In medical journals there is something called the art of title writing. The idea is that readers look at the table of contents, where the titles of the articles are listed, and decide what may be interesting enough to read based on what the titles say. The best way to get doctors to read an article is first to do a study that produces interesting results and then write a title that tells the reader what you discovered in your research.
This is science, of course, so the title cannot be misleading. Editors and readers alike would take a very dim view of a title that drew in the reader but did not accurately reflect a study's findings. Often the title is a question, which can certainly draw in the reader who wants to know the answer. A good example of this is the title of a recent article from the Annals of Emergency Medicine: "Is MRI More Accurate Than CT in Patients with Acute Stroke?"
My favorite style of title is the kind that tells you the answer. Another recent example from Annals: "Emergency Department Crowding is Associated with Decreased Quality of Care for Children with Acute Asthma."
Either approach works well. Publish a study that answers an important question, and write a title that tells me what the question was, so I will read it to learn the answer. Or cut to the chase, so to speak, and tell me the answer in the title. (I'll still read the paper if the answer is important.)
Why can't the popular press do that? Don't tell me it's because doctors are different from the general population of folks who read the popular press. We are people, too. But the general reader is treated differently. And so we get a headline on Yahoo Health News that says, "Boost Your Memory: Don't forget your vitamins - they may aid your memory as you age."
So if, like me, you're killing time and decide to click on the link, you read the article and learn - surprise! - that the study about which they are writing found no such thing. The paper appeared in the American Journal of Clinical Nutrition, and even the authors say their findings should be interpreted with caution, although they deftly spin results that are most likely meaningless into something vaguely positive. But the article reporting on the study includes comment from other experts making it quite plain that the results tell us exactly nothing. To the credit of the health reporter for Reuters, the article explains that when you do a bunch of memory tests and find a difference in performance on only one of them, it is probably simply a matter of chance.
The article's conclusion? Eat a balanced, healthful diet that provides amounts of nutrients sufficient to meet recommended allowances. And, by the way, you don't need supplements.
(Oh, for anyone who is a stickler for detail and looks up the Reuters article, you will find that the reporter used the phrase "healthy diet," and I have corrected it to "healthful." Sorry. This is just one of the many common errors I find irritating. The diet is healthful. The person is healthy. We hope the former will lead to the latter.)
Maybe the folks at Yahoo Health News figure an article headlined "Taking Vitamins Will Do Nothing for Your Memory" will draw in no readers. They may be right. They could try it and see. If no one reads it, maybe it's time to stop publishing articles for the lay reader telling them about meaningless clinical studies.
Friday, July 29, 2011
Saturday, July 23, 2011
When You Say Dylan....
From time to time I see a patient in the emergency department, usually a youngster, whose name is Dylan. On each such occasion I am reminded of a verse:
“I knew a man, his brain so small,
He couldn't think of nothin' at all,
He's not the same as you and me,
He doesn't dig the poetry.
He's so unhip, that when you say Dylan,
He thinks you're talkin' about Dylan Thomas,
Whoever he was.
The man ain't got no culture."
- from "A Simple Desultory Philippic" by Paul Simon
Rich in irony and allusion, as is true for so much of Simon's poetry-as-song-lyric, this song was recorded in the mid sixties, a time when popular culture would have brought most quickly to mind the name Bob Dylan. Folk-rock insiders recognized several references to that Dylan in Simon's lyric.
In a recent conversation I mentioned this to a physician colleague, an intelligent, articulate man who seems well educated but did not know who Dylan Thomas was. Sigh. I knew the profession was on the wrong track when the Medical College Admissions Test (MCAT) was changed (30 years ago) such that its content, once broad, was limited to science and mathematics.
I told him a bit about this Welsh-born poet whose public readings made him quite popular in 20th-century America.
Some weeks later I picked up a chart and walked into a room to see a patient who had been sent from a nursing home. He was demented, said the nursing home record, and coherent conversation with him was rarely possible. I introduced myself:
"Hello, Mr. Blake. I'm Dr. Solomon. How are you feeling today?" His eyes opened. He looked at me as if he realized I had said something but he was unable to process it. His nurse told me she hadn’t been able to get him to answer any questions. Then I noticed, as I glanced at his chart, that his name was William Blake.
I leaned over and said, “Tiger, tiger, burning bright.”
He looked at me, eyes widening in surprise. “I haven’t heard that poem in years.”
During the rest of his visit he seemed much more animated. I challenged the ED staff to find out why those words meant something to him. Google yielded the answer, as it so often does nowadays.
But save for Google there was no spark of recognition, no distant glimmer, no dredging of the depths of memory from a long-forgotten poetry class. Are there no more English teachers willing to rage against the dying of the light and try to instill in their students a lifelong love for words on a page as an art form?
And so I found myself there on the sad height, regarding the youth whose minds will not blaze like meteors because they do not know Bob Dylan from Dylan Thomas from Thomas Aquinas.
We are always hearing about how important it is to read to our children. Someone should read poetry to Mr. Blake at the nursing home every night. Imagine what it could do for his quality of life.
“I knew a man, his brain so small,
He couldn't think of nothin' at all,
He's not the same as you and me,
He doesn't dig the poetry.
He's so unhip, that when you say Dylan,
He thinks you're talkin' about Dylan Thomas,
Whoever he was.
The man ain't got no culture."
- from "A Simple Desultory Philippic" by Paul Simon
Rich in irony and allusion, as is true for so much of Simon's poetry-as-song-lyric, this song was recorded in the mid sixties, a time when popular culture would have brought most quickly to mind the name Bob Dylan. Folk-rock insiders recognized several references to that Dylan in Simon's lyric.
In a recent conversation I mentioned this to a physician colleague, an intelligent, articulate man who seems well educated but did not know who Dylan Thomas was. Sigh. I knew the profession was on the wrong track when the Medical College Admissions Test (MCAT) was changed (30 years ago) such that its content, once broad, was limited to science and mathematics.
I told him a bit about this Welsh-born poet whose public readings made him quite popular in 20th-century America.
Some weeks later I picked up a chart and walked into a room to see a patient who had been sent from a nursing home. He was demented, said the nursing home record, and coherent conversation with him was rarely possible. I introduced myself:
"Hello, Mr. Blake. I'm Dr. Solomon. How are you feeling today?" His eyes opened. He looked at me as if he realized I had said something but he was unable to process it. His nurse told me she hadn’t been able to get him to answer any questions. Then I noticed, as I glanced at his chart, that his name was William Blake.
I leaned over and said, “Tiger, tiger, burning bright.”
He looked at me, eyes widening in surprise. “I haven’t heard that poem in years.”
During the rest of his visit he seemed much more animated. I challenged the ED staff to find out why those words meant something to him. Google yielded the answer, as it so often does nowadays.
But save for Google there was no spark of recognition, no distant glimmer, no dredging of the depths of memory from a long-forgotten poetry class. Are there no more English teachers willing to rage against the dying of the light and try to instill in their students a lifelong love for words on a page as an art form?
And so I found myself there on the sad height, regarding the youth whose minds will not blaze like meteors because they do not know Bob Dylan from Dylan Thomas from Thomas Aquinas.
We are always hearing about how important it is to read to our children. Someone should read poetry to Mr. Blake at the nursing home every night. Imagine what it could do for his quality of life.
Wednesday, July 13, 2011
High-Cost Decision Making: More Than Just "Defensive Medicine"
Last month (June 11) I wrote about defensive medicine and how it drives up health care costs. I also said there was more to the story and promised to return to that subject, so here it is.
As explained in that essay, concern about the risk of becoming a defendant in a medical negligence lawsuit may drive a physician to order or recommend tests or treatments that clinical judgment suggests are not really necessary. Instead, those interventions are pursued in order to show that the physician was extra diligent, careful, and thorough in evaluating and treating the patient. In the event of a bad outcome - and those sometimes occur even in the context of excellent care on the part of a physician - a review of the record will show the physician did "everything possible" and should, therefore, not be blamed.
So "defensive medicine" is all about building a case for the defense, in advance, to protect the physician should there be a bad outcome. But there are other reasons doctors order or recommend tests or treatments that are arguably unnecessary.
The first steps in the evaluation of a patient, taught to every medical student (usually in the second year of medical school) are described as a "History & Physical" or "H&P." This means interviewing the patient to obtain a detailed account of the problem about which the patient is consulting a doctor (and sometimes, depending on the context, a much more extensive account of the patient's entire medical history, which is what medical students are taught to do). The history is followed by a physical examination. This, again, is "problem focused" in ordinary circumstances, but medical students are taught a thorough, head-to-toe approach to encompass every body part and organ system.
Once the H&P is done, a doctor formulates something called a differential diagnosis: a list of possible causes of the patient's symptoms (from the history) and signs (findings on physical examination). This list is usually made in order of probability, with the most likely cause at the top.
Depending on the nature and complexity of the case, a doctor may be highly confident that the cause is the one listed at the top of the differential diagnosis (at the "simple" end of the spectrum) or may have little or no idea which of numerous possibilities explains the clinical picture (at the "complex" end). In the latter instance, in fact, the list of possibilities may be constructed not in order of probability, in the physician's judgment, but simply in order of how common the diseases are.
In the former situation, the doctor likely will order no testing of any sort but proceed directly to inform the patient of the apparent diagnosis and make recommendations for treatment. In the latter circumstance, by contrast, there may be a great deal of diagnostic investigation. Much of the time, of course, the approach is somewhere in between, with a few possibilities vying for the top spot and only one or a very few tests needed to sort them out.
Judicious ordering of tests requires the use of clinical judgment. Often there is a question of how much to do in the pursuit of diagnostic certainty. It may be that, after the H&P, the doctor is 90% certain of the diagnosis. Should testing be done to raise that to 97%? (Of course, we are doctors, not engineers, and while we sometimes have real numbers from the published scientific literature in what we call "evidence-based medicine," more often such numbers are very rough estimates.)
As I have already said, fear of litigation is a commonly cited motivation in the pursuit of diagnostic certainty. But it is not the only one. In their education (medical school) and training (residency programs after medical school leading to specialty certification) doctors are taught that diagnostic error is unacceptable. No one puts it quite that way, and we all know that there is an irreducible error rate in everything we do in life as human beings. But we are constantly called to account for every error, and that experience is commonly unpleasant and uncomfortable. The implicit message conveyed, over and over, is that diligence, care, and thoroughness in pursuit of diagnostic certainty are good things. There is typically far less emphasis placed on balancing the risks associated with our interventions with the benefits. And there is, in my view, far too little emphasis placed on the practice of cost-effective medicine. Sure, we can improve our diagnostic certainty by ordering more tests, but is that worth the price tag? Some tests are quite expensive. Far too often there is no discussion, between doctor and patient, of these considerations when ordering tests: is the additional information worth the risk and the expense?
And that brings me to the third major driver of "unnecessary" ordering of tests and treatments: customer satisfaction. This is a hot topic in medical circles, especially among those of us who were trained back in the days when no one called patients customers and few of us thought of our profession as a business or trade. (Yes, running a medical practice has always been a business, but we thought of our profession chiefly as applied science with an overlay of humanistic arts.)
Now, it seems, everyone (especially managers and administrators) is passionately interested in customer satisfaction: how we can measure it, how we can improve it, and how we can market it when our numbers look good. I could write a whole series of essays on customer satisfaction, but others have already done that, and I'll make my contributions to the profusion of opinion out there in the blogosphere little by little. For now, I will just say this. There has been a great deal published on how to improve customer satisfaction in health care. Some of it is good science, and some of it is rubbish. But doctors are human beings and tend to approach many things intuitively. The intuitive approach is very simple. If your goal is to have a satisfied customer, give him what he wants. So doctors figure out what the patients want and give it to them. Patients who want tests they don't really need tend to get them. Patients who want antibiotics for colds usually walk out of the doctor's office with a prescription.
A recent study provided an excellent illustration. Patients visiting an emergency department with abdominal pain were asked about their confidence in the physician's evaluation. If that evaluation consisted of H&P alone, the level of confidence was only 20%. It increased dramatically as tests were added, reaching 90% if the evaluation included a CAT scan.
This study only confirms what doctors already know intuitively: patients like tests. If you want satisfied customers, order lots of tests.
That is the wrong conclusion. Doctors, don't order lots of tests. Patients, don't go to the doctor wanting or expecting lots of tests. Instead, after the H&P, talk about the differential diagnosis and diagnostic certainty, and give fair consideration to the benefits, risks, and expense associated with testing. This is more easily said than done, given that doctors are seeing more and more patients in a day that has only so many hours, and thoughtful discussions are time-consuming. But give it a try. Although you may sacrifice a little bit of diagnostic certainty, there is quite often little risk in that. You may avoid tests that have their own inherent risks, and you may save yourself, and the health care system, lots of money.
As explained in that essay, concern about the risk of becoming a defendant in a medical negligence lawsuit may drive a physician to order or recommend tests or treatments that clinical judgment suggests are not really necessary. Instead, those interventions are pursued in order to show that the physician was extra diligent, careful, and thorough in evaluating and treating the patient. In the event of a bad outcome - and those sometimes occur even in the context of excellent care on the part of a physician - a review of the record will show the physician did "everything possible" and should, therefore, not be blamed.
So "defensive medicine" is all about building a case for the defense, in advance, to protect the physician should there be a bad outcome. But there are other reasons doctors order or recommend tests or treatments that are arguably unnecessary.
The first steps in the evaluation of a patient, taught to every medical student (usually in the second year of medical school) are described as a "History & Physical" or "H&P." This means interviewing the patient to obtain a detailed account of the problem about which the patient is consulting a doctor (and sometimes, depending on the context, a much more extensive account of the patient's entire medical history, which is what medical students are taught to do). The history is followed by a physical examination. This, again, is "problem focused" in ordinary circumstances, but medical students are taught a thorough, head-to-toe approach to encompass every body part and organ system.
Once the H&P is done, a doctor formulates something called a differential diagnosis: a list of possible causes of the patient's symptoms (from the history) and signs (findings on physical examination). This list is usually made in order of probability, with the most likely cause at the top.
Depending on the nature and complexity of the case, a doctor may be highly confident that the cause is the one listed at the top of the differential diagnosis (at the "simple" end of the spectrum) or may have little or no idea which of numerous possibilities explains the clinical picture (at the "complex" end). In the latter instance, in fact, the list of possibilities may be constructed not in order of probability, in the physician's judgment, but simply in order of how common the diseases are.
In the former situation, the doctor likely will order no testing of any sort but proceed directly to inform the patient of the apparent diagnosis and make recommendations for treatment. In the latter circumstance, by contrast, there may be a great deal of diagnostic investigation. Much of the time, of course, the approach is somewhere in between, with a few possibilities vying for the top spot and only one or a very few tests needed to sort them out.
Judicious ordering of tests requires the use of clinical judgment. Often there is a question of how much to do in the pursuit of diagnostic certainty. It may be that, after the H&P, the doctor is 90% certain of the diagnosis. Should testing be done to raise that to 97%? (Of course, we are doctors, not engineers, and while we sometimes have real numbers from the published scientific literature in what we call "evidence-based medicine," more often such numbers are very rough estimates.)
As I have already said, fear of litigation is a commonly cited motivation in the pursuit of diagnostic certainty. But it is not the only one. In their education (medical school) and training (residency programs after medical school leading to specialty certification) doctors are taught that diagnostic error is unacceptable. No one puts it quite that way, and we all know that there is an irreducible error rate in everything we do in life as human beings. But we are constantly called to account for every error, and that experience is commonly unpleasant and uncomfortable. The implicit message conveyed, over and over, is that diligence, care, and thoroughness in pursuit of diagnostic certainty are good things. There is typically far less emphasis placed on balancing the risks associated with our interventions with the benefits. And there is, in my view, far too little emphasis placed on the practice of cost-effective medicine. Sure, we can improve our diagnostic certainty by ordering more tests, but is that worth the price tag? Some tests are quite expensive. Far too often there is no discussion, between doctor and patient, of these considerations when ordering tests: is the additional information worth the risk and the expense?
And that brings me to the third major driver of "unnecessary" ordering of tests and treatments: customer satisfaction. This is a hot topic in medical circles, especially among those of us who were trained back in the days when no one called patients customers and few of us thought of our profession as a business or trade. (Yes, running a medical practice has always been a business, but we thought of our profession chiefly as applied science with an overlay of humanistic arts.)
Now, it seems, everyone (especially managers and administrators) is passionately interested in customer satisfaction: how we can measure it, how we can improve it, and how we can market it when our numbers look good. I could write a whole series of essays on customer satisfaction, but others have already done that, and I'll make my contributions to the profusion of opinion out there in the blogosphere little by little. For now, I will just say this. There has been a great deal published on how to improve customer satisfaction in health care. Some of it is good science, and some of it is rubbish. But doctors are human beings and tend to approach many things intuitively. The intuitive approach is very simple. If your goal is to have a satisfied customer, give him what he wants. So doctors figure out what the patients want and give it to them. Patients who want tests they don't really need tend to get them. Patients who want antibiotics for colds usually walk out of the doctor's office with a prescription.
A recent study provided an excellent illustration. Patients visiting an emergency department with abdominal pain were asked about their confidence in the physician's evaluation. If that evaluation consisted of H&P alone, the level of confidence was only 20%. It increased dramatically as tests were added, reaching 90% if the evaluation included a CAT scan.
This study only confirms what doctors already know intuitively: patients like tests. If you want satisfied customers, order lots of tests.
That is the wrong conclusion. Doctors, don't order lots of tests. Patients, don't go to the doctor wanting or expecting lots of tests. Instead, after the H&P, talk about the differential diagnosis and diagnostic certainty, and give fair consideration to the benefits, risks, and expense associated with testing. This is more easily said than done, given that doctors are seeing more and more patients in a day that has only so many hours, and thoughtful discussions are time-consuming. But give it a try. Although you may sacrifice a little bit of diagnostic certainty, there is quite often little risk in that. You may avoid tests that have their own inherent risks, and you may save yourself, and the health care system, lots of money.
Sunday, July 3, 2011
Wear a Helmet!
Over the last quarter century I have told many patients in the emergency department, "You get only one head. There are no replacement parts. Take care of it." Very often what I'm getting at is very simple: wear a helmet.
Helmets are becoming more and more common on ski slopes. Skateboarders often wear them now. Most bicycling children protect their heads. Most states require motorcycle riders to wear helmets.
But there is an intense and vocal segment of bikers who don't want to wear helmets. They oppose helmet laws as an infringement upon their individual liberties. I wrote my first article on the subject more than a decade ago, and the available data strongly supported the protective effects of helmet use in preventing death and serious long-term disability from head injury. In the years since then, data have continued to accumulate, providing ever more convincing proof of the benefits of helmet laws for the public health.
Still, the bikers oppose efforts to enact helmet laws in the states that don't have them yet, and they mount repeated attempts to repeal these laws in states that have them. My home state of Pennsylvania is an example of success of those repeal efforts. Data collected since the repeal tell a grim and tragic tale.
One of my favorite expressions in scientific medicine is, "The plural of 'anecdote' is not 'data.'" What this means is that reports of single incidents, observations, or experiences, accumulated or aggregated, do not tell you anything of validity comparable to that of a systematic analysis of data from a scientific study.
Nevertheless, anecdotes often sway public discourse and public policy, because average citizens and politicians find them persuasive. So now, along comes an anecdote that brings a tragic irony to the public debate. The Associated Press is reporting that two days ago in upstate New York a 55 year old motorcyclist, riding without a helmet in an organized protest by a group of bikers opposed to helmet laws, lost control of his bike, flipped over the handlebars, struck his head on the pavement, and was subsequently pronounced dead from his head injury at a local hospital. Police opined that he would likely have survived had he been wearing a helmet. The effect of this incident on New York legislators' view of helmet laws seems sure to be the opposite of what the motorcyclists had in mind.
My personal political philosophy has strong libertarian leanings. And so I understand the arguments against helmet laws as infringements upon personal freedom. The data, however, tell us that unhelmeted riders cost the rest of us a lot of money. Head injuries cause a great deal of disability, and societal costs are impressive. Some say that issue is addressed when riders have health insurance, but of course it isn't. Insurance is a mechanism for sharing risk, and so the costs incurred when an insured rider is injured are spread among a larger group. All having insurance means is that you are putting money into the risk pool. Engaging in risky behavior still costs everyone else in the pool money when your behavior has unfortunate consequences.
The conclusion brings us full circle: wear a helmet!
Helmets are becoming more and more common on ski slopes. Skateboarders often wear them now. Most bicycling children protect their heads. Most states require motorcycle riders to wear helmets.
But there is an intense and vocal segment of bikers who don't want to wear helmets. They oppose helmet laws as an infringement upon their individual liberties. I wrote my first article on the subject more than a decade ago, and the available data strongly supported the protective effects of helmet use in preventing death and serious long-term disability from head injury. In the years since then, data have continued to accumulate, providing ever more convincing proof of the benefits of helmet laws for the public health.
Still, the bikers oppose efforts to enact helmet laws in the states that don't have them yet, and they mount repeated attempts to repeal these laws in states that have them. My home state of Pennsylvania is an example of success of those repeal efforts. Data collected since the repeal tell a grim and tragic tale.
One of my favorite expressions in scientific medicine is, "The plural of 'anecdote' is not 'data.'" What this means is that reports of single incidents, observations, or experiences, accumulated or aggregated, do not tell you anything of validity comparable to that of a systematic analysis of data from a scientific study.
Nevertheless, anecdotes often sway public discourse and public policy, because average citizens and politicians find them persuasive. So now, along comes an anecdote that brings a tragic irony to the public debate. The Associated Press is reporting that two days ago in upstate New York a 55 year old motorcyclist, riding without a helmet in an organized protest by a group of bikers opposed to helmet laws, lost control of his bike, flipped over the handlebars, struck his head on the pavement, and was subsequently pronounced dead from his head injury at a local hospital. Police opined that he would likely have survived had he been wearing a helmet. The effect of this incident on New York legislators' view of helmet laws seems sure to be the opposite of what the motorcyclists had in mind.
My personal political philosophy has strong libertarian leanings. And so I understand the arguments against helmet laws as infringements upon personal freedom. The data, however, tell us that unhelmeted riders cost the rest of us a lot of money. Head injuries cause a great deal of disability, and societal costs are impressive. Some say that issue is addressed when riders have health insurance, but of course it isn't. Insurance is a mechanism for sharing risk, and so the costs incurred when an insured rider is injured are spread among a larger group. All having insurance means is that you are putting money into the risk pool. Engaging in risky behavior still costs everyone else in the pool money when your behavior has unfortunate consequences.
The conclusion brings us full circle: wear a helmet!
Saturday, July 2, 2011
Success in Major League Baseball: Is It All About the Money?
If you're a baseball fan or if you live in the tri-state area that includes southwestern Pennsylvania - and especially if you fit both descriptions - you know that the Pittsburgh Pirates have compiled an unenviable record. They have put together a streak of 18 losing seasons, which is said to be a record for all major sports. Some of us remember that the Pirates were arguably the best team in Major League Baseball (MLB) in the 1970s, winning the World Series in 1971 and 1979 and playing consistently well in the intervening years. Those a bit younger recall that the Pirates won their division in 1990, '91, and '92. But they haven't had a season since in which they finished with more wins than losses.
There are many explanations offered up for this seemingly interminable slump. The most common is payroll. Fans have observed that players are brought up from the minor league farm clubs, developed into solid performers (even stars), and traded away when their contracts come up for renewal and they can find teams willing to pay them much more than the Pirates will shell out to keep them. When we watch these players do well on teams that go to the post-season, we may be happy for them at the same time we despair over the Pirates' consistently low payroll.
Baseball may be America's favorite pastime, with a very long tradition, but it's also a business - show business, really - and some franchise owners are much more focused on maximizing profit than on putting a winning team on the field. And it's clear that in some markets, one of which is Pittsburgh, a team's performance does not have as large an effect on revenues as one might expect. So the calculus leads to a simple conclusion: keep payroll low, and even if the effect is that the team is a consistent loser, revenues will be only modestly lower than if the club fielded a winning team at much higher cost.
So what is the correlation? A look at a decade of numbers, 2001 through 2010, yields one striking finding. Of the 30 teams in MLB, the Pirates' average rank in payroll was 26.3. The team's average rank in the standings at season's end? Also 26.3! I think that's a remarkable coincidence.
But a somewhat more expansive look at the numbers shows that a low payroll need not doom a team to dismal performance. The 2001 Oakland Athletics ranked 25th in payroll but finished 2nd in the overall standings. In 2002 they were 27th in payroll and again finished 2nd. In 2005 the Cleveland Indians ranked 26th in payroll but finished the season with a #6 overall ranking, numbers matched by the 2007 Colorado Rockies. The 2008 Tampa Bay Rays ranked #29 in payroll but finished the season with the 3rd-best record in MLB. And last year, when the Pirates were #30 in both payroll and end-of-season standing, the San Diego Padres were #29 in payroll but finished the season ranked #9.
After 1992 the Pirates were so consistently bad that the latest in any season they had as many wins as losses was in June 2005, when they were 30-30 after 60 games. Their season then hit the skids, as they went on a losing streak and won only two games of the next ten.
Will this year be different? The payroll numbers put the Pirates in a familiar position for 2011, #28. As of this writing they have just won the first game in a double header and have a record of 42-40, placing them at #13 in the overall MLB standings. Fans who have listened to the players in post-game interviews sense a winning attitude. Maybe there really is more to this than money. We shall see.
There are many explanations offered up for this seemingly interminable slump. The most common is payroll. Fans have observed that players are brought up from the minor league farm clubs, developed into solid performers (even stars), and traded away when their contracts come up for renewal and they can find teams willing to pay them much more than the Pirates will shell out to keep them. When we watch these players do well on teams that go to the post-season, we may be happy for them at the same time we despair over the Pirates' consistently low payroll.
Baseball may be America's favorite pastime, with a very long tradition, but it's also a business - show business, really - and some franchise owners are much more focused on maximizing profit than on putting a winning team on the field. And it's clear that in some markets, one of which is Pittsburgh, a team's performance does not have as large an effect on revenues as one might expect. So the calculus leads to a simple conclusion: keep payroll low, and even if the effect is that the team is a consistent loser, revenues will be only modestly lower than if the club fielded a winning team at much higher cost.
So what is the correlation? A look at a decade of numbers, 2001 through 2010, yields one striking finding. Of the 30 teams in MLB, the Pirates' average rank in payroll was 26.3. The team's average rank in the standings at season's end? Also 26.3! I think that's a remarkable coincidence.
But a somewhat more expansive look at the numbers shows that a low payroll need not doom a team to dismal performance. The 2001 Oakland Athletics ranked 25th in payroll but finished 2nd in the overall standings. In 2002 they were 27th in payroll and again finished 2nd. In 2005 the Cleveland Indians ranked 26th in payroll but finished the season with a #6 overall ranking, numbers matched by the 2007 Colorado Rockies. The 2008 Tampa Bay Rays ranked #29 in payroll but finished the season with the 3rd-best record in MLB. And last year, when the Pirates were #30 in both payroll and end-of-season standing, the San Diego Padres were #29 in payroll but finished the season ranked #9.
After 1992 the Pirates were so consistently bad that the latest in any season they had as many wins as losses was in June 2005, when they were 30-30 after 60 games. Their season then hit the skids, as they went on a losing streak and won only two games of the next ten.
Will this year be different? The payroll numbers put the Pirates in a familiar position for 2011, #28. As of this writing they have just won the first game in a double header and have a record of 42-40, placing them at #13 in the overall MLB standings. Fans who have listened to the players in post-game interviews sense a winning attitude. Maybe there really is more to this than money. We shall see.
Friday, July 1, 2011
July: Is It Safe?
If you're going to get sick, perhaps you should hold off until next month. Or so you might think if you have heard of something called the "July phenomenon."
New doctors finish medical school and move on to graduate training programs in teaching hospitals across the country this month. At more advanced levels of training, many others move up to positions with greater responsibility, including supervising those junior to them. After completing post-graduate residency training, some newly-minted "real doctors" will take jobs as academic staff in teaching hospitals, and make the symbolic transition from learner to teacher. At every level, then, it would seem there are doctors who are in brand new roles with responsibilities that are at least somewhat unfamiliar.
[Even at a hospital where there are no training programs, if you are a patient in the emergency department, the emergency physician taking care of you could be someone who just completed training in the specialty. And that raises the more general and very interesting subject of wanting a doctor with plenty of experience. Come to think of it, I want that in my plumber, my electrician, and my car mechanic, too.]
Over the last 25 years numerous interesting studies have sought to examine and explore the notion of a July phenomenon. I won't torture you with the details, but they seem to reach some straightforward conclusions. More mistakes get made, but rates of significant complications (including death) are not higher.
Costs are somewhat higher, mainly because more junior trainees tend to order more tests. This happens partly because they have less confidence in their clinical judgment and what they can learn from interviewing and examining a patient, and therefore have a greater inclination to rely on what they might find out by ordering lots of blood tests and imaging studies (x-rays, CAT scans, etc.). It's also partly because they are still learning to be selective and judicious in ordering tests and to question the value of what each test might have to offer in illuminating the patient's condition. The supervising doctors tend to be more focused on making sure the junior trainees don't miss anything and not quite as attentive to assuring that they practice cost-efficient medicine.
Is there an upside? Maybe so. There is a lot of enthusiasm and intensity in July. As newly graduated medical students assume some real responsibility, and those more senior take on supervisory roles, the fresh enthusiasm for learning and teaching makes July an exciting month. (And I mean exciting in a good way.) There is some sense of anxiety that comes with new responsibilities, but that has a positive influence as well, as it gets everyone more intensely focused on doing the best possible job. We are all determined not to screw up in whatever our new roles may be. Sure, if you make a mistake, people will understand that can happen to a newbie, but no one wants to be branded a bungler.
I'm not recommending that you get sick or hurt this month, as opposed to any other month. And it's not like you can plan such things, anyway. But I do think it's reassuring to know that, on balance, the care you receive in our nation's teaching hospitals will be just as good in July as at any other time of year.
New doctors finish medical school and move on to graduate training programs in teaching hospitals across the country this month. At more advanced levels of training, many others move up to positions with greater responsibility, including supervising those junior to them. After completing post-graduate residency training, some newly-minted "real doctors" will take jobs as academic staff in teaching hospitals, and make the symbolic transition from learner to teacher. At every level, then, it would seem there are doctors who are in brand new roles with responsibilities that are at least somewhat unfamiliar.
[Even at a hospital where there are no training programs, if you are a patient in the emergency department, the emergency physician taking care of you could be someone who just completed training in the specialty. And that raises the more general and very interesting subject of wanting a doctor with plenty of experience. Come to think of it, I want that in my plumber, my electrician, and my car mechanic, too.]
Over the last 25 years numerous interesting studies have sought to examine and explore the notion of a July phenomenon. I won't torture you with the details, but they seem to reach some straightforward conclusions. More mistakes get made, but rates of significant complications (including death) are not higher.
Costs are somewhat higher, mainly because more junior trainees tend to order more tests. This happens partly because they have less confidence in their clinical judgment and what they can learn from interviewing and examining a patient, and therefore have a greater inclination to rely on what they might find out by ordering lots of blood tests and imaging studies (x-rays, CAT scans, etc.). It's also partly because they are still learning to be selective and judicious in ordering tests and to question the value of what each test might have to offer in illuminating the patient's condition. The supervising doctors tend to be more focused on making sure the junior trainees don't miss anything and not quite as attentive to assuring that they practice cost-efficient medicine.
Is there an upside? Maybe so. There is a lot of enthusiasm and intensity in July. As newly graduated medical students assume some real responsibility, and those more senior take on supervisory roles, the fresh enthusiasm for learning and teaching makes July an exciting month. (And I mean exciting in a good way.) There is some sense of anxiety that comes with new responsibilities, but that has a positive influence as well, as it gets everyone more intensely focused on doing the best possible job. We are all determined not to screw up in whatever our new roles may be. Sure, if you make a mistake, people will understand that can happen to a newbie, but no one wants to be branded a bungler.
I'm not recommending that you get sick or hurt this month, as opposed to any other month. And it's not like you can plan such things, anyway. But I do think it's reassuring to know that, on balance, the care you receive in our nation's teaching hospitals will be just as good in July as at any other time of year.
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