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Advertising Failure

Counterintuitivity in Medicine

Advertising Failure

By which we mean: “Announcing Where and When Failure has Occurred as a Method for Reducing Failure.”

The story of Doctor Kim A. Adcock’s approach to solving a problem in the radiology department at Kaiser Permanente in Denver reads like script background for one of those “procedural” TV shows such as CSI. We know who died (far too many) and we know who did it (doctors, sort of) but we’re not sure how to handle the evidence to make sure nobody gets killed next time.

Procedures that seemed reasonable to Kaiser in 1995 because they “had always been done that way,” turned out to be entirely unreasonable, with deadly consequences. And a solution that seemed impossible because of fear, turned out to be the best and most logical of solutions, and has saved countless lives.

Microsoft PowerPoint - EKA.RSNApressimages.2012.10.08.pptxMicrosoft PowerPoint - EKA.RSNApressimages.2012.10.08.pptx

[Caption above and below:Mammography images (from 2010, left; and 2012, right) of a woman in her forties with no family history of breast cancer who missed a year of screening and in the interval developed suspicious right upper out calcifications [ ] and a suspicious mass { }, both of which underwent biopsy, yielding invasive carcinoma.]

Microsoft PowerPoint - EKA.RSNApressimages.2012.10.08.pptxMicrosoft PowerPoint - EKA.RSNApressimages.2012.10.08.pptx

I read this story when it first appeared in 2002 and have cherished its insights ever since. Now 16 years later, I had to go find it to share it with this class. Since reading it, and other stories like it, I cannot look at statistics of any kind without wondering what they really mean. If the crime rate goes down, does that mean there is less crime? Maybe not. It might mean fewer people are reporting crimes.

For example, in New Orleans after Katrina, distrust of the police ran so high most citizens in some neighborhoods preferred to suffer crime in silence than to involve the police. The very first thought that came to my mind listening to that story was, “I’ll bet the crime rate has gone down in those neighborhoods” and not because there’s less crime. The mayor though, and the chief of police, can trumpet those statistics as if they’re doing a better job in those same neighborhoods.

But I digress. Before you read the article, “Mammogram Team Learns From Its Errors,” I want you to make predictions on a variety of factual situations that lend themselves to counterintuitivities. (I’m going to keep using this word until the rest of the world adopts it.)

Open the post Counterintuitive Predictions and react to the 50 claims by making a long Reply below the post. When you finish classifying the 50 claims, try to summarize the article you’ve never read based on the claims you find in the list.

Photo Source: Radiologic Society of North America RSNA

The Article

Against the possibility that we will some day be unable to access the original article at the New York Times, I reproduce here the contents:

”Every mammography program in the country should be doing something like this,” says Dr. Robert A. Smith, the American Cancer Society’s screening chief.

Very few do. In fact, what Dr. Adcock has created is a mirror image of American mammography as usual — an industry that remains deeply troubled 10 years after Congress set out to clean it up through its own experiment in medical regulation.

At the heart of Dr. Adcock’s experiment was his willingness to confront his doctors and focus on their skill in spotting tumors in the swirls and shadows of X-ray film, what experts call the hardest job in radiology. For the government, facing withering resistance from physicians, regulating doctors proved too politically risky. At the very moment in 1995 that Dr. Adcock was beginning to hold his doctors to the statistical fire, regulators were settling for a system that concentrated on the X-ray machines and the images they produced.

In that breach, a yearlong examination by The New York Times has found, the government has fallen far short of its pledge to ensure high-quality mammography for all. Here in Denver, Dr. Adcock has winnowed his team down to a few specialists. By contrast, most of the 20,000 doctors in the United States reading breast X-rays are generalists with limited training and practice in mammography. Many lack the skill needed to do so effectively, yet neither they nor their patients have the tools to find out who is good and who is not.

Keeping score, though, is not simply a matter of identifying and weeding out the worst practitioners. For Dr. Adcock and his admirers, the statistics offer a way to approach a more pervasive, and more elusive, problem that increasingly preoccupies the entire medical profession: the mistakes that, to varying degrees, all doctors make.

At Kaiser in Denver, the statistics anchor a regimen of continuous education that far outstrips the few hours a year the government requires. The Denver doctors are constantly analyzing their errors, searching for those meaningful patterns of shadow that they have missed, perhaps again and again.

The Denver group is not the first to use statistics to track doctor performance. A small but growing number of other mammography programs are beginning to keep score. Several states now publish individual doctors’ death rates for open-heart surgery. But seven years in, the Kaiser mammography group has perhaps gone as far as anyone in creating a statistical system for holding doctors accountable for their work.

Still, even many of Dr. Adcock’s admirers point out that he has achieved his success in the closed and relatively manageable confines of a health maintenance organization. They wonder if it can be replicated broadly, especially since the government has not fulfilled its promise of a national registry of cancer cases. At Kaiser, if a woman receives a breast cancer diagnosis, a doctor can find past mammograms and see if her case was missed. In the world at large, a doctor will often do a mammogram and never see or hear of the patient again.

In the end, though, the most delicate obstacle may be the doctors themselves. Doctors have been pushed a good distance from their traditional pedestals. But few have done so especially happily, and rare is the physician eager for the psychic roughing up that comes when the Denver doctors are forced to confront their mistakes.

Dr. Ken Heilbrunn, a Seattle radiologist who says he admires what Dr. Adcock has done, calls this the ”shame” factor, and manipulating it is the stealth ingredient of the Kaiser method. ”To really improve your skills,” he explains, ”you have to repeat this shameful moment over and over.”

It’s a tricky business, this question of the doctor’s image. Even today, Kaiser is reluctant to advertise its turnaround, and it would share only some data with The Times. Too many people still believe doctors walk on water, one official explained, so how can we brag about making fewer mistakes?

In wielding those mistakes, Dr. Adcock says he pledged from the first to avoid emotions and hold everyone accountable, including himself. After all, he says, ”it is easy for us to delude ourselves about the quality of our work.”

Setting a New Standard

The revolution began with a shot in the dark.

When several physicians complained about an apparent missed case in September 1994, Kaiser dealt with it in a typically ad-hoc way: the radiologist in question was encouraged to have another doctor double-read his films for a while. There was no reason to go further, Kaiser reasoned, since even experts make mistakes.

But soon after, the H.M.O. named a new radiology chief, Dr. Adcock, with a different approach, drawn from his personality and personal experience.

Five years before, Kaiser had hired Dr. Adcock for a variety of X-ray work. He had little grounding in mammography and a cautious, statistical turn of mind not entirely common in a doctor. In fact, he had thought about becoming a lawyer, and in medicine had sought out a specialty about as far removed from patients — and especially, he says, their blood — as possible.

Starting out at Kaiser, he had dreaded missing too many tumors. ”A good deal of what we do in radiology does not have the same sort of health implications,” he says. ”’With mammography, you’re looking for the opportunity to save a life.”

He devised a personal oversight system, using what are known as medical-outcome data, in which a doctor’s action is tracked to see how the patient fared.

Mammography, he felt, was well-suited to a statistical approach. Unlike, say, hip surgery, with its many gradations of success — is it the ability to walk, or run, with or without a limp? — the equation in mammography is fairly straightforward. The radiologist concludes that a woman appears to have cancer or not, and over time that judgment is proved right or wrong.

If mammography was the ideal medium, Kaiser was the ideal laboratory, since it already tracked its members. So when Dr. Adcock began his new job, he quickly homed in on his suspect employee. The doctor, it turned out, had not missed just one case; he had apparently missed a lot.

In taking the matter to his bosses, Dr. Adcock says now, he realized he was stepping into a running debate. He remembered the furor, and the mixed lessons, of the heart-surgery initiative in New York.

After the surgeons’ scores began appearing, the heart-surgery death rate had fallen by about 40 percent. Dr. Mark Chassin, a former New York State health commissioner, says hospitals were pressed to fix underlying problems. New Jersey and Pennsylvania have since begun their own listings.

Some researchers suggested, however, that other factors might have driven down the death rate. They questioned the soundness of the data. They warned that surgeons might be increasing their scores by avoiding higher-risk patients, a criticism that prompted the state to refine its system.

But where others saw controversy, Dr. Adcock saw opportunity.

”For me,” he recalls, ”it was a feeling of exhilaration that here at last was some aspect of medicine that could be measured and managed.”

He rechecked his numbers, then sat down with Kaiser officials, lawyers and public-relations people. They were worried about many things — negative publicity, malpractice claims, women turning away in skepticism. How many might die because they stopped getting tested?

But there was another danger they could not ignore. The radiologist had read 3,000 mammograms, and if Dr. Adcock was right, a dozen or so women he had said were fine in fact had breast cancer.

Making Tough Decisions

Finding those women was a huge job. The radiologist’s films had to be culled from the files and reread by several doctors.

They concluded that 259 women needed follow-up X-rays. Kaiser brought these women back in, gave biopsies to 30, and in the end, 10 women were found to have cancer, the H.M.O. says.

Word eventually reached The Rocky Mountain News, a local newspaper, which reported it as a front-page medical scandal.

In its defense, Kaiser said it had uncovered the situation through its own detective work. Steve Krizman, who edited the Rocky Mountain News’ coverage and later joined Kaiser as a spokesman, said he was skeptical enough about Kaiser’s assertion to mention it only briefly in the pieces.

”I thought, ‘That’s how they are trying to spin it,’ ” Mr. Krizman recalls.

But if the news media missed the broader story, some of the women involved did not.

At first, Ann Veenstra felt spun when she got a phone call asking if she would mind getting another mammogram. ”I felt something was wrong,” says Ms. Veenstra, an administrative assistant.

It felt especially wrong in her case. The mammogram had been her first, a baseline test at 40; she had not planned another for five years. When she turned up with cancer, she says, ”I was so very angry.”

But Kaiser explained how it had found her cancer, and she realized that after potentially killing her off, the H.M.O. may have saved her. ”After I got over my initial shock and anger, I appreciated that someone was checking and double-checking,” she says. ”It’s unbelievable to me this is not nationwide.”

Missed breast cancer is a leading malpractice complaint. But Kaiser was sued by just one woman, who eventually settled.

The radiologist, Dr. James A. Walsh, was crushed when Kaiser asked him to leave, his former colleagues say. He was 60, with two children in graduate school. ”It was a painful moment,” he said recently.

Dr. Walsh said he felt singled out for undue scrutiny and had been treated unfairly and unprofessionally. He said that an expert had found that only three of the missed cancers could be legitimately blamed on him, and that such an error rate fell within acceptable bounds.

”I think I was right and they were wrong,” he says.

The Kaiser official who headed the Denver affiliate’s quality-control program, Dr. Andrew M. Wiesenthal, says the treatment of Dr. Walsh was ”exceedingly fair.”

”We didn’t take any action until it was patently clear that he didn’t do this very well,” Dr. Wiesenthal says.

The Colorado medical board placed Dr. Walsh on probation, and he eventually moved to North Carolina. He says he attended numerous training programs and is now reading mammograms as a fill-in radiologist in four or five states.

”All the medical staffs I work for have no problems at all with my work,” he says.

Starting Fresh

Even with all the hubbub, Dr. Adcock’s bosses gave him a free hand to dig deeper.

”Jim Walsh was a lovely, lovely guy,” says Dr. Deborah S. Shaw, one of the radiologists on the team. ”But we knew this was the right thing to do.”

Which is not to say that the team did not feel wrenched by the firing, and by all the publicity. The doctors could not help but wonder who would be next.

Over the next few years, several more radiologists were fired or resigned in the face of concerns about their interpretive skill. Then Dr. Adcock spotted an even trickier problem. Nearly half the original 20 radiologists were reading far fewer mammograms than the others. They met the federal minimum of 480 a year, but with the others reading as many as 14,000, Dr. Adcock agreed with experts who say the government minimum is far too low.

Moreover, the low-volume doctors were not accumulating enough data to show if they were good. So he simply assumed they were not, and restricted them to other radiology tasks, like CAT scans.

How did they feel? Rather relieved, it turns out. Dr. John A. Siebert, for one, says mammography was monotonous, particularly since he might screen 200 healthy women before finding one cancer. An instructor once told him to pretend that each X-ray was his mother’s, but that trick, he says, went only so far. ”It’s sort of tedious,” he says. ”You have to sort of slap yourself to look at them.”

Others say they had trouble mustering — and holding onto — the intense yet relaxed concentration needed to find the more subtle tumors, what some of the Denver doctors call ”the Zen zone.”

”It was hard for me to get in the groove,” Dr. John W. Grudis says.

Improving Accuracy

In a dark basement room, Dr. Shaw takes a deep breath, clears her mind and begins the hunt for breast cancer. It takes her just minutes to stumble.

She sits facing a large machine shaped like a player piano that holds a reel of mammograms, and when she spins the films of a 55-year-old woman into view, she is riveted to a whitish spot in the shadows.

”This one cluster has my attention,” she says. ”I can’t tell you why, but it looks funny.”

She dictates instructions for the woman to return for further testing. But the biopsy finds only normal cells.

The doctors do not take these ”false positives” lightly, given the physical and psychic pain they can inflict on a patient. But there is a weightier side of the coin, the moment when a doctor finds a tumor that looks as if it has been around awhile. Then the question becomes, was the cancer visible on earlier films? If so, who read them?

”It’s a horrendous experience, just an explosion of emotions at once,” says Dr. Gerald L. Lourie, another team member. ”You know you are either going to be free as the judge says, ‘Not guilty,’ or you look and you know you just missed this one cold.”

What distinguishes the Denver team from most others is its systematic embrace of frequently occurring shame.

Once a year, Dr. Adcock also sends out lists of actual cancers missed, known as false negatives, so the doctors can pull the files and commit their mistakes to memory.

”That’s your boss telling you, ‘These are the ones that weren’t so hot,’ ” says one of the doctors, Richard A. Propper.

Last comes the toughest scrutiny of all. The doctors’ hits and misses and other statistical variables are displayed in brightly colored charts for all to see.

Mammography everywhere is a constant balancing of possible harm: between missing too many cancers and ordering too many needless biopsies. But the Denver doctors say their continuous scrutiny enables them to spot weaknesses in their work before they do inordinate harm.

Over time, they say, they have made an important discovery about why they miss some tumors. Breast cancer has many different shapes on an X-ray: a line of little white dots, perhaps, or a star-shaped blob known as architectural distortion. By testing and keeping score, the Denver doctors found that they sometimes obsessed over one type and neglected the others.

Today, the team’s accuracy is close to what experts say is the best mammography can offer.

Women have been told that mammograms can find 90 percent of breast cancer. But that figure stems from ideal conditions in research, and recent real-world samplings in two states show that doctors are finding just over 70 percent of the cancers in women who get regular exams.

Some clinics are doing much worse. Four of the six busiest centers in a study of screening in North Carolina are averaging about 65 percent. That is, they miss one cancer for every two they find. (Not all missed cancer can be blamed on the doctor; the X-rays might be poorly taken, and many tumors are simply too hard to see.)

The Denver team, stuck near 70 percent before it began its makeover, is now scoring 80 percent. By another measure, it is finding cancers at an earlier stage, allowing for earlier treatment. It did this without increasing the number of women it sends to biopsy. Just as critically, the group says, its team is consistently good, doctor to doctor. Women need not worry about having their X-rays read by a weak member of an otherwise strong team.

What that means, in the simplest terms, is that the Denver doctors are finding about 15 more cancers a year than they would have at their previous accuracy level. (Kaiser says it does not know if that improvement has affected its breast-cancer death rate.) In a country where 192,000 breast-cancer cases are diagnosed each year, that same increase in accuracy could mean finding upwards of 10,000 more annually.

Seeking a Better Way

Dr. Adcock is branching out. He has begun looking at outcome data for other radiology procedures, like breast biopsies, in which doctors can cause bleeding or miss the targeted cells.

And the news from Denver is starting to get around Kaiser’s loose nationwide confederation of H.M.O.’s.

”Kim Adcock is at the cutting edge of everything in radiology,” says Dr. William E. Drobnes of Kaiser’s Maryland affiliate, ”and I’m shamelessly trying to steal this.”

A similar effort is under way in British Columbia, and about 120 clinics in the United States, mostly in North Carolina and New Hampshire, are volunteers in a study designed to help doctors improve their skills.

Still, this is a revolution of small steps. Even at the nation’s leading cancer centers, doctors say they cannot do all Dr. Adcock has done.

Partly, it is that vast and inevitable well of psychic resistance. Equally important, few medical organizations can control information the way Kaiser can, as an H.M.O. that provides all of its patients’ care.

”Everybody would like to do this if they could. It’s a wonderful learning experience,” says Dr. David Dershaw, the mammography chief at Memorial Sloan-Kettering Cancer Center in New York. ”But the search for false negatives is difficult, cumbersome and expensive.”

Sloan-Kettering does track false positives, and Dr. Dershaw says he is confident that his doctors, all trained by him, are highly skilled.

Still, he has never calculated their skill by tracking missed cancers. That would require contacting all the women who got negative mammograms — tens of thousands each year — to see if they later received diagnoses of breast cancer.

”I’ve been trying to reach one woman for three days,” Dr. Dershaw says. ”And I’m trying to give her the results of her biopsy. Just imagine what it would take to reach every woman who comes in.”

In pursuit of a better way, Congress a decade ago ordered the creation of a national cancer registry that radiologists could search for patient records. But the system remains a cumbersome and piecemeal hodgepodge of state archives.

The data are also difficult to interpret, especially for the many doctors reading just a few hundred films a year. Several years’ worth would be needed to be meaningful.

Some clinics are trying other approaches. A few have two radiologists read every X-ray independently; others are using novel computer programs that show promise in seeing some hard-to-find cancers.

Even so, when experts talk about doctors’ skills, the discussion almost always circles back to the conundrum federal officials wrestled with when they wrote the mammography rules a decade ago: How to improve quality without diminishing access to care. If doctors start dropping out of mammography because they score badly in tests or performance audits, where will women go?

The balancing act gets trickier and trickier. New research is stoking concern about doctors’ competency. At the same time comes anguished talk about doctors driven away by skyrocketing malpractice rates and shrinking reimbursement.

To some experts, the solution lies in a radical-sounding reorganization: centralized facilities across the country where large numbers of mammograms would be read by small teams of highly skilled, and presumably enthusiastic, experts. In the future, digital mammography, a recent and still-experimental innovation, could make sending films as easy as e-mail.

Which is remarkably similar to what they do in Denver. Call it the two-step mammogram. Women are still X-rayed at satellite offices, but the films are shipped to the central complex where Dr. Adcock’s six-member team works. This has also meant lower costs for a procedure that many radiologists see as a money-losing obligation.

For now, though, many people are banking on the federal government, hoping it will pay more attention to the doctors.

Legislation moving through Congress to extend the federal mammography rules would have the Institute of Medicine, an independent research group, study several matters, from doctor training to interpretive skill. Breast-cancer screening advocates are quietly pushing Congress to take strong steps, sooner. The American College of Radiology, which accredits the nation’s mammography doctors, says it would support a federal requirement for periodic competency drills.

Many experts, like Dr. Robert A. Schmidt of the University of Chicago, say that only a complete government overhaul can do the job, starting with financial incentives and ending with tools to assess doctor skill.

He is not holding his breath. ”There are lots of arguments you can make in deciding to do nothing,” he says. ”Even with the way mammography is now, you could still say you’re still doing more good than harm.”

Working as a Team

Even Dr. Adcock is wary of having the government police doctors’ performance. ”I could see that being counterproductive,” he says.

On the other hand, left to themselves, it is not clear how many doctors would do what Dr. Adcock did when his data turned on him.

The Denver doctors all have their own reading styles. Dr. Shaw likes to press her red-nailed fingers against the X-rays when she zeroes in on a problem spot. Dr. Geoffrey D. Friefeld burns through films at a torrid two-minute pace.

Dr. Adcock is a fretter. ”Oh boy, I hate it when that happens,” he said one afternoon last summer when he couldn’t make up his mind. ”This one is very hard to let go.”

Then his latest scores came in, and he really started to worry. He was dumping more X-rays into an ambiguous pile, having failed to decide if they showed cancer or not. Holding his charts, he said, ”I look at that and think, my goodness, have I forgotten how to read mammograms?”

He labored over the tougher cases, and even his body language — big exhales and slouching — seemed to show his concern. He thought about the radiologists he had exiled, including Dr. Walsh.

Then his volume began to slip as he spent more time on management duties, and he wondered: If his accuracy slipped, too, would he see it in his data? ”That was the hardest thing,” he says, ”knowing that I might not be able to tell.”

Late last year, his volume slipped below 200 a month, and as his colleagues watched his numbers drop, they feared the worst. If he did not stop himself, Dr. Shaw says, ”I would have had to tell him to.”

On Jan. 1, Dr. Adcock decided to stop reading mammograms. He did not want to burden the team with his workload, since the original group of 20 was down to 6. But he says he had a bigger obligation in bailing out of a task he had come to love: ”I’m protecting the patients against myself.”

Tips on Mammography Clinics

Dr. Barbara Monsees headed the expert panel that helped write the federal mammography rules. But when women ask her where to get a good mammogram, she does not tell them to look for the government seal of approval. ”I tell them to go to a place where people specialize in mammography,” she says.

Comparison shopping for mammograms is not easy. The government does not gather much of the information that experts say women need. Women in rural areas may have to travel long distances to find expert doctors. Some doctors may bristle at being grilled. Even high-technology radiology clinics in fancy neighborhoods may be staffed with doctors who do not have the training, experience or knack to read mammograms well.

Still, Kaiser in Denver is hardly the only place that offers high-quality mammography. Several experts offered these thoughts about how to find one of the others:


Find a clinic where doctors read large numbers of mammograms, far beyond the 480 a year required by the F.D.A.

Insist on having your films read by the ”lead interpretive physician,” who oversees a clinic’s quality controls.

Look for doctors who did fellowships in mammography, or those who spend at least half their time reading mammograms. At the very least, seek out an enthusiast who goes to meetings and perhaps writes about mammography. (They show up on the Internet.)

Look for clinics where two doctors independently interpret every film.

Ask about ”medical audits,” which show if a doctor sends too many women for biopsies.

Use open-records laws to obtain a clinic’s inspection reports, which list violations and chart the image-quality test known as the ”phantom.” Look for a combined score of 12 or more. Beware of citations for equipment failures or missing ”QC,” or quality control records.


Don’t press for an instant interpretation of your films. A day’s delay through ”batch” reading can maximize a doctor’s power of concentration.

Don’t put too much faith in a doctor being board certified in radiology. Many doctors passed before the late 1980’s, when mammography was added to the exam. In any case, the number of practice mammograms on the test does not reflect the rigors of real-world screening.

Don’t judge doctors by the lawsuits they have lost for misreading mammograms. Even the best doctors will miss some cancers.

Don’t put too much faith in promising but still experimental technologies like digital X-ray machinery and computer programs that look for cancers doctors might miss.

Don’t have your mammogram done on Mother’s Day, when many clinics offer free or discounted exams. These programs can swamp the doctors and rush the reading.

Counterintuitive Predictions

Counterintuitive Predictions

1. True or False. What occurs in the world is not always reasonable, logical, or right. Even so, it might be true. You’ll decide whether the Premises below are True or False.

2. Reasonable or Unreasonable. People act for reasons other than logic; among them sympathy, loyalty, hope, fear, vested interest, greed, and ineptitude. You’ll decide whether the Premises below are Reasonable or Unreasonable.

3. Right or Wrong. Decisions based on logic or reason can be ethical and moral, unethical or immoral. You’ll decide whether the Premises below are Good or Bad, Ethical or Unethical, Moral or Immoral.

Your Predictions

Before hearing about the Mammogram team at Kaiser Permanente Hospital or reading the associated article, respond in three ways to the Premises below.

First: declare whether the statements made appear to be True or False (you could also answer Likely or Unlikely).

Second: declare whether the statements appear to be Reasonable or Unreasonable (or if you prefer: Batshit Crazy, or Not Insane).

Third: Declare the statements’ moral or ethical position to be Good or Bad. (If the statement doesn’t permit a moral judgment, you could still pronounce it a Good thing, or fundamentally Just Wrong.)

Respond in three ways for each Premise.

1. Likely / Batshit Crazy / Bad
2. False / Reasonable / Good
3. Unlikely / Unreasonable / Wrong
4. True / Not Crazy / Right

Of course, in paradise, the Reasonable would always be True and Good, and the Crazy would always be Untrue, and universally recognized as Bad. But we know better, don’t we? At the end of class, return to your predictions. How many of your expectations were met?

The Article

Mammogram Team Learns from its Errors

The Premises

1. Women who find out how many cancers their doctors miss in routine mammograms stop getting mammograms.
2. Radiologists who perform mammograms are held accountable for the accuracy of their readings.
3. A doctor who finds hundreds of tumors in a year and a half, but who misses 10, is almost always fired.
4. Doctors who read only a few mammograms a month are removed from film-reading teams so that they read none at all.
5. Publishing the failure rates of radiologists improves their accuracy to the best the discipline can achieve.
6. The best technique for improving diagnosis accuracy has been adopted by almost no radiology departments.
7. Congress demands that radiologists be held accountable for their accuracy at detecting tumors in mammogram films.
8. The 20,000 US doctors who read breast X-rays are trained to do so; their accuracy is known and tested.
9. The medical profession accepts that, to varying degrees, all doctors make the same mistakes.
10. Doctors who do mammographies follow up with those patients to discover whether their diagnoses were correct.
11. Doctors appreciate knowing whether they missed actual tumors or misread the “shadows and swirls” of a mammogram as a tumor.
12. The “shame” of confronting an incorrect diagnosis is a valuable teaching tool for doctors who diagnose cancers from mammograms.
13. An accuracy rate of 80% in detecting cancers from mammograms is something to brag about.
14. The best doctor to head a radiology department is a squeamish physician who trained as a lawyer and prefers not to deal with patients “and their blood.”
15. Radiology can be tracked well statistically because patients either have tumors or they don’t.
16. When the director of the radiology department discovers a way to improve the accuracy of cancer diagnoses, his method is immediately embraced by hospital administrators.
17. When New York hospitals began to publish their surgeons’ heart surgery successes and failures, the death rate fell by 40%.
18. The falling death rate meant that heart surgeons were doing more careful work.
19. Hospitals that reduce their false diagnoses proudly advertise that they “make 20% fewer errors” than their competitors.
20. Publishing the error rates of mammography radiologists results in an uncertain but significant number of cancer deaths in women who avoid testing.
21. A radiologist who is known to have missed a tumor is likely to have missed a dozen out of 3000 he declared to be tumor-free.
22. Out of those 3000, when 250 were scanned again, and 30 were biopsied, 10 were found to have cancers he had missed.
23. Finding those 10 cancers was reported as a front-page medical scandal instead of a triumph of an enlightened new technique for avoiding missed diagnoses.
24. Many of the 250 women who were told they needed followup were angry.
25. Of the ten whose cancers were missed by the first doctor but discovered in followup screenings, most sued the hospital for malpractice.
26. The doctor who missed the 10 tumors felt he had been treated unfairly, that only 3 of the cancers could be blamed on him, and that his error rate was acceptable.
27. After being fired, he was hired as a fill-in radiologist in five states bordering North Carolina.
28. The radiologists on the terminated doctor’s team supported him, not the hospital, and resent having their work scrutinized and their failure rates published.
29. While some doctors read 14,000 films a year, and others fewer than 500, failure rates are very similar.
30. Doctors who read just 500 films a year get re-assigned to other work since their sample size is too small to determine their accuracy.
31. Doctors who are “fired” from film reading based on low volume are relieved to have the diagnostic responsibility taken from them.
32. Doctors would rather bring a patient back for a second look or a biopsy than miss a tumor.
33. Doctors are much happier to find evidence on the film of a cancer that has “been around for awhile.”
34. Routinely experiencing the shame of missed diagnoses in tests every four months builds confidence in radiologists.
35. Most hospitals send out lists of actual missed tumors or “false negatives” to their radiologists every year so they can study the films they misinterpreted.
36. The Kaiser Permanente department has learned to detect various “presentations” of tumors on film by studying films of actual missed tumors after the fact.
37. In North Carolina, for every two cancers radiologists find, they miss one.
38. If the results at Kaiser Permanente were replicated nationwide, better than 80% of cancers would be found and 10,000 more cancers would be correctly detected each year.
39. False positives are easy to track, but almost nobody tracks false negatives (missed tumors that show up in later mammograms).
40. There is no routine followup for women who, on the basis of their mammograms, are determined to be tumor free.
41. Holding radiologists to a higher standard of competency results in reduced access to quality care.
42. Making failure rates public increases the likelihood of malpractice claims, which in turn drives up insurance rates, which in turn drives good doctors from the field.
43. Having two doctors instead of one review every film improves accuracy and drives down costs.
44. A nationwide 70% effectiveness rate is considered the best that can be achieved practically and politically.
45. Government oversight of physician performance to standardize techniques nationally has actually reduced accuracy.
46. Dr. Adcock, who improved effectiveness in his radiology department by 25%, took himself off the team when his volume dropped.
47. The most conscientious doctors, who agonize over the presence or absence of tumors on every film, are by far the most effective.
48. When they have a choice, women are best served by the doctors who send the largest percentage of women for biopsies because they miss the fewest cancers.
49. The best indicator of whether a doctor is competent to read mammograms is the number of times she’s been sued.
50. A good day for mammograms is Mother’s Day, when many clinics offer free or discounted exams.

The Blind Summary.

When you finish classifying the claims for Truth/Reasonableness/Goodness, in one paragraph, try to summarize the article you have not read. Use the heading “BLIND SUMMARY.”



Quotation Marks for Articles

In the Milton Friedman’s piece The Island of Stone Money, I noticed an idea.

In Milton Friedman’s piece, “The Island of Stone Money,” I noticed an idea.

Capital I
Quotation Marks for Articles

When i came across the article by Milton Friedman named The Island of Stone Money I was intrigued.

When I came across the article by Milton Friedman titled “The Island of Stone Money,” I was intrigued.

In-Text Citation, not parenthetical APA

Use in-text citation instead of the APA parenthetical method.

Friedman also discussed an instance where the french technically owned some portion of gold. However, they never physically retrieved the gold, instead a deal was made with the U.S and was stored in a drawer on our homeland. (Friedman)

In “The Island of Stone Money,” Friedman demonstrated the abstract nature of ownership with an anecdote in which the French took possession of some US gold not by physically retrieving it but by permitting the US to store it in a drawer labeled “France.”

Miscellaneous Grammar Corrections

1. Money only has value due to the fact that everyone wants it.
“Due to” means “caused by,” so your sentence would read:
Money only has value caused by the fact that everyone wants it.
You’d probably agree that a better version would be:
Money only has value because everyone wants it.

2. Money only has value because everyone wants it.
“Only” always modifies the word or phrase that follows it.
Your sentence, therefore, means: Money only has value. Which means the only relationship money has to value is that it has it. By that logic, money can’t earn value, lose value, find value, etc.
You’d probably agree that a better version would be:
Money has value only because everyone wants it.

3. Before people use to barter or trade for things they wanted.
The phrase for things often happened in the past is “used to.”
Your sentence, therefore, should be:
Before people used to barter or trade for things they wanted.

4. Before people used to barter or trade for things they wanted.
Your sentence needs a comma. If people used to barter at an earlier time, the comma follows Before:
Before, people used to barter or trade for things they wanted.
But since “used to” indicates clearly an earlier time, you’d probably agree a better version would be:
People used to barter or trade for things they wanted.

5. An example of this is trading cattle for different herbs, spices, or supplies.
Different from what?
An example of this is trading cattle for herbs, spices, or supplies.

6. Money however is a form of middle man.
When it interrupts a sentence, however is surrounded by commas.
Money, however, is a form of middle man.

7. Money, however, is a form of middle man.
Unless you’re going to distinguish between kinds or types or forms of middle man, you should avoid the words kind, and type, and form.
Money, however, is a middle man.

In Class Exercise

Use the Reply field to make one fluent sentence from this mess:

The softball game is cancelled due to the impending storm only threatening the different southern counties that are use to mild types of weather. Classes however will be held.


Not Because

Sentences that follow a negative verb with because create confusion for readers.

I don’t love you because you’re beautiful.

No man can safely say this to his girlfriend because she hears the negation first and doesn’t listen to anything else he says. Our readers, like the girlfriend, hear “I don’t love you,” and then believe what follows to be an explanation for our heartlessness.

We meant to say, of course, that we do love our girlfriend, but that she is special in many ways, only one of which is her beauty. But that’s not what we said. To make sure she listens to our entire declaration, not just the first four words, we need to revise our first draft:

Good: I love you, but not because you’re beautiful.

Good: I love you not just for your beauty.

BEST: I love you for your beauty and your generous heart.

Clearly (at least I hope it’s clear to you, gentlemen) the boldest, most specific, most straightforward claim, without negatives, is the best. And of these sentences, the best are those that eliminate the because altogether.

In Class Exercise

Copy these sentences adapted from student essays into the Reply field below and revise them for boldness, specificity, and directness. Replace negative verbs with positive verbs. (Example: replace didn’t resign with declined to resign)

1. Coats wasn’t fired because he was using a legal drug, marijuana, for a legitimate purpose for which he had a prescription. He was fired for violating workplace policy.

2. An employer isn’t able to fire a person who has anxiety because they are taking the correct medication to deal with the issue.

3. Employees don’t get fired for going out and having a few beers after work because alcohol is legal, but in Colorado so is marijuana.

4. Coats shouldn’t have been fired because he was trying to treat the pain he endured on a daily basis.

5. It’s not fair to discriminate against him because he was able to ease the pain of his multiple spasms by using marijuana.

6. Coats wasn’t harming anyone at his job because he was smoking marijuana but he was doing so on his own time and not at work.

BACKGROUND FOR 7-10: The director of the Secret Service ordered an internal review of its security procedures around the White House after a man armed with a knife who jumped the fence at 1600 Pennsylvania Avenue on Friday night managed to make his way through the front door of President Obama’s home before being stopped, officials said Saturday.

7. Omar Gonzalez didn’t penetrate deep into the White House because of the swift actions of Secret Service agents.

8. The Secret Service isn’t being compelled to explain its actions because of the way it  responded to the breach of the White House, but how the breach occurred is under question.

9. Secret Service chief Julia Pierson won’t be fired because of her testimony before Congress yesterday. Her incompetence might cost her her job though.

10. Secret Service agents didn’t use deadly force against the intruder because he was carrying a knife with a 4-inch blade.

Draft Causal Argument Prof-2020

9/11 Made America More Racist

It seems that racism has been around since before the dawn of time itself. It has thrived in the best and worst of times and in every corner of the earth, doing particularly well in the United States of America. America’s relationship with racism has been a very long one and it’s still going strong. As if the situation hadn’t been dire enough, then the twin towers in New York City were attacked in an act of terrorism more horrific and devastating than the world had ever known. Whether or not the 9/11 hijackers understood the consequences of their actions is irrelevant. The after-effects rippled outwards and caused further damage more than what anyone could have expected. Fifteen years later, Americans are still dealing with the repercussions of one man’s decision to attack the United States. 9/11 shocked and terrified the world. That day set a new precedent for the future of public safety all over the globe. The TSA was exploding with new rules and restrictions on who and what can be on a plane. Americans become even more wary of anyone who didn’t look like them. The media turned the situation into a joke. Tabloids were printing new conspiracy theories everyday while shows like “South Park” and “Family Guy” turned the whole ordeal and those behind the attacks into a punchline. The saddest part is that we had an opportunity to make a comeback. It would have been one of the most difficult things our country had ever done and would have further changed the world forever but we failed to take advantage of our opportunity to find good in the situation. We’ve let the 9/11 attacks define our foreign policies, world relations and even how America functions domestically. Furthermore it’s changed how we relate to others. Our culture had never been particularly welcoming to new elements but more now than ever, we bristle at the idea of welcoming anyone or anything we’re not immediately familiar with. In recent years this reaction has softened, especially with younger generations rising up and becoming more politically aware but the majority of America still holds deeply rooted emotions against anything related to the 9/11 hijackings. The ripple effects of the attacks still continue outward even today. Presidential nominee Donald J. Trump made it a main point in his campaign to assure Americans that he’d place restrictions on allowing muslims to enter our country. Regardless of whether or not his prejudice stems from the attacks, many his voters share this sentiment because of the events of 9/11.

Rose, S. (2013, September 12). Since 9/11, Racism and Islamophobia Remain Intertwined. Retrieved November 04, 2016, from

Poladian, C. (2015, September 11). The United States After 9/11: 6 Things That Have Changed Since 2001. Retrieved November 09, 2016, from

Open Strong—Anne Frank

Essay in need of a Strong Opening

Anne Frank, the Jewish girl whose diary and death in a Nazi concentration camp made her a symbol of the Holocaust, was allegedly baptized posthumously Saturday by a member of the Church of Jesus Christ of Latter-day Saints, according to whistleblower Helen Radkey, a former member of the church. The ritual was conducted in a Mormon temple in the Dominican Republic, according to Radkey, a Salt Lake City researcher who investigates such incidents, which violate a 2010 pact between the Mormon Church and Jewish leaders.

Radkey discovered that Annelies Marie “Anne” Frank, who died at Bergen Belsen death camp in 1945 at age 15, was baptized by proxy on Saturday. Mormons have submitted versions of her name at least a dozen times for proxy rites and carried out the ritual at least nine times from 1989 to 1999. This time, Frank’s name was discovered in a database that can be used for proxy baptism — a separate process, according to a spokesman for the church. The database is open only to Mormons.

A screen shot of the database shows a page for Frank stating “completed” next to categories labeled “Baptism” and “Confirmation,” with the date Feb. 18, 2012, and the name of the Santo Domingo Dominican Republic Temple.

Mormon posthumous proxy baptisms for Holocaust victims or Jews who are not direct descendants of Mormons has continued, despite church vows to stop such practices. Negotiations between Mormon and Jewish leaders led to a 1995 agreement for the church to stop the posthumous baptism of all Jews, except in the case of direct ancestors of Mormons, but some Mormons have failed to adhere to the agreement.

The name of Nobel Peace Prize winner Elie Wiesel was recently submitted to the restricted genealogy website as “ready” for posthumous proxy baptism, though the church says the rite is reserved for the deceased, and Wiesel is alive. Wiesel, a Holocaust survivor, was among a group of Jewish leaders who campaigned against the practice and prompted the 2010 pact by which the Mormon Church promises to at least prevent proxy baptism requests for Holocaust victims.

Wiesel last week called on Republican presidential candidate and Mormon Mitt Romney, a former Mormon bishop who has donated millions to the church, to speak out about the practice. The Romney campaign did not immediately reply.  The Frank case follows closely on an apology from the Mormon Church last week for recent posthumous baptisms of Nazi hunter Simon Wiesenthal’s parents.

The latest baptism of Frank by proxy is especially egregious because she was an unmarried teenager who left no descendants. Mormon officials have stressed that in accordance with the agreements, church members are supposed to submit only the names of their own ancestors.

“The security of the names submissions process for posthumous rites must be questioned, in view of the rash of prominent Jewish Holocaust names that have recently appeared on Mormon temple rolls,” Radkey said about her latest find. “This one sailed straight through, with Anne’s correct name in their ‘secure’ database.”

Radkey said she expects, once word gets out, that church officials will scrub the records as they did with Wiesel and Weisenthal’s parents. The Mormon Church responded later Tuesday in a statement: “The Church keeps its word and is absolutely firm in its commitment to not accept the names of Holocaust victims for proxy baptism. While no system is foolproof in preventing the handful of individuals who are determined to falsify submissions we are committed to taking action against individual abusers who willfully violate the Church’s policy. Ritual baptism should be understood to be an offering based on love and respect; we regret when it becomes a source of contention.”

Exercise Specifics

In the Reply field below this post, write your strongest Opening Paragraph.

Your paragraph must contain a thesis sentence that clearly and boldly proclaims the claim you promise readers you will prove.

In addition, your Opening Paragraph:

  1. Will make strong, perhaps paradoxical claims.
  2. Will sum up a very strong argument your essay will make.
  3. Will NOT LOSE the argument.
  4. Will itself be an arugment.
  5. Will be memorable.
  6. Will be debatable, demonstatable, illustratable.
  7. Will be a good example of itself.

Well, maybe it won’t accomplish all 7 goals, but the more the better!

You have until the end of the period to write your best first draft.