Resilience and sustainability

Hack the Planet: Tega Brain on Leaks, Glitches, and Preposterous Futures

This quote is actually from an article about washing machines, water supplies and ‘wastage’. But it just reminds me of the technical and intellectual debt that is drowning health care and the NHS

That balancing act reminds me of something engineer and professor Deb Chachra wrote in one of her newsletters. She wrote, “Sustainability always looks like underutilization when compared to resource extraction.”

UK Universities and their dismal future

The Guardian view on funding universities: the market model isn’t working | Editorial | The Guardian

But perhaps the time has come for a deeper rethink. The marketisation of the higher education sector, through the loan system, successfully expanded access and fears of social exclusion were not borne out. But the numbers are not looking good, and there has also been a significant cultural cost. Universities, increasingly run as competing businesses by overpaid vice-chancellors and a coterie of financial managers, have lost touch with the collegiate ethos that used to inform campus life. Crude systems of measurement and monitoring have eroded trust and generated false incentives, leading, for example, to grade inflation. A drive to cut costs has targeted staff pay and pensions, and created a disillusioned underclass of pitifully rewarded young academics on insecure short-term contracts. Strike action, currently taking place at the universities of Leicester and Liverpool, has become commonplace.

Removing, or greatly reducing, upfront fees and recasting the direct funding relationship between government and universities could help address such problems. The market model pioneered 10 years ago has begun to look dated and unsustainable. New thinking is needed.

Yes, I know all of this. But solutions, please. And ones that can be defended and not crapped all-over in that place 400 miles south of me.

After thirty-five years of teaching medical students dermatology the 2021 GMC’s Medical Licensing Assessment (MLA) content map makes for dispiriting reading. The document states that it sets out the core knowledge expected of those entering UK practice. It doesn’t.

My complaint is not the self-serving wish of the specialist who feels that his subject deserves more attention — I would willingly remove much of what the GMC demand. Nor is it that the document elides basic clinical terminology such as acute and chronic (in dermatology, the term refers to morphology rather than just time). Nor, bizarrely, that it omits mention of those acute dermatoses with a case-fatality rate higher than that of stroke or myocardial infarction: bullous pemphigoid, pemphigus, and Stevens-Johnson syndrome/Toxic Epidermal Necrolysis are curiously absent. No, my frustrations lie with the fact that the approach taken by the GMC, whilst superficially attractive, reveals a lack of insight into, and, knowledge of medicine and expertise in medicine. The whole GMC perspective, based on a lack of domain expertise, is that somehow they can regulate anything. That somehow there is a formula for ‘how to regulate’. This week, medicine; next week, the Civil Aviation Authority. The world is not like that — well it shouldn’t be.

Making a diagnosis can be considered a categorisation task in which you not only need to know about the positive features of the index diagnosis, but also those features of differential diagnoses that are absent in the index case (for Sherlock Holmes aficionados, the latter correspond to the ‘curious incident of the dog in the night’ issue). It is this characteristic that underpins all the traditional ‘compare and contrast’ questions, or the hallowed ‘list the differentials, and then strike them off one-by-one’.

Take melanoma, which the MLA content guide includes. Melanoma diagnosis requires accounting for both positive and negative features. For the negative features, you have to know about the diagnostic features of the common differentials that are not found in melanomas. This entails knowing something about the differentials, and, as the saying goes, if you can’t name them, you can’t see them. A back of the envelope calculation: for every single case of melanoma there are a quarter of a million cases made up of five to ten diagnostic classes that are not melanomas. These include melanocytic nevi, solar lentigines, and seborrhoeic keratoses; these lesions are ubiquitous in any adult. But the MLA fails to mention them. What is a student to make of this? Do they need to learn about them or not? Or are they to be left with the impression that a pigmented lesion that has increased in size and changed colour is most likely a melanomas (answer:false).

Second, the guide essentially provides a list of nouns, with little in the way of modifiers. Students should know about ‘acute rashes’ and ‘chronic rashes‘ — terms I should say that jar on the ear of any domain expert — but which conditions are we talking about, and exactly what about each of these conditions should students know?

In some domains of knowledge it is indeed possible to define an ability or skill succinctly. For instance, in mathematics, you might want students to be able to solve first-order differential equations. The competence is simply stated, and the examiner can choose from an almost infinite number of permutations. If we were to think about this in information theory terms, we would say we can highly compress in a faithful (lossless) way what we want students to know. But medicine is not like this.

Take psoriasis as another example from the MLA. Once we move beyond expecting students to know how to spell the word watch what happens as you try to define all those features of psoriasis you wish them to know about. By the time you have you finished listing what exactly you want a student to know, you have essentially written the textbook chapter. We are unable to match the clever data compression algorithms that generate MP3 formats or photograph compressions. Medical texts do indeed contain lots of annoying details — no E=MC2 for us — but it is these details that constitute domain expertise. But we can all agree, that we can alter the chapter length as an explicit function of what we want students to know.

Once you move to a national syllabus (and for tests of professional competence, I am a fan) you need to replace what you have lost; namely, the far more explicit ‘local’ guides such as ‘read my lecture notes’ or ‘use this book but skip chapters x, y and z’ that students could once rely on. The most interesting question is whether this is now better done at the level of the individual medical school or, as for many non-medical professional qualifications, at the national level.

Finally, many year ago, Michael Power, in his book, The Audit Society: Rituals of Verification demolished the sort of thinking that characterises the whole GMC mindset. As the BMJ once said, there is little in British medicine that the GMC cannot make worse. Pity the poor students.

The philosopher Stuart Hampshire served in British military intelligence during the Second World War. When we were colleagues at Princeton he told me about the following incident, which must have taken place shortly a)er the Normandy landings. The French Resistance had captured an important collaborator, who was thought to have information that would be useful to the Allies. Hampshire was sent to interrogate him. When he arrived, the head of the Resistance unit told Hampshire he could question the man, but that when he was through they were going to shoot him: that’s what they always did with these people. He then le) Hampshire alone with the prisoner. The man said immediately that he would tell Hampshire nothing unless Hampshire guaranteed he would be turned over to the British. Hampshire replied that he could not give such a guarantee. So the man told him nothing before he was shot by the French.

Another philosopher, when I told him this story, commented drily that what it showed was that Hampshire was a very poor choice for the assignment.

LRB Vol. 43 No. 11 · 3 June 2021, Types of Intuition, by Thomas Nagel.

How ‘creative destruction’ drives innovation and prosperity | Financial Times

From time to time, I vow not to read any more comments on the FT website. Trolls aside, I clearly live in a different universe. But then I return. It is indeed a signal-noise problem, but one in which the weighting has to be such that the fresh shoots are not overlooked. I know nothing about Paul A Myers, and I assume he lives in the US, but over the years you he has given me pause for thought on many occasions. One recent example below.

Comment from Paul A Myers

Science-based innovation largely comes out of the base of 90 research universities. One can risk an over-generalization and say there are no “universities” in a non-constitutional democratic country, or authoritarian regime. Engineering institutes maybe, but not research universities. Research is serendipity and quirky; engineering is regular and reliable. Engineering loves rules; research loves breaking them. The two fields are similar but worship at different altars.

This contrast is also true of medicine and science. Medicine is regulated to hell and back — badly, often — but I like my planes that way too. But, in John Naughton’s words, if you want great research, buy Aeron chairs, and hide the costs off the balance sheet lest the accountants start discounting all the possible futures.

Keyboard warriors and the reverse Voltaire

We are living through a time of online outrage and increasing irrationalism, and the combination has not been a happy one for public discussion. Generally, shallow emotion seems to be in the driving seat for many keyboard warriors: not the slow burn of genuine anger that fuels the prolonged, difficult pursuit of a worthwhile goal, but rather a feel-good performative outrage whose main expression is typing furious snark onto a computer screen before switching over to Netflix. [emphasis added]

Material Girls, by Kathleen Stock.

And applicable to a lot more than the topic of her excellent book. Sometimes, it takes a philosopher to spell out exactly what people are saying. She also introduced me to the reverse Voltaire from Mary Leng

I agree with what you have to say, but will fight to the death to prevent you from saying it.

The following is from Pulse, a magazine that is aimed at GPs. My point is not so much about the specifics but a more general point.

Headache, runny nose and sore throat top three symptoms of Delta variant, says researcher – Pulse Today

Professor Spector said cases were rising exponentially and people who have only had one vaccine dose should not be complacent.

The UK really does now have a problem and we’ll probably be seeing, in a week, 20,000 cases and by 21st June well in excess of that number,’ he said. ‘Most of these infections are occurring in unvaccinated people. We’re only seeing slight increases in the vaccinated group and most of those in the single vaccinated group,’ he said.

He goes on to say:

Covid is also acting differently now. Its more like a bad cold in this younger population and people don’t realise that and it hasn’t come across in any of the government information.This means that people might think they’ve got some sort of seasonal cold and they still go out to parties and might spread around to six other people and we think this is fuelling a lot of the problem.

He added:

The number one symptom is headache, followed by runny nose, sore throat and fever. Not the old classic symptoms. We don’t see loss of smell in the top ten any more, this variant seems to be working slightly differently.

He advised people:

who were feeling unwell to stay at home for a few days, use lateral flow tests with a confirmation PCR test if they get a positive result.

Now comes the boilerplate Orwellian response from the Department of Health and Social Care

[A] spokesperson said: ‘Everyone in England, regardless of whether they are showing symptoms, can now access rapid testing twice a week for free, in line with clinical guidance.

Experts keep the symptoms of Covid-19 under constant review and anyone experiencing the key symptoms – a high temperature, a new continuous cough, or a loss or change to sense of smell or taste – should get a PCR test as soon as possible and immediately self-isolate along with their household.’ [emphasis added]

Two points:

1. The spokesperson, as usual, is not named nor are the credentials of this person available. How are we to assess their competence or reliability? At least you can look Prof Spector up and check out his work.
2. Following on from the first point, which experts are we talking about? Most expertise, we know, is not within the Dept of Health. One of the most interesting features of the pandemic has been the recognition that the government nor the state (including the Dept of Health) have a monopoly on knowledge. Of course, we know they will seek to conceal and dissemble for political reasons. But the fact remains that many people now appreciate that knowledge is diffused more widely within society. David King and his alternative SAGE group have played an important role — beyond just Covid.

The following excerpts are from a letter in the FT from Professor Rachel Jenkins from Kings College, London.

Letter: West’s wooing of medical staff weakens pandemic response | Financial Times

An effective pandemic response capability requires such a framework to give legal bite to the 2010 WHO code of practice on how health personnel are recruited globally — something with which rich countries, especially the UK, have singularly failed to comply.

The code recommends that member states discourage active recruitment from so-called low and middle income countries facing critical shortages of health workers; that they never recruit from the 57 poorest countries and create their own sustainable workforce through workforce planning, education, training and retention strategies.

The OECD club of rich nations recently reported that the number of migrant doctors and nurses from low and middle income countries working in OECD member states had increased by 60 per cent over the last 20 years. This trend has been further exacerbated by the pandemic, as rich countries have deliberately loosened their health worker recruitment requirements.

The UK’s long standing failure to train adequate numbers of medical students and to show global leadership in reversing this enormous subsidy of skilled health workers from poor countries to rich countries is not only a national disgrace.

I have thought about this issue for years. Thought might not be the right word, however, as I have never worked out the ‘why’ of what is going on. I do not know the correct figure, but from memory perhaps 40% of UK practising doctors trained overseas. Why? A few thoughts.

1. People argue that it is extremely expensive to train doctors. I do not find this a convincing argument. First, I do not believe the government’s figures which are top-down flows, rather than costs identifiable at the coal-face. Second, even if I did believe the government’s figures, a crucial question remains: does it need to be this expensive? I don’t think it does. Of course, that the argument is mistaken, doesn’t mean that it cannot be widely quoted or used for political purposes.
2. The more doctors you have, the higher health care expenditure will be. I suspect that is something to this argument, and it will appeal to chancellors. But of course, the issue is not that we cap doctor numbers, but that we don’t train enough to begin with. Still, I wouldn’t dismiss this line of thinking out of hand.
3. I don’t think you can predict how many doctors you need. Not just for the future, but for any time-point. Sorry. But of course you can make mistakes of varying size and direction.
4. Pace the late Henry Miller, I would encourage medical graduates to look at the possibilities of working outwith the UK. Some might like it.
5. I wonder why people think this whole topic has anything to do with the government. They may be the problem rather than the solution. Besides, if we gave the ‘tuition’ money directly to the students, it might be spent more prudently.
   

No mothers’ milk here

Nestlé document says majority of its food portfolio is unhealthy | Financial Times

Nestlé document says majority of its food portfolio is unhealthy

An internal company presentation acknowledges more than 60% of products do not meet ‘recognised definition of health’.

No surprises here, then.

It is one of dermatology’s tedious and fun facts that, in contradistinction to say scabies or head lice, you treat body lice by treating not the patient (directly) but the clothing. The pharmacological agent is a washing machine. But the excerpt quoted below tells you something wonderful about science: you get things out that you never expected. Spontaneous generation — not in the real world — but in the world of ideas. Well, almost.

How clothing and climate change kickstarted agriculture | Aeon Essays

Scientific efforts to shed light on the prehistory of clothes have received an unexpected boost from another line of research, the study of clothing lice, or body lice. These blood-sucking insects make their home mainly on clothes and they evolved from head lice when people began to use clothes on a regular basis. Research teams in Germany and the United States analysed the genomes of head and clothing lice to estimate when the clothing parasites split from the head ones. One advantage of the lice research is that the results are independent from other sources of evidence about the origin of clothes, such as archaeology and palaeoclimatology. The German team, led by Mark Stoneking at the Max Planck Institute for Evolutionary Anthropology, came up with a date of 70,000 years ago, revised to 100,000 years ago, early in the last ice age. The US team led by David Reed at the University of Florida reported a similar date of around 80,000 years ago, and maybe as early as 170,000 years ago during the previous ice age. These findings from the lice research suggest that our habit of wearing clothes was established quite late in hominin evolution.