One thing that sticks with me from medical school onwards (both as student and faculty) is the partisan nature of specialties. Most of this is harmless fun: my organ (skin, liver, kidney etc) is bigger than your organ; the brain is more complicated than any other organ and therefore neurologists must be smarter than everybody else (although curiously this doesn’t seem to stretch to neurosurgeons — at least when neurologists are talking). Let’s call it organ imperialism. The humour of little boys judging their vitality by how high they can p*** up the wall. There are more vital things to get angry about.

There are however some darker sides to this professional ethnicity. Doctors indulging in advocacy for particular patient groups can often seem like doctors wishing their own unit or disease of interest receives more resources. A salient example in dermatology is the way that NHS resources for cancer (or children) frequently trump other demands. It is easier to lobby successfully for skin cancer¹ than acne or hair loss in the absence of any meaningful attempt to weigh patient suffering (or just to assume it is self-evident)². The contrast between paediatrics and geriatrics is often informative about underlying values.

One area that does worry me more is the encroachment of politics on medical education. I am thinking in particular on a priori claims about the superiority of certain models of care, or the attempts to subvert student choice of career in the name of what the ‘NHS needs’.

Undergraduate medical education should be both scholarly and intellectually neutral as to how health care is organised. We should of course introduce students to the various systems, and encourage them to criticise them. We should teach them to be analytical, and to understand the various reasons why people have chosen different systems (or how their views are manipulated). But we should be neutral in the sense that judgments need to be based on rational argument rather than slogans, and that students must be able to argue based on evidence.

I would say the same about career choice. Our primary duty in a university is to students. If a university were to demand that their graduates in computing were only to work for a British computing company and confine themselves to topics of ‘national importance’, or that its graduates in economics were only to work for the public rather than the public sector, they would no longer be taken seriously as an educational institution. And rightly so. Medicine should be no different.

1. And note my clinical interests were focussed on skin cancer. ↩
2. I am of course neatly sidestepping the existential difficulty of comparing oranges and apples here. Do not tell me that QUALYs are the answer: it is easy to construct a spreadsheet that tells you the area of skin involvement in a patient with psoriasis, but do not confuse this with the human judgment of whether somebody has bad psoriasis. ↩

Defining the appropriate probability space is often a non-trivial bit of statistics. It is often where you have to end up leaving statistics and formal reasoning behind. The following quote puts this in a more bracing manner.

There are no lobby groups for companies that do not exist.

The same goes for research and so much of what makes the future captivating.

Some quotes from William Gibson in an interview with the FT

“we’re looking at the collapse of the only liveable planetary ecosystem we know of anywhere”.

He fears that the world’s FQ — or F***edness Quotient, as he calls it — is rising to a worrying degree.

And this one gets you

If I could learn one thing about the future,” he says, “I would want to know what they think of us because that would tell me everything I’d want to know about them.”

William Gibson — the prophet of cyberspace talks AI and climate collapse | Financial Times

Peter Piot in the Guardian

As with HIV, “an epidemic reveals the fault lines in society. The big one this epidemic has revealed is how we treat the elderly. We often park them in pre-mortuary type institutions and give a bit of money and hope it is OK”.

Make masks compulsory in public in UK, says virus expert | Coronavirus outbreak | The Guardian

When the tide goes out you see who is not wearing bathing costumes…

Once there was General Practice, medicine in the image of the late and great Julian Tudor-Hart. Then there was Primary Care. The following article from Pulse made me sit up and wonder whether we have got it right.

Under the five-year contract announced last year, networks were to receive 70% of the funding to employ a pharmacist, a paramedic, a physiotherapist and a physician associate, and 100% of the funding for a hiring social prescriber, by 2023/24… Six more roles will now be added to the scheme from April  ‘at the request of PCN clinical directors’ – pharmacy technicians, care co-ordinators, health coaches, dietitians, podiatrists and occupational therapists…PCNs can choose to recruit from the expanded list to ‘make up the workforce they need’…The document added that mental health professionals, including Improving Access to Psychological Therapy (IAPT) therapists, will be added from April 2021 following current pilots…NHS England will also explore the feasibility of adding advanced nurse practitioners (ANPs) to the scheme [emphasis added].

PCNs to get 100% funding for all extra clinical staff as further roles are added | News Article | Pulse Today

Adam Smith among others pointed out the advantages of specialisation. We owe virtually all of the modern capitalist world to the power of this insight. But we also know that there are opposing forces — and not just those of the Luddites. Just think back to Ronald Coase and the Theory of the Firm. Why do companies not outsource everything? Why are there companies at all? Simply because under some circumstances transaction costs and formalisation of roles and contracts limit outsourcing ¹. Contra the English approach is that of the Buurtzorg (links here, here and here) in the Netherlands where it is explicit that many of the tasks undertaken by highly skilled staff do not require high level skills. But — so the argument goes — the approach is more successful, robust and rewarding for both patients and staff. This is closer to the Tudor-Hart model. It really does depend on what sort of widgets you are dealing with, and whether fragmentation of activity improves outcomes, or merely diminishes costs in situations where outcomes are hard to define in an Excel spreadsheet.

1. I realise I am speaking more metaphorically here than literally in terms of Coase’s work. My argument is about transaction costs in domains where much knowledge is not explicit or capable of easy formalisation, and where there is in one sense path dependency between patient and clinician. ↩

Read that again

Zuckerberg also said the company will not be changing its policies that allow lying in paid political advertisements.

Facebook policy changes fail to quell advertiser revolt as Coca-Cola pulls ads | Facebook | The Guardian

‘Today’s meritocratic ideology glorifies entrepreneurs and billionaires. At times this glorification seems to know no bounds. Some people seem to believe that Bill Gates, Jeff Bezos, and Mark Zuckerberg single-handedly invented computers, books, and friends.’

Thomas Piketty, Capital and Ideology. p713

Another telling figure from Thomas Piketty’s Capital and Ideology. The stiking thing about much of this book is how predicable and widespread so many social trends are.

From the Financial Times a few months back, this is a story about Facebook and the life of its content moderators (as in, the people who watch those videos of obscene or violent acts).

The document was distributed to all moderators at the European facility in early January via email, asking them to sign it immediately. It stated: “I understand the content I will be reviewing may be disturbing. It is possible that reviewing such content may impact my mental health, and it could even lead to post-traumatic stress disorder (PTSD).”

The two-page form also outlines Accenture’s WeCare programme, which provides employees with access to “wellness coaches” from whom they can receive mental health support. The company says, however, that “the wellness coach is not a medical doctor and cannot diagnose or treat mental disorders”.

What caught my eye was a phrase that you see more and more: ‘X’ is not a medical doctor and cannot diagnose or treat mental disorders’. ‘X’ can be a person or simply some text on a web page.

Too much of modern hypercapitalism is about arbitrage between honesty or morality, and the law as it is codified. The business model is dishonesty, or worse. It would be impossible to act this way if the contact was human rather than digital. This is the very feature (not a bug!) that allows the push-button extinguishing of civilian lives in far-away parts of the world by people who drive to work and pick up the kids on the way home. As for medicine, corporations will insist on exploiting similar fault lines. There was once a time when ‘medicine’ was a small part of the economy, and when it could play by an insular set of rules that both society and the practitioners recognised, if not agreed upon. Nowadays there is simply too much money to be made.

A comment from Icarus Fallen on this article:

In the new social network gig economy, your mental health, has an hourly price. Try not to sell it.

(1) Facebook content moderators required to sign PTSD forms | Financial Times

Another revealing figure from Thomas Piketty’s Capital and Ideology. French education is highly stratified but this pattern will be there in the UK too.