An open letter to my past and future students

As most of my readers know, I teach Public Health graduate students and the University of Massachusetts, sometimes on campus, and sometimes online. This is an open letter to all of my past and future students. 

First, I want to thank everyone in my June course who took the time to complete the evaluation -- the feedback is very helpful to me. I also want to thank the whole class (and all my previous and future classes) for the privilege of learning together with you. Looking at this and previous rounds of evaluations made me realize that I need to make a public statement that all students contemplating taking my courses can read before they commit.

My evaluations tend to be bimodal -- a peak around "love", a (smaller, thankfully) peak around "hate", and mostly a trough in between. Oddly, the reasons for the love and the hate are the same: not too much structure, not too much interim formal performance evaluations, a lot of opportunities for discussions and questions. Everyone seems to appreciate my effort to make the material interesting and relevant, but a substantial number do not seem to like it.

I am actually fascinated by the convergence of the reasons for liking and disliking. By way of inference, I am going to suggest that where you fall out on the teaching should tell you more about your learning style than how I teach. To clarify, let me spell out my philosophy of teaching.

Whether I teach on campus or online, I limit my classes to graduate students. The reason for this is not that I do not think that undergrads cannot handle the material. Rather it is because I believe nothing replaces time with a topic to develop a depth of understanding and discussion about it. So, I view my classes as incubators of ideas. I do not see myself as the oracle delivering answers. My role is to get you excited about the questions. Furthermore, it is not my questions that should excite you, but the questions that you come to at the limits of your knowledge seen through the prism of the class material and discussions.

To be sure, I realize that this not a comfortable place for many. Most of us glide through an educational system that convinces us that there is a single correct answer, and, after teaching us to parrot it compliantly, punishes us if we stray. So, swimming in the sea of questions, seemingly answering them only to realize that the answers lead to further questions is disquieting. Yet it is at this edge that we gain access to the next level of understanding of our universe. Here, the feedback is not about an arbitrary letter, but about the exuberance of ideas, discussion generated and the richness of asking the questions.

I cannot tell you how much I love the learning environment that we create together. I gain something from each and every one of you, and I hope that each of you walks away with at least one idea that is new. What I suggest to you if you are a potential student considering taking a course with me in the future is to contemplate the boundaries of your own comfort zones in learning. If you like the feeling of vertigo that you get when old dogmatic answers are shattered and uncertainty reigns, take my classes. If you are worried about how it might feel, but curious to try, I will meet you where you are and help you weave a net to cradle your fall. But if you know that uncertainty cripples you, that you would rather have a map for every step of the way, my classes may be the wrong stop along your educational path at this time. But perhaps sometime in the future?

Again, thanks to everyone for enriching my learning. I miss you and look forward to future opportunities for exchanging ideas.                    

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Clinician as the Politbureau of medicine?

Do you think that medicine in the US is centralized? I do, but not in the way that we generally understand centralization. And furthermore, it is this centralization that I believe is making the idea of shared decision making so intimidating to some. Here is what I mean.

If you read management texts, centralization refers to an organization that is run predominantly top-down. In other words, a couple of oligarchs at the top of the ladder make all the decisions without consulting anyone below. In this way all the power is concentrated in the hands of the few. In an antithesis to this, in a decentralized organization, grassroots input and initiatives are incorporated into the fabric of the organization. And while in the times of a great crisis, when rapid decisions are necessary, the benefits of centralization may outweigh its risks, during normal day-to-day operations, such unilateral power can result in obviously negative consequences, from discontent among the employees to making the wrong choices. Furthermore, as organizations grow in size, it gets that much more difficult to run them effectively within the centralized paradigm.

Now, let us look at medicine. The traditional model of the doctor-patient relationship relies on the clinician to know what is right for the patient: take this pill and don't worry about the side effects, dear. Now, clearly, when someone shows up to the emergency room in septic shock, there is very little room for a democratic process; we want the doctor to do rapidly what needs to be done to save the patient. But this is a catastrophic exception to the rule of what modern medicine cares for. From pre-diabetes to pre-hypertension to "borderline cholesterol" to osteopenia to mild depression, these are the "diseases" that are prevalent in the office of the 21st century. None of these is particularly urgent or life-threatening. And if we are honest with ourselves, even a devastating diagnosis of cancer does not demand an instantaneous intervention: in the vast majority of cases there is ample time for discussion and contemplation. So, the centralized approach is the wrong way to go. Thus enter the robust discussion about shared decision making. 

Another reason that centralization of medical decisions is crumbling is the expanding patient panels that clinicians need to engage with in order to stay solvent, all within the context of increasing compliance and regulatory burdens along with decreasing reimbursements. Without an equal growth in one's cognitive ability to multi-task, this escalating imbalance is creating a rising risk for unilateral decisions to be plain wrong.

So, in my mind, this is yet another argument for all parties to embrace shared medical decision making to the extent we as patients are willing and able to do so. Because what is the alternative?          

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Why patient lab data should be liberated, with a few caveats

I am admittedly not an expert on health IT, but I am a firm believer in the empowerment of patients to be the driver of her/his health decision making. So this whole discussion about lab data being available directly to the patient is of great interest to me. But it does seem like yet another instance of the two sides coming together not to listen to each other but to be heard by the other side. And as well know, this works so well for any relationship!

Each side's view is represented roughly thusly:
Patients -- these are my data and I have the right to access them as soon as they are available.
Doctors -- we are worried that the sheer volume, complexity and irrelevance of (much) of the data will make it confusing and unnecessarily alarm the patient
Both arguments are valid, of course. But it is important to ask what lurks below the visible portion of each iceberg.

Let's take the patient view. Why do I want immediate access to my data? Well, obviously, because it is mine, it represents the results of testing on my body, and the record should belong to me. I should be able to access it freely whenever I damned well please. I am also more than a little exasperated with having to wait sometimes days to hear from my doctor's office about a result that has been available for a while, but was buried under the reams of paperwork on the MD's desk or his/her assigning a low priority to my data. And I am most exasperated when my lab results get lost or otherwise never make it to me at all. Perhaps if I have direct and unfettered access, this will make thing more efficient for me as an individual.

The doc's view, on the other hand, is that the patient does not necessarily understand what the notation of "low"connotes in reference to, say, total bilirubin, or how to interpret the RDW data. Even more importantly, what if there is an outrageously abnormal value for some important test? Surely the patient will desire an immediate explanation of it and its implications.

So, clearly, both sides have valid concerns. I do think that those of access predominate, as ethically it just makes sense. But for a non-medical person, looking at a lab sheet is like trying to read information about yourself in Chinese: your success in understanding is largely dependent on your ability to read and understand Chinese. So, before that horse leaves the barn, we should think through how to execute this most sensibly. For example, perhaps it is not sensible to have the lab computer directly vomit all of the inane values that no one really looks at right to the patient's account. And backing up a step, perhaps it is time for our lab use to be driven not by the lab equipment packages and processes, but to test only for factors that are of value. If I want to know the patient's creatinine, maybe the other 6 components of the Chem-7 should not be run, or at least not reported. And obscure values like the ones I mentioned above, e.g., RDW, MCHC, etc., should only be available when the situation actually makes them useful, and not just distracting.

I can see a potential positive unintended consequence of this development as well: maybe clinicians will be less trigger-happy ordering all kinds of labs for all kinds of oblique reasons. Maybe, just maybe, this apprehension about the patient's access to all the labs will result in more Bayesian thinking in the office and a lot less shot-gunning. Finally, it will not be all patients that choose to access their data. Let us hope that the selection bias does its job and assures that only those who are truly ready to be educated and empowered decide to do so.

All in all, I am looking forward to the liberation of my lab data. What I worry about is all the calls I will be getting from friends and family to help them understand them. All the same, I will do my part for the education and empowerment that absolutely needs to happen for this to be a successful and meaningful change.        

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Eminence or evidence, or how not to look like a fool when reporting your own data

A study presented a the ICAAC meeting was reported by the Family Practice News that piqued my interest. Firstly, it is a study on C. difficile infection treatment, and secondly it is counter to the evidence that has accumulated to date. So, I read the story very carefully, as, alas, the actual study presentation does not appear to be available.

Before I launch into the deconstruction of the data, I need to state that I do have a potential conflict of interest here. I am very involved in the CDI research from the health services and epidemiology perspective. But equally importantly, I have received research and consulting funding from ViroPharma, the manufacturer of oral Vancocin that is used to treat severe CDI.

And here is an important piece of background information: the reason the study was done. The recent evidence-based guideline on CDI developed jointly by SHEA and IDSA recommends initial treatment with metronidazole in the case of an infection that does not meet severe criteria, while advocating the use of vancomycin for severe disease. We will get into the reasons for this recommendation below.  

OK, with that out of the way, let us consider the information at hand.

My first contention is that this is a great example of how NOT to conduct a study (or how not to report it , or both). The study was a retrospective chart review at a single VA hospital in Chicago. All patients admitted between 1/09 and 3/10 who had tested positive for C. difficile toxin were identified and their hospitalizations records reviewed. A total of 147 patients were thus studied, of whom 25 (17%) received vancomycin and 122 (83%) metronidazole. It is worth mentioning that of the 122 initially treated with vancomycin, 28 (23%) were switched over to metronidazole treatment. The reasons for the switch as well as their outcomes remain obscure.

The treatment groups were stratified based on disease severity. Though the abstract states that severity was judged based on "temperature, white blood cell count, serum creatinine , serum albumin, acute mental status changes, systolic blood pressure<90, requirement for pressors," the thresholds for most of these variables are not stated. One can only assume that this stratification was done consistently and comported with the guideline.

Here is how the severity played out:

Nowhere can I find where those patients who were switched from metronidazole to vancomycin fell in these categories. And this is obviously important.

Now, for the outcomes. Those assessed were "need for colonoscopy, presence of pseudomembranes, adynamic ileus, recurrence within 30 days , reinfection > 30 days post therapy, number of recurrences >1, shock, megacolon, colon perforation, emergent colectomy, death." But what was reported? The only outcome to be reported in detail is recurrence in 30 days. And here is how it looks:

The other outcomes are reported merely as "M was equivalent to V irrespective of severity of illness (p=0.14). There was no difference in rate of recurrence (p= 0.41) nor in rate of complications between the groups (p=0.77)."
What the heck does this mean? Is the implication that the p-value tells the whole story? This is absurd! In addition, it does not appear to me from the abstract or the FPC report as if the authors bothered to do any adjusting for potential confounders. Granted, their minuscule sample size did not leave much room for that, but a lack of attempt alone invalidates the conclusion.

Oh, but if this were only the biggest of the problems! I'll start with what I think is the least of the threats to validity and work my way to the top of that heap, skipping much in the middle, as I do not have the time and the information available is full of holes. First, in any observational study of treatment there is a very strong possibility of confounding by indication. I have talked about this phenomenon previously here. I think of it as a clinician noticing something about the patient's severity of illness that does not manifest as a clear physiologic or laboratory sign, yet is very much present. A patient with this characteristic, although looking to us on paper much like one without a disease that is that severe, will be treated as someone at a higher threat level. In this case it may translate into treatment with vancomycin of patients who do not meet our criteria for severe disease, but nevertheless are severely ill. If present, this type of confounding blunts the observed differences between groups.

The lack of adjustment for potential confounding of any sort is a huge issue that negates any possibility of drawing a valid conclusion. Simply comparing groups based on severity of CDI does not eliminate the need to compare based on other factors that may be related to both the exposure and the outcome. This is pretty elementary. But again, this is minor compared to the fatal flaw.

And here it is, the final nail in the coffin of this study for me: sample size and superiority design. Firstly, the abstract and the write-up say nothing of what the study was powered to show. At least if this information had been available, we could make slightly more sense out of the p-values presented. But, no, this is nowhere to be found. As we all know, finding statistical significance is dependent on the effect size and variation within the population: the smaller the effect size and the greater the variation, the more subjects are needed to show a meaningful difference. Note, I said meaningful, NOT significant, and this they likewise neglect. What would be a clinically meaningful difference in the outcome(s)? Could 11% difference in recurrence rates be clinically important? I think so. But it is not statistically significant, you say! Bah-humbug, I say, go back and read all about the bunk that p-values represent!

One final issue, and this is that a superiority study is the wrong design here, in the absence of a placebo arm. In fact, the appropriate design is a non-inferiority study, with a very explicit development of valid non-inferiority margins that have to be met. It is true that a non-inferiority study may signal a superior result, but only if it is properly designed and executed, which this is not.

So, am I surprised that the study found "no differences" as supported by the p-values between the two treatments? Absolutely not. The sample size, the design and other issues touched on above preclude any meaningful conclusions being made. Yet this does not seem to stop the authors from doing exactly that, and the press from parroting them. Here is what the lead author states with aplomb:

              "There is a need for a prospective, head-to-head trial of these two medications, but I’m not sure who’s going to fund that study," Dr. Saleheen said in an interview at the meeting, which was sponsored by the American Society for Microbiology. "There is a paucity of data on this topic so it’s hard to say which antibiotic is better. We’re not jumping to any conclusions. There is no fixed management. We have to individualize each patient and treat accordingly."

OK, so I cannot disagree with the individualized treatment recommendation. But do we really need a "prospective head-to-head trial of these two medications"? I would say "yes," if there were not already not 1 but 2 randomized controlled trials addressing this very question. One by Zar and colleagues and another done as a regulatory study of the failed Genzyme drug tolevamer. Both of the trials contained separate arms for metronidazole and vancomycin (the Genzyme trial also had a tolevamer arm), and both stratified by disease severity. Zar and colleagues reported that in the severe CDI group the rate of clinical response was 76% in the metronidazole-treated patients versus 97% in the vancomycin group, with the p=0.02. In the tolevamer trial, presented as a poster at the 2007 ICAAC, there was an 85% clinical response rate to vancomycin and 65% to metronidazole (p=0.04).

We can always desire a better trial with better designs and different outcomes, but at some point practical considerations have to enter the equation. These are painstakingly performed studies that show a fairly convincing and consistent result. So, to put the current deeply flawed study against these findings is foolish, which is why I suspect the investigators failed to mention anything about these RCTs.

Why do I seem so incensed by this report? I am really getting impatient with both scientists and reporters for willfully misrepresenting the strength and validity of data. This makes everyone look like idiots, but more importantly such detritus clogs the gears of real science and clinical decision-making.

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Adventures with American or Flying, American Style

So, we all know that the time for a doctor's appointment is merely a suggestion, not a mandate, as the doctor is hardly ever on time. We have even started of necessity to apply this theory to air travel. But to end up arriving 5 hours late and... to the wrong city? Well, this was a new one on me. Here is what happened.

I went to ICAAC for the day yesterday to present some of our data on predictors of a mixed skin and soft tissues infection. If it had not been a podium presentation, I would have considered skipping the whole meeting, since it was my son's birthday. Instead, I decided to swoop in for the day.

I chose American Airlines, as it is one of the few carriers that can get me to Chicago without a lay-over. The flight there was fine, and I had plenty of time to get myself to McCormick Convention Center, have lunch with a colleague, get to the session and do my thing. My schedule was such that I had to get in the cab immediately after presenting to get to my flight, which I did.

Getting to the airport was a challenge, as after 3:00 PM the perennial Chicago traffic jams are just a fact of life. But get there I did, with time to spare. The lines at the check-in counters were daunting, and luckily I was able to find a self-service kiosk, where I swiped my credit card. With a predictable automaticity I went to press the "Print boarding pass" icon when something caught my attention: this did not look my itinerary! I had been meant to fly to Bradley International Airport on the 5:25 PM flight. Now the screen was trying to push someone else's trip on me that went from Chicago to Bradley via Dallas-Fort Worth. Luckily there was an option on the screen to decline the itinerary as not owned by me, which I did. Alas, the second try resulted in the same baffling error.

A lovely young man with the American Airlines uniform on standing next to my kiosk noticed my confusion and asked how he could help. I pointed to the screen. He smiled broadly and sweetly and delivered the bad news that my flight had been canceled, and I was being re-routed via Texas, and that instead of getting to Hartford around 8:00 PM, I would be getting there well after midnight. The shock prevented me from stopping him from printing out the boarding pass. Before I had recovered my ability to speak, he furrowed his brow while examining the pass. Glancing at his watch, which read 3:30 PM, seemingly speaking to himself, he said "I wonder why they put you on a 3:05 flight when it is already 3:30?" As I was catching my breath, he continued "Oh, this flight is tomorrow afternoon!"

With these words my hopes of seeing my son before the end of the day of his birth hopelessly vanished. Yet I was not to be defeated yet. Although I was told that a later flight to Hartford was still happening, but was already overbooked, I was not ready to give up. Instead, I asked how close to Hartford they could get me on the same night. Turned out that there was a 5:05 to Boston, which was now going to be delayed until 6:30, but there was a coveted seat available and did I want it. Well, given my choices, I desperately wanted it, and luckily got it. So, now, instead of getting home by 10:00 PM I was looking at getting into Boston at a yet undetermined time, renting a car to get myself to Bradley, picking up my car from the garage there and driving home. If luck was with me, I would be home before 3:00 AM. Well, at least I would not have to go to Texas. Tomorrow.

Now that I had indefinite time before boarding, I treated myself to a latte and a book, Paolo Coelho's The Alchemist. It felt somehow luxurious to be suspended in this space without time, where I could just concentrate on the rich story and language and question my Personal Legend, though I was pretty sure that awaiting a late flight at O'Hare only to land in the wrong city and then drive for hours to get home was not it. Nevertheless, peculiarly, this departure from the rush of traveling felt like a little spa break, albeit in the midst of a chaotic throng craning their necks for the arrival of the aircraft.

Well, we finally were airborne a little after 8:00 PM, the flight was uneventful, I rented a car, got to Bradley before Avis closed (no, they are not open 24 hours), got into my car and got myself home just before 3:00 AM. All in all, it could have been a lot worse (I could have had to go through Dallas... today). And everyone was so frightfully nice, especially the young man with large brown eyes and a feline manner at O'Hare. The epiphany for me was that I could not even be angry -- there was no one or nothing to be angry at, and anger would have been disempowering, impotent. Instead, the lesson was that this is air travel in the 21st century -- crowded, uncertain, thoroughly unappealing. The only thing one can do, aside from avoiding it, is to accept it for what it is and go on. Though I have to say that being screwed is much nicer with a smile.      

              

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So I got my son a tracfone...

Wanted to post some follow up to my absurd interaction with AT&T, the beginning of which can be found here. Briefly, all I wanted to do was add one more line to my family plan for $9.99 per month. Instead of making it simple, the web site demanded personal information (including my social security number) for the purpose of doing a credit check. Now, I already have a monthly family plan for which I pay over an order of magnitude more than $9.99, and on time. Yet now they wanted to subject me to an additional credit check. Well, I said no and wrote the post in question.

What was interesting and even encouraging to me was that I got the following comment from an AT&T customer service rep, and responded in kind:

attcathyw said...

Hi Marya- I am with AT&T and saw your post. We would like to assist with and answer any questions/concerns that you may have. Please email your contact information to one of our managers at attcatherinew@att.com and include your name in the subject line. Thanks.

September 7, 2011 4:12 PM 

Marya Zilberberg said...

Thanks to all of you who tweeted and facebooked (as a verb?) me about this post. My impression that there is growing dissatisfaction out there with the way business is done is being confirmed. I wanted to update you all on what the follow-up has been. I e-mailed Cathy (see comment above) yesterday. Last night I got this message from her coworker: "Hi Dr. Zilberberg, Cathy is out of the office so I am reaching out on her behalf. In order for me to research your wireless account further, I would need either the account number or the mobile number in question. In additionally, a good contact number for you would be great. Once I receive the information, I will partner with a wireless customer service manager to see what we can possibly do. I do hate to see the frustration in your post. While I cannot guarantee, I will do my best to see what can be done to provide the extra line without the credit verification. Of course we will not make any changes without your consent. Please email your contact information, account number or mobile number to me at attannellem@att.com and include your name in the subject line. Please provide a best time to contact you. Thanks and have a good evening! Thanks, ATTAnnelle M" OK, so again I am the one wasting my time having to contact yet another person because the original individual I was told to contact for customer service is not there? Wow! Nevertheless, this morning I e-mailed Annelle and let her know that I simply do not have the time to keep explaining the issue, and that unless she can do what I need without wasting my time, she should go ahead and let me know by mail. I reiterated what the issues were and also that this is a corporate culture problem that needs to be rethought in light of its ethical implications. Will let you know what happens.

September 8, 2011 10:43 AM 

The following correspondence ensued between me and Annelle (emphasis mine; numbers x'ed out to protect my privacy, which I am still interested in maintaining, despite Mark Zuckerberg's assertions to the contrary):

September 8: me

Dear Annelle,

Thank you for your e-mail. Unfortunately, I do not have the time to spend explaining (again!) what I need and waiting for you to see what can be done without any guarantee of the outcome. I hope that you see my point about the futility of a credit check for a $10/month line, since for the last 6 years I have paid my approximately $xxx monthly mostly on time. Additionally, no credit checks were necessary for the last x family lines added, and I was also able to increase my service by about $xx without a credit check. And this does not even get into the minimum $20 for the texting feature on my son's line -- one of my family lines has 50 messages for $2.99, but this option no longer seems to be available.

I realize that you are trying to help me, and I thank you for it. My cell number is xxx-xxx-xxxx. But as I said I simply do not have the time to spend on these endless phone calls with your company. If you can resolve something for me, great, let me know via e-mail. If not, it is fine, as I plan to visit my local AT&T store shortly. 

The bigger issue is how user-unfriendly this whole process has become, and it is your marketing executives that need to do some soul searching about whether this is an ethical or sustainable way to continue doing business.

Thanks once again.

September 8: Annelle

Hello Dr. Zilberberg,
I appreciate your candid response and your patience.  I know your time is valuable therefore I will keep this brief...
What kind of wireless device were you interested in for your son?  I know from your email that you want to keep your same plan and to place him on texting pay per use at a cost of .20 per text (incoming/outgoing, each are charged per text).
Please advise and I will continue to work on this end.  Hopefully you will not have to travel to the store if I can get this done for you.
Thanks so much!
Annelle M

September 8: me

Annelle,

Thank you for following up.
I want to get him a very simple flip phone that is free or very cheap. It does not have to have a camera or any other fancy features.

Thank you once again.

 September 8: Annelle

Good evening Dr. Zilberberg,

After great effort, I have found that ALL entities (including the store) will require a credit verification for new lines of service even though the monthly cost is not very great. The other option, without performing the credit verification, is prepaid. 
I know this is disappointing and I hate to be the bearer of bad news.  However, if you do consent to the credit verification, I can have a nice phone ordered for you son at no cost sent directly to your home in roughly 2 days. There are approximately 15 different devices available for new activations such as samsung solstice 2, palm pixi, sharp fx, pantech impact, samsung strive, etc.
Please kindly respond and let me know how you would like to proceed either postpaid or prepaid.  I will be looking for your response.
Thanks!

Annelle M

September 9: me
Dear Annelle,

Thank you for your diligence.

There is absolutely no way I am consenting to disclosing this highly sensitive information for a $9.99/month fee. Furthermore, my impression was that AT&T charges one month ahead, so there is no credit involved. Is this not correct?  

This feels like a frivolous usurpation of what is reasonable. And given the frequent reports of confidential data breaches, I am not interested in subjecting myself to this risk. I will have to withhold this portion of my business form AT&T and go with the pay-as-you-go scheme. 

Thank you. I would appreciate if this issue were brought to the attention of the management of AT&T so that a more reasonable policy can be developed. 

This was the last correspondence, and I purchased a Tracfone for him. Researching it made me think seriously why more people are not using it and why we continue to allow ourselves to be strong-armed by these mammoth corporations who in a purely Orwellian example of doublespeak want to convince us that handing over the reins to them is a good thing for us. Tracfone: no activation fee, no contract, no intrusive credit check, pay as you go, full texting, web and e-mail capabilities, reasonable rates. What more does one need, especially as an emergency use phone for a kid?

So, thank you, AT&T, I am eternally impressed with and grateful for your customer service.  

 

 

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Supersize me, the AT&T way

File this under "etc."

I had one simple goal -- add a line to my AT&T family wireless plan for my son. I know, I know, I did check other carriers' plans and deals, since my contract with AT&T ran out long ago. But for various reasons I decided to stay with them. Why trade a known headache for an unknown one? Anyway, I went online with every intention of being finished in the space of 10 minutes. How naïve...

I wanted to get a basic plan, with just voice and minimal text messaging -- say 20 texts per month -- so that he can reach us in case of an emergency, but not abuse this disembodied conversation mode. And you would think that it would be easy to get this, right? Well, not so much. The only text option that came up on the screen was unlimited texting for $20/month. This was infinitely more than I needed, so I initiated a chat with a representative. He was effusively polite, and every time I volunteered information or responded to a question he thanked me very much for sharing this information. After several volleys, in which I thought I had conveyed my dilemma clearly and succinctly, he came back with "So, if I am understanding you correctly, you wish to change the text messaging plan on your phone." I did a rapid-fire "No, no, no," trying to get ahead of his rogue fingers as I imagined them poised to hit "change plan." You see, I am still traumatized from a recent experience with the cordial AT&T customer service representatives who "helped" me with an issue.

Just to give you the flavor for that episode, in the process of resolving a signal issue, they implemented such changes in my texting and data plans as to require several weeks of phone calls with the AT&T business office, a call and a correspondence with the Attorney General of Massachusetts, and a follow-up call with AT&T on the heels of their communication with the AG. So, no, I am not interested in having them "help" me with plan changes. I politely excused myself from the chat and decided to tackle it on my own.

But first I chose to distract myself from the problem at hand by doing another task that I had meant to do: increase my monthly minutes. This I was able to do without any glitches, and my success encouraged me to try again with the new line. Perhaps I missed something the first time?

Having considered my choices at this point, I made the decision that I would pay for a limited number of text messages for my son, at $.20/message, and this would take care of things. Smugly congratulating myself on such a creative solution, I went to complete the purchase. After addressing just a couple of minor issues stemming from the fact that my billing address is a PO Box and not a street address, and because lately everyone except the USPS has decided that I have played a joke on them by giving a non-existent address (don't get me started on the joys of living in rural America), I was almost home. I just needed to input my credit card information and... Wait a second! What's this? A credit check consent? I had to give them my social security number and consent to a credit check? Because I tacked an additional $9.99 monthly service fee to my (much larger than that) bill? After being a customer for nearly 6 years? After being able to up my monthly minutes by more than $9.99/month, without being subjected to a credit check?!!

Well, I did what anyone in my position would have done: I ignored this prompt hoping that it was optional. But it wasn't. Fill it in or else take yourself to a brick-and-mortar store to get this settled. Which is what I am choosing to do. But there is a larger moral here.

How did we get to this place, where our anti-trust protections have resulted in basically two gargantuan corporations essentially screwing the public in any way they see fit? Why do they get to dictate the devices and services that I need to purchase? How is this a free market? And how is it that this technology, whose intent is to make our lives so much easier, made me go through a bewildering amount of useless machinations only to end up with what? An offer to take my social security number and subject me to a credit check? Really?

And lest AT&T feel singled out by my rant, this is the trend with many events and purchases in life. Home insurance, for example, which, despite rising premiums, does not give you a penny towards rebuilding a retaining wall that collapses in a flood. In fact, the system is set up in such a way as to require you to file a claim, get it rejected and give the company the reason to fire you as a customer for filing too many claims. Health insurance (I don't have to remind you the galloping pace of the rise in those premiums), which covers less and less every year. Cable companies, computer manufacturers, automobile vendors, they are the ones that seem to know better than I what it is that I need, and they constantly and with impunity wrestle me into straightjackets of their packages. Where am I, the customer in all this? This old familiar strategy to maximize returns has been so successful in the food business that its legacy is the obesity epidemic, proliferation of chronic disease and shortening life spans. Is this really how we want to continue?  

I will get that line for my son, and I will get only what I need. I would prefer not to be so dependent on this stuff; alas, I am. But mark my words, there is enough bad taste building among my fellow humans to start exploring alternatives. I only wish that the government were really in the business of protecting its citizens from unethical practices rather than pandering to the highest bidder. I am ready to stop being viewed as a giant walking ROI potential, and start being respected as a citizen and a human. How about you?                

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You want to know #6?

Actually, it should really be #1. I am referring to the list I blogged yesterday of my top 5 reasons for rejecting a manuscript. The most important reason, which I failed to mention is...

... drum roll, please...

6. No "Limitations" paragraph
This is something that no manuscript should neglect, as every study, even the most well designed and executed randomized controlled trial, has limitations. So, in every paper that I write, my third paragraph from the end is devoted to the laundry list of limitations. And it should not be merely a laundry list, no. Each limitation mentioned needs to be put into the context of how it may have influenced the results, directionally and magnitudinally (oh, whatever), if applicable.

So, no limitations paragraph, no "Accept" from me!  

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