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Saturday, January 31, 2015

Title IX hysteria

I am supposed to live in an academic world where we value critical thinking skills. However, I have a growing concern about the clash between the skepticism required for reflective thought and the academic embrace of advocacy driven "scholarship". Nowhere is this more apparent than the recent injection of Title IX fever into college campuses, driven by a zealotus Federal bureaucracy.

Stories about an epidemic of sexual violence on college campuses have peppered the new outlets this past year. There is an industry out there looking for growth opportunities in this realm and some within the industry do not appear to be constrained by any desire to operate driven by fact or truth. One of the more egregious examples centered around the story that came out of the University of Virginia which was reported in Rolling Stone magazine. Whether it represented a complete or partial hoax is not entirely clear but there is no question that many if not most of the story's details were completely implausible.

However, recent initiatives driven by the Federal government have been driven by the impression that there is a huge problem on college campuses which can only be addressed by imposition of new rules driven by the Feds. The leverage they have is through the federalization of higher education funding which allows them to hold virtually all colleges hostage to whatever bureaucratic whim is fashionable in Washington DC.

The data which appears to justify such an overarching reach by the Feds has been called into question. There is a figure thrown around of 1 in 5 women as being a victim of sexual assault. This figure comes from a 2007 survey from the DOJ. Shortly after this study was reported in a story in Slate, a much larger survey done the Justice Department Bureau of Justice Statistics found a rate of 0.6%, substantially lower than the 20% figure previously reported. The former study involved two unnamed public universities while the latter surveyed 90,000 households and 160,000 individuals encompassing a much broader swath of students.

Imagine my surprise when I received an email from my Title IX compliance officer ordering me and all of my colleagues to take a course regarding sexual violence on campus. When the Feds say jump, we say, how high? This enterprise comes directly assault). Consistent with his activist roots, President Obama does not appear to be troubled by citation of the questionable 1 in 5 statistic. Advocacy is generally not effective when accompanied by any sort of self reflection of self skepticism.

To further my surprise, when I logged into the learning module to "educate" me and bring my into compliance with Title IX training, what statistic was placed immediately front and center? The same 1 in 5 number . I went online and did an internet search for Title IX training materials and what did I find in these as well? The same statistic. If I were grading a presentation by one of my students and I found that they had chosen to highlight a single study which was flawed and ignore information from more robust studies, they would get a failing grade.

 However, I soldiered through the roughly one hour course, clicking through a series of scenarios and questions, picking the "right" answers. The scenarios were ambiguous and the exercise resembled an indoctrination more than an educational activity. The scenarios dealt with perhaps the most complex, difficult, and ambiguous contexts of human interactions; sexual encounters and alcohol. Each one perhaps could serve as a starting point for thoughtful discussions which might go on for an entire semester and PhD ethics thesis. However, in this training session and in final exam, I was called upon to pick the one and only right answer.  I was being put on notice. No input was asked of me and there is essentially no mechanism where I can provide feedback on this. I understand. No feedback is wanted.

More than two dozen luminaries within the Harvard Law School have come out with a statement protesting their University's new rules regarding title IX. They have the standing and legal scholarship  to do  so. I do not. I know in my heart that continuation in the direction will end badly for most of us. The same people who vetted the online training courses have already shown they are not objective and will not let disparate opinions and data get in the way of furthering their particular lines of advocacy. Yet, they are ones who will be put in charge of adjudicating Title IX issues on campus. They will direct investigations, oversee tribunals, and render decisions.

Colleges and universities are in a similar position to me. They are not in a position to bargain with the Feds. To much money is at stake and there is no foreseeable pathway to success that can be envisioned by confrontation. The risk of losing the income stream driven by fully federalized tuition loans, federal research grants, and federal health care dollars. Monopsony in business has its downside.  

Human interactions are complex. Human sexual relations are the most complex subset of interactions within these interactions. I will be the first to admit we have not yet worked out all the rules on this realm, despite working on them for thousands of years. What the Federal government is trying to do is to create some sort of separate formal review and response structure on college campuses based upon the idea that an urgent need exists. That perceived need is likely based faulty data. The solutions proposed ignore basic concepts of due process and protection of the accused. It seems like such a bad idea. However, very few are in a position to raise our concerns.

Sunday, January 11, 2015

The world is a work in progress

I saw the movie "Imitation game" last night. It is about Alan Turing and his efforts to break the Nazi Enigma code in WWII. It was simply a tragedy of epic proportions that the world lost him at the young age of 41, after he was convicted of solicitation of homosexual sex and forced under court order to take medications which chemically castrated him. Britain at that time considered homosexuality a crime. He committed suicide in the year of my birth.

I remember my first exposure to homosexuals when I was in college. There were a cadre of effeminate men which I did not recall from my high school experience. I may have simply been unaware of this cohort earlier in my schooling. I was rather young and not tuned into these issues. The thought of being attractive to other men was completely alien to my preferences. It had simply never even occurred to me that could be an option at that point in my life. However, I could not consider that homosexuality was a crime at that time, although I think anti-sodomy laws were on the books. They may still be on the books.

This particular cohort at college was almost universally ridiculed among those who I associated with. At that point in time I did not view this with any sort of moral dimension. I perceived this cohort simply as something very strange. I never acted in a way to personally ridicule anyone for their apparent homosexuality. However, I also did not take any action to step up in defense of anyone or call anyone out on their anti-homosexual actions. Knowing what I know now, I could have been more heroic in coming to the defense of those who were identified as being homosexual men. I was simply struggling to find my way at that time.

Roll the clock forward more than forty years. The world is a very different place. I am a very different person or at least I have a very different perspective on my world. I have had the experience of meeting literally thousands of people, both personally and professionally. I have come to realize just how remarkably diverse people are in terms of motivation, responses to incentives, preferences, talents, virtues, and vices. I have come to realize that David Hume was correct in terms of "reason being a slave to passion" and that many if not most of our passions are beyond our choice.

The world is a simpler place when the choices are binary. It makes for simpler law and simpler choices in the personal realm. However, the world is generally not black and white in terms of our choices. The growing acceptance of homosexuality and what could viewed in historical terms  as atypical sexual practices is a product of recent decades in a small subset of human cultures. It may be viewed as part of a longer term trend in human societies of greater acceptance of diversity in general. It is my belief that this is a consequence of greater human affluence in general.

Cultures which live on the edge have less reserves to play with. Mistakes which affect the ability to feed or defend themselves literally can represent existential threats. An almost universal characteristic of human societies has been to hold anyone or anything that is different with great suspicion. Call it the stranger heuristic. The default response to strangers was violence. The default response to almost everything was violence. In a zero sum world which was the world until that past 500 years, that response may have had some survival advantages.

I have had the opportunity to live and experience a world where we can tolerate outliers. In fact, our world may benefit from harnessing the talents of those who we might view initially as strange.  It is not as if we cannot define certain actions as unacceptable. We need to re-examine what we might have viewed as outside the bounds as acceptable. We will not all agree on what is acceptable or not acceptable but we should be very careful about using the coercive power of the state to enforce anything but the most egregious and unacceptable actions. On the flip side, we should also allow leeway to individuals to define their own comfort zones, using social sanctions to provide feedback to those within voluntary social networks. The world is a work in progress.

Saturday, January 10, 2015

Needing an industrial revolution in healthcare

I recently finished a Teaching Company course on the Industrial Revolution, taught by Dr. Patrick Allitt. In this course he detailed the development of industrialization of manufacturing over the course of almost 500 years. It is a remarkable story of human ingenuity, technological progress, and extraordinary impact on the human condition. He presents a story of a world not so long ago where human existence was precarious because the tools and systems in place to meet human needs were rudimentary. The remarkable development of industrial technologies in conjunction with effective approaches to motivate and coordinate human activity resulted in a complete transformation of human existence where these tools were deployed.

The progress did not take place in a straight line. There were failures and the achievements made were the product of much tinkering and some planning. The exact outcomes were not necessarily predictable but the themes in retrospect were recurrent. At each step of the way, huge breakthroughs happened when tools were developed that freed humans from manual tasks and automated activities. These breakthroughs were almost always very disruptive of selected industries and populations but the net effects for the broader population were hugely positive. People got more to eat at lower prices as well as better living and working conditions.

Another aspect of this evolution was the ability of the industrial revolution to deliver not only more, but more at a lower price and higher quality. Nowhere is this more evident than in the 20th century where we observed an explosion of increasingly sophisticated consumer goods where after particular product introductions prices would tumble while simultaneously the functionality and quality increased. This includes computers, home appliances, and automobiles. What drove this remarkable expansion of high quality plenty was a combination of science, breakthroughs in human organization, and information systems which could track key elements of cost and quality.

Dr. Allitt tracks all of these elements going back to their origins, which he tracks back to the building and operation of large ships in England. What does this have to do with medicine and biomedical research? Simply that the health care delivery and research relating to health care benefits from the same tools which made the industrial revolution possible. The holy grail for basically any human activity is to get more out of any particular inputs in terms of making human lives better. It has been well documented that, unlike the productivity gains associated with virtually all commercial activities in the US since WWII, health care has shown essentially no productivity gains. As noted by by Kochner, et all in the NEJM (N Engl J Med 2011; 365:1370-1372October 13, 2011DOI: 10.1056/NEJMp1109649):

Of the $2.6 trillion spent in 2010 on health care in the United States, 56% consisted of wages for health care workers. Labor is by far the largest category of expense: health care, as it is designed and delivered today, is very labor-intensive. The 16.4 million U.S. health care employees represented 11.8% of the total employed labor force in 2010. Yet unlike virtually all other sectors of the U.S. economy, health care has experienced no gains over the past 20 years in labor productivity, defined as output per worker (in health care, the “output” is the volume of activity — including all encounters, tests, treatments, and surgeries — per unit of cost). Although it is possible that some gains in quality have been achieved that are not reflected in productivity gains, it's striking that health care is not experiencing anything near the gains achieved in other sectors. At the same time, health care labor is becoming more expensive more quickly than other types of labor. Even through the recession, when wages fell in other sectors, health care wages grew at a compounded annual rate of 3.4% from 2005 to 2010.
 In addition, it is very difficult to demonstrate gains in quality as well. I contend that these two shortfalls are in fact related to the inadequacy in information systems used in health care. When you can't reliably track things, you end up wasting resources and generating poor quality products.

The story in biomedical research is perhaps a bit more nuanced. Biomedical research has revolutionized diagnostics and therapeutics but we are facing issues of diminishing returns. The antibiotic and vaccine revolution deployed in the early to mid 20th century made huge impacts at very modest cost. Arguably the returns of these endeavors dwarfed the costs of development and deployment. We are at a different point now where the cost of new drugs to treat chronic diseases is simply off the charts. Every new decade moves the decimal place over one place. Furthermore, the deliverables for individual researchers is not necessarily something that has an impact on people in the near term. The funding system values a different sort of productivity based upon publications. The explosion of scientific publishing has until recently, not been accompanied by any real change in the mechanics of vetting and review and the problem which has arisen is one of quality control.

However, funding agencies have attempted to develop models to oversee quality and independent entities such as Retraction Watch ( have stepped up to inject quality control in the process not adequately addressed with peer review. Not surprisingly there has been an explosion of paper retractions as well as exposees revealing major issues with reproducibility (Nature article). This is very disturbing because what separates science from magic and alchemy is the ability to reproduce results.

What all of these contemporary processes have in common is they are very dependent upon human beings using manual processes and judgement requiring much subjectivity to do their jobs. Furthermore, the products of these efforts cannot be readily and consistently assessed for quality. As long as these remains the case in health care delivery and biomedical research, it will be hard to reap the sort of gains from investment in these sectors when compared to investments made in areas where productivity and quality can be assessed more robustly.