Cancer Screening-Overused for Older Individuals

Cancer is one of the most frightening diseases out there. Many forms are difficult to treat, particularly if they are not caught early. The routine use of many screening tests to catch cancer in its early, more treatable phases over the last few decades has allowed many individuals to be cured before their disease progressed into its later stages. However, the overriding fear of cancer in public consciousness may have led to an unintended effect. Many older adults, long past the age when they should be receiving screening for some forms of cancer, are still receiving these tests on a regular basis. A recent report reveals that Medicare spent $1.9 billion between 2003 and 2008 on cancer screening for adults who were older than government recommended age guidelines for cancer screenings.


On the plus side, all this spending does create jobs that let people look at breasts all day.

Why do these age guidelines exist?
One of the reasons why cancer screenings eventually lose efficacy is that life is finite. Eventually heart disease, strokes, or other conditions are going to end it. If someone is ninety years old and has severe heart disease, they are going to be dead before a newly discovered case of prostate cancer becomes a problem. Cancer has become a rather potent fear in society so it's hard to just believe that letting it go on and grow is the best option, but sometimes it simply is. There's no reason to put a person with a host of other health problems through chemotherapy and surgery for a tumor that isn't going to cause any problems before the individual is likely to die.


Although it does give a good excuse for wearing a Hawaiian shirt.

Why are excessive screenings harmful?
There's a basic idea that more screenings and tests must be better than less. After all, if it can potentially locate something that can be treated early, why not do it? The problem with this thinking is that these tests and screenings are expensive and they are not always accurate.

Every screening test has the risk of false negatives and false positives. A false negative means that a case of cancer was missed by the test. A false positive means that a case of cancer was falsely identified as being present. A false negative means that cancer isn't being treated and may even result in early cancer symptoms being ignored because, hey, the screening last year didn't show any problems. A false positive is extremely frightening for a patient and may result in unnecessary biopsies and surgical procedures, which also pose their own risks.


Wait... it was benign?

An additional problem is that screening tests should also be shown to have some sort of benefit on survival of patients. For example, let's say there's a new screening test for metastatic pancreatic cancer. It detects it successfully 100% of the time. Unfortunately, there isn't anything at all that can really be done to treat metastatic pancreatic cancer, the median survival is between 6-10 months. At best, treatment will give a patient a couple months of extra life. This means that there is no point in using this screening test for the general population-it will not cause any improvements in survival and is thus just a waste of money.

It's actually pretty difficult to create screening tests that do not have too many false negatives or positives and are shown to improve survival rates for patients. Even some formerly routine tests are more controversial lately as research results have come back.

A good example is the Prostate-Specific Antigen test for prostate cancer in men. It used to be done routinely for men after age 50, but now the evidence reviewed by the United States Preventive Services Task Force suggests that Prostate-specific antigen–based screening results in small or no reduction in prostate cancer–specific mortality and is associated with harms related to subsequent evaluation and treatments, some of which may be unnecessary. Many physicians are still debating whether to continue performing the test or not, but it's certainly an example of a potentially gigantic waste of money.

Conclusion
Cancer screenings are a great tool to reduce cancer-associated mortality when they are used appropriately. However, they have become over-utilized in inappropriate groups of people, particularly the elderly. In many cases cancer may simply be able to be ignored in older adults because they are likely to die from something else first. As one example, many older men die WITH prostate cancer, but very few die FROM prostate cancer.

Perhaps the best way to view this information is to take a look at the overall health status of the person in question. If they are an extremely healthy eighty year old, maybe it's worth doing a screening because they may get a decade or more of life out of an early identification and treatment of cancer. If they have severe heart damage, Alzheimer's disease, and other problems, maybe it's a better idea to avoid doing the screening.

Deus ex Machina Ruins Another Novel-Out of the Dark

A few months ago I read the book Out of the Dark by David Weber. It caught my eye in the library for two reasons. One was that the cover featured a passing interest of mine, an alien invasion of present-day Earth.


Although I wonder how that floating city stays in the air.

The other reason was that it was a stand-alone novel. I figured this meant I could get a satisfying ending without having to read four or five other books afterward. It's a rare thing to find a single fantasy or science fiction novel anymore. I suppose the trilogy or series is something of a standard of the genres now, but most authors just pad their books with trivial details and conflicts just so they can get three books out of one big idea. Unfortunately, my expectations for a good ending were betrayed by Mr. Weber. Let's go through the book and see what the problem was.

The Plot
The basic plot is that a group of aliens invade the Earth hoping to colonize it and use us as a client species for their own future conquests. They were dispatched because of a scouting expedition that witnessed the battle of Agincourt and were apparently horrified by the barbarity of man in that fight. Unfortunately for the aliens, humanity advanced at a much faster rate than any other species that they had previously encountered. They expected humans to stay at a Medieval level of technical development, so when they arrived to find assault rifles, Abrams tanks, and the internet they were taken aback. However, the aliens had the ability to bombard the Earth with meteorites so they went ahead with their invasion, destroying most major cities, military bases, and armies with their orbital bombardment.

At this point, the story got quite interesting. Although the aliens had impressive looking technology, such as hover tanks, spacecraft, and drones, their tactics and equipment were inferior to modern weaponry. Their ground based vehicles did not have enough armor to withstand handheld anti-tank weapons or even small arms fire in some instances. Additionally, their infantry were mostly unarmored with weapons inferior in range and power to modern firearms. They also used appalling tactics to fight against human forces.

The explanation given for this was that the aliens were accustomed to fighting technologically inferior foes so all of their equipment was developed with subduing primitive societies in mind. Armor that blocks a spear isn't very difficult to design while armor that stops a high explosive shell is quite a bit more challenging. The result of this imbalance in power was that the only superior force the aliens could offer was their ability to send in meteorites to destroy anyone resisting them. This is a rather indiscriminate way to eliminate enemies which limits its viability since the aliens wished to colonize, not destroy, Earth.

Mr. Weber did an excellent job through the beginning and middle of his book by describing the improvised efforts that local forces throughout the world used to battle the aliens. In the United States, national guard forces who grabbed equipment from their armories and civilians with personal firearms inflicted a heavy toll on the aliens. Similar events occurred in Russia and Romania. The aliens, in reaction to this, tried to build trust and rapport with humanity by working with some of the few remaining human authority figures to get the remaining rebels to stand down.

The building drama was that the aliens realized that they were going to lose way too many of their soldiers and vehicles trying to fight this war so they decided that they had to find a way to end it. Since they still wanted Earth, an asteroid bombardment was out of the question. That left them to decide that a virus was a good idea, which they decided to develop on the surface using human test subjects. Some information on this leaked out to the resistance forces, who realized that they needed to do something about this.

The Problem
At this point, I had about fifty pages left in the novel and wondered how the hell David Weber was going to end this book successfully. I figured maybe he would have a resistance group break into one of the virus manufacturing facilities and retool it to kill the aliens. This wouldn't be very creative, as it is only a slight twist on War of the Worlds, but it would have been a plausible ending.

Instead, Mr. Weber came up with a "brilliant" idea. Remember how one of the areas featured resisting the aliens was Romania? Weber brought them into the picture by having a soldier returning from Afghanistan have his C-130 plane crash in the area, leaving him and a few other Americans stranded in the area. They were found by a local group of backwoods Romanians, who led the American soldiers back to their camp. They fought a few times against the aliens alongside the U.S. soldiers. The Romanians were represented by Weber as being extremely stealthy guys able to sneak up and slit the throats of alien soldiers. The climax of this portion of the novel was that the aliens decided to send a large force to attack the Romanian camp, prompting a large fight that eventually killed most of the Americans.

This pissed the Romanians off quite a bit, so they revealed their true nature by turning into gas clouds and slaughtering all the aliens with their vampiric powers. They then flew up to the alien ships in orbit and killed all of them up there as well. Apparently their stealthy nature was supposed to foreshadow that the Romanian leader was Dracula and his companions were vampires hiding out for all these centuries in the Romanian backwoods.

Wait what?


I guess David Weber feels like he might have a good reason to keep that cross handy around his neck.

Why this is a Bad Ending
Besides the fact that vampires are massively overused in books right now as it is, there was absolutely no hint that this was going to happen anywhere before the end of the book. David Weber did a great job building up a somewhat plausible story where resistance forces acquired weapons and figured out how to fight an enemy capable of throwing meteors down on top of anyone putting up too much resistance. He then threw all of that away in the final couple of chapters by throwing in invulnerable vampires with godlike powers to easily slaughter every single one of the aliens and save humanity. As an author, if you're going to have some crazy shit like that happen at the end of your novel, you really need to foreshadow it, not spring it up out of nowhere because you only have a few pages left to end the book.

About the only positive thing I have to say about the vampires is that at least they didn't sparkle.

Civilization V-An Improved Combat System

Although Civilization V received many good reviews from professional reviewing groups, popular reception was mixed. Many complained that changes to the game just left them clicking the end turn button repeatedly since there just wasn't much to do in a typical turn. Although I agree with many of those comments, one aspect of the game that I found much improved was the combat system.

The Major Changes
The single largest change is that you can no longer stack units together on the same hex. Every unit needs its own hex space. This changes the look of a major battle from this:


San Antonio is besieged by an entire army, from artillery to cavalry to infantry, all secure in one hex of jungle terrain.

To this:


Two sides face off in Civilization 5

Just from a glance at the game's main map, you can tell how much opposition you will be facing. In previous civilization games, a player can store an entire legion of troops in one hex that slowly advances toward your cities. In Civilization V, you see the entire horde spread out and can also easily tell what kind of units are attacking.

Another advantage of this system is that it requires players to think more about the terrain they are advancing through. In previous games it was easy to throw all your troops up on top of a mountain or another formidable defensive bastion, but now terrain with more marginal defensive benefits have to be considered as well. After all, only one unit can go up on the mountain or inside the city, the rest need to find a place to camp out as well.

The last major change is that certain units, such as archers and artillery, can fire at enemy soldiers from a distance rather than having to just directly attack like every other unit in the game. In the past, this ranged advantage was noted by making archers have defensive advantages or by allowing them to inflict some damage on attacking units before the random dice rolls began to play out. Now archers can pick off some enemy soldiers before they get in range to retaliate, a much more interesting system. Additionally, it requires a player using archers or artillery to protect them with melee units in front so that these valuable soldiers don't get slaughtered in close combat.

Why is this an improvement?
My biggest complaint with the combat systems in Civilization II-IV is that the defender received an overwhelming advantage at times. If an enemy is advancing, the solution is to garrison your towns and cities with every nearby unit, which apparently have no trouble housing or feeding the entire army of a nation, and it will be very difficult for the attacker to defeat them unless they brought a far superior number or quality of units along for the fight.


The entire population of Greece defends Athens.

Civilization II at least had a couple features that made it a little easier to take out a defending army. If you stacked units outside of a city or a fortress and you lost a defensive battle, the entire stack of units was destroyed. Additionally, when a unit defending a city lost a battle, the city lost one unit of population. This could even cause a city to be destroyed if it was reduced to a population of 1. Unfortunately, these were removed in Civilization III and IV.

The worst part for Civilization IV is that there are so many features that should add depth to the combat system. There are many units with bonuses against other units. For example, macemen gain a significant bonus in strength against other melee units like swordsmen and pikemen gain a significant bonus when fighting cavalry. There is also unit veterancy, which allows for units to gain bonuses to their basic combat abilities or to gain extra potency against the units they specialize in fighting. Unfortunately, these don't add a lot of depth to combat because of two problems. One is the ability to stack a limitless number of units on top of each other. The other is that when attacking a stack of units, the best defensive unit is always picked to defend. So, if you're attacking a archer and a knight with a pikemen and a horse archer, the archer will be chosen to defend against the pikemen and the knight against the horse archer. This means that you are guaranteed to lose either way when you attack.


Even Landsknecht in their snazzy uniforms have to follow those rules.

All of this isn't to say that winning a military victory was impossible in previous Civilization games, but it was only possible if your opponents didn't know what they were doing. All you have to do to survive an assault is spam units to defend your cities with and it becomes cost prohibitive to try and defeat an opponent in warfare. Although Civilization V was a step backward in many respects, the combat system certainly added a lot of depth and interest for me.

Vladimir Putin-Action Hero

Vladimir Putin, the current Prime Minister and former President of Russia, has taken greater advantage of masculine photo-opportunities than any other current political leader. This is partly because he's stayed in great shape for his age, still participating regularly in Judo. Compared with Boris Yeltsin, who was wracked with heart failure for much of his Presidency, Putin's general good health has allowed him to participate in many physically taxing jobs that his constituents hazard on a regular basis.


Such as tiger tracking.

Here's a collection of photos from Putin's political career, showing the various jobs that needed the assistance of a Russian leader to tackle.


Check it out or Prime Minister Putin might take you out!

The Future of NATO

Shortly before his retirement from the position of U.S. Secretary of Defense, Robert Gates made a speech regarding the future of NATO. Support of NATO has been a fixture of U.S. foreign policy since 1949, but the demise of the Soviet Union in 1991 calls its purpose into question. Even though NATO membership has grown since the end of the Cold War, the United States still provides the lion's share of military support for the alliance. As Gates noted in his speech, there is a "two-tiered" membership structure where there are members "willing to and able to pay the price and bear the burdens of commitments, and those who enjoy the benefits of NATO membership but don’t want to share the risks and the costs." Europe's military spending has continued to drop over the last decade or so in comparison with the United States. Looking at the military budget's of all of NATO for 2010, the United States leads with 687 billion dollars, trailed distantly by France and the UK with 61 and 57 billion dollars respectively. Even if you combine the military budgets of the rest of NATO together, the United States still spends about twice as much each year as all of the rest of the alliance.


Although every member still gets an equal seat at NATO's master planning conference table.

The NATO military interventions in Afghanistan and Libya certainly show the differences in military strength and willingness to fight between the United States and its allies. Looking at Afghanistan, for example, the United States currently has 90,000 soldiers deployed, more than double the rest of the International Security Assistance Force combined. The initial air campaign against the Taliban was also largely led by the United States, including helicopters, carrier-based airstrikes, and AC-130 gunship assaults.


American air-power at work.

Even though every NATO member endorsed intervention in Libya, more than half have not contributed anything at all to the effort. Even the NATO allies that did deploy aircraft to Libya are sometimes placed under severe restrictions by their home countries that limit their usefulness. For example, many allies deploying aircraft to Libya only authorize their air forces to enforce the no-fly zone and not conduct any bombing at all. This means that they may shoot down Libyan aircraft in the air. As there are no Libyan aircraft flying around anymore, that's not a very challenging task.


Mr. Gates sees a problem with this situation.

The question becomes, will the United States continue to provide the bulk of funding and military support for this alliance when the rest of the allies are not contributing an equal share of the budget? Given the current financial problems in the United States, it seems likely that NATO contributions will be one promising area to cut in the future.


After all, these things are expensive!

Conclusion
The contributions of NATO members to conflicts in Kosovo, Afghanistan, and Libya are certainly appreciated by the United States, but the unequal military contributions of the United States and the rest of the alliance will lead to tension in the future. It may reduce the importance of NATO or simply end the alliance altogether. Europe needs to take more responsibility for their own defense and not rely on the United States to take the lead in every major military action.


Particularly when a little bit of ocean separates the United States from the conflict zones in North Africa and the Middle East.

College is an Investment

The current perception in the United States is that a four year college degree is the secret to financial success. Many high schools expect their graduates to move on to a university and continue their education. Students who don't plan to move on tend to be lectured by counselors, teachers, and principals about how they are giving up on their future dreams by not getting a degree. For those who do choose to advance their education, there are many scholarships that can be applied for. Unfortunately, for most students, scholarships alone are not going to be enough to pay for books, tuition, rent, and other expenses. This leaves loans, either through the government or private parties, as the only option to afford a four year degree. This is where it becomes critical to plan ahead when seeking a degree.

The Reality of a Degree
When considering college, the first question to consider is "why am I doing this?" Unless your family is independently wealthy, the purpose is usually to increase your lifetime earnings potential and find a good career. You may also learn a lot of interesting facts, make some good lifelong friends, find a girlfriend/boyfriend, and have other valuable experiences, but your financial future should be one of the primary reasons for attending.


If your degree isn't passing these out, you might want to pass on it.

It's true that those who have a college degree tend to make more money overall than those who don't. Unfortunately, that depends strongly on what degree you get while you're there. Some majors don't leave students with great job prospects after graduation. For instance, you might go through four years of college, get an English degree, and be completely unable to find a job or only find one that barely pays above minimum wage. Additionally, tuition fees have risen dramatically over the last decade and financial aid has not risen correspondingly. For instance, one political science student in this story has $140,000 in debt and was only able to find a position at a non-profit that pays poorly.

It's important to look at what job opportunities are out there for your prospective degree choice. Look through job postings that you would qualify for with that degree, take a peek at the average salary, and evaluate the tuition and fees of your college to see whether you can make a living doing that. Consider whether you're willing to move to find a job or not-if you are you're likely going to have a lot more options. If you live in a state like Michigan that's currently losing a lot of the population, you're likely to have a lot more difficulty finding work than if you live in Texas.

Where to go to School
One factor that makes a huge difference in the price of a school is whether you attend a public or private university. For example, compare the price of one year at private Albion College with the public University of Michigan. One full year of tuition at Albion is about $32,100. A full year at the University of Michigan is about $12,634. If you include room and board, Albion costs significantly less there and the prices become closer, but are still roughly a $10,000 a year difference.

Another significant expense is choosing to attend school outside of the state you have residency status in. At the University of Michigan, Michigan residents pay that $12,634 a year fee, but out-of-state residents have to pay $37,782, about three times as much. Over four years of school, that's a solid $90,000 price difference. Some universities allow certain out-of-state attendees to receive in-state tuition, but it's very important to look into that before picking a school.


You may not need a passport to cross this line, but it will certainly make college more expensive!

Attending a community college, even though it is not as prestigious as a four year university, can save you a huge amount of money. 18 credits for two semesters at Washtenaw Community College is only about $3,500 for a resident. Compared with $12,000 for a year at the University of Michigan that's quite a bargain! One nice way to utilize community colleges is to take classes that transfer to a four year university. That way you get the prestige of a bachelor's degree from that larger university but pay significantly less money.


The only downside is the line for using the Community College's computer.

Where to Live
The final major component of the price of college is housing-and there are important choices to make here too. Living in the housing provided by colleges and universities is rarely a good deal. Usually you will end up paying $5,000-$10,000 for two semesters of housing. Assuming you're at school for about 9 months of the year, that's %555-1,111 a month! That fee also typically includes a roommate and sub-par housing conditions.


Roommates are also typically randomly assigned.

A less expensive option is to live off-campus. Most colleges and universities tend to draw a large number of rental properties in the area, ranging from apartments to houses. With the aid of a few friends, the rent for these living arrangements can be quite reasonable.

By far the best deal, if you can get it, is to live with your parents until you're done with school. It may be a bit hindering but it saves you around $10,000 or so a year in room and board. For a 4 year degree, that's $40,000 in your pocket. For a lot of college graduates I know, that 40K would be enough to pay off all their student loan debt and leave them with no debt as they begin their careers.


Good times!

Conclusion
Before planning which college to attend and what degree to major in, look at what the purpose of college is for you. For most, the purpose is to achieve financial independence and to find a solid lifetime career. Hold that purpose foremost in your thought process when looking for schools to attend and you will graduate with much less debt and a better career future than many of your compatriots.

National Balanced Budget Amendment

One of the more popular ideas circulating to reduce federal government spending is for a balanced budget amendment to be added to the U.S. Constitution. Almost every U.S. state constitution currently has some version of a balanced budget amendment in place. Republican presidential candidate Rick Perry has said that it is one change to the Constitution that he would strongly support. Newt Gingrich and several other presidential candidates agree with Perry, a balanced budget must be a short-term goal for the United States. It's also a popular idea with voters; one poll shows that about 66% of Americans want a balanced budget for the federal government.


Governor Perry's preferred method to deal with federal overspending.

But what is popular is not necessarily a good idea. Let's look at the history of the U.S. budget and show how a balanced budget amendment would work and see if it seems like a great idea for the federal government.

A look at Federal Debt
One important fact to keep in mind when considering a balanced federal budget is that the United States government has always been in debt. Budget surpluses have occasionally allowed for a large portion of that debt to be paid back, but it has never been paid off. Even when it has been mostly paid off, a war usually ensued that rapidly escalated the debt back to a high level. For a recent picture of the debt, here's an image showing it since 1940, with a sharp increase right at the start due to WWII.



Since the United States is still involved with two wars and also invests a significant amount of money into combating worldwide terrorism, it doesn't seem out of place for there to be significant government debt right now. Perhaps once President Obama's withdrawal plan for Afghanistan is completed it will be possible for the debt to be reduced significantly. Wars are expensive, so it shouldn't be a surprise to anyone that the debt has kept increasing.


Military supplies brought to you courtesy of the national debt.

The addition of revenue loss due to the large tax cuts passed during the last decade basically guaranteed that the national debt was going to be quite large. With the description of the current situation out of the way, let's look at the inner workings of a balanced budget plan for the government.

How a Balanced Budget Amendment Works
Fortunately, it's easy to see how a balanced budget amendment works since most states have one in place. They force the state's legislature to make up for any budget shortfalls each year by reducing spending or increasing taxes to ensure that the state does not fall into debt. There isn't much tolerance for increases in taxes lately in the U.S. so states have had to rely on spending cuts in order to meet their balanced budgets. This has resulted in layoffs of state employees and deep cuts in spending due to falling tax revenues stemming from economic turmoil from the recession. Although this has been painful for vulnerable segments of society that are reliant on state programs for support, state spending cuts typically are not that noticeable for citizens who can support themselves financially. Unfortunately, that would probably not be the case for federal spending cuts.

State vs. Federal Balanced Budget Amendments
The biggest reason that state spending cuts are not all that noticeable for most of the population is that a lot of the most important spending, such as Defense, Medicare, and Social Security, takes place at a federal level. The federal government also gives a lot of money to states to fund education and other state programs. So, even if Maryland decided to not spend any money for a year, they would not be vulnerable to foreign invasion since they're still protected by the national military and some services, particularly those directed toward the elderly, would still be provided courtesy of federal spending. Additionally, while it would be painful for residents of Maryland, the rest of the country would likely not even notice.

In comparison, if the federal government needed to cut back on spending suddenly, the entire country would feel the impact. The federal government spends trillions of dollars each year, including billions of dollars that go to each state in the union. The problem with a balanced budget amendment is that the federal government responds to major challenges for the country.


Such as this, for example.

So, if something like Pearl Harbor were to occur today, the states are not responsible for the response to it. It's the federal government that has to rebuild the Pacific fleet and create a military capable of fighting in Asia and Europe. This is why it's acceptable for states to have balanced budget amendments, they are not the level of government that responds to large-scale disasters. Even with major floods and hurricanes, it's the federal government that provides the bulk of the money for rebuilding efforts.

One important point to bring up is that proponents of balanced budget amendments do typically allow for an exception to be made in times of war and national emergency. Congress would be able to vote for a time of national emergency to be declared so that the need for a balanced budget could be ignored for a few years while the war or whatever is resolved. However, the current political environment in Washington shows that it may not be possible for Congress to agree on whether the country is in a major emergency or not. Earlier this year, Republicans and Democrats could not even come to agreement on raising the federal debt limit, even with months of warning, resulting in the United State's credit rating being reduced for the first time. Compromise just seems to be impossible in the government right now, so I wouldn't count on the political parties putting aside their differences to allow a little matter like a major war to determine that the balanced budget needs to be ignored for a year or two.


Particularly when some members of government point to federal spending as being a worse enemy than the Nazis.

The Potential Consequences of a Balanced Budget Amendment
So, let's say the worst case scenario of a major war or other unanticipated and extremely expensive disaster occurs and Congress doesn't agree to lift the balanced budget requirement to deal with the problem. Let's use the example of the wars in Iraq/Afghanistan as a new budget issue. They have cost around $3.7 trillion so far. That number is as large as the entire yearly U.S. budget! Now, that cost has to be spread over 10 years of budgets, but that's still a hell of a large unanticipated expense. Well, here's the budget:


What do you want to cut out?

Basically, no matter what part of the budget you want to cut, it will be a hell of a painful cost for the country. Perhaps that's part of the point of a balanced budget amendment, it makes for some really hard decisions that maybe the United States should have to make. But still, do you really want those decisions to have to be made while we're in the middle of a national disaster? In this instance, I think Rick Perry and other supporters are a little off the mark in what needs to be done to fix the U.S. budget. Yes, it needs to be reduced, but it should not be forced in this manner.


Without a serious discussion on the budget, we may end up not aiming at the right parts to cut.

Using Auto Resolve for Battles

One feature that many turn-based games allow is for a battle to be fought off-screen automatically by the computer. This can be helpful in situations where one army vastly outmatches the other and the player doesn't want to waste his time fighting it out manually. It's a good feature for a game to have if battles take a lot deal of time to complete, especially if you can't save the game in the middle of one.


No game developer wants time to be what a player is most focused on.

However, one concern I always have when I use auto-resolve is how does the computer calculate who wins? Does it actually fight the battle out using its own AI in the battle system quickly? Does it roll some dice behind the screen based on the relative strength of both sides? Let's look at a couple turn-based games to see how this seems to work.

Heroes of Might and Magic
The earlier Heroes of Might and Magic games are some of the easiest to see how the computer resolves battles. You don't have an option to have it resolved off-screen, but you can have the computer automatically fight for you if you choose, saving a few mouse clicks. It does a fairly competent job, focusing on taking enemy ranged and flying troops out of the action as soon as possible.


In this instance, the computer has the player's hero cast meteor swarm to kill some enemy gryphons.

In later games in the series, the option was added for the computer to do this completely off-screen. I tried it a couple times and it seemed to not be too unfair, the side that seemed to have a superior force won. I never attempted it for a fairly even battle though.

The one time I would complain about this system is that the computer is no good at unconventional strategies. For example, in most of the Heroes games when you are defending a castle under siege you have arrow towers that fire each turn to hurt the enemy. One way to win if you are vastly outnumbered can be to avoid fighting and move your soldiers around all over the battle map so that the enemy troops can't catch up to kill them. Over time, the arrow towers can potentially kill the entire besieging force.

Another example is that heroes can learn to cast a spell that summons stacks of creatures like air or fire elementals. A player with a weak to nonexistent army could choose to keep casting this spell for as long as they have magic points left and win a battle through attrition if the enemy force can't kill them fast enough. They will lose all of the summoned creatures after the battle and die, but at least they'll take out the enemy as well.


A Pyrrhic victory is still better than no victory at all for some.

So the lesson from the Heroes series is that auto resolve can be programmed to be pretty fair, just don't rely on it to win any battle for you that require guile or odd tactics.

Medieval II Total War
I apologize for writing so much about this game, but it's the only game I've played much recently so it's fresh in my mind. Every battle that's initiated on the main world map has a screen go up beforehand that shows the strength of all of the sides involved.


In this instance, Admiral Davy of England vastly outmatches the opposing pirate navy, as indicated by the bar in the center.

A player may then choose to fight the battle manually or have the computer resolve it instead. If it is a naval battle, auto resolve is the only option available. For the most part, it seems to be a fair system. The system weighs the odds and then fights it out. There are a few large problems with it though.

One issue appears when an army fights one vastly inferior to it. For example, if 500 plate armored knights with swords forged by master blacksmiths fight 20 unarmored peasants with pitchforks you would expect the peasants to be utterly annihilated. Well, they are, but instead of being eliminated from the world map entirely they usually are reduced in number slightly and stay on the map, now as a force of 15 unarmored peasants. This can be extremely irritating when you're trying to eliminate some of the rebel armies that randomly appear on the world map every now and then. It seems stupid to go through all the effort of commanding your giant army to kill 20 peasants, but you have to do it if you want them to actually be removed completely from play.

The only reason I can think of for why this occurs is that when you fight a battle manually it can end in two ways-when the enemy army is completely slaughtered or when every enemy army unit is routed and fleeing. When the enemy is routed you can choose to end the battle there or continue the battle and capture as many of the fleeing soldiers as possible. I guess that auto resolve must stop the battle when it determines that the enemy has routed so it doesn't finish the gruesome business of killing everyone.

Another problem occurs with the traits and rewards for the commanding generals of battles. During the game, each of a player's generals can acquire better traits when they win a battle. For instance, they might gain another star of command rating, which gives all units under their command bonuses in battle. They also might acquire new people to their retinue of support staff, most of which give small bonuses to the general. A victorious general might get a shieldbearer, who gives the general more health, making him more difficult to be killed during a battle.

When a battle is resolved automatically, it seems that these bonuses are not granted as frequently as when the player fights them on the battle map. This may not be a problem, as it offers an incentive to actually use the real time battle system, but it can be disappointing if you're in a hurry and don't have time to fight every battle of a campaign out.

The last problem is the most major one-the auto resolve system does not appear to consider city or castle walls at all in its calculations.


Which may just be a little bit of an oversight when those walls are as tough as these. And also feature ballista and arrow towers that hurl hundreds of fiery bolts at the attacker.

Even in a battle where the town defender is nothing more than one old man with a stick, any attacking force will take at least 5-10% casualties just getting over or through the walls. When the defenders have archers and some spearmen to hold the gate and walls, the attacker needs to have 2-3 times the number of defenders to have a chance of winning. Why is this the case?

Well, an attacker has four options to attack a city. When besieging a city, an army can construct three items: rams, ladders, and siege towers. Rams can be used to break down the main gate of the castle and also to break wooden walls that are part of the lowest upgraded levels of towns and castles. Ladders can be used by infantry units to climb the walls of a castle or town and try to take the battlements. Siege towers are slowly rolled up to the walls and then open up to unleash the troops inside on the battlements. The fourth option is to bring along artillery such as ballistas, catapaults, or cannons to destroy the walls and towers entirely.

These sound like good options, but in practice, rams and artillery are the only good tool from this list. Soldiers climbing up on ladders take heavy casualties when walking up to the wall and don't reach the top in numbers sufficient to defeat any units they encounter, even the weakest defenders like peasant archers. Siege towers are a little better than ladders, as 20 or so troops instantly deploy on to the battlements instead of 3 at a time when ladders are used, but they still tend to lose to any decent defending troops.


They also can be set on fire while they're moving into position, which makes them just a little bit unreliable.

So that leaves rams, which can destroy the main gate to allow the besieging force to move in for the kill. Unfortunately, the nature of a gate is that it forms a stopgap that's difficult to pass. Any wise defender positions most of their soldiers at the gate so that when it's broken down the attacker cannot rush in, they're stuck trying to make it past a hedgehog of spears, pikes, and swords. Even a tiny defending force can usually hold the gate, it's just too difficult for attackers to get a foothold inside.


Venice's armored knights aren't having much luck making it past England's spear militia.

In addition to that problem, the attacking force still has a tail end waiting to move in that's stuck receiving the fire of all the archers and towers, resulting in heavy casualties before they get under cover.


Finally out of bowshot, the Venetian soldiers were relieved. Unfortunately, they barely caught a breath before being hurled into fierce close combat fighting with spears and swords.

That leaves the best option for a besieging force, bringing along artillery to destroy the walls and arrow towers entirely. This limits casualties the most of the four options, but even opening holes in the walls is not sufficient to protect an attacking force enough. Each of those gaps in the walls still leaves a plug which a defending force can assemble behind to limit the number of attackers who can enter at a time.

When auto-resolve is used for a castle siege, the game doesn't seem to consider any of this and will tend to base it entirely on the number and quality of troops involved. If you instead choose to fight it manually, the result is that the defender will almost always prove victorious.


Usually decisively so.

Conclusion
When using auto resolve for turn-based games, try and figure out how it bases the result. It may be that you are at a severe disadvantage if you use the system, as if you rely on it for defending your castles in Medieval II Total War. It may also be quite fair, as in Heroes of Might and Magic.

Macromanagement in Total War

This article covers macromanagement in the Total War series. Again, it's best to begin with a definition of the term.

Macromanagement refers to actions taken by the player that build buildings, units, gather resources, etc. It basically contains all of the generalized actions that make your army larger and more powerful. An example of a game with an extremely heavy macromanagement focus is Age of Empires II.


An example of an Imperial Age Teuton player's military.

In this game, the player has to spend a significant amount of resources to advance their age through four ages, from the Dark Age to the eventual Imperial Age. Each time a player upgrades their age they gain access to many new units, buildings, and upgrades. There are also four resources in the game where most RTS games have one or two at the most. This means that players have to make a lot more resource gathering workers than is typical and also choose where to deploy them to fit the needs of their military. For instance, if a player wishes to build large numbers of knights they will need to focus on gathering food and gold. The primary focus of combat in the game is focused principally on building larger numbers of better upgraded soldiers than an opponent. This makes the game a macromanagement oriented player's dream-whoever does the best at gathering resources and building the largest army usually proves victorious.

Macromanagement in Total War
All of the macromanagement actions in the Total War series are performed during the turn-based portion of the game. To some extent, this makes it less stressful than in other RTS games, as you don't have to figure out which workers to send to gather resources while also managing all of your military units. You have time to think about the best choices to make.

So where does the challenge of macromanagement come into play in Total War? There are four main strategic areas a player must consider: income, costs, construction time, and troop deployment.

Income
Resource gathering works a bit differently than in many strategy games. In Medieval II Total War the currency in use is called florins, and it is used to purchase everything from buildings to mercenaries to regular units. The major difference is that instead of workers you control producing income, settlements produce almost all of a player's income. This wealth is produced through taxation of the population, farming incomes, mining incomes, and trade. Players can choose to upgrade the buildings in a settlement to produce more income from each of these revenue streams.


For instance, adding mines to Genoa adds 200 florins a turn in revenue to the city.

The main difficulty is that the player must balance producing, maintaining, and moving armies around the world with building revenue enhancing structures, improving military producing structures, taking new settlements, and maintaining good public order in existing settlements. This can be quite a challenge because players can't just build more workers to produce gold, the only major way to improve income is to take new cities. Unfortunately this requires sending out armies to claim them, which costs money in itself.


Plus Milan isn't happy when the reason you attacked their capitol is that "you needed the cash."

One of the additional changes in Medieval II Total War is that settlements may be castles or towns. Towns produce much higher trade incomes than castles so they tend to yield a great deal more money than castles. Castles, on the other hand, are harder for an enemy to take in combat and build stronger military units. A player may choose to change a castle to a town or vice versa until they reach the highest level of upgrade.


The screen to switch settlement types.

This leads to one strategy to maximize income-convert castles in well protected areas of your empire to towns so that you get more money out of them. It doesn't make sense to have a fortress in the middle of Ireland where there aren't any enemies around.

There are also two smaller ways to produce income in the game. One new unit added to Medieval II Total War is the merchant. There are numerous small resources scattered about the world map in the game, ranging from slaves to gold to amber. A player can place a merchant on these resources to trade in them, which generates a sum of gold based to some degree on the rarity of the resource, the merchant's skill level, (which rises with time spent trading and also by taking out rival merchants), and how far the resource is from the player's base of power. For instance, an English player's merchant gathering lumber right next to London would probably generate about 7 florins a turn, which is about enough to buy five spears for a single spearmen unit. If that merchant was instead gathering ivory in the Sahara desert, that would produce 200-300 florins a turn, a much better option.


A Moorish merchant trading in France.

However, I do not personally think merchants are worth the time and effort to manage. The main issue is that merchants can be "attacked" by other faction's merchants and taken off the field of play if the other merchant has a higher finance skill. This is calculated somewhat randomly so if you aren't the type of player who likes to reload the game a lot you will not have merchants for very long. One of the few things the computer does well is to build lots of merchants and use them to attack rival player's merchants. Additionally, the wealth generated by merchants is quite small compared with settlement revenue. Even if you have four merchants generating 300 or more florins a turn, an exceptional occurrence, that still only generates as much money as a typical small town.

The final small income boost is generated by stationing a general or family member in a town or castle. This allows them to be the governor of the settlement, adding his own personal bonuses to the town's incomes. For example, if a general with mining knowledge is in a settlement with extensive mines, that mining revenue is boosted by 10%. Generals can also improve public order, allowing more military units to be pulled from the town to fight elsewhere, lowering upkeep costs.


Unfortunately, most generals get traits like "Sadly Ignorant" which reduces a town's trade and tax income by 5%...

That sums up the discussion of income, so what does all that money get used to buy?

Costs in Total War
The largest costs in the game are incurred when upgrading and adding structures that allow new military units to be produced. The best units in the game require humongous investments of resources to field-sometimes going up to 30,000 florins or more. When a basic infantry unit costs about 300 florins, that's basically the price of a small army. Even mid-range units like armored swordsmen in the image below cost a good 10,000 florins to be able to produce.


Although they look awesome enough to be worth the price.

Even worse-each of the types of units-cavalry, archers, infantry, etc. is built through a different building upgrade tree. So if you want to build a force of the best infantry and archer units for your faction you have to upgrade two different structures to the maximum level. This is quite an expensive task. So why is it important to do this? It seems like it would be more cost effective to just build a bunch of the cheap spearmen units instead.

The main issue is that the less expensive units just don't stand up in a fight later in the game. A force of knights will carve up a group of peasants with pitchforks without losing more than a couple men at the most. Additionally, every unit in the game has an upkeep cost that has to be paid every turn. The upkeep costs for cheap units aren't much lower than the more expensive ones, meaning that you aren't saving much money in the long run.


It's also a bit embarrassing when your entire army consists of these guys.

This leads to another concern when upgrading your military unit producing structures-building time.

Time
Most structures take multiple turns to construct with more advanced military and economic structures taking half a dozen of more turns. This means that a player has to consider their goals carefully when deciding what to build. It is foolish to try and upgrade every city and castle to produce the best available units. That takes far too much time for each settlement and also is a waste of hundreds of thousands of florins that could be put to better use building more soldiers. A better idea is to coordinate building upgrades among the settlements in a region. For instance, in a section of the map with three castles, a player could upgrade one to produce heavy cavalry, one to produce heavy infantry, and the last to produce archers.

For an example of how much money and time that coordination saves, let's assume that it costs 5,000 florins to build each building for each unit type and that they each take five turns to construct. The price for upgrading every castle for all three units versus one unit type in each is as follows:

5,000 x 3 castles x 3 unit types = 45,000 florins
Build time- 5 turns x 3 structures= 15 fifteen turns

Compare that with only upgrading one in each castle:
5,000 x 3 castles x 1 unit type each= 15,000 florins
Build time- 5 turns x 1 structure= 5 turns

A 66% discount is a pretty good deal, no?

An additional consideration is that revenue producing structures like mines, docks, and farms also take multiple turns to complete. It's important to consider where to place them in the construction docket so that you have more income later.

That brings us to the last main macromanagement area of Medieval II Total War, troop deployment.

Military Deployment
One common military maxim is that one soldier on hand is worth more than ten available at some unknown point in the future. This is extremely important throughout any Total War game as armies are spread out over a continent-spanning world map. It doesn't matter how many soldiers you have in Africa if the battle is in Europe.

This maxim even applies to individual armies. It's better to have all of your soldiers consolidated in one army if possible. This is because reinforcement military units don't deploy alongside your army on the real-time battle map. They will enter the field from a different direction-possibly one that is a long hike from the main army. This can allow an enemy army to destroy your main army in detail and then turn to crush the reinforcing army as well.


As in this example, where the total numbers of all three Scottish armies were roughly equivalent to the English force, but the English force charged forward and destroyed each individual Scottish force with ease in the actual field battle.

This has a great deal of relevance to strategic decisions throughout the empire as well. It makes no sense to leave large forces to garrison cities and castles that are not near enemy factions. They are most unlikely to be attacked, send those soldiers forward to towns and castles that are on the front lines of whatever wars you current face.

Conclusion
Although the macromanagement of Medieval II Total War is done in a turn-based setting, taking away the urgency of decision-making, it still takes a good deal of thought to do well. A player who does not make good choices will end up bankrupt and with inferior forces to their opponents. Also consider that a Total War game takes a lot longer than most other games so short-sighted economic and military decisions to win a current war may come back to haunt you later in the game!

Errors in Healthcare-Medications & Surgery

It's become a well known fact that healthcare systems throughout the world make a large number of errors every year that can have horrific consequences for patients. Patients may receive the wrong medication, medications that have unexpected interactions with each other, and suffer surgical errors. The reasons for these problems can be anything from a misidentified patient receiving a different patient's medication, a surgical team confusing a left arm for a right arm, or a medication order not being updated to reflect a patient's changing condition.

The one element most of these errors have in common is that they are usually inflicted when hospital staff are in a hurry, either because they are behind schedule or there is an emergency situation. A surgical team starting a routine procedure one hour late may try and rush through all of the pre-operative steps in order to get done for the day on time. This can be problematic if one of those steps that was glossed over was which kidney was supposed to be removed. To paraphrase comedian Tom Shllue, "So you're telling me that one of my kidneys is bad... and now you have the good one!?"


Unfortunately, saying oops isn't usually enough in healthcare.

How bad is the problem?
Unfortunately, medical errors are a humongous problem in the United States. Medical errors of all sorts kill approximately 43,000 Americans a year according to the CDC. Medication errors alone kill 7,000 or so and inflict grievous harm on many more. As medical technology improves it has allowed many patients to be saved but it also means that healthcare workers need constant reeducation on how to perform those new skills, handle that new equipment, and the risks and dangers of new medications and treatments. When that constant flow of new information is combined with a hectic hospital environment where each staff member has to treat multiple people each day, it can easily lead to serious problems.

For an example of how easy it is to make an error, most hospitalized patients are on at least five different medications. Some of these may be pills taken orally, other drugs go through IVs, some are injected into the skin, and some are pushed through J or G tubes-devices that enter the stomach or small intestine. So with a typical 3-4 patient caseload for a nurse, that's twenty or so different medications for different patients, some with different routes of administration, some of which may have to be given multiple times each day. Combine that amount of information to remember with the exhaustion brought on by 12 hour or longer shifts that some healthcare workers perform and you have a recipe for disaster.


How a hospital looks after 16 hours of working there. Medication labels don't look any sharper unfortunately.

When a sleep deprived person tries to deal with information that has multiple steps, like what medication is supposed to go to who, or which patient is getting what surgery on which body part, it's easy for screw-ups to occur. So how do we fix this problem? Fortunately there are a couple methods to stop the easily preventable mistakes that keep occurring in healthcare-medications errors and wrong-site or incorrect surgery.

Medication Barcoding
Barcoding medications works like it does with UPCs in a supermarket. Every patient room is equipped with a computer and a barcode reader. All the medications in the hospital are labeled with a barcode that can then be scanned, verifying what the medication is, its dose, and other important information about it. This is compared with the patient's medication profile in the hospital's computer system to make sure that everything is correct-this is the right medication and dose for this patient.


Aricept tablets with barcode on the side.

The scanner is then used to scan the patient's wristband. Every patient in hospitals has these wristbands nowadays to ensure that they can be identified easily. If the medications that were scanned don't match up with the wristband that is scanned, the barcode system will deliver an error message and the person giving the medications will know that something is wrong and take a look at the problem.


Unfortunately, you can't just call for a price check to figure out the problem like you can at Wal Mart.

If used properly, this system prevents the vast majority of medication errors. Any staff member will get a warning that they're doing something wrong if they brought the wrong patient's medications into a room, have the wrong dose, or some other problem.

The main problem with the system is that it takes a bit more time than older methods of medication administration. Barcodes can also be torn, difficult to scan, or non-functional for other reasons. This necessitates a manual override being available for the system, but many staff members misuse this to give a lot of medications in a hurry when they're busy or behind in their shift. It's important for this inappropriate use of manual overrides to be unacceptable in a hospital organization for the system to work. Fortunately, it only takes one error being caught to make staff members get on board with the system.

Surgical Checklists
Airlines and other complex high risk industries have been using checklists in their normal course of operations for decades. They make sure that pilots and other staff don't forget any important details when they are preparing to do their job.


Killer shades? Check!

Most surgeries, particularly routine surgeries, still have a number of steps that have to be taken before each procedure to make sure that everything is correct. The patient is usually under anesthesia when they are brought into the operating room, so they are unable to verify any of this information. The patient must be identified, the surgical site and surgical procedure confirmed, the use of pre-incision antibiotics discussed, and any potential complications brought up as well. For instance, if the patient had a blood clotting problem that might be a special concern to bring up, as blood would need to be available in the event of an unanticipated severe bleed.

To resolve this problem, many hospitals now use a timeout before a surgery begins that discusses all of these problems. Look at this video to see an example of a good timeout.



Of course, there are plenty of surgeons and other staff who don't see the point of taking a few minutes at the start of every procedure to do this. Here's a couple examples of poor timeouts.





Conclusion
Medical errors continue to occur at unacceptable rates. Barcoding medications and surgery timeouts are too ways to prevent some of the worst errors-inappropriate medication administration and wrong site or wrong procedure surgery. However, they are only effective when they are taken seriously by staff. It may take a few minutes of time, but it's well worth it when it prevents a lifetime of disability to the patient.