Sunday, July 21, 2024

Signaling for medical residencies: the first few years

Two papers report on signaling in Otolaryngology and Orthopaedic surgery.

 The Otolaryngology societies have a summary of the current state of affairs that's worth hearing. A number of specialties (including Oto) allow many signals, and these seem to be acting as a soft cap on applications, rather than as a signal of special interest as in specialties that (like Economics) allow only a small number of signals.

Preference Signaling in Otolaryngology—Past, Present, and Future: A Comment From the Society of University Otolaryngologists (SUO), Association of Academic Departments in Otolaryngology (AADO), and the Otolaryngology Program Directors Organization (OPDO)  by Steven D. Pletcher MD, Bradley F. Marple MD, David J. Brown MD, The Laryngoscope Early View,  First published: 04 July 2024

"The year 2020 was a year of change. The residency application process, already suffering from spiraling application numbers,1 now faced the COVID-19 pandemic with a loss of away rotations and apprehension about virtual interviews. In the face of change, the Otolaryngology Program Directors Organization Council (OPDO) approached the leadership of the Association of Academic Departments in Otolaryngology (AADO) and the Society of University Otolaryngologists (SUO) with a recommendation to implement preference signaling. This system, originally described in the economics PhD marketplace,2 allows students a set number of signals (Otolaryngology used 5 in its inaugural year) to send to programs of particular interest. 


"Following the lead of Otolaryngology, Urology, General Surgery, Internal Medicine, and Dermatology implemented preference signaling the following year. Since that time, signaling has grown exponentially and is now utilized in the residency application process of nearly every specialty. 


"In the 2024-2025 residency application cycle, the evolution of preference signaling continues. Building on Otolaryngology's experience, in the 2023 application cycle Orthopaedic Surgery implemented a high-signal approach, providing applicants with 30 signals. This transition shows promise for reversing the vexing problem of spiraling application numbers—“Big Signaling” has now been adopted by Otolaryngology and four additional specialties the majority of whom have shown a 25%–30% decrease in applications submitted per student saving students a combined $2.5 million in application fees alone. Obstetrics and Gynecology has piloted a tiered signaling system, providing three gold and 15 silver signals to their students. 


"Because the number of signals received by programs is not publicized, students are unable to reliably target programs where their signals are less likely to be diluted by competing signals. Specialties should consider providing voluntary “signal cohort” (i.e., my program received between 75 and 100 signals in the 2024 application cycle) data to help applicants make more informed signal decisions and programs with low signal numbers will likely attract additional candidates. 


"One of the key statistics to guide applicants in high signal specialties is the interview offer rate for non-signal applications: this helps define the value of applications beyond the set number of signals."


Preference Signaling in the Orthopaedic Surgery Match: Applicant and Residency Program Attitudes, Behaviors, and Outcomes, by Guthrie, Stuart Trent MD, FAOA1,a; Dagher, Tanios BSE2; Essey-Stapleton, Jodi MS, MEd3; Balach, Tessa MD, FAOA2,  JBJS Open Access 9(2):e23.00146, April-June 2024. | DOI: 10.2106/JBJS.OA.23.00146

"In the first year of preference signaling, applicants reported applying to 16% fewer programs than if preference signaling had not been available. These results align with AAMC data, which report applications per program dropping 17.4% (from an average of 639.6 to 774.6), and applications per applicant dropping to 76.9 from 86.07,8. Further changes could occur in future cycles as students become more accustomed to the influence of signaling on their application."

Saturday, July 20, 2024

Black markets in everything bagels (in S. Korea)

 South Korea is not a hub of everything bagels, it turns out. In fact they are banned.

The NYT has the story:

Why Everything Bagel Seasoning Was Banned in South Korea. The seasoning is sold by Trader Joe’s, a brand whose popularity has skyrocketed in the region in recent years.By Eve Sampson

"Food containing poppy seeds, “including popular bagel seasoning blends,” is considered contraband in South Korea, according to the U.S. Embassy, making the coveted topping a forbidden treat.


"As more travelers have tried to bring the popular seasoning mix into South Korea, local news and social media sites have reported in recent weeks on an increase in confiscations at airports.

"Poppy seeds are not opiates but may be contaminated by the plant’s fluid, which contains opiates, when they are harvested. 


"In South Korea, poppy seeds are banned because they are considered a narcotic.


"South Korea is among the few countries with laws regulating poppy seeds. The United Arab Emirates bans the seed, and Singapore requires anyone wishing to import poppy seeds to submit a sample for opiate testing.

"In the United States, there has also been mixed messaging about poppy seeds. In 2023, the Department of Defense warned members of the military that eating poppy seeds could result in a positive drug test, despite the military previously feeding service members poppy seed breads in ready-to-eat meals."

Friday, July 19, 2024

Congratulations to ESA Fellows

 The Economic Science Association (ESA) has decided that the stock of old experimenters is sufficient to start naming fellows.  (I heard of this when I saw an announcement from UC Santa Cruz celebrating Dan Friedman as an inaugural fellow:)

I was president of the ESA from 2011-2013, and the list includes many past presidents.

Here's the announcement:

The ESA Fellows program

The ESA was first established in 1986 as a society organized to promote experimental methods in economics. We can safely say that our endeavor has been a resounding success. Experiments are well established as a mainstream economic methodology. Numerous individuals have devoted their careers to accomplishing this remarkable feat.

We have instituted a designation of Fellow of the Economic Science Association to recognize the lifetime contributions of ESA members who have advanced the frontier of knowledge in economics through the use of laboratory and field experiments. The designation of an individual as an ESA fellow is intended as a permanent recognition of their contribution to experimental science and to economics. The contributions may be scientific in nature or consist of activities that have furthered the establishment and growth of the ESA. The ideal candidate should have made contributions in both areas. The appointment to fellow does not include a monetary award.

The Inaugural 2024 ESA Fellows are (in alphabetical order):

James Andreoni

Colin Camerer

Timothy Cason

Yan Chen

James Cox

Catherine Eckel

Ernst Fehr

Robert Forsythe

Daniel Friedman

Jacob Goeree

Elizabeth Hoffman

Charles Holt

John Kagel

Thomas Palfrey

Charles Plott

Alvin Roth

Andrew Schotter

Vernon Smith   

Thursday, July 18, 2024

Kidney exchange in Germany: draft of a proposed law

 Yesterday the German Federal Cabinet published the draft of a law that would allow kidney exchange in Germany. Below is the text of the press release from the Ministry of Health,  via Google Translate. (Prof. Dr. Karl Lauterbach is the Federal Minister of Health.)

Lauterbach: Überkreuzspende gibt Nierenkranken Hoffnung  Cross-donation gives hope to kidney patients

July 17, 2024

"In the future, kidney donations should also be possible between two different couples. This is the aim of the draft of a third law amending the Transplantation Act - amendment of the regulations on living organ donation, which was approved by the Federal Cabinet today.

This makes it possible for a donor's kidney to go not only to their partner, but also to a recipient from a second couple who in turn donates a kidney (living cross-donation). At the same time, the law ensures increased protection for donors, who should receive better information and medical and psychosocial support.

Dying on the waiting list must come to an end. In the long term, we therefore need the opt-out solution. In the short term, we can make more organ donations possible through cross-donation: those who donate themselves can be helped more quickly in their personal environment. Up to now, living donations have only been possible between partners. In the future, it should also be possible between couples who are not so close. This initially gives hope to many kidney patients.

Federal Minister of Health Prof. Karl Lauterbach

The main changes

Cross-living kidney donations are made possible

Donation and receipt of a kidney “crosswise” by another organ donation partner in medically incompatible organ donation couples.

In the case of a cross-donation, the two couples no longer have to know each other - but the close relationship between the incompatible partners remains mandatory.

Regulation of non-directed anonymous kidney donations.

The tasks of the transplant centers in the context of a cross-living kidney donation and a non-directed anonymous kidney donation are regulated. The transplant centers decide on the acceptance of incompatible organ donation pairs and non-directed anonymous kidney donations from donors and transmit the data required for the placement to a central office for the placement of kidneys in the context of the cross-living kidney donation. After the placement decision has been made, the transplant centers concerned organize the removal and transfer jointly.

Establishment of a national program for the arrangement and implementation of cross-living kidney donations. A body for the arrangement of kidneys within the framework of cross-living kidney donations will be established or commissioned. The arrangement procedure will be laid down by law.

Distribution of kidneys in the context of cross-living kidney donations exclusively according to medical criteria and while maintaining anonymity. The authorization of the German Medical Association to determine the state of medical science in guidelines is expanded to include the rules for accepting and distributing kidneys from incompatible organ donation pairs and from non-directed anonymous kidney donations in the context of cross-living kidney donations.

The previously applicable principle of subsidiarity in Section 8 Paragraph 1 Sentence 1 Number 3 TPG is repealed in order to also enable preemptive kidney transplants.

Previously: removal of organs from a living person only if no post-mortem organ was available.

Donor protection is further strengthened

Expansion of the regulations to clarify and specify donor suitability.

Introduction of compulsory psychosocial counseling and evaluation. The necessary knowledge and skills for the

Psychodiagnostic evaluation and psychotherapeutic treatment can only be carried out by medical or psychological specialists with specific training or further education in psychological, psychosomatic or psychiatric issues (so-called mental health professionals). The independence of the expert ensures that the consultation and evaluation is not influenced by the transplant medical managers in the transplant center, that there are no professional dependencies with these managers and that the expert is solely committed to the interests of the donor. The requirements for the qualifications of the independent expert will in future be set out in the guidelines of the German Medical Association.

Individual support for donors through the introduction of a living donation companion who accompanies and advises the donor throughout the entire donation process in the transplant center. The living donation companion must be a doctor, nurse or person experienced in psychological or psychotherapeutic issues and must be professionally experienced and independent of the specific transplant process. He or she may not be involved in the removal or transfer of the organs, nor be subject to instructions from a doctor who is involved in these measures.

Introduction of federal legal requirements for the activities of living donation commissions.

Granting of additional points

Living kidney donors who themselves require a kidney transplant later in life due to an illness should receive additional points when kidneys are arranged, the amount of which should be determined in the guidelines of the German Medical Association."


Axel Ockenfels writes:

I took a quick look at the draft bill that was passed by the federal cabinet in Germany today and that would allow kidney exchange. There are many good aspects in the bill, such as the mandatory participation of hospitals in a national exchange program and the possibility of non-directed donations (which was more controversial), as we suggested to the Ministry in a paper by Ashlagi, Cseh, Manlove, Ockenfels and Pettersson.   

"I am happy to see that the draft seems to agree that the details of matching should be delegated to experts and not overly specified in the law, as suggested by Tayfun Sönmez, Utku Ünver and me in a comment on the previous draft, as well as by others.  

"One consequence of the previous draft would have been that non-directed donations would almost always have gone to patients on the waiting list and would not have been included in the kidney exchange. We advised against this and are happy to see that the draft bill document now states that "a non-directed anonymous kidney donation is in principle initially made in favour of a recipient of an incompatible organ donor pair" (p. 67, DeepL translation), and that it also allows chains of kidney donations initiated by non-directed donors (although I find the wording of the draft somewhat unclear in this respect).  

"We also strongly recommended that compatible pairs be allowed to participate in kidney exchanges, yet the bill would still make this impossible: "Participation as a pair of compatible organ donors and organ recipients in a crossover living kidney donation, on the other hand, is not envisaged, as a living organ donation would be immunologically possible in these pairs. There is therefore no need to enable cross-living kidney donation for these couples as well" (p. 66, DeepL translation). 

"This is unfortunate because the inclusion of compatible pairs has many benefits and can sometimes make everyone better off, including the patient in the compatible pair, additional donor-patient pairs, and patients on the waiting list. However, this may not be the last word, as there is still room for change in the upcoming legislative process. 

"The document also comments on the possibility of cross-border exchanges: "Commissioning the institution that already handles the procurement of post-mortem donated organs [namely Eurotransplant] also opens up the option of establishing an international programme - comparable to the exchange of post-mortem donated organs - within the Eurotransplant Network" (p. 31, DeepL translation)."


Here are all my posts on Germany and kidney exchange.

Wednesday, July 17, 2024

Becoming a matchmaker

 The company built around the marriage pact is now offering matchmaking tools to the public: Matchbox.

"Matchbox is the matching algorithm behind your next great event.

"We know how to make great matches, but the event is yours⁠—⁠decide who to invite, where to host, and when.

"We’ll give you everything you need to run the matching algorithm."

Tuesday, July 16, 2024

Surrogacy in Israel

In Israel, where commercial surrogacy is legal, surrogates are more and more coming from educated and religious communities. 

Haaretz has the story:

Married, Educated, Not in It for the Money: The New Profile of Israeli Surrogate Mothers. Who are the Israeli women who wish to be pregnant and give birth for others? The answer to that question has changed dramatically over the past decade  by Ronny Linder

""I'm a little tired of women telling me how disadvantaged all surrogates are, so I thought of starting a thread just for surrogates, with: name + our occupation + town. I'll go first." This is what one moderator of an open Facebook surrogacy group wrote, about a year ago – and the responses came pouring in: a computer programmer from Tekoa, a sociolinguistics Ph.D. from Kfar Sava, a school principal from Jerusalem, a postgraduate student of gender studies from Hatzeva, a lawyer from Gush Etzion, an oncology nurse from Mevasseret Zion and so on and on.

"The post and the responses to it, written in reaction to the prevalent perception that views surrogacy as bearing the potential for exploitation of disadvantaged women who must "hire out" their uteruses for money, largely reflects the great transformation, over a few short years, in the profile of surrogate mothers and of the entire field in Israel. 


"Since the surrogacy law was legislated in 1996, almost 1,300 children have been born in Israel through surrogacy procedures. In recent years, the number has averaged around 80 children per year. Data collected by the Health Ministry about surrogate mothers between 2022 and 2023, reveals the changes in the profiles of women who choose to take on the task, as compared with the last study, in 2010. That study, which reviewed surrogate mothers during the years 1996-2010, was conducted by Etti Samama as part of the work for her doctoral thesis in health-system management at Ben-Gurion University. To compile recent data, Adam Ringel and Eti Dekel, for many years the national supervisor of the surrogacy law, collected information from 246 cases – 90 percent of the cases filed with committee in the last couple of years. 


"The data indicate a fundamental change in the socio-economic status of women who choose to become surrogates. In terms of education, while in 2010 the majority of surrogate mothers had a high school education (70 percent), nearly one fifth (18 percent) had less than 12 years of schooling, and only 7 percent had academic degrees. Less than a decade and a half later, however, the picture has been transformed: 65 percent of surrogate mothers have an academic degree, and only about one fifth have only a high school education (14 percent) or less than 12 years of schooling (8 percent). The proportion of those with academic degrees among surrogates is significantly higher than that group's share of the population, which is 38 percent.

"A similarly changed picture emerges in terms of employment: In 2023, only 2.5 percent of surrogates were unemployed, compared with 25 percent in 2010. No less interesting is the finding regarding geographical dispersal of surrogates, as compared with the general public: In recent years, almost half (45 percent) of them come from kibbutzim, moshavim and organized communities – compared with just 12 percent in 2010.


"An absolute majority of surrogates come from [the world of] religious Zionism, on the one hand, or are secular women from kibbutzim and other organized communities, on the other," Ringel elucidates. "These two groups are seemingly worlds apart, but in the world of surrogacy, you see the resemblance between them. These are independent, strong women, with a fully developed values-based worldview, who are looking to do something big for others, who see surrogacy as a calling, as female empowerment and as the ultimate giving."

"What happened between 2010 and 2024 that led to such dramatic change in the profile of surrogate mothers? Experts in the field ascribe the change mainly to the opening up of the option for married women to become surrogates, beginning in 2010 – a move that significantly increased the pool of potential surrogates and also changed their socio-economic backgrounds.

"This is indeed a transformation: in 2010, all surrogates were unmarried women, 75 percent of them divorced, the rest single (and a few widows). In contrast, in 2022-2023, 80 percent of surrogates were married or in relationships, and only 20 percent were divorced or single.


 "There was always an altruistic element with surrogates, but ever since married and more affluent women entered the picture – the economic part became more of a bonus, rather than the main motive," Dekel points out."

Monday, July 15, 2024

Dealing with the harms of harm reduction

 Some of the jurisdictions that pioneered harm reduction measures to reduce drug overdose deaths are dealing with problems of public drug use.

The NYT has this story:

Bold Experiment or Safety Risk? Canada Is Divided on How to Stop Drug Deaths.  British Columbia’s partial retreat from an experiment to decriminalize drug possession reveals a political shift in Canada over combating the opioid crisis. By Vjosa Isai

"decriminalization, a policy introduced as a way of alleviating the opioid crisis, has instead been blamed for deepening it. Scenes of people openly using drugs on city streets have led several elected leaders, other critics and even some supporters to say that decriminalization is contributing to a sense of public disorder.


"In May, the federal government, which regulates controlled substances, approved a provincial request to reverse the policy and again make public drug use and possession in British Columbia a crime.

"The shift came not long after a similar experiment in Oregon ended in April, following a vote by the state Legislature to re-criminalize drugs amid soaring overdose deaths.


"practices, collectively known as harm reduction, are driven by a strategy meant to keep drug users alive rather than getting them to quit.

"Services that fall under this category include needle exchanges, safe injection sites, the distribution of naloxone, a drug used to reverse overdoses, and the testing of street drugs to reveal the presence of any other harmful substances.


"Safe injection sites, along with decriminalization, are among the harm reduction measures that have come under attack from critics who claim they lead to crime and perpetuate a cycle of drug abuse.

"In British Columbia, critics say the province should not have pursued decriminalization without also bolstering other services that drug users need, like housing and addiction treatment.


"Many residents, he added, complained of increased drug use on public transit, near schools and in entrances to businesses.


"Some frontline workers say harm reduction practices are being targeted to score political points at a time when death tolls are reaching new highs and different approaches are necessary to keep users alive."