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?

Neo goes running

I love the differences in how each foot will strike the ground.
From: http://goo.gl/Wpqn

Back in med school I started training for a marathon.  It seemed a good and ambitious goal.  I was excited about the prospect of saying I had done it.  What I wasn't so excited about was the part whre I have to run a whole lot to get ready for it.   Running is, generally speaking, miserable... especially in Dallas.  You have your ludicriously hot, combined with a good chance of pain.  I soldiered through, making it to about 12-15 miles at a (rather slow) time.

Then my shins started hurting.  Soon it was interview season for residency, and I was travelling a good bit.  The two combined were enough to throw me off my training regimen and I gave up.

Fast forward 5 years and I haven't really run since.  When we moved to Salt Lake City my new job afforded me the time to do some regular exercise.  So back to the running I came.  But it still wasn't much fun.  The odd thing is that part of me wants to enjoy running.  I like being outside.  I like not being a pudgy slob.  I don't really like running.

Recently Julia and I heard Christopher McDougall on NPR discussing his increasingly well-known book Born to Run.  The basic gist is this: mankind is designed to run.  We probably hunted millenia ago by running animals to death over the course of many hours. (Humans can sweat and therefore cool ourselves while exercising, our early prey couldn't, so they eventually drop from heat exhaustion... there's a pleasant thought for you.)  We didn't have big cushioned shoes when we were doing this, so why is it that we think this is how we need to dress our feet for running now?

The common wisdom is that you need the right shoes for your particular shape of foot, and that you need shoes that correct for the deficiencies in your stride etc.  But there's no real research to support this, and most of what does was paid for by shoe companies.  The military did an experiment where they assigned recruits to get running shoes specific for their foot shape or a style of shoe regardless of their foot shape.   Their results showed no difference between the groups, and possibly an increased risk of injury in those assigned shoes based on their arches.  A study in 1989 by Bernard Marti found that in his sample of over 4000 runners the most common factor in who was injured and who wasn't was the cost of their shoes.  If your shoes cost over $95 you were 2x as likely to be hurt than those who had shoes under $40.  A 1999 study out of McGill university in Montreal showed that thicker soles doubled the risk of injury.  The same authors did another interesting study where volunteers were asked to step off a slightly raised platform onto a platform covered in shoe sole material.  They were told that one material offered superior absorption, one was neutral and one had a warning that it offered poor absorption.  When stepping off onto the superior material subjects landed with significantly greater force.  The kicker is that all three materials were identical.  What varied was the advertising associated with each material.  A similar study showed that gymnasts will land harder when there is more padding beneath them.  The speculation is that they are instinctively trying to do what it takes to feel stability under them.  Or maybe it's just compensatory behavior.

So while the issue isn't fully proven, I was intrigued enough to give it a shot.  I bought some Vibram Fivefingers and set out for a quick one mile jaunt to see how my body naturally wanted to run and all that.  Well my body may be made to run, but it's gotten stupid over time.  I thought one mile would be a very conservative distance to go for my first time at this ("go slow" being the most ubiquitous advice anyone will give you about barefoot or minimalist shoe running).  The fiery pain in my calves attested to the fact that one mile is in fact not slow enough.  I was used to running a few miles at a time without it being insanely difficult.  But that was not using the same muscles as this.  I felt like the running version of Neo from The Matrix.

Runner Neo: Why do my calves hurt?
Morpheus: Because you've never used them before.  Now weep quietly.  Answers are coming.

After recovering from that I was motivated to do the homework I should have done first.  Something along the lines of 1/8th of a mile would have been a better place to start.  I've built up to about 2/3rds of a mile without a problem.  I've also started running barefoot more and in the Vibrams less.  That may well change as it gets cold here.  But the whole thing is a lot more fun, which was kind of the point.  I mean look at those dudes in the picture up top... which one looks like he's having more fun?

Why can't I choose my battery?

Mr. McGuire: I want to say one word to you. Just one word.
Benjamin: Yes, sir.
Mr. McGuire: Are you listening?
Benjamin: Yes, I am.
Mr. McGuire: Batteries.

OK, that's not how it goes. But if it were made today, that's how it should go. Allow me to descend into wanton nerdery for a minute. My wife is thinking of joining the 21st century (or perhaps the 20th) and getting a cell phone she will carry around with her and actually use on a daily basis. As anyone who has tried to call her cell # can attest, it's rarely with her, and if it is the battery is probably dead. I have been a happy iPhone user for a couple of years now. If it weren't for Twitter I don't think she'd have much motivation to get with the times, but the idea of updating on the go (as was the original intent) appeals to her.

So we're looking at our options. The iPhone is nice and all, but depending on where we move to there may not be very good coverage with AT&T. Verizon seems much more likely to work out, so we're looking at Android based phones. But regardless of what we end up getting her, I am struck by our lack of choices. Oh sure, there are a number of good phones. And with something like the iPhone you can even pick how much storage space you want on it. But increasingly that's irrelevant.

I carry only a portion of my music on my phone. The rest I can stream from my home computer, or listen to internet radio like Pandora or Last.fm. Google documents abound, our email is all web based... on mobile devices cloud computing isn't some emerging thing, it's already here. I also drain my battery to near death over the course of every single day. So what matters isn't how much storage space you can give me, it's how long my battery will last while I access all that decentralized information. And that's where I run out of choices. I can choose the storage space, or color, or calling plan, etc of my phone, but I can't do a thing about the battery. Increasingly this is what matters. Batteries are the new storage space for mobile devices. Why doesn't anyone offer the option of paying extra for a more robust battery?

Perhaps it is that we lack choices in general when it comes to batteries. It seems like they are the bottleneck to electric cars, and that by and large we haven't seen a breakthrough battery technology in a long while. But I have to believe that there will be a market for battery choice. I also wonder how long it will take before we're as fluent in battery terminology (NiCd, Li-ion, cell number, energy density, etc) as we are in horsepower, CPU clock speed or other more traditional metrics of speed or power. In the near future I think the battery is going to be the key thing we care about in a lot of devices.  Now if they can just let me care about it in the next couple of months, that would be great.

If You're Going to Salt Lake City

I recently visited Salt Lake City to interview for a position with an allergist there.  Once I found out I was going to go out there I could not stop thinking about Scott McKenzie's San Francisco.  But in my head it's something along the lines of:

If you're going to Salt Lake City

Be sure to wear a three button suit with care.

If you're going to Salt Lake City

You're going to meet some business people there.

It's a work in progress.


At any rate, the trip was very good, and we'll see what comes of it.  The opportunity seems like a really good one for a lot of reasons.  Professionally it's very good: a solo practice that is growing, with people that seem like they would be very good to work with.  The timing is right, as the doctor wants to make a decision in the next few weeks.  The area is stunningly beautiful.  Maybe for people who grew up in the mountains it's no big deal, but I sort of feel like a landlocked person visiting the ocean for the first time.  "Look!  Snow!  Mountains!  Seasons!"  The city itself is an interesting issue.

The SLC area seems to be growing, and from a professional standpoint that's of course a good thing.  We initially were looking at Portland, Seattle, etc.  While those are great places, it turns out that we're not the only ones who think so, and the market for allergists is pretty saturated.  There are a couple of advertised jobs in SLC, which says something right off the bat.  Some people speculate that Salt Lake of today is Portland or Denver from a decade or so ago.  Soon maybe it too will be a hip destination where all the cool kids will want to live.  We had some concerns about the LDS influence there, but I think we've become much more comfortable about that.  For starters the city is very kid friendly as a result of their influence, and in many ways they are fantastic neighbors.  But in SLC itself the population is only 30-40% LDS.  It goes up as you get out into the suburbs and other parts of Utah, but Salt Lake itself turns out to be a fairly liberal college town.

The LDS issue made me think on a number of levels though.  The biggest one is what it will be like for our kids.  Will they be socially isolated for not being Mormon?  If so I think it's probably our fault in large measure, for not finding some of the few thousand kids who also aren't Mormon for them to relate with if need be.  It would also be very interesting to live in a place where orthodox Christianity is undeniably the minority opinion.  If we're being honest with ourselves pretty much every place in the country fits this bill.  But we're not honest, and still hold to the notion that this is a Christian culture and a Christian country.  Perhaps in name it is, but in many respects that name has been co-opted by politics and agendas and a great many non-spiritual driving factors.  I have to imagine that living in a place where the dominant religion is not your own will help you to understand the first century church better.  It will force you to decide what it really means to live what you believe.  Plus I don't think the Mormons are going to be burning any evangelicals on the stake.

In fact, I find it interesting to ponder the very systematic and organized way that relationships are built between the LDS and their neighbors.  I was told that each house on a street is assigned to an LDS-member who lives nearby.  They are responsible for that house, regardless of what type of people live in it.  Should a natural disaster or a power outage or whatever occur, it is their job to make sure everyone in that house is OK.  Say what you will about the structure and the expansion efforts and such of the LDS church, and you could argue that being told to do these things by your leadership is merely legalism and not true spirituality, but how much of that has mainstream Christianity lost?  Maybe you're being a good samaritan because you were told to, but for the person you help the impact is the same.  I am forced to wonder what the country would think of evangelicals if each one had to look out for their neighbors and do good deeds in the name of the church.  To my discredit I don't even know most of my neighbors.  We drive all over the city to go to work, shop miles from where we live, and go to churches that have little to do with location and much to do with finding the people and the beliefs most similar to our own.  Not that these things are all bad, and some of that is a natural result of how we build our cities and organize our lives.  But I have to wonder if a little forced neighborliness would really be a bad thing.

Abandon All Hope, Ye Who Vomit Here

I am the last of my kind: the lone healthy survivor of the gastroenteritis that destroyed our household empire at the end of 2009.  It attacked the smallest among our ranks first, and then nefariously turned her against us, as she became an agent of disease, spreading the sickness wherever she crawled and cuddled.  It worked its way up the ranks from there, as the eldest child complained of "tummy hurts" from bath time until bedtime, and then vomited soon after going to bed.  Having somehow never experienced this most unpleasant sensation in her four years of life I had to explain to her that what she was doing was called throwing up.  "Why am I throwing up?" she asked innocently and imploringly.  Curse you evil virus! Curse you!

Not satisfied with taking our young, the creature aimed higher, and Julia was in its clutches from midnight on.  Rest was fleeting at best, as every 10-15 minutes someone would need attention, or a sip of water, or a run to the lavatory.

Now I sit alone in my household, the last healthy member of the family.  Every female human is passed out asleep under heavy blankets, but mercifully keeping their fluids to themselves.  I don't know how much longer I have.  I'm trusting in my immune system's years of hospital exposures to get me through this.  It's either that, or sheer willpower, because man I cannot emphasize enough how much I loathe vomiting.

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The Christmas Baby

We're getting very close to Violet's first birthday, which of course makes me reflective.  I remember all the anticipation of her coming, the lingering concern over unknowns, and the joy of her arrival.  Now as we read Grace her little Christmas books and ponder the birth of Christ, I can't help but think how wrong we get that whole event in these stories.

I understand that they're written for little kids, and that the Bible is not an obstetrics textbook, but reading them it's easy to think that Jesus popped into the manger as easily as a thought would pop into Mary's head.  Or perhaps he was delivered by the UPS man late in the night, as he sure seems to be working late around our house this time of year.  "During the night, Mary's baby was born."  This is how the kids' books put it.  Christmas carols are really no better.  "The cattle are lowing / The poor baby wakes / but little Lord Jesus / No crying He makes."  Really?  Not only is this stupid, it's horrid theology if Christ is to be both fully God and simultaneously fully human.  No human newborn I've met wakes up quiet and still, much less one woken up by a cow mooing and chewing cud in his ear.  Getting to that point is equally succinct in Grace's books.  "Mary and Joseph were very tired, but there was no place for them to stay."  Yes, Mary and Joseph were both tired.  Equally so.  Long trip and all.  Oh, and one of them was 9 months pregnant and, unless human physiology has changed significantly in the last 2000 years, in labor with her first child.  But they were both really tired.

I think it is likely the cultural norms of the 1st century that kept the Gospel authors from going into any specific details of Christ's birth, and I guess you could argue that such details aren't really necessary to understand the significance of God taking on flesh.  But I think the whole thing is more legitimate if you think about what really happened in that stable, and what led up to it.

Mary was a teenager pregnant with her first (out of wedlock) child.  I've been around plenty of teenagers giving birth to their first.  Their labors tend to be long and painful.  Mary had been riding on a donkey all day, and while they are looking for a place to stay it's entirely possible she was already in labor.  Inn keeper after inn keeper keeps turning them away, despite the fact that Mary is very obviously pregnant, and as the day wears on likely having contractions.  The Bible makes no mention of the desperation that Joseph and Mary must have been feeling.  As they go around the city they must be increasingly aware of what is about to happen, and increasingly aware that they will not be able to deal with it in the usual fashion.  I recall my weak attempts to meet Julia's needs as she labored, in an advanced medical facility, and can only imagine what powerlessness Joseph felt as he couldn't even find a room.  Angels did not promise her an easy labor, or forewarn them that they'd be staying the night in a place that smells of animal waste and moldy hay.

But that's exactly where they ended up, at some point deciding that this was their best option.  Mary is fully in active labor soon, and since the Bible makes no mention of a third party, there is no midwife in sight (unless the cow counts, because I bet she's given birth a few times at least).  This means that not only did Joseph accept that his bride-to-be is pregnant with God's son and not send her on her way, he was the only person available to help Mary with the delivery.  There is no reason to think that Joseph had ever been present at a birth before, or that he had any clue what to do to assist Mary.  He surely had no idea what to do if something went wrong, which had to be on his mind and Mary's.

After a long and painful labor Mary gives birth to a screaming baby boy with blueish hands and feet.  She does not wrap him in swaddling cloths and plop him down in a manger straight away.  Joseph wipes him off as best he can, and Mary puts him on her chest, where he tries his first feeble attempts at nursing.  Contrary to the happy pictures we see, Mary is covered in sweat, if she's anything like my wife she's popped a few blood vessels in her cheeks or eyes, and she's utterly exhausted, but at the same time ecstatic.

This is what I think Jesus Christ's birth was really like.  Scary, difficult, and not at all according to the normal plan.  But such is life, and if Jesus is to have experienced all that man has to go through, I can't imagine a more fitting way for it all to start.

And then some random shepherds scrambled into the stable in the middle of the night.

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

The Delightful Paradox

The decision to have a child was not a hard one for me. I love kids. I went into pediatrics because of the patients, not the medicine. But I have to admit, there was some serious trepidation on my part about having a second child. What would it do to my relationship with Grace? What would it mean for us as a family? Underlying it all, the nagging question: can I love two kids equally? Or would I then be splitting the love I have for Grace between two kids?

The answer to this is that I don't have to worry so much. There is a model readily established for dealing with dividing your love between two people... your first kid. Grace, too young to be stymied by logical arguments and mutual exclusivity, when professing her love for her parents will often say to me: "I love you better. I love Mommy the most." Yeah. I can't really say it much better than that, so thank you not-yet-four-year-old. I will always treasure Grace as my first child, the first one to evoke such deep rooted sensations of love and protection in me. I love Violet the same way, and yet differently. She didn't cause such a sea change in the makeup of our family as Grace did. But in her own way she has dramatically altered who we are as a family, and how I view myself as a dad. Now I am the father of kids, not just a kid. She looks (I think) more like me than Grace does. She sleeps differently, she babbles differently, and in many ways I have no idea yet what kind of little person she'll become. The excitement/uncertainty that was present with Grace is still very much there, I just have a bit more experience now.

So it's with this in mind that I have to approach the daunting task of preparing to adopt, which is how we've elected to expand our family to five. There is a whole new realm of murkiness and doubt in this. Will I be able to love my nonbiological child as much as my biological kids? Will I deal well with all the complexities and loss this child will face as he/she ages with me as a parent instead of the person who gave them life? Two worked out all right, but will I be able to split my love between three children?

But I know now that there is no splitting involved. The love you have for your kids is not a bag of candy, at constant risk of being emptied the more you dip into it. It's a living and growing thing, perhaps a fruit tree that's never out of season. And very large. And the fruit grows really fast. And you can't pick it all, because more will replace it. And... yeah, it's like that. I'm not so good at analogies. Maybe it's just a bettermost tree.

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.

Why So Contrary?

So after a considerable hiatus I've dusted off the blog.  I've imported most of the old posts here. It seemed a good idea at the time, but maybe I'm just furthering Google's takeover of all digital information in the world.  Who can say?

The last year has been interesting to say the least.  New job, new city, new baby, and along with it all a new year, a new president, and some new outlooks on life.  Living back in Dallas has reminded me of a lot of things I don't particularly like: consumerism, selfishness, insincerity of faith, disdain for honest thought or debate.  That's not to say I'm above those things.  In fact, what I think bugs me about them is that I see them in myself quite readily, either lurking at various depths beneath the surface, or bobbing merrily along on the waves and soaking up the sun.  But being back here has also made me very aware of something else.  I'm not sure I play well with others.  In Connecticut I rolled my eyes at all the liberal elitism and self-righteous political leanings.  Now that we're back in Dallas I can't stomach what seems like conservative greed, lack of concern for others, and self-righteous political leanings.  No matter where we go I think I'll be going against the dominant culture.

It's not helped by the fact that we live in a society where the majority opinion has little incentive to pay any attention whatsoever to the minority opinion.  Chances are that's just who I am; it could be that I just like to stir up trouble.  I probably should have been a lawyer after all.  (But I am rather fond of the fact that my dad speaks to me, and I can't guarantee that would be the case had professional arguer been my career choice.)  So while it normally seems to apply to contrary financial investment strategies, The Contrarian seems an appropriate enough title for this thing.  I'll try to periodically update with what's bouncing around in my head.

GraceCast #1 - Candy

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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.

One Man and a baby

OK, toddler. Due to the recent sad events in Julia’s family, she’s off to be with her family for the weekend. This means it is Grace and me (and the dog) left to our own devices for two days.

So far things have been pretty good. When she woke up this morning to find that Mommy was gone there was a period of 10-15 minutes of pouting, not wanting to be in the same room as me, etc. We got over that pretty quickly though, and things have been pretty smooth since. We have come to terms with the fact that “Mommy on plane, see Nana and Granddaddy” although we’ll see how that goes tonight.

Lunch was a fun experience. Grace has been on quite the non-eating kick of late. We had a showing of the house at 11:00 this morning, so after some frantic house cleaning, bathing, snow shoveling and dog walking we jumped in the car to go to a local burger/hot dog joint. Two weekends ago the three of us went there to be out of the house when people came to see it, and at that point Grace was very into french fries. I thought perhaps I could capitalize on this to get her to eat something. It worked! Well, sort of. She greatly loved dipping french fries in ketchup. She also loved sucking the ketchup off of the fries. Eating the fries? Not so much. There were some solid (albeit not the most healthy) calories consumed though. Afterwards we got a cup of chocolate ice cream. Gracie devoured it. By which I mean she devoured it the way a glacier devours a mountain range. I might have saved us both some time and just acquired a milkshake. But, by the time she was done converting herself into a messy chocolate monster it was time for us to go back home, so I can’t complain.

Some other things I’ve learned this afternoon:

• Grace lies. She will tell you she wants to go upstairs and go night-night at nap time. Do not believe her.

• Grace hates Guitar Hero and Rock Band. I’m not sure why, but something about that guitar controller sets her off. Needless to say, I won’t be making much progress this weekend on either game.

• Grace has a renewed love with keys. Every infant loves to jingle them around. Now that she’s figured out what they’re for, she goes around sticking my keys into everything: door knobs, cabinet pulls, DVD players. Some of these tolerate unlocking better than others.

• Grace is a harsh music critic. Guitar Hero aside, she also makes amazing snap judgements on whatever music we’re playing on the stereo. Within about two notes on some songs she will loudly declare “no like song” followed imploringly by “diffint song”.

So far so good though. I may be singing a different tune if I can’t get her to bed until 10:30 or something, but I choose to be optimistic. Now I have to run, before Grace tries to unlock the dog or something.

Daddysitting

Tonight Julia is off doing grown up things, leaving me (however unwisely) in charge of the child.

6:30- We eat dinner. Sort of. By eat dinner I mean that I set food in front of Grace, which she plays with for awhile, but refuses to eat. This is par for the course. So far I am not a failure as a parent. We are however very excited by peas ("peez") and eat a few of them.

6:40- We go out to walk the dog, Grace strapped to my back in the Ergo. Grace is very helpful in holding the plastic bag should any business be taken care of by Abbey. ("Poo poo" is a favorite word. As I discovered last night it's exceptionally hilarious if you can get her to whisper it to you.)

6:47- We talk on a toy cell phone left by our babysitter. I am not sure what message this is sending our daughter. Grace clamps her finger in the clamshell halves. I kiss it, unsure of whether or not I am a failure yet or not.

6:50- Grace chases the dog ("Aaa") around and tries to hold the phone up to her massive doggy head. Dog is amazingly tolerant of this, but uninterested in talking on the beeping Minnie Mouse cell phone. I cannot blame her. Earlier finger trauma seems forgotten. My prospects of being a successful father are restored.

6:52- Grace holds on to a blanket and waves it frantically around while throwing little toy children up in the air. Soon this gives way to putting the blanket in my lap, pointing at it, and grunting incomprehensible baby noises. I am unclear on what I am meant to do.

7:01- Grace flaps her arms up and down as if a bird. Unable to fly she resorts to gathering toys and piling them up on the stairs. I throw the blanket over her head a great many times. It does not get old.

7:09- Grace attempts to type on this laptop. She is disturbingly proficient at using the mouse. Typing becomes difficult. Thankfully our attention span is very short and we go back to playing with foam block thingies.

7:14- We spend some quality time with said foam block thingies. They have cutouts in the center of them with various shapes. We try to put the shapes back into their proper squares. Grace masters ball, all else is up to me. Grace seems awed by my seemingly mystical ability to get a shape back into its square with one good push.

7:17- We put the foam squares back into the toybox.

7:19- We get the foam squares out of the toybox.

7:29- After making me put all the pieces in the squares we put the foam squares back in the toybox.

7:30- We get the foam squares out of the toybox.

7:37- Grace runs the foam inserts in and out of the kitchen. They seem to enjoy the tour.

7:39- Minnie Mouse is calling Grace again. I am allowed to browse the internet.

7:44- Browsing is over. My job of putting foam cutouts in their squares is needed.

7:48- Foam squares are put back in the toybox. I smell something fairly noxious.

7:49- Grace checks out clean in the diaper department. I narrow my eyes at the dog.

8:00- I ask Grace if she wants to go night-night. She repeats "night-night". I am not sure if she knows what she's saying. However, she then points up at the stairs, so I feel reassured.

9:15- I return downstairs. The last hour and 15 minutes have consisted primarily of me practicing for a job with the CIA. After torturing my own child by refusing to pick her up when she is in “I don’t want to sleep in my crib” distress for about an hour, I feel well equipped to waterboard terrorism suspects. How much harder can it be? Eventually Grace caves and falls asleep, I count it a small victory that she still wanted to be held by me until the bitter end, despite the fact that I was clearly a horrible and uncaring parent.

9:45ish- Julia returns. All is set back to right in the world. Until next time.