Computers and efficiency: Here's my middle digit!

The curriculum proposal process at my university is now paperless and all electronic.  We upload documents, which are then routed through the process and the personnel ... all in the name of efficiency.

Is it really more efficient?

When it was time for me to submit proposals, I ran into dead ends, one after another.  And every time I had to email two people, who then spent time fixing the problems.

Another colleague wrote to me about his experience:

I was just about to email you that any frustration in my last email isn't directed one bit towards you but rather to this new "more efficient" process. What used to take me five minutes of behind the scenes paperwork will now take 30 mins of emailing and portal submission, plus waiting on the CC to meet etc. And that's going to be true for every dang term going forward. You and I both like reading articles about automation and the future of work, and this new process reminds me that just because a computer process can be programmed doesn't mean it's an improvement.

As if I needed more evidence that "digital" does not always mean more efficient.  I am all set to extend my middle digit to those who claim otherwise ;)

At least my work is not about life and death, which is the case in healthcare.  Atul Gawande writes about this in "Why Doctors Hate Their Computers."

Something’s gone terribly wrong. Doctors are among the most technology-avid people in society; computerization has simplified tasks in many industries. Yet somehow we’ve reached a point where people in the medical profession actively, viscerally, volubly hate their computers.

Welcome to the club, Dr. Gawande!

Questions that doctors had routinely skipped now stopped them short, with “field required” alerts. A simple request might now involve filling out a detailed form that took away precious minutes of time with patients.

Doesn't this sound similar to the experiences I described about the curriculum process at my university?

Gawande talked to others, like Susan Sadoughi, who is a primary care physician.  What was her experience?

Early on, she recognized that technology could contribute to streamlining care. She joined a committee overseeing updates of a home-built electronic-medical-record system we used to rely on, helping to customize it for the needs of her fellow primary-care physicians. When she got word of the new system, she was optimistic. Not any longer. She feels that it has made things worse for her and her patients. Before, Sadoughi almost never had to bring tasks home to finish. Now she routinely spends an hour or more on the computer after her children have gone to bed.

Efficiency,my ass!

The software “has created this massive monster of incomprehensibility,” she said, her voice rising. Before she even sets eyes upon a patient, she is already squeezed for time. And at each step along the way the complexity mounts.
“Ordering a mammogram used to be one click,” she said. “Now I spend three extra clicks to put in a diagnosis. When I do a Pap smear, I have eleven clicks. It’s ‘Oh, who did it?’ Why not, by default, think that I did it?” She was almost shouting now. “I’m the one putting the order in. Why is it asking me what date, if the patient is in the office today? When do you think this actually happened? It is incredible!”

Seriously, how and why do people so fervently believe that digital means more efficient?

Gawande reviews the research on computers and productivity and writes that "one of the strongest predictors of burnout was how much time an individual spent tied up doing computer documentation."

This is awful!  And we let this happen!

We can retune and streamline our systems, but we won’t find a magical sweet spot between competing imperatives. We can only insure that people always have the ability to turn away from their screens and see each other, colleague to colleague, clinician to patient, face to face.

Face to face, yes.

Recently, I met with a student who was trying to get transfer credits for a course he had completed elsewhere.  I told him to meet with the person in-charge.  "Email to set up the appointment, but discuss the issue in person," I advised.  He did.

Wishing for the Day “The Machine Stops”

Forrest Gump got it wrong.  It is not life that is like a box of chocolates where you never know what you gonna get.  A box of chocolates always makes it clear what kind of chocolates have been packed inside.  There is no surprise whatsoever.  It is, instead, in reading that we never know what we gonna get, which is a big reason why reading becomes so rewarding.  Of course, reading while eating chocolates is heavenly ;)

So, there I was reading Atul Gawande's homage to Oliver Sacks in the New Yorker, of course.  Gawande is a medical specialist like Sacks was, and a writer like Sacks was.  Gawande writing about Sacks is, thus, to be expected like knowing you are going to taste milk chocolate if the box said it contained milk chocolates.

But, I did not know what Gawande's comments might include. And therein lies the beauty of reading.  In his essay, Gawande writes "Sacks had asked me whether I’d read Forster’s “The Machine Stops.”  I remembered a reference to this, but in a different context.  It was more than four years ago in an interview with Jaron Lanier, which I watched after reading a lengthy profile of him in the New Yorker.

Lanier is often described as “visionary,” a word that manages to convey both a capacity for mercurial insight and a lack of practical job skills. In the nineteen-eighties, he helped pioneer the field of virtual reality, and he is often credited with having coined the term. He has also dabbled in film. In 2001, he advised the writers of “Minority Report,” Steven Spielberg’s film about a dystopian future. Since 2006, he has worked as a consultant at Microsoft Research.
More recently, he has become the go-to pundit for people lamenting the social changes wrought by modern technology.

Lanier is a technology guru who worries about the dehumanizing effects of a rapidly evolving technology, and the profile essay highlighted our collective struggle on this issue:

[Part] of what Lanier finds most regrettable about Facebook—the way it mediates social contact—is precisely what makes it so appealing to most people. “We use technology this way all the time,” Andy van Dam, a professor of computer science at Brown University, notes. “To create a layer of insulation. We send an e-mail so we don’t have to call someone on the phone. Or we call someone so we don’t have to go over to their house.” Many of us also use technology, he might have added, when we’re too isolated: when someone wants to find a new friend just because he’s feeling alone—or because he’s living with his father in a freezing tent in the desert.

It was after reading that profile essay that I decided to watch an interview with Jaron Lanier, where he referred to Forster--the same reference that Sacks had made when talking with Gawande.  You se how reading makes life so fascinating?

Gawande ends his essay with a reference to Forster's "The Machine Stops":

It’s about a world in which individuals live isolated in cells, fearful of self-reliance and direct experience, dependent on plate screens, instant messages, and the ministrations of an all-competent Machine. Yet there is also a boy who, like Sacks, saw what was missing. The boy tells his mother, “The Machine is much, but it is not everything. I see something like you in this plate, but I do not see you. I hear something like you through this telephone, but I do not hear you. That is why I want you to come. Pay me a visit, so that we can meet face to face, and talk about the hopes that are in my mind.”

We live in a world that Forster wrote about back in 1909.  Screen time of all kinds.  Instant messages.  Tweets and Facebook status reports and blog posts like this all passing of as knowledge, just as Forster had feared.  We have replaced real human interactions with virtual ones.  So "satisfied" with the virtual interactions, and thinking that the virtual even eliminates the need for real interactions, we seem to believe that visiting with parents, children, friends, is not needed anymore.  We live in our own cells.

Through his writing and his own life Oliver Sacks reminded us all about us humans in the flesh, writes Gawande:

He was drawn to the homes of the sick, the institutions of the most frail and disabled, the company of the unusual and the “abnormal.” He wanted to see humanity in its many variants and to do so in his own, almost anachronistic way—face to face, over time, away from our burgeoning apparatus of computers and algorithms. And, through his writing, he showed us what he saw.

Like I said, you never know what you gonna get when you read.

Lessons from a rural hospital in Uttar Pradesh for Higher Education and MOOC in the US

MOOC is the latest of many four letter words.  Ok, it is not a word.  But, it has all the potential to become a cherished curse word.

As much as I am into using technology as much as I can--in my professional and personal worlds--and as much as I am disgusted with the pathetic outcomes delivered by the current higher education structure, I am far from supporting MOOC.

MOOC--“massive open online course"--delivers courses online to a gazillion students. Well, thousands of students.  Any rational person's first question would be this: "how can one instructor teach thousands of students at the same time?"  The answer is simple: there is no "teaching" involved.

Step back for a second.  Think about a C-Span book discussion program. Or a PBS Nova piece on string theory.  I can watch them at home. I can learn from them.  And I do. This C-Span or Nova program simultaneously goes out to hundreds of thousands of viewers.   (Ok, that is an exaggeration. Maybe ten other people watch the C-Span discussions with me!)  Both these programs have immense learning materials, and provide phenomenal education.  Right?

So, does it mean that we can use these as formal higher-educational materials?  Yes, we certainly can.  But, will that work for the typical undergraduate student?  Now, that is a different question, wouldn't you think so?

The PBS Nova or C-Span examples work as educational materials for me because by now I have learnt how to learn.  It has taken me years of formal schooling to figure out how to listen to a lecture, or watch a program, and think through it.  Learning how to learn might be intuitive for some, but I think that "some" is a minuscule number.  The rest of us need a structured way to learn how to learn.

MOOC is not about that deeper sense of learning. Not even close.  What a typical MOOC class is nothing but:

What you can do over the Internet this way is deliver information, but that's not education. Education, as any real teacher will tell you, involves more than just transmitting facts. It means teaching students what to do with those facts, as well as the skills they need to go out and learn new information themselves.

How do they know whether or not MOOC helps students learn?  How are students assessed?

the most common way to assess learning in the MOOCs offered by the largest providers is a single multiple-choice question after approximately five-minute chunks of pre-taped lectures. 

The reason why MOOC appeals to people, in addition to the obvious labor-saving cost advantages, is that most faculty's classes even now are nothing but the same MOOC in the real world.  I.e., students go to classes, listen to the faculty lecture on and on, and then they take multiple-choice tests.  If that is how it is in the real world even now, then why not get rid of that and replace it with MOOC, right?

The problem lies with what faculty do in the classrooms.  It is not a place to lecture and put students to sleep.  It is not a place to conduct multiple-choice tests.  Classrooms ought to be the places where students come to learn. More importantly, classrooms are places where students come to learn not merely about the contents of courses but also to learn how to learn.

However, over the years, faculty have, by and large, abandoned the task of helping students learn in that larger sense, and have merely focused on simplistic measurements via multiple-choice tests. Faculty have abandoned the Socratic questioning and discussing, and have favored the sage-on-the-stage lecturing.  And lecturing from the same notes. Using texts written by somebody else.  One can, therefore, easily see why people want to throw this out and replace with MOOC that would save a whole lot of money.

MOOC will do a typical undergrad worse service than even the horrible system we now have in place.   A C-Span or PBS program is not what a typical undergrad student watches.  A MOOC would do no better for this demographic.

In the New Yorker,  Atul Gawande discusses how some ideas seem to catch on really fast, while others are not adopted.  His article, which is about medical practices, especially in the primary health centers in rural India, has some important lessons for this MOOC discussion too.

Sister Seema Yadav, a twenty-four-year-old, round-faced nurse three years out of school, was one of the trainers. (Nurses are called “sisters” in India, a carryover from the British usage.) Her first assignment was to follow a thirty-year-old nurse with vastly more experience than she had. Watching the nurse take a woman through labor and delivery, she saw how little of the training had been absorbed. The room had not been disinfected; blood from a previous birth remained in a bucket. When the woman came in—moaning, contractions speeding up—the nurse didn’t check her vital signs. She didn’t wash her hands. She prepared no emergency supplies. After delivery, she checked the newborn’s temperature with her hand, not a thermometer. Instead of warming the baby against the mother’s skin, she handed the newborn to the relatives.
When Sister Seema pointed out the discrepancy between the teaching and the practice, the nurse was put out. She gave many reasons that steps were missed—there was no time, they were swamped with deliveries, there was seldom a thermometer at hand, the cleaners never did their job. Sister Seema—a cheerful, bubbly, fast talker—took her to the cleaner on duty and together they explained why cleaning the rooms between deliveries was so important. They went to the medical officer in charge and asked for a thermometer to be supplied. At her second and third visits, disinfection seemed more consistent. A thermometer had been found in a storage closet. But the nurse still hadn’t changed much of her own routine.

You see how difficult it is to make sure that learning happens?  And that the lessons learnt will be practiced?  Despite the hand-holding teaching by a qualified teacher?  All those practices--from washing hands to noting the temperature to everything else--can be instructed via a video, right?  Make those rural hospital staff watch the videos and problem solved?  It does not happen that way.

In the era of the iPhone, Facebook, and Twitter, we’ve become enamored of ideas that spread as effortlessly as ether. We want frictionless, “turnkey” solutions to the major difficulties of the world—hunger, disease, poverty. We prefer instructional videos to teachers, drones to troops, incentives to institutions. People and institutions can feel messy and anachronistic. They introduce, as the engineers put it, uncontrolled variability.
But technology and incentive programs are not enough. “Diffusion is essentially a social process through which people talking to people spread an innovation,” wrote Everett Rogers, the great scholar of how new ideas are communicated and spread. Mass media can introduce a new idea to people. But, Rogers showed, people follow the lead of other people they know and trust when they decide whether to take it up. Every change requires effort, and the decision to make that effort is a social process.

Learning is a complex process that requires us to change our thinking and behavior in so many different ways.  Whether it is learning about the diverse cultural practices in Papua New Guinea or the Big Bang Theory or about hand-washing and germs, learning requires us to shed what might have previously been our gut-instincts and routines.  We humans are, naturally, resistant to changes.  Learning forces us to change.  Very rarely does that not require change agents.  MOOC is no active change agent.

We are approaching the challenge in education from a messed-up perspective.  The challenge is to figure out how to make the faculty change their practices in the classroom, similar to how the thirty-year old nurse in the rural hospital was taught to change her practices.  Otherwise, whether it is the current system or MOOC, the patients--students--will not benefit.

From curmudgeon to cowboys and commencement

The best lines I read today are from this rather polemic op-ed by the curmudgeonly Harvey Mansfield:

A graduate student in sociology is one who didn't get his fill of jargonized wishful thinking as an undergraduate. Such a person will never fail to disappoint you. But sociology has close competitors in other social sciences (including mine, political science) and in the humanities.

With all his writing on manliness and gripes about a feminized culture, Mansfield does come across at times, if not all the time, as an academic cowboy of sorts.  Atul Gawande uses the same cowboy metaphor, but in a completely different way in his commencement address to the graduating class of Harvard's medical students.  Even if I were not the Gawande fan that I am, well, it is a kind of commencement address that makes a lot of sense.  Speaking about the changes in the medical profession over the last couple of generations, and the spiraling cost of healthcare, Gawande notes that "We train, hire, and pay doctors to be cowboys. But it’s pit crews people need."

The metaphor is easy to grasp--we have seen how fast and efficient the pit crew people work, and work as a team.  We imagine the cowboy to be a lonely horseback rider herding cattle.  And then Gawande concludes with this:

Recently, you might be interested to know, I met an actual cowboy. He described to me how cowboys do their job today, herding thousands of cattle. They have tightly organized teams, with everyone assigned specific positions and communicating with each other constantly. They have protocols and checklists for bad weather, emergencies, the inoculations they must dispense. Even the cowboys, it turns out, function like pit crews now. It may be time for us to join them.

To some extent, the old-fashioned academe too used to function like pit crews more than as cowboys.  But, the rapid and over-specialization of academics even at teaching universities like mine has transformed faculty into pedantic cowboys, I suppose.

“Is she dying?”

When I spotted Atul Gawande's name in the New Yorker, my first thought was nothing to do with the content of the essay, and instead it was "where does this guy manage time for such writing?"  A surgeon, not at some back-of-beyond place, but in Boston--at Harvard's outfit--and the guy has such fascinating and easy-to-read in-depth pieces.  Awesome!  And not simply because of his Indian heritage :)

This one, too, is about healthcare--about hospice care.  The title of this post is one of the question's the sisters of one of his patients apparently asked him.  What was the patient's condition?

The septic shock had left her with heart and respiratory failure as well as dry gangrene of her foot, which would have to be amputated. She had a large, open abdominal wound with leaking bowel contents, which would require twice-a-day cleaning and dressing for weeks in order to heal. She would not be able to eat. She would need a tracheotomy. Her kidneys were gone, and she would have to spend three days a week on a dialysis machine for the rest of her life.

So, back to the question, "Is she dying?”

I didn’t know how to answer the question. I wasn’t even sure what the word “dying” meant anymore.

It used to be a simple question when I was young!

For that matter, less than a decade ago, when one of my favorite uncles was diagnosed with an advanced case of cancer, the oncologists at India's leading hospital advised the family to take him home.  They may not have uttered the "d" word, but the message was clear.

But, things have changed now; Gawande writes:

medical science has rendered obsolete centuries of experience, tradition, and language about our mortality, and created a new difficulty for mankind: how to die.

Perhaps I am in the minority who have pondered way too much about our own death.  Even by the time I turned 30, I had given explicit instructions to my (then) family on what they ought to do if I developed serious health complications.  If I were to die today, I am confident that it will be in peace.  But then this is the view when I am healthy when the end of life does not seem to be that near.  But, what if tomorrow I am told I have probably about six months left; would that change my perspective?  I hope not.  Because, of what Gawande writes here:

Two-thirds of the terminal-cancer patients in the Coping with Cancer study reported having had no discussion with their doctors about their goals for end-of-life care, despite being, on average, just four months from death. But the third who did were far less likely to undergo cardiopulmonary resuscitation or be put on a ventilator or end up in an intensive-care unit. Two-thirds enrolled in hospice. These patients suffered less, were physically more capable, and were better able, for a longer period, to interact with others. Moreover, six months after the patients died their family members were much less likely to experience persistent major depression. In other words, people who had substantive discussions with their doctor about their end-of-life preferences were far more likely to die at peace and in control of their situation, and to spare their family anguish.

Can mere discussions really do so much?

Yes.

But, when I reached the end of the essay, I choked up and became emotional.  Pain, suffering, and death are simply awful.

It is amazing that even when we are fully aware of the very short lives we have, we manage to make life unpleasant for others.  I don't have to wonder what Kafka might say; he did address it in a very short story titled "The Next Village."

The following poem by John Updike, might be a an appropriate ending to this lengthy post on death.

Requiem

It came to me the other day:

Were I to die, no one would say,

"Oh, what a shame! So young, so full

Of promise — depths unplumbable!"

Instead, a shrug and tearless eyes

Will greet my overdue demise;

The wide response will be, I know,

"I thought he died a while ago."

For life's a shabby subterfuge,

And death is real, and dark, and huge.

The shock of it will register

Nowhere but where it will occur.