that either of these lives could now be lived. And medicine— and our world— is much the poorer for it. When we choose students, so obsessed are we with the avoidance of risk, that we have forgotten that the best defence against whatever adversity the future might throw against us, is diversity. Two books,  two lives, and a sense of ennui.

[direct link to this aside] 

I go this figure from here, and the source is here. I am trying to get my head around what it really means on the ground.

 

BB King has died. What a life.

“I was a regular hand when I was seven. I picked cotton. I drove tractors. Children grew up not thinking that this is what they must do. We thought this was the thing to do to help your family,” he said.

When the weather was bad and he couldn’t work in the cotton fields, he walked 10 miles to a one-room school before dropping out in the 10th grade.

I saw him just once, on a double bill with Miles Davis in Vienna, sometime in 86/87. Just listen: one note fills.

“We thought if you found the gene that caused a disease you would simply be able to ‘drug it’. The technology had great promise, but then we realised it would take decades.”

This is from an article in the FT about biotech. The quote has more to do with layering dishonesty on dishonesty, than insight. Nobody who knew anything about disease thought that finding genes was a quick way to improving care. Rather, what those who professed this belief were doing, was talking up a movement, only to cash in their shares before the bubble burst, which most of those on the inside were aware would happen. This was always an investor strategy, rather than a credible view about science or medicine. There will be more bubbles. Here is another.

More than half a million Americans consumed at least $50,000 worth of prescription drugs last year, a jump of 63 per cent compared to a year earlier, …The number of Americans taking at least $100,000 worth of prescription drugs jumped almost threefold to 139,000

It can’t go on. FT [direct link to this aside]