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“Moneyball,” the 2012 election, and science- and evidence-based medicine

Regular readers of my other blog probably know that I’m into more than just science, skepticism, and promoting science-based medicine (SBM). I’m also into science fiction, computers, and baseball, not to mention politics (at least more than average). That’s why our recent election, coming as it did hot on the heels of the World Series in which my beloved Detroit Tigers utterly choked got me to thinking. Actually, it was more than just that. It was also an article that appeared a couple of weeks before the election in the New England Journal of Medicine entitled Moneyball and Medicine, by Christopher J. Phillips, PhD, Jeremy A. Greene, MD, PhD, and Scott H. Podolsky, MD. In it, they compare what they call “evidence-based” baseball to “evidence-based medicine,” something that is not as far-fetched as one might think.

“Moneyball,” as baseball fans know, refers to a book by Michael Lewis entitled Moneyball: The Art of Winning an Unfair Game. Published in 2003, Moneyball is the story of the Oakland Athletics and their manager Billy Beane and how the A’s managed to field a competitive team even though the organization was—shall we say?—”revenue challenged” compared to big market teams like the New York Yankees. The central premise of the book was that that the collective wisdom of baseball leaders, such as managers, coaches, scouts, owners, and general managers, was flawed and too subjective. Using rigorous statistical analysis, the A’s front office determined various metrics that were better predictors of offensive success than previously used indicators. For example, conventional wisdom at the time valued stolen bases, runs batted in, and batting average, but the A’s determined that on-base percentage and slugging percentage were better predictors, and cheaper to obtain on the free market, to boot. As a result, the 2002 Athletics, with a payroll of $41 million (the third lowest in baseball), were able to compete in the market against teams like the Yankees, which had a payroll of $125 million. The book also discussed the A’s farm system and how it determined which players were more likely to develop into solid major league players, as well as the history of sabermetric analysis, a term coined by one of its pioneers Bill James after SABR, the Society for American Baseball Research. Sabermetrics is basically concerned with determining the value of a player or team in current or past seasons and with predicting the value of a player or team in the future.

There are a lot of parallels between moneyball and “evidence-based medicine” (EBM), as you might imagine, as Phillips et al point out:

In both medicine and baseball, advocates of evidence-based approaches argued for the enhanced vision of statistical techniques, which revealed what tradition or habit had obscured. The difference between an all-star and an average hitter, for example, works out to about one hit every other week, a distinction that’s almost impossible for even a trained scout to recognize. Statistical power can be as relevant as opposite-field hitting power in the assessment of players. Early proponents of controlled medical trials similarly pointed to how difficult it was for an individual practitioner to determine a treatment’s efficacy or distinguish real effects from apparent ones after seeing only a small number of clinical cases. Mathematical measurements and calculations were meant to push practitioners away from naive visual biases — a player who “looks right” or a therapy that seems to work. Walks are far more important than they first appear in baseball; walking is more important than it first appears in medicine.

Moneyball has also entered politics in a big way over the election cycles of 2008, 2010, 2012. In the run-up to the 2012 election, I, like many others, became hooked on FiveThirtyEight, a blog devoted to applying rigorous statistical analysis to the polls. (FiveThirtyEight refers to the number of votes in the Electoral College.) As political junkies (and even many casual observers) know, the man responsible for the blog, Nate Silver, got his start as a “moneyball”-style sabermetrics baseball analyst. In 2002, he developed a model to assess and predict a baseball player’s performance over time, known as PECOTA, which stands for “Players Empirical Comparison and Optimization Test Algorithm.” Silver brought his model to the Baseball Prospectus. Several years later, he was applying his statistical methods to the 2008 election, and the rest is history. Indeed, in this year’s election, Silver correctly called all 50 states.

Silver’s model basically works by looking at polling data from a wide variety of polls, particularly state-level polls, weighting the data based on how recent it is, sample size, and the pollster’s history of accuracy. The polling data are then used to calculate an adjusted polling average subject to trend line adjustment, house effects adjustment, and likely voter adjustment, after which they are adjusted based on various factors, such as a state’s Partisan Voting Index, and the like. Ultimately, Silver takes his aggregated poll data and uses them to run simulations that estimate the likelihood of a given outcome. That’s how he came up with his famous estimates of how likely various scenarios were. For example, the day before the election Silver was estimating that Mitt Romney only had an 8% chance of winning the Electoral College. Republicans howled. We all know the results of the election and that President Obama won reelection more easily than the conventional wisdom had been predicting. Silver also had an excellent track record predicting the Republican landslide in the 2010 midterm elections. Back then, Democrats howled.

Not surprisingly, there was considerable resistance in baseball to “moneyball” at first. The “old guard” initially didn’t like the implication that statistical modeling could judge the value of a player better than scouts, managers, and the front office. Moreover, the statistical predictions made by “moneyball”-inspired sabermetric analysis often clashed with conventional wisdom in baseball. Similarly, this year we were treated to a similar spectacle, where Nate Silver unwittingly became a political flashpoint, as his numbers, which at no point over the last couple of months favored Romney. This led to considerable resistance to the statistically-based methods of not just Nate Silver, but Sam Wang of the Princeton Election Consortium and others as well. The highest Romney’s estimated probability of winning the Electoral College according to Silver’s model ever got was 39% on October 12. That’s actually not bad, but Obama was the favorite in Silver’s model and remained the favorite up until the end. So different was Silver’s prediction from the conventional wisdom (a super-tight election that would not be called until very late on election night or might even end up with Obama winning the Electoral College but losing the popular vote) and Republican expectations (a Romney win), that on election night when the networks called Ohio for Obama not long after 11 PM, Karl Rove initially refused to accept the outcome, even though Fox News had also called it. Overall, predicting this election ended up being portrayed as a battle between data-driven nerds over ideological political pundits.

Of course, doctors are not baseball managers or ideologically-driven political pundits. Or, at least, so we would like to think. However, we are subject to the same sorts of biases as anyone else, and, unfortunately, many of us put more stock in our impressions than we do in data. Overcoming that tendency is the key challenge physicians face in embracing EBM, much less SBM. It doesn’t help that many of us are a bit too enamored of our own ability to analyze observations. As I’ve pointed out time and time again, personal clinical experience, no matter how much it might be touted by misguided physicians like, for example, Dr. Jay Gordon, who thinks that his own personal observations that lead him to believe that vaccines cause autism trump the weight of multiple epidemiological studies that do not. The same sort of dynamic occurs when it comes to “alternative” medicine (or “complementary and alternative medicine” or “integrative medicine” or whatever CAM proponents like to call it these days). At the individual level, placebo effects, regression to the mean, confirmation bias, observation bias, confusing correlation with causation, and a number of other factors can easily mislead one.

Yet, in medicine there remains resistance to EBM. Indeed, there is even an organization of physicians that explicitly rejects EBM and frequently publishes screeds against it in its major publication. This organization is known as the Association of American Physicians and Surgeons, and I’ve written about it before. For example, a former president of the AAPS, Lawrence Huntoon, MD, once dismissed EBM, represented by clinical care pathways, systems-based care, and other products of EBM as “medical herdology.” Other articles include titles such as Evidence-Based Guidelines: Not Recommended. In it, its author, Dr. Norman Latov, writes:

On its face, evidence-based medicine is just what the doctor ordered. What rational person would argue that medical decisions should not be based on evidence?

Upon closer examination, however, the term is deceptive. Evidence-based guidelines (EBGs) in fact only use evidence from controlled trials, and deny other types of evidence or clinical judgment, thereby distorting the decision process.

Indeed, when you read various critiques of EBM, they are almost inevitably different from our critiques of EBM (namely that EBM doesn’t adequately take prior probability into account). There is also a difference between CAM practitioners and apologists and doctors who think they support evidence and science in medicine. For instance, when most doctors criticize EBM, they tend to attack it because they see it as limiting their “clinical judgment” or on the basis that there are things that “EBM can’t account for.” (See the parallel here between baseball and medicine?) While it is true that there are things that EBM can’t account for, that doesn’t necessarily mean that personal experience does better. Indeed, when it’s tested rigorously, it tends not to. As for CAM practitioners, I tend to liken them to political operatives: Driven by ideology more than science, rather than simply being used to old ways of doing things, like baseball leaders in the age before “moneyball.” For instance, take a look at Andrew Weil, who most definitely does not like EBM, going so far as to write:

RCTs have dominated decision making about efficacy in health care for almost 50 years. Many researchers have explored the difficulty of subjecting IM treatment approaches to RCTs. There are some characteristics of IM interventions that make RCTs particularly difficult to carry out, and perhaps even less relevant, than for conventional allopathic medicine. As Fønnebø pointed out, the gap between published studies of integrative approaches on the one hand, and the clinical reports by practitioners on the other hand, may partially result from the fact that placebo-controlled RCTs are designed to evaluate pharmaceutical interventions.

One can almost see Karl Rove railing against Fox News analysts about calling Ohio at 11:15 PM on election night 2012 or Democratic partisans attacking Nate Silver in 2010 when he kept predicting a Republican landslide. Whatever the reasons, be they ideological, a misguided belief in their own “clinical judgment,” or just plain cussedness, there are a lot of doctors who don’t like EBM, and there are a whole lot of CAM practitioners that don’t like SBM, because CAM exploits the blind spot in EBM. But let’s get back to the analogy between moneyball and EBM:

Critics of moneyball approaches have nonetheless been quick to emphasize the way in which perspective can be distorted, not enhanced, by statistics. One might overapply concepts such as Bayes’ theorem or develop a habit of plugging data into statistical software simply to gain a patina of precision, regardless of appropriateness (tendencies that cause medical practitioners, in Alvan Feinstein’s pithy phrase, to be blinded by the “haze of Bayes”).3 Critics have also pointed to what might be termed the “uncertainty principle” of statistical analysis: general data (How well does this player hit against left-handers? How well does this therapy work in myocardial infarction?) often fail to take into account consequential distinctions; but more specific data (How well does this player hit against hard-throwing left-handers on warm Sunday afternoons in late September? How well does this therapy work in right-sided myocardial infarction in postmenopausal women?) can involve too few cases to be broadly useful. Individuals, and individual scenarios, might always be idiosyncratic on some level — a truth perhaps borne out by long-standing efforts to appropriately apply the scientific results of clinical trials to individual patients in the clinic.

Here’s where Phillips et al go wrong. As we have pointed out here on this very blog many, many times before, the problem with EBM is not that it overapplies Bayes’ theorem. Rather it’s that EBM uses frequentist statistics over Bayes’, often massively underplaying the importance of prior plausibility, estimates of which Bayesian statistics demands. Indeed, not making Baysian estimates of prior plausibility leads to EBM’s blind spot towards CAM, such that statistical noise and bias in trial design can lead to the appearance of efficacy for therapies whose rationale, to be true, would require that much of modern physics and chemistry be not just wrong but massively wrong. I’m talking, of course, about modalities like homeopathy, reiki and other “energy healing” treatments, and the like. While “moneyball” does take Bayes into account somewhat, there is one big difference between moneyball and medicine, and that’s science. There are certain things in medicine that can be dismissed as so implausible that for all practical purposes they are impossible based on physical laws and well-established science (i.e., homeopathy). The result was hilariously illustrated in a very simple way in a recent XKCD cartoon that asked if the sun just exploded.

Where Phillips et al do better is in pointing out that EBM has difficulty as the groups under study are chopped finer and finer, with the ultimate goal of developing “personalized medicine,” EBM gets harder, as does SBM. It’s also where the critics miss the boat as well. It’s just for these idiosyncratic cases where clinical judgment is still very important and EBM doesn’t banish clinical judgment. Clinical judgment instead becomes the science and art of applying medical and scientific evidence to individual patients who don’t fit the mold. They’re also correct in pointing out that another area in which moneyball can help in medicine is to increase value. Remember, the very reason moneyball was used in the first place was to help a team at a financial disadvantage compete against teams with a lot more money to burn. On the other hand, in medicine EBM and SBM are not necessarily the cheapest. It’s all tradeoffs. For instance, EBM would tell us that for women above a certain risk level for breast cancer it is better to add breast MRIs to their screening regimen, which definitely costs more. What SBM should be able to do is to produce better outcomes.

Finally, one of the biggest impediments to data-driven approaches to almost anything, be it baseball, politics, or medicine, is the perception that such approaches take away the “human touch” or “human judgment.” The problem, of course, is that human judgment is often not that reliable, given how we are so prone to cognitive quirks that lead us astray. However, as Philips et al point out, data-driven approaches need not be in conflict with recognizing the importance of contextualized judgment. After all, data-driven approaches depend on the assumptions behind the models, and we’ll never be able to take judgment out of developing the assumptions that shape the them. What the “moneyball” revolution has shown us, at least in baseball and politics, is that the opinions of experts can no longer be viewed as sacrosanct, given how often they conflict with evidence. The same is likely to be true in medicine.

Posted in: Clinical Trials, Politics and Regulation, Science and Medicine, Science and the Media

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47 thoughts on ““Moneyball,” the 2012 election, and science- and evidence-based medicine

  1. Badly Shaved Monkey says:

    Great post, Dr G. As a Brit, I follow cricket rather more than baseball. At the same time, I have recently been engaged in the developing world of Evidence-Based Veterinary Medicine.

    Although I like cricket, I have a fundamental problem that prevents me ever being a fan following all of its detail. Cricket pundits talk with great authority, but from data that is simply too sparse to support meaningful conclusions, as far as I can see. Test cricket (international matches played between the major countries, my ignorant Yankee cousins) is the flagship format, but presents us with insurmountable problems that, properly, should prevent us ever making confident assertions about much of what goes on in the game. There are relatively few matches: national teams play ten or a dozen matches in any year. The conditions under which these matches are played vary hugely: weather conditions, ground conditions, effects of long-distance travel. On any given day, a team might score 500 runs and be accounted a success because two out of eleven players scored significantly more than 100 while the rest might as well have stayed in the dressing room. And one of those players may only have made that total because they had a catch dropped when they were on 20 runs. Such minor occurrences can be pivotal n the outcome of a game. League baseball, by contrast presents a wealth of trial data. Playing conditions are standardised to a very high degree and teams meet over many innings, so you get to play with more data and those data will have smaller statistical variation.

    In clinical decision-making, as a vet, I’m stuck with data comparable with Test cricket information: small pockets of data with huge potential for wild variation. This is true of our daily clinical practice as well as the formally acquired information from trials. At a recent meeting hosted by the Royal College of Veterinary Surgeons entitled ” The Sceptical Vet: Eminence or Evidence” the problem of data volume and data quality was recognised, but no real solution emerged. Readers of SBM might like to know that veterinary contributor Brennen McKenzie gave one of the best presentations in what was otherwise a rather weak programme, although that stems, I think, from the immature state of EBVM and this problem of evidence quality.

    My concern is that the EBVM project risks proceeding as if there is a valid and complete workaround for having thin data. My problem is that, however you set about meta-analyses and systematic reviews, if the trial data is of poor quality these reviews do not deserve the status that will be conferred upon them as representing the pinnacle of the EBM pyramid. Garbage in, garbage out. Or, you can’t polish a turd.
    At the meeting it emerge that the number of systematic reviews in veterinary medicine rose from single digits to over 200 in the last decade. I wonder what the figure for human medicine is, but an example that was held up for approval was
    Interventions for atopic dermatitis in dogs: a systematic review of randomized controlled trials.
    Olivry T, et al.
    Vet Dermatol. 2010 Feb;21(1):4-22.

    In its abstract we read,

    One high-quality RCT showed that an oral essential fatty acid supplement could reduce prednisolone consumption by approximately half.

    This study was;

    Saevik BK, Bergvall K, Holm BR et al. A randomized, controlled study to evaluate the steroid sparing effect of essential fatty acid supplementation in the treatment of canine atopic dermatitis. Veterinary Dermatology 2004; 15: 137–45.

    Not a bad study, but just 60 dogs and some inevitable statistical jiggery-pokery about p-values and timing of assessments. However, that is not my point, which is that this single study has reached the abstract of the systematic review of this topic and risks being enshrined as a permanent established fact. Should two groups of 30 subjects be able to do this? I don’t think so.

    I think the only way that the EBVM approach can work is to ensure that the issue of the quality of trial evidence is kept front and centre in all analyses and presentations of data and to couple this with a sound basis in scientific prior knowledge. For us vets, this prior knowledge must include a recognition of the evidence-base that exists in people. Yes, species differences are important, but you poor benighted souls restricted to working on badly shaved monkeys as your chosen species do give us a head-start.

    One of the reasons I am so keen on the SBM approach is that it takes a “holistic” attitude to the information available to us. Oh the irony. Good underlying science is the only thing that can partially rescue a sparse clinical trial record: if science gives us a high prior plausibility then the likelihood ratio of making a good clinical judgement as to the utility of an intervention is adequate even if the trial data are a bit thin. And that judgement is likely to be better than if you have a tiny prior plausibility even if you have quite a bulk of trial data appearing to show an effect. Hello, Mr Hahnemann.

    We can never have perfect knowledge of what truly works, but if we put together logically consistent strands of evidence from basic science and clinical trials, we maximise our chances of supplying treatments to our patients that actually work. But, in doing this we must always remember that we might be wrong in our judgement and have the discipline not to allow our personal experiences to trump objective data if the two are at odds. My fundamental beef with the SCAM lobby is that they fail to do the former and stubbornly insist on the latter.

    I will continue to watch Test cricket for the interesting narrative that a day’s play can provide, but I will continue to be irritated by the confident punditry that surrounds it.

  2. Scott says:

    The thing that REALLY ticks me off about baseball statistics is that most of the ones presented are just meaningless – as per the quote regarding

    more specific data (How well does this player hit against hard-throwing left-handers on warm Sunday afternoons in late September? How well does this therapy work in right-sided myocardial infarction in postmenopausal women?) can involve too few cases to be broadly useful.

    Way too often, I’ll see “ooh, this pitcher does so much better against that batter than this other one – a 1/3 margin!” When the underlying numbers are 1/2 and 2/3. The concept of “statistical significance” seems completely lost on pundits and commentators, though I can’t speak to whether the managers and coaches have the same issue.

    Seriously – in one game I watched a bit of recently, I kept track and found that only 2 out of 30 statistical differences presented were statistically significant. And those two weren’t significant to the game. An ancedote, but a really annoying one.

  3. BKsea says:

    As I was reading through the first half of this post, that xkcd comic came to mind. Then, Boom, there it was. I’m glad you posted it – I think it is perfect.

  4. mousethatroared says:

    Warning partisan statements ahead –

    Appropriate post! I will say that I found the success of Nate Silver’s predictions AND watching the clips of the Fox election melt-down incredibly satisfying. I like to think that this is not only because I am quite liberal but also because I am getting really fed up with the anti-science, anti-math, anti-fact, pro-faith, very vocal and powerful segment that is FOX, the religious right, the tea party*, etc.

    Leading a country is complicated, we need leaders that are willing to be informed by reality over ideology, but not only that…The point of having two parties or more is to build a diversity of solutions to complex problems. When politicians over-ride science, math, reality in favor of ideology, it limits our practical options.

    It is like only having a naturopath available to give you a second opinion on how to treat a rare and complicated disease.

    I’m really hoping this will be a wake up call to the republican party that they not only should start listening to the more logical, rational voices inside their party but also stand up to those who would chose fantasy over fact.

  5. Scott says:

    @ mtr:

    I share your hope – but I’m not optimistic. I suspect the reaction will be more along the lines of “well, see, we SAID that Romney wasn’t ‘conservative enough.’ Obviously the right answer is to get much more extremist.”

  6. The Dave says:

    as a (moderate) member of the GOP, I’ll say that, unfortunately, it probably won’t. Just like the 2008 election, when McCain got smashed, they will probably say they need to be *more* conservative, (ie partisan, ideological, extremist, etc.) in order to attract the independents (because somehow moving *away* from the center makes a lot of sense to attract the people sitting *in* the center)

  7. rork says:

    I’m not sure baseball and medicine are different cause of science, but perhaps in baseball really crackpot theories are less often considered. Using a bat the size of a toothpick is not seen often, even though that’s a thousand times more than what my homeopathic batting coaches recommend. Belief that controlling the flight of the ball with prayer or previous laying on of hands hasn’t yet stopped me from running over to where the ball is apparently flying. In these simple matters, baseball is actually rather data-rich.

    It’s not experts vs non-experts, it’s that experts who actually formulate and test their models can outperform experts who use no such tools (even if the set of models considered are all incorrect).

  8. DugganSC says:

    Honestly, I’m more expecting some of the Democratic party to start appealing with the less extreme of the socially conservative, things like advocating contraception while decrying abortion in cases where it’s not due to medical emergency. Although, if they went that route, I suspect that what we’d see is a growing fracturing of the Democratic party until the Republican party is relatively non-existent, replaced by a more conservative Democratic party.

    *shrug* But who knows… my personal hope is that we’ll start to see more politicians not rigidly defined by their party such that they whole “party” distinction becomes meaningless.

  9. mousethatroared says:

    @ The Dave – maybe the moderate GOP* folks should start their own science based party.

    You could call it the Real-I-Tea Party.

    *could draw in some Independant and some moderate DEMS too.

  10. The Dave says:

    I agree DugganSC. I find myself agreeing more with a (by lieral stabndards) ultra-conservative democrat than many of the party-line repubs, and, like I mentioned above, I’m a registered republican. I would love to see either the 2-party system disbanded altogether, or see an increase in the prevalence and power of many “third-party” parties

  11. The Dave says:

    @mtr:

    The Dave for president, running on the Real-i-tea ticket!. I like the sound of that, but I’m not 35 yet. :)

  12. windriven says:

    @mouse & The Dave

    I love the Real-i-tea idea! Somewhat like The Dave, I tended to a socially liberal / economically conservative moderate Republicanism for many years. This year with Romney’s fiscal policies divorced from reality and Obama’s divorced from his rhetoric, I voted for Pat Paulson. I should have voted for The Dave. At least he’s still alive.

    Bringing things back to the discussion at hand, it is one thing (and a valuable thing at that) to apply statistics and a willingness to assess data coolly to the science of wind direction (think Dylan) and quite another unfortunately to apply it to the development of political policies – a practice in which neither party can claim much interest.

  13. Janet says:

    @Mouse

    “I found the success of Nate Silver’s predictions AND watching the clips of the Fox election melt-down incredibly satisfying.”

    ME TOO. Loved both your comments today!

    @Dave

    Wouldn’t an “ultra-conservative democrat” be somewhat indistinguishable from a “very moderate republican”?

    I like the two part system–if you read both party platforms, it’s fairly easy to decide which one to cast your lot (and your ballot) with. It avoids all the obsession with personality, gaffes, “style”, and such. You just vote for the party that best represents your values and has the most science-based policies.

    Having said that, I could easily be persuaded to have a more proportionally representative system where more voices could be heard and more coalitions formed.

    What I’m saying is that how can anyone read the republican platform (which is horrifically anti-science) and then vote for anyone from this party, especially when even “moderate” members of this party are either pressed to vote in lockstep or be ousted? If you say it’s for “fiscal reasons”, then I have to ask you if any of their fiscal policies are based on any better facts/science than the rest of their policies?

  14. The Dave says:

    @Janet

    Well, I think we disagree on gun-control and maybe a few other social issues, but yeah, i think for the most part you’re right.

    With regards to the 2 party system, if we look at just fiscal and social factors, I think there should be a bare-minimum 4 parties with equal weight:

    fiscally conservative/ socially conservative
    fiscally conservative/ socially liberal
    fiscally liberal/ socially liberal
    fiscally liberal/ socially conservative

    (and by “conservative” and “liberal” I mean how much government intervention they want. So for example, classical Republicans would be fiscally conservative and socially liberal, classical democrats would be fiscally liberal and socially conservative, Libertarians would be both fiscally and socially conservative, and I’m not sure what would be both fiscally and socially liberal. But correct me if I’ve characterized them wrong. I’m kind of a political amateur/novice. Maybe all the more reason to run for president as a Real-i-tea-ist :) )

  15. DugganSC says:

    @Janet:
    Honestly, I think the abortion platform continues to be significant when it comes to these elections. And I think it’s where the overall Democratic Party plank refuses to bridge with these voters. The perception, whether right or wrong, is that the Democratic Party supports there being no restrictions and to disenfranchise unborn children as human beings wholesale. Personally, I think that’s the wrong way to look at it since there are moderates in the party who agree with the GOP position of medical necessity or are willing to reach a compromise for cases of rape and incest, but one of the hazards of the party system is that the politicians get tarred by a broad brush. Complicating things is the broader spectrum as to whether other changes (increased use of contraception, changes of educational standards, reduction of medical expenses) might be more effective in reducing the abortion count. *wry grin* As I’ve said to some of my friends, the Democratic platform sometimes feels like one of those science fiction stories where the aliens offer advanced technology that will aid humanity so long as they’re allowed to cart off X individuals every year for their food supply. What price is the life of a man?

    In regards to the actual article topic, there is some traction to be gained by these “situational statistics”. In baseball, it doesn’t necessarily matter what a pitcher’s pitching statistic is for sunny days because an owner doesn’t necessarily know how many sunny days versus rainy days they’ll be facing. Let’s compare medicine instead to horse racing where you lay your bets based on who looks to be the winner given the immediate suggestion. Suddenly, a rainy day may make a huge difference in which horse you pick (To quote Guys and Dolls, “It all depends if it rained last night. He likes mud, likes mud; the X means the horse likes mud”) just as the choice of medication may depend on your patient’s history both immediate (are they in poor health contraindicating a more aggressive treatment?) or further back (does this medication interact badly with people of a history of hypertension like this guy?). The catch is when people take narrow claims (“This form of chemotherapy is 5% more effective in middle-aged white males with diabetes”) and turns them into broader ones (“Polyphrastic Zoditor cures cancer!”).

  16. mousethatroared says:

    DugganSC – I hope it’s okay if I butt in. You say ” is that the Democratic Party supports there being no restrictions and to disenfranchise unborn children as human beings wholesale.”

    Here is a question from my Democratic viewpoint. I agree that a goal to reduce the number of elective abortions is excellent. But I strongly suspect that the emphasis on legally restricting abortions undermines rather than furthers that goal. We know before abortion was legal that many abortions still took place. We can also look to drug laws to see that laws do not nessasarily reduce the incidence of the illegal activity. So instead of leaning on expectations that restrictions on abortion will make everything all right, what if we look for the strategies that are the most successful in reducing elective abortions and implement them?

  17. DugganSC says:

    @MTR:
    {nods} As I said above, I think that, by supporting the other side, we are undermining the overall cause. But again, it’s a difficult position. If someone says that they can make sure that fewer people die so long as you don’t mind them killing this smaller group, do you go along with them? It’s kind of a devil’s deal.

  18. windriven says:

    @DugganSC

    Relitigating Roe will always bring us back to this point: at what point does a fetus become imbued with the rights of a human being? I don’t think any answer you can come up with would be objectively better than the one that Blackmun elucidated in the majority opinion.

    Politics is not the solution to every problem. If you dislike abortion you are free to proselytize against it.

    The Supreme Court made its ruling broadly allowing abortion during the first trimester. Even if you were able to pack the Court with 8 of Antonin Scalia’s closest friends, the Court would be unlikely to trample stare decis in a broad reversal. So until you can get a majority in 3/4 of the States to vote a constitutional amendment, abortion rights rabble rousing just pollutes the political dialogue with a polarizing futility.

  19. NYUDDS says:

    It has been said that Republicans care mightily for humans in the womb. After they are born…..not so much.

  20. mousethatroared says:

    Sorry, DugganSC, I am not following you. I talk about reducing the overall number of abortions through the best proven stratgies and you return with we are killing some to save others…How does less abortions not equal less abortions?

    It all just comes across as caring more about the idea that abortion should be condemned than caring about reducing abortions. And this is the very thing I find problematic.

    Of course, maybe you are not saying that, like I said, I’m not following you.

    Also, I completely agree with what windriven says on polarizing futility.

  21. @DugganSC:

    Honestly, I’m more expecting some of the Democratic party to start appealing with the less extreme of the socially conservative, things like advocating contraception while decrying abortion in cases where it’s not due to medical emergency. Although, if they went that route, I suspect that what we’d see is a growing fracturing of the Democratic party until the Republican party is relatively non-existent, replaced by a more conservative Democratic party.

    I think they already have to some extent over the past decade. Remember Colin Powell, Lincoln Chafee, Michael Bloomberg or Jim Jeffords? All moderates. While they didn’t necessarily switch to the Democratic Party, some of them (Jeffords) did caucus with them.

  22. windriven says:

    @Francois Luong

    ” Remember Colin Powell, Lincoln Chafee, Michael Bloomberg or Jim Jeffords? All moderates.”

    Unfortunately, moderates are a vanishing species. When the tea party-istas ran off the venerable Richard Lugar I knew that the last vestiges of “big tent” Republicanism had come to an end. The Democrats can use Joe Lieberman as their own poster child for hardening partisanship. The result, especially at the national level, is candidates who appeal to the idiot wings of their respective parties.

  23. pharmavixen says:

    There are data showing that improving access to abortion actually reduces abortion rates:

    From: Induced abortion: incidence and trends from 1995 to 2008. The Lancet 2012; 379: pp. 629-32.

    http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)61786-8/abstract

    “The abortion rate was lower in subregions where more women live under liberal abortion laws (p<0·05)….Restrictive abortion laws are not associated with lower abortion rates."

    Makes sense when you think about it; basically, more liberal abortion laws come hand-in-hand with better access to contraception. But if you google the above Lancet article, you'll find all the folks on the Christian right who are objecting mightily to this paper because it contradicts their real agenda, which has more to do with controlling women's bodies, and less to do with saving the precious bébés.

    [/rant]

    Speaking of Republicans, here in Canada, we have a right-wing government that also objects to reality. When the Minister of Public Safety was confronted by the media about why the gov't is building more prisons when crime rates are actually dropping, he retorted, "We don't let statistics stand in the way of getting tough on crime."

    Let's hope Obama's re-election helps belay all these bullies who object to how reality contradicts their dogma.

  24. DavidRLogan says:

    Just as a point of interest, I’m fairly skeptical the “moneyball” statistics are as valuable as they purport. (no disrespect Dr. Gorski…and I defer to you in all matters medical, of course :))

    First, the Oakland A’s have been fairly underwhelming since 2006 (4 or 5 bad years), until they shockingly made the playoffs this year. I presume they placed great value on Sabermetrics during these mediocre/bad years as well as the MB years (during which they had awesome pitching by conventional analysis…not mentioned at all in MB movie though somewhat in book).

    Second, contra to at least the movie, Boston’s first World Series win was not obviously tied to sabermetrics. It was based largely on the signing of Curt Schilling and the existence of other players-like Manny-who excel on more conventional indices of performance. However I do not remember if the book made such an implication.

    Lastly, there were huge small market winners (like Florida in 97) before the mass popularization of sabermetrics. And as far as I can tell (ask a Mariners fan) there has not been much a change to baseball’s power structure over the past 10 or so years.

    My own view (somewhat generally and vaguely) is these metrics are harmless in baseball but not always in other avenues (like mean-variance analysis and saying the risk of CDO’s could be understood mathematically in 2007).

    Again, great article Dr. G and I defer to you on all medical matters.

    FWIW…

  25. Quill says:

    Finally, one of the biggest impediments to data-driven approaches to almost anything, be it baseball, politics, or medicine, is the perception that such approaches take away the “human touch” or “human judgment.”

    That perception is fatally flawed but not for the reasons it believes. Data, math, science, analysis — they’re all products of human thinking and reasoning. The fallacy is in thinking mankind is somehow more “natural” without his own creations, without his own methods of making sense of it all.

    The same line of reasoning would lead a CAMster to urge people to go build their own houses wherever it feels good, and never mind flood plain maps and for heaven’s sake, don’t use power tools. Just follow your bliss!

  26. BA says:

    This election showed how the Rethuglican party (teabagger version) has such blinders that they snow themselves. Polling is very systematic and Silver has developed excellent methodology for culling the trends from various data sources. My favorite analysis of the election coverage in the media came from the Simpsons. In the opening segment, Bart at the chalkboard has been writing “I will not concede the election till Karl Rove gives me permission.”

  27. Jose A Hernandez says:

    Real question:

    Could prior plausibility be considered clinical judgment?

    And now my partisan “question”:

    What prior plausibility value should be assigned to President Obama fighting to bring the deficit under control?

  28. windriven says:

    @Jose A Hernandez

    Define “under control”.

    In any event the prior plausibility is zero. President Obama has no authority to bring the deficit under control. The power to levy taxes rests in the House of Representatives. And almost none of the spending is discretionary. His biggest guns right now are the bully pulpit and the fiscal cliff … a political version of the old Mexican standoff.

    The House is controlled by the Republicans, the vast majority of whom have signed a mind-numbingly stupid pledge not to raise taxes under any circumstances including direct intervention by god. Thank you Grover Norquist.

    Mitt Romney claimed he didn’t need additional taxes, in fact he would cut taxes, protect the middle class, increase defense spending and take an immense whack out of the deficit within ten years. There might have been something in there about Wal-Mart gift cards too. The American people, demonstrating a rare flight from credulity, called bullsh|t on him.

    Barack Obama had some opportunities and a bag of cash to spur growth during his first term. Growth helps because it expands the tax base. But instead he let Geithner and his ilk spend a good chunk of the money on sensual back rubs for stressed out Wall Street bankers. Later, Wall Street showed its thanks by becoming huge supporters of Mitt Romney.

    So it doesn’t look good Jose. There aren’t many people in the House who could tell you the difference between fiscal policy and monetary policy except they’re certain that taxes are bad. The president talks a good game but doesn’t have many tools and hasn’t shown much aptitude for using the few that he has. But what’s to worry? Most of the people who’re going to pay the price for all this haven’t even been born yet. So let’s PAH-TAYYYY!

  29. Jose A Hernandez says:

    If you close loopholes, revenues will increase. Obama could have achieved this goal by supporting the prescription of his own appointed commission, the Bowles-Simpson committee. He chose to ignore it. Given this behavior, I’ll agree, the prior plausibility is zero. Even with a Republican held House, if Obama were to push for it as hard as he did for Obamacare, it could pass.
    I repeat, if you close loopholes, revenues will increase – no need to raise tax rates to bring in more revenues. But given that this tax rate mantra has become an excuse to do nothing about the National Debt, I’ll accept the raising of taxes, just so we can remove Obama’s smokescreen.
    Also, blaming the House Republicans forgets that for the first two years the House was under the control the Democrats. And still nothing happened to rein in the debt.

  30. windriven says:

    @Jose A Hernandez

    “for the first two years the House was under the control the Democrats.”

    That would be 2008 and 2009. As I recall those were the first two years of a financial meltdown and a very deep recession. One doesn’t have to be a Keynesian to understand that reining in spending is not an appropriate response to sharp recession.

    “If you close loopholes, revenues will increase.”

    Yes, they will. But spend a little time analyzing the loopholes that would have to be closed and the growth that would have to occur to make a difference. The only way that I can see this happening is by eliminating preferential tax treatment for capital gains. The argument in favor of preferential treatment is that it spurs investment. In most cases this is a canard. When you buy a block of GE from me, $250,000 leaves your pocket and enters my pocket (less commissions paid on both sides of the transaction). GE never sees any benefit. No jobs are created, no capital equipment is purchased, no markets are expanded. One might retain preferential taxation on the first sale of capital stock acquired directly from a company; that would spur the kind of investment that does lead to a bigger pie.

    ” I’ll accept the raising of taxes, just so we can remove Obama’s smokescreen.”

    You credit the president with powers that just aren’t his. Mr. Obama cannot cannot close loopholes or cut entitlement payments, he cannot raise the retirement age, he cannot cut payments to hospitals or physicians and he cannot tell grandma that she can’t have a cholecystectomy. He could unilaterally cut some military spending but that would only lead to open warfare with the Republicans and with many in his own party.

    Mr. Obama has not been a particularly effective president. Hold him to account for the failures and omissions that are his. But it is not fair, and more importantly it does not help to solve our fiscal problems, to hold him accountable alone for failures that rest more squarely on the House. Mr. Obama’s failure is one of leadership. Messrs. Boehner and Cantor’s is a failure of both leadership and action.

  31. windriven says:

    I apologize for the failure to close the italics after ‘bigger pie.’

  32. mousethatroared says:

    @windriven – while I’m not sure that I would say that the president is not particularly effective, considering what he has had to work with (this would depends upon context, and the criteria you have for deeming effectiveness) two thumbs up on a reality based critique.

  33. windriven says:

    @mouse

    Thank you. I wish that we could all bring a little more reason, evidence and science into the political process. But I’m not holding my breath.

  34. DugganSC says:

    @mousethatroaredon

    I apologize. I didn’t think that I’d made a jump there. Legalizing a crime to reduce it may reduce the incidence of the crime, but at the cost of approving it. Thing is, any example I can think of for “suppose this horrible thing could be reduced by legalizing it” would likely be labeled as me trying to be sensationalistic and/or insensitive, but I’ll try a borderline example. We all disapprove of child abuse. There was a time when it was considered to be a non-issue because children belonged to their parents and their parents could do what they wished with their property. Let’s suppose that making child abuse legal was shown to reduce the incidence of it, possibly because having it out in the open makes people more likely to seek help rather than commit it. Is it inherently an improvement to reduce the number of cases of child abuse by making it legal?

    While I understand why people invoke the drugs example, I don’t know that it entirely fits. The reason it works in most peoples’ minds is that drugs seem to be a “victimless” crime. Most drugs don’t make you hurt other people intentionally. Yes, there’s cases of people leaving their families to starve because they spend all of their money on drugs, but frankly, that happens with almost anything people can be addicted to from cigarettes to sex to MMORPGs. Of course, I frequently see the comparison to the drug wars by people who’ve already resigned the fetus to being a parasite or waste tissue, so it’s probably a victimless crime here too in their eyes.

  35. mousethatroared says:

    You think there is no difference between an embryo and a child? You must be for banning IVF then, right?

  36. mousethatroared says:

    I do not view a embryo or a fetus as waste tissue or a parasite but that is the typical way that “right to life” folks like to portray folks who think a woman shouldn’t have a choice over what she does with her body.

    I view an embryo or fetus as a potential life. One that is usually mourned when it is lost, but also one that will take a parent’s lifetime and large amount of money to support if it is realized. A potential life that increases the health risks to the mother and substantially decreases her earning power at least temporarily, if not long term.

    The fact is, you can not give that potential life rights without infringing on the rights of a woman to privacy and autonomy, because that potential life is reliant on the woman to be realized.

    How about if I decide your sperm are babies and that the government should be able to control your health decisions to protect those babies. Maybe I should start declaring anyone who uses a condom as a war criminal? It’s practically genocide all those babies murdered. And hot tubs, running, bicyles, steroids…

  37. mousethatroared says:

    who think women SHOULD have a choice, that is.

  38. windriven says:

    @Duggan

    “Legalizing a crime to reduce it may reduce the incidence of the crime, but at the cost of approving it.”

    What is the crime?

  39. mousethatroared says:

    I think the crime is against consistent ethics.

    If you follow DugganSC’s ethical reasoning all the way through, then you will inevitable end up with either Murdocks conclusions or a conclusion that it’s acceptable to euthanize an infant or child who is the result of rape, incest or when their death is needed for the health of a parent.

    Personally I differentiate between fetuses and infants/children and I choose to focus on getting those infants and children the care and education they need. Many, Many of them don’t. Apparently, in DugganSC’s mind, caring about inant/children more than fetuses makes me someone who tactically approves of child abuse and views a potential life as a parasite or waste material.

    And yup, I’m pissed off. And yup I should probably withdraw from the commens here because of that.

  40. Jose A Hernandez says:

    @# windriven

    Obama had time during the first two years to implement Obamacare that passed on March 23, 2010, after a lengthy battle, which included cajoling and downright paying Senators off (this is during, as you correctly stated, “a financial meltdown”); but he did not have time to support the Bowles-Simpson recommendation (2010)? He did not fight for fiscal responsibility because his priorities are a reflection of his ideology.

    The closing of loopholes can proceed as Romney outlined, everyone gets a $25,000 deductible based on prescribed deductibles, and that’s it. One should invest because it makes sense in the private world, not because of the benefits hidden in legal loopholes. (In my opinion, these loopholes are the reason for most of the lobbying, and hence the corruption of our government.)

    It is true that “Mr. Obama cannot cannot close loopholes or cut entitlement payment,” but he can fight for them if that was a priority of his.

    Finally, no one has posted an answer to my “real question,” I repeat: Could prior plausibility be considered clinical judgment?

  41. BillyJoe says:

    Jose;

    “no one has posted an answer to my “real question,” I repeat: Could prior plausibility be considered clinical judgment?”

    Maybe no one understands your question.

  42. Scott says:

    I would say that evaluating prior plausibility is on the scientific, rather than the clinical, side of medicine.

  43. WilliamLawrenceUtridge says:

    Clinical judgement should only be used in the absence of existing scientific guidelines. If a guideline exists that white women between the ages of 40 and 60 should be regularly tested for foo, and you’re the doctor of a white woman, you should test her for foo. If you have a patient who does not meet these guidelines, then clinical judgement is an appropriate, if debatable and far inferior decision-making tool.

    In cases where prior probability is an issue, there would not be evidence-based guidelines and thus clinical judgement would have to be used. Prior probability has been established, in fact supplanted, by the evidence-base supporting the guideline.

    CAM is a special case in that the interventions are generally based on prescientific thinking and assertions – but most importantly the interventions are unproven. CAM that has been proven loses the “CA” and becomes merely medicine. CAM also occupies a critical blind spot for most doctors and patients, based as it is on illogical appeals to emotion, popularity, naturalism, authority, age and other fallacies.

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