Tuesday, August 5, 2014

Training for Mars – Mind over Matter

In the laundry list of requirements for the colonization of Mars one important issue that is commonly placed on the back burner is the type of training that will be required for the colonists. The success of any Martian colonization mission will depend on how colonists handle new psychological experiences that will affect their behavior as well as their internal biology. Any belief that current NASA training will be sufficient is shortsighted. The most significant difference between performing scientific experiments on the International Space Station (ISS) and building a colony on Mars is the dearth of resources. While resources are limited on the ISS re-supply from Earth is just a few days away whereas any re-supply from Earth for a Martian colony is at least six months away (three to four months if new propulsion technology is developed). Therefore, not only must potential colonists be trained in certain colony critical specializations, but they also must have appropriate physiological and psychological training to ensure a maximized probability of success.

There are typically two types of astronauts: pilots and mission specialists. Due to the requirements of pilots to fly the launch craft and command missions their training focuses on space station and launch craft systems as well as leadership whereas mission specialists are trained in operation of robotics, spacewalks and other modalities for their specific scientific research. Joint training is also conducted in numerous simulators to emulate the vibrations and noise associated with take-off, guidance for payload docking, and buoyancy training in a pool to emulate movement in a weightless environment. Additional water training involves becoming SCUBA certified and endurance training (i.e. 75 consecutive meters of swimming in a flight suit and treading water continuously for 10 minutes in a flight suit).1 To appreciate the importance of current NASA astronaut training, a six-month mission to the ISS typically involves up to five years of training.

Psychological training will be the greatest difference between current astronaut training and future training involving Martian colonists. Currently the psychological makeup of an astronaut can have breaking points because most of the problems on the ISS can be resolved either through a simple EVA or assistance can be quickly dispatched from Earth. Also mission durations are typically only three to six months, thus any negative influences of monotonous actions or interactions with other crewmembers is limited in scope where astronauts depart before reaching their breaking points. However, for colonists there are no escape routes; problems with the equipment, one’s own self and/or other individuals will have to be addressed. While telecommunications will produce some minor outlets to seek professional counseling to manage some problems, other environmental problems cannot be resolved with outside assistance and instead will require adaptation or increased resolve.

Colonists will also be faced with various psychological stressors or “asthenia” [depressive and dissociative symptoms]. In the past these stressors have typically been divided into three stages: 1) an acute phase with a maximum duration of two months brought on by general biological and psychological adaptation to new surroundings; 2) an intermediate phase with more defined and persistent symptomatology including physical and mental fatigue, irritability and motivation loss; 3) a long-duration phase where the intermediate phase symptoms become permanent to the environment and cause significant damage to performance and intra-crew relationships.2-4

One of the most prevalent psychological stressors facing colonists is how to react to new physical limitations. For example colonists will experience a consistent feeling of physical fatigue due to a lack of sleep, lack of calories, limited ability to refresh (meditation, showers, sex, etc.) and a lack of complete nutrition born from balanced vitamins and minerals. Finally there is a large unknown with regards to nutrient absorption for no one really understands how reduced gravity and reduced calories will change a colonist’s microbiota. This change could increase calorie and nutrient absorption limiting reduced energy symptoms or decrease it further reducing energy levels.

It stands to reason that the notorious type A personalities will have difficulties adjusting to this “new normal” because of such a significant reduction in productivity and energy levels. The ability to neutralize frustration will be a key attribute to warding off negative psychological elements associated with this increased physical fatigue. In addition colonists will need to effectively budget their time to compensate for the reduced energy (i.e. work smarter due to it being more difficult to work harder).

Training to handle an increase in physical fatigue is an interesting issue. On its face one would think that the best way to prepare for this environment would be to emulate it. Potential colonists would have a restricted diet (similar to the one on Mars) and reduced sleep (4-5 hours) to psychologically experience the new physical reality on Mars. However, one question arises with this strategy, when should the “simulation” end? If this strategy is to expose and even acclimate colonists to the physical realities on Mars should it even end, i.e. should the Mars colonization mission simply extend the experiment?

Basically the question comes down to what is more important: ensuring the colonists are at peak physical health immediately before starting the mission, yet also have psychological awareness of how they will physically respond on Mars or not allow their bodies to reacclimate to normal conditions avoiding any discomfort associated with going through the physical adjustment again? In essence is the purpose physical adaptation or mental adaptation? If physical then the “simulation” should not end, but instead simply flow into the launch, if mental then the “simulation” should end with sufficient time for physical recovery before the launch.

A good analogy for this question is to think about a person that will need to tread cool water for two straight hours. Does the person enter the water five hours before the test begins to get them mentally and physically familiar with the temperature of the water and how it will affect them, then the individual leaves the water until the time of the test or does the person enter the water a half-hour before the test to allow his body and mind to acclimate to the change in temperature and then remain in the water until the test begins? Barring any strong and consistent negative biological responses among candidates, it seems better to facilitate mental training and preparedness versus physical training (i.e. the first option from above).

The issue of reduced calories creates a type of “double whammy” effect where not only will the reduction in calories reduce available energy creating greater fatigue, but it may also produce physical and psychological pain. Therefore, colonists will need to psychologically train for the reality that they will be hungry a significant portion of the first few years of colonization, especially because boredom/monotony tends to augment hunger due to a lack of attention occupation. The level of hunger will depend on how much money is spent transporting food both in the initial mission and any future supply missions and the level that colonists rest or sleep. If society is willing to spend enough money this potential psychological drawback can be mitigated completely; however, it stands to reason that society will not be willing to make this payment in full, especially with the ecological damage that the Earth could be suffering during the timeframe of the first Mars colonization mission.

Stress management is important both in reducing the probability of occurrence for stressful events and their associated magnitude of influence. Reducing the magnitude of events should be far easier due to much greater levels of certainty and associated preparation mechanisms like biofeedback systems, relaxation techniques, systematic desensitization, meditation and even the consumption of various drugs (if need be). Addressing the probability that stressful and dangerous events actually occur is difficult because one cannot prepare for everything, various things can go wrong during transit to Mars and after landing during the initial colonization period.

Events that unexpectedly occur outside the interaction between two or more colonists are best prepared for through simple decision making training. The most dangerous events are those that have an unpredictable element either in the timing of their occurrence or what is required to solve the problem (i.e. a new problem one did not expect). The reason for such danger is that the probability for poor decisions increases with respect to the lack of relevant knowledge regarding the current situation. Therefore, one important training exercise would be to give prospective colonists numerous tests that involve unexpected events with a lack of certain information.

Individually these scenarios will help develop important types of thought, both lateral and creative thinking as well as enhancing their ability to organize their ideas and thoughts into coherent strategy. These scenarios will also help colonists cope with panic and stress that comes from having incomplete information to solve an important problem. Within a team environment these types of scenarios should help interpersonal interaction through developing a methodology of how the colonists combine their individual efforts and reactions to these unexpected problems to form a cohesive strategy. The purpose of these tests is not to attempt to cover all possible negative scenarios, but instead familiarize colonists to types of thought processes that will increase their probability of successfully solving problem scenarios no matter what type of scenario occurs.

Some of the existing research on military decision making categorized five principal elements to addressing uncertainty (sometimes referred to as RAWFS): 1) Reduce uncertainty by collecting additional information; 2) Make reasonable assumptions to fill in gaps; 3) Weigh evidence and create multiple competing hypotheses (i.e. do not simply create one solution strategy based on existing information, but multiple ones); 4) Forestalling/foresight through development of future solution strategies that may be need to counter problems stemming from the existing solutions; 5) Suppress future uncertainty (i.e. through limiting its relevance or relying on unwarranted rationalization).5,6

Of these five elements the first four are effective and reasonable components to formulating an effective problem solving strategy. However, the inclusion of the fifth element is somewhat controversial. Obviously one could argue that the fifth element is important because it informs individuals not to place unnecessary emphasis on unknown information otherwise that unknown information could create a conflicting response relative to the known information. This reasoning does make sense, but unknown information should not simply be mitigated or ignored because it still plays a relevant role in future events. Simply ignoring something because it is unknown is not the proper strategy to solving a problem. Instead one must anticipate how the unknown information could influence future solutions and plan accordingly based on how the solution will change the scenario both in a positive and negative manner.

Additional psychological training may be necessary to addressing potential interpersonal problems, depending on the construction of the initial colonist crew. A crew comprised of different religions, different cultures, and even different genders will create additional stressors in the colonization process. While from a logical standpoint a homogenous colonist demographic would be ideal from a standpoint of neutralizing these stressors, it may be difficult for the public to accept 4 30 something heterosexual white males being the first colonists on Mars. Therefore, part of the psychological training could involve potential colonists accepting the fact that they would have to give up most of their specific religious and cultural demonstrations due to a lack of resources, space and conflict with those beliefs possessed by other colonists. This adjustment does not mean that these colonists need to give up their beliefs, but they will not be able to exercise these beliefs as publicly as they currently do.

Some may disagree with the idea that individuals would have to restrict their individualistic displays of culture suggesting that the other colonists should simply be tolerant of such actions. This belief is rather irrational considering the scenario involved with Mars colonization. As available resources and space are reduced individual freedom of expression also must be reduced for the sake of harmony. Some would counter this idea with the old Franklin quote, “Those who would give up essential liberty, to purchase a little temporary safety, deserve neither liberty nor safety.” Unfortunately these individuals appear to be arguing for perfect or unrestrictive freedom, which is foolish. Again colonists are not being told that they should give up their cultural/religious beliefs (the essential freedom), but their more demonstrative demonstrations (dispensable freedom). Those who cannot comply with this requirement have a shallow and too rigid belief structure.

Another problem will be a lack of water. Unfortunately some colonization proponents have this “pie-in-the-sky” idea that incorporating a strict water recycling methodology will neutralize the prospect for any water shortages. Clearly while water recycling will be a critical element in ensuring a maximum amount of water availability, a 100% recycling efficiency is impossible. Therefore, there may be times when individuals will have to manage being thirsty. In addition with a reduction in water use individuals will have less ability to wash themselves increasing levels of body odor. Thus, in most situations individuals will have to deal with unpleasant odors from themselves as well as other colonists.

In addition other psychological pressures like the workload and its survival importance (numerous people state that certain things are life or death, but while this is over-the-top hyperbole, on Mars most things will be), lack of privacy, reduced novel sensory stimulation and reduction in familiar social support could all impact mental health. Smart habitat design should create enough personal secluded areas within the habitat to manage any lack of privacy issues. Early in Mars colonization most colonists, especially those who have not previously been astronauts, will have numerous novel experiences; however, these experiences will soon move from novel to monotonous increasing the probability for negative psychological events. The monotonous reality of early Mars colonization can be overcome by simple psychological discipline as well as common enjoyable and personalized actions. Everyone has a favorite song or food or something that no matter how many times they interact with it they never get tired of it, this psychological attribute can assist colonists in neutralizing less enjoyable monotonous events that will be experienced on Mars.

The lack of familiar social support is only illusionary because communication mediums on Earth have created an environment where individuals are able to interact with family and friends in general whenever they want facilitating a form of communication entitlement. When communication ability is restricted this sense of entitlement is broken creating stress; i.e. this stress is not born from a lack of familial support. This rationality is supported by the fact that most individuals do not have meaningful amounts of unique information to share with friends or family when contact is constant. Interaction with family is still possible through restricted telecommunications and email, so overcoming the psychology of not being able to communicate whenever one wants is the real challenge. Pressures associated with the severity of colonization workload and survival can be managed effectively through positive crew interaction and stable meeting periods removing the “individual” mindset and instilling a “team” mindset neutralizing a significant amount of the pressure.

As most individuals recall from their own high school and college experiences the lull of a break from specific study can catalyze the loss of information. Preparation training is important, but over the course of six months of travel to Mars it stands to reason that skills and training will diminish at some unknown variant rate. Therefore, it is important to equip prospective colonists with the ability to review and augment their training in transit. Simulator software packages already exist that emulate in-flight software, but operation of these simulators can become somewhat tedious after a large number of views due to their stiff instructional nature. One idea that could be further explored to break-up this tedious structure is the creation of a competitive instructional platform.

Basically one could focus on creating a game of sorts to augment training; the computer game could resemble a structure like the game “Trivial Pursuit” where players are assigned certain “occupations” that would exist in the process of Mars colonization. Answering questions pertaining to duties and skills associated with these occupations would results in points eventually crowning a winner. Such a system would also benefit other players through creating a form of “osmotic” redundancy where other colonists may not be an expert at occupation x, but would know enough of the necessary skills to take over duties if the expert become incapacitated. The redundancy would eliminate the biggest flaw in a specialized system structure, what to do when a specialist is not long available to perform his/her duties.

Expanding on that idea obviously while specialization is important the subject training cannot be so myopic that only one potential solution is presented for a given problem. Martian colonists need to be trained to think like physicians: make a diagnosis and then determine the best course of action to address the problem. This training must also coordinate between colonists because studies have shown that high performing teams have fewer interaction patterns as well as engage in shorter more concise interactions.5,7,8 Basically for problem A colonists 1 should have a general idea what colonist 2 wants to do. This training strategy should also help the emotional state of colonists for they will not feel intellectually isolated and pressured as the only individuals to have information about subject A.

Some individuals have claimed that it is important to ensure that the medium utilized to augment training is significantly entertaining. While an entertaining medium will make training more enjoyable, it is not an essential element. Remember that the first colonists will be professionals and will have their lives on the line; the expectation that these individuals will not perform necessary training supplementations due to it being “boring” is rather far-fetched. Therefore, it would be beneficial if the entertainment factor for supplementary material could be enhanced, but effort should only be applied in this area after all other important factors have been addressed.

Current medical care in space for severe conditions involves patient stabilization until a launch craft can retrieve the ill astronaut for transport back to Earth. Unfortunately this aspect of training will have to change for a Mars colonization mission because transport back to Earth for medical care will be impossible. Therefore, medical training will have to be expanded to develop the ability to treat a variety of conditions during transit and on the surface with one of the critical medical strategies will be dealing with secondary motion sickness brought on by microgravity negatively influencing the vetibular system in the inner ear due to a reduced responsiveness of the otoliths.9 Other medical emergencies will involve the failure in part or whole of life support, capsule depressurization or fire.

Astronauts typically have one of three types of medical training: basic training for a medical officer, more advanced training for a paramedic and full training for a physician. 75% of astronauts have either experienced a medical event or utilized medication to treat a non-emergent problem.9 Most of these injuries involve, excluding motion sickness, minor trauma to the skin, various muscle ailments due to too much or improper exercise, space motion sickness (which is very common despite preparation training), sleep deprivation, headaches from excessive CO2 exposure and general psychological fatigue.2,10,11

However, there are limitations involved when focusing on the history of medical outcomes in space largely due to small sample size, genetic variation in astronauts, inaccurate historical information due to changes in data storage over decades and inadequate controls to confirm the significance of the data collected.2,12 Despite all of these caveats historical data is still important to consider in gauging what will be expected for colonists during transit and on Mars and should be incorporated into medical training. Unfortunately the biggest variable in expectant negative medical outcomes involves the duration of exposure to a reduced gravity environment. With most astronauts only staying for a maximum of six months on the ISS, it is difficult to gauge what type of medical training colonists need for permanent stay on Mars at 1/3 the gravity of Earth.

Overall with regards to medical care it would be incredibly valuable to have a fully medically trained physician, most likely a general practitioner, among the first set of colonists. One of the principle reasons for the inclusion of a general practitioner is that while training for a Mars mission will be extensive, becoming a physician involves even more training including various real-world experiences acquired as an intern, resident and practicing physician. Therefore, instead of using some percentage of training time creating an individual with skills inferior to a physician on some level, the physician can receive secondary training in another field further enhancing the effectiveness of the crew. Also an effectively trained physician can reduce the amount of required medical equipment, especially with regards to complexity and redundancy, reducing launch costs. Finally trained physicians have unique perspectives and greater understanding of how to deliver treatment over a short, medium and long-term setting.13,14

The progression of how colonists react to changes in their ability to act, in part due to changes in the autonomic nervous system (ANS), is one of the biggest current question marks due to long-term simulation difficulties. The ANS plays a large role in almost all unconscious/subconscious actions and is made up of three different operations: the enteric systems, the sympathetic system and the parasympathetic system. Sympathetic predominance occurs largely when an individual is awake to facilitate engagement with the surrounding environment, especially those that require quick responses and parasympathetic dominates during sleep to facilitate biological recovery.13

The operation of the ANS can change for astronauts. For example some studies of both pre-flight supine position and habitation of the ISS have shown a decrease in mean arterial blood pressure and heart rate15,16 as well as a decrease in parasympathetic activity,17 which could influence sleep quality, alertness and even nutrient processing. However, the pilot portion (105 days) of the Mars 500 isolation study demonstrated an increase in parasympathetic activity with no significant difference in length or phase of sleep-wake periods.18,19 Either parasympathetic activity radically shifts between 105 days in isolation and 180 days in isolation (in space) or this change is cannot be effectively biological modeled naturally in Earth-based simulations. Thus this significant biological change must either be ignored (which is dangerous) or potentially chemical induced during Mars mission simulations. In addition part of the reduction in physical daily activity levels could be attributed to this change in parasympathetic activity, which could also explain the increased amount of rest seen in the Mars 500 study has the experiment went on.19

Another concern may be how sympathetic activity changes with respects to type and duration of light exposure. Typically sympathetic activity increases with color light wavelength20 and light intensity,21 thus prolonged exposure to most artificial lights, which are normally of lower intensity and color wavelength than natural light, could reduce sympathetic pre-dominance. One way to address this problem could be to incorporate different colored LEDs that would make up for changes in wavelength with intensity and visa-versa.

There are two chief subject areas for training: expected events and unexpected events with three sub-subject areas: biological, equipment, and interpersonal. Not surprisingly expected events are the easiest to manage because they are expected, thus only a proper solution methodology is needed to neutralize them when they arise. The problem with the expected events is ensuring that the determined methodologies are recalled and available when needed. To increase the probability of positive outcomes training should involve redundant learning where multiple individuals have knowledge of a given solution. Such an environment can be created where one individual has detailed knowledge of the entire solution strategy and other individuals understand the solution in broad strokes to ensure redundancy.

Unexpected events must be addressed through intensive preparation of generally unexpected events. Due to training and memory time constraints one cannot directly prepare a crew for an event that does not have a reasonable probability of occurrence; however, the crew can be prepared indirectly through engagement with various unexpected events and then observing the solution methodology that the crew utilizes to solve those events. Understanding and editing the methodology that the crew uses to address unexpected problems will maximize their ability to deal with unexpected problems during colonization. Finally interpersonal events differ somewhat from biological or equipment in their unpredictability. Potential negative crew events must first be marginalized through intelligent and practical crew selection, which may need to sacrifice diversity for simplicity. In addition negative crew events can be neutralized through constant team meetings and interactions so no one feels isolated or unimportant. Overall training for a Mars colonization mission should be exhaustive focusing on increasing psychological fortitude, developing team cooperation and producing effective execution methodologies to develop solutions to both expected and unexpected problems.



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Citations

1. Johnson Space Center. “Training for Space: Astronaut training and mission preparation.” NASA. http://www.nasa.gov/centers/johnson/pdf/160410main_space_training_fact_sheet.pdf

2. Bridge, L. “Impact of medical training level on medical autonomy for long-duration space flight.” NASA (TP–2011-216159). Jan. 2012.

3. Grigoriev, A, Kozlovskaya, I, and Potapov, A. “Goals of biomedical support of a mission to Mars and possible approaches to achieving them.” Aviat Space Environ Med. 2002. 73:379-84.

4. Davis, J. “Medical issues for a mission to Mars.” Aviat Space Environ Med. 1999. 70:162-8.

5. Noe, R, et Al. “Team training for long-duration missions in isolated and confined environments: a literature review, an operational assessment, and recommendations for practice and research.” NASA/TM-2011-216162. Oct. 2011.

6. Lipshitz, R, and Strauss, O. “Coping with Uncertainty: A Naturalistic Decision-Making Analysis.” Organizational Behavior and Human Decision Processes. 1997. 69(2):149-163.

7. Orasanu, J. “Crew collaboration in space: A naturalistic decision-making perspective.” Aviat Space Environ Med. 2005. 76:B154-B163.

8. Stachowski, A, Kaplan, S, and Waller, M. “The benefits of flexible team interaction during crisis.” J Appl Psychol. 2009. 94:1536-1543.

9. Wikipedia Entry: Space Medicine

10. Summers, R, et Al. “Emergencies in space.” Ann Emerg Med. 2005. 46:177-84.

11. Scheuring, R, et Al. “Musculoskeletal injuries and minor trauma in space: incidence and injury mechanisms in U.S. astronauts.” Aviat Space Environ Med. 2009. 80:117-124.

12. Cermack, M. “Monitoring and telemedicine support in remote environments and in human space flight.” Br J Anaesth. 2006. 97:101-14.

13. Recordati, G. “A thermodynamic model of the sympathetic and parasympathetic nervous systems.” Auton Neurosci. 2003. 103:1-12.

14. Taylor, J, et Al. “Mechanisms underlying very-low-frequency RR-interval oscillations in humans.” Circulation. 1998. 98:547-55.

15. Verheyden, B, et Al. “Adaptation of heart rate and blood pressure to short and long duration space missions.” Respir Physiol Neurobiol. 2009. 169(Suppl 1):S13–6.

16. Verheyden, B, et Al. “Operational point of neural cardiovascular regulation in humans up to 6 months in space.” J Appl Physiol. 2010. 108:646-54.

17. Baevsky, R, et Al. “Autonomic cardiovascular and respiratory control during prolonged spaceflights aboard the International Space Station.” J Appl Physiol. 2007. 103:156-61 .

18. Vigo, D, et Al. “Sleep-wake differences in heart rate variability during a 105-day simulated mission to Mars.” Aviat Space Environ Med. 2012. 83:125-30.

19. Vigo, D, et Al. “Circadian rhythm of autonomic cardiovascular control during Mars 500 simulated mission to Mars.” Aviation, Space, and Environmental Medicine. 2013. 84(9):1-6.

20. Yasukouchi, A, and Ishibashi, K. “Non-visual effects of the color temperature of fluorescent lamps on physiological aspects in humans.” J Physiol Anthropol Appl Human Sci. 2005. 24(1):41-3.

21. Yokoi, M, et Al. “Exposure to bright light modifies HRV responses to mental tasks during nocturnal sleep deprivation.” J Physiol Anthropol. 2006. 25(2):153-61.

Thursday, July 17, 2014

Youth Suffrage: Is it time?

One of the chief theoretical advantages of a democracy is the idea of “one person one vote”, a characteristic that limits the total power that can be accrued by a select oligarchy. However, there is always the lingering question of what parameters should be applied when creating requirement criteria for voting. Throughout U.S. history these parameters have become less and less restrictive including age. Based on the important issues in present society the question of whether or not the voting age should be adjusted again becomes even more prevalent. Note that when the term “voting age” is used it references the minimum age that a state and the federal government cannot deny an individual the ability to vote.

The most common argument for lowering the voting age harkens back to a perceived central theme of the Revolutionary War, “no taxation without representation.” A number of 15-17 year olds have jobs that require them to pay income taxes as well as other smaller taxes like payroll taxes, yet do not provide them with an ability to participate directly in the political process. Therefore, some argue that it is historically prudent that these individuals are given the capacity to vote. Unfortunately this mindset is not as clear-cut as its proponents would like to believe.

First, with the current state of modern technology individuals as young as ten can create marketable content on the Internet or fashion and/or custom jewelry pieces. So under the above premise should such ten year olds be given the right to vote as well? Second, the idea of “no taxation without representation” is not as noble as one might think. The idea was largely peddled as a “call to arms” so that the colonial public would accept the Revolutionary War, which on its face provided much more benefit to the merchant and upper class sectors of the colonies versus simple common land owners, especially since most of the dying would be done by the colonial public. Third, the idea of “no taxation without representation” is used literally by proponents, thus the literal application would imply that only individuals with jobs that pay a large enough wage should be allowed to vote, this is certainly not in the spirit of democracy. Fourth, the idea of representation itself is flawed because without a reasonable probability to produce an informed mindset, that representation produces a detriment to society.

An example of this important fourth reason is as followed: suppose Apartment Complex A is having a vote among its 50 residents on whether or not to establish a new more restrictive noise ordinance. 10 residents are opposed to this new ordinance because they commonly have parties that involve loud music and do not want these “rituals” interrupted. 20 residents are in favor of this new ordinance because they are frequently bothered by the noise that emanates from these parties. The final 20 residents have no strong opinions on this vote and are not aware of the grievances of 20 pro ordinance residents because they are far enough away from the 10 con ordinance residents that they do not experience the loud music. Under these conditions these final 20 residents should not vote because of their lack of interest and information; however, more than likely if they vote they will vote against the ordinance due to reasons of either simplicity or avoiding future restrictions on themselves. Therefore, these 20 “neutral and uninformed” voters will ineffectively swing the results of the vote because they do not understand how the outcome of the vote affects all residents in Apartment Complex A.

Some proponents of youth suffrage would argue that age does not define maturity and/or information acquisition, which is true. However, age does create greater chances for opportunity and experiences that can increase the probability of intelligence and maturity. Probability is what matters in the case of the blind voter. Clearly not all adults are sufficiently informed of the depth of their votes, but there is a higher expected probability that these individuals have the ability to inform themselves. For example based solely on life experience an 18-year old individual has a higher probability of having the tools to understand the significance of his/her vote over a 16-year old individual.

Proponents typically put forth various other less meaningful rationalities like 16-year olds can drive, drop out of high school, be charged as an adult in certain crimes, encourage greater interest in politics, etc., but none of these reasons have sufficient ability to challenge the uninformed voter argument. So does that mean that the idea of youth suffrage is logically dead? Not really for proponents have missed the very idea behind the initial age change in suffrage (age 21 to age 18), a reasoning that now applies now to even younger individuals.

Sadly in modern society very few individuals focus on the welfare of the future when crafting public policy and legislation, choosing instead to focus on the present. Unfortunately this focus results in the application of numerous strategies that damage the future in order to provide greater benefit for the present. These policies that damage the future inherently damage the future health (at all levels) of the nation’s youth. However, youth are not given the appropriate mechanisms to defend themselves against this threat because they cannot participate in the political process. The idea that a significant portion of voting influence occurs through the intent of parents to protect and grow the future for their children, i.e. make a better life, does not appear to be valid due to the lack of policy addressing income inequality and global warming, the two most important issues for the future; neither of these issues have been tackled with the necessary urgency that their solutions require.

This betrayal of the future can be demonstrated through the following example. Suppose Person A is given the opportunity to select one of two options:

Option 1 – Receive 5 dollars now and receive another 5 dollars 2 years from now;

Option 2 – Receive 15 dollars now and lose 5 dollars 2 years from now;

While the net outcome for both choices is +10 dollars, the future is supported by only one of those choices. Some would argue that due to economy of scale the second option is actually better for the future because the present has more ability to solve existing problems with 15 dollars than 5 dollars. This statement is true, but only in theory. Unfortunately the present is not using the sacrifices they are demanding of the future to create a better future.

For example the prospect of global warming has been a serious problem for over two decades, yet industrial society, outside of a global recession, has increased the amount of greenhouse gases emitted into the atmosphere over those two decades by a significant amount and the money made from that pollution is not being redirected into a new energy infrastructure and other strategies for the reduce global warming damage for the future.

Overall this lack of power is the real reason to ask whether or not the age of suffrage should be extended to individuals younger than the age of 18. Originally the age of 21 was decided as the voting age by the Founding Fathers because of the importance of the age in English culture at the time (21 was the age of legal drinking, voting and knighthood). This limit was significantly challenged by the logic associated with the Vietnam War where individuals between the age of 18-20 could be drafted, sent to war and die without the ability to influence the political process (lack of power). To rectify this hypocrisy the voting age was lowered to 18.

However, while the lack of power issue is a more viable rationality for youth suffrage over more inaccurate and simplistic arguments like “no taxation without representation”, the problem of the uninformed voter still looms. This concern can be addressed by tying a simple test to voting registration for 14 to 17 year olds. The test would focus on simple and basic, yet important concepts to demonstrate that these individuals are capable of effectively participating in the democratic process. A vast majority of 18 year olds have taken some form of civics and/or government class as a requirement to graduate high school, thus this test would be designed to encapsulate the basics of the knowledge acquired from that study.

For example this type of voting test could be conducted at a federal or state government building. The test would be comprised of three sections: 1) identify the three branches of the federal government and briefly describe their roles in government; 2) identify the holders of the major positions of governmental power in the applicant’s state (i.e. governor, two federal senators, which political party controls the legislature, mayor of the city of residence, etc.); 3) identify how one would acquire information about a particular political topic to improve his/her understanding of the issue;

Section 1 is required to ensure that the applicant understands the basic structure and function of government otherwise the importance of voting is lost. Section 2 is required to ensure that the applicant has a basic understanding of the political environment of his/her own state and understands the hierarchical structure of local and state government. Section 3 is required to ensure that these younger individuals have the ability to rid themselves of ignorance in order to limit the probability that they are simply voting as extensions of their parents or friends. Basically this test should ensure that applicants have an understanding of process, an awareness of reality, and an ability to acquire relevant information for the future.

While the problem of rationality has been solved above, a secondary problem of application still exists. This problem can be seen by reviewing the history behind the 26th Amendment. On June 22, 1970 an extension of the Voting Rights Act of 1965 was passed that required changing the legal voting age from 21 to 18 in all federal, state and local elections. Soon after both Oregon and Texas challenged the change to this age change leading to the case Oregon v. Mitchell (1970). The Supreme Court declared that it was unconstitutional to force states to register 18-year olds for state and local elections, while retaining the federal election age limit change. Without state involvement it was deemed too expensive to create and maintain separate voter rolls (one federal and one state), thus the 26th Amendment was crafted to eliminate this problem associated with the previous legislative action.

Overall it is unclear whether or not the same constitutional problem may exist for extending youth suffrage, but it stands to reason that it does. Also while the 26th Amendment was passed very quickly it is reasonable to assume that certain states will not be as forthcoming with an amendment that lowers the minimum voting age to 14 or even 16. The reasoning behind opposition to youth suffrage may not be valid due to the securities provided by the required voting examination to substitute for the experience of age, but that does not eliminate the possibility that states will still oppose such a change. Therefore, the reasoning for lowing the voting age may be sufficient (allow teenagers to protect their future because enough adults certainly are not taking the proper steps to do so), the drive by states to allow such a change may not be sufficient. Unfortunately as it currently stands the application of youth suffrage may simply suffer from a lack of motivational drive for its establishment versus a lack of logic.

Friday, June 27, 2014

ER Crowding – Current and Future Issues

Crowding in emergency rooms (ERs) has been an increasing problem in the developed world for the last few decades, especially in the United States. However, the political and medical arenas are not appropriately addressing this problem as from 1995 to 2009 annual ER visits in the U.S. increased by 41% (96.5 million to 136.1 million), but the number of hospital ERs have decreased by 27% (2,446 to 1,779)1-3 Among U.S. ERs in 2010 a mere 31% achieved their triage targets and only 48% were able to admit patients within 6 hours of registration.4 One of the immediate problems with this overcrowding problem is that it has become a normal occurrence. How could ERs effectively respond to outbreaks of highly contagious pathogens, industrial accidents, terrorist attacks, etc. if currently over half of the non-critical patients have to wait 6+ hours before receiving treatment? Apart from disasters ER crowding increases patient mortality, reduces quality of overall care, impaired transport access and increases financial losses and stresses. Also note that ER crowding is not a unique problem to market economics, but also affects countries with universal systems of medicine like Canada, Australia, New Zealand, etc., thus the passage of the American Care Act will not systematically result in a reduction in crowding.

ER operations have numerous metrics to measure the effectiveness of operations, but typically the most commonly used ones are length of stay (LOS), % of patients who leave without being seen (LWBS), wait time (WT), and ambulance diversion (AD).5,6 However, while these metrics are commonly used, they should not be utilized in a vacuum because some ERs do not even have the ability to divert ambulances and patient wait metrics like LOS and WT are influenced by case complexity. Another concern about these metrics is that most of them are rarely made public nor are there set standards regarding quality, thus it is difficult to have common up-to-date information to determine whether or not a given community is receiving adequate medical care in both absolute and relative terms.

Opposite the fast-paced ambulatory delivery of a critical patient into an emergency room who is immediately admitted, the general operation of an emergency room from the perspective of an individual who enters outside an immediately apparent life threatening condition is as followed:

First, the attending nurse (rarely a physician) conducts a basic triage. Triage itself typically adheres to the Emergency Severity Index (ESI), which is a 3 or 5-tier categorization that combines urgency with an estimate of the resources required to treat the condition.7-9 In the original, now less common 3-tier system the three groups are: immediate treatment required (emergent); urgent, but not currently life or permanent health threatening; or minor condition that can be addressed in time (non-urgent); obviously these categorizations are required to ensure the best and most appropriate care for all potential patients.

In the 5-tier system an additional two groups are added: resuscitation and less urgent making the whole tier structure – 1) resuscitation; 2) emergent; 3) urgent; 4) less urgent; 5) non-urgent.8,9 Realistically the addition of these two new tiers seems rather unnecessary because resuscitation is an obvious choice for immediate treatment not requiring its own category and the difference between less urgent, urgent and non-urgent is marginal. However, it seems to work and does not appear to create significant complications with its seeming unnecessary redundancy.

Clearly individuals with urgent conditions should be seen by physicians before individuals with minor conditions even if the individual with a minor condition arrived first. Triage typically involves acquiring major vital signs (temperature, pulse, respiratory rate, blood pressure, etc.) and a short interview to assess what the patient is feeling and the major details regarding medical and medication history. Depending on the type of classification the new patient will be placed in a certain position on a waiting list.

The triage system typically functions under a scoring system to evaluate the condition of the individual. In addition to physical scoring, physiological scoring is also used to address urgency for treatment. Utilized scoring systems include APACHE II (which is also the most common ICU system to measure prospective mortality), SAPS II, MODS, PRM and GCS (becoming more popular due to its simplicity, sensitivity and specificity).10-14 Scoring systems have also demonstrated that ER care is significantly more important than follow-up care in the ICU showing significant drops in predicted mortality for proper ER care.15 In addition to the older tests, a newer test, the Mortality in Emergency Department Sepsis Score (MEDS), was recently been developed to predict the probability that ER patient contract an infection that could increase complications and/or mortality.16

While tests like APACHE II, SAPS II and MODS are important analysis elements, the development of new ER specific scoring systems like MEDS is important because the older systems were designed to measure illness severity and mortality risk probabilities in a less time dependent nature within the confines of an ICU whereas the ER environment is fast-paced and more time dependent creating a lead-time bias.10,15 Factors that are considered important for ER based scoring systems include: 1) variables that reflect pre-hospital illness severity; 2) illnesses that can be contracted from the ER; 3) ability to be incorporated into a multi-center database with sufficient size and power to validate the model’s accuracy; 4) analytical ability for the relationship between the predictive variables and actual patient outcome for calibration and reliability measurement; 5) secondary predictive effects beyond simple mortality to measure LOS, WT and return visits; 6) use of time-indexed variables to reflect treatment response during care.10,17,18

While a nurse typically governs triage, some studies have suggested that when a physician is in charge of triage instead of a nurse various performance metrics like LOS, LWBS and AD all decrease.19-21 Of course the trade-off for this potential improvement is an increase in cost due to hiring another physician. Otherwise in-room care for patients that have moved from the ER waiting room to an exam or operating room will suffer because of the lack of a physician or one being stretched between exams and triage.

Second, individuals who do not require immediate treatment enter the registration process where the patient officially registers as a patient, which involves filling out all of the relevant paperwork familiar to any first-time patient in a general practitioners office. This step is relevant to consolidate all relevant information including a more detailed medical history and payment information (insurance, etc.). These details are important to create a single medical record that can be referenced during the patient’s stay in the ER. It is important to note that a number of people incorrectly believe that an uninsured individual receives free medical care when going to an ER. This is not correct. The Emergency Medical Treatment and Active Labor Act of 1986 only obligates ERs to care for individuals regardless of ability to pay. Uninsured individuals that receive care from an ER still receive a bill for the services rendered. If they are unable to pay the bill then their credit score is negatively affected and if the hospital/physician so desires they can be sued for the amount. This billing is why uninsured individuals in the past did not go to the ER for every little thing that may be wrong with them.

Afterwards the ER visit proceeds similar to an standard physician visit where when it is an individual’s turn the individual enters an exam room where a nurse reassesses blood pressure and temperature, and if necessary draws blood and/or collects a urine sample for lab testing purposes. Next a physician visits the patient and after a brief discussion makes a differential diagnosis. After the diagnosis for conditions that are not immediately critical the patient is prescribed a treatment and sent home.

One of the major reasons critics cite for continued difficulty in transforming ERs to better manage their patient flow is their tradition/culture. As described above the standard operation of an ER is one person – one task with little intra-staff interaction, a methodology that in the era of computers and multi-tasking is viewed as inefficient and costly. A significant amount of this inefficiency comes from having different doctors and nurses repeat information gathering due to lost or “mistranslated” previous attempts. This problem is augmented by poor coordination among providers, which are typically highly fragmented encompassing multiple emergency medical service agencies with different standards and different practices to the point where agencies in different, but adjacent jurisdictions have difficulty communicating. This coordination is difficult due to turf wars and because transport options are limited.

To maximize the effectiveness of reform interventions dramatic improvement in intra and inter-hospital coordination will be required including standardization of procedures and practice. Incorporation of electronic health records would help in managing this concern, but applying electronic health records for an ER is significantly more difficult than a standard physician office due to the required pacing and lack of consistency in the repeat visitation of patients. Unfortunately in addition to the incorporation of electronic health records, the expanded coordination discussed above has always been the go-to solution and the general dream of individuals trying to address crowding problems, but this coordination is very slow to developed despite the desire to produce it.

One strategy to increase coordination is to increase multi-tasking. However, while some cite some limited studies about the improved efficiency born from multi-tasking there is concern about expanding this strategy for other studies suggest that demonstrated reduced cognitive efficiency in individuals who engage in multi-tasking versus focusing on a single task and then moving on to a secondary task.22 Reduced cognitive efficiency would increase the probability of medical errors and increase the probability of detrimental medical outcomes including death. In addition the demographic of ER patients and the seriousness and complexity of their conditions are changing with more older patients with chronic conditions and multiple co-morbidities with younger patients having fewer non-urgent and more semi-urgent and urgent visits.23 Increase the level of complexity in condition and diagnosis while decreasing the attentiveness and focus will further increase the probability of negative outcomes.

One of the past arguments rationalizing ER crowding was that too many uninsured individuals used the ER as a primary care physician because the lack of insurance dramatically reduced their ability to schedule appointments with general practitioners. Individuals who frequent the ER constantly are referred to as “frequent flyers” and typically make up 8-14% of ER patients and were thought to include large numbers of uninsured individuals.24 Therefore, one solution was increasing the probability that these individuals get insurance so instead of going to the ER they would go to a general practitioner to receive general medical care. Unfortunately this solution, while sound in theory, has not followed theory in reality. Both the expansion of insurance availability in Massachusetts in 2006 and various other states through the American Care Act have resulted in increases in ER patients with state based insurance (Medicare, Medicaid).25 So why is reality apparently trending contradictory to theory?

Two principle reasons jump to mind. First, most common analysis overestimated the number of individuals with no insurance who were using the ER for basic and principle medical care. While frequently flyers make up anywhere from 8-14% of the total patients during the day, most of these individuals have insurance. Recall that the ER is only bound to treat individuals regardless of ability to pay ensuring that they will receive treatment. However, that treatment is not free. Therefore, in the past individuals without insurance who received medical care from an ER would still have to pay for those services. It stands to reason that these individuals would not attend the ER constant because if they could not afford insurance, then they would not have consistent levels of disposable income to cover numerous ER visits for every nick and scrap.

This rationality hints at the second reason for why ER patients have increased. The primary assumption was that uninsured individuals would stop attending the ER when they received insurance. However, what appears to be happening is that previously uninsured individuals are actually attending the ER more often. The reason behind this behavior is probably derived from the fact that government sponsored insurance has significantly increased the number of individuals with insurance while the number of available general practitioners that are able to service these newly insured patients as well as past/current insured patients has increased at a much slower rate. Therefore, there are significant shortages between insured patients and available doctors to see them via appointment. With the lack of consistency in acquiring an appointment with a general practitioner, the consistency of an ER is appealing. The only real ways to resolve this behavior is train and certify more general practitioners, something that will not happen in the immediate future.

Interestingly enough this premise of ER crowding due to uninsured individuals using the ER for basic medical care in the past is not supported by research. Research suggests that while it was initially reported that this input factor was meaningful26,27 that initial interpretation was probably incorrect. ED crowding is more influenced by sickly and chronic patients who are admitted to the hospital than individuals who have minor injuries and are sent home after routine care/check-ups.28-32 Not surprisingly hospital occupancy (i.e. the number of available beds) versus the number of patients, which leads to boarding, is the strongest element correlated to length of stay in the ER and overall wait times.31,32 Other smaller factors leading to crowding are inappropriate ambulance diversion and direction33 and recently discharged inpatients looking for additional care under various motivations.34 However, as mentioned above boarding due to a lack of bed is the chief element responsible for ER crowding.

The most important consideration when identifying possible solutions to ER crowding is to create a standardized evaluation system to determine which solutions are effective, which are not effective and which are mediated by unique environmental conditions (i.e. effective for one particular hospital, but not for another). Developing this evaluation system would also make it much easier to assign accountability and measure overall and sector specific performance to create effective strategies to correct any problems. In addressing “quality” the Institute of Medicine (IOM) defined quality as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” and described six dimensions of quality care: a care that is safe, effective, patient centered, timely, efficient, and equitable.35

Not surprisingly various individuals have suggested that to measure the true value of a system an ER must be evaluated on the application of evidence-based medicine. While this solution should be effective it is sometimes difficult to coordinate the necessary information to ER doctors who typically have little downtime and do not want to spend it reading the latest meta-study. Ideally the practice of extensive evidence-based medicine is one of the dreams of incorporating technology into hospitals to the point where a physician can simply type a condition into a computer and the most effective treatments (as defined by existing evidence) with their corresponding caveats would appear. Unfortunately this reality has not arrived, but a less efficient substitution strategy involves conducting frequent physician meetings for brief reviews of the newest treatment strategies.

Some have suggested that patients define whether or not the quality metrics have been met through evaluations. However, patient evaluation is troublesome because patients may regard elements or instances of discomfort through their own personal lens without understanding or acknowledging the bigger picture. For example a patient may want a glass of water, but due to nurse/physician preoccupation in other more pressing tasks this individual waits a long time before getting the water and possibly develop a slight case of dehydration while waiting. For the patient such an event could easily be worth a quality demerit, but from the perspective of the hospital such an event is irrelevant. Similarly patients are not aware of a significant amount of “behind the scenes” actions relative to their treatment, thus have incomplete information regarding overall treatments and may mischaracterize certain outcomes as poor or negative. This is not to say that patients should not have the ability to make evaluations of their care, but it must be understood that there is high probability that those evaluation cannot be viewed as accurate inside the vacuum of the patient’s own opinion.

Another idea would be to create a small group of government based auditors who would periodically visit ERs and after observation and various informal interviews these individuals would evaluate ER performance and quality based on a series of standardized evaluation metrics. Under this system the bias of patients can be neutralized by an individual who has an understanding of a bigger picture and the bias of the ER authority will be eliminated by a neutral un-invested individual as well as dramatically reduce the time requirements that would be required for mandatory employee based evaluations. The one major drawback to this method would involve producing additional money to fund these government-sponsored auditors.

As mentioned above creating an effective evaluation system will increase the ability to produce quality solutions. Currently one of the most obvious solutions to addressing ER crowding is to reduce boarding. Boarding is the official term to describe when a patient who cannot be moved into an inpatient unit due to a lack of beds remains in the general ER area and receives periodic treatment within. During normal operating hours boarding represents anywhere from 20-40% of the total ER patient population.36 Boarding levels are also significantly influenced by financial decisions in effort to maximize hospital revenues. Not surprisingly average revenue per patient is higher for non-ER admissions than for ER admissions,37 thus hospitals favor giving beds and rooms to those higher value patients leaving ER patients waiting for a bed. The easiest method to reduce boarding is to increase the number of beds available in a hospital. However, this method costs significant amounts of money not only for the beds, but also for hospital expansion to place the beds. Hospitals have already attempted to increase bed number by placing more beds in single rooms, but this strategy can reduce patient welfare being counterproductive.

Some argue that how the bed is utilized also needs to be considered. There are two major types of beds: observation and inpatient. Observation beds are less costly to construct and staff due to building code requirements and upkeep relative to the patients that utilize them.38 In addition in Certificate of Need states constructing additional observation beds do not require the approval of a state agency unlike constructing additional inpatient beds.38 However, when constructing beds in general it must be understood that there are diminishing returns based on changes in patient inflow and medical requirements. Roemer’s Law is frequently cited when considering bed expansions because if one expands bed capacity one is expected to need it and use it. In some context similar to the psychology behind the Jevons paradox if beds are constantly used then the perception for more beds typically results. Basically there appears to be a positive feedback between bed capacity and number of beds used, which may create an inverse relationship where increased capacity increases demand rather than addresses it.39 Thus characteristics behind bed addition must be carefully analyzed before it occurs.

While the metric behind the need to increase bed occupancy is not standard, some research has suggested that a consistent level of 85% during measurements taken at midnight is the minimum level required before beds should be added.40 Note that the average “midnight census” typically calculates the minimum level of occupancy in a given day. The principle reason for this characteristic is the process of the “23-hour patient”. These types of patients are admitted in the morning and discharged in the late evening as a means to allow for evaluation of patients, yet avoiding unnecessary hospitalization. While estimating the difference between the midnight census and the actual occupancy is not universally deterministic most estimate a 5-15 absolute percentage point increase from the midnight census percentage value.40 However, it must be noted that the “23-hour patient” was a popular strategy in managed care, with the ebb and flow in the popularity of managed care it is difficult to estimate how significant this strategy will have in the future.

85% occupancy is the target more cited by professionals and in research, but this figure is typically applied universally not considering the size of the hospital and the number of people that seek medical services. Due to a lack of economies of scale and usage flows, smaller hospitals should have smaller target levels because they will typically have a smaller number of beds creating a greater sense of urgencies when facing greater than average patient visitation. For example if hospital A has 100 beds, an 85% occupancy utilizes 85 beds leaving 15 free; however, hospital B may only have 35 beds, an 85% occupancy utilizes 30 beds leaving only 5 free placing them in more danger for exceeding capacity on an above average admittance day.

Also there are some elements that must be considered including the difference between certified beds and staffed beds. Certified beds are those that are approved by authorities for use on a permanent basis and have been deemed to have sufficient staff to support its use where staffed beds are those that designated only for inpatient or day case care. One commonly suggested improvement to manage bed use is to establish a management program run by a “bed team” who would operate discharge, facilitate rapid turnaround of newly vacated beds, initiate ambulance diversion, and assign waiting patients to an inpatient bed.35 Unfortunately for most hospitals increasing the number of beds is not a viable option without a significant increase in funding, a result that is not forthcoming from state or Federal legislatures.

Another popular method that has been explored to improve ER crowding is the “fast track”. Broadly stated “fast track” is a system designed to process lower acuity patient quicker in order to increase bed turnover and reduce boarding.41 Individuals with injuries like superficial wounds, minor allergic reactions, small bone fractures and minor burns are typical fast track candidates. Interestingly enough fast tracking patient with minor injuries is not new and has been utilized by a number of ERs since the late 1980s.41 Due to this significant penetration fast tracking has been studied the most of any ER reform strategy and has demonstrated reductions in LOS and WT,42-44 yet almost all of this study has focused on LOS and WT and not whether or not patient safety outcomes are improved. One of the concerns with evaluating the efficacy of fast track is that there really is no standard evaluation protocol instead many hospitals have their own rules and criteria. While fast track proponents sing its praises, the overall ability to expand fast tracking is limited because most studies estimate fast tracking only encompasses 10-30% of the total patients seen in an ER and any gains seen when applying a fast track strategy only occur during peak hours.43,45,46

Unfortunately benefits from fast track only emerge when patients are discharged, not streamed through hospital admission.46 Also fast track benefits may be negatively impacted in the future because it largely depends on eliminating technological diagnostic procedures (blood tests, x-rays, CT scans, etc.) versus physical cues that can be evaluated by physicians. The need for diagnostic procedures will more than likely increase in the future as the number of elderly patients with more extensive health histories continue to increase in the future. This demographic change in ER population will not eliminate the advantages of fast track, but should reduce its rate of use limiting its usefulness. This additional testing will add to the already 60-70% of individuals who require laboratory tests when visiting an ER.47

While some strategies have been introduced to reduce testing time like pre-defined test panels for specific symptoms, faster laboratory transportation and early ordering,48 realistically testing takes time and little can be done about it. Some believe that the most useful strategy may be point-of-care testing (POCT) which involves moving laboratory analysis and tests to the ER. As expected undertaking a POCT strategy reduces WT and LOS through a reduction in turn-around time in the laboratory.48 However, a POCT strategy typically involves either large capital expenditure for hospital expansion or giving up space in other areas of the ER which may increase inefficiency and/or boarding for patients with more severe conditions due to a reduction in beds. The potential loss of some beds will be detrimental, but with reasonable expectation in the future for the expansion of primary care from general practitioners (when they eventually start to expand) and the increased need for laboratory services for elderly patients, currently preparation for and utilization of a POCT strategy seems beneficial overall.

A consideration for the increasing elderly population must be made in the scope of ER reform for all signs point to this increase continuing and accelerating. It is projected that demographically elderly patients will increase from approximately 15% to 25-35% of ER visits over the next 30 years.19 As previously mentioned elderly individuals typically require more time and resources for their medical care both on a logistics level (greater medical history) and a biological level (higher probability something can go wrong). Unfortunately there is also a side concern with the elderly. Typically seniors have fewer travel options than younger individuals and may have difficulty attending routine physical examinations (from general practitioners or the ER) even if appointments can be made. Therefore, this lack of option for travel can increase the probability that these elderly individuals put off medical care until it becomes critical creating a problem from nothing.

Another issue with the elderly is that nearly 25% of nursing home residents visit the ER at least once per year.49 Unfortunately a number of nursing homes tend not to promote good health, but instead attempt to simply keep their residence alive, thus those who are suffering from deteriorating health continue to have failing health. This “strategy” produces ER patients that are typically in poorer health than those elderly individuals who live on their own, about 67% of nursing home ER patients have cognitive impairment50 that complicate medical history collection and the nursing home records are rarely helpful. In fact 10% of nursing home ER patients arrive without any written medical documentation and 90% have significant gaps in their histories.51-53 Thus there is little coordination between ERs and nursing homes, largely because it appears that nursing homes do not care enough to apply the effort. However, ERs do need to be more diligent in ensuring that elderly patients across the board receive more clearly written instructions regarding their outpatient care.

Addressing current and future crowding in the ER will first require the development of a standard definition for quality and measurable components that encompass that definition because it is difficult to identify and classify problems when those problems cannot be identified. Independent government sponsored auditors, to ensure effective care and root out any problems quickly, should periodically evaluate these quality metrics. ERs should develop strategies to better manage beds through understanding real average occupancy values, not those taken from overnight values, to determine where there are excess beds and where/when bed demand is greatest. Finally it should be useful to study strategies that will increase the ability to manage elderly patients due to the logical expectation that their ER demographic will increase in the future. It stands to reason that areas with large elderly populations and quality ER service should have some effective strategies that can be applied to other ERs. Overall there are solutions that can be applied to the problem of ER crowding, but it is important that individuals ask the right questions and appreciate the change in future trends rather than declare simplistic panaceas like the incorporation of electronic health records.

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Citations –

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Black Incarceration Rates: How Much Are They Driven By Racism?

It should be no surprise to anyone who has done their homework that the United States incarcerates the largest number of individuals per capita.1 It is also not a surprise that black individuals make up the largest single demographic percentage of these individuals significantly outpacing their per capita population relative to other race and ethnicities.1 Individuals when discussing the nature of the criminal justice system frequently cite statistics to validate this racial/ethnic disparity. Typically there are two types of responses by most individuals when exposed to these statistics depending on personal perspective: 1) Currently the criminal justice system is unfair to black individuals; 2) black people commit a disproportionate amount of the prosecuted crime. Interestingly enough most people seem to think that these two rationalities are mutually exclusive because rarely does anyone cite both when discussing how blacks and the criminal justice system interact. The question is which of these two rationalities is the chief governing factor behind the incarceration rate for blacks in the United States?

It would not be surprising if at this moment a number of the individuals who prescribe to the first school of thought taking offense to the very possibility of legitimacy for the second rationality, which goes to show the emotional reality of this issue. The chief problem with individuals who lament the number of blacks in prison is that they avoid asking whether or not those individuals actually broke the law and are in jail for legitimate reasons. While there certainly are individuals who have been denied justice and are incarcerated on fraudulent grounds for crimes they did not commit, the simple fact is that a vast majority of individuals, regardless of race or ethnicity, are in jail because they were appropriately convicted a crime.

Addressing the last sentence, realistically there are five explanations for the disparity between incarceration rates of blacks and those of other races/ethnicities:

1 - These individuals are actually committing crimes and are legitimately getting caught supporting the above contention that blacks commit a disproportionate amount of the criminal activity in the United States.

2 - Blacks only commit a small amount of the total crime in the United States, but are less able to conceal their criminal activity, thus their demographic is disproportionally represented in the incarcerated population versus the total number of crimes that are actually committed; this rationality supports neither of the above initial viewpoints.

3 - Bias actively leads the criminal justice system to pursue charges against crime committing black individuals versus crime committing individuals of other races and ethnicities when available evidence is significant in all scenarios supporting the position that the criminal justice system is currently unfair to blacks.

4 – Blacks receive unjustified jail sentences that exceed sentencing guidelines set forth for the associated committed crime supporting the position that the criminal justice system is currently unfair to blacks.

5 - A disproportionate percentage of jailed blacks are innocent of the convicted crime; whether racism played a role in that fraudulent conviction is unclear, but probable for a number of them supporting the position that the criminal justice system is currently unfair to blacks.

The third reason differs from the second reason because of the actions of the individual committing the crime relative to the actions of law enforcement agencies. For example the second reason could be invoked in a situation where a black individual shoots someone in the middle of a neighborhood with numerous witnesses available to testify where a non-black individual shoots someone in a private residence when there are no witnesses, thus there is significantly less evidence to promote an arrest or a conviction. The third reason could be invoked in a situation where the circumstances and scenario of the criminal behavior are similar, but law enforcement agents pursue charges against the black individual instead of the non-black individual. Of course a final point must be made in that for all reasons other than the last one the black individual did actually commit a crime, thus one should not argue that this individual is inappropriately incarcerated.

It is important to consider for the statistics that are frequently cited that suggest racism in the criminal justice system the lopsided nature of non-violent drug offenses. Individuals who use and/or sell illegal drugs make up the largest number of incarcerated individuals (for a specific crime) and it is this crime that produces the most significant portion of the disparity between incarcerated blacks and those of other races/ethnicities. Based on this disparity numerous individuals/groups have claimed that non-violent drug offenses are evidence of racism in the criminal justice system. Unfortunately for a vast majority of these individuals blindly citing the statistics is as far as they go in their analysis. Recall what Mark Twain once said, “There are three kinds of lies: lies, damned lies and statistics.” Without understanding the origins and the “why” behind the raw data that create the statistics, using statistics to argue for a certain perspective is inappropriate and foolish.

With regards to the issue of black incarceration rates a chief point is whether or not drug related crimes are bias against blacks (or to a larger extent minorities in general). However, it is up to those who believe this characterization to prove it; i.e. the burden of proof is on those individuals to demonstrate that drug laws are bias against minorities. There are certain issues that must be addressed by these proponents outside of simply citing statistics.

First, one must analyze whether or not minority users are being sent to jail due to a higher wrongful conviction rates than white users not just arrested at a higher rate despite the arrests being appropriate. To justify this conclusion one would have to conduct an analysis that demonstrated more aggressive incorrect convictions for minorities. For example in county A consider that there are 100 white and 100 black people, 80 black people are accused of violating drug laws with 75 being rightfully convicted and 5 being rightfully acquitted versus 40 white people being accused of violating drug laws with 37 being rightfully convicted and 3 being rightfully acquitted. In this scenario there is no racism as the conviction rates are similar, black drug use is simply higher than white drug use. In a county B consider that there are 100 white and 100 black people, 50 black people are accused of violating drug laws with 45 being rightfully convicted and 5 being rightfully acquitted versus 50 white people accused of violating drug laws with 5 being rightfully convicted and 5 being rightfully acquitted and 40 being wrongfully acquitted.

In the second scenario one would argue racism because the justifiable conviction rate is skewed so much in favor of blacks and typically whether or not an individual is guilty of a drug offense is rather simplistic (i.e. there is little room for subjective rationality or interpretation). Unfortunately those arguing racism must address the issue of unequal justice between economic classes. Despite the contrasting ideological belief in the judicial system, it is widely understood that empirically the poor receive less equitable treatment in the legal system than the rich and a larger percentage of minorities are poor. Therefore, to prove racism in the execution of drug-based court convictions one has to identify a wrongful conviction pattern and then untangle the web of bias between race/ethnicity and economic standing, a difficult task.

A second issue that must be addressed is analyzing the second and third points above by looking at how different races violate drug laws. For example initially when looking at the available information for marijuana arrest rates one could argue in favor of racism in that minorities are arrested at a disproportional rate than whites for drug possession despite similar usage rates, or even higher usage rates by whites (depending on what type of polling information is used). However, this accretion of racism hits a snag when considering how the crime is committed. Middle class and rich individuals, more often white, have resources available to them to make their illicit drug use more evasive than less wealthy individuals. It is inappropriate to suggest that a law is racist if one group has less ability to evade it than another group when there is no selective enforcement intent. Committing a crime in a public area and then being arrested and convicted for it cannot be viewed as selective targeting in any reasonable way.

A third issue that is imperative to making a claim of bias in the enforcement of drug laws is whether or not the law itself is bad. Unfortunately an argument that drugs laws are bad cannot be made as an element of necessity. Individuals that are convicted of various drug crimes are not akin to Jean Valjean stealing bread for his sister’s starving child. One does not need to consume various illicit drugs to survive nor does the consumption of these types of drugs produce unique positive effects that cannot be otherwise derived through legal means. It is also difficult to argue this point rationally on the basis of race with respect to stating that just because one group of individuals are convicted of a given crime that the crime is racist. If this logic were sound then one could argue that if a majority of individuals convicted of embezzlement were Jewish then embezzlement is a bias law.

Based on these three elements of that have yet to be proven one cannot accurately argue that drug laws are racist simply because a lot of black individuals are convicted. In reality a vast majority of black individuals commit a criminal offense involving drugs and are appropriately convicted for that violation. Perhaps one can attempt to rationally argue that certain drugs laws involving simple possession have too strict a penalty from a relative standpoint of their negative influence on society, but as it stands one cannot make that argument on grounds of simple racism or other bias.

That said it would be understandable to move from the issue of crippling bias in their execution, there is the question of whether or not drug laws carry the appropriate punishment. Setting aside mandatory minimums because most people misrepresent their application due to confusion between associated violence and quantity of drugs possessed, some argue that bias exists in habitual offender laws that mandate harsher sentences for repeat offenders. The problem with making this argument is that repeat offenders are not deterred from their criminal behavior by the same level of penalty or certainty of punishment previously accepted hence why they committed the crime again. Individuals commit crimes in order to produce some form of advantage in life. Most individuals either out of concern for the associated punishment or through general positive morality do not commit crimes. However, obviously some individuals are not concerned about the base severity of the punishment or its certainty because they actually engage in criminal behavior. Therefore, what should be the response if an individual continues to violate the law?

It is difficult to argue for the decriminalization or penalty reduction for certain laws simply because one demographic is unable to conceal their violation of those laws. However, some people seem to argue exactly that, but would that strategy actually solve the problem? While a number of minorities, including blacks, are incarcerated for drug crimes one particular demographic of blacks are missing from jail cells, well-off or rich blacks. Rarely does an upper-middle class or rich black person go to jail for simple drug possession, thus most of the blacks in jail for drug possess are low income. What happens to these individuals in a world where drug use is legalized? A number of addicts are unable to identify that they have a problem with drug use, therefore, if the law is unable to “reach” these individuals what will ever stop them from abusing drugs?

While it can be argued that certain laws, most notably some drug possession laws, could be better addressed by court ordered drug rehabilitation versus incarceration, individuals who reference the criminal justice system as racist tend not to make this suggestion. As mentioned above these individuals are so distracted by the number of black individuals in jail that they forget that a vast majority of them actually did break the law they are in jail for. A better strategy would be to decriminalize minor drug possession from any felony to misdemeanors forcing repeat violators to seek treatment or accept incarceration. Some argue for the exact system utilized by Portugal, but those individuals must understand the difficulty of this idea by appreciating the logistics difference between enforcement in the U.S., a country with over 300 million individuals, and enforcement in Portugal, a country with around 10 million individuals.

The best thing individuals can do to help drug users appears to have two prongs: 1) ensure the proper measures are available to identify improper drug use and assign these individuals to appropriate treatment arenas; 2) petition for the passage of a guaranteed basic income (GBI) to ensure that low income individuals have the resources to effectively recover and stay recovered from any drug addiction.

Overall drug law enforcement is not racist and because most of the prison demographic disparity occurs through drug laws, the disparity itself is not racist. If one wants to argue for a different way to respond to those who violate certain laws over simply throwing the individual in jail that argument needs to be done logically not through inaccurate over-emotional race baiting because while on a whole the criminal justice system is not perfect, blindly proclaiming it racist is foolish.


Citations –

1. Carson, A, and Golinelli, D. “Prisoners in 2012 – Advance Counts.” Department of Justice. July 2013. http://www.bjs.gov/index.cfm?ty=pbdetail&iid=4737

Friday, May 30, 2014

Defamation and Internet Reviews

The balance between free speech and defamation has frequently been a tricky one with free speech understandably given significant lenience. However, as times have changed and the power of the Internet as a commercial tool continues to grow the emergence of social critiquing websites have become important enough that a positive majority opinion can result in millions in additional revenue and a negative majority opinion can result in millions of lost dollars for authors as well as consumer and service businesses.

Unfortunately the anonymity provided by these websites and the general simplistic nature of their review system has created an environment where the “public” evaluation of services and products can be easily manipulated by political and/or competitive elements. Sadly still there are frequent instances when these websites do not behave as reasonable and rational stewards when issues of defamation arise continuously differing to 1st Amendment protection for their users failing to even ask the question of whether or not an act of defamation has even taken place, an obvious abdication of their responsibility.

Defamation occurs when an individual(s) make false statements about another individual or group that harms its reputation. There are typically three elements to supporting a defamation charge: the statement must be false, cause harm psychologically, socially or financially and be made negligently and/or deliberately (i.e. the individual did not take time to determine the truthfulness of the statement or flat out lied). Also defamation is commonly divided between written statements (libel) and spoken statements (slander). With respect to the Internet almost all defamation cases are libel due to written statements on message boards or review websites and because almost all products reviewed cannot be viewed as “public entities or officials” proving malice is not necessary to prove defamation. Finally with the commercial nature of these types of product review statements neither type of privilege, absolute or qualified, can be applied to avoid defamation charges.

The most common defense against defamation charges, and only real defense with regards to reviewing a product, is that the statement rendered is simply an opinion rather than a statement of fact. Frequently opinions, due to their personal and somewhat subjective nature, are not viewed as falsifiable. However, the Supreme Court has ruled that the “opinion defense” has certain conditions and cannot be treated as a third universal privilege. Other common defenses for defamation where individuals believed in statement accuracy due to a secondary source provider (i.e. newspaper or television report) or emotional/satiric utterance are not applicable to reviews because there is no secondary source provider and the review is considered a statement that is supposed to be believed.

Beyond opinion the only other reasonable defense for libel in a product review environment is if the reviewed product is not reasonably capable of further damage to its reputation. Obviously if the reputation of an entity has “bottomed out” in the eyes of the public then no further negative statements regarding that entity, true or not, can damage the reputation of that entity. However, for this defense to work the accused individual must demonstrate that the review did not create a “chain-reaction” that caused the reputation to bottom out due to the “pile-on” nature of the Internet.

So if there is no opinion privilege what defines a review that is negative and legal versus one that is negative and libel? Largely the deciding factor is whether or not the review contained information that a reasonable analysis could disprove. Basically the more detailed an opinion the less likely an individual is able to make a successful “opinion” defense against a libel charge. Of course this characterization is an interesting element because the most valuable reviews are those that are thoroughly detailed.

Reviewing in general, but especially online reviews, typically creates a reverse bell curve in the respondent spread that then creates an intermediate based mean. This characteristic occurs because most people do not take the time to review products they view as average (i.e. 2 – 3.5 stars). Instead most non-paid reviewers have to feel strongly about what they are reviewing, which commonly will result in 1, 4 or 5 star reviews. Therefore, for a number of products these reviewers tend to somewhat neutralize each other resulting in a large number of products receiving an average 2.5-3.5 star ranking (out of 5). With this typical result it is important that reviewers be expected to provide sufficient reasoning for why their experience with the reviewed product/service was positive or negative for the general extreme nature of these reviews can produce significant movement for products that lack a large number of reviews.

Unfortunately a number of reviewers do not provide sufficient depth, reasoning and logic to their reviews instead substituting emotion and personal political/philosophical beliefs, which are subjective and uncharacteristic to all potential future users. In addition this reasoning is marred by a lack of consistency in the rationalization. The lack of a consistent format in the review process can also lead to confusion and inaccuracy when determining why an individual enjoyed or did not enjoy a particular experience. This confusion and inaccuracy can then result in libel suits. Realistically this problem should be solved by all websites that conduct structured product reviews having a universal format. The following format is an example of what could be used in the future:


User Name:

Location:

Ranking the Experience (out of 5 stars in half star increments):


Reason 1 for the Above Ranking
Subject:
Text/Rationality:


Reason 2 for the Above Ranking
Subject:
Text/Rationality:


Additional Comments:


While it would be preferable for individuals to use their real names when reviewing items/services, it is not required because the important element is the content of the review not the simple star measure. If the generally used star system is retained then it should include the ability to evaluate with half star increments because there are a number of times when an experience is not bad enough to warrant 2-stars, but not quality enough to earn 3-stars. Without the ability to award a 2.5-star ranking the review is inherently inaccurate.

In all types of reviews the rationality for why an experience produces a certain ranking is paramount. There should be at least two major rationalizations to why an individual evaluated the experience his/her particular way. These reasons need to be clearly identified and transparent instead of potentially hiding in a large wall of text. Initially some may argue that contemplating at least two significant reasons why the product/experience was good or bad is too much work. This reasoning is foolish because if one cannot met this requirement then why is that individual taking the time to write a review in the first place because clearly the product/experience was not memorable or did not have a significant impact.

Also these reasons need to be included for the review to be accepted by the particular website. Basically these reviews would be encoded as required fields. If additional commentary is desired a non-required space would be available after the two principle rationality sections. This additional commentary section is largely reserved for individuals that had a significantly positive or negative experience.

This new review format would create significant transparency and clarity behind the rationality leading to the ranking produced by the reviewer. In addition this new format actually demands the reviewer apply some effort to the review of the product eliminating the “drive by” review of a single sentence stating that the product is “awesome” or “sucks” thereby eliminating poor quality reviews, either positive or negative, from consideration for the average ranking. This elimination is important because not all reviews provide equal value, yet in the simplistic “average score” system used by review websites they are treated equally. Changing the format of the review process should not be difficult for these review websites. Reviews using the old method could remain in the database, but would need to be isolated into a separate category where a viewer could select to view either reviews with the old system or reviews with the new system.

It is also important to note that defamation is a legitimate challenge to the 1st Amendment. There are some individuals who seem to believe that attacking any negative comment on a review website is a violation of the 1st Amendment and is somehow inherently bad business. The common statement by these individuals to that effect is something along the lines of:

“How does company A expect to get more customers when they are suing review website A over some bad reviews. Clearly company A cannot take criticism, so they lack flexibility and cannot cater to their potential customer base. Instead of adapting their only response is to sue. I would never do business with company A.”

Of course this statement is inherently flawed because it assumes all negative comments as valid, truthful and constructive criticism. Clearly any rational person who has ever viewed the comments that certain products receive on these review websites understands that this assumption is frequently not valid. Basically these individuals need to understand that there is a difference between a justified negative review that uses facts and evidence to support its stance and an unjustified negative review that embellishes and lies to “support” its stance. All parties should herald the above changes to the review process because it makes defining and supporting a defamation charge easier by eliminating the ambiguity that sometimes leads to fair negative reviews drawing legal attacks from individuals/groups.

Overall one of the biggest problems in the relationship between professional review websites and the businesses/products that are reviewed on them is that the review websites largely view themselves as only a platform to host the reviews with no responsibility for the content of those reviews. It is this attitude that leads to the “surprise” when they receive numerous complaints from individuals and companies for libel reviews. Changing the review system to demand more clear and transparent rationality from reviewers would be a significant step in better controlling the content of a review while no stripping the ability of reviewers to make a positive or negative review on a whole. This change should also limit the tension between these review websites and product developers/companies changing the certainty and validity among the number of complaints and potential libel inquiries and lawsuits. In the end something needs to change in the way these review websites handle their roles in modern business otherwise the merry-go-round of complaint/lawsuit – denial – complaint/lawsuit will continue, simply with continuously increasing stakes.