Archive for the ‘medicine’ Category

White coats, white lies? Or black marks?

August 7, 2011

In which Dr Aust ponders what one should do about students who are ‘economical with the actualité’.

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One of my scientific internet friends, Steve Caplan, was blogging a week to two back about a student in a lab he worked in who was, shall we say, less than truthful about their actions.

Steve says at one point, recounting what he said to the lab boss about the student:

“Imagine if s/he lied about little things like salt buffers [experimental reagents], what kind of data s/he might have fabricated later on,”

Which caught my attention – partly because research misconduct, and what should be done about it, is in the news at the moment.

But also partly because it deals with a regular part of University life – that problematic character, the student whose habits give cause for concern.

Much of the debate about student conduct recently has tended to focus on plagiarism, but here I am not talking about that, or even what one might call “academic misconduct’. I am talking about the more subtle things to do with how people behave, and how they interact with their colleagues.

Apart from in the lab, another place this turns up  – and perhaps a slightly special setting – is medical school. There is a long-standing debate about how sub-standard conduct should be dealt with, and what behaviours students should be ‘pulled up’ for – especially for students in the pre-clinical years where we have historically tended to take a more relaxed view of how students should behave than our clinical colleagues.

[The main point was that in the past students did not see patients until their third year of medical school. Nowadays in many courses they are around hospitals and GP clinics from the very start of their student career. So they are under the microscope rather more than was formerly the case.]

One argument for what one might call a “Zero tolerance” policy is studies like this one, in the New England Journal of Medicine a few years back.

Of course, the counter-argument, which also has force, is the ‘youthful high jinks’ one – that is, that everyone does daft, or even idiotic, things, and behaves like a plonker, when young, and mostly people grow out of it. For some medical examples you could try many a medical memoir – or for a recent political example you could try Louise Mensch MP’s robust riposte to the Daily Mail a couple of weeks back. There has even been a discussion in the medical literature of whether previous criminal convictions – which one could call an extreme example of idiotic behaviour – should be an absolute bar to entering medical school.

On the whole, when we hear about misbehaviour by students, we tend to try and distinguish between “stupid stuff” (they really don’t know);  and “worrying stuff” (they know, but do it anyway) – of which the most worrying is usually “dishonest stuff”.

A couple of examples of the latter.

In our lab classes for medical students we teach them stuff that they are later tested on, like using peak flow meters and spirometers, and measuring blood pressure. The test they get on this later is in the form of a what is called an OSCE, a kind of practical exam in which students pass through a series of “stations’ where they have typically 5 or 6 minutes to do a task – like measure a volunteer subject’s blood pressure.

As well as teaching students these skills in scheduled classes, we run revision classes a couple of weeks before the OSCE takes place.

Now, the people who teach these revision class are adamant that these classes are for revision – NOT for teaching the skills from scratch to students who couldn’t be arsed to turn up to the regular scheduled sessions earlier in the semester. So the rule for students is that, if you have missed more than 20% of the semester’s scheduled lab classes without explanation, you cannot come into the revision session,

Though this is well publicised, it sometimes seems to come as a shock to less, errm, organised students.

A good few years ago now, a couple of my colleagues were checking the students in at the door on such a revision class when a student appeared who the records showed had exceeded the allowed number of absences. They pointed this out to him and said he would not be allowed in.

“Oh no” said the student “I gave in notes explaining that absence and that absence” (this would get him into the revision class, as ‘excused for something you couldn’t help’, like a doctor’s appointment or illness, or some other stuff, usually doesn’t count as ‘absent without reason’).

Now, one of my colleagues was a touch suspicious, trotted off to the Faculty Office that ‘logs’ such notes, and checked what the student had said.

The student had handed in nothing for the dates in question. No notes. No reasons for the absences.

The student was told to leave the class, and was, I am pretty sure, reported to the Course Director for what in the old days would have been called ‘a right bollocking’.

It was not the being absent from the earlier classes that was the most worrying thing, but rather that the student had flatly and directly fibbed (about the notes for his absences) to a member of the academic teaching staff.

I am curious to know what my readers, especially the medical ones, make of this.

Now, Mrs Dr Aust, the family’s medical expert, has little (read: “no”) sympathy for the student in this story. She is suspicious as to whether leopards change their spots, for one thing. And she says that people who will lie, or even just bend the truth a bit, to get themselves off the hook are a flat-out liability in medicine, full stop. The standard scenario she tends to give is one like this:

In an urgent diagnostic discussion about patient Mr X, gets-by-on-charm-but-a bit-of-an-idler junior doctor Dr Y is asked by a more senior colleague about the result of test Z that he, Dr Y, was supposed to have ordered yesterday. Dr Y had forgotten to order the test. However, fearing a public kicking, he does not admit this but says instead ‘ Errm… the result’s not back yet’.

Of course, you can argue that that latter scenario is unrealistic. But Mrs Dr Aust says that this happened sufficiently frequently to her over the years that eventually she took to phoning the lab herself when she heard this line – to be told, on more than one occasion: “Nope, there’s no sample”.  She also says that there were junior doctors who, when confronted about this, would respond with anger rather than holding their hands up. She says one even called her ‘A Fascist’.

You can also argue that this kind of behaviour is a long way from the skiving student-in-the-lab-class example that I gave above.  But, and this is the crux of the matter,  there is always a suspicion that people who are prepared to lie about one thing are more likely to be prepared to lie about other stuff too.

And there is also a sense that, the more they get away with it, the more they will carry on doing it.

So where should we draw the line? 

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The day after I wrote the first version of the above, I was reminded by a discussion on Twitter about something else in a similar vein (artery?).

In our practical tests of measuring blood pressure, which is one of the skills we teach to students, the examiner almost always listens to the same Korotkoff sounds that the student hears via a dual stethoscope.

One of the things you regularly experience as an examiner for this is the student who, when no sounds whatsoever have been audible – typically because the stethoscope bell is in the wrong place – announces:

“One twenty over eighty”

(i.e. a blood pressure of 120/80 mm Hg, which is normal and thus a good random guess for an adult – though it is usually a little high for a fit younger adult, like most of our volunteer subjects tend to be. Of course, we take their BP at the start of the day and periodically thereafter, so we know what their BP is really likely to be).

We were talking about this today, and the thought occurred to me: is offering that answer, when you could not possibly have got a reading of blood pressure, actually – or at least arguably – an attempt to deceive?

And – it would be a pretty draconian way to do it, but should we automatically fail anyone who says it?  

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Postscript:

Just to expand on this a bit:

There is always a kind of tension in professional degrees between the need of students repeatedly to pass exams to progress on the course, and the ultimate need for them to learn to do certain things (like measuring blood pressure). One is regularly told (and it is a reasonable axiom) that ‘assessment drives learning’. So if you have a test where there is no downside to guessing (apart from not getting the mark you would get for getting the right answer), students will guess.  [Many University multiple choice exams use what is called 'negative marking' specifically to give students a downside to guessing at random when they don't know the answer].

But in the setting I have described, there are several problems with this.

One is the problem described above – you could say we are allowing the students to assume it is OK to make up an answer, when really it shouldn’t be.

Two is that it is of course important to be able to measure blood pressure accurately; the students should, in turn, be able to see that it is important that they learn to do it properly. If you are being really earnest, you might say they should be able to see that ‘fronting it’ (doing a third rate version but trying to look super-confident) is not really on.

Three is that you could say this represents a lost opportunity – perhaps the students should be pulled up straight away and asked to expand on why they had trotted out a number when there were no sounds.

The point there being to get them to think about why there might be problems with what they had just done that might make it more than just the equivalent of a random guess in a multiple choice exam.

After all, if behaviours that are not acceptable are not identified and challenged, how do the students actually learn…. that the behaviours are not acceptable?

Or – am I just being a hopelessly crusty old git? Highly possible, after all. I am undeniably middle-aged. And famously curmudgeonly.

Anyway – opinions, anyone?  I know it’s a bit cheeky asking for views when it’s been so long since the last post, but I would be interested in what the readers, young and old(er), think.

 

PS – I should also say that, though I’ve been around medical schools a long time, I don’t pretend to claim any great expertise in assessment. Far greater minds than mine etc etc.

Getting the bird

January 11, 2011

In which Dr Aust ponders language and its obscurities.

You lookin' at my bird?

One of Dr Aust’s current nightly rituals is reading a bedtime story to one, or both, children.

This evening we were reading a story – one of this charming series – which contained the word:

“budgerigar”

This reminded Dr Aust of an event, over a dozen years ago now, which exemplifies the problems with language (and perhaps also cultural differences) that can turn up unexpectedly in Universities.

The story concerns an exam sat by our undergraduate medical students some time in the mid to late 1990s. Back in those days we academics used to, as they say, “invigilate” all the exams ourselves. Nowadays we have special people – often retired academics – who do this, and the word “Invigilate!” instead tends to conjure up for me a vision of someone casting a spell in a Harry Potter book. But in those days, we would be there ourselves to hand out the exam papers and terrify the students with dire announcements about the consequences of cheating, or inadvertently having any notes about your person. Then we would spend a few hours patrolling the exam room trying to look grim and/or spot students with suspect programmable calculators.

Next, you need to know what sort of exam it was. This was what we called a “Case paper”, in which the students were presented with a short medical case history. The idea was that they should try and figure out what was going on, first trying to recognise so-called “cues”, and symptoms, in the history, and then suggest what kinds of tests or investigations they would order.

The particular case in this exam paper involved a man called “Mr Polly” (sic) who kept budgerigars. The birds actually appeared in the first line, which went something like:

“Mr Polly was devoted to his budgerigars, and kept several dozen in a shed at the back of his house. They were his pride and joy.”

Now, you need to know that the word “bird” appeared nowhere in the exam paper, though “budgerigar” was in there several times.

Perhaps you can guess what happened next.

A student stuck their hand up.

Dr Aust hurried over. Students sticking their hands up in exams are not unusual, since requests for extra paper, or to be allowed to visit the toilet facilities, were a regular part of invigilating then and doubtless still are. Of course, a minute or two after the exam started was a little bit early.

Dr Aust asked the student what s/he wanted.

The student replied nervously “I don’t understand this word”.

…And pointed to the word “budgerigar”.

This put Dr Aust in a bit of a quandary. He was a fairly junior academic at the time, and was not one of the people who had actually set the exam paper, so he didn’t really feel he had the authority to just tell the student that a budgerigar was a small bird. Scanning the paper, Dr Aust hunted for something else that might offer a clue. His eye fell on a passage more or less like this:

“One day, Mr Polly felt short of breath and a bit faint – walking up the stairs was an effort. Nonetheless, he was determined to attend to his budgerigars. Whilst cleaning out his aviary, he became dizzy and breathless and collapsed. His wife found him and called an ambulance”

Dr Aust pointed at this last sentence and whispered to the student:

“This sentence should help you. Look at this word. he said, underlining the word aviary.

The student, who judging by appearance and accent was clearly from outside the UK, looked panic-stricken.

“I don’t know what that word means either” s/he said.

Which is an object lesson, I guess, in being careful what words to use. And in what settings. Especially settings where it is difficult for people to ask clarifying questions.

The story does have a happy ending. After a few words with the Senior Examiner who had set the paper, we decided to make an announcement to all those in the exam hall to tell them that a budgerigar was a small parrot.

It turned out afterwards that several other students had been equally flummoxed by “budgerigar” and “aviary”, though most had not put their hands up.

Over the years I have sometimes wondered if any of those flummoxed students, now doubtless many years qualified in medicine and quite possibly GPs and consultants in the NHS, have ever again encountered the words “budgerigar” or “aviary”.

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PS Mr Polly’s complaint, which I dare say all my medical readers will have guessed, goes by the common name of “Bird Fancier’s Lung”, and is a form of extrinsic allergic alveolitis or hypersensitivity pneumonitis (more here).

PPS Language and comprehension is, of course, an issue in many settings in academia, and more so in medicine. Dr Aust has always (he hopes) been reasonably good at spotting – mostly from the non-verbal cues – when people working in his lab did not understand what he was saying, and adjusting his language accordingly. Not everyone does, though. One eminent Professor I knew was famous in the Department for fixing non-English-native-speaking research assistants with his most gimlet gaze and then saying, in his slowest and loudest voice:

“Do. You. Understand?”

The joke was that he often did this to people who came from cultures where to admit that you hadn’t understood the Great Man’s pearls of wisdom would be a terrible source of shame, and also a grave slight to the Eminent Professor. Thus the unfortunate subordinate would nod meekly, and the Great Man would depart satisfied that he had got his meaning across. Whereupon Dr Aust and the other more junior lab people would explain to the quivering research assistant what the Prof had been saying.

A slightly different problem arises for doctors who work in countries where the language is not their native one. Apart from just the language, they have to cope with regional accents and dialects. In the UK they also have to cope with the British talent for slang and euphemisms.

When Mrs Dr Aust first arrived in the UK to work as a junior doctor in a North West England-shire hospital, she was presented with a glossary of “local terms that your patients may use”. The list ran to a fair few printed pages. I suspect it may have had some similarities to the Yorkshire one here, which was discussed by the august British Medical Journal a while back.

Fox…Chicken Coop.. Contd

December 4, 2010

In which Dr Aust  is still convinced that you couldn’t make it up.  Though there is disagreement as to whether satire is dead, is alive but in intensive care, or has left the building.

Well… it has been a bit silent on the blog here recently, mainly because I have been feeling, as I said to some of my online friends somewhere: “writer’s blocked, sunlight-deprived and winter-torpid”.

So winter-torpid, indeed, that I have been shamefully slow responding to comments on the last post.

[Incidentally, the last blogpost was, I discovered to my surprise, the 100th one since Dr Aust's Spleen opened for business. True].

One commenter I finally got around to replying to this week was “David Cruise (no relation, honest)”, who was commenting on my incredulity at the idea that the Govt was proposing inviting the fast food giants to be part of the strategy-setting group for tackling obesity.  (And, indeed, the booze conglomerates to be part of the similar set-up for tackling heavy drinking, though I didn’t put that in the original post).

David posted:

“I’m not sure what the ruckus about this story really is about. If it were a campaign of road safety nobody would bat an eyelid if Volvo, Mercedes, Nissan etc. were participating.”

My reply to this is here, should you be interested. But David’s comment did make me have a think about whether I was getting over-exercised about this.

On the whole, though, I don’t think so.

Partly this is because other people in a position to speak with some authority about it seemed, and seem to be saying the same.

For instance, here is a quote about Professor Sir Ian Gilmore, leading liver specialist and until recently president of the Royal College of Physicians, taken from the Guardian:

“[Sir Ian] said he was very concerned by the emphasis on voluntary partnerships with industry. A member of the alcohol responsibility deal network, Gilmore said he had decided to co-operate, but he doubted whether there could be

“a meaningful convergence between the interests of industry and public health since the priority of the drinks industry was to make money for shareholders while public health demanded a cut in consumption”.  …”  (italics added)

 

A White Paper…  White as in “fresh look”? Or as in “bogroll”?

One notable development, since the original Guardian article I was writing about was published, is that we now have an actual White Paper on Public Health, released at the start of this week, setting out the Government’s ideas.

So has this allayed the fears of people like Sir Ian? And undercut the cynicism of people like me?

I have to say that seems doubtful.

The headline messages of the White Paper (or perhaps the ones the Govt has been keenest to promote) are that public health and health promotion budgets and responsibility will be devolved down to local authorities. and that the money will be ringfenced.

Less prominently featured were that overall there would be less money for public health, the  “responsibility deal partnerships” (as before), and the clear steer that legislation (for instance, to curb sales of cheap booze) would be a last resort – or “vanishingly unlikely under this government”, if you prefer.

The Guardian:

“The Royal College of Physicians, which has always provided strong leadership on public health, said it welcomed a ringfenced budget and the attempt “to bring to the field a much-needed strategic focus and coherence”. But, said its president, Sir Richard Thompson, “the RCP is disappointed by the lack of detail, especially around how to deal with the threats posed by alcohol misuse, obesity and smoking. We wait keenly to see if the promised subsequent strategies will fill in the gaps”.

Which, translated, means, I think: “we are deeply unconvinced, to put it mildly”.

The Guardian goes on:

“[Thompson] warned that it took six years for the last government to realise that voluntary agreements with industry would not necessarily deliver on public health.

“On a whole raft of issues it has been clearly demonstrated that a laissez-faire attitude does not work, either in terms of promoting responsible behaviour among the manufacturers and retailers of potentially harmful products, or in creating an environment that would allow individuals to make healthier choices,” he said.

An example of the latter would be, perhaps, the “Traffic Light” food labelling scheme. This kind of “red light” system was supported by real studies, preferred by consumers in tests, and universally backed by the public health people, the charities that are concerned with the health consequences of things like obesity and diabetes, and the UK Food Standards Agency. However, it was deeply unpopular with the food industry, and  was ultimately killed off by the European Union, an act widely understood to have come after determined lobbying from the industry.

In this context, and given the traditional closeness between big business and the Tory party, Gilmore’s and Thompson’s coded but fairly clear meanings do not inspire one with confidence.

A less carefully phrased take on the White Paper can be found in a recent blog by Andy Cowper, the shoot-from-the-lip editor of the online magazine Health Policy Insight.

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Public health White Paper out ahead of schedule; not worth the abbreviated wait

This public health White Paper takes the piss more thoroughly than a phalanx of urinals.

Is there a contest in the DH [Department of Health] for silliest policy of the year?

Its foreword states, “Britain is now the most obese nation in Europe. We have among the worst rates of sexually transmitted infections recorded, a relatively large population of problem drug users and rising levels of harm from alcohol. Smoking alone claims over 80,000 lives every year. Experts estimate that tackling poor mental health could reduce our overall disease burden by nearly a quarter. Health inequalities between rich and poor have been getting progressively worse. We still live in a country where the wealthy can expect to live longer than the poor.

“The dilemma for government is this: it is simply not possible to promote healthier lifestyles through Whitehall diktat and nannying about the way people should live. Recent years have proved that one size-fits-all solutions are no good when public health challenges vary from one neighbourhood to the next. But we cannot sit back while, in spite of all this, so many people are suffering such severe lifestyle-driven ill health and such acute health inequalities.

“We need a new approach that empowers individuals to make healthy choices and gives communities the tools to address their own, particular needs. The plans set out in this White Paper put local communities at the heart of public health. We will end central control and give local government the freedom, responsibility and funding to innovate and develop their own ways of improving public health in their area. There will be real financial incentives to reward their progress on improving health and reducing health inequalities, and greater transparency so people can see the results they achieve.”

Umm. There is a problem with this, which is that other than the stats on ‘Our Unhealthier Nation’ (to coin a phrase), it’s talking, in civil-service-speak, round objects.

A few examples of the more egregious bits of crap:

“…it is simply not possible to promote healthier lifestyles through Whitehall diktat and nannying about the way people should live”. Blatant horseshit. Public health measures that made undeniable and significant impacts include: seatbelt laws, drink-driving laws, the smoking ban. Public health is not solely about using the tax system and legislation to ban things, but both are vital tools in the arsenal.

McDonalds, KFC and Pepsi (or whoever) are not going to do things that meaningfully threaten their core business: the vending of youth-branded convenience, high-energy or high-fat products. It is Pollyanna-ish optimism to think otherwise.”

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More in the same vein here. It is a bracing read.

And, having read it, I don’t think satire is getting off the ventilator any time soon. Unless the lure of a Big Mac and large fries becomes too great.

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PS  As I was (finally) getting this ready to post, I heard the re-run of The Now Show on Radio 4, and was interested to hear the team offering their own take on Health Minister Andrew Lansley’s public health ideas.  On the plus side, they have found something to satirise. On the minus side – at least for public health – they seem to see things rather the same way I do.   You can listen to the programme here (for the next 7 days; the relevant bit is at 13 min 40 sec in).

The Mass Libel Reform Blog – Fight for Free Speech!

November 10, 2010

Dr Aust, in common with many far better known bloggers, is delighted to host the following, written by scientific libel hero Simon Singh.

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“This week is the first anniversary of the report Free Speech is Not for Sale, which highlighted the oppressive nature of English libel law. In short, the law is extremely hostile to writers, while being unreasonably friendly towards powerful corporations and individuals who want to silence critics.

The English libel law is particularly dangerous for bloggers, who are generally not backed by publishers, and who can end up being sued in London regardless of where the blog was posted. The internet allows bloggers to reach a global audience, but it also allows the High Court in London to have a global reach.

You can read more about the peculiar and grossly unfair nature of English libel law at the website of the Libel Reform Campaign. You will see that the campaign is not calling for the removal of libel law, but for a libel law that is fair and which would allow writers a reasonable opportunity to express their opinion and then defend it.

The good news is that the British Government has made a commitment to draft a bill that will reform libel, but it is essential that bloggers and their readers send a strong signal to politicians so that they follow through on this promise. You can do this by joining me and over 50,000 others who have signed the libel reform petition at:

http://www.libelreform.org/sign

Remember, you can sign the petition whatever your nationality and wherever you live. Indeed, signatories from overseas remind British politicians that the English libel law is out of step with the rest of the free world.

If you have already signed the petition, then please encourage friends, family and colleagues to sign up. Moreover, if you have your own blog, you can join hundreds of other bloggers by posting this blog on your own site. There is a real chance that bloggers could help change the most censorious libel law in the democratic world.

We must speak out to defend free speech. Please sign the petition for libel reform at http://www.libelreform.org/sign.    ….”

Simon Singh

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Some more background – [Dr Aust speaking again]:

As long-time readers (survivors?) of this blog will know, Simon Singh’s defence of the libel claim against him by the British Chiropractic Association eventually ended in a victory for free speech. However, free speech in similar cases remains insecure while the underlying structural problems with the English libel law remain.

From the Judgement of the Court of Appeal in the BCA vs. Singh libel case (via Jack of Kent).

[On matters of libel and scientific controversy]

“We would respectfully adopt what Judge Easterbrook, now Chief Judge of the US Seventh Circuit Court of Appeals, said in a libel action over a scientific controversy, Underwager v Salter 22 Fed. 3d 730 (1994):

“”[Plaintiffs] cannot, by simply filing suit and crying ‘character assassination!’, silence those who hold divergent views, no matter how adverse those views may be to plaintiffs’ interests. Scientific controversies must be settled by the methods of science rather than by the methods of litigation. … More papers, more discussion, better data, and more satisfactory models – not larger awards of damages – mark the path towards superior understanding of the world around us.”” [para. 34, emphasis added]

Now, it may appear clear from this passage where their Lordships’ view lies. Note though, that this is a suggestion, albeit a strongish one (“adopt”). It is not a law. It is not a part of the judgement that is binding on judges hearing further libel cases.

If you doubt for a moment how dangerous it can still be to speak out on matters of scientific and medical controversy, read this. Or this.

(For more medical-technical coverage of the Wilmshurst case, you could start here – links to further information at the bottom – or on Aubrey Blumsohn’s excellent blog.)

If this appals you – as it does me – then now is your chance to do something about it.

Sign the petition, and encourage others to do so.

The recent Science is Vital campaign shows that issue-based campaigns can move politicians to action.

The more people that sign the libel reform petition, the more the politicians will take notice.

So please sign.

Do it now.

“Never doubt that a small group of thoughtful, committed citizens can change the world”

- generally attributed to American cultural anthropologist Margaret Mead (1901-1978)

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PS – 11th Nov: No sooner had all these libel reform posts gone up yesterday, then we went from the depressing to the depressing AND ridiculous with the “boob job cream” libel story: read more here.

You. Couldn’t. Make. It. Up.

Unless you have a product to sell, of course…


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