Tuesday, October 29, 2013

Errors in Medical Treatment

Medical care is simple in theory, but complex in execution due to additional difficulty factors associated with human behavior, thorough record keeping and bureaucratic overview that go beyond diagnosis and treatment. Therefore, while most lay individuals were surprised when the Institute of Medicine (IOM) estimated an annual death total between 49,000 and 98,000 stemming from medical errors, most individuals with experience in the field were saddened, but not surprised.1 After the IOM issued the estimate in “To Err is Human: Building a Safer Health System” the medical community was initially galvanized ready to act to correct these unnecessary deaths developed through miscommunication, inefficiency and/or neglect.

Early results from this resolve demonstrated positive results such as a reduction in deaths from accidental injections of potassium chloride, lower rates of hospital-born non-MRSA infections, fewer warfarin derived complications in addition to the Institute for Healthcare Improvement’s (IHI) 100,000 Lives Campaign and companion 5 million Lives Campaign.2-5 However, a number of individuals believe that these successes are marginal for other negligent hospital/physician actions have increased in addition to those who believe that the initial IOM figure was underestimated.6-9 Overall within the environment where various groups “duke it out” over whether or not medical care has become safer from a patient perspective over the last two decades, the real questions are how can safety be improved and why are these ideas not being implemented as effectively as theory suggests.

One of the chief concerns with actually accurately identifying negative instances or preventable adverse events (PAEs) at hospitals and/or under physician care is the issue of various conclusions amid a feedback environment. Basically regardless of what side one takes on the issue of PAEs and their prevalence that individual can find valid evidence to support his/her position. Therefore, individuals who want to believe that PAEs have increased will principally cite evidence that suggests this reality whereas individuals who believe that PAEs have decreased will principally cite evidence of such a reduction. This researcher behavior creates a feedback environment were neither side will gain much ground because each side is simply reinforcing their own bias. Note that according to the IOM a PAE is defined as an “unintended harm to the patient by act of commission or omission rather than by underlying disease or condition of the patient”.

Part of the reasoning behind why such a contrasting reality can exist is that calculated PAEs can either go up or down depending on the type of boundary conditions and assumptions an investigator applies. For example what element is important when considering PAEs in hospital settings? Should the goal be to lessen the severity of the event (reduce the probability of death), lessen the number of events period, record all occurred events, how much should a patient’s health be compromised before it qualifies as a PAE, etc.? Without clearly identifying the expectations of the study and correcting for the goals of the hospital with relation to PAEs little useful knowledge can be gleamed from these numerous studies about PAEs in hospitals.

Another issue is the separation of responsibility between physician and patent. Rarely does research that concludes an increase in PAEs differentiate fault for particular PAEs between physicians and patients. For these researchers the entirety of the fault for any PAE is placed upon the physician. This mindset is an interesting one and seems to apply a negative bias against physicians (NBAP), which can be highlighted by the following analogy.

Currently in 2013 there are numerous reality television shows that involve a specialist of sorts intervening in a failing business and changing various elements in an attempt to make it a success. Two particular “hosts” have dramatically different mindsets when it comes to the structural operational methodology of business. In the show “Bar Rescue” Jon Taffer believes that while management leadership, direction and training are important, individuals have pride, self-respect, honor and intelligence and even in situations where training and leadership is lacking should be expected to act in a certain manner and perform their job with some level of competency, honesty and dignity. In contrast “Restaurant Stakeout” host Willie Degel seems to believe the opposite, that management and training are the foundation of praise or blame regarding job performance. Basically Mr. Degel seems to believe that employees are sheep without any ethics, ambition or pride, thus if the proper training is not provided it should be expected that these individuals will fail miserably at their jobs.

The mindset of Mr. Degel mimics the one possessed by most NBAP researchers where the physician is responsible for all mistakes regardless of the behavior or actions of the patient. For example suppose a patient suffers from an episode of respiratory distress during aerobic activity. After visiting the hospital resultant tests fail to find any obvious underlying causes for the episode. Clearly it is not entirely the responsibility of the physician to inform the patient not to engage in aerobic activities in the near future. The patient has to have some understanding that without a clear diagnosis future aerobic activities must be undertaken with significant caution and care otherwise an even more detrimental condition may arise. If the patient forgoes this common sense understanding and befalls a more detrimental condition, it should not be regarded as the fault of the physician. Similar blame elements would involve patients not telling physicians about certain allergies or other utilized medications that lead to complications brought on by negative reactions between the old medication/allergy and the new medication.

High quality medical care is a partnership between the physician, the hospital and the patent; for those who want to reduce/eliminate medical errors it is necessary to differentiate between errors caused by patents and those caused by physicians/hospitals. This differentiation must not be sought with the intention of assigning responsibility, but to properly assign responsibilities to all parties to maximize the probability of eliminating errors. Individuals who refuse to identify events where patient behavior increased the probability of an eventual PAE are doing a disservice to the goal of eliminating medical errors.

Even if individuals differentiate between patient and physician/hospital fault when attempting to determine the cause behind certain PAEs it is irrational to expect all PAEs to be eliminated due to the simple fact that mistakes will always happen. The general mindset should be to limit the severity of PAEs as much as possible. For example if the PAE magnitude is converted from 1000 harms with 100 deaths to 1043 harms with 50 deaths such a change can be considered a short-term victory with more improvement desired in the future.

Some investigators believe that there are numerous unreported PAEs and justify this belief through the use of the discrepancy between PAEs reported in outpatient surveys and official medical reports.10 Weissman and colleagues found that 6 to 12 months after their discharge, patients could recall 3 times as many serious PAEs as were reflected in their medical records. Unfortunately there are some concerns with this study. First, there is no clear understanding that patients and physicians/hospitals have a similar definition for a PAE, which could result in patients overestimating the number of PAEs during their treatment. For example failure to give a certain medication at a certain time could technically be regarded as a medical error, but if said medication is given within a given time boundary beyond that specific time no harm should befall the patient. So while such an event could be regarded as an error, it is not a PAE.

Second, patients may regard elements or instances of discomfort through their own personal lens as a PAE. For example a patient may want a glass of water, but due to nurse/physician preoccupation in other more pressing tasks this individual waits a long time before getting the water and possibly develop a slight case of dehydration while waiting. For the patient such an event could easily be a PAE, but from the perspective of the hospital such an event is irrelevant. Third, patients are not aware of a significant amount of “behind the scenes” actions relative to their treatment, thus have incomplete information regarding overall treatments and may mischaracterize certain outcomes as PAEs.

Most individuals classify PAEs into four separate categories:

- Diagnostic Errors
- Communication Errors
- Omission Errors
- Commission Errors

Diagnostic errors are rather self-explanatory, but are also the trickiest of the four categories when attempting to deduce between honest or negligent mistakes. If one could have all possible information available through various diagnostic tests (MRI, CT, PET, etc.), a full accurate medical history and a patient with a photographic memory who did not withhold information then it could be determined that all diagnostic errors were the fault of the physician either due to lack of knowledge or negligence. Unfortunately never are these environments of complete information available; therefore one must judge diagnostic errors within effective probability matrices. For example if patent A presents with a list of symptoms that suggest a 74.1% probability that condition A is the cause, which has a low probability of significant damage versus a 4.6% probability that condition B is the cause, which has a high probability of significant health damage and the physician treats for A instead of B, even if B turns out to be correct the physician should not be viewed at fault.

Communication errors are commonly defined by misinformation between two interacting parties resulting in a negative health occurrence. Normally communication errors stem from incomplete or inaccurate patient information due illegible writing leading to confusion between drug prescriptions, disconnected or fragmented reporting systems and/or inconsistent or repetitive care due to numerous physician interactions. Lack of patient background and disclosure can also be viewed as communication errors originating with the patient. Most believe that the adoption of electronic health records (EHRs) will reduce a significant percentage of the communication errors by creating a redundant system of error checking. More than likely this assertion is correct; however, implementation and proper use of HER in hospitals nationwide is still problematic and slow.

Commission errors are the easiest error to detect after the fact for it involves a physician or hospital taking a form of negligent action: either the wrong methodological action or a right action executed improperly that results in harm to the patient. The most common publicized commission errors seem to be surgical mistakes where foreign objects are left in patients, incorrect procedures are carried out (amputating the wrong limb is a noteworthy one) or accidentally damaging a part of the body (nicking a blood vessel when conducting a heart bypass, etc.). Fortunately commission errors can be managed because most occur due to carelessness born more not from physician incompetence, but other environmental factors like time pressures, fatigue, short-term psychological stress and/or too any patients.

Omission errors typically contrast commission errors, where an obvious action was required for treatment, but was not executed; similar to commission errors, omission errors can be easily detected after looking at properly compiled medical records. The most common omission errors involve the lack of drug administration to augment a specific treatment like an alpha- or beta-blockers for certain heart procedures.

One of the biggest issues regarding medical errors is the physician culture. In the past the physician was largely regarded as a position of great respect held by learned individuals. Compound this element with the fact that most physicians hyperbolize the capacity of their position “commanding” life and death, the ego and stress related to the position with regards to being “perfect” is further augmented. When a physician makes a mistake those who are not complete assholes or in denial take direct damage to their self-image and may attempt to hide the error behind a wall of cognitive dissidence in order to maintain the “perfect” persona. Public acknowledgment of the error limits the effectiveness of this cognitive dissidence strategy, thus could further increases the desire to hide the error. Therefore, for a number of physicians lawsuits may be of secondary concern versus potential psychological damage. This shame factor would probably explain most of the “hidden” errors that many NBAPs claim exist.

Unfortunately modern times have only applied more pressure to this “perfect” persona, especially due to the rise of the Internet. Now vast amounts of patients “research” potential causes for their medical conditions on broad kitchen sink websites like WebMD and make suggestions or even challenge diagnostic conclusions made by physicians damaging their authoritative specialization. The most problematic element of introducing this “research” into the diagnostic equation is that most patients will credit a much higher than rational occurrence probability for lethal or seriously detrimental conditions. Worse yet this unsubstantiated fear will be utilized as blame and legal ammunition on the extremely small probability that the cause of said condition was actually a low probability condition and the physician did not prescribe every possible test, regardless of cost and stress to the patient, to deduce it. Such a probability irrational environment adds even more pressure to physicians.

Now some cynics may simply state that physicians need to drop the narcissus act and man/women up. Outside of the simple retort that such a “solution” can be levied against numerous problems in various occupations, the problem with this belief is that physician training encourages this narcissus attitude out of belief necessity with a little ego of status. With regards to belief necessity what patient wants an indecisive physician? Physicians need to exhibit confidence, even on the borderline of arrogance (especially surgeons), to assure patients that they have a high probability of certainty regarding the type of ailment and the treatment protocol. Of course the ego element comes from the notoriety of the position in society despite its erosion in recent decades in part due to the Internet. Overall it can be argued that change is needed, but it would be more useful for cynics to offer a psychological means to drive that change rather than simply state that change should happen.

Another concern is the perception of medical mistakes. As stated above due to authority and prestige issues most physicians, especially specialists, become perfectionists out of medical school. This characterization creates a black-and-white mindset where physicians are either perfect or terrible, which is reinforced by morbidity and mortality review boards. A single mistake, whether understandable or not, can result in a “killer”, “007” or some other “clever” characterization for a physician. Most NBAPs say they could forgive an “honest” mistake, but a vast majority of those who say this have never been on the receiving end of these types of mistakes, so with their inherent bias towards physicians already would this proclamation hold true actually when tested?

Unfortunately some have attempted to adjust these review boards by making them more team centered. However, this strategy seems to be in error because while the motto “We win as a team we lose as a team” may work for sports it does not work in medicine. Such a strategy creates an unrealistic micromanage mentality for the “leaders” of these medical teams due to the level of work that is required. It also mitigates the responsibility of the error, which could reduce the shame individually associated with it, but will also reduce the probability that the individual learns from and corrects the behavior that created the error in the first place. Instead the boards should be teaching environments where blame is not shamed nor avoided, but identified and corrected. Pursuant to a significant error individual actions within the appropriate acting team should be identified to determine where the error occurred, what type of error it was and why it occurred. Medical personnel will also be penalized through a clear transparent evaluation system, which will eventually result in job termination if enough mistakes are made.

One of the major concerns with physician training is that some believe the process of becoming physicians erodes empathy from medical students even though they enter medical school with plenty. Part of the rationality is that the third and fourth years, which are clinical, are disjointed and emasculating due to constant testing and relocation fostering an attitude of “just another cog in the machine”. Another aspect of training that enhances this mindset is its monotonous nature with each sleep-deprived day bleeding into the next.

However, empathy is a two-way street. While a number of physicians have problems properly exhibiting it, if they have it at all, patients also fail to appreciate what physicians have to deal with in an average day. From the patient’s mindset he/she only cares about getting attention and an effective analysis and conclusion regarding diagnostic and treatment. He does not care that the physician has patients other than him, who expect the same, and other tasks that need to be completed beyond his medical treatment. Certainly one can somewhat understand this mindset as patient attitude can range from frustration due to being sick to panic due to the potential for having a serious medical condition, but empathizing with this attitude is no excuse for the hypocritical reasoning of criticizing lack of empathy in physicians, but ignoring it in patients.

One way to potentially manage the empathy erosion that occurs in medical school is to breakup the process itself. In most medical school training the first two years involve classroom and lab study with the second two years involving medical training and residency. This process should be adjusted. In a new system the first year would involve basic medical training. Remember that almost all medical students are “pre-med” so they have rudimentary medical knowledge about biology and chemistry, thus this first year should not be review, but involve new medical training and procedure information. In the second year students would enter a clinical environment to apply their knowledge and get a feel for their occupational requirements. The third year would involve returning to the classroom to acquire more advanced medical techniques, organization skills and logistics, and psychological coping techniques. Introducing these advanced techniques after exposure to a clinical environment will increase the probability that medical students appreciate their importance and can better incorporate them into their behavior. The final year would involve selecting a specialization (or general practice) and tailoring their clinical experience towards this specialization to lead into residency.

A further concern with the education structure for physicians is the lack of a well integrated and effective occupational education system. Basically after a physician graduates from medical school and residency it is “assumed” that physicians possess all requisite knowledge for the remainder of their medical careers. Of course such an assumption is wrong, especially when dealing with technology, so why are there not small periods of time where physicians are required to update their skill sets (similar to a sabbatical). Some would argue that due to general physician shortages (especially at the general practitioner level) there is little ability to develop effective downtime to acquire new skills or update existing ones. Regrettably this is a relevant retort and add to that concern that an additional 35 to 50 million uninsured individuals with at least 15 million having chronic and/or pre-existing conditions have now or will soon acquire health insurance finding time for physicians to skill enhance becomes even more difficult. Unfortunately there may not be an effective solution to this issue beyond simply creating more physicians and hospitals may have to augment physicians with hired secondary help for specific technological skills.

Numerous suggestions in the past through various communication mediums have been made regarding how to reduce the probability of medical errors and below will be no exception. Clearly one of the most obvious strategies is to create checklists for each type of medical procedure and diagnostic exam ensuring that proper methodologies are followed, which will heavily reduce the probability of any stupid careless mistakes. An additional easily applicable safety measure is redundant question asking among physicians, nurses and pharmacists to patients to confirm unanimous agreement regarding action among relevant parties. Clearly the introduction of electronics from physician order entry (POE) for prescriptions to EHR will reduce transcription and medication assignment, cross-reaction and dosage errors. Finally creating better ways for physicians to manage fatigue through efficient on-call rotations and nutrition/diet recommendations should reduce errors.

Another issue with correcting medical errors can come from addressing the “perfection” mindset by creating a more transparent legal avenue for redress steaming from negligent behavior. Part of the problem is that some individuals who experience a PAE in a hospital feel that it is their right to receive some monetary compensation for their negative experience; a sincere apology will not be sufficient. Some have attempted to address this “sue-happy” litigation culture through the use of monetary malpractice caps, but this response is not structured properly because the ceiling is universally blind; it does not appreciate that certain medical errors impact an individual both physically and psychologically in different ways and more severely than others.

To better address the issue of medical errors and their proper disclosure one has to focus on the environment of perfection and fear. Beyond the perfectionist characteristics of physicians there is some natural fear as well when interacting with patients that have experienced a PAE. The first element that drives this fear is the natural aversion most individuals have to confronting angry individuals when it is suspected that the anger will be justifiably directed at them. The second is that admitting to the mistake will open the door for a lawsuit through the general admission of guilt when discussing the error. This lawsuit would then result in potential lost employment and increased malpractice insurance premiums. This aspect of the fear is the driving force behind the common “deny and defend” strategy utilized by hospitals in response to lawsuits. Finally due to the “deny and defend” and “sue-happy” environments an inherent adversarial relationship has developed between lawyers and physicians.

A cap limit on medical malpractice claims is not the only legal reform attempted to ease the difficulties between patient and physician interaction after an error. Thirty-six states have passed “apology laws”, which limit the admissibility of physician statements of a sympathetic nature in a civil lawsuit regarding the incident for which the statements were made.11

One theoretical success of apology laws is that it allows honest communication between patient and physician. For example one study determined that one of the primary factors behind attorney acquisition is patient frustration born from a lack of adequate answers to their questions about significant negative experiences during a hospital visit.12 Some even think that they are helping future patients by demonstrating to the hospital/physicians that there are consequences to an avoidance and denial strategy. For these patients an honest and clear explanation along with an apology would have eliminated the need to seek the services of outside council.

The overall results of whether or not more disclosure catalyzed by apology laws would increase or decrease total liability remains mixed. Some risk managers still feel that while specific statements will be excluded due to apology law, the admission itself still confirms that the hospital/physician made an error opening the door for a lawsuit13-15 However, other studies have demonstrated that within certain operational parameters that a disclosure program can be successful without increasing liability claims or costs.11,16

So what should be the proper procedure when a medical error is discovered:

1. Unless the medical error is one of life-threatening immediacy the medical team treating the individual should be gathered and informed of the medical error with instruction regarding how it will influence current and future treatment. The gathering should not occur immediately after the error is discovered (due to the potential for other ongoing obligations), but should occur in a timely fashion. Immediately after coming to the necessary conclusions regarding future actions, those actions should be executed.

2. Assign an individual to officially document the medical error and report it to the appropriate authoritative body. In addition add the information to the patient’s official medical records so future healthcare providers are aware of its occurrence so it can be utilized later in potential future diagnostics.

3. Inform the patient and any potential medical proxies about the error itself, why it occurred, how it occurred and what future steps are now recommended because of the error. Inform the patient and appropriate parties of their role, responsibilities and rights in addressing the reporting of the error. Finally sincerely apologize for the error and communicate what type of consequence was applied to the offending party.

4. During the next medical and mortality board all recorded medical errors are reviewed with the intent to explain to all other parties what the error was, why it occurred and what actions were taken after the mistake was identified. There is no need to identify the responsible parties behind the mistake because responsible parties have already been brief on the mistake and its consequence to their careers in the above earlier meeting. Due to this previous briefing there is little reason to officially “introduce” the individuals behind the error to the rest of the hospital for the general purpose of ridicule.

The advantages of such a system for addressing medical errors are numerous: 1) the patient receives prompt information regarding their current situation, transparent facts about the reasons behind any errors and consequence to the responsible party; 2) all relevant hospital staff are informed of the error and instructed to learn from it without direct reputation consequence to the offending party (whether or not staff hear something through the “grapevine” is uncontrollable); 3) the error is addressed openly, thus reducing the probability of escalating any detrimental condition derived from the error because corrective treatment will begin much quicker;

While there is still robust debate about how many individuals unfortunately lose their lives in hospital settings due to some significant form of medical error, the response to these events should be the same because a large number are born from negligence either on the side of the patient or the physician/hospital. There is large agreement regarding what needs to be done, but both meaningful and superficial obstacles remain in the way. Meaningful obstacles involve the incorporation and proper use of technology, getting patients and insurance companies to buy into the advantages of evidence-based medicine and creating effective networks between medical institutions and home life for various patients. Superficial obstacles are largely psychological and cultural between both patients and society regarding egos and expectations. Much to the chagrin of some individuals, the expectation for private driven compliance and evolution of medical safety in hospitals is short-sighted due to a lack of motivation; therefore, the intervention of penalties and an organized central entity should be encouraged to catalyze the administration of safety procedures in medical institutions.

Citations –

1. Kohn, K, et Al. “To Err is Human: Building a safer health system.” Washington D.C.: National Academy Press. 1999.

2. Joint Commission on Accreditation of Healthcare Organization. Sentinel event trends: potassium chloride events by year.

3. Kelly, J, et Al. “Patient Safety Awards: safety, effectiveness, and efficiency: a Web-based virtual anticoagulation clinic.” Jt Comm J Qual Saf. 2003. 29:646-651.

4. Whittington, J, and Cohen, H. “OSF Healthcare’s journey in patient safety.” Qual Manag Health Care. 2004. 13:53-59.

5. Leape, L, and Berwick, D. “Five years after ‘To Err is Human’ What have we learned?” JAMA. 2005;293:2384-2390.

6. James, J. “A new, evidence-based estimate of patient harms associated with hospital care.” Journal of Patient Safety. 2013. 9(3):122-128.

7. Landrigan, C, et Al. “Temporal trends in rates of patient harm resulting from medical care.” N Engl J Med. 2010. 363:2124Y2134.

8. Hayward, R, and Hofer, T. “Estimating hospital deaths due to medical errors.” JAMA. 2001. 286:415Y420.

9. Brennan, T, et Al. “Incidence of adverse events and negligence in hospital patients: results of the Harvard Medical Practice Study.” N Engl J Med. 1991. 324:370Y376.

10. Weismann, J, et Al. “Comparing patient-reported hospital adverse events with medical records reviews: Do patients know something that hospitals do not?” Ann Intern Med. 2008. 149:100Y108.

11. Kachalia, A, et Al. “Liability claims and costs before and after implementation of a medical error disclosure program.” Ann Intern Med. 2010;153:213-221.

12. Vincent, C, et Al. “Why Do People Sue Doctors? A Study of Patients and Relatives
Taking Legal Action.” Lancet. 1994. 343:1609-1613.

13. Butcher, L. “Lawyers say ‘sorry’ may sink you in court.” Physician Exec. 2006. 32:20-4.

14. Kachalia, A, et Al. “Does full disclosure of medical errors affect malpractice liability? The jury is still out.” Jt Comm J Qual Saf. 2003. 29:503-11.

15. Studdert, D, et Al. “Disclosure of medical injury to patients: an improbable risk management strategy.” Health Aff (Millwood). 2007. 26:215-26.

16. Boothman, R, et Al. “A better approach to medical malpractice claims? The University of Michigan experience.” J. Health and Life Sci. 2009. 2(2):125-159.

Addressing One Aspect for the Future Stability of Society

The structural evolution of society has depreciated recently due to the catalyzation of what could be described as the triangle of deterioration. The three separate legs form this triangle are unequal economic growth, technological advancement and population growth. Unequal economic growth represents significant economical differences between multiple parties with excessive and superficial growth concentrating towards a select few who facilitate little societal stability. Technological advancement represents the increased capacity of non-human elements to perform human-related tasks. Population growth is self-explanatory representing a large and steadily increasing population.

Representation of a triangle is appropriate to describe the incompatibility of these three elements together as a group. For example if a society has unequal economic growth and a large population, but has little technological advancement there are still numerous occupational and financial opportunities for various individuals; these individuals can later unionize, if so desired, to expand this economic opportunity to maintain societal stability. In a society that has a large population and high technological advancement, but equal economic growth and distribution there is enough man power for both societal advancement and stability because a vast majority of the population, if not all, are able to support economic stability due to wealth distribution equality. A society with high technological advancement and unequal economic growth, but a small population is similar to the first example where even though the unequal economic growth produces stresses on the stability of society the small population reduces the level of competition between individuals ensuring a sufficient level of economic and societal stability. Of course for the existing consumerism economic system that currently exists this scenario is the most unstable of the three above scenarios. Note that the “escape hatches” for society in each of the above scenarios is eliminated when adding the missing triangle element.

So how does each leg of the triangle limit the positive evolution of society and significantly increase the probability of societal collapse.

Inequality –

The chief problem found in inequality is the finite nature of economic exchange. Basically there is a limited amount of capital that society can support at any given time; any attempt to breach this perceptive barrier results in inflation reducing the efficiency of capital. Unfortunately inequality with vast amounts of capital going to already wealthy individuals also creates huge capital efficiency losses. Certain parties believe that concentration of vast wealth in a small population is effective because of the power of scale (1 person with $1000 can have a greater positive influence on economy versus 1000 people with $1). However, while the power of scale can make money more efficient, in reality those currently with the ability to induce this efficiency choose not to do so and there is no evidence that this philosophy will change in the future.

This destabilizing and inefficient reality flies in the face of the common refrain by some parties that the wealthy are “job creators” who create further economic activity. It is difficult to be a “job creator” when one does not spend the necessary money to fill such a role. Instead this excessive wealth is sequestered from society where it still exists, but is not available to society for use. Therefore, the more capital acquired by the wealthy the less efficient the entire economy because of the inflation ceiling. Creating inefficiency in a consumer based economy that breeds specialization puts all individuals at risk.

Another problem with top funneling inequality is that society has determined that non-essential occupational elements are of superior value versus essential occupational elements. The jobs that “earn” the most money are largely in the financial sector (hedge fund managers, stock brokers, CEOs in various companies, etc.) and entertainment sectors (musicians, sports athletes, actors, etc.) instead of in the medical sector (physicians and nurses), education sector (elementary and high school teachers), law and order sector (police, correctional officers and legal aids) and the emergency services sector (fire fighters and EMTs). Notice the difference between the two fields, which one of those groups is more important to the stability of society? Yet ironically that group of occupations is far less financially rewarded by society than the other, thus in times of economic stress the latter group, which is far more important for structural stability of society, is more immediately threatened creating a positive feedback effect which further threatens the stability of society.

Interestingly the acquisition of vast wealth not only increases the probability for societal destabilization, but also reduces the meaning of having vast amounts of wealth for the individual(s) in question. The purpose of having wealth versus just having significant amounts of money can be defined in two ways: 1) increasing available opportunities for material purchase or skill/experience acquisition; 2) lauding over others how much more important one is because of the difference in wealth; while these two purposes seem separate the second one is defined by the first because having large amounts of money is pointless if one is unable to utilize that wealth differently than those who have less money. However, when society struggles various specialization elements will also struggle limiting the goods and services they can provide reducing the variety and prestige advantages to having wealth over significant amounts of money. Basically concentrating wealth increases the probability that the wealth becomes less significant.

On a related note it is interesting that the Republican Party in United States seems to adhere so vehemently to the power of the free market, but refuses to acknowledge the gross inefficiencies created in the marketplace by significant levels of inequality (they instead incessantly focus on the inefficiencies caused by government though). How can they respect and believe in a system when ignoring such crippling flaws?

Technology –

Technology has two major detriments and a forked road on the triangle. The first and most obvious detriment is that technological advancement creates tools that can replace humans for certain tasks. While such advancement potentially increase efficiency and decrease costs associated with production it also decreases the amount of jobs available, especially those that pay well and justify the costs, both financial and opportunity, that were invested in acquiring the skills to perform those lost jobs.

The second detriment is the elimination of regional experts in favor of universal experts. For example suppose Sam wanted to learn how to weld sheet metal. The most efficient option is to identify someone who is experienced and skilled at welding sheet metal and learn the proper techniques from that individual. In the past this would involve searching the area in which Sam lived and selecting an instructor from the experienced individuals within that area. However, with the advent of the Internet Sam can merely go online to a video sharing website like Youtube and learn how to weld for free or attend an online lecture for a fixed fee bypassing the regional individual in favor of a highly skilled “universal” instructor.

Now most individuals would conclude that such a system is appropriate; that technology has removed the inefficiency of “settling” for an instructor that is more than likely inferior to another instructor who simply resides further away and in the past was inaccessible due to distance. However, the problem with this philosophy is the unbalanced two-pronged system that it creates.

In this environment the regional instructors now receive much less business and will find it much harder to make a living as an instructor in that particular field while the select few “elite” instructors will make more money than they can reasonably spend creating significant market inefficiencies similar to the inequality aspect above. Unfortunately this division is self-catalyzing because the individuals who are taught by these universal instructors must surpass them to take their customers otherwise they will end up just like the regional instructors they bypassed to learn from the universal instructors.

The argument made by some in favor of this system that these regional instructors must simply diversify their education acquiring the necessary skills to obtain another middle-class to high paying job is seriously flawed, flaws that are discussed in a past blog post here. The newspaper industry is another example of how technology has marginalized regionality with no appropriate response by society.

The sad thing is that regionality elimination will also permeate the developing world in a similar manner. While numerous people want to praise technology and its catalyzation of globalization for pulling millions out of poverty the elimination of regional interaction will dramatically limit these gains, especially when technology penetration is great enough that experts in the developed world start acquiring developing nation customers. In a consumer based economy the catalyzation of inequality by technology creates greater societal instability in both the developed and the developing world. This is not to say that technology is inherently bad, but that society must create appropriate strategies to address the detrimental elements that technology brings and so far society has yet to act.

Population –

The population element of the triangle is rather obvious, but not simply statistical. Clearly the more people that exist create a greater competition for jobs, but also in a consumer driven economy create a larger customer base. The general theory behind consumerism is that population increases can be managed through the increase in consumption; however, in a resource finite world this theory breaks down. In addition growing rates of inequality create greater consumption inefficiencies in the marketplace further damaging the validity of this theory.

Part of the problem with population is that a number of people simply pigeonhole the numbers themselves without looking at their influence. The 7 billion humans living on Earth is an extremely large number, but the number by itself is somewhat irrelevant. While all humans consume thus more humans equal more consumption, consumption rates are dramatically skewed between regions. For example if all individuals living in Africa were killed tomorrow very little would change in the world regarding the triangle and the speed of resource consumption despite the global population being cut by approximately 14%. This unequal resource consumption is obviously not lost on some who constantly lament the level of consumption in the developed world. Unfortunately little can be done about the consumption levels at the moment regardless of inequality because of the consumption dependency of the global economy.

So what can be done to elimination the action of the triangle of deterioration on global society? The obvious answer is to break it some how, but the how of that strategy is the problem. Clearly one cannot break the population element because of all of the indiscriminate killing; even if one could manage the moral question such a strategy would more than likely still be immaterial because a vast majority of those killed have consumption rates below global average consumption rates. Therefore, breaking the population leg, before it is self-broken by societal deterioration, would demand selective killing. However, selective killing instantly invokes questions of morality when deciding who determines the criteria involved for selecting who gets killed. On the “supply side” clearly elements can be applied to limit population growth like birth control and education, but these factors can only go so far to reducing the overall population growth and do not address those already in existence. The economic dependency of consumerism limits significant widespread changes in overall global consumption patterns when refraining from killing anyone.

It would be difficult to advocate breaking the technology leg of the triangle due to simple momentum. Certainty the global community could pass laws restricting the use and sale of certain technology, but the logistics of enforcing these laws would be nightmarish, especially because most of the global public would not be forthcoming in their adherence to them. One could argue that individual enforcement would not be necessary instead focusing on enforcement against large corporations and websites like Youtube. This is a valid argument because most of the detrimental elements associated with the spread of technology are derived from these agencies, but global cooperation would be required and sacrifices made, something not widely practiced by various countries. For example would country A really enforce technology restriction against company A if tax revenues from such enforcement fell 32% due to income reductions? If country B has little confidence that country A will adhere to the restrictions would they bother to adhere to them either?

Based on the above two problems with two aspects of the triangle it appears that to prevent the eventuality of the society destabilization one must address the inequality leg. Addressing the inequality leg is actually quite easy in theory although numerous powerful people will certainty object to the required policies. As mentioned above inequality stems from the lack of ceilings applied in capitalism. While philosophically understandable the lack of capital ceilings creates significant inefficiencies, which damages society as a whole and also damages the individuals who are taking advantage of the lack of ceilings despite their lack of acknowledgement of this situation.

There are two strategies to address this inequality problem. The first option is to change the balance of importance in society. Recall that the principle reason inequality is destructive is not because it is inherently bad, although it is inherently inefficient, but because it culminates in occupational operations that are not essential to the positive evolution and stability of society. If society determines that police officers, public school teachers, lab technicians, etc. are more important than movie and television actors, basketball players, singers, hedge fund managers, etc. then the destructive nature of inequality against the stability of society is significantly lessened.

Unfortunately this first solution is not ideal because if this switch occurs society may be saved, but numerous people will still be bypassed by society and struggle to survive including the rich individuals who used to occupy the higher tier of wealth before having their salaries cut due to the change in societal priorities. The second solution would be to apply a ceiling to the growth potential of wealth in capitalism. A legislative derived ceiling would make sense both from an efficiency and stability standpoint.

For example suppose an individual became a billionaire at the age of 30, lived to the age of 90 (60 years between becoming a billionaire and death), and never made any more money the rest of his/her life. This individual would have to spend approximately $45,662 each day to completely exhaust that one billion dollars before death. Such a spending pattern, even when including the purchase of a $4-5 million dollar home, is ridiculous and would involve the purchase of numerous frivolous items or items which would go solely to waste neither of which will result in significant job creation or retention. Dividing the above billion dollars into $1 million dollar increments among one-thousand separate individuals will result in the purchase of more bulk goods which more than likely will result in more job creation and retention due to greater economic activity. Based on the way consumerism is practiced in society wealth-based power of scale can be likened to that of a bell curve.

How would such a ceiling cap operate and where would it begin? It would be difficult to determine a quantitative optimal point for a ceiling, thus the best option would be to establish the ceiling through an instinctual mindset of what would be fair. One possibility would create a ceiling of personal finance (cash, assets, etc) at $50 million dollars and a corporate ceiling for net revenue (profits) at $1 billion dollars. All capital accrued beyond this ceiling would be taxed by the appropriate government entity at 100%. The ceiling would operate in real-time versus lifetime implying that if an individual acquired $50 million dollars and he/she later bought a house for $3 million dollars, he/she would be free to acquire another $3 million dollars before acquired capital would be taxed at 100%. Capital acquired by the appropriate government agency would be earmarked to fund food banks, education, apprenticeships and small business loans to increase both the job pool and the number of qualified applicants. Finally in the United States the IRS would be given much greater authority to pursue and charge tax cheats/thieves and all tax cheats found guilty would receive jail terms in medium security prisons with minimum sentences equating to 1 year per $100,000 that was concealed.

Of course a number of rich individuals would cry fowl after reading the last paragraph. They would opine that placing a ceiling on the amount of money an individual or corporation could accrue would be an affront to the drive and ambition elements that characterize capitalism as well as be unfair to those individuals that acquire the most success. The problem with this point of contention is that the current system of capitalism rewards needless consumption and entertainment over intelligence and calculated risk-taking. The ambition argument is also derailed when one considers that 99+% of success is determined by where an individual is born and who his/her parents are, two elements that are completely outside the control of the individual. Finally what is more important: being more fair to society and eliminating the market inefficiencies born from wealth inequality and limited spending constructs or being more fair to a very small group of individuals most of whom were born to favorable conditions?

Overall the elements that make up the triangle will hasten the destabilization of society. Now it can be said that the destabilization of society may not hasten the extinction of humanity, but the destabilization of society will certainly create an environment where quality of life is decreased. Therefore, faced with this coming reality, one separate from global warming entirely, what will society do to ensure its long-term survival?

Monday, October 21, 2013

3D Printing … in space

Although 3D printing has existed for years, originating in the 1970s, only recently has it caught the imagination of the public. Numerous optimistic claims have been made about how 3D printing will change the face of manufacturing. One of the more optimistic beliefs regarding 3D printing is how it will change the nature and planning of space colonization, especially prospects for colonizing Mars and the Moon. While on some level such excitement is understandable, it is not appropriate to presume that the inherent problems with incorporating 3D printing into a colonization mission will be solved in the near future or even at all.

For example the most overplayed aspect of 3D printing in a colonization mission is its versatility. Proponents argue that the idea of rationing and scarcity are eliminated in the world of 3D printing. Unfortunately such hopes are rather confusing when compared against reality. The biggest concern for 3D printing is this perceived greatest strength. The versatility of 3D printing is drawn from a blank canvas, but that canvas requires more material than is needed for the particular design in question because what will be needed overall is not known.

Granted the additive process of 3D printing is more efficient at reducing waste than subtractive processes, but waste will exist unless all material is used. At the current stage of launch technology weight is the most important aspect of mission planning as it relates to cost and design. Additional material that will not be used for anything creates additional deadweight costs for the mission. Compare this deadweight cost against a properly planned mission with appropriate organization and logistics and costs should be reduced.

Another problem with costs associated with blank canvases is the volume constraints. Both cost and time exponentially increase to the third power relative to the size of the manufactured product. Basically if one wants to double the size of the product it will cost eight times to produce and take eight times as long to print. The cost and weight issue relative to the canvas also assumes 100% efficiency/reusability when producing an item otherwise the costs and weight required will increase further.

There has been some interest in foregoing the use of Earth-derived source materials and incorporating local surface regolith in the development and maintenance of a lunar or Martian colony.1 While this idea is promising there are still numerous elements that need to be considered before implementation and even if studied may never come to pass (note all of the scientific desires/predictions of last century that failed to culminate into reality even those that attained laboratory success). There is reason to hope though as the European Space Association is teaming with various private corporations to continue to study the necessary processes.

Regolith structure is the chief problem for its use as a source material for while one can create a binding ink that interacts with metallic oxides in the regolith to initiate a crystallization process, regolith on both the Moon and Mars (especially Mars) is heterogeneous with shards of glass, sand and other particles. Also most of the regolith is inert, thus it will have to be doped to form an anhydrous characteristic to increase efficiency.1 The size and surface area of regolith particles is also important, for particles that are too large or too small will create structural inefficiencies and weaknesses, especially if initial results from vacuum reticulation are to be believed.1 Therefore, some mechanism will have to be utilized to filter out particles of inappropriate size.

Somewhat ironically the advantage of the 3D printer in colonization is that of a safety tool versus an efficiency tool. When constructing and expanding an off-Earth colony almost all of the materials will be in-situ limiting the need for inter-planetary resources. Therefore, the additional material designated for use in a 3D printer originating from Earth will largely be utilized in quasi-emergency situations to manufacture semi-critical life support parts. The reason for this limited niche (at this time) is due to the accuracy, power and speed limitations of 3D printing. Common use items will not be created through 3D printing because it is simply easier to provide them during transit reducing costs. Emergency items will typically not be printed because of the time constraints associated with manufacture of the item, especially speed because the most important factor influencing manufacture time is the chemical properties of the utilized material, not the structure/design of the 3D printer.

Additional concerns that will hopefully be addressed in the future are how micro-gravity, inconsistent air pressure and greater temperature shifts will affect the manufactured products. Made In Space has conducted some small short-term tests, but the range of tests does not produce much practical information for long-term utility. Also the biggest current problem for 3D printing is the limited ability to manufacture an item derived from only a single source material, at the moment plastic is typically used. The principle reason combining materials is not applicable at the moment is most materials of significant structural difference (various metals, plastics, etc.) have melting temperatures hundreds to thousands of degrees apart creating structural problems in alloy creation. Some small advances have been made in regards to incorporating electronics, but this type of manufacturing is still in its initial prototype stage. In space colonization some of the other concerns with 3D printing like required CAD blueprints and prototyping are not significant, but it does limit the usefulness of 3D printing largely to the expected “unexpected”.

However, another significant concern for creating quasi-emergency parts is the inaccuracy of 3D printing. Most popular news stories about 3D printing fail to mention that currently 3D printing has a common error rate of about +/- 0.1 mm for various materials. For critical smaller life support parts such error rate may be too costly. Also this error rate may increase due to changes in post-build cooling temperature and micro-gravity environments, which will be more prevalent in colonization missions. Finally current 3D printing commonly produces products that have inferior tensile strength versus standard manufacturing. The additive methodology through the layered construction creates a laminate weakness due to incomplete bonding between the Z-axis and X and Y planes.

Overall at the moment the idea that a 3D printer can revolutionize space colonization should be more reserved. Part of the problem is the limitations of 3D printing, especially with the costs associated with the blank canvas materials that currently need to originate from Earth. The niche role of 3D printing also may need to be expanded to justify its inclusion in colonization missions. Additionally most 3D printer colonization enthusiasts forget that the rise of 3D printing has not occurred alone, but in consort with casting, laser cutters, mills, lathes and routers as an entire manufacturing process. Finally more than likely years of testing will need to be conducted in space type environments like on the International Space Station to gauge the effectiveness and problems with 3D printing in these environments, including situations of very low power. Therefore, 3D printing in space may require such a culmination of various operating and manufacturing elements versus just a single 8’ x 8’ rapid prototyping unit.
Citations -

1. Ceccanti, F, et Al. “3D printing technology for a moon outpost exploiting lunar soil.” 61st International Astronautical Congress. Prague. 2010. IAC-10-D3.3.5 1-9.