It's been just about ten days since the announcement by Rob Portman that his previously-held opposition to gay marriage has melted away following the acceptance that his son is gay. There was a minor flurry of commentary and people have moved on to matters both weightier (Cyprus, Middle East) and less so (the aptly-named Shockers). So I'm a touch behind on weighing in on this; such is the life of an intermittent blogger. But so far I haven't seen anyone make the point I wanted to so here goes.
Matt Yglesias of Slate confesses to annoyance with the narcissism of Portman's stance that he had to arrive at gay marriage support only through direct experience. But there's more here than mere narcissism, and it's indicative of the general Republican approach to policy questions. The post-Nixonian Team Elephant doesn't employ reason as the primary tool to solve societal problems. It's the price of the Southern Strategy that shifted political power to the Republicans for nearly two generations. (An emblem: whatever one may think of her, there once was Jean Kirkpatrick addressing a Republican National Convention; now Sarah Palin stands and opines before them to yowling approval.)
Rather than providing a heartwarming tale about new found openness, Portman's reversal only serves to illustrate that very troubling underlying tendency. He didn't simply think about the issue and come to support gay rights. It's not like he hasn't had multiple opportunities to think this matter through. Instead it took something visceral to get him to budge from his bigotry. Although he should surely be commended for embracing a more progressive approach--he could have, in the manner of so many parents, simply cast his son away for either political expedience or genuine hatred or both, and did not--it's very unclear whether that process will be of any help where popular Republican sentiment still skews medieval, such as the understanding of evolution or the reality of climate change or the importance of evidence in public discourse.
As for Henrietta Lacks, today's New York Times brings word that a European research team last week had published Ms. Lacks's genome without anyone's consent. (If you don't know the story, Rebecca Skloot's The Immortal Life of Henrietta Lacks is a must-read; Skloot is also the author of today's Times piece.) There is a whiff of outrage in Skloot's prose that no consent was sought, although precisely how that could be accomplished is anyone's guess, as Lacks died over 60 years ago, long before current standards of consent even remotely began to address issues like this.
Skloot proposes that the family should have served as the surrogate for consent, but this seems at best to be an unwieldy solution. Who counts as family for a woman who passed away in 1951? What happens when there is a split decision? Based on my experiences with families of patients in end-of-life situations in ICUs, split decisions are the norm rather than the exception. And the publication of Lacks's genome has real--though difficult to quantify--scientific value, as her cells, the so-called "HeLa" cells, remain the workhorse cell line that forms the backbone of all biomedical research on the planet.
I have no idea how this is to be addressed. I am in agreement with Skloot that scientists need to be exquisitely sensitive to these issues. But I fear that our best intentions of outreach may not be sufficient to overcome objections to research--and HeLa cell research really is critical, and has the potential to improve or even save the lives of many people in the future.
--br
Sunday, March 24, 2013
Tuesday, February 5, 2013
Conflation Of "Education" With "Lecture" Is, At Best, Questionable Pedagogy
I do not often snoop about the blog pages of the Cato Institute owing to time constraints and a general sense that I won't find much enlightenment there. Hence, my acquaintance with Professor Alex Tabarrok's really interesting essay "Why Online Education Works"--which he wrote back in November 2012--came via a glance at Brad DeLong's blog today. But it's a provocative read, and at least in DeLong's blog, the commentary afterward was fascinating (and, I note with a certain delight, mostly free of the smack talk that so pervades online discussions that touch upon politics...mostly, anyway).
Tabarrok mainly argues that the reason why online education will largely displace university brick & mortar education as currently constituted is because it is wildly more efficient. In essence, he believes that one very, very, very large virtual lecture "taught" by one professor is a much less expensive model than lots and lots of smaller lectures taught by many professors. Since traditional universities, with their relatively-smaller-but-still-impersonal lecture-style format, are vastly more expensive than the online model, they will eventually be forced to adapt or face extinction since students will eventually realize that they don't have to bear the crushing debt associated with modern higher education. He uses his own TED talk as an example, as he writes, "the 15 minutes of teaching I did at TED dominates my entire teaching career: 700,000 views at 15 minutes each is equivalent to 175,000 student-hours of teaching, more than I have taught in my entire offline career."
What follows on DeLong's broadsheet is a discussion about how much Tabarrok's observations can be generalized--and thus how valid his basic point may be. For my part, I sit somewhere in the middle of the continuum: I think big universities had better listen up really quick or else find themselves losing students in the coming years to University of Phoenix in large numbers. Sooner or later there are going to be some enterprising "traditional" students who will decide to roll the dice at much cheaper online schools, and they will eventually find "traditional" employers in the workforce who are willing to roll the dice on students with online degrees. And if they discover that these students are just as prepared as ones from State U, the exodus from the traditional schools will accelerate.
That said, I also side with those in the discussion who point out that undergraduate education is much more commonly smaller classes with more individualized attention, and that Tabarrok is sounding the death-knell of a type of University that almost certainly doesn't exist at the smaller, lib-arts school. Moreover, he sidesteps the fact that the majority of an education of an intellectually curious undergraduate happens outside the classroom walls: a university's appeal--and value--lies in "the close, dense concentration of fellow students, and the close, dense concentration of adults interested in said students, and the dense array of programs tailored to students" in the words of one commenter.
Mostly, though, I viewed Tabarrok's points as well as the replies through the lens of my work at a medical school. I am, at present, basically a 60 percent doctor and 40 percent teacher. You can dress it up in fancy titles but I'm a teacher, no different than a senior grad student lecturing to Chem 101 freshmen. That is, with one critical difference: my students are apprentices. The lecture hall is an inpatient hospital room, or an outpatient exam room. There is simply no legitimate way, thus far, to train a physician by anything other than working with them in a nearly one-on-one manner, right in front of the patient (or away from the patient's eyes listening to presentations and discussing medicine). It is an education where doing and theorizing cannot be separated. You can't solely watch TED talks to become a physician. You must learn at the feet of a master (typically, several masters) to develop your craft.
Which is why one terse little quip from a gentleman named Colin, whose twitter handle is mcgilcoli, caught my eye, and serves as a nice title for this post: conflation of "education" with "lecture" is, at best, questionable pedagogy. Whether Tabarrok would agree with that sentiment or not I do not know. However, I am certain that it highlights what we do at a medical school with our 3rd year students all the way through our interns, residents, and fellows. Education is an intensely personal experience in medicine.
I hadn't understood that at all when I got into this business, and it is certainly one of the most rewarding aspects of my career at this point. I don't think they're going to find an online me anytime soon that can replace the flesh-and-bones me in the medical school. Whether they can find a different flesh-and-bones person to replace the flesh-and-bones me is a separate matter. We promise to provide updates on that front to our intrepid readers.
--Billy
Tabarrok mainly argues that the reason why online education will largely displace university brick & mortar education as currently constituted is because it is wildly more efficient. In essence, he believes that one very, very, very large virtual lecture "taught" by one professor is a much less expensive model than lots and lots of smaller lectures taught by many professors. Since traditional universities, with their relatively-smaller-but-still-impersonal lecture-style format, are vastly more expensive than the online model, they will eventually be forced to adapt or face extinction since students will eventually realize that they don't have to bear the crushing debt associated with modern higher education. He uses his own TED talk as an example, as he writes, "the 15 minutes of teaching I did at TED dominates my entire teaching career: 700,000 views at 15 minutes each is equivalent to 175,000 student-hours of teaching, more than I have taught in my entire offline career."
What follows on DeLong's broadsheet is a discussion about how much Tabarrok's observations can be generalized--and thus how valid his basic point may be. For my part, I sit somewhere in the middle of the continuum: I think big universities had better listen up really quick or else find themselves losing students in the coming years to University of Phoenix in large numbers. Sooner or later there are going to be some enterprising "traditional" students who will decide to roll the dice at much cheaper online schools, and they will eventually find "traditional" employers in the workforce who are willing to roll the dice on students with online degrees. And if they discover that these students are just as prepared as ones from State U, the exodus from the traditional schools will accelerate.
That said, I also side with those in the discussion who point out that undergraduate education is much more commonly smaller classes with more individualized attention, and that Tabarrok is sounding the death-knell of a type of University that almost certainly doesn't exist at the smaller, lib-arts school. Moreover, he sidesteps the fact that the majority of an education of an intellectually curious undergraduate happens outside the classroom walls: a university's appeal--and value--lies in "the close, dense concentration of fellow students, and the close, dense concentration of adults interested in said students, and the dense array of programs tailored to students" in the words of one commenter.
Mostly, though, I viewed Tabarrok's points as well as the replies through the lens of my work at a medical school. I am, at present, basically a 60 percent doctor and 40 percent teacher. You can dress it up in fancy titles but I'm a teacher, no different than a senior grad student lecturing to Chem 101 freshmen. That is, with one critical difference: my students are apprentices. The lecture hall is an inpatient hospital room, or an outpatient exam room. There is simply no legitimate way, thus far, to train a physician by anything other than working with them in a nearly one-on-one manner, right in front of the patient (or away from the patient's eyes listening to presentations and discussing medicine). It is an education where doing and theorizing cannot be separated. You can't solely watch TED talks to become a physician. You must learn at the feet of a master (typically, several masters) to develop your craft.
Which is why one terse little quip from a gentleman named Colin, whose twitter handle is mcgilcoli, caught my eye, and serves as a nice title for this post: conflation of "education" with "lecture" is, at best, questionable pedagogy. Whether Tabarrok would agree with that sentiment or not I do not know. However, I am certain that it highlights what we do at a medical school with our 3rd year students all the way through our interns, residents, and fellows. Education is an intensely personal experience in medicine.
I hadn't understood that at all when I got into this business, and it is certainly one of the most rewarding aspects of my career at this point. I don't think they're going to find an online me anytime soon that can replace the flesh-and-bones me in the medical school. Whether they can find a different flesh-and-bones person to replace the flesh-and-bones me is a separate matter. We promise to provide updates on that front to our intrepid readers.
--Billy
Thursday, January 24, 2013
Letter to Momma, re David Brooks
Dear Mom,
Thanks for the link on David Brooks!
I cannot be precisely sure what you mean by your quick attached note: “I’m just sayin’.” I mean, I get the phrase in general—like “I’m just sayin’ that someone else out there agrees with me”—as a simple for instance. But both Jonathan Bernstein and Jonathan Chait operate from the assumption that pretty much everything that David Brooks writes is either stupid or crazy or disingenuous or all three; they only quibble over whether such nonsense defines his character (Chait’s point of view) or his job (Bernstein’s point of view). I happen to think that Chait is more correct on this point than Bernstein, although it is very nearly a distinction without a difference.
The problem, in a nutshell, with David Brooks and his ilk is that he puts on the appearance of reasonableness, but this is a very thin patina covering over the madness that is today’s Republican Party. Whether he knows that his chiding of Obama for not “coming to the center” (when in fact Obama is a deeply centrist—or even center-right!—President) is pure bullshit, or is just a clever ruse as part of the role of “House Conservative” at the Gray Lady, is immaterial. Pure and simple, he serves as a polite apologist for the ugliest elements of power, and neither the article you link nor the one on which it is based would disagree with that sentiment.
Now, I know that I’m decidedly un-DavidBrooksian, and I’m not simply referring to my political views. I know that I crew cut half my head when I was sixteen while leaving the other mop-top long, much to your general consternation (a view I would probably share if one of my eleven year-old children tried today; I have gotten a touch more conservative, at least in certain ways, as I've grown older). I know that I pepper my conversation with far too much foul language, writing such impolite disquisitions during college to garner the somehow less than subtle nickname “Billy ‘Pigfucker’ Rubin” in a nod to a moniker I once applied to a philosophical foil. I know that my rhetoric tends toward what one might call “destructive”—or what dad used to describe with glee as my “vitriolic prose”—although in my defense, I note that have worked and worked and worked toward keeping my verbal TNT reserved for only the most outrageous and cynical actions/statements/personalities and whatnot. Whether I have succeeded at that I leave you and others to judge, though I keep in mind Paul Fussell’s immortal words of advice, “contempt for the contemptible”. Words by which to live! (Plus, there's just so much crap out there for which utter contempt is the only reasonable response. And note: in my blog incarnation, I’m incredibly well behaved.)
All of which is to say that, though I know David is the son you may have wished for, you are, now and forever more, stuck with your sometimes rude and nearly constantly foul-tongued son.
But know this as well: I care about those people whom power ignores—or worse (to hear the squawks of outrage from the Neanderthals who found Obama’s Second Inaugural references to Selma and Stonewall objectionable), actively vilifies. I will always be on their side. (Well, almost always. That’s a longer discussion.) David? Not so much. Never forget that key difference between the Nice Jewish Boy and the Boy Who’s Jewish And Nice Underneath It All.
Your loving son, (and seriously, I rilly do love you!),
With a wink,
Billy
Thanks for the link on David Brooks!
I cannot be precisely sure what you mean by your quick attached note: “I’m just sayin’.” I mean, I get the phrase in general—like “I’m just sayin’ that someone else out there agrees with me”—as a simple for instance. But both Jonathan Bernstein and Jonathan Chait operate from the assumption that pretty much everything that David Brooks writes is either stupid or crazy or disingenuous or all three; they only quibble over whether such nonsense defines his character (Chait’s point of view) or his job (Bernstein’s point of view). I happen to think that Chait is more correct on this point than Bernstein, although it is very nearly a distinction without a difference.
The problem, in a nutshell, with David Brooks and his ilk is that he puts on the appearance of reasonableness, but this is a very thin patina covering over the madness that is today’s Republican Party. Whether he knows that his chiding of Obama for not “coming to the center” (when in fact Obama is a deeply centrist—or even center-right!—President) is pure bullshit, or is just a clever ruse as part of the role of “House Conservative” at the Gray Lady, is immaterial. Pure and simple, he serves as a polite apologist for the ugliest elements of power, and neither the article you link nor the one on which it is based would disagree with that sentiment.
Now, I know that I’m decidedly un-DavidBrooksian, and I’m not simply referring to my political views. I know that I crew cut half my head when I was sixteen while leaving the other mop-top long, much to your general consternation (a view I would probably share if one of my eleven year-old children tried today; I have gotten a touch more conservative, at least in certain ways, as I've grown older). I know that I pepper my conversation with far too much foul language, writing such impolite disquisitions during college to garner the somehow less than subtle nickname “Billy ‘Pigfucker’ Rubin” in a nod to a moniker I once applied to a philosophical foil. I know that my rhetoric tends toward what one might call “destructive”—or what dad used to describe with glee as my “vitriolic prose”—although in my defense, I note that have worked and worked and worked toward keeping my verbal TNT reserved for only the most outrageous and cynical actions/statements/personalities and whatnot. Whether I have succeeded at that I leave you and others to judge, though I keep in mind Paul Fussell’s immortal words of advice, “contempt for the contemptible”. Words by which to live! (Plus, there's just so much crap out there for which utter contempt is the only reasonable response. And note: in my blog incarnation, I’m incredibly well behaved.)
All of which is to say that, though I know David is the son you may have wished for, you are, now and forever more, stuck with your sometimes rude and nearly constantly foul-tongued son.
But know this as well: I care about those people whom power ignores—or worse (to hear the squawks of outrage from the Neanderthals who found Obama’s Second Inaugural references to Selma and Stonewall objectionable), actively vilifies. I will always be on their side. (Well, almost always. That’s a longer discussion.) David? Not so much. Never forget that key difference between the Nice Jewish Boy and the Boy Who’s Jewish And Nice Underneath It All.
Your loving son, (and seriously, I rilly do love you!),
With a wink,
Billy
Saturday, January 19, 2013
Flu: Yes, the Vaccine Works
If you have been stranded on a desert island the past month, you may not be aware that this year's flu season has been, to use not fully professional terms, a bitch. "Thirty states and New York City are reporting high ILI activity, an increase from 24 states last week," the CDC says in its typically restrained fashion ("ILI" stands for "influenza-like illness"--since a good percentage of these illnesses turn out on closer inspection to be due to other viruses such as metapneumovirus or parainfluenza). The city of Boston declared a state of emergency last week, and plenty of other places are buckling under the strain that the epidemic has placed on hospitals, nursing homes, doctors' offices, and pretty much everywhere else too.
I've been hearing various comments, sometimes from health professional colleagues, that the magnitude of the outbreak is the fault of a lousy vaccine--as many patients these docs and nurses have encountered with lab-confirmed flu did receive the vaccine. (I've seen about three such patients myself.) Hard not to conclude that we just had a dud of a vaccine, and if it weren't for that, we'd be in for smoother sailing this winter.
But it's worth noting that the influenza vaccine does, in fact, actually work. The data this year, while preliminary, indicate that the vaccine is about 60 percent effective--which means (roughly) that for every 10 people who would become sick from influenza infection as a matter of course, only four would become sick if those 10 people were vaccinated. That may not sound hugely effective but that's well within the range of a typical influenza vaccine, as this report demonstrates. And from a public health standpoint, a 60 percent effective vaccine translates to a tremendous preservation of resources.
That is, assuming people actually take the vaccine. Currently the vaccination rate appears to be hovering around 30 percent. Wouldn't it be fiendish if we charged higher copays for unvaccinated people who get hospitalized for influenza? Or made them pay full cost for oseltamivir (aka Tamiflu) once they develop symptoms? Now that might serve as a motivator to get people to offer their arms for the vaccine needle!
Also worth noting, since vaccines are so wildly misunderstood, that while the flu vaccine is only 60 percent effective, most other vaccines--especially the ones we offer children like the MMR--have effectiveness rates in excess of 95 percent. And there is no proof--none--that vaccines cause autism. For further reading, see here.
--br
I've been hearing various comments, sometimes from health professional colleagues, that the magnitude of the outbreak is the fault of a lousy vaccine--as many patients these docs and nurses have encountered with lab-confirmed flu did receive the vaccine. (I've seen about three such patients myself.) Hard not to conclude that we just had a dud of a vaccine, and if it weren't for that, we'd be in for smoother sailing this winter.
But it's worth noting that the influenza vaccine does, in fact, actually work. The data this year, while preliminary, indicate that the vaccine is about 60 percent effective--which means (roughly) that for every 10 people who would become sick from influenza infection as a matter of course, only four would become sick if those 10 people were vaccinated. That may not sound hugely effective but that's well within the range of a typical influenza vaccine, as this report demonstrates. And from a public health standpoint, a 60 percent effective vaccine translates to a tremendous preservation of resources.
That is, assuming people actually take the vaccine. Currently the vaccination rate appears to be hovering around 30 percent. Wouldn't it be fiendish if we charged higher copays for unvaccinated people who get hospitalized for influenza? Or made them pay full cost for oseltamivir (aka Tamiflu) once they develop symptoms? Now that might serve as a motivator to get people to offer their arms for the vaccine needle!
Also worth noting, since vaccines are so wildly misunderstood, that while the flu vaccine is only 60 percent effective, most other vaccines--especially the ones we offer children like the MMR--have effectiveness rates in excess of 95 percent. And there is no proof--none--that vaccines cause autism. For further reading, see here.
--br
Saturday, December 15, 2012
The Epidemiology of Senseless Agony
Like millions of other Americans did yesterday, I listened to the news of the tragedy in the Sandy Hook neighborhood of Newtown, Connecticut while my emotions rapidly oscillated between fear, anxiety and outrage. I spent most of the day seeing patients in the hospital and so was only vaguely aware that something terrible had happened. I got into my car in the early evening and soaked in what details were known as I made my way on the hour long commute into Boston where we were having dinner with some friends. I walked into the door, found my child, and held him while I wept.
Surely that scene must have played out in countless homes across the United States yesterday--private moments of utter grief as we contemplate the suffering that must be taking place for the families of those children and teachers in Connecticut. So too are the numerous public expressions of shock and horror that could be found on Facebook or Twitter. Everyone wants to express something of the peculiar emotional state in which we find ourselves after yet another mass killing of people whom we do not know but whose lives very much resemble our own. And so we have, and it is very nearly unbearable to read a Facebook news feed today.
I am no different in wanting to say something to help process my own sorrow, and the words I can summon have already been used by tens of thousands of others: unspeakable and unthinkable and horrific and on and on. But Sandy Hook can also be described in different terms besides moral outrage, and one term in particular leapt to mind because I am a physician and because I treat infectious diseases.
Sandy Hook is part of an ongoing epidemic.
It is an epidemic in every traditional sense of the term: it affects "many persons at the same time, and spreads from person to person in a locality where the disease is not prevalent", as dictionary.com describes it. It is prevalent, and it is widespread. It is, in a very meaningful way, a disease that continues to afflict our country, and will continue to reach new communities unless it is stopped.
For Sandy Hook is, as everyone knows, not an isolated incident, but rather simply the latest in a string of horrors that began its modern phase with the Columbine massacre in 1999 and has included the Virginia Tech massacre in 2007 and this year's repeat performance in Colorado at a movie theater in Aurora. Like, say, HIV, where strange isolated cases cropped up decades before the full-scale epidemic began in the 1980s, almost serving as a warning of things to come, mass shootings also have much earlier precedents, the most famous being the University of Texas shootings in 1966 and, more obscurely, the Bath School incident in 1927 (which was for the most part a bombing rather than a shooting). Since Columbine, however, we've witnessed a steady stream of mass death.
Against the backdrop of these earthquakes of violence are what might be thought of as tremors of shooting--dozens of one- or two-person killing events that would hardly garner a blip on national news coverage today, so desensitized have we become to gun violence that mere individual shootings do not merit our attention or alarm. (The Wikipedia link only deals with school shootings: actual gun violence in the United States currently accounts for over 30,000 deaths per year, which is roughly the same number of people that die of influenza on average in any given year.)
From an epidemiologic perspective, gun violence precisely resembles any number of lethal infectious diseases. And like other infectious diseases, it will not abate simply of its own volition, our expressions of rage and grief notwithstanding. No amount of candlelight vigils or eloquent statements from public officials will put a dent in this problem. We'll see another Sandy Hook, and we'll probably see it again within the next year or two if this behaves like any other uncontrolled epidemic.
So what will make a difference?
I think it's helpful again to look at how we treat infectious epidemics. Over the past several months there has been a very deadly multistate meningitis outbreak; 37 people--almost exactly the number of the Aurora and Sandy Hook casualties combined--have died thus far. And the response of our government has been swift and definitive. The company which was the source of the outbreak was quickly investigated and shut down, as were other pharmacies who were immediately inspected as well. The FDA, CDC and various state health authorities worked in close coordination. And as a consequence of a government that functions to protect its citizens, the outbreak appears to be under control. Should we expect less of our government to address the problem that led to Sandy Hook?
Yet the epidemic of gun violence, which is a far more serious and prevalent problem in the United States, remains "untreated". Indeed, even initiating a discussion about how such a treatment should be administered can cause fierce recriminations. Only a week ago, sports journalist Bob Costas opined in his typically erudite fashion that the Jovan Belcher tragedy might not have happened at all had it not been for Belcher's possession of a gun; the roar of the right wing could be heard immediately. Even the President's statement about Sandy Hook, while unquestionably tactful, was extremely cautious on the subject of gun access. No such caution would have been in evidence had he been speaking about a case of Ebola.
As someone who knows something about how infections and epidemics behave, I'm confident that if we don't change the way we understand an unregulated gun culture, Sandy Hook won't be the last victims this disease will claim.
--br
Surely that scene must have played out in countless homes across the United States yesterday--private moments of utter grief as we contemplate the suffering that must be taking place for the families of those children and teachers in Connecticut. So too are the numerous public expressions of shock and horror that could be found on Facebook or Twitter. Everyone wants to express something of the peculiar emotional state in which we find ourselves after yet another mass killing of people whom we do not know but whose lives very much resemble our own. And so we have, and it is very nearly unbearable to read a Facebook news feed today.
I am no different in wanting to say something to help process my own sorrow, and the words I can summon have already been used by tens of thousands of others: unspeakable and unthinkable and horrific and on and on. But Sandy Hook can also be described in different terms besides moral outrage, and one term in particular leapt to mind because I am a physician and because I treat infectious diseases.
Sandy Hook is part of an ongoing epidemic.
It is an epidemic in every traditional sense of the term: it affects "many persons at the same time, and spreads from person to person in a locality where the disease is not prevalent", as dictionary.com describes it. It is prevalent, and it is widespread. It is, in a very meaningful way, a disease that continues to afflict our country, and will continue to reach new communities unless it is stopped.
For Sandy Hook is, as everyone knows, not an isolated incident, but rather simply the latest in a string of horrors that began its modern phase with the Columbine massacre in 1999 and has included the Virginia Tech massacre in 2007 and this year's repeat performance in Colorado at a movie theater in Aurora. Like, say, HIV, where strange isolated cases cropped up decades before the full-scale epidemic began in the 1980s, almost serving as a warning of things to come, mass shootings also have much earlier precedents, the most famous being the University of Texas shootings in 1966 and, more obscurely, the Bath School incident in 1927 (which was for the most part a bombing rather than a shooting). Since Columbine, however, we've witnessed a steady stream of mass death.
Against the backdrop of these earthquakes of violence are what might be thought of as tremors of shooting--dozens of one- or two-person killing events that would hardly garner a blip on national news coverage today, so desensitized have we become to gun violence that mere individual shootings do not merit our attention or alarm. (The Wikipedia link only deals with school shootings: actual gun violence in the United States currently accounts for over 30,000 deaths per year, which is roughly the same number of people that die of influenza on average in any given year.)
From an epidemiologic perspective, gun violence precisely resembles any number of lethal infectious diseases. And like other infectious diseases, it will not abate simply of its own volition, our expressions of rage and grief notwithstanding. No amount of candlelight vigils or eloquent statements from public officials will put a dent in this problem. We'll see another Sandy Hook, and we'll probably see it again within the next year or two if this behaves like any other uncontrolled epidemic.
So what will make a difference?
I think it's helpful again to look at how we treat infectious epidemics. Over the past several months there has been a very deadly multistate meningitis outbreak; 37 people--almost exactly the number of the Aurora and Sandy Hook casualties combined--have died thus far. And the response of our government has been swift and definitive. The company which was the source of the outbreak was quickly investigated and shut down, as were other pharmacies who were immediately inspected as well. The FDA, CDC and various state health authorities worked in close coordination. And as a consequence of a government that functions to protect its citizens, the outbreak appears to be under control. Should we expect less of our government to address the problem that led to Sandy Hook?
Yet the epidemic of gun violence, which is a far more serious and prevalent problem in the United States, remains "untreated". Indeed, even initiating a discussion about how such a treatment should be administered can cause fierce recriminations. Only a week ago, sports journalist Bob Costas opined in his typically erudite fashion that the Jovan Belcher tragedy might not have happened at all had it not been for Belcher's possession of a gun; the roar of the right wing could be heard immediately. Even the President's statement about Sandy Hook, while unquestionably tactful, was extremely cautious on the subject of gun access. No such caution would have been in evidence had he been speaking about a case of Ebola.
As someone who knows something about how infections and epidemics behave, I'm confident that if we don't change the way we understand an unregulated gun culture, Sandy Hook won't be the last victims this disease will claim.
--br
Tuesday, December 4, 2012
Pure Paul Krugman: Healthcare Costs
"The point is that if you want to control Medicare costs, you can’t do it
by kicking a small number of relatively young seniors off the program;
to control costs, you have to, you know, control costs...The key is having a health insurance system that can say no — no, we
won’t pay premium prices for drugs that are little if any better, we
won’t pay for medical procedures that yield little or no benefit."
This from his blog. I'd only add that we also need to figure out a way to say "no" to the needless prolongation of life in ICUs in people who have virtually zero chance of recovery. It accounts for an enormous amount of our expenditures, although I don't have the references on that at my fingertips.
--br
This from his blog. I'd only add that we also need to figure out a way to say "no" to the needless prolongation of life in ICUs in people who have virtually zero chance of recovery. It accounts for an enormous amount of our expenditures, although I don't have the references on that at my fingertips.
--br
Sunday, November 25, 2012
Write Shallow, Narcissistic Prose, Become a Published Author in the Times!
With our limited audience at the Billy Rubin Blog, we pine for the kind of attention that Lori Gottlieb has received throughout her professional career. Dating back to her days as a post-bac premed student, she was earning a name for herself in national publications: here, for instance, she dished up the skinny in Salon on interviews with mean people at Harvard Medical School back in 1999. Since then she has undertaken a rather dizzying set of career changes (for instance, she dropped out of med school after two and a half months because "she didn't like being around sick people"--even though the first two years of med school involve almost zero exposure to sick patients) but all the while pumping out essays and eventually, books, mostly memoirish accounts of her various professional adventures and misadventures. Today she has the kind of legitimate following that would make us pee our pants out of delight. Our envy is unadorned.
That said, much though we covet her following--or at least the idea of a following, though not so much hers in particular--we'd never stoop to the type of writing in which Ms. Gottlieb engages. Key recent examples include last year's offering in The Atlantic, "How to Land Your Kid in Therapy", as well as this week's remarkable meditation on the decline in psychotherapy, "What Brand is Your Therapist?", which appeared in the Friday edition of the Paper Of Record. "Remarkable" in that it really isn't an analysis at all of the profession and the challenges it faces, although it does provide some verbal window dressing in the first few grafs to make it seem so. Instead, it's the kind of piece for which Gottlieb is justly renowned: a me-me-me account of her experiences trying to start up her practice. Fully, three out of the 39 paragraphs do not contain the words "I", "me", or "my"--and the remaining 36 typically feature one of those three words in the first or second sentence. You may think you're reading about the modern state of psychotherapy; actually, you're reading about--may we use her first name?--Lori.
Here at the Billy Rubin Blog we have no qualms with the memoir, nor with centering a narrative around the concept of me. We are huge fans of Hunter Thompson, Ruth Reichl, PJ O'Rourke, Bill Bryson, Joan Didion, and Calvin Trillin--all fine writers whose central subject is often (sometimes only) the first person. But Gottlieb is playing at something else entirely: she's posing as a serious analyst about serious issues when in fact she is, at best, a shoddier version of the above masters of the craft. "How to Land Your Kid in Therapy" is in essence the uninformed musings of a trainee. She displays no evidence of having spent any serious time studying such an important topic or having considered what the research might have to say about parenting styles. Basically, she used her media persona to spin a couple of therapist-patient sessions (while a greenhorn, no less) into a full-fledged theory of childhood emotional development. Was The Atlantic doing anyone any favors by publishing this? Is the New York Times doing the same this week?
We think not, so waste not your time when you see her name in print, unless you, like us, can't avert your eyes from disaster in the same manner as watching the aftermath of a car accident. Which is, in summary, an apt description of her oeuvre.
--br
That said, much though we covet her following--or at least the idea of a following, though not so much hers in particular--we'd never stoop to the type of writing in which Ms. Gottlieb engages. Key recent examples include last year's offering in The Atlantic, "How to Land Your Kid in Therapy", as well as this week's remarkable meditation on the decline in psychotherapy, "What Brand is Your Therapist?", which appeared in the Friday edition of the Paper Of Record. "Remarkable" in that it really isn't an analysis at all of the profession and the challenges it faces, although it does provide some verbal window dressing in the first few grafs to make it seem so. Instead, it's the kind of piece for which Gottlieb is justly renowned: a me-me-me account of her experiences trying to start up her practice. Fully, three out of the 39 paragraphs do not contain the words "I", "me", or "my"--and the remaining 36 typically feature one of those three words in the first or second sentence. You may think you're reading about the modern state of psychotherapy; actually, you're reading about--may we use her first name?--Lori.
Here at the Billy Rubin Blog we have no qualms with the memoir, nor with centering a narrative around the concept of me. We are huge fans of Hunter Thompson, Ruth Reichl, PJ O'Rourke, Bill Bryson, Joan Didion, and Calvin Trillin--all fine writers whose central subject is often (sometimes only) the first person. But Gottlieb is playing at something else entirely: she's posing as a serious analyst about serious issues when in fact she is, at best, a shoddier version of the above masters of the craft. "How to Land Your Kid in Therapy" is in essence the uninformed musings of a trainee. She displays no evidence of having spent any serious time studying such an important topic or having considered what the research might have to say about parenting styles. Basically, she used her media persona to spin a couple of therapist-patient sessions (while a greenhorn, no less) into a full-fledged theory of childhood emotional development. Was The Atlantic doing anyone any favors by publishing this? Is the New York Times doing the same this week?
We think not, so waste not your time when you see her name in print, unless you, like us, can't avert your eyes from disaster in the same manner as watching the aftermath of a car accident. Which is, in summary, an apt description of her oeuvre.
--br
Monday, November 5, 2012
One Offs: MA Question Two and Nate Silver F/U
Normally at the Billy Rubin Blog we like giving a good 12 paragraphs to explore the intricacies of an idea, but no time for that today. Before the election, though we want to follow-up on two themes about which we have been writing this year: Physician-Assisted Suicide and, more recently, the phenomenon of Nate Silver.
In Massachusetts this year, Question Two on the ballot proposes a legalization of PAS. It is often described as a "liberal" issue. I don't think it is, and I'm voting No--as emphatically as one can, given that voting consists of coloring an oval black, but there you have it.
The reasons to oppose PAS, especially from a lefty point of view, are twofold:
a. Hospice is wildly underutilized; and
b. PAS should only be practiced in a place in which all citizens have equal access to good health care, and even with the Affordable Care Act we are still a long way from that.
PAS has the feel of a hot-button issue--strong opinions on both sides with heated rhetoric and fierce stands based on core moral beliefs. But unlike, say, abortion, PAS is mostly a smoke-and-mirrors debate where there's very little "there" there. Even in Oregon, the PAS pioneer, there have been only about 600 "prescribed" suicides in 18 years since legalization. But PAS has substituted for a more substantive discussion about how we will treat end-of-life issues in the US. At a time when we need to examine how we spend money on our health because we cannot sustain our current model (which isn't a good model anyway), that's lousy politics for the left, right, and center.
Onto Nate Silver.
We wrote that being "against" Nate Silver generally showed a contempt for science and mathematics, and we still stand by that claim. However it's important to note that Silver isn't a stand-in for Truth, and that if his success in political prediction matches that of his baseball analysis acumen, the Dems may be in for a very rocky night tomorrow and the Billy Rubin Blog staff will have one phenomenal hangover Wednesday morning. That is, Silver's statistical baby for baseball, named "PECOTA", hasn't performed significantly better than other models predicting player performance and has done so using a cranky, Rube Goldberg-like statistical contraption. Colby Cosh of Maclean's (a Canadian publication) heaps reams of skepticism on the Silver phenomenon here.
Cosh's writing is really good and provides some fresh insight from a guy who appears to be steeped in the numbers, although that said I think he's mostly missing the point. As can be found here and here (and talked about over here), there are number-crunchers who can provide plausible scenarios of why we might wake up trying to familiarize ourselves with the phrase "President Mitt Romney". But this is a question of "what is the underlying reality of the campaign, and how do we find data to help make an accurate prediction?" That question of late has frequently become morphed with "which guy do you want to win?", and Silver, who is almost completely a numbers geek with very few overt partisan leanings, has gotten pegged by conservatives as being in the tank for the Obama cause: right wing paranoia if ever there was any. This is why people have been giving pushback on Silver attacks.
Indeed, there were plenty of Dem-leaning commenters on the Cosh/Maclean's piece that welcomed the critique, because they endorsed the idea of data-driven analysis and not cult-of-personality devotion to Silver. Said one commenter: "I think Silver is a good thing for journalism, but it is misleading to call him a statistician or a scientist. He's something else entirely: a data journalist. He's a very bright guy to have spotted the gap in the market which opened up thanks to the easy availability of data, which mainstream journalists have no training or inclination to use." That sounds right to me, and is the best explanation of King Nate's popularity. Indeed, Silver's book Signal and the Noise is mostly a journalist's account, and it's a really good read.
We will wake up Wednesday morning and will know, given many Senate and House races in addition to the 50 state Presidential races, whether Rasmussen's polls, which have always favored Republicans by about 2 points this year, are more accurate than Quinnipiac's or anyone else's. If so they're probably doing something right and have a better model. Sure, some on the left have foolishly conflated support for Silver with support for liberal political issues, but crying foul against libs who Don't Get It is an exercise in false equivalence. The vast majority of the right wing screeching about Silver has not had to do with an opposition to Silver's possibly errant calculations, but rather with a resistance to any data that does not support one's ingrained assumptions.
More than anything else, this is why we find the Republican Party as currently constituted a menace to society, and until this problem is fixed, we have a very deep political problem in this country.
--br
In Massachusetts this year, Question Two on the ballot proposes a legalization of PAS. It is often described as a "liberal" issue. I don't think it is, and I'm voting No--as emphatically as one can, given that voting consists of coloring an oval black, but there you have it.
The reasons to oppose PAS, especially from a lefty point of view, are twofold:
a. Hospice is wildly underutilized; and
b. PAS should only be practiced in a place in which all citizens have equal access to good health care, and even with the Affordable Care Act we are still a long way from that.
PAS has the feel of a hot-button issue--strong opinions on both sides with heated rhetoric and fierce stands based on core moral beliefs. But unlike, say, abortion, PAS is mostly a smoke-and-mirrors debate where there's very little "there" there. Even in Oregon, the PAS pioneer, there have been only about 600 "prescribed" suicides in 18 years since legalization. But PAS has substituted for a more substantive discussion about how we will treat end-of-life issues in the US. At a time when we need to examine how we spend money on our health because we cannot sustain our current model (which isn't a good model anyway), that's lousy politics for the left, right, and center.
Onto Nate Silver.
We wrote that being "against" Nate Silver generally showed a contempt for science and mathematics, and we still stand by that claim. However it's important to note that Silver isn't a stand-in for Truth, and that if his success in political prediction matches that of his baseball analysis acumen, the Dems may be in for a very rocky night tomorrow and the Billy Rubin Blog staff will have one phenomenal hangover Wednesday morning. That is, Silver's statistical baby for baseball, named "PECOTA", hasn't performed significantly better than other models predicting player performance and has done so using a cranky, Rube Goldberg-like statistical contraption. Colby Cosh of Maclean's (a Canadian publication) heaps reams of skepticism on the Silver phenomenon here.
Cosh's writing is really good and provides some fresh insight from a guy who appears to be steeped in the numbers, although that said I think he's mostly missing the point. As can be found here and here (and talked about over here), there are number-crunchers who can provide plausible scenarios of why we might wake up trying to familiarize ourselves with the phrase "President Mitt Romney". But this is a question of "what is the underlying reality of the campaign, and how do we find data to help make an accurate prediction?" That question of late has frequently become morphed with "which guy do you want to win?", and Silver, who is almost completely a numbers geek with very few overt partisan leanings, has gotten pegged by conservatives as being in the tank for the Obama cause: right wing paranoia if ever there was any. This is why people have been giving pushback on Silver attacks.
Indeed, there were plenty of Dem-leaning commenters on the Cosh/Maclean's piece that welcomed the critique, because they endorsed the idea of data-driven analysis and not cult-of-personality devotion to Silver. Said one commenter: "I think Silver is a good thing for journalism, but it is misleading to call him a statistician or a scientist. He's something else entirely: a data journalist. He's a very bright guy to have spotted the gap in the market which opened up thanks to the easy availability of data, which mainstream journalists have no training or inclination to use." That sounds right to me, and is the best explanation of King Nate's popularity. Indeed, Silver's book Signal and the Noise is mostly a journalist's account, and it's a really good read.
We will wake up Wednesday morning and will know, given many Senate and House races in addition to the 50 state Presidential races, whether Rasmussen's polls, which have always favored Republicans by about 2 points this year, are more accurate than Quinnipiac's or anyone else's. If so they're probably doing something right and have a better model. Sure, some on the left have foolishly conflated support for Silver with support for liberal political issues, but crying foul against libs who Don't Get It is an exercise in false equivalence. The vast majority of the right wing screeching about Silver has not had to do with an opposition to Silver's possibly errant calculations, but rather with a resistance to any data that does not support one's ingrained assumptions.
More than anything else, this is why we find the Republican Party as currently constituted a menace to society, and until this problem is fixed, we have a very deep political problem in this country.
--br
Saturday, November 3, 2012
What Being "Against" Nate Silver Really Means
Here's a prediction:
Barack Obama is going to win the Presidency.
Does that mean he's definitely going to win it? No.
Is he likely to win it? Yes, he is. He's got about a 3 in 4 chance of winning. It's not a coin flip. Romney has to have a lot of things break his way on Tuesday to capture the White House.
Why am I fairly--but not absolutely--confident that this will be the outcome? Because I've been following the polling for the past two months. There are a lot of sites that analyze various kinds of data and have a computer model to predict who is going to win, including elecotral-vote.com, the Princeton Election Consortium, Votamatic, Real Clear Politics, and a host of others (see Votamatic's blogroll for the others). I have been keeping up with them, and for the most part, they're generally in agreement that Obama is the clear favorite.
The most famous of these predictors is a geeky stats guy named Nate Silver, whose blog fivethirtyeight.com back in 2008 became so popular that the New York Times incorporated it into their product. And as the campaign has proceeded, Silver has analyzed the race and provided reams of commentaries, caveats, and digressions worthy of a Talmudic scholar. But he's been extremely clear about the bottom line over the past few weeks: Obama is the favorite.
That means he is likely to win but is not a lock. A very simple analogy will suffice: as of today, with three days to go in the race, Obama is up by two and Romney has the ball on his own 17 with one timeout and 1:20 on the clock. Most teams in that situation won't win, although of course some will. Now, if you were to bet on Team Romney, you'd want something better than even-up odds. If you offered a bet with anyone at that moment in the game that Team R would win, you would find no end of people willing to take you up on the bet. This is where we are in the Presidential Race, and this is what Silver has been writing for some time.
The bet scenario is in fact quite real, as Silver, in what appears to have been a fit of pique, took an even-up bet on Obama with Joe Scarborough, host of MSNBC's "Morning Joe". Two grand will be donated by the loser to the Red Cross. The bet arose from some trash talking on Morning Joe, where Scarborough called Silver "a joke" and more-than-implied that he was in the tank for Obama. See here for further explanation (including the incoherent warbling of NYT's most famous tweedle-dee, David Brooks), and here for a rundown of other attacks on Silver.
The comments indicate that Scarborough is either irredeemably stupid, or frightfully uninformed for a TV news anchor, or deeply cynical, or some combination of all three. A casual perusal of Silver's blog indicates that he's a guy fascinated with statistical analysis much more than he is of partisan politics. There is never a potshot laid at Romney, even when he so richly deserves it. Yet because he happens to be a guy delivering news that one with a Republican bent doesn't want to hear, suddenly Silver himself becomes the subject of personal attacks due to his perceived partisanship.
Ladies and gentlemen: the Republican Party of 2012.
What being against Nate Silver really means is that you are against a particular way of thinking about the world, and the boundaries go well beyond calling the Presidential horse race. It's a mindset that refuses to accept any information that does not fit with predefined conceptions about the world, whether that information relates to an increase in global temperatures, the existence of evolution, or the value of public health. In short, it is a medieval understanding of the world, and the contempt shown for Nate Silver--an otherwise harmless and bright dweeb--is an exemplar of that way of thinking, if it is worthy of the term "thinking" at all.
I am distrustful of Republican political philosophy for a variety of reasons, all of which may be wrong. But I will be voting for Barack Obama--a politician for whom I now have very little enthusiasm--not so much because of these differences in philosophy, but because of the Brownshirt-flavored anti-intellectualism of the modern Republican party.
--br
ps. Also worth noting that Silver's new book, The Signal and the Noise, is an exceptionally good read.
Barack Obama is going to win the Presidency.
Does that mean he's definitely going to win it? No.
Is he likely to win it? Yes, he is. He's got about a 3 in 4 chance of winning. It's not a coin flip. Romney has to have a lot of things break his way on Tuesday to capture the White House.
Why am I fairly--but not absolutely--confident that this will be the outcome? Because I've been following the polling for the past two months. There are a lot of sites that analyze various kinds of data and have a computer model to predict who is going to win, including elecotral-vote.com, the Princeton Election Consortium, Votamatic, Real Clear Politics, and a host of others (see Votamatic's blogroll for the others). I have been keeping up with them, and for the most part, they're generally in agreement that Obama is the clear favorite.
The most famous of these predictors is a geeky stats guy named Nate Silver, whose blog fivethirtyeight.com back in 2008 became so popular that the New York Times incorporated it into their product. And as the campaign has proceeded, Silver has analyzed the race and provided reams of commentaries, caveats, and digressions worthy of a Talmudic scholar. But he's been extremely clear about the bottom line over the past few weeks: Obama is the favorite.
That means he is likely to win but is not a lock. A very simple analogy will suffice: as of today, with three days to go in the race, Obama is up by two and Romney has the ball on his own 17 with one timeout and 1:20 on the clock. Most teams in that situation won't win, although of course some will. Now, if you were to bet on Team Romney, you'd want something better than even-up odds. If you offered a bet with anyone at that moment in the game that Team R would win, you would find no end of people willing to take you up on the bet. This is where we are in the Presidential Race, and this is what Silver has been writing for some time.
The bet scenario is in fact quite real, as Silver, in what appears to have been a fit of pique, took an even-up bet on Obama with Joe Scarborough, host of MSNBC's "Morning Joe". Two grand will be donated by the loser to the Red Cross. The bet arose from some trash talking on Morning Joe, where Scarborough called Silver "a joke" and more-than-implied that he was in the tank for Obama. See here for further explanation (including the incoherent warbling of NYT's most famous tweedle-dee, David Brooks), and here for a rundown of other attacks on Silver.
The comments indicate that Scarborough is either irredeemably stupid, or frightfully uninformed for a TV news anchor, or deeply cynical, or some combination of all three. A casual perusal of Silver's blog indicates that he's a guy fascinated with statistical analysis much more than he is of partisan politics. There is never a potshot laid at Romney, even when he so richly deserves it. Yet because he happens to be a guy delivering news that one with a Republican bent doesn't want to hear, suddenly Silver himself becomes the subject of personal attacks due to his perceived partisanship.
Ladies and gentlemen: the Republican Party of 2012.
What being against Nate Silver really means is that you are against a particular way of thinking about the world, and the boundaries go well beyond calling the Presidential horse race. It's a mindset that refuses to accept any information that does not fit with predefined conceptions about the world, whether that information relates to an increase in global temperatures, the existence of evolution, or the value of public health. In short, it is a medieval understanding of the world, and the contempt shown for Nate Silver--an otherwise harmless and bright dweeb--is an exemplar of that way of thinking, if it is worthy of the term "thinking" at all.
I am distrustful of Republican political philosophy for a variety of reasons, all of which may be wrong. But I will be voting for Barack Obama--a politician for whom I now have very little enthusiasm--not so much because of these differences in philosophy, but because of the Brownshirt-flavored anti-intellectualism of the modern Republican party.
--br
ps. Also worth noting that Silver's new book, The Signal and the Noise, is an exceptionally good read.
Monday, October 1, 2012
Ezra Klein's Medical Metaphor of Congress
With which we agree entirely: "If Congress was your doctor, they'd give you too few antibiotics and, when that failed, give up on the idea of antibiotics altogether".
We'd frame it ever-so-slightly differently here: first they'd give you the wrong antibiotic (military spending), then underdose it (budget sequestration), then give up on the idea of antibiotics altogether (threaten to default), then claim you do not suffer from an infection (return to embrace of Bush 43 economic policies), and then deny that there are such things as germs in the first place and allege that your illness is due to insufficient faith (self-explanatory). Only Twitter will not allow for that length, which is among the reasons why we've never been able to embrace Twitter.
--br
We'd frame it ever-so-slightly differently here: first they'd give you the wrong antibiotic (military spending), then underdose it (budget sequestration), then give up on the idea of antibiotics altogether (threaten to default), then claim you do not suffer from an infection (return to embrace of Bush 43 economic policies), and then deny that there are such things as germs in the first place and allege that your illness is due to insufficient faith (self-explanatory). Only Twitter will not allow for that length, which is among the reasons why we've never been able to embrace Twitter.
--br
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