Outcome measures

Atul Gawande has a tremendously important article in the 1 June 2009 issue of The New Yorker, which should be read by everyone, regardless of ideological bent, who cares about health care reform in both the United States and Canada. It is very enlightening: does spending a lot of money on health care actually produce better outcomes for patients? (Answer: no! but not for the reasons you might think.)

The truly telling part, for me, was the discussion about overutilization:

I gave the doctors around the table a scenario. A forty-year-old woman comes in with chest pain after a fight with her husband. An EKG is normal. The chest pain goes away. She has no family history of heart disease. What did McAllen doctors do fifteen years ago?

Send her home, they said. Maybe get a stress test to confirm that there’s no issue, but even that might be overkill.

And today? Today, the cardiologist said, she would get a stress test, an echocardiogram, a mobile Holter monitor, and maybe even a cardiac catheterization.

“Oh, she’s definitely getting a cath,” the internist said, laughing grimly.

I was floored by this passage — and by the later discussion about the motivational role that money plays in clinical decision-making. (That’s an educational piece that probably should be saved for another day.)

What’s really interesting to me, though, is what this implies about scarcity and resource allocation. One of the more annoying complaints from Republicans and their proxies on this side of the border is that Canada’s health care system has shortages of all kinds of stuff, and that you’ll have to get in line to have your MRI or whatever, and it’ll take six months. Ok, fine, that’s probably true a lot of the time, and in the United States you could probably have that test, and a whole bunch more, within a matter of hours. (I think Phoenix has more MRI suites that the entirety of western Canada.) But what I want to know is this: how many of these tests, more freely available in the United States than in Canada, are clinically relevant, how time-sensitive are they, and (this is the critical part) how many fail to turn up anything of significance? Great, so you catheterized that patient, and the coronary arteries were clear. Yay. What have you done? What value have you provided the patient? (We’ll ignore the very real risks of cardiac catheterization here.)

I don’t get it. But that might be why I work here, not there.

Quick hits

A collection of things I’ve been reading:

  • Fascinating thread on cryptography (which hilariously few people read) on the street price of illicitly obtained digital goods, by analogy with the price of heroin as a measure of the success of the war on drugs. I had no idea this stuff even existed, never mind was tracked (though in hindsight I guess I shouldn’t be so stupid).
  • Also from cryptography, is privacy possible in public places? Answer: Probably not.
  • Chantal Hebert has a blogue.

The hummingbirds

, a collection of nine hummingbird photos, some of them more successful at capturing the feel of these really cool birds than others. This was mostly an experiment from start to finish — how well does my beloved 100/2.0 marry up with the EOS 10D’s small sensor? (Answer: Reasonably well; it turns into a 160/2.0-ish lens.) How much depth of field do you really have when wide open on that body? (Answer: Not much.) What kind of a workflow is going to be least irritating for moving 10D images onto the Web? (Answer: Not this one.) How does my idealistic new design template work for photo galleries? (Answer: Jury still out.)

I am, as the note says, still playing around with the best way to present these. Comments are, of course, welcome.

Dr. Hazmat


Mariners 7, Athletics 3

And so we head into the All-Star Break and baseball takes a three-day holiday. For reasons I can’t really articulate, it feels like the whole world is going on holidays for the next little while; I woke up thinking about how odd it was that CBC’s morning programming was exactly like any other weekday. But, of course, it is exactly like any other weekday because it is any other weekday.

This was a good game. No, scratch that. It was a great game. How much did I love it? I loved it very much. I don’t want to go so far as to say it was the best game I’ve seen all year, but it was pretty damn close. I was watching this one on KSTW and on Fangraphs at the same time, as well as continually hitting refresh at USSM, and for some reason I felt much more connected to the game than I usually do when the game’s on TV. (Three different information sources at once will probably do that to you.) The see-saw back and forth, then the bases loading, then Ibanez’s bases-clearing double, and the brawl that followed… it was great baseball. No, scratch that too: It was great entertainment, a fun, wild, crazy game and a perfect way to spend a Sunday afternoon. The great performance by Ellison was just icing on the cake — I’ve hardly been one of Ellison’s bigger defenders, and frankly I doubt the club would miss him were he DFA’d, but it was a great day for him, and a pleasure to watch.

That’s not why I’m writing this, though, why I’m trying to record this so I remember it. This was the first game in a long time where I never really worried about the Mariners being able to win. Even after Seattle lost the lead, after Ellis singled and two guys scored on Beltre’s error, I somehow knew we were going to pull it out — because we’ve been pulling these out all season, and while we’ll always have screwed up plays and bad games, I felt somewhere inside of me that this wasn’t to be one of those bad games. And though I couldn’t have predicted how it was going to get pulled out of the fire, it was, and we won, and I was deliriously happy for the rest of the day.

It’s an interesting feeling. I haven’t felt that way about the Mariners since 2002, maybe 2003 if I’m feeling charitable. It is almost the exact opposite of what I felt on a regular basis last season — “we may be up by five runs in the bottom of the seventh, but don’t worry, they’ll find some way to fuck it up” — and the worst part was that feeling was confirmed more often than not. This season has been different. I went into it with the sense of impending doom, that it was going to be another losing season, another year of futility, another six months of watching the Mariners screw up and play bad baseball, and that hasn’t happened yet, in spite of the shitty trades and frankly awful performance from some players. Sure, there that pair of obnoxious six-game losing streaks, but the losing stopped, and there’s also been a couple of fairly long winning streaks, too. I no longer have this lingering fear that the bullpen will cough up a bunch of runs and turn a W into an L, though a lot of that has to do with Mateo being gone. I realize that I am now going into every game with the expectation that the Mariners will, if not win, then at least give the other team a very good run for their money, and that’s something I haven’t been able to say for at least four years, maybe five.

To be clear, there are still problems with this team. There are still 77 games left, and we have many questions about starting pitching and the vortex of suckitude they call Jose Vidro. But Adam Jones in Tacoma will help — this is a matter of when, not if, and sooner, rather than later — and probably help more than most think. And really, in spite of the problems that have, in all fairness, been there since the beginning of the season, they’re 13 games over .500, 2.5 back in the West, and unless the team collapses in some kind of dramatic and horrifying way… well, part of me thinks it may still be too early to think about that.

But we’re here, at the All-Star Break, and the team is still in contention. In no way are the Mariners out of it. After that last six-game losing streak I thought for sure we were toast, but then the Angles got swept by Kansas City (!) and we reeled off a host of wins, and suddenly we’re nipping at their heels with half a season left. The second half is going to matter, in a way that it hasn’t in a very long time, and I have a feeling it’s going to come down to those final weeks in September, and maybe particularly the double-header in Safeco… and when was the last time you could say that?

A second half that matters. A real penant race. Who’d have thought?

But that never happens!

<ring ring!>

Who the hell could that be? I know, like, four people and they’re all busy tonight.




“Hi, this is Adam Stirling from CFAX radio. I have a jackpot here if you can tell me who the newsmaker of the hour is!”

“Huh? Um. Oh. Er. I have no idea.”

“Sorry to bother you!” <click!>

I always assumed the “we’ve randomly selected someone from the phone book and called them to see if they can answer our question on the off-chance they actively listen to us” was some kind of a cheap gimmick but, holy cats, it’s really not. Of course, me being me, I can think of about a half-dozen more witty ways to answer the question rather than sounding like the clueless dolt I am. Starting with, “Well, I have no idea, but I could guess depending on how much this is worth…”

Scooter Libby! Michael Jackson! Alan Lowe! VANOC! The dude with the pickaxe the cops picked up yesterday! I don’t know! Loser.

Things You Can No Longer Do

As of sometime in the intermediate future, you will no longer be able to:

Boy! I feel well-cared for!

Siddown and shuddup

I came home early Monday morning after an eventful night that never seemed to end, only to fall into a fitful sleep punctuated by frequent phone calls from Scheduling. In between, I had my first baseball dream of the season. I don’t really remember what it was about, but I do remember waking up in the early afternoon with this strange, giddy feeling: Two hours to first pitch!

This was not a good winter to be a Mariners fan. The team made some dumb, dumb moves. I don’t want to re-hash them now. For the first time in a long time, I let my subscription to Baseball Prospectus lapse, didn’t buy the book, didn’t read the papers, didn’t entertain the notion of going to Arizona in February or March. Why would I? It was only going to depress me, and the team wasn’t going anywhere at all. I tried to tell myself that opening day was going to be just another day, a post-nights day, and that I’d pretend not to care — so that the inevitable collapse and impending season-of-doom (does Ichiro leave? does Sexson’s shoulder implode again? do Joses Vidro and Guillen stink up the joint? will Bloomquist get a starting job?) wouldn’t hurt as much as it might if I were with it from the very beginning.

And yet, there I was: 1535, glued to my XM receiver, listening to that asshole Rick Rizzs ramble on and on about the pre-game festivities. This is going to be a long, long summer.

Then Felix threw a strike.
Then he threw another one.
He’d go on to throw 75 more.

I listened to most of this game on the radio and saw some bits and pieces on TV and my god! every time Felix threw that ball I could feel shivers going up and down my back. Like it was some kind of history in the making. It wasn’t, of course, but as Dave says, there were only a handful of pitching performances in the AL last year that were better than the one we just saw.

Baseball’s a funny game. You think you’re OK without it, you think you don’t really need it, and then suddenly opening day is here, with your favorite team stepping in for the first time, and you think, “they’re gonna suck again this year, I’m not gonna pay attention.” And then some 20 year-old kid, the future of the franchise, puts up a line like this: 8 IP, 3 H, 0 R, 0 HR, 2 BB, 12 K.

And all you can think is, “Sweet Zombie Jesus the baseball gods know how to get my attention.”

Baseball’s back. I couldn’t be happier.

Will you be my friend?

I have decided that if you look at this series of cartoons (1, 2, 3) and declare them hilarious, we can be bestest friends in the whole wide world.

Otherwise, bring cash.

(This offer does not apply to existing friends and/or well-wishers. Valid only on this earth. Not to be combined with other promotions.)

This just in: UK census identifies 390,000 fanboys as demographic group

Daily Mail: Jedi Knights demand Britain’s fourth largest ‘religion’ receives recognition:

With their vast intergalactic knowledge and ability to harness the Force, the task of convincing UN officials to recognise their cause should be a walkover for a pair of Jedi Knights.

But self-proclaimed Jedis Umada and Yunyun, better known as John Wilkinson and Charlotte Law, have adopted a more conventional approach in their pursuit of recognition – delivering a protest letter.

The unconventional pair are calling for the UN to acknowlegde what has become Britain’s fourth largest ‘religion’ with 390,000 followers.

The UN International Day of Tolerance, which takes place annually on November 16, is aimed at emphasising the dangers of intolerance and promoting integration and cohesion across the globe.

Part of me wants to ascribe Britain’s national ills to this phenomenon, but I can’t. It seems far too difficult to think that almost 400,000 people are weird enough to (a) believe that pretending to be a Jedi leads to a better life and (b) actually put that on their census forms. It’d be like finding out that a million Americans listed Oprahism as their faith — you want to make a joke, but can’t quite bring yourself to pick on them because you suspect they have other, uh, problems.

I wonder when the Star Wars Trek will begin in earnest?