NRMP Match Day, 2019

Today is match day, when imminent medical grads find out where they'll be starting residencies in July.

Here's the NRMP's press release:
Thousands Of Resident Physician Applicants Celebrate NRMP Match Results
2019 Main Residency Match is largest on record with 44,600 registered applicants and more than 35,000 positions offered

Here are some data tables, including this one on couples:

Here's an article in Stat reflecting on some current issues of marketplace maintenence, related to what certainly seems to have become excessive pre-match interviewing:

Ideas for easing medical students’ Match Day ‘frenzy’
By ALISON VOLPE HOLMES and MONA M. ABAZA MARCH 15, 2019

"The National Residency Matching Program is an admirable invention. Now more than 30 years old, it is the system through which medical students get their first paid, professional positions. It corrected past abuses that took advantage of students, often pressuring them to accept binding offers within 24 hours of a residency interview. The Match is sufficiently noteworthy that its creator, Alvin Ross, won a Nobel Prize in economics for his work on matching theory. His algorithm continues to place half of U.S. medical school graduates in their first-choice programs. Other professions and selection processes could be improved by using a similar matching system.

Yet the Match and what leads up to it are having growing pains. Medical students are applying to increasing numbers of residency programs, sometimes to all of the programs in a field. Residency program directors are flooded with applications, and have trouble identifying which students are truly interested.

...

"Otolaryngology (also known as ear, nose, and throat) offers a telling illustration of this problem, and a potential solution that failed. In 2010, the average student interested in an otolaryngology residency applied to 47 programs, and the average residency program received 200 applications from U.S. medical students — to fill just two to six positions. By 2015, this increased to 64 applications per student and 275 applications per program.

"The program directors attempted to exert some control over application inflation by asking students to write a paragraph about their interest in the program they were applying for. This reduced applications, but also backfired. In 2017, the number of applications fell back to 200 per program, but 10 programsfailed to get the number of residents they needed. The otolaryngology program directors removed the supplemental requirement and applications jumped back up to 278.

...

"The Match was once a brilliant solution that everyone in medicine was proud of. There are still lessons to be learned from it for other selection processes, including undergraduate admissions. But if we — students, advising deans, and residency program directors — do not come together and work on solutions, we risk losing the Match’s great many advantages."

Ongoing controversies about same sex marriage

Relatively recent stories, about the Methodist world and the Arab world remind us that there remains considerable active repugnance to same sex marriage.

From the Washington Post:

Reeling from contentious LGBT vote, some Methodists pledge to fight while others mull leaving

"Dumbarton United Methodist Church is the oldest United Methodist congregation in Washington, D.C., dating almost 200 years before the United Methodist denomination was created — even before the United States was created.

"On Wednesday, when the church’s minister, the Rev. Mary Kay Totty, traveled back to Washington from a groundbreaking meeting in St. Louis, where the denomination decided to uphold its opposition to same-sex marriage and LGBT clergy, she said she thought that centuries-old history might be at a breaking point.

“To think of not being Methodist,” she said, then stopped, unable to complete the sentence. Dumbarton voted to affirm gay worshipers more than 30 years ago, and the church has performed 20 same-sex marriages since 2010, breaking the rules of the denomination every time. Now such actions will be met with much harsher penalties."
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(The NY Times reports that there were some voting irregularities:
Improper Voting Discovered at Methodist Vote on Gay Clergy)

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And from the Guardian:

Luxembourg PM takes Arab leaders to task on gay rights at summit
Xavier Bettel says his same-sex marriage would condemn him to death in some countries

"Luxembourg’s prime minister, Xavier Bettel, has confronted Arab leaders over the repression of gay rights, telling them his same-sex marriage would condemn him to death in some of their countries.
...
"Bettel, the first EU leader to be married to a same-sex partner, had planned to make the intervention before arriving at the summit in Sharm El Sheikh, Egypt, which was the first gathering between the EU and Arab League.

"Homosexuality is punishable by death under sharia law in Saudi Arabia, Sudan and Yemen. Other countries in the region prohibit same-sex acts, including Algeria, Morocco, Oman, Tunisia, Syria, Kuwait and some of the United Arab Emirates.
...
"Bettel’s point is underscored by the treatment of the lesbian, gay, bisexual and transgender community in Egypt, the country that hosted the summit.

"Homosexuality is not illegal in Egypt, but LGBT people are frequently detained on euphemistic charges such as “debauchery”. After the Egyptian president, Abdel Fatah al-Sisi, came to power in a coup in 2013, he “appeared to embrace persecution of gays and trans people as a political strategy” according to a report by Human Rights Watch.

...

"The European commission president, Jean-Claude Juncker, defended the bloc’s decision to hold the summit. “If I only talked to flawless democrats, then I would end my week already by Tuesday,” he said."

Organ donor compensation in New Zealand

Organ donation is being reorganized in New Zealand:
First step toward more life-saving organ transplants
Wednesday, 13 March 2019, Press Release: New Zealand Government

"The Organ Donors and Related Matters Bill introduced today enables the New Zealand Blood Service to take on the role of a national organ donation service. The Bill also extends in certain situations, the financial compensation for qualifying donors while they recuperate.
...
“The Bill also amends the Compensation for Live Organ Donors Act 2016, which gives qualifying donors financial compensation while they recuperate.

“While the Act is largely working well, donors who return to work part time are not eligible, nor are donors who could be part of the proposed trans-Tasman kidney exchange. The Bill will amend the Act to allow for compensation in these situations,” David Clark said.

"In 2018, there were 62 deceased donors who enabled 192 recipients to receive kidney, liver, lung, heart or pancreas transplants, and many more recipients received tissue transplants. There were also 84 live donor kidney transplants and 2 live donor liver transplants."

Disrupting black markets

If markets can be facilitated, they can also be obstructed. The NSF announces some grants aimed at this:

NSF invests in research to help disrupt operations of illicit supply networks
9 early concept awards to detect, disrupt, disable networks that traffic people, weapons, drugs and more

"Networks that illegally traffic in everything from people and opioids to human organs and nuclear material pose threats to U.S. health, prosperity and security. Nine new awards from the National Science Foundation (NSF) will advance the scientific understanding of how such illicit supply networks function -- and how to dismantle them.

"The new awards support research that combines engineering with computer, physical and social sciences to address a danger that poses significant consequences for national and international security. Nimble and technologically sophisticated networks traffic in contraband that includes people, illegal weapons, drugs, looted antiquities, and exotic animal products. Unencumbered by national boundaries, they funnel illicit profits to criminal organizations, and fuel transnational and terrorist organizations.

"Other federal agencies and organizations have worked on this issue for many years, with involvement of specialized fields in the academic community. The new NSF awards leverage fundamental research, taking an engineering systems-based approach made far more powerful by the integration of other scientific disciplines.

"We've been studying commercial supply chains for years and figuring out how to make them resilient -- now we want to use these same principles to make illicit networks less resilient. We want to break them," said Georgia-Ann Klutke, NSF program director for Operations Engineering in the Directorate for Engineering. "These are systems that operate by the same dynamics and use the same infrastructure components as legal commercial distribution systems. Our goal is to provide fundamental insights into the operations and economics of these networks that other federal agencies and organizations can use to attack this very complex problem."
...

Below are the nine new projects being funded, along with the principal investigators and awardee organizations.

• Disrupting exploitation and trafficking labor supply networks in post-Harvey rebuild: an evidence-based multi-agent stochastic decision-making framework, Matt Kammer-Kerwick, University of Texas, Austin
• Network analysis and optimal interventions for disruption of organ trafficking, Naoru Koizumi, George Mason University
• A data analytic approach to understanding human trafficking networks, Renata Konrad, Worcester Polytechnic Institute
• Unraveling illicit supply chains for falsified pharmaceuticals with a citizen science approach, Marya Lieberman, University of Notre Dame
• Anticipatory interdiction in narco-trafficking networks, Nicholas Magliocca, University of Alabama
• Modeling operations of human trafficking networks for effective interdiction, Lauren Martin, University of Minnesota-Twin Cities
• Detecting and disrupting illicit supply networks via traffic distribution systems, Nick Nikiforakis, Stony Brook University
• A new multi-layered network approach for improving the detection of human trafficking, Louise Shelley, George Mason University
• Advanced analytics, intelligence and processes for disrupting operations of illicit supply networks, Steven Simske, Colorado State University

Legal lotteries and illegal numbers games: some history

The NY Times published a nostalgic look back at the widespread illegal gambling on the "numbers" that preceded the introduction of a legal state run lottery, which eventually competed away the illegal game. It's a story of both market design, to produce a trustworthy lottery that could be run by criminals, and a story of how a legal market eventually replaced it (although, as I recall, only slowly...)

The Daily Lottery Was Originally a Harlem Game. Then Albany Wanted In.
The numbers were a sprawling, black-run business for decades.

"In the early 1920s, Casper Holstein, a black man from the Danish West Indies who worked as a porter for a Fifth Avenue store, liked to study the “Clearing House” totals published in a year’s worth of newspapers he’d saved. The Clearing House was an operation that managed the exchanges of money among New York City banks on a daily basis. It occurred to Holstein that the numbers printed were different every day.

"Until then, lottery games existed, but the winning numbers were often chosen in unreliable ways that could produce rigged results. According to the 2010 book “Playing the Numbers,” Holstein came up with an ingenious solution. Using the Clearing House totals to produce a random combination between 000 and 999, he came up with a daily three-digit winning number for a new kind of lottery game. His invention became known simply as the numbers.

It was an immediate hit and quickly created a sprawling underground economy that moved through Harlem and other black communities in the U.S. For 60 years, the numbers reigned supreme as New York City’s pre-eminent daily lottery game — until 1980, when the state decided it wanted in."
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And here's a 2013 story, about how the numbers hung on for a while, but its customers got older and older:
Relics of the Bygone (and the Illegal)
The numbers game is dwindling, even in Harlem, once its stronghold, but it’s not obsolete.
"Back then, there were an estimated 100,000 numbers workers and more than 8,000 arrests a year. In neighborhoods like Harlem, the game became an element of black and Latino identity and culture. Black leaders called for black-owned rackets in the 1960s, and there were conflicts with the Mafia.

Several years later, with the state lottery offering a similar game, runners and numbers bankers openly protested in Manhattan. They feared the legal game would wipe out the rackets and their jobs. They were, for the most part, right."
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I have an unreliable memory that I can't now confirm online that when I matriculated at Columbia University in 1968, the local weekly Harlem newspaper (probably the Amsterdam News) didn't publish any financial information except for a single number, which I recall not as the clearinghouse numbers described above, but something like the volume of trade on the New York Stock Exchange the previous day.  I remember naively inquiring why this should be the one number reported in a weekly newspaper, and it was explained to me that its last digits were the weekly number.  (I think it was published on the front page, but looking online at old photos of the Amsterdam News front page I don't see it.)  If anyone has a more reliable/correct memory, I'd be glad to hear of it.

Cornell celebrates Eva Tardos

In the Cornell Sun:

A Tribute to the Women in Lab Coats, Behind the Microscopes and Computer Screens
By Sophie Reynolds, Catherine Cai, Caroline Chang

"Professor Eva Tardos, Computer Science

Cornell Professor Eva Tardos, computer science, focuses her research on the effects of “selfish users” in networks. A “selfish user” optimizes resource usage for their own benefit like in packet routing, crowdsourcing and bitcoin mining. Selfish optimization by one user can have a negative effect on other users because it could limit access to resources and subsequently slow down processes in their respective areas of a network.

“Understanding the tradeoff between more complicated designs that can mediate effects of selfish users versus a simpler design […] is an area that I have been working on for 20 or so years, and I still find it fascinating,” Tardos said.

Tardos’ research also overlaps heavily with algorithmic game theory. Tardos notes that her research is extremely interdisciplinary and that she actively communicates with Cornell faculty such as Professor David Easley, economics, as well as economics graduate students.

“The graduate course that I last taught, CS 6840: Algorithmic Game Theory, had econ grad students in it and those are the people I often talk to, even after the course.”

Tardos not only collaborates with economists at Cornell, but also with larger scientific communities such as in the Association for Computing Machinery (ACM) Conference on Economics and Computation, a forum to exchange ideas and converse over technical papers.

In addition to her research, Tardos teaches CS 4820: Analysis of Algorithms, a core class in Cornell’s computer science curriculum that focuses on the design and analysis of computer science algorithms.

“The best part of teaching undergraduate students is to teach students a principled way of thinking about algorithms,” Tardos said.

Tardos, a strong advocate for women in computing fields and an advisor for Women In Computing At Cornell, acknowledges that the number of women getting involved in computer science has not steadily risen like in many other STEM fields.

According to Tardos, the 1980’s were a high point for women in computing but after the dot com boom and bust, the number of women in computer science started to drop.

“Fortunately, in recent years that trend has reversed, and we are doing much better in attracting women to the field,” Tardos said.

Cornell is already ahead of the curve in achieving a 1:1 ratio of women to men in engineering disciplines, and Tardos remains very optimistic about the prospect of more women in computing fields entering academia.

Tardos hopes that this generation of women does not underestimate the excitement of being a computer scientist at a research university."

First-person account of a four-way kidney exchange in Houston, in the WSJ

Here's a moving first-person account by journalist Yogita Patel in the Wall Street Journal, about her decision to donate a kidney to her brother, through kidney exchange.

I Gave My Kidney to a Stranger to Save My Brother’s Life
By Yogita Patel, March 9, 2019

It's full of interesting introspection. Here's one bit:
"As I expressed my growing concerns, my brother quietly acknowledged to other family members some of his own doubts. “I wasn’t sure if it would always be something you’d hold over me,” he recently admitted. I wasn’t sure, either."

I was also interested in a technical part of the story about the lengths that Houston Methodist Hospital goes to try to perform all the kidney exchange transplants they do internally, i.e. at their own hospital.  In this case, a four-pair exchange was assembled over a period of months, that included at least one non-directed donor who participated in the exchanges, which all took place on the same day.

"Houston Methodist first aims to create a donor chain without other hospitals—its longest involved 12 people. If appropriate matches fail to come together, the hospital expands the search regionally, then ultimately to a national registry that helped create a 30-pair swap the hospital took part in eight years ago.
...
"As months went by, our small network continued to come together behind the scenes.
...
"Twice, Pesh got word from his coordinator that it was nearly go time in what turned out to be false alarms.As the wait dragged on, he made two trips to the ICU because of complications tied to dialysis. Each episode left him fearing that the prospect of a donation was fading.

"Finally in June, we got word that they had found matches for both of us. Our four-pair exchange took place on the same day, Aug. 7, with everyone having surgery at Houston Methodist."

Deceased donation of organs for transplant: recent policy discussions

Here's a list of links about recent discussions about how deceased donor organs are recovered and used in the U.S.

First, a 2017 article in the American Journal of Transplantation on how OPO's (Organ Procurement Organizations) are measured:

Changing Metrics of Organ Procurement Organization Performance in Order to Increase Organ Donation Rates in the United States
D. Goldberg  M. J. Kallan  L. Fu  M. Ciccarone  J. Ramirez  P. Rosenberg  J. Arnold G. Segal  K. P. Moritsugu  H. Nathan  R. Hasz  P. L. Abt

Abstract: The shortage of deceased‐donor organs is compounded by donation metrics that fail to account for the total pool of possible donors, leading to ambiguous donor statistics. We sought to assess potential metrics of organ procurement organizations (OPOs) utilizing data from the Nationwide Inpatient Sample (NIS) from 2009–2012 and State Inpatient Databases (SIDs) from 2008–2014. A possible donor was defined as a ventilated inpatient death ≤75 years of age, without multi‐organ system failure, sepsis, or cancer, whose cause of death was consistent with organ donation. These estimates were compared to patient‐level data from chart review from two large OPOs. Among 2,907,658 inpatient deaths from 2009–2012, 96,028 (3.3%) were a “possible deceased‐organ donor.” The two proposed metrics of OPO performance were: (1) donation percentage (percentage of possible deceased‐donors who become actual donors; range: 20.0–57.0%); and (2) organs transplanted per possible donor (range: 0.52–1.74). These metrics allow for comparisons of OPO performance and geographic‐level donation rates, and identify areas in greatest need of interventions to improve donation rates. We demonstrate that administrative data can be used to identify possible deceased donors in the US and could be a data source for CMS to implement new OPO performance metrics in a standardized fashion.
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Here's an optimistic report from the Bridgespan Group, sponsored by the Arnold Foundation:
Reforming Organ Donation in AmericaSaving 25,000 Lives per Year and $13 Billion in Taxpayer Funds over Five Years

"There ispotential to recover up to 28,000 more organs from deceased donors per year, saving thousands of lives and billions in taxpayer funds from the avoided costs of dialysis and increased productivity.The gap between the number of transplants performed and this potential persists in great part due to a system of misaligned policy incentives—key players have competing agendas that are not aligned to maximize the number of organs transplanted. Transplant centers, while dedicated to patient care, adjust their level of risk aversion based on overly strict acceptance criteria and at times decline to use lifesaving organs. Organ procurement organizations (OPOs), which lead procurement of organs from deceased donors, must comply with an evaluation system that does not actually reward pursuing every organ, every time. Donor hospitals lack incentive to do more than the bare minimum of referring potential deaths to OPOs. ..."
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Here's a pessimistic report from the Washington Post:

Despite low performance, organ collection group gets new federal contract

"Federal regulators in June took the unusual step of announcing they would shut down a New York-based nonprofit organization responsible for recovering human organs for transplantation. On Friday, regulators reversed that decision even though the organization, LiveOnNY, has received poor performance scores for nearly a decade and its organ recovery rates remain among the lowest in the nation."
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And another: LIVES LOST, ORGANS WASTED

"27,455 Total potential donors
Using the latest data and methodology, The Post identified a large pool of ideal donors: People who were already on ventilators when they died and were either declared brain dead or whose organs could be recovered after their hearts stopped beating.
...
"9,971 Actual organ donors
The U.S. transplant system recovered organs from less than half of potential donors in 2016."

Why is it hard for securities exchanges to restore price competition (instead of speed competition)?

Many stock exchanges earn rents by giving privileged access to high speed algorithmic traders.  Why doesn't a new exchange enter the market with a design that would privilege price competition over speed competition?  Budish, Lee and Shim have some thoughts on that:

Will the Market Fix the Market?A Theory of Stock Exchange Competition and Innovation
 Eric Budish, Robin S. Lee and John J. Shim
February 27, 2019

Abstract As of early 2019, there are 13 stock exchanges in the U.S., across which over 1 trillion shares ($50 trillion) are traded annually. All 13 exchanges use the continuous limit order book market design, a design that gives rise to latency arbitrage—arbitrage rents from symmetrically observed public information—and the associated high-frequency trading arms race (Budish, Cramton and Shim, 2015). Will the market adopt new market designs that address the negative aspects of high-frequency trading? This paper builds a theoretical model of stock exchange competition to answer this question. Our model, shaped by institutional details of the U.S. equities market, shows that under the status quo market design: (i) trading behavior across the many distinct exchanges is as if there is just a single “synthesized” exchange; (ii) competition among exchanges is fierce on the dimension of traditional trading fees; but (iii) exchanges capture and maintain significant economic rents from the sale of speed technology—arms for the arms race. Using a variety of data, we document seven stylized empirical facts that align with these predictions. We then use the model to examine the private and social incentives for market design innovation. We show that the market design adoption game among exchanges is a repeated prisoner’s dilemma. If an exchange adopts a new market design that eliminates latency arbitrage, it would win share and earn economic rents; perhaps surprisingly, the usual coordination problems associated with getting a new market design off the ground are not central. However, imitation by other exchanges would result in an equilibrium that resembles the status quo with competitive trading fees, but now without the rents from the speed race. We conclude that although the social returns to adoption are large, the private returns are much smaller for an entrant exchange and negative for an incumbent that currently derives rents from the inefficiencies that the new design eliminates. Nevertheless, our analysis does not imply that a market-wide market design mandate is necessary. Rather, it points to a more circumscribed policy response that would tip the balance of incentives and encourage the “market to fix the market.” 

Prosecuting customers in the fight against sex trafficking of illegal immigrants in American massage parlors

Recent headlines from an investigation into sex trafficking have included the arrests of high profile customers, which may do more to limit the market than targeting massage parlor brothels and those who work in them and operate them.

Here's a NY Times headline that has garnered more attention than most prostitution investigations:

Patriots Owner Robert Kraft Charged in Florida Prostitution Investigation
"Robert K. Kraft, the billionaire owner of the Super Bowl champion New England Patriots, was charged on Friday with two counts of soliciting sex as part of a wide-ranging investigation into prostitution and suspected human trafficking in South Florida.

"The charges against Mr. Kraft, 77, in Jupiter, Fla., came after the police used video surveillance to observe activity inside several day spas and massage parlors. The police said that the parlors had been used for prostitution and that many of the women involved were considered to be victims."
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And here's a followup story that describes the working conditions, which are themselves violations of American labor laws. But the sex workers are in no position to seek help from the law, since they are vulnerable twice over, first as illegal immigrants (who have typically entered on a short term visa and overstayed) and second as illegal sex workers (although they can be counted as crime victims rather than as criminals in some investigations of trafficking).

Behind Illicit Massage Parlors Lie a Vast Crime Network and Modern Indentured Servitude

"The frequently middle-aged women who work in parlors with names like Orchids of Asia and Rainbow Spa are often struggling to pay off high debts to family members, loan sharks, labor traffickers and lawyers who help them file phony asylum claims. In some cases, their passports are taken and their illegal immigration status keeps them further in the shadows, with some of them rotated every 10 days to two weeks between spas operated by the same owners. Forced to pay for their own supplies and even their own condoms, many women must sleep on the same massage tables where they service customers and cook on hot plates in cramped kitchens or on back steps.
...
"Law enforcement officials said there were an estimated 9,000 illicit massage parlors across the country, from Orlando to Los Angeles.
...
"The women are paid just a sliver of the $60 or more the client pays for an hourlong massage. Their real money — and chance at a better life — comes in the form of tips, which they are encouraged or forced to amplify through illegal means.
...
"The ubiquity of the massage parlors offers an accessibility and sheen of normalcy not offered by traditional brothels. And as the massage parlors have expanded even into small-town America in recent years, meticulously detailed review sites like Rubmaps have served as the Yelp and Foursquare of the illicit parlor business, with graphic anatomical descriptions of the women and explicit breakdowns of the sexual services proffered.
...
"A federal law enforcement official...said that the most common method for smuggling women from Asian countries was either a fraudulent tourist visa or a fraudulent work visa, such as for nursing work.
...
"One reason the Asian massage parlors remain so poorly understood is the extreme reluctance of the women to speak with the police and even with their own lawyers.
...
"Some fear retaliation by traffickers to their families in China, and some feel morally indebted to those who helped find them a job, said Chris Muller, the director of training and external affairs at Restore NYC, an anti-sex-trafficking organization.
...
"Bradley Myles, chief executive of Polaris Project, a nonprofit that works to combat human trafficking, said that the madams arrested on big raids like the recent ones in Florida — known as “mamasans” — are often women in their 60s and 70s who have spent decades in the sex trade but are usually pretty far down in the organization."

Working alone: sex work in Britain

In Britain, prostitutes often feel compelled to work alone because working together puts them at risk of arrest for brothel-keeping.  But working alone is dangerous.  The Guardian has the story:

Decriminalise sex work to protect us from crime, prostitutes say
English collective says laws forcing women to work alone expose them to violence

"Prostitution should be decriminalised in the UK to make it safer for vulnerable women, a sex worker organisation has said.

The English Collective of Prostitutes is calling for the removal of laws relating to consensual adult sexual behaviour, arguing that the legislation forces sex workers to operate alone, leaving them vulnerable to crime and reluctant to report violence to the police because they fear arrest.

...

"The announcement comes ahead of International Sex Workers’ Rights Day, an annual event on 3 March. The government is about to publish research it commissioned on sex workers in coming months.

"In 2016, the home affairs select committee recommended decriminalising prostitution. The interim report on prostitution said the Home Office should immediately change the legislation so that soliciting was no longer an offence, and change brothel-keeping laws to allow sex workers to share premises without losing the ability to prosecute those who used brothels to control or exploit sex workers."

Repugnant transactions on NPR's Hidden Brain (podcast)

I discuss repugnant transactions with Shankar Vedantam, who intersperses our conversation with audio clips of illustrative examples... He's an effective interviewer and editor.

For Sale, By Owner: The Psychology Of Repugnant Transactions

March 4, 2019 • You own your body. So should you be able to sell parts of it? This week, we explore the concept of "repugnant transactions" with the man who coined the term, Nobel Prize- winning economist Al Roth. He says repugnant transactions can range from selling organs to poorly-planned gift exchanges — and what's repugnant in one place and time is often not repugnant in another.

Tuskegee and transplantation

Here's a complex story from the Chicago Tribune, that conveys just some of the complicated ways that many African Americans relate to transplantation:

Chicago has one female, African-American organ transplant surgeon. She fights disease — and distrust of doctors

“I’ve had patients tell me that they know transplant is experimental,” Simpson said. “I’ve had patients tell me they know white people get preference when it comes to time on the waiting list.”

"(Neither is true.)

“Patients are very frank with me in telling me they know things are unfair or experimental, and they’re the hardest to convince otherwise,” Simpson said. “Those are some of the most heartbreaking cases for me.”

"In some families, a deeply ingrained sense of betrayal, passed down through generations, can permeate doctor visits. It’s a product of medical experiments widely performed on slaves in the mid-1800s, a product of the 40-year Tuskegee syphilis experiment, begun in 1932, that denied hundreds of black men a proper diagnosis or treatment for a debilitating disease, a product of quality medical care existing just out of geographic reach."
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This remindes me of two related papers on the Tuskegee effect on black patients' relationships to American medicine, coauthored by my remarkable colleague Marcella Alsan:

Tuskegee and the Health of Black Men

Marcella Alsan and Marianne Wanamaker

The Quarterly Journal of Economics, Volume 133, Issue 1, 1 February 2018, Pages 407–455,https://doi.org/10.1093/qje/qjx029

Abstract

For 40 years, the Tuskegee Study of Untreated Syphilis in the Negro Male passively monitored hundreds of adult black men with syphilis despite the availability of effective treatment. The study’s methods have become synonymous with exploitation and mistreatment by the medical profession. To identify the study’s effects on the behavior and health of older black men, we use an interacted difference-in-difference-in-differences model, comparing older black men to other demographic groups, before and after the Tuskegee revelation, in varying proximity to the study’s victims. We find that the disclosure of the study in 1972 is correlated with increases in medical mistrust and mortality and decreases in both outpatient and inpatient physician interactions for older black men. Our estimates imply life expectancy at age 45 for black men fell by up to 1.5 years in response to the disclosure, accounting for approximately 35% of the 1980 life expectancy gap between black and white men and 25% of the gap between black men and women. 

and (from a previous post)

Saturday, August 18, 2018

Diversity isn't just about role models: Alsan, Garrick and Graziani on black male doctors and patients

Medical compliance--following the doctor's "orders,"--is a big issue in medical care, and here's an article that reports a novel field experiment suggesting that black male doctors treating black men may have more success than non-black docs.

Does Diversity Matter for Health? Experimental Evidence from Oakland
Marcella Alsan, Owen Garrick, Grant C. Graziani
NBER Working Paper No. 24787

"We study the effect of diversity in the physician workforce on the demand for preventive care among African-American men. Black men have the lowest life expectancy of any major demographic group in the U.S., and much of the disadvantage is due to chronic diseases which are amenable to primary and secondary prevention. In a field experiment in Oakland, California, we randomize black men to black or non-black male medical doctors and to incentives for one of the five offered preventives — the flu vaccine. We use a two-stage design, measuring decisions about cardiovascular screening and the flu vaccine before (ex ante) and after (ex post) meeting their assigned doctor. Black men select a similar number of preventives in the ex-ante stage, but are much more likely to select every preventive service, particularly invasive services, once meeting with a doctor who is the same race. The effects are most pronounced for men who mistrust the medical system and for those who experienced greater hassle costs associated with their visit. Subjects are more likely to talk with a black doctor about their health problems and black doctors are more likely to write additional notes about the subjects. The results are most consistent with better patient-doctor communication during the encounter rather than differential quality of doctors or discrimination.Our findings suggest black doctors could help reduce cardiovascular mortality by 16 deaths per 100,000 per year — leading to a 19% reduction in the black-white male gap in cardiovascular mortality.
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And here's a related very recent obituary:
Bill Jenkins, Who Tried to Halt Tuskegee Syphilis Study, Dies at 73

"Bill Jenkins, a government epidemiologist who tried to expose the unethical Tuskegee syphilis study in the 1960s and devoted the rest of his career to fighting racism in health care, died on Feb. 17 in Charleston, S.C. He was 73."

Impossibility Results in Fairness (from Adventures in Computation)

Here are excerpts from a post at Adventures in Computation that will be of interest to market designers:

Impossibility Results in Fairness as Bayesian Inference

"One of the most striking results about fairness in machine learning is the impossibility result that Alexandra Chouldechova, and separately Jon Kleinberg, Sendhil Mullainathan, and Manish Raghavan discovered a few years ago. These papers say something very crisp. I'll focus here on the binary classification setting that Alex studies because it is much simpler. There are (at least) three reasonable properties you would want your "fair" classifiers to have. They are:

1. False-Positive Rate Balance: The rate at which your classifier makes errors in the positive direction (i.e. labels negative examples positive) should be the same across groups.
2. False-Negative Rate Balance:  The rate at which your classifier makes errors in the negative direction (i.e. labels positive examples negative) should be the same across groups.
3. Predictive Parity: The statistical "meaning" of a positive classification should be the same across groups (we'll be more specific about what this means in a moment)

What Chouldechova and KMR show is that if you want all three, you are out of luck --- unless you are in one of two very unlikely situations: Either you have a perfect classifier that never errs, or the base rate is exactly the same for both populations --- i.e. both populations have exactly the same frequency of positive examples. If you don't find yourself in one of these two unusual situations, then you have to give up on properties 1, 2, or 3.
...
"So why is this result true? The proof in Alex's paper can't be made simpler --- its already a one liner, following from an algebraic identity. But the first time I read it I didn't have a great intuition for why it held. Viewing the statement through the lens of Bayesian inference made the result very intuitive (at least for me). With this viewpoint, all the impossibility result is saying is: "If you have different priors about some event (say that a released inmate will go on to commit a crime) for two different populations, and you receive evidence of the same strength for both populations, then you will have different posteriors as well". This is now bordering on obvious --- because your posterior belief about an event is a combination of your prior belief and the new evidence you have received, weighted by the strength of that evidence.  "
...
"So the mathematical fact is simple --- but its implications remain deep. It means we have to choose between equalizing a decision maker's posterior about the label of an individual, or providing an equally accurate signal about each individual, and that we cannot have both. Unfortunately, living without either one of these conditions can lead to real harm."

John Nash, his life and untimely death: an update by Sylvia Nasar

The link may be gated, but here's a lovely piece that fills in some of the gaps for those of us who know the work that led to Nash's Nobel Prize better than the work that led to his Abel Prize.

John Nash, His Life, by Sylvia Nasar

1. 1.

Chapter First Online: 24 February 2019 The Abel Prize 2013-2017

 pp 357-377| 

Part of the The Abel Prize book series (AP)


In the same volume:

Autobiography

John Forbes Nash, Helge Holden, Ragni Piene

Pages 351-355

Another kidney donor from the Freakonomics interview

Yesterday I got this cheerful email from Harry Huggins at Freakonomics, about another nondirected donor motivated to start a kidney exchange chain, after learning about them on Freakonomics:

"Hello Professor Roth,

I'm a producer at Freakonomics Radio. I just wanted to let you know that we've published a post on our blog about another listener inspired by your episode to donate a kidney. You can find it (the blog post, not the kidney) here: 

Another Kidney-Donation Story to Make You Smile

Hope all is well,

Harry Huggins
Managing Producer
Freakonomics Radio"

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

I now know of several donors who heard the original 2015 Freakonomics story on kidney exchane (Make Me a Match (Ep. 209)). The first was Ned Brooks (who writes about it at the link), and whose web page/organization Donor to Donor speaks about others.

And here are all my posts that mention Freakonomics, many of them (but not all) related to kidney exchange.

Embryo adoption

The NY Times has the story:

Embryo ‘Adoption’ Is Growing, but It’s Getting Tangled in the Abortion Debate

"As evangelical Christians, Paul and Susan Lim believe that life begins at conception. So when they decided to have a third child, in vitro fertilization was out of the question, since the process often yields extra embryos.

"But “adopting” the frozen embryos of another couple who had gone through I.V.F. was not.

"Dr. Lim called it a “rescue operation.” To him, transferring donated embryos to his wife’s uterus was akin to saving a life. “These children are being abandoned in a frozen state,” he said. “If they don’t get adopted, they’re dead.”

"As I.V.F. becomes more widespread and the number of spare embryos rises, giving birth with donated embryos is becoming more popular, especially among couples who oppose abortion and are struggling with infertility. But many of the agencies that offer donated embryos, including a vast majority of those supported by federal grants, are affiliated with anti-abortion rights or Christian organizations, leading some people to question whether single people, gay couples and others who might be interested could be missing out.
...
"According to the Centers for Disease Control and Prevention, there were more than 260,000 attempts at I.V.F. in 2016, the most recent year for which data is available. Of those attempts, about 150,000 resulted in transfers of embryos. There is no reliable data on the number of frozen embryos in the United States, but experts estimate the total between 600,000 and one million.

Of the two million transfers of embryos to a woman’s uterus recorded by the C.D.C. from 2000 to 2016, only 16,000 were donor embryos. But over that period, the annual number of donor transfers rose sharply — from 334 in 2000 to 1,940 in 2016 — and experts say it is continuing to increase.
...
"National Embryo Donation Center, based in Knoxville, Tenn., is the largest embryo donation clinic in the country. It also requires potential families to be heterosexual couples who have been “married for a minimum of three years.”
**********
Here is the Center for Disease Control (CDC)'s Assisted Reproductive Technology (ART) page, and their
Assisted Reproductive Technology  National Summary Report for 2016

 *Noted earlier: "Of the 263,577 ART cycles performed in 2016, 65,840 cycles (25%) were started with the intent of cryopreserving (freezing) and storing all
resulting eggs or embryos for potential future use. However, because this cycle type (a banking ycle) cannot result in immediate pregnancy, the 65,840 banking cycles started in 2016 are not included in the majority of this national report."

Organ trafficking in Egypt--the Guardian

From the Guardian's series on Trafficking and exploitation :

Organ trafficking in Egypt
"Desperate to reach Europe, migrants from Africa are travelling to Egypt and selling body parts to pay for their passage"

"The trade appears to be flourishing in Egypt, bolstered by an EU-funded clampdown on refugees by security forces. There, the hostile environment created by the arbitrary detention of migrants, and the hike in smugglers’ fees, is creating a perfect opportunity for unscrupulous organ brokers who prey on those desperate to raise funds to cross the Mediterranean.

Big game hunting for a fee, and conservation

The Washington Post has the story, which reports expressions of both repugnance and support:

A U.S. trophy hunter paid $110,000 to kill a rare mountain goat in Pakistan

"American hunter Bryan Kinsel Harlan poses with an Astore markhor, a mountain goat found in the Himalayan ranges of Pakistan, India and Afghanistan, that he killed this month as part of a conservation program. Harlan paid $110,000 to shoot the goat, with the funds to be distributed to impoverished residents in the goats' habitat areas. (Tabarak Ullah)"

Congestion in resident and fellowship applications and interviews: Plastic Surgery

Medical graduates can enter plastic surgery through a residency immediately upon graduating.  As in many other specialties, there is lots of applying and interviewing before the residency or fellowship Match.  Here's a proposal to limit the number of applications:

Solving Congestion in the Plastic Surgery Match
Molina Burbano, Felipe, B.A.; Yao, Amy, B.S.; Burish, Nikki, M.D.; Ingargiola, Michael, M.D.; Freeman, Matthew, M.D.; Stock, Jeffrey, M.D.; Taub, Peter J., M.D.
Plastic and Reconstructive Surgery: February 2019 - Volume 143 - Issue 2 - p 634–639

"Summary: Plastic and reconstructive surgery is among the most competitive specialties in the residency match. Applicants seeking to maximize their chances of a successful match often submit numerous applications to the National Residency Matching Program. It is not uncommon for those applying to plastic and reconstructive surgery to apply to every program. The high application volume imparts significant time and financial burden for applicants and programs alike. Furthermore, it makes distinguishing between applicants with a genuine interest in a specific program and those who are merely hoping to improve their chances vastly more difficult. The authors sought to characterize trends in the match rate, as the number of integrated plastic and reconstructive surgery programs continues to increase. Furthermore, they reviewed the literature on game theory for possible solutions to residency application congestion. The authors propose the use of the game theory model to explain the observed results and show why an application limit is the most reasonable approach to address this issue.
...
"it is not uncommon for those applying to plastic and reconstructive surgery to apply to every program. In fact, of a total of 73 available training programs in the 2017 season, senior U.S. applicants applied to a median of 70 programs

"Such a high application volume imparts significant time and financial burden for all parties involved. Applicants spend an average of $6073 and up to $15,000 on applications and interview travel.3 Residency program directors, in turn, must review a greater number of applications and conduct additional interview dates. Furthermore, distinguishing between applicants with a genuine interest in a specific program, versus those who are merely hoping to improve their chances, has become vastly more difficult, with some preferred applicants possibly getting overlooked in the process.4

"Weissbart et al. observed the same trend in the urology match and other competitive specialties.
...
"Introducing an application limit would guide applicants to apply to programs based on fit (i.e., where they felt they were viable applicants). Similarly, the reduction in applications would allow programs to focus more carefully on reviewing all received applications. A more thoughtful application process, with increased focus on each individual, will likely produce “better” matches. Further research would need to be conducted on the correct application limit and the possibility that less competitive students could be left unmatched if not allowed to apply as widely.
***********

Plastic surgery was also attractive at Hogwarts, although not to Harry:

Harry Potter and the Resident Match | ZDoggMD.com