What is Good for the Goose

Now I have problems with Microsoft. They are in no way customer friendly. In fact it may be possible to call them customer hostile. Now come a tale of young Master Gates returning and trying to get his new Microsoft computer to function with Windows 8.1

As the New Yorker states:

Bill Gates’s first day at work in the newly created role of technology adviser got off to a rocky start yesterday as the Microsoft founder struggled for hours to install the Windows 8.1 upgrade. The installation hit a snag early on, sources said, when Mr. Gates repeatedly received an error message informing him that his PC ran into a problem that it could not handle and needed to restart. After failing to install the upgrade by lunchtime, Mr. Gates summoned the new Microsoft C.E.O. Satya Nadella, who attempted to help him with the installation, but with no success. While the two men worked behind closed doors, one source described the situation as “tense.”

Tense? That is why there are more users still on XP! Windows 7 is not bad, I have it on almost all systems but I still have a few XPs hanging around and no way are they getting changed. They run in the lab anyway so  it would be tough to access them.

But this has been the problem with Microsoft. Simply Windows 7 works for those of us who do real work, like spreadsheets, writing, software etc. Windows 8 is the toy stuff for pads. Try and type a book on touch screen sitting 2' from your eyes. Those trapezius muscles will get awful sore after a while. Then my android works just fine thank you Microsoft!

This may be the death knell for Microsoft. We shall see. Clearly they have screwed up again and again. They learned nothing with Vista. They just sent another arrogant team to tell the customer what they should do.

Peer Review Again

In a recent paper in Nature the author states:

Over the past two years, computer scientist Cyril Labbé of Joseph Fourier University in Grenoble, France, has catalogued computer-generated papers that made it into more than 30 published conference proceedings between 2008 and 2013. Sixteen appeared in publications by Springer, which is headquartered in Heidelberg, Germany, and more than 100 were published by the Institute of Electrical and Electronic Engineers (IEEE), based in New York. Both publishers, which were privately informed by Labbé, say that they are now removing the papers.

Now I have no knowledge of IEEE since I no longer kept up my membership after some 45 years because I saw a dramatically declining quality of papers. My concerns were:

1. Multi author papers: There was an explosion of papers, especially at conferences, where the number of authors approach a large class size. One would logically as; who wrote what? There was the "name" author, who I often wondered had even read the paper, and then a swarm of others, and amidst the mess was probably an author.

2. Repeat of Old Stuff: No one ever seemed to examine if what they did was just a rehash. In my opinion that was especially true of IEEE papers. One wondered if they just accepted anything that was generated in the "club" and ignored everything else.

3. Awards: There has become a proliferation of various awards and the sole purpose is to gather credits for academic status. It used to be that certain journals were controlled by Bell Labs and that they set the standard, namely support AT&T or else. Now it is not clear who they are but it is just a rebirth of the same old stuff.

The article continues:

“The papers are quite easy to spot,” says Labbé, who has built a website where users can test whether papers have been created using SCIgen. His detection technique, described in a study¹ published in Scientometrics in 2012, involves searching for characteristic vocabulary generated by SCIgen. Shortly before that paper was published, Labbé informed the IEEE of 85 fake papers he had found. Monika Stickel, director of corporate communications at IEEE, says that the publisher “took immediate action to remove the papers” and “refined our processes to prevent papers not meeting our standards from being published in the future”. In December 2013, Labbé informed the IEEE of another batch of apparent SCIgen articles he had found. Last week, those were also taken down, but the web pages for the removed articles give no explanation for their absence.

 Integrity is an essential element in science and engineering. Apparently there seems to be no check on it in certain publications. Perhaps a real house cleaning is in order. Yet, perhaps those in the house just want to shovel it under the rug and go on as the do. It is ironic that IEEE is now one of the few journals that has no open access. Perhaps that says something.

Neanderthals

The Neanderthal Man, by Svante, is a compelling recount by a principal in the discovery of genes of the Neanderthals. It starts with the interest in recovering DNA from old sources, and in this case some liver bought at the local market and then desiccated in an oven at 50C. The tale spans over some twenty years, with diversions typical of science, and ultimately ends with the publishing of some of the most interesting results in understanding man and his evolution.

Svante is an exceptionally good writer and the tale flows quite smoothly. If one understands the science, then one can fill in the gaps and the tales is well presented. If one does not understand the science then one can still appreciate what is happening by taking the results presented at face value.

The tale works back and forth from the fundamental science to the interrelationships between various players in the overall search. Svante shows how he managed to deal with the anthropologists and others to get samples of Neanderthals from as far away as Siberia. It also demonstrates some of the more cooperative nature of science as new techniques is shared and how Svante is assisted by many others who are but in related fields.

The efforts span from California to Eastern Russia and it shows that in today's environment the ability to communicate changed what would have been multi-lifetime efforts into a fast paced move to provide the final answers.

This book is a stark contrast to Watson's Double Helix. The Helix is a strong interplay of personalities; it portrays competitiveness and at times pettiness that is common in certain scientific endeavors. Helix was a true race, a sprint to get DNA right, and a succinct set of observations which became the underpinnings of Svante's efforts. Svante is the opposite of Watson. The ego is missing; the collegiality if present, yet one still sense the pace. Yet it is not a pace with an edge, it is a steady pace to get it right.

This is definitely a great book for those seeking to understand the Neanderthal developments as well as understanding perhaps how the research community has matured as it has expanded.

Also, upon some reflection, I recall when I first read Watson's Double Helix just after it was published I could recognize the highly competitive world of research since I was still at MIT. In contrast Svante portrays a totally different world, one more of communications and cooperation. The worlds of Watson and Svante are separated by some half century, and the difference is startling, one is near ruthless and the other collegial, with a sense of cooperation moving forward. Great job!

Google is Becoming Microsoft

Try and find out anything in Microsoft Help. First it is written in a language that has become extinct and no human can translate it. Second when you search you get nonsense to begin with. The Microsoft indirectly destroys your data. Example, PowerPoint before Office 2000 is unreadable by Office 2007 and after, even some of Office 2003.

Now what has Google done? Some Microsoft infected character took Google maps and turned it into an incomprehensible mess, no warning, no way to go back, and years of storing directions into the system leads to a total loss. Take printing a map. They say Ctrl P. No way, tried it on 7 machines. Try and find out how to do it and they send you to a blog with hundreds of complaints. Some Google genius decided that their idea was better and wham, millions left as road kill!

Are there any adults out there? It is like some 20+ year old who says follow me and off the character goes in some Shelby Cobra at 100+ and there are twenty others trying to follow on the LI Expressway on a Friday night in July out to Shelter Island! And the rest of the crowd are in Honda Civics!

Every once in a while a seminal event demonstrates the coming collapse, albeit slowly, of an entity. With Microsoft it was Vista, the Office 2003 SP3, then Windows 8. For Google it is the death of a great system. Congratulations to whoever was the brainchild of this disaster!

Maybe Verizon could acquire Google, they could probably not make things worse!

I Remember the Old KGB

In the old Soviet Union almost every third person was in some way a KGB informant. Not that they now collect pensions but then the collected data. There was the Key Lady on every floor of an Intourist Hotel, the desk clerk the taxi drivers, the airport check in agents, the restaurant staff, the book store managers, the fellow at the news stand. After a while you just assumed everyone was watching.

Then there were the interrogators. Why are you here, where are you going, who is with you. What is in your bag. In fact when you got a safe for your room it was pretty certain that whatever you put there was examined, and they often let you know they were there.

Thus you were always on guard, especially if you were an American. Added to that was the "visitors" to your hotel room at night, knocking on the door, and you knew very well who sent them and you looked around for the cameras and microphones. They put the NSA to shame, almost.

Now comes the FCC and the assault on News Media! What type of character thought this up? Just look and you can find out. As the FCC states:

“However, in the course of FCC review and public comment, concerns were raised that some of the questions may not have been appropriate. Chairman Wheeler agreed that survey questions in the study directed toward media outlet managers, news directors, and reporters overstepped the bounds of what is required. Last week, Chairman Wheeler informed lawmakers that that Commission has no intention of regulating political or other speech of journalists or broadcasters and would be modifying the draft study. Yesterday, the Chairman directed that those questions be removed entirely.

The very notion demonstrates  what has taken over the Government. One of the very basic principles was Freedom of the Press. There are stations that just spew garbage, but economics should delimit what they say. If no one watches then they go away. There must be some trust in the American people, after all the same group votes. But this was a clear overstepping bounds. Blocking a bridge is foolish, blocking the free press is, well I let you guess.

Impossible!

There are times when I read things that are totally illogical but then I just say, so what. But this one beats all. Some writer at Fierce Wireless considers a merger of Verizon and Google.

He states:

However, a merger between the two of them in the next few years is not so far-fetched, according to an opinion column from FierceCable .... A Google-Verizon marriage would be the largest corporate merger ever. The companies had a combined market cap of $537 billion at Wednesday's market close. Yet there are more than a few reasons why such a deal might work, including the fact that there is no overlap (yet) between Verizon's FiOS footprint and Google Fiber deployments. The combined company could also deliver affordable high-speed Internet service through both wired and wireless networks, and it could provide competition to a combined Comcast and Time Warner Cable.

Now I could not consider two more different cultures. Verizon is fundamentally the classic "knuckle dragger" company. People do what they are told by people who often succeeded by doing what they were told! And often in my experience they made it near the top by never making a mistake or if they did to find someone else to blame.

At Google you sometimes had to be creative and profitable. At Verizon, well, if it were up to them we would still have black rotary dials! I was there, I saw it.

So putting these two together not only stretches the imagination it goes well beyond that!

Just look at fiber. Verizon very wisely saw where wireless could go and is betting the ranch, and winning. In contrast Verizon saw the folly of fiber and stopped it. The stopped it just when Google started to get into it. With multibands, OFDM, etc wireless can do HDTV etc. In fact after Sandy Verizon is not rebuilding any physical plant, only wireless in certain areas. Great idea.

So why is Google running full bore on fiber? Good question, sooner than later they will get hit with the Comcast sledge hammer and come to a halt. The Franchise is that hammer. Doing a trial in a friendly city, one city, well that may work. But their roll out,not really. But then Google has enough money to waste learning the hard way.

When I see things like this I just shake my head. I guess someone has to fill up the world with words, meaningful or not.

I Just Lost My Mailbox!

Now I am not a non-believer in global warming. I see it in my species plants. But frankly, since I have recently lost my mail box under a five foot tall or higher snow pile, I would really be grateful for a bit of that warming to return.

Now I write this in response to a Gore piece in the NY Times Book section.  It is a review of some book written by some non-scientists who envisions another extinction. But Gore in his inimitable style states:

The extra heat is also absorbed in the top layer of the seas, which makes ocean-based storms more destructive. Just before Hurricane Sandy, the area of the Atlantic immediately windward from New York City and New Jersey was up to nine degrees warmer than normal. And just before Typhoon Haiyan hit the Philippines, the area of the Pacific from which it drew its energy was about 5.4 degrees above average.

Hey, I have been yelling about Hurricanes and New York Harbor for years. It was in the early 1950s that I recall, having lived there, that for three years in a row the harbor came a mile or so inland. So nothing new here, it was just that those summer "cottages" became homes and the City allowed building where frankly there should not have been any. The same for many places on the Jersey Shore. Thus nothing new and people had seen it all before. It will happen again!

Now for the Philippines, I know that area well, It is subject to many Typhoons, the best was the classic Halsey Typhoon which hit late in 1944 just after the Battle of Leyte Gulf, where on the north side is Tacloban. You see when I wrote my book on that battle I interviewed thirty remaining crew members who sailed the much damaged vessel through that second disaster. In Tacloban they just built up to the shore line, in an area know for massive Typhoon impacts. This was State Island all over again.

Thus was this all Global Warming or just a repeat of what humans had seen and were forewarned about. I would consider the latter.

Finally he states:

Despite the evidence that humanity is driving mass extinctions, we have been woefully slow to adopt the necessary measures to solve this global environmental challenge. Our response to the mass extinction — as well as to the climate crisis — is still controlled by a hopelessly outdated view of our relationship to our environment.

 I just finished reading a fantastic book on Paleobotany. I would strongly recommend it. The area is one of my night time readings for relaxation. It depicts over 400 Million years of plant evolution over some 5-6Billion years of what we currently know as history. Strange for us now to think that billions is not much after we watch out Federal budget, they spent almost ten billion on broadband in the Stimulus. Well back to Paleobotany. Frankly the extinctions allowed for new species. For almost all of that time we humans were not even capable of being assembled. But new species came and went, it is part of evolution.

Yet the author of the book, Extinction, interviewed in the Independent,  focuses solely on animal "extinctions". Extinctions are quite complex. The "extinction" of the dinosaurs allowed the proliferation of the mammals. Yes, us eventually. So was that good or bad. The extinction of the conifers, yes there was such, led to angiosperms, and yet conifers survived. One could say that these extinctions are just part of evolution. Let things just go so far and then try again. Yet to have a real extinction one needs a truly catastrophic event that blocks sunlight or exhausts oxygen or water. Raising the temperature some 6F most likely will not do that. A big asteroid may, flooding Wall Street may not. They will just move across the river, now Bay, to stay dry.

So history has a short time frame and the long time frame. Perhaps understanding the long one will help. You see plants have learned a lot more than us, animals are recent arrivals. Plants use carbon dioxide, the spew oxygen, and it is to them we owe our existence.

I think I will climb over a snow mound and thank my Ginkgoes. Perhaps I will exhale some CO2.

Bringing a Grown Person to Tears

The Massachusetts implementation of the ACA web services has apparently been a fiasco[1]. The Globe states:

The head of the state’s beleaguered health insurance marketplace, which was once a national model, broke down in tears Thursday, as she described how demoralizing it has been for her staff to struggle with a broken website that has left an unknown number of people without coverage...., the executive director of the Massachusetts Health Connector, wept at a board meeting, where it was disclosed that 50,000 applications for health insurance are sitting in a pile, and have yet to be entered into a computer system.

Now this is the state that had the infrastructure in place and had something working. They claimed 97% enrollment. So why change, simple the ACA. The result is a catastrophic collapse of the system. No computer access and apparently all those fellow “executives” managing all the paper work.

Now previously this individual, showing her exuberance in how well the ACA would be accepted, stated[2]:

How will the ACA, the national health care overhaul, affect the Connector? It really strengthens the Health Connector in a number of ways. As I mentioned, a very important part of what we do is to offer subsidies to a certain part of the population to help them pay for health insurance. The ACA expands that opportunity, so there will be more people able to access subsidies through the exchange. For example, low-income workers who currently have access to employer insurance but are unable to afford it will be eligible for subsidies. The ACA also makes major investments into the exchange so we can update our technology. Our goal is to offer a significantly better user experience, an easy-to-navigate process.

Now the State Web site states[3]:

Before joining the Health Connector, ... was Director of Contracting Strategy Analytics at Tufts Health Plan in Massachusetts, where she worked extensively on health care reimbursement issues and payer-provider collaboration initiatives. ... started her career as a management consultant with McKinsey & Company and subsequently Deloitte Consulting, where she served a wide variety of clients in the health care industry. ... graduated from Peking University of China and earned her M.B.A. from Harvard Business School.

Yes, a Harvard MBA. I guess the new strategy for Harvard is that if you can’t get the web site to work you just break down in tears. Never saw that at MIT but after all we had to make things work. So here we have a case of how we take a “manager” and place them in a task which requires some technical capabilities and apparently they collapse. Even Mankiw bemoans the problem[4].

One of the themes that we have all heard over the past few years is that President Obama's healthcare reform is merely bringing the kind of changes Massachusetts had under Governor Romney to the nation. If that were really true, you would think that these national reforms would have minimal impact on the state of Massachusetts.

On the other hand we have Gruber from MIT still arguing for the benefits of the ACA predicating it on the benefits of the Massachusetts Plan[5]. He comments when criticizing the CBO report stating that 2.5 million or so will drop from the workforce, and he like so many other Left leaning folk see that as a positive opportunity. After all who really wants to work? Gruber states:

Mulligan—like so many of the law’s critics, in and out of the economics profession—gives a more one-sided view. He talks only about the marginal tax rates. A reader who relied exclusively on his column would have no idea the CBO cited multiple reasons for the shrinking workforce—and that some of these reasons were utterly defensible.  Ironically, while making a surprisingly moral case against examples of 100% tax rates, he ignores the moral case for leveling the playing field by breaking the link between work and insurance, so that workers are not chained to jobs where the value of their compensation is well below their disutility of working. The Affordable Care Act, like any major reform, has its virtues and its flaws. The best economists, like the best public officials, are the ones who deal with both.

But the Massachusetts problem is not an Economics problem. Frankly there are no Economics problems, unless we are discussing political philosophy. Reality has met that philosophy. The web site and all its environs just do not work. Now I have done large scale computer system developments since 1967, starting with the Apollo mission and moving on from there. They are really tough things and need good people. Oftentimes in today’s world the Beltway Bandits who end with the job are the lowest bidders, and look at these jobs as Golden Geese to feed them again and again. That is they never really finish, just get more change orders.

Reality is not economics. You do not draw two intersecting lines and jabber about some gross behavior principle which most likely will be disproved in a decade or so. Reality is making something work. Engineering is reality, Science is reality, Medicine is Reality, and even Law has elements of reality, especially when up against a jury.

Massachusetts shows a frightening example of what can happen even in the most experienced and most friendly environment. It already had 97% covered, but not by the ACA.

---

[1] http://www.boston.com/lifestyle/health/blogs/white-coat-notes/2014/02/13/facing-application-backlog-insurance-marketplace-chief-breaks-down-tears/jeWUxJyrG9tx3lnkuJ4iCJ/blog.html

[2] http://www.bostonglobe.com/business/2013/07/20/hot-seat-with-health-connector-jean-yang/GMXAFtLV0URopJFLOoYGvN/story.html

[3] http://www.mass.gov/anf/budget-taxes-and-procurement/oversight-agencies/health-policy-commission/meet-the-board.html

[4] http://gregmankiw.blogspot.com/2014/02/obamacare-versus-romneycare.html

[5] http://www.newrepublic.com/article/116613/obamacare-critics-still-tell-just-one-side-jobs-story

Weather and Climate

 Well here we are on Valentine's Day, another 18" of snow, a dead snow blower, and the snow plows keep putting a ton or more in the drive which I now shovel by hand. Primitive man returns. Got the driveway clean and the roof raked of excess snow. Don't want any collapses.

Now about weather and Global Warming. Based on the weather it is going into a freeze cycle. Based on 25 years of data the Hemerocallis still are blooming earlier. They integrate light and warmth. But this year we won't see grass until May! So will this change things. Microclimates are funny that way.

The interesting factor is all this snow really changes the albedo. Namely heat goes back out to space. Plants are kept at just above 32F but get no sun. Thus I am interested in the data of first bloom. The Hemerocallis is a sentinel plant, namely the bloom date of the early bloomers integrates many climactic factors, even from year to year. I am interested in how this will play out.

We will wait and see. While we do we expect another snow fall tonight and my new snow blower is not due until March 1. Perhaps I may see my car soon.

Burn the Boats

Cortes is alleged to have issued the order to "burn the boats". Simply there is no way back, you have no lifeline. You must move forward. The counter to that is the Wing Walkers Rule, "Don't let go of something until you have a firm hold on something else.". Entrepreneurs are of the former category. Corporate Executives are of the latter. Now the Left's assertion that the ACA enables someone to "take a chance" and try to become an entrepreneur is absurd at its face value. Entrepreneurs to be successful must believe that there is no way but forward. They have abandoned all that had come before and just move forward, not just "lean" forward, but to abandon all that had been safe and go where none have been.

Being an true creative entrepreneur means having faith that you can do the impossible because the challenge is there. Most good entrepreneurs I have known did not worry about health care, in fact the denied their very mortality. It did catch up from time to time, but they went into a state of total denial of any negative consequences. It was that drive that filters out the good from the wannabes.

There is a problem today that I see with the very concept of an entrepreneur. First we have academic institutions who try to "teach" it. In fact it is a Heidegger "throwness" to be an entrepreneur, you do not learn it you do it. Then the incubator concept, a comfortable transition environment to go and "think through" the plan. In reality it should be a garage, basement, spare room, and then the first office should be one where you have the early employees buy and assemble their low cost desks. If they want an expensive chair, no problem, let them buy it.

Cortes did not offer his mean health care, a pension, a nice work space, he burned the boats.

Progressives and Cable

Comcast plans to buy Time Warner Cable. Now as a former Warner Cable executive from the early 80s I remember when some of our overseers, Board members, saw cable as an empty pit. They went on to other successes and Cable just passed them by. But this merger/acquisition would set Teddy Roosevelt and Woodrow Wilson afire, except for say MSNBC. I believe we still have Hart Scott Rodino and the Sherman and Clayton Acts. But alas, I suspect the behemoth that will be Comcast since it appears to align with the powers that be shall be passed over with no faults being seen. Clearly Cable and especially Comcast may very well capture the entire pie, as I had indicated a decade ago.

Just Nice for a Winter Day

Given that we speak of genetics a bit here I thought I would provide on this snowy Winter day my introductions for 2014. They are:

Hopefully Spring will be here soon!

Employment in 2014

Things are really not that good. The real unemployment based on the workforce participation in January 2008 is about 9.75% and has remained constant. The percent population employed has remained steady and well below the 2008 number. The only reason unemployment is "low" is the farce concerning participation. DoL fails to count people out of work permanently.

Here we see employment and population and the gap is what is a concern. The gap is actually widening.

The real concern above is the workforce as percent population. It has decreased! That should send off alarm bells but alas no one any longer cares.

The above clearly shows the employment gap, that is the percent employed in 2008 times the new population less the actual new employees. This is a measure of what is necessary to go no where! It was negative last month and is near zero this month. That means there is no way to grow!

Finally we show the gap above. This is the worst recession recovery ever! And I believe it is getting worse.

Billions and Billions

The Innovation Center under CMS has gotten a bit of light shown upon it. Like PCORI and the dozens of other multi-billion dollar boondoggles spawn by the ACA this gem also got a negative write up by the NY Times.

The Times bemoans:

But now that the center has gotten started, many researchers and economists are disturbed that it is not using randomized clinical trials, the rigorous method that is widely considered the gold standard in medical and social science research. Such trials have long been required to prove the efficacy of medicines, and similarly designed studies have guided efforts to reform welfare-to-work, education and criminal justice programs. But they have rarely been used to guide health care policy — and experts say the center is now squandering a crucial opportunity to develop the evidence needed to retool the nation’s troubled health care system in a period of rapid and fundamental change.

If one were to examine their web site one would see a real unorganized collections of "projects" without any apparent cohesive plan. It appears as if they just want to find ways to spend our money. This appears to be a common practice of the ACA as was promised by the San Francisco Congress person. It was passed and now we keep finding out how much it wastes!

Comparative Clinical Effectiveness: Some Thoughts

The book, Comparative Effectiveness Research: Evidence, Medicine, and Policy by Ashton and Wray is an exceptionally well written presentation of the issues and politics behind CER through the current time. As the authors state, there are many definitions of what CER or its implementation as Comparative Clinical Effectiveness (“CCE”) is. A simple but reasonable definition is that CER is the process of examining various modalities of medical treatment for some specific disease state and the determination of what one may be the most effective according to some metric (See pp 122-123 for various definitions).

CCE is then the dissemination of the results of the CER and its use in day to day clinical practice. An additional condition on CER is that unlike FDA randomized clinical trials the CER is conducted in “real life” clinical environments. In the current ACA the CER has been embodied in a non-Governmental entity called PCORI. This book ultimately is a justification of this entity, its purpose and goals and the very nature of its embodiment. Fundamentally the authors make presentations which covers the need for CER/CCE and then provide an exceptionally detailed and well written expose of how it was ultimately implemented in the ACA and why.

Let me first summarize the material presented and then I will provide a critique on it and the approach taken by the authors.

Part I of the book covers the principles of evidence based research and practice. Part II presents the political story of the development of PCORI and the institutionalization of CER/CCE under the ACA. Part III is the authors’ presentation of their views on the politics and the implementation and usefulness of CER/CCE.

On p 23 the authors use the prostate cancer (“PCa”) studies as a vehicle to discuss CER. This relates to procedures which are used to treat PCa. PCa can be treated in a variety of means, ranging from surgery, radiation therapy, nuclear implants, proton beam, and the cheapest, called watchful waiting. The problem with PCa is that about 90% of it is indolent, namely the patient will never die from it and the treatment is worse than the disease. However some 10% or so, we really do not know the number is aggressive. The typical case goes from a PSA of 4 to 40 in two years and 40 to dead in another two. The challenge is how do we save the 10% while not making the 90% have a higher morbidity? The therapies all too often depend on who the patient see and not based upon any clinical evidence of efficacy or patient satisfaction, the Patient Reported Outcomes (“PRO”). The problem the authors have here is that the problem is more complex than how they present it and it is that complexity that the physician does or should intermediate with.

On p 51 the authors again come back to PCa. Now they address the issue of robotic surgery. It is costly, is advertised, and results in less than clear advantages. Now for clarity purposes the robot is not really some autonomous entity. It merely allows for better controlled movements under the total control of the surgeon. Prostatectomies are difficult because of all the nerve involvement and one prostate is not necessarily the same as all others. The intent is to remove all the malignancy while retaining nerve functions. Frankly a superb surgeon can do this without any “robot” and usually do. The problem is that the patients may not have a clue and somehow want the “robot”. Thus the authors make a good argument for CER/CCE being targeted at not only the physicians but the patients.

Chapter 3 is an excellent expose of FDA assessment of therapeutics. The FDA has over the last half century developed a set of scientifically based procedures to ascertain the safety and efficacy of drugs. This is the randomized placebo based clinical Trials. There generally are three phases before approval and hopefully by the end of Phase III we can rely on the therapeutic doing what is says and not having any morbidity or mortality effects. Sometime that is not the case since the Trials are small and may not be large enough for some of the negative effects. The authors explain this in superb detail.

Chapter 4 will make all surgeons happy. Not really. It is a discussion on the fact that all too often surgeons perform procedures for which there may be little if any clinical evidence. To take the authors back even further, in the 40s and 50 tonsillectomies were almost a child’s rite of passage. The Table on p 82 is a good example of the many surgeries performed where there is little if any evidence of efficacy.

P 103 discusses the problems with imaging. I remember in 1972 when the second CAT system was introduced to MGH. It allowed a neurologist to ascertain a block of bleed stroke. It was quick and saved lives. The problem now is that when a CAT is performed, along with massive amounts of radiation, one can find “incidental” observations which then demand follow up despite no clinical evidence of necessity other that shadows.

On p 113 the authors commence discussing the creation of clinical guidelines.  The problem, however, is that all too often medical knowledge changes so quickly that the physician is incorporating this knowledge in the way they treat a patient. On the other hand the compilation of CCE procedure such as that proposed by the USPTF is based upon oftentimes decade’s old data which was predicated on now outdated medical practice. This is the fundamental flaw of CCE guidelines. They are outdated and often too static. If then developed by Governmental entities they may also often end up becoming the least common denominator.

On p 130-131 the authors make the attempt in discussing the concept of “producing a public good” as the basis for arguing that only the Government can be the creator and manager of CER/CCE. Frankly this is the weakest part of the book and would best have been left aside. However it does provide a vehicle to understand from whence the authors come at this issue.

The Part II discussions are quite interesting. The authors clearly present the Washington drama behind the development of the PCORI side of the ACA, pre current Administration and in the current Administration. For anyone interested in Washington politics this compares well with Woodward and his presentations. The influence of the various stakeholders is discussed and for those not familiar with Washington the key role of Congressional Staff is portrayed effectively.

On p 193 as I comment on later, the authors go off on Rush Limbaugh. Clearly the ACA was a political issue and received not a single Republican vote. Yet the Limbaugh discussion has a question of relevancy. They continue on p 195 regarding the death panel issues etc. Inflamed words are all too often used in politics and one must ask; what was the basis of this phrase? To some degree, being part of the discussion at the time, it related directly to CCE, and the NHS use of QALY measures in the UK. Namely if one examines the PCa problem, then using a USPTF result and the recommendation to no use PSA on any many over 75, and also mammograms in women over 75, despite what health they may be in and despite any family predispositions, was sending a chilling effect to those affected.

Chapter 10, p 208 and on, is an excellent presentation of PCORI, the non-Governmental entity set up to do CER and assist it to be converted into CCE recommendations. Any reader interested should go to their web site as well. It is too early to determine what they will accomplish but with a $500 million a year budget paid for by the taxpayers they should have no excuses. However when one looks at the FDA, it took then a good half a century to reach the point where they are today. The FDA still has some issues but it is the sine qua non entity in the world. It has developed methodologies and procedures which albeit costly had led to better safety and efficacy in devices and pharmaceuticals. PCORI lacks many of the elements of the FDA and furthermore it is not clear that it can draw on the competencies that exist in the field. The author’s speak of what it can do but fail to discuss just how it will go about it.

As the authors reach their concluding comments they seem to go into niches that may or may not be warranted. On pp 248-249 there is a discussion of the public and scientific evidence. They return to their attack on the “political Right” and its “anti-science” philosophy. The problem they are discussing is that of educating patients as well as physicians. Again take the PSA issue. What should a general physician know and what should a patient know? Here we have the problem that PSA management is recording test data over significant time spans. Assume starting at 40 years of age baselines should be take and then data analyzed periodically. It is thus not any single reading, as is the case with BP or fasting blood glucose, but the temporal behavior. However physicians do not have the data and patients do not understand it. It is not because patients are politically influenced to not believe it, the Press oftentimes has a stronger confusing influence, but because they do not get the information. Thus the discussions on these pages warrant attention but not the way the authors provide it.

On pp 250-251 the authors sink into the Medicare swamp. First to make some statements of fact, more than 45% of those on Medicare have or will have paid in more than they will ever receive in benefits. 55% of participants will have paid in substantially less and will have received a dramatically greater share. Medicare is an insurance plan and not a Government benefit, albeit a bit poorly managed. On p 251 the authors say, “Medicare is a federal health insurance program, tax-supported, that was established in 1965” It is tax supported only for that portion of subscribers who have not made enough in their lifetimes. It is subscriber supported by those who have made enough and who continue to make money after 65. This is a distinction and a difference that many fail to understand. It also colors the perception of Medicare of many.

One topic that seems not to have been discussed is that of Patient Reported Outcomes (“PRO”), as an integral part of CER. PROs are complicated testing methodologies to ascertain what the patient felt was the result of a procedure. It should be an integral part of any of the CER efforts. I was disappointed that they failed to focus on this area.

To examine CER/CCE in some specific detail, let us consider the Prostate Cancer debate. The key observation that one should make is that what we understand in Medicine is changing almost daily so what we think today is common practice will be unacceptable in short order. In 2009 there were two papers published in NEJM, one American and one European, which stated that there was no significant different in death rates between men who were PSA screened and those who were not. Now one can examine the data and see some fundamental flaws, after the fact. The study regarded a PSA level of 4.0 as the point at which one should take action. That was acceptable in 1995 but by 2009 we knew that velocity of PSA, % Free PSA, volume adjusted PSA, as well as age adjusted PSA were more critical. Thus, the reports using a 1995 standard presented results that were devoid of 20 years of information.

More importantly, the question posed was: "Using a PSA of 4.0, and using a PSA testing methodology on a biennial basis, did such a testing procedure have an effect upon mortality?" The question which should have been asked was: "Is there a PSA screening methodology which when adjusted for patient classes results in a material change in patient PCa mortality?" The first question was good for 1995 with the limited knowledge available then. The second question opens the door for expanded insight into temporal PSA evaluation. The problem with many CCE trials is that they fixate on the wrong question and thus produce potentially deleterious rules of treatment.

Furthermore as the reports were published a plethora of genetic markers were being developed. Disregarding all of this, the USPTF then graded PSA testing as a D, a level which would prohibit Medicare patients from receiving its benefit. This type of CER/CCE demonstrates the fundamental flaw in CER/CCE in toto. It uses clinically collected data which may be flawed based upon the significant changes in medical knowledge over the time frame of the study and thus potentially inflicting a lethal sequella upon patients. This may not be a death panel but it is flawed medicine.

Overall the authors present a clear picture of CER and its positive benefits. However there are two basic flaws in their presentation. First they fail to fully discuss and disclose the fundamental flaws that may be part of CER/CCE. Second, they fill their presentation with comments as regards to conservative opponents which may add some color but on the other hand actually colors their own attempt at a professional presentation. Frankly the book would have been much better served without references to Rush Limbaugh and the negative comments regarding conservatives as a whole.

Finally one should more carefully examine PCORI. It is a non-Governmental entity like Ginnie Mae and Fannie Mae, albeit not a financial entity, but it has a $500 million annual fund taken from taxes on insurance plans. Recently PCORI awarded NIH a $5 million contract to study their PRO, patient reported outcome questionnaire, which has been around for a while. What is especially strange is why the Government did not fund NIH directly. In this case the taxpayer pays a tax to the insurance company, which hands it to the IRS, which gives it to The Comptroller of the Currency, which hands it over to PCORI who awards it to NIH who now has to manage the contract as external funding. One estimate is that the $5 million funding may result in $4 million of work at a costs of $12.5 million! Only a Congressionally mandated schema like this would produce such a result. That perhaps is a dark side of the PCORI effort.