“Gawande’s Kitchen”

An insightful critique:

But there is a much more important question being ignored by Gawande — How well does The Cheesecake Factory analogy really apply to health care? We can see how similar the kitchen is to an operating room — lots of busy people rushing about in a sterile environment, each concentrated on a task. But what about the rest of the “system?”
At The Cheesecake Factory, the customer is the diner. That’s who orders the service, pays the bill, and comes back again if he is happy. That is who all of the efficient, standardized food preparation is designed to please.
In Gawande’s ideal health care model, however, the customer isn’t the patient, but the third-party payer, be it an insurer or government. Let’s call that entity the TPP. The TPP never enters the kitchen. The TTP has no idea what happens in there, and doesn’t really care as long as the steak is cooked to his satisfaction and the tab is affordable.
In this model, the patient is actually the steak. It is the steak who is processed in the kitchen. It is the steak that is cut and cooked and placed on a platter. The steak doesn’t get a vote. Nobody cares if the steak is happy. The steak doesn’t pay the bill. The steak isn’t coming back again.
So here we are in Dr. Gawande’s kitchen, where you and I are slabs of meat and Chef Gawande will cook us to the specifications of his TPP customers — satisfaction guaranteed.

Worth reading in full.

(Via The Right Coast.)

TSA fail: the end of the road is now visible

There was an attack in Saudi Arabia using internally placed explosives up the lower GI tract. These explosives cannot be detected by pat downs, metal detectors, or millimeter wave machines. Much more powerful scanning machines would be required or a cavity search. But no follow up bombs have happened using this method. I’d always wondered why. Now things are becoming clear. Apparently there’s been something of a theological problem. It appears that butt bombs are not permitted due to Islam’s prohibition of sodomy. But that prohibition seems to be loosening.

It will take years for the theologians to digest this new complication but once it has been let loose, it is clearly foreseeable that some portion of islamic scholars will hold this position. The consequences for our travel security regime are rather scary. We’re going to have reached the end of the line because routine x-rays at each flight segment are just not going to happen. The accumulated radiation would cause too many cancers. And cavity searches are simply unreasonable. So where does that leave TSA’s current security strategy?

Like most of their terror innovations, I expect that this will take some time for them to organize. It looks like they’ve already put 4 years into it. It may take them another 4 before they’ve worked the theological problems out sufficient to recruit bombers. But then what?

(A) Quote of the Day


But though they may hate the Pax Americana, the Greens probably can’t live without it. Can’t live without the Ipods, the connectivity, the store-bought food, the cafe-bought lattes — all the ugly things made by private industry. And by paring down the redundancies in the system as wasteful and unsightly; by reducing the energy reserves of the system in favor of such fairy schemes as windmills and carbon trading the Greens have made the system far less robust than it could have been. Because they are never going to need the Design Margin. Ever. Until they do.

Estimating Odds

From a comment by “Eggplant” at Belmont Club:

Supposedly the US has war gamed this thing and the prospects look poor. A war game is only as good as the assumptions programmed into it. Can the war game be programmed to consider the possibility that a single Iranian leader has access to an ex-Soviet nuke and is crazed enough to use it?
Of course the answer is “No Way”.
A valid war game would be a Monte Carlo simulation that considered a range of possible scenarios. However the tails of that Gaussian distribution would offer extremely frightening scenarios. The Israelis are in the situation where truly catastrophic scenarios have tiny probability but the expectation value [consequence times probability] is still horrific. However “fortune favors the brave”. Also being the driver of events is almost always better than passively waiting and hoping for a miracle. That last argument means the Israelis will launch an attack and probably before the American election.

These are important points. The outcomes of simulations, including the results of focus groups used in business and political marketing, may be path-dependent. If they are the results of any one simulation may be misleading and it may be tempting to game the starting assumptions in order to nudge the output in the direction you want. It is much better if you can run many simulations using a wide range of inputs. Then you can say something like: We ran 100 simulations using the parameter ranges specified below and found that the results converged on X in 83 percent of the cases. Or: We ran 100 simulations and found no clear pattern in the results as long as Parameter Y was in the range 20-80. And by the way, here are the data. We don’t know the structure of the leaked US simulation of an Israeli attack on Iran and its aftermath.

It’s also true, as Eggplant points out, that the Israelis have to consider outlier possibilities that may be highly unlikely but would be catastrophic if they came to pass. These are possibilities that might show up only a few times or not at all in the output of a hypothetical 100-run Monte Carlo simulation. But such possibilities must still be taken into account because 1) they are theoretically possible and sufficiently bad that they cannot be allowed to happen under any circumstances and 2) the simulation-based probabilities may be inaccurate due to errors in assumptions.

“Statistical Quality Control Meets the NYPD”

An excellent post by Mark Draughn that reminds how we get the behavior we incentivize. In this case the NYC govt incentivized its police to ignore violent crimes and to make bogus arrests to boost their cleared-case stats:

This is a standard recipe for disaster in quality control — and CompStat is at heart a statistical quality control program. Take a bunch of people doing a job, make them report quality control data, and put pressure on them to produce good numbers. If there is little oversight and lots of pressure, then good numbers is exactly what they’ll give you. Even if they’re not true.

Worth reading in full.