healthsignals new york

Decision making in complex systems emergencies

By way of A Chance to Cut is a Chance to Cure, we have Stephen Cass's Apollo 13, We Have a Solution on IEEE's Spectrum.

Rather than hurried improvisation, saving the crew of Apollo 13 took years of preparation.

And I would add simulation and not making hasty decisions. This is a fairly lengthy story, but it's engrossing and has useful lessons in other sphere's, including ours.

Before there was the Internet or Viagra

Ever been to Del Rio, Texas? It's in the Rio Grande valley with mostly Mexican desert on the other side of the river. Even today it can feel isolated. In the 1930s, it must have been ... well, you can imagine. Just farming, ranching, and smuggling.

Gene Fowler and Bill Crawford co-wrote Border Radio: Quacks, Yodelers, Pitchmen, Psychics, and other Amazing Broadcasters of the American Airwaves (Amazon link). It's about the "border blaster" outlaw radio stations that set up across the Mexican border to evade U.S. regulations, and beamed broadcasts into the US and around the world. Here's a very entertaining Crawford interview on WHYY's and NPR's Fresh Air.

The book covers the period from the 1930s through the 1960s.

What's the medical angle? It all started with a doctor with an ... uhhh ... unconventional treatment for male impotence.

In the 1930s, Dr. (Doc) John Brinkley was a successful physician and surgeon in Kansas. He started a radio station to entertain his patients. You'll have to listen yourself to the interview (or buy the book) to learn what Doc Brinkley's treatment was. Described today, it was an "agricultural version of Viagra." But that's not what got him in trouble.

People would send letters to Doc Brinkley describing their symtoms. He would read the letters on his radio station and broadcast a prescription. He then took a cut from the pharmacists. Well that pushed the boundaries a bit too much.

But, no he didn't lose his medical license. He lost his radio license. It was the first the FCC ever revoked.

So the good people of Del Rio invited Doc Brinkley to open a clinic there and to set up his radio station on the unregulated, Mexican side of the border. He took the deal, built the world's most powerful radio station, and, in addition to his own prescriptions, broadcast a stream of off-the-charts, off-the-wall characters including Wolfman Jack, Rev. Ike, Rose Dawn, and Pappy O'Daniel (who, by beating Lyndon Johnson in the 1941 Senate election, taught him the importance of stealing more votes than your opponent).

Man, you just can't make this stuff up.

Friday afternoon fun

It's too late in the week and too late in the day to go back to posts drafted, but unfinished, much less start any new ones.

So why don't we visit Elyse at AntiClue and watch the end of the world.

Have a great weekend.

Rules for wonks & hacks

So today was budget hearing day for health and mental health, replete with the regular Chicken Little routines. If I come across anything worthwhile or even a bit different, I'll note it. But since that's unlikely, and since this Kabuki drama is the same that has played for years, what have we learned besides the ritual? Let's amuse ourselves ...

1. Wonks and hacks rarely understand one another. The rare wonk who understands the politics or the rare hack who understands the technical will always be able to finesse those who only understand only one or the other. Those who understand neither should be in another business ... but don't count on their leaving because of rule number 2.
2. Once you're here, the odds are you'll stay here. Like so many states, and even the Federal government, we've gotten into the incumbency protection game. It's really hard to get run out of town. And Civil Service? Well, you need the "jaws of life" to get out of that.
3. If you don't have the money (or the stomach) for a lobbyist, start outside of the Capitol and change the public's mind. If you don't have the money to change the public's mind, target 200-1,000 influentials and change their minds.
4. The less money you have to lobby or to change the public's mind, the more time it takes. Figure that in years, not months.
5. It's better if the first time you come to Albany, you don't ask for anything.
6. If you lose on the same issue year after year, change the subject.
7. If you need help from Albany, it's better if you can describe your problem without attacking a major interest group, i.e., defining them as the problem. (Witness, doctors attacking lawyers for the last 25 years. It's gotten them a lot, right?)
8. When your lobbyist reports that an issue that makes you crazy is bubbling again, check the age of his car. He may be in the market for a new one. And he wants you to pay for it. Lobbyists call these issues "annuities."
9. Really good lobbyists can move a lot of money with a mere phrase.
10. If you can't afford a large PAC, don't have any. You won't be able to compete with the big guys, but those seeking contributions will still expect them.
11. If you're a healthcare or other service provider, elected officials never value your services as much as they do when their mothers-in-law need them.
12. Everyone pleading their case to the State lies about their profits and financial condition.
13. Prior to the budget release, the projections will always show a deficit.
14. Prior to the budget release, masked news stories will begin to appear about some horrible situation, but they're really about what large constituencies want. (See rule 3.)
15. Beware of new services sold to save money. They don't.
16. Real innovation never comes from government funded demonstration projects.
17. Bureaucratic politics are rougher than legislative politics.
18. Everyone complains about excess regulation ... except when you deregulate. Then they complain about how they're going to be disadvantaged.
19. It's always better to write the first draft. You can slant things your way and, if you're good at it, you can hide things as well. If you're reacting to someone else's proposal or to someone else's draft, you are always playing catchup.
20. Republicans like personal stories. Democrats like data. It's best to have both. Neither Republicans nor Democrats are frightened by data or stories alone.
21. If an experienced analyst can't explain a program to you, it's time to change the program rather than the analyst. However, it's easier to change the analyst. And it's better still to learn the complexities yourself and to use your knowledge to your own advantage. (See rule 9.)
22. Regulations are silt in a river. They pile up invisibly, grain-by-grain. Individually they don't make any difference, but collectively, they make movement impossible.
23. More agency personnel than you would think actively dislike the clients of the programs they're responsible for.
24. If you're around long enough, there will always be an opportunity to get even. That applies to the other guy as well as you however.
25. We ought to systematically evaluate the effects of the programs we operate. But we rarely do. And when we do, we spend too much on the evaluation and we usually don't learn much.
26. The quantity of data submitted to state agencies always exceeds the quantity of information they release.
27. A scrupulous reporter may be a pain when they're on your case, but they are to be treasured nevertheless.
28. Beware of reporters who try to put words in your mouth when they're interviewing you. They'll do the same in their stories and neither you nor your mother will like it.
29. Beware of lazy reporters. You may be able to put something over on them from time-to-time, but eventually, it will backfire.
30. If you don't have money or power, the next best thing to have a sense of humor.

Feel free to add your own.

Some New York flavor

Elizabeth Kolbert covered New York politics as a reporter for many years. Here she's interviewed by the Gotham Gazette on her latest book. Nothing in particular about healthcare, but a there are some good stories, providing some texture to Albany politics.  

EBM a little late to help this patient?

An early version of, "which was worse, the disease or the treatment?"

Get past the Infectious Disease Society's headline, "Shakespeare's Writings Indicate He May Have Had Syphilis," and you'll find speculation that he inhaled mercury vapor as a treatment. That may have led to tremors, social withdrawl and baldness.

C'mon, gimme a break. We can't be serious here all the time.
 

Not quite the "break" I'd anticipated ...

If you live in New England, there are few winter sounds quite as startling as running water inside your house when you haven't been in it for days (or weeks as was the case here).

Yup, it was the classical New England nightmare: furnace off in bitter cold weather leading to multiple burst pipes, two inches of water in the kitchen, five inches in the basement, soaked rugs, warped flooring planks, cracked sinks and toilet.

The week over New Year's is usually spent in NH and this was how it began - and ended. The house, built in 1812 or so, was once the village store and post office. Like most older New England structures, there's not a square corner in the joint (and wasn't even before this). But it's a neat little place with lots of history and in a great little town.

So instead of doing some reading, quiet writing, and socializing, I've spent the week dealing with plumbers, furnace repairmen, "water mitigation" experts, etc.

After hearing the water through the door on the back porch, I moved more quickly than most would imagine. So quickly in fact that I broke the key off in the door. Of course, that might also have had to do with the four-inch ice damn that had built up on the inside of the door. How I managed to get the water main shut off was a story in itself.

My brother and a house guest showed up within minutes, our nephew and his girlfriend and their kerosene heater within an hour, others with a pump and the furnace guys (though there wasn't much they could do immediately in five inches of water) shortly afterwards. Family, friends and neighbors have been great. All the professionals, and even my insurance company, USAA, have been helpful and industrious.

So recovery is well underway. The basement is now pretty close to dry, the heating system is repaired (both pipes and furnace). Plumbing should be back together tomorrow or Tuesday. Drying should be done on Tuesday. The dump run with a bunch of stuff will come Wednesday.

While not the "break" I'd been looking forward to, the past week has been gratifying in dealing with other folks. And compared to the headlines of this past week from South Asia, it's been nothing at all.

Know your limits

This doesn't just apply to football (football as the rest of the world knows it, soccer). From the British Medical Journal, Can the human eye detect an offside position during a football match?

The physiology of the eye dictates that the answer is no. Francisco Belda Maruenda, MD a Spanish family physician:

By reviewing the physiology of the eye movements likely to be involved in assessing an offside position, I have shown that the relative position of four players and the ball cannot be assessed simultaneously by a referee, and unavoidable errors will be made in the attempt. The use of modern technology during games—freeze frame television and frame by frame analysis—is advisable to limit these errors. 

Our ability to gather and process data, and to understand the limits of our information systems and information flows especially when data are flowing from many sources is one of the great challenges of our time (think national security); it's true in clinical medicine; it's true in healthcare systems.

Operationally, we can use technological aids (instant replay) as proposed by the author, but whatever the system, we can't function well without understanding the limits of our system and being prepared to use our imaginations.

But it is leadership that must always be reviewing those limits and revamping systems to enable us to gather and process more, process more quickly, and process more accurately.

Antique anatomical images

From the National Library of Medicine, a history of anatomical imagery.

The interior of our bodies is hidden to us. What happens beneath the skin is mysterious, fearful, amazing. In antiquity, the body's internal structure was the subject of speculation, fantasy, and some study, but there were few efforts to represent it in pictures. The invention of the printing press in the 15th century - and the cascadeof print technologies that followed - helped to inspire a new spectacular science of anatomy, and new spectacular visions of the body. Anatomical imagery proliferated, detailed and informative but also whimsical, surreal, beautiful, and grotesque - a dream anatomy that reveals as much about the outer world as it does the inner self.

Pause and reflect.

Happy Thanksgiving

This link won't be active long, but it's one of those stories that brings me up short wondering whether I would have the courage. We all hope so, but don't know until the challenge arrives. First we have to recognize the challenge. Then we have to be up to it. In the New York Times, Thanksgiving day, 2004 the story of a reunion:

... They first met in 1942, when Morawiecka, her two sisters and their mother took in the Nowacki family after Nowacki's father was sent to a Nazi death camp. The Catholic family, at risk to their own lives, provided a safe haven for the Jewish mother and son at their Warsaw home ...

On this Thanksgiving day, the best to you and yours.