What if I am wrong and everyone else is right? How will I
reconcile my thoughts to the reality? Indeed what if I am right and everyone
else is wrong? What do I do?
These scenarios play out in our lives daily. Risk mitigation
strategies are nothing more than links of multiple “What ifs!” The actuarial data creates the template and
probability thrashes out through the Bayesian lens, numbers that speak to the
risks. All is contained. All is accounted for. All is measured.
Is it?
Yet, yet the blood curdling thought turns black the
phantasmagoria of the colorful dream when the “What if” chimes in. And it does,
if one does not swim in the lake of delusions.
Let me take you on a short aviation encounter of the real kind…
Flying as we all know has known risks. The fatality rate of
commercial operators as in Airlines and General Aviation is a miniscule 0.42
per 1,000,000 passenger miles travelled while Auto accident related fatality
rates are 3.4 per 1,000,000 passenger miles travelled or 10 fold more. So
neither modes of travel are exempt from risk. And if you carry this thought
forward, it seems that the drive to the airport is almost 10 times more
hazardous than the flight itself.
Since we are inclined to toast the virtues of aviation and
link them to the nearby disciplines of medicine and in some cases of business, let
us carry this heavy ball and chain further. I commented while delivering a
lecture on Aviation Safety, “What if things don’t go the way you anticipate?”
There was silence. “What if you run out of fuel in the air?” A hand arose from
the rear of the room. “You wouldn’t let that happen!” the voice claimed.
“What if the High Pressure turned into a Low Pressure area
and you were faced with head winds instead of tail winds as calculated in your
trip planning?” Again the hand raised, “Set the plane down at a nearby field,
anticipate the potential based on the speed, fuel and distance calculations.”
What if you are over a mountainous terrain?” I countered.
This time there was silence. Inspiration hit the back of the mind that had been
responding, “Set the plane down before the mountainous region, fuel up again
and then continue the journey.”
“What if there were no airports within a 50 mile radius?”
Stumped? Not really, the Phoenician hand rose again, “You have to anticipate
that when you begin your journey!” She was right again!
Having found one listener who was engaged, I switched tack, “What
if you lose engine power on take-off at 400 feet?” A hand rose across the sea
of heads, this time from the back again but the other side of the room, “Go
back to the airport!” The baiting was over and the opening I had been waiting
for had arrived.
“If you make a turn back to the airport below 700 feet
universally that is a no, no! As you turn you lose the vertical component of
lift and the potential for stall and spin is extremely high. So the only option
is to land straight ahead or 30 degrees left or right of the departure end of
the runway wherever there is an open field.” I paused and a few heads nodded. “This
brings me to another question, what do you think the main reasons are for doing
a traffic pattern at a non-towered airport?” More hands raised, a cacophony of,
“See other aircraft in the pattern, arriving and departing and any potential
hazards on the airfield itself, such a waste of time, waste of fuel, totally
unnecessary” were the main thrusts. “What about using the traffic pattern as a
means to observe both the departure end and the arrival end of the runway for
the potential of what if?” Blank stares greeted me on that. “What if you lose
an engine on departure from the same airport and having surveyed the field on arrival, knowing the terrain
surrounding the airport, one can safely figure out a location to set down the
aircraft and walk away from potential of harm.” The bulbs of inspiration
and understanding lit up. Hey that makes sense was the general brightness that
illuminated the attendees.
What if, is a game of chance and played by those that seek
not to rely on luck but on mitigating the potential of risk. In business, the
smart money always plays the game. Ever see Shark Tank on TV, it is all about
the potential of success vs the potential of Risk. The ratio above 1 gains an
investment from the Wealthy Sharks while those with an irrational number
(fraction) go home. The Sharks look for fiscal trends of the business, the emotional
needs and the desires of the public at large, the investment costs and their
Return on Investment (ROI) through acquisition of part of the business. Sharp, shrewd
and uncannily business wise!
In medicine too doctors continually play the game in their
minds and when discussing cases with colleagues. What if I give this medicine,
how would the heart react to it and what would that do to the kidney function and
how would that affect the lungs. Or this chemotherapy or biologic therapy harms
the heart x% of times and the benefits are y%, if the y% exceeds the x%
substantially then it’s a go otherwise search for another option. Oh by the
way, if you didn’t know this, here is a clue, the practice of medicine is every
bit art as it is science. Don’t let the pundits and experts fool you otherwise,
they for the most part sit and push papers.
Life is a game of chance and not as the current cookbooks
concocted in the ivory tower realms of population medicine purport. Each human
is unique and each human has a unique genetic signature that determines a
different response than what might have worked within the 2 standard deviations
of the normal distribution curve for the majority. My genetic signature is as unique as yours, like
East and West and never the twain shall meet in health nor in disease
manifestation nor in the response to similar treatment. We are a unique species
conceived of a 25,000 gene product built on the foundation of a four nucleic
acid code. Now that is impressive in terms of uncanny diversity within a 7
billion population spread across the globe!
Technology can crunch numbers faster than the human mind!
Yes, but what if a 50% benefit based on a 95% Confidence Interval is the metric
utilized to treat an individual that has a completely different set of genomic
signature and does not comport to the “landmark study” being used as the
template for treatment? What if the numbers in the medical study were derived
from a subset of population that does not equate to the region from whence this
patient came? What if the “large” data set of a 1000 patient in that study is a
very small subset of a larger population that does not represent the whole even
within the 95% Confidence interval and even after the Bayesian rules have been
brought into play, but skews it downwards to an alpha of 10 or more in reality?
What if we are wrong in using population statistics to govern the health of
individuals? What if?
"What if" scenarios are thought experiments without real
consequences. These are designed solely to appoint a guardian of luck as you
travel across your chosen path. Humans have the uncanny ability of using this argument and making appropriate decisions as they wade through the murky waters of chance.
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