Tag Archives: doctors and teachers

Links and Lessons for K-12 Schools and Hospitals (Jeff Bowen)

Dr. Jeffrey Bowen has served as superintendent of the Yorkshire Pioneer Central School District in western New York, research director for the New York State School Boards Association, and supervisor of on-the-job training in an Air Force hospital.  He is a founding member and vice president of the Healthy Community Alliance in Gowanda, New York.  

Since 2000, hospital bills have increased at an annual average rate of 10 percent.  Surveys show most Americans think that health care costs seriously threaten the economy.  Issues of access and quality complicate the picture.  Health care is gobbling up 20 percent of the Gross Domestic Product (GDP).

Meanwhile, funding cutbacks are distressing K-12 schools.  More than half the states are spending less per student this year compared to last.  As thousands of teachers are laid off, school boards and superintendents are reverting to bare-bones core academic programs and nervously depleting fund balances..

Schools and hospitals have many similarities.  These include for profit and nonprofit types, boards of directors and CEO’s, differentiated patient or pupil treatments, stringent confidentiality of records, specialized and licensed staff, extensive professional development, substantial physical plants and technology, and diverse business functions.  Schools and hospitals are communities as well as bureaucracies.

Hospitals depend on individual plans for each patient.  They keep detailed records regarding what intervention has been tried, which ones have succeeded or failed and for what length of time.  They must measure change carefully because lives depend on it.. At least for nondisabled children, Schools are less conscientious about individual plans for children .

Schools should take the cue from hospitals and strive toward complete, flexible individual plans for all students.  Thereby, interventions can be applied consistently and for the right length of time.  Special education has helped schools build bridges between themselves and the medical world.  Like medical professionals, school staffs have adopted the use of Response to Intervention (RTI).  Teachers vary the time, frequency and duration of an intervention to meet individual needs, assess and compare data regarding its effects, and then if necessary utilize an alternative intervention. RTI gets at problems before the child fails dismally and has to be remediated.   Educators should expand and refine this model, along with other medical inspirations like brain-based learning, doing group rounds, action research, scientifically valid practices (a federal Race To The Top program priority), referrals and preventive counseling.

Teachers hope to be publicly respected like doctors.   This will not happen unless school boards empower teachers to exercise more discretion to generate students’ individual plans.  Joint accountability for results would be a must, but teachers and children would benefit from more responsive and tailored support.

 Teachers and doctors alike are grappling with an explosion of internet-based information and new technology.  Educators are encouraged to coach or guide students to self-directed learning, while doctors and other medical staff are exploring telemedicine to facilitate prevention, diagnosis, treatment, and rehabilitation in home settings.  The key is to use technology more creatively, not as a convenient substitute for the status quo.

A warning: as technology redefines relationships, shoddy education or physical damage can occur as individuals self-diagnose or take intellectual shortcuts over the Internet.  Technology must reinforce rather than substitute for licensed professional expertise, solid thinking and good judgment.

 The intersection of medicine and education could be called health.  Public schools struggle to combine core academic subjects with learning about mental, emotional and physical health.  By the same token, hospitals and doctors are challenged to reach out to their surrounding communities in ways that could definitely strengthen health services

By promoting healthy communities, schools and hospitals could better serve the public at lower cost.

For many years I have served on the board of a nonprofit network called the Healthy Community Alliance (HCA) in rural western New York.  Largely state grant-funded with six full-time employees, the network  provides or coordinates programs that address chronic disease awareness and prevention, youth mental health, parent education and management including physical activity and nutrition.

The Alliance takes advantage of emerging health and lifestyle priorities for both young and older populations.  It maintains an impressive list of partnerships and affiliations, but relationships with both hospitals and school districts are hampered by apathy or uneasiness because silo thinking lingers.  School and hospital executives should prioritize alliances with regional health networks to close community service gaps more efficiently and cost effectively.

Funding is a minefield for both schools and hospitals.  However, public schools operate in a comparatively controlled fiscal environment.  Elected school boards, annual public budget or tax rate referenda, property tax caps, and mandated reporting requirements keep schools more accountable to their constituencies than most hospitals are accountable to theirs.

Hospital charges depend on a confusing combination of costs derived from different sources.  Hospitals do not publicize standardized fees for specific services.  Usually patients are not in any position to make informed choices.

In a recent Time Magazine special report, Stephen Brill urges significantly lowering the eligibility age for Medicare to 40 so that insurance limits can be extended on certain expensive tests, drugs, and services. Medicare controls costs by reimbursement based on certain standards for treatment.  The standards are published, specific, measurable, and reasonably scientific.  Connecting performance standards to cost reimbursements seems to hold promise not just for medicine, but as well for schools where politics often override educational performance. Medicare may have big flaws, but it also saves big money.   

Everyone wants measurable results to assure performance quality and bang for the buckSchool and hospital leaders should make time to discuss their commonalities.  By climbing out of their boxes, these two institutions could reconnect cost with quality and multiply productivity.

  References

Anderson, G. (Johns Hopkins University) as cited in Babcock, C.R. (2013, March 12). Americans without insurance face escalating hospital bills. The Buffalo News. Buffalo, New York.

Brill, S. (2013, March 6). Bitter Pill: How outrageous pricing and egregious profits are destroying our health care. Time Magazine.

CBS News/New York Times. (2009, June 20). The Debate Over Health Care. National Poll Conducted by CBS News/New York Times.

Healthy Community Alliance, Inc. (2012).  Community Value Report. Gowanda, New York: Author.

Mellard, D.F., and Johnson, E. (2008). RTI: A Practitioner’s Guide to Implementing Response to Intervention. Thousand Oaks, CA: Corwin Press.

Oliff, P., Mai, C, and Leachman, M. (2012, September 4). New School Year Brings More Cuts in State Funding For Schools.  Center on Budget and Policy Priorities. Washington, D.C.

Richardson, W. (2013, March). Students First, Not Stuff. Educational Leadership, 7 (6), 10-14.

USDOE. (2012). The Condition of Education. Washington, D.C.: Author.

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Money Spurs Use of New Technologies in Medical Practice: Schools Also?

Physicians have steadily adopted new technologies from the early 19th century stethoscope to the X-ray decades later to late-20th century computer-tomography scans. Such rapid adoption of new technologies has been (and is) common in medicine. What is uncommon is that medical technology spurred by new ways of funding in the past half-century has come to dominate clinical practice among specialty doctors (but less so among primary care physicians whose revenue is largely generated by office visits). How come? [i]

Public and private insurers pay doctors not only for visits to offices, clinics, and hospitals but also for the diagnostic tests they order such as blood work, sonograms, X-rays, scans, and the treatments they deem best in light of an emerging diagnosis. They also prescribe medications and screen healthy patients for possible diseases including more tests since this system of payments–called fee-for-service–encourage such practices. Fee-for-service payments from private and public insurers depend upon counting patient visits, diagnostic tests, and treatments.

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Surveys of physicians, in part, support this view of doctors ordering additional tests beyond what may be necessary for the patient. Consider “aggressive care.” In a recent survey of primary care physicians, 28 percent said they ordered more tests or referred patients to specialists—their operational definition of “aggressive care.”  When asked why, physicians responded that they feared malpractice litigation, had to meet clinical performance measures set by insurers, and had insufficient time with patients. Recently a group of nine medical groups of specialists laid out recommendations that would reduce diagnostic tests (e.g., imaging tests for many cases of lower back pain).

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To see how fee-for-service infiltrates daily clinical practice, do the following thought experiment. Suppose you want to build a house for your family. You will need experts, expensive equipment, and materials and have to coordinate all of these. Instead of hiring a general contractor to oversee brick masons, carpenters, electricians, plumbers, and other specialists, you paid electricians for every outlet they recommended, carpenters for cabinets they thought you needed, plumbers for faucets they wanted to install, and brick masons for sidewalks they thought you should have. As an owner of the house, you would have hundreds of outlets, scores of cabinets and faucets and sidewalk after sidewalk winding around your house. The expense would be astronomical and the house would be in dire trouble a few years later.

Physicians, researchers, and policymakers say that lack of coordination and mindfulness in building such a house is what has occurred with fee-for-service dominating private and public payments to most physicians. One doctor pointed out that in the analogy the “general contractor” is what primary care physicians do in coordinating health care for patients. But family medicine and primary care practitioners are shrinking in numbers. Economic incentives through fee-for-service, however, nudge specialists to order diagnostic tests and prescribe treatments using the latest technologies.[ii]

When specialists form groups or hospitals invest in the latest equipment (e.g., imaging machines) and procedures (e.g., arterial stents), incentives to use both often multiply. For cardiologists inserting stents (cost: $30-50 thousand per procedure) to keep arteries open is a huge money-maker. As one medical researcher said: “In many hospitals, the cardiac service line [stent] generates 40 percent of the total hospital revenue, so there’s incredible pressure to do more procedures.”

Financial incentives do reshape clinical practice especially when the federal government puts its fiscal muscle behind certain medical technologies. For example, in the 1960s, a machine was invented to cleanse blood of impurities because of kidney failure. This invention saved lives but was so expensive that only the wealthy could afford it. In 1973, The U.S. Congress amended Medicare to cover full costs for dialysis of patients who would otherwise die.

Uses of technological tests for diagnosis and treatment in medical practice is, in part, a function of financial incentives–the market at work–put in place by private and public systems of funding. Whether it makes a difference in caring for patients–either in healing or extending lives–remains unclear.

Now, switch from doctors using new technologies to diagnose and treat patients to teachers and principals working in classrooms and schools. Think about school reformers who press administrators and teachers to use online instruction, blended learning, iPads, etc., etc., etc. What, if anything, can be learned from the impact of fee-for-service funding spurring greater use of high-tech tests in medical practice and how market incentives can be applied to schools and classrooms?


[i] Stanley Reiser, Medicine and the Reign of Technology (New York: Cambridge University Press, 1978). To be clear, when I refer to medical technology I mean the equipment, devices, drugs, procedures, and processes used to deliver diagnoses and treatments to patients.

[ii] Joel Merenstein, MD. suggested this to me. For shrinking number of primary care physicians, see Thomas Bodenheimer, MD, “Primary Care-Will It Survive?” New England Journal of Medicine, 2006, 355, pp. 861-864.

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Trusting Teaching and Doctors

When was the last time you heard an elected policymaker tell lawmakers the following about state and federal mandates for curriculum standards, accountability, and testing?

The laws that are in fashion demand tightly constrained curricula and reams of accountability data. All the better if it requires quiz-bits of information, regurgitated at regular intervals and stored in vast computers. Performance metrics, of course, are invoked like talismans. Distant authorities crack the whip, demanding quantitative measures and a stark, single number to encapsulate the precise achievement level of every child.

We seem to think that education is a thing—like a vaccine—that can be designed from afar and simply injected into our children. But as the Irish poet, William Butler Yeats said, “Education is not the filling of a pail but the lighting of a fire.”

This year, as you consider new education laws, I ask you to consider the principle of Subsidiarity. Subsidiarity is the idea that a central authority should only perform those tasks which cannot be performed at a more immediate or local level. In other words, higher or more remote levels of government, like the state, should render assistance to local school districts, but always respect their primary jurisdiction and the dignity and freedom of teachers and students.

Subsidiarity is offended when distant authorities prescribe in minute detail what is taught, how it is taught and how it is to be measured. I would prefer to trust our teachers who are in the classroom each day, doing the real work – lighting fires in young minds.

Those words come from Governor of California, Jerry Brown, where 300,000 teachers teach six million children in his State of the State address to the Legislature on January 24, 2013.

Re-read that last sentence. “Trust our teachers.”

That is a stunner given the reform-inflated air we breathe filled by federal, state, and district officials eager to evaluate teachers on the basis of student test scores, implement pay-for-performance plans, and get teachers to prepare lessons for state-adopted Common Core standards in reading and math.

On the heels of a statewide referendum that increased taxes—yes, increased taxes for seven years–Jerry Brown is no novice bellowing the latest school reform slogan. He is a 75 year-old veteran of school reform having served eight years as governor before and after Proposition 13 (1978). He is a hard-driving, practical political leader who knows the ins-and-outs of both local and state politics (e.g. mayor of Oakland, 1999-2007, state Attorney General, 2007-2011). When he says “trust our teachers” he means have confidence in teachers to do the right thing and continually work to improve their performance. That is good news for the state and nation.

Does that mean that the reform tide has turned and teachers will no longer be blamed for mediocre schooling and ignored in policy circles? Hardly. For all I know, Governor Jerry Brown may be an outlier and not the vanguard of a movement to restore trust in teachers by shrinking mandates telling them what to teach and how what is taught will be measured. But it is a welcome sign that has been missing for many years.

Less welcome has been the news for doctors who are hip-deep in pay-4-performance plans across the country. There is a national movement afoot to raise the quality of patient care and contain ever-escalating costs by launching plans that measure how well doctors treat their patients. In New York City public hospitals, for example,  doctors’ annual raises will depend upon performance metrics that include:

“how well patients say their doctors communicate with them, how many patients with heart failure and pneumonia are readmitted within 30 days, how quickly emergency room patients go from triage to beds, whether doctors get to the operating room on time and how quickly patients are discharged.”

The evidence over the past century has been clear that when policymakers and managers concoct high-stakes incentives to measure job effectiveness, award dollar bonuses, or fire employees, professionals and non-professionals learn to game the metrics. Incentives corrupt measures time and again.  There is a history in finance, the military, government, education, and other sectors of how metrics get gamed that policymakers ignore repeatedly. What’s worse, of course, is that doctors, like teachers, become the target rather than the political and socioeconomic structures within which they labor. In doing so, their loyalty to the helping profession in which they serve,  erodes.

Thus, over time, teachers and doctors come to see the “quality” measures used to evaluate and pay them as perverse destroying bonds they have to their students and patients, the institutions, and the very process of teaching and healing. Perhaps, the oath that medical school graduates take upon receiving the M.D. degree should also be taken by policymakers eager for pay-for-performance: Do no harm.

One top policymaker, Governor Jerry Brown, understands that admonition. Not trusting teachers (or not trusting doctors’ professionalism) and making rules that attempt to control performance will ultimately do harm.  I do not know whether you are an outlier or a sign of an emerging sensibility but I thank you Governor Brown for your recent words.

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Reshaping Teaching through Managerial Use of Student Test Scores

The path of educational progress more closely resembles the flight of a butterfly than the flight of a bullet.  Philip Jackson, 1968

Top governmental policymakers and private insurance companies, deeply concerned over ever-rising health care costs and unwilling to rely upon doctors to restrain expenditures, have built structures over the past quarter-century to hold physicians accountable for their actions in diagnosing and treating patients. These structures leaned heavily upon a research base built up over decades from clinical trials on screening procedures to the effects of drugs on an array of diseases. Combining evidence-based medicine with incentives and sanctions, public and private insurers have measured, reported, and rewarded doctors’ performance in hospitals, clinics, and office practices.
In copying outcome-driven corporations, these medical policymakers and insurers relied upon performance-based metrics. They assumed that creating economic incentives for individuals and organizations would increase innovation, lower costs, and improve patient care. They identified numerous measures, confirmed in large part by results from randomized clinical trials embedded in evidence-based medicine, and implemented those measures in hospitals, clinics, and doctors’ offices. Physician “report cards” and pay-for-performance plans, however, have yet to yield promised innovations, high quality care, and reduced costs.

Educational policymakers have made a similar set of assumptions in constructing accountability structures and using metrics for managing how teachers are to be evaluated and paid. In doing so, however, these decision-makers lack the knowledge base in educational research that physicians have had available in evidence-based medicine.

While social scientists and educational researchers have used randomized control group studies to uncover what caused phenomena in schools and classrooms, such studies have been the exception, not the rule. Ethical considerations, cost, and the complexity of schools, teaching, and learning reduce experimental-control research designs.

Qualitative research studies using surveys, interviews, case studies, and ethnographies are not designed to draw causal inferences; moreover, they cannot, given the questions asked, the samples drawn, and methodologies used. Qualitative studies ask different questions and provide rich data for exploring other issues that are missing from experimental-control designs.

As a consequence, unlike physicians who can draw from a literature of randomized control trials and use results for diagnosis and treatment of common and uncommon illnesses (e.g., Cochrane Collaborative), only a small and emerging body of knowledge drawn from randomized clinical trials about teaching, learning, and effective schools yet exists that policymakers and practitioners can tap (e.g., U.S Department of Education, “What Works Clearinghouse,” and Campbell Collaborative).[i]

That slim database, however, has not lessened the current passion among educational policymakers and politicians for using test scores to evaluate teacher performance (and pay higher salaries). The current “science” of value-added measures (VAM) leans heavily upon the work of William Sanders. Smart researchers and officials are determined to re-engineer teaching to make it closer to the “flight of a bullet” rather than the “flight of a “butterfly.” In seeking the Holy Grail, they have ignored the long march that researchers and policymakers have slogged through in the past century to make teaching scientific.[ii]

Not many contemporary reformers can recall Franklin Bobbitt in the 1920s, Ralph Tyler and Benjamin Bloom in the 1950s, Nathaniel Gage in the 1970s and 1980s, and many other researchers who worked hard to create a science of curriculum and instruction.  These scholars rejected the notion that teaching can be unpredictable and uncertain–”the flight of a butterfly.” They believed that teaching could be rational and predictable through scientifically engineering classrooms.

In How To Make a Curriculum (1924), Franklin Bobbitt listed 160 “educational objectives” that teachers should pursue in teaching children such as “the ability to use language …required for proper and effective participation in community life.” Colleagues in math listed 300 for teachers in grades 1-6 and nearly 900 for social studies. This scientific movement to graft “educational objectives” onto daily classroom lessons collapsed of its own weight by the 1940s, and was largely ignored by teachers.[iii]

By the early 1960s, another generation of social scientists had advanced the idea that teachers should use “behavioral objectives” to guide lessons. Ralph Tyler, Benjamin Bloom and others created taxonomies that provided teachers with “prescriptions for the formulation of educational objectives.” Teachers generally ignored these scientific prescriptions in their daily lessons.[iv]

In the 1970s and 1980s, Nathaniel Gage and others sought to establish “ a scientific basis for the art of teaching.” They focused on teaching behaviors (how teachers asked questions, which students are called upon, etc.)–the process of teaching leading to the products of effective teaching, student scores on standardized tests. This line of research called “process-product” continued the behavioral tradition from an earlier generation committed to a science of teaching. Using experimental methods to identify teaching behaviors that were correlated to student gains in test scores on standardized tests, Gage and others came up with “teacher should” statements that were associated with improved student achievement.[v]

The limitations of establishing a set of scientifically prescribed teaching behaviors soon became apparent as critics pointed out how many other factors (e.g., teacher knowledge and beliefs, the content of the lesson, students themselves, the classroom environment, the school) come into play when teachers teach students. Again, teachers generally ignored the results from “process-product” studies.[vi]

And here in 2013, re-engineering teaching through science again seeks “the flight of the bullet.” Evaluating and paying teachers on the basis of student test scores through value-added measures dominates policy talk and action.

In establishing new accountability structures that used squishy metrics and attached high-stakes rewards (e.g., cash bonuses for individual teachers) and sanctions (e.g., no diploma for failing high school students; teachers fired for being ineffective) educational policymakers have plunged into a highly contested arena where the search for teacher effectiveness—“the flight of the bullet”—has generated anger, fear, and lowered morale among those who work daily in classrooms. And, at the same time, generated political gains for elected policymakers.

Recall that under President George W. Bush, the Teacher Incentive Fund made grants to districts for overhauling their teacher evaluation systems. After Barack Obama became President in 2009, the U.S. Department of Education launched Race to the Top, a multi-billion dollar competition among states during a recession when school budgets were cut. To win, states had to meet certain conditions to collect federal dollars. One of those conditions was that states had to create new systems of teacher evaluation that included student test scores. Furthermore, in another federal initiative to turn around failing schools, the U.S. Secretary of Education dispensed School Improvement Grants to districts to overhaul schools with persistent low academic achievement. One of the strategies to turn around such schools included using student test scores to evaluate teachers.[vii]

Philanthropists have pursued similar policies. The Bill and Melinda Gates Foundation awarded grants to six districts to create and establish “fair and reliable measures of effective teaching” including the use of student test scores.  Yet even with all this federal and private money being spent the question remains whether these structures and metrics have reshaped classroom practices.[viii]


[i] Michael Feuer, Lisa Towne, and Richard Shavelson, “Scientific Culture and Educational Research, Educational Researcher, 2002, 31(8), pp. 4-14; for a direct comparison between EBM and EBE see: John Willinsky, “Extending the prospects of evidence-based education. In: Insight, Vol. 1, No. 1, pp. 23-41. For the Cochrane Collaborative, see http://www.cochrane.org/ ; for Campbell Collaborative, see: http://www.campbellcollaboration.org/ ; for What Works Clearinghouse, see: http://ies.ed.gov/ncee/wwc/ .

[ii] Quote comes from: Philip Jackson, Life in Classrooms,  (New York: Holt,Rinehart, and Winston,1968, pp. 166-167. William Sanders and Sandra Horn, “The Tennessee Value-Added Assessment System (TVAAS): Mixed Model Methodology in Educational Assessment,” Journal of Personnel Evaluation in Education, 1994, 8(3), pp. 299-311; Daniel McCaffrey, et. al., “Models for Value-Added Modeling of Teacher Effects,”  Journal of Educational Behavioral Statistics, 2004,  29(1), pp. 67-101.

[iii] Elliot Eisner, “Educational Objectives: Help or Hindrance?” The School Review, 1967, 75, pp. 250-260.

[iv] Ibid.

[v] N.L. Gage, The Scientific Basis for the Art of Teaching (New York: Teachers College Press, 1978).

[vi] Walter Doyle, “Paradigms for Research on Teacher Effectiveness,” Review of Research in Education, 1977, 5, pp. 163-198; N.L. Gage and Margaret Needels, “Process-Product Research on Teaching: A Review of Criticisms,” The Elementary School Journal, 1989, 89(3), pp. 253-300.

[vii] Sarah Garland, “Federal teacher evaluation requirement has wide impact,” http://hechingerreport.org/content/federal-teacher-evaluation-requirement-has-wide-impact_8360/ .

[viii] Bill and Melinda Gates Foundation, “Working with Teachers to Develop Fair and Reliable Measures of Effective Teaching: The MET Project,” 2010. The MetLife Survey of The American Teacher: Teachers, Parents, and the Economy, 2011 (Report published, March 2012), pp. 6-7;  See Scholastic, Inc. and Bill & Melinda Gates Foundation, Primary Sources: 2012: America’s Teachers on the Teaching Profession, pp. 27-29.

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Evaluating Doctors on Their Performance with Patients

The Centers for Medicare and Medicaid Systems (CMS) and private insurers have identified numerous pay-for-performance measures, confirmed in large part by evidence-based medicine, and implemented them in hospitals, clinics, and doctors’ offices.

For example, there are process measures for hypertension and heart disease where, for example, periodic readings of patient’ blood pressure and blood sugar levels are reported. But testing does not tell you whether the patient is bringing these diseases under control. So intermediate outcome measures that focus on patients’ actual blood pressure and blood sugar levels are noted to indicate whether the patient is improving, stable, or deteriorating.

Then there are final outcome metrics that demonstrate what happened to patients who received treatment in hospitals, went to another facility, or returned home. Complications after surgery such as infections, strong reactions to chemotherapy that requires re-admission into hospitals for further treatment, or death are examples of such outcome measures.  CMS and private insurers identified scores of such measures as a basis for allocating or withholding payments to hospitals, groups of physicians, and individual doctors ( pay for performance of doctors)

As one would expect when attaching high stakes to metrics in a helping profession such as medicine where there are many stakeholders (e.g., insurers, employers, doctors, medical staff, patients) views on pay-for-performance measures diverge, especially since insurers have published “report cards” displaying rankings, percentages, and results of these different measures for organizations and individual doctors. Divergent views of performance measures and “report cards” are inevitable when one examines the complex terrain that physicians inhabit and the predicaments they inherently face: expertise is never enough, making decisions amid uncertainty is common, and dependence upon the patient for improvement is essential. No surprise, then, these metrics and their outcomes, thus far, have generated mixed reactions. See here, here, and here.

Many policy makers, administrators, and doctors are satisfied that the measures are consistent with findings derived from evidence-based medicine and their experiences with patients. They welcome efforts to raise the quality of care and reduce costs. While many primary care doctors do agree with the policy initiative, they still question the measures because they know that these metrics—even when evidence-based medicine endorse the measures–seldom pick up individual differences among patients who have breast cancer, heart disease, or diabetes.

Consider a pediatrician whose practice includes adolescent girls. He tells the story of what happened to him when one of his insurer’s measures of quality care is a requirement to test all sexually active girls for chlamydia, a sexually transmitted disease. Since insurers do not and cannot read every single medical chart, they use a proxy measure to determine whether a girl is sexually active. They check to see if patients take birth control pills. That proxy complicates matters greatly because the pediatrician’s patients don’t take those pills for contraception, but for acne and menstrual pain.

The pediatrician asks a colleague: “So do I skip the testing for Chlamydia and fail my quality standards?” he asked. “Or do I order a test that the patient doesn’t need and that will probably not be covered by her insurance?” He ended his story by saying: “I’m all for quality. I just don’t think this is quality.”

For another primary care physician who has been highly ranked in the past on these measures from the local health insurer, her current “report card” left her dismayed.

“The quarterly “report card” sits on my desk. Only 33% of my patients with diabetes have glycated hemoglobin levels that are at goal. Only 44% have cholesterol levels at goal. All my grades are well below my institution’s targets. It’s hard not to feel like a failure when the numbers are so abysmal.”

She pondered the report card and told a colleague: “[They] focus on diabetes in pristine isolation [when] my patients inconveniently carry at least five other diagnoses and routinely have medication lists in the double digits.”

Moreover, according to the doctor, one of her patients has diabetes that can be controlled but has failed to come into the office regularly even though staff had contacted her many times. The doctor told her colleague that the patient “just can’t afford to take that much time off from work.”  “Does that,” the physician asked the colleague, “make me a worse doctor?”

These recent policy efforts to create accountability through establishing performance measures and dispensing monetary rewards to those who reach the benchmarks end up steering clinical practice toward standardization. These physicians I described are caught in multiple predicaments. They are involved, unknowingly, in the  struggle that has gone back and forth in medical circles for decades over the worth of doctors’ intuitive judgments vs. empirical evidence when uncertainty reigns and the abiding quandary of being dependent upon patients for success when the metrics make the doctor wholly responsible for outcomes. And now there is a full-court press that policymakers, saturated with data, have mobilized to standardize medical decision-making to increase efficiency and effectiveness.


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Why I Compare Primary Care Physicians to Classroom Teachers

In a forthcoming book, I compare the practice of primary care physicians to that of K-12 teachers. For some readers, the comparison may be a stretch since so many differences separate the two professions. [i]

Consider the following:

*Doctors go to school eight years (undergraduate and graduate) to secure an M.D. and then spend another two to six years (of which most are clinical practice) learning a specialty; most teachers spend five years (of which six months to a year are in supervised classroom practice) to earn a bachelors and then a master’s degree in education; those who receive alternative certification have little to no time in supervised teaching prior to entering the classroom.[ii]

*Doctors see patients one-on-one; teachers teach groups of 20 to 35 students all day.

*Most U.S. doctors get paid on a fee-for-service basis; nearly all full-time public school teachers are salaried.

*Evidenced-based practice of medicine in diagnosing and caring for patients is more fully developed and used by doctors than research on teaching and learning available to and accessed by teachers.[iii]

*Medicine has been largely male-dominated until the past quarter-century while K-12 schooling has been female-dominated for over a century and a half.[iv]

*In terms of both social status and respect, polls rank doctors higher than teachers.[v]

While these educational, organizational, demographic, and societal differences are substantial in challenging comparisons, there are fundamental commonalities that bind teachers to primary care doctors. First, both are helping professions that seek human improvement. Second, profound structural changes in funding, technology, and professional autonomy have occurred in both occupations that have penetrated doctors’ offices and teachers’ classrooms.

Helping professions.

From teachers to social workers to therapists to doctors, these professionals use their expertise to transform minds, improve skills, deepen insights, cope with feelings, and mend bodily ills. In doing so, these helping professions seeking human improvement face at least two predicaments.[vi]

*Expertise is never enough.  A primary care physician facing a chain-smoking patient knows that this behavior has a high probability of leading to lung cancer—even the patient knows that—yet the doctor’s knowledge and skills are insufficient to get the private equity fund CEO to quit.

Some high school teachers of science with advanced degrees in biology, chemistry, and physics believe that lessons should be inquiry driven and filled with hands-on experiences while other colleagues, also with advanced degrees differ. They argue that uninformed students must learn the basic principles of biology, chemistry, and physics through rigorous study before they do any practical work in class.

In one case, there is insufficient know-how to stop a patient from smoking and, in the other instance, highly knowledgeable teachers split over how best to have students learn science. As important as expertise is to professionals dedicated to helping people, it falls short—and here is the second predicament–not only because expertise is insufficient but also because professionals seeking human improvement in any helping profession need their clients, patients, and students to engage in the actual work of learning and becoming a better, healthier person.

*Helping professionals are utterly dependent upon their clients’ cooperation. Physician autonomy, anchored in expertise and clinical experience, to make decisions unencumbered by internal or external bureaucracies is both treasured and defended by the medical profession. Yet physicians depend upon patients for successful diagnoses and treatments. If expertise is never enough in the helping professions, patients constrain physician autonomy and effectiveness.

While doctors can influence a patient’s motivation, if that patient is emotionally depressed, resistant to recommended treatments, or uncommitted to getting healthy by ignoring prescribed medications and prevention of harmful behaviors–the physician is stuck. Autonomy to make decisions for the welfare of the patient and effectiveness of treatment become irrelevant when patients cannot or do not enter into the process of healing.

For K-12 teachers who face captive audiences among whom are some students unwilling to participate in lessons or who defy the teacher’s authority or are who uncommitted to learning what the teacher is teaching, then teachers have to figure out what to do in the face of students’ passivity or active resistance.

These predicaments common to the helping professions are the basis for my comparing, what appears at first glance, two very different occupations. Beyond serving in helping professions and facing similar predicaments, there is yet another reason why I compare teachers to primary care physicians. Both occupations have undergone similar structural changes.

For decades, just as policy elites have tried to reshape teaching through reforming old structures and creating new ones, health care policymakers have tried similar ventures in medicine.  New structures in funding, use of technologies, and managerial control have affected professional autonomy in the practice of medicine without altering those insoluble predicaments that physicians face daily with their patients.

And that is why I will compare doctors and teachers in my next book.


[i] I chose primary care physicians to focus on.  Included in primary care are internists, pediatricians, and other physicians who are the first contact for patients with non-emergency medical problems. These physicians diagnose and treat common illnesses and medical conditions. They collect information from patients on their symptoms, their medical history, do physical examinations, and basic medical tests like blood work and X-rays. They then make a diagnosis and plan with patients what next steps to take in treatments including referral to specialists. Primary care doctors also counsel and educate patients on preventing illnesses and encouraging healthy behaviors. They build relationships with patients over time getting to know them as individuals, family members, workers, and whole human beings. They provide services in their offices, emergency rooms, hospitals, and nursing home care. I exclude those doctors who practice surgery, psychiatry, obstetrics, cardiologists, oncologists, and scores of other specialties. My rationale is that primary care physicians as first contacts with patients and as generalists are most similar to K-12 teachers who, using their expertise, get to know students, develop relationships with them, and figure out how best to teach knowledge and skills and help students learn both.

[ii] Kenneth Ludmerer MD and Michael Johns MD, “Reforming graduate Medical Education,” JAMA, 2005, 294(9), pp. 1083-1087; Linda Darling-Hammond, et. al., “The Design of Teacher Education Programs,” in Linda Darling-Hammond and John Bransford (eds.) Preparing Teachers for a Changing World (San Francisco: Jossey-Bass, 2005), pp. 390-441.

[iii] David Sackett, et. al., “Evidence-based Medicine: What It is and What It isn’t,” BMJ, 1996, accessed February 11, 2012 at: http://www.bmj.com/content/312/7023/71?view=long&pmid=8555924 ; Mary Kennedy, “The Connection between Research and Practice,” Educational Researcher, 1997, 26(4), pp. 4-12.

[iv] Ann Boulis and Jerry Jacobs, The Changing Face of Medicine: Women Doctors and the Evolution of Health Care in America (Ithaca, NY: Cornell University Press, 2008).

[v] Tom Van Riper, “America’s Most Admired Professions,” Forbes.Com, July 28, 2006 accessed February 11,2012 at: http://www.forbes.com/2006/07/28/leadership-careers-jobs-cx_tvr_0728admired.html

[vi] The dilemmas that professionals face in the helping professions are well known among the inhabitants of each occupation. The work of David K. Cohen has brought together these cross-professional quandaries in Teaching And Its Predicaments (Cambridge, MA: Harvard University Press, 2011).  He examines teachers, psychotherapists, social workers, pastors, and organizational developers who “work directly on other humans in efforts to better their minds, lives, work, and organizations.”(p. 4). Although he initially excludes medical doctors from human improvement, he does allow that occupations change over time and that doctors may be included: “Physicians conventionally defined their work in terms of patients’ physical health and many still do, but increasingly they see that physical health can depend on how well patients understand their problems and how firmly they commit to the solutions; hence physicians work more and more on understanding and mutual commitment” (p. 19).  He is correct in that the thinking about medical practice has moved from physician-centered to patient-centered where doctors routinely include patients’ questions, concerns, and views in diagnosing and treating illnesses.  See, for example, Christine Laine, MD and Frank Davidoff, MD, “Patient-Centered Medicine; A Professional Evolution,” Journal of American Medical Association, January 10, 1996, 275(2), pp. 152-155

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A Surgeon Gets a Coach

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Mention progress in medicine, business, and education and the first thought is usually getting new technologies that are faster, better, and more efficient than current ones. New drugs and new communication devices cure diseases  and speedily digest information to make breakthroughs in better health, increase productivity, and improve teaching and learning. But even more important to many folks than progress through new technologies are enhancing the capabilities of doctors, CEOs, and educators. “What ultimately makes the difference is how well people use technology. We have devoted disastrously little attention to fostering those abilities.” Surgeon Atul Gawande is correct. And he should know.

A veteran surgeon, Atul Gawande had hit a plateau. As he said: “I compared my results against national data, and I began beating the averages. My rates of complications moved steadily lower and lower. And then, a couple of years ago, they didn’t. It started to seem that the only direction things could go from here was the wrong one.” He was 45 years old. He pointed out that surgery is a “late-peaking career” unlike sports, theater, and mathematics. The average age for hiring CEOs is 52 (for Texas superintendents, the average is 53); geologists, he says, reach maximum productivity around 54. Gawande figured out that surgeons are somewhere in that late-peaking vicinity. So he hired a personal coach.

Robert Osteen, a surgeon who had trained Gawande and for whom he had great respect, agreed to be his coach and watched him perform surgeries. After an operation to remove a tumor from the thyroid gland, Gawande met with Osteen to go over what his former teacher saw, answer questions, and make suggestions.

Gawande thought that “the case went beautifully. The cancer had not spread beyond the thyroid, and, in eighty-six minutes, we removed the fleshy, butterfly-shaped organ, carefully detaching it from the trachea and from the nerves to the vocal cords. Osteen had rarely done this operation when he was practicing, and I wondered whether he would find anything useful to tell me.

“We sat in the surgeons’ lounge afterward. He saw only small things, he said …. He noticed that I’d positioned and draped the patient perfectly for me, standing on his left side, but not for anyone else. The draping hemmed in the surgical assistant across the table on the patient’s right side, restricting his left arm, and hampering his ability to pull the wound upward. At one point in the operation, we found ourselves struggling to see up high enough in the neck on that side. The draping also pushed the medical student off to the surgical assistant’s right, where he couldn’t help at all. I should have made more room to the left, which would have allowed the student to hold the retractor and freed the surgical assistant’s left hand.

“He had a whole list of observations like this. His notepad was dense with small print. I operate with magnifying loupes and wasn’t aware how much this restricted my peripheral vision. I never noticed, for example, that at one point the patient had blood-pressure problems, which the anesthesiologist was monitoring. Nor did I realize that, for about half an hour, the operating light drifted out of the wound; I was operating with light from reflected surfaces. Osteen pointed out that the instruments I’d chosen for holding the incision open had got tangled up, wasting time….

“That one twenty-minute discussion gave me more to consider and work on than I’d had in the past five years. It had been strange and more than a little awkward having to explain to the surgical team why [the retired surgeon] was spending the morning with us. “He’s here to coach me,” I’d said. Yet the stranger thing, it occurred to me, was that no senior colleague had come to observe me in the eight years since I’d established my surgical practice. Like most work, medical practice is largely unseen by anyone who might raise one’s sights. I’d had no outside ears and eyes.”

Most teachers, principals, and superintendents would probably agree with Gawande that “no outside ears and eyes,” ones trusted and respected as the veteran surgeon’s coach were, had seldom looked over their shoulders, took notes, and conferred afterwards.

Coaching is popular today in many districts for beginning teachers and even veteran ones if the schools are on probation or about to be closed.  In the New Yorker article, Gawande describes admiringly the coaching work of  former teacher Jim Knight of the Kansas Coaching Project.  As for superintendents and principals, professional associations and for-profit firms offer “leadership coaches” or “executive coaches.” Coaching has become an industry complete with certification requirements and charlatans.  In subsequent posts I will take up coaching for teachers, principals and superintendents.

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The Conundrum of Blaming Teachers and Doctors: Second Time Around

I published this post over two years ago about blaming teachers and doctors for institutional low performance.  Both teachers and doctors are blamed for the problem, on the one hand, yet, on the other hand–give thanks that we only have two hands–they are expected to solve the very problems for which they are blamed. The conundrum is still alive and breathing in 2011.

Has anyone noticed that much of the blame showered on teachers and unions for blocking school reform by business-admiring pundits and policymakers is usually followed by perky pay-for-performance plans and other solutions wholly dependent upon teachers embracing the changes? Framing teachers as both the problem and the solution is a tough conundrum to unravel. Teachers, however, are not the only ones to grapple with the paradox of being blamed for a problem and then expected to turn around and solve the very same problem.

Consider medical care. Patients, insurance companies, and federal officials criticize physicians and hospitals for errors in practice and ignoring the accelerating cost of providing health care. Tough questions are asked: Which hospitals are best and worst for cardiac surgery or for treating children with cystic fibrosis? Why do doctors commit many errors (illegible handwriting on prescriptions, incomplete charts, etc.)? Should doctors get paid for how often they treat patients or how well they treat them?

In an era of rising health care costs, voter reluctance to increase taxes, holding doctors publicly and personally responsible for outcomes and containing costs have spurred market driven reforms that have swept over the practice of medicine heretofore immune to such debates. For-profit hospitals and private insurers now compete for customers, magazines publish rankings of best U.S. hospitals, and insurance companies link doctors’ practices to their pay. Such instances of business-inspired reforms seek improved delivery of health care to Americans.

These market-driven solutions for health care problems—let’s call them reforms–raise serious issues of trust between doctors and patients over the degree to which private insurance companies or physicians will control medical practice. Deep concerns over doctor-patient relationships and practitioner autonomy get entangled in volatile policy debates over the quality and cost of national health care thus sharply spotlighting the contradiction of more than 800,000 doctors and nearly 6,000 hospitals getting singled out as being a serious problem while looking to these very same people and institutions to remedy the health care crisis.

Teachers in largely minority urban and rural schools have been framed as both the problem and solution for low-performing students. Expanding parental choice through charter schools, advocating higher pay for administrators and teachers who can show student gains in test scores, promoting more competition among schools are only a few of the packaged ideas borrowed from the business community. This shared paradox among medical and school practitioners of being bashed and then expected to solve the problems for which they are bashed is like a virus that has infected two social institutions critical to the nation’s future. No vaccine, however, exists for this virus. The conundrum is here to stay.

What to do about this abiding paradox?

1. Were national and state leaders to openly acknowledge that blaming teachers as a group for the ills of poor schooling and then expecting those very same awful teachers to turn around and work their hearts out to remedy those ills is simply goofy. Over 3.5 million teachers do the daily work of teaching; they teach reading, wipe noses, find lost backpacks, write recommendations, and grade tests. No online courses, charter schools, vouchers, home schooling, or any other star-crossed idea that business-driven, entrepreneurial reformers design will replace them. So blaming and shaming teachers into working harder is no recipe for improved student learning. Surely, like any group of professionals, teachers have to be prodded and they have to be supported. Prodding they get a lot of; support is where these so-called leaders fall down badly.

2. De-escalating the virulent rhetoric about unions and incompetent teachers would be a reasonable first step. Lowering the noise level from 24/7 cable, the Internet, and talk radio is as hard to do as it is to get bipartisan support among Republicans and Democrats over health care reform in a polarized political climate. Respect for teachers, never high in the U.S. to begin with, has unraveled even further with constant bashing. But hard as it is to ratchet down the noise level does not mean it is impossible.

3. Moving away from critics’ obsessive concentration on unions and the small number of incompetent teachers (or “rubber room” examples of non-working but paid teachers in New York City) and focus on the structures that keep even mediocre teachers from improving is another step. Such structures as single-salary schedule, evaluation procedures, hit-and-miss professional development, daily load of students to teach, number of courses taught, and the age-graded school—all influence what happens in classrooms.

None of these in of themselves can end the conundrum of blaming teachers for untoward student outcomes and then depending on them to fix the problem. But they are a start.

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Narrow Thinking about Health and Schools

In 1965, Jack Geiger, a doctor working in the Mississippi Delta, founded one of the first federally-funded community health centers in the U.S. There he treated many children who were seriously malnourished. He wrote “prescriptions” for meat, milk, vegetables, and fruit that were to be “filled” at nearby grocery stores. Grocery store owners then submitted bills to the community health center where Geiger used the pharmacy budget to pay the bills.

The federal agency that funded community health centers, then called the Office of Economic Opportunity (OEO),  sent an official to tell Geiger that he cannot use health center funds for groceries called “prescriptions.” Geiger met with the federal official and said: “The last time I looked in my textbooks, the specific therapy for malnutrition was food.” End of OEO complaint in 1965. Community health centers  have grown since 1965 to number 1100 and serve 19 million low-income people.

Geiger knew then that supplying the right food would cure malnutrition. He understood that malnourishment does not come from mothers’ refusal to give their babies food; it comes from the lack of the right food and money to get that food. In a word, poverty. He saw malnutrition as a public health problem located in socioeconomic and political structures that cause and sustain poverty. He saw that for the health of the poor community to improve, the center he directed had to do more than diagnose medical conditions and write prescriptions for pills and ointments. He did not draw a line between his community health center and the poverty that Mississippi Delta families experienced daily. He saw the connection between better health and a better life for malnourished children and did something about it.

Since the mid-1960s, he and thousands of medical professionals and policymakers in the U.S. and internationally have come to understand that “social determinants of health,” especially the impact of poverty, affect which babies live beyond infancy, who succeeds in schools, who has access to high quality health care, and when we die (Marmot-Social determinants of health inqualities ).

Can anyone deny that ill health affects success in school? The stark example of malnutrition makes the connection obvious. Researchers and policymakers today know well the strong correlations between health and level of education. Whether more schooling creates better health (less smoker-related diseases, less obesity-linked conditions, etc.) or better health generates higher levels of education can be debated endlessly. What is less debated and generally accepted internationally and within the U.S. is that early education from birth to four years of age is crucial to both good health and school success (see Can Education Policy be Health Policy? In short, there are “social determinants of school success.”

These “social determinants of school success,” of course, are at the heart of the current debate among school reformers. One crowd–the “no excuses” reformers (e.g., Michelle Rhee, Joel Klein, Bill Gates, Eli Broad)–argue that schools alone can erase the achievement test score gap and insure that all student go to college. They focus on recruiting, training, and rigorously evaluating teachers–the single most important in-school influence on children–as the road to school success.  They say that effective teachers and schools can overcome the effects of poverty and other “social determinants.”

Another crowd–and I include myself among them–champion programs where schools not only prod and support low-income students to achieve academically in school but also provide ready access for students and their families to an array of social, medical, and mental health services from birth to adulthood. This crowd recognizes the importance of upgrading the teacher corps, having strong principals, and pushing students to achieve but also know that “social determinants” shape school success.

Surely, paying attention to “social determinants of school success” costs more money, funds that cannot be provided wholly by the private sector or foundations. Federal and state government episodically have provided such funds.  Like community health centers in the 1960s, community schools that see the child and family as as part of a social system, schools can and have provided an array of services that help toddlers, children, and youth achieve and grow into healthy adults.

At a time in U.S. history when the role and size of government are being heatedly debated and, for now, has tilted toward reducing government-sponsored social safety nets and cutting back expenditures in the name of controlling national debt and deficit reduction, the reform ideology of “no excuses” has the virtue of being less expensive. In the short-term, at least. In the long-term, as Jack Geiger knew in 1965 and does today, the “social determinants of health” cannot be ignored if children are to grow into healthy adults. And so it is with the “social determinants of school success.”

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Do Doctors Resist Reform? The Case of Evidence-Based Medical Practice

Many school reformers blame teachers for supporting the status quo and resisting change. In a previous post (April 30, 2011), I argued that, sure, many teachers question classroom-directed policies coming from top officials who last set foot in a classroom when they were high school seniors. And, yes, many teachers point out defects in the innovative program, curriculum, or software  that designers missed. Being a skeptic of a new policy or program, however, is not rejecting change per se since teachers have altered their lessons and activities over the years while introducing new ways of teaching familiar topics. If this is the case for teachers, what about physicians who also have been accused of resisting a major reform introduced two decades ago called evidence-based medical practice.

EVIDENCE-BASED MEDICINE (EBM)

When a doctor sees a patient, takes a history, does a physical examination, and listens to what the patient says, that doctor circles around a possible diagnosis. Using EBM, the doctor would access the clinical literature on his office computer or on a hand-held device to answer questions and reach a diagnosis of what the patient has. The doctor then looks at the guidelines of standard practice for similar cases, critically appraises the evidence, and then decides on the treatment that fits the patient.

One of the designers and promoters of described EBM as follows:

“The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research….”(Sackett_EBP_Spine).

Seems straightforward enough. If you are seeing an asthmatic child, an adult with Type 2 diabetes, a patient experiencing atrial fibrillation for the first time–you access the clinical research database on what are the best treatment guidelines for the particular patient, determine benefits and side effects, costs, and then decide what to do.

DOCTORS RESIST EBM?

Over the past decade, the use of EBM clinical practice guidelines by medical practitioners in the U.S. and Europe has been disappointing across specialties and been estimated at just over 50 percent of doctors who follow guidelines.

One medical director noted: “What makes me change—it’s not scientific, but when I know what my peers are doing.  We meet, we talk, we look at publications”

A general practitioner observed: “If the information is easily available, some people will change.  When sufficient numbers of informed people make changes in their practice then peer pressure will make the rest change”( Giluk & Rynes EBM ch 3-8-11, p. 48)

Although some doctors may find access to and use of clinical guidelines too cumbersome or for other physicians dismissed as “cookbook medicine– Health (London)-2003-Dopson-311-30 ), there are many factors in the profession, workplace and larger environment that account for less use of EBM than advocates may care to admit publicly.

For example, while there is much that separates teachers from doctors (see post for April 24, 2011), as  practitioners in helping professions both doctors and teachers have experienced a loss of autonomy in their daily work (physician autonomy). In the past quarter-century, health management organizations and Medicare have accrued more and more authority to determine payments for diagnosis and treatment; they have adopted evidence-based clinical guidelines to determine payment schedules for fee-for-service doctors in solo and group practices as well as hospitals. What’s more these HMOs use cash incentives to spur doctors to use clinical practice guidelines in improving patient health care.

In public schools, teacher discretion has been squeezed also. Under pressure from state and federal officials for higher student test scores, more districts, particularly in big cities, have centralized their authority in central offices to determine curriculum, school organization, and instructional tools including high-tech devices. District officials have tightened procedures for principals and teachers in gathering and reporting information,  organized incentive plans, and holding practitioners accountable through evaluation and compensation for raising student test scores.  Both professions, then, have felt the pinch of reduced discretion with patients and students.

As with teachers, then, what appear to champions of EBM as individual doctors’ resistance to applying scientific studies to clinical practice is, in reality, doctors raising valid issues  stemming from professional, organizational, and societal factors that go well beyond epithets hurled at doctors (and teachers) of being “stone age obstructionists.”  Both the practice of teaching and medicine combines science and art. Often when reformers accuse practitioners of  being stubborn or supporting the “status quo,” the words mask the continuing tension that exists in both of these helping professions over which aspects of daily practice with individual patients and groups of students are scientific and which are artistic.

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