The rise in mental health problems - and other measured diseases

Over on Club Troppo, The Mental Health puzzle, part III: the cultural hypothesis continues Paul Frijter's examination of the puzzle of the measured increase in in mental health problems (depression, anxiety, and obesity in particular) across the Western world since the 1950s and in Anglo-Saxon countries in particular. In looking at this, Paul explicitly took it as a given that that this was a real increase and not just a measurement issue.

Now I have only just come across the series (I missed the earlier posts), so have nor properly absorbed Paul's arguments. However, the discussions links to some things that I have been thinking about that I just wanted to jot down.

The rise in measured diseases is not limited to mental health. My impression is that we are looking at a pattern that is broader than that. I suppose that the two that have most puzzled me are the apparent rise in asthma and in allergies of all sorts. If we take asthma as an example, I was in my early twenties before I met anyone with serious asthma. It wasn't talked about in a day to day sense. Now I see puffers everywhere and I have met multiple people suffering from what appears to be relatively severe asthma.

No doubt part of the answer lies in the increase in population. Where serious conditions are rare, the visible numbers and hence the commentary rise as the population rises. However, it would appear to be more than that. Here, and just looking at social things, I want to list three interacting things.

The first is the combination of reporting and measurement. Our capacity to collect data has risen sharply, as has the desire to report on different things. There is, I think, plenty of evidence to show that better reporting and data management systems leads to a rise in the number of recorded incidents and responses to those incidents.

The second is the professionalisation and especially the medicalisation within our community. All professionals look for problems that they can solve with their respective tool kits. They classify things in terms of their own taxonomies. You can see this in the mental health field, for example, where there has been a very large expansion in the things classified as "mental Illness" and therefore addressable via medical means. This is not helped by our own desire for answers.

The third can be classified as feed-back loops. As we become more aware of things, we apply them to ourselves. We seek help and advice on more things. This is reported. We become more aware. Its kind of a reverse placebo effect.

These three interacting things to my mind play a significant role in some of the trends that we see. If we really want to measure something like the of serious allergies, asthma or mental illness we have to be able to net these other trends out, and this can be hard.      

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Sunday Essay - the strange case of a wounded knee

One of the things that I have written about from time to time on this blog is the the way in which the combination of rules based approaches with concerns about legal liability and the avoidance of risk have led to increasingly crazy outcomes. I wrote about this a lot while the girls were at school, for then I saw it all the time.

Friday I got an annoyed email from a colleague that again illustrates the problems I refer to. With his approval, I repeat the story.This photo shows the wound in question. 

On Friday my colleague got a call from his son's school nurse saying the boy had an injury and that he should come to school to take the 10 year old to a doctor. The child's mother had been called too but was not available as she was in a business's meeting.

Very concerned my colleague got into a cab to home, then drove to the school to pick up his son. The child had a heavily bandaged knee, but could walk just fine, had next to no pain, and only a mild stinging feeling near the injured knee.

Upon arrival at the family doctor's clinic, the doctor unbandaged the  knee; there was now no bleeding (child said there had been "A lot before"). After checking the date of the last tetanus shot, the doctor passed the child to support staff, a nurse. With professionalism, nurse stuck on a bandage after a bit of wound cleaning.

A little more than $50 was paid by the father, about $30 will be reimbursed by Medicare. In addition, and this is my comment not the father's, my colleague lost four or five hours charge time in addition to taxi costs to get home. This brings the total cost to over $900. 

My colleague was cranky. To his mind, the case illustrated the deskilling of the school nurse  and her disempowerment by concerns about legal liability or unduly concerned parents. "Yet all this", he wrote, " people need professionals and social medicine payments just to put a bandaid on a bruise. Common sense has been lost and we need it back!"

He is right, of course. Now when I talk about these cases, the response I get from some parents and others is simply better to be safe than sorry. I shudder at this.

Nursing is a profession, as is medicine. This involves judgement calls. Sometimes those calls may be wrong. The school nurse did not feel that she had the power to make that call despite the minor nature of the wound. Apart from some minor first aid that could have been done by anyone, she passed the responsibility to the parent and the doctor.

Doctors, too, are disempowered. There were a number of times I took the girls to the doctor after a school incident only to be told  look, I think that she is okay. but to be on the safe side, you should take her to casualty for tests. In the end, it was easier just to go to casualty and spend the many hours there waiting to see the first available over-burdened doctor.

Am I wrong in thinking that all this is a bit crazy?

Sunday Essay – obesity, fads and the failure of specialisation

According to an article the Sydney Morning Herald (A big problem calls for children on scales) by Rachel Brown, school children should be put on the scales and measured every time they have a health check, because parents and doctors can no longer identify weight problems purely on sight.

According to the Wikipedia article on the epidemiology of obesity, the World Health Organisation formally recognised obesity as a global epidemic in 1997. Obesity is most pronounced in developed countries (as early as 1962, 45 per cent of adult Americans were reported to be overweight; 13 per cent obese), but is spreading. It is largely an urban problem, and has spread with urbanisation.

The concern with obesity and with weight has become an obsession that affects every aspect of life.

In public policy and political debate, we look to ban or at least control junk food. We debate controls over advertising looking to protect children. Our papers, magazines and TV screens are full of stories about weight and diet and of ads for magical cures. The Biggest Looser reality TV show gains major ratings.

These concerns affect all aspects of domestic life: conversations centre on diet and healthy life style; the daily routines of life are affected by the need to accommodate specific weight loss diets; family cooking becomes more difficult.

One striking thing about obesity if the way it has been defined as a medical problem. The Sydney Morning Herald article appeared in the health section of the paper and focused on medical responses. The WHO uses the word “epidemic” to describe the spread of obesity, a word with specific medical connotations. Doctors have become the new gurus and advisers to us as individuals and to Governments.

Frankly, I am sick of it.

No one doubts that more people are overweight. No one doubts that obesity can have adverse health affects. Yet obesity itself is not a medical condition as such, it is not a disease. There are cases where obesity does have physiological causes, where it can be classified as a medical condition because the causes properly fall in the field medicine and can be addressed though medicine. However, this is simply not true in most cases. A best, medicine may help delineate some of the causes, may help deal with some of the results.

In my professional writing, I have explored to some degree the way in which specialisation affects the way problems are defined and responded to.

In law, for example, lawyers automatically look at the legal aspects of issues. They give legal responses to problems that are not in fact legal at all. Something similar happens in medicine. The problem and suggested responses are forced into the professional’s mental frame.

To counter this, I have argued in part that we need to develop a general discipline of professional practice, one that applies across professions. I have suggested that one aspect of that should be the diagnostic, the proper identification of the problem to be addressed. This includes the proper identification of those aspects of the problem actually relevant to the professional in question.

The rise of “the professional” was one of the defining features of the last few decades of the twentieth century. We saw a proliferation of specialisation and specialists to the point that much of the work force now carries some professional claim. We also saw an explosion in of Government enforced credentialism to the point that nearly everything now requires some form of ticket; the role of experience and broad based skills has been devalued as a consequence.

In another part of my writing I have focused on the importance of multidisciplinary approaches, trying to explore just what was required to make these work. Central to this was the need to define common frames that would allow different professions to work together, to overcome that blindness created by training and professional practice.

I still regard this as important. However, I also think that it’s sad that interest in multidisciplinary working peaked in the 1990s. Then many of us thought that such working would be central to future work. The explosion in credentials and in professions has increased the need for multidisciplinary approaches, but also reduced real interest in and capacity to actually do real multidisciplinary work.

If we apply this analysis to the obesity issue, you will see that the proliferating “solutions” are dictated by the professional backgrounds of those involved, as well as the perceived need to control actions and symptoms through direct controls.

To my mind, there is remarkably little discussion that looks at obesity in a holistic way as one subset in a range of social issues. Without such discussion, fad and fancy will continue to rule.

Note to readers:

This brief Sunday Essay draws together some of the threads in Belshaw thought. I will add a few links later.

Dark arts at Macquarie University

I had no intention of posting again today, but I couldn't resist this one. I was thinking of of one my New England blogging colleagues when I wrote, Le Loup's A Woodrunner's Diary. His blog is full of strange arcane things connected with past life at a period, a sort of living history blog.

want to know which is best, a rifle or a smooth bore musket? L can tell you. Want to light a fire by striking sparks? Again, LL can tell you.

Anyway, yesterday Clare, youngest, went off to Macquarie University dressed in a toga. Today, she borrowed some money to buy kerosene for her fire sword!

Turns out it was Ancient History Week at Macquarie University.

Now as a sometimes curmudgeon who complains that universities were not what they were, I have to say that of all the Sydney universities Macquarie sometimes reminds me of a real university.

To my mind, universities are not just about getting through to that ticket, but a brief space in life to do new things, to experiment.

I think that this holds for all ages, not just the young. New England has always had a lot of mature age students. My experience with them has been the same.

If you look at the poster, you will see that one of the sponsors is the Macquarie Dark Ages Society MACDAS). Now we mustn't actually use that term any more, it's unfashionable. Still, it's not a bad name.

As part of the week, MACDAS put on some mediaeval battles. Anybody could join in but, sensibly, you had to do some basic training first.

Youngest, never averse to a battle of any type, happily joined in.

I think that Clare was a bit of a surprise to MACDAS. She has great upper body strength, is an actress and is used to wielding weapons of various types!

It's hard to believe that this is the girl who, on the best teacher and professional advice, had such bad coordination that she might not be able to complete the HSC without permission to use a computer, such bad coordination that she might struggle to complete normal schooling. Highly advanced in some areas, she registered as well below her age in others.

I am in danger of getting onto another of my hobby horses, that linked to professionalisation, medicalisation, the need to find problems to solve, the difficulties of dealing with kids who fall outside parameters defined as normal. 

Of course, some kids have problems that need professional help. Yet the reality is that most kids work their way through problems, that help often hinders because (among other things) it makes the kid focus on the perceived problem.

In Clare's case, she actually never saw the limitations. Sport and activity cleared the coordination problem. Her spelling is sometimes dreadful, so is mine, but she has also completed three books. Clare's only problems are nothing to do with those identified, but instead reflect focus and interest.         

Cognitive bias and the practice of law

This post is for Legal Eagle.

In a post at the start of May I wrote:

Staying with Club Troppo, Ken Parish's Rooting out Cognitive Bias 101seeks advice - a wisdom of crowds thing - on some seminars in jurisprudence seeking to correct perceptual bias. This led skepticlawyer to write a companion piece, Crowdsourcing bleg – getting lawyers to think creatively.

Now this must seem pretty dry stuff, and in some ways it is. However, bear with me for a moment.

One of the issues that I have been trying to think through is the reason why lawyers so often fail to address the real needs of their clients. This is directly related to cognitive bias installed during legal training, as well as the dynamics of the profession.

I decided to write a companion post, but found it almost impossible. Both Ken and SL address the issue from a macro level whereas my concern is very micro, professional failure in the handling of individual matters. I do want to write something on this, for I actually spend a lot of time on this blog trying to address cognitive bias, the way in which our mental frameworks affect our perceptions and judgements. However, it will have to wait.

Legal Eagle encouraged me to write my post. Normally I would put it on my Managing the Professional Services Firm blog, although my purely professional writing is suffering just at present. However, I decided to say something here because this blog has a wider audience.

In considering the brief remarks that follow, I think that it would be helpful to keep in mind that:

• Lawyers are trained to think in terms of law and legal responses.
• Legal agreements of all types are simply the legal wrapping placed around a transaction or arrangement. A fair bit of law is linked in one way or another to the interpretation of that wrapping. 
• Transactions generally fail not because of the legal wrapping, but because of failures in the transaction or arrangement.

Issues

In medicine, the first thing a doctor does is to undertake a diagnostic.

No doctor worth his professional salt would take what the patient says and simply prescribe based on that. Have a bad headache, here is a powerful pain killer. Yet this is what many lawyers actually do. Here's my transaction or arrangement. Please draw up a contract  or arrangement. Yes, client.

I accept that clients are their own worst enemy. I accept that we live in a just in time world in which clients have too little time to think and then issue skimpy email instructions expecting an instant response since its now at the top of their mind. Still, the reality is that lawyers are not trained in diagnostic techniques that force the client to define and test the detail of what they have in mind. Not the law, but the underlying transaction.

The case studies included in this post are all actual if disguised examples 

Case study. A Government agency was concerned about a GST issue. They went to a leading law firm seeking advice and a tax ruling. The law firm did not test the client's thinking, but simply accepted the instruction. The client did not fully understand what they were doing, nor the advice provided. Finally, the assignment was cancelled when the client realised that what they wanted could not work for practical policy reasons. The cost to the taxpayer was over $57,000. The failure was foreseeable.

Once the instructions have been issued, the legal document is drawn up. Most legal documents incorporate a series of standard clauses - definitions, remedies etc. For efficiency reasons, most law firms use templates and clause libraries to streamline the process. Nothing wrong with that, but!

Anybody who has seen a variety of legal agreements will agree that some of the clauses seem a little strange, even over-kill. This reflects the fact that the lawyer has not thought through properly the underlying purpose of the agreement. Play it safe and slot the past in.

During this drafting process, failures in the diagnostic increase costs. This leads to higher costs on both sides through a more extended drafting process. It also increases risk compounded by the mechanistic drafting process. 

Case study. The matter involved a joint commercialisation venture between a private company and a research institution to commercialise technology. The two parties had worked together well for some time. The challenge was express the new arrangement in a way that reflected agreed principles while terminating previous agreements.

The initial legal material supplied by the lawyer representing one party was unclear and missed several important steps. The new arrangements required intellectual property (IP) to be clearly specified. The other lawyer investigated and found problems in the definition of IP. When the lawyer tried to insist that the IP be properly specified, the impatient client terminated the assignment.

This case illustrates two very different issues.

The first is the failure of the supplying lawyer to properly identify the issues involved, relying to much on precedents with insufficient real analysis of the issues around which the agreement was to be wrapped. The second was the unwillingness of the client to take the time to supply proper information.

Impatient clients are a very real professional problem for lawyers. Clients feel that lawyers who try to insist on proper information are acting to inflate their bills. This can be hard to manage and requires people management skills, something that most professionals are not well trained in.

The problem of bill inflation and of cutting corners to get things done all links to charging patterns. The critical variables of time credited to a client, work in progress, the transmission of work in progress to client bills and the degree of time write-offs in the process are individually measured. This can make it hard to commit time that professionals believe is warranted when that time might have to be written off. 

in the case I was talking about, the final result may be okay so long as nobody else challenges the IP and the parties themselves do not fall out. In either case, the dance of litigation may begin.

Litigation is a chancy business because it favours the big, is often uncertain in legal terms and becomes a gladiatorial content that feeds egos. To a substantial degree, litigation is as much about non-legal tactics and strategy as it is about the law itself.

Effective litigation requires an understanding of client objectives and options especially when representing smaller clients, for these clients are at greater risk. Good lawyers have to make judgements that have nothing to do with law although they may take legal expression, everything to do with negotiating or forcing an acceptable outcome. Many lawyers just get locked into the gladiatorial contest or lack the skills to understand their client's real commercial position. Other lawyers and barristers become too locked into specific legal issues when the case itself actually has little to do with law as such.    

Discussion

This post is not an attack on the legal profession. I actually have  a very high opinion of lawyers as a whole. Rather, I have been setting a context focused on the practice of law.    

Both the teaching and practice of law are changing. Once the majority of those studying law whether as articled clerks or at university planned to go into private practice and were taught by those in practice. Today, the majority do not intend to go into private practice, nor are they taught by those in practice. This changes things.

If we look just at those going into practice, the way that they are taught does introduce perceptual bias. They are trained to think of the law as the law, not a means to an end. This is not new, but is deeply embedded.

Obviously, clients expect lawyers to have a knowledge of law, to be lawyers. That is a necessary precondition of practice, but it is not a sufficient condition. Lawyers are failing clients because they cannot stand outside the law and recognise and analyse other elements.

The solution? I do not have one. I can only indicate things that I consider to be important.

One thing is to focus on the discipline of professional practice, not just legal practice. Doctors do face similar problems to lawyers. Lawyers can learn from the concept of the diagnostic.

A second thing is to force lawyers to recognise the non-legal aspects of the work they do, forcing them to think outside the box while acquiring new skills.

This may sound abstract, so let me make it concrete.

I have been involved in the development of training on contracts and contract drafting. These are pretty important to the practice of law. We use case studies that require participants to actually analyse the business problems facing their clients and to relate suggested legal solutions directly to those business problems.

A small thing, but quite effective in forcing paradigm shifts.

Postscript

I woke up this morning still thinking about this post. Sad, I know!

All professions teach ways of thinking. One of the problems in multidisciplinary work, the reason why true multidisciplinary working is so difficult, lies not just in variations in fields of knowledge but also in patterns of thought. For that reason, some of the professional writing I have done has been concerned with ways of encouraging true multidisciplinary working.

In his original post that started this discussion, Ken Parish referred to the concepts of frames and framing. I first came across this concept a long time ago through the work of economist Kenneth Boulding on images, the term he used to describe the frameworks that we all use to simplify and interpret a complex world. In my writing on this blog I have used the term mental mudmaps.

At the time I first read Boulding I was back at UNE doing postgraduate research in history. I found the concept useful not just in thinking about the past, but also my own interpretation of the past. Take, as a simple example, the effects of speed of travel on the way we see the world around us. This really does affect the way we see the world.

A little later, I found Boulding's concept and the ideas I had developed based on the concept very helpful in developing new policy that required changes in thought. One problem today is that so much politics and policy actually plays to, reinforces, current frames.

Ken's focus in his post was on the possibility of introducing his students at CDU to problems of cognition and cognitive dissonance. He wrote:

I have in mind a couple of seminars that would explain the basics of each of these research approaches to cognitive biases or shortcomings.  We would also have students undertake versions of some of the surveys that led to these research findings.

However, what I’m also wondering is whether there are any well accepted practical techniques for diagnosing and correcting such cognitive biases in ourselves, other than the obvious but difficult one of attempting to adopt a skeptical stance in interrogating one’s own thought processes, especially when dealing with a question likely to arouse strong emotions?  And what useful indicators might exist to tell us when to engage in that sort of careful skeptical reflection about our own motives, assumptions and thought processes?  Heuristics and habit are unavoidable and useful behaviours.  None of us has the time or energy to reflect carefully and skeptically on every decision we make in our daily lives, and in most cases repeating behaviour that worked previously is both efficient and sensible.  Are there any reliable guides for picking when that might not be so?

I obviously come at the problem that Ken is trying to address in a different way. I think that you can make people aware of things like framing and the way it affects thought in a general sense. I think that you can use examples that will help people interpret the effects of frames or images, aiding them in understanding others.

To go from this to increased ability to critically monitor our own frames and preconceptions on an on-going basis is much more complex. I'm not sure that there is an answer to Ken's final question. I also wonder a little whether or not its the right question in the specific context Ken is talking about.

This is not a criticism. Ken was trying to articulate ideas. But its a big leap from increasing understanding in a general sense to individualising it. I suppose my feeling is that it would be best, and that was in a sense the purpose of this post, to link the concepts to the actual theory and practice of law.                

Cognitive bias & Australia's position in the world

In yesterday's post Blog performance & a blogging meander I referred to problems associated with perceptual or cognitive bias in the practice of law. Legal Eagle kindly commented:

Can't wait for your cognitive bias and lawyers post, Jim. One of my theories is that lawyers get too tied up in the arguments and the joy of the fight, and forget that they are there to do what is best for their clients... I saw it a few times when I used to work for a judge...

It will take me a little while to put that post together. I am sure that LE is right so far as court is concerned. But in many areas of law and especially commercial law, the core problem lies much earlier in the process, in the drafting of the original documents. Lawyers are trained in law and are there to provide legal advice and "solutions". I have put solutions in inverted commas for emphasis. This leads to the misapplication of law to what are in fact non-legal problems.

You see the same problem in public policy as well in the proliferation of legislation and regulation. However, I want to focus just on the processes involved in giving legal advice and then drafting legal documents.

Problems with Kiki dealt with a quite entertaining (entertaining for the audience) problem that arose for a Newcastle woman because her personalised number plates carried her nickname Kiki. The New South Wales Roads and Traffic Authority asked her to show cause why the plates should not be withdrawn because Kiki apparently means vagina in Tagalaog. Ramana has an old friend called Kiki and responded with  Language And Bureaucracy. Now in a comment on the post, cousin Jamie reports that they have a friend called Kiki whose mother named her after an 80s English television character called Kiki the Frog!

My post Tinkler rides to Newcastle's rescue - again began with the line "I have to say that it's helpful to have a local billionaire."

To those that have shall be given. That phrase encapsulates one of my concerns about the process of economic change.

I have written a fair bit on this blog about the University of New England because it's my university and deeply entwined with my family.

When UNE began, there were local businesses and families that had money and backed the place. It would not exist otherwise. Putting it in today dollar terms, you had a million here, four million there, a couple of hundred thousand top up to fill a gap. The problem for UNE is that the economic changes in the second half of the twentieth century effectively destroyed much of the local donor base. This puts UNE at a growing disadvantage as compared to, say, Sydney University.

Obviously I am concerned with UNE because it is my university, but it actually bears upon something that I have been writing about in regard to Australia's position in the world, the hollowing of the Australian economy.

Just as those in New England did not properly envisage the impact of changes over which they had no effective influence, so with Australia today. Market forces in a globalised economy may redistribute economic activity so as the maximise global gains, but one should make no assumptions about Australia's place in the process.

Australia today could well be like UNE in the past, about to have its economic underpinnings ripped out. This won't happen overnight. It took three decades to destroy the economic base from which UNE drew part of its strength. But it can happen.

I am now straying into territory that I have previously marked out for a new series of posts. Still, consider this.

In the 1980s, the NSW and Australian Governments began to talk about the role of Sydney as a global financial centre. The term global Sydney dates from this time. All sorts of reasons were advanced as to why this might happen: good telecoms, stable government, closeness to Asia.

Has it happened? To my mind, no. It is now hard to see Sydney as anything but a subsidiary centre.

This post is long enough. Part of the problem is actually cognitive bias created by Sydney's place as a big fish in a very small pond. That happened to UNE as well. But that's another story.  

Issues with spin

I spent my normal writing hours this morning tidying up my blog list. There are too many on the list, many of which have not been updated for some time. Given this, I decided today just to point to a few of the posts I noticed in passing.

A little while ago in The art of slow reading, Neil quoted a Guardian piece on the decline in our ability  to read and contemplate. The piece said in part:

Which all means that although, because of the internet, we have become very good at collecting a wide range of factual titbits, we are also gradually forgetting how to sit back, contemplate, and relate all these facts to each other.

I have to agree. It has always been the case that an on-line page needs to contain less content to be comprehensible than the equivalent printed page. However, it's not just the impact of on-line, but also and especially the rise of powerpoint. This has affected authors as much as readers.

I have noticed the change in part because I use writing as a way of extending my own understanding of ideas. People are less able to understand the nuances that are central to proper debate. They require things to be far more packaged.

In The Worm, Legal Eagle expresses her disillusionment with the current political process. As always, the post is well written.   I dealt with related issues in Gillard's a blowin in the wind.

Those brave enough to read this blog on a regular basis will know that I often focus and at length on the way things are done. I do so because of my experience not just as a former public servant, but also as a management consultant. You have to understand how things work if you are to make sensible suggestions for improvement.

The problem with things like spin and focus groups lies in the way they have inserted deep roots into the policy process. The rank top growth we can all see is really just that, the leaves of a much larger plant.

Following my Gillard post, my old friend and colleague Noric Dilanchian sent me an email linking to an earlier article he had written on spin.

Both Noric and I are framework people. Working together, we have developed a number of integrated structures designed to facilitate explanation of complex processes. Both of us have had to learn, however, that explanations of those structures have to be limited on a need to know basis.

Our private sector and increasingly public sector clients need stuff tailored to their immediate problems. That's fine, but what do you do when the client actually needs to understand the broader context if they are to get full value from the advice?

Let me use a legal example. Noric is an expert on contracts. His central theme in this area is that if the lawyer does not understand the business problem involved, then the resulting contract is likely to be ineffective. The starting problem is a business, not legal one. The contract then becomes the legal wrapping.

Lawyers aren't cheap. Their fees are very visible. Clients just want their contract and are reluctant to pay for the time required to properly understand the problem, even though this will save them money in the longer term.

This is not an academic argument. I saw a case a year or so back where the client failure to properly identify the business problem actually doubled the legal fees. We are not talking small change here. The extra cost was equivalent to the annual salaries of the client's staff involved.

I may seem to have come a long way from the question of spin, focus groups and the influence of public opinion. I have not.

In the case of spin, the community is the client, the pollies and their advisers the lawyers. Unless we as a community are prepared to invest the time to understand what is happening, then our responses will do no more than lop of a few of the ranker leaves. The costs will continue.     

Systemic failures in health and other services

On Monday in a post on the New England Australia blog, Tamworth GPs close their books, I spoke of some of the workforce problems created by our current approaches to training doctors. This drew a very well informed comment from Martina.

The comment follows. Please read it. My own response follows at the end. 

We have been doing some very intensive research into medical workforce issues in rural Victoria and I would agree with the comments. The specialisation of the medical workforce means that there are no pathways to 'general' medicine which is what rural communities need most.

Hospitals need salaried medical staff but where do they get them from especially if they cannot provide enough supervision to employ PGY1+2 doctors straight out of university? If they are not in a District of Workforce Shortage (and many smaller rural centres are not classified in this way) they cannot even employ overseas trained doctors who are working towards full registration.

If they employ doctors who have not got a Medicare Provider Number, they cannot access Medicare funding and have to finance the doctor's salary themselves - and thats not going to be an attractive salary.
And if they do employ salaried medical officers, what is their career pathway? They can't really get full registration unless they are vocationally registered - or working towards vocational registration. So there is no other pathway than a specialist pathway (even for GPs).

The decision to require GPs to jump through the numerous hoops required by other "specialities" means that nobody can become an independent medical practitioner in less than 12-14 years - if my calculations are correct. That means that the GP has lost the key attraction it once held - that it was an easier and quicker pathway to becoming an independent practitioner. Without that edge, why wouldn't you become an opthalmologist, anaesthetist or cardiologist and get some real money and a lot more prestige?

With increasing feminisation of the workforce, the decision to require doctors to 'specialise' in General Practice (an obvious oxymoron) is a great way to ensure that we have less GPs.... Many women want to have families and don't want to spend 14 years getting their professional qualification....

Why can't we have some kind of Diploma in Family Medicine which can be done in two years and with less associated costs?

Martina points to some very real problems, problems that have been known of for many years and yet have not been addressed. Nor are these problems limited to medicine. In our obsession with "quality", "standardisation" and "professionalisation" we are creating systems that no longer work. This may sound extreme, but bear with me for a moment.

Whatever the general arguments may be about the overall standard of medical services in this country, it really doesn't matter a damn if you don't have access to a GP at all or if the centralised out patient service is not easy to access because of distance.

Similar arguments apply to specialist medical services or even to basic obstetrics and to dentistry. We have developed a two tier system in which the best treatment is very good, but in which availability of basic services is less than it was fifty years ago.

We have known for twenty years that these problems were coming, yet the actions taken have at best been band-aid, at worst have simply compounded the problem.

Australia has a housing shortage, yet we build fewer houses than we did in the past. I think that this is true in absolute terms at least in NSW, but it is certainly true in relative terms. Just look at how many people we housed after the Second World War.

The size and standard of the houses we build is higher, but the number is less because of the rules and regulations associated with both subdivision and building. That's fine if you can afford to build or buy, small compensation if you cannot.

Fifty years ago, those on low incomes could access social housing with the later possibility of purchase. Now social housing is limited strictly to those in greatest need. We worry about the creation of affordable housing to try to meet the expanding gap between the diminishing numbers eligible for social housing and those who can afford to buy or rent in a private market whose costs have been regulation increased. 

Turning now to food.

As I understand the numbers, the cost of food has increased faster than the CPI. Indeed, as an average the CPI increase has been held down because the real cost of certain manufactured goods has declined, while the cost of essentials has increased. This explains why so many lower income families feel worse off. They are!

Fifty years ago, the average household had access to home gardens including, in a lot of cases, chooks for eggs and meat. This is less and less true today.

Education.  

As with health, the gap between the best and worst education has widened. Debates about the My School web site or about overall standards of education do not have a lot of resonance when your school cannot get basic teachers.

Fifty years ago, a primary school teacher was two year trained, a secondary teacher four year including a Diploma in Education. Most teachers did more formal training, but this was generally done after graduation. Training times have increased, while the scholarships that used to be available have gone.

I could outline similar arguments for many other professionals including nurses, accountants and lawyers. In law, for example, there are major shortages in many country areas.

I am not arguing in this post for any particular solution. I am saying that if systems don't work, you change them. This includes simplification, clarification, acceptance of variety and multiple pathways. As part of this, we have to deal with what I call professional bracket creep.

Take nurses as an example.

To accommodate the professionalisation of nursing including increased training times, we have actually had to create new occupational groups to do some of the work that nurses used to do. With increasing doctor shortages, there is an increasing need in some areas for nurses to do the work once reserved for doctors. This has led to conflict over things such as prescribing rights. Professional bracket creep leads to professional boundary wars

I don't necessarily have a problem with any of this beyond the fact that things are clearly not working very well for particular and growing groups of Australians. If existing systems don't work, let's change the system.

It may be that we have to give up on the illusion that all Australians can have access to the same type of services and instead focus on the minimum level of service that must be supplied to all. It may be that we have to do away with certain standards and instead just focus on ensuring supply. It may be that it is time to review all professional structures and instead introduce a more varied approach. 

Postscript:

Since writing this post, The Australian has carried a story on the next stage in the creation of national standards for teachers. I quote:

The standards, which are expected to be released for public consultation this week, are the first step in a planned uniform system of teacher accreditation and registration, which will also provide national accreditation and standards for teacher education courses in universities......

The four levels of expertise in the proposed national standards are graduate, proficient, highly accomplished and lead.

Beginners must meet "graduate" standard to be registered and "proficient" a year later to qualify for a permanent licence. "Highly accomplished" and "lead" are open to all experienced teachers but not mandatory.

"The standards . . . support the collective responsibility of the profession to ensure that those who teach have the essential knowledge and skills," the draft says.

"By publicly articulating what is required of teachers at each level, they support improved access to quality teaching for all Australian students."

Back in August 2008 in Problems with teacher accreditation I spoke of my reservations about NSW plans to introduce a standards based accreditation system. The proposed national approach mirrors the same four step approach.

The difficulty I have with the national scheme lies in the way it mixes together different things.

One is the desire to professionalise teaching, something supported by many in the teaching profession. This is linked in supporter's minds not so much with standards as with improving the prestige of teaching. There is also the hope that the approach will make it easier to reward better teachers with higher pay, thus retaining more teachers in the system. Present pay structures with quite high starting salaries but limited top salaries do lead to loss of teachers after the first few years in the profession.

The second thing is the application of standards based approaches. As I have said before, standards deal with what we can call fit for purpose, the capacity to do at a specified level. This is quite a different concept to the common idea of a standard as in some ways a mark of excellence.

Whether such approaches actually improve performance depends critically on the size of the gap between the standard or standards and existing performance. By implication, the idea that the new system will in fact raise standards means that the existing system must be failing in some way across the spectrum set by the four levels of expertise as specified in the proposed national system. It is not clear to me that this is in fact the case.

What the proposed system actually does is to superimpose a new work based qualifications framework on top of existing educational qualifications. The dynamic effects of this are a little unclear.

On the surface, teachers classified simply as proficient will be disadvantaged in job terms, creating an incentive to move to the next level. Depending on the degree of effort required to meet the formalities, some teachers may not bother. In other cases they may actually leave the system. It is quite possible that we may end up with greater teacher losses and with schools now streamed by the proportion of their staff in the two higher categories, something easily measurable for the purposes of the My School web site.

The impact on formal postgraduate study by teachers is also unclear. Traditionally, many teachers have gone on to do further university courses in their key subject areas. Time is limited. Depending on the exact form of the new standard and of the associated assessment criteria and processes, the new approach may encourage more formal study or, alternatively, substitute for that study.

Finally, the actual impact on entry to the profession is unclear.

Just at present, we have a shortage of teachers. There is anecdotal evidence, I base this just on conversations that I have had, that existing structures discourage entry by people with required subject knowledge but who lack teaching qualifications as such. We have outwards mobility, inwards immobility. Depending on the way the new system works in practice, it may simply act to create a new barrier to entry.

Of itself, none of this means that we should not introduce the new national approach. However, we do need to recognise that we are adding a new level to an already complex system whose exact effects are unclear.

What we can be reasonably certain of is that the new system will not achieve the overall stated outcome: supporting improved access to quality teaching for all Australian students. I have added the bold.      

Problems in attracting professionals to Australia's regions - a note

In Bush lawyers Legal Eagle reports on the problems involved in attracting young lawyers to practice in regional Australia. This problem is not unique to law, nor just to the professions. There are trades shortages as well.

I have been writing about this issue for a number of years. The effects are quite profound. It's not just the lost services that these people could provide, but the flow-on economic effects. If we could fill available jobs, then the income from those people would flow on to other parts of the regional communities, creating further new jobs.

The causes of this people problem are complex, involving structural and cultural issues. So far, responses to it have been spasmodic and ad-hoc. I doubt that this will change.

The problem is not unique to Australia. We can see similar problems in Canada or China. A key here lies in the nature of economic, social and political competition between major cities and their surrounding areas. To those that have shall be given.

Perhaps it's time to revisit and update some of my earlier analysis.

Problems with teacher accreditation

I started reading an article in the Sydney Morning Herald suggesting that teachers who met new professional standards would elevate themselves above their colleagues.

When I first read this I thought good thing, recognition for better teachers. Then I looked at the details and found myself reacting very badly - this is another professionalisation thing that really is independent of performance.

In this part of the post I am simply registering my concern. I will outline the reasons a little later.

Later

Before setting out my concerns, some factual information.

The process we are talking about is an accreditation process managed by the NSW Institute of Teachers. Accreditation simply means that some form of process has confirmed that your knowledge, skills and performance at a point meet a defined standard.

To this point there have been two standards - Graduate Teacher and Professional Competence. Two more are now being added - Professional Accomplishment and Professional Leadership - creating a standards' ladder. If you are interested, you can find details of the standards here.

If you look at the Australian debate about teaching you will see that it has centered on the attraction and retention of teachers on one side, the desire to improve teaching performance on the other. Central to this debate has been the need to create structures and opportunities that will reward and retain good teachers.

Accreditation based approaches of the type we are talking about have a different focus. They are concerned with professionalisation, the establishment of and recognition of benchmarks that those in the profession should meet.

I was a strong supporter of standards based approaches because I saw them as a device for establishing standards and then recognising performance against standards. In recent years I have become increasingly concerned at the way that they have led to creeping credentialism and to the creation of professional barriers independent of performance.

Most professionals learn their craft by doing. The best push the boundaries. The problem is that when you mandate formal standards you create a focus on the formal standard rather than performance. You cut out out those who want to try new things independent of the restrictions mandated by the standard. You also cut out those who may perform remarkably well, but who are not interested in complying with the professional consensus encapsulated in the standard.

I have had direct experience of this at a professional level.

Working as a consultant, a significant market was destroyed when the Federal Government was persuaded by a professional body to mandate their professional qualification as a pre-condition. The entry point then became the credential, not the competence to do the job.

This is my concern about the message in the Herald article. In broad terms, I have supported the Institute's desire to create standards that would enhance teaching's professional reputation. If those standards become the requirement rather than actual performance, then we may have a very real problem.

As a broader comment, the NSW Government's obsession with standards and measurement does not seem to have made NSW a model for good public management.

Why can't professionals sell?

One of my clients is a CBD law firm. Their professionals find marketing hard. The same thing holds with the professionals in my own Ndarala Group. They know that they have to get the work through the door, but find it hard to go and chase the necessary clients. Why is this so?

I think that part of the reason lies in the combination of personality and training. The professions attract people who can examine problems objectively. Our training reinforces this. But sales works on emotion, on the ability to explain to the prospective client why we can solve their problem. Our training in objectivity makes this hard.

But I also think that part of the problem lies in intellectual arrogance. We actually expect the client to understand why they should use our services simply because we are a professional. But why should they? It is our task to help them identify their needs, to give them the information to choose us.