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Travellers in your Cab

May 28, 2010 in Books | No comments

“Reading is human contact, and the range of our human contacts is what makes us what we are. Just imagine you live the life of a long-distance trucker.  The books that you read are like the travellers you take into your cab.  If you give lifts to people who are cultured and profound, you’ll learn a lot from them. If you pick up fools, you’ll turn into a fool yourself.”

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Applying the Toyota Production System to Healthcare

May 21, 2010 in Books | 4 comments

Until their most recent quality stumbles, Toyota’s production techniques were the darlings of the management consulting world.  The Toyota process is embodied by the concept of kaizen, a Japanese notion of continuous improvement. The latest gurus have even applied the production techniques to the health care arena (see Designed to Adapt). A Health Affairs article by John Toussaint (2009) shows how Wisconsin has used Toyota-style production techniques to improve quality.

Some of the problems an improved production process could solve include:

  • A large fraction of steps in the health care process have no apparent value for the patient.  Touissaint estimates that this figure is currently 90%-95%.
  • A lack of trust of less-qualified peers.  Cardiologists often do not trust ED physicians to accurately diagnose a heart attack, resulting in a repetitious diagnosis process.
  • Most physicians are “…more loyal to their specialty than to the team with whom they work every day.”

Some of the solutions the Toyota production system offers include:

  • Decreasing wasted time can increase quality.  ”In 2002, for instance, our morality rate for coronary bypass surgery was nearly 4 percent.  After several kaizen projects in this area, typically removing 40 percent of the waste each time, mortality dropped to 1.4 percent in 2008 and has been 0 percent through six months of 2009.”
  • Making medical care more collaborative can improve care. For instance, in one hospital’s Collaborative Care wing, the nurse owns the care process. “The nurse remains in contact with the doctor but does not wait for instruction. Often, it is the nurse who instructs the physicians about a needed step or a critical time in the patient’s care.”

This quality improvements are sound good on paper, but take serious efforts to implement in practice.  In addition, current insurance payment schemes are not conducive to collaborative care.  Touissaint claims that Medicare pays $2,000 less per patient on average in Collaborative Care than in a traditional medical wing.

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The Boids and the Bees: A Book Review

February 19, 2010 in Books | 1 comment

The book The Boids and the Bees by A.H. Jones and Jerry Bozeman can be summarized in one acronym: CASY.  This stands for Complex Adaptive Systems.  The point of the book is that CASYs are more complex than we think and that most of life is make up of CASYs.

Let us take the example of your car (which is not a CASY).  If you have a problem with a cracked part in your engine, by replacing the part, the engine will be as good as new.

However, if you address the problem in such a direct manner for a CASY, the effect may not be what was intended.  For instance, antibiotics kill bacteria.  One would think that the use of antibiotics will make humans healthier.  However, bacteria adopt to the antibiotics through evolution.  The strong survive and then the most prevalent bacteria strains becomes the ones that are drug resistent.  Using antibiotics may, in the long-run, make humans more susceptible to disease.

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World War I’s Greatest Killer

February 12, 2010 in Books, Contagious Disease | No comments

“It is sometimes called the Great Swine Flu epidemic and sometimes the Great Spanish Flu epidemic, but in either case it was ferocious.  World War I killed twenty-one million people in four years; swine flu did the same in its first four months.  Almost 80 percent of American causalities in the First World War came not from enemy fire, but from flu.  In some units the mortality rate was as high as 80 percent.”

This passage is from an interesting book I am currently reading called A Short History of Nearly Everything by Bill Bryson.  An (unfortunately) prescient passage in the book describes a certain flu virus we all became familiar with last summer:

“From time to time certain strains of virus return.  A disagreeable Russian virus known as H1N1 caused severe outbreaks over wide areas in 1933, then again in the 1950s, and yet again in the 1970s.  Where it went in the meantime each time is uncertain.  One suggestion is that viruses hide out unnoticed in populations of wild animals before trying their hand at a new generation of humans.  No one can rule out the possibility that the Great Swine Flu epidemic might once again rear its head.“

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Three Cups of Tea

January 9, 2010 in Books | 1 comment

I just finished reading Three Cups of Tea, an interesting book chronicling of an amazing man dedicated towards bringing schools to rural areas of Pakistan and Afghanistan.  The book describes Greg Mortenson’s single minded purpose and reinforces the saying that the pen is mighter than the sword.  In fact, according to one Pakistani Brigadier General, Mortenson’s work can also have an effect on the war on terror.

“Osama is not a product of Pakistan or Afghanistan.  He is a creation of America.  Thanks to America, Osama is in every home.  As a military man, I know you can never fight and win against someone who can shoot at you once and then run off and hide while you have to remain eternally on guard.  You have to attack the source of your enemy’s strength.  In America’s case, that’s not Osama or Saddam or anyone else.  The enemy is ignorance.  The only way to defeat it is to build relationships with these people, to draw them into the modern world with education and business.  Otherwise the fight will go on forever.”

To donate to Greg Mortenson’s Central Asia Institute, please visit this website.

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What is it like to be a librarian? “Essentially, it is all about money and power.”

April 5, 2009 in Books | 2 comments

Harvard Professor Robert Dardon has a fascinating piece on books, college libraries, copyrights, and what’s Google’s drive to digitize the world’s books means to society.  Some excerpts from the original New York Review of Books article are below.

  • One of my colleagues is a quiet, diminutive lady, who might call up the notion of Marion the Librarian. When she meets people at parties and identifies herself, they sometimes say condescendingly, “A librarian, how nice. Tell me, what is it like to be a librarian?” She replies, “Essentially, it is all about money and power.”
  • In 1790, the first copyright act—also dedicated to “the encouragement of learning”—followed British practice by adopting a limit of fourteen years renewable for another fourteen.  How long does copyright extend today? According to the Sonny Bono Copyright Term Extension Act of 1998 …it lasts as long as the life of the author plus seventy years. In practice, that normally would mean more than a century. 
  • Encyclopédie of Diderot, which organized knowledge into an organic whole dominated by the faculty of reason, with its successor from the end of the eighteenth century, the Encyclopédie méthodique, which divided knowledge into fields that we can recognize today: chemistry, physics, history, mathematics, and the rest. In the nineteenth century, those fields turned into professions, certified by Ph.D.s and guarded by professional associations. 
  • Along the way, professional journals sprouted throughout the fields, subfields, and sub-subfields. The learned societies produced them, and the libraries bought them. This system worked well for about a hundred years. Then commercial publishers discovered that they could make a fortune by selling subscriptions to the journals.
  • The Journal of Comparative Neurology now costs $25,910 for a year’s subscription; Tetrahedron costs $17,969 (or $39,739, if bundled with related publications as a Tetrahedron package); the average price of a chemistry journal is $3,490
  •  If approved by the court—a process that could take as much as two years—the settlement will give Google control over the digitizing of virtually all books covered by copyright in the United States.

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The History of Least Squares

March 23, 2009 in Books, Econometrics | 1 comment

Let us say you have 10 observations of 2 different variables.  How do you determine which of the observations to use?  Should you throw out the outliers?  Should you only include the most similar values?  Does more observations increase or decrease the amount of measurement error?

These problems can be answered by the discipline of Statistics.  An interesting book by Stigler recounts The History of Statistics.  Astronomers lead many of the statistical advances in the seventeenth and eighteenth centuries.  Accurate measurement is very important to astronomers.  Further, observations with respect to the circumference and oblateness of the earth were made at different times and places throughout history.  This leaves a conundrum of  how best to combine these observations.

Mayer, Boscovich, and others contributed to the development of the idea of least squares, but Stigler credits Legendre with the invention of least squares.  Legendre came up with the idea in his attempt to measure the length of the median quadrant (the distance from the equator to the North Pole) through Paris.  

To demonstrate some of his ideas, I will use a simpler example.  Let us assume that a drug can have a dosage level between 0 and 5 and we want to find it’s impact on health (measured from a 0-10 scale).  Let us look at the following data.  The goal is to find the parameters m (slope) and b (intercept) that accurately measure the relationship between drug dosage and health (ignore any questions of endogeneity).  Should we include all 10 observations?

Although Euler recognized that including more observations increases the maximum possible error, Legendre realized that adding more observations also greatly increased the probability of getting close to the true value of the parameters of interest.  

In my example, we need to fit a line to measure the parameters m and b.  How do we set up the errors so that we have the most accurate calculations.  Laplace believed that the following two conditions would need to hold:

  1. Σi Dosagei*ei = 0
  2. Σi |Dosagei*ei| = minimum

The first condition basically says that the errors are uncorrelated with the independent variables on average.  The second condition hopes to minimize the errors.  Legendre extended Laplace’s second condition to minimize the sum of the squared errors rather than just the absolute error level.

Another key point is that this regression line must go through the “center of gravity.”  In my example, the average dosage for the ten observations is 2.2 and the average health level is 5.9.  This means the center of gravity is at the coordinates (2.2, 5.9).  In the solution in my example is to set m=1.1456 and b=3.3797.  We see that if we plug 2.2 into the equation, the output is 5.9; thus, the regression line does indeed go through the center of gravity.

Understanding the historical development of modern statistical techniques is an interesting task, and Stigler’s book enlightens the reader with much detail.

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Why don’t Americans read foreign books?

March 19, 2009 in Books | 1 comment

Percent of books published in each country that were translated works:

  • South Korea: 29%
  • Spain: 25%
  • Italy: 22%
  • China: 4%
  • U.S. (adult fiction): 3.5%
  • U.S. (total): 3%

Kushner, Aviya (2009) “McCulture” Wilson Quarterly, Winter 2009, 33(1):22-29.

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Book Review: The Great American Heart Hoax

January 13, 2009 in Books | 2 comments

A new book by Dr. Michael Ozner takes on the cardiovascular surgery industry head-on.  The aptly titled Great American Heart Hoax claims that although insurers pay $60 billion per year  invasive cardiovascular surgery, 70%-90% of these procedures are unnecessary.   The book has three major themes: What is heart disease?  Why is heart surgery a hoax?  and What is the solution?

What is heart disease?  

The book has a nice summary of some of the risk factors from heart disease as well as the types of cardiovascular surgeries.  Dr. Ozner also describes the different the side effects from bypass surgery and pharmaceuticals used to treat atherosclerosis.  This portion of the book is educational and clearly explained.

Why is heart surgery a hoax?

Dr. Ozner cites numerous studies demonstrating that bypass surgery does not generally help heart patients.  Two studies–the Coronary Artery Surgery Study (CASS) and the European CASS–both found that “a majority of patients who underwent bypass surgery did not live significantly longer or have fewer heart attacks than those who did not undergo surgery.”  However, bypass surgery can be beneficial for patients with “critical left main coronary artery disease and a weak heart muscle, and patients with severe disabling chest pain despite maximal medical therapy.”  Most patients who undergo bypass surgery, however, do not fall into these groups.

Dr. Ozner also criticizes the use of other surgical procedures.  The Atorvastatin Versus Revascularization Treatments (AVERT) Trial found that “the lives of patients treated with angioplasty were not significantly prolonged compared to similar patients who received medical therapy alone, nor did they suffer fewer heart attacks.”  Stents were also shown to be problematic in the Occluded Artery Trial.  

Even CAT scans are dangerous because they expose patients to excessive radiation.  CAT scans can be useful when heart disease symptoms appear, but Dr. Ozner finds that CAT scans are counterproductive for healthy patients.  When the doctor conducts a CAT scan, it may substitute for time spend taking the patient’s medical history–which is much more useful. 

The problems with these types of surgeries are certainly the heart of the book.  Financial incentives, however, continue to give doctors the motivation to continue performing these surgeries.  Showing that these high cost surgeries may not be in the patient’s best interest is the most important contribution of the book.

What is the solution?

This portion of the book is fairly disappointing.  Dr. Ozner’s solution is to eat healthier and exercise more.  This is nothing new.  In the “eating healthier” portion, Dr. Ozner pushes the “Mediterranean Diet” he advocated in an earlier book.  Getting people to eat healthier and exercise is easier said then done.  Deep dish pizza tastes better than broccoli; eating healthier means forgoing some of these tasty treats.  Further, some people enjoy exercise while others dread it.  Working out 30 minutes per day involves a significant time and energy commitment.  Thus, while Dr. Ozner’s solution is sensible, it is not easily implemented.  

Conclusion

Overall the book is important in that it clearly explains the dangers of excessive heart surgery.  However, the solutions of eating healthy and exercising are already well-known and the Dr. Ozner’s support of the Mediterranean Diet dominates the last half of the book.

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How important is credit?

December 22, 2008 in Economics - General | No comments

“Adequate credit is to trade what altitude is to aircraft; without it, the odds of coming to grief over preilous commercial terrain are great.  All merchant enterprises sooner or later lose cargoes or encounter soft markets.  Without ample capital reserves and the ability to borrow at low rates of interest, bankruptcy is inevitable.”

~ William Bernstein (2008) on the importance of credit to the East India Company, in A Splendid Exchange.

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