Individual Rights on Campus
The Foundation for Individual Rights in Education (FIRE), on whose board I serve, reports on the issues it tackled in 2004.
Dynamist Blog
A Cultural Revolution?
I've made the big time! Reader Clark Thomas calls my attention to an item way down the DMN's fashion section's year-end in-vs.-out list. "At some level," he writes, "I suppose that is an honor, though I can think of a number of others to put on the 'out' list."
Clark is also kind enough to supply this NYT book review, which will help readers who don't understand why this comparison is so funny, yet not entirely inconceivable. "Perhaps, though, yours [your book, that is--vp] will also inspire 'readers everywhere to rise up and rip one another limbless,'" he writes.
On a more serious note, Strategy+Business has named The Substance of Style to its year-end list of Best Business Books. (Because of the magazine's lead time, books published in the fall, e.g., September 2003, get included in the following year's list.) A review essay is here and editor-in-chief Randall Rothenberg discussed the choice on NPR's "Morning Edition".
It Started Here
Here's an interesting roundup of business (and one nonprofit) innovations that started in Dallas. It appeared in the always-boosterish Dallas Morning News, but what makes it worth reading is not the local angle but the sheer diversity of innovation it illustrates. Good ideas come in many forms. That all these different ideas came from a single place only makes that diversity more striking.
Medical Kaizen
In response to the post below about Atul Gawande's article, several readers have sent links to these posts. Without any prompting from me, Professor Postrel emailed the following to Soxblogger James Frederick Dwight, thereby saving me the trouble of composing a response (and giving Dynamist readers the benefit of his statistical training and years of following the quality revolution in manufacturing):
Mr. Dwight: I have read with interest your posts on the New Yorker article by Dr. Gawande. It is undoubtedly correct that a rigorous analysis would require some sort of multiple regression approach to control for patient differences, assuming that genetic data at the patient level are available across the entire sample. Then coefficients on the dummy variables for each clinic would presumably capture the effect of each clinic (subject to the usual caveats about potential omitted variables).
The vehement tone of your criticism is, however, unwarranted, because it seems very unlikely that the superior performance of the clinic in Minneapolis is entirely or largely due to random assignment of genetic types. I conclude this on the basis of the following factors:
1) The types of CF that result in rapid death will constitute a vanishingly small percentage of the population at any one time, for the obvious reason that these unfortunate patients die off quicky. If, as I suspect from the crudity of measures that you highlight, the data have not been corrected for this bias, the hardest cases will have almost no effect on the performance differences found.
2) You provide no links or citations for your claims about genetic variants and their impact on longevity. Perusal of the CF Foundation website provides no such information. Taking your word for it, however, the key datum we need to evaluate Gawande's claim is NOT how many genetic variations there are but how big the range of severity is across those variants (weighted for their persistence in the clinic patient pools).
(Beyond evaluating Gawande's claims, it might be interesting to see if dummy variables on each genetic variation, both independently and in interaction with the clinic dummies, explain much of the variation. This would get at whether certain clinics were especially good at handling particular genetic variants. I don't know if we would have enough data points to do this though--degrees of freedom could be an issue.)
3) Your confidence about the low variance of performance among physicians is unwarranted. Even conditional upon being in the upper tail of a distribution of attribute X, there may still be substantial variation within that upper tail. More importantly, if attribute X is imperfectly correlated with what we really care about, attribute Y call it, then a group from the upper tail of the X distribution may well look like a bell curve in the Y dimension. Let X be the attributes that get people through medical licensing and let Y be proficiency in treating CF. It would not be shocking if professional training captured only some of the factors that ON THE MARGIN make one practitioner more effective than another.
4) It seems cosmically unlikely that the best clinic in the sample just happened to be the one run by the pioneer in comparative methods, the one who used demonstrably different techniques for treatment, quality assurance, and patient compliance. The idea that Minneapolis just happened to get a phenomenally favorable genetic draw AND was an innovator in treatment (doing things very differently) seems far-fetched.
5) The Gawande article claims that not only is there a bell curve in performance, but the leaders are IMPROVING faster than the average and below-average clinics. Unless patient turnover is negligible, that militates strongly against the suggestion that it is all the luck of the genetic draw. If patient turnover is negligible, then at best one could argue that there are genetic types that are not only easier to treat but that have initially hidden pathways to improvement not present in other types. This seems strained as well. More likely, we have an example of organizations exhibiting what the Japanese call "kaizen" or "continuous improvement through incremental refinement."
6) There is a vast body of empirical evidence in fields ranging from computer programming to automobile manufacturing that performance variations among similar units are large and persistent. To the extent that these are differences at the individual level (e.g. programming) no known intervention exist, to my knowledge. To the extent that they exist at the organizational level (e.g. auto factories), they can be addressed with a variety of management practices, many of which can help but none of which promise immediate performance convergence. For example, the Wall Street Journal [actually the NYT--vp] has just run an article on how getting hospitals to follow established standards of care in a few selected disease categories can have huge impacts on mortality. Failure to follow these standards of care is attributed primarily to physicians' inability to remember all the things that should be done given the stress and information overload they face and/or their cultural unwillingness to follow codified protocols consistently.
7) The CF Foundation website makes laudatory mention of the Gawande article and registers no objection whatsoever to its use of the data.
For all of these reasons, your tone of accusation and conclusive dismissal of Gawande's thesis is premature. Ideally, we would have peer-reviewed econometric studies to settle these matter conclusively. Absent those, however, your objections fall short of discrediting Gawande or the New Yorker.
Mr. Dwight has not had a chance to respond yet. I'm posting this because I thought readers would be interested in the counterargument.
"Stingy" or Not? Drezner Weighs In
In response to my post below, Dan Drezner runs through the numbers on whether or not the U.S. is "stingy" with aid. He also catches the Washington Times with a misleading headline on a careful story. As anyone who writes for a newspaper can tell you, you can't trust headlines to be either interesting or accurate.
Two Frustrated P.R. Departments
From Claudia Deutsch's NYT article on companies outsourcing their design, a significant trend but not as new as the article suggests:
"There's no question: the 2004 models of competitive cars look a lot more alike than the 1994 models did," said Sunil Chopra, a professor of operations management at the University of Chicago's Kellogg School of Management.
Kellogg, where Chopra works, is, of course, part of Northwestern University, which is in Evanston, just north of Chicago. The University of Chicago Graduate School of Business is called just that.
What the Riots Wrought
Nostalgic pop culture recalls 1967 only as the Summer of Love, but it was also summer race riots burned through Detroit and Newark, to name only the deadliest incidents. Back in the '60s, inner-city property values were the last thing opinion elites were concerned with. But the riots of the 1960s had devastating long-term effects on the most significant assets owned by urban blacks: their homes. Those effects that may still exacerbate the so-called wealth gap between blacks and whites. My latest NYT column looks at research on the 1960s riots' long-term economic impacts:
As an economic historian, Robert A. Margo has long wanted to study the 1960's. But, he says, "for the longest time people would say, 'That's too close to the present.' "
Not so anymore. The 1960's are as distant from today as the Great Depression was from the 1960's, and economic historians, including Professor Margo, of Vanderbilt University, are examining the decade's long-term effects.
Consider the wave of race riots that swept the nation's cities. From 1964 to 1971, there were more than 750 riots, killing 228 people and injuring 12,741 others. After more than 15,000 separate incidents of arson, many black urban neighborhoods were in ruins.
As soon as the riots occurred, social scientists began collecting data and analyzing the possible causes. Until recently, however, few scholars looked at the riots' long-term economic consequences.
In two recent papers, Professor Margo and his Vanderbilt colleague, William J. Collins, do just that by estimating the impact on incomes and employment and on property values.
The riots not only destroyed many homes and businesses, resulting in about $50 million in property damage in Detroit alone, but far more significantly, they also depressed inner-city incomes and property values for decades.
Read the whole thing here, and check out the photo.
Satellite Blogging on Tsunami Damage
My pal Charles Oliver points me to Chuck Watson's satellite blogging on the tsunami and its effects, with photos from low earth orbit. Based on what he sees from space, Chuck is estimating at least 128,000 deaths from the immediate impact of the tsunami, with more to come in the aftermath. In other news, he also has photos of fires in the Hamrin and Kirkuk oil fields.
More on Medicine
Responding to the post below, my friend Jennifer George points me to this terrific Atul Gawande article in The New Yorker on the questions raised, for doctors and patients, by tracking and reporting the different outcomes from different medical centers. By definition, not everyone can be the best. What happens to doctors who are in the middle of the bell curve? How would their otherwise satisfied patients react to knowing their physicians' results are merely normal?The article focuses on cystic fibrosis treatments. Here are a few excerpts, but it deserves a full read:
Like most medical clinics, the Minnesota Cystic Fibrosis Center has several physicians and many more staff members. Warwick established a weekly meeting to review everyone's care for their patients, and he insists on a degree of uniformity that clinicians usually find intolerable. Some chafe. He can have, as one of the doctors put it, "somewhat of an absence of, um, collegial respect for different care plans." And although he stepped down as director of the center in 1999, to let a protege, Carlos Milla, take over, he remains its guiding spirit. He and his colleagues aren't content if their patients' lung function is eighty per cent of normal, or even ninety per cent. They aim for a hundred per cent--or better. Almost ten per cent of the children at his center get supplemental feedings through a latex tube surgically inserted into their stomachs, simply because, by Warwick's standards, they were not gaining enough weight. There's no published research showing that you need to do this. But not a single child or teen-ager at the center has died in years. Its oldest patient is now sixty-four....
We are used to thinking that a doctor's ability depends mainly on science and skill. The lesson from Minneapolis is that these may be the easiest parts of care. Even doctors with great knowledge and technical skill can have mediocre results; more nebulous factors like aggressiveness and consistency and ingenuity can matter enormously. In Cincinnati and in Minneapolis, the doctors are equally capable and well versed in the data on CF. But if Annie Page--who has had no breathing problems or major setbacks--were in Minneapolis she would almost certainly have had a feeding tube in her stomach and Warwick's team hounding her to figure out ways to make her breathing even better than normal.
Don Berwick believes that the subtleties of medical decision-making can be identified and learned. The lessons are hidden. But if we open the book on physicians' results, the lessons will be exposed. And if we are genuinely curious about how the best achieve their results, he believes they will spread.
The Cincinnati CF team has already begun tracking the nutrition and lung function of individual patients the way Warwick does, and is getting more aggressive in improving the results in these areas, too. Yet you have to wonder whether it is possible to replicate people like Warwick, with their intense drive and constant experimenting. In the two years since the Cystic Fibrosis Foundation began bringing together centers willing to share their data, certain patterns have begun to emerge, according to Bruce Marshall, the head of quality improvement for the foundation. All the centers appear to have made significant progress. None, however, have progressed more than centers like Fairview.
"You look at the rates of improvement in different quartiles, and it's the centers in the top quartile that are improving fastest," Marshall says. "They are at risk of breaking away." What the best may have, above all, is a capacity to learn and adapt--and to do so faster than everyone else.
Once we acknowledge that, no matter how much we improve our average, the bell curve isn't going away, we're left with all sorts of questions. Will being in the bottom half be used against doctors in lawsuits? Will we be expected to tell our patient how we score? Will our patients leave us? Will those at the bottom be paid less than those at the top? The answer to all these questions is likely yes....
The hardest question for anyone who takes responsibility for what he or she does is, What if I turn out to be average? If we took all the surgeons at my level of experience, compared our results, and found that I am one of the worst, the answer would be easy: I'd turn in my scalpel. But what if I were a C? Working as I do in a city that's mobbed with surgeons, how could I justify putting patients under the knife? I could tell myself, Someone's got to be average. If the bell curve is a fact, then so is the reality that most doctors are going to be average. There is no shame in being one of them, right?
Except, of course, there is. Somehow, what troubles people isn't so much being average as settling for it. Everyone knows that averageness is, for most of us, our fate. And in certain matters--looks, money, tennis--we would do well to accept this. But in your surgeon, your child's pediatrician, your police department, your local high school? When the stakes are our lives and the lives of our children, we expect averageness to be resisted. And so I push to make myself the best. If I'm not the best already, I believe wholeheartedly that I will be. And you expect that of me, too. Whatever the next round of numbers may say.
Read the whole article here.
A Nagging Question about Susan Sontag
In my world, or perhaps my generation, Susan Sontag was mostly famous for being famous and having a skunk streak in her hair. I'll leave serious comment on her work to those who know it better than I do. (I've only read "Notes on Camp" and some selections on Cuban posters.) As a self-employed writer, however, I was struck by this passage in the NYT's long obit:
She found the form an agony: a long essay took from nine months to a year to complete, often requiring 20 or more drafts.
"I've had thousands of pages for a 30-page essay," she said in a 1992 interview. " 'On Photography,' which is six essays, took five years. And I mean working every single day."
How do you earn a living like that? The audience for intellectual essays is not big to begin with, and one book in five years, with no other career on the side, is hardly enough production to pay normal bills, let alone support a collection of 15,000 books and space to house them in Manhattan.
Professor Postrel, whose job conveniently provides health insurance for his self-employed spouse, suggests that the answer lies at the end of this less-than-favorable obit by Roger Kimball.
UPDATE: Christopher Hitchens, who most certainly does not take nine months to write an essay, sheds no light on the mysteries of Sontag's finances. But his appreciative obit does balance Kimball's jaundiced view.