[Third in a series on Daniel Kahnemann’s Thinking Fast and Slow]
Again, one of Kahnemann’s major themes is that that the intuitive part of the brain commits numerous fallacies except when operating in highly regular, predictable, environments or when subjected to hours of practice and immediate and reliable feedback.
This means that educational theorists are unreliable. It also means that one of their biggest fads, Constructivism, is misguided in yet another way. For consider which sort of pedagogy provides a regular, predictable environment with lots of practice and immediate and reliable feedback: one in which the material is delivered by teachers and textbooks, or one in which students discover things on their own in cooperative groups; one in which students practice particular patterns or particular optimal strategies repeatedly in a large number of carefully constrained exercises, or one in which students apply multiple invented strategies to a small number of open-ended prompts and problems; one in which student responses and student work is corrected right away, or one in which all responses are considered “valid” and in which student work isn’t handed back until the end of the marking period in a “portfolio assessment.”
Sunday, September 30, 2012
[Third in a series on Daniel Kahnemann’s Thinking Fast and Slow]
Wednesday, September 26, 2012
[Second in a series on Daniel Kahnemann’s Thinking Fast and Slow]
One of Kahnemann’s major themes is that that the intuitive part of the brain commits numerous fallacies except when operating in highly regular, predictable, environments or when subjected to hours of practice and immediate and reliable feedback.
This has some interesting implications about what kinds of “expert opinions” we can trust. Different people in different professions work in environments that are more or less regular and predictable, and that provide greater or lesser amounts of immediate and regular feedback. People who work in fields governed by logical regularities, like math, or ongoing and immediate empirical feedback, like certain of the empirical sciences and performing arts, and professions based on regular (and open) interactions with others, are more likely to give reliable expert opinions (and to be corrected by their peers when they slip up) than are armchair theorists and long range forecasters.
In particular, classroom teachers are a more reliable source of information on classroom pedagogy than are educational theorists and curriculum developers--especially if they use assessment tools that gauge the efficacy of their instruction (rather than assessing simply for the sake of assessment) and if they regularly check in with students and parents. So why is it that all the op-ed pieces on education are written by the theorists--many of whom don’t even attempt to become experts in education?
Monday, September 24, 2012
After so many books and articles and social memes about the virtues of intuition (e.g., Gladwell’s Blink, Peirce’s The Intuitive Way), it’s refreshing to find a book that takes intuition down a few notches and focuses on the many cases in which good judgment depends instead on the rational side of the brain. Daniel Kahneman’s book, Thinking Fast and Slow, does just that. It’s one of the best books I’ve ever read, chocked with fascinating and important findings, so many that I actually took notes, many pages of them, all the better to retain them.
In turns out that the intuitive part of the brain works best in highly regular, predictable, environments, or when subjected to hours of practice and immediate and reliable feedback. But elsewhere it often warps both judgment and action unless the rational brain intervenes. Here are some examples:
The Anchoring Effect: encountering a number can bias subsequent numeral judgment in the direction of that number, even when that number is unrelated to the judgment in question. The size of initial offers effects the price buyers are willing to settle on; so does the random number a spinner lands on.
The Florida Effect (an example of the Priming Effect): students who encountered more words relating indirectly to old age (wrinkled, Florida…) walked more slowly down a hallway than controls did.
The Accessibility Effect/The Focusing Illusion: We tend to exaggerate the significance of things that come more readily to mind or that we are currently focusing on—overestimating the risk of flying, for example, right after the latest well-publicized airplane crash.
Averaging/Norming and Prototyping (rather than summing up): people tend to judge that an intelligent, politically active woman is less likely to be a bank teller than “a bank teller and a feminist”; people rate themselves as less assertive after listing 12 times they were assertive than after listing 6 times they were assertive (the second 6 examples are harder to call to mind and less compelling than the first 6).
The Substitution Effect: we tend to substitute harder questions with ones with easier, more available answers. For example, when asked how someone might be to lead an organization, we might base our answer entirely on how likable and articulate we find him or her.
The Halo Effect: once we start liking someone, we tend to make various unfounded and self-reinforcing assumptions about positive traits we haven’t actually observed.
A Preference for Causal over Statistical Explanations: we tend to vastly underestimating the role of chance and ignore statistical phenomena like regression toward the mean.
Denominator Neglect/the Planning Fallacy: we fail to take into account all that can go wrong in executing a project, and neglect to ask what the statistical success rates of similar projects has been.
In general, the intuitive part of the brain seeks out consistency at the expense of recognizing unknowns and random elements, and tries to understand propositions, in Kahnemann’s words, “by making them true.” One particularly sinister result of this is that a message, unless immediately recognized as a lie, will have the same effect on the associative/intuitive brain regardless of its actual reliability.
Saturday, September 22, 2012
I've long been skeptical about whether the Common Core Standards, however well intentioned, can spur positive education reform. As I argued earlier on the Core Knowledge blog, the vagueness of these standards leaves way too much room for interpretation:
Given the dominant Constructivist paradigm, there’s way too much room, in particular for a Constructivist interpretation and implementation of the Common Core standards, and, thereby, for even further Constructivist penetration of America’s K12 classrooms.An article in the latest Edweek on the common core English standards, for example, teems with Constructivist buzzwords: "inquiry;" "habits of mind;'" "cross-disciplinary." It also describes a hypothetical assignment, inspired by the core standards, that reeks of Constructivism's fuzzy open-endedness, "real life" relevance, personal connections, and interdisciplinary sprawl:
Students might be asked what it means to live in a globally interdependent world. They could be sent home with an assignment to examine the labels on their clothing and food and note their countries of origin. As a class, they can graph those nations and examine the emerging portrait of importers and exporters. Each student could dive into his or her country's place in that system and write about the perils and promises of that role. Then, imagining themselves as ambassadors at the United Nations, they would have to figure out what issues are most pressing for their country and how best to plead for funding.A look through the 66-page Common Core Standards for English, Language Arts and Literacy in History/Social Studies, Science, and Technical Subjects shows a couple of occurrences of cross/inter-disciplinary, a couple of occurrences of "inquiry" (though not in a particularly Constructivist sense), and no occurences of "habits of mind." There's certainly plenty of room for a Constructivist interpretation of the core standards, but there's also room for much more.
In particular, there's apparently room for a rather bizarre conclusion about what sorts of texts to assign, at least according to the Edweek article:
The common standards have prompted school librarians to "take a hard look" at their collections to weed out dated material and bolster challenging fiction and nonfiction resources, said the AASL's Ms. Ballard. In doing so, they are looking especially closely at the rigor of the readings they offer, since the standards emphasize assigning students "on-grade-level" texts, even if that means extra supports are needed to help them."Rigor," apparently, is defined entirely by the Lexile rating system:
Many 9th and 10th graders read Agatha Christie's mystery And Then There Were None, which Lexile rates as appropriate for 2nd and 3rd graders. Ms. Jaeger is encouraging teachers to consider instead The Curious Incident of the Dog in the Night-Time, about an autistic boy's attempt to solve a dog's murder. Instead of The Catcher in the Rye, which Lexile pegs to the 4th grade level, she suggests sophomores could read The Stone Diaries, which Lexile places at the 11th and 12th grades.But Lexile is not designed to be the sole basis for determining rigor. Lexile ratings are based on just two factors: word frequency and sentence length. From Lexile's own website:
Many other factors affect the relationship between a reader and a book, including its content, the age and interests of the reader, and the design of the actual book. The Lexile text measure is a good starting point in the book-selection process, with these other factors then being considered.Who in their right mind would think that "The Catcher in the Rye" should be read by fourth graders--let alone "The Sun Also Rises" and other works by that author so well-known for his simple sentences and vocabulary?
Second, where does Edweek get the idea that all students should be assigned "on-grade-level texts"? This idea--in the same spirit as Constructivism's half-baked "differentiated instruction" paradigm--is nowhere in the common core document. Nor is it a good way to teach the many students who are reading substantially below grade level. (Their schools' insistence that all students be taught on-grade-level texts was one of the biggest complaints of my TFA students).
Interestingly, crude word counting along the lines of Lexile rating seems to be the basis for some of this Constructivist exegesis of the Common Core Standards. For example, librarian Paige Jaeger, who proposed the clothing label/UN ambassadors' project above as a rigorous, "inquiry-based" project, was inspired in part by having counted:
more than 700 "power verbs" in the standards, such as "analyze," "integrate," and "formulate," that press students toward more rigor and inquiry-based learning.But true reading comprehension is much more than word counting, and before anyone can "analyze," "integrate," and "formulate," say, a document like the Common Core Standards, he or she must first be able to comprehend full sentences--however short, and however high the frequency of the words they contain. Given how deathly boring the Common Core Standards documents are, this is, however, a very tall order, and one that I myself have no intention of actually following.
Tuesday, September 18, 2012
Of all the warped messages I've heard emerging from Paul Tough's ubiquitously referenced new book, How Children Succeed, the worst one so far comes from this past week's This American Life. The hour-long show, normally divided up into distinct segments, devotes itself entirely to Tough's "findings" and what to do about them, with interviews with Tough and with James Heckman, the economist whose research informs some of Tough's conclusions.
Heckman, equating "cognitive skills" with IQ scores, argues that the latter are relatively stable throughout a person's life and therefore resistent to intervention. Schools, he says, should be focusing on "noncognitive skills," which are much more malleable. These include social skills, impulse control, resilience, optimism, and grit--all the things Tough talks about as being more important than "cognitive skills" in whether children succeed.
Heckman may be right--at least about some of these skills--and here the This American Life episode is quite interesting. There seems to be some evidence that problems with impulse control result from stressful home environments in which children don't form secure attachment with parents, and that impulse control can be improved, even in stressful home environments, if home visitors coach parents in how to "attach" to their children. A combination of early parental attachment and encouragement, and parental tolerance of children trying new things and sometimes failing at them, seems to encourage resilience. Positive stories about the ability of similar peers to overcome adversity and achieve success seems to encourage optimism.
My background in autism has me questioning the teachability of the most fundamental aspects of social skills, but social skills training conducted by trained social skills professionals (as opposed to K12 teachers) seems somewhat effective.
But what about grit? Nowhere do Heckman or Tough make any mention of how one teaches grit, and in the earlier interview I blogged about, Tough admits that the data here is lacking.
The bigger problem is the warped message I mentioned earlier, which is this: it's easier to teach non-cognitive skills than cognitive ones, so schools should mostly be focusing on the former. Schools, as suggested above, aren't the most appropriate venus for much of this "noncognitive skills" development. Furthermore, to most people, "cognitive skills" include much more than IQ scores, and much of this can improve, assuming effective learning environments. Here, schools are (for many children) the most appropriate venues. But unless they start carefully qualifying exactly what they are and are not saying, Tough and Heckman risk giving schools even more reason to continue abdicate their responsibility to provide such environments.
Sunday, September 16, 2012
Yet another breathless account of the wonders of computerized learning appears in this weekend's New York Times Magazine in an article entitled "The Machines are Taking Over: advances in computerized tutoring are testing the faith that human contact makes for better learning."
The article opens with a scene of an actual human being tutoring a fellow species member. While her tutee works on a problem (calculating average driving speed), the tutor provides lots of interactive feedback. Neil Heffernan, the tutor's fiance, catalogued the various different types of feedback she gave under such categories as “remind the student of steps they have already completed,” “encourage the student to generalize,” “challenge a correct answer if the tutor suspects guessing”). According the the article, Heffernan then "incorporated many of these tactics into a computerized tutor," which he spent nearly two decades refining. Now called ASSISTments, it is used by by more than 100,000 students "in schools all over the country." The article describes the experience of one of these 100,000 students with the program's interactive feedback:
Tyler breezed through the first part of his homework, but 10 questions in he hit a rough patch. “Write the equation in function form: 3x-y=5,” read the problem on the screen. Tyler worked the problem out in pencil first and then typed “5-3x” into the box. The response was instantaneous: “Sorry, wrong answer.” Tyler’s shoulders slumped. He tried again, his pencil scratching the paper. Another answer — “5/3x” — yielded another error message, but a third try, with “3x-5,” worked better. “Correct!” the computer proclaimed.In other words, it's the same old binary right-or-wrong feedback that nearly every educational software program has been using for decades. As the article notes:
In contrast to a human tutor, who has a nearly infinite number of potential responses to a student’s difficulties, the program is equipped with only a few. If a solution to a problem is typed incorrectly — say, with an extra space — the computer stubbornly returns the “Sorry, incorrect answer” message, though a human would recognize the answer as right.True, the program is still a work in progress. But what's being refined, according to the article, isn't the feedback. Rather, it's the program's ability to detect when a student is getting bored, frustrated, or confused (via facial expression reading software, speed and accuracy of responses, and special chairs with posture sensors "to tell whether students are leaning forward with interest or lolling back in boredom."):
Once the student’s feelings are identified, the thinking goes, the computerized tutor could adjust accordingly — giving the bored student more challenging questions or reviewing fundamentals with the student who is confused.Or "flashing messages of encouragement... or... calling up motivational videos recorded by the students’ teachers."
Also being refined is the "hint" feature, which users click on when stumped. Human beings (particularly teachers) track common wrong answers and have other human beings (particularly students) come up with helpful hints. These hints are then incorporated into the next generation of ASSISTments.
Cognitive Tutor, a more established software program that is "used by 600,000 students in 3,000 school districts around the country," also limits its feedback to hints and right-or-wrong responses. And it, too, is being refined based on data from human users:
Every keystroke a student makes — every hesitation, every hint requested, every wrong answer — can be analyzed for clues to how the mind learns.Ultimately, this data will be put to use not to refine feedback on particular student responses, but to help decide how to space out material and schedule periodic reviews.
But it's carefully tailored feedback on particular responses by particular students that makes human tutoring--the inspiration for all these programs--as powerful is it is.
In my earlier post on Cognitive Tutor, I wrote that programming sufficiently perspicuous feedback for mathematical problems "strikes me as even more prohibitive" than the feedback I labored for years to provide in my GrammarTrainer program. Last night I ran this impression past a mathematician friend of mine who cares a lot about effective math instruction. She emphatically concurs.
When it comes to educational software developers--as opposed to educational software users--there is some somewhat perspicuous feedback on whether their answers (answers to students' educational needs) are on track. As I write earlier, that feedback isn't particularly encouraging.
Thursday, September 13, 2012
I. From Investigation 3 of the "Describing the Shape of the Data" unit of the 4th grade TERC/Investigations Sudent Activity Book [click to enlarge]:
II. Exercise 3 of the "Data Analysis" unit of the 4th grade Singapore Math (Standards Edition) Primary Mathematics 4B workbook [click to enlarge]:
Tuesday, September 11, 2012
A recent parent survey reported on by Reuters finds that nearly half of teenagers with autism are bullied at school. Particularly affected are those mainstreamed into regular classrooms.
The study's authors suggest that schools need to target their anti-bullying campaigns more towards the AS population. Bullying researcher Debra J. Pepler adds that classes should create"circles of support," which, quoting Reuters, "are groups of children who are educated about a student's condition and able to provide help and support." Pepler also told Reuters that classrooms should set the expecation "that everyone has the right to be safe, and just because someone is different doesn't mean it's OK to make fun of them or bully them."
One remedy no one mentions is reducing the amount of time kids spent working in classroom groups.
Indeed, as I've argued here and in my book, no teacher, even the best multitasker, can supervise multiple groups simultaneously, and the more collective control kids have in the classroom, the more school yard dynamics creep in. (I say "collective control" to distinguish what I'm talking about from the sort of individualized control you'd get if you instead allowed independent, self-paced learning).
A friend of mine just told me about how her son's 2nd grade teacher invited the kids to vote on who would get which of several end-of-year-awards. My friend's son, an avid reader, was awarded the "bookworm" award. When his classmates made the negative connotations of "bookworm" clear to him, he felt so bad that he lost interest in reading for pleasure. It took his mother some effort to undo the damage of what to the teacher had probably seemed like a wonderful way to let students "take ownership" of their classroom.
Sunday, September 9, 2012
Though I haven't read it, I honestly don't get what the big deal is about Paul Tough's new book, How Children Succeed. From what I gather from various reviews and interviews, Tough's Big Idea is that persistence and curiosity matter more than IQ does for success. But was there ever a time or place when this statement wasn't obvious? Of course IQ means little if you don't apply yourself; of course intelligence leads nowhere interesting if you lack curiosity. Does anyone--especially in this Emotional Intelligence-obsessed world of ours--really think that the successful people out there--even the genuises--achieved what they did primarily because of their IQ scores? Didn't Malcolm Gladwell already write a book back in 2008 on the findings that what makes an expert is 10,0000 hours of practice? What is it about Tough's book that's garnering so much attention?
A slightly different take on Tough's Big Idea is voiced by Joe Nocera in yesterday's New York Times:
Tough argues that simply teaching math and reading--the so-called cognitive skills--isn't nearly enough, especially for children who have grown up enduring the stresses of poverty. In fact, it might not even be the most important thing.Notice how quickly Nocera slips from the obvious--that teaching teach math and reading isn't nearly enough--to the ridiculous. To say that learning to read and do math might not be the most important elements of success is like saying that adequate food and shelter might not be the most important elements of staying alive (after all one must also breathe oxygen). When it come to essential elements, it's pointless to quibble over what's most important.
In interviews Tough is careful to admit that, while schools need to do more to encourage persistence and curiosity, there are no clear studies on how to do this. Refreshing though this caveat is, it, too, raises the question of what this book has to offer that's new and plausible, or at least useful.
There is one disturbing answer to that last question. To the careless reader who approaches the book from the perspective of the dominant educational paradigm, it offers yet another reason to water down academics in favor of "the whole child." The connections between grit and academic rigor, and between curiosity and well-taught academic subjects, should be as obvious as inherent importance of grit is. Indeed, I'm guessing these connections are obvious to most people. But they clearly aren't obvious to many of those wielding the greatest power over whether or not our children succeed.
Friday, September 7, 2012
I. The first estimation/multiplication problem in the 4th grade Investigations Student Activity Book [click to enlarge]:
Wednesday, September 5, 2012
"Engineers solve problems."
After all these years of drive-by exposure to Critical Theory, Post Modernism, and the Poor Man's Post Modernism (aka Constructivism) that passes for Theory in certain education school departments, I found it wonderfully refreshing to hear this line ring through of the Dean of Engineering's speech at the freshman orientation my oldest son and I attended several weeks ago.
Engineers solve problems, hard problems, while all too many of their armchair counterparts in the humanities problematize (their term; not mine) simple pseudo-problems.
As college students wise up to the job market, and perhaps also to Post Modernism's ravaging of core knowledge in the humanities, more and more are choosing the problem solving route. Every other kid I know wants to be an engineer or computer scientist.
I view this as a great development, and I say this as someone whose major was in the humanities, and who has great respect for what the humanities can potentially offer even today's debt-burdened, job-prospect-impaired student. The big picture of how humanity got where it is now; a foundation for current events; insights (both cognitive and literary) into the human mind; enhancement of empathy with all types of people (real and fictional; local and at great remove); opportunities to engage with major ethical puzzlers--to name just a few things. And all of this in the typical humanities' course setting: small group discussions, where one learns to engage in a civil fashion with multiple view points and to fine tune and communicate back one's own. (Yes, for all my loathing of K12 group work, the college humanities seminar is something completely different, where all these good things actually do happen).
But given today's options, engineering is the best choice for many undergraduates--as more and more people are realizing.
Many, however, still tar engineering, and engineers, as (among other things) lacking in creativity. Doesn't engineering amount to simple rule-following and analytical reasoning: the rather straightforward application of math, physics, and chemistry to the world as we know it, as opposed to broadening this knowledge with novel discoveries and concepts?
Every so often, even in the popular press, an article comes along that debunks this. This Monday a wonderful example appeared in the Philadelphia Inquirer--one worth remembering the next time someone invokes the engineering stereotype. Here's the opener:
When a wet dog shakes himself dry, he does something amazing. He hits just the right rhythm to maximize the drying effect with minimal effort.
The seemingly casual jiggle imparts enough centrifugal force to expel 70 percent of the water in his coat in a fraction of a second.
This fact comes courtesy of experiments by David Hu, a professor of mechanical engineering and biology at Georgia Tech. He and his students found that the highly tuned drying ability is shared by 30 other furry mammals.
Hu thinks engineers can learn from some of the remarkable features that evolution has built into living things. He envisions harnessing this ability for devices that can dry or clean themselves, something like a Mars rover programmed to jiggle the dust off its solar panels.Hu's inspiration? "a toy poodle named Jerry, who was a gift to his current fiancee from her former boyfriend."
How's that for a problematization of the engineering stereotype?
Monday, September 3, 2012
I can't imagine what it would be like to be regularly dependent on state welfare agencies for securing basic needs. My one entanglement with a state welfare agency pertains to J's Medicaid benefits, an annual nuisance that involves enough Kafkaesque burden and potential menace to make me wish I could somehow pay someone enough money to opt out of the system entirely.
J needs Medicaid benefits for one reason: they pay for the one-to-one aide that makes it possible for him to attend regular public school classes. Currently in PA, such one-to-one aides (Therapeutic Support Staff, or tss) are funded primarily through Medicaid and not through the schools. And, so long as a child has a major disability, he or she automatically qualifies for Medicaid funding--independent of parent income, insurance, and other financial and familial circumstances. Nonetheless, the annual, one-size-fits-all, multi-page renewal form requires us to fill out detailed information about income, insurance, property, the birthdates and marital statuses of everyone in the family, etc., etc., and track down paystubs and other documentation. The whole process takes a couple of hours, and yet all that matters is J's unchanging diagnoses and his rights to a free and appropriate public education.
This year I completed the form several weeks early, back in June, and felt the annual lifting of weight from my shoulders as I handed the fat envelope to the postal clerk and walked back home from the Post Office. Two months later--last week--there appeared in our mail pile a notice from the county welfare agency stating that J no longer qualified for Medicaid. The reason: "Failure to turn in the renewal form."
It was now two weeks before the start of the school year. I was stuck. My complacency had grown over the years, and I hadn't used a return receipt or certified mail. I had no way to prove them wrong. And, of course, it went without saying that I was guilty until proven innocent.
Luckily the denial of services mailing included a mercifully short appeals form. I filled that out immediately, walked over to the P.O., and sent it by certified mail. I then tried to track down a new renewal form online, which took a while, and the form I found, though it was clearly marked as appropriate for PA Medicaid renewal, was even more extensive than the original. What with reading and rereading all the new fine print and filling out all the additional information--and tracking down all the backup documentation--and double and triple-checking all my entries, it took me about 3 hours to fill everything out. Not counting the time it took me to photocopy everything and return to the P.O. once again and sent it by certified mail.
In the course of all this I called up the county welfare office multiple times. What with cordless speaker phone technology, being on hold isn't nearly so bad as it used to be. You just have to tolerate the Musak and repeated recorded interruptions about your call being answered "in the order in which it was received," and remain "on call" for whenever a human being finally picks up. Because of that, phone queues are probably fuller than ever with people patiently waiting it out--beyond the capacity of the more dysfunctional agencies, as it turns out. So Things Bite Back. After a minute or two in a modern-day PA welfare office phone queue, an automatic recording comes on and tells you that they're experiencing "an unusual high call volume" right now, invites you to call up later, and disconnects the call.
This, of course, is a lot more likely to happen with "public" agencies--monopolistic and often under-funded. Imagine if there were multiple Medicaid renewal agencies all competing with one another for people's patronage. Then the last thing they'd do is misplace our forms and hang up on us when we called them.
But I'm afraid this is a fantasy up there with true school choice.
Meanwhile I can't help stressing out about worst case scenarios. What's to stop Them from continuing to lose forms? What's to stop Them from cutting off his benefits as soon as school starts?
J saw how upset I was and asked why. I explained what had happened. J, who'd rather not have a tss, and who's finally showing a few inklings of sympathy, tried to reassure me. "I can behave without a tss."; "I can focus without a tss."
"Can you avoid getting into fights with classmates?"
I think he can-almost. It sure is tempting to hope so. He's traveled a huge distance since he started school--largely thanks to ongoing tss support. But, mixing metaphors, we're on shaky ground here, and if the rug is yanked out too suddenly from under our feet, things could easily spiral out of control.
In my fantasy world, not only are there school choice and truly public welfare agencies, but also childhood disability insurance for expectant parents. No prospective parent knows what the future holds, and the future is often scary. Wouldn't it be nice if one could insure oneself at least against the financial costs having a disabled child?
Though it's too late for me, I grew curious after last week's debacle. I went online and searched for sites containing "childhood," "disability," "insurance," and "pregnancy." I visited site after site, and ultimately came up dry. It would seem that, at least for now, all of us disability parents--like disabled adults and others in challenging situations--are stuck with what our "public" agencies are able and willing to provide.
Saturday, September 1, 2012
In an earlier post, I compared modern classrooms to modern appliances--lots of high-tech bells and whistles; deteriorating basic machinery. Two New York Times opinion pieces about the medical establishment suggest a similar comparison.
First, in a recent Op-Ed piece, Gilbert Welch, a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice, and a co-author of “Overdiagnosed: Making People Sick in the Pursuit of Health,” writes about trendy treatments that sometimes backfire:
In 2002, a randomized trial showed that preventive hormone replacement caused more problems (more heart disease and breast cancer) than it solved (fewer hip fractures and colon cancer). Then, in 2009, trials showed that P.S.A. screening led to many unnecessary surgeries and had a dubious effect on prostate cancer deaths.And about the systematic failure to test the efficacy of novel treatments in general:
The problem goes far beyond these two. The truth is that for a large part of medical practice, we don’t know what works. But we pay for it anyway. Our annual per capita health care expenditure is now over $8,000. Many countries pay half that — and enjoy similar, often better, outcomes. Isn’t it time to learn which practices, in fact, improve our health, and which ones don’t?And about how the current profit flow in the Medical Industrial Complex (my term) favors novelty for the sake of novelty:
Medical research is dominated by research on the new: new tests, new treatments, new disorders and new fads. But above all, it’s about new markets.Next up, Tara Parker-Poper, in Tuesday Well Column, writes about an epidemic of testing and overtreatment:
But an epidemic of overtreatment — too many scans, too many blood tests, too many procedures — is costing the nation’s health care system at least $210 billion a year, according to the Institute of Medicine, and taking a human toll in pain, emotional suffering, severe complications and even death.She cites a woman who was given a CT scan for a black eye, a stroke victim whose multiple medications were making him hallucinate and show signs of dementia, and a premature baby who was subjected to "a battery of tests for symptoms that other doctors had dismissed as normal for her condition":
Recently, when doctors suggested an M.R.I. that would require that their daughter be anesthetized, Ms. Gullo and her partner, Katie Ingram, said they asked two key questions: “What new information will this give us?” and “Will it change what we are doing?” After talking to the doctor, they declined the M.R.I.“What new information will this give us?” and “Will it change what we are doing?” These are questions that patients absolutely must ask, because too few doctors are. I'm reminded of autism research, where so much of the focus is on early identification of autism rather than effective interventions. And I'm reminded of the Educational Industrial Complex's obsession with testing for the sake of testing. What good is testing in the absence of effective follow-up procedures?
Of course, I'm also reminded of the tendency of the Educational Industrial Complex to view novel technology as the panacea for all its ills.
When it comes to technology and testing in the Medical Industrial Complex, Gilbert Welch recommends skepticism:
Mammograms are increasingly finding a microscopic abnormality called D.C.I.S., or ductal carcinoma in situ. Currently we treat it as if it were invasive breast cancer, with surgery, radiation and chemotherapy. Some doctors think this is necessary, others don’t. The question is relevant to more than 60,000 women each year. Don’t you think we should know the answer?
Or how about this one: How should we screen for colon cancer? The standard approach, fecal occult blood testing, is simple and cheap. But more and more Americans are opting for colonoscopy — over four million per year in Medicare alone. It’s neither simple nor cheap. In terms of the technology and personnel involved, it’s more like going to the operating room. (I know, I’ve had one.) Which is better? We don’t know.
We don’t need to find more things to spend money on; we need to figure out what’s being done now that is not working. That’s why we have to start directing more money toward evaluating standard practices — all the tests and treatments that doctors are already providing.
Here’s a simple idea to turn this around: devote 1 percent of health care expenditures to evaluating what the other 99 percent is buying. Distribute the research dollars to match the clinical dollars. Figure out what works and what doesn’t.Maybe we could do the same for education. (And do it right; i.e., not via the What Works Clearing House.)