The Student-As-a-Customer Model Will Be the End of Academia

When I flunked a biostats course (and, by flunked, I mean I got a C), someone suggested to me that I approach the professor and asked what I could do as extra credit to get a B. If the C stuck, I’d have to take the course again one year later, and who has time for that?

A year later, there I was, front and center of the biostats class, writing my notes and paying attention. I’d go on to get an A in the course, but not without the professor stopping in the middle of the first lecture to look at me and ask me in front of everyone why I was there. “You know how it is,” I told her. “You get one C and everyone at the best school of public health in the world freaks out.”

Indeed, that was my point of contention with people who were shocked that I got a C. First of all, I had lab-confirmed influenza the day of the midterm. I showed up with a fever and stupidly took the exam, and, second of all, I did so because I come from an academic culture where you don’t ask for extra credit and you don’t argue your grades. You get what you get and you make the most of it.

It was good practice for the real world, where bosses don’t take excuses, and neither does my wife.

I knew they could run. I didn’t know they could fly!

I first started noticing something was up when I met some of the high school students in the town where I worked as a medical technologist. They were bright kids, and a few of them were looking to go to medical school. One of the local OB/Gyn physicians brought several of these kids to the hospital for a tour. As I gave them a tour of the lab, one of them asked me why I didn’t go to medical school.

“I don’t like people that much,” I told her. “This is where I belong. And, besides, I’m working on an MPH so I can work at a health department.” Upon hearing this, the students launched into a description of all the extracurricular activities she was involved with to make herself a better candidate for medical school. Mind you, she had not even graduated from high school yet.

When she was done, the physician talked to her about how she needed to do more. This was surprising to me as she seemed to have completely filled her schedule with stuff to do. “You should look into working here in the lab,” he said. “You’ll learn some good stuff and get experience in this environment.”
“Whatever it takes,” she replied.

A few weeks later, I noticed a man and a woman talking to my boss. It turned out that they were the girl’s parents, and they were there to argue with my boss on why a 16 year-old couldn’t work in the lab. My boss explained that there were no positions open, and that she had to have an official position to work with all of the private information handled in the lab. (Some of the lab tests to be performed are right on the label of the tubes of blood we collect, and the labels also have the patients’ names.)

They wouldn’t listen to reason and were quite rude.

Fast-forward a few years later, and I’m sitting in Colombia (South America) as a visiting docent at a local university. Suddenly, a parent and his child walk out of an office, screaming at the professor something about the school stealing their money. The professor later explained to me that the student flunked organic chemistry and could not continue the program until the following year. “I did everything I could to help him, but he was late to class, late to office hours, and he kept playing with his phone instead of paying attention,” the professor said. “And now his father is angry that the tuition was somehow wasted.”

Then fast-forward to the last year and a half of my doctoral education, when I was the lead teaching assistant for a couple of courses. The number of students who were dissatisfied with the professor and me because they didn’t understand the material was, to put it mildly, troubling. They even carried out their threat of revenge via the course evaluations. (The leadership really loves course evaluations.) One student even complained that one of the professors I worked with — whose first language was not English but speaks English well — was unintelligible. And me? I wasn’t “flexible” with their needs… Needs that apparently included being on Reddit during the class.

And I won’t even tell you about the one student who I caught doing his taxes during a lecture.

You’re a mean one, Dr. Ren

The most recent example of things turning upside down in academia comes from one of the recent students I tried to tutor. We set up an appointment to meet online for a lesson in epidemiology. Twenty minutes after the session should have started, the student had not shown up. I emailed them to tell them that I was not waiting anymore.

Ten minutes after that, about 30 minutes after the lesson should have started, the student emailed me to tell me that they were having technical issues in logging into the system. Another ten minutes later, they emailed me again to tell me that they finally logged into the system. Their main argument as to why they had technical difficulties was a lack of experience in using the system.

In an email to the student the next day, I explained to them that they should have taken the time to log in with plenty of time to understand how the system worked. I also explained to them that I had shuffled around other students since this particular student needed a lesson quickly. Finally, I pointed out the lack of professionalism shown by just kind of not being prepared.

Always be prepared.

Well, this didn’t go over so well with the student. They kind of blew a fuse and decided to leave some pretty bad feedback. Didn’t I know that it was not their fault that they didn’t prepare? Didn’t I know that they didn’t bother to log in ahead of time to make sure they understood how everything worked, especially if this was their first time doing it? Didn’t I know that I was supposed to wait, sitting on my hands for a whole hour while they were AWOL?

Not only did I respond to the feedback, but I also emailed the student and told them that they had basically burned a bridge. The world of public health is quite small, and I’m sure I’m going to meet them in person at some point… And they better not even bother introducing themselves to me. I’m done with them.

Just doing it for the MD

Then there are the students who didn’t get into medical school on their first try, so they’re making themselves “better candidates” by getting a master of public health degree or even a doctorate. I understand why they are doing this, but it troubles me a little bit because they could very well be taking away a slot from someone who sincerely wants to be a public health worker. Now, this is not to say that a physician with an MPH is a bad thing, or that they wouldn’t be a public health worker.

What I am saying is that, usually, everything students learn in an MPH or even a PhD program is lost when they go through medical school. There is only so much the brain can absorb, and not everyone can absorb the knowledge from a bachelor’s, a master’s and a medical degree… Or a bachelor’s, a master’s, a doctoral and a medical degree. But students still try, and they still cry their eyes out when they get a B in a course because, somehow, medical schools won’t let them in with a B in a master’s or doctoral-level course.

(Pro tip: You don’t want to go to a medical school that will not accept you with a B or even a C here or there.)

Yes, there are some very bright physicians who go into research, and they need all of the skills learned in those programs in order to make sense of all the projects they’ll be involved in. But they’re far and few in between, and perhaps there should be dedicated programs to produce “research physicians” instead of physicians with a master’s and a PhD whose concepts they’ve forgotten over the course of medical school, residency and fellowships.

But That’s Just Me

Again, maybe it’s just me. Maybe it’s always been the case that college and graduate students have brought in their parents into discussions with professors about grades. Maybe my parents just didn’t love me enough, so they let me make my own mistakes and own them. Maybe.

But what if there really is something going on and helicopter parents have become the norm? What if, God forbid, the students really have become more delicate and something as trivial as a bad score on a test or a grade less than an A really does pose some sort of existential threat to them? Where will that lead us?

A quick aside… I do realize that there are students who are living with mental health conditions that are exacerbated by things such as the stress of having to redouble their efforts just to pass a class. And I realize that, many times, colleges and universities are not well-equipped to help them, so they end up bringing in their caretakers into the equation. Often enough, those caretakers are their parents. I’m not addressing those students. They’re not the problem.

The problem are the students who are perfectly capable of dealing with the world around them as demonstrated by their social media activity and their list of extra-curricular activities. Suddenly, students who participate in running marathons and raising money for charity are unable to deal with the stress of an exam, and they crack… And they lash out at everyone in sight, most often the professor.

So What Do We Do Now?

How can we reverse this trend, if it is indeed a trend? How do we make sure that college and beyond are opportunities for young adults to hone their real-life skills and learn how to deal with adversity, how to work in teams and how to know which bridges to burn? I really don’t know. It really does seem to me that this is a bit of a tsunami that is going to take some time to sort out.

In the meantime, I’m going to continue to work in training my colleagues, not teaching my students. I’m going to pass on knowledge and wisdom, not just show how to repetitively and mechanically do a menial task. As I told a student the other night, they need to know how to calculate the numbers in a biostatistical analysis and to understand if the results they’re getting make any kind of sense. Because, in the words of my old boss at the lab, “I can train a monkey to push a button. I want to mentor you to do good work.”

Which Is Better? A False Positive? A False Negative? A True Positive? Or a True Negative?

It’s the age-old question of laboratory test and analyses, “How accurate is this?” The answer to this question is always, “It depends…” This answer is then followed by some lengthy explanation of what is best for the person being tested. When it comes to individual medical decisions, these discussions are best when had by a healthcare provider and the patient, not the patient and Google. But what about a question at the population level?

Take, for example, influenza surveillance. When I started working at a state health department, one of the first things I did was to reach out to clinical laboratories and ask that they provide the number of rapid influenza tests and their results. This would help me inform the public and public health workers of when and where influenza was active. But I had to keep in mind the performance of these tests as well as the prevalence (the existing cases of a disease) of influenza in the places where the tests were being done.

The rule of thumb is: If prevalence is low, then false positive rate will be high. If prevalence is high, then the false negative rate will be high. It’s all based on math and how that math breaks down on a 2×2 table based on a test’s sensitivity and specificity. Sensitivity is the probability that the test will detect a disease when the disease is there. Specificity is the probability that the test will be negative when there is no disease.

Let’s say that a test is 99% sensitive and 99% specific. That’s pretty good, right? It will catch 99% of all true cases with a positive test, and it will rule out 99% of non-cases with a negative test. If you have ten minutes, here’s how I explain it…

If you don’t have the ten minutes, then just know that there are four categories being looked at: TRUE positives, FALSE positives, TRUE negatives and FALSE negatives. As prevalence increases, the chance that a positive test is true increases. You have more true positives. The chance of a false positive decreases. Likewise, the chance of a negative result being a true negative decreases as prevalence increases.

So we go back to the question of what you want to achieve… If you are a physician and you want to catch the most number of cases, then you want the patients that you’re testing to be in a group with the highest prevalence. This is why healthcare providers will ask you all sorts of questions before you get tested. They want to make sure you fall into the categories for testing that will yield the highest POSITIVE PREDICTIVE VALUE. They want that positive test to have the highest chance of being a true positive. They also want to miss the fewest number of cases possible by increasing the chances that a negative test is negative, or having the highest NEGATIVE PREDICTIVE VALUE. There is a “sweet spot” when it comes to prevalence where this happens, but that’s for a whole other lecture.

Now, if you are an epidemiologist working an Ebola outbreak, then you don’t want to have false negatives that end up being sent home to infect others. You want that number low. Do you care about false positives? Well, maybe not if the therapy won’t kill someone, or maybe you do if a positive test means being put into a ward with people who are sick. It’s a delicate balancing act.

What about pregnancy tests to take at home? You probably don’t worry too much about false negatives (pregnant women who test negative) because those women will still be pregnant and probably take the test again if they continue to miss their period or feel other signs/symptoms of pregnancy. And you maybe care about false positives because a positive test means a trip to the obstetrician, blood work, and (if you’re anything like me) an ensuing panic of epic proportions for the would-be dad.

If you’re me and you just want to keep tabs on flu activity, you don’t say that the flu has arrived based on a screening test. You use a gold standard test for influenza, like a viral culture or a polymerase chain reaction test. Once the gold standard is positive, then you know the virus has arrived, and the chances of screening (aka “rapid”) tests being true influenza cases rise to tolerable levels. Once you stop seeing positives on gold standard tests, or you see that a lot of the rapid tests were in people without symptoms, then you stop using it as a marker of influenza activity.

Again, it’s all a balancing act. It’s kind of like the justice system. You want the chances of an innocent person going to jail to be as low as possible, so you set up all sorts of systems. You also want the chances of a guilty person to be as high as possible to protect the population from criminals, so you set up those systems. You’re still going to have innocent people going to jail and criminals getting out, but it’s all about minimizing it. (Don’t get me started on how the current justice system in the United States is failing at this.)

Now you know why a test that is 99% accurate (99% sensitive and 99% specific) is still going to throw out a lot of false positives or false negatives, because it’s about prevalence. If you’re a healthy person in the middle of the summer in the United States, and you haven’t traveled abroad or work with pigs/chickens, then you probably will not get tested for the flu. There’s a very high chance that you’ll test positive when you’re not. On the other hand, if you’re feeling miserable, it’s the middle of winter in the United States, and you have been around other sick people, then you have a very low chance of testing negative when you are indeed sick.

These are the kinds of things that one needs to think about very, very carefully when using a screening test of device. But you also need to think about the population you’re testing in general, the individuals you’re testing in particular, how they would benefit or be hurt by the test results, and whether or not you should just use the gold standard or diagnostic (not screening) test instead if your degree of suspicion is high enough to warrant it.

What worries me is a researcher who sees too many false positives or too many false negatives and gets all riled up over them without seeing the bigger picture. Maybe, in the situation you are describing, too many of either is not bad. Maybe the proportion of each (i.e. the Positive/Negative Predictive Value) is really what you should be worried about? Context matters when dealing with these things. And context is something epidemiologists need to have in mind when interpreting results of their research, especially if they’re calling for any kind of action.

Don’t you love thinking of all the possible scenarios?

I do.

Learn medical terms the easy way

When I was in high school, I joined a “magnet school” for kids who wanted to go into the medical field. One of the first things that they taught us there was medical terminology. It wasn’t easy to learn what things like “subcutaneous” meant at that time because they were words that we all hardly ever used day-to-day. To make matters harder, a lot of us spoke English as a second language, so these words were even more foreign, even if most of the words were based in Latin and sounded a lot like Spanish.

I remember very clearly how I learned what the suffix “-itis” meant. They showed us a cartoon of a teacher holding tests in her hands and saying, “I test.” What she was saying sounded a lot like -itis, so the narrator of the cartoon said, “Now imagine your teacher in flames.” The cartoon then showed the teacher holding the tests and being covered in flames. From that image of her, I never forgot that -itis is the suffix for “inflammation.” So it amazes me that so many people add -itis to the end of words to mean that it’s a disease, like “freshmanitis” for suffering from being a freshman when it really means an inflammation of the freshman.

The suffix for “having a condition” or “suffering from a condition” is “-osis.” The way I learned that was from a cartoon where a little boy drops an air conditioner on his sister and screams, “Oh, sis!” Get it? We went from “Oh, sis!” to “-osis” to the image of the air “conditioner” on the sister. Thus, I associated the suffix with “a condition.” This went on for weeks, and I learned a lot because of that visual style of teaching us those words.

Of course, not everyone is a visual learner, but visualization and repetition are pretty good ways of learning for most of us.

melanoma cartoon
Some things are more complicated than others. (Comic cartoon via Jorge Muniz at medcomic.com)

The other day, my wife pointed out to me this Kickstarter campaign created by a physician assistant who aim to use his cartoon skills to help students in all medical fields learn about medical conditions. Kickstarter is an online platform for innovators and entrepreneurs to showcase their products and get financial backing straight from the public. (There are some risks associated with some projects, especially the ones that sound too good to be true, so do your due diligence before supporting this or any other project.)

Here’s the link to the Kickstarter page: https://www.kickstarter.com/projects/1881653671/medcomic-the-most-entertaining-way-to-study-medici

As you can see, he uses his excellent cartoon skills and humor to teach some not-so-simple medical terms and even “dives” into explaining infectious disease. I hope you find it in your heart, and wallet, to support this project. I know I will.

The anti-psychiatry, anti-Big Pharma blog post that reads like a science blog post

I’ve long been a fan of Io9.com, a blog about science fiction and other things to do with science. The writers of that blog have been, for the most part, very reasonable in their approaches to things having to do with science. They’ve come out against antivaxxers and all their nonsense. But I guess the streak had to end at one point.

In a blog post titled “The Most Popular Antidepressants Are Based On A Theory We Know Is Wrong“, blogger Levi Gadye, a neuroscience graduate student, postulates that the theory that depression is the end result of neurotransmitter function deficits or defects is wrong. Further, he seems to imply that Big Pharma had something to do with hooking “one in ten Americans” on antidepressants.

But let’s not get ahead of ourselves. Let’s take his blog post one piece at a time. Continue reading

This is the reply of a homeopath who says he can cure Ebola

There’s a discussion online on this article about a group of homeopaths who wanted to go to West Africa and treat people sick with Ebola with homeopathy. For those of you who don’t know what homeopathy is, homeopathy basically boils down to magic. Homeopaths claim that water has “memory” and that you can dilute something beyond the point where any of the original solute is present but the water’s memory will somehow help you. Again, it’s magic.

One of the biggest arguments for homeopathy that you’ll encounter is that homeopathy is “natural” and “safe,” or that it performs just as good as placebo. Here’s a pro tip, folks. When something performs just as good as a placebo, it means that it’s a placebo, not a remedy, not a cure. Also, homeopathy is safe because it’s a placebo. Rarely does anyone overdose on nothing. Continue reading

When the law, just like the times, needs to change

If there is one thing that I like to think I am is flexible. I don’t like to be set in my ways because I could be wrong and have no way of correcting myself. As Moriarty said in the season finale of the first season of “Sherlock”, “I’m so changeable. It is a weakness with me, but, to be fair to myself, it is my only weakness.” Except that I don’t see it as a weakness.

There used to be a time when I believed that marihuana was an instrument of the Devil. Well, not THE Devil but a demon of its own. I was raised to believe that anyone and everyone who used marihuana was a bad person, worthy of being shunned or jailed. “Pot heads” had to be thrown away into a prison, no questions asked.

Continue reading

Discussing the things that work and the things that don’t work

If you know me, you know that I’m a big proponent of evidence-based medicine. (Some are calling it “results-based” or “clinically significant” medicine.) There is nothing I despise more than charlatans who sell remedies that have been shown not to work. People who say that this or that is a cure for cancer and that “big pharma” doesn’t want to acknowledge that there is a cure for cancer… Those people annoy me and make me very, very angry.

I’m passionate about this subject because, in my personal and professional life, I have witnessed the harms brought to people who gravitated toward sham treatments instead of following their healthcare providers’ advice. I have seen what happens when someone with a treatable cancer decides to go the “natural” route and ends up in trouble, or dead. Someone sold them something that simply does not work, promising them that it does.

Are there natural alternatives to medication? Absolutely. There are many, many times when we take antibiotics for viral infections when staying home, resting and drinking a nice tea will do just as well. There are other times when we take painkillers when exercise and physical therapy will do wonders.

And that last part is the part that got my wife into a discussion with a friend the other day. She is a physician assistant. He is a medical doctor. She has worked for over eight years in family practice and urgent care. He has worked double that (and then some) in cancer care. Their discussion was about the use of “alternative medicine” (which is not medicine, in my opinion) for the treatment of fibromyalgia.

Depending on whom you ask, fibromyalgia is a physical manifestation of something real or something in the patient’s psyche. Either way, the true one cause is still unknown. But there is plenty of evidence that things like exercise and relaxation work. In some cases, these may work better than painkillers.

So my wife and my friend discussed (on Twitter of all places) where things like acupuncture fit into the equation of treating fibromyalgia. She contended that, yes, acupuncture doesn’t physically do anything, but the process of being treated with it is relaxing and may even trigger the placebo effect on a person with fibromyalgia — something that could be beneficial and effective. He contended that acupuncture relies on magical thinking for it to work, so it wouldn’t do any physical good to the person receiving it. So the person was better off seeking true medicine.

And, you know what? They were both right.

Yeah, I’d be a fool to go against my wife on anything, right? Not so. She is a very smart and rational woman. As long as I bring a reasonable argument, she will hear me out. So I’m with my friend in that acupuncture physically does absolutely nothing. If anything, it increases the risk of infections. (Have you seen anyone wearing gloves while doing it?) At the same time, I’m with my wife in that a psychogenic condition can be treated by manipulating the person’s perception of the world. Put a person exhibiting signs of pain from a psychological stress into a peaceful and relaxing situation, and I bet you anything that the pain goes away. It’s in maintaining that peace that the challenge comes.

I’m also with my wife in her assertion that narcotics for psychogenic pain are a bad, bad idea. We are seeing more and more evidence of people getting addicted to narcotics when regular non-steroidal anti-inflammatories (e.g. tylenol or motrin) or relaxing and exercising more often will do the trick. But it’s a tricky thing to discern whether pain is the manifestation of something wrong with the body or something awry in the mind.

It’s hard to be on any side on this because fibromyalgia is such a complex thing. There are other diseases and conditions that are just as difficult to deal with. I mean, look at the “controversy” of chronic Lyme disease. Lyme is caused by a bacterium that is susceptible to antibiotics, so it should be cleared reasonably quick. But there are people whose symptoms do not resolve right away and demand to be on prolonged antibiotics until the symptoms do clear up. For that, there is little evidence that the infection is active that long and that this effect is more a result of the “return to the mean” effect that we see in diseases all the time. It’s just that it takes some time for the effects of Lyme to go away. Or you can get reinfected if you live in a place where Lyme is endemic and the ticks that carry it come into contact with you time and again.

Nevertheless, I’m glad that this discussion happened. It was cordial. Although he’s known for his snark, my friend was not snarky. And my wife said she learned from the discussion. It was a win-win. I wish all conversations on controversial issues were the same.

The relative risk of population-based studies

I’m with my wife in Boston for a conference this Memorial Day weekend, and I caught a presentation by two very knowledgeable women on what “risk” means to everyday medical practice. The presenters did a heck of a job in explaining risk and what it means to a provider as they speak to their patients about possible therapies. For example, if a patient comes in with pericarditis, how would you explain to them that a therapy was found to have a relative risk reduction of 10% in patients who took it compared to patients who didn’t?

I’m not a healthcare provider, so I have no idea how you would explain this to a patient. Also, I’m an epidemiologist, so I understand what a relative risk reduction is. So the presenter was kind of preaching to the choir when it came to myself, but others in the room had different approaches. Some said that they would tell their patients that they would be 10% more likely to be cured with the therapy. (This was wrong, and I’ll tell you why in a little bit.) Someone else said that 1 in 10 people benefit from the therapy, so the patient had a 1 in 5 chance of getting better. (This is a better answer, and I’ll tell you why in a little bit.) Continue reading