Are 83% of Medical Doctors considering leaving medicine?

Aaron Carroll rightly argues that any such claim is silly:

Let’s get past even that. Let’s just take the top line result. Does it pass the smell test? Do you really believe that 83% of doctors are considering quitting because of the ACA? Do you really believe that only 17% of docs are NOT considering quitting? Really? Anecdotally, I’ve heard of no physicians whatsoever who are quitting; I work with a lot of docs. But let’simagine my experience is abnormal. Remember that about 20% of physicians make an earning placing them in the top 1% of the country. Medicine, above any other profession, is more likely to earn you that much. This survey would have you believe that more than 80% of us are willing to throw all that away, just because of the ACA.

Notice that this implies that medical doctors would have to be complete and utter morons in order to do this.  And over ACA?  Now, I could imagine a scenario in which medicine was becoming less attractive as a career path and some doctors might have decided they would have been better off as MBAs, for example -- ignoring whether they could have been a successful MBA even if they had wanted to.

Heck, would not the MA experiment have shown these kinds of effects if 83% of MDs were honestly considering leaving? 

Why can't we have a press corp that would make fun of such an unlikely claim? 

Stock Market Bubbles and the Near Miss Effect

This American Life had another remarkable episode a few weeks ago on blackjack (which I just got around to). As usual, there's lots of good stuff here, but two parts in particular caught my eye. The first was this work from two researchers at Southern Illinois University, Reza Habib and Mark Dixon (the second will have to wait for an upcoming post):

Sarah Koenig
In 2006, Dixon teamed up with Habib to see if they could figure out what was happening to people neurologically when they saw near misses. They scanned the brains of 22 gamblers-- 11 addicted, or what they called pathological gamblers, and 11 non-pathological gamblers-- as all these people watch near misses on slot machine displays. 

 The results surprised them. Because while both addicted and non-addicted gamblers said the near misses felt more like wins, their brains said something different. Here's Reza Habib. 

Reza Habib
What you see in the non-pathological gamblers is that the regions that are activated for losses, those same regions tend to be also activated for near misses. And so the brain, at least, processes these near misses in the same way that it processes losses in the non-pathological gamblers. In pathological gamblers, the same regions that are activated for wins are also activated for near misses.

And so these include regions such as the amygdala, which is a region involved in emotional processing, as well as parts of the brain stem which are involved in reward and dopamine function, which is part of the reward system. So the pathological gamblers, their brains, at least, are responding to these near misses in the same way that they respond to wins.

Mark Dixon
This is Mark again. And one of the effects of this, or the implications of these data, are that a pathological gambler going into the casino who's actually losing, his brain is firing like he's winning. Disturbing, isn't it.

Sarah Koenig
Yeah. It's crazy.

Mark Dixon
Oh, it's way crazy. And so you are experiencing those same sensations as a win when you're not winning.

This got me thinking about bubbles. Even in normal times, traders experience constant near-misses; they get in a bit too late or stay in a bit too long or buy a dud only to watch its nearest competitor shoot through the roof. In bubbles those near miss moments easily increase by an order of magnitude. Every time a trader talks to a friend or picks up the Wall Street Journal, he or she hears about an almost-purchased stock doubling in value.

I wonder how much of the curious behavior of markets in bubbles is driven by those traders whose brains are scoring near misses as wins? I'm sure someone's looking at this from the neuroscience side. It might also be worth factoring in when doing agent-based simulations of the market.

"The mind reels with sarcastic replies"*

Today is International Media Ethics Day.



* A quote from the great Charles Schultz

The part where the vet sees the closet should break your heart

Two incredibly touching and (for what they imply) troubling stories from NPR, one about veterans and one about families with small children. Two groups that receive ever-increasing lip service and steadily diminishing support.

"I give up a little bit of my world each day"

NPR is running an extraordinary series on the return of a disease we thought we had beaten:

The Federal Coal Mine Health and Safety Act of 1969 was supposed to sharply cut exposure to coal mine dust. The act set a standard for coal dust exposure (2 milligrams per cubic meter of air), which was as little as 1/4 of the concentrations miners breathed at the time.

The act's passage followed a 23-day unauthorized and rowdy strike in which 40,000 West Virginia coal miners demanded government efforts to prevent the disease and to compensate victims.

By the end of the year, tough dust exposure limits were in place. Miners were offered free diagnostic chest X-rays every five years, and federal compensation became available. The X-rays showed 4 in 10 miners tested had black lung. The disease killed 1,800 miners in a single year. But diagnoses soon plunged more than 90 percent, according to NIOSH data.

"They anticipated that no one would develop progressive massive fibrosis," says 84-year-old Donald Rasmussen, a pulmonologist in Beckley, W.Va., who says he's tested 40,000 coal miners in the last 50 years.

"In 1969, I publicly proclaimed that the disease would go away before we learned all about it," he adds. "And I was dead wrong."

Rasmussen first started charting an increase in serious black lung cases about 15 years ago.

"We began to see the appearance of younger miners who had worked in the mines only since the dust suppression following the '69 act that were showing up with complicated pneumoconiosis or progressive massive fibrosis," he says.

Since 1970, NIOSH epidemiologists documented test results for 43 percent of the nation's coal miners. In 1995, the tests began to indicate more and more black long, rapid disease progression and the unexpected occurrence among relatively young miners.

"From the patterns and from the severity, from the prevalence of the disease, this must be a situation in which the dust in many, many mines is simply not adequately controlled," says Edward Petsonk, a pulmonologist at West Virginia University and a consultant for NIOSH. "There's nothing else that could possibly cause this."

And its human toll:

"Now it feels like I've got a heavy wet sack on each lung," McCowan says, between long, deep breaths. "Breathing has become a conscious effort. ... It seems like I give up a little bit of my world each day, that it gets smaller and smaller." 

Simple tasks become enormous challenges — "a Mount Everest every day," he calls it — including holding his 2-year-old grandson.

"I say, 'Little buddy, I got to put you down for a few minutes,'" McCowan says with a deep sigh. "And he's learned to run a little bit. He'll say, 'Run, paw-paw, run.' He wants me to chase him. And I can't."

The sad part is the may not be the worst education reform proposal I've seen.

From the in box

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I suspect that English may not be the first language here.

Quote of the day

Matt Yglesias:

I'm not much of a car guy, but the way I understand this metaphor to work is that if you want to give rich people credit for being "the engine of the economy" then if the economy is performing subpar it follows that something's wrong with your engine. And yet I suspect Zambrelli wouldn't take kindly to that diagnosis.

I actually found this interesting as it speaks to an odd sort of logic.  People wanting to claim credit for the good pieces but not for the bad ones (like economic downturns).  And yet if you want the credit for good performance you really ought to take your lumps for when things are bad. 

The increasingly self-serving ethics of journalism

(As usual, Brad DeLong gets credit for spotting this one)

Just to recap, I've been complaining (whining, moaning, bitching, etc.) about the state of journallism for a while. Many of those complaints assume (explicitly or implicitly) that journalism is forming a dangerously insular and cohesive group identity (I'm writing outside my field so my terminology might be a bit off -- if a social scientist out there has any notes, I'm open to suggestions).

Assuming I'm on to something here, one of the things we would expect is an ethical code that has notably different standards of behavior inside and outside of the group. Intra-group crimes (like plagiarism where the primary victim is another journalist) would be viewed as grave while offenses against subjects and readers would be seen as less serious. This difference would be particularly notable where journalists and non-journalists are mutually responsible for an offense.

Which takes us to the example of the day. As you probably know, the recent health care decision has produced as usual amount of leak-driven coverage. This has deeply offended Charles Lane of the Washington Post. Here's are some of the phrases that Lane uses when discussing the leaks and leakers:

"slimy"

"oozing slime"

"Cassius and Brutus inside the court, creeping up behind the chief justice with their verbal daggers"

"shame on the treacherous insiders"

And here's how Lane talks about Jan Crawford, the reporter who published the leaks,

"a fine journalist"

"kudos to Jan Crawford for a nifty little scoop"

According to Lane, Crawford's story damages the Supreme Court and misleads the reader, but the responsibility is apportioned so that all of the blame falls on the sources for passing the story on to the reporter. He even goes further and praises the reporter for passing the story on to us.

I suppose it might be possible to come up with a situation where two parties knowingly work together to produce something bad for society and yet one party shoulders all of the blame while the other is praiseworthy but Lane is no where near making that case here, nor does he seem to realize that he needs to.

One more locavore note

While I was looking up background on Pierre Desrochers (author of the Locavore's Dilemma) for the last post I noticed a favorable notice by Tyler Cowen and it got me thinking. Cowen is well known as what we used to call a gourmet. He has written extensively and knowledgeably on all matters culinary. He obviously cares deeply about good food.

As mentioned before, Desrochers is a defender of the far-traveled Florida tomato, a type of produce notable only for its durability (as described here by Barry Estabrook, author of Tomatoland, in an NPR interview):

Yeah, it was in southwestern Florida a few years ago, and I was minding my own business, cruising along, and I saw this open-back truck, and it looked like it was loaded, as you said, with green apples.

And then I thought to myself wait, wait, apples don't grow in Florida. And as I pulled up behind it, I saw they were tomatoes, a whole truckload mounded over with perfectly green tomatoes, not a shade of pink or red in sight. As we were going along, we came to a construction site, the truck hit a bump, and three or four of these things flew off the truck.

They narrowly missed my windshield, but they did hit the pavement. They bounced a few times, and then they rolled onto the shoulder. None of them splattered. None of them even showed cracks. I mean, a modern-day industrial tomato has no problem with falling off a truck at 60 miles an hour on an interstate highway.

I can't help but wondering what it would take to get Cowen to actually eat one of these things.

"Is not" journalism and our excessive tolerance of silliness

On Marketplace yesterday, Pierre Desrochers, author of the Locavore's Dilemma, presented his case against locavores. It did not go well.

There are good arguments against the locavore movement, that it's a distraction, that it isn't scalable, that it's a solution only available to the well-off, that the superiority of local produce is largely due to suggestion, that there's no good business model to support it, that frozen vegetables are actually more nutritious. I don't necessarily agree with all of these, but they're serious arguments that an advocate of the locavore movement have to address.

Desrochers doesn't make any of these arguments, nor will you see him addressing issues like asymmetry of information or monocultures. Instead we get what we so often get from contrarians, shrill and unadulterated silliness. The bar for these "is not" pieces is so embarrassingly low as to barely exclude grunts and spit bubbles. In this case, Desrochers' "arguments"* depend on the following assumptions:


1. Almost everyone will become a locavore;


2. Rather than trying to eat more locally grown food, locavores will eat nothing but local;


3. Even in times of shortage and crop failure, there will be no imports;


4. and despite all of this locavores will continue eating the exact same food in the same seasons.


On top of this, Desrochers doesn't even seem to have kept up with the debate. Consider this:

It's better to grow tomatoes in the Florida sun than in a heated greenhouse in upstate New York because the energy required to transport them 1200 miles is only a fraction of that required to heat greenhouses for several weeks. 

Florida tomatoes are literally the worst possible crop  to use as an example here.

In addition to being tasteless, Estabrook also points out that compared to tomatoes from other sources or from a few decades ago, the modern Florida variety have fewer nutrients, more pesticides (particularly compared to those from California), and are picked with what has been described as 'slave labor' (and given the use of shackles this doesn't seem like much of an exaggeration). 

Estabrook's book got a tremendous amount of press and it's hard to imagine that anyone who encountered any of that coverage would use Florida tomatoes as an anti-locavore example.
By the same token it's hard to imagine that anyone who had been following the discussion of the trend toward fewer varieties of crops with more geographic concentration would use blights and pests to support the status quo as Desrochers does.

I don't want to spend too much time on the locavore debate (if that's what you're looking for, Felix Salmon's a good place to start ). What interests me here is the journalistic phenomena of is-not-ism, We start with a trendy, over-hyped movement. For bonus points, its promoters tend to be self-satisfied, upper class liberals, they kind who annoy even other liberals.

At this point, if you can get someone with reasonable credentials to write an "is not" book taking the opposite position, that's really all that's required. The actual content doesn't matter. Commentators of similar persuasion will promote the book (even those who are smart enough to see through it).. Mainstream media outlets will give the authors airtime in the name of openness and balance.

>But openness to new ideas is only a virtue if it's accompanied by some sort of critical facility. We need to start recognizing silliness again and, more to the point, we need to start demanding more.

"Does Medicaid Make People Healthier?"

From NPR's Planet Money:

On the face of it, it seems like Medicaid would make people healthier, by giving them access to health care they wouldn't otherwise be able to afford. 

But there is a counterargument. It says that being on Medicaid is really worse for you than being uninsured, because it provides you with such low-quality health care. 

The debate has raged for decades because every study has lacked a control group. There was no way for researchers to randomly assign people to either receive Medicaid or go without. The Oregon lottery allowed them to do just that. 

Katherine Baicker, a professor of health economics at Harvard University, compared those who won the lottery, and those who entered but did not get covered. 

Fifty thousand mail surveys and 750 in-person interviews later, they concluded that Medicaid did, in fact, make people healthier. 

"People reported their health to be much better once they were insured," Baicker says. "The probability that they reported themselves to be in good, very good or excellent health increased by 25 percent." 

People on Medicaid were far less likely to borrow money or have a medical bill sent to a collection agency. And total health care spending (including what is covered by insurance) increased for people on Medicaid.

Happy 4th from 1909

Full Employment

This really is a good point from Matt Yglesias:

One concept that I was surprised to see both sides of the debate leave off the table is full employment. Nothing is quite so empowering in the workplace as the knowledge that if your boss treats you like a jerk, you'd be able to quit and go get a roughly similar job with a less jerky boss. Even a guaranteed social minimum isn't nearly as good as another job because there's disapprobrium attached to being unemployed. In a world of human beings, some bosses are always going to be two standard deviations jerkier than the average boss. Full employment punishes asshole bosses as a class rather than seeking to bureaucratically circumscribe them with a narrow list of specific prohibited abuses. Conversely, most of the pragmatic economic arguments against labor market regulation are developed assuming a background condition of full employment. If governments are going to fail to deliver full employment over extended periods of time (as the governments in the US, EU, Japan, and UK are doing right now) then all those assumptions are thrown out of whack. Both those who yearn for micro-efficient labor markets and those who yearn to empower people vis-a-vis their bosses have an enormous amount to gain from a robust full employment agenda.

In this case, I am very sympathetic to Matt's view here.  A lot of the issues about employment regulations go away when people have labor market mobility.  I have worked in a "at will" employment environment in a full employment environment and it never bothered me in the least.  After all, so long as I was an effective employee my employer would have been nuts to let me go.

In the same sense, the ridiculous rules linking employment to health insurance drastically reduce labor mobility once you enter your forties and develop medical conditions.  In this sense, the health insurance exchanges of ACA will help this issue a lot.  Still, if people could easily change jobs most of the paradoxes of employment regulation would go away.

So clearly the best way to improve people's lives would be to create economic opportunity.  If people who want to work are able to do so then a surprising number of difficult (nearly intractable) problems can end up being somewhat beside the point.

Remembering Andy Griffith

The television play No Time for Sergeants was the breakthrough for Griffith and for adapter Ira Levin (yes, that Ira Levin), both of whom would take the show on to a successful Broadway run and a popular film. 

"America's wealth gap -- in 1776"

The good people at Marketplace have a sharp Independence Day spin on a big ongoing story.

Jeffrey Williamson: In 1774, the top 1 percent of households got 9.3 percent of income. 

Compare that to America today, when the top 1 percent is bringing in about 20 percent of income. Nine percent, versus 20 percent. Wow. 

Williamson: Wow. 

Even when you include slaves, Williamson says America was actually the most egalitarian country in the world when it came to the difference between rich and poor. 

So what did the founding fathers have to say about that? I called up a guy who should know. 

Clay Jenkinson: Hello my dear citizens, this is Thomas Jefferson. 

Actually it's Clay Jenkinson, a historian and Jefferson impersonator. And he says the writer of the famous phrase -- "All men are created equal" -- thought a lot about income inequality. In a letter to a friend describng the 13 colonies, he wrote "The great mass of our population consists of laborers. The rich, being few and of moderate wealth..." 

Jenkinson (Quoting Jefferson): Can any condition of society be more desireable?

I realize that we shouldn't treat the writings of the Founding Fathers as sacred text but you know they were pretty sharp...