Atul Gawande on Social Structures in Medicine

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Atul Gawande has a terrific article in the New Yorker about how the way doctors organize themselves into social groups affects the effectiveness and cost of the medical care.  (I first got turned on to Gawande by my daughter Karen, who gave me two of his books to read.  He’s very thoughtful and very smart about the problems of medical care — and a terrific writer as well.)

There are tons of interesting thoughts in the article, which is a great read, as well as insightful.  Here I’ll just piece together the high-level flow of the argument around the structure of doctor’s organizations within a locale.

1) The most expensive areas of the country for Medicare are 2-3 times the cost of the least expensive.  If these most expensive areas could be changed to cost the same as the average areas, most of the expense problems of Medicare could be solved.

2) The most expensive areas of the country do NOT get better health outcomes than the less expensive areas.  They do provide substantially more “services” — hospitalizations, tests, surgeries, etc. — but patients don’t have live longer, aren’t healthier, and aren’t happier with the results.

3) By comparing expensive locales with less expensive locales, we can rule out most of the obvious causes of the difference.  The expensive locales are very similar in types of patients, the problems those patients have, the training their doctors received, etc.

4) One key difference is that in the LESS expensive locales the doctors have organized themselves to create a medical system that changes substantially the motivations.  Doctors are evaluated on long-term patient outcomes, and cannot make themselves richer by performing additional procedures on patients.  The doctors work together collaboratively to learn how to better serve patients.

Fascinating article.  Check it out!  (Yes, it is a stretch for this blog.  Perhaps we could argue that the connection is in understanding how big a difference social structure makes in the performance of an organization.  In our work we’re building computer tools to support those social structures; in this article, the doctors are inventing the structures themselves.)

John

Pay Per Tweet

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Interesting article about pay-per-tweet technology from izea, the company that already leads in pay-per-blog.  Seems like an awkward way to fund a social medium, having people pretend to like stuff because they’re getting paid to pretend.  Of course, we’re used to that from our funding for radio and television and publishing and …  Interesting that books, for instance, work on a completely different model, and that most movie revenue still comes from direct pay.  What’s different about the media we refuse to directly pay for, and the media we are willing to directly pay for?  Is it possible to change one into the other?

If the hidden price model is the only choice, we should seek a set of ethical rules for it.  Perhaps the adverts could just be clearly marked as being for-pay.

John

Co-Credit

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Very fun article about apportioning credit among multiple authors of academic papers.  Read the article for the details, but the author’s basic argument is that at equilibrium the total value per paper had better be constant with number of authors, or economists will start putting in tons of extra authors on their papers to boost their total credit.  (Assuming quality is held constant.)

I see the economic argument.  OTOH, it is also true that doing joint work takes more interaction and negotiation (and hence is more difficult) but often seems to me to lead to work that has a bigger impact.  Hence, an organization might prefer the joint work even if it is slower per person hour, if they believe the style leads to more impact.  (I suppose this is a cheap way of saying I don’t think you can really hold quality constant.)

John

Economy down, Traffic down

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Interesting post on Freakonomics blog about “at least the traffic is down”.  The really sad thing is that according to the book Traffic, traffic will rebound as people realize that driving isn’t as bad as it used to be.  Sigh.