Catch-22 in mental health: An open letter to Andrew Williams, CEO of Stratford General Hospital and Randy Pettapiece, MPP

Dear Andrew Williams and Randy Pettapiece,

Recently, my father was hospitalised for schizophrenia in the psychiatric ward at the Stratford General Hospital. This was good news. It was a welcome change after months of increasingly abusive and dangerous behaviour on his part that affected the entire family. Not only was he suffering from disordered thoughts and paranoid delusions, he lost his impulse control with regard to money (and some other things as well). Due to his condition he lacks the ability to deal with his own finances. He was admitted to the Stratford General Hospital and shortly thereafter, a medical tribunal determined that he was not competent to make his own medical decisions. My mother was assigned to be his medical decision-maker and power of attorney.

Yesterday, we found out that some unscrupulous lawyer visited the Stratford General Hospital to arrange the papers so that my dad could transfer his medical decision-making and power of attorney away from my mother, and give it to another patient on the psychiatric ward. As far as we know, this other patient is just some guy that my dad met less than two weeks ago when he was admitted. The name sounds made-up, though, so for all we know, it’s not his real name. This “other patient” could even be a delusion of my dad’s.

Needless to say, we were upset.

We contacted the lawyer to ask him what he thought he was doing. He said he didn’t do anything—that it was my dad who made it happen, and that he had training to determine when someone was competent to make such decisions. We will be inquiring about what legal options we have against this individual.

When we told our own lawyer about the problem, his administrative assistant broke out laughing, because it was such a ridiculous turn of affairs. He advised us to get a letter from dad’s psychiatrist, and on the basis of such a letter, it would be possible to have this transfer of power of attorney reversed. This seemed reasonable. On contacting the doctor, we were told that he could not release such a letter, since my dad has requested that his medical information not be shared with us (one of his paranoid delusions is that we’re out to get him), and my mother no longer had her status as his medical decision-maker and power of attorney.

In the face of this Catch-22, we’re not sure what to do next. As of today, the doctors at the Stratford General are still refusing to provide a letter indicating my dad’s condition, because they are afraid of being sued.

I’d like to emphasise at this point that the unscrupulous lawyer got paid for what he did. Paid with money. He came in to the locked ward of the Stratford General and walked out substantially richer, thanks to money he took from a person who was determined by a medical tribunal to be incapable of making his own medical decisions.

If someone walked into a hospital and found an old woman with dementia and exploited her condition for his own financial gain and gave her nothing in return, that conduct would be reprehensible, but it still wouldn’t be as bad as what this lawyer did to my dad yesterday. Not only did he take money from someone whose mental condition renders him incompetent to handle his own financial affairs, but he made it a thousand times harder for us to get my dad back on his meds to stop the paranoia and abuse.

So, Andrew Williams: When do your doctors plan on doing the right thing for their patient and his family?

Yours angrily,

Benjamin Carlisle

(Edit 21h00—the original version had more cursing, but as my friend advised, “Try not to swear so that your interlocutor doesn’t have an excuse to dismiss you.”)

McGill wins the Canada Cup again—surprise ending this time

McGill wins the Canada Cup ... again!
McGill wins the Canada Cup … again!

For the second year in a row, McGill University left the Canada Cup as the national champions in the sport of quidditch. For the record, there have only ever been 2 Canada Cups. There were some really intense and close games—ones that were too close to call until the final snitch grab—which made them very exciting to watch.

I went to the Cup this year as one of the golden snitches. This tournament was remarkable for a couple reasons. First off, it was very well organised. I can honestly say that I haven’t been to any tournament that was better-run than this one. The weather was ideal: brisk and sunny. The grounds were perfect for off-field snitching: a million places to hide. It was great. Also, there were about a million snitches, too. Almost every quidditch tournament I’ve been to has been lacking in snitches, and this one had an overabundance.

This was why I felt so honoured to be able to snitch for the consolation match (the match to determine 3rd and 4th place). I didn’t want to snitch the finals, since McGill was playing, and I just don’t want questions like, “did you let the McGill seeker catch you?”

The consolation match ended up going later than the final match, and I enlisted some of my McGill snitch friends to engage in some on-field mischief.

When I came back to the field, the score was 30-0, which meant that the snitch-catch tied the game. It’s sometimes said in quidditch that the only player who’s guaranteed to lose every match is the golden snitch. Tonight I made history, because the only possible exception is that of a tied game: When a game is tied, it goes into overtime in which the snitch does not leave the field, and at the end, the team with the most points wins. Overtime ends after a period of 5 minutes or by a snitch-catch. The five-minutes of overtime came and went, and by the end of it, I hadn’t been caught.

Carleton, the team that won, hoisted me up on their shoulders. I won the game! As the golden snitch! This almost never happens. It was the perfect conclusion to a fantastic tournament: my team won (congrats McGill!) and I won too!

Below is a video of me snitching another game earlier in the day. It’s not as consequential as the consolation match later in the day, but it gives you an idea. :)

Borrowing e-books from the library

I’m currently reading The Handmaid’s Tale by Margaret Atwood. I borrowed the e-book from the Québec National Library. Just the process of borrowing an e-book has been fascinating. When an e-book is borrowed from the library, it is no longer available for other users to borrow, because the library uses a particular kind of DRM software.

This is interesting to me because traditional borrowing of library books had the “scarcity” of the books (and thus the protection of the author/publisher’s rights) built-in to the “hardware” itself. That is to say, by the nature of the physical book itself, two people could not be borrowing it from the library at the same time.

This is manifestly not true of digital materials. Much to the chagrin of publishers of all types, it’s difficult to stop people from sharing media if it’s digital, and in fact it takes a good deal of effort to stop people from doing so, while still allowing for legitimate uses of the media in question.

I’m 67% of the way through, and I’ve come across a couple typos. Nothing major—nothing that changes the content of the book, or even makes it much more difficult to read. I don’t know why, but I can’t resist keeping a record of when I find typos.

  • “It isn’t the sort ofthing you ask questions about …” p. 29
  • “I press my hands against the sides of my thighs, breath in, set out along the hall …” p. 142

Maybe I’m reading too much between the lines here, but when I saw these typos, I started thinking about maps. Stay with me, here. I don’t know if it’s actually true, but it used to be said that map-makers would put fake streets—small ones that no one would notice—into their maps, so that if someone copied their work, they would know that it was copied.

I’m sure it’s possible to find software that will strip an e-book of its DRM, and so I wonder if these typos are like that—little “fake streets” that the publisher has inserted into the e-book, so that if it’s copied, they’ll know. If they were sophisticated about it, they could probably even make up a way of encoding which library and even which user stripped the DRM by inserting particular “typos” into the borrowed e-book.

So here’s my question for all you Margaret Atwood fans out there: Does anyone have a physical copy of The Handmaid’s Tale? If you do, can you tell me if the typos are there in your copy? Also, does anyone else feel like borrowing the e-book from the library to see if the typos are there (or in the same place)?

Side-note: How long before we drop the hyphen from “e-book” and “e-reader” the way we dropped the hyphen from e-mail?

Review of the Kobo Touch e-reader

I recently bought a Kobo Touch, which is not a new piece of technology. Here, I review it anyway, since it’s new to me. I’ll start with the negative and work my way to the positive.

For the non-initiates out there, a Kobo is an “e-reader.” That means it’s a handheld piece of electronics for consuming media—mostly books/magazines/things that would have otherwise been print media. A Kindle is also an e-reader, but made by a different company. I refuse to get a Kindle because of the sorts of things that Amazon does to customers who own Kindles. You could also put the iPad into this category, but it’s more of a tablet than an e-reader, I think. Anyway, a Kobo is a kind of e-reader that doesn’t have a back-lit display.

Things that the Kobo doesn’t do well

  • PDF documents—if the PDF wasn’t formatted for a Kobo or something, you’ll have to zoom and scroll all over, which will get really annoying really fast.
  • Apps—if you want to play games, don’t get a Kobo. You will be disappointed. It doesn’t do apps at all. There’s sort of an app where you can draw with your finger, but it is terrible.
  • Web browsing—there is a browser. No, don’t try it. You’ll be happy you didn’t.
  • Social integration—it keeps trying to post things to my Facebook. I really don’t like Facebook all that much. I would actually be okay if it offered to tweet things, but there’s no Twitter integration on the Kobo.
  • Annotations—entering text using the touch keyboard on a Kobo is slow, inaccurate and frustrating. Highlighting text is similarly difficult, but not as bad as annotating. Selecting text takes a while, and it sometimes can’t figure out where your finger is on the screen.
  • Discoverability of features—it took me a long time to figure out that I can bookmark a page by just tapping the top-right corner of a page. I’m still not sure if there’s a way to know how many pages in a book on my Kobo.
  • Buying books from the Kobo store sucks. It sucks pretty bad. It’s hard to browse for books on the Kobo e-reader, so I tried finding a book on the website and adding it to my “wishlist” so I could buy it. But it turns out that my wishlist doesn’t sync between my Kobo e-reader, the Kobo web store and the Kobo desktop app. Not only that, but it’s hard to get things onto your wishlist from the desktop app in the first place. This is something I hope they figure out soon, because it’s a fairly essential part of their business model—getting people to pay for their content.

Things that the Kobo does really well

  • It’s excellent for reading in direct sunlight. Due to the nature of the e-ink screen, the Kobo is perfect for reading outdoors. I have tested this extensively in the park near my house this summer. It’s wonderful, and it’s something that you can’t really do with an iPad.
  • Further, the Kobo doesn’t cause much eye strain. first off, the Kobo formats EPUB books so that the text is a nice size for reading. Also, the e-ink screen has no back-light, so it’s way easier on the eyes. Reading from a Kobo screen is really no more tiring than reading from a book.
  • There are lots of free books. this is not exclusive to the Kobo. Come to think of it, I always had access to these free books through Project Gutenberg, which you should check out if you haven’t yet. There are thousands of free books to be downloaded. These are largely classic works of literature whose copyright has expired, putting them in the Public Domain. But really, I never read these books before I had an e-reader, because it sucks to sit in front of a computer screen and read, even a laptop.
  • It’s “tossable.” I feel like I can throw it across the room, shove it in my bag, etc. There’s no glass screen, and it’s not very heavy. I feel like if I dropped it, it’s not heavy enough to break itself when it hits the floor.
  • Last thing is battery life, which I regard to be one of the biggest assets of the Kobo. I charged my Kobo for the first time on Tuesday July 24, 2012. Since then, I had the wifi turned off, except on three occasions during which I downloaded new books. It has now been just over four weeks since the last charge, and the battery indicator is around the one-quarter mark.
    To give you an idea of how much use I made of the Kobo during that time, I used it at least twice a day, every day, having taken up the habit of reading while using the stationary bicycle at the gym, and reading before bed each night. And because it was something new and shiny, I used it much more than that, just out of novelty, at the beginning of its life.

Overall assessment

All in all, I’m pretty happy with the thing. It was a fraction of the price of an iPad, and for reading books, at least, I think it does a better job. I’m enjoying it thoroughly and I’ve got about a million books I plan to read on it. Well, no more than 1 GB at a time, anyway.

Semantic video indexing app

The newest version of Mac OS, called “Mountain Lion,” includes “Dictation,” which is a piece of system software that takes speech and converts it to text. This is nothing new, of course. I remember that I had a piece of dictation software for my old Windows 98 PC. You had to “train” the software to understand what you said, and even then it was wildly inaccurate, but in principle, this sort of software has existed for a long time. Dictation on Mac OS is much better than the one I had back in 1998, but of course it is not perfect.

That particular piece of software I had on my PC was not built in to the operating system. I had to pay for it. Not only that, but because it didn’t work very well, I never got another dictation programme again. But now that this one is built into the OS, I think I’m going to try an experiment.

Here’s my inspiration: In Star Trek, every character keeps a “log,” and because it’s the future, it’s an audio log. In The Next Generation, they were often shown as video (b)logs. Sometimes, in order to advance the plot, a character would be shown searching through his own (or another person’s) logs. What was interesting was that the search would usually be a semantic keyword search. Something like, “Computer, show me all log entries relating to the warp core” (or whatever they were interested in at the time). With dictation software now a standard feature in OS X, we’re at a point where we could write an app that does exactly what the computer did in Star Trek.

The workflow will be as follows: Take a video (or a set of videos) that you’re interested in, and extract the audio. Divide the one big audio file into hundreds of smaller (say, ten-second-long), overlapping audio files that are annotated with their start time in the original video. For each of these smaller files, pass them through the dictation software and generate a text file that includes the text that has been generated by the system’s text-to-speech dictation software. And voilà, you have generated a time-encoded text index for your video—just like the one on YouTube, but you wouldn’t have to upload the file.

Wrap this all up in a shiny OS X app wrapping and put it on the App Store. Sell it for $0.99.

Then, if you had a bunch of videos—say, seasons 5–6 of Doctor Who, and you wanted to find all references to “the Silence,” you could install the app, have it index your iTunes library, and then do a search through your videos for certain keywords or phrases.

Actually, this might work. If anyone wants to collaborate with me on this one, hit me up in the comments.

Edit: I take it back. A quick experiment with Dictation indicates that we are nowhere near having the technology to be able to do this.

Rethinking Research Ethics: The Case of Postmarketing Trials

Good news!

Toward the end of the year in which I was working on my thesis, my supervisor had me write up a shorter version of my thesis for an attempt at publication. This was no small feat—imagine trying to compress a 90-page master’s thesis into 2 pages!

After my RA-ship ended, my supervisor, Jonathan Kimmelman, and Alex John London took the paper, made some substantial edits, and submitted it to a couple journals. The paper was accepted, and as of this week, it was published in Science.

Needless to say, I’m thrilled. :D

The Carlisle-Desroches Quidditch Hoop Construction Manual

I discovered last week that the Carlisle-Desroches Quidditch Hoop Construction Manual was incorporated into the latest version of the IQA rulebook! Hooray!

We never received any official notice from the IQA—we found out about this when one of my teammates noticed a reference to the design on the IQA site. Anyway, we’re honoured, and this has inspired us to put some more work into it. Also, one of the members of the McGill Quidditch team has asked us to re-think the bases for the hoops this summer.

Hence, we plan to build, test and release the Mark II Carlisle-Desroches Quidditch Hoop over the course of the summer. The new design which will be the same as the original, but with an alternate base that’s probably made of PVC rather than the current bucket-o-concrete. For the record, I like the bucket-o-concrete, but some have raised concerns about safety. They’re afraid that people will hit their heads.

Chord progression for “Mad Man with a Box”

For those who are interested in such things, the chord progression (well the interesting part of it anyway) for “Mad Man with a Box” (one of the themes from season 5–6 of Doctor Who) is as follows.

Key area: d-

i-V43/V-viiº-i64-III6 (or I6/iii—it’s a pivot chord to the relative major, F+, the key in which the remaining chords will be written)-IV-I64-V7/vi-vi

I resolved it to a vi chord, but often it’s left unresolved.

If you wanted to keep it all in the key area of d minor, you could write it more simply like this:

i-V43/V-viiº-i64-I6/iii-IV/iii-I64/iii-V7-i

Game theory and medical research

I recently learned what exactly a Nash equilibrium is, and like any obnoxious academic with a new idea, I’m really excited about it. Hence, I will apply what I’ve learned in Game Theory so far to the field of medical research ethics.

First, some definitions: A Nash equilibrium is a set of strategies that the players in a formalised game adopt such that the utility that each player receives for her chosen strategy is the greatest, given the choices of strategies of all the other players in the game.

This could be formalised as follows:

A Nash equilibrium exists when ui (ai, a-i) ≥ ui (ai′, a-i) for all ai′ and all i, where:

  • ui is a function whose range is utility values for player i and whose domain is an ordered n-tuple of strategies taken by all the players in the game
  • ai is the chosen strategy of player i
  • a-i is the set of chosen strategies for all the other players, and
  • ai′ is some alternate strategy that player i might adopt.

What’s interesting about Nash equilibria is that given a particular formalised game, other non-Nash sets of strategies are “unstable”—that is, if a player finds out that given the strategy choices of the other players, she could have made a better decision, she will change her strategy accordingly.

The famous Prisoner’s Dilemma (look it up if you haven’t heard of it) is a great example of a Nash equilibrium where the outcome for each of the players is not optimal, even though they are in equilibrium.

What’s interesting to me about things like this is how it can be applied to medical research, if we make certain simplifying assumptions. Let’s imagine that medical research is like a two-player game. The players are the pharmaceutical industry on the one hand and some other participant in human research on the other.

In the tables below, Big Pharma has two strategies open to it—developing a “seeding” study or developing a “quality” study. The other participant (who could be a research subject or a physician-investigator or a journal that publishes medical research papers) also has two strategies available—participating in the study developed by Big Pharma, or not participating.

If the other stakeholder in the research project doesn’t participate, neither Big Pharma nor the participant receive any benefit. The utility outcomes for Big Pharma and the other stakeholder are 0, 0, respectively.

If the other stakeholder participates and the study is a high-quality study that provides socially valuable medical information, Big Pharma and the other stakeholder receive utilities of 1, 1, respectively.

But, if it turns out that the pharmaceutical company has produced a “seeding” study—one that is designed for narrow ends, namely those of being a marketing tool to get physicians used to prescribing a drug that has already received licensure—the pharmaceutical company receives a utility of 2 and the other stakeholder receives a utility of -1. That is to say, Big Pharma gets a big payout, because hundreds of doctors are now prescribing the drug, but the other stakeholder incurs a net harm in some way. (If she is a study participant, he may feel used or cheated. If she is a doctor, it may be a source of professional embarrassment. If it is a journal that published a “seeding” study, that journal will lose some of its reputation, etc.)

Participate Not
“Seeding” study 2, -1 0, 0 *
“Quality” study 1, 1 0, 0
Table 1. Asterisk (*) indicates Nash equilibrium.

So if we go through each set of strategies that the players in this game can take, we find that the one with the asterisk is the only one that is a Nash equilibrium. This is because if you are Big Pharma in this game, given that the other stakeholder has chosen not to participate, you are indifferent between strategies, and if you are the other stakeholder, given that Big Pharma has chosen to develop a “seeding” study, your best choice is to not participate.

It’s interesting to note that this setup is analogous to markets for financial products and other “confidence goods,” where the buyer has a really hard time telling the difference between high and low quality products.

But what if no one caught on that the study was a “seeding” study? Let’s imagine that Big Pharma got away with running a seeding study and no one ever figured out that that’s what it was. We would end up with a game that can be represented as follows:

Participate Not
“Seeding” study 2, 1 * 0, 0
“Quality” study 1, 1 0, 0
Table 2. Asterisk (*) indicates Nash equilibrium.

Here, the equilibrium has shifted. This explains why pharmaceutical companies try to develop “seeding” studies, and why they try to hide it.

So the question becomes, how can we set up the “rules of the game” of medical research in order to shift the equilibrium such that other stakeholders will participate and the pharmaceutical company will develop quality studies?

Or to put it another way, if we assume that the utility for non-participation for all players is 0, and that both the pharmaceutical company and the other stakeholder should both come away from a quality study having received some utility, what value for x will put the Nash equilibrium where the asterisk is in the table below?

Participate Not
“Seeding” study x, -1 0, 0
“Quality” study 1, 1 * 0, 0
Table 3. Asterisk (*) indicates Nash equilibrium.

The value of x must be less than 1 in order for the Nash equilibrium to fall where the pharmaceutical company develops a “quality” study and the other stakeholder participates. This is because if x = 1, Big Pharma will be indifferent between its strategies, given the choice of the other player, and if x > 1, as we saw in Table 1, the equilibrium will shift to where Big Pharma produces a “seeding” study and the other stakeholder declines to participate.

So in real life, how do we make x to be less than 1? There has to be some sort of sanction or penalty for pharmaceutical companies for producing seeding studies that makes their expected utility less than that of a quality study. This can be done by either putting a tax on seeding studies or by making regulations against seeding studies outright.

Game theory course

So the Online Game Theory course that I was talking about started, and it’s just as good as I thought it would be! As of when I’m posting this, you have forty-five minutes left to register, if you want to join me.

I took an actual university course for credit in Decisions Analysis when I was an undergrad, which was one of the best educational experiences of my life. Decisions Analysis is the science of making rational decisions under conditions of uncertainty. The way that the profs for the online Game Theory course describe Game Theory is that it is the science of describing the actions of idealised actors within a particular system, given certain simplifying assumptions. Decision Theory, they say, is like a subset of Game Theory—it is like Game Theory where there’s only one player. This is very exciting to me.

I have already learned how to formalise a number of things that I investigated during the course of my thesis. Further, I now know what the actual definition of a Nash equilibrium is. It’s a concept that I had a sort of fuzzy handle on before, but now I think I could express it formally using proper notation and apply the concept to ideas like the medical research enterprise or smartphone application development systems.

I’ll keep you updated with regard to some of the more interesting results that I find. :)