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.

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.

Creating Challenging Enemies

After replaying a few videogames that I enjoyed in my youth, I noticed one big problem. There isn't much of a challenge to the enemies. This led me to think about the usual ways developers use to make opponents more difficult and which methods work best.


The challenge level of many current games

Method 1: Add more enemies
This is the Serious Sam approach to difficulty-add a whole ton of additional foes and the game will indeed be harder. Bonus points if the game requires the player to individually click for each attack-eventually their finger will get tired.


Eventually they'll get tired!

Although this method does work, I find it to be a cop out. In many action RPGs your character will not even take significant damage from these types of enemies because you have sufficient armor and hit points to resist their attacks. This means that you don't succeed in adding a sense of danger and challenge-the player never feels menaced, just inconvenienced.


A similar obstacle would be a room full of kittens you have to pet

Method 2: Add health and damage to the enemies
This is another pretty easy approach to make the game more difficult-just make the monsters harder to kill and make them injure you more. This is better than method 1 because it at least makes you feel that enemies are a real threat, but it's difficult to balance. It's hard to find the sweet spot of difficulty where they are hard enough to pose a threat but not at an unreasonable level of challenge.


The tricky seesaw of game balance

The other problem with this method is that it may not fit the game world very well. For example, in the The Elder Scrolls IV: Oblivion all of the monsters increase in strength along with your own character. This means that toward the end of the game every common bandit will still be an equal threat for your battle-hardened warrior who has won thousands of engagements, which doesn't make a whole lot of sense.

If this method is chosen ideally it should be implemented by making different enemies appear that look like they should be more challenging. For instance, if you were fighting bandits and thieves at the start of the game, add better equipped mercenaries or knights later on.


This enemy might pose a plausible threat at the start of the game-not at the end of the game

Method 3: Limit the player's resources
This is one of my favorite ways to add difficulty to a game. It forces the player to consider what to use in every situation as they may need that grenade or healing potion more later on. Many RPGs and survival horror games use inventory limits to impose this on the player-you're physically unable to carry everything you might want so you have to pick and choose what you take with you. Other RPGs don't have limits to your inventory but you don't have unlimited cash so you have to pick what to buy very carefully.

However, this system poses a difficult balancing act once again, as there may be situations where limiting player resources results in being stuck in a situation with no way out except reloading or restarting the game from an earlier point. This results in the player being forced to slog his way through a bunch of stuff he's already done earlier-or more likely to quit the game entirely.


and you really don't want to be stuck in the torture dungeon

Method 4: Make enemies only vulnerable to specific attacks
This is another one of my favorite methods-and can be done in many different creative ways. Add a specific weakness to an enemy-such as taking extra damage from silver weapons. Require the player to use a certain item to damage their foe-such as a stake to kill vampires. However, it's very important that there be a way for the player to KNOW what the enemy's weakness is before or during the encounter, so that they can potentially prepare for and beat it without having to go to Gamefaqs. You can do this by having hints in the game-such as NPCs you talk to in town or a book you find saying that the enemy is afraid of light.

You can also ask the player to use logic-for example the first boss in Final Fantasy Nine is a big plant. Astute players might realize that plants tend to not like being set on fire.


The dreaded Plant Brain

There should also be some visible or audible sign that you have successfully identified the enemy's weakness-anything from a shout of agony to simply taking significantly more damage from your attacks.

Method 5: Impose additional restrictions on the player
This is a great way to not only make the game more difficult, but to make the game feel more unique and original. In Final Fantasy Seven-players need to have various materia which have to be equipped to cast magic spells that can cause damage to enemies or heal allies. At one point in the game, players have all of their materia stolen by Yuffie.


Don't trust anyone who dresses like this

Obviously they want to get it back, but Yuffie is kidnapped by an enemy and the player has to fight their way through them without being able to use their magic to help. What I found extremely clever about this part of the game was that while you weren't able to cast magic and this was an abrupt, unexpected occurrence, there were ways around it. The store in town sold items that could be used to cause high damage to enemies, as well as healing potions that you could use to substitute for the cure spell.

In the Trauma Center game for the Wii you have to perform surgery on patients. You are used to being able to see the entire patient's body so that you can treat them quickly. Well, in one scenario you get involved with a car crash in a tunnel with no lighting. All you have available to light the scene is the flash on a camera that needs a few seconds to recharge. So you have to remember what's going on as the flash dims and you return to being completely in the dark so that you don't injure or kill your patient.


Nothing could possibly go wrong with doing surgery in the dark

Method 6: Make the enemy smarter
Unfortunately, making good AI for opponents seems to be extremely difficult. They are able to execute what they are programmed to do with perfection but they are also extremely predictable. Even in FPS games with the best enemy AI, after you've been through one or two rooms of enemies you pretty much know what they will do for the rest of the game. In RTS games, after the first few difficulty levels the AI is made more difficult by giving it resource gathering bonuses instead of making it better at the game.


Artificial Intelligence has not reached this point yet unfortunately

I think the best way to make the AI seem more intelligent is to constantly add new tricks that the enemies use with the precision that the AI can offer.

Using a FPS game where you attack a facility as an example, in the first engagement the enemy is stunned by you showing up and just returns fire while in the open as you gun them down. The next guards you meet are prepared and use cover to protect themselves. After that, there's an alarm in the room that you have to keep them from pressing and summoning reinforcements. Later on they turn the lights out in the room so you're blind and have to return fire to their muzzle flashes or at their flashlights. Maybe a later room has tear gas or something that floods it and you have to deactivate it.


Far too many FPS games stop at the second stage of AI-they take cover and then you spend the rest of the game popping out to blast at them for a few seconds before returning to your own cover

Summary
There are many ways to add difficulty to a game but if you want to separate your game from the pack, try and use more creative options. Don't just add more monsters with more health and damage-try and force the player to think. There are already tons of games out there that add enemies with slightly more health and damage-players won't remember those. They will remember trying to suture bleeding lacerations from the light of a camera flash.