The NYT offers short videos most days. I enjoy watching them, partly because I am trying to produce some very humble efforts for student teaching. I am keen to learn. I am gradually finding my way through FCPX, audio recording and how to produce simple animations. One of today’s videos is about the sound studio Skywalker Sound. Some of what is said is not surprising. Most us know how sound influences our degree of fear in scary films, and how sound and music sets action in context. And yet, the degree of sophistication and invention does surprise me. Films are very complicated giant artefacts, the result of large teams working collectively, but with a mixture of authority, vision, and emergence. Contrast this with the novel, or even the modern textbook. In the former there is a single creator at work, and accepting the need for publishers, typesetters and so on, the cast is small. Textbooks might involve more staff in their creation but, in general, I do not think most textbooks are as sophisticated or skilful as most films. A course module might not stand comparison either.

So, what has this got to do with medical education? Well, in an earlier post on the importance of design, I described my own (middle or late-life?) epiphany. In medicine the idea that you just string modules together, with lecturers who have rarely sat down together, all producing their own little snippets, is no longer sensible. A bit like trying to make sense of a William Burroughs novel. Asking externals to come to exam boards rather than being involved in the development of course material is another reflection of a broken system. So, whilst in many disciplines, an individual lecturer might produce a series of lectures, and students may indeed get used to the style, feedback and so on, for medicine I do not think this system is appropriate. Medicine is, by its nature multimedia, but is frequently delivered by people who have little oversight of what students are supposed to know. The origins of this are of course in the apprentice system: whereas postgraduate education can follow this model to a limited degree (although the various NHSs are doing their best to destroy it), much of undergraduate medicine is still sadly bums on seats in lecture theatres. Depressing, given how much the kids are paying. We need the equivalents of sound teams, video teams, animators, support staff etc. And stars!
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Another computing metaphor might be useful at this stage, but it points us in a very different direction. Based on the paradigm that pharma companies have to follow to obtain drug registration, we have assumed that guides to clinical practice have to be hierarchical and bureaucratically “quality assured.” This is most obvious in countries such as the United Kingdom (UK), where the state wishes to be the sole arbiter of how people are treated (in part because much health care is tax-payer funded but also because the state likes to assert control of health). The World Wide Web offers us another model of  (clinical) expertise, one in which the idea of a single central authority assuring the truth or falsity of statements has been replaced by a community—or cacophony, depending on one’s viewpoint—of voices. Here expertise is distributed, and the measures of truth are perhaps much more nuanced and fluid, subject to change as data and clinical experience changes. Curiously, it is this latter model, albeit using earlier methods of communication, that was the basis for the growth of scientific ideas and our interpretation of evidence about the world. It might be worth revisiting. Here

As mentioned, I am giving a talk tomorrow on research at ATRIUM (academic training in undergraduate medicine): how to get on and have some fun —assuming there is still some left to go around. Some of the references I cite are below:

Rees, J.L. (2005). The problem with academic medicine: engineering our way into and out of the mess. PLoS Medicine 2, e111.
Rees, J.L. (2002). Complex Disease and the New Clinical Sciences. Science 296, 698.
Brenner, S. (1998). The impact of society on science. Science 282, 1411-12.
Crick, F. (1988). What mad pursuit : a personal view of scientific discovery (New York: Basic Books).
Feigenbaum, E.A. (2001). Herbert A. Simon, 1916-2001. Science 291, 2107.
Goldstein, J.L. (1986). On the origin and prevention of PAIDS (Paralyzed Academic Investigator’s Disease Syndrome). J Clin Invest 78, 848-854.
Goldstein, J.L., and Brown, M.S. (1997). The clinical investigator: bewitched, bothered, and bewildered–but still beloved. J Clin Invest 99, 2803-812.
Hubel, D.H. (2009). The way biomedical research is organized has dramatically changed over the past half-century: are the changes for the better? Neuron 64, 161-63.
Hubel, D.H., and Wiesel, T.N. (2004). Brain and Visual Perception: The Story of a 25-Year Collaboration (OUP).
Pincock, S. (2007). Bjørn Aage Ibsen. The Lancet 370, 1538.
Pincock, S. (2008). Colin Murdoch. The Lancet 371, 1994.
Semm, T.A.K. (2003). a pioneer in minimally invasive surgery (Obituary). Br Med J 327, 397.
Tuffs, A. (2003). Kurt Semm. BMJ: British Medical Journal 327, 397.
Watson, J.D. (1993). Succeeding in science: some rules of thumb. Science 261, 1812-13.
Alan Kay. http://en.wikipedia.org/wiki/Alan_kay

“As an educational leader if the outcomes that I am offering are [just] information and knowledge, then I am screwed,”

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“Pace Arrowsmith, most of us find the flash of personal insight that leads to scientific advance more attractive than the gradual accrual of knowledge from giant research teams. Most of us prefer the idiosyncrasies of the quixotic Sherlock Holmes to the giant team-based logistic-rich police forces that are said to be more efficient in dealing with modern crime. Most of us prefer the idea of the personal physician to the medical production line. But, most of us would, I suspect, choose a production line Volkswagen or Toyota than a car made by a single craftsman, however skilful the latter.”  Here.

“What of attempts to improve skin cancer diagnostic skills in primary care, or to develop GP specialists as seen in Australia or the UK? There are various points to make here, and perhaps a lot of wishful thinking about how the problem could be solved if only ‘GPs’ knew more about this or that subdomain of medical knowledge. In truth, such blandishments, must be frustrating to many GPs: there are only so many hours in the day. There are studies showing that it is possible to improve diagnostic skills over the short term following organised tuition (cited in Rees (16)). To find anything else would of course be surprising: if we expose intelligent people to formal tuition or learning, we expect short-term performance to improve. But, the critical point is whether this improvement is maintained, and what aspects of performance suffer because they have been replaced by training in another domain (16). There is no free lunch. If we run a course on skin cancer, then the rheumatologists, cardiologists etc. will all want to run courses. And much of what we know about such one off tuition is that in the absence of consolidation and feedback, the benefits are short lived only. How many of us remember all the history and geography we learned at school?” Here.

It would have been possible for Wiseman to tilt his documentary toward an indictment of the administrators who are presiding over what his film represents as a probably irreversible transformation of the greatest public higher education system in the world into a relatively costly, semiprivatized, insufficiently competitive, and perennially underfunded one. He has the footage for it: the student protesters in the plaza with their idealism, earnestness, and anxiety; the administrators in their corporate offices with their cheerful enthusiasm for the police, their well-oiled public relations machinery, their savvy political calculations, and their willingness to knuckle under to budgetary constraints.

Review of ‘At Berkeley’ by Stephen Greenblatt

There is a piece in the NYRB well worth reading. The author, the distinguished physician Arthur Relman gives an account of falling down the stairs, and breaking a number of cervical vertebrae. He was on anticoagulants, and needed a tracheostomy, and suffered multiple cardiac arrests. He makes a number of very valid points, and highlights how the care provided by a  personal physician out with the hospital can be integrated with inpatient care (not by sending emails, but by the primary care physician being on the staff of the hospital). He highlights not unexpectedly, the lack of contact between doctors and patients, and the harmful side-effects of computers and the data deluge. So, we are not surprised to read:

Reading the physicians’ notes in the MGH and Spaulding records, I found only a few brief descriptions of how I felt or looked, but there were copious reports of the data from tests and monitoring devices. Conversations with my physicians were infrequent, brief, and hardly ever reported.

But he then goes on to say:

In the MGHICU the nursing care was superb; at Spaulding it was inconsistent. I had never before understood how much good nursing care contributes to patients’ safety and comfort, especially when they are very sick or disabled. This is a lesson all physicians and hospital administrators should learn. When nursing is not optimal, patient care is never good.

Well said. But really, how on earth can any physician imagine it be otherwise?

Whenever I talk to you, you always make me feel very optimistic. What worries you?

We have interlocking institutional systems that are in place solely to protect the status quo. [John Seely Brown]

I am talking next week at the ATRIUM meeting  here in Edinburgh, and musing over what to say. One perspective I wanted to mention, was the likely changes in universities relating to teaching and the influence of MOOCs, student debt, and however broadly defined, ‘value’. There is a fairly uncritical piece in the Economist on MOOCs  but some of the readers’ comments are worth a look (they reflect the landscape of viewpoint). Another point is how opting for fashionable areas in science is not always wise: Sydney Brenner wrote a piece years ago in Current Biology, on how important it was to be out of phase with much of what your colleagues do. For some reason this made me google Tim O’Shea, our principal. He has worked on the use of computers in education for a long time, and I think is the author of one of various maxims about technology in education (Q: What was the last useful technology for assisting learning? A: The blackboard, or the school bus?).

Anyway I looked of course at the UoE site, but also Wikipedia. The latter draws attention to his most recent book (he is a co-editor), ‘In Order to Learn’. I haven’t read it, so looked for it on Amazon. If you search for it, the first hit is a book by Bert Weedon on learning guitar. Small world. That was my first guitar tutor and I, and others, think there are big parallels between learning a musical instrument and acquiring high level expertise in medicine (Frank Davidoff, has written on this, as well). There is also a lesson for universities in how expertise can be acquired out with formal structures. O’Shea’s book is there however, too.