Tuesday, March 31, 2015

Making college admissions work better; in today's NY Times

In today's NY Times, several very very short contributions, including one by me....

How to Improve the College Admissions Process


rfdadmissionsAndré da Loba
The Times columnist Frank Bruni’s new book, “Where You Go Is Not Who You’ll Be,” appeals to teenagers and their parents to relax, because the college decision won’t matter as much as they think it will. But as those thin and thick envelopes arrive in mailboxes across the country, don’t colleges and universities share some of the responsibility for the absurd competition?
What can selective colleges and universities do to improve the admissions process?


Repeated Games, by Jean-Francois Mertens, Sylvain Sorin, and Shmuel Zamir

Repeated games can last a long time, and it turns out they also take a long time to write about.  But the wait is over for the definitive book that Bob Aumann, in his foreword, notes was fifty years in the making.
Repeated Games, by Jean-François Mertens, Sylvain Sorin, Shmuel Zamir 

Aumann has written a five page, fascinating historical foreword that is well worth reading. Here are a few paragraphs:

"The theory born in the mid to late sixties under the Mathematica-ACDA project started to grow and develop soon thereafter. For many years, I was a frequent visitor at CORE – the Center for Operations Research and Econometrics – founded in the late sixties by Jacques Dreze as a unit of the ancient university of Leuven-Louvain in Belgium. Probably my first visit was in 1968 or ’69, at which time I met the brilliant, flamboyant young mathematician Jean-Francois Mertens (a little reminiscent of John Nash at MIT in the early fifties). One Friday afternoon, Jean-Francois took me in his Alfa-Romeo from Leuven to Brussels, driving at 215 km/hour, never slowing down, never sounding the horn, just blinking his lights – and indeed, the cars in front of him moved out of his way with alacrity. I told him about the formula, in terms of the concavification operator, for the value of an infinitely repeated two-person zero-sum game with one-sided incomplete information – which is the same as the limit of values of the n-times repeated games. He caught on immediately; the whole conversation, including the proof, took something like five or ten minutes. Those conversations – especially the vast array of fascinating, challenging open problems – hooked him; it was like taking a mountain climber to a peak in the foothills of a great mountain range, from where he could see all the beautiful unclimbed peaks. The area became a lifelong obsession with him; he reached the most challenging peaks.

"At about the same time, Shmuel Zamir, a physics student at the Hebrew University, asked to do a math doctorate with me. Though a little skeptical, I was impressed by the young man, and decided to give it a try. I have never regretted that decision; Shmuel became a pillar of modern game theory, responsible for some of the most important results, not to speak of the tasks he has undertaken for the community. One problem treated in his thesis is estimating the error term in the above-mentioned limit of values; his seminal work in that area remains remarkable to this day. When Maschler and I published our Mathematica-ACDA reports in the early nineties, we included postscripts with notes on subsequent developments. The day that our typist came to the description of Zamir’s work, a Jerusalem bus was bombed by a terrorist, resulting in many dead and wounded civilians. By a slip of the pen – no doubt Freudian – she typed “terror term” instead of “error term.” Mike did not catch the slip, but I did, and to put the work in its historical context, purposely refrained from correcting it; it remains in the book to this day.

"After finishing his doctorate, Shmuel – like many of my students – did a postdoctoral stint at CORE. While there, he naturally met up with JeanFrancois, and an immensely fruitful lifelong collaboration ensued. Together they attacked and solved many of the central unsolved problems of Repeated Game theory.

"One of their beautiful results concerns the limit of values of n-times repeated two-person zero-sum games with incomplete information on both sides – like the original repeated Geneva negotiations, where neither the US nor the SU knew how many nuclear weapons the other side held. In the Mathematica-ACDA work, Maschler, Stearns, and I had shown that the infinite repetition of such games need not have a value: the minmax may be strictly greater than the maxmin. Very roughly, that is because, as mentioned above, using information involves revealing it. The minmax is attained when the maximizing player uses his information, thereby revealing it; but the minimizing player refrains from using her information until she has learned the maximizing player’s information, and so can use it, in addition to her own. The maxmin is attained in the opposite situation, when he waits for her. In the infinitely repeated game, no initial segment affects the payoff, so each side waits for the other to use its information; the upshot is that there is no value – no way of playing a “long” repetition optimally, if you don’t know how long it is.

"But in the n-times repeated game, you can’t afford waiting to use your information; the repetition will eventually end, rendering your information useless. Each side must use its information gradually, right from the start, thereby gradually revealing it; simultaneously, each side gradually learns the information revealed by the other, and so can – and does – use it. So it is natural to ask whether the values converge – whether one can speak of the value of a “long” repetition, without saying how long. Mike, Dick, and I did not succeed in answering this question. Mertens and Zamir did: they showed that the values indeed converge. Thus one can speak of the value of a “long” repetition without saying how long, even though one cannot speak of optimal play in such a setting. This result was published in the first issue – Vol. 1, No. 1 – of the International Journal of Game Theory, of which Zamir is now, over forty years later, the editor.

"The Mertens–Zamir team made many other seminal contributions. Perhaps best known is their construction of the complete type space. This is not directly related to repeated games, but rather to all incomplete information situations – it fully justifies John Harsanyi’s ingenious concept of “type” to represent multi-agent incomplete information.

"I vividly remember my first meeting with Sylvain Sorin. It was after giving a seminar on repeated games (of complete information, to the best of my recall) in Paris, sometime in the late seventies, perhaps around 1978 or ’79. There is a picture in my head of standing in front of a grand Paris building, built in the classical style with a row of Greek columns in front, and discussing repeated games with a lanky young French mathematician who actually understood everything I was saying – and more. I don’t remember the contents of the conversation; but the picture is there, in my mind, vividly.

"There followed years and decades of close cooperation between Sylvain, Jean-Francois, Shmuel, and other top Israeli mathematical game theorists...

(The book seems to be available online for free to members of the Econometric Society, and here is some other information:
Cambridge Books Online http://ebooks.cambridge.org/
Book DOI: http://dx.doi.org/10.1017/CBO9781139343275 )

Monday, March 30, 2015

A first kidney exchange in Argentina

Julio Elias writes:

"yesterday was performed the first kidney exchange in Argentina.
It was a two-way kidney exchange. The four surgeries were performed at Fundacion Favaloro in Buenos Aires, a very well known Hospital and Research Center in Argentina. The 4 patients are in good condition after the surgery.

Even though the kidney exchanges (donacion cruzada) is not legislated in Argentina yet, and not considered in the Law of Transplants (Ley Nacional de Trasplantes), a judge authorized them to do it, after they presented an appeal.

There were some attempts to modify the law in 2012 and 2013 to incorporate the possibility of Kidney Exchanges, but it didn't go through. So, I think that this exchange may help to develop kidney exchanges in Argentina.

This kidney exchange received a lot of attention in the news because one of the recipient was Jorge Lanata, one of the most famous journalist in Argentina.

Fundacion Favaloro, the center where they did the transplants, was founded in 1975 by Rene Favaloro, best known for his pioneering work on coronary artery bypass surgery."

Here are some articles in Spanish, which Google Translate does a reasonable job of making comprehensible (while showing the limitations that machine translation still labors under)

News in Spanish about First Kidney Exchange in Argentina
-        JorgeLanata fue trasplantado de un riñón en la Fundación Favaloro (Jorge Lanata was transplanted a kidney in the Favaloro Foundation), Diario La Nacion, Argentina, March 29,2015.

-        Enuna operación inédita, Jorge Lanata recibió un trasplante de riñón (In an unprecedented operation, Jorge Lanata received a kidney transplant), Diario Clarin, Argentina, March 28, 2015.

-        ParteMédico del Trasplante Renal con Donantes Vivos Intercambiados (Medical Reports of the Kidney Exchange), Fundacion Favaloro (https://www.fundacionfavaloro.org/ ), Argentina, March 28, 2015.

-        A video where the journalist Jorge Lanata explains everything about the transplant exchange some days before the surgery.

Sunday, March 29, 2015

A proliferation of single-center kidney exchanges

Kidney exchange is becoming a very standard part of kidney transplantation in the United States, which is good news. But, as more and more transplant centers gain experience with kidney exchange, a good deal of it is being conducted within single centers: i.e. among the patients at a single hospital.

This is mixed news...since even more transplants can be achieved in thicker markets.

Here are some of the recent, celebratory announcements about exchanges and chains at Yale, in New Haven, and California Pacific Medical Center in San Francisco ...

8 patients, 4 kidney exchanges, all in one day at Yale New Haven Hospital

Members Of Successful 8-Person Organ Exchange Meet, Feel Like One Big Family


Saturday, March 28, 2015

In Canada, Doctors worry how organ donations will be affected by Supreme Court ruling on assisted suicide

Here's the story from the National Post
Doctors worry how organ donations will be affected by Supreme Court ruling on assisted suicide

"As the nation awaits legalized doctor-assisted death, the transplant community is grappling with a potential new source of life-saving organs — offered by patients who have chosen to die.

"Some surgeons say every effort should be made to respect the dying wishes of people seeking assisted death, once the Supreme Court of Canada ruling comes into effect next year, including the desire to donate their organs.

"But the prospect of combining two separate requests — doctor-assisted suicide and organ donation — is creating profound unease for others. Some worry those contemplating assisted suicide might feel a societal pressure to carry through with the act so that others might live, or that it could undermine struggling efforts to increase Canada’s mediocre donor rate.

“Given the controversy and divided opinion regarding physician-assisted suicide in Canada, I don’t think we are anywhere near being ready to procure the organs of patients who might choose this path,” said Dr. Andreas Kramer, medical director of the Southern Alberta Organ and Tissue Donation Program in Calgary.

“I think there is a legitimate possibility that advocating aggressively for this could compromise the trust that the Canadian public has in current organ-donation processes,” Dr. Kramer said.
"Organ harvesting after doctor-assisted death is already a reality in Belgium, which became the second country in the world, after the Netherlands, to legalize voluntary euthanasia in 2002.

"In 2011, Belgian surgeons reported the first lung transplants using lungs recovered from four donors put to death by lethal injection. All — two patients with multiple sclerosis, one with a neurological disorder and the other a mental illness — explicitly and voluntarily expressed their wish to become an organ donor after their request for euthanasia was granted, the team reported.

“We now have experience with seven lung donors after euthanasia,” Dr. Dirk van Raemdonck, a surgeon from University Hospitals Leuven, told the National Post. “All recipients are doing well.”

Lungs, as well as kidneys and livers, have been retrieved and transplanted from a total of 17 euthanasia donors, Dr. van Raemdonck said. The results will be presented next week at the annual meeting of the Belgian Transplantation Society in Brussels."

Friday, March 27, 2015

Are we nearing a turning point for doctor-assisted suicide/death with dignity?

The NY Times has a thoughtful piece looking back at recent changes, and considering what hasn't changed:  Stigma Around Physician-Assisted Dying Lingers

"Five states, in various forms, countenance doctor-assisted dying. Others are considering it. In California, legislation to permit such assistance is scheduled to receive a hearing this week. A lawsuit in New York that seeks a similar result was filed in State Supreme Court last month by a group of doctors and dying patients. The emotional wallop of these issues is self-evident, and it is captured in the latest installment of Retro Report, a series of video documentaries that explore major news stories of the past — looking back at where we have been to see where we may be headed.
"Arguments, pro and con, have not changed much over the years. Assisted dying was and is anathema to many religious leaders, notably in the Roman Catholic Church. For the American Medical Association, it remains “fundamentally incompatible with the physician’s role as healer.”
Some opponents express slippery-slope concerns: that certain patients might feel they owe it to their overburdened families to call it quits. That the poor and the uninsured, disproportionately, will have their lives cut short. That medication might be prescribed for the mentally incompetent. That doctors might move too readily to bring an end to those in the throes of depression. “We should address what would give them purpose, not give them a handful of pills,” Dr. Ezekiel Emanuel, a prominent oncologist and medical ethicist, told Retro Report.
But to those in the other camp, the slippery-slope arguments are overwrought. Citing available information from the few jurisdictions where assisted dying is permitted, supporters of “dying with dignity” laws say that those looking for an early exit tend to be relatively well off and well educated. There is no evidence, they say, to suggest that such laws have been used promiscuously by either patients or their doctors. As for the medical association’s ethical judgment, it “focuses too much on the physician, and not enough on the patient,” said Dr. Marcia Angell, a former executive editor of The New England Journal of Medicine. Writing in The New York Review of Books in 2012, Dr. Angell asked, “Why should anyone — the state, the medical profession, or anyone else — presume to tell someone else how much suffering they must endure as their life is ending?”

Thursday, March 26, 2015

Redesigning the Israeli Medical Internship Match

Israel has a new system for allocating medical intern positions. It's quite different from the system in the U.S., in large part because hospitals are passive. Assaf Romm and Avinatan Hassidim are playing a big role in the design of several markets in Israel, and some papers just appeared on this one in the Israel Journal of Health Policy Research:

Original research article   Open Access
Slava Bronfman, Avinatan Hassidim, Arnon Afek, Assaf Romm, Rony Sherberk, Ayal Hassidim, Anda MasslerIsrael Journal of Health Policy Research 2015, 4:6 (20 March 2015)

Commentary   Open Access
Alvin E Roth, Ran I ShorrerIsrael Journal of Health Policy Research 2015, 4:11 (25 March 2015)

Assaf Romm writes:

"Every year about 500 medical students in Israel are assigned to 23 different hospitals in Israel for an internship (in Hebrew this phase is called סטאז') that lasts one year. Unlike the American market, in which both interns have preferences over being hired by different hospitals, and hospitals have preferences over hiring different resident, in Israel the market is one-sided, and hospitals (which are owned by the government) are not allowed to express their preferences. The reason for that is that the Ministry of Health (MoH) does not want the better medical students to do their internships in the big cities (Tel Aviv and Jerusalem) only, but instead prefers to scatter across the country. Then again, students do have diverse preferences because of family issues or other issues, and we would like to accommodate those preferences if possible. There is also the option of being matched as a couple, and in 2014 there were 24 couples in the market.

In the past the MoH employed the random serial dictatorship mechanism (RSD). Ex-post trades (with no monetary transfers) were allowed, which created a black market (with monetary transfers) for internships in Tel-Aviv and other highly demanded places. This led to MoH banning trading positions if one of the positions traded was ranked in the first to fourth places by the intern that received it through RSD.

Last year our team helped in redesigning the mechanism. The change was meant to improve the efficiency of the results, by moving from RSD which is ex-post efficient, to a mechanism which is rank-efficient (see Featherstone C., 2014, working paper). Using surveys we tried to assess interns' "utilities" from being assigned to differently ranked hospitals, and then we were able to maximize a linear program given those weights (while making sure, per the student body's demands, that no student's "utility" goes below her RSD allocation).

The interesting thing from a theory standpoint is that most of the algorithms that we know of and that provide an ordinally-efficient result require Birkhoff-von Neumann (BvN) decomposition. However, when there are couples in the market it can be shown that some matrices cannot be decomposed to a convex combination of valid "permutation" matrices. Furthermore, the problem of determining whether a matrix can be decomposed is NP-complete. We decided to consider algorithms that approximately decompose matrices, i.e., they result in a convex combination of valid matrices, but the sum of the combination is only very similar to the original matrix, and not exactly equal to the original matrix.

We were able to prove a lower bound on the distance between the approximation and the original matrix, and then came up with an approximation algorithm that manages to almost exactly hit this lower-bound. We tested the algorithm on actual data (and bootstrapped data) from recent years and showed it performs very well.

The new algorithm was deployed last year and was since used three times. The responses were very good, and we've also seen (as expected) a major improvement in rank distribution. MoH has agreed to continue running the new mechanism in the coming years. The student body related to the 2015 lottery also voted for continuing with the new mechanism. (We also ran a survey on medical interns that took part in the match, but unfortunately participation was very low.)

This project is summarized in two papers: the first one above in the IJHPR, and this one:

Redesigning the Israeli Medical Internship Match (Noga Alon, Slava Bronfman, Avinatan Hassidim and Assaf Romm) - Intended for Economics and CS audience. Includes detailed introduction about the market, analysis of interns' preferences, the NPC result, the approximation algorithm, and simulations that show performance on preference data."

Wednesday, March 25, 2015

A scary homophobia headline and story: repugnance is alive and well in California

It's not just anti-semites who speak of extermination (see David Brooks on that), anti-gays do too: here's a story just out in the NY Times. California Seeks to Head Off Initiative to Execute Gays

"The California attorney general, Kamala D. Harris, moved Wednesday to block a proposed voter initiative that would mandate the execution of sexually active gay men and women, calling it “patently unconstitutional” and a threat to public safety.
Ms. Harris said she would ask the state Superior Court in Sacramento to relieve her of having to write the title and summary for the Sodomite Suppression Act, which would clear the way for the author, Matthew G. McLaughlin, a lawyer in Huntington Beach, to begin gathering signatures to get it on the ballot.
The highly unusual announcement by Ms. Harris — by all appearances, California law gives no discretion to the attorney general in handling these kind of initiatives — comes as gay groups and others have called on her to block the measure. Ms. Harris, who was just elected to a second term, announced earlier this year that she would run for the Senate in 2016.
In her statement, Ms. Harris signaled her lack of legal options as she threw the ball to the courts. “If the court does not grant this relief,” she said, “my office will be forced to issue a title and summary for a proposal that seeks to legalize discrimination and vigilantism.”
Even if she is forced to proceed, Mr. McLaughlin — who did not return a telephone call seeking comment Wednesday — has a tough road ahead. He would have to gather the signatures of 365,880 registered voters, and it seems highly unlikely that if he succeeded at that, voters in the state would approve a measure like this."

School choice and medical residency matching in Forbes

I was in New York City yesterday for an IIPSC-organized conference on school choice, and it was a nice coincidence to see that Forbes had an article on school choice and other matching processes, that mentions IIPSC.

Prerna Sinha writes about deferred acceptance algorithms, in the medical match and in NYC high school choice: Quantifying Harmony: The Matchmaking Algorithm That Pairs Residents With Hospitals, Students With Schools

"In 2003 Professor Roth (Stanford), who has played a major role in the dissemination of the deferred acceptance algorithm, worked with Atila Abdulkadiroglu (Duke) and Parag Pathak (M.I.T.) to replace the broken high school match system that was previously in place in New York City.Roth realized similar to a stable marriage or residency-student match, a high school-student match would work if individuals and schools were permitted to select alternative options after their most preferred options were rejected.

He is confident that the deferred acceptance algorithm provides a significant improvement over the system that was previously in place, but he believes the school choice system could work better. He clarified, “... there is a problem with how to disseminate information to families about schools.” He also suggested that there would be less congestion and it would be a more efficient process if all charter schools and private schools participated too.
 Roth continues to work closely with Neil Dorosin, who was the director of high-school admissions in New York City at the time of the redesign. Dorosin is now the Executive Director of Institute of Innovation in Public School Choice (IIPSC), and Roth sits on the advisory board. IIPSC is a team of specialists in the design and implementation of enrollment and school choice systems. The organization helps communities integrate the latest market design research and technology to solve school choice problems.

Roth calls Dorosin the “Johnny Appleseed” of getting systems like the one in NYC into New Orleans, Denver, and Washington.

Dorosin told FORBES, “Public school choice, this two sided matching market where there are two interested parties (schools and students), exists all over the country, in every big city and most small cities too. In most cases the systems that are set up to organize that two sided matching market, unintentionally, are failing. Failing the kids and the families that are supposed to use them, failing the systems of schools that are supposed to be administering them.”

Private dealings between parents and schools, limited resources and information for some parties, and congestion caused by lack of centralized communication are examples of market malfunctions that lead to disorganized systems.

According to Dorosin, the market design approach (deferred acceptance) addresses the central problem of matching students with schools: high school seats are a scarce resource that needs to be allocated efficiently and transparently in a manner that allows students and parents to feel safe when participating.

Parents and students need to feel safe in listing their preferential choice of schools, free of fear that ranking School A as a top choice will hurt their chances of getting into School B, their second choice. Efficiency involves getting optimal results on the first try and avoiding numerous offers or back and forth between parties. Transparency would allow lottery numbers, school information, and reports about outcomes to be easily accessible by all in a centralized location.

Dorosin says, “These are the elements that lead to a better system. We call this universal enrollment.”

The deferred acceptance algorithm, which is the basis of Dorosin’s universal enrollment concept, has a proven track record with the students of New York City and medical residents across the country. It may yet have applications beyond those it has now. At the very least, you can expect urban districts around the country and possibly around the world to continue to adopt some of the principles."

Tuesday, March 24, 2015

A non-repugnant transaction that reads like a riddle, reflecting cultural changes

When I was in elementary school (yes, there were schools then), I more than once heard the following riddle, which was a sign of the times:
"a father and his son are in a car crash that kills the dad. The son is rushed to the hospital; just as he’s about to go under the knife, the surgeon says, “I can’t operate—that boy is my son!” How could this be?"

I thought of this riddle (and the role that conventional assumptions about gender roles play in it) when I saw this recent headline in the Telegraph:
Mary Portas: My brother is the 'father' of my son

The story answers the riddle in a way that indicates how much times have changed once again.

"Mary Portas has disclosed how her own brother helped her become a mother for the third time, after becoming a donor for an IVF procedure.

Portas, nicknamed the "Queen of Shops", has told how her wife Melanie Rickey became pregnant with their son thanks to help from her younger brother Lawrence."

Monday, March 23, 2015

The new economics of matching and market design, at Haverford

I'll be giving the Comanor Lecture at Haverford College today.

Here's the announcement:

The Economist as Engineer: The New Economics of Matching and Market Design, a talk by Nobel Laureate Al Roth, Professor of Economics at Stanford University, Monday, March 23rd, 2015 ~ 5:30pm, Sharpless Auditorium

Sunday, March 22, 2015

The market for breast milk

Should breast milk be bought and sold?

Andrew Pollack in the NY Times has the story:
Breast Milk Becomes a Commodity, With Mothers Caught Up in Debate

"Breast milk, that most ancient and fundamental of nourishments, is becoming an industrial commodity, and one of the newest frontiers of the biotechnology industry — even as concerns abound over this fast-growing business. The company that owns the factory, Prolacta Bioscience, has received $46 million in investments from life science venture capitalists.
"But the commercialization of breast milk makes many people uneasy. They worry that companies might capture most of the excess breast milk and make products that would be too costly for many babies, while leaving less milk available for nonprofit milk banks.

“The competition comes in the form of how much surplus breast milk is there in the country and who’s getting it,” said Kim Updegrove, executive director of the nonprofit Mothers’ Milk Bank at Austin. “The nonprofit milk banks have a long history of providing milk to the sickest babies, and provide it based on medical need and not on insurance reimbursement or financial resources.”

Debate is also intense over whether women should be paid for their milk or donate it altruistically. Opponents of payments, worried about breast milk “farming,” say women might try to increase their milk output unsafely, hide health problems that could make the milk unsafe, mix in cow milk to increase volume or deprive their own babies so they can sell more."

Here are my earlier posts on breast milk.

Saturday, March 21, 2015

Organ donation in Mexico: new campaign by the Carlos Slim Foundation

The Carlos Slim Foundation backs organ donation

"MEXICO CITY – Mexico isn’t living up to its potential when it comes to life-saving organ transplants that thousands of Mexicans need in order to continue living, said the Carlos Slim Foundation.

The foundation launched the 2015 “Héroes por la Vida” (Heroes for Life) campaign last month in a bid to encourage more Mexicans to talk with their families about donating their organs in the unfortunate event of their death.

“Today in Mexico, 19,000 people are waiting for an organ transplant,” Vanessa Slim de Hajj said at the campaign launch. “This number is growing every day, and the number of donors in our country is only 3.6 people for every 1,000.”

To put things into perspective, consider that in Spain, an international leader in transplants from cadavers, 36 of every 1,000 people are organ do- nors, 10 times the rate in Mexico. The national rate of postmortem trans- plants is less than many other Latin American countries as well.

“This campaign calls on Mexicans to be everyday heroes,” Slim said. “Today we can make a simple decision to save lives.”

On the campaign website (www.heroesporlavida.org), volunteers can find information about how to register as a donor and order a donor card. However, the volunteer card isn’t a legally binding document and the ultimate decision falls to family as to whether their loved-one’s organs will be used to save lives.

and here: Campaña de donación: Héroes por la vida

Here's some background: the Slim family has personal experience with kidney transplantation: Slims’ Transplant Inspires Push for Organ Donations

Friday, March 20, 2015

Match Day 2015! 1,035 couples participated...

Congratulations to all the new docs!  Today was Match Day for the National Resident Matching Program (NRMP)

Here's a selection of stories that crossed my screen today:

Press Release: 2015 Residency Match Largest On Record With More Than 41,000 Applicants Vying For Over 30,000 Residency Positions In 4,756 Programs
" An all-time high of 1,035 couples participated in the Match, 110 more than last year, with a 94.8 percent match rate."

The fates of thousands of med school students are decided by this Nobel Prize winning algorithm

Match Day: Then & now

Matching Dreams: Students ring in the future of medicine on the first day of spring (Harvard)

Medical students open envelopes and glimpse their futures: A national event that places graduating medical students into residencies, Match Day is both a celebration and a nerve-wracking affair. (Stanford)

The residency match in Otolaryngology

A recent paper looks at the resident match in Otolarygology, in the context of the overall resident match.

State of Otolaryngology Match: Has Competition Increased since the ‘‘Early’’
Match?  by Cristina Cabrera-Muffly, Jeanelle Sheeder, and Mona Abaza, in the journal Otolaryngology--Head Neck Surgert 2015 Feb 24

"Over the past 60 years, the United States residency match process and characteristics of medical students applying to the match have changed considerably. Centralized matching of postgraduate training positions was successfully implemented nationwide in 1952.1 At that time, just over 10,000 positions were offered through the match. In the 2013 match cycle, there were almost 50 different specialties that offer PGY-1 positions through the National Residency Matching Program (NRMP) match and a total of 26,392 positions offered.2
In 2006, in response to concerns about physician shortages, the Association of American Medical Colleges (AAMC) recommended an increase in the number of medical student postions.3 There was an overwhelming response among allopathic programs in both new schools (13 have matriculated their first class since 2006) and larger class sizes in established schools, with rosters expanding 15% to 18%.3,4 Meanwhile, osteopathic medical schools have doubled in number from 15 to 30 over the past 20 years.3 Therefore, the overall number of graduating medical students has increased considerably, reaching an all-time high in 2013.5 This has a direct effect on the quantity of medical students seeking any residency position, including otolaryngology.
The otolaryngology match has also undergone several iterations since its beginnings. In late 1977, otolaryngology and ophthalmology specialties officially separated.6 In 2006, the otolaryngology match transitioned from coordination by the San Francisco match (SF match) to become part of the NRMP. This transition altered the timeline of the application process in otolaryngology and potentially affected the applicant pool. Prior to 2006, the interview season for early match was generally from October to December, with the rank list submission deadline in early January. Match notification occurred in mid-January.7 This allowed applicants who did not match to complete a separate application for other specialties, although interview periods often overlapped. Once the NRMP began coordinating the otolaryngology match in 2006, the interview season was delayed to November through January, with the rank list submission deadline at the end of February. Match notification now occurs in mid-March.8
The change from the SF match to the NRMP match occurred as the required general surgery intern year became integrated with otolaryngology residencies, eliminating the need to separately interview for a preliminary general surgery position.9 Since 2006, otolaryngology programs have an integrated intern year, eliminating the need for a separate match. The early timing of the otolaryngology match allowed for applicants who did not match into otolaryngology to apply for a different specialty during the regular match of the same year through the NRMP. Applicants participating in the couples match during the early match likely found it more difficult to coordinate match cities when one partner applied to otolaryngology and the other to a regular match specialty. It is unclear whether the competitive nature or the couples match situation was considered when the match timing was changed.
"Over the past 16 years, we have seen an increase in the number of US seniors applying to residency. Fortunately, during the same time period, the number of first-year residency positions in all NRMP specialties increased as well. This rate of growth of residency positions appears to be consistent with the recommendation by the Council on Graduate Medical Education, who recommended increasing the number of first-year residents to 27,000 per year by 2015.4 In the same time frame, the number of unfilled NRMP residency positions has decreased by 55.8%. These positions are being filled by non–US seniors since the overall rate of applications and matches increased while the rate of US senior applications and matches stayed constant. Non–US seniors include prior US medical school graduates and IMG. IMG includes both US citizens attending medical school outside the United States and citizens of other countries attending international medical schools. Data suggest that the IMG portion of this group is filling the additional residency positions. In 2002, 18.6% of all NRMP positions were filled by IMG, while in 2013, IMG matched into 24.8% of NRMP positions. Meanwhile, the percentage of NRMP positions filled by prior US graduates has remained stable (between 2% and 3%). The decrease in percentage of unfilled positions is also due to increased IMG matching.
"The advantages of the otolaryngology conventional match are the elimination of one of the interview processes (since the preliminary general surgery intern year is now included), as well as improved ability for couples to match together."

Thursday, March 19, 2015

Who Gets What--and Why. My forthcoming book now has a website

The June 2 publication date is coming. Here's the publisher's website for my book: Who Gets What--and Why. (The new economics of matchmaking and market design)

Part I . Markets Are Everywhere
1. Introduction: Every Market Tells a Story 3
2. Markets for Breakfast and Through the Day 15
3. Lifesaving Exchanges 29
Part II . Thwarted Desires: How Marketplaces Fail
4. Too Soon 57
5. Too Fast: The Greed for Speed 81
6. Congestion: Why Thicker Needs to Be Quicker 101
7. Too Risky: Trust, Safety, and Simplicity 113
Part III . Design Inventions to Make Markets Smarter, Thicker, and Faster
8. The Match: Strong Medicine for New Doctors 133
9. Back to School 153
10. Signaling 169
Part IV . Forbidden Markets and Free Markets
11. Repugnant, Forbidden . . . and Designed 195
12. Free Markets and Market Design 217
Notes 233
Index 247

One surgeon's argument against compensating organ donors, but for removing financial disincentives

Here's another addition to the discussion of how and whether to incentivize live kidney donation, and/or remove financial disincentives to donating, by the medical director of Kidney and Pancreas Transplantation at New York Presbyterian Hospital/Columbia University Medical Center,

Cash for human kidneys: A bad idea is back, By David Jonathan Cohen, MD

Here's the part of his argument--about how incentives in a poorly regulated market could introduce lower quality kidneys from less medically qualified donors--that may be less familiar to readers of the "compensation for donors" posts on this blog. My comments follow...

"I’ve arrived at this position based on my three decades of experience as the medical director of one of the largest kidney transplant programs in the United States, performing more than 100 live donor transplants every year. In this role, as I examine potential live kidney donors, I have seen first-hand how far people will go to try to help loved ones. Many unsuitable donors try to persuade me to allow them to donate anyway, despite high medical risks. Others take steps even more extreme—and dangerous. Consider the 37-year-old woman who, without telling me, stopped her anti-depressants knowing that a history of depression might make her ineligible to donate to her friend. Or the 51-year-old cocaine addict who wanted to help her brother and forged a letter from her physician stating that the cocaine was treatment for a nasal condition. Had we not uncovered this, the outcome for donor and recipient would likely have been disastrous. 
Some go to other transplant centers and change their stories or covertly take medications to normalize their blood pressure or blood sugar in hopes of passing the evaluation, putting their own health at risk and potentially leading to the donation of unsuitable kidneys. 
Now imagine if there were a significant financial reward at stake, increasing the incentives to lie or dissemble. Many would surely do their best to disguise any medical conditions that might prevent them from donating in order to collect the reward, thereby adding to their own medical problems and potentially donating kidneys of lesser quality and thus harming the recipients. After all, they would now be donating to a stranger in order to enrich themselves or to address an urgent financial need, not to save a loved one. 
Doctors, too, would be confronted with terrible dilemmas. Take the potential donor who desperately needs cash or cash equivalent to prevent foreclosure on a home, pay for education for their children, or keep their business open. What is the responsible caring physician to do? It’s easy to say that this would not factor into a medical decision, but doctors are human. It’s hard to see how such considerations could be entirely avoided. " 
This is just a small piece of the longer post, so take a look yourself.

I follow this whole debate closely, and I'm struck by how arguments about many aspects (both pro and con, or con and pro, depending on where you stand) are hampered by the lack of data. So arguments are theoretical, and it seems to me that many of the arguments used with confidence to support one conclusion could equally support the opposite.

Here, Dr Cohen notes the desperation which motivates the "many unsuitable donors" who would like to give a kidney to a loved one to conceal aspects of their medical history (so that they can donate anyway). He argues that would only get worse if kidneys could be purchased. (Just to fix ideas, let's suppose that kidneys could only be purchased by the Federal government, that they would be distributed as deceased donor kidneys now are--i.e. without too much regard to ability to pay--and that there would be stringent health checks before donation--and followup after.)  In such an environment, one could imagine that the need for potential donors to mis-represent their medical history would decrease, rather than increase, if, in this hypothetical world with payments, their loved ones would get transplants through the national system. (To be clear, I am also speaking here without data, since outside of Iran there aren't any legal markets for kidneys, and the Iranian market doesn't work at all like the hypothetical I've just described...)

Speaking of Iran, the same kind of argument-that-could-support-opposite-positions is made with respect to whether large monetary payments might 'coerce' unwilling or unsuitable donors to sell their kidneys. That's an interesting question, but Iranian surgeons have sensibly pointed out that there can be coercion without money: if your mom thinks you should give a kidney to your brother you might be coerced, and that kind of coercion might be decreased if kidneys were more available through e.g. a national market.

So...speaking as an experimental economist and market designer who has watched the waiting list for kidneys grow and grow (see my post on kidney statistics)...I'm increasingly inclined towards allowing the States to experiment cautiously with increasing incentives and removing disincentives to donation...

Wednesday, March 18, 2015

Four recent calls for removing disincentives for organ donation

There are a number of efforts underway to reduce the financial dis-incentives to kidney donation, with more or less emphasis on opposition to, and how removing dis-incentives is different from, compensating donors.

The first I'll mention is a March 13 blog post from Kenneth A. Newell, the president of the American Society for Transplantation:  Why all the talk about incentives?
Here's his whole post:
Last summer, the ASTS and the AST held a workshop to discuss the financial barriers faced by living organ donors. All of us who are engaged in the practice of living donor transplantation realize that the entire healthcare delivery system (providers, hospitals, insurers, and the government), as well as the recipient and society as a whole, benefits financially from the practice of living donation. Disturbingly, the donors are the group most at risk for adverse financial events. In many cases, donors incur expenses related to travel, meals, and lodging, as well as lost wages. In addition to these concrete financial consequences, living donors also face very real concerns about the loss of employment and the impact their donation will have on future insurability. Programs such as the HRSA-funded National Living Donor Assistance Center (NLDAC) provide critical support to those donors with the most extreme financial need, but this support is limited to travel and travel-related expenses.
The aim of the first meeting was to explore whether the AST and the ASTS could articulate a common vision on the topic of financial disincentives and incentives as they pertain to organ donation. The two societies agreed to work to remove all financial disincentives to organ donation, and consider pilot projects to study what some might consider to be true incentives. These ideas are more fully articulated in a New York Times editorial authored by Daniel Salomon and Alan Langnas, as well as in a manuscript soon to be published in the American Journal of Transplantation.
As a second step, representatives of the two societies met last month in Minneapolis to discuss how the goals articulated at the first meeting could be operationalized. Presentation topics included the perspective of payers, overviews of NOTA and NLDAC, and consideration of how changes to NOTA could be effected. Attendees discussed where the societies might draw the line between the removal of disincentives and the provision of true incentives for living organ donation, and how an expanded program to remove all disincentives for all living donors might be administered (assuming that funding could be obtained). This second meeting focused almost entirely on the removal of financial disincentives with the goal of making the donor financially whole. This position was recently advanced by the AST Best Practices in Living Donation Consensus Conference. At this second meeting, there was little discussion about incentives or pilot projects to test the impact of true incentives, as these are more controversial and will require substantially more effort and time to engage a broader set of transplant stakeholders. In other words, both the AST and the ASTS agreed that the task of operationalizing the original workshop’s ideas must be strictly pragmatic and start with those changes that are largely agreed upon now: removing all disincentives.
So why all of the talk about incentives (and disincentives)? Because any changes to the current financial practices of organ donation will require the AST and the ASTS to engage in ongoing discussions with a larger set of stakeholders: patient groups, transplant professionals, government leaders, and society as a whole. Any changes must have the support of these groups as well as our membership, and any changes must meet the real needs of patients, donors and their families.
Over the next several months, the AST will reach out to our membership and these other groups to discuss the removal of financial disincentives, the definition of true incentives, and the challenge of possibly testing incentives in pilot projects. The conversation starts here: please share your opinions in the comment section.

Next, the open letter linked and excerpted below, is from the Declaration of Istanbul Custodian Group and signed by many prominent opponents of compensation to donors: the first signer is Frank Delmonico.
An Open Letter to HHS Secretary Burwell on Ethically Increasing Organ Donation

"In 1984, Congress passed the National Organ Transplant Act (NOTA). That statute not only established the Organ Procurement and Transplantation Network but also enshrined in law a principle that had guided the development of organ transplantation worldwide over the previous 30 years: organs from living and deceased donors are precious gifts, and should not be bought and sold as market commodities.

Remove the Obstacles to Donation

The growing demand for transplants currently exceeds the supply of donated organs. In the previous decade, a collaborative effort among the Department of Health and Human Services, organ procurement organizations, physicians, and community groups produced a 25% increase in the number of deceased donor organs. Yet, over the course of the past ten years in the United States, the number of kidney transplants (which account for more than two thirds of all transplants) made possible by living donors has declined by approximately by a thousand.One major reason for this decline is that living donors in the United States incur on average more than U.S. $6000 in out-of-pocket costs. Potential donors may not be able to afford these expenses and may either be unaware of, or not meet the strict requirements for, programs that cover some but not all of donors' financial costs and losses.If the United States wants to increase organ donation, we should begin by removing these financial disincentives. We are aware that some people have recently called on the President and Congress to repeal, or at least suspend, NOTA's prohibition on paying organ donors. However, when it looked at “Ways to Reduce the Kidney Shortage” (September 2, 2014), the New York Times rightly concluded that “there are lots of reforms that could be made without resorting to paying for kidneys.”

The post goes, on, you should read the whole thing, but here are the two concluding section heads:
Appoint a New Task Force on Organ Donation and Transplantation
Financial Incentives for Donation Would Violate Global Standards and Will Not Work

Below is a statement from an organization whose very name reflects the complicated politics: it is called STOP ORGAN TRAFFICKING NOW!, and it describes its goal as "Working to Remove Barriers to Living Donations". That is, it is an organization seeking to remove disincentives to donation, that wants to distinguish itself from black markets, and perhaps from those proposing compensation. (Forming coalitions is hard, and politics is incremental...)

The SOTN Proposal In Simplest Terms
"• Increase penalties for organ brokering at home and abroad.
• Follow original intent of NOTA and have Medicare help patients in greatest medical need first and according to UNOS current wait list criteria by:
(a) paying expenses of donors willing to give to top match in their region, and
(b) paying the Organ Procurement Organizations (OPOs), which currently match deceased donor organs with recipients, to arrange living matches as well.
• Allow 501(c)(3) public charities (and recipients themselves) to cover all donation related expenses – The same expenses that currently can be deducted from state income taxes at the state level. Charities can help any donor, not just those giving to front of the list.
• Create living donor registry that puts donor AND one relative to the front of the list at any time donor chooses."

Finally, I'm keeping an eye on a newly formed organization called Waitlist Zero, in part because its co-founder and executive director is Josh Morrison, a young lawyer and kidney donor (who thinks of kidney donation as an example of effective altruism), with whom I had the privilege to work when he was the general counsel at the Alliance for Paired Donation (Mike Rees' kidney exchange organization).

Here is their statement of goals, principles and policies:

Our Goals. We come together as a coalition to advocate that the Health Resources and Services Administration:
  1. Publicly support the goal of increasing living kidney donation;
  2. Allow grant funding, including that pursuant to 42 U.S. Code §274f–1(b), to go to projects intended to increase living kidney donation;
  3. Allocate such funds in rough parity between living and deceased donation projects; and
  4. Include metrics and goals related to the increase of living donation on HRSA’s FY 2016 Annual Performance Report.
Our Principles. Collectively, the Coalition believes:
  • Deceased donation alone can never end the deadly kidney shortage, and any policy that takes that shortage as given is morally unacceptable.
  • Living donation is a noble choice that is not right for everyone, but donors themselves can benefit from the better health of their loved ones and the psychic gains to donation. Since studies show the vast majority of living donors do not regret donating, federal policy should presume donation to be a positive choice worth promoting.
  • Informed consent must be maintained for every kidney transplant. Any effort to coerce or pressure someone into donating is unacceptable.
  • Improvements are always possible, but the current transplant system does an excellent job of ensuring informed consent for the thousands of living donors who give each year.
  • Government programs to increase living donation should not and will not impinge on the ability of transplant centers to ensure informed consent and guarantee the absence of coercion.
Our Policies. Collectively, the Coalition hopes that HRSA’s support for increasing living kidney donation will lead to policies along the lines of the following:
  • Donors should not be worse off for having donated. Government should: (1) guarantee the reimbursement of donor lost wages, (2) provide health insurance coverage to alleviate risks of donation, and (3) devote appropriate resources to ensure long-term donor follow-up.
  • Transplant awareness and education should be increased for the public, patients, and patient families. All patients and patient families should receive comprehensive transplant education before they go on dialysis (when possible) and immediately thereafter (when necessary). Access to paired kidney donation should be universal.
  • Members of the Coalition may have different views as to the advisability of incentives for living donation, but the Coalition believes there are many ways the federal government can increase living donation that do not raise the controversy of incentives, and this campaign is not intended to promote the adoption of incentives.

HT: Frank McCormick, et al.