EM Drive; Trump; ISIS; and a very mixed bag.

Chaos Manor View, Sunday, August 09, 2015


Once more I am in fiction mode, and will be tomorrow as well.

I do not think Mr. Trump strengthened his position as a Republican candidate; It will be interesting what that does to his decision as to whether to run without the Republican nomination.

It is clear to me that he has the Presidency in his gift to Hillary: if he runs as an independent, she wins, and I do not see how to avoid that. It is also unlikely that he will be nominated by the Republican Party, which will probably retain control of Congress.



60 years ago: The famous Boeing 707 prototype barrel roll over Lake Washington | The Seattle Times

I remember it well. Tex Johnson’s secretary was a subject in some of my Human Factors Laboratory experiments. It was a wild day; and a week later every senior pilot in the airline business was in his boss’s office gasping “You gotta get me one!”


EmDrive – dark matter thruster?
This probably qualifies as a crackpot theory, but what if the EmDrive gets its thrust by redirecting dark matter? That would get around the problems with current scientific theories. Maybe a Dark Matter Thruster could be used in some sci-fi stories as an interstellar drive.

Stephen Walker

That’s an arguable theory assuming that the EmDrive actually produces thrust; that has not yet been proven to satisfaction for something so impossible under current theory, but there seems to be far more than enough evidence to justify more rigorous tests. If there be thrust, then we need theories to explain it.

The EmDrive has *not* been ‘peer-reviewed’, for any meaningful value of ‘peer-reviewed’.

And ‘peer-reviewed’ isn’t as sacred a thing as civilians seem to think it is.


Roland Dobbins

Agreed to both statements; “peer reviewed” is often merely a way of defending a consensus theory. Alas, it doesn’t even filter out nonsense. On the other hand, given the ease of “publication” now, there has to be a way to filter publication to find what’s worth your time. I don’t have a good method for accomplishing that, but it’s obvious we need one. With the EmDrive, the process seems to be working, although it may be a bit vigorous in the filtering; yet given how extraordinary the claim of reactionless thrust (at least reaction against ordinary matter) certainly we are correct in insisting on extraordinary proof.

I certainly hope it proves out, and I vigorously support further tests – I’d love to be in on them. I expect when it’s all over it will not produce useful thrust, but the reward if it does justifies a lot of testing. If it’s a con, it is a bit more clever than most. Newton’s Third Law is a serious limit to space exploration; that rocket equation is brutal…


The Starborn

Dear Dr. Pournelle,

This isn’t directly related to your question, but I think it worth mentioning even so.

In church on Sunday I spoke  to a woman who had fertility problems, so she had her eggs harvested. Since she was determined that all fertilized embryos would be brought to term if possible, they created 8 fertilized embryos , and put them in the freezer until such time as it was possible to try to carry them.

8 embryos, 3 survived pregnancy, and now she has three lovely girls. Ironically, though the oldest and youngest girl are about seven years apart physically, the were *conceived at the same time*  — it’s just that the years that the oldest was developing , the other spent in a freezer. 
It made me wonder — we often talk about cold-sleep as one way to travel between stars. While the techniques to induce long-term hibernation in adult human beings are under development, the techniques to hibernate fertilized embryos exist * today *.
I was wondering if that might be another way to start an interstellar colony — to ship the colonists as frozen embryos.  This would require some kind of ‘caretaker’ to thaw them out and raise them up into functioning adults, either a robot crew or a generation ship “caretaker” family, a family of priests, as your other commenter mentioned, who could maintain their lives and their teachings, passing them through the generations, until planetfall, at which point it would be their jobs to literally act as mothers and fathers to the newly thawed colonists.
This would naturally make the caretakers a literal aristocracy which might cause friction among their children — especially if, several hundred years down the line, there is no more obvious difference between thawed and caretaker, but the caretakers still retain their privileges. Sequel fodder?
In any event, I would suggest that teaching in interstellar colonies will look remarkably like the teaching methods we have used to date. Reason: As you have argued in other books,  it isn’t practical to maintain a high-technology civilization on a new colony.  So until a new industrial base can be created, humans will have to use sustainable resources. Horses instead of tractors.  Animal labor in place of machines. Mechanical calculators and abacus devices instead of electronic calculators. They may eventually develop the tools to build the tools to create such things , but until they do any kind of sophisticated memory transfer technology will have to wait — or be the privilege of the caretaker family.
Some thoughts and ideas. I hope they are useful!

Brian P.

Intriguing. It is actually close to what we did in Legacy of Heorot Most of the colonists were in cold sleep, and the rest were frozen embryos; the last of the first settlers was to raise a generation while building a medium tech society; all went well until it didn’t. The book we’re working on now is the third in the series. The second, Beowulf’s Children comes after they recovered from their first near fatal problems; the third takes place about a generation after that. It’s 14 light-years from Earth (and thus at least a century of travel, and 14 years each way communications), so no help there…



Banned in Beijing.



Roland Dobbins



Russia Wants War.



Roland Dobbins

A scary proposition indeed; I can hope that Putin has a more clever scheme in mind. He wants, with reason, to end the encirclement. From our view, we don’t need it; the Europeans don’t contribute much to our defense; and if they want a cordon sanitaire around Russia, surely they ought to pay for most of it?


ISIS: Predictable and Predicted

You can comfortably eat and drink in front of your PC while reading this as you’ll find no surprises:

To date, the intelligence view has been that ISIS is focused on less ambitious attacks, involving one or a small group of attackers armed with simple weapons. In contrast, al Qaeda in the Arabian Peninsula, or AQAP, has been viewed as both more focused on — and more capable of — mass casualty attacks, such as plots on commercial aviation. Now the intelligence community is divided.

Meanwhile, the U.S. effort to train rebels in Syria to fight ISIS is having trouble. The few rebels that the U.S. has put through training are already in disarray, with defense officials telling CNN that up to half are missing, having deserted soon after training or having been captured after last week’s attack by the al-Qaeda-affiliated Nusra Front attack on a rebel site.

Yeah, so putting a feather duster up your butt doesn’t make you a bird. Now, can we get back to reality and deal with this?

◊ ◊ ◊ ◊ ◊

Most Respectfully,
Joshua Jordan, KSC

Percussa Resurgo

I could end ISIS within a year, probably a lot less, with two Divisions and the Warthogs. [By that I mean we have commanders who could do it if told to do so.] The battles would be bloody but one-sided; the casualties among civilians would be high because they will not give up without a fight. We could then recruit a Foreign Legion to protect our interests, and Auxiliaries to fight our battles preserving the conquests ( Most of which would be given away to appropriate allied protectorates; we would have the consent of the governed to rule in only a few places, but that’s a detail we can put off). ISIS – the Caliphate – ceases to exist if it has not a territory to rule. Our objective is to preserve former allies, and leave the area.

We can do that now. Perhaps we will not be able to do it later. I would, of course, require the rescued or the recipients of our conquests to pay for our efforts.

America at an Ominous Crossroads | The American Spectator


I have decided that this book is on my reading list.

“Why the ISIS Threat Is Totally Overblown” – by John Mueller

“Outrage at the tactics of ISIS is certainly justified. But fears that it presents a worldwide security threat are not. Its numbers are small, and it has differentiated itself from al Qaeda in that it does not seek primarily to target the ‘far enemy,’ preferring instead to carve out a state in the Middle East for itself, mostly killing fellow Muslims who stand in its way. In the process, it has alienated virtually all outside support and, by holding territory, presents an obvious and clear target to military opponents.”

Braxton Cook

They grow rapidly; it will not be long before it will take more than two divisions and air support to eliminate them. By then all Christian, Jewish, Druze, and Shiia will be gone, and the inhabitants remaining will be Caliphate under sharia; they will be damn near unconquerable by an army except by extermination.

Perhaps you are right; I certainly regret the passing of Saddam; our destroying him proves that often things go from bad to worse. I am not convinced that there is much worse than the Caliphate which takes seriously their mission to put all to the choice of Islam or the sword.


Footfall fan art by William Black

Hello! I thought you might appreciate this CGI model of the “Michael”, by William Black on Deviant art. Really, it’s well worth looking at his whole gallery, particularly the Orion models, but I thought this one would appeal to you for obvious reasons.



SUBJ: Wanna read a good, short military story?

Dear Jerry,

Perhaps you can use this theme some day. It is a military story I don’t think I have EVER read of in military sci-fic literature and only occasionally in military tv and movies. Pity. It wants more telling.




What can I say to add to this?

Corroded By Urine, San Francisco Light Pole Collapses, Nearly Killing Man

Such a metaphor for a totally progressive run city and state government.



Good morning Jerry,
I’ve not written you in a while as I know you’ve been busy with important things, however my iPhone beeped at me today to remind me it’s your Birthday.  Assuming I’ve not boggled up the date, I wish you a Happy Birthday and may you have many more pleasant ones surrounded by your family.
I see I’ve been remiss in my subscription, so I’ve just sorted that out.  It’s not a great birthday present, but consider blowing most of it on Wine, Women and Song.  The other ten percent, you can just waste.
I know your recent stroke has made things more difficult for you physically, but keep at it, you will improve.  And you will improve if you keep at it.
and now, the brain dump.
Keyboard Recommendations:
Logitech K750r
This keyboard strikes all the right nerd buttons with me.  Wireless, Solar Powered, no more !@#$! batteries!  How great is that?  It works at a decent distance from the transceiver, has a good feel (not like the excellent IBM Model M keyboards, of course) soft, decent key travel, full sized and works well with my PCs or Macs.  Oh and it has an on-board capacitor/batter(?) so it also works in the dark.  I now own several and use them everywhere. 
On Mice:
My favorite mice have pretty much been the Microsoft mice due to their excellent tracking on just about every surface, but I’m beginning to warm up the some of the Logitech mice.  The m325 has a decent feel and incredible battery life.  The box says 18 months between changes, yet I cannot recall changing the battery in over two years.  My apple touch mouse seems to need a change every two weeks, and it uses two batteries! (my recollection might be off, but it sure seems that way).  I got tired of feeding that monster.  The Microsoft mouse I have is much better but even so, I have to change the battery every couple of months.
I see Logitech offers a mouse that claims three years on a single battery.  I’d believe their claims.
Operating Systems:
Mac OS X continues to work very well for me.  Being an old bearded Unix type, I appreciate having a real operating system underneath a very pretty gui.  It just works.
Windows 8.x belongs in the trash heap with Vista and ME.  I cannot stand what they’ve done with it.  Windows 7 is pretty good and a worthy XP successor (in my not so humble opinion).  Windows 10 looks promising and I’m cautiously optimistic.  At the very least, I’ll recommend that any v8.x users take advantage of the upgrade – in about three months.  Let someone else find the bugs I say.  At any rate, Win7 is good enough.

I’m glad to hear that Janissaries is coming along.  I know of at least three people who will be looking forward to reading it.
The “There Will Be War” series was interesting to reread after thirty years.  My old versions have disappeared into the brotherhood of book lenders, so I’ve purchased them again from Castallia house.  I hope you can find the time see the others released.


The “em” drive news is fascinating.  Could this be what we’ve been waiting for?  I’m afraid I’m more hopeful than optimistic in the matter, but if it does turn out to be the real deal, it means that mankind will have another renaissance in exploration and adventure that the West has been lacking for over a century.  If anything could breath some life into our decaying society, it would be this and a new frontier to exploit/explore. 
Here’s a link that I think you will appreciate reading – it’s an email exchange between two US veterans of different generations:
This should come as no great surprise, but a lot of people thing you still have many important things to day, so please take care of yourself and continue doing what you do best. 
Thanks for letting me bend your ear, and I hope you have a fantastic day.
– Paul

A good keyboard but not for me. For touch typing I preferred the comfort curve; alas I am a two finger typist now. The Logitech K360 lets me bang away with fewer errors; the chicklet keys are well separated, and that helps a lot.

I think they have done well with the There Will Be War series.

Thanks for the kind words.


Russia and rocket engines

So way back when our government spent zillions of taxpayer dollars learning to make rocket engines.
Our brave capitalist ‘job creators’ decided that they did not care to make rocket engines – so messy! So hard! So much easier to just play the stock market and get bailed out with the public treasury when you mess up!
But now some people see that we are signing a zillion dollar contract with Russia to buy their rocket engines because we can no longer make our own. But not to worry, our brave capitalists say that, if we give them ten zillion dollars, they might (might! no promises) be able to make rocket engines again by 2030. Or 2040. Or they might just buy them from Russia and slap a ‘made in USA’ sticker on them.
Commenting on ‘free’ trade, Alexander Hamilton said ‘who would console themselves with the loss of an arm, with the idea that they could buy their shirts for 40% cheaper?’ Well, obviously, our own elites.
You have previously commented that unregulated laissez-faire capitalism ultimately results in human flesh being sold in the market. Perhaps not yet, but it has resulted in our technological supremacy being given away for a nominal price. In less enlightened times this would have called that treason.



full orwell

Google link should avoid the paywall at

Was that the worst speech ever delivered by a U.S. president? Maybe not—our knowledge of 226 years worth of presidential oratory is less than comprehensive—but no rival comes to mind.

Rather than enumerate every flaw of Barack Obama’s defense of his Iran deal yesterday, we’d like to look deeply at the most glaring one, namely this passage:

Just because Iranian hard-liners chant “Death to America” does not mean that that’s what all Iranians believe.

In fact, it’s those hard-liners who are most comfortable with the status quo. It’s those hard-liners chanting “Death to America” who have been most opposed to the deal. They’re making common cause with the Republican caucus.

Unsurprisingly, that partisan smear, vicious even by Obama’s standards, has drawn a good deal of comment from the right.<snip>

I think I can convince nearly anyone that the Iran deal is not best for the US, but I am not President. The Congress may be able to stall, although I think they will not be successful; and if Hillary wins the 2016 election as she almost certainly will if Trump runs as an independent, I doubt she will undo it.

Iran will have nuclear weapons; live with it. There really is no choice now.


Army is breaking, let down by Washington


Army is breaking, let down by Washington

By Robert H. Scales

Special to The Washington Post

Published: August 2, 2015

Last month, Gen. Ray Odierno, outgoing Army chief of staff, and Gen. Mark Milley, his successor, testified to the difficulties faced by the Army. I’d like to make the same points by telling a story.

When I was a boy, tonsillitis was a dangerous illness. In 1952, it kept me in Tokyo General Hospital for weeks. I shared a cramped ward with dozens of soldiers horribly maimed in Korea. The hospital had only one movie theater. I remember watching a Western sandwiched between bandage- and plaster-wrapped bodies. I remember the antiseptic smells, the cloud of cigarette smoke and the whispers of young men still traumatized by the horrors of the war they had just left.

My dad came from Korea to visit me, and I recall our conversations vividly. At the time he was operations officer for the 2nd Engineer Battalion. He told me how poorly his men were prepared for war. Many had been killed or captured by the North Koreans. During the retreat from the Yalu River, some of his soldiers were in such bad physical shape that they dropped exhausted along the road to wait to be taken captive.

“We have no sergeants, son,” he told me, shaking his head, “and without them we are no longer an Army.”

In the early ’70s, I was the same age as my Korean-era dad. I had just left Vietnam only to face another broken Army. My barracks were at war. I carried a pistol to protect myself from my own soldiers. Many of the soldiers were on hard drugs. The barracks were racial battlegrounds pitting black against white. Again, the Army had broken because the sergeants were gone. By 1971, most were either dead, wounded or had voted with their feet to get away from such a devastated institution.

I visited Baghdad in 2007 as a guest of Gen. David Petraeus. Before the trip I had written a column forecasting another broken Army, but it was clear from what Petraeus showed me that the Army was holding on and fighting well in the dangerous streets of Baghdad. Such a small and overcommitted force should have broken after so many serial deployments to that hateful place. But Petraeus said that his Army was different. It held together because junior leaders were still dedicated to the fight. To this day, I don’t know how they did it.

Sadly, the Army that stayed cohesive in Iraq and Afghanistan even after losing 5,000 dead is now being broken again by an ungrateful, ahistorical and strategically tone-deaf leadership in Washington.

The Obama administration just announced a 40,000 reduction in the Army’s ranks. But the numbers don’t begin to tell the tale. Soldiers stay in the Army because they love to go into the field and train; Defense Secretary Ash Carter recently said that the Army will not have enough money for most soldiers to train above the squad level this year. Soldiers need to fight with new weapons; in the past four years, the Army has canceled 20 major programs, postponed 125 and restructured 124. The Army will not replace its Reagan-era tanks, infantry carriers, artillery and aircraft for at least a generation. Soldiers stay in the ranks because they serve in a unit ready for combat; fewer than a third of the Army’s combat brigades are combat-ready.

And this initial 40,000-soldier reduction is just a start. Most estimates from Congress anticipate that without lifting the budget sequestration that is driving this across-the-board decline, another 40,000 troops will be gone in about two years.

But it’s soldiers who tell the story. After 13 years of war, young leaders are voting with their feet again. As sergeants and young officers depart, the institution is breaking for a third time in my lifetime. The personal tragedies that attended the collapse of a soldier’s spirit in past wars are with us again. Suicide, family abuse, alcohol and drug abuse are becoming increasingly more common.

To be sure, the nation always reduces its military as wars wind down. Other services suffer reductions and shortages. But only the Army breaks. Someone please tell those of us who served why the service that does virtually all the dying and killing in war is the one least rewarded.

My grandson is a great kid. He’s about the same age I was when I was recovering at Tokyo General. Both of his parents served as Army officers, so it’s no wonder that in school he draws pictures of tanks and planes while his second-grade classmates draw pictures of flowers and animals. The other day he drew a tank just for me and labeled it proudly “Abrams Tank!”

Well, sadly, if he follows in our footsteps, one day he may be fighting in an Abrams tank. His tank will be 60 years old by then.

At the moment I’d rather he go to law school.

Robert H. Scales, a retired Army major general, is a former commandant of the U.S. Army War College.


A Guy Came Across This Enormous Abandoned Building. What’s Inside It Shocked Him.



Freedom is not free. Free men are not equal. Equal men are not free.




Educating the Starborn

Chaos Manor View, Sunday, July 26, 2015

It’s Sunday night, and I’m still in fiction mode. This is short shrift…



Educating the Starborn

Dear Jerry:
In your View for 7/23/2015 ( you wrote:

I have been worrying about education: what is the curriculum for children on an interstellar colony? There must be some common culture, and it won’t all be science and technology.

Would the answer not depend on what kind of common culture you want to establish among the starborn?
I immediately thought of Dr. John Patrick’s comments about children and stories. Recall from my previous e-mails that Dr. Patrick is a pediatrician and a founder and president of Augustine College in Ottawa.

Dr. Patrick tells how children love hearing stories repeated over and over because the stories inform the child about his place in the world.
At one time in western civilization the most widely known stories were from the Holy Bible. Every one of those stories was about moral consequence. People were so familiar with those stories that it is said that the miracle of Dunkirk was launched by a three-word message from a British officer trapped on the beach: “But if not”.
(See George Will’s “A Dying Tradition” at,764718&hl=en
or Will’s more recent “Closing the book on literature” at
More recently in America the most widely known stories come from television advertising, stories with no moral consequence in which the most frequently taught lesson is “Just do it!” This week we have seen one result of that teaching. We have watched videos of highly-schooled physicians negotiating the selling prices for the brains and hearts and livers of human beings who were dissected as living babies in their mother’s wombs.
As Arthur Leff wrote in “Unspeakable Ethics, Unnatural Law”, “As things now stand, everything is up for grabs.”
(Duke Law Journal, Vol. 1979, No. 6, pp. 1229-1249 (December 1979). Available as a PDF file from
Dr. Patrick points out that the Jews have survived for more than 2,000 years without a homeland and are still identifiable as Jews. That is a miracle. If you took a bunch of Americans to an isolated desert island, for how many years would they remain Americans? The reason for the Jews’ survival can be found in Deuteronomy 6, where parents are instructed by Moses to tell their story to their children:

In the future, when your son asks you, “What is the meaning of the stipulations, decrees and laws the Lord our God has commanded you?” tell him: “We were slaves of Pharaoh in Egypt, but the Lord brought us out of Egypt with a mighty hand.

In other words, tell the children the stories, and tell them over and over again:

Impress them on your children. Talk about them when you sit at home and when you walk along the road, when you lie down and when you get up. Tie them as symbols on your hands and bind them on your foreheads. Write them on the doorframes of your houses and on your gates.

One place Dr. Patrick discusses this is in his lecture “Why Ethics Courses Do Not Make Us Ethical.”
(A recording can be found at )
What kind of sustainable common culture do you want for your starborn? Will they have a high view of humankind? Or will they have a diminished view of what it means to be human in which their fellow humans are no more than meat to be used by others.
Best regards,
–Harry M.

You have raised some of the questions that concern me; I can’t really comment, but I hope to address them in the book


RE: Educating the Star Born

You asked: “I have been worrying about education: what is the curriculum for children on an interstellar colony? There must be some common culture, and it won’t all be science and technology. Sure, as time goes on, there will be those who choose to specialize, “Classicists”, Shakespearian experts, and so forth; but, besides Dr. Seuss, what books have all the kids read? And whose history?”

E.D. Hirsch Jr.’s What Your [K-6th] Grader Should Know series might be a good place to start.  It may be too USA specific but the series is based on his concept of Cultural Literacy or a common knowledge base for educated people.

After that perhaps the Harvard Classics and Fiction instead of Britannica’s Great Books. Your own suggestions on history and math plus one or two ‘foreign’ languages after all if the Swiss can have 3 official languages why not our Star Born?

Thanks for keeping us informed,

Paul Evans


educating the starborn

Dear Mr. Pournelle,
You ask “what books have all the kids read? And whose history?” A fascinating question. What I’m wondering is, how might we avoid a dystopian answer?
On the assumption that “everything” (or near enough) is available electronically, there will be easily enough available for multiple intellectual universes. We already do that: interesting studies have found that politically-literate readers in the United States tend to cluster in two groups, one of which would never read Ann Coulter and the other would never read Michael Moore. Both are convinced the other group has nothing worth considering.
So: given the easy availability of “everything,” how do we avoid smug echo chambers? Alexei Panshin once wrote of our desperate need for Inspectors General, and the problem that anyone suited for the post would never have the arrogance to apply. Perhaps an electronic society will need a wise, honest and open-minded Board of Censors? Such a thing being implausible, I find myself at a loss for any good answer to your question…
Allan E. Johnson

I can’t be at a loss; we have a book to write…


Some thoughts on curricula for the starborn

On Jul 25, 2015 4:32 PM, “Gary Pavek” <> wrote:

Jerry –

Saw your mention of wondering about curricula for the starborn, and then this morning ran across a brief review of Ender’s Game which had some salient points.

The second and third paragraphs are the payload that relates to your question. Orson began the thinking that led to Ender’s Game when he read the Foundation Trilogy and wondered how one would train soldiers in microgravity. That led to the Battle Room and the selection of children as trainees because they would not have years of habit in gravitational thinking to unlearn.

This caused me to realize that there would probably be an entire curriculum in microgravity physical activities, and another in physical activities in higher-gravitational environments. One of the expected results of the latter would probably be broken bones and casts, possibly such that one could not graduate without breaking something. After all, nothing teaches caution as well as pain, and gravity demands caution.

My understanding is that current medical theory requires some exercise in gravity or else the bones will weaken and muscles will atrophy, etc. One might offset some of that with novel medications and various therapies (muscle stimulation, ultrasound, standing while strapped onto a vibrating plate, etc.) but it looks like humans need gravity. There is also no reasonable theory that I’ve seen that points the way to a workable artificial gravity, so the spinning hollow asteroid/ship or the giant spinning centrifuge/wheel seem to be the only viable means of keeping humans healthy without requiring multiple hours per day of physical training or physical therapy.

I realize that this doesn’t exactly fit your question, which seems to be more about the humanities, but if nothing else it does point to how strange that world would seem to us ground pounders.

Where will children get their sense of wonder? No fireflies? No fireworks? No snowflakes, butterflies, or lightning and thunder? No clouds, no rain, no dawn, and no sunset? No baking in the long days of the summer sun. Of course they’ll have the stars, but if that’s all you’ve known, will they still inspire wonder? Especially in the deeps between the stars, when the stars don’t seem to change.

Good luck with your ruminations!

–Gary P.

Oops. Forgot one source of gravity: acceleration, but that does require mass to discard.

How long would it take to get a xenon ion thruster up to ram scoop speed, anyway?

Fortunately I don’t have that kind of education in my story. Scott did his well, of course. As to enough acceleration to provide gravity, unless you have reactionless drive you are talking about really big ships. Fortunately I have a planet to provide gravity…


Islam & the rest of the world
Hello Dr Pournelle,
I’ve been thinking about this a for a couple of days now..
If The Islam world is following “the duty to bring the entire world under submission; there could be truces with the infidels, but peace with them is forbidden by the black letter law of the text” then there is no hope for peace.
Either the world adopts their belief system or their belief system is removed….one way or another. This is their choice, war is the game you play when the other person want to or you lose.
Half measures don’t do it.

Rob M

That was also what we faced in the Cold War: Communist theory was chiliastic, and that was taught in compulsory Marxist theory classes in every University and High School and Grade School in the Warsaw Treaty Organization. Fortunately much of the ruling class did not believe it in the last years of Communist rule; even more fortunately, the United States adopted strategies of containment and technology early after World War II and avoided a destructive war. You may credit Stefan Possony with part of that.


Giving Doctors Grades    (nyt)

JULY 22, 2015 

ONE summer day 14 years ago, when I was a new cardiology fellow, my colleagues and I were discussing the case of an elderly man with worsening chest pains who had been transferred to our hospital to have coronary bypass surgery. We studied the information in his file: On an angiogram, his coronary arteries looked like sausage links, sectioned off by tight blockages. He had diabetes, high blood pressure and poor kidney function, and in the past he had suffered a heart attack and a stroke. Could the surgeons safely operate?

In most cases, surgeons have to actually see a patient to determine whether the benefits of surgery outweigh the risks. But in this case, a senior surgeon, on the basis of the file alone, said the patient was too “high risk.” The reason he gave was that state agencies monitoring surgical outcomes would penalize him for a bad result. He was referring to surgical “report cards,” a quality-improvement program that began in New York State in the early 1990s and has since spread to many other states.

The purpose of these report cards was to improve cardiac surgery by tracking surgical outcomes, sharing the results with hospitals and the public, and when necessary, placing surgeons or surgical programs on probation. The idea was that surgeons who did not measure up to their colleagues would be forced to improve.

But the report cards backfired. They often penalized surgeons, like the senior surgeon at my hospital, who were aggressive about treating very sick patients and thus incurred higher mortality rates. When the statistics were publicized, some talented surgeons with higher-than-expected mortality statistics lost their operating privileges, while others, whose risk aversion had earned them lower-than-predicted rates, used the report cards to promote their services in advertisements.

This was an insult that the senior surgeon at my hospital could no longer countenance. “The so-called best surgeons are only doing the most straightforward cases,” he said disdainfully.

Research since then has largely supported his claim. In 2003, a study published in the Journal of Political Economy compared coronary bypass surgeries in New York and Pennsylvania, states with mandatory surgical report cards, with the rest of the country. It found a significant amount of cherry picking in the states with mandatory report cards: Coronary bypass operations were being performed on healthier patients, and the sickest patients were often being turned away, resulting in “dramatically worsened health outcomes.”

“Mandatory reporting mechanisms,” the authors concluded, “inevitably give providers the incentive to decline to treat more difficult and complicated patients.” Surveys of cardiac surgeons in The New England Journal of Medicine and elsewhere have confirmed these findings. And studies from 2005 and 2013 have shown that report cards on interventional cardiologists who perform angioplasty procedures are having similar results.

Surgical report cards are a classic example of how a well-meaning program in medicine can have unintended consequences. Of course, formulas have been developed to try to adjust for the difficulty of surgical cases and level the playing field. For example, a patient undergoing coronary bypass surgery who has no other significant diseases has an average mortality risk of about 1 percent. If the patient also has severe kidney dysfunction and emphysema, the risk of death increases to 10 percent or more. However, many surgeons believe that such formulas still underestimate surgical risk and do not properly account for intangible factors, such as patient frailty. The best surgeons tend to operate at teaching hospitals, where the patients are the most challenging, but you wouldn’t know it from mortality statistics. It’s like high school students’ being penalized for taking Advanced Placement courses. College admissions officers are supposed to adjust grade point averages for difficulty of coursework, but as with surgical report cards, the formulas are far from perfect.

The problem is compounded by the small number of operations — no more than 100 per year — that a typical cardiac surgeon performs. Basic statistics tell us that the “true” mortality rate of a surgeon is not what you measure after a small number of operations. The smaller the sample, the greater the deviation from the true average.

Report cards were supposed to protect patients by forcing surgeons to improve the quality of cardiac surgery. In many ways they have failed on this count. Ironically, there is little evidence that the public — as opposed to state agencies and hospitals — pays much attention to surgical report cards anyway. A recent survey found that only 6 percent of patients used such information about hospitals or physicians in making medical decisions.

It would appear that doctors, not patients, are the ones focused on doctors’ grades — and their focus is distorted and blurry at best.





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