At my old university, we were encouraged to explore our subjects and to love what we were studying. Now, at medical school, the emphasis seems to be don’t burnout, focus on not making mistakes, and understand that life is going to be hard, so develop the resilience to cope.

The above is from a letter to this month’s Academic Medicine [83(12) 1745-1884, 2018] written by a graduate student at Warwick medical school (TC Shortland). The title is what caught my eye: “Enjoying, and Not Just Surviving, Medical School”

He goes on:

At Warwick Medical School, staff and students are trying to build a more positive environment. Staff and students have organized art classes, interstaff/ student sports events, and several baking competitions; the last winner featured cupcakes that could be injected with either a salted caramel or raspberry filling. As positive health care workplaces and positive cultures are associated with better patient outcomes,why shouldn’t medical schools try and create such environments for future medical professionals?

I am not against the various suggestions (…well, I am actually), but what I and others are in despair about is how much (?most) medical education has become so dull, tedious, and brutal, rather than humane. When I have spoken to others, some hold similar views: the students put up with it, because they want to be doctors, but they no not enjoy most of it. If they are obliged to attend, they do; but out of choice, many would skip much of what we offer.

Now this is not a new thought or phenomenon. I didn’t enjoy — in fact I actively hated — the preclinical years (aka: the prescientific years) — but I did get a big kick out of the clinical years, and loved my intercalated degree. What made the clinical years work, was that the opportunity for some kind of personal  bond with some teaching staff made up for all the despots and dull souls who should have been destined to be gravediggers. And unless somebody has recently discovered something I have missed, scale and intimacy rarely go together.

Of course, what makes matters worse, is that the ennui and anomie will get worse: for many junior doctors, after the initial high of being qualified, their working jobs are miserable. If they get to higher training, things may improve, but not for all.

George Steiner’s comments in a slightly different context are apposite:

“Bad teaching is, almost literally, murderous and, metaphorically, a sin. It diminishes the student, it reduces to gray inanity the subject being presented. It drips into the child’s or the adult’s sensibility that most corrosive of acids, boredom, the marsh gas of ennui.”

The NHS (for this is the fault of the NHS rather thant the universities) is accumulating a massive moral debt, borrowing on the very market it has rigged (because it can!), forgetting that this is like PFI on steroids. It assumes it is too big to fail: I think otherwise.

Hemingway:

How did you go bankrupt: slowly and then suddenly.

 

This is from an editorial in the NEJM, discussing the results of a trial of a synthetic peanut antigen to facilitate tolerance. Prevously the ‘raw’ stuff had been shown to be useful. The synethic version will of course cost a lot, and might be considered IPR created through regulatory arbitrage.

AR101 and other, similar products such as CA002, which is being developed by the Cambridge group, would therefore appear to have a role in initial dose escalation. The potential market for these products is believed to be billions of dollars. It is perhaps salutary to consider that in the study conducted by the Cambridge group, children underwent desensitization with a bag of peanut flour costing peanuts.

Costing penauts: I wish I had said that

Oral Desensitization to Peanuts | NEJM

(Professor) John Burton died recently. He worked in Newcastle before my time there, but his reputation was ever present. When I did some research on eccrine glands as a medical student, I came across some of the papers he published with Sam (Shuster) on sebum. But it was his textbook “Essentials of Medicine” that I still marvel at. A textbook that in places made you break out in laughter the way a Tom Sharpe novel did (The scene on a train was as follows: somebody quietly reading would foolishly try to suppress the inevitable convulsion of laughter — a glance at the book cover, would confirm the hypothesis). I suspect subsequent editions of ‘Essentials’ were sanitised — not certain the Welder from Wigan with Warts, or the differential diagnosis of lipstick on that most prized of organs, survived.

When I actually got to meet John, what struck me most was how dull and conventional he appeared. I am not certain what I expected, but at least with Sam, when you got to meet him, his appearance betrayed his intellect and ability to prick pomposity.

Since I was in charge of organising Sam’s retirement festivities in 1992, I invited John to provide the humour. The ‘old’ seminar room was standing room only, and John’s irreverence and ability to play an audience was — and I realised it at the time — magical. Perhaps the only occasion I ever saw Sam reduced to silence. As they say in Wales about such moments, ‘I was there’.

John Kennedy told the story of Marshal Hubert Lyautey (1854–1934), a French army general and colonial administrator in Morocco. Lyautey asked his gardener to plant a certain tree. The gardener objected that the tree would grow slowly and wouldn’t reach maturity for a century. “In that case,” the marshal replied, “there is no time to lose. Plant it this afternoon.”

From Larry Lessig in America, Compromised.

There is one of those beautifully written pieces on Medium, written by the ex-editor of Nature, Philip Ball [link]. It speaks of something particular, and also in the round.

My handwriting has been terrible as long as I can remember. I have tried on various occasions to improve it, but these attempts seldom last as long as the end of the day. In truth, it is not just others who find my writing hard to decipher — after a few minutes I seldom can make much sense of it. And much as though I would like to blame being a doctor for my troubles, I suspect this is just wishful thinking.

Ball’s article is about the fixation on cursive versus, rather than manuscript writing. He writes:

Something like modern cursive emerged from Renaissance Italy, perhaps partly because lifting a delicate quill off and on the paper was apt to damage it and spatter ink. By the 19th century cursive handwriting was considered a mark of good education and character.

I just smile when I read titbits like this. One of those fascinating explanations for something I had never considered or thought about. He argues that the usual arguments for cursive writing — that it is faster, or that it helps with spelling, or that it is useful for those with dyslexia are not well founded. So why does it persist?

He fixes (rightly) on the strange set of beliefs that constitute considered thought in education. You know, the sorts of things that are not far away from the “ I went to school, so I understand education” trope. (The medicine version is of course: ‘I know how to treat people, so I know how to teach other people to treat people’).

He writes:

It suggests that what teachers “know” about how children learn is sometimes more a product of the culture in which they’re immersed than a result of research and data. It seems unlikely, in this regard, that teaching cursive is unique in educational practice. Which forces us to wonder: What happened to evidence?

And then:

This must surely lead us to wonder how much else in education is determined by a belief in what is “right,” unsupported by evidence. Education and learning are difficult to pin down by research. Teaching practices vary, it’s often impossible to identify control groups, and socioeconomic factors play a role. But it’s often the case that the very lack of hard, objective evidence about an issue, especially in the social sciences, encourages a reliance on dogma instead. The danger is greater in education, which, like any issue connected to child rearing and development, is prone to emotive views.

This all bothers me. Not that I think he is wrong, but rather, I find it hard to conceptualise what character of enquiry is both robust and useful in this domain. One look at medical education, and you realise, we are nowhere close to being there.

Over 40 years ago, I remember lectures on basic demography, and what changes to the  population  mix of the UK were likely. The late John Grimley Evans was one lecturer, but others went over cognate themes including Klaus Bergmann who pointed out the relevance of increased mobility when considering family and / or social support. ‘Were we prepared to adopt each other people’s grannies?’, stuck in my mind. If you look at the family structures in some working class areas (think parts of Newcastle), and how they have changed, it was obvious what might happen. The sociologist Peter Townsend published studies based in London, highlighting the depth of community support that once existed.

Which is why I get so cross when you come across this as a new problem, as though all these baby boomers (like me) were born yesterday. As though we didn’t know; as though nothing could have been done to prepare for such a change. Remember too, when to study dementia or stroke, or seek funds for such topics was……well futile.

The following is from an article  in the FT (How Britain can heal its ailing social care system | Financial Times). Once again the dismal leadership of the UK compares unfavourably with that of some other European countries

The pressure on staff is becoming unbearable. Good social care is about creating relationships. Staff who work for domiciliary care operations like those run by Allied Healthcare must walk into the home of a stranger, reassure them, figure out what is needed, and build trust. That takes maturity, emotional resilience and time. Yet, all too often, the reality is rushed visits from a plethora of different faces.

A few years ago, I met an 89-year-old man who had made a note of every carer who had crossed his threshold in the past year — Meals on Wheels, district nurse, domiciliary care staff. He showed me the list. There were 102 names on it. Some had only come once, then vanished — probably into better paying jobs at a supermarket. That is the stark reality of how little we value our elderly.

A tidy phrase from Stephen Downes in a comment on corporate cash and universities:

There’s nothing especially new here, though it is helpful to remember that when for-profit corporations donate money, it is with a for-profit objective.

[Link]

A few words from Melvyn Bragg about his radio programme ‘In our time’

He insisted that the programme should be “never knowingly relevant” and jumped wildly from the gin craze of the 18th century to the Palaeocene-Eocene thermal maximum. He expected to be out of a job in six months

The Economist | Sweetness and light

In times like ours, not a bad motto to live by.

Leading universities should pledge to actually read the work of applicants for research positions rather than use controversial metrics during the selection process, a Nobel prizewinner has argued.

No, not a spoof, but words from Harold Varmus. Sydney Brenner, a good while back, observed that people tended not to read papers anymore, they just xeroxed them.