How should parents make tough decisions about returning their kids to school this fall?

One of the most challenging and divisive decisions of the coronavirus pandemic is whether and how to reopen schools this fall.

We heard the same thing from a dozen nationally prominent psychologists, parenting experts and authors with whom we met by Zoom recently. One after another admitted that they, too, were unsure what they will do for their own children.

“We want our children to return to school for a variety of reasons, but safety is our top priority right now,” says Katie Hurley, a child and adolescent psychotherapist.

If experts aren’t sure what to do, how should parents decide?

In a new story in The Washington Post, co-written with the esteemed (and I would say beloved) parenting author Jessica Lahey, we summarize the data pro and con returning kids to school and provide a decision-making checklist to help parents make the right call for their own families.

The quick summary is that there is no one-size-fits-all answer, and parents and schools need to individualize decisions based on local epidemiology, family health issues, and how seriously schools take science-based prevention. Here’s a tweetorial.

What's the best way to incentivize immunizations?

Vaccination saves lives.

Yet, resistance to immunization has become entrenched in some sociodemographic strata. Wealthy, educated liberals who care about organic food and "natural" products among them. 

Under-immunization of school-aged children in turn has led to outbreaks of measles and other transmissible infections, and contributes to  thousands of preventable influenza deaths in children each year. 

It's not enough to tout the benefits of vaccines, and then stand back with syringe in hand. Potential vaccines want to know vaccines are safe, and hear misconceptions about the low risks of vaccines. A seminal article by my Dartmouth colleague Brendan Nyhan showed that trying to disabuse vaccine skeptics of their misconception too may fail. 

Many states and countries are piloting various incentive programs designed to enhance immunization rates without engaging in potentially polarizing debate. From making immunizations mandatory to attend school to linking welfare benefits to vaccine receipt and even straight up cash incentives, lots of experiments are happening. Some of them even work.

Check out this great article by Susan Scutti of CNN and its accompanying video. I was proud to be quoted in it.

Was a study about bias - biased?

Sexism is a major problem in the sciences, technology, engineering and medicine, and the first step to fix this problem is awareness.

Yet a new study suggests awareness is exactly what many men lack.

Moss-Racusin et al write in Psychology of Women Quarterly that among 423 respondents in an online forum about articles on sexism in STEM fields, men were more likely to suggest sexism isn't a problem even when confronted with clear evidence to the contrary.

Let that sink in a little.

Men sure are clueless, aren't they. Let's get out the cattle prods. 

BZZT!

Or... maybe not.

A closer reading of the study reveals the way it was conducted could lead to bias. Not bias in the sense of being sexist, but bias in the statistical sense of the word, i.e. that the authors' conclusions may be invalid.

Here's why.

It turns out the authors collected 831 responses from an online forum regarding articles on sexism in STEM fields. We don't know who responded, and how they might differ from those who didn't. Were non-sexist men less likely to opine, leaving the sexist trolls to put the dark side of their humanity on full display? Probably - but we just can't really know because the information is unavailable. 

That's not all. From out of those 831 responses, the authors analyzed data only from the 423 in which the respondent's sex could be inferred from their response. If the respondent said, "As a man, I am aggrieved that women are scientists but there is no evidence of sexism," then their rabidly sexist and clueless response was included in the study. If a man wrote, "Yay women in science - but they face sexism all the time" without indicating his sex, his more enlightened response was thrown out.

That's right: the authors did not systematically evaluate the major variable of interest - respondent sex - in an unbiased way. As a result their analyses were potentially biased to include people who mention their sex when writing about sexism. If, for instance, male sexists are more likely to mention that they are men, then the study conclusions are completely invalid. 

The authors do cop to some of the study limitations, but not this one. They write, regarding study limitations, that the study approach,

necessitated the usage of a non-random, self- selected sample of commenters. ... Commenters were limited to those who had access to the Internet, were sufficiently interested in bias in STEM to read an article on the topic, read one of our three selected articles, and decided to leave a comment. As such, although our sample may be representative of the focal underlying population of individuals who are interested in such issues, as well as read and comment on such articles, these commenters may not be representative of other groups.

True enough. As a man in STEM, I hope they aren't representative of me! 

But more centrally, can the authors really conclude they know how aware men (or even men online) are of sexism in STEM if they do not even know how many of the original 831 respondents are men? (Not to mention the full group of men who read the articles in question in the first place.) Similarly, how can they conclude that men are more likely to be skeptical of sexism in STEM fields if they cannot compare all men's responses to all women's responses.

Short answer: they can't. 

What is sad is that the authors are able to cite a bevy of other articles that DO suggest some men in STEM fields are sexist, and that some men deny that sexism exists. I don't doubt it: I've seen both, and wouldn't argue otherwise. 

Here's a random sampling of anonymized Twitter commentary about the findings:

Reading this I realize that stepping into this issue could leave me with egg on my face or something stinky on my shoe.

I would guess that the lived experience of these and other commentators - like mine, let me emphasize, wait, here are some emphases: like mine - supports the idea that some men in STEM disregard sexism even when it's staring them in the face.

With such preexisting beliefs - realities! - appear to be confirmed by a study like this one, it's easy to turn off our critical thinking skills and trot it out for the world to see. The risk of course is that the clear problems with study structure, platinum-plated as the authors' intentions surely are, come to light, the ensuing discussion can undermine the true message we were trying to convey. 

We should call out and fight sexism in STEM fields. It is pernicious, archaic and it must go. While fighting that noble fight - which we are winning by the way - we should not undermine the effort by basing conclusions on flawed data.

This blog was cross-posted at KevinMD.

How to Read Education Data without Jumping to Conclusions

Education has entered the era of Big Data. The Internet is teeming with stories touting the latest groundbreaking studies on the science of learning and pedagogy. Education journalists are in a race to report these findings as they search for the magic formula that will save America's schools. But while most of this research is methodologically solid, not all of it is ready for immediate deployment in the classroom.

To read the rest of my new article, written with the lovely and talented education writer Jessica Lahey, visit The Atlantic.

Bearing the weight of mistakes

I stopped breathing when the syringe filled with bubbles. The resident and I stood silently for a couple of breaths, watching the syringe fill with more pink bubbles each time the patient’s chest filled with air.

“Shit,” said the resident, taking the syringe from my hand. He withdrew the syringe from the vein, and applied pressure with a gloved hand. I watched, my own carotid pulsing at my chin.

A STAT chest x-ray confirmed our worst fears...

To read more, visit my article in the Living Hand medical humanities section of the Journal of General Internal Medicine.

Changing the Water in Which We Swim

As the lights in the auditorium go down, just before I flick on my microphone, I remember what media critic Marshall McLuhan once said about culture: We live “in an electric information environment that is quite as imperceptible to us as water is to fish.”

As a leader of my institution’s curriculum redesign effort, I often speak with departments and even the whole faculty about our plans for the new curriculum. These experiences have made me acutely aware of how well McLuhan’s quote applies to what has been called the “hidden curriculum” in medical education. Medical education, and the culture of medicine in which it occurs, influence personal identity and perception so pervasively that it can be a challenge to talk clearly about how to change the hidden curriculum.

Read the rest of my blog at Health Affairs. It is a response to a very nice article by Liao et al in the January issue of that same journal.

Toward fewer demons

My New Year's resolution 2014: fewer demons.

There were a lot of demons in 2013. Some like Typhoon Haiyan were faceless, and not of our making. Most demons, though, were human, and their demonism was a false and human creation. 

2013 saw many people treated like demons: Ted Cruz, Barack Obama, Justine Sacco, Miley Cyrus, gays, the GOP, Paula Deen, Pope Francis. The list goes on*. I revere some of these demonized people, and others I don't. But inarguably these people and many others like them have fallen prey to our abbreviated, stereotyped, uncharitable understanding of the Other. The Other is, like us, flawed. Capable of great sin, even. But when we sit in judgment of them, dispassionately, unforgivingly, we commit a second sin of our own. 

My trip to the United States Holocaust Memorial Museum was a powerful reminder of how this kind of polarization and demonization can lead to evil. One large portion of the determination it took to build that institution came from one of my favorite Georgetown professors, Michael Berenbaum. Berenbaum was an inspirational teacher at Georgetown, and in between classes he flew frequently to Europe to collect artifacts for the Holocaust Memorial Museum. A student once asked Berenbaum how he accomplished so much. Berenbaum paused at the front of the class, silent for a moment with his tie torn in honor of his recently deceased father. He had bags under his eyes from a recent transatlantic flight. "You know how you doubt yourself?" he asked, "You spend time asking, 'Can I do this?' or saying to yourself, 'I'm not smart enough?'" He said he used the time most spend on self-doubt to accomplish a little more of his life mission. In his case that mission was to help avert future evil through the remembrance of the Shoah, but whatever your mission, that there is sound advice.

So: in 2014, I will debate the issues, perhaps even loudly, but I will try my best to be civil and respectful and not to make a demon out of anyone. This is especially important precept to follow amid strong disagreement. Along the way, as much as I can, I will keep my focus on achieving my mission and not on how great or poorly I am looking along the way. 

In a related vein, critic Frank Bruni had a timely message recently: Tweet less, read more. Bruni argues that in the Age of Twitter we are too apt to make snap judgments without letting the full complexity of the situation "steep" in the way it may when we take time to ponder. As we do when reading fiction. Amen, I say, amen! Hallelujah! 

Prohibitions like these - don't hate, don't fear - are good, but they don't fill me up. As a result, I will keep this photograph in mind as well. 

Taken from the Year in Pictures at The New York Times, this is an Afghan schoolgirl, reading. Considering how hard-won the freedom to read a few words of text can be in towns like hers, this powerful reminder of the preciousness of learning and education will be one guide for me through the challenges of 2014.

Gratitude, too, will guide me. I am grateful for the connections I made in 2014: my wonderful patients, an inspiring troupe of medical educators, our vibrant hospital ethics committee, and a motley cast of Twitter characters. I cannot imagine better company in 2014.

Happy New Year!

* PS Shortly after I posted this article, I was pained to see a crowd of science writers whom I respect sit in rather snarky judgment of another excellent writer (and my former editor), Bora Zivkovic.

Way back in 2013, Zivkovic had apologized (imperfectly) when accused of sexual harassment by more than one female science writer. As New Year's Day unfolded, Zivkovic's story looked like a hunk of red meat amid a pack of wolves. Much as it had in fall 2013.

There were many reasonable-sounding justifications for the public flogging: sexual harassment must be stomped out, Zivkovic appeared to want to make a fresh start without making enough apologies to satisfy everyone, this was a pattern that exemplifies the male power structure in science, etc etc.

What reasonable person would argue these points? What emerging science writer would dare raise his or her voice amid all that certainty, and blood? Such a person risks being lumped with perpetrators, surely.

Yet silence is not always golden. What was lost amid the din was the idea that there are more effective and more humane ways of rectifying such wrongs than a Twitter hanging. Some writers wrote they were done hearing from not only Zivkovic but a friend who supported him. "They're dead to me," that writer and her supporters seemed to say. Others, most of them not at least publicly victims of the behavior of which Zivkovic is accused, critiqued whether his apology felt ... apologetic enough.

For all involved, I hope this private problem can have a private fix. I just don't see how this public excoriation helps anybody. Certainly decrying sexual harassment in public can do good: it may well discourage other perpetrators and help define what is and what is not harassment. This is the core story to which the public dialog should hew. But this public mastication and remastication of one man's sin went beyond PSA - it looked to me like bloodlust and distracted from the main story.

Instead, private apologies and a private plan for prevention seem the way to salvage some good from this story. Most importantly, any victims (identified in public or not) should have the opportunity to hear an apology and some assurances that harassment will not recur. I get the sense from Zivkovic's writing that he is willing to make such amends and hope this indeed occurs at least to some degree of satisfaction of those he harmed.

What should the rest of us do with our typing fingers while such things occur in private? Get a PSA out there, for sure. Learn. Listen. Consider if we could commit that same sin and how we might avoid it. Most of this can occur with mouths shut and fingers still. (See Bruni, above.) And then: we move forward. 

When identifying a sin such as Zivkovic's, it is too easy to think of him as equivalent to and nothing more than the sin itself. Without considering the full scope of his humanity and his personhood, we essentially commit a second sin. It's an easy sin - we make a joke, we pass judgment, we block a Twitter account. No one of these acts is a major problem. But I worry about a society build on such a foundation.

Some would say such protestations enable the original sin itself. That whatever is done in the defense of those wronged women is fair game. This is the game of empowered white men, goes the screed. They should be quiet and take their licks. It is the turn of the downtrodden to rise up and take the stage.

I disagree. Unless we are simply trading bad power for bad power, we who think of ourselves as good should be able to think with nuance, and to hold two ideas in our heads at once. A sinner can be wronged. A victim can do wrong. (Not to imply this has occurred; I'm saying we should be able to think in more than black and white.) It'd be great if the world were divided into good and evil but the truth is most of us fall somewhere in between. Sinners and pundits look quite a lot alike, it turns out. Perhaps it is the similarity that motivates the pundits to make a starker distinction than really exists? Or perhaps we forget our own troubles for a while when we decry someone else's?

I can only hope the virtual community erected on Twitter and on blogs can learn from the mistakes made in the corporeal society that preceded it. Yes, there are invidious power structures here and we should fight them. We too need justice. But, a system of justice build on vengeance and demonization will ultimately be the downfall of all our lofty ideals. We aren't being soft on crime - we are trying not to compound the original crime with a new one.

The way forward? The original victims should expect reparation. Absolutely. But those looking on from their typewriters, from their comfortable seats at the edge of the town square, should behave as gently and as humanely in their responses to this sinner - this man - as they would hope to be treated when they too walk out into the middle of the square with their sin in full view. We all have our day. What kind of people are we? Are we vengeful, or are we just? 

The Design of a Medical School Social Justice Curriculum

Well over 100 years have passed since Virchow wrote that “physicians are the natural attorneys of the poor, and social problems fall to a large extent within their jurisdiction.” Since that time, the world’s population has septupled, and billions of people are “trapped in the health conditions of” his era.

As a result, many medical students in the 21st century want to work to decrease health disparities, and increasing numbers of medical graduates indicate they intend to work with people who are often underserved. This groundswell of medical student interest in remedying health disparities joins urgent calls for the integration of specific social justice competencies into medical school curricula and aligns with new considerations and the ranking of the quality of institutions’ “social mission.”

Yet, how can medical students learn about global health and social justice without recapitulating the mistakes of their forebears? 

What skills do they need to be effective in social justice outreach abroad and at home? 

What are physician obligations toward "social justice" if any?

We take on these and additional questions in our new article in Academic Medicine, "The Design of a Medical School Social Justice Curriculum." 

Quoted @ MIND/Shift

Holly Korbey has a great new article about the death of lectures in which I was quoted. Okay, maybe not the death of lectures - but definitely their dethroning. 

Teachers are wrong to assume that their role is to only convey information, and that merely saying the magic words will translate into learning for students.

Click here to read Holly Korbey's "Anyone Still Listening? Educators Consider Killing the Lecture" @ MIND/shift

How Middle School Failures Lead to Medical School Success

At the end of a long day -- Jessica teaching middle school and Tim teaching medical students -- we settled into bed and began trading war stories.

We discovered we were both reading the same author, and that this linked middle school failures to success in medical school better than we could have predicted.

Click to read our full article at The Atlantic.