Wednesday, December 5, 2012

Dr. House Cures The Fiscal Cliff

Dr. House Cures The Fiscal Cliff

There is a fascinating article in the Tuesday, December 4, 2012 edition of The New York Times “Could a Computer Outthink This Doctor” which focuses on Dr. Gurpreet Dhaliwal, an associate professor of clinical medicine at The University of California, San Francisco.

Dr. Dhaliwal does on-stage presentations in which he is given small bits of data about an ill patient at intervals; the initial presentation, subsequent examinations, lab and diagnostic tests, the emergence of new symptoms, etc.  He has 45 minutes to diagnose the illness.

Being a devourer of the early episodes of “House” (I lose patience with TV after a while, having a deficiency in the enzyme that allows one to sit still for more than fifteen consecutive minutes) I found this story particularly appropriate as we careen towards December 31, and the cliff/slope/chasm/abyss awaits.

On “House” the drug and pain addled Dr. Gregory House races the clock to save dying patients from obscure disorders. His methods are a tad unconventional, but have involved breaking and entering, consumption of large quantities of illicit substances, odd pieces of equipment and unexpected tests, and, occasionally, more conventional diagnostics, such as extreme forms of sarcasm.

In the real world Dr. Dhaliwal sometimes uses a computer program called Isabel.  Isabel, like the chess playing Watson, can cross reference symptoms and test results against a huge database of diseases, including obscure ones that the average (or even “House-like”) doctor simply wouldn’t have been familiar with or able to recognize.

The developer of Isabel is Jason Maude, a former London-based money manager who created it after his then 3-year-old daughter, Isabel, developed chicken pox. The doctors were so focused on the chicken pox that they failed to place the proper weight on the rest of her symptoms: high fever, vomiting and skin rash, and missed an extremely serious complication—necrotizing fasciitis. 

Isabel survived, but is still, at 17, undergoing plastic surgery for the damage caused by the flesh-eating bacteria. 

In talking about Isabel’s experience, Mr. Maude refers to “anchoring bias”.  In investing, that can mean having an initial value or impression (such as the price of a stock a year ago) bias future investment decisions.  In medicine, it refers to the cognitive trap of allowing first impressions to exert undue influence on the diagnostic process, even in the face of later and contradictory bits of information. 

In Isabel’s case, her doctors’ anchoring bias was her chicken pox; in doing so, they saw but did not observe the severity of her other symptoms, with calamitous results.

In politics, “anchoring bias” stems from ideological inflexibility, party loyalty, or sometimes cold cash.  It can be hard to determine what precisely motivates which elected, since all claim the cloak of principle.  In practice, however, it is irrelevant, a point vividly demonstrated by both sides in the fiscal cliff debate.

President Obama floated a plan that had $1.6 Trillion in tax increases on the wealthy, to be achieved by letting the Bush tax cuts expire, and $400M combined in reductions to Social Security and Medicare.  And a provision that would raise the debt limit.  The problem with the President’s plan is that it doesn’t do enough towards deficit reduction.  It’s anchoring bias seems to be what worked under President Clinton can work again.  Of course, that was 12 years ago, before massive tax cuts, unfunded wars, and TARP.

Speaker Boehner put on the table his plan: $800M in “new revenues” which he proposes to get from eliminating unspecified deductions. And he proposes $600M in Medicare cuts, $200M from Social Security, and $600M in other unspecified cuts to domestic spending.  No cuts to the military, no tax rate increases.

To say Boehner’s plan is not credible is an understatement.  It’s a GOP fantasy, harsher than Romney campaigned on (particularly the cuts to Social Security and Medicare).  It also fails to raise the debt limit (so the GOP can extract more concessions after the deal is struck) and it mostly exempts the only two things that the GOP seems to care about: the wealthy and defense contractors. 

The White House quickly rejected the Speaker’s plan, but they barely got there first.  Boehner’s own Republican Caucus, including Jim DeMint, Godfather of the Tea Party, and Mitch McConnell, Senate Minority leader, denounced it.  Raising taxes in any way is anathema to these people.  All the deficit reduction must come from entitlements and domestic spending. The conservative Heritage Foundation put out the following statement “Rarely in modern American politics have more counterproductive, more foolish words been set to paper.”

A rational person might point out that we have just had an election where Mr. Obama won decisively, and the Democrats picked up both House and Senate seats.  The GOP has apparently drawn from those results two interesting conclusions.  The first, since they kept the House (through gerrymandering) the Constitution apparently requires that all fiscal policy meet their needs only.  The second is that Mr. Obama didn’t actually win. Radioactive Romney lost; meaning any Romney campaign idea that doesn’t reflect the most extreme views of the caucus is similarly radioactive.  Mr. Obama, and his plans, received no votes at all. 

Under ordinary circumstances, I would have thought that McConnell and DeMint and the Heritage Foundation’s objections would merely be a feint, to make Boehner’s proposal appear more balanced.  But it doesn’t seem that way at all.  Their anchoring bias is so strong it reflects itself in a messianic sense that elections, and the wishes of the electorate, are not worthy of notice. 

Mr. Boehner, for all his oleaginous perma-tanned appearance, is actually a very smart man.  GOP House leaders have been punishing Members who strayed too far from the party line by denying them committee appointments.  Boehner knows that if he can’t bring his caucus with him, he can’t negotiate at all.  And he knows Obama knows it as well. So Boehner tried another tack-he demanded that Obama counter the offer his own caucus rejected.

So far, Mr. Obama hasn’t taken the bait.  Having been rolled badly the first time around; he isn’t likely to make the same mistake twice. 

But Obama has a problem as well. Not only does he have the unions, traditional liberal groups, and AARP telling him they can give nothing, but he can’t make a deal in a vacuum. He needs a bargaining partner, and if Boehner isn’t it, it’s hard to see who would be. 

The problem with all this Kabuki is that it might not be Kabuki.  The anchoring bias might be the only thing that matters; these folk may not be able to disengage themselves to see clearly. As the patient (that would be all of us) careens towards the cliff, there is a very real risk that no deal can be made. 

How would Dr. House, or Dr. Dahliwal deal with this disease?  Without preconceived notions, without an anchoring bias. I think we can be pretty certain they would have kept searching for answers until they were certain.      

As a child, I read a story about the 16th Century French physician, Ambroise Paré, who served several French Kings on the battlefield.  At the time, firearms were wildly inaccurate, and wounds were both ragged and covered with powder burns.  Limbs often had to be cut off.  The conventional treatment for gunshot wounds was to pour boiling oil over them, and for the stumps, to cauterize with heated irons.   Paré, observing the agonies of the men, tried ligature on the stumps, and a light dressing with turpentine and oil of roses for the wounds.  The outcomes improved vastly.

Not surprisingly, Paré’s innovations were opposed by much of the medical establishment.  But he persisted, and the soldiers adored him. A deeply religious man, he once wrote, “I bandaged him and God healed him.”

There’s always prayer.