Statement of Policy Principles and Solutions: Living Organ Donation, from the American Association of Kidney Patients (AAKP), the American Society of Transplant Surgeons (ASTS), and the American Society of Transplantation (AST)

 Here's a joint statement about living-donor kidney transplantation from the American Association of Kidney Patients (AAKP), the American Society of Transplant Surgeons (ASTS), and the American Society of Transplantation (AST). The statement opposes rethinking the ban on compensation for donors, suggests that other policies should be evidence-based, and opposes increased bureaucratization and cumbersome regulation of the transplant process.

Statement of Policy Principles and Solutions:  Living Organ Donation

"We stand together in our conviction that any policy changes impacting living organ donation, including those aimed at improving access to living donor transplantation and increasing the survival of already transplanted patients, must begin with principled and transparent dialogue with patients and the expert transplant teams who care for them.  

...

"The United States ranks in the top tier of nations in terms of living donor transplant rates,[1] meaning the current system for living donation works. However, disparities in access to living donor transplantation remain, and we must continue to improve and expand living donor transplantation for those in need.  As such, we support policy changes that are patient-centric, fiscally realistic, and ethically and legally sound. 

"Over the past decade some well-intended organizations and advocates have advanced ideas to increase access to living donor transplantation, including direct payments for or large financial incentives for organ transplants, that may appear expedient but can result in serious adverse consequences for transplantation and for patients. Many of these proposals pose serious unintended negative consequences to both donors and to public trust in organ donation. We fundamentally reject efforts to model changes to the current US system based on research or organ transplant practices in nations such as China and Iran whose governments fail to meet or ignore high international and US standards for ethical medical research and basic human rights.

...

"AAKP, ASTS, and AST strongly support the elimination of disincentives to transplantation and adamantly oppose coercive financial incentives to donate.

...

"AAKP, ASTS, and AST believe that improvements to the transplant system can best be made through ethically and legally sound, evidence-based, data driven policies informed and guided by patients and transplant professionals rather than by overhauling the entire transplant system.

"The transplantation system is a public-private partnership between the federal government and the transplant community and is designed, in part, to prevent overt political influence or other governmental interference in shared patient-physician decision making and clinical judgement. The relationship between patients, including living organ donors, and the doctors and medical institutions they choose to care for them must be protected and respected, as should the ability of individual transplant professionals to make clinical decisions in the best interest of those patients.

"Transplantation is heavily regulated by multiple federal agencies, including the Centers for Medicare and Medicaid Services (CMS), the Health Resources Services Administration (HRSA), and two HRSA contractors (the Organ Procurement and Transplantation Network (OPTN) and the Scientific Registry of Transplant Recipients (SRTR)).  Transplant centers are subject to duplicative (and often conflicting) requirements and surveys imposed by CMS and the OPTN. Living donor transplant programs are subject to additional scrutiny to ensure that donors are not pressured, coerced, or intimidated into donating an organ.  All living donor transplant programs are required to have independent living donor advocates that ensure that donors’ full and informed consent is given with a full understanding of the procedure and its potential risks and consequences.

"Into this existing and complex regulatory framework, some organizations are proposing policy and legislative changes that would either expand federal control over transplant by inserting yet another federal agency into the process or overhauling the entire transplant system to give federal agencies, as well as political appointees and politicians, greater authority to regulate living donor transplantation. Exposing the living organ donation system to such political influence and putting decision-making in the hands of non-transplant experts is a mistake with dangerous consequences for patient health, public trust, and donor and patient confidence.

"These proposals raise the possibility that the federal government would mandate a “one-size fits all approach” to an incredibly complex set of clinical problems. Such an approach would likely result in fewer innovations and fewer opportunities to reduce barriers to transplantation, especially for historically underserved communities. There are many potential reforms to the transplant system that can be effective, have been suggested by the wider transplant community over the past decade, and should be adopted by Congress and federal agencies. However, any policy or legislative proposal that seeks to amend or replace the existing system with an even larger federal bureaucratic reach with the potential for federal interference in decisions made among organ donors and patients and the doctors and medical institutions they choose to receive care from should be viewed with skepticism.

"We oppose policy efforts that seek to place any governmental entity in the position of determining clinical criteria for living donor transplantation or otherwise interfering with the relationship between and among potential recipients, potential donors, and their caregivers.

*******

As a reader of many such joint statements, I wonder if the phrase  "coercive financial incentives" resulted from a compromise between those who believe that all financial incentives are coercive, and those who wish to leave the door open in the future to ordinary, non-coercive financial incentives, of the kinds that attach to so many human activities, and have done so much to relieve other kinds of shortages.

HT: Laurie Lee via Frank McCormick

Resident match video from the NRMP

 Different labor markets are organized differently. One difference between the market for new doctors and the markets for new Ph.D.s is that doctors use a centralized clearinghouse, so a lot of things happen at the same time.  Here's a video from the National Resident Matching Program that gives some idea about that.

Interesting development in the transition from medical school to residency: connecting applications and interviews

 The market for new doctors has been suffering from congestion in applications and interviews, in the runup to the resident Match (see recent post with a diagram). The American Association of Medical Colleges runs the main application server, ERAS. A private company called Thalamus runs a growing interview scheduling service. Now they are looking to collaborate.

 Here's  yesterday's press release from Thalamus:

AAMC, Thalamus Announce New Collaboration to Improve Transition to Residency

April 27, 2023 by Team Thalamus

Collaboration will increase transparency and make the residency process easier for applicants and programs  

Washington, D.C., April 27, 2023—Today the AAMC (Association of American Medical Colleges) and Thalamus announced a strategic collaboration to accelerate innovation and ease the transition to residency for medical students, medical schools, and residency programs. The collaboration will combine the AAMC’s long-established leadership in innovation along the continuum from medical school to residency training and continuing medical education with Thalamus’ market-leading product and software development expertise. 

“The transition from undergraduate medical education to graduate medical education is a critical period in any learner’s journey to becoming a physician,” said David J. Skorton, MD, AAMC president and CEO. “We know the community is seeking enhanced tools and integrated services that better support application and recruitment processes. We listened, we have made improvements, and, with Thalamus, we are excited to make this vision a reality.” 

The organizations will collaborate to leverage their data, technology, and expertise to transform the medical residency and fellowship recruitment processes for applicants and programs. Their efforts will focus on increasing transparency, supporting equity through holistic review, and improving the learner experience by consolidating the fragmented interview management process. 

“We are thrilled to be collaborating with the AAMC to provide a comprehensive solution that will streamline graduate medical education recruitment processes,” said Jason Reminick, MD, MBA, MS, CEO and founder of Thalamus. “But even more, we are looking forward to building new and innovative tools that improve the experience, are cost-effective, and leverage data for the benefit of the medical education community and the advancement of our collective missions.” Dr. Reminick applied to residency in 2012 during an eventful recruitment season disrupted by Hurricane Sandy. “I’m particularly excited to provide applicants with a comprehensive platform to manage their interview season.” 

The collaboration between the AAMC and Thalamus will enable data-sharing and innovative research that will benefit the undergraduate to graduate medical education community and advance both organizations’ missions. The initiative also demonstrates the commitment of both organizations to addressing the concepts and themes outlined in the 2021 report from the Coalition for Physician Accountability’s Undergraduate Medical Education-Graduate Medical Education Review Committee.

In recent years, the AAMC has completed significant in-depth research and upgraded technology to enhance the Electronic Residency Application Service® (ERAS®) suite of application and selection tools, such as updating the MyERAS® application content, building analytics tools for institutions, and partnering on collaborative research initiatives. Thalamus has completed unique research related to the physician workforce, including how geography influences The Match® and specialty-specific interview practices. The Thalamus technology will continue the upgrade of the ERAS suite of application and selection tools. The AAMC and Thalamus remain committed to future innovations that will enable the ERAS program to continue to evolve faster and better. 

Beginning in June 2023, all ERAS residency and fellowship programs will receive complimentary access to Thalamus’ leading interview management platform, Thalamus Core and Itinerary Wizard, as well as Cerebellum, a novel data and analytics dashboard to assess recruitment outcomes, specifically from a diversity, equity, inclusion, and geographic perspective. Programs may also elect to purchase Thalamus’ video interview platform and Cortex, its technology-assisted holistic application review and screening platform. 

According to AAMC data, the U.S. is expected to experience a shortage of up to 124,000 physicians by 2034. Given the burnout and other challenges to the health care system caused by the COVID-19 pandemic, the AAMC and Thalamus look to use their collective expertise to promote a diverse and representative workforce that will enhance health care and patient outcomes. 

The data and research the AAMC and Thalamus have amassed to identify resident, fellow, and physician recruitment trends can potentially have a major impact on diversity in medicine and begin to address several well-established and longstanding systemic challenges. These efforts will support not only the application and selection processes in graduate medical education but also aim to improve the experiences of the U.S. physician workforce over the long term. 

Related Resources 

• Frequently Asked Questions 
• AAMC ERAS Collaboration Page
• Thalamus Collaboration Page

###

Note for editors: Leaders from the AAMC and Thalamus are available to speak with media about this new collaboration and what it means for residency programs and applicants. 

The AAMC (Association of American Medical Colleges) is a nonprofit association dedicated to improving the health of people everywhere through medical education, health care, medical research, and community collaborations. Its members are all 157 U.S. medical schools accredited by the Liaison Committee on Medical Education; 13 accredited Canadian medical schools; approximately 400 teaching hospitals and health systems, including Department of Veterans Affairs medical centers; and more than 70 academic societies. Through these institutions and organizations, the AAMC leads and serves America’s medical schools and teaching hospitals and the millions of individuals across academic medicine, including more than 193,000 full-time faculty members, 96,000 medical students, 153,000 resident physicians, and 60,000 graduate students and postdoctoral researchers in the biomedical sciences. Following a 2022 merger, the Alliance of Academic Health Centers and the Alliance of Academic Health Centers International broadened the AAMC’s U.S. membership and expanded its reach to international academic health centers. Learn more at aamc.org. 

Thalamus is the premier, cloud-based interview management platform designed specifically for application to Graduate Medical Education (GME) training programs. The software streamlines communication by eliminating unnecessary phone calls/emails allowing applicants to book interviews in real-time, while acting as a comprehensive applicant tracking system for residency and fellowship programs. Thalamus provides comprehensive online interview scheduling and travel coordination via a real-time scheduling system, video interview platform, AI application screening/review tool (Cortex) providing technology-assisted holistic review, and first-in-class DEI-focused analytics dashboard (Cerebellum). Featured nationally at over 300+ institutions and used by >90% of applicants, Thalamus is the most comprehensive solution in GME interview management. For more information on Thalamus, please visit https://thalamusgme.com or connect with us on LinkedIn, Facebook, Instagram, Twitter, or YouTube. 

More anti-gay legislation in Uganda

 The NY Times has the story about new anti-gay legislation awaiting signature by Uganda's president:

We Will Hunt You’: Ugandans Flee Ahead of Harsh Anti-Gay Law. The bill, passed last month, calls for life in prison for anyone engaging in same-sex relations. President Yoweri Museveni congratulated lawmakers for their “strong stand” against L.G.B.T.Q. people.  By Abdi Latif Dahir

"Uganda’s Parliament passed a sweeping anti-gay bill in late March that threatens punishment as severe as death for some perceived offenses, and calls for life in prison for anyone engaging in same-sex relations.

...

"The bill, which passed 387 to 2, punishes anyone who leases property to gay people and calls for the “rehabilitation” of those convicted of being gay. President Yoweri Museveni, who has commended the bill, sent it back to Parliament on Thursday for “improvement,” his party said in a statement.

"The president congratulated lawmakers and religious leaders on what he called their “strong stand” against L.G.B.T.Q. people. “It is good that you rejected the pressure from the imperials,” he said, a reference to Western countries, in footage released by the public broadcaster. He spoke hours after the European Parliament denounced the bill.

"The legislation follows a groundswell of anti-gay rhetoric that has swept African countries in recent years, including in Ghana, Zambia and Kenya. Last month, lawmakers from more than a dozen African countries gathered in Uganda and promised to introduce or pass measures in their own countries that they said would protect the sanctity of the family and children against “the sin of homosexuality.”

...

"The latest move to target L.G.B.T.Q. people in Uganda has drawn support from local Christian and Muslim groups, and for years the financial and logistical backing o"f some conservative evangelical groups in the United States." 

Banned books

 The LA Times has the story:

Book bans are soaring in U.S. schools, fueled largely by new laws in Republican-led states by  ALEXANDRA E. PETRI

"Fearing criminal penalties, public schools throughout Missouri removed hundreds of books from their libraries after state lawmakers last year made it illegal to provide students with “sexually explicit” material — a new law that carried punishment of up to a year in prison.

"The dangers are playing out in public school districts and campus libraries across the United States, First Amendment advocates warn: Book bans, gassed up by state legislation pushed by conservative officials and groups, are stacking up at an alarming rate.

"In a report published Thursday by PEN America, the nonprofit free speech organization found 1,477 instances of books being prohibited during the first half of the 2022-23 academic year, up 28.5% from 1,149 cases in the previous semester. Overall, the organization has recorded more than 4,000 instances of banned books since it started tracking cases in July 2021.

"At issue is more than “a single book being removed in a single district,” said Kasey Meehan, the Freedom to Read program director at PEN America and a lead author of the report.

“It’s a set of ideas, it’s themes, it’s identities, it’s knowledge on the history of our country — these are the kind of bigger buckets of what is being removed, restricted, suppressed in public schools and public school libraries,” Meehan said."

It's against the law in North Korea to use South Korean words

 From Radio Free Asia:

North Korea sentences 20 young athletes for ‘speaking like South Koreans’. Skaters and skiers were caught on video using banned words while playing a game during training.  By Jieun Kim for RFA Korean

"About 20 aspiring North Korean winter athletes were abruptly sentenced to three to five years of hard labor in prison camps after they were found to have used South Korean vocabulary and slang while playing a word game, sources in the country say.

"It’s the latest example of authorities imposing draconian punishments to try to stamp out use of the “puppet language” and “capitalist” influences in daily life – despite the flood of illegal South Korean dramas and songs that many North Koreans secretly watch after obtaining them on thumb drives smuggled into the country.

"The ice skaters and skiers, all high school graduates under the age of 25 from Ryanggang province, were publicly disgraced at a square in Hyesan on April 3, a resident in the city on the Chinese border told Radio Free Asia’s Korean Service on condition of anonymity for security reasons.

“Residents think that it is excessive that they were sentenced between three and five years” of hard labor, another source in the city said. “It would be impossible to count how many hundreds or thousands of South Korean movies and dramas are easily available to us.”

...

"Apparently, one of the athletes took a video of the young people playing a word game called mal kkori itgi, where the object is to make a sentence that starts with the final word of the previous player’s sentence, and some of the athletes used vocabulary that was distinctly South Korean, a second source from the same province said.

"The video was found on the phone of one of the female athletes during a random inspection raid by police of her home – a frequent occurrence in North Korea when police look for contraband – and was reported to authorities. It wasn’t clear if she had taken the video or if it was sent to her, the first source said.

...

"The North Korean government recently passed the Pyongyang Cultural Language Protection Act, which underscores that the Pyongyang dialect is the standard language, and doles out severe punishments for speaking like a South Korean, or the death penalty for teaching others how to."

Michigan Senate seeks to repeal 1931 ban on unmarried cohabitation

 Michigan now has a more liberal senate than in 1931.  The Guardian has the story, about how even fossil repugnance dies hard:

Michigan Republicans fight effort to repeal ban on unmarried cohabitation. Law signed in 1931 is rarely enforced but carries penalty of prison time and $1,000 fine. by Erum Salam

"An attempt to repeal a Michigan law that punishes unmarried couples who live together is being thwarted by Republicans in the state legislature.

"The law, which dates to 1931, targets “any man or woman, not being married to each other, who lewdly and lasciviously associates and cohabits together”.

"It is rarely enforced but violations carry a penalty of up to a year in prison and a $1,000 fine.

"Senate Bill 56, which seeks to repeal the law, attracted support from all state senate Democrats and half of Republicans. But nine Republicans voted against.

...

"The bill now moves to the statehouse."

*********

Michigan Senate Bill 56: "Crimes: other; lewd and lascivious cohabitation; repeal prohibition. Amends sec. 335 of 1931 PA 328 (MCL 750.335)."

Medical aid in dying: access for children, and for mental illness

Two recent articles discuss whether there should be categorical limits on medical aid in dying (MAID).  In the Netherlands, the law now permits euthanasia for children in certain horrific situations, and in Canada, a debate continues about the status of patients with mental illness.

 From The Conversation:

Dutch government to expand euthanasia law to include children aged one to 12 – an ethicist’s view  by Dominic Wilkinson

"Ernst Kuipers, the Dutch health minister, recently announced that regulations were being modified to allow doctors to actively end the lives of children aged one to 12 years who were terminally ill and suffering unbearably.

"Previously, assisted dying was an option in the Netherlands in rare cases in younger children (under one year) and in some older teenagers who requested voluntary euthanasia. Until now, Belgium was the only country in the world to allow assisted dying in children under 12.

...

"Dutch paediatricians and parents had reported that in a small number of cases, children and families were experiencing distressing suffering at the end of life despite being provided with palliative care.

"That included, for example, children with untreatable brain tumours who developed relentless vomiting, screaming, and seizures in their dying phase. Or children with epilepsy resistant to all treatment with tens to hundreds of seizures a day.

"The study recommended improvements in access to palliative care for children, as well as altering regulation to provide the option of assisted dying in these extreme cases.

"It has been suggested that five to ten children a year might be eligible for this option in the Netherlands.

*********

From the NYT, an opinion piece:

Medical Assistance in Dying Should Not Exclude Mental Illness By Clancy Martin

"I am a Canadian, where eligible adults have had the legal right to request medical assistance in dying (MAID) since June 2016. Acceptance of MAID has been spreading, and it is now legal in almost a dozen countries and 10 U.S. states and Washington, D.C. To my mind, this is moral progress: When a person is in unbearable physical agony, suffering from a terminal disease, and death is near, surely it is compassionate to help end the pain, if the person so chooses.

"But a debate has arisen in Canada because the law was written to include those living with severe, incurable mental illness. This part of the law was meant to take effect this year but was recently postponed until 2024."

Strategy-proofness in Berlin in July

 "The WZB is planning an international conference on matching markets “Matching Market Design: Strategy-Proofness and Beyond” held as a two-day workshop on July 13–14, 2023, at the WZB Berlin Social Science Center, Germany. The conference will be organized by Dorothea Kübler (WZB), Christian Basteck (WZB/FU) and Vincent Meisner (TU)."

Here's the full announcement

Matching Market Design: Strategy-Proofness and Beyond  13. - 14. Juli 2023

"In the design of matching markets, it is important to elicit the privately known preferences of participants. Therefore, economists have focused on strategy-proof mechanisms which incentivize the truthful revelation of preferences and rule out any incentives to strategically misreport them. Unfortunately, as a growing body of evidence documents, strategy-proofness by itself is not sufficient to elicit truthful information on preferences.

"The workshop will bring together leading international researchers from North America, Europe, and Asia to present their latest research on this central design objective, including its limitations. In particular, we aim to discuss theoretical contributions on axiomatic characterizations, complexity notions, behavioral biases, and non-standard constraints, as well as applied work that incorporates experimental and field data."

Here's the preliminary program.

Transition from medical school to residency: defending the parts that work well (namely the NRMP Resident Match)

This post is about a recently published paper concerning the design of the market for new doctors in the U.S.  But it will require some background for most readers of this blog.   The short summary is that the market is experiencing problems related to congestion, and one of the proposals to address these problems was deeply flawed, and would have reduced market thickness and caused substantial direct harm to participants if implemented, and created instabilities that would likely have caused indirect harms to the match process in subsequent years. But this needed to be explained in the medical community, since that proposal was being  very actively advocated.

For those of you already steeped in the background, you can go straight to the paper, here.

Itai Ashlagi, Ephy Love, Jason I. Reminick, Alvin E. Roth; Early vs Single Match in the Transition to Residency: Analysis Using NRMP Data From 2014 to 2021. J Grad Med Educ 1 April 2023; 15 (2): 219–227. doi: https://doi.org/10.4300/JGME-D-22-00177.1

If the title doesn't remind you of the vigorous advocacy for an early match for select positions, here is some of the relevant back story.

The market for new doctors--i.e. the transition from medical school to residency--is experiencing growing pains as the number of applications and interviews has grown, which imposes costs on both applicants and residency programs.  

Below is a schematic of that process, which begins with applicants submitting applications electronically, which makes it easy to submit many.  This is followed by residency programs inviting some of their applicants to interview. The movement to Zoom interviews has made it easier to have many interviews also (although interviews were multiplying even before they moved to Zoom).  

After interviews, programs and applicants participate in the famous centralized clearinghouse called The Match, run by the NRMP. Programs and applicants each submit rank order lists (ROLs) ranking those with whom they interviewed, and a deferred acceptance algorithm (the Roth-Peranson algorithm) produces a stable matching, which is publicly announced on Match Day. (Unmatched people and positions are invited into a now computer-mediated scramble, called SOAP, and these matches too are announced on Match  Day.)

The Match had its origins as a way to control the "unraveling" of the market into inefficient bilateral contracts, in which employment contracts were made long before employment would commence, via exploding offers that left most applicants with very little ability to compare options.  This kind of market failure afflicted not only the market for new physicians (residents), but also the market for later specialization (as fellows). Consequently, over the years, many specialties have turned to matching for their fellowship positions as well.

  The boxes in brown in the schematic are those that constitute "The Match:" the formulation and submission of the ROLs, and the processing of these into a stable matching of programs to residents.  Congestion is bedeviling the parts in blue.

The boxes colored brown are 'The Match' in which participants formulate and submit rank order lists (ROLs), after which a deferred acceptance algorithm produces a stable matching of applicants to programs, which is accepted by programs and applicants on Match Day. The boxes in blue, the applications and interviews that precede the Match, are presently suffering from some congestion.  Some specialties have been experimenting with signals (loosely modeled on those in the market for new Economics PhDs, but implemented differently by different medical specialties).

The proposal in question was to divide the match into two matches, run sequentially, with the first match only allowing half of the available positions to be filled.  The particular proposal was to do this first for the OB-GYN specialty, thus separating that from the other specialties in an early match, with only half of the OB-GYN positions available early.

This proposal came out of a study funded by the American Medical Association, and it was claimed, without any evidence being offered, that it would solve the current problems facing the transition to residency.  Our paper was written to provide some evidence of the likely effects, by simulating the proposed process using the preferences (ROLs) submitted in previous years.  

The results show that the proposal would largely harm OB-GYN applicants by giving them less preferred positions than they could get in a traditional single match, and that it would create instabilities that would encourage strategic behavior that would likely undermine the successful operation of the match in subsequent years.

Itai Ashlagi, Ephy Love, Jason I. Reminick, Alvin E. Roth; Early vs Single Match in the Transition to Residency: Analysis Using NRMP Data From 2014 to 2021. J Grad Med Educ 1 April 2023; 15 (2): 219–227. doi: https://doi.org/10.4300/JGME-D-22-00177.1

Abstract:

"Background--An Early Result Acceptance Program (ERAP) has been proposed for obstetrics and gynecology (OB/GYN) to address challenges in the transition to residency. However, there are no available data-driven analyses on the effects of ERAP on the residency transition.

"Objective--We used National Resident Matching Program (NRMP) data to simulate the outcomes of ERAP and compare those to what occurred in the Match historically.

"Methods--We simulated ERAP outcomes in OB/GYN, using the de-identified applicant and program rank order lists from 2014 to 2021, and compared them to the actual NRMP Match outcomes. We report outcomes and sensitivity analyses and consider likely behavioral adaptations.

"Results--Fourteen percent of applicants receive a less preferred match under ERAP, while only 8% of applicants receive a more preferred match. Less preferred matches disproportionately affect DOs and international medical graduates (IMGs) compared to US MD seniors. Forty-one percent of programs fill with more preferred sets of applicants, while 24% fill with less preferred sets of applicants. Twelve percent of applicants and 52% of programs are in mutually dissatisfied applicant-program pairs (a pair in which both prefer each other to the match each received). Seventy percent of applicants who receive less preferred matches are part of a mutually dissatisfied pair. In 75% of programs with more preferred outcomes, at least one assigned applicant is part of a mutually dissatisfied pair.

"Conclusions--In this simulation, ERAP fills most OB/GYN positions, but many applicants and programs receive less preferred matches, and disparities increase for DOs and IMGs. ERAP creates mutually dissatisfied applicant-program pairs and problems for mixed-specialty couples, which provides incentives for gamesmanship."

************

I'm hopeful this paper will effectively contribute to the ongoing discussion of how, and how not, to modify the design of the whole process of transition to residency with an aim to fixing the parts that need fixing, without damaging the parts that work well, i.e. while doing no harm. 

(Signaling will likely continue to play a role in this.)

Workshop on Experimental Economics and Entrepreneurship: call for papers

 Nico Lacetera writes:

We are happy to announce the Third Workshop on Experimental Economics and Entrepreneurship, sponsored by the Belk College of Business of the University of North Carolina at Charlotte.

The workshop is organized by David J. Cooper (University of Iowa), Florian Englmaier (Ludwig Maximilian University of Munich), Nicola Lacetera (University of Toronto), Krista Saral (University of North Carolina at Charlotte) and Artie Zillante (University of North Carolina at Charlotte). It will take place in Charlotte, NC on October 18-19, 2023, immediately preceding the North American Annual Meeting of the Economic Science Association, in the same location.

The workshop is meant to promote partnerships between economic experimenters and scholars studying entrepreneurship, and to expose graduate students and recent PhD graduates in Economics and Management to the benefits and challenges of research at the intersection of experimental economics and entrepreneurship. The workshop will include a mixture of presentations by senior scholars in entrepreneurship and experimental economics, talks by more junior scholars, and presentations by graduate students. The conference is designed to encourage participants to interact and hopefully discuss ideas for future projects.

This is an open call for submissions for doctoral students, post-doctoral researchers, and faculty who obtained their doctoral degrees in 2019 or later. If you are interested in participating and presenting your research, please apply by submitting the following material to esaconference@uncc.edu by June 1, 2013:      

•    A cover letter including contact information.
•    An extended abstract of the paper you plan to present.  This should not be more than a page long.  If a paper is available, this can be submitted as well, but this is not required for consideration.

 The decision about accepted applications will be communicated not later than June 20, 2023. Each accepted and confirmed applicant will have two hotel nights covered as well as normal travel expenses.  

In addition to the selected workshop presentations, here is the current list of invited speakers who will be attending:

 

Jennifer Brown (University of Utah)

Jana Gallus (UCLA)

Orsola Garofalo (Copenhagen Business School)

Rem Koning (Harvard Business School)

Ronnie Chaterjee (Duke University)

Tim Salmon (Southern Methodist University)

We look forward to receiving your applications!

David, Florian, Nico, Krista, Artie

Transplantation: progress and continued shortcomings

 Here's a guest essay from the NYT that focuses on a different set of shortcomings of organ transplantation than organ availability. The author writes about how her long history of immunosuppression, to keep her transplanted organ(s) alive, has left her vulnerable to cancer.

My Transplanted Heart and I Will Die Soon.  By Marine Buffard

"My 35 years living with two different donor hearts (I was 25 at the time of the first transplant) — finishing law school, getting married, becoming a mother and writing two books — has felt like a quest to outlast a limited life expectancy. 

...

"Organ transplantation is mired in stagnant science and antiquated, imprecise medicine that fails patients and organ donors. And I understand the irony of an incredibly successful and fortunate two-time heart transplant recipient making this case, but my longevity also provides me with a unique vantage point. Standing on the edge of death now, I feel compelled to use my experience in the transplant trenches to illuminate and challenge the status quo.

"Over the last almost four decades a toxic triad of immunosuppressive medicines — calcineurin inhibitors, antimetabolites, steroids — has remained essentially the same with limited exceptions. These transplant drugs (which must be taken once or twice daily for life, since rejection is an ongoing risk and the immune system will always regard a donor organ as a foreign invader) cause secondary diseases and dangerous conditions, including diabetes, uncontrollable high blood pressure, kidney damage and failure, serious infections and cancers. The negative impact on recipients is not offset by effectiveness: the current transplant medicine regimen does not work well over time to protect donor organs from immune attack and destruction.

"My first donor heart died of transplant medicines’ inadequate protection of the donor heart from rejection; my second will die most likely from their stymied immune effects that give free rein to cancer.

...

"Without vigorous pushback, hospitals and physicians have been allowed to set an embarrassingly low bar for achievement. Indeed, the prevailing metric for success as codified by the Health Resources and Services Administration is only one year of post-transplant survival, which relieves pressure for improvement."

*************

That one year of measured graft survival is both too short, as the author points out, and too long.  By penalizing transplant centers for transplants that fail to survive a year, the current regulations make transplant centers too risk averse, so that kidney transplants that would have only, say, an 85% chance of working well are often not conducted, leaving patients to remain on dialysis, often til death,  for that 85% chance of life.

Transplantation is, still, a modern miracle. But until we can do without it, we'll have to keep trying to do it better.

The World Health Organization (WHO) at 75

 An editorial in Nature considers the complicated history of  the World Health Organization. 

The WHO at 75: what doesn’t kill you makes you stronger. The World Health Organization is emerging from the peak of the pandemic bruised. Its member states must get back to prioritizing universal health care.

"When thinking about the WHO’s 75 years, it’s worth remembering the time and circumstances of its creation. In the aftermath of the Second World War, the newly established United Nations and its specialized agencies, including the WHO, were designed to future-proof the world from another global conflict. Around 80 million people died during the two world wars, many from famine or disease.

"The WHO deserves more money for its core mission — and more respect

"The WHO’s founding constitution states unequivocally: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.”

"And yet, the agency’s creators chose not to prioritize robust systems of universal health care that would meet these goals. This absent focus is one factor in why infectious diseases continue to impact populations in low- and middle-income countries. The eradication of smallpox in 1980 was a big win. But for other diseases, the agency and its donors have been unable to reach targets, including in the elimination of HIV and AIDS, malaria and tuberculosis.

"The WHO does, however, have a consistent record for establishing itself as the go-to organization for setting global standards for the efficacy, safety and quality of vaccines and medicines. As we have seen during the pandemic, the agency is central to alerting the world to new infectious diseases, helped in no small measure by the revolution in biomedicine and health data, especially genomics."

In general I think the WHO does important work reasonably well, but I have reservations about their policies concerning blood and transplants, which seem to me to reflect some now outdated repugnance to the complexities of “Substances of Human Origin (SoHO)." (Not that these issues don't remain complex.)

Discriminatory quotas in admissions to universities and graduate schools (and some black humor from my father's generation)

 History doesn't exactly repeat itself, but it rhymes. (Mark Twain apparently missed the opportunity often attributed to him of saying that.) Here's a story about the history of ethnic quotas for Jews, as it played out in medicine in the 20th Century. (And at the bottom, some old jokes about coping with it...)

The History of Discriminatory Jewish Quotas in American Medical Education and Orthopaedic Training, by Solasz, Sara J. BA1; Zuckerman, Joseph D. MD1; Egol, Kenneth A. MD1,a, The Journal of Bone and Joint Surgery 105(4):p 325-329, February 15, 2023. | DOI: 10.2106/JBJS.22.00466

"By the early 1920s, formal quota systems were put in place to limit the number of Jewish applicants admitted to many American medical schools. This quota was partly a result of the second wave of Jewish immigration and the subsequent rise in antisemitism in the country. As a sign of the growing antisemitism in America, in 1920, Henry Ford published a weekly series called “The International Jew: The World’s Problem” on the front page of his newspaper, The Dearborn Independent. In this series, which continued for years, Ford fueled antisemitism both at home and abroad. The effect at the time was enormous: the feeling was that if an American icon as rich and powerful as Ford could hold this conviction so strongly, then it must be credible5,6. In addition to the effect on medical school admissions, measures were taken to deny Jewish people access to social institutions, neighborhoods, swimming pools and beaches, and employment.

...

"Harvard was known to have quotas restricting the number of Jewish students admitted to the college under the leadership of Lowell. In a letter to a philosophy professor, Lowell wrote that admitting Jewish students would ruin Harvard, “not because Jews of bad character have come; but the result follows from the coming in large numbers of Jews of any kind, save those few who mingle readily with the rest of the undergraduate body.”8

"It is within this social and political climate that the Jewish quota system appeared in medical schools throughout the U.S. Although medical school officials have always denied the existence of Jewish quotas, records from schools across the country reveal a systematic and intentional anti-Jewish prejudice. The medical historian Henry Sigerist wrote that Jewish students were subject to a “tacit, but nevertheless highly effective, quota system and in most schools the number of Jewish students rarely exceeds 10 per cent.”9 Many mainstream thinkers in higher education argued for further reductions in the acceptance rate for Jewish students, advocating for discrimination against Jews under the guise of keeping the “national ratio correct,” which would bring down the number of accepted students to represent only 3% to 4% of the total class.

...

"The most significant decrease in the number of admitted students occurred at Columbia University, which asked for the applicant’s religion, parents’ birthplaces, racial origin, and mother’s maiden name11. At the Columbia College of Physicians and Surgeons, the rate of enrollment of Jewish students between 1920 and 1940 dropped from 47% to 6%; during the same period, the rate dropped from 40% to 5% at Cornell University Medical College3. Throughout the Northeast, where the concentration of Jewish applicants was the highest, quotas appeared at schools such as Harvard Medical School, Yale School of Medicine, and the Woman’s Medical College of Pennsylvania3.

...

Facing this widespread sentiment, Jewish students hoping to gain admission to medical school were forced to take action—with some even changing their last names to avoid discrimination. Medical schools identified “Jewish names” on applications, especially when the applicants were from areas with large Jewish populations, to indirectly discriminate against Jewish students. Soon, schools expanded applications to require completion of a “change of name” section. *

...

"Prior to the establishment of the current U.S. residency “match” system, each residency position was sought individually with an application and interview and was typically followed by a near-immediate offer of a position. This system certainly provided a biased and unfair method for filling training programs.

...

"In New York State, the Education Practices Act (1948) set a precedent for other states to pass legislation to eliminate discriminatory admissions practices. As the wave of antisemitism began to fade and the need for physicians grew, medical schools and graduate medical education programs started to remove the quota systems, which came to a complete end in the 1970s."

##############

*Black humor was common in my dad's generation, including jokes about name changing (sometimes told in Yiddish). Here are two, approximately remembered.

1. Shmuel and Moshe, friends from Odessa, meet in New York after both have immigrated to America.  Moshe spots him from a distance and rushes over, calling out "Shmuel!"  They embrace, and Shmuel says, "I'm called Sam now, in America.  How about you?"

Moshe says "my American name is Sean Ferguson."  Sam is astonished, and asks "how come?"  "Well," says Moshe/Sean, I had picked out a good American name, but I was so nervous when I got to Ellis Island that I couldn't remember it. So when the immigration officer asked me my name, all I could think of to say was "I've already forgotten/ ikh hab shoyn fargesn, which is what he wrote down."  (איך האב שוין פארגעסן)

2. A few years later, Sean Ferguson goes to court to change his name again, to John McMillan. The judge asks him why he wants to do that.  He says "When I apply for positions, people ask what my name used to be..."

The (American) market for assault rifles

There was a time when Americans thought that rifles were for hunting game, and assault weapons were banned.  That has changed.

The Washington Post has the story:

The gun that divides a nation. The AR-15 thrives in times of tension and tragedy. This is how it came to dominate the marketplace – and loom so large in the American psyche. By Todd C. Frankel, Shawn Boburg, Josh Dawsey, Ashley Parker and Alex Horton 

"The AR-15 wasn’t supposed to be a bestseller.

"The rugged, powerful weapon was originally designed as a soldiers’ rifle in the late 1950s. “An outstanding weapon with phenomenal lethality,” an internal Pentagon report raved. It soon became standard issue for U.S. troops in the Vietnam War, where the weapon earned a new name: the M16.

...

"Today, the AR-15 is the best-selling rifle in the United States, industry figures indicate. About 1 in 20 U.S. adults — or roughly 16 million people — own at least one AR-15, according to polling data from The Washington Post and Ipsos.

...

"One Republican lawmaker, Rep. Barry Moore of Alabama, introduced a bill in February to declare the AR-15 the “National Gun of America.”

"It also has become a stark symbol of the nation’s gun violence epidemic. Ten of the 17 deadliest U.S. mass shootings since 2012 have involved AR-15s.

...

"the U.S. firearms industry came to embrace the gun’s political and cultural significance as a marketing advantage as it grasped for new revenue.

"The shift began after the 2004 expiration of a federal assault weapons ban that had blocked the sales of many semiautomatic rifles. 

...

"Today, the industry estimates that at least 20 million AR-15s are stored and stashed across the country.

"More than 13.7 million of those have been manufactured by U.S. gunmakers just since the Newtown massacre in late 2012"

*************

NPR puts some history into perspective:

The Nashville school shooting highlights the partisan divide over gun legislation , by Ron Elving, April 1, 2023

"The Stockton schoolyard shooting in 1989

...

"The Stockton story was national news, featured on the cover of Time magazine with the headline "Armed America." Public alarm at Stockton pushed the legislature to be the first to prohibit the sale of assault weapons that year.

"Stockton was still reverberating three years later when California, the home of Republican presidents Richard Nixon and Ronald Reagan, sent two liberal Democrats, both women, to the U.S. Senate It also stocked its legislature and congressional delegation with big Democratic majorities and gave its Electoral College vote to Bill Clinton.

"One of the two women senators elected that year was former San Francisco Mayor Dianne Feinstein, who had first become mayor when her predecessor was shot to death in his office in the 1970s. She had long been outspoken on gun control and brought that commitment to Washington, D.C., becoming one of the principal sponsors of a bill banning assault weapons ban in her first year.

"The Assault Weapons Ban of 1994

"Feinstein and her cosponsors wanted to end the sale or manufacture of 14 categories of semi-automatic assault weapons. They also wanted to go beyond the California ban by outlawing copycat versions of earlier models and high-volume detachable magazines that held more than 10 rounds.

"But the bill did not address the status of an estimated one million assault weapons nationwide. "Essentially what this legislation does is create a freeze," she said. She lamented the resistance that rarely produced actual arguments among her colleagues. She said had never realized "the power of the NRA in this town."

...

"There were literally hundreds of exceptions included in the final version, distressing many of the bill's supporters. But getting the ban into the crime package to be passed in that Congress (with billions in new police funding) required many compromises. Ultimately, to get to a majority, Feinstein would have to accept a sunset provision by which her restrictions would need reenactment after 10 years.

...

"So when the 10-year expiration date on Feinstein's bill arrived in 2004, Democrats were no longer the majority party in Congress and all attempts to extend the 1994 ban were unavailing.

...

"The Sandy Hook Test in 2012

The next time serious energy developed behind renewing the ban was in the winter of 2012-2013. Barack Obama had just been reelected president, and the Senate was still in Democratic hands.

"Just as important, the effort to address the gun issue had been given an enormous boost by a new and more horrific tragedy.

"On Dec. 12, 2012, Adam Lanza, 20 — described by counselors as fascinated with mass shootings — killed his mother and took guns she had legally purchased to a Sandy Hook Elementary School in Newtown, Conn.

"There he shot dead 20 children, ages 6 and 7. He also killed six adults on the school staff. Then he killed himself.

"The national shock at the time is hard to appreciate a decade later, as there have been so many like it. 

...

"But the 113th Congress came and went in 2013 and 2014 without passing notable gun legislation. A compromise measure on background checks, offered by West Virginia Democrat Joe Manchin and Pennsylvania Republican Pat Toomey, got 54 votes in the Senate but needed 60.

"As for prospects for reviving gun legislation in the current Congress, the situation looks much as it did a decade ago. The 118th Congress has a Senate where Democrats have a nominal majority that depends on the cooperation of several independents. Feinstein is still in the Senate, the longest-serving incumbent Democrat, but planning to retire next year.

"The current House, like that of a decade ago, has a Republican majority led by a speaker whose power depends on placating a hardcore group known as the House Freedom Caucus."

Jobs at risk from AI chatbots

 The WSJ has the alarming news:

The Fortune Cookie Industry Is in Upheaval. ‘Expect Big Changes Ahead.’ Factories split over whether to use software, instead of humans, to write the random bits of wisdom inside the wafers. ‘Society is moving too fast.’  By Angus Loten

"Over the past two decades, Charles Li, the owner and chief executive of Chicago-based fortune-cookie factory Winfar Foods Inc., has drawn on Chinese proverbs and popular sayings to write thousands of messages that go into the wafers. Mr. Li says he and his 80-year-old father-in-law spend long hours coming up with lines that are clever but still brief enough to fit on a ribbon of paper.

...

"OpenFortune Inc., a New York-based company that supplies printed messages to well over a dozen fortune-cookie factories around the world, says it has started using ChatGPT technology to potentially generate a near-limitless inventory of new messages.

"Making up the sayings in the cookies is a vigorous line of work. By some estimates, three billion fortune cookies are made by factories around the world every year. Nearly all are written by a handful of fortune-cookie factory owners, their families or small teams of copywriters."

Kidney transplants from donors who died from illegal drug use

 There was a time when the modal deceased kidney donor had suffered a head injury in an auto accident, but that time is long gone, due to increased auto safety and to the rise in drug overdose deaths.  Those latter deaths now constitute a large proportion of deceased donors, and here's a report from Canada confirming that those kidneys work well in their new owners.

Xie, Max Wenheng, Sean Patrick Kennan, Amanda Slaunwhite, and Caren Rose. "Observational Study Examining Kidney Transplantation Outcomes Following Donation From Individuals That Died of Drug Toxicity in British Columbia, Canada." Canadian Journal of Kidney Health and Disease 10 (2023): 20543581231156853.

"Abstract:

"Background: The illicit drug toxicity (overdose) crisis has worsened across Canada, between 2016 and 2021 more than 28 000 individuals have died of drug toxicity. Organ donation from persons who experience drug toxicity death has increased in recent years. 

"Objective: This study examines whether graft loss after kidney transplantation differed by donor cause of death. 

Design: Retrospective cohort. 

"Setting: Provincial transplant program of British Columbia, Canada. 

"Patients: Transplant recipients who received kidney transplantation from deceased donors aged 12 to 70 years between 2013 and 2019 (N = 1012). 

"Measurements: Transplant recipient all cause graft loss (graft loss due to any cause including death) was compared by donor cause of death from drug toxicity or other. 

"Methods: Five-year Kaplan-Meier estimates of all-cause graft survival, and 3-year complete as well as stratified inverse probability of treatment weighted Cox proportional hazards models were conducted. 

"Results: Drug toxicity death donors donated to 25% (252/1012) of kidney transplantations. Drug toxicity death donors were more likely to be young, white, males, with fewer comorbidities such as diabetes or hypertension but were more likely to have a terminal serum creatinine ≥1.5 mg/dL or be hepatitis C virus (HCV) positive. Unadjusted 5-year estimate of all cause graft survival was 97% for recipients of drug toxicity donor kidneys and 83% for recipients of non-drug toxicity donor kidneys (P < .001). Recipients of drug toxicity death donor kidneys had decreased risk of all cause graft loss compared to recipients of non-drug toxicity death donor kidneys (hazard ratio [HR]: 0.30, 95% confidence interval [CI]: 0.12-0.77, P = .012). This is primarily due to the reduced risk of all-cause graft loss for recipients of younger (≤35 years) drug toxicity death donor kidneys (HR: 0.05, 95% CI: 0.00-0.55, P = .015). 

"Limitations: Potential selection bias, potential unmeasured confounding. 

"Conclusions: Donation after drug toxicity death is safe and should be considered more broadly to increase deceased donor kidney donation."

...

"illicit drug toxicity remains the leading unnatural cause of death in BC accounting for more deaths than homicides, suicides, and motor vehicle incidents combined.

...

"The United States is also undergoing an opioid epidemic which began earlier than Canada and has recorded similar increases in organ donation from individuals that died of illicit drug toxicity.9-11 Studies in the United States have found that recipient survival after kidney transplantation from individuals who died from drug toxicity was similar for recipients of kidneys from donors that died of any other cause of death."

Brain Death

 Before there was the possibility of organ transplantation, determining that someone was dead could be a relatively leisurely affair. But transplants depend on organs remaining alive after the potential organ donor has died.  If the death is due to irreversible absence of circulation and respiration (Donation after Circulatory Death – DCD), it has to be declared quickly, so that preparation for organ recovery can begin promptly. If the declaration of death is based on brain death, i.e. on irreversible absence of whole brain function (Donation after Death declared by Neurologic Criteria - DDNC), then it must occur while the potential donor is on a ventilator, so that his/her organs continue to be oxygenated.  This means that the declaration of death occurs while the ventilator is still maintaining many of the signs (respiration, heartbeat) that are usually evidence of a living person.  So deciding when someone is brain dead requires both expertise and consensus.

Here's a recent discussion of all this, including some controversy, in JAMA: 

The Uncertain Future of the Determination of Brain Death, by Robert D. Truog, JAMA. 2023;   329(12): 971-972. doi:10.1001/jama.2023.1472

"In 1980, the US Uniform Law Commission (ULC) established the Uniform Determination of Death Act (UDDA), which was subsequently adopted (with some modifications) by all 50 states.1 The law states that death is defined as either (1) the irreversible cessation of circulatory and respiratory functions or (2) the irreversible cessation of all functions of the entire brain, including the brainstem.

...

"The framers of the UDDA rejected the claim that this was a new way of defining death.2 Instead, they pointed to evidence at the time suggesting that the brain is necessary for maintaining biological functioning and that when this brain regulation is absent, homeostatic mechanisms fail, with cardiac arrest invariably occurring within 1 to 2 weeks at most. In other words, brain death and cardiopulmonary arrest were seen as equivalent and equally valid criteria for diagnosing the biological death of a patient.

"However, with improvements in critical care medicine, this equivalency has been called into question. With modern intensive care unit support, some patients can be stabilized and, if provided with mechanical ventilation and tube feedings, their bodies may survive for many years.

...

"In fact, patients with brain death may retain most of the capacities of living people, including the ability to absorb nutrition, excrete waste, heal wounds, grow, undergo puberty, and even gestate. This has led many families to reject the diagnosis and insist on the continuation of medical support for their loved ones.

"In addition, a second issue has been that, although the UDDA requires “the irreversible absence of all functions of the entire brain,” the current guidelines from the American Academy of Neurology (AAN) test for only a select number of functions and most notably do not test for hypothalamic functions, which are sometimes present in patients who are diagnosed with brain death

"In the wake of an increasing number of legal challenges related to the determination of brain death, ULC began a process in 2021 to assess whether the UDDA should be revised.1 At least 3 distinct proposals have been considered.

"Proposal 1: Revise the Guidelines to Align With the Current Definition

"One option would be to leave the UDDA intact, but revise the AAN guidelines to include testing for the absence of hypothalamic function.

...

"Proposal 2: Revise the Definition to Align With the Current Guidelines

"A second proposal has been to change the definition of brain death to be in alignment with the guidelines.

...

"Revising the UDDA so that it required not the irreversible loss of all brain functions, but rather only those functions that support consciousness and spontaneous respiration, would bring the UDDA into alignment with the AAN guidelines. This approach also has precedent, in that it is the definition that was adopted by the United Kingdom in 2008.

...

"Proposal 3: Maintain the Status Quo

"If the position endorsed by commissioner Bopp were to prevail, some states could choose to entirely eliminate the determination of death by neurologic criteria. The impact would be 2-fold: in those states it would no longer be permissible to procure transplantable organs from patients diagnosed with brain death and physicians could be required to continue to provide intensive care unit beds and life support to patients who will never regain consciousness. Such an outcome could have disastrous consequences for our existing systems of organ procurement and transplantation, leading to thousands of otherwise avoidable deaths.

"This has led some commissioners to lean in favor of not making any major revisions to the UDDA, leaving well enough alone."

Mega-Journals and scientific publishing

 Academic publishing is getting more varied. A recent article in JAMA focuses on the rise of 'mega-journals,' which seek to publish papers that are correct, without filtering for (referees' opinions about) novelty or importance.

The Rapid Growth of Mega-Journals: Threats and Opportunities  by John P. A. Ioannidis, MD, DSc1,2; Angelo Maria Pezzullo, MD, MSc3; Stefania Boccia, MSc, DSc, PhD3,4, JAMA. Published online March 20, 2023. doi:10.1001/jama.2023.3212

"Mega-journals, those that publish large numbers of articles per year,1 are growing rapidly across science and especially in biomedicine. Although 11 Scopus-indexed journals published more than 2000 biomedical full papers (articles or reviews) in 2015 and accounted for 6% of that year’s literature, in 2022 there were 55 journals publishing more than 2000 full articles, totaling more than 300 000 articles (almost a quarter of the biomedical literature that year). In 2015, 2 biomedical research journals (PLoS One and Scientific Reports) published more than 3500 full articles. In 2022, there were 26 such prolific journals (Table). The accelerating growth of mega-journals creates both threats and opportunities for biomedical science.

...

"we define mega-journals as open-access peer-reviewed journals that charge article processing fees and publish more than 2000 full articles in a calendar year. The 2 early-launched mega-journals, PLoS One and Scientific Reports, were also characterized by very broad publishing scope, covering scientific topics in general. 

...

"Mega-journals typically claim to publish articles based on whether they are scientifically sound rather than important and novel. Accordingly, their acceptance rates, when disclosed, are 20% to 70%

...

"It would be unfair, nevertheless, to dismiss mega-journals as simply a negative development. Several of their characteristics could be aligned also with desirable scientific practices. First, open access is a good starting point, and it can be coupled with greater transparency. If these journals routinely adopt transparent research practices, such as sharing of data, code, protocols, and statistical analysis plans, they can have a transformative effect, given their large output. Several older, broad-scope mega-journals (eg, PLoS One, Royal Society Open Science) have already championed such efforts. It is crucial that disciplinary-focused mega-journals do the same. Second, publishing technically sound scientific work regardless of the nature of the results is highly commendable. It offers opportunities to curb publication and selective reporting bias. Empirical studies are needed to investigate whether mega-journals do achieve this goal or still have selective reporting biases and variants thereof (eg, “spin”). Third, mega-journals may allow publication of results deemed undesirable in traditional specialty journals with entrenched, inbred publishing practices. Enhanced diversity of perspectives and opportunities to challenge orthodoxy are welcome, provided the journals publish rigorous data and safeguard against conflicts of interest. Securing editorial independence and maximizing transparency about conflicts for editors, reviewers, and authors will be key in reaping such benefits.

...

"At the publisher level, competition may have major indirect effects on medicine and science at large. Scientific publishing has an annual work cycle exceeding $30 billion and very large profit margins, which are possible in part because approximately 100 million hours of peer reviewers’ time is offered free yearly.8 The publishers behind the new generation of specialized mega-journals (Table) are taking this money-making recipe to new heights. Science and scientists may feel thwarted, if not entirely powerless, while big publishing corporations fight for field domination. However, it would be to the benefit of all if scientists, medical and research institutions, and funders gave credit to and rewarded journals (and publishers) that promote more transparent research and more rigorous research practices."