All entries for February 2006

February 27, 2006

Hospitals and Misdiagnosis

The NYT writes about how rates of misdiagnosis in US hospitals haven’t fallen over time despite great improvements in technology.

With all the tools available to modern medicine — the blood tests and M.R.I.'s and endoscopes — you might think that misdiagnosis has become a rare thing. But you would be wrong. Studies of autopsies have shown that doctors seriously misdiagnose fatal illnesses about 20 percent of the time. So millions of patients are being treated for the wrong disease.
How can this be happening? And how is it not a source of national outrage?A BIG part of the answer is that all of the other medical progress we have made has distracted us from the misdiagnosis crisis. Any number of diseases that were death sentences just 50 years ago — like childhood leukemia — are often manageable today, thanks to good work done by people like Dr. Bergsagel. The brightly painted pediatric clinic where he practices is a pretty inspiring place on most days, because it's just a detour on the way toward a long, healthy life for four out of five leukemia patients who come here.

But we still could be doing a lot better. Under the current medical system, doctors, nurses, lab technicians and hospital executives are not actually paid to come up with the right diagnosis. They are paid to perform tests and to do surgery and to dispense drugs.

Read in full here (Free subscription) (via Reddit)

My knowledge of medicine is limited to Scrubs, Grey’s Anatomy & House M.D. In any case, the real world must deal with which medical practitioners who are stressed, limited by the finances of hospitals and limited in the time they can devote to any one case. This necessitates shortcuts and thus errors. Consistency in errors doesn’t in itself signal a crisis. However, the article’s claim that doctors should receive greater feedback seems fair. That feedback may be produced internally (e.g. internal audits), or via the market (e.g. payment by results). Without feedback, incentives to learn and correct mistakes are limited. Autopsies are a means of generating feedback; a means of comparing causes of death to prior diagnoses. This article states that autopsy rates in the US need to be increased significantly so as to uncover systematic errors. I don't know details, but this piece from the president of the Royal College of Pathologists suggests the UK isn't too dissimilar.

Despite the obvious value of autopsies, the proportion of deaths (disregarding those investigated at the request of a coroner) subjected to this highly informative medical investigation has fallen steadily during the last few decades. Now, even in UK teaching hospitals, the autopsy rate is usually below five per cent. This has serious implications for clinical governance and audit, for the detection of unexpected adverse effects of medical interventions, and for undergraduate and postgraduate medical education. Regrettably, many doctors are now graduating from UK medical schools without ever having witnessed an autopsy.

February 21, 2006

Parliamentary Reform Bill

Edward Cooper earlier linked to an article about the Legislative and Regulatory Reform Bill. Here’s another piece from yesterday’s Times.

I don’t know enough to add anything worthwhile, though it’s easy to see why the proposals are causing concern. has a transcript of a very interesting though extremely long Commons debate on the issue. What comes out of it is the gains that could be had from easing the regulatory burden on businesses. Something the current system makes difficult, and the primary problem the Bill is intends to solve. Conservative MP Oliver Heald says the following

Other measures, such as the International Institute for Management Development's "World Competitiveness Yearbook", show that the UK has fallen from ninth to 22nd since 1997. The London School of Economics recently warned about "concerns that tougher competition could be undermined by increasing regulation".

The CBI has said: "Many businesses believe regulation is damaging the UK's attraction as a place to invest . . . the burden has grown and expect it to increase further."

The Library has shown that there are 3,887 regulations a year on average under this Government—15 every working day. That is a 50 per cent increase on what happened under the last Conservative Government.

Still, good intentions and economic benefits must be weight against ambiguous and lax safeguards as compared with the status quo. Lib Dem MP David Howarth says this

Obviously, I welcome, as we all do, the Minister's assurances that his test of whether something is controversial or highly controversial, and the mechanism of the Committee veto, will offer extra safeguards, but the problems are clear with those two safeguards. There is at the moment no definition of "controversy" in the Bill and the Committee majority mechanism does not deal with the controversy point. It is possible for a matter to be highly controversial with only a minority of members. A Committee could easily decide in favour of taking the order through the procedure introduced by the Bill, even though the matter was highly controversial in other parts of the House.

Read the whole debate here.

It may be ill-considered to boldly declare this Bill the end of parliamentary democracy. Nonetheless, it undoubtedly requires further delegating of authority, and increased trust on the part of MPs and constituents. One’s level of concern will vary with the extent ministers are deemed to be reactionary, self interested and overconfident about their opinions and abilities.

February 18, 2006

Employers & Employee Benefits

The Independent writes about comments made by Wal-Mart CEO to a disgruntled manager. The manager in question wanted to know why such a large company wasn’t doing more for its low-wage employees.

The manager had asked Mr Scott why "the largest company on the planet cannot offer some type of medical retirement benefits?" Mr Scott replied: "Quite honestly, this environment isn't for everybody. There are people who would say, 'You should take the risk and take billions of dollars out of earnings and put this in retiree health benefits and let's see what happens to the company'. If you feel that way, then you as a manager should look for a company where you can do those kinds of things."

Scott’s ‘take it or leave it message’ certainly won’t do anything to help the firm’s already run-down reputation. That said, Scott has a point, which is bolstered by an observation about the problems facing General Motors he makes in the full letter here.

GM has seen failing demand for its products over time and has underestimated its pension liabilities. Its future as a firm is sometimes questioned. For more, see this NYT article

"The thing that annoys me about GM is that when I retired I had a letter that said I would receive health care for life at no cost," said Chester Clum, 79, a former sales and service manager at GM who retired in 1981 after 38 years of service. "They never brought up that they could change that at will." But, in fact, the change has been long in coming. While there are exceptions in industries less subject to intense competition, GM is like many other once impregnable American corporate titans in arguing that reducing the burden of caring for retirees has become essential to compete against foreign companies with lower benefit costs and domestic rivals with younger work forces and less generous benefit packages.

With retirees living longer and accounting rules forcing companies to more honestly reflect their full costs on their books, the corporate-sponsored social contract is no longer sustainable. Something else, experts say, needs to replace it.

"It was easy to offer these things 40 years ago because they were cheap," said Paul Fronstin, director of the Health Research and Education Program at the Employee Benefit Research Institute, a nonpartisan group in Washington. "They're not cheap anymore."

Wal-Mart could certainly pay it’s staff more and contribute towards healthcare plans but it comes at the cost of a) taking on fewer people in the first instance b) being more vulnerable to competitors c) being more vulnerable to economic changes that affect all companies. The effects of the first are more immediate whereas the latter two get ignored because they’re non-tangible probabilities. None of these things are good for the groups who’re supposed to gain from higher wage/non-wage benefits. Of course the scale of the benefits granted by the ailing GM may dwarf those Wal-Mart’s employees are asking for; after all, many firms offer good packages without any problems. The main point is that one-sided accusations of greed and exploitation are unfair.

February 15, 2006

Student Union on Tuition Fees

Yesterday’s Warwick Boar briefly touched on union president Brian Duggan’s view of tuition fees.

Students will expect a lot more, because they’re paying a lot more, from their institutions and their unions and we’ll have to be at the forefront of direct representation for students not only to make sure students are getting value for their educations, but to ensure we’re providing the right representations and services, and also making sure we fight fees..The only thing that has been done on fees in the past four years is this leaflet that I’ve made.

That’s fair enough. I hadn’t seen the leaflet he refers to, but there’s some info on tuition fees on the student union website. As regards undergraduate fees for domestic students it says the following

Labour promised not to introduce Top-Up Fees…and then they did. From next year Home Undergrads will pay £3000 a year tuition fees. They will leave Uni with an average debt of £20–25k each. Applications are down across the country; clearly high tuition fees are a barrier to involvement. Students from lower socio-economic backgrounds will recieve help, however the system is confusing and offputting, with many students simply not even considering University because of a fear of debt.

Won't the money be useful to Uni's?

We are all being told that Top-Up Fees are necessary if we are to have enough funding in our Uni's for decent facilities and teaching. This is not true! Fees don't cover it. There is a serious funding problem in Higher Education but £3000 per student does not come close to fixing the problem.

Read in full here.

The first paragraph makes a fair point. The prospect of debt will be a deterrent to some groups even if they would be well equipped to make future repayments. Could we encourage teachers to stress the upside potential to such groups? Could short term grants and bursaries help overcome resistance? Who knows; it’s not discussed. The second paragraph appears confused. It admits to a serious funding problem in higher education, but seems thinks that because £3000 fees are insufficient, we should maintain the status quo. Perhaps the author meant the burden should be shifted to taxpayers. Or maybe the benefits of a relatively cheap education far outweigh the benefits of more money and more resources. Again, we’re not told.

Merely saying that ‘Everyone has the right to education that is FREE, FAIR and FUNDED’ doesn’t make it so. The union needs to better explain why a free university education leads to better outcomes than the alternatives. I don’t mean better outcomes for just the students involved. One must consider all the other parties affected: the lecturers, the universities and the taxpayers who never had the benefit of a university education themselves. I know it's not supposed to be a means of getting change, but the union website seems like a perfect place to fully explain the tuition fee stance to those who're unsure; a place to dismiss the notion that students are selfish and unwilling to endure discomfort for long term gain. At present, it just seems lazy.

February 13, 2006

Corporate Welfare

Not too long ago, outgoing David Cameron boldly said the Conservative party wouldn’t be in the pocket of Britain’s businessmen. From the guardian

Britain's business leaders could be forgiven for being confused. David Cameron gave a rousing speech to the CBI conference in November, promising he would lead a 'campaign for capitalism'. Yet by last week, he was delivering a new year message in which he pledged to 'stand up to big business' and relegated capitalism to the same category as communism – that of outdated 'isms' he wants nothing to do with.

On those lines, here’s a great article from John Stossel about the benefits the already wealthy are able to gain from government. Stossel comments on state insurance schemes for those building on land private insurers avoid, corporate subsides in general and eminent domain. A quote –

A limo took us to Dwayne Andreas’ [Archer Daniels Midland chairman] office. Once the cameras were rolling, I brought out the questions about "corporate welfare." I foolishly thought I could get him to admit he was a rich guy milking the system. I thought he’d at least act embarrassed about it. Fuggeddaboutit. He was unfazed.

Stossel: Mother Jones [magazine] pictured you as a pig. You’re a pig feeding at the welfare trough.
Andreas: Why should I care
Stossel: It doesn’t bother you?
Andreas: Not a bit.

I still wonder why he granted the interview. I asked him about his bribes -- I mean, contributions. For example, Andreas gave the Democrats a check for $100,000. A few days later, President Clinton ordered 10 percent of the country to use ethanol.

Stossel: And the purpose of this money wasn’t to influence the president?
Andreas: Certainly not.
Stossel: So why give him the money?
Andreas: Because somebody asked for it.

Because they asked for it? Give me a break.

Read in full here.

By virtue of size, wealth and organisation certain groups can wrangle favours though the benefits accrue to a closed group rather than society as a whole. What can be done about it? People can’t be prevented from exercising free speech and asking for what they want. Nor does it seem fair to categorically prevent monetary & non-monetary contributions to policymakers. Full disclosure of links between policymakers and special interest groups doesn’t seem to make much difference either. After all, any assistance provided is professed to be in the country’s best interests and thus nothing to be ashamed of.

February 09, 2006

Worker Shortages

Lew Rockwell comments on statements from business groups and politicians about shortages of scientists, engineers and mathematicians.

Think of how jobs have changed. We have fewer people around today who know how to farm because fewer people are necessary to do the job. More kids than ever are going into computer sciences because of the perception that these fields will be lucrative in the future. In neither case was a government program necessary. People entering the job market find out quickly what is in demand and what isn't and compare that to their own capacity for doing the job.

The reason the whole math and science racket bamboozles us again and again has to do with our own limitations and our perceptions of foreign countries. We think: heck I know nothing of these subjects, so I can believe that there is a shortage! And surely math and science are the keys to just about everything.

Read in full here.

The word ‘shortage’ may be used a little loosely in the media when applied to jobs and skills. Not every instance of lack deserves to be taken seriously. It makes no sense for me to say there’s a shortage of Ferraris merely because my student budget would get me laughed out of a dealership. I’m simply not willing to pay what its worth. If I say there's a shortage of Ferraris it should be qualified with a statement of a) why I don't think they're worth what I'm willing to pay, and/or b) why it is impossible to pay the going rate. Even when the latter is the case, the harm being done must be considered before declaring a crisis or deciding active intervention is needed.

Take the issue of teachers. The DfES recognises the obvious (albeit not instant) solution to shortages, as evidenced by generous training bursaries of up to £7000 and Golden Hellos of up to £5000 for PCSE candidates hoping to teach maths and science. Given that it knows the solution, the government couldn't blame poor quality education in certain areas on a lack of staff if it refuses to go further with it’s recruitment efforts.

If there are strong financial constraints on their ability to do this (beyond obstinacy), like an unwillingness amongst the populace to pay more tax, then claims of shortages are more credible. Here we’d need to accept that teachers in state schools aren’t necessarily going to hold degrees in their teaching field. Lower expertise may be a suitable trade-off for lower wages given the difficulty of the material being taught. Perhaps the expectations of teacher expertise are too high.

That said, I doubt the constraints faced are insurmountable. Sure, you may not be able to hike taxes, but I bet there are reasonable sacrifices to be made within government. Could policymakers genuinely say that education is important, but not important enough to warrant sacrificing other schemes, and cutting salaries in other areas? Such reorganisation is difficult politically, but probably not operationally. Shifts in resource use needn’t be radical to have a beneficial impact. As long as reasonable sacrifices exist, claims that poor education is down to a shortage of skilled staff is inaccurate. Like my Ferrari, policymakers just doesn’t want to pay what good (by its own definition) teachers are worth.

February 07, 2006

Signalling & Alternatives to University

Here Bryan Caplan of Econlib, a supporter of the view that a degree is primarily for signalling desirable traits, discusses the value of a degree. Idea is, you’re valued as a graduate not so much for the knowledge you come away with but because sitting through lectures and jumping through exam/assignment hoops for three years implies you’re reasonably productive and capable of learning. That many of the firms we see on campus don’t require specific degrees suggests this is often true. What I liked was a suggestion by a later commenter

Start up a school that screens for IQ, and basically puts students through hell — difficult topics involving critical thinking, research, teamwork, and long hours, all without any grade inflation. It would be cheaper because you wouldn't necessarily need well-educated professors. That would be extremely powerful signaling. You might not even have to charge tuition — if you could run it cheaply enough.. Also, you might be able to pack four years' worth of standard signaling into two years, and people who only made it through one year would still prove something. If it failed, so does the signaling thesis.

Clearly needs refining, but the idea has some appeal. The assessment days (featuring tests, group exercises, presentations and interviews) used by large employers could be a model. University helps develop workplace skills, but for non-technical jobs I doubt the gain significant enough to warrant not considering an 18 or 19 year old, or that lessons wouldn’t be learned anyway, once in a pressured work environment.

There must be quicker ways of verifying the existence of certain traits in candidates / cheaper ways for candidates to convey their ability. That job prospects aren’t the sole concern of most people is deliberately ignored. Taking this into account together with subsidies to education, it’s understandable why such alternative schemes (run by independent firms or employers themselves) aren’t around.

February 02, 2006

George Monbiot

Just found the blog of journalist George Monibot who I’d heard of before, but didn’t know was a Guardian writer. There’s plenty to agree and disagree with but I like his writing. For something of more universal interest (and in keeping in the theme of wealth & happiness) take a look at this article on choosing a career –

How many times have I heard students about to start work for a corporation claim that they will spend just two or three years earning the money they need, then leave and pursue the career of their choice? How many times have I caught up with those people several years later, to discover that they have acquired a lifestyle, a car and a mortgage to match their salary, and that their initial ideals have faded to the haziest of memories, which they now dismiss as a post-adolescent fantasy? How many times have I watched free people give up their freedom?

So my second piece of career advice echoes the political advice offered by Benjamin Franklin: whenever you are faced with a choice between liberty and security, choose liberty. Otherwise you will end up with neither. People who sell their souls for the promise of a secure job and a secure salary are spat out as soon as they become dispensable. The more loyal to an institution you are, the more exploitable, and ultimately expendable, you become.

Read in full here.

February 01, 2006

Is £25k enough?

Yesterday’s T2 supplement contributed to the long running discussion about wealth and happiness. The general thrust is that “Once you’re earning £25 000 and becomes increasingly irrelevant to genuine happiness”. Methodological issues relating to surveys of subjective well being suggest claims like that could be treated with caution; particularly when accompanied with suggestions for government policy. Still, it’s worth a read.

True happiness, said Bob Monkhouse, is when you marry a girl for love and later discover that she has money. We all appreciate the joke, of course, because though one side of us knows that a loving relationship provides a good chance of happiness the other thinks it would be guaranteed if that relationship made us rich as well.

Yet study after study shows that money fails to buy happiness. Incomes have increased threefold in Britain since 1950 but contentment levels have barely shifted. European research indicates that lottery winners revert to their previous levels of happiness within a year of their windfall. One look at the permanently sullen face of the multi- millionairess Victoria Beckham appears to prove the point.

Full article here.

Around the web, there has been some discussion of the role research on subjective well being should play in policy formation. See this post from Will Wilkinson on the Happiness and Public Policy blog and this from Chris at Stumbling & Mumbling. One World Week also featured a talk on the issue.

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