Teleonomy

Information Use in Health Care

2005-04-09T12:36:00.000+02:00

I recently read an interesting article from the December 6th (2004) edition of the New Yorker.1 Gawande reports on a trend he'd like to see broaden in the medical community: disclosure of doctors' records.

He does not mean simply their historical background, but he argues for the inclusion of statistical measures of doctors' performance. Although his argument for why this is a good idea seems to be shrugged off2, the existence of a bell curve in medical practice seems to make the case for requiring disclosure fairly self-evident, especially in instances where the doctor or hospital falls on the lower slope of the curve.

But the more interesting issue, which Gawande only hints at, is how patients will use this new information. Hospitals and HMOs will certainly be in a position to expend time and money on the problem of interpreting doctor grades, but for the consumer, this increase in the volume information may turn out to be superfluous in many health care decisions. Patients will be, after medical professionals and institutions, the third major consumers of this new information. How does access to this information affect patient choice, such as it exists in the HMO field?

From the perspective of the HMOs, the ball seems to already be in play.

"Recently, there has been a lot of discussion, for example, about 'paying for quality.' (No one ever says 'docking for mediocrity,' but it amounts to the same thing.) Insurers like Aetna and the Blue Cross-Blue Shield companies are introducing it across the country. Already, Medicare has decided not to pay surgeons for intestinal transplantation operations unless the achieve a predefined success rate."3

If medical insurers are taking this into account, it that would seem to be to consumers' benefit.

But what if the consumer has access to the information directly? What if family members decide that the standards set by an HMO or hospital simply are not high enough? Or will they be willing to settle for a somewhat middling quality in health care?

The question might seem to be answered most simply by economics, with the formulation being something like:

1) What is the quality of care available locally?

2) How does that compare with the highest available care?

3) What is the cost-benefit tradeoff of increasing the quality of care, including things like transportation to better clinics and the cost of more expensive medicines or treatments?

If the question were so straight-forward, we would expect to see a stratification tied to income level. Higher-income consumers would have access to the information, the time to incorporate it, and the extra income to invest in better health-care quality. Lower-income consumers would have less access, time, and money to spend and would therefore be relegated to lower tiers of quality.

However, if patients and their family members have access to the comparative data and know that they cannot afford top quality treatment, what will happen? How will they react, knowing that they are priced out of the best health care? Is this not exactly the problem that Medicare and Medicaid were supposed to fix in the first place?

To complicate this issue, Gawande gives us the interesting example of Honor Page, the mother of a cystic fibrosis patient.

"I asked Honor Page what she would do if, after all her efforts and the efforts of the doctors and nurses at Cincinnati Children's Hospital to insure there 'there was no place better in the world' to receive cystic-fibrosis care, their comparative performance still rated as resoundingly average.
'I can't believe that's possible,' she told me. (...)
After I pressed her, though, she told me, 'I don't think I'd settle for Cincinnati if it remains just average.' Then she thought about it some more. Would she really move Annie away from people who had been so devoted all these years, just because of the numbers? Well, maybe. But at the same time, she wanted me to understand that their effort counted for more than she was able to express."4

The doctor-patient relationship, in this case, has an (inestimable) value, influencing what would seem to be a straight-forward economic decision.

Often, economic formulas fail to take into account the fact that human beings, as a rule, do not follow the wisdom of economics in decision making. This isn't a case of stupidity on either the part of consumers or economists; it is, rather, a misunderstanding of the psychology of decision-making. This is not limited to health-care, either.

"The most widely known fact about George H. W. Bush in the 1992 election was that he hated broccoli. Eighty-six per cent of likely voters in that election knew that the Bushes’ dog’s name was Millie; only fifteen per cent knew that Bush and Clinton both favored the death penalty. It’s not that people know nothing. It’s just that politics is not what they know."5

Christopher Caldwell identifies the underlying problem in another New Yorker piece addressing decision making. "A few decades of research has made it clear that most people are terrible choosers—they don’t know what they want, and the prospect of deciding often causes not just jitters but something like anguish."6

We do not necessarily make political decisions the way John Locke insisted that we should, and an increase in volume of available information through newspapers, twenty-four hour cable news, and blogging has not changed that fact. Why would health care operate any differently? For most healthy people (and Americans, with the exception of the 60% rate of maintaining excessive weight, are overwhelmingly healthy), health-care decisions will be confined to catastrophic circumstance; these circumstances foreshorten the time allowed for making decisions. Digesting relative rates of performance between clinics is not a viable option for people who's relatives need immediate care. For the majority, then, who will most likely only interact with the health-care system under the stress and constraints of traumatic illnesses, economic decision making simply is not an issue. In these instances, it is easy to imagine that economically unquantifiable elements -- such as the comfort-level with the institution, trust in the doctors, and personal investment in the clinic -- will, as Page hinted, play an important role in the decision-making process.

Will consumers then be satisfied settling for average (or even below-average) health care, knowing that they doctors are "good people" who "tried their best"? Possibly. But comparing the relative scores of various surgical teams will probably only benefit those with both high levels of income and long-term health problems. The quality of catastrophic care will still be tied to circumstances of time and location: in other words, luck.

-----------

1. "The Bell Curve," from The New Yorker, December 6th, 2004 edition, pp. 82-91. (Available online at http://www.newyorker.com/fact/content/?041206fa_fact.
2. "We in medicine are not the only ones being graded nowadays. Firemen, C. E. O.s, and salesmen are. Even teachers are being graded, and, in some places, being paid accordingly." (Ibid., p. 91)
3. Ibid., p. 91.
4. Ibid., p. 91.
5. Menand, Louis. "The Unpolitical Animal" from The New Yorker, August 30, 2004. (Available online at http://www.newyorker.com/critics/atlarge/?040830crat_atlarge.
6. Caldwell, Christopher. "Select All," from The New Yorker, March 1, 2004. (Available online at http://www.newyorker.com/printables/critics/040301crbo_books.

Two Somewhat Unconnected Thoughts

2005-04-05T11:56:00.000+02:00

1--

"The topographic survey, the use of maps, the plan of campaigns -- long before business men devised organization charts and sales charts -- the coordination of transport, supply, and production [mutilation and destruction], the broad divisions of labor between cavalry, infantry, and artillery, and the division of the process of production between each of these branches; finally, the distinction of function between staff and field activites -- all these characteristics put warfare far in advance of competitive business and handicraft, with their petty, empirical and short-sighted methods of preparation and operation. [1]"

We've all seen this argument (that warfare drives other societal processes) before, but one aspect of it that I have not seen sufficiently reviewed is the level to which military spending leads to overall economic health. Is it possible that the huge military expenditures of the Cold War was a contributing (or determining factor) of the United State's lead over the rest of the world in the economies of technology, currency and information?

I've seen this theory before, but it's never gotten much past the 1980's, when a recession coincided with increased military spending, undermining the basic principle. An update, including the overall effects of military technology trickle-down into the civilian economy would be interesting. Could it be that the huge and expanding military budget is important (even vital) to the health of the North American integrated economy? This would be a sad case for the Progressive movement's efforts to reduce military spending. I hope no neo-cons read this page.

2--
As far as tracing references go, I realized this morning that because of the date-stamp on this blog, and the date-stamps I've put into my reading list, it's possible to figure out what I've been reading, and re-reference myself to the specific work that may have sparked the comment or idea, without necessarily having a quote in the blog post itself. This is one of the benefits that Jon's been noticing recently, one of those little invisible coincidences that opens up new possibilities for using the technology.

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[1] Lewis Mumford. Technics and Civilization. 89.

"When it's done."

2005-03-29T09:23:00.000+02:00

Much too long since last update.

Currently writing the article (although it's slowly turning into a chapter); will publish when finished.

A descriptive definition of technological history

2005-03-12T19:11:00.000+01:00

"Technological historians share certain biases. They prefer working with artifacts or pictures to working with descriptions. They believe that technological change is, by and large, gradual and that there is usually at least one middle stage to be discovered between one type of device or process and any significantly improved versions of the same device or process. And they tend to favor diffusionist theories linking technological developments into chains stretching back chronologically and geographically to a single point of origin to theories of simultaneous discovery or parallel evolution. They are always ready, naturally, to throw over these biases in the face of persuasive evidence, but they influence nevertheless the direction they take in investigating a problem, and they have influenced this study of the camel." (37)

--Richard W. Bulliet, The Camel and the Wheel for a little light reading.

Running Bibliography for Thesis

2005-03-06T19:31:00.000+01:00

(Organized by reading order)

--Bulliet, Richard W. The Camel and the Wheel. Cambridge, Mass.: Harvard University Press, 1975. ISBN:0-674-09130-2.
--Schroeder, Ralph, ed. The Social Life of Avatars. London: Springer-Verlag, 2002. ISBN: 1-85233-461-4.
--Murphie, Andrew and John Potts. Culture & Technology. New York: Palgrave Macmillan, 2003. ISBN: 0-333-92929-2.

More information on the general reading list.

mediageek Discussion with Dave Salinsky

2005-02-19T20:02:00.000+01:00

1

I would like to respond to mediaGeek's interview of Salinsky, a virtual reality programmer2, on the grounds that they managed to ignore major applications of virtual reality. The interview stuck too closely to the mode of "virtual reality" (VR) as an immersive and/or responsive sensory experience, specifically directed at human eyes and ears. This was especially confusing because, as they pointed out repeatedly during the interview, this old conception of virtual reality is long-since dead.

Since immersive VR systems proved too complex and bulky to be made marketable, the "death of VR" has meant it's relegation to firms and institutions with large budgets and complex design and observation requirements (a point which Salinsky makes pretty clearly). What both he and the interviewer ignore, however, is that the original idea of virtually realized systems never went away; it's simply been modified to meet current, affordable technological limits.

The idea behind virtual reality is, in essence, the manufacturing or simulation of pseudo-real interactions between or among two or more objects in some non-real space. At first, this was mainly thought of as projection of real objects or sensations into some sort of false-space, i.e., VR "cages" and the "feelies" that Salinsky mentioned. From a technology perspective, this approach has yielded fairly little in terms of ersatz realities. Cages, fake cockpits and bulky headwear notwithstanding, there has not been a technology that readily replicates real objects with convincing fidelity and simultaneously allows the user to be credibly interactive with them. Hence, the "death" of commercial VR.

But that is not the whole picture. Physical objects are not the only things that can be virtualized. Indeed, we can see that VR has invaded many areas of what Salinsky identifies as interactive forms of entertainment. Video games, especially Everquest and World of Warcraft, are excellent examples of this virtualization.

If you step back from game and the hardware platform on which it runs, you will begin to see that the user's experience of the game is not rooted so much a convincing representation of "real-space and -time," but rather a virtualization of society itself.

Anyone with first-hand knowledge of an Everquest junkie will attest to the following points:

1. The game simply is not very photo-realistic. Ignoring the problems of the graphics capabilities of older computers, the aging engine on which the game was built, the designers' presumed intention to maintain a balance between realism and a broad computer platform, and the real limits of data transportation across networks, the "art" of the game suffers from real problems of perspective; objects are often just too out-of-proportion to be convincingly real.
2. For obvious user-driven reasons, Everquest-time and -space are not accurately modeled on a 1:1 scale with real-time and -space.
3. Social interaction is what many (I'd be willing to bet "most") players say they enjoy about the game. Furthermore, the game is designed to reward players who conform to the social rules of the world.

To take point number three somewhat further, and bring me around to my point, the social rules of the Everquest world are more or less the same rules that govern the player's societies. What this means is that the game can offer players a reasonable facsimile of real-society, complete with social hierarchies, social "events" and even economies. 3 Furthermore, this community mimics or recognizes real-world events; this was demonstrated in 2000, when an alleged suicide rocked the Everquest community both in and outside the game.

Because this community is exclusive and contains organizing principles (among them an ersatz mythology), I would suggest that it displays several, although not all, traits of the anthropological definition of a culture.4 This is, I would argue, a virtual simulation of reality. Moreover, it is much more in-depth and interactive than early physics-based VR simulation.

If we expand our definition of virtualized realities even further, we could incorporate what Jon Udell refers to as "shifting time and folding space." In this instance, what is virtualized is the commoditization of time and space. TiVo and podcasting both allow the user to transport data away from the place and time of it's creation or broadcast. TiVo is a more limited example5, where only the original broadcasting parameters are simulated. 6 In podcasting, however, the user can transport data in both time and, with the aid of an MP3 player, space. In a sense, the podcaster is thus recreating the (recorded) conditions of the data outside of the show's real-time (broadcast time) and real-space (the recording studio).

As a functional version of a new definition for virtual reality, this second example may prove too slippery, but it is important to discuss ways in which non-tangibles are virtualized. To understand and discuss the impacts of VR technologies, we need to move away from the idea that the main goal of virtualization should necessarily be the replication of real-space and –time in some virtual environment. Accurate physical simulation makes VR technologies valuable to companies, but beyond the more or less trivial trickle-down effects into society, that does not mean much to the average end-user.

To the user, virtual realities are not pie-in-the-sky technologies; they exist as real and current aspects of his life. In order to understand their effects, we need to start seeing virtualizations in fewer dimensions, not more.

--Endnotes--
1. Sorry to Dave, but I do not see your name anywhere on the mediageek webpage. So, if I have misspelled it, please forgive.
2. mediageek podcast. "The Myth and Reality of Virtual Reality," 11 February, 2005. http://www.mediageek.org/radioshow/002492.html#002492
3. My best supporting evidence of this is a spill-over effect into real-space. I have seen Everquest players carry over ideas of status developed in the game into real-societies by mimicking their Everquest-assigned social role around other players in their daily lives. A more common and notorious example of spill-over is the Ultima Online marriage, which also includes marriage of two players who met online. Also, the in-game economy has it's own reflection in the eBay trade in game-space items and game accounts, which have been known to sell for thousands of dollars.
4. More likely, this is a cross-cultural subculture – a culture that can be contained within another culture but is capable of crossing many different ones.
5. Although, I now see that TiVo is advertising something called TiVoToGo, which promises to allow you to "take your favorite shows anywhere." (It seems that if we even stop for a second, we'll be overwhelmed by change.)
6. "Simulate," I admit, is a big stretch. In this case, I include "replay" in the definition of a simulation, although recordings and simulations are technically and rhetorically different.

Ernst Mayr (1904 - †2005)

2005-02-06T13:35:00.000+01:00

Ernst Mayr, wem diese Blog sehr schuldig ist, ist am Donnerstag (3.2.2005) gestorben.

Von einem FAZ-Artikel um den Biologe:

Die blanke, wabernde Natur, in der sich Mayr als Mann bewähren mußte und zugleich als Theoretiker und Erkenner entpuppt hat, existiert noch heute. Doch entweder ist sie leergedacht, da schon lange niemand mehr mit einer wirklich großen Idee von einer großen, einsamen Expedition zurückgekehrt ist, oder der Rückzug in die vollklimatisierten molekularbiologischen Labors, in denen alle Gefahren in Plastikhüllen verschweißt sind, zeigt bei aller Publikationshektik in Wahrheit einen Rückzug, eine Verkümmerung, ein Vergessen der Biologie an.

Es ist keine kleine Ironie, dass in diesem FAZ-Artikel der folgende anti-technikische Ausspruch stattfindet.

Was Biologen heute in der Natur noch auffinden, läßt sich im Format von ”National Geographic“ und ”Discovery Channel“ verstehen. Vielleicht ist mit Mayr eine umfassende, in der mesoskopischen Natur beheimatete Erkenntnisfähigkeit verschwunden. Vielleicht halten Goretex, Satellitentelephone und Solarduschen die Explorierenden von heute nicht nur von Härten, sondern auch vom Denken ab. Daß ausgerechtnet die Natur in ihrer organismischen Erscheinung aufgehört haben soll, die Biologie jenseits der auf die Biodiversität bezogenen Verlustängste anzutreiben, ist jedenfalls erstaunlich.

Ist das wirklich so? Es kann nicht so einfach sein, meiner Meinung nach, dass Technik als Entfernungsmittel zwischen Menschen und die Natur wirken soll. Natürlich ist das in unserem Alltag so, wo unser Häuser, Autos, und Büros stets weiter entfernt von die echte Natur gingen, aber es ändert sich etwas bei Biologen. Die können jetzt mit viel mehr Präzision in der Welt angucken, und das geschieht nicht nur in der Labor. Auch im Dschungel kann man jetzt mit hochtechnikischen Geräte die Natur anschauen, sowie meinen von Delphine interessierten Vater in der letzten paar Jahre im Peru schafftet.

Anderseits hat der Autor recht – das Erlebnis der Natur soll nicht so bequem wie der bügerliche Alltag. Es gibt Vorteilen bei der Zurückkeherung in der nicht von Menschen betrogenen Urwälder.

Weiter mit dem Artikel:

Jenseits der engeren Evolutionsbiologie und deren Popularisierung besteht Mayrs übergreifender Verdienst in der Abgrendzung der Biologie von den naturwissenschaftlichen Diziplinen der Physik und der Chemie. Auch im Lichte des Humangenomsprojekts und inmitten einer globalen Erregung über die Möglichkeiten der Biomedizin erzählte er, wie traurig er Anfang der fünziger Jarhe gewesen sei, als in Cold Spring Harbor ”echte Biologen“ duch Chemiker ersetzt worden seien.
(...)
Mayr hat sich energisch gegen einen physikalischen Reduktionismus gestellt, der das Leben in Atome auflöst, wieder zusammensetzt und dabei berechenbar machen will. Die Natur, wie er sie sah, ist ein System voll von Unvergleichbarem, das sich der Verfügung starrer Gesetzte entzieht. – Schwägerl1

Der 1904 geborenen Mayr war 100 Jahre alt. Herr Mayr, ich hoffe, dass Sie jedenfalls einen Tee mit Darwin jetzt trinken. Gute Reisen.

--Endnotes--

1. Schwägerl, Christian. ”Der Zusammendenker.“ Frankfurter Allgemeiner Zeitung, Nr. 30 / S. 37:1, 5 Februar 2005. Frankfurt a.M.: Frankfurter Allgemeiner Zeitung GmBH.

A Shot in the Arm for the Teleonomist

2005-02-02T15:26:00.000+01:00

Teleonomy: Day 4 -- Things seem to be going well.

People tend to become experts in highly specialized fields, learning more and more about less and less.

Unfortunately, so much specialization falsely creates the illusion that knowledge and discovery exist in a vacuum, in context only with their own disciplines, when in reality they are born from interdisciplinary connections. Without an ability to see these connections, history and science won't be learnable in a truly meaningful way and innovation will be stifled. -- James Burke's KnowledgeWeb Project

That's why I'm here, doin' these doings. Although this website seems to be overly-emblazoned with James Burke's name, it could be an interesting piece of technik. Development blog for the project here.

Still seeking the first Teleonome.

A Thesis on Technology

2005-01-30T13:11:00.000+01:00

The wide-spread use of technology in the so-called Western world most obviously separates it from those worlds that occupy the rhetorical North, South, and “Oriental” positions. North America, Europe, and Japan are the most technologically sophisticated regions on the planet, meaning that their citizens have most thoroughly incorporated the most recent inventions into their day-to-day activities.1 China, Brazil, and other areas of the developing world are following suit, and, in some cases, overtaking the West.2 Nevertheless, a tremendous gap exists between those countries who’s citizens have daily access to the technologies of the twentieth- and twenty-first centuries and those that do not.

The spread of these "modern" technologies is oft-heralded by the World Bank, the International Red Cross and other humanitarian and development agencies as a godsend, an expansion of curative medicine, a furthering of market capitalism, a death-knell for dictatorships, the sign of rising prosperity and the promise of a bright future to come.

Behind these exclamations lie many unexamined premises and questions. For instance, what role does technology play in the day-to-day business of societies; furthermore, what role should it play? How can individuals be affected, either positively or negatively, by technological introductions into their society? Is the path of technology linear, and if so, does it necessarily trend upwards?

Many of these are old questions that have been discussed and addressed, some satisfactorily, others not. (Within the narrow cultural terms of the West, these are usually examined by philosophers, inventors, and businesspeople.) Others are new, conceived from unique and modern circumstances and have not yet been completely debated. In all cases, however, there is not yet a body of theory, a measure of practice, nor is there a philosophical grounding on which to anchor any study. The very thesis upon which we define Westernness, our technological “advancement,” lies on very shaky rhetorical, philosophical, moral and technical foundations.

That is not to say that technology is inherently evil and that a reorganization of humanity to mirror pre-Fall conditions should be our goal. I simply suggest that our Erweiterung der Geräte, this evangelism of Gadgetry, should not go unobserved. It deserves a commentary.

Why Teleonomy?

teleonomy – n., the property, common to all living systems, of being organized towards the attainment of ends. -- the OED

In other words, systems can have end goals, be organized to a purpose and/or enact a process that is itself meaningful.

In the old days, barring any consistent observation to the contrary, it was widely believed that evolutionary processes were teleonomic, that they produced “perfect” species, given enough time. This view went out of vogue in the biological field long ago, yet, in the world of technology, especially in the dialogues of Business and Engineering, this idea still holds sway.

According to the Progressive conception, technology is “developing” – a term that inherently connotes progress – and will someday reach unprecedented peaks of wizardry, sophistication and ability. That day may be (admittedly) far off, but every toy, pen, car and knife can and will be perfected, according to our model and understanding of technological development.

But is that so? Every scientific or engineering puzzle solved creates three new problems to tackle. Reality seems to resemble Alexander’s Knot – not something to be tackled by traditional, linear problem-solving methods, but rather attacked from the outside, ever inwards. This is a Pseudo-progressive approach, when viewed from the beginning- and endpoints; in between, everything is matted and unclear. Behind lies a clear pathway from There to Here, ahead is only the Knot, a jungle of rope.

If both the Progressive and Pseudo-progressive approaches seem to accurately reflect our attitude towards technology, the its nature would seem to be contradictory. Both view are seemingly exclusive – linear versus knotted – yet both describe and are defined by goal-oriented processes: a steady progression towards "perfection," one the one hand; a brazen tinkering within the bounds of "the modern", on the other.

The Progressive process can be seen in the arch of technological improvement.3 The gestalt of the Western conception of technological improvement is epitomized by the triumvirate of Invention, Necessity, and their chauffeur, Mass Production. Each invention piles upon and fuels further inventions. In the plural, these form a technological family tree that could be traced from our Blackberrys all the way back to paleoliths.4
On a smaller scale, though, invention looks a bit more like Alexander, hacking away at the knot. Each filed patent is a small solution for a small problem within a greater context. Invention can be a clumsy process, whose means often look much like strokes of Alexander’s blade; in the end, besides an untangled knot, frayed rope -- cut to bits -- litters the Temple floor.

So, which approach correctly describes how technology really progresses? Is it one giant teleonomic process whose end goals might mirror (or be) perfection?5 Or is it a series of teleonomic actions on a small scale with limited ends, whose sum adds up to less than its constituent parts? (The question of whether technological change is even human-directed is another thing altogether – on par with whether human existence itself is somehow teleonomic and directed towards other purposes.)

--Endnotes--

1. From a technological perspective, Japan should be included in any discussion of the West.
2. I am toying with the idea of lumping China, India, Brazil, South Africa, Indonesia and certain other countries together in a block of Emerging Technological powers.
3. A side goal of this blog: find some progress-neutral terminology.
4. The caveat, of course, being that this is a very clear path from the modern perspective, but that is not at all the case from the starting point. In technological discourses, material determinism, and its inherent modernity-bias, should be avoided, as should historical and cultural determinisms.
5. If so, could we not infer the end product based on our knowledge of the process? For example, we could certainly infer what comes out of the digestive system of a Hippopotamus, although very few people have actually seen the process, including excretion, in its entirety.6
6. On a technology-related sidenote, thesaurs.reference.com offers the following fantastic list of synonyms for excrete:

defecate, egest, ejaculate, eject, eliminate, emanate, evacuate, exhale, expel, exudate, exude, give off, leak, pass, perspire, produce, remove, secrete, sweat, throw off, urinate, void

and furthermore adds “discharge,” “emit” and “purge” as further options. I am simply giddy – at least three of these words are unknown to Microsoft Word!