Sunday, June 24, 2007

What I learned at Johns Hopkins last week



Well, I saw something completely unexpected yesterday.

I wasn't posting here for most of last week because on Friday I completed a course, "Social and Behavioral Aspects of Public Health", at Johns Hopkins School of Public Health. I thought it was a good course and covered many key ideas, although I did wish it had gone into them in a little more depth.


But, I am a finishing 3rd year student, (my last class! Hooray!). and most of the class had just started two weeks ago, so I could understand the need to not overwhelm people with new concepts. And that's what I thought was happening, but now I'm not so sure.

This is like those scenes in the movies where the music changes and everyone knows that the monster is approaching but our hero and heroine happily play on, oblivious.

During lectures, sometimes we would have a simple summary slide with content such as "Poverty is a carcinogen." We were supposed to evaluate that assertion, tease it apart, sort out what portions were true and how you could tell. This is part of a debate that's been raging for at least 400 years.

Many of these lectures were met with a startling silence by the students, who often had no questions at all. This surprised me as I thought there would at least be a heated discussion. Well, I thought, they're tired from working half the night on their classwork, or don't want to ask "dumb questions."

Still it was eerie to have the professor ask something and the room of 100 or so just sit there.

After the class, in the big blue shuttle to Baltimore - Washington BWI airport, I discovered something I wish I'd known the first day, as it would have totally changed my behavior.

I chanced to ride with another MPH student I recognized and asked her what she thought of the class we'd just had. I hit a nerve. She had thought the class was a total waste of time and money, and put up with it just because it was required. She thought, basically, that the lessons the class taught were stupid, wrong-headed, wrong, soft, politically-motivated, you name it, and she had already discarded all of her notes. She was just livid.

Wow. None of that had come out in class. And, obviously, "my mileage varied." I liked the course and I don't think I'm an easy sell. I'm used to executive education programs where "students", often CEO's of companies, wouldn't hesitate a second to challenge something they disagreed with.

Apparently I had fallen into the common trap of interpreting stony silence as agreement, or consent. In point of fact, it was total disagreement and scorn, suppressed by a need to just complete the required course, hold one's breath, and put up with all this "psycho-babble" for two weeks. (She didn't say "psycho-babble", but could have.)

So we had missed a tremendous teaching opportunity to get this debate and dispute out on the table and have at it. What a great opportunity to get our feet wet on what it means to assert that "A causes B", and how we "prove" things, and what level of skepticism is expected, and what the burden of proof is on someone asserting some new claim, and how to meet that burden, etc.

It would have been a perfect chance to show a snippet of Crime Scene Investigator's CSI TV show where CSI Head Gil Grissom could lecture us all on the need to suspend our suspicions and "let the data talk." We could have viewed a few cases where it was way too easy to believe that Mr. Jones obviously "did it" when, in fact, it was Miss Smith, in the Kitchen, with a lead pipe.

We could have talked about how civilized grown ups in the field disagree with each other's conclusions while remaining cordial and committed to careful ways to defend against being too gullible (a "type I error") or too skeptical (a "type II error").

But, at least for this one student, that chance was missed. She had interpreted this class as just one more of those annoying things in life where a person in authority states or does something stupid and the best thing to do is just shut up and pretend you agree. In fact, silent and sullen obedience is the expected and demanded and rewarded behavior.

I guess it was rewarded here too, because I think she "passed." Hmm.

Way too many years ago, before I had taught in trade school or taught MBA's, a book came out titled "Summerhill", I think. It described a school in England that I actually went to go visit because of the book. The school challenged the prevailing "infectious disease" notion that I can recall quite well:

Courses are something like the measles. They are something you "have", and then, since you've "had it" you don't need to "have it again."
Again, wow. I had thought that concept had died in the 60's. It seems to be resurgent. Or maybe it never left and I'm just finally looking up and noticing it.

Now, I'm the first to agree that I went into undergraduate Engineering at Cornell, after reading C.P. Snow's Two Cultures, because I just couldn't figure out how to deal with classes where the teacher would ask "What did Hemmingway mean when he said X?" and I had no idea what to say next after I offered an opinion and the teacher told me I was "wrong". What the heck? What's with that?

At least in Engineering, if you say something should work and someone else says "No, it shouldn't" you can just both happily go down to the lab machine-shop and build one and just see whether it flies or not. No one ever wastes time talking about the "true nature of causality."

We'd just happily compute what size resistor to put at this point in a circuit without losing sleep over what the meaning was of "resistance" and if we could actually be "certain" that changing the value would have the desired impact on the radio receiver actually working. If in doubt, put in a variable resistance potentiometer ("a pot") and turn the screw to change the value while watching the output on an oscilloscope, and when you got it where you wanted it, Bingo, pull out the "pot"and measure what resistance it was set to and solder a permanent resistor of that size into the circuit and go play volleyball. No big deal.

Maybe it's because I'm looking at social issues more than I used to, or maybe it's because society is changing, but that sort of way of gaining an answer to a question seems to be vanishing as the expected behavior of people.

Without some training and skill in the tools of Public Health, or other rigorous but often qualitative fields, we've reverted back to the Middle Ages where causality is either magical or determined by which "authority" one follows blindly.

Again, wow.

So, if I hold out my pencil and release it, and it falls to the ground, and I ask "Why does that happen?" I'm as likely to hear "God made it move" as "Gravity."

So, hmm. Is this an "either/or" question or an "and" question or what? Personally, I prefer to think that "gravity" made the pencil move, and allow that, if you like, you can add "... and God made gravity." At least with the "theory of gravity" I can write some equations, design equipment, know exactly how fast something will fall, plot trajectories, etc. It's a "theory with meat on the bones" that I can rely on to build stuff that works. I don't get much "predictive value" out of "God made it move."

But, I guess if you never had the math, and never did "get" introductory Physics, and the concept of "potential energy" baffled you, so the equations never gave you any insight or power, then it's pretty much equivalent to you to say "God made it move" or "magic made it move" or "gravity made it move." They're all invisible anyway, right?

I was busy raising children and missed the whole 80's and 90's trend towards cultural relativism applied to everything, including physical laws, so that "your idea of how gravity works is no better than anyone else's" and we should agree to let all three just get along - physics, magic, or God."

Besides, frankly, hey, when you get right down to it, I can't "see" gravity anyway. All I can "see" is the pencil. Your invisible force against my invisible force, it's a tie, right?

All of which gets me back to class. I guess we might need to add an introductory class that we never needed before, to socialize students to an accepted way of challenging assertions and assumptions and accepted ways of meeting the burden of proof without being blindly stubborn or gullible about it. We need to know when and how it's appropriate to raise our hand and say "How can you prove that?" in a neutral, polite, but insistent tone.

As about a zillion (technical term) of my previous posts discussed, a key requirement for a "high-reliability" culture is "mindfulness," which requires the ability and sensed-permission and sensed-expectation that you will surface questions you have, not submerge and suppress them.

If we can't have that discussion first, all the rest of this business with models and hypothesis testing and "p-values" and study design and statistical tests is, indeed, just magical rituals that you have to go through for some stupid legacy reason in order to get published. All this demand for "evidence-based" practice is just a waste of time, then. No wonder students are baffled by it.

Well, we all know the rule that "All Indians walk single-file .... at least the one I saw did."

So, I'm extrapolating to an entire entering class of students from observed puzzling behavior of stony silence and from one accidentally chosen student's opinion in a cab on the way to the airport. That suggests an underlying teaching opportunity that maybe I'm imagining or maybe is real.

How would we decide which it is?

I'm concerned that not a single student challenged the teachings and yet clearly, from this and other conversations, many others I checked with also disagreed -- in complete silence.

Again, wow. And these are all students with undergraduate degrees and at least two years work experience and decent GRE scores. Maybe a third of them are already Medical Doctors. (MD's)

What have we done? Can we trace this defect back upstream and find out where it's coming from? (You can click on this next image to zoom up to a readable scale).


And how can we undo it? And how could we measure our impact and know whether we had succeeded or not?

Those are good Public Health questions that deserve some time on the agenda. They're also major business problems that directly short-circuit techniques like "The Toyota Way" that I've discussed, that require that everyone should work with their eyes open and with permission, and even expectation, that they'll spot things that need to be changed and announce them.

An army of silent, obedient, sullen, blind robot lemmings is not a very solid basis on which to build a competitive economy or a good public health infrastructure that actually works, or an army that works, or anything that works, instead of one that everyone pretends works.

What have we done to our children?

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