Risk Compensation Revisited

A few years ago I got interested in risk behavior, and wrote about it on this same infrequently updated blog. Fast forward 3 years and we now have a son. Theoretically and stereotypically, sons dream of playing football. Julia and I have joked about that before, and I say a manly son of mine is free to play football... so long as he's the kicker. Lewis has been growing at a rate that leaves us scratching our heads compared to our two daughters. He weighed at 3 months what they weighed at a year. (And they were right in the middle of the growth curve. So I guess he's about average too, if he were a small baby elephant.) Obviously growth patterns can fluctuate with age, but if he were to keep this up he'd be a fairly huge young man, ripe for competitive sports one might think. Grace wants to try out basketball and soccer, and who knows what Violet will take an interest in. Given her wild 3-year old independent streak it would seem full contact gymnastics would be right up her alley.

Julia just referred me to this interesting piece which is yet another article in the  popular press on the risks of concussions in football. Part of that article is a brief consideration of helmet technology, and whether or not we can invent our way out of this problem. As should be obvious from my take on seat belt laws and the like, I would argue no. In fact some people say we should get rid of facemasks and remove protective equipment to alter player behavior. The safer a player feels, the more risks they will take is the theory, and I think there's good evidence from other arenas of life to back that notion up. More on that later.

The literature on concussions largely uses the concept of Athletic Exposures. An Athletic Exposure (A-E) is generally defined as one athlete participating in one practice or a game/match. So, what is the rate of injury (in this case concussion) across various sports? Studies vary, but generally high school football is around 0.5-0.6 concussions per 1000 A-E (see Lincoln et al and Gessel et al). Those numbers may be under-appreciated. With time the rate of concussions seem to be going up. The argument is often made that we're just increasingly aware of concussions and diagnosing them more, and that may be. But how do other sports compare? According to this paper by Marshall and Spencer the concussion rate for rugby is 3.8 per 1000 A-E. That's admittedly a small study, but the article does contain a review of other published studies on the topic, and most of them are significantly higher than what the estimates are for American football. Ice hockey in various studies is also north of 3 per 1000 A-E, and individual contact sports (boxing, martial arts, etc) are higher still. So when they propose a mixed martial arts club at your kid's high school in 15 years, say no. 

Also, girls seem to be at more of a risk of concussion injury than boys. The Lincoln data show that for similar sports (basketball, soccer, baseball/softball) girls have a rate of concussion more than double that of boys. 

And girls' soccer had the second highest incidence of concussion after football. I can't help but wonder how accurate the reporting is here when we are comparing boys' and girls' sports. It would not surprise me at all to learn that the culture of boys' sports encourages them to "tough it out" and not report symptoms of concussion. But that's another topic entirely. 

From that epidemiological data, flawed though it may be, it would seem that American Football is not as bad as  some alternatives. It is the most risky of all the sports we play here though. It is also the sport that captures the national attention (sorry baseball), and the sheer volume of young men playing it means that we're talking about a whole lot of A-Es here. So what can we do about the concussions? Will better monitoring and better protective equipment reduce that rate of injury? So far, signs point to no. The monitoring has only served to make us more aware of concussion. This paper has a nice rundown on what is involved in monitoring head forces in football with the HITS system and what it has been showing (hint: 25g forces applied to the head about 10-15 times per A-E). What can we say about concussion risk and protective equipment? Virginia Tech has done some nice work comparing different helmets, but this is matching impact data in a lab with incidence data and drawing conclusions on which would be the most protective. There is no evidence that I can find that shows players wearing one type of helmet have a lower risk of concussion than those wearing another type. 

Padded headgear made no difference in head injury or concussion risk in rugby. In soccer (or football to all the rest of the world) there is mixed evidence. Some retrospective studies suggest headgear is protective. But controlled studies in the lab suggest that headgear doesn't provide significant protection, and broader reviews of the literature have not found a consensus agreement that they do any good. There's similarly mixed evidence on full face protection in hockey (it may be helpful in reducing severity of concussions). But in the discussion of most of these papers there is always the specter of our good friend risk compensation. This summary paper goes through what limited data there are on how interventions alter risk taking behavior. The authors note that in the 1940s American football players were taught to initiate contact with the shoulder. After the introduction of the plastic helmet they were taught to strike first with the head, and that tackling drill fatalities increased after the introduction of the plastic helmet. Surveys of rugby players showed that 67% felt more confident and able to tackle harder if wearing protective headgear. 35% of those involved in ski/snowboarding fatalities were wearing a helmet, which is well above what was average for the time in those not injured. 

In the end, most academic papers on the matter make mention of one common factor that seems to mitigate increased risk taking behavior, and makes more of a difference in injury rates than advancing technology and protective equipment. That factor? Changing the rules of the game. Commentators and good ole boys may whine about how new rules are making football not football anymore. If we banned heading the ball in soccer there would be a similar outcry I'm sure. But what we're learning is that the human skull/brain combo aren't well suited to running into things with force. Things like other skulls, the ground, the inside of a Humvee, etc. But equipment can't make inherently unsafe activities safe. Safer, maybe, but still risky to the millions of young people participating. If we really want to protect them, we have to change the games they're playing. 

The Breast Cancer Conspiracy

Cancer is bad.  I get that.  Each of my parents has survived two distinct kinds of cancer.  My grandmother died of multiple myeloma.  I'm going to say that the genetics aren't exactly in my favor here.  Now none of them were breast cancer, but I surely understand the urge to do something about it.  But this Facebook purse crap?  Uh, no.  Last year it was your bra color, this year it's purses.  We're raising awareness by being obtuse and dropping double entendre?  And what the heck do purses have to do with breast cancer anyway?  Women have purses?  And breasts?

Somehow these Facebook status updates are supposed to titillate and get so much attention that we'll all have our awareness raised about breast cancer.  Great!  But even if it works... so what?  What does awareness do in the face of a huge problem like cancer?  Awareness without action or a response is meaningless.  If we are aware of a great  truth but don't share it we haven't done anyone any favors.  As a doctor, if I'm aware of a problem but don't do anything it's called negligence.  We have vigorous conspiracy theories about politicians supposedly being aware of Pearl Harbor or 9/11 and taking no action.  Is breast cancer a conspiracy?  One where we have all manner of awareness but don't do anything about it?  Talking about it via Facebook statuses is the best we can do?

This purse wannabe-meme is ridiculous to me on another level.  It does nothing, and yet is all about  something that can effect real change.  Inside all those purses that women are innuendoing across Facebook lie wallets.  In those wallets lie money.  In money, there lies research and healthcare.  So I say we turn this silly thing on itself.  How much did that purse cost?  Give that much to cancer research.

I replace plenty of functional gadgets and gizmos with newer versions all the time, so I'm no better.  But I'm guessing that the purse replaced one that was still totally functional but out of style.  If we can afford that, we can afford cancer research for better treatment and more cures.  What if everyone gave to the American Cancer Society or some similar organization what their (or their significant other's) last purse cost?  Then you can update your Facebook status with that instead. Heck, you can be as salacious as you want about it.  "I pay $100 to get it." "I charged my husband $75 for it." Whee! We're having innuendo-laden fun now.  Or you could say what I'm about to, no innuendo required:

I donated $160 to the American Cancer Society's breast cancer efforts today.  How about you?

Risky Business

I have been thinking about risk of late, in a variety of contexts.  It seems like we are surrounded by the concept.  Listen to the news (or read it, if you're so quaint) and you will hear numerous stories on the government trying to reduce the risk to its citizens.  We invaded Iraq to ostensibly reduce the risk posed to U.S. citizens by that country, and by the terrorists that were supposed to be scheming there.  We are trying to establish various and sundry new financial measures to reduce the risk posed to the economy by rogue institutions and individuals.  We are inundated with advertisements for cars with more and more safety features, not to mention larger and heavier cars by the year.  This has contributed, in part, to the fact that fuel efficiency hasn't improved much in decades (Julia's '89 Corolla got 40+ mpg on the highway, comparable to the Prius we own now).  The latest risk that must be eliminated is being pitched to me by our church.  We may spend millions to build a new childrens'/education wing in part because the old one has security flaws (as well as a perceived lack of space, aesthetic appeal, etc).  My struggle to see the necessity in this is a post unto itself, but I found it odd that one of the main points was that we need greater security in this one part of our church.  Maybe I shouldn't have been surprised as a post 9/11 mentality permeates all aspects of life now.  But call me naïve, I was.

And it got me thinking, how safe can we really be?  How much risk can we really avoid?  I don't know exactly what security measures the church thinks we need in place, but I'm guessing there will be technological solutions involved.  Badge access, cameras, etc, etc.  I'm a doctor.  We're pretty obsessed with evidence to support promised outcomes these days.  Is there evidence that risk-reducing measures work as advertised?  Yes and no.  If you evaluate populations already at risk, measures can be effective in reducing that risk.  Condoms used by people already engaging in risky sexual behavior do in fact reduce their risk of acquiring HIV.  But what is often not discussed are the unintended consequences of enforcing such measures. Is there a behavioral compensation when we know, or at least believe, we are safer?

This is of course a loaded question.  There are always unintended consequences of broad policies, and most of the examples I'm talking about affect large groups of people.  Unintended consequences are essentially unavoidable in complex systems when you don't fully understand every aspect of the system. This is why it's so infuriating to me to hear politicians try and oversimplify issues and assure people that their policy will absolutely work, or alternatively that there is no way the opposition's policy could possibly have any benefits.  But I digress.

Are we safer because our cars have airbags, or because seat belt laws have been passed, or because we're using condoms?  Not definitively.  There is no clear evidence that condom use promotion has decreased HIV transmission.  Countries with high uptake of condoms (Thailand for example) do show a drop in the rate of transmission.  But countries with a low rate of condom uptake (Uganda) show a very similar decline in the rate of transmission.  The argument is that all epidemics will peak and decline as vulnerable populations become saturated, and avoidance measures are undertaken by those not most at risk.  At some point a steady-state should be expected.  This is in no way to suggest that condom use doesn't work.  But the benefits of mass campaigns to promote condom use are difficult to prove.  Furthermore, there is some evidence that people compensate their behavior when they feel safer in regards to HIV.  Otten et al showed that among patients that had a positive HIV test and received counseling there was a decrease in further sexually transmitted infections.  However, in those who tested negative, the rate of STI doubled when you compared the six months before their negative test to the six months after. 

In the '70s and '80s when seat belt laws were being passed in countries around the world, people were extolling the thousands of lives that would be saved when everyone was buckling up.  However, the data show that such predictions never really came to bear.  Consider this figure from an opinion piece in the Lancet in 2000 (ref here):

Of the 17 countries with the most cars, death rates fell in all of them, whether they enacted a law or not.  In fact, the four countries that didn't enact a law had a more pronounced drop in death rates.  The authors speculate that what was really driving the death rate down was the economic downturn and energy crisis (people driving less, and driving at slower speeds to conserve fuel presumably) and a movement to reduce drinking and driving that was afoot at the same time.  What's perhaps even more interesting, is that death rates among those not in cars rose.  The death rates among pedestrians, bicyclists, etc went up.  "In the 23 months that followed the introduction of the UK seat-belt law, the number of deaths among pedestrians, cyclists, and unbelted rear seat passengers rose by 8%, 13%, and 25%, respectively." Why?  People wearing seat belts feel safer, and their sense of individual risk is reduced.  In turn they may be inclined to drive faster, drive more, or be more daring on the road.  Peterson and colleagues (article here) studied the effects of airbags in the early '90s as they were becoming more standard on cars.  They found that people in airbag equipped cars tend to drive more aggressively, and multi-car crashes were more likely to be initiated by the car with an airbag.  In single car accidents people in airbag equipped cars were no less likely to die than people in cars that lacked them.  Passengers were more likely to die if the car had an airbag (remember that this is before passenger-side airbags were common).  Again, if the driver feels safer, everyone else had best watch out. 

James Hedlund suggests in a lecture (which is fascinating and I encourage anyone who finds this even remotely interesting to read it) that if you want to reduce risk without creating compensatory behavior, you need to aim for measures that "are invisible to people, or that do not affect their actions or attitudes, or for which they have no motivation or freedom to change behavior."

I have to wonder what actions of my own are compensatory in nature because I do not perceive risk.  What industrial or governmental policies are we just waiting to see the compensation for as everyone tries to make our lives safer?  And in the end, just how "safe" do I want my life to be?

 "Playing it safe will always end in disaster"
-Banksy

Just Say No, Kids

The other day I was sitting around having lunch with the other fellows in my allergy program.  Talk turned to healthcare reform, and from there I had to ask the group: would you tell your kids to go in to medicine?  The nearly universal answer was a quick "no".  The lone exception was a pediatrician.  Which I think is revealing.

In general pediatricians, or pediatric specialists (pediatric cardiology vs. adult cardiology, etc), make significantly less than their adult medicine counterparts.  This is generally attributed to the fact that the complexity of medical problems is less in pediatric patients.  Allergy is an odd bird in that it is the only specialty that can be entered from either pediatrics or medicine, and you see both pediatric and adult patients in your training.  As people discuss reducing doctors' pay and other cost-cutting measures, you might expect that those on the lower end of the medical financial ladder would have the least incentive to want to perpetuate the career in their offspring.  But I think the variable here is that despite lower compensation, pediatricians generally like what they do a whole lot more than medicine doctors.  The money is secondary.  This is not to say that people going in to internal medicine or medicine specialties are in it for the money.  At least not initially.  I think the system makes our lives so messy and focuses on so many things other than the practice of medicine that it makes it about the money.  If you're going to have to put up with fighting through insurance prior authorizations, and lack of funds for the homeless guy you're trying to take care of, and 10,000 forms for every new patient... you're going to start to demand compensation for all the headache.

[As an aside, anyone who thinks that we don't already ration healthcare in the US has clearly never dealt with an insurance company.  We have a multi-level rationing approach.  Level 1) Do you have insurance or medicare/medicaid?  If not, you will likely not be getting basic preventative medicines or procedures because you can't afford them (a month's supply of the basic inhaled steroid we use for most asthmatics would cost you $80-100 a month out of pocket).  Level 2) If you do have insurance, will they go along with what your doctor wants to do?  You have to ask for permission for a great number of procedures and medications, which often are initially rejected to see if you're serious about it, and when you fill out more paperwork will be reviewed by the insurance company to see if they agree with the treatment, having never seen the patient.  In fairness, doctors when given free reign to do what they want may not give the most cost-effective medicine.  Rationing is not inherently evil, society just has to decide on what basis we're going to ration the limited resources we have.]

Pediatricians perhaps have fewer hoops to jump through, and unlike medicine it's easier to get kids on some type of insurance program, but the big difference is that they feel compensated by the act of caring for their patients.  Whether this is part of the culture of pediatrics, or just the nature of people who go into pediatrics I don't know.  But from talking to my colleagues who come through the medicine side of things, and from my dealings with adult patients in fellowship, I have to say that the reward of the job doesn't feel like adequate compensation.  So it comes down to financial compensation.  And increasingly doctors feel like we can't help people anymore, except to guide them through this giant machine that is our patchwork healthcare system as best we can.  It basically boiled down to "I'm not getting paid enough to put up with this".

Me?  While I am a pediatrician, I have to say that I wan't the pediatrician saying I'd encourage my kids to become physicians.  I think that the reality of what it means to be a doctor nowadays is very difficult to convey to people thinking of going in to it.  I heard similar complaints when I was entering medical school, but chalked them up to sour old doctors that weren't able to change with the times.  In retrospect I had no intention of hearing the downsides of a career in doctoring, and perhaps was a bit naïve in dismissing the complaints I heard.  If my girls want to be doctors, I would be all in favor of it, but I would do my darndest to make sure they knew what they were getting into.

By and large people felt that healthcare was still interesting and rewarding, but that having that shiny M.D. after your name wasn't likely to be the best way to be a part of the system going forward.  The general consensus was: tell your kids to be nurses, or PAs, or researchers, or policy makers, but momma don't let your babies grow up to be doctors.

The Last Last

Things are winding down here in New Haven. Actually, that’s not quite true. Winding down implies a slow and steady decrease in pace. This was more like a frenetic dash through calendar days until suddenly... there’s nothing left to do.

We sold our house. We went to Texas and bought a new one. I gathered multiple documents and applied for my for-real-grown-up-doctor medical license. We packed up and moved our belongings. I went to the Pediatric Academic Society meeting in Hawaii to interview for the Pediatric Scientist Development Program. I studied for (and passed) the Texas Medical Jurisprudence exam. I worked long into the night making and editing our final residency class skit. I went to my graduation dinner (skit a huge success, thank you very much). I found out that I was awarded a PSDP grant.

Now I find myself vaguely blue, or at the least sentimental. It’s not that I’m not ready to move on with life. I most assuredly am, and will be glad to be done with residency. It’s just that our time here has been so filled with change and intensity. Despite how ready I am to be done there’s this angle of bitter-sweetness or melancholy that I can’t seem to shake.

I’ve been ticking lasts off of a mental list. Last call night. Last day on the wards. Last ED shift. Last night in the first house we owned. Last visit to restaurants we like. Last time I’ll see this friend or that attending. Last end of the year dinner. Last night with Julia and Grace in New Haven. Soon last continuity clinic and last night of pager call. After that, last day of residency. Then... what? I get in a car with the dog and drive out of town. And somewhere in there is the last last. At some point I have to stop counting lasts and start counting firsts.