Assorted links

by on December 5, 2011 at 9:42 am in Uncategorized | Permalink

1. Good background on Sargent and Sims.

2. Lost puffin found in sex clinic, and David Warsh baits Greg Ransom.

3. How doctors die.

4. Short history of Unix.

5. Will Japan and Russia clone a woolly mammoth?

6. A total coincidence, but here is a list of the most corrupt eurozone countries.  And I am still skeptical, but it seems markets really like the new Italian austerity plan.

Daniel Kuehn December 5, 2011 at 9:47 am

Baiting Greg Ransom is not a hard thing to do. Many people do it without even realizing it. :)

Tom December 5, 2011 at 12:48 pm

Glass houses, Daniel

Roy December 5, 2011 at 10:13 am

5. This has long been my dream, I am even so wildly irresponsible that I would like to see them released in the wild, maybe in ANWR. I’d love to try and regenerate the mammoth steppe.

Slugger December 5, 2011 at 10:22 am

Watch out, people! Fukushima giant radioactive mammoths will soon be stampeding all over the earth. I hope that they are working on a Mothra to save us!

iamreddave December 5, 2011 at 10:34 am

4. See if you can lead a meaningful life without having heard Ken Thompson’s Bell Labs alligator story
http://www.youtube.com/watch?feature=player_embedded&v=p-kWw0UTD2A#!

bob December 5, 2011 at 10:40 am

The how doctor’s die link doesn’t work

Rrr December 5, 2011 at 12:08 pm

From the cached version, it’s worth it:

http://webcache.googleusercontent.com/search?q=cache:http://zocalopublicsquare.org/thepublicsquare/2011/11/30/how-doctors-die/read/nexus/

How Doctors Die

It’s Not Like the Rest of Us, But It Should Be

by Ken Murray

Years ago, Charlie, a highly respected orthopedist and a mentor of mine, found a lump in his stomach. He had a surgeon explore the area, and the diagnosis was pancreatic cancer. This surgeon was one of the best in the country. He had even invented a new procedure for this exact cancer that could triple a patient’s five-year-survival odds—from 5 percent to 15 percent—albeit with a poor quality of life. Charlie was uninterested. He went home the next day, closed his practice, and never set foot in a hospital again. He focused on spending time with family and feeling as good as possible. Several months later, he died at home. He got no chemotherapy, radiation, or surgical treatment. Medicare didn’t spend much on him.

It’s not a frequent topic of discussion, but doctors die, too. And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.

Of course, doctors don’t want to die; they want to live. But they know enough about modern medicine to know its limits. And they know enough about death to know what all people fear most: dying in pain, and dying alone. They’ve talked about this with their families. They want to be sure, when the time comes, that no heroic measures will happen—that they will never experience, during their last moments on earth, someone breaking their ribs in an attempt to resuscitate them with CPR (that’s what happens if CPR is done right).

Almost all medical professionals have seen what we call “futile care” being performed on people. That’s when doctors bring the cutting edge of technology to bear on a grievously ill person near the end of life. The patient will get cut open, perforated with tubes, hooked up to machines, and assaulted with drugs. All of this occurs in the Intensive Care Unit at a cost of tens of thousands of dollars a day. What it buys is misery we would not inflict on a terrorist. I cannot count the number of times fellow physicians have told me, in words that vary only slightly, “Promise me if you find me like this that you’ll kill me.” They mean it. Some medical personnel wear medallions stamped “NO CODE” to tell physicians not to perform CPR on them. I have even seen it as a tattoo.

To administer medical care that makes people suffer is anguishing. Physicians are trained to gather information without revealing any of their own feelings, but in private, among fellow doctors, they’ll vent. “How can anyone do that to their family members?” they’ll ask. I suspect it’s one reason physicians have higher rates of alcohol abuse and depression than professionals in most other fields. I know it’s one reason I stopped participating in hospital care for the last 10 years of my practice.

How has it come to this—that doctors administer so much care that they wouldn’t want for themselves? The simple, or not-so-simple, answer is this: patients, doctors, and the system.

To see how patients play a role, imagine a scenario in which someone has lost consciousness and been admitted to an emergency room. As is so often the case, no one has made a plan for this situation, and shocked and scared family members find themselves caught up in a maze of choices. They’re overwhelmed. When doctors ask if they want “everything” done, they answer yes. Then the nightmare begins. Sometimes, a family really means “do everything,” but often they just mean “do everything that’s reasonable.” The problem is that they may not know what’s reasonable, nor, in their confusion and sorrow, will they ask about it or hear what a physician may be telling them. For their part, doctors told to do “everything” will do it, whether it is reasonable or not.

The above scenario is a common one. Feeding into the problem are unrealistic expectations of what doctors can accomplish. Many people think of CPR as a reliable lifesaver when, in fact, the results are usually poor. I’ve had hundreds of people brought to me in the emergency room after getting CPR. Exactly one, a healthy man who’d had no heart troubles (for those who want specifics, he had a “tension pneumothorax”), walked out of the hospital. If a patient suffers from severe illness, old age, or a terminal disease, the odds of a good outcome from CPR are infinitesimal, while the odds of suffering are overwhelming. Poor knowledge and misguided expectations lead to a lot of bad decisions.

But of course it’s not just patients making these things happen. Doctors play an enabling role, too. The trouble is that even doctors who hate to administer futile care must find a way to address the wishes of patients and families. Imagine, once again, the emergency room with those grieving, possibly hysterical, family members. They do not know the doctor. Establishing trust and confidence under such circumstances is a very delicate thing. People are prepared to think the doctor is acting out of base motives, trying to save time, or money, or effort, especially if the doctor is advising against further treatment.

Some doctors are stronger communicators than others, and some doctors are more adamant, but the pressures they all face are similar. When I faced circumstances involving end-of-life choices, I adopted the approach of laying out only the options that I thought were reasonable (as I would in any situation) as early in the process as possible. When patients or families brought up unreasonable choices, I would discuss the issue in layman’s terms that portrayed the downsides clearly. If patients or families still insisted on treatments I considered pointless or harmful, I would offer to transfer their care to another doctor or hospital.

Should I have been more forceful at times? I know that some of those transfers still haunt me. One of the patients of whom I was most fond was an attorney from a famous political family. She had severe diabetes and terrible circulation, and, at one point, she developed a painful sore on her foot. Knowing the hazards of hospitals, I did everything I could to keep her from resorting to surgery. Still, she sought out outside experts with whom I had no relationship. Not knowing as much about her as I did, they decided to perform bypass surgery on her chronically clogged blood vessels in both legs. This didn’t restore her circulation, and the surgical wounds wouldn’t heal. Her feet became gangrenous, and she endured bilateral leg amputations. Two weeks later, in the famous medical center in which all this had occurred, she died.

It’s easy to find fault with both doctors and patients in such stories, but in many ways all the parties are simply victims of a larger system that encourages excessive treatment. In some unfortunate cases, doctors use the fee-for-service model to do everything they can, no matter how pointless, to make money. More commonly, though, doctors are fearful of litigation and do whatever they’re asked, with little feedback, to avoid getting in trouble.

Even when the right preparations have been made, the system can still swallow people up. One of my patients was a man named Jack, a 78-year-old who had been ill for years and undergone about 15 major surgical procedures. He explained to me that he never, under any circumstances, wanted to be placed on life support machines again. One Saturday, however, Jack suffered a massive stroke and got admitted to the emergency room unconscious, without his wife. Doctors did everything possible to resuscitate him and put him on life support in the ICU. This was Jack’s worst nightmare. When I arrived at the hospital and took over Jack’s care, I spoke to his wife and to hospital staff, bringing in my office notes with his care preferences. Then I turned off the life support machines and sat with him. He died two hours later.

Even with all his wishes documented, Jack hadn’t died as he’d hoped. The system had intervened. One of the nurses, I later found out, even reported my unplugging of Jack to the authorities as a possible homicide. Nothing came of it, of course; Jack’s wishes had been spelled out explicitly, and he’d left the paperwork to prove it. But the prospect of a police investigation is terrifying for any physician. I could far more easily have left Jack on life support against his stated wishes, prolonging his life, and his suffering, a few more weeks. I would even have made a little more money, and Medicare would have ended up with an additional $500,000 bill. It’s no wonder many doctors err on the side of overtreatment.

But doctors still don’t over-treat themselves. They see the consequences of this constantly. Almost anyone can find a way to die in peace at home, and pain can be managed better than ever. Hospice care, which focuses on providing terminally ill patients with comfort and dignity rather than on futile cures, provides most people with much better final days. Amazingly, studies have found that people placed in hospice care often live longer than people with the same disease who are seeking active cures. I was struck to hear on the radio recently that the famous reporter Tom Wicker had “died peacefully at home, surrounded by his family.” Such stories are, thankfully, increasingly common.

Several years ago, my older cousin Torch (born at home by the light of a flashlight—or torch) had a seizure that turned out to be the result of lung cancer that had gone to his brain. I arranged for him to see various specialists, and we learned that with aggressive treatment of his condition, including three to five hospital visits a week for chemotherapy, he would live perhaps four months. Ultimately, Torch decided against any treatment and simply took pills for brain swelling. He moved in with me.

We spent the next eight months doing a bunch of things that he enjoyed, having fun together like we hadn’t had in decades. We went to Disneyland, his first time. We’d hang out at home. Torch was a sports nut, and he was very happy to watch sports and eat my cooking. He even gained a bit of weight, eating his favorite foods rather than hospital foods. He had no serious pain, and he remained high-spirited. One day, he didn’t wake up. He spent the next three days in a coma-like sleep and then died. The cost of his medical care for those eight months, for the one drug he was taking, was about $20.

Torch was no doctor, but he knew he wanted a life of quality, not just quantity. Don’t most of us? If there is a state of the art of end-of-life care, it is this: death with dignity. As for me, my physician has my choices. They were easy to make, as they are for most physicians. There will be no heroics, and I will go gentle into that good night. Like my mentor Charlie. Like my cousin Torch. Like my fellow doctors.

Ken Murray, MD, is Clinical Assistant Professor of Family Medicine at USC.

Roy December 5, 2011 at 12:29 pm

Considering this clashes rather strongly with my anecdotal experience, I’d like to see something other than an anecdote.

Dan Weber December 5, 2011 at 1:08 pm

Your anecdotal experience is that doctors cling to life? All the people I know who worked in an ICU have well-documented DNR orders.

This article probably documents the #1 reason that health care is so expensive in America. It doesn’t fit into an easy narrative for either the left or the right so they don’t say much about it.

Rahul December 5, 2011 at 1:11 pm

Some of the stuff the guy writes is downright dangerous. In the middle of that rant is he actually trying to dissuade people from giving CPR?

Roy December 5, 2011 at 1:12 pm

Your sample probably a different sample from mine, and of the people in ICU staff, how many are MDs? My experience is with internal medicine, oncologists, and most strikingly neurologists.

This is exactly why we need some actual data on this and not dueling anecdotes.

Davis December 5, 2011 at 1:48 pm

and all the people i know who were in ICU’s more than 1 year ago were happy that they survived. Any anecdotes here are absurdly biased not only by survivorship, but by demographics (age of your friends, practice area of MD), and by psychological biases of the doctors (there’s a reason hospitals don’t typically let doctors treat themselves and lawyers rarely represent themselves).

Dan Weber December 5, 2011 at 4:14 pm

> Not dueling anecdotes.

Well, he did say this:

Amazingly, studies have found that people placed in hospice care often live longer than people with the same disease who are seeking active cures.

This is a fairly well-known phenomenon. Here’s one study: http://www.nhpco.org/files/public/JPSM/march-2007-article.pdf

The scary thing is that I’d have to fight like mad to not get the crazy level of care.

msgkings December 5, 2011 at 4:23 pm

@ Dan Weber

+100 re health care expense. Solve the end of life $ suck and the highest compensated doctors on earth problem and health care is no longer a $ issue.

Easier said than done. In the comments to the original article a couple folks make the good point that while this writer may not want heroic measures, many do and their choices should be respected too.

NPW December 5, 2011 at 5:45 pm

@Rahul After the first 4 years of Iraq/Afganistan the US Army stopped teaching CPR as part of first aid because it saved exactly zero lives.

maguro December 5, 2011 at 10:27 pm

Yeah, CPR won’t be much help if your humvee gets blown up by a mine.

Rahul December 6, 2011 at 12:32 am

@NPW

That’s interesting; thanks! I had no idea Army stopped CPR.

BTW, do you have a citation? I couldn’t find info on this change online.

Bartram's Garden December 6, 2011 at 3:39 am

“Some of the stuff the guy writes is downright dangerous. In the middle of that rant is he actually trying to dissuade people from giving CPR?”

CPR has been wildly oversold to the public. It rarely works for medical illness. It never works for trauma (because you’re trying to solve a surgical problem with a medical treatment), and the Army was doubtless right to stop it.

There’s only one therapy that has been proven to work for cardiac arrest: electricity. Rapid defibrillation in individuals who have had a heart attack and have developed a certain abnormal, lethal rhythm, ventricular fibrillation, if it is administered rapidly, within the first 4 minutes, and if the patient was otherwise healthy to begin with. That works, sometimes. All the other stuff we do has never been shown to actually work. We do it because… because the person is dead, we feel we have to do *something*, and here are some things that seem sort of reasonable based on dog studies, and that are recommended by the American Heart Association.

People learn about medicine from media, though, and on TV, CPR works about half the time. That’s a lie. Like the many other attractive lies media tells.

I’m a doc, BTW. I agree with “How Doctors Die” article, although I wish it had more documentation of its assertions.

Bartram's Garden December 6, 2011 at 3:47 am

Oh, just to clarify something. Saying that futile CPR is done because “we feel we have to do *something*” makes the decision sound personal and almost casual. It isn’t. ‘We’ is society. These are the feelings of society, not the individual doctor. Since the 1970s, these feelings have been codified into hospital protocols and malpractice law. If the family wants CPR, or if the doctor has reason to believe the patient wanted CPR, or if no one knows (frequently the case), the doctor on the spot must do CPR. He doesn’t have a choice, if he doesn’t want to be sued into insolvency, lose his job, lose his license, or even be tried for murder.

Rahul December 6, 2011 at 7:52 am

@Bartram’s Garden etc.

It seems that professionally administered CPR boosts survival rate (1 month) more than 4 times in case of cardiac arrest. That sounds good enough evidence to try CPR.

http://www.ncbi.nlm.nih.gov/pubmed/15950357

Of course, I’m not a doctor so I don’t have the anecdotal evidence. But a 12 year study on 29,000 cardiac arrests seems strong evidence to me. The Army operates in injury profiles not typical of civilian life so their decisions are somewhat separate.

Do the CPR mockers have data that challenges this? The cited article and comments seem to be very anecdote driven.

Dan Weber December 6, 2011 at 11:35 am

All the other stuff we do has never been shown to actually work.

This is true for a scary amount of stuff that everyone just assumes improves health.

kevin h December 6, 2011 at 12:14 pm

“More commonly, though, doctors are fearful of litigation and do whatever they’re asked, with little feedback, to avoid getting in trouble.”

I don’t understand why economists do not take this point of view as relevant in assigning reasons for the high cost of medical care in this country. It is very easy to blame it on the doctor’s salaries.

Ken Rhodes December 5, 2011 at 10:42 am

In re: number 2–Imagine my disappointment after the title about a puffin in a sex clinic.

Andrew' December 5, 2011 at 11:40 am

Don’t believe him. I’d “claim” to be “lost” too.

vm December 5, 2011 at 11:54 am

Filthy degenerate puffins. Also, MORE PUFFIN LINKS!!!

dearieme December 5, 2011 at 6:32 pm

This morning’s Telegraph reported that the puffin had died. (Otherwise I’d have brought it to Tyler’s attention.)

PP December 5, 2011 at 10:42 am

4. says “[Linux] even runs some supercomputers.”

Linux runs on NEARLY ALL supercomputers.

Henry December 5, 2011 at 10:46 am

4. says “[Linux] even runs some supercomputers.”

Linux runs on NEARLY ALL supercomputers.

Not quite true… Linux runs on “Virtual Machines” (VM technology by the way is older than Unix), those VM run on top of proprietary versions of Unix optimized for massively parallel processing.

Rahul December 5, 2011 at 12:07 pm

Virtual machines for supercomputers? Are you sure?

I doubt it. When it’s the Teraflops that matter a VM is too big of a drag on efficiency. VM’s are in run of the mill datacenters running webservers etc.

I’ve never heard of a VM on a Supercomputer.

Henry December 5, 2011 at 12:19 pm

http://gcn.com/Articles/2009/08/04/Sandia-Million.aspx

There are running a million in this one…on a stripped version of Linux too…

But you are mostly right, research facilities don’t usually run VMs, most of what their doing is proprietary or home grown. My brother used to work for a supercomputer manufacturer and they sold a handful of them to the private sector and those guys did need VMs to run their RDBMS.

rpl December 5, 2011 at 12:35 pm

There are running a million in this one…on a stripped version of Linux too…

Read the article carefully. They are not using VMs to run the cluster. The researchers are studying botnets, which they simulate by running all those VMs on a linux cluster. In this case, the VMs are not part of the host cluster; they are the user application that the cluster is running.

rpl December 5, 2011 at 12:29 pm

Which systems are you referring to? Most of the top500.org entries are Linux+Infiniband clusters which certainly do not use the setup you are describing. The Cray XT and XE series don’t use it either, although the version of Linux that runs on their compute nodes is heavily customized and proprietary (but it doesn’t have any VM running on top of it). There may be a few oddball systems that use some scheme involving VMs and proprietary Unix, but they are surely a small minority.

According to the latest Top 500 list, the breakdown of the 500 largest computing systems by operating system is:

Linux: 457
Unix (unspecified): 30
Mixed: 11
Windows: 1
BSD: 1

That’s close enough to “NEARLY ALL” for me.

Rahul December 5, 2011 at 1:08 pm

The Windows cluster is a joke in the HPC community. Legend has it that when Microsoft came up with Windows-HPC they had to actually pay some clusters to be early adopters. Yes, it is THAT bad. I can’t see Supercomputers running on Win anytime soon.

rpl December 5, 2011 at 1:23 pm

I’m familiar with Windows HPC Server. I can’t say I’d want to use it, but I could see where it would fill a niche in shops that are already developing under Windows. I can’t see it getting much use beyond the “departmental scale” clusters, but that market segment is likely to be a lot more profitable than petascale systems anyhow, so perhaps that’s enough for them. I think the real problem with using Windows in supercomputing is that Microsoft’s commitment to HPC has always been lukewarm. They seem to go through these cycles of putting out supercomputing products, only to abandon them a few years later when they rediscover that the HPC market is really tiny. Two years ago, for example, they were really pushing WHPCS at Supercomputing 2009. This year, they didn’t seem to have a product on offer at all; most of their booth was taken up with a Kinect demo (which was cool, but it’s hard to see how it’s related to supercomputing).

DK December 5, 2011 at 10:49 am

#5. No, they won’t.

londenio December 5, 2011 at 11:31 am

If someone ever wants a good example of what “Assorted Links” means in MR, this is a nice portfolio of links to represent the premise.

ft December 6, 2011 at 12:13 am

Agreed, good links today.
The ‘Counterparties’ links on Felix Salmon’s blog used to be on-par with MR (maybe not so assorted, but usually pretty broad), until Nick Rizzo started doing them.

jimi December 5, 2011 at 12:07 pm

#5- God I hope so!

I hope the miniaturize them down to about 60 pounds, too!! How f***ing cute would that be??

Roy December 5, 2011 at 12:37 pm

There were pygmy mammoths on Santa Catalina until very close to the modern era, and on Wrangel Island in the arctic they may have survived until the early part of the first millenium.

There were also pygmy elephants on Sicily and Cyprus until they were exterminated, I have actually stood next to an unfossilized skeleton, it was the cutest skeleton I ever saw. Since we humans exterminated them, I think we have a responsibility to try and bring them back, anything else would be unethical.

doctorpat December 5, 2011 at 11:12 pm

A stampeding wave of woolly mammoths, miniature, full sized, and supersized, is really the best solution for Greece at this point.

Silas Barta December 5, 2011 at 12:16 pm

2) is a wall of text. Can someone please summarize the part that baits Greg Ransom?

Andrew' December 5, 2011 at 12:36 pm

Summary: Hayek is no Tim Tebow.

NAME REDACTED December 6, 2011 at 9:09 am

roflcopters

Wu December 5, 2011 at 1:36 pm

lrn2read

Silas Barta December 5, 2011 at 2:57 pm

lrn2economize on time by not reading people who use 1000 words when 10 would have sufficed.

EM DC Economist December 5, 2011 at 12:44 pm

A total coincidence ? Hardly. There are several common factors that drive both phenomena.

merci December 5, 2011 at 12:49 pm

There is a mistake. Slovakia falls between Italy and Portugal in terms of Transparency’s corruption index and is the member of the eurozone.

Claudia Sahm December 5, 2011 at 1:17 pm

#1 Great article..especially for economists and/or those who seek to understand the recent debates in the profession. Sargent and Sims were always names attached to papers I needed to learn in grad school or concepts I needed to be aware of in my work. I think their career paths are instructive (albeit *just* two data points) of some broader issues. I was going to post a favorite quote from the article, but as I read further I gave up. There’s lots of good stuff in there..just depends what you’re looking for.

Barkley Rosser December 5, 2011 at 9:19 pm

Regarding the Italian plan, really they do not need one except to put on a show that Monti really is not Berlusconi, whose antics had completely put everybody off. Italy is one of the only four countries in the eurozone that is running a primary surplus (Luxembourg, Belgium, and Germany are the others). They really do not have a fundamental crisis. Their crisis has only been one of high interest rates driven by a fear of high interest rates. Their high debt ratio is not a big deal as a majority of it is domestically owned and they have had such a high ratio for years. The hysteria over Italy has been one of the more absurd spectacles of the recent period.

NAME REDACTED December 6, 2011 at 9:11 am

Imo: Italy’s problem is demographic decline and banks looking for liquidity.

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