You need a wallet biopsy

“However, if a wallet biopsy – one of the procedures in which American hospitals specialise – discloses that the victims are uninsured, it transfers them to public institutions.”

In Paul Starr, ‘The Social Transformation of American Medicine’.

Direct URL for this post.

Late night thoughts on medical education #6: Structures

In the previous post in this series (Late night thoughts #5: Foundations) I wrote about the content or material of medical education, hinting at some of the foundational problems (pardon the meta). We have problems distinguishing between knowledge that is essential for some particular domain of medical practice, and knowledge that is genuinely foundational. The latter is largely speciality independent, less immediate than essential knowledge, and is rightly situated within the university. The expertise necessary to teach foundational knowledge lies within universities.

What I have not made explicit so far in this essay is also important. The best place to learn much essential knowledge is within the hospital, and during a genuine apprenticeship. There are various ways we can hone a meaningful definition or description of apprenticeship but key is that you are an employee, that you get paid, and you are useful to your employer. Our current structures do not meet any of these criteria.

How we got here

Kenneth Calman in the introduction to his book ‘Medical Education’ points out that medical education varies enormously between countries, and that there is little evidence showing the superiority of any particular form or system of organisation. It is one of the facts that encourages scepticism about any particular form, and furthermore — especially in the UK — leads to questioning about the exorbitant costs of medical education. It also provides some support for the aphorism that most medical students turn into excellent doctors despite the best attempts of their medical schools.

Across Europe there have been two main models of clinical training (I am referring to undergraduate medical student training, not graduate / junior doctor training). One model relies on large lectures with occasional clinical demonstrations, whereas the UK system — more particularly the traditional English system — relies on ‘ clerkships’ on the wards.

At Newcastle when I was a junior doctor we used to receive a handful of German medical students who studied with us for a year. They were astonished to find that the ‘real clinical material’ was available for them to learn from, with few barriers. They could go and see patients at any time, the patients were willing, and — key point— the clinical material was germane to what they wanted to learn. The shock of discovering this veritable sweetshop put some of our students to shame.

The English (and now UK) system reflects the original guiding influence of the teaching hospitals that were, as the name suggests, hospitals where teaching took place. These hospitals for good and bad were proud of their arms length relationship with the universities and medical schools. The signature pedagogy was the same as for junior doctors. These doctors were paid (poorly), were essential (the place collapsed if they were ill), and of course they were employees. Such doctors learned by doing, supplemented by private study using textbooks, or informal teaching provide locally within the hospital or via the ‘Colleges’ or other medical organisations. Whatever the fees, most learning was within a not-for-profit culture.

 Scale and specialisation

It was natural to imagine or pretend that what worked at the postgraduate level would work at the undergraduate level, too. After all, until the 1950s, medical education for most doctors ended at graduation where, as the phrase goes, a surgeon with his bag full of instruments ventured forth to the four corners of the world.

This system may have worked well at one stage, but I think it fair to say it has been failing for nearer a century than half a century. At present, it is not a system of education that should be accepted. There are two reasons for this.

First, medicine has (rightly) splintered into multiple domains of practice. Most of the advances we have seen over the last century in clinical medicine reflect specialisation, specialisation as a response to the growth of explicit knowledge, and the realisation that high level performance in any craft relies not solely on initial certification, but daily practice (as in the ‘practice of medicine’). Second, what might have worked well when students and teachers were members of one small community, fails within the modern environment. As one physician at Harvard / Mass General Hospital commented a few years back in the New England Journal of Medicine: things started to go awry when the staff and students no longer ate lunch together.

Unpicking the ‘how’ of what has happened (rather than the ‘why’ which is, I think obvious), I will leave to the next post. But here is a warning. I first came across the word meliorism in Peter Medawar’s writing. How could it not be so, I naively thought? But of course, historians or political scientists would lecture me otherwise. It is possible for human affairs to get worse, even when all the humans are ‘good’ or at least have good intentions. The dismal science sees reality even more clearly: we need to only rely on institutions that we have designed to work well — even with bad actors.

Biology is just messy

Some traits, such as adult height, are readily measured. The heritability of this trait is ∼60 to 80%. Attempts to characterize “height genes” have resulted in the identification of tens of thousands of genes, each of which contributes a small amount to this heritability. The plethora of factors is almost inevitable, given the vast number of cellular and physiological steps involved in the development of an adult human being. A model that accounts for ∼40% of height variability predicts individual heights to within 4 cm for 50% of people, but with errors of more than 10 cm for 5%. Thus, a sophisticated genomic analysis can predict height to some extent, but not well enough for use in ordering tailored clothing. Most direct-to-consumer genomic results are based on much less detailed analyses and many involve complex traits, so considerable skepticism is appropriate.

But such sensible comments, will not stem the hype — or the investors.

Consuming personal genomics | Science

Direct URL for this post.

It’s not all physics

This is why I have doubts about mechanical theories such as disruptive innovation. Too often, they’re presented as a type of physical law: You drop a glass of wine, it always falls to the ground with an acceleration of 32.17405 ft/s2. This truth is indisputable…but it ignores the drunken clumsiness of the oaf who knocked the glass over, and discounts the quick reflexes and imaginative solutions you only get when there’s a human nearby.

Jean-Louis Gassée. A nice summary of why human agency matters, and also why companies fail.

First Winning Wars, Only To Lose Them Later – Monday Note

Direct URL for this post.

Late night thoughts on medical education #5: Foundations

We sought out an examiner who would understand that anatomy was being taught as an educational subject and not simply for the practice of surgery. I thought I had found such a man in an old colleague. I listened while he asked the student to name the successive branches emerging from the abdominal aorta in a cadaver. When we got to the inferior mesenteric he asked what viscera were supplied by that vessel. The student gave a complete and correct answer but did not know the exact amount of the rectum supplied. The examiner asked me what I thought and I said that I thought he was very good, that the only question he had missed was the last one, which in my opinion, was trivial. No, said the anatomist, by no means trivial. You have to know that before you can excis the rectum safely.

My mind still boggles at the thought of a newly graduated doctor undertaking the total excision of the rectum on the faint remembrance of the anatomy he learned as a student.

George Pickering, “Quest for Excellence in Medical Education: A Personal Survey”

When I was a medical student I read this book by Sir George Pickering. It was published in 1978, and I suspect I read it soon after the Newcastle university library acquired it. Why I came across it I do not know, but at the time ‘new volumes’ were placed for a week or two on a shelf adjacent to the entrance, before being assigned their proper home (or ‘final resting place’). It was a way to find things you didn’t know you might enjoy. I liked this book greatly, and have returned it on many occasions. Parts of it are wonderfully dated (and charming), but it remains a wonderful young man’s book written by an old man. Now I am an old man, who read it first as a young man.

Roger Schank summarise the problems of education this way:

There are only two things wrong with the education system:

1. What we teach, and
2. How we teach it

George Pickering’s quote relates to ‘what we teach’ — or at least what we expect students to know — but in clinical medicine ‘what we teach’ and ‘how we teach’ are intimately bound together. This may be true for much  education, but the nature of clinical exposure and tuition in clinical medicine imposes a boundary on what options we can explore. The other limit is the nature of what we expect of graduates. People may think this is a given, but it is not. If you look worldwide, what roles a newly qualified doctor is asked to fill vary enormously (something I discovered when I worked in Vienna).

Here is another quote, this time from the philosopher, Ian Hacking, who has written widely on epistemology, the nature of causality and the basis of statistics (and much else).

Syphilis is signed by the market place where it is caught; the planet Mercury has signed the market place; the metal mercury, which bears the same name, is therefore the cure for syphilis.

Ian Hacking | The Emergence of Probability

Well, of course, this makes absolutely no sense to the modern mind. We simply do not accept the validity of the concept of entities being ‘signed‘ as a legitimate form of evidence. But no doubt medical students of the time would have been taught this stuff. Please note, those priests of Evidence Based Medicine (EBM), that doctors have always practiced Evidence Based Medicine, it is just that opinions on what constitutes evidence change. Hacking adds:

He [Paracelsus] had established medical practice for three centuries. And his colleagues carried on killing patients.

I am using these quotes to make two points. The first, is that there is content that is correct, relevant to some clinical practice and which medical students do not need to know. This may seem so obvious that it is not necessary to say it. But it is necessary to say it. Pickering’s example has lots of modern counterparts. We could say this knowledge is foundational for some medical practice, but foundational is a loaded term, although to be fair I do not know a better one. The problem with ‘foundational’ is that it is widely used by academic rent seekers and future employers. Students must know this, students ‘must’ know X,Y and Z. I once started to keep a list of such demands, but Excel spreadsheets have limits. You know the sort of thing: ethics, resilience, obesity, child abuse, climate change, oral health, team building, management, leadership, research, EBM, professionalism, heuristics and biases etc. Indeed, there is open season on the poor undergraduate, much of which we can lay blame for at the doors of the specialist societies and the General Medical Council (GMC).

My second point, stemming from the second quote, is to remind that much of what we teach or at least ask students to know is wrong. There is a feigned ignorance on this issue, as though people in the past were stupid, whereas we are smart. Yes, anatomy has not changed much, and I am not chucking out all the biochemistry, but pace Hacking, our understanding of the relation between ‘how doctors work’ and ‘what underpins that knowledge’ is opaque. We can — and do — tell lots of ‘just-so’ stories that we think explain clinical behaviour, that have little rational or experimental foundation. Clinicians often hold strong opinions on how they arrive at particularly decisions: there is a lot of data to suggest that whilst you can objectively demonstrate clinical expertise, clinicians often have little insight into how they actually arrive at the (correct) diagnosis (beyond dustbin concepts such as ‘pattern recognition’ or ‘clinical reasoning’).

What is foundational knowledge?

If you are a dermatologist, and you wish to excise a basal cell carcinoma (BCC, a common skin cancer) from the temple, you need to be aware of certain important anatomical structures (specifically the superficial temporal artery, and the temporal branch of the facial nerve). This knowledge is essential for clinical practice. It is simple to demonstrate this: ask any surgeon who operates in this area. Of course, if you are a lower GI surgeon, this knowledge may not be at your finger tips. Looked at the other way, this knowledge is in large part specialty specific (or at least necessary for a subset of all medical specialties). What happens if you damage these structures is important to know, but the level of explanation is not very deep (pardon the pun). If you cut any nerve, you may get a motor or sensory defect, and in this example, you may therefore get a failure in frontalis muscle action.

This knowledge is not foundational because it is local to certain areas of practice, and it does not form the basis or foundation of any higher level concepts (more on this below). The Pickering example, tells us about what a GI surgeon might need to know, but not the dermatologist. Their world views remains unrelated, although the I prefer the view of the latter. There is however another point. We should be very careful about asking medical students to know such things. So what do we expect of them?

Beyond essential

I find the example of anatomical knowledge as being essential compelling. But only in terms of particular domains of activity. Now, you may say you want students to know about ‘joints’ in general, and there may well be merit in this (Pickering, I suspect, thought so), but knowing the names of all the bones in the hand or foot is not essential for most doctors. If we move beyond ‘essential’ what is left?

At one time anatomy was both essential and foundational. And I am using the term foundational here to mean those concepts that underpin not just specialty specific medicine, but medicine in the round. A few examples may help.

Whatever branch of medicine you practice, it is hard to do so without some knowledge of pharmacology. How deep you venture , is subject to debate, but we do not think knowing the doses and the drug names in the BNF is the same as knowing some pharmacology. 

Another example. I would find it very hard to converse with a dermatologist colleague without a (somewhat) shared view of immunology or carcinogenesis. Every sentence we use to discuss a patient, will refer and make use of concepts that we use to argue and cast light on clinical decisions. If you want to explain to a patient with a squamous cell carcinoma (SCC) who has had an organ transplant why they are at such increased risk of tumours, it is simply not possible to have a meaningful conversation without immunology or carcinogenesis (and in turn, genetics, virology, and histopathology). And for brevity, I am putting to one side, other key domains such as behaviour and behaviour modification, ethics, economics and statistics etc.

To return to my simple anatomical example of the excision of the BCC. The local anatomy is essential knowledge, but it is not foundational. What is foundational is knowing what might happen if you cut any nerve.

Sequencing of learning

Let me try and put the above in the context of how we might think about medical education and medical training.

Foundational knowledge is specialty (and hence career) independent. Its function is to provide the conceptual framework that underpin much clinical practice. This not to say that the exact mix of such knowledge applies to all clinical domains, but we might expect most of it to be familiar to most doctors. But none of it will, years later, have the same day-to-day immediacy of ‘essential knowledge’ — think of my example of the temporal branch of the facial nerve for the dermatologist excising facial tumours on a weekly basis.

In this formulation, the core purpose of undergraduate medical education is to educate students in such knowledge. The purpose is not therefore to produce doctors at graduation who are ‘just not very good doctors’ but graduates who are able to pursue specialty training and make sense of the clinical world around them. The job of a medical school is to produce graduates who can start clinical training in an area of their choice. They are now in a position to — literally — understand the language of the practising doctors that surround them. They are not mini-doctors, but graduates, embarking on a professional career.

By contrast most specialty knowledge is not foundational, but essential for those within that specialty — not medical students. If you learn dermatology, you might come across things that help you learn respiratory medicine or cardiology but to be blunt, not very often. Specialties are not foundational domains of knowledge. You do not need to know dermatology to understand cardiology or vice versa.

Place of learning

The best place to learn the ‘foundations’ are universities. Anatomy, again may be an exception, but if you want to learn immunology, genetics, statistics or psychology you have, I think, no alternative. Hospitals simply cannot provide this.

On the other hand, using Seymour Papert’s metaphor, if you to want learn French you should go to Frenchland, if you want to learn maths, you should go to Mathland and if you want to learn doctoring, you need to go to doctorland. Medical schools are not the place to learn how to find you way around doctorland — how could they be?

NB: I will use the epithet TIJABP, but as subsequent posts will confirm, I am serious.

WD (Bill) Hamilton

Scope for recognizing and accommodating exceptional individuals has been diminishing in British universities ever since. Hamilton published relatively few papers, in generally low status journals, and gained only a handful of grants much later in life. Bureaucratic measures of performance are increasingly important and judge the impact of an article only by the journal it is published in. This seriously undervalues radical originality, which although extremely rare is utterly vital to science. It is disturbing that a young Bill Hamilton today would probably find an academic career even more difficult to pursue.

Alan Grafen, in his obituary of Bill Hamilton (Biogr. Mems Fell. R. Soc. Lond. 50, 109–132 (2004)).

I post this excerpt following a discussion with somebody who had never heard of him. Hamilton’s enormous contributions to biology are not well known. You also have to wonder if the lack of a Nobel for biology diminishes medicine in the long run. Some things do indeed get worse.

Direct URL for this post.

Why wait so long?

Apparently, on average, doctors interrupt patients within eighteen seconds of beginning their story. When we tell lawyers about this, they wonder why their medical friends wait so long.

Quoted in the ‘The Future of the Professions‘

Direct URL for this post.

Sydney Brenner has died. Not quite the last of the handful of scientists who made one of the two scientific revolutions of the 20th century. The first half belonged to physics, the second to the biology that he co-created.

A precocious boy—a student at the University of the Witwatersrand by the time he was 15—and bullied for it, reading was his connection to the wider world. Courses, he said, never taught him anything. The way to learn was to get a book that told you how to do things, and then to start doing them, whether it was making dyes or, later in life, programming computers. If he thought more deeply than the other great biologists of his age, which he did, it was surely because he read further, too.

Reading Brenner was a staccato of insights. I hadn’t come across the ‘courses’ quote before, but no surprises there.

Obituary: Sydney Brenner died on April 5th – Irrepressible

I read an earlier book of Eric Topol’s (The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care) and got a lot out of it, although I don’t know to what extent his ideas will come to pass. The Economist reviewed his more recent book, “Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again”.

The Economist reports:

The fear the author harbours [referring to Topol] is that AI will be used to deepen the assembly-line culture of modern medicine. If it confers a “gift of time” on doctors, he argues that this bonus should be used to prolong consultations, rather than simply speeding through them more efficiently.

But then goes on, in true Economist style:

That is a fine idea, but as health swallows an ever-bigger share of national wealth, greater efficiency is exactly what is needed, at least so far as governments and insurers are concerned…. An extra five minutes spent chatting with a patient is costly as well as valuable. The AI revolution will also empower managerial bean-counters, who will increasingly be able to calibrate and appraise every aspect of treatment. The autonomy of the doctor will inevitably be undermined, especially, perhaps, in public-health systems which are duty-bound to trim inessential costs.

Modern medicine — as implied — is already an assembly line culture. And yes, many of us think it will get worse. Staff retention will get worse, too. If you want to see the future of medicine as a career, look at what has happened to school teachers within public systems (or academics in most universities in the UK). Blame it all on poor Max Weber, if you will. Those in charge have very little feel for what ‘doing medicine’ is all about. But there seems to an elision between ‘greater efficiency is needed’ and talking to patients being ‘costly and valuable’. Interesting to note that only the public systems are obliged to trim ‘inessential costs’: Crony Capitalism feasts on the wants rather than the needs.

“There’s a classic medical aphorism,” he recalls. “‘Listen to the patient, they’re telling you the diagnosis.’ Actually, a lot of patients are just telling you a lot of rubbish, and you have to stop them and ask the pertinent questions.”

Jed Mercurio: ‘Facts used to have power. Now stupidity is a virtue’ | The Guardian

The question is when?

Direct URL for this post.