Category Archives: compare education and medicine

It’s Ridiculous to Treat Schools Like Covid Hot Zones (David Zweig)*

This article appeared in Wired Magazine June 24, 2020.

David Zweig writes about technology and culture for a number of publications, including the New York Times, the New Yorker, and the Atlantic. He is also the author of the book Invisibles: Celebrating the Unsung Heroes of the Workplace.”

On May 18, education ministers from the EU gathered on a conference call to discuss the reopening of schools. Children had been back to class for several weeks in 22 European countries, and there were no signs yet of a significant increase in Covid-19 infections. It was early still, but this was good news. More than a month later, the overall mortality rate in Europe has continued to decline. Now, as we look to the fall, the US belatedly appears keen to follow Europe’s lead.

The question of how US schools should be reopened—on what sort of schedule, with what degree of caution—has yet to be determined. But recent guidance from the US Centers for Disease Control and Prevention, released May 16, conjures up a grim tableau of safety measures: children wearing masks throughout the day; students kept apart in class, their desks surrounded by 6-foot moats of empty space; shuttered cafeterias and decommissioned jungle gyms; canceled field trips; and attendance scattered into every other day or every other week. Reports suggest that certain US schools may even tag their kids with homing beacons, to help keep track of anyone who breaks the rules and gets too close to someone else. It seems that every measure, no matter how extreme, will be taken in an effort to keep the students and the staffers safe.

This could be a grave mistake. As children return to school this fall, we must take a careful, balanced view of all the safety measures that have been proposed and consider which are really prudent—and which might instead be punitive.

It’s certainly true that reopening our schools, however carefully, could increase transmission of the virus. Some countries that have done so—Israel and France, for instance—did see clusters of infections among students and staff. But these outbreaks were both small and expected, officials in both countries told the press; and the evidence suggests that the risks, overall, are very low.

Let’s review some facts: Children are, by and large, spared the effects of the virus. According to the latest data from the CDC, infants, little kids, and teenagers together have accounted for roughly 5 percent of all confirmed cases, and 0.06 percent of all reported deaths. The Covid-linked child inflammatory syndrome that received fervent media attention last month, while scary, has even more infinitesimal numbers. “Many serious childhood diseases are worse, both in possible outcomes and prevalence,” said Charles Schleien, chair of pediatrics at Northwell Health in New York. Russell Viner, president of the UK’s Royal College of Pediatrics and Child Health, noted that the syndrome was not “relevant” to any discussion related to schools.

There is also a wealth of evidence that children do not transmit the virus at the same rate as adults. While experts note that the precise transmission dynamics between children, or between children and adults, are “not well understood”—and indeed, some argue that the best evidence on this question is that “we do not have enough evidence”—many tend to think that the risk of contagion is diminished. Jonas F. Ludvigsson, a pediatrician and a professor of clinical epidemiology at Sweden’s Karolinska Institute, reviewed the relevant research literature as of May 11 and concluded that, while it’s “highly likely” children can transmit the virus causing Covid-19, they “seldom cause outbreaks.” The World Health Organization’s chief scientist, Soumya Swaminathan, suggested last month that “it does seem from what we know now that children are less capable of spreading” the disease, and Kristine Macartney, director of Australia’s National Centre for Immunisation Research and Surveillance, noted a lack of evidence that school-aged children are superspreaders in her country. A study in Ireland found “no evidence of secondary transmission of Covid-19 from children attending school.” And Kári Stefánsson, a leading researcher in Iceland, told The New Yorker that out of some 56,000 residents who have been tested, “there are only two examples where a child infected a parent. But there are lots of examples where parents infected children.” Similar conclusions were drawn in a study of families in the Netherlands.

None of this implies that Covid-19 couldn’t still spread efficiently among a school’s adults—the teachers and staff. Under any reopening plan, those who are most vulnerable to the disease should be allowed to opt out of working onsite until there is a vaccine or effective treatment. And adults who are present, when around each other, should wear masks and maintain proper social distancing. Distancing among adults may be easier to implement in schools, where teachers tend to spend their days divvied up in different rooms, than it would be in some work environments that have already reopened, such as offices, factories, and stores.

A month ago, as schools were reopening in Europe, I made the case in WIRED that the US should consider doing the same. Asking when we should reopen, though, was somewhat easier than asking how. Lots of other countries are already in agreement on the first question, but it turns out there’s no consensus whatsoever on the second. Schools’ specific safety measures vary not only from one nation to another, but also, commonly, within each nation. In Taiwan and South Korea, among other countries, plastic barriers have been placed on students’ desks, creating Lilliputian cubicles. In France, some districts have children wearing both masks and plastic face shields; while others just use masks. In Germany, masks are suggested for common areas only. In Denmark and Sweden, masks for students are not required at all. Some countries are encouraging classes to be held outdoors. (Outdoor classwork is not mentioned in the CDC guidelines, though preliminary plans for some states and counties do list this as an option.)

Which of these measures are effective and appropriate? No one knows for sure. Still, it’s possible to flag the ones that seem least necessary. For instance, the French schools that employ the belt-and-suspenders approach of having students wear both face shields and masks, are doing so in direct contrast to a letter signed by the heads of 20 of the country’s pediatric associations, which states that wearing even just a mask—never mind the face shield—“is neither necessary, nor desirable, nor reasonable” in schools for children. Meanwhile, lower schools have been open in Sweden, without masks, for the entirety of the pandemic, and there has been little evidence of major outbreaks coming out of them.

Ludvigsson told me that the widespread use of masks in schools “cannot be motivated by a need to protect children, because there is really no such need.” He’s similarly unimpressed by efforts to implement plastic barriers, playground closures, or any other measure beyond common-sense distancing and hygiene. Such precautions to prevent the spread of the infection from children to adults make no sense, he said, “since children are very unlikely to drive the pandemic.” Another Karolinska Institute epidemiologist, Carina King, said there is currently “weak evidence on children transmitting to each other or adults within school settings,” and suggested the most appropriate safety measures for schools might include testing and contact tracing, improved ventilation, and keeping students with a single group of peers throughout each day.

A report released last week by a panel of experts affiliated with the Toronto Hospital for Sick Children in partnership with the Ontario Ministry of Education, recommends against masks in class, noting that it is “not practical for a child to wear a mask properly for the duration of the school day.” The report also advises that “strict physical distancing is not practical and could cause significant psychological harm,” since playing and socializing are “central to child development.” Instead, the report recommends the adoption of smaller class sizes, so long as this does not disrupt a school’s daily schedule.

Strangely, American policy officials have not said much about the potential infeasibility and associated costs of the most extreme measures on the table. It’s not a big deal for an adult to wear a mask in a store for 15 minutes. But it’s entirely different to ask a child to wear a cloth face covering, as the CDC recommends for US schools, over many hours every day. The guidelines helpfully suggest that children “should be frequently reminded not to touch the face covering.” Have these people ever been around a bunch of 7-year-olds?

One of the more ostensibly benign, but actually most consequential, measures is the spacing of desks 6 feet apart. As a practical matter, few US schools have the room to accommodate all their students being so spread out. This means many institutions will be all but required to operate at reduced capacity, with students spending up to half their time at home.

The alternating-days approach is euphemistically referred to as “blended learning.” Considering the dismal failure that “distance learning” has proven to be in much of the country this spring, it implies that students will be educated for only half the year. Kids affected by the spring’s school closures are already showing knowledge deficits—what’s being termed “the Covid-19 slide”—and the learning gaps are disproportionately wider for lower-income students. Worse, perhaps, than being off for a block of time, is the intermittence that blended learning will oblige. Students need continuity in attendance to prosper, socio-emotionally and educationally. (This problem will only be exacerbated by inevitable closures as new cases are found. None of the experts I spoke with could give clear benchmarks for what prevalence of infection should trigger a closure.)

There also has been little acknowledgement or plan for how working parents are supposed to earn a living when their children are home for half of every school day, or every other school day, or every other week. “No credible scientist, learning expert, teacher, or parent believes that children aged 5 to 10 years can meaningfully engage in online learning without considerable parental involvement,” stated an editorial in JAMA Pediatrics. Nevertheless, the prospect of having children sit alone and stare at a computer screen instead of engaging with their teachers and peers is not only a certainty for many students in the US, it’s one that some officials—such as New York governor Andrew Cuomo—have characterized as educational progress. Last month, Cuomo wondered aloud at a press briefing why, with the power of technology, the “old model” of physical classrooms still persists at all.

Blended learning appears to have become accepted as a foregone conclusion for US schools, with little acknowledgement of how radical it is.

When students are actually in the schools, the overarching theme will be one of isolation: desks spaced apart and turned to face the same direction; closure of communal areas such as dining halls; staggered arrival and departure times to avoid any socializing before and after school; limited extracurricular activities; low-occupancy buses with one child per bench, seated in every other row. This deprivation of touch and physical proximity to others is unhealthy in the short term. Over a span of many months (and perhaps more than a year), one must imagine an existential toll on children when their physical experience with each other is that of repelling magnets.

In theory, many US schools could choose to avoid the most oppressive measures. The CDC itself presents a graded set of safety rules—some for “distancing,” others for “enhanced distancing”—that are meant to correspond to different levels of disease risk in the community. The phrases if possible and if feasible are peppered throughout the document, which also notes that “all decisions about following these recommendations should be made in collaboration with local health officials and other state and local authorities.”

But veering from the CDC’s or states’ advice would require a renegade spirit not likely to be found among those who’ve risen in such bureaucracies. While hedged language empowers localities to make choices on their own, an official guideline that suggests doing something “if possible” is like a mafioso asking a shopkeeper to do him “a favor.” I live in New York state, where guidelines for reopening have not yet been issued by the governor’s office. Yet the superintendent of my district’s schools has already sent an email to parents suggesting that we procure face shields for our children for the fall.

When much of the world reopened their schools this past spring, America neglected to follow. Now, the US seems eager to copy the most excessive measures implemented elsewhere, despite the evidence of minimal pediatric risk and infectiousness, and against the advice of many epidemiologists, infectious disease specialists, and pediatricians, and with a seeming obliviousness to their costs.

For years, many schools have had their drama and arts departments budgets reduced. It would be a sour irony if mandatory masks, half-vacant school buses, and shuttered jungle gyms ended up as our schools’ most grand theatrical production.

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*Thanks to Sondra Cuban for sending me this article.

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Polio Epidemic in 1937 Closed Chicago Schools: Kids Learned at Home from Radio (Michael Hines)

An assistant professor at Stanford University’s Graduate School of Education, Michael Hines researches and teaches the history of education in the United States. His articles have appeared in the Journal of the History of Childhood and Youth and History of Education Quarterly; he is writing a book on race, democracy and Chicago’s schools during World War II. This piece appeared in the Washington Post, April 3, 2020.

A rapidly spreading virus with no known cure or vaccine. Chicago-area schools closed. Experiments in remote learning and concerns over access to technology. This has happened before.

While the challenges to education stemming from the novel coronavirus pandemic may seem unprecedented, educators may be surprised to learn that almost 100 years ago Chicago’s schools faced similar circumstances.

In the fall of 1937, an outbreak of poliomyelitis, or polio, a highly infectious disease that can lead to paralysis and death and is especially dangerous to young children, swept through the Chicago area. It forced schools to delay the opening of the academic year and prompted widespread alarm about lost instructional time and students left to their own devices.

Determined to continue instruction for the district’s nearly 325,000 elementary age students, then-Superintendent William H. Johnson and then-Assistant Superintendent Minnie Fallon initiated a massive experiment that brought school lessons directly into the homes of students through the coordinated efforts of public schools, major radio stations, daily newspapers and local libraries.

Although some of the area’s more well-heeled schools had already begun using radio inside the classroom, the technology itself was still fairly new and largely untested in education in the 1930s, and the idea of school-by-radio was highly innovative, prompting excitement and comment from educators around the country.

As Chicago and other cities and school districts again prepare to tackle the challenge of virtual learning and instruction, this time online, they’d do well to remember some of the strategies of their forebears.

First, the school-by-radio programs were well-organized. Elementary teachers and principals wrote and prepared each lesson, overseen by subject area committees who ensured overall quality and continuity. Once the material was ready, the segments were presented in 15 minute slots of airtime (short and to the point), donated by six cooperating radio stations: WENR, WLS, WIND, WJJD, WCFL and WGN.

The schedules of broadcast times and dates, along with “directions, questions, and assignments” were available in the local papers each morning so that students could find the lesson for their own grade level and be prepared to set their dials.[1]

Different subjects were also covered on specific days; Mondays, Wednesdays and Fridays were devoted to social studies and science, with Tuesdays, Thursdays and Saturdays slotted for English and mathematics content. After each airing, a committee of two principals reviewed the lessons and rated them on aspects like “clearness of articulation and suitability of vocabulary,” giving a basis for improvement on the next broadcasts.[2]

Second, the radio programs were entertaining. Educators quickly found, as anyone who has hosted a virtual meeting of any kind might agree, that without physically sharing a location it was much more difficult to be sure of their audience’s attention and that “any other distraction, more attractive for the moment, may lure the listener away.”[3]

In response, the school district adopted tactics from the commercial broadcasting world, including “the introduction of a guest star on one of the lesson broadcasts.”[4] Carveth Wells, a British “explorer and globetrotter” known for leading expeditions throughout Africa, India, and other exotic locales, was scheduled to speak on the broadcast for the third and fourth grades, ensuring that some of the lessons at least entertained as well as informed.[5] The Chicago Tribune reported that it expected a “shrill cheer of joy when small people hear that hear will be no multiplication exercises.”[6]

Third, they actively sought to involve parents and communities. A hotline was established through the school district’s central office, staffed by 16 teachers, and parents were encouraged to call in with questions or comments. After logging more 1,000 calls on the first day of the program, five more teachers were soon added.

As papers reported, “the fact that the plan is being followed … is evidenced by the telephone calls of parents who are distressed if they are unable to get a certain station on the radio and some child has missed a lesson, or if some speaker has given directions a little too fast, and the child did not get it all.”[7]

Other means to increase parent involvement included urging families to set aside blocks of time for daily study periods after the radio lessons with their children. One Chicago Daily Tribune reader even made the suggestion of offering a prize to the “parents who write the best letter on any lesson they are interested in,” as a way of prompting them to engage with the material themselves.[8]

Of course, as with any experiment, school-by-radio had its flaws as well. Some listeners, as noted above, complained that the broadcasts moved too quickly, causing them to miss critical information.

Another problem, and one which schools and colleges will likely face in the current crisis as well, was uneven access to technology. Although Johnson estimated that some 315,000 students tuned in to the radio lessons during the weeks they aired, schools also created make-up work for students whose families did not own radios, had poor reception, or were forced to leave Chicago altogether during the crisis.

While some homes reported that they were able to go to great lengths to continue ensure their children could listen in, setting up radios in different rooms so that their multiple students could listen to the broadcasts for their respective grades for example, such luxuries were not available to all. In addition, students who needed more attention or remediation struggled through one-size-fits-all radio lessons.

Ultimately, these gaps left educators and observers worried that “the pupils who benefit by the radio lessons” might ultimately be “those who need them least” and “who would suffer least by curtailment of their classroom instruction.”[9]

Though school-by-radio’s initiators were optimistic about the power of technology, they knew that the success of the project ultimately hinged on the dedication, creativity, and resourcefulness of teachers and their students. As one report stated, “with the advent of broadcasting some 15 years ago there were prognosticators who expected radio to supplant the textbook — and even the teacher.”[10]

Yet, as the polio crisis showed, it had “become increasingly more apparent that the most radio can do in the teaching role is to stimulate thinking and to inspire further study.”[11] Even though technology has come a long way in the decades since, it is a safe bet that any plan for virtual instruction now will come to the same conclusion.

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[1] William H. Johnson, “Air Lessons Offer New School Test: Educators Show Wide in Experiment, Forced on Chicago by Poliomyelitis,” New York Times, Sept. 19 1937.

[2] Ibid.

[3] Larry Wolters, “Broadcast Food for Thought? Use Sugar Coating!” Chicago Daily Tribune (Chicago, IL), Sept. 19, 1937.

[4] Larry Wolters, “Radio School Will Present a Guest Star,” Chicago Daily Tribune (Chicago, IL), Sept. 16, 1937.

[5] Ibid.

[6] Ibid.

[7] William H. Johnson, “Air Lessons Offer New School Test: Educators Show Wide in Experiment, Forced on Chicago by Poliomyelitis,” New York Times, Sept. 19 1937.

[8] E. D. G, “Radio Lessons,” Chicago Daily Tribune (Chicago, IL), Sept. 16, 1937.

[9] “Lessons by Radio,” Chicago Daily Tribune (Chicago, IL), Sept. 14, 1937.

[10] Larry Wolters, “Broadcast Food for Thought? Use Sugar Coating!” Chicago Daily Tribune (Chicago, IL), Sept. 19, 1937.

[11] Ibid.

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The “Magic Bullet” in School Reform

In the recent past, when school reform cheerleaders touted a particular design or program, they would often drop the phrase “magic bullet” into the discussion. While in 2020 the phrase has become passe’ the thought behind it remains solidly planted in reformers’ imaginations.

Today, the words would be used disparagingly since few believe in any “quick fix” for the achievement gap or re-engaging unmotivated students into learning. However, amid the coronavirus pandemic, the search for a “magic” pill or eventually a vaccine has the ring of that outdated phrase.

The phrase, however, was commonly used in earlier decades of school reform. Remember “Career Education” in the 1970s; “restructuring schools” in the 1980s; “systemic school reform” in the 1990s. Don’t forget “choice” in the 1990s when John Chubb and Terry Moe pronounced it as a “panacea.” And for the past decade, champions of “magic bullets” have touted “teacher pay-for-performance,” Reading First, Teach for America, and principals as instructional leaders. I could go on and on but the point of very smart people believing in one or a few “magic bullets” turned out to be duds. Such a phenomenon raises a few obvious questions.

1. What is the origin of the phrase?

2. Why do policymakers, practitioners, parents, and reform-driven folks hunt again and again for the next magic bullet?

3. Are “magic bullets” unique to education?

What is the origin of the phrase? If you guessed the field of medicine, you are correct. Paul Ehrlich (1854-1915) used “magic bullet” to describe a chemical that “would seek out and specifically destroy invading microbes or tumor cells.” He and another researcher discovered a treatment for syphilis called Salvarsan that destroyed the bacteria causing the disease while not killing healthy cells. Ehrlich’s laboratory work helped create the fields of hematology, immunology, and chemotherapy. In 1908, Ehrlich received the Nobel Prize in medicine.

Why do policymakers, practitioners, and reform-driven folks hunt again and again for the next “magic bullet?” Ah, this is a tougher question. You cannot Google an answer since it is deeply embedded in the popular hope of tax-supported public schools solving problems besetting a democracy.

For nearly two hundred years, schools have been expected, at various times, to create engaged citizens, instill moral character, sustain community values, reduce social inequities, prepare youth for the labor market, and produce independent thinkers. Since the early 20th century, determined reformers have dreamed of improving government, society, and culture through schooling the young. Yes, achieve all of these competing purposes and, in addition, solve serious problems from poverty to slow economic growth to defending the nation, and even reduce obesity. The constant failure to do so speaks to the frustrated but yet undeterred reform-driven efforts captured in two book titles: Tinkering toward Utopia and Spinning Wheels. And that is why the hunt for “magic bullets” persists.

Are “magic bullets” unique to education? There is a long and short answer.
The long answer is historical and has to do with American colonies founded nearly four centuries ago by dissenters, free thinkers, and outcasts—emigrants from despotic monarchies who yearned for freedom, liberty, and independence–but also believed that humans can be made perfect. Ergo, reform the individual and society. They also believed that too much power in the hands of a few could damage these values. These colonists rebelled against the British monarchy in 1775 and achieved their independence after an eight-year war.

Experiments in government led to a Constitution that created a federal system of governing with explicitly divided powers between the national,s state, and local authorities. A slowly evolving democratic society over the next two centuries became increasingly and steadily inclusive after Americans expunged slavery in a bloody Civil War, then a century later ended a brutal caste system, and in the last half-century fought furious battles over who should be treated as equal.

Those colonists, Founders, and subsequent generations not only fashioned a federal government with separated powers but they also believed in the perfectibility of humankind through reason, education, and law. Those beliefs fueled constant reform efforts over the past few centuries for individuals and institutions to improve themselves. Thus, government agencies, churches, medical practice, criminal justice, and, yes, public schools have been the target for reform. That’s the long answer.

The short answer is that “magic bullets” aimed at unraveling knotty problems are common across institutions. Take medicine and the “war on cancer” announced in 1971. Since then, over $200 billion has been spent by public and private agencies to cure more than 100 diseases grouped under the word cancer. With over a half-million deaths a year and 1.5 million cases in the U.S. in 2009, cancer is the second leading cause of death just behind heart disease. Consider further than 1 out of 2 men and 1 out of 3 women will be diagnosed with cancer in their lifetime. “Magic bullets” in prevention and treatment (new chemo drugs, radiation pellets, and surgical procedures) have been announced time and again since 1971 and still cancer persists.

Today, when educational and medical reformers use the language of reform they deny that “magic bullets” can end serious problems and diseases. They often refer to prevention and awareness. And yet, the allure of a new program, a new drug continues to entice Americans into believing that the cure is just around the corner.

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Personalized Learning and Personalized Medicine (Part 2)

No more bumbling Inspector Clouseau who I introduced in the previous post (for snippets from his films, see here, here, and here). For this post, I turn to another film character for inspiration: scientist Mr. Spock on the starship Enterprise. Logical and imperturbable–see here and here— I (but without the pointed ears) copy him by comparing and contrasting Personalized Learning (PL) and Personalized (or Precision) medicine (PM).

Similarities:

*History of individualizing treatment.

In medicine, currently, the mantra repeated in medical journals, conferences, and in hospital corridors is “patient-centered” care. Within the past half-century, the explosion of technology-driven diagnosis and treatment, rising costs, and growing dismay with patients being sent from one specialist to another has led to calls for clinicians to individualize their diagnosis and therapy to the varied needs of their patients.

…. In the quest to conquer disease, the fact that the patient is a person can often get overlooked. In the predominant U.S. healthcare model, people are often treated as a collection of diseases that episodically rear their ugly head and require drastic, increasingly expensive medical interventions. Practitioners of patient-centered medicine hope to change this, focusing on the overall well-being of the patient from day one with a combination of prevention, early detection and treatment that respects the patient’s goals, values and unique characteristics.

Counter to “doctor-centered,” the individualizing of diagnosis and treatment can be traced back to Hippocrates.  But it is only in the past half-century that calls for “patient-centered” practice have become front-and-center in the debate over how to deal with chronic diseases which afflict nearly half of all adult Americans.

As for schools, historical efforts to “personalize” teaching and learning have periodically occurred ranging from getting rid of the age-graded school to varied groupings of children during a lesson to teaching machines used in the 1920s and 1950s to the technology-driven “personalized learning” in the early 21st century (see here, here, and here)

*Reliance on technology to diagnose and treat differences among patients and students.

Hospital nurses have COWs–Computers on Wheels–that they bring to a patient’s room; doctors have scribes who take down what they say to patients. And teachers carry tablets with them as they traverse a classroom while students click away on their devices.

Technologies for diagnosing and treating patients’ new and chronic ailments and technologies that assess students’ learning strengths and limitations have become ubiquitous in doctors’ suites and classrooms.

*Over-promising and hype.

From miracle drugs to miracle software, both medical and school practitioners have experienced the surge of hope surrounding, say, a new treatment for Alzheimer’s disease or a quicker way to learn math.

Doctors will diagnose and treat diseases through mapping a person’s genome or by analyzing one drop of blood from a prick of the finger; childhood cancers will disappear (see here and here).

Claims that children using computers will have higher test scores and get high-paying jobs came with the earliest desktops in the 1980s. Promises that teachers will teach faster and better (see here and here) accompanied those devices then and since.

In a society where both business and government compete to provide private and public goods, where Americans are both consumers and citizens, the tension between making money and providing the best medicare care and education inexorably lead to over-promising and hyperbole.

Differences:

*In PM, analysis of patient’s DNA to find genetic disease markers (found in human genome) and then matching a specific, already tested drug matched to specific gene in patient’s genome that is connected to patient’s disease is common practice now.

In PL, no such intense and specified diagnosis of each student’s strengths and limitations currently exists. Nor are treatments for students–new curricula, new devices– tested clinically prior to use on individuals. Finally, the essential, overall knowledge and skills of a subject such as math, biology, U.S. history, or reading–analogous to the human genome–that can be targeted to the strengths and weaknesses of an individual child or youth is, in a word, absent (see here)

*In PM, individual patients do decide whether a new treatment for diabetes or atrial fibrillation should be administered.

In PL, however, adults decide on overall goals for students to reach. Both content and skills necessary to master come from state and district standards upon which students are tested to see if they have acquired both. In some settings such as problem-based instruction, students may decide what goals they want to achieve on a particular day in a particular lesson but not what they should learn overall–that is what district and state curriculum standards and tests determine.

*While in PM there is some research and clinical trials on specific therapies for particular diseases (e.g., breast and ovarian cancers), very little research (or clinical trials) for brand-name software content and skills exists currently. If anything, use of new math, reading, science, and social studies software in classrooms becomes a de facto clinical trial but without control groups.

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These are similarities and differences between PL and PM that I see. I am certain there are more than what I have listed. Readers can suggest others.

Like Inspector Clouseau I stumbled over the connection between PL and PM and, unlike the French detective, I now, inspired by Mr. Spock, have analyzed both similarities and differences in being applied to both students and patients. Thank you Peter Sellers and Leonard Nimoy!

 

 

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Personalized Learning and Personalized Medicine (Part 1)

Inspector Clouseau was the bumbling French detective (played with spirited, egotistic aplomb) by Peter Sellers in the series of Pink Panther films beginning in the 1960s and running through the early 1990s.  His incompetent investigations into crime that tumbled into chaos yet ended with miraculously identifying and arresting the culprit kept me in stitches. I experienced an Inspector Clouseau moment recently.

I had been reading about medical advances in technology since I see many parallels between doctors’ use of new technologies and teachers’. I came across a growing number of articles about “precise” or “personalized medicine.” The increasingly popular phrase  touted as the future of medicine is used by clinicians, pharmaceutical companies, and health insurers. As one would expect, definitions vary. One that captures much of what is meant by the phrase is: “customizing care to patients based on their predicted responses to treatments given their individual genetic profiles or other analyses.”

And this is where the Inspector Clouseau moment occurred. Had I stumbled over an obvious comparison between medical and educational practice that I had not considered? The answer is the Clouseauian response: “oui.”

In this series of posts, I will draw comparisons and contrasts between the practice of “personalized learning” in classrooms with the practice of “personalized medicine” as both unfold in doctors’ suites and public schools.

I begin with examples of personalized (or precise) medicine (PM hereafter) and then move to examples of “personalized learning” (PL hereafter),.

Personalized/Precision Medicine

 

Personalizedmed-1600x1253.jpg

An example of PM in action

For Janice King Poulsen, 71, of Sandy, Utah, the crucial treatment match involved the “ALK” genetic mutation. Poulsen, a lifelong nonsmoker, was diagnosed with Stage IIIA lung cancer in May 2007. That lung cancer spread to her brain. Home radon exposure, it later turned out, was the likely culprit.

Poulsen had to retire from work as a travel agent and from managing a synchronized skating program. Cancer became the priority. She went through a grueling array of standard treatments: radiation, chemotherapy, brain surgery and gamma knife therapy, or stereotactic radiation, as new brain tumors developed.

Eventually, Poulsen connected with the Huntsman Cancer Institute at the University of Utah. She learned she might benefit from a targeted drug called Zykadia, or ceritinib, for treating non-small cell lung cancer. Genetic testing of her tumor revealed the ALK mutation, she says – the right type for the drug.

It’s been three years since Poulsen started her precision therapy. She takes three capsules daily, with minimal side effects of nausea and diarrhea. She says she feels great. Her cancer appears to be under control.

Insurance helps pay for the expensive medication, which costs about $13,000 a month, and Poulsen’s family pays roughly $460 a month out of pocket. “Cancer isn’t cheap,” she says. In comparison, Poulsen, who now advocates for stronger home radon-testing policies, notes: “If you put in a radon mitigation system, it’s about $1,500.”

Another example:

Tania Swain got bad news: her ovarian cancer had come back. This was in November 2013; almost three years before, Swain, who is herself a physician, had been surprised by the initial diagnosis. And despite the surgery that removed 30 pounds of liquid and tissue from her ovaries, spleen, and appendix, and the chemo drugs that were swished around the space they left, the cancer was back. She feared that this time the diagnosis was truly the “kiss of death.”

But this time, Swain learned about the Clearity Foundation, a nonprofit organization that compiles its own database of mutations that cause ovarian cancer and help patients find the best individualized treatment. After another surgery in December 2013, her doctors sent a tissue sample to Clearity. “They look at the proteins and receptors, and the different ways that the tumor tissue itself has mutated to find how they can best attack it,” Swain says. Her tumor had an unusually high concentration of a protein called Ki-67, which was good news—her cancer would be more responsive to typical chemotherapy agents.

The treatment worked well—Swain felt less ill after the chemo than she had the last time. Though her cancer has since returned, she’s hopeful because she’s so impressed by the progress of cancer treatment, and advances in precision medicine in particular. “I finished my training [to become a doctor] in 1982, when CAT scans were just coming online. I think cancer treatments now are as different as night and day compared to then,” Swain says….

For Swain, the choice to get a genetic test was an obvious one. She knew it would help her find the best possible treatment, but even as a doctor she struggled to understand just what was going on in her body. “It was still a little overwhelming. All that information just comes at you,” she says. Without that treatment, however, she may not have survived; when she was first diagnosed with Stage 3 ovarian cancer, in 2011, she had a 39 percent chance of living at least five more years. Now, almost five years later, Swain is hoping that this third round of treatment has finally rid her body of ovarian cancer. The genes driving her cancer have changed—“which speaks to the polymorphism of this cancer,” she says—and the drugs she’s using to kill it have changed accordingly. But she’s optimistic: “I am very happy with the status of my markers and I’m feeling good.”

 

Examples of PL in action

 

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Sitting in front of a laptop, Chris Pozo, a sixth-grade student at Truesdell Education Campus in Washington D.C., opens his Summit calendar to show his daily goals. “My goal is to do my task and get 50 percent or more,” it reads.

Like every other student using the Summit Learning platform, Pozo must start each class by setting his goals before doing activities. The goals are either typed or picked by the student from a drop-down list of options created by the teacher.

“Every morning I change it, and we type our goals right here,” explains Pozo, pointing to his screen. He then opens up an assignment on a Google Doc and a grading rubric, reviewing the comments and feedback his teacher has left on his work.

Sixth-grader, Chris Pozo, using the Summit Platform in is science class. Photo Credit: Jenny Abamu

When EdSurge visited Chris Pozo’s sixth-grade science class at Truesdell, the student was reviewing comments left by his teacher, Courtney Grant, on his writing assignment. He glanced back and forth between his Google Doc and the grading rubric on the right side of his screen. This is how he decides what to do to get a 4 (equivalent to an A) on this assignment.

“I have to add more transition words and make it organized,Pozo explains as I visit his class. “This is what they are going to be grading us about,” he continues, pointing to the rubric on the screen.

Another example:

Over the past two years, educators at Windy Hill Middle School in Clermont, Florida have been transforming their teaching, tailoring instruction to students’ individual needs and interests. Students have been using new tools to learn content at their own pace and taking ownership of their learning in the process. The whole school community has been building a culture of personalized learning.

As principal William Roberts describes it: “Personalized learning is considering the interests of your students, giving them choice in their learning, and meeting them where they’re at—academically and personally.” The approach appealed to the team at Windy Hill as a way they could reach all students and make their learning even more powerful. So, in the fall of 2015, a small group of teachers who wanted to try out personalized learning began piloting the approach in their classrooms.

Teachers in the pilot created units aligned with Florida’s Sunshine State Standards and with multiple pathways for students at different levels, organized around the prerequisite knowledge students may or may not have. Students worked through the unit content at their own pace on their own laptops, conferencing with their teachers and working on projects with their fellow students along the way. Teachers still provided direct instruction, but they also spent more time circulating classrooms and supporting small groups of students, or working with students one-on-one. And they reviewed their students’ data to better understand where individual students needed more support—or where they were excelling and needed more of a challenge.

The results have been encouraging. All 101 seventh-graders that participated in a personalized learning math class at Windy Hill last year scored satisfactory or above on the math portion of the 2016 Florida Standards Assessments. By comparison, only 55 percent of Windy Hill seventh-graders not in a personalized learning math class scored satisfactory or higher.

Mary Ellen Barger, a personalized learning facilitator at Windy Hill, also has seen how personalized learning can be especially powerful for struggling students. “In the traditional classroom, little Johnny is bored and doing things to distract the class because he is so afraid of being seen as behind. In personalized learning, Johnny has a goal, knows what he is supposed to learn and that he can do it, and knows how to get extra help,” Barger explains. “He knows that we are going to keep working with him until he understands.”

This year, personalized learning at Windy Hill has expanded even more. The number of teachers using personalized learning in their classrooms has grown from 14 to 47—about half of all instructional staff. And as the team continues to make the culture shift to personalized learning, they also are focusing on personalizing the curriculum in all core subjects as well as electives. Making these changes isn’t easy, but the community is dedicated to personalized learning and excited about the positive impacts. As one eighth-grader put it: “It’s beneficial to everyone.”

For other examples of how PL is used in schools, see (here, here, and here).

Like Inspector Clouseau, it took me awhile to figure out the similarities and differences    between PM and PL. Part 2 elaborates on each.

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To Hug or Not: Physicians Differ on What’s the Right Behavior (Sandra Levy)

This article appeared February 19, 2018 in Medscape. Because clinical medicine is called a helping profession (as is teaching, nursing, psychotherapy, and social work) the relationship between doctor and patient is crucial to improving health and providing care for those whose health is deteriorating beyond what doctors can do. In such professions, dilemmasare rife. Whether or not to hug patients, a dilemma known to others in the helping professions where values of being a professional and being personal and humane clash, speaks to educators as well.

 

Avoid Hugging Your Patient

Although there are many pro-hug physicians, there are also many who are strongly against it. Many physicians are adamantly opposed to hugging because they believe that it changes the physician/patient relationship and creates potential risks.

A neurologist said:

I was always taught a hug can be misconstrued. I still stand by this concept. If someone has a loss, I will touch their arm and express my sympathy. This is why it is good to keep a certain distance to avoid this situation in the first place. To treat a patient, you must have their respect. If someone is too familiar, it can get in the way of treatment. Just my two cents. You want to be treated by your physician whom you respect, not your buddy you can have a beer with.

An infectious disease physician agreed:

I try not to hug anyone when I am in a professional setting. I try not to even handshake, in that I consider that action a business-to-business relationship (sealing the deal with a realtor, for example). Furthermore, in my subprofession, infectious diseases, I think some patients are appreciative not to shake my hand upon entry to the exam room or arriving at the patient’s bedside.

One anesthesiologist talked about potential risks:

A physical exam includes more than enough touch to comfort a patient. Take the vitals yourself, listen to the heart, lungs, and abdomen, and that is more than enough touch. Do not put your career in the hands of a potential nut-job or gold-digger (they do exist, you know). If a woman accuses a man of improper touch, Oprah says we have to believe her. The risk/benefit ratio is too high.

An ob/gyn echoed the comments above:

What you think will be a good idea hugging the patient may come back to haunt you. You’re not a mind-reader. You don’t know how the patient will react or what the patient thinks about you reaching over and hugging them. It’s like walking through a minefield. Maybe you get across without being hurt. One misstep and it can blow up right in your face.

A dermatologist who is against hugging, but who has been hugged by a patient, said:

I have grappled with this question over the years, but I mostly settled on total avoidance of embrace. An occasional hug when there has been a death in a patient family, but I recall this as once every few years. I have also been caught unawares on a few occasions when the embrace was initiated by the patient.

Awkward, but I have always managed to extricate myself from it. Those of us who have chosen a single lifestyle do have to be that much more careful. In the current environment, I will institute total avoidance without exceptions henceforth. Fortunately for me in a consultative specialty practice, long-term relationships are few.

 

This physician concurred: “My office visits are strictly on a professional level for the benefit of the patient. I do not hug any patients, or allow any patients to hug me.”

The reasons to avoid hugging are plentiful, says an emergency medicine physician. Hugs may make the recipient feel better, but the cons include the following: “The recipient calls the police and files charges of sexual battery. The district attorney chooses to prosecute. The patient files a lawsuit. The medical board revokes the doctor’s license. The doctor becomes bankrupted from the costs of his legal defense, plaintiff’s award, and loss of income and restriction from practicing medicine.”

 

Another emergency medicine physician agreed. “Many a career has been ruined by three simple words: ‘He touched me.’ It all comes down to how the recipient perceives the contact. If it is perceived as a physical violation, then that’s what it becomes.”

 

Another healthcare provider said that listening is better than hugging. “No, we should not ever hug patients. It is an unequal relationship and can be misconstrued. Shaking hands, speaking kindly, and spending time are proper. And practicing the lost art of listening. That’s what patients want.”

 

Another physician adamantly opposed to hugging said, “No hugging. This is not a friendship; it’s a professional interaction with a patient. Businesspeople don’t hug, lawyers don’t hug, we shouldn’t either.”

 

This physician offered an alternative to hugging:

I shake hands or say a traditional ‘namasthe’ with both hands touching as in praying, which conveys all of my good feelings, thoughts, and wishes to my patients effectively. I go out of my routine and keep a hand on the shoulder of the depressed and those suffering a poor prognosis. The mind conveys everything. I have never had to hug a patient to convey my best intentions or my empathy. I am in the business for the past three-plus decades.

 

One psychiatrist suggested an interesting interpretation of the hugging interaction:

Come on! Who is this hug for? The hugging doctors sound like they are tethered to prove something to themselves and by extension to their patients. I’m a nonhugger with exceptions, but as a psychiatrist, respecting the boundaries of people for whom that has not always been the case is something I can do for them. If a doctor hugged me, I’d get another doctor. I’m not convinced the hugging docs truly read their patients correctly because of the inherent power imbalance.

 

Finally, although it appears that there are numerous reasons why physicians have different views when it comes to hugging patients, they have also made it clear that in the current climate where hugs may be misconstrued as sexual harassment, it is wise to assess the situation and to use a cautious approach when initiating a hug or when receiving a hug.

 

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Learning from the Past? An Analogy between Compulsory Public Schools and Health Insurance*

The U.S. Senate’s failure to either repeal or repair the Affordable Care Act (Obamacare) means that the existing law, its strengths and flaws, will be around for the immediate future. A half-century ago, President Lyndon Johnson signed amendments to the Social Security law that the then Democrat-controlled House of  Representatives and Senate passed with large majorities. Thus, Medicare became the law of the land in 1965 for Americans 65 and older and Medicaid for the very poor. It was a single payer system of what was then called “socialized medicine.”

The first enrollee for Medicare was former President Harry Truman. Truman had initially promoted health insurance for all in 1945 and 1949 as had President Franklin Delano Roosevelt before him and President John F. Kennedy after him. So it took decades to get health insurance for the elderly.

 

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For those under the age of 65, however, health insurance was largely managed by private companies with prices set by the market. Even though most democracies in the world already had national insurance for all, the plans were funded differently (e.g., Britain, Netherlands, and Australia). Not until 2010–nearly a half-century later–when President Barack Obama signed the Affordable Care Act did the U.S. provide ways for millions of uninsured Americans under 65 to get health insurance.

The Affordable Care Act aimed at the 48 million Americans without health insurance in 2010. That number of uninsured Americans fell to 28 million in 2016, a drop (the highest ever) from 18 percent to 10 percent uninsured. Uninsured poor Americans in 31 states got Medicaid. Still there were defects in Obamacare that both Democrats and Republican legislators saw needed correcting.

Neither the bill passed by the House in 2016 and the bills that failed in the Senate in 2017 corrected the major flaws and even threatened to double the numbers of uninsured. With the recent Congressional debacle over health care bills, Obamacare remains intact but still millions of Americans under the age of 65 cannot afford market-driven prices for insurance.

To recap then: between the mid-1930s to 2017, nearly nine decades, old and young, economically comfortable and poor Americans have slowly gained health insurance in increments but Medicare for all or universal health care–is still in the distance. Although a majority of Americans polled (53 percent) say they want a single-payer plan, that would take a unified U.S. Congress and a determined President who could shove that ball yard-by-yard over the goal line. When that will happen, I surely do not know.

Affordable health care covering all Americans is, I believe, similar to the slow but steady incremental progress of tax-supported public schools that moved from private tutors, tuition-paying academies, and “Dame schools” in the 17th and 18th centuries to property owners being taxed, voters authorizing the “common” public school before the Civil War, and states later passing compulsory attendance laws in the late-19th and early 20th centuries (see here here, and here). Today, free public schools in the U.S. enroll over 50 million children and youth between the ages of 4 through 17 (depending on the state) in over 13,000  districts housing over 100,000 schools. The process of insuring that all boys and girls will go to school took many decades just as health care has in the 20th and early 21st centuries.

This is the analogy I use in this post. But historical analogies are dicey.

Uses of the Past

When policymakers, practitioners, and public school students ask about the usefulness of history they want guidance from the past to avoid making mistakes now; some even want predictions. Invariably, historians disappoint them.

Most historians believe that the past can surely inform current policy but extracting direct “lessons” and making confident predictions, while playing well on cable news, last little longer than the 24-hour news cycle and are often, there is no other word, wrong (see here and here).

So historians of education, for example, (and I include myself in that group) argue that even if “lessons” cannot be extracted from the past, policymakers and practitioners can surely profit from looking backward when, say, earlier generations of well-intentioned reformers worked hard to improve schooling. These scholars say that they can aid contemporary policymakers by pointing out similarities and differences between previous and current situations (i.e., analogies). Finally, historians can alert policymakers to what did not work, what might be preferable and what to avoid under certain conditions.

In historians offering their knowledge of how previous generations approached the problems of the day and crafted solutions, they can inform contemporary, serious reformers as they wrestle with a different context from their cousins a half-century to century ago.

The Spread of Tax-supported Public Schools

Beginning in colonial years, proceeding through the Revolutionary decades and responding to the social and political reform of the early 19th century, funding public schools in a mostly rural nation was seen as crucial to the political, social, and cultural health of the new nation. Reformers such as Thomas Jefferson, Horace Mann, and Noah Webster in these years spoke often of creating Americans who knew and performed their civic duties, understood the Bible, could read and write to get jobs, improve their moral character, and create a republican society that Americans prized. Yes, more than two centuries ago, there were multiple (and conflicting) purposes for schooling the young (see here, here, and here).

Slowly, the idea of tax-supported public schools took hold in New England spread to the Midwest but barely penetrated the pre-Civil War South. In rural and urban areas, primary and grammar schools grew. After the Civil War, more and more parents voluntarily sent their sons and daughters–racially segregated, however, by law until the 1950s–to school (see here and here).

Not until the early decades of the 20th centuries had all states passed  Compulsory attendance laws mandating parents to send their children to school. The ever-shifting but crucial purposes for schooling the next generation in a democracy required everyone to pay taxes and send their children to school.

By the middle of the 20th century, kindergartens, junior high and senior high school had been added to the age-graded elementary school. Increased graduation rates meant that the high school diploma became common. While the purposes for public schooling shifted from time to time (e.g., dropping Bible study, increased attention to job preparation) and while a private school K-12 sector grew slowly–about 10 percent of public school enrollment now–going to school became the dominant experience for children and youth.

By the end of the century, reformers called for all students to go to college (although most of higher education both public and private required families to pay tuition) bringing into daily conversation the question of whether youth would go 16-plus years to tax-supported institutions.

The point of this brief sprint through history of tax-supported schools and their purposes in a democratic society is that much time was taken and incremental steps occurred to make tax-supported public schools a virtual right for every U.S.family.

I believe a similar process is at work in providing universal health care as well.

______________________

*I thank Beverly Carter for suggesting this analogy.

 

 

 

 

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All Doctors Should Teach (Paula Cohen)

I have written often about the cluster of occupations that make up the “helping” professions: teaching, clinical medicine, nursing, therapy, and social work. These professionals help students, patients, and clients learn and become healthy. They are all teachers albeit in different settings.

Most important, these “teachers” in helping professions are totally dependent upon their students, patients, and clients to learn and get healthy. Regardless of the degree earned, annual income, and social status, these professionals cannot reach their goals without the cooperation, compliance, and involvement of those being helped.

Those who recognize this inherent dependency of professionals upon whom they serve have occasionally recommended that all physicians, nurses, therapists, and social workers become teachers before they enter the other helping professions. Here is one such recommendation for those seeking to become physicians.

Paula Marantz Cohen is dean of the Pennoni Honors College and distinguished professor of English at Drexel University and the author of Jane Austen in Scarsdale or Love, Death and the SATs. This post appeared in The American Scholar, September 18, 2012

 

My daughter, Katherine Penziner, wrote the essay that follows in response to my last column. She is spending a few years teaching in Southwest Arkansas as part of the Teach for America program. She plans eventually to go to medical school.

Every aspiring doctor should be required to teach a year of high school science. First, there is nothing more grueling than standing up, day after day, in front of hormonal and angsty teenagers who are having trouble controlling their attitudes. The emotional toll teaching takes can be exhausting–a perfect training ground for the taxing years of medical school we premeds are always hearing about. Still, a good day of teaching makes you feel good about yourself, and your students.

But what makes teaching most valuable for an aspiring doctor are the communication skills that must be developed in order to convey information to people who don’t yet have the vocabulary to engage fully with a concept. I firmly believe that the principles of chemistry and physics I teach to 15- and 16-year-olds are inherently exciting when the delivery is right.

That delivery is the crucial element missing when people complain of doctors’ bedside manner. Doctors who do not put their patients at ease are generally not bad people. It’s hard for me to believe that my friends who are in medical school now could alienate their patients–they are great communicators. However, there is a difference between the communication of facts and the explication of them. The gap between communication and explication is precisely the point at which the doctor-patient relationship can disintegrate fastest.

On tests in college and, I’m guessing, in medical school, you answer questions for professors, people who already know the answers. Why tell them what they already know? The truest test is if a doctor can give the answer to those who have no idea what hemoglobin is, could not guess the function of the gallbladder, and have never heard of the nephron.

In a recent article about health care in rural areas, a woman commented that poor black Americans might not trust doctors that don’t look like them. I can imagine that in the Mississippi Delta a black patient might be skeptical that white doctors could truly understand their situation, socially and economically. But though skin color can’t change, the vocabulary doctors use can.

I often use words in the classroom that my students don’t know. But I also make sure to either provide plenty of context for them to figure out the meaning, or clearly define them. I’ve seen students shut down when they don’t understand what I’m saying.  But with the right explanation, I’ve seen my weakest students grasp a concept.

Similarly, doctors must explain what they are doing to patients without alienating them with the vocabulary they use. I’ll never forget going to the dentist when I was very young and being frightened when he didn’t explain what he was doing. For years, that experience made going to the dentist into an ordeal.

Patients can develop a basic understanding of their illness and their treatment with the guidance of their doctors.  Good teachers can make a difference between success and failure in students’ lives. Doctors, if taught to be good teachers, can be the difference between health and sickness, and even life and death.

 

 

 

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How Technology Integration Has Altered Doctor/Patient Care in Hospitals (David Rosenthal, M.D. and Abraham Verghese, M.D.)

Over the past few years, I have compared physicians and teachers because even with so many differences in preparation and the nature of their work, they share two core principles. Both professionals belong to helping professions where their success, in part, is dependent upon the patient and the student. And success, however defined, depend upon each professional developing close relationships with their patients and students. The degree to which labor-saving devices have increased the efficiency of both physicans and teachers in carrying out their daily work, there are, nonetheless, tradeoffs that have become apparent as professionals practice in hospitals and schools.

The following article, “Meaning and Nature of Physicians’ Work,” appeared in the New England Journal of Medicine, November 16, 2016. To see citations, click on footnote number in NEJM article.

….Typically in our field, internal medicine, residents arrive at the hospital at 7 a.m., get sign-outs from nighttime residents, and conduct “pre-rounds” to see patients they have inherited but don’t know well, before heading to morning report or attending rounds. Attending rounds often consist of “card-flipping” sessions held in a workroom, frequently interrupted by discharge planning and pages, calls, and texts from nurses and specialists. Finalizing discharges before noon can feel more important than getting to know new patients. Increasingly, the attending physician doesn’t see patients with the team, given the time constraints.

No longer are there paper charts at the bedside. The advent of the electronic era, while reducing the time required for tracking down laboratory or radiology results, has not substantially changed the time spent with patients: recent estimates indicate that medical students and residents often spend more than 40 to 50% of their day in front of a computer screen filling out documentation, reviewing charts, and placing orders. They spend much of the rest of their time on the phone coordinating care with specialists, pharmacists, nutritionists, primary care offices, family members, social workers, nurses, and care coordinators; very few meetings with these people occur face-to-face. Somewhat surprisingly, the time spent with patients has remained stable over the past six decades.1

The skills learned early by today’s medical students and house staff — because they are critical to getting the work done — are not those needed to perform a good physical exam or take a history, but rather the arts of efficient “chart biopsy,” order entry, documentation, and sign-out in the electronic age. When a medical team gets notice of a new admission, it seems instinctive and necessary to study the patient’s record before meeting him or her. This “flipped patient” approach2 has advantages, but it introduces a framing bias and dilutes independent assessment and confirmation of history or physical findings.

In short, the majority of what we define as “work” takes place away from the patient, in workrooms and on computers. Our attention is so frequently diverted from the lives, bodies, and souls of the people entrusted to our care that the doctor focused on the screen rather than the patient has become a cultural cliché. As technology has allowed us to care for patients at a distance from the bedside and the nursing staff, we’ve distanced ourselves from the personhood, the embodied identity, of patients, as well as from our colleagues, to do our work on the computer.

But what is the actual work of a physician? Medical students entering the wards for the first time recognize a dysjunction, seeing that physicians’ work has less to do with patients than they had imagined. The skills they learned in courses on physical diagnosis or communication are unlikely to improve. Despite all the rhetoric about “patient-centered care,” the patient is not at the center of things.

Meanwhile, drop-down menus, cut-and-paste text fields, and lists populated with a keystroke have created a medical record that (at least in documenting the physical exam) at best reads like fiction or meaningless repetition of facts and at worst amounts to misleading inaccuracies or fraud. Given the quantity of information and discrepancies within medical records, it’s often impossible to discern any signal in the mountains of noise. Yet our entire health care system — including its financing, accounting, research, and quality reporting — rests heavily on this digital representation of the patient, the iPatient, and provides incentives for its creation and maintenance.3 It would appear from our hospital quality reports that iPatients uniformly get wonderful care; the experiences of actual patients are a different question.

It’s clear that physicians are increasingly dissatisfied with their work, resentful of the time required to transcribe and translate information for the computer and the fact that, in that sense, the work never stops. Burnout is widespread in the workforce, and more than a quarter of residents have depression or depressive symptoms.4 In response, health care leaders have advocated amending the “Triple Aim” of enhancing patients’ experience, improving population health, and reducing costs to add a fourth goal: improving the work life of the people who deliver care.

A 2013 study commissioned by the American Medical Association highlights some of the factors associated with higher professional satisfaction. Perhaps not surprisingly, the investigators found that perceptions of higher quality of care, autonomy, leadership, collegiality, fairness, and respect were critical. The report highlighted persistent problems with the usability of electronic health records as a “unique and vexing challenge.”5

These findings underscore the importance of reflecting on what our work once was, what it now is, and what it should be. Regardless of whatever nobility inhered in the work of physicians in a bygone era, that work was done under conditions and quality standards that would now be unacceptable. We practice in a safer and more efficient system with measurable outcomes. Yet with the current rates of burnout, our expectations for finding meaning in our profession and careers seem largely unfulfilled.

We believe that if meaning is to be restored, the changes needed are complex and will have to be made nationally, beginning with a dialogue that includes the people on medicine’s front lines. Perhaps the greatest opportunity for improving our professional satisfaction in the short term lies in restoring our connections with one another. We could work on rebuilding our practices and physical spaces to promote the sorts of human connections that can sustain us — between physicians and patients, physicians and physicians, and physicians and nurses. We could get back to the bedside with patients, families, and nurses. We could get to know our colleagues from other specialties in shared lunchrooms or meeting spaces.

In addition, we believe that in the coming years, the U.S. medical community will have to rethink the human–computer interface and more thoughtfully merge the real patient with the iPatient. We have an opportunity to radically redesign electronic health record systems, initially created for fee-for-service billing, as our organizations shift toward bundled payments, capitation, and risk sharing. Perhaps virtual scribes and artificial intelligence will eventually reduce our documentation burden.

But technology cannot restore our professional satisfaction. Our profession will have to rebuild a sense of teamwork, community, and the ties that bind us together as human beings. We believe that will require spending more time with each other and with our patients, restoring some rituals that are meaningful to both us and the people we care for and eliminating those that are not.

Solutions will not be easy, since the problems are entangled in the high cost of health care, reimbursement for our work, and obstacles to health care reform. But we can start by recalling the original purpose of physicians’ work: to witness others’ suffering and provide comfort and care. That remains the privilege at the heart of the medical profession.

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How Measurement Fails Doctors and Teachers (Robert Wachter)

Robert M. Wachter is a professor and the interim chairman of the department of medicine at the University of California, San Francisco, and the author of “The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age.This post appeared in the New York Times on January 16, 2016

 

Two of our most vital industries, health care and education, have become increasingly subjected to metrics and measurements. Of course, we need to hold professionals accountable. But the focus on numbers has gone too far. We’re hitting the targets, but missing the point.

Through the 20th century, we adopted a hands-off approach, assuming that the pros knew best. Most experts believed that the ideal “products” — healthy patients and well-educated kids — were too strongly influenced by uncontrollable variables (the sickness of the patient, the intellectual capacity of the student) and were too complex to be judged by the measures we use for other industries.

By the early 2000s, as evidence mounted that both fields were producing mediocre outcomes at unsustainable costs, the pressure for measurement became irresistible. In health care, we saw hundreds of thousands of deaths from medical errors, poor coordination of care and backbreaking costs. In education, it became clear that our schools were lagging behind those in other countries.

So in came the consultants and out came the yardsticks. In health care, we applied metrics to outcomes and processes. Did the doctor document that she gave the patient a flu shot? That she counseled the patient about smoking? In education, of course, the preoccupation became student test scores.

All of this began innocently enough. But the measurement fad has spun out of control. There are so many different hospital ratings that more than 1,600 medical centers can now lay claim to being included on a “top 100,” “honor roll,” grade “A” or “best” hospitals list. Burnout rates for doctors top 50 percent, far higher than other professions. A 2013 study found that the electronic health record was a dominant culprit. Another 2013 study found that emergency room doctors clicked a mouse 4,000 times during a 10-hour shift. The computer systems have become the dark force behind quality measures.

Education is experiencing its own version of measurement fatigue. Educators complain that the focus on student test performance comes at the expense of learning. Art, music and physical education have withered, because, really, why bother if they’re not on the test?

At first, the pushback from doctors and teachers was dismissed as whining from entitled and entrenched guilds spoiled by generations of unfettered autonomy. It was natural, went the thinking, that these professionals would resist the scrutiny and discipline of performance assessment. Of course, this interpretation was partly right.

But the objections became harder to dismiss as evidence mounted that even superb and motivated professionals had come to believe that the boatloads of measures, and the incentives to “look good,” had led them to turn away from the essence of their work. In medicine, doctors no longer made eye contact with patients as they clicked away. In education, even parents who favored more testing around Common Core standards worried about the damaging influence of all the exams.

Even some of the measurement behemoths are now voicing second thoughts. Last fall, the Joint Commission, the major accreditor of American hospitals, announced that it was suspending its annual rating of hospitals. At the same time, alarmed by the amount of time that testing robbed from instruction, the Obama administration called for new limits on student testing. Last week, Andy Slavitt, Medicare’s acting administrator, announced the end of a program that tied Medicare payments to a long list of measures related to the use of electronic health records. “We have to get the hearts and minds of physicians back,” said Mr. Slavitt. “I think we’ve lost them.”

Thoughtful and limited assessment can be effective in motivating improvements and innovations, and in weeding out the rare but disproportionately destructive bad apples.

But in creating a measurement and accountability system, we need to tone down the fervor and think harder about the unanticipated consequences.

Measurement cannot go away, but it needs to be scaled back and allowed to mature. We need more targeted measures, ones that have been vetted to ensure that they really matter. In medicine, for example, measuring the rates of certain hospital-acquired infections has led to a greater emphasis on prevention and has most likely saved lives. On the other hand, measuring whether doctors documented that they provided discharge instructions to heart failure or asthma patients at the end of their hospital stay sounds good, but turns out to be an exercise in futile box-checking, and should be jettisoned.

We also need more research on quality measurement and comparing different patient populations. The only way to understand whether a high mortality rate, or dropout rate, represents poor performance is to adequately appreciate all of the factors that contribute to these outcomes — physical and mental, social and environmental — and adjust for them. It’s like adjusting for the degree of difficulty when judging an Olympic diver. We’re getting better at this, but we’re not good enough.

Most important, we need to fully appreciate the burden that measurement places on professionals, and minimize it. In health care, some of this will come through advances in natural language processing, which may ultimately allow us to assess the quality of care by having computers “read” the doctor’s note, obviating the need for all the box-checking. In both fields, simulation, video review and peer coaching hold promise.

Whatever we do, we have to ask our clinicians and teachers whether measurement is working, and truly listen when they tell us that it isn’t. Today, that is precisely what they’re saying.

Avedis Donabedian, a professor at the University of Michigan’s School of Public Health, was a towering figure in the field of quality measurement. He developed what is known as Donabedian’s triad, which states that quality can be measured by looking at outcomes (how the subjects fared), processes (what was done) and structures (how the work was organized). In 2000, shortly before he died, he was asked about his view of quality. What this hard-nosed scientist answered is shocking at first, then somehow seems obvious.

“The secret of quality is love,” he said.

Our businesslike efforts to measure and improve quality are now blocking the altruism, indeed the love, that motivates people to enter the helping professions. While we’re figuring out how to get better, we need to tread more lightly in assessing the work of the professionals who practice in our most human and sacred fields.

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