Unintended consequences

In 2003, fearing that overworked medical residents were committing errors due to fatigue, the Accreditation Council for Graduate Medical Education put limits on how many consecutive hours residents could work on a shift.

Now, ten years later, it's not clear the change has had the desired effect. 

One study, led by Sanjay Desai at Johns Hopkins, randomly assigned first-year residents to either a 2003- or 2011-compliant schedule. While those in the 2011 group slept more, they experienced a marked increase in handoffs, and were less satisfied with their education. Equally worrisome, both trainees and nurses perceived a decrease in the quality of care—to such an extent that one of the 2011-compliant schedules was terminated early because of concerns that patient safety was compromised. And another study, comparing first-year residents before and after the 2011 changes, found a statistically significant increase in self-reported medical error.

While these studies suggest the complex nature of patient safety—that manipulating one variable, like hours worked, inevitably affects another, like the number of handoffs—there is another tradeoff, more philosophical than quantifiable. It has less to do with the variables within the system and how we tinker with them, and more to do with what we overlook as we focus relentlessly on what we can count.

Caveat: this essay by Lisa Rosenbaum in the New Yorker is a bit short on data for my liking, the above study feeling like just one insufficient data point. 

But the meta point about unintended consequences and complexity is worth noting. The increase in handoffs of patients, the decrease in time any one doctor spends with a patient, these all have consequences that work against the quality of healthcare, even as I believe more well-rested residents are a good thing, many of my doctor friends having been put through grueling rotations.

Is violence really down in the U.S.?

Perhaps to the public at large, it effectively has. However... 

...the figures that suggest that violence has been disappearing in the United States contain a blind spot so large that to cite them uncritically, as the major papers do, is to collude in an epic con. Uncounted in the official tallies are the hundreds of thousands of crimes that take place in the country’s prison system, a vast and growing residential network whose forsaken tenants increasingly bear the brunt of America’s propensity for anger and violence.

Crime has not fallen in the United States—it’s been shifted. Just as Wall Street connived with regulators to transfer financial risk from spendthrift banks to careless home buyers, so have federal, state, and local legislatures succeeded in rerouting criminal risk away from urban centers and concentrating it in a proliferating web of hyperhells. The statistics touting the country’s crime-reduction miracle, when juxtaposed with those documenting the quantity of rape and assault that takes place each year within the correctional system, are exposed as not merely a lie, or even a damn lie—but as the single most shameful lie in American life.

From 1980 to 2007, the number of prisoners held in the United States quadrupled to 2.3 million, with an additional 5 million on probation or parole. What Ayn Rand once called the “freest, noblest country in the history of the world” is now the most incarcerated, and the second-most incarcerated country in history, just barely edged out by Stalin’s Soviet Union. We’re used to hearing about the widening chasm between the haves and have-nots; we’re less accustomed to contemplating a more fundamental gap: the abyss that separates the fortunate majority, who control their own bodies, from the luckless minority, whose bodies are controlled, and defiled, by the state.

A bit more, emphasis mine.

In January, prodded in part by outrage over a series of articles in the New York Review of Books, the Justice Department finally released an estimate of the prevalence of sexual abuse in penitentiaries. The reliance on filed complaints appeared to understate the problem. For 2008, for example, the government had previously tallied 935 confirmed instances of sexual abuse. After asking around, and performing some calculations, the Justice Department came up with a new number: 216,000. That’s 216,000 victims, not instances. These victims are often assaulted multiple times over the course of the year. The Justice Department now seems to be saying that prison rape accounted for the majority of all rapes committed in the US in 2008, likely making the United States the first country in the history of the world to count more rapes for men than for women.

Here's the kicker: 

America’s prison system is a moral catastrophe. The eerie sense of security that prevails on the streets of lower Manhattan obscures, and depends upon, a system of state-sponsored suffering as vicious and widespread as any in human history.

All from a fascinating essay by Christopher Glazek, one well worth reading all the way through.  My quotes may make it seem very one-sided, and Glazek's view on the issue is clear, but the statistics make the tradeoffs clear, so where you fall on the issue is not a given. It's worth making the costs transparent, as in cases like Abu Ghraib, so we understand how we purchase our way of life.

The Horror

We’ve become more interested in the response than in the event that occasioned it. The emanations from the Miley performance very soon overtook the performance itself, and they were stranger and more interesting.

Sasha Weiss on reactions to Miley. 

All this time, we wondered what the guy in Edvard Munch's The Scream was reacting to. Munch saw all of this coming long before this year's VMA's. 

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Explaining Twerking to Your Parents

Every child dreads this day: sooner or later, your parents will come to you, innocently wide-eyed, to ask you about twerking. How you handle this difficult conversation is extremely important and could have a significant impact on the way your parents think about twerking for years to come. You may prefer to put off the big “twerk talk,” but remember that it’s far better for you to be the one to explain than for them to learn on their own by searching YouTube.

A critical first step is to acknowledge that twerking is a normal part of life and that there is nothing shameful in their questions. They’re parents, after all, and this is the sort of thing they hear about on NPR, and, well, they’re curious.

 Hilarious.

The ethics of Candy Crush Saga

A coercive monetization model depends on the ability to “trick” a person into making a purchase with incomplete information, or by hiding that information such that while it is technically available, the brain of the consumer does not access that information. Hiding a purchase can be as simple as disguising the relationship between the action and the cost as I describe in my Systems of Control in F2P paper.

Research has shown that putting even one intermediate currency between the consumer and real money, such as a “game gem” (premium currency), makes the consumer much less adept at assessing the value of the transaction. Additional intermediary objects, what I call “layering”, makes it even harder for the brain to accurately assess the situation, especially if there is some additional stress applied.

This additional stress is often in the form of what Roger Dickey from Zynga calls “fun pain”. I describe this in my Two Contrasting Views of Monetization paper from 2011. This involves putting the consumer in a very uncomfortable or undesirable position in the game and then offering to remove this “pain” in return for spending money. This money is always layered in coercive monetization models, because if confronted with a “real” purchase the consumer would be less likely to fall for the trick.

From The Top F2P Monetization Tricks by  Ramin Shokrizade. F2P stands for free-to-play and refers to games where you can start playing the game without paying. The most popular of such games, at least it certainly seems that way, is Candy Crush Saga. I know a few people who are struggling with a borderline addiction. When you add up the man-hours that have been dedicated to the game, it might be the most potent destroyer of productivity in recent human history.

Shokrizade makes a convincing case that Candy Crush Saga lulls the user into thinking they're playing a game of skill when in reality it's a game of luck (Shokrizade calls it a game of money, as noted in the excerpt below). Unable to make the distinction, players stuck on the more difficult levels later in the game end up making in-app purchases to keep feeding their addiction.

A game of skill is one where your ability to make sound decisions primarily determines your success. A money game is one where your ability to spend money is the primary determinant of your success. Consumers far prefer skill games to money games, for obvious reasons. A key skill in deploying a coercive monetization model is to disguise your money game as a skill game.

King.com's Candy Crush Saga is designed masterfully in this regard. Early game play maps can be completed by almost anyone without spending money, and they slowly increase in difficulty. This presents a challenge to the skills of the player, making them feel good when they advance due to their abilities. Once the consumer has been marked as a spender (more on this later) the game difficulty ramps up massively, shifting the game from a skill game to a money game as progression becomes more dependent on the use of premium boosts than on player skills.

Note that the difficulty ramps up automatically for all players in CCS when they pass the gates I discuss later in this paper, the game is not designed to dynamically adjust to payers. 

If the shift from skill game to money game is done in a subtle enough manner, the brain of the consumer has a hard time realizing that the rules of the game have changed. If done artfully, the consumer will increasingly spend under the assumption that they are still playing a skill game and “just need a bit of help”. This ends up also being a form of discriminatory pricing as the costs just keep going up until the consumer realizes they are playing a money game.

It's tough not to admire the skill with which Candy Crush Saga was built. Something about destroying tiny colored candies satisfies some reptilian instinct in people in the most addicting way possible. The guile with which the game entices users into forking over for in-app purchases makes me a bit squeamish, but no more than a casino should.

If you're going to give in to the temptation of CCS, just know that it's largely a game of luck, and resist the temptation to fork over dough when you get stuck unless you know what's being done to your brain and you're okay with it.