The Paradox of Medicine -- Why More is Not Always Better

I am in the process of writing a new book so it takes a lot to divert my attention.

Dr. Sanjay Gupta's brilliant OpEd in yesterday's New York Times, "More is not always better in medicine," which has been reprinted on cnn.com  not only have I read and reread but it deserves a commentary. Unlike Andrew Hacker's OpEd, also in the Times, to which I, and many of my colleagues, had strong negative reactions, I applaud Dr. Gupta's brilliant OpEd.

Of course, the OpEd title itself intrigued me,  especially the part --  more is not always better.  Although his OpEd  is focused on medicine,  it reminded me of  the Braess paradox in transportation and the Internet -- when adding capacity can actually make everyone (travelers, or computer messages) worse-off in terms of travel time. In that context, we also speak of the price of anarchy, which seems, to me, also very relevant in the medical context.

His OpEd begins with the doctor's oath:  "First, do no harm," and notes that, whenever a medical professional makes a mistake that affects a patient, this oath is violated.Coincidentally, this past Sunday, in holding a second and belated graduation party for my daughter, a mother of a fellow Deerfield Academy graduate, remarked to me, that, as a child of doctors, she would regularly hear: "Do no harm," and, interestingly, she brought this up in talking about college guidance counselors (I may cover that topic in a future blogpost).

Dr. Gupta's  major thesis is that, in practicing defensive medicine, with many more tests given to patients and medicines prescribed, patients are being injured, since the former  may result in false positive results with infections and other complications possibly occurring and the latter may result in allergic reactions, or inappropriate treatments (and he gives examples from his own experiences).

According to Dr. Gupta:

It is a given that American doctors perform a staggering number of tests and procedures, far more than in other industrialized nations, and far more than we used to. Since 1996, the percentage of doctor visits leading to at least five drugs' being prescribed has nearly tripled, and the number of MRI scans quadrupled.

Each additional procedure or test, no matter how cautiously performed, injects a fresh possibility of error. 

Certainly many procedures, tests and prescriptions are based on legitimate need. But many are not. In a recent anonymous survey, orthopedic surgeons said 24% of the tests they ordered were medically unnecessary. This kind of treatment is a form of defensive medicine, meant less to protect the patient than to protect the doctor or hospital against potential lawsuits.

He cites the horrific, tragic death of 12 year old Rory Staunton, who died in NYC due to an infection that was not properly recognized and  treated.

Dr. Gupta eloquently argues for medical quality assurance through M and M's -- Mortality and Morbidity meetings in which medical professionals regularly discuss what has transpired in their hospital/practice, etc., so that proper procedures can be followed and lessons learned from mistakes made.

My colleague, Dr. Soren Bisgaard, who passed away in December of  2009 of lung cancer, attributed to his childhood spent hanging around the shipyards of his native Greenland, edited a volume, "Solutions to the Health Care Quality Crisis," published in 2009.  

A few years back, Dr. Gupta withdrew his name for consideration for the US Surgeon General position..Perhaps one day he will reconsider -- although he already is doing incredible work not only as a practicing neurosurgeon, CNN commentator and reporter in the field, but also as a  brilliant writer.

It is truly frightening that, when people are most vulnerable,  that is, when they are sick, that those that they trust and depend on  -- the medical experts -- may let them down.

Simons Foundation Funds Major Computing Institute at UC Berkeley

I was delighted to read in The New York Times that the University of California Berkeley has been selected as the home of a new Computing Institute to be headed by Richard Karp with support from  Christos Papadimitrou. Papadimitrou, you may recall, is credited for the term "price of anarchy,"  which I have written about in some of my work, including in  the Fragile Networks book co-authored with Qiang "Patrick" Qiang.

The Institute is being funded by the Simons Foundation.

The Simons Foundation was established by James Simons, who had been a faculty member at SUNY Stony Brook in Math (I had an offer from the department when I was on the job market finishing up my PhD at Brown University) and then went on to establish and lead the very successful hedge fund, Renaissance Technologies. He is now one of the wealthiest people in the world but doesn't just sit on his gold.

I have written about the good work that his foundation has been doing in supporting research and education on this blog.

It is thrilling to see that this institute will be focusing on computing and will support research and applications in algorithmics and computational thinking that are now permeating so many disciplines.

I wish UC Berkeley lots of success in bringing disciplines together and in making discoveries through analyzing big data. I appreciated also seeing massively parallel architectures noted in the Times article and seeing Jeannette Wing quoted.  Yes, there are females that love to compute and to solve problems.

Supernetwork Analytics -- Paying for the True Cost of Transportation and Negative Externalities

How many of us realize the true costs of the impact of our driving on others?

Of course, those of us who work on networks and transportation regularly compute costs of operating various systems (system-optimization) as opposed to figuring out which is the best route of travel from an origin to a destination (user-optimization). Typically, the costs that we consider in such applications reflect time or a monetarization of time and costs of fuel consumption and since the classical work of Beckmann, McGuire, and Winsten's (1956) book, "Studies in the Economics of Transportation," we also include congestion, which is a negative externality and what, in economics and beyond, refers to the negative impacts of one's activities.

Increasingly, we are also utilizing generalized costs, which, for example, can include other costs such as the emissions generated and many of us have worked on the price of anarchy, relevant to congested networks from transportation to the Internet.

What if there was a computerized financial and telecommunications system that could quantify the true cost of using our transportation networks? Such a system might actually provide a powerful feedback loop to alter individuals' driving behavior and might even motivate them to switch to more environmentally friendly modes of travel, such as public transportation, bicycles, or even one's feet.

While traveling recently in San Diego on, yes, 8 lane highways (each way), I was stunned by the passing on the right, on the left, but overall quite decent drivers although the wide spans of highways made me yearn for the northeast of the US (weather notwithstanding). There was limited public transit in sight and we spent 6 days there.

The Netherlands has begun an experiment, which demonstrates supernetworks (networks of networks) in action. Various vehicles, including cars, were installed with high technology to track vehicle movements in order to calculate not only the distance traveled, but also the fuel efficiency of the vehicle, the associated emissions, plus the expected "business" of the roads, as well as the wear and tear of the vehicle on the roads (very cool but more on this aspect later).

Other factors that I might include would be the number of passengers traveling (of course, the greater the number the greater impact on fuel consumption but a lightening of the congestion).

The New York Times reported on this experiment in a recent article, Netherlands Meter Plan Links Gas Pedals to Wallets, from Eindhoven, which, interestingly, is the location of a fellow research group on supernetworks, and our Virtual Center for Supernetworks is planning on hosting a visiting scholar from that group this Fall.

My research team has been working on sustainable transportation for many years now and in my Sustainable Transportation Networks book I describe many different policies to alleviate congestion and emission including marketable pollution permits, emission and congestion tolls, etc. The book is focused on transportation whereas our Environmental Networks book emphasizes models and algorithms to enhance sustainability on a macro scale.

Now for the clincher, as my students in transportation and logistics know, we can construct link tolls and they will always be nonnegative, but path tolls can be constructed that take on negative values (think of subsidies and one of my favorite ones is that children in strollers and their caretakers ride free on busses in Stockholm, Sweden, which I even took advantage of when we lived there with our daughter and the busses are so comfortable and handsome).

So, as someone who is extremely frustrated by the low quality of road infrastructure in the area of Massachusetts that I live in, would the government pay the vehicle operators for the wear and tear on their vehicles (plus their anatomies) if such a supernetwork system were to be installed in the US?

Infrastructure matters and with the right public and private partnerships we should be able to make the US a model for transportation and logistics but in whose lifetime?

A Logistics Nightmare in Haiti Post the Earthquake and the Price of Anarchy

The New York Times is reporting today on the logistical nightmare faced by relief workers in trying to get the critical needs supplies to the victims of the earthquake in Haiti. Airplanes have had to circle from 2 to 3 hours before landing; there is no central control of distribution of supplies even after the planes land, plus many of the roads (which were not in good shape even prior to the quake) are now severely damaged if not littered with debris, and the principal port and equipment for unloading supplies have also been seriously affected. The relief workers are trying to determine alternative routes so that they can deliver the clean water, medical supplies, and food. At the same time, congestion is becoming an issue (sometimes referred to as convergence in humanitarian logistics parlance) since vehicles and supplies do not have sufficient warehousing capacity in which to offload and from which to distribute.

The situation in Haiti brings to mind a measure in network analysis, notably, in transportation and telecommunications, called the price of anarchy, which is the ratio of the total cost under user-optimizing (decentralized) behavior to the total cost under system-optimizing (centralized) behavior. We recently published a paper on transportation network robustness in the presence of degradable links in the International Transactions in Operational Research and related our new measures to the price of anarchy. Had Haiti had a more resilient and robust network infrastructure, the losses may not have been so severe.

As this article in the Times and others in the press have stated, this is a disaster of monumental proportions. What will happen in the next few hours and days will determine also how many of those who have survived will be able to go on in such horrendous circumstances.

What will transpire in the next couple of weeks and months in Haiti will be a serious case study on the interplay of development, reconstruction, and humanitarianism.

Being Thanked in the Top Physics Journal

One of the truly gratifying aspects of being a Professor is having students that have graduated write back and stay in touch. Last semester, one of my former undergrads, who had taken my transportation & logistics class, brought to my attention a paper that had been published in the top journal in physics, known as "Phys. Rev. Letters." What amazed this graduate of our Operations Management program at the Isenberg School of Management was that he understood the material and much of it was familiar. News about this article, entitled, "The Price of Anarchy in Transportation Networks: Efficiency and Optimal Control," [Phys.Rev.Lett. 101,128701(2008)] had gone viral with articles appearing in The Economist, the Boston Globe, and the New York Times.

After reading the article it became clear to me that many references were missing and, in scholarship, it is imperative to do a thorough literature search, which establishes precedence. Towards that end, with my husband, who has a PhD in physics, we wrote a response documenting some of the major relevant milestones in transportation network research that should have been included in the article. The rebuttal was not published but, lo and behold, this week there is an errata by the authors in Phys. Rev. Letters {Phys. Rev.Lett. 102, 049905 (2009)], which thanks us and includes some of our suggested references. We are pleased that the authors now understand that science moves forward by standing on the shoulders of giants.

The original article had also motivated my Letter to the Editor to The Economist.

Scientific American, the Braess Paradox, and the Price of Anarchy

I was interviewed by the journalist, Linda Baker, for her article, "Detours by Design," which appears in the February 2009 issue of the Scientific American. The article talks about the Braess paradox, which dates to 1968, and demonstrates that the addition of a new road may make all travelers worse off in terms of travel time/cost. The Scientific American article highlights a recent example from Seoul, Korea, in which the inverse/converse occurred, that is, the removal of a road made users better off. The Braess paradox is classical and those of us in transportation and operations research have used it regularly in our classes and lectures. What continues to fascinate is how this paradox keeps on getting discovered and, sometimes, rediscovered in other network settings -- from the Internet to electric power distribution and generation networks. There is a clear, deep lesson here as we begin to invest in infrastructure -- one has to capture users of the network systems and their behavior (do they cooperate or act independently/selfishly) in identifying which network components (roads, cables, lines, etc.) to add and/or improve. At the same time, we are seeing a convergence of interest in networks by researchers and practitioners in different disciplines -- from operations researchers / management scientists to computer scientists, physicists, and engineers, behavioral scientitsts, economists, and even political scientists. This is very exciting but proper effort must be taken to give proper citation to the scientific literature.

Our group at the Isenberg School of Management had the privilege of hosting the visit of Professor Dietrich Braess of the Braess paradox fame. His visit took place in 2006 and we have both the original article of his (which was in German), and the translation of it, which was done by Braess, Nagurney, and Wakolbinger, along with photos and additional material, posted at: http://supernet.som.umass.edu/cfoto/braess-visit/braessvisit.html

The Braess paradox is explicated at: http://supernet.som.umass.edu/facts/braess.html

For an excellent book on the price of anarchy, which is the ratio of the total cost to society evaluated at the user-optimized flow, to the total cost to society evaluated at the minimal system cost, see the book by the same name by Tim Roughgarden, published by MIT Press in 2005.