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Teachers complain that primary education threatens to become a process of teaching to the test. They wince as the content of standardized tests increasingly drives their lesson plans, and the results of these tests define their accomplishments. We share their pain: Doctoring to the tests is every bit as dispiriting.<br>Some medical tests, like blood pressure checks, are cheap and simple. Some are pricier and more complicated, like mammograms or assays for various molecules in the blood that correlate with various diseases. We order them all at prescribed intervals, and if we happen to forget one, either by accident or design, electronic medical records nag us mercilessly until we capitulate. As in education, our test-ordering behavior. and our patients’ results increasingly define our achievements, and in the near future our remuneration is likely to follow. Still, like all test-based quality control systems, ours can be gamed. Our tests can also inflict unnecessary psychic damage, and occasional physical damage as well. Most distressing: Ordering tests, chasing down and interpreting results, and dealing with the endless cycle of repeat testing to confirm and clarify problems absorb pretty much all our time.<br>It is all in the name of good and equitable health care, a laudable goal. But if you reach age 50 and I cannot persuade you to undergo the colonoscopy or mammogram you really don’t want, am I a bad doctor？ If you reach age 85 and I persuade you to take enough medication to normalize your blood pressure, am I a good one？<br>I am not the only one who wonders. A cadre of test skeptics at Dartmouth Medical School specialize in critically examining our test-based approach to well adult care. If you are confused about mammography, colonoscopy or the PSA test for prostate cancer, these folks deserve much of the blame: They have repeatedly demonstrated that these tests and many others do not necessarily make healthy people any healthier, any more than standardized testing in grade school improves a child’s intellect. Dr. H. Gilbert Welch, a Vermont physician who is part of the Dartmouth group, has a new book that might serve as the test skeptic’s manifesto and bible. Its title, “Less Medicine, More Health,” sums up his trenchant, point-by-point critique of test-based health care and quality control.<br>In medicine, “true quality is extremely hard to measure,” Dr. Welch writes. “What is easy to measure is whether doctors do things.” Only doing things like ordering tests generates data. Deciding not to do things and let well enough alone generates nothing tangible, no numbers or dollar amounts to measure or track over time. Dr. Welch points out that doctors get to become doctors because they are good with tests, and know instinctively how to behave in a test-focused universe. Rate them by how many tests they order, and they will order in profusion, often more than the guidelines suggest. They will do fine on assessments of their quality, but patients may not do so well. Even perfectly safe tests that are incapable of doing their own damage may, given enough weight, trigger catastrophe.<br>Yes, little blood pressure cuff over there in the corner, that means you. The link between very high blood pressure and disease is incontrovertible, and the drugs used to control blood pressure are among the cheapest and safest around. Even so, as Dr. Welch pointed out in a recent conversation, systems that rate doctors by how well their patients’ blood pressure is managed are likely to invite trouble. Doctors rewarded for treating aggressively are likely to keep doing so even when the benefits begin to morph into harm. That appears to happen in older adults, at least in those who avoid the common complications of high blood pressure and continue on medication. One study found that nursing home residents taking two or more effective blood pressure drugs did remarkably badly, withdeath rates more than twice that of their peers. In another, dementia patients taking blood pressure medication with optimal results nonetheless deteriorated mentally considerably faster.<br>Yet no quality control system that I know of gives a doctor an approving pat on the head for taking a fragile older patient off meds. Not yet, at least. Someday, perhaps, not ordering and not prescribing will mark quality care as surely as ordering and prescribing do today. Children go to school to learn. Adults go to the doctor … why？ If they are sick, to get better, certainly. But for the average healthy, happy adult, let’s be honest: We really haven’t completely figured out why you are in the waiting room. And so we offer a luxuriant profusion of tests.
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Poverty, crime and education.<br>The paradox of the ghetto.THE poorest people in Leicester by a wide margin are the Somalis who live in the St Matthews housing estate. Refugees from civil war, who often passed through Sweden or the Netherlands before fetching up in the English Midlands, they endure peeling surroundings and appalling joblessness. At the last census the local unemployment rate was three times the national average. But Abdikayf Farah, who runs a local charity, is oddly upbeat. Just look at the children, he says.<br>Close to Mr Farah&39;s office is Taylor Road Primary School—which, it turns out, trumps almost every school in Leicester in standardized tests. Its headmaster, Chris Hassall, credits the Somali immigrants, who insist that their children turn up for extra lessons at weekends and harry him when they seem to fall behind. Education is their ticket out of poverty. Poor district, wonderful school, well-ordered children: in Britain, the combination is not as unusual as one might suppose.<br>Britain has prized the ideal of economically mixed neighbourhoods since the 19th century. Poverty and disadvantage are intensified when poor people cluster, runs the argument; conversely, the rich are unfairly helped when they are surrounded by other rich people. Social mixing ought to help the poor. It sounds self-evident—and colors planning regulations that ensure much social and affordable housing is dotted among more expensive private homes. Yet “there is absolutely no serious evidence to support this,” says Paul Cheshire, a professor of economic geography at the London School of Economics (LSE).<br>And there is new evidence to suggest it is wrong. Researchers at Duke University in America followed over 1,600 children from age five to age 12 in England and Wales. They found that poor boys living in largely well-to-do neighbourhoods were the most likely to engage in anti-social behavior, from lying and swearing to such petty misdemeanors as fighting, shoplifting and vandalism, according to a commonly used measure of problem behavior. Misbehavior. starts very young (see chart 1) and intensifies as they grow older. Poor boys in the poorest neighbourhoods were the least likely to run into trouble. For rich kids, the opposite is true: those living in poor areas are more likely to misbehave.<br>The researchers suggest several reasons for this. Poorer areas are often heavily policed, deterring would-be miscreants; it may be that people in wealthy places are less likely to spot misbehavior, too. Living alongside the rich may also make the poor more keenly aware of their own deprivation, suggests Tim Newburn, a criminologist who is also at the LSE. That, in turn, increases the feelings of alienation that are associated with anti-social conduct and criminalbehavior.<br>Research on England&39;s schools turns up a slightly different pattern. Children entitled to free school meals—a proxy for poverty—do best in schools containing very few other poor children, perhaps because teachers can give them plenty of attention. But, revealingly, poor children alsofare unusually well in schools where there are a huge number of other poor children. That may be because schools have no choice but to focus on them. Thus in Tower Hamlets, a deprived east London borough, 60% of poor pupils got five good GCSEs (the exams taken at 16) in 2013; the national average was 38%. Worst served are pupils who fall in between, attendingschools where they are insufficiently numerous to merit attention but too many to succeed alone (see chart 2).<br>Mr Cheshire reckons that America, too, provides evidence of the limited benefits of socialmixing. Look, he says, at the Moving to Opportunity program, started in the 1990s, through which some poor people received both counseling and vouchers to move to richer neighbourhoods. Others got financial help to move as they wished, but no counselling. A third group received nothing. Studies after 10-15 years suggested that the incomes and employmentprospects of those who moved to richer areas had not improved. Boys who moved showed worse behavior. and were more likely to be arrested for property crime.<br>In Britain, this pattern might be partly explained by the existence of poor immigrant neighbourhoods such as St Matthews in Leicester. The people who live in such ghettos are poor in means, because they cannot speak English and lack the kind of social networks that lead to jobs, but not poor in aspiration. They channel their ambitions through their children.<br>Another probable explanation lies in the way that the British government hands out money. Education funding is doled out centrally, and children in the most indigent parts tend to get the most cash. Schools in Tower Hamlets receive 7,014 ($10,610) a year for each child, for example,compared with the English average of 4,675. Secondary schools also get 935 for each poor child thanks to the “pupil premium” introduced by the coalition government. Meanwhile Teach First sends top graduates into poor schools. In America, by contrast, much school funding comes from local property taxes, so those in impoverished areas lose out.<br>As the Duke University researchers are keen to point out, all this does not in itself prove that economically mixed neighbourhoods are a bad thing. They may be good in other ways—making politicians more moderate, for example. But the research does suggest that the benefits of such districts are far from straightforward. Patterns of social segregation reflect broadersocial inequality, argues Mr Cheshire, who has written a book about urban economics and policy. Where mixed neighborhoods flourish, house prices rise, overwhelmingly benefiting the rich. Spending more money on schools in deprived areas and dispatching the best teachers there would do more to help poor children. Assuming that a life among wealthy neighbors will improve their lot is too complacent.
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