Guest Post: What Makes a Good Clinician?

This post is by Adam Clemans.

Marco Arruda, an MD and PhD in the Department of Pediatric Neurology at the Glia Institute (São Paulo, Brazil) is the author of a recent editorial in JAMA Pediatrics about the use of Triptan for headaches in children. There’s a lot of controversy because placebos work very well for headache — so much so that they often have to use some tricky methods to actually show a treatment effect with the real drugs.

In a recent article on Medscape, Dr. Arruda is quoted as saying: “Although placebo is the enemy of great clinical trials, it is likely the best friend of good clinicians.”

This makes me wonder what he thinks makes a good clinician. If Triptan and a placebo are equally effective, it is curious that anyone would skip the placebo and prescribe the drug, which has listed as side effects:

Anaphylactic shock, angina, angioedema, breast pain, colitis, coronary artery vasospasm, hemiplegia, hypertension, myocardial ischemia, MI, neuropathy, rash, seizure, syncope, tachycardia, ventricular fibrillation, ventricular tachycardia

Why does putting patients in harm’s way make one a good clinician?

Assorted Links

Giving Computer Science Students Freedom

After my post about how I stopped grading, Eric Chown, who teaches computer science at Bowdoin, said he did something similar. In upper division courses, he wrote, “All that matters is student engagement. When students are engaged . . . my job is to stay out of their way.” I asked him for details. His reply:

Independent Study: I run a lot of them. Many are in areas that I’m not an expert in. This started out of necessity – some of our students wanted to learn things that we simply do not have in our curriculum and if they were exceptional students I knew they’d be able to learn those things on their own. Over the years I’ve come to see that all any of our students need to succeed in an independent study is a high level of motivation. I make sure they have picked a useful topic and are sufficiently motivated and have a general plan. After that I turn them loose. I meet with them once a week to see where they are. I rarely give them explicit assignments. I’m almost never disappointed by what they learn and accomplish.

Projects: I teach a Projects course. The goal of the course is engagement pure and simple. Students choose a project at the start of the term (approved by me). There are no lectures in the course nor any required reading. Course time is used for 1) sweekly short (5-10 minute) student presentations on where they are, what problems they are having, etc., 2) to meet with each other if they are working in groups, 3) to share ideas. Students hand in weekly “work logs” (which I don’t grade). As the course goes on, I encourage the students not only to present on their project, but also on the process of the project. Themes always emerge, particularly “what I expected to accomplish versus what I actually accomplished” and “how I learned to motivate myself”. At the end of the term they do traditional presentations of their projects and hand in their software and a short paper about it. Student projects have become so central to our curriculum that we now require that all majors take at least one project-centric course to graduate. Probably more than half of our upper level courses have migrated in this direction.

Mobile Computing: Last year I started teaching a course on Mobile Computing. I had zero experience in this area. My goal was to try and stay about a week ahead of the class. . . . I told them that as computer scientists they should be able to do what I was doing — figure stuff out on the fly and learn where to look to find answers. Most of the grade for the course was based on a large project (no tests and a couple of easy warm up assignments). Students absolutely didn’t care that I wasn’t an expert, they were simply thrilled to have an opportunity to work in an area they were excited about. Many have since told me that it was their favorite course at Bowdoin. My experience as a computer scientist was all the expertise that they required. I’m teaching it again this term and while I’m more of an expert now I doubt the course will be more successful. If anything, my increased expertise may be a little more threatening to them. Around the college people are amazed that I would try something like this (I suspect some folks are even offended that I would teach outside my training). It has been great and has helped energize me.

Cognitive Architecture: I base what I do in this course largely on how my advisor taught at Michigan. I assign readings for each class but never lecture. A lot of the course is about the advantages of “Active Learning” and I try to put it into practice in how I run the course. When we come to class I have the students make a list of questions inspired by the reading. Class is spent discussing those questions. As the semester goes along the choice of readings becomes more and more influenced by the particular interest of the students. I give students a choice between a project and a final. The only constraint on the project is that it should have something to do with the topics of the course and that I’d like them to connect those topics to their major (I get a lot of Neuroscience and Psych majors). Sometimes the biggest problem with the projects is that students simply get too involved. That happened this term with a group that made a robot boat based on Braitenberg’s “Vehicles” using Arduino [open-source prototyping]. Neither they nor I knew anything about Arduino ahead of time, but they had an absolute blast with it. Not only did they learn a lot more about Braitenberg’s ideas, but they learned about Arduino and even how to solder! By the end of their project I found myself reminding them that they had other classes.

RoboCup: I’m head of the Bowdoin RoboCup team. RoboCup is a worldwide competition where robots play soccer against each other. I started teaching robotics to get students interested in Computer Science. My knowledge of robotics going in was basically that one of my best friends in graduate school was a roboticist and I helped him implement some cognitive theories on a mobile robot. I told my students that RoboCup looked like fun and I didn’t see why Bowdoin couldn’t have a team (I had an NSF grant to start a robotics lab). That was in 2005. By 2007 we had won the world championship, beating teams like Carnegie Mellon. We’re still competing almost 10 years later. My best students still know more about robotics than I do. What I know is how to engage them, how to put them on tasks that suit their particular talents and how to see the big picture. I’m a huge believer in the idea of “ownership” so I absolutely give the students ownership of the team. When they make choices that I disagree with I simply make my opinion known. Sometimes I am proven right, often I am proven wrong. We are competing with the top engineering schools in the world as a dinky (1800 students) undergraduate college of liberal arts students. My students on the team (typically from 8-12 at any given time) learn way more doing RoboCup than they do in their classes. Mostly they do this in their free time. Occasionally they can work on it as part of one of my classes or an independent study. They want to learn and they do. I give them opportunity. A steady stream of them are ending up in graduate school at CMU, Georgia Tech, Michigan, etc. [When I was 8 years old, I learned the concept of college major. I asked my mother: “What did you major in?” “Extracurricular activities,” she said. She spent more time on the student paper than on her classes. — Seth]

I asked him how his approach differs from what other computer science teachers do.

Here are some differences:

1) I don’t see my job as trying to transplant my knowledge to my students. I see my job as a facilitator and guide.

2) I tell my students ahead of time in some of my courses that I’m not going to tell them everything they need to know. Instead I’m going to try and teach them what to do when they don’t have all of the knowledge they need.

3) I try to adjust what I do on the fly to the students I have (this is easier at a small school). If I can get the students to come to key material through their own means (normally projects) it will be far more meaningful to them and they will learn it much better.

4) I’m not afraid of not knowing everything. If I only teach what I know everything about, it really limits what my students can get from me.

5) Fairly open ended projects are a great way for students to learn, and they don’t have to be a time sink for me. However, even the most motivated students need “nudges.” Part of my job is to figure out (or help them figure out) what nudge any given student needs. Weekly logs, frequent short presentations, etc. seem to work well.

Computer Science lends itself well to projects. However, many or most CS courses are typically taught either through a series of small, well-defined programs, or by standard projects where everyone in the class has the same goal. Most people in the field cling tenaciously to a core of material that they feel absolutely must be taught. Sometimes I think we’re headed in a direction where half of the people teaching CS will use the same Power Point slides for their lectures (which helps explain the appeal of things like Coursera). My feeling is that if I can get a student excited about just about anything within the field they will naturally encounter the important stuff in the course of engaging their interests.

Movie Directing and Teaching

In my last post I described the result of giving my students more freedom. The more freedom I gave them, the harder it became to grade them. So I stopped grading them — giving them even more freedom. Here is what the director Steven Soderbergh said in a recent interview about giving actors freedom:

INTERVIEWER You’ve talked at length about giving actors as much freedom as possible. That’s resulted in a number of performances that have launched, revived, and revitalized careers. In the case of Jennifer Lopez in Out of Sight, you’re responsible for her only good film performance.

SODERBERGH It’s not that I never say no; I’m just not trying to control them. I’m looking to amplify and showcase whatever it is about them that I find compelling.

I assume that each of my students wants to learn something (related to the class). I try to make use of that desire rather than push them to learn something else. Whatever my students are good at, I want to make them better at. Here is an old post of mine about how this way of teaching resembles the way good managers manage.

What Happens If I Stop Grading?

I believe two things about teaching:

1. The best way to learn is to do. From an article by Paul Halmos about teaching math. I began self-experimentation to learn how to do experiments.

2. Everyone’s different. My theory of human evolution says we changed in many ways to facilitate trading. (For example, language began as advertising.) The more diverse the expertise within a group, the more members of the group can benefit from trade. Following this logic, mechanisms evolved to increase diversity of expertise among people living in the same place with the same genes. (For example, a mechanism that causes procrastination.) The theory implies that there is something inside every student that pushes them toward expertise — they want to learn — but they are being pushed in many different directions — what they want to learn varies greatly. If you accommodate the latter (diversity in what students want to learn), you can take advantage of the former (an inner drive to learn).

The novelty is #2 — the idea that #2 is relevant to teaching. Human nature: People who are the same want to be different. Formal education: People who are different should be the same. At Berkeley, most professors appeared to have little idea of the diversity of their students. (At least I didn’t, until I gave assignments that revealed it.) Almost all classes treated all students in a class the same: same lectures, same assignments, same tests, same grading scheme. I heard dozens of talks about how to teach. Supporting or encouraging individuality never came up. Now and then I told other professors these ideas — at a party, for example. “Everyone’s different, but our classes treat everyone the same,” I’d say. No one agreed. It was a new and apparently distasteful idea. Too much work was one response.

I believed my theory of human evolution partly because it explained what I saw with my students (Berkeley psychology majors in undergraduate seminars): The more freedom I gave them, the more they learned. I gave them great freedom with their term project (except I forced them to do it off-campus). That worked fine. One student had an intense fear of public speaking. Her project: give a talk to a high school class. She succeeded. “What did I learn? I learned that if I have to, I can conquer my fears,” she wrote. I wrote an article about it. I taught a whole class where the students (all 10 of them) were given great freedom to do something off campus. That worked, too. But the class was too niche and the term project too small. It wasn’t obvious if the ideas would work in an ordinary class.

The more freedom I gave my students, the more difficult it became to grade them. At Tsinghua I teach a required class for freshman psychology majors called Frontiers of Psychology. There are 20-30 students. It covers recent research. For the first few years, I had students write comments on the reading. “Write something only you could write,” I said. The students struggled to figure out what that meant. I struggled to grade their answers.

Before last semester began, I had an idea: no grading. Maybe other sources of motivation, would be enough.

Last semester, my Frontiers class had two parts:

1. Reading. During this section, they read a variety of things: recent experimental papers (e.g., from Psychological Science), book excerpts (e.g., from The Man Who Would Be Queen) where I said “read any 60 pages you want”, and my long self-experimentation paper (“read any third you want”). This taught them how to do research, not just subject-matter content. A typical assignment included a class presentation. For example, each student read a different experimental paper (they chose) and gave a presentation about it. Another assignment involved an in-class debate. I discussed the readings — for example, the controversy around The Man Who Would Be Queen — and gave feedback on presentations but rarely lectured. The main lecture I gave was at the beginning to explain the course. This part of the course resembled a traditional course, except (a) no grades, no tests, (b) many class presentations (public speaking is an important skill), and (c) lots of choice in what they read.

2. Doing. This section had two parts: (a) a short (2 week) experiment where they tested the effect of whatever they wanted (chocolate, piano music, exercise, and naps of different lengths were some choices) on brain function measured by a reaction-time test written in R. They gave presentations about their results (I regret not requiring written reports). (b) a long project (4-5 weeks) where they could study whatever psychological topic they wanted. It might or might not involve data collection. The topics they chose to study included dreams, procrastination, the perception of psychologists, fujoshi, the relative femininity of different sports, the accuracy of first impressions, different ways of teaching English, comparison of Tsinghua students and Peking University students (the top two universities in China, with stereotypically different students), cognition in native versus non-native language, reading screens versus reading books, and positive psychology. They could work in groups or by themselves. They had to get my approval for what they did so that they wouldn’t try to do too much or too little. At the end they wrote a report and gave a class presentation. I met with each student or group of students individually to discuss their work, usually for 30-60 minutes. During these discussions they provided evidence (e.g., photographs, recordings) that they had done what they said.

I did give grades (I was required to) but they were minimal. The final grade was entirely based on the final project. I divided each project into parts (e.g., background research, data collection, class presentation) and gave each part a point value such that the points add up to 96 (= A). If you finish Part X, you get the associated points. (Everyone completed all parts.) If they did really well I gave them slightly more points (e.g., 97). If they failed in some serious way I gave them slightly fewer (e.g., 94). So grading was close to binary: yes or no. You could get a good grade simply by doing what you said you would do.

It was the most pleasant teaching experience of my life. It was also the easiest by far, in contrast to my Berkeley colleagues’ claim that my ideas led to “too much work.” The hours I had spent every week grading homework in previous versions of the course — the part of the course I liked least — was gone. At the end of the class, I spent many hours discussing the student projects, but I enjoyed these discussions. They didn’t feel like work. The students had chosen topics they wanted to study and seemed happy to talk about what they had done. Unlike an oral exam, almost nothing was riding on what they told me and they could be proud of what they were talking about, since it was almost entirely their idea.

The students’s work was the highest quality I have ever seen. Two of their final projects might be publishable. (And these are first-semester freshmen.) It’s not my field, so I can’t be sure, but they have great inherent interest and no obvious flaws. The students seemed to like the class, too. On the final day, which happened to be Christmas, they gave me a Christmas card signed by everyone in the class. One student gave me a card separately. “Thank you,” I said. “Why did you give me this?” Among other things, she said I had high standards. Given the absence of grades, that was interesting. Maybe it came from the fact that after every presentation, I would point out something I liked and something I thought could be better. I tried to do that with all of my feedback. Another student told me, after the final class, that what I had said about “the best way to learn is to do” was, in her case, very true. She said she had learned more in my class than in all her other classes put together.

There were about 25 students and 12 assignments = 300 (= 25 x 12) assignments total. There were about 4 instances where a student did not do an assignment. In other words, the students did the assignments 99% of the time although there was no obvious penalty for not doing an assignment. Had I given grades, I might have gotten 100% compliance rather than 99%. To use a costly (in terms of time and student anxiety) grading scheme to get a 1% improvement in compliance is absurd. Yet that may be what most professors are doing — at least, my experience suggests they could get very high compliance without expensive grading.

I think this class worked well for both my students and me because it contained several elements: 1. A “core curriculum” (recent psychological research) taught in several different ways. 2. Good-quality materials. For example, The Man Who Would Be Queen is much better than what psychology students typically read. One student told me she read the whole book even though only a third of it was assigned. 3. Plenty of doing. A class presentation counts as doing. 4. Plenty of student choice. 5. Absence of grading, which has bad side effects.

I think several things caused students to learn a lot: 1. The material was interesting. 2. To some extent — far more than in other classes — they could choose what they wanted to learn, especially during the second half of the class. 3. Peer pressure. They wanted to look good in front of their peers. It would have been embarrassing to not be able to do a presentation when called upon. 4. The instinct of workmanship. Thorstein Veblen wrote a book called The Instinct of Workmanship. People inherently want to do a good job, said Veblen. I agree. 5. Doing is fun.

Would this work with other students? My students were/are very smart, yes. Tsinghua is extremely hard to get into and entrance is mostly based on a standardized test. My students, in other words, did very well under the usual system of teaching. This can be interpreted two ways: (a) They like the usual way of teaching, it fits them (they succeeded because of the usual methods) or (b) like everyone else, they dislike the usual way of teaching but unlike everyone else figured out how to learn on their own. The first interpretation suggests that my students would benefit less than other students from the novelty of my approach. The second interpretation suggests they would benefit more. What is clear is that Tsinghua students are known for studying very hard — yet my class required no studying beyond reading and understanding.

What did I learn? I learned that I can stop grading and things get much better, not worse. I learned that motivations other than grades are plenty powerful.

Assorted Links

Thanks to Bryan Castañeda and Dave Lull.

Late Comment on Battle Hymn of the Tiger Mother

Amy Chua wondered if all the pressure to practice (piano, older child, violin, younger child) she put on her two children was worth it. But then there were moments like these:

In a glass-windowed room overlooking the Mediterranean, Sophia played Mendelsohn’s Rondo Capriccioso, and got bravos and hugs from all the guests.

Which I found the most chilling sentence in the whole book. Her daughter’s recognition (“bravos and hugs”) made Chua very happy. But did it make Sophia happy? Chua doesn’t answer that question. She doesn’t follow the sentence I’ve quoted with “I could see how pleased she was” or “Years later she would say what a good time she had”. Nope, the chapter ends there.

Are Low-Carb Diets Dangerous?

A link from dearieme led me to a recent study that found low-carb high-protein diets — presumably used to lose weight — associated with heart disease. The heart disease increase was substantial — as much as 60% in those with the most extreme diets. (A critic of the study, Dr. Yoni Freedhoff, called the increase in risk “ incredibly small“.) Four other studies of the same question have produced results consistent with this association. No study — at least, no study mentioned in the report — has produced results in the opposite direction (low-carb high-protein diets associated with a decrease in heart disease).

I find this interesting for several reasons.

1. I learned about the study from a Guardian article titled “What doctors won’t do”. A doctor named Tom Smith said, “I would never go on a low-carbohydrate, high-protein diet like Atkins, Dukan or Cambridge.” Fine. He didn’t say what he would do to lose weight. The psychological costs of obesity are huge. The popularity of low-carb diets probably has a lot — or everything — to do with the failure of researchers to find something better. I have never seen people who criticize low-carb diets appear aware of this. I disagree with a lot of Good Calories Bad Calories but I completely agree with its criticism of researchers.

2. There has never been a good explanation of the success of low-carb high-protein diets (why they cause weight loss), although this has been well-known for more than a century. (A good explanation would be a theory that made predictions that turned out to be true.) Such diets require a big change in what you eat. A big change is likely to have big health consequences in addition to the weight loss, and those side effects could be either good or bad. It now appears bad is more likely. With a good theory of weight control, you should be able to find a much smaller change that produces the same amount of weight loss as a low-carb high-protein diet. Because the change is much smaller, it should have much smaller side effects. Much smaller side effects (unknown whether they are good or bad) are much less likely, if bad, to outweigh the benefits of the weight loss. I have never come across a low-carb advocate who seemed to understand this (that we don’t know why they work and it would be a very good idea to find out).

3. The Japanese are remarkably healthy (live very long), slim, and have very little heart disease, yet eat lots of rice. Which makes absurd the notion that all high-carb diets are unhealthy or fattening.

4. The comments on the low-carb study are mostly critical and the criticisms are terrible. For example, Dr. Yoni Friedhoff, who blogs about weight control, says, “The paper’s basing all of its 15 years worth of conclusions off of a single, solitary, and clearly inaccurate, baseline food frequency questionnaire”. The authors of the study correctly reply that inaccuracy would reduce the associations.

5. Until nutrition scientists do better research, our best source of nutritional guidance may be what we like to eat. Evolution shaped us to like foods that are good for us, at least under ancient conditions. We like carbs and we don’t like foods high in protein (lean meat is barely edible) so a low-carb high-protein diet is on its face a bad idea. This is why I find it plausible that the low-carb high-protein association with heart disease reflects cause and effect (low-carb high-protein causes heart disease) and that in particular a high-protein diet causes heart disease. (Too little of the right fats?) We very much like fat. Under ancient conditions, the fat people ate was mostly animal fat and, before that, if you believe in aquatic apes, fish oil. It is quite plausible that lactose tolerance spread so quickly throughout the world because at the time everybody was starved of animal fat — high-fat mammals had been hunted to extinction — and dairy products were a good source of it.

 

 

Creating More Diversity

Like Tyler Cowen, I found this interview with Harvard professor of genetics George Church bizarre, in the sense of un-self-aware. Here is the most telling part:

SPIEGEL: Wouldn’t it be ethically problematic to create a Neanderthal just for the sake of scientific curiosity?

Church: Well, curiosity may be part of it, but it’s not the most important driving force. The main goal is to increase diversity. The one thing that is bad for society is low diversity. This is true for culture or evolution, for species and also for whole societies. If you become a monoculture, you are at great risk of perishing.

“The main goal is to increase diversity”. Fine. Yet in Church’s own classes — if he is like 99.9% of professors I know — he treats all the students the same (same lectures, same assignments, same tests, same grading scheme), apparently not understanding that such treatment decreases diversity.

When I was a graduate student, I had lunch (along with other graduate students) with Richard Herrnstein, another Harvard professor (of psychology). Herrnstein was on Harvard’s admissions committee. The perfect candidate, he said at lunch, would be a flute-playing football player with perfect SAT scores. Jane Jacobs describes an equally dispiriting lunch with a Harvard professor of urban studies.

What is it about Harvard professors? As Ron Unz says, “the elites they have produced have clearly done a very poor job of leading our country.”

Personal Science = Insourcing Your Health

I recently blogged about undisclosed risks of medical treatments. For example, sleeping pills are associated with a big increase in death rate. Patients are rarely (never?) told this. One reason risks are undisclosed is ignorance: Your doctor doesn’t know about them. Another likely reason is that you and your doctor have different goals. If a treatment harms you, your doctor is not harmed, in all but a few cases. If you refuse a treatment (such as a surgery), your doctor may make less money. This pushes doctors to overstate benefits and understate costs.

This is the simplest case for personal science: You care more about your health than any expert ever will. The experts have advantages, too (such as more experience with your problem) so it is not obvious that personal science will be better than expert advice — you have to try it and find out. When I started to study my acne, I was stunned how easy it was to improve on what my dermatologist had told me.

A recent article in The Atlantic (“The Insourcing Boom”) describes a similar revelation at General Electric. GE executives wondered if they could build a certain water heater (the Geospring) just as profitably in America as in China. They looked at it carefully:

The GeoSpring in particular, Nolan says, has “a lot of copper tubing in the top.” Assembly-line workers “have to route the tubes, and they have to braze them—weld them—to seal the joints. How that tubing is designed really affects how hard or easy it is to solder the joints. And how hard or easy it is to do the soldering affects the quality, of course. And the quality of those welds is literally the quality of the hot-water heater.” Although the GeoSpring had been conceived, designed, marketed, and managed from Louisville, it was made in China, and, Nolan says, “We really had zero communications into the assembly line there.”

To get ready to make the GeoSpring at Appliance Park, in January 2010 GE set up a space on the factory floor of Building 2 to design the new assembly line. No products had been manufactured in Building 2 since 1998. . . .

“We got the water heater into the room, and the first thing [the group] said to us was ‘This is just a mess,’ ” Nolan recalls. . . . “In terms of manufacturability, it was terrible.” . . . It was so hard to assemble that no one in the big room wanted to make it. Instead they redesigned it. The team eliminated 1 out of every 5 parts. It cut the cost of the materials by 25 percent. It eliminated the tangle of tubing that couldn’t be easily welded. By considering the workers who would have to put the water heater together—in fact, by having those workers right at the table, looking at the design as it was drawn—the team cut the work hours necessary to assemble the water heater from 10 hours in China to two hours in Louisville.

In the end, says Nolan, not one part was the same.

So a funny thing happened to the GeoSpring on the way from the cheap Chinese factory to the expensive Kentucky factory: The material cost went down. The labor required to make it went down. The quality went up. Even the energy efficiency went up. . . . The China-made GeoSpring retailed for $1,599. The Louisville-made GeoSpring retails for $1,299.

That’s what happened when designers and manufacturers were no longer so far apart. As far as I can tell, the designers at GE had no idea such big improvements were possible, just as I was shocked how easy it was to do better than my dermatologist.

There are dozens of ways to bring the incentives of doctor and patient closer together but that would be like trying to bring the Chinese workers and GE designers closer together. Personal science is much easier. No one besides you needs to change. It corresponds to insourcing: insourcing responsibility for your health.