POMS talk: Aviation 1940 = Medicine 2005

B-17 Throttles

B-17 Throttles (Photo credit: rkbentley)

On Sunday I gave a capstone talk at the Production & Operations Society meeting in Denver.  I oriented my talk toward a comparison of health care now, with aviation’s transition to Standard Procedure Flying in the 1940s and 50s. BOHN POMS Standard procedure flying 2013e

As in medicine now, experienced expert flyers who did not use standard procedures were still better than newly trained pilots who did. And there was resistance to the changes. But aviation had a couple of advantages in making the transition: New pilots who did not learn SPF died quickly, usually in accidents. And the old experts got rotated out of combat positions (United States Army Air Force), or eventually got shot down no matter how good they were. (Germany)

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Technology’s Real Benefits- NOT so much in cancer research

The first example is cancer research. … The genomic approach helps establish the right treatments today, and will likely lead to new and better drugs in the next few years. ….” this is something that will be useful 200 years from now. This is a landmark that will stand the test of time.”

via Technology’s Real Benefits (Hint: They’re Not Economic).

Sorry, Andy, we have been getting hype about contributions of computers to biotech, and biotech to cancer, for 20+ years.  It’s past time to be highly skeptical that medical breakthroughs are “around the corner… just give us another $X billion for research…” Although the research results have been fascinating, the practical impacts have been modest. I think one reason is that the Big Pharma/Big Academia model of R&D is  inefficient and ineffective. Everyone hoards their data, and pursues their own stove pipe. There’s little collaboration or interchange among computer modelers, in-vitro, animal models, epidemiologists, etc. This is not something that better technology can solve – it’s a problem with business incentives and the academic promotion system.

Case in point: According to a friend, there have been no Randomized Clinical Trials on the relationship between crystalline salt and kidney disease. Everyone assumes there is a relationship, but what is the exact causal link? What’s the magnitude? What are the mediators of the effect (e.g. different diets, different climates). And what effects do intervention at different points (diet versus medications) have?  This is not cancer research, but same principles hold.

Other benefits of technology: sure. Cultural and scientific and business. Mapping Inca ruins: awesome. Effect of Facebook on daily lives: large,and not captured in GDP statistics. So your basic thesis is good; just don’t use medical promises as cases in point!

Screening tests and invasive biopsies « Punk Rock Operations Research

screening tests and invasive medical procedures « Punk Rock Operations Research.

A nice blog post by Laura McLay on a few of the paradoxes of cancer screening, and the human reactions to it. Everyone should read this weekend’s NYT article on breast cancer screening, by Peggy Orenstein. Title is Our Feel-Good War on Breast Cancer.  One of my reactions to Peggy Orenstein being the author: age really does bring wisdom!

My extended family went through a scare caused by over-testing a few years ago. Nobody was at fault, but different family members have very different responses to uncertainty.

Here is the abstract to the article Laura mentions on prostate screening.

Debate regarding the prostate-specific antigen (PSA) screening test centers around test reliability and whether screening reduces mortality.1– 3 We consider yet another potential downside to the widespread use of unreliable screening tests: the downstream effect of receiving inconclusive or ambiguous results. When receiving information from screening tests, we usually want to know whether the result is a “yes” or a “no.” Receiving an inconclusive result amounts to a “don’t know”; this situation should have a level of uncertainty regarding the diagnosis similar to that of not conducting the test at all. Yet, we propose that the psychological uncertainty experienced after an inconclusive test result can lead to investigation momentum: additional, and potentially excessive, diagnostic testing. In contrast, not conducting the unreliable test would result in no further action. To investigate this, we evaluated whether receiving an inconclusive result from an unreliable test (the PSA screening), compared with undergoing no test, motivated more individuals to undertake an additional, more invasive and costly, test (a prostate biopsy).


Fiscal FactCheck: payroll tax = income tax!

Fiscal FactCheck.

Astonishing fact is buried here: Payroll taxes (social security, medicare etc) have almost caught up with federal income tax. Payroll taxes are 40% of federal receipts in 2010, while personal income tax was 41.5%.

Payroll taxes tend to be quite regressive — they start at about 10% of ALL payroll income for your first dollar, and fall to about 2.3% above $100,000 or so. So this means we have a bizarre combination of progressive and regressive tax rates. And it’s more evidence of how high health care costs are dragging everything down (in this case, via Medicare costs).

By the way, many “conservatives” have suggested a “flat income tax”  e.g. 17%. As far as I can tell, this does NOT include payroll taxes. So it would not be flat at all – it would be highly regressive. Another factor is that richer people earn more from capital gains and other sources not counted as income. I’d love to see someone lay out the numbers carefully on this. Some information is in this report by Congressional Research Services. 

JAMA — Ensuring Integrity in Industry-Sponsored Research: Primum Non Nocere, Revisited, March 24/31, 2010, DeAngelis and Fontanarosa 303 12: 1196

The evidence on false conclusions from drug trials, and their publications, is mounting. I am forced to the conclusion that, most likely,

1) This has been going on for a long time; the big change is that it’s occasionally getting noticed now, and

2) The results of this over many years must be that  doctors are prescribing based on incorrect evidence. Specifically, lots of drugs are getting prescribed when they shouldn’t be.

According to the article by Nissen,1 the report of the Senate investigation,2 and published media accounts,8-9 the manufacturer of rosiglitazone exerted inappropriate influence during the conduct of a pivotal safety study of this drug, the RECORD Rosiglitazone Evaluated for Cardiac Outcomes and Regulation of Glycaemia in Diabetes clinical trial,10-11 which included undertaking nonprespecified unblinding of study data; attempting to undermine the authority and responsibilities of the study steering committee; expediting publication of an unscheduled interim analysis,10 specifically to counter2 the publication of a meta-analysis by Nissen and Wolski12 that suggested increased cardiovascular risk associated with rosiglitazone; having employees extensively involved in statistical analysis,11 and preparation of the manuscript10 reporting the results of the trial; and reportedly2 failing to fully acknowledge the significant cardiovascular risk associated with this drug.

via JAMA — Ensuring Integrity in Industry-Sponsored Research: Primum Non Nocere, Revisited, March 24/31, 2010, DeAngelis and Fontanarosa 303 12: 1196.

Your Brain on Computers – NYTimes.com

Article yesterday on the brain-altering effects of constant computer use. It’s a complex topic and I think a lot more research is needed, but there is certainly something going on. The reporter, Matt Richtel, won a Pulitzer last year for his series on distracted driving while using cellphones. (I’m quoted in the article, but not by name.)

Scientists say juggling e-mail, phone calls and other incoming information can change how people think and behave. They say our ability to focus is being undermined by bursts of information.These play to a primitive impulse to respond to immediate opportunities and threats. The stimulation provokes excitement — a dopamine squirt — that researchers say can be addictive.

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How American Health Care Killed My Father – Magazine – The Atlantic

The problems with the US Health care system are at their root not so complicated. This author seems to have done a pretty good assessment, with a year of research. The “system” is very good at delivering elaborate procedures and medications; there are few incentives for anything else. And it turns out that elaborate procedures are a gamble.  The old joke was “The surgery was a success, but the patient died!” But it’s no longer a joke.

Like every grieving family member, I looked for someone to blame for my father’s death. But my dad’s doctors weren’t incompetent—on the contrary, his hospital physicians were smart, thoughtful, and hard-working. Continue reading