A great take on medical career progression from SLOMO. http://nyti.ms/1s0fcv2

Yet Coursera, which has raised at least US$65 million in investment capital, still faces the challenge of generating enough revenue to support itself as a private company.

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A couple of things interested me in the Times Higher this week. Echoes of memes I have come across before, but given an edge because of some work by Derek Muller I chanced upon via Kelly Walsh.

The first was an article by Jack Grove quoting work showing that certain types of student feedback on teaching quality tend to reduce learning. I have come across similar findings before, but I do not know the primary literature well. Of course it is not at all surprising. I think it was Clark Glymour who quoted that every time you put an equation in a lecture to those enrolled on degrees that are viewed as being non-mathematically challenging, then student evaluations of lecturers go down. If you tie this sort of silly feedback to staff progression or reward then you are on a race to the bottom. I think the phenomenon is real, and at the softer edge, widespread. Learning is hard, and should be challenging. The pleasure and reward of mastery, only come with effort. The teacher and learner share an asymmetrical relationship.

The second article, brought a smile to my face, because my own university—like most others I imagine— is anxious about what students say about it in the National Students Survey (NSS). Economics students at Manchester have been campaigning for their course to give greater prominence to alternative theories, especially in the light of the 2008 financial crash. They are asking students to withhold filling in their NSS feedback until a decision is reached about including a course with the title ‘Bubbles, Panics and Crashes’. The students are quoted:

The university is very keen to get students to fill out the NSS, saying that they take their feedback very seriously – but this approach does not always seem to translate to non-NSS forms of feedback, like our petition, which is quite sad…

(more…)

 It’s understandable that it should be demanding: most of us, if we were to have our brains cut open, would prefer it be done by someone who prioritises their work over their personal life. As a trainee I realised that I had too many other interests to be a good neurosurgeon, and quit for emergency medicine – a tranquil backwater by comparison.

 

From a review, of ‘Do no harm’ by Henry Marsh, in the Guardian. I think it is increasingly hard to explain to many, that for many walks of medical life, part time working may be suboptimal. The next issue, is how academics are to figure in all of this?  It was David Hubel, the Nobel Laureate, who qualified in medicine but did not practice, who pointed out that the best doctors see more patients: there is he believed (as I do) a relation between clinical load, and competence. The caveats relate to, breadth of practice, and how you ensure that the hierarchy of practice does not waste scarce high-level expertise on cases that do not require it. I think we are getting these things wrong.

Of the 401 residents who received the e-mailed survey, 226 (56.3%) completed it. Of these, 97.7% reported spending at least one hour per week engaging in extracurricular education, and 34.5% reported spending two to four hours per week (P < .001). Time listening to podcasts was the most popular (reported by 35.0% of residents), followed by reading textbooks (33.6%) and searching Google (21.4%; P < .001). Residents endorsed podcasts as the most beneficial (endorsed by 70.3%) compared with textbooks (endorsed by 54.3%), journals (36.5%), and Google (33.8%; P < .001). Most respondents reported evaluating the quality of evidence or reviewing references “rarely” or less than half the time. A majority (80.0%) selected the topics they accessed based on recent clinical encounters.

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I believe the problems with the fourth year of medical school may reflect a larger problem—the failure to articulate a vision for the outcome of medical school education.

 

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I was musing over this article, party because it is a longstanding interest of mine—how do we acquire useful new knowledge— but also in the context of this blog on medical education, how do we get across to students how medical advance has occurred. Without getting into the ‘what can we learn from history’ subroutine, I think the topic important, and one that we cannot assume students will learn to think deeply about, without some guidance or prompting. To my mind, the role of education here is the classic one: as a detergent to propaganda.

The editorial describes changes at the mental health part of NIH (NIMH) in which the new director has made clear that to be funded, clinical trials have to include some test of the underlying biological mechanism. The line is that too many trials are black-box tests, in which if the results are negative, nothing is learned. ( It is suggested that 50% of the studies currently funded, would not be funded if submitted as new grant proposals at some future time). I think they are targeting the sort of pragmatic NHS style RCT which I find so depressing. The reason is simple: without a construct, or a genuine scientific hypothesis (and I do not mean a statistical one), we have no idea whether the conclusions of any study will apply at any future time, or in any other population. And a cognate fact is that we know trials are noisy and often unreliable guides to what is going on. Fisher warned of this nearly a century ago: we tend to try and rely on statistics when we know little about what is really going on, when what we need is more thinking, and much more repetition.

As it is, we often capture very little of the routine clinical encounter in many clinical trials. They are guides to what is going on, not rules to tell us how to behave. If the effects are very large, we can perhaps ignore much of this. But so often, we only conduct large studies, because the effect sizes are so small. If we think about it in simple terms, the R2 values are far too low: most of the variance is random, and unexplained. They are not good experiments and, it is no surprise, that we are finding out that so many papers published are wrong. Most RCT do not present the information this way, because it would be apparent we know little about what will happen to our patients. Not always, however. Systemic retinoids for acne have, I suspect, an NNT of close to 1. But even there, we had a clear demonstration of efficacy, before we had much insight into mechanism —but researchers went searching to complete the circle—not to the next RCT in a different domain.
However, what the editorial dismisses, is what I would most want to get across to students. The article (discussing psychiatric drugs) states that:

By the early 1990s, the pharmaceutical industry had discovered — mostly through luck — a handful of drug classes that today account for most mental-health prescriptions.

This is a real travesty, and again supports my adage that Nature doesn’t really understand medical research or medicine. Many of the leads were not luck, but the results of astute clinicians / pharmacologists interested in what happened to their patients. Not so much those immersed in the use of rating scales, or obsessed by assuming anything interesting must be due to chance, but acute observers that provided insights worth following by pharma. Calling this luck, is like saying Charles Darwin was just lucky (although I would accept Wallace was deeply unlucky). This for me is just another representation of the master clinician, one whose expertise is based around a knowledge of patients, and who thinks about what happens to them. This is a style of medicine we are in danger of losing. Students should know that the obsession of thinking about patients is what underpins and drives clinical advance. This is not at the expense of sensible clinical experiments, or wet-bench work, just an acknowledgement that medicine has its own intellectual heartlands, and we need to communicate this to the next generation, because it is in danger of being  killed off by a pincer movement of ‘protocols’ on the one hand, and a confusion that biology and medicine are synonymous, on the other. As far as discovery in psychiatry is concerned, few can equal David Healy for explaining how we got where we did. For some other areas, see what I wrote in Science over 10 years ago. The problem for the undergraduate teacher is how to integrate real knowledge of statistics and experimental design, with a knowledge of how genuine clinical advance occurs.

One of my old bosses always said that if you have more than a 3 arrows on a slide, you don’t know what is going on. The context was very much classical medical research, but I think there is something to be said for his scepticism. There is a quote from Paul Valery, I think to the effect of: that which is simple, is wrong; that which is complicated is useless. I looked at this whiteboard content and wondered how much it reminded me of med ed gone wrong. More HR speak, than education. The whiteboard was seen in a gym, and I think referred to dance.

Professor Cooper described a “very special pedagogy” at the university, based on face-to-face teaching, “high contact hours” and “intensive problem-solving”

 

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