#the gender ratios also speak volumes

[the-final-sif]

So for those unaware, dasnerth is apparently banned from Karl & MrBeast challenge, accord to the discord message he showed today (1/29/2024), (which notably is from 8/30/2023)

basically, as it stands, almost all the "content" you provide by being in a video almost always gets cut out because you're generally pretty toxic, you take the gameplay extremely seriously which makes your time on-screen inherently destructive / toxic. If you are genuinely super interested in not being blacklisted, if you could just refrain from being toxic we can lift the blacklist. It would also mean reporting any exploits instead of abusing them.

A message he published himself, claiming he was only being competitive.

I've seen in response, certain people claiming that this is unfair, that he needs to be defended, or that this will inevitably lead towards toxicity towards people like Sapnap/Punz/Hannah.

This is not true, and I think people need to understand that there is a line between being competitive and being toxic to be around and effectively unwatchable and making others uncomfortable.

First, take note for a moment that Dasnerth has been banned for well over 5 months, and despite being very clearly and flatly told he's unwelcome, he's not only still stalking the discord to try to join stuff, but also then turned to twitter to kick up a fuss about the ban still being enforced.

This is pretty telling of him as a person. He's clearly been told that he's blacklisted and unwelcome, and five months later he's still trying to sneak in. That is a very clear indication of failing to respect boundaries, feeling entitled to participate in contests, and being unable to take no for an answer.

Putting that aside though, you can still clearly draw lines between taking competition seriously and being a toxic asshole in a game. I think a really good example of this is actually, weirdly enough, 5up's lobbies.

If you don't know 5up, he's a guy who plays among us. When he was starting out, he often played with what were called "sweat lobbies". These lobbies often devolved into yelling, shouting, insults, etc. 5up was noteworthy for generally not falling to that level. You can watch how awful of a viewing experience this is here. These lobbies are very competitive, and also suck so bad 5up left despite generally being willing to tolerate a lot of bullshit.

Contrast this to his later lobby that he built with Hafu, a very experienced streamer with a much calmer vibe. The morning lobbies that they built are known for being relatively serious and competitive, but not being toxic messes. Here's a good example, In this game 5up played an amazing crewmate much like the XQC, and caught Steve and Tina (Tinakitten) as imposters. Tina's distressed but not angry or being mean, and Steve compliments him on figuring out! It's a complete flip of the above. People sometimes yell and get excited, throw a bit, or get a bit salty, but it's nothing like what you see above with the constant screaming and insults. People from other lobbies that are more chaotic come in and are generally surprised by how seriously they take stuff.

To go even further, 5up also plays in the stell lobbies, which are very competitive and take the game very seriously. Listen to a meeting in the stell lobbies. Nobody is yelling, even when directly accused. They all remain calm and polite. They're still playing the game very seriously, they're playing to win, but nobody's being toxic or mean.

There's a difference between being competitive in a fun way, where you take a game seriously and try to win, and just being an asshole and disregarding good sportsmanship. It's perfectly valid for contests to ban players for violating good sportsmanship and abusing exploits. Technoblade was a very competitive person, but even when he's being teasingly toxic to squidkid for example, it's clearly in good fun. The two of them became friends. There's a fundamental level of respect there, and nobody is going over the top.

So yeah, while we don't have the specific behavior cited, it's perfectly valid for an event to ban someone for being toxic, and no, banning someone for being toxic isn't bait or eliminating competitiveness. It's just showing an asshole the door.

[jcmarchi]

Building a diverse cyber security workforce, 2023 and 2024

New Post has been published on https://thedigitalinsider.com/building-a-diverse-cyber-security-workforce-2023-and-2024/

Building a diverse cyber security workforce, 2023 and 2024

At Check Point, I am responsible for enabling National Channel Partners to drive sales and increase revenue by developing technical training programs for Partner sales engineers and security architects to keep them up-to-date with new technologies to prevent advanced persistent threats and zero day attacks. I work with Regional Channel Managers and Field Engineers to develop and execute strategies to implement new products across regions.

To effectively protect the cyber sphere, we need to harness the power of diverse perspectives. Diverse teams solve problems faster and are more innovative than homogeneous teams. They’re also widely recognized as critical in strengthening an organization’s cyber readiness, increasing employee and customer satisfaction, and better enabling organizations to achieve long-term goals.

In this interview, Cyber Talk speaks with Check Point expert Miguel Angulo about the topic of cultivating a diverse cyber security talent pool. Let’s dive in:

Can you share a bit about the trends related to diversity in cyber security?

In cyber security, diversity and inclusivity has been a much-discussed topic. Let’s begin by examining the state of the cyber security workforce. According to the ISC2 Cybersecurity Workforce Study 2022 (link), the gap in the number of cyber security experts continues to widen. At the time of reporting, there were an estimated 4.7 million cyber security professionals worldwide in this field. Despite the addition of 464,000 positions in 2022, there are an additional 3.4 million cyber security professionals needed to adequately safeguard corporate assets.

When examining the current threat landscape, the situation appears concerning as revealed by the Check Point 2023 Cyber Security Report. This report highlights a significant surge in phishing attacks, which escalated from 33% in 2018 to a staggering 86% in 2022. The rising volume of threats, the scarcity of cyber security experts, and the complexity of security measures are collectively leading to growing frustration among existing cyber security professionals. As a result, there is an urgent call for an increase in the cyber security workforce.

To ensure the effective safeguarding of corporate assets, it is vital to acknowledge and address the existing gender disparity within the cyber security field. Despite the current male-to-female ratio being 3 to 1, it’s noteworthy that the number of women in cyber security is on the rise, indicating a positive trend. In 2022, the global cyber security workforce saw a 5% increase in female representation, with women now comprising 25% of the total, as opposed to the 20% they represented in 2019. By placing emphasis on certification and education, women are not only making their way into leadership roles, but are also setting an example for other women and future generations to pursue a career in cyber security, where they can succeed.

Another trend in cyber security is the need for diverse skill sets, encompassing technical proficiency, risk management, and effective communication. Diverse teams in security operations (SecOps) and security operations centers (SOCs) are widely recognized as crucial for strengthening an organization’s security readiness. These teams, consisting of individuals from varied backgrounds, bring unique perspectives and innovative problem-solving approaches. This diversity is especially valuable in cyber security, where professionals combat global threats. It results in fresh insights that help analysts understand adversaries better, enhancing threat detection and response capabilities.

You’ve been part of some exciting initiatives! Would you like to share a bit about them?

When I’m confronted with the question, “How did you get started in the cyber security field?” it offers me an opportunity to recount my path. Nevertheless, conveying my story to a solitary individual is insufficient. I actively searched for a platform that would enable me to inspire a more extensive audience to contemplate a career in cyber security.

By collaborating with various nonprofit organizations like HISPA, ISC2 NJ Chapter, and We Are all Human, I’ve found the means to connect with people. Through HISPA, I engage with middle school students and convey my experiences as a cyber security professional. Through ISC2 NJ Chapter, I can mentor college students seeking to enter the field and professionals from other IT sectors looking to transition into cyber security. Furthermore, my involvement with We Are All Human allows me to reach the Hispanic community and enlighten them about the career prospects that cyber security offers.

Miguel Angulo of Check Point Software Technologies takes a selfie with PCAI participants during a networking event (link).

What points do you make to young people to let them know that this is an interesting and viable career path?

Considering a career in cyber security offers numerous benefits. First and foremost, the field is in high demand, driven by the escalating frequency and complexity of cyber threats. This demand ensures job security, as  skills are continually needed to safeguard data and systems. Moreover, the cyber security sector offers diverse opportunities, spanning roles from ethical hacking to risk management, appealing to various interests and skills.

Cyber security experts essentially serve as digital detectives, utilizing problem-solving skills and creativity to outwit cyber criminals, making it a dynamic and intellectually stimulating field. The competitive salaries in the industry reflect the high demand for expertise, which is particularly advantageous for young professionals.

Additionally, the global impact of cyber security is notable, as your work contributes to a safer online environment worldwide. Continuous learning is inherent in cyber security, making it ideal for those who enjoy staying current with technology trends. The field also offers an ethical dimension, allowing individuals to be the “good guys” in the digital realm, protecting privacy and security. Furthermore, the sense of community and collaboration within the cyber security profession offers the opportunity to learn and grow alongside experienced colleagues, making it a fulfilling career choice for young professionals.

How did you get involved in cyber security?

I held several roles in IT, from upgrading hardware on desktops and laptops, deploying Windows operating system, building custom Windows images, rack and stack servers for telecommunication companies and financial services, to cloud infrastructure, virtualization, networking, and backup operations. Given the numerous advantages cyber security offers, I found it to be a captivating career choice. I jump-started my career through comprehensive training, including participation in a SANS training boot camp, Security+ and Network+. I also recognize the significance of partner training, which allowed me to gain insights into cyber security while learning about specific vendor technologies and their approaches to safeguarding customers against cyber threats.

What advice would you give to people from underrepresented backgrounds who are interested in pursuing a career in cyber security?

There’s a common misunderstanding about the nature of cyber security. Many individuals envision cyber security professionals as solitary figures in dimly lit basements, surrounded by numerous screens, munching on Cheetos and sipping Mountain Dew, while writing code to breach networks. This portrayal often stems from the way the movie industry depicts cyber security experts. Even the adversaries in the field are often shown working in regular office settings, but that’s a topic for another discussion. Here, I’d like to offer some advice that I typically share with my mentees:

Do not get intimidated. Many individuals believe that a technical foundation is a prerequisite to launch a cyber security career, but this is a misconception. Cyber security primarily involves understanding the workings of technology as it evolves over time.

Network and Seek Mentorship. In the realm of cyber security, it’s a continuous journey, and mentors play a pivotal role in providing direction on commencing your cyber security career. They can offer insights on where to begin, recommend the suitable training and certifications, and help you steer clear of common pitfalls along this path.

Connect and Pursue Mentorship. Navigating the world of cyber security is an ongoing voyage, and having a mentor can help steer you in the right direction when commencing your cyber security career. They can advise you on how to initiate your journey, identify the necessary training and certifications, and help you avoid problems along the way.

Engage with local non-profit cybersecurity organizations. I highly recommend becoming a part of a nonprofit cyber security organization as a valuable step on your journey in the cyber security field. These organizations are composed of experienced cyber security professionals, many of whom serve as mentors or trainers dedicated to supporting individuals interested in entering the industry. They offer the tools and skills necessary for entering the workforce. These organizations are typically organized into chapters, and they organize year-round events to assist you in shaping your career. These events cover various aspects, including resume building, interview skills, training, and the opportunity to network with existing chapter members who are actively engaged in the field. Networking within these organizations provides a fantastic opportunity to gain deeper insights into the industry, understand certification requirements, and explore potential job openings.

Continuing education, training, and certification. Ongoing learning, training, and certification are essential in the ever-evolving realm of cyber security. Commit to continuous education, keeping yourself informed about the most recent trends, tools, and threats. Contemplate the pursuit of pertinent certifications and formal education in the field, as these credentials can boost your reputation and expertise within the cyber security domain.

Broadly speaking, how can companies create a more inclusive environment for professionals of diverse backgrounds?

In today’s workplaces, diversity, equity, and inclusion (DEI) have become a central focus. When I observe individuals who resemble me occupying positions at higher levels of the organization, such as directors, C-level executives, and board members, it instills a sense that the company is actively taking strides to establish a more diverse environment. This environment not only fosters opportunities for learning, personal growth, and voicing opinions, but also makes individuals feel valued.

Numerous blogs discuss best practices and initiatives for cultivating a more inclusive workplace. However, I’d like to emphasize a few key points. Firstly, organizations need to establish an inclusive atmosphere where every individual is treated with respect, granted equal empowerment to contribute, and provided with equitable access to resources and opportunities, regardless of their demographic characteristics.

To foster a greater sense of inclusivity, companies can begin by conducting a self-evaluation to gauge their current status in terms of diversity, equity, and inclusion (DEI). Establishing a baseline understanding of their workforce will reveal any disparities and enable them to take targeted measures to rectify these issues.

Senior leadership, spanning from C-level executives to the board of directors, must demonstrate their endorsement of DEI endeavors. In the event of a significant crisis occurring in a specific global region, it is crucial for the senior leadership to extend their backing to employees hailing from that area. This message should be conveyed not only internally but also externally, reaching both their customers and business partners.

Review your recruitment procedures to identify non-inclusive language in job postings. For instance, if you’re seeking a software developer proficient in Java, Python, or GO, but your job description mandates a college degree, you might inadvertently discourage qualified candidates who lack formal degrees. When job descriptions and hiring practices create barriers for certain groups, the organization will encounter challenges in attracting a diverse workforce. Ensure that the definitions you set for job descriptions and their associated requirements are in harmony with the actual expectations of the role.

Through their investment in Employee Resource Groups (ERGs), organizations provide employees with a platform to connect, share experiences, and contribute innovative ideas aimed at improving the workplace. Furthermore, supporting mentorship and sponsorship initiatives allows employees from diverse backgrounds to connect with seasoned mentors who can provide guidance and advocate for their professional advancement. Companies that actively encourage these internal mentorship and sponsorship programs not only enhance employee satisfaction, but also tend to retain their workforce for more extended periods.

What strategies do you recommend for attracting more underrepresented groups to cyber security at an early age?

Getting underrepresented groups interested in cyber security from a young age is a key step in fostering diversity. Here are some strategies:

Early Education Programs: Collaborate with schools to develop cyber security educational programs for students at the elementary and middle school levels. These programs can introduce cyber security concepts in a fun and engaging way.

Youth Cybersecurity Clubs: Support and sponsor youth cyber security clubs or organizations. These clubs can provide a safe and inclusive space for young individuals to learn and explore the field.

Mentorship and Role Models: Connect young students with mentors and role models from underrepresented backgrounds in cyber security. Seeing someone who looks like them in the field can be highly motivating.

Scholarships and Grants: Offer scholarships and grants specifically aimed at underrepresented groups pursuing cyber security education. Financial support can make a significant difference.

Hackathons and Competitions: Organize hackathons and cyber security competitions for students. These events can be exciting and provide practical experience.

Curriculum Integration: Advocate for the inclusion of cyber security topics in school curricula. Make it a part of the standard educational experience.

For more cyber security insights from Miguel Angulo, click here. Lastly, to receive timely cyber security insights and cutting-edge analyses, please sign up for the cybertalk.org newsletter.

[amazonjax]

The persisted concealment of intersex historical artworks within public places of exhibition: 2019, The British Museum, London.

Despite global activism for museums to reveal true records of human history, depictions of intersex historical figures are still considered too ‘lewd’ or ‘inappropriate’ to validate public viewing alongside all of the male and female artifacts blatantly displayed. Such acquisitions are purposefully veiled within the secret catacombs of museum depositories, available for private viewing by appointment only. It could be argued that this persistent Interphobia within museums is a reflection of the medical and cultural attitudes towards this marginalised area of our society today: Intersex anatomies and identities depicted through art are masked, hidden, and sometimes even mutilated if they do not conform to the ‘Adam and Eve’ socially constructed, patriarchal archetype of sex and gender (as is the case with many of the historical Intersex and Transgender artworks that remain in existence today). 

For too long intersex existence has been pinned with hands tied, to the binary wall that has been catastrophically and socially constructed around us. 

Activists still fight to lift the disguise of male and female sex as the be-all and end-all of human existence, in the hopes that society can unburden itself from the weight of these statue-concealing tarpaulins which conceal our true history.

Our identities have always been a part of historical art and human cultures. The difference is, in the age of international communications and social media, we are now creating unification and safe spaces for our true human footprint to finally emerge, and the message is becoming clear as the volume is increased: 

Intersex people will not allow their identities, or their histories, to be erased any longer.

A pure example of intersex erasure:

The British Museum currently has 71 artifacts listed as "Representations of Hermaphroditos" in its inventory. Unfortunately, after checking all pieces online, I found that only five items are currently on public display within this colossal museum. Furthermore, the pieces they have chosen to exhibit are all small broach like cameo's and gems that show vague or obscure representations of the intersex deity - a tiny little nod to the invisible specs of dust they continue to sweep away.

Amongst the many shrouded prints, carvings, playing cards and etchings laying dormant until the scholar calls, are two physical statues which on both occasions have been decapitated. This is something the museum should be highlighting as part of their Ancient Greek collection: the execution, denial and erasure of Intersex identities throughout history as well as showing depictions of intersex history through statuesque art. There are no features or markings to suggest any deity or historical figure is associated with these two statues so they are simply listed as 

‘A depiction of an hermaphrodite'. 

Hermaphroditos is a Greek deity; a hermaphrodite, in human society today, is what we would call an intersex person, or a person with variations of sex characteristics. The Museum needs to check itself on this one and perhaps add a further description to these pieces to help shed a light on what the word means when applied to an unknown identity in modern-day language. This would help to dissipate the conflations and enable better understanding away from the stigma and shame of a mostly-misleading word that still incites ‘freakish’ or ‘abnormal’ connotations for most members of the public who do not have any knowledge of intersex people existing outside of these false notions. Something polite yet with slightly condescending overtones to match the Museums’s general attitude should suffice: 

“Although historically we have used the word ‘hermaphrodite’ to describe all intersex people, there are over 30 different bodily variations, and a spectrum of unique human characteristics that could apply to the 1.7% of our population born with intersex traits. Therefore we no longer generally use the word hermaphrodite to describe these identities as it is considered misleading. Unless the word is being reclaimed by an intersex person themselves, when referring to intersex people or their bodies in the future, we should always use the word ‘intersex’”.

Then again, what is the point of trying to be accurate and informative when these grotesque, anomalous ‘who-knows-what’s’ are safely locked away from the Museum’s tapestry of truth?

A couple of weeks ago I visited the Museum and spent time looking through their collections before eventually asking at the information desk for representations of intersex deities within their collections. The person trying to help me seemed quite perplexed by my initial request yet eventually this friendly faced assistant managed to find two prints on their computer that unfortunately weren’t on display. In recompense I was handed their alternative: a leaflet the Museum has to cover such awkward questions entitled "Desire, Love, Identity, Follow the LGBTQ History Trail".

The online version is here 

There are mentions of possible identities that could be deemed ‘intersex’ with notions of forbidden sexuality or figures having ‘gender identities that were regarded as in some way irregular’ or ‘gender dualities’. There are also details of deities that could change sex themselves or affect the sex of other people and descriptions being used such as ‘androgynous mask’. However, the general consensus I took from this guide is that when non-binarised identities are alluded to, there’s always a sensationalist, dark approach towards sexuality and gender, with beings and notions depicted as having the ‘wrong’ type of body; the ‘abnormality’ that exists away from what we have become accustomed to within the male/female binary lie of Human existence. No mention whatsoever of Hermaphroditus or Cybele or The Galli in their ‘LBGTQ’ teachings whatsoever.

As they point out while ignoring their own ignorance:

“Gender and sexual diversity was suppressed by colonial administrators and has often been forgotten, creating the impression that it never existed.”

The Museum anathematizes colonial administrators while falsely claiming diversity itself.

For the record, lots of intersex people identify with the LGBTQ acronym, yet it is clear from the Museum’s stance on this controversial decision to exclude the I or the + from the acronym and their failure to mention the words Intersex, Non-binary or Transgender to speculate on possible identities speaks volumes about how these areas of our society are regarded currently by the British Museum.

Recently, the artist Ela Xora and other supporters around the world protested as it was revealed last year that (to quote directly from the Artlyst article): “religious curators in Cambridge Museums banned ancient non-binary deities like Hermaphroditus and Cybele because their bodies “were not fit for public viewing”, as well as covering naked statues in sheets when certain religious groups of children visit. The worlds most famous classicist Professor Mary Beard, issued a curt one word apology to intersex people for erasing non binary history within the Roman Empire at the University of Cambridge, after Xora publicly challenged her through a performance art piece called “Sleeping Hermaphroditus Hunger Strike”, which saw the artist reenact the most famous non-binary sculpture in the world for 8 days without food, until Professor Beard said “sorry!”. However like Lewis Hamilton, soon after apologising she began to ‘love’ tweets from her fans telling her not to apologise for hiding transgender and intersex history, including one which contained an image saying she should behave like a dog saying “If you can’t eat it or play with it, just pee on it and walk away”

Sadly this persistent attitude from scholarly figures and classicists insulates the ignorance we fight to overcome this oppression. 

As more and more intersex people and allies join the fight for greater understanding, we are all starting to realise the need for an end to the harmful non-consensual, un-necessary medical surgeries and procedures performed on intersex children in order to cosmetically define their body’s into the male/female binary. Intersex people born with variations of sex characteristics have a right to be treated like any other human being, with dignity, respect, and accuracy. It is why we now ask the British Museum to adopt a new perspective on how it records and displays its inventories; this fine, leading institution of world knowledge should fully examine the details of our past, so that we can present the truth fully to the many generations of our future.

You have 8 million items in your inventory, you display 80 thousand. The worldwide estimated population of intersex people is almost 2%. Surely we need to be seeing more than 5 intersex items on display amongst the 80 thousand exhibits, if you apply my non-maths-person, simple ratio.

Please, British Museum, join the campaign for awareness. That’s all that we ask. 

(Link to British Museum online gallery listing ‘representations of Hermaphroditos)

Final note:

The Museum explains in its LGBTQ pamphlet:

“The Museum is beginning to update its collections database so that objects with an LGBTQ connection are more easily identifiable, and language used is more suitable and relevant. Please share with us your own selection of objects from the Museum that you feel have an LGBTQ connection. Help us with our ongoing exploration of LGBTQ narratives in the collection by sharing your thoughts and images using #LGBTQ_BM.“

If you agree that our Human history deserves honest visibility, please retweet/share/Tumblr-ize this post with the #LGBTQ_BM hashtag and let’s all try and affect change where it’s needed. 

[artedemiparte]

Cantinflas & Mapy Cortés in Mexico : "Mexican Moods" ~ 1943 US Office of InterAmerican Affairs from Jeff Quitney on Vimeo.

"Describes various aspects of Mexico, including the celebration of Mexico's admittance to the United Nations, silver making in Taxco, airports throughout the country, Aztec ruins and rituals, and Mexican comedian Cantinflas." Also features Mapy Cortés.

Originally a public domain film from the Library of Congress Prelinger Archives, slightly cropped to remove uneven edges, with the aspect ratio corrected, and one-pass brightness-contrast-color correction & mild video noise reduction applied. The soundtrack was also processed with volume normalization, noise reduction, clipping reduction, and/or equalization (the resulting sound, though not perfect, is far less noisy than the original).

en.wikipedia.org/wiki/Cantinflas Wikipedia license: creativecommons.org/licenses/by-sa/3.0/

Fortino Mario Alfonso Moreno Reyes, although he called himself Mario Moreno, (August 12, 1911 -- April 20, 1993), was a Mexican comic film actor, producer, and screenwriter known professionally as Cantinflas. He often portrayed impoverished campesinos or a peasant of pelado origin. The character came to be associated with the national identity of Mexico, and allowed Cantinflas to establish a long, successful film career that included a foray into Hollywood. Charlie Chaplin once commented that he was the best comedian alive, and Moreno has been referred to as the "Charlie Chaplin of Mexico". To audiences in the United States, he is best remembered as co-starring with David Niven in a Golden Globe Award-winning role in the 1956 film Around the World in 80 Days.

As a pioneer of the cinema of Mexico, Moreno helped usher in its golden era...

Moreover, his character Cantinflas, whose identity became enmeshed with his own, was examined by media critics, philosophers, and linguists, who saw him variably as a danger to Mexican society, a bourgeois puppet, a kind philanthropist, a transgressor of gender roles, a pious Catholic, a verbal innovator, and a picaresque underdog...

en.wikipedia.org/wiki/Mapy_Cortés

Mapy Cortés (March 1, 1910 -- August 2, 1998), born Maria del Pilar Cordero in Santurce, Puerto Rico, was an actress who participated in many films during the Mexican film industry's golden era. Contrary to popular belief, Cortés was not Mexican; she was Puerto Rican, but she adopted Mexico as her residential country from her youth and almost until she died...

Biography

Mapy Cortés began experimenting as an actress since an early age, working in various Puerto Rican radio shows, with lukewarm success. Never considered a superstar, glamour girl, or actress of merit, she was a beloved fan favorite.

During the early 1930s, Cortés decided to look for fame in other places, and she arrived in Mexico, where she met and married the already famous Puerto Rican actor and producer Fernando Cortés who had already adopted Mexican citizenship. This marriage proved to be a blessing for the Puerto Rican actress, both romantically and professionally speaking. By 1933, Mapy Cortés participated in the first of over 50 films she would make in Mexico and in Puerto Rico. Her film debut was in a movie named Dos Mujeres y un Don Juan (Two Women and a Womanizer). By the time this movie was released, Cortes had a nephew, Paquito Cordero, who himself became a legendary figure in Puerto Rican show-business...

The Cortés couple became a phenomenon across Latin America, when, after 1940, they set out to film movies in practically every Latin American country... Cortes, who was also a comedian and a musicals actress, parlayed her acting career into a singing one, recording various albums while still active as an actress. In 1944, she participated in La Picara Susana (Mischievous Susan), followed by 1945's La Corte del Faraon (Pharaon's Court).

The Cortés family spent much of the 1950s making movies and participating in a television show in Puerto Rico. Mapy and her husband Fernando returned to the island and presented an idea for a comedy show to Ángel Ramos, owner of El Mundo Enterprises. On March 28, 1954, Puerto Rico received its first television transmission from Angel Ramos' WKAQ-TV Telemundo Channel 2. The first comedy show to go on the air was "Mapy Y Papi" which also included Maria Judith Franco and Paquito Cordero.

... Her niece Mapita Cortés, also born in Puerto Rico, became a renowned telenovela actress in Mexico.

After Fernando Cortés died in 1982, Mapy Cortés led a relatively quiet life, without getting involved in many scandals or public activities.

She died at her home in Puerto Rico in 1998, of a heart attack...

[newstfionline]

The maligning of early Christianity

Pascal-Emmanuel Gobry, The Week, June 12, 2018

Christianity is, if nothing else, one of the most successful cultural phenomena in all of human history, and still powerfully shapes the world. But in many ways, this is happening reactively in much of the secular West, where a major plank of the Enlightenment sought to use history to show that Christianity represented a steep decline in our history.

This anti-Christianity revisionism is basically political propaganda. As George Orwell pointed out so masterfully, you can change how people think if you can change their vocabulary. A term like “the Middle Ages” is meant to imply that a thousand years of European history was basically just an ellipses between antiquity and “the Renaissance,” a loaded term if there ever was one, when it was only the “rediscovery” of ancient Greek and Roman philosophy--which had been suppressed by fundamentalist Christians--that enabled the start of a “new age” of “rationality” and “free inquiry.” Even if we didn’t pay much attention in history class, we’re all familiar with this narrative, because it’s everywhere. The ancient world, we are told, was tolerant, open-minded, and believed in philosophy and free inquiry, and the advent of Christianity ruined all of that.

You can find this narrative in countless works of popular culture. The latest salvo is a book by the historian Catherine Nixon whose title, The Darkening Age, speaks volumes. As a review in The New York Times puts it, Nixon casts the early Christian church as “a master of anti-intellectualism, iconoclasm, and mortal prejudice.”

I hope I don’t have to spell out the political advantages that this narrative can have today. Too bad it’s wrong.

Take the ancients’ supposed open-mindedness and pursuit of rational inquiry, and Christians’ supposed anti-intellectualism. The fact of the matter is that in the ancient world educated Christians were just as enamored of scholarship and philosophy as anyone. The early Christian writers spoke of the spoliatio aegyptorum, which meant the use of concepts from pagan philosophy in Christian theology, which they did avidly and gratefully. Stories of early Christian mobs attacking pagan sites are used to portray fanatical Christianity crushing whatever opposed its “dogmas.” But pagan mobs attacked Christians too. And let’s remember that Christianity was illegal, and that these mobs were often incited and abetted by Roman officials as a convenient way to put down those unruly Christians.

What of scientific inquiry? The idea, again, that ancient society had any sort of commitment to open scientific inquiry and that the Christians did not is false. Most historians today admit that the Romans were pretty much stagnating technologically by the time Christianity came on the scene and that there was very little scientific progress in the intervening centuries. Scientific progress started accelerating in the Middle Ages. Building a cathedral would have been just as out of reach of the Roman Empire at its height as building a moon rocket.

And what of the supposed open-mindedness of pagans when it comes to sex, which contrasts with Christians’ much-mocked prudishness? I think this one takes the cake. Did the pagans have orgies? You bet they did. But people typically forget to point out that in those merry occasions depicted in Roman art, the women would typically be slaves. Indeed, buying, selling, and renting slaves for sex was absolutely legal, and not even frowned upon--including that of children--and was therefore done on an industrial scale, in a society with permanently skewed sex ratios due to gender-selective infanticide.

Did Christians “impose their beliefs” when they got into power? Yes. For example, one of their first acts was to ban the use of slaves for sex. As a Christian, somehow, I don’t feel shame about that. Did Christian mobs deface pagan statues and monuments? Absolutely, yes. In the ancient world, pagan religion represented an entire social order that sanctioned all kinds of terrible things. It’s not hard to imagine why someone might want to deface a statue or two. I wish they hadn’t, but it’s not exactly monstrous that they did.

Remember that early Christianity did an awful lot of good, too. It created the first organized welfare system in all of human history, enabling the poorest and most destitute in Roman society to lead lives with dignity. Christians paid widows pensions, in a society where unmarried women had no rights and widows (of which there were many) were forced to remarry or face destitution. Other notable innovations of the early Christian church included the first schools (for children whose families could not afford private tutors) and the first hospitals (for those who could not afford doctors). They had to build all these things because they believed in serving the poor and pagans did not.

Christianity was indeed a rebellion against a lot that the ancient world stood for, in particular paganism, which suffused through the social order. Society was dominated by the idea that the entire cosmos was essentially a celestial hierarchy, ruled by fate, with the hierarchy of gods, also bound by fate, up top, and free male citizens somewhere in the middle, and everyone else below. And that any violence, any cruelty, in the service of this order, or by those higher up against those lower down, was basically fine.

Did Christianity “destroy the ancient world”, as the Times review of Nixey’s book has it? My first thought is “not enough.” Sadly, Christianity in its early centuries did not destroy cruelty or evil, which would continue to haunt it throughout its history, as we all well know, but instead only the belief, which lay at the heart of pagan philosophy and religion, that cruelty and evil is right and proper. I, for one, don’t have a problem with that.

[samanthaviolet]

your final paper

I took a history of american television class in the spring, and after turning in my final paper, my TA emailed me with an email whose subject was “your final paper.” My heart sank as I opened an email that I was sure was going to be bad news, and she said something along the lines of how she was super impressed with it and that if I wanted to get it published, I probably could. 

now, I don’t know how valid that is, nor do I care too much to go into the detail of how to achieve actual, real life publication. But, i do know that I can copy and paste it here, and that throws it out into the world and reaches the potential that Victoria saw in me. 

This one’s for you, Vicki. 

LADIES WHO LAUGH: Exploring Feminist Progress in Saturday Night Live 

“Live from New York, it’s Saturday Night!” These seven words explode from the mouths of varied celebrities and comedians at 30 Rockefeller Center into the homes of millions across the nation, always at the same time each Saturday night. Saturday Night Live, the late night sketch comedy show created by Lorne Michaels and produced by NBC (commonly referred to as SNL), has been entertaining audiences since its premiere in 1975. With over thirty years of sketches, political commentary, and social spoofs, the show has been a breeding ground for discussions on representations in the world and workplace, specifically with regards to gender. Through an analysis of casting and a variety of show content, this paper will prove Saturday Night Live’s reflection of the women’s movement, effectively portraying women’s changing societal roles during the thirty-two years it has been on the air.

The format and structure of Saturday Night Live has stayed relatively in tact from the first episode to present day. Having a show primarily driven by the cast, beginning with seven members and getting all the way to sixteen by Season 42, an additional celebrity host appears on each episode. The ratio of male to female cast members is fairly close (in fact, they made it a point from the beginning for it to be equal among the genders, even though they have strayed from this ideal in recent years), but the number with regards to the hosts is startling and gives a good insight on which gender mainstream audiences. Over the forty years of SNL, there were 370 men as hosts and only 175 women (Baskin). Women have always been seen as the outcast with regards to entertainment, especially comedy, and this statistic proves that SNL was not doing much to break that. They had to give the people what they wanted in order to keep their ratings up, and instead of using their platform for good, they used their platform to perpetuate the inequality of women in entertainment.

These gender dynamics are not only seen on stage, but in the writer’s room as well. Saturday Night Live organizes the content of its show on a week-by-week basis — pitches happen on Mondays, table reads happen on Wednesdays, and material that worked from these move on to the shows on Saturdays. The weekly process weeded out all the ideas until only the best remained for the live airing on Saturday night. For sketches to proceed to the actual show, they had to be “funny in the room.” The problem is, is that most of the people in the room were men. Doug Hill and Jeff Weingrad state in Saturday Night: A Backstage History of Saturday Night Live that “a lot of the women writers’ sketches weren’t making it on the air, and the women performers were getting too many secretary and receptionist parts, written by the men” (Murphy). The gender binary was alive and well in the writing room, but of course, it was alive and well in every aspect of professional work, even in the wake of second-wave feminism. This misogynistic environment wasn't actively being worked against, either. Original SNL cast member John Belushi is often cited with his claim that “women aren’t funny.” His stunts to get women off the show included sabotaging table reads and even pressuring executive producer Lorne Michaels. He also refused to appear in the sketches written by women writers (Miller). This attitude toward women existing, as well as being tolerated by network executives, dominated for most of SNL life in the 20th century.

From the beginning of the show, the male-dominated aura of production prevailed. Women, as stated before, were cast as receptionists, nurses, makers of the household, and waitresses. Besides their actual roles on the show, they were also commonly seen solely as the objects of the male cast members. A great example of this is seen in the recurring sketch “The Festrunk Brothers,” featuring SNL greats Dan Aykroyd and Steve Martin. In this sketch from the third season, debuting on September 24, 1977, the duo try to pick up two women played by fellow cast members. The lines they give to the women are outlandish and supposed to garner some laughs, but causes more of a head-turning reaction than they probably intended. After some small talk, they lead into, “You know, you American girls have such big breasts all the time! Well, I guess you must like us by now, so please give us the number of your apartment so we can go up and have sex with you right now.” The antics between the two pairs continue until the end of the sketch (Baskin). Of course, it leaves live audiences and the people at home laughing at the absolute ridiculousness of the interaction. But, why would it be acceptable to be saying that to a woman at all, especially on national television? In a textbook on arts analysis, scholar Mark Fortier defines feminist theory as “profoundly concerned with the cultural representation of women, sometimes as a strictly masculinist fantasy with no relation to real women, sometimes as the appropriation of women and women’s bodies to masculine perspectives” (Fortier 72). This sketch violated both of these ideas by simply having the women in the sketch portrayed as the object of the men’s desires. Until the turn of the century, this is what plagued the women of the highest rated comedic variety show since the inception of television. Women already have the lower hand with regards to their legitimacy on screen (in both television and film), and portraying them in this light does not lend itself to improving this situation.

By 2000, SNL was dealing with some low ratings and trying to keep the show fresh and interesting after 25 years on the air, and to combat this, they began to flip societal expectations. In 2002, Newsweek proclaimed: “For most of its 27 years, Saturday Night Live has been comedy’s premier boys club. But not anymore.” This sudden influx of women increased the amount of women performers seen on screen and the show was carried with show-stopping females. It led into the time of Tina Fey, Amy Poehler, Maya Rudolph, and Kristin Wiig, the women who have made names for themselves in the entertainment world, using SNL as a springboard. This is directly related to the increase of women and women’s power in the writing room (Murphy).

As the years went on, there was increase of women on the production side, which correlated to an increase and improvement of female representation on the performance side. While of course it wasn’t perfect, there were not only were more women included in the acts, but the way that they were represented did not always align with traditional gender roles. For the first time ever, there were sketches entirely comprised of female cast members, without leaning on the stability of a man. “The Women of SNL” parody sketch (spoofing The Real Housewives) is a 2010 special from Season 36 that premiered on November 1, 2010, featuring women cast members and alumni. Seeing a couch full of just women was a sight that was not commonly seen, and relying on each other for the comedic effect was particularly successful. The fact that this special could stand alone separate from the season speaks volumes. Even so, women had to fight to get on. For example, comedian Rachel Dratch (famous especially for her hilarious “Debbie Downer” persona) took multiple auditions to get on the show. After her first audition, she recounted that “I didn’t get it that year...they said, ‘we’re not taking any women this year. But maybe next year.” She got casted three years later (Itzkoff).

Reporters began to claim at the beginning of the 21st century that women had moved from “saucy sidekick to stand-alone stars.” Helmed as the “Tina Fey” era, this is when cast members such as Tina Fey and Amy Poehler began to be known as the faces of the show as a franchise, both on screen and off screen. Here is when sketches such as “Debbie Downer” and

“Target Lady” became recurring, and women sketches took up a bulk of the program time. Another big marker of women’s progression on Saturday Night Live was the addition of female anchors on the weekly segment “Weekend Update.” A spoof on current events, “Weekend Update” features commentary and satire in the middle of each episode, usually led by a male cast member who is presented as themselves (rather than as a character). Jane Curtin was the first female anchor in the second season of the show. While it was great that she was at the desk, the treatment she received from aforementioned John Belushi contradicted any kind of advancement that the presence of a woman created. Belushi would scream and raise fists in the air, telling Jane to calm down. Of course, the famous phrase “Jane, you ignorant slut!” proclaimed by co-star Dan Ackroyd resulted from her stint on “Weekend Update” during an episode premiering on May 26, 1979. Lorne Michaels did nothing to stop these slanderous and misogynistic ad-libs. In an interview with Curtin, she stated, “Lorne didn’t help, because that isn’t what Lorne did. Oh, it was ridiculous. It was just insane...you just have to learn to live with it, [and] plod on” (Miller). After Curtin’s departure in 1980, a woman didn’t sit behind the desk until twenty years later, with Tina Fey’s addition in 2000. In the beginning of Tina Fey’s reign as “Weekend Update” anchor (co-anchor with Jimmy Fallon), there was a part of the segment entitled “Women’s News,” in which Fey commented on issues such as reproductive rights and women’s roles in the home and at work (this is seen in a Season 28 episode from 2002). This direct dealings with issues of women was a direct result as Fey’s appointment of head writer. The progress of Tina Fey’s work on “Weekend Update” compared to Jane Curtin’s shows the amount of progress that SNL took in the women’s movement on television.

Broadly looking at television in the 1970s, the medium was struggling itself with its identity just as the female population of the United States was. As Kirsten Lentz says in her essay, “Quality versus Relevance,” “If 1970s feminism, broadly speaking, sought to champion the ‘rights’ of women, drawing attention to the inequities of gender role socialization and attempting either to revalue or to eschew femininity, 1970s television was similarly enmeshed in an attempt to resist its inferior status in relation to other media (especially cinema) and to revalue or reverse its associations with femininity... Scholars of television and feminism have tended to assume that the relation between the television industry and the feminist movement is primarily a negative one. According to this model, television has generally acted to distort, trivialize, or erase feminist issues and the women’s movement” (Lentz). However, as time goes on, to its credit, Saturday Night Live did do a lot to help progress the movement. Seeing women on TV and talking about women’s issues became a normal thing for the American household, making the feminist movement less of a political craze and more of something that every citizen can take part in. And this quality is what makes SNL so popular and a show that hasn’t gotten old for the forty plus years it has been on air —it reflects an ever changing society and challenges old- school ways of thinking.

However, that’s not to say that Saturday Night Live is perfect in the representation game by any means. Minority women, especially LGBTQ women and African American women in particular have always faced adversity in the entertainment industry, and Saturday Night Live has not properly used its platform and clout to change this. In its entire history up until 2013, there have only been four African-American women featured. After Maya Rudolph’s departure in 2007, there were none. Long-time cast member Kenan Thompson has had to cross-dress to impersonate several women, from Maya Angelou to Jennifer Hudson. In an interview with TV Guide, Thomspon made statements refusing the show’s request to portray black women, hoping that his resistance would prove to the network that advancements have to be made. Sasheer Zamata being hired was the first African American to be hired since Rudolph, and still stands as the only African American woman on the show today (Weisman).

By analyzing Saturday Night Live with a feminist lens, viewers can view the show as a program that did a lot for women in the entertainment industry, yet still is not reaching its full potential in what it can do for women as a whole. Women will always have the lower hand in regards to equality in entertainment, however, seeing the progress in the past gives hope that it will continue to improve, on Saturday Night Live and beyond.

[juditmiltz]

Bridging the gender divide in commercial real estate

Barbara Liberatore Black’s rise to managing director of JLL’s South Florida office was not an easy one. Currently the only female executive in her office, Black was also one of the first women in commercial real estate in Miami.

She got her start doing tenant representation for Julien J. Studley Inc., the precursor to Savills Studley, in 1981. “I was the only female tenant adviser for years,” Black said. Before securing that gig, she’d tried to get her foot in the door elsewhere, to no avail. 

“If you were a man today, I would hire you,” an interviewer told her, reasoning that as a woman who was going to get married, she wouldn’t have the time for the job. Instead, he offered Black a secretarial position. She turned it down.

Times have clearly changed, but in the wake of the allegations of sexual harassment and assault by Harvey Weinstein — and the many similar charges against high-profile men that followed, including starchitect Richard Meier — several, if not all, industries are facing profound questions about company culture and fairness.

However, many women in South Florida’s commercial real estate industry are not seeing a major push to close the gender gap. They say the #MeToo movement hasn’t kicked off the kinds of productive conversations it was intended to inspire. Rather, many male colleagues are “now afraid to say hello” to women, Carol Brooks, co-founder of the brokerage Continental Real Estate Companies (CREC), said. “It’s coming more from a place of their own self-preservation. It’s interesting to see how men are reacting; it’s more fear than compassion or anything,” she said.

The Real Deal examined the male and female representation of agents working for South Florida’s top five commercial brokerages (determined by the dollar volume of sales and leases as reported by the South Florida Business Journal) by analyzing broker license data filed with the state as of Feb. 23. Marcus & Millichap had the lowest percentage of female agents in the tri-county region of Miami-Dade, Broward and Palm Beach counties, with 18 percent.

Lori Schneider, senior managing director of investments at Marcus & Millichap, said she thinks the firm has fewer women than the others because the company focuses only on investment sales, which takes time and money “until you establish yourself.” Women typically have less of both than men, she said. Leasing, on the other hand, often provides agents with a crucial base salary.

CBRE had the highest percentage of women agents, with 39.8 percent, and JLL closely followed with the second highest representation of women, 38.6 percent, according to TRD’s analysis.

Both CBRE and JLL recently won industry awards for their gender inclusion. CBRE, where three of the firm’s board members are women, received the Diversity & Inclusion Award from the Mortgage Bankers Association in February. In March, JLL was named one of the National Association for Female Executives’ “Top Companies for Executive Women.”

CBRE and JLL’s numbers of female brokers in South Florida are better than national averages. The Commercial Real Estate Women (CREW) Network Benchmark study conducted in 2015 — the most recent data set of its kind that’s available — showed that only 23 percent of leasing and sales brokers in the U.S. were women in 2015. But that number was up from 20 percent five years earlier. Between 2010 and 2015, women went from representing 32 percent of the total commercial real estate workforce to 36 percent nationwide. The subsector with the highest concentration of women was property management, with 51 percent of the asset, property and facilities management workforce female, up from 47 percent in 2010.

And while the CREW research found that women made 23.3 percent less than men in the field in 2015, all of the women contacted for this story had a different experience. Female brokers said that because most positions are commission-based, the wage gap isn’t much of an issue. “The good news about that is a woman who is driven can be equal or better [than a man], and she will get paid,” Black said. “I think this is one of the few careers where women get equal pay.”

The achievement gap

Although there’s been progress in overall male-to-female ratios, the gender gap is still quite vast when it comes to women in leadership positions. CREW’s 2015 study found that only 9 percent of the women who were surveyed held executive roles, compared to 17 percent of the men who participated in the study.

The industry is also facing an aspirational gap between men and women. Forty percent of men surveyed by CREW said they wanted C-suite positions compared to only 28 percent of women. And once men had between six and 10 years of experience, they rose through the ranks at a faster pace than women, the report found.

“Men are much more vocal than women. When you don’t speak up and you don’t ask for the job, you don’t get it,” said Sara Hernandez, president of CREW-Miami.

  Women developers are also lacking in the industry because the field requires a track record and capital, said Avra Jain, a commercial developer in Miami’s MiMo, Little Haiti, Miami River and Overtown neighborhoods.

“When I first came down to Miami [17 years ago] and I walked into a meeting to buy a piece of property, the broker kept talking to the man next to me,” Jain said.

The perils of after-hour events

“‘Welcome to the company. I Googled you hoping to find some bikini shots online,’” Pauldine France, vice president of strategic investments at FIP Commercial, recalled a man saying on her first day at a new job. “I once had a COO I ran into at a party who was trying to get me drunk to take me home. His wife was at the same party,” she added.

Most women in the industry who were contacted for this story agreed that there’s been some progress in hiring more women, but the presence of some bad actors remains a big issue.

France got her start in 2003 as a brand ambassador for Tony Cho when he launched Metro 1 Properties. She was later a financial adviser at Morgan Stanley, then worked for Shawmut Design and Construction in New York, Thor Equities in Miami and, more recently, spent a year working for RKF, also in Miami.

France is, as she describes herself, a “six-foot-tall black chick with green eyes.” She’s faced more than her share of unwanted attention, she told TRD. “I’m used to people looking at me. In commercial real estate, I am a unicorn of a unicorn,” she said. “I’ve had inappropriate, ‘let me take you home’ comments.”

The necessity of after-hours networking doesn’t help things. Going to nightclubs, strip clubs and bars is still a way to get deals done in Miami, sources said. There’s also still a lot of golfing.

“Half of these guys just want to party, and the business facilitates partying” said Mika Mattingly, executive vice president of Colliers International South Florida.

Some women push themselves to head to the golf course or boozy networking events even when it’s uncomfortable. CBRE’s Carol Ellis-Cutler, first vice president of advisory and tenant services in Miami, attended a conference earlier this year where she was one of a handful of women out of a crowd of 800. She later attended the golfing event, where she was the only woman — alongside 32 men.

However, Ellis-Cutler and Arden Karson, senior managing director of CBRE South Florida, both said they also use their gender to their advantage. “Being the only woman at the table, they love that,” Karson said, referencing her male colleagues. She squeezed her way into a dinner during a CRE Finance Council event because she wanted to do business with the group.

“I was the only woman out of 20 people, and they all wanted to sit with me,” Karson said, noting that the extra attention she received was not inappropriate. The men, she said, just wanted to speak to a woman because it was “a refreshing change.”

Men can be more inclined to share information with women, some female brokers said. But that too can have its downside. There’s a fine line between being “approachable and nice” and being “firm,” France said. “You have to deliver this coolness while still keeping that meter stick in front of them,” she said. “Nine out of 10 times, ‘super cool’ can become ‘I can make comments about your new push-up bra.’”

Mentoring the next generation

When considering ways to resolve some of these murky issues, many women said that mentoring a new generation of female brokers is the most important work that needs to be done. And South Florida’s a good place for that: A number of women in leadership roles in commercial real estate own their own companies or work for women who do.

Brooks, of CREC, got her start working in the corporate real estate lending department at Southeast Bank and moved on to the Continental Companies, where she was director of the commercial office leasing department. In the late ‘80s, she considered working at other brokerages and said, “Screw that, I’ll start my own company.”

At that company, a boutique commercial firm she co-founded with Warren Weiser, 51 percent of its 120 employees are female. Two of its six partners are women, and half of its department heads are women. More than 60 percent of CREC’s property managers are women, and 26 percent of the company’s brokers are women. “There are just such high barriers to entry otherwise, so we’ve created our own system,” Brooks said.

Her approach to nurturing female talent development has paid off in the eyes of Sabrina Stimming. Brooks mentored Stimming, who started as an executive assistant and was promoted to marketing assistant, then marketing director. An opening appeared in retail leasing, and now Stimming is director of retail leasing and a partner at CREC. She believes that had she started her career at a traditional brokerage like a CBRE, “it’s probably not likely I would be a head of a department there.”

“If you look around at other firms in our industry, the only women you see in any sort of leadership positions are women who form their own companies,” Stimming added.

Without a mentor, Collier’s Mattingly developed her own strategy for success that many women in the industry adopt: Be the best at the job. She’d pick a neighborhood or area and become an expert on it. “I picked Sunset Harbour, which I liked at the time, and I farmed the fuck out of it,” she said. 

From Metro 1, where Mattingly started in 2006 as a commercial associate, she went to Sterling Equity Commercial, where she’d “transact all day off-market, but no one would trust me with big listings.” She eventually represented Moishe Mana in nearly all of his acquisitions in downtown Miami’s Flagler District, which to date has totaled $267 million on 1 million square feet of building space and eight acres of land.

In 2016, Mattingly joined Colliers and is building her team out of an office in downtown Miami. Although it’s not her own company, it’s clear that she’s running her own operation out of the ground-floor retail space on Flagler Street. She said she’s teaching her team to become neighborhood experts, as she did, by learning every property and zoning before they start selling.

Tere Blanca, founder, chairman and CEO of Blanca Commercial Real Estate, also wants to nurture female talent. She left Cushman & Wakefield to start her own firm in 2008 and is responsible for mentoring everyone in the 22-person office, including a few female agents. In her view, the lack of women in the field may stem from them just not knowing about it. “I don’t think a lot of young women understand the opportunities that exist in the industry,” she said.

Ellis-Cutler and some of her colleagues at CREW-Miami introduced themselves to a group of high school girls by telling them, “We don’t sell single-family homes. We can sell the entire multifamily building.”

CBRE created its Women’s Network in 2000; it now has 3,500 members nationwide and hosts quarterly events. The gender gap at CBRE and other major commercial brokerage persists, but Karson acknowledged that the firm’s numbers are going up.

Forging ahead

While women in commercial real estate today see some struggles and disparities, JLL’s Black said the industry has grown to include more women since she got her start in the early ‘80s. “The one thing I’ve noticed is that women feel more empowered to say to their peers or their managers, ‘Hey, that was an off-color joke’ or ‘I didn’t really like the way you said that about me.’ Women are using their voice now to explain that it’s not right,” she said.

However, Black sees two areas where female representation is lacking: tenant advisory and capital markets, both of which are especially profitable sectors of the business. “That’s predominantly still occupied by men, but in time that will change,” she said.

Jain is also optimistic about closing the gender gap in development.

“We’re starting to see more women take on those roles within their families and more women who want to be developers,” Jain said.

from The Real Deal Miami https://therealdeal.com/miami/issues_articles/bridging-the-gender-divide-in-commercial-real-estate/#new_tab via IFTTT

[kristinsimmons]

The Evidence Crisis: Causal Inference – Don’t be a chicken (Part 3)

By ANISH KOKA

Part 1

Part 2

Physicians have been making up numbers longer than people have been guessing weights at carnivals.  How much does this statin lower the chances of a heart attack? How long do I have to live if I don’t get the aortic valve surgery?

In clinics across the land confident answers emerge from doctors in white coats.  Most of the answers are guesses based on whatever evidence about the matter exists applied to the patient sitting in the room.  The trouble is that the evidence base used to be the provenance of experts and anecdotes that have in the past concluded leeches were good for pneumonia.

And so came the randomized control trial to separate doctors from homeopaths.  Random assignment seeks to achieve balance between two groups for everything but the treating variable to isolate the effect of the treatment.  But does randomization really guarantee a balance between groups?  At least the known confounders may be measured in the two groups, but what about unknown confounders?

Consider some examples:

Blood stream infections are currently treated by antibiotics targeted towards the specific organism found in the blood.  The distribution of organisms within the blood stream is as follows:

Vancomycin is active against S.aureus, Coag Negative Staph (CoNS), and other gram (+) organisms.  Cefepime is active against Gram negatives.  Now imagine a world where there was no understanding of the different organisms that caused blood stream infections, and an earnest researcher seeking to do right by patients with blood stream infections ran a trial which randomized all blood stream infections to either Vancomycin or Cefepime.  In the beautiful table that would accompany the published article to demonstrate balance via randomness of age, sex, gender and perhaps some type of frailty index, the most important factor – the type of organism – would be missing.  What we don’t know in this case drives the outcome.  A trial with a high population of homeless patients could have a very different distribution of organisms than a trial performed in suburban patients in the rich Mainline of Philadelphia.  The inability to generalize a trial of mainline moms to other populations means a trial fails to have external validity.  There are other problems as well.  Perform a large trial that combines the homeless with suburban soccer moms and the average treatment effect loses meaning unless you are a clinician that may randomly take care of a mainline mom or a homeless person on any given day.

But if we knew of this difference in organism prevalence between populations prior to trial initiation, and an analysis of these groups was prespecified, at least there is hope.  Our statistical friends could then very easily account for the difference at the end of the study.  But what if we were unaware of this difference?  We would then have to hope that randomization ensured that unknown confounders spread themselves similarly between the two groups.   Statisticians, interestingly, are unconcerned about the spread of unknown confounders between two groups.

A game of dice

Stephen Senn, the grand emperor of statisticians famously explains this using a game where 2 fair six sided dice are thrown, and the observer is asked to guess the probability the sum of the die will be 10 under three conditions.  In the first condition we are asked to guess the probability of this as the two dice are thrown.  Since there are only three out of thirty six combinations that will work (4/6, 5/5, 6/4), the probability is 3/36, or 1/12th.

In the second condition, the first dice is cast and the number revealed prior to guessing.  In this case if the first die roll is 1, 2 or 3, the probability of getting a 10 is zero.  But if the first die cast is a 4,5 or 6 the probability of a 10 is 3/18 or 1/6.   In the last condition (Variant 3), the first die is cast but the observer is not told what the number is.  Since we don’t know what the first die roll is, the probability here is the same as the first condition.

The moral of the story, Senn tells us, is that we should not throw knowledge away once attained (we can’t and shouldn’t pretend to unsee the roll of the first die), but not knowing doesn’t create a fatal problem because the probability distribution of an outcome is the same whether there is an unknown confounder or not.  So covariates/confounders that could have an effect don’t really have to be balanced between the two groups as long as the distribution of the outcome in the two groups is the same.

This sounds good, but to return to the blood stream infection example, this is like saying that it doesn’t matter what the distribution of vancomycin susceptible organisms were between two groups as long as we don’t know the distribution of organisms.  Statisticians get frustrated with this line of reasoning from ‘algebra challenged’ physicians.  I sympathize.  I’m frustrated with statisticians that are ‘medically challenged’.

Regardless, we have to operate and deal with what we don’t know in the real world, and the point that I gather from Senn is that it is always better to know, but if you don’t know, randomization is your best bet to getting at the truth.  It would also seem that randomization is the best chance for an even distribution of unknown confounders between groups.

Unfortunately, even with all of this a perfectly balanced RCT is no protection to falling prey to false inferences.

Purposeful blindness

Consider the real life case of strokes and patent foramen ovales (PFOs).  PFOs are small congenital connections between the right and left atrial chambers of the heart that persist in ~25% of adults.  In the fetus, this connection is a vital conduit that allows the immature, nonfunctioning lungs to be bypassed.  In adults, this connection closes, and the lungs become not just the oxygenator of the body, but also serve as a filter for little clots and debris that frequent the venous circulation.

As our ability to see this connection developed with the advent of ultrasound, clinicians began to report cases of blood clots transiting through this connection from the right heart to the left heart.  This is a problem because the left heart pumps 1/5th of its blood volume to the brain, and so a cerebral embolism (or stroke) is the feared complication of clots that find their way into the left heart.  When a much higher proportion of patients than expected (40%) with uncertain causes of stroke were found to have a PFO, clinicians suspected these conduits as the cause of the stroke.

In response, cardiologists began closing these connections via catheters that delivered ingenious little double umbrellas to the heart.  Unfortunately, as the experience with these devices closures grew, it turned out that there were possibly other causes of stroke in this population.  Closing a PFO in someone who had a stroke because of a certain type of arrhythmia of the heart made the device company that sold the closure device happy, but did precious little else.  Three randomized control trials comparing PFO closure with medical therapy were carried out to test the prevailing strategy of PFO closures – CLOSURE 1, PC, and RESPECT.

All three were negative trials.  The prevailing wisdom suddenly became that there was no evidence that PFO closures worked in preventing recurrent strokes.  The American Academy of Neurology even put out a position paper arguing against PFO closures. Yet, I read the same trials and arrived at very different conclusions.  There were major issues with the trials that explained the negative results to me.  The CLOSURE 1, and PC trials included patients with Transient Ischemic attacks (TIAs).  For those who don’t know, TIAs are brief neurologic episodes that don’t last long enough to be considered a stroke.  Numbness and tingling on one side of the face could be a TIA, or it could be nothing.  Subjectivity reigns even among neurologists about this diagnosis, and it seems imminently plausible that many of the patients enrolled in these two trials had PFO closures for events that may not have been neurologic.  These first two trials also included patients with lacunar strokes – small strokes that could be a result of hypertension, high cholesterol or advanced age rather than embolism of a clot.  The last trial of this initial set of three studies -the RESPECT trial – sought to rectify the errors of its predecessors by excluding TIAs, and lacunar strokes.  They also sought to analyze the risk of stroke as it related to the size of the PFO.  Not all PFOs are equal – some are very small defects that only allow a minimal passage of blood, while others are much larger conduits.  The reasonable presumption was that most of the benefit to closing PFOs came from closing the large PFOs – the subset analysis would allow an analysis of this potential heterogenous treatment effect.  Strictly speaking, the RESPECT trial was a negative trial – another disappointment.  No statistically significant difference in was found between the PFO closure group and medical therapy group.

There were half as many strokes in the closure groups – 9 strokes in the PFO closure group, vs. 16 strokes in the medical therapy group.  But the trial was reported as negative because when comparing those assigned to the closure device vs. medical therapy, the hazard ratio crossed 1, and the p value was a little over the magical and somewhat arbitrary 0.05 threshold.  The analysis also took the form of the conventional ‘Intention To Treat (ITT)’ where patients are analyzed based on their initial assignment rather than the treatment that was ultimately received.  While this is statistically pure, it does not account for the fact that 4 patients who suffered a stroke after being randomized to a PFO closure device had a stroke while waiting to receive the device.

Effectively, the four strokes were ‘blamed’ on the PFO device.

RESPECT Trial Outcomes

One common explanation for analyzing by ITT is that ITT may best simulate the real world effect size when clinicians assign patients to a certain treatment.  While that is possible, it could also be that clinicians respond to this data by placing closure devices more expeditiously.   Not counting the four strokes that happened before the closure device was placed, (also called as treated, or the per protocol analysis) the numbers (5 vs. 16) did reach statistical significance.  Also not reflected in the yes/no world of clinical trial reporting in journals was the fact that of the 5 patients with a device that had a stroke, only one was considered moderate, or massive, compared to 9 in the medical therapy arm. Finally, the  subgroup analysis of the size of shunt, confirmed that the larger the shunt size, the higher the risk of recurrent stroke, and the greater the benefit of closure.

The other important point was that while closing the PFO may be an effective strategy to prevent recurrent strokes, blood thinners like coumadin to prevent blood clots from forming in the first place were another option supported by prior observational data.  The three initial RCTs had allowed participating investigators free reign with regards to choice of medical therapy in the medical arm – some chose antiplatelet drugs and others chose anticoagulation.  It seemed very unlikely  that closure devices could outperform systemic anticoagulation – yet another possible reason for the lack of effect of closure devices seen.

To me, the RCTs were helpful in confirming who likely had a small or no benefit to closure- patients with TIAs/lacunar strokes and small PFOs.  I wrote about the saga – and concluded that PFO closures were a good option in patients with large PFOs who had suffered a stroke and were loathe to be on blood thinners.

Much of the neurology community and many EBM experts ignored the subtext and focused on the lack of statistical significance.  Luckily, the clues readily apparent to me were also apparent to folks far more significant than me.  The longer term results of the RESPECT trial was enough to convince an FDA panel that despite the lack of statistical significance, there was a clear signal for clinical significance to merit approval of PFO closures for preventing cryptogenic stroke after a careful evaluation to rule out other causes of stroke.

But since we live in a world where no story is settled until an RCT is positive,  unbeknownst to me there were additional trials taking place to prove to the god of epistemology (currently a part-time oncologist in Oregon) that PFO closure devices were indeed beneficial.  In the Sep 14, 2017 issue of the New England Journal of Medicine – three RCTs were published.  One of the trials was a long term follow up of RESPECT that now showed a statistically significant benefit of PFO closures.  The two other trials were the GORE-REDUCE, and the GORE-CLOSE trial.  These latter trials enrolled mostly patients with large PFOs and strokes.  The GORE-CLOSE trial randomized patients to antiplatelet therapy only, PFO closure, as well as oral anticoagulation, while the GORE-REDUCE trial compared PFO closures to antiplatelet therapy.  Clearly the investigators had learned from the prior missteps, by focusing on larger PFOs, sidestepping the subjective nature of TIAs,  and mandating a treatment arm that consisted of antiplatelet therapy only.  Apparently there was clinical equipoise to do this.

Nonsense.

The RESPECT trial should have confirmed to those paying attention that patients presenting with a stroke and a large PFO should NOT be treated with antiplatelets only.  The only folks with equipoise here were those that were logically challenged or those that allowed EBM to suppress what should have been intuitive.  There was a price to pay for suspending logic.  In the GORE-CLOSE trial, which at least allowed for an anticoagulation arm,  14 patients in the antiplatelet group had a stroke, compared to zero in the PFO closure arm, and two in the oral anticoagulation arm.  In the GORE-REDUCE trial 12 patients had a stroke in the antiplatelet only arm, compared to six in the closure group.

So the positive signals gleaned from the original ‘negative’ RCTs had been on the mark.  The perfect balance of the known covariates in the trials had provided no protection against an erroneous inference.  As the subsequent positive trials demonstrated, the initial analysis that got it wrong wasn’t derailed because of unknown confounders, known confounders, poor randomization, or inaccurate average treatment effects.  It was a failure to ask why.

Bertrand’s Chicken

As physicians, it has become our practice to bring experience and personal observations together to allow us to doctor patients.  The fallibility of eminence and personal observations lead us to the realm of hypothesis testing and RCTs.  The idea was that adding this interlocutor would bring us closer to the truth, or at least result in fewer dead ends.   In reality we only ever had the illusion of a more certain truth.  It turns out that regurgitating the weekly New England Journal of Medicine conclusions fortified with p values may have been far less valuable than I thought as Ioannidis and others document.

Bertrand Russell, British philosopher, logician and mathematician wrote about these very same difficulties as it relates to the simple chicken.  The chicken bases what he expects on his experience.  Every day the farmer shows up and food appears.  To the chicken what happens tomorrow is based on the sum total experience of all the days before.  The chicken fully expects the farmer to come tomorrow with food because that has happened every prior day of existence.  Except tomorrow is the day the farmer arrives and wrings its neck.  The chicken got it all wrong.  Before scoffing too much at the chicken’s primitive way of thinking, consider that Russell started his chapter on the problems inherent with inductive inference by asking us to consider why the sun should rise tomorrow.  If your answer is because it has risen every day prior, you are guilty of chicken-headed thinking.

Unfortunately RCTs and null hypothesis testing would serve to advance neither the chicken’s search for the truth or ours, unless we ask questions that lead us to cause.  For this it is important to know why.  Understanding cause has little to do with what happens.  We reduce ourselves to chicken-headed thinking if our efforts are directed at what happened.  Chickens know what happened, what beasts of nature fail to understand is why things happen.  The analogy in medicine is to observe the initial PFO closure trials, note no statistically significant difference, and go no further.  This is chicken-headed.  Dive deeper, understand why the inclusion of patients with TIAs may have resulted in patients without cerebral embolic events being included.  Don’t dogmatically attribute strokes to PFO closure devices if they happen prior to the device being implanted.  And please don’t smugly discount the observations of thrombi transiting through PFOs into the left side of the heart, and the subsequent stroke that happened as true, true and unrelated.

Yes, biological models (leeches for bad humors) have been wrong, but don’t discount all future proposed models out of hand because of it.  By all means allow data in its many forms (case series, anecdotes, parallel control RCTs, adaptive design RCTs, etc. ) to modify, sharpen, or even discard a model.  But don’t give up on models, don’t give up on seeking out why, and please don’t listen to this guy –

Change medical school. Teach EBM first, pathophysiology later. Make students care about whether something does or doesn’t work before they care about why.

— Kenny Lin, MD, MPH (@kennylinafp) April 19, 2018

The common refrain from some quarters is that statistics has come a long way from Fisher’s t-test and the basic parallel controlled randomized control trial.  Different trial designs as well as methods to analyze randomize control trials post-hoc to account for some of the weakness discussed abound.  Bayesian statistics seeks to incorporate various priors – optimistic, neutral, skeptical – to arrive at a range of posterior probabilities.  I am sympathetic to the number crunching whiz kids earnestly trying to help us arrive at scientific truth by better parsing what the data tells us.  But it is a mistake to think that the heavy lifting needed to understand the recent randomized control trial comparing ablation for atrial fibrillation to placebo that had 30% of patients crossover to the treatment arm will come via instrumental variables or something that sounds even sexier.  The closest we can hope to get to the truth at any point in time will lie somewhere within the community of physicians managing patients with atrial fibrillation because they are best able to provide the context any one study needs.  And while this certainly introduces bias and subjectivity into the interpretation of results, it is neither possible or wise to eliminate this.

The move to strip biases, to fight instincts, to discard knowledge at times painstakingly acquired outside of the hallowed RCT construct is ultimately misguided.  The current crisis of evidence will not be soothed by analyzing data better, or by stripping the biases of clinicians.  The words of Bartlett as he explained his reasoning for proceeding with the ECMO RCT should be chilling: ” we felt compelled… we knew that 90% of patients assigned to the control group would die..”  It should have been enough for Bartlett to convince his peers in the intensive care unit of the value of what he was doing.  Statisticians, hospital administrators, and insurance carriers have no business demanding ‘higher’ levels of evidence here, in part because they are woefully unqualified to evaluate any evidence that’s even compelled to be produced.   The creation of clinical equipoise by statisticians who can never be certain of anything is a self defeating proposition.  Causal inference comes from searching for the why of it. If 200/10000 patients exposed to a certain meteorite are stricken with cancer, and only 10/10000 patients not exposed get the same cancer, the question that should consume the clinician and researcher is why this happened.  Why didn’t all 10000 patients in the affected neighborhood get cancer.  What could the underlying mechanism be?  Is there an activator of some kind common to the 200 unfortunate patients?  Do they share some genetic code that predisposes them to being stricken?  Not asking these questions, or proceeding with blinders on to test random treatments in a hundred RCTs lowers us to the level of chickens.  The less we think as chickens, the better.

  Anish Koka (@anish_koka) is a cardiologist in private practice in Philadelphia.  Many thanks to those who provided comments including David Norris (@davidcnorrismd), Saurabh Jha (@roguerad), and John Tucker (@JohnTuckerPhD).  Insights/examples gleaned from the wonderful works of Stephen Senn (@stephensenn ), William Briggs/Uncertainty. Errors in translation of concepts are solely the fault of @anish_koka.

The Evidence Crisis: Causal Inference – Don’t be a chicken (Part 3) published first on https://wittooth.tumblr.com/

[isaacscrawford]

The Evidence Crisis: Causal Inference – Don’t be a chicken (Part 3)

By ANISH KOKA

Part 1

Part 2

Physicians have been making up numbers longer than people have been guessing weights at carnivals.  How much does this statin lower the chances of a heart attack? How long do I have to live if I don’t get the aortic valve surgery?

In clinics across the land confident answers emerge from doctors in white coats.  Most of the answers are guesses based on whatever evidence about the matter exists applied to the patient sitting in the room.  The trouble is that the evidence base used to be the provenance of experts and anecdotes that have in the past concluded leeches were good for pneumonia.

And so came the randomized control trial to separate doctors from homeopaths.  Random assignment seeks to achieve balance between two groups for everything but the treating variable to isolate the effect of the treatment.  But does randomization really guarantee a balance between groups?  At least the known confounders may be measured in the two groups, but what about unknown confounders?

Consider some examples:

Blood stream infections are currently treated by antibiotics targeted towards the specific organism found in the blood.  The distribution of organisms within the blood stream is as follows:

Vancomycin is active against S.aureus, Coag Negative Staph (CoNS), and other gram (+) organisms.  Cefepime is active against Gram negatives.  Now imagine a world where there was no understanding of the different organisms that caused blood stream infections, and an earnest researcher seeking to do right by patients with blood stream infections ran a trial which randomized all blood stream infections to either Vancomycin or Cefepime.  In the beautiful table that would accompany the published article to demonstrate balance via randomness of age, sex, gender and perhaps some type of frailty index, the most important factor – the type of organism – would be missing.  What we don’t know in this case drives the outcome.  A trial with a high population of homeless patients could have a very different distribution of organisms than a trial performed in suburban patients in the rich Mainline of Philadelphia.  The inability to generalize a trial of mainline moms to other populations means a trial fails to have external validity.  There are other problems as well.  Perform a large trial that combines the homeless with suburban soccer moms and the average treatment effect loses meaning unless you are a clinician that may randomly take care of a mainline mom or a homeless person on any given day.

But if we knew of this difference in organism prevalence between populations prior to trial initiation, and an analysis of these groups was prespecified, at least there is hope.  Our statistical friends could then very easily account for the difference at the end of the study.  But what if we were unaware of this difference?  We would then have to hope that randomization ensured that unknown confounders spread themselves similarly between the two groups.   Statisticians, interestingly, are unconcerned about the spread of unknown confounders between two groups.

A game of dice

Stephen Senn, the grand emperor of statisticians famously explains this using a game where 2 fair six sided dice are thrown, and the observer is asked to guess the probability the sum of the die will be 10 under three conditions.  In the first condition we are asked to guess the probability of this as the two dice are thrown.  Since there are only three out of thirty six combinations that will work (4/6, 5/5, 6/4), the probability is 3/36, or 1/12th.

In the second condition, the first dice is cast and the number revealed prior to guessing.  In this case if the first die roll is 1, 2 or 3, the probability of getting a 10 is zero.  But if the first die cast is a 4,5 or 6 the probability of a 10 is 3/18 or 1/6.   In the last condition (Variant 3), the first die is cast but the observer is not told what the number is.  Since we don’t know what the first die roll is, the probability here is the same as the first condition.

The moral of the story, Senn tells us, is that we should not throw knowledge away once attained (we can’t and shouldn’t pretend to unsee the roll of the first die), but not knowing doesn’t create a fatal problem because the probability distribution of an outcome is the same whether there is an unknown confounder or not.  So covariates/confounders that could have an effect don’t really have to be balanced between the two groups as long as the distribution of the outcome in the two groups is the same.

This sounds good, but to return to the blood stream infection example, this is like saying that it doesn’t matter what the distribution of vancomycin susceptible organisms were between two groups as long as we don’t know the distribution of organisms.  Statisticians get frustrated with this line of reasoning from ‘algebra challenged’ physicians.  I sympathize.  I’m frustrated with statisticians that are ‘medically challenged’.

Regardless, we have to operate and deal with what we don’t know in the real world, and the point that I gather from Senn is that it is always better to know, but if you don’t know, randomization is your best bet to getting at the truth.  It would also seem that randomization is the best chance for an even distribution of unknown confounders between groups.

Unfortunately, even with all of this a perfectly balanced RCT is no protection to falling prey to false inferences.

Purposeful blindness

Consider the real life case of strokes and patent foramen ovales (PFOs).  PFOs are small congenital connections between the right and left atrial chambers of the heart that persist in ~25% of adults.  In the fetus, this connection is a vital conduit that allows the immature, nonfunctioning lungs to be bypassed.  In adults, this connection closes, and the lungs become not just the oxygenator of the body, but also serve as a filter for little clots and debris that frequent the venous circulation.

As our ability to see this connection developed with the advent of ultrasound, clinicians began to report cases of blood clots transiting through this connection from the right heart to the left heart.  This is a problem because the left heart pumps 1/5th of its blood volume to the brain, and so a cerebral embolism (or stroke) is the feared complication of clots that find their way into the left heart.  When a much higher proportion of patients than expected (40%) with uncertain causes of stroke were found to have a PFO, clinicians suspected these conduits as the cause of the stroke.

In response, cardiologists began closing these connections via catheters that delivered ingenious little double umbrellas to the heart.  Unfortunately, as the experience with these devices closures grew, it turned out that there were possibly other causes of stroke in this population.  Closing a PFO in someone who had a stroke because of a certain type of arrhythmia of the heart made the device company that sold the closure device happy, but did precious little else.  Three randomized control trials comparing PFO closure with medical therapy were carried out to test the prevailing strategy of PFO closures – CLOSURE 1, PC, and RESPECT.

All three were negative trials.  The prevailing wisdom suddenly became that there was no evidence that PFO closures worked in preventing recurrent strokes.  The American Academy of Neurology even put out a position paper arguing against PFO closures. Yet, I read the same trials and arrived at very different conclusions.  There were major issues with the trials that explained the negative results to me.  The CLOSURE 1, and PC trials included patients with Transient Ischemic attacks (TIAs).  For those who don’t know, TIAs are brief neurologic episodes that don’t last long enough to be considered a stroke.  Numbness and tingling on one side of the face could be a TIA, or it could be nothing.  Subjectivity reigns even among neurologists about this diagnosis, and it seems imminently plausible that many of the patients enrolled in these two trials had PFO closures for events that may not have been neurologic.  These first two trials also included patients with lacunar strokes – small strokes that could be a result of hypertension, high cholesterol or advanced age rather than embolism of a clot.  The last trial of this initial set of three studies -the RESPECT trial – sought to rectify the errors of its predecessors by excluding TIAs, and lacunar strokes.  They also sought to analyze the risk of stroke as it related to the size of the PFO.  Not all PFOs are equal – some are very small defects that only allow a minimal passage of blood, while others are much larger conduits.  The reasonable presumption was that most of the benefit to closing PFOs came from closing the large PFOs – the subset analysis would allow an analysis of this potential heterogenous treatment effect.  Strictly speaking, the RESPECT trial was a negative trial – another disappointment.  No statistically significant difference in was found between the PFO closure group and medical therapy group.

There were half as many strokes in the closure groups – 9 strokes in the PFO closure group, vs. 16 strokes in the medical therapy group.  But the trial was reported as negative because when comparing those assigned to the closure device vs. medical therapy, the hazard ratio crossed 1, and the p value was a little over the magical and somewhat arbitrary 0.05 threshold.  The analysis also took the form of the conventional ‘Intention To Treat (ITT)’ where patients are analyzed based on their initial assignment rather than the treatment that was ultimately received.  While this is statistically pure, it does not account for the fact that 4 patients who suffered a stroke after being randomized to a PFO closure device had a stroke while waiting to receive the device.

Effectively, the four strokes were ‘blamed’ on the PFO device.

RESPECT Trial Outcomes

One common explanation for analyzing by ITT is that ITT may best simulate the real world effect size when clinicians assign patients to a certain treatment.  While that is possible, it could also be that clinicians respond to this data by placing closure devices more expeditiously.   Not counting the four strokes that happened before the closure device was placed, (also called as treated, or the per protocol analysis) the numbers (5 vs. 16) did reach statistical significance.  Also not reflected in the yes/no world of clinical trial reporting in journals was the fact that of the 5 patients with a device that had a stroke, only one was considered moderate, or massive, compared to 9 in the medical therapy arm. Finally, the  subgroup analysis of the size of shunt, confirmed that the larger the shunt size, the higher the risk of recurrent stroke, and the greater the benefit of closure.

The other important point was that while closing the PFO may be an effective strategy to prevent recurrent strokes, blood thinners like coumadin to prevent blood clots from forming in the first place were another option supported by prior observational data.  The three initial RCTs had allowed participating investigators free reign with regards to choice of medical therapy in the medical arm – some chose antiplatelet drugs and others chose anticoagulation.  It seemed very unlikely  that closure devices could outperform systemic anticoagulation – yet another possible reason for the lack of effect of closure devices seen.

To me, the RCTs were helpful in confirming who likely had a small or no benefit to closure- patients with TIAs/lacunar strokes and small PFOs.  I wrote about the saga – and concluded that PFO closures were a good option in patients with large PFOs who had suffered a stroke and were loathe to be on blood thinners.

Much of the neurology community and many EBM experts ignored the subtext and focused on the lack of statistical significance.  Luckily, the clues readily apparent to me were also apparent to folks far more significant than me.  The longer term results of the RESPECT trial was enough to convince an FDA panel that despite the lack of statistical significance, there was a clear signal for clinical significance to merit approval of PFO closures for preventing cryptogenic stroke after a careful evaluation to rule out other causes of stroke.

But since we live in a world where no story is settled until an RCT is positive,  unbeknownst to me there were additional trials taking place to prove to the god of epistemology (currently a part-time oncologist in Oregon) that PFO closure devices were indeed beneficial.  In the Sep 14, 2017 issue of the New England Journal of Medicine – three RCTs were published.  One of the trials was a long term follow up of RESPECT that now showed a statistically significant benefit of PFO closures.  The two other trials were the GORE-REDUCE, and the GORE-CLOSE trial.  These latter trials enrolled mostly patients with large PFOs and strokes.  The GORE-CLOSE trial randomized patients to antiplatelet therapy only, PFO closure, as well as oral anticoagulation, while the GORE-REDUCE trial compared PFO closures to antiplatelet therapy.  Clearly the investigators had learned from the prior missteps, by focusing on larger PFOs, sidestepping the subjective nature of TIAs,  and mandating a treatment arm that consisted of antiplatelet therapy only.  Apparently there was clinical equipoise to do this.

Nonsense.

The RESPECT trial should have confirmed to those paying attention that patients presenting with a stroke and a large PFO should NOT be treated with antiplatelets only.  The only folks with equipoise here were those that were logically challenged or those that allowed EBM to suppress what should have been intuitive.  There was a price to pay for suspending logic.  In the GORE-CLOSE trial, which at least allowed for an anticoagulation arm,  14 patients in the antiplatelet group had a stroke, compared to zero in the PFO closure arm, and two in the oral anticoagulation arm.  In the GORE-REDUCE trial 12 patients had a stroke in the antiplatelet only arm, compared to six in the closure group.

So the positive signals gleaned from the original ‘negative’ RCTs had been on the mark.  The perfect balance of the known covariates in the trials had provided no protection against an erroneous inference.  As the subsequent positive trials demonstrated, the initial analysis that got it wrong wasn’t derailed because of unknown confounders, known confounders, poor randomization, or inaccurate average treatment effects.  It was a failure to ask why.

Bertrand’s Chicken

As physicians, it has become our practice to bring experience and personal observations together to allow us to doctor patients.  The fallibility of eminence and personal observations lead us to the realm of hypothesis testing and RCTs.  The idea was that adding this interlocutor would bring us closer to the truth, or at least result in fewer dead ends.   In reality we only ever had the illusion of a more certain truth.  It turns out that regurgitating the weekly New England Journal of Medicine conclusions fortified with p values may have been far less valuable than I thought as Ioannidis and others document.

Bertrand Russell, British philosopher, logician and mathematician wrote about these very same difficulties as it relates to the simple chicken.  The chicken bases what he expects on his experience.  Every day the farmer shows up and food appears.  To the chicken what happens tomorrow is based on the sum total experience of all the days before.  The chicken fully expects the farmer to come tomorrow with food because that has happened every prior day of existence.  Except tomorrow is the day the farmer arrives and wrings its neck.  The chicken got it all wrong.  Before scoffing too much at the chicken’s primitive way of thinking, consider that Russell started his chapter on the problems inherent with inductive inference by asking us to consider why the sun should rise tomorrow.  If your answer is because it has risen every day prior, you are guilty of chicken-headed thinking.

Unfortunately RCTs and null hypothesis testing would serve to advance neither the chicken’s search for the truth or ours, unless we ask questions that lead us to cause.  For this it is important to know why.  Understanding cause has little to do with what happens.  We reduce ourselves to chicken-headed thinking if our efforts are directed at what happened.  Chickens know what happened, what beasts of nature fail to understand is why things happen.  The analogy in medicine is to observe the initial PFO closure trials, note no statistically significant difference, and go no further.  This is chicken-headed.  Dive deeper, understand why the inclusion of patients with TIAs may have resulted in patients without cerebral embolic events being included.  Don’t dogmatically attribute strokes to PFO closure devices if they happen prior to the device being implanted.  And please don’t smugly discount the observations of thrombi transiting through PFOs into the left side of the heart, and the subsequent stroke that happened as true, true and unrelated.

Yes, biological models (leeches for bad humors) have been wrong, but don’t discount all future proposed models out of hand because of it.  By all means allow data in its many forms (case series, anecdotes, parallel control RCTs, adaptive design RCTs, etc. ) to modify, sharpen, or even discard a model.  But don’t give up on models, don’t give up on seeking out why, and please don’t listen to this guy –

Change medical school. Teach EBM first, pathophysiology later. Make students care about whether something does or doesn’t work before they care about why.

— Kenny Lin, MD, MPH (@kennylinafp) April 19, 2018

The common refrain from some quarters is that statistics has come a long way from Fisher’s t-test and the basic parallel controlled randomized control trial.  Different trial designs as well as methods to analyze randomize control trials post-hoc to account for some of the weakness discussed abound.  Bayesian statistics seeks to incorporate various priors – optimistic, neutral, skeptical – to arrive at a range of posterior probabilities.  I am sympathetic to the number crunching whiz kids earnestly trying to help us arrive at scientific truth by better parsing what the data tells us.  But it is a mistake to think that the heavy lifting needed to understand the recent randomized control trial comparing ablation for atrial fibrillation to placebo that had 30% of patients crossover to the treatment arm will come via instrumental variables or something that sounds even sexier.  The closest we can hope to get to the truth at any point in time will lie somewhere within the community of physicians managing patients with atrial fibrillation because they are best able to provide the context any one study needs.  And while this certainly introduces bias and subjectivity into the interpretation of results, it is neither possible or wise to eliminate this.

The move to strip biases, to fight instincts, to discard knowledge at times painstakingly acquired outside of the hallowed RCT construct is ultimately misguided.  The current crisis of evidence will not be soothed by analyzing data better, or by stripping the biases of clinicians.  The words of Bartlett as he explained his reasoning for proceeding with the ECMO RCT should be chilling: ” we felt compelled… we knew that 90% of patients assigned to the control group would die..”  It should have been enough for Bartlett to convince his peers in the intensive care unit of the value of what he was doing.  Statisticians, hospital administrators, and insurance carriers have no business demanding ‘higher’ levels of evidence here, in part because they are woefully unqualified to evaluate any evidence that’s even compelled to be produced.   The creation of clinical equipoise by statisticians who can never be certain of anything is a self defeating proposition.  Causal inference comes from searching for the why of it. If 200/10000 patients exposed to a certain meteorite are stricken with cancer, and only 10/10000 patients not exposed get the same cancer, the question that should consume the clinician and researcher is why this happened.  Why didn’t all 10000 patients in the affected neighborhood get cancer.  What could the underlying mechanism be?  Is there an activator of some kind common to the 200 unfortunate patients?  Do they share some genetic code that predisposes them to being stricken?  Not asking these questions, or proceeding with blinders on to test random treatments in a hundred RCTs lowers us to the level of chickens.  The less we think as chickens, the better.

  Anish Koka (@anish_koka) is a cardiologist in private practice in Philadelphia.  Many thanks to those who provided comments including David Norris (@davidcnorrismd), Saurabh Jha (@roguerad), and John Tucker (@JohnTuckerPhD).  Insights/examples gleaned from the wonderful works of Stephen Senn (@stephensenn ), William Briggs/Uncertainty. Errors in translation of concepts are solely the fault of @anish_koka.

Article source:The Health Care Blog

[eleganthologrambouquet-worl-blog]

Literature Spotlight Peering Into an Alien Mirror

 Literature Spotlight: Peering Into an Alien Mirror

Literature Spotlight: Peering Into an Alien Mirror

Science fiction is one of my favorite genres. I love it (and I suspect many of its readers love it) because despite its trappings of the future, good science fiction is very much a reflection of the time period in which it is written. One of Sci-Fi's major draws for me is that it can highlight and discuss social issues that might be touchy to talk about in the present day. Through the skillful use of spaceships, aliens, utopian planet colonies, and other 'flight-of-fancy' scenarios, a science fiction author can hold a mirror up to the way our current society deals with an issue by showing how their fictional society does. By reading sci-fi from previous eras, then, we can catch a glimpse of what people of that era were thinking about – and what was considered an acceptable 'flight of fancy.'

The Skylark of Space, written by E. E. 'Doc' Smith in the 1920's, included an equal ratio of women to men on the spaceship – surprising for such an early entry into the genre. However, what is not so surprising is that the women involved are cast in incredibly traditionally 'female' roles – they are the wives of the scientists who invent the spaceship, and play a very motherly role on the ship. In particular, one comedic scene shows the women in the kitchen, trying in vain to make sandwiches in zero gravity. It plays out like a Jules Verne-esque slapstick routine, with the ham and cheese floating all over the room. Tellingly for the time it was written, the only thing the women seem to feel like they can take the initiative to do is fix lunch for the menfolk.

Contrast that with the Original Series of Star Trek, first aired in the 1960's. Star Trek depicts a world where gender no longer matters – a black woman has an important bridge position as the Communications Officer, and even if her lines are mostly comprised of “Hailing frequencies open, sir,” still, nobody bats an eye at a woman doing more than just fixing lunch. Further contrast that with the Expanse series by James S. A. Corey, which began with the novel Leviathan Wakes in 2011. The second book in the series, Caliban's War, contains not one but two female main characters, a Martian space marine and an Earth diplomat. Both are in positions where they are well-respected (though they receive pushback throughout the book, but it's plot-related, not related to simply being female). Both radiate power in different ways and both are treated equally in terms of gender.

Original series Star Trek also dealt with racial tensions. Lieutenant Uhura may have been a well-respected and equally-treated bridge crew member within the context of the show, but the show's writers still received pushback from the network about her place in the story. In the 1968 episode “Plato's Stepchildren,” there is a scene where Uhura (played by Nichelle Nichols) and Captain Kirk (played by William Shatner) share a kiss, widely cited as the first example of a scripted inter-racial kiss on US television. The network wanted them to film the scene both with and without the kiss, so that they could decide later whether to air it. The actors chose to intentionally flubb every take without the kiss so that the network would be forced to air it. The story of that episode serves as a reminder that Original series Star Trek, like most good science fiction, prodded at the boundaries of what was considered an acceptable social construct at the time.

While Star Trek's society treats all races and genders equally where Earth humans are concerned, it does still get a chance to display ideas of racial tensions and play with the theme of racial equality – through the clever use of aliens. Mister Spock is a great example of this – here is an alien as First Officer of an Earth Federation starship, who frequently gets mocked and insulted by the other crewmembers for his pointy ears, his green blood, and his unusual customs. Uhura may have been indicative of what race relations could be, but Spock depicted race relations as they were. Certain episodes also dealt more pointedly with the idea of race prejudice, most notably the episode “Let That Be Your Last Battlefield,” which dealt with the last two survivors of a war-torn planet still hell-bent on destroying each other. This is the famous episode with the 'black-and-white' aliens – their feud was based on which half of their body was black and which one white. While a bit heavy-handed, it does still speak volumes about the sometimes silly things that drive us to war and the dangers of prejudice.

Caliban's War displays racial tensions as well, but in a different way – by highlighting the fact that they are all humans. When I mentioned the two female leads up there, you probably thought of them as different species – perhaps the Martian space marine was an 'alien' and the Earth diplomat was a 'human.' Well, in actuality, they are both human. In fact, the three-way war between the Outer Planets Alliance, Earth, and Mars is essentially an entirely human war – there are no aliens to speak of in the whole book (with one exception – no spoilers!). But the stark differences in lifestyle, outlook, and even physical appearance between someone born on Mars and someone born 'down the well' on Earth leads to them treating each other as aliens. You can easily see, through the diplomat's eyes, how different humans can become in different circumstances, and how these differences could lead them to fail to understand each other on a primal level.

Race and gender are not the only social issues that can be depicted in science fiction. Plenty of other issues are presented, all depending on the time period in which the work is written and the aspect of society that the author wants to explore. Caliban's War includes a scene that will stick with me for months, where the female space marine visits Earth for the first time and chats with a young barista. The barista talks about the Earth policy of having young people work for a few years after high school to make sure they like working before the government spends money sending them to college. The planet has become so over-populated that not everyone needs to work, so those who don't like working can simply go on basic support and devote themselves to leisure. For the space marine, who grew up in a colony where everyone has a place and a job to do, this concept is foreign, almost incomprehensible. By contrasting these two personalities, Corey allows us to consider the ideas of single-payer systems like free university education and healthcare from multiple perspectives, and draw our own conclusions.

This is precisely why one of my favorite recent sci-fi works is Larry Niven's The Draco Tavern. This collection of super-short stories centers around Rick Schumann, the bartender at an alien bar called the Draco Tavern. The stories are between 5 and 10 pages long on average, generally taking the form of a conversation Rick has with one or several of his alien patrons. The stories present little vignettes that bring up a question and then end, leaving the reader to think about their answer. The Draco Tavern's questions range from 'What if you could choose when you died?' to 'If a human kills an alien, should he be subjected to the alien form of punishment?' to 'Should I feel weird knowing that this alien race took samples of my DNA and are using it to lab-grow meat for their own consumption?' The beauty of The Draco Tavern is that it doesn't attempt to answer any of these questions, just present them and leave the reader to chew on them for a bit.

Science fiction may seem fanciful, with all those aliens running around on starships firing photon torpedoes at each other. But in reality, a skilled science fiction author can often tell you more about your own beliefs and opinions by comparing them to those of his aliens than you might ever get from sharing them with a therapist. I've only scratched the surface here, but this deeply personal self-searching that arises from peering into an alien mirror is one of the many things that keeps me coming back to science fiction, time and time again.

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[hcwjared5756330-blog]

First Elegance Competition.

Perform you continuously obtain denied for projects also just before the job interview phase? Through this sort of technique you evaluate the scenario that you are in and think about the way that you can easily use valuable suggestions to the lady who you have an interest in. Exactly what is wonderful regarding through this of moving toward a female is you come off as a specialist and some of the important things that appeals to most girls is a person that takes charge.

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[kenyonexeter-blog]

Vessels

​It is not until the first of the reds that I suspected I’ve made a mistake. My arms move heavily across the smooth wooden table. The dark wine inside the glass spins as if it were a gelatin disk. 

​“This one has that weight,” says the voice of Marc Millon ’77. “It has the glucose.” There is far too much Red Burgundy Cabernet in my mouth. Bombarded by a thousand small fruity fists, I swallow all the wine to save myself. However much I have drunk reaches my everywhere and the word mistake appears in my head in stone-grey Apple Chancery. Marc mentions periodically that these particular wine types are particularly expensive, but doesn’t mention their expense particularly. I wonder how much wine in pounds sterling I’ve just hastily consumed because of a mistake caused, ironically, by the wine. You should never trust a product that influences the way you consume it. And yet, here I am. I set the glass down, sliding it into the other glass. The ring fills the room and the eyes of the others at the table shoot to me with my hand still on the stem. The defined ring dissipates into the now monastic air. The eyes remove themselves and my hand unfreezes from the glass. My face goes up a few stovetop settings. I hear the various voices as if through a thin glass door. 

​This one is not my friend. The smell burns my nose like Purell, and the taste somehow reminds me a conversation I once had where someone described their undying love for a book I hated. Professor Singer is right, red wines are gross. Regardless, the effect of the wine appears to be the same. ​

“I think I’ve made a severe mistake,” I tell Fletcher and Isaiah, both of whom sit opposite me. ​

“Whatever do you mean?” Fletcher asks with one eyebrow raised. ​

“Nobody else has been spitting any of it, right?” 

​“Oh, no,” Fletcher assures me. Isaiah shakes his head in complement. “No,” Fletcher continues. “We have all been, certainly— I have consumed all of the wine.” He grins. ​ 

“I think I now have consumed a combined total of at least more than three glasses,” I note. ​

“Probably,” Fletcher replies. 

​I nod. “And I have the strong urge to sing the Kokosing Farewell.” 

​“Don’t do that,” Isaiah says. “This is not the place for that.” 

​“I’m well aware. It will happen, though, eventually. It is inevitable.” ​

Isaiah nods. “Well let’s just hope that happens after we leave.” ​

Marc stands by the table next to ours. “Do you like the wine?” 

​I took too long trying to decide if, by “the wine” he meant the wine we had had over the course of the night or the wine currently in my glass, because I have different answers. “Yes,” I say, meaning all of them. ​

He nods, raising his wine glass slightly and taking another sip. I resist the urge to ask him ten thousand questions about Kenyon. I succeed, in that I only ask him two. ​

“You’re class of ‘77?” ​“Yes, I am,” he grins and makes a pronounced nod. “Class of 77.” 

​“Do you know Mark Robinson? He would have been a few years behind you, he was ’79, and so you would have been on campus together for only one year…” ​

“No, I don’t know him. What’s your connection to him?” ​I very suddenly don’t want to say. Will it seem I brought it up to mention I’m a Kokosinger? Why would I do that? I also know nothing of the Kokes’ reputation in 1977. They could have been absolutely loathed, after all this was years before— ​

“When was Professor Tazewell a Koke?” asks Professor Singer. ​

“He graduated in 1987,” I reply, perhaps too quickly. Had the way I said it implied he was too young? Had I offended Marc? I crinkle my face. 

Before I am able to instinctively ask him what he studied and what dorm he lived in as a Freshman and where his department was based when he was there and who the head of the department was and how many students there were and what the gender ratio was and what he did on campus he, ever so fortunately, began a leisurely return to the center of the room. I pour the remainder of my glass into the silvery bucket in front of me. I let curiosity reign and, without hesitation, peer over the edge to see the contents, which resembles red wine exactly. Disappointed, I sit back down. 

“This next wine is a little heartier, and far darker, just note the difference in the shade.” He pours the purple wine into my empty glass, and Fletcher and I hold the two wines up to each other, marking the “radically different colors,” although they both look mostly black with different-colored lights shining through. We toast rigidly, laughing, before taking a sip. I curse myself for skipping over the smelling stage. Oh well. ​

“Wine is such a personal experience,” Marc reminds us, “created with so much individuality. Wine is really about community. It’s about getting to know the maker of the wine, the land that it comes from, the people from that land, and the friends you share the wine with.” ​

“And if you go to these places,” Professor Lynn adds from all the way down the column of tables, “then when you have this wine again you will be reminded of that place. Wine is a vessel, for alcohol certainly,” he grins at all of us, “but it’s really a vessel for memory.” ​ 

Marc comes round with the final wine of the night: Riesling, a golden liquid disco ball. On the sheet where I’m supposed to write a description of its smell, I write without hesitation New Years Eve, a tap on the shoulder. I don’t know. I described a white Sancerre as gladiatorial, I’m clearly bad at this. Wine never seemed to be for me. At my father’s house, wine (red wine) was a callous, pernicious, and expensive beverage that sat in the center of the dinner table and in a glass in front of me for the rest of the night, and apparently also came with a more absurdly complex playing system than the Yugioh trading card game. At Kenyon, it was another way for people who apparently didn’t have ten pages on Boccaccio due by 10am to forget the hopelessness of it all. But this. This is a discovery. I say “wow” aloud, involuntarily, with enough force to make Professor Singer recoil in surprise. Fletcher raises both eyebrows. Isaiah blinks. Shame attempts to scurry around, but has to hold its breath in the new basin of wine that now flows through my body. I, again aloud, remark that it tastes similar to cider. Marc pauses and gives me a disapproving look, but mutters, “okay.” It does taste like cider. Or maybe it feels like cider on my lips and in my mouth. It bubbles around, having a party, but careful not to break anything. Marc offers everyone a second glass. I accept with a quickness I should be ashamed of, but I’m not. 

​Still in the thorough bright beige light of the wine cellar I push my left arm through the polyester inside of my coat, and Fletcher nonchalantly plants my right hand onto his recently shaved head. His head is sweaty, but the collective of short stiff hairs is strangely relaxing on my palm, so I go with it and put the other hand on there as well, and start humming a single low note. ​

“Is this some sort of mind meld?” Fletcher asks quickly. “What’s happening?” ​

“You were the one who put it there.” ​

“Fair enough.” ​

We stay for a few moments until my hands slide off of his head, and everyone files out. I hear thank yous directed back at Marc from ahead of me. I turn back toward him myself, open my mouth, contract a muscle in my throat, but merely exhale. We walk the damp streets of Topsham. Short bursts of voice volley back and forth in front of me, but I forget each word instantly. For a while no one speaks to me any more than the small figurines in the shop windows do. The buildings are all charcoal-colored and neon yellow, the street pavement is its color when wet, the brown coat hangers and hand-carved chess sets and shoes are black. Eric’s skin is grey. Bailey’s is grey, then suddenly thrice-diluted yellow in front of some shrubbery under a street light, then grey again. ​

The color palette more or less returns at the train station. The shingle roofs of Topsham still surround us but they fade out. My world is a few rows of train tracks, and a small crowd of Kenyonites on the slatey platform before them. I begin to sing the Kokosing Farewell. 

​Fletcher joins me. His eyes hide behind his glasses as if they are screen doors overlooking a backyard ruckus. I can’t tell if he is following me in the song, or simply confused as to why I am making eye contact with him. I turn and notice Professor Lynn has also joined in, arms motionless at his sides, his brimmed hat turning in the dark as he nods at the start of each line. Two or three voices accompany mine, sometimes following exactly, sometimes only a few milliseconds behind. I fear if I make a mistake it will stop, which, once we have begun, seems unacceptable to me. Behind his hat and his beard Professor Lynn’s either stares straight on or looks at me, it is unclear. His look tells me he is also determined to finish the song. I wonder whether it is out of a sense of duty, or enjoyment, although he seems somehow annoyed, or perhaps under “some strange spell.” The spell isn’t strange to me anymore. It is quite familiar. I’ve been at the Topsham station before, but tonight, for about two of the minutes we stand here, we are not at Topsham Station. We are at Kenyon. Not Kenyon College, just Kenyon. The heaths and hills of Devonshire still lie in wait just outside the edge of the station’s overhead lamp, but everything the light touches is Kenyon. So long as the song continues. ​

“In meadows sweet with asphodel…” I stop. The other voices stop. ​

“What is the next line,” I ask aloud. This is the part I’ve sung ten thousand times, and yet. And yet. ​

“I can’t remember,” Fletcher relents. ​The individual words sit in the air around me— “reposing,” “memory,” “dwells”— but I can’t organize them into the penultimate line. I start singing pieces of the line out of order, at half volume. I am a jukebox running out of batteries. Fletcher and Isaiah turn back to the train tracks, and Professor Lynn adjusts his hat. The circle is incomplete, the spell is broken. ​

“That song will be with you for the rest of your life,” Professor Lynn says, hands in his pockets, walking slowly up the edge of the platform. “Every time you hear that song, you will think of Kenyon.” ​

A minute of vigorous tapping brings me to a lavender web page on my iPhone in a grey broken case. I sing the rest of the song. I mean to do it quietly, but eyes start turning back to me, more confused than the last time. I finish anyway. I step onto the train after Emma Longstreth. The professors wave briskly and march down the platform in the opposite direction. The train doors close. I have a window seat, but I don’t look out of it once. We take up three rows on either side of the train. I can see everyone from my seat at the edge of the section. I want to sing the song again, but we’re on a train. 

​Six of us get off at St. James’ Park. This part of the city is newer than the rest, even newer to me. I’ve never been before. We scale a somehow rural staircase up to streets of whitewashed buildings and stone walls no taller than six and a half feet. Trampling down a small hill, my arms and legs and torso are warmer than they should be. The wind cools my face in a consistent layer, I feel the cold as one point, one color of a single pixel. Behind my face, my thoughts move by a giant iron wheel powered only by my forward momentum. If I stop walking maybe I’ll just collapse on the floor. Not so fast. Not so fast indeed, I agree at the mouth of another alleyway. It opens up onto a larger road: Pennsylvania. We walk up and suddenly the trip is identical to coming back from Tesco, back from the firehouse, back from anywhere in the City. The small wall at our side is ancient and quaint and matches the street that makes me think the word “cobblestone” even though it’s paved. The way I feel I might as well be coming back from Rosse Hall, from Kokes practice. It’s the same lighting, that makes me wish there was some other place, somewhere I could justify walking to, somewhere I could sing all night. I don’t want my throat to cool down. I don’t want to sit back down at a desk, and edit ten pages on Salvador Dalí by 10am. That’s what I’m doing, though. That’s Kenyon for you. No matter where you actually are, there’s always ten pages due tomorrow by 10am. And I had all of that wine anyway.

[juditmiltz]

Bridging the gender divide in commercial real estate

Barbara Liberatore Black’s rise to managing director of JLL’s South Florida office was not an easy one. Currently the only female executive in her office, Black was also one of the first women in commercial real estate in Miami.

She got her start doing tenant representation for Julien J. Studley Inc., the precursor to Savills Studley, in 1981. “I was the only female tenant adviser for years,” Black said. Before securing that gig, she’d tried to get her foot in the door elsewhere, to no avail. 

“If you were a man today, I would hire you,” an interviewer told her, reasoning that as a woman who was going to get married, she wouldn’t have the time for the job. Instead, he offered Black a secretarial position. She turned it down.

Times have clearly changed, but in the wake of the allegations of sexual harassment and assault by Harvey Weinstein — and the many similar charges against high-profile men that followed, including starchitect Richard Meier — several, if not all, industries are facing profound questions about company culture and fairness.

However, many women in South Florida’s commercial real estate industry are not seeing a major push to close the gender gap. They say the #MeToo movement hasn’t kicked off the kinds of productive conversations it was intended to inspire. Rather, many male colleagues are “now afraid to say hello” to women, Carol Brooks, co-founder of the brokerage Continental Real Estate Companies (CREC), said. “It’s coming more from a place of their own self-preservation. It’s interesting to see how men are reacting; it’s more fear than compassion or anything,” she said.

The Real Deal examined the male and female representation of agents working for South Florida’s top five commercial brokerages (determined by the dollar volume of sales and leases as reported by the South Florida Business Journal) by analyzing broker license data filed with the state as of Feb. 23. Marcus & Millichap had the lowest percentage of female agents in the tri-county region of Miami-Dade, Broward and Palm Beach counties, with 18 percent.

Lori Schneider, senior managing director of investments at Marcus & Millichap, said she thinks the firm has fewer women than the others because the company focuses only on investment sales, which takes time and money “until you establish yourself.” Women typically have less of both than men, she said. Leasing, on the other hand, often provides agents with a crucial base salary.

CBRE had the highest percentage of women agents, with 39.8 percent, and JLL closely followed with the second highest representation of women, 38.6 percent, according to TRD’s analysis.

Both CBRE and JLL recently won industry awards for their gender inclusion. CBRE, where three of the firm’s board members are women, received the Diversity & Inclusion Award from the Mortgage Bankers Association in February. In March, JLL was named one of the National Association for Female Executives’ “Top Companies for Executive Women.”

CBRE and JLL’s numbers of female brokers in South Florida are better than national averages. The Commercial Real Estate Women (CREW) Network Benchmark study conducted in 2015 — the most recent data set of its kind that’s available — showed that only 23 percent of leasing and sales brokers in the U.S. were women in 2015. But that number was up from 20 percent five years earlier. Between 2010 and 2015, women went from representing 32 percent of the total commercial real estate workforce to 36 percent nationwide. The subsector with the highest concentration of women was property management, with 51 percent of the asset, property and facilities management workforce female, up from 47 percent in 2010.

And while the CREW research found that women made 23.3 percent less than men in the field in 2015, all of the women contacted for this story had a different experience. Female brokers said that because most positions are commission-based, the wage gap isn’t much of an issue. “The good news about that is a woman who is driven can be equal or better [than a man], and she will get paid,” Black said. “I think this is one of the few careers where women get equal pay.”

The achievement gap

Although there’s been progress in overall male-to-female ratios, the gender gap is still quite vast when it comes to women in leadership positions. CREW’s 2015 study found that only 9 percent of the women who were surveyed held executive roles, compared to 17 percent of the men who participated in the study.

The industry is also facing an aspirational gap between men and women. Forty percent of men surveyed by CREW said they wanted C-suite positions compared to only 28 percent of women. And once men had between six and 10 years of experience, they rose through the ranks at a faster pace than women, the report found.

“Men are much more vocal than women. When you don’t speak up and you don’t ask for the job, you don’t get it,” said Sara Hernandez, president of CREW-Miami.

  Women developers are also lacking in the industry because the field requires a track record and capital, said Avra Jain, a commercial developer in Miami’s MiMo, Little Haiti, Miami River and Overtown neighborhoods.

“When I first came down to Miami [17 years ago] and I walked into a meeting to buy a piece of property, the broker kept talking to the man next to me,” Jain said.

The perils of after-hour events

“‘Welcome to the company. I Googled you hoping to find some bikini shots online,’” Pauldine France, vice president of strategic investments at FIP Commercial, recalled a man saying on her first day at a new job. “I once had a COO I ran into at a party who was trying to get me drunk to take me home. His wife was at the same party,” she added.

Most women in the industry who were contacted for this story agreed that there’s been some progress in hiring more women, but the presence of some bad actors remains a big issue.

France got her start in 2003 as a brand ambassador for Tony Cho when he launched Metro 1 Properties. She was later a financial adviser at Morgan Stanley, then worked for Shawmut Design and Construction in New York, Thor Equities in Miami and, more recently, spent a year working for RKF, also in Miami.

France is, as she describes herself, a “six-foot-tall black chick with green eyes.” She’s faced more than her share of unwanted attention, she told TRD. “I’m used to people looking at me. In commercial real estate, I am a unicorn of a unicorn,” she said. “I’ve had inappropriate, ‘let me take you home’ comments.”

The necessity of after-hours networking doesn’t help things. Going to nightclubs, strip clubs and bars is still a way to get deals done in Miami, sources said. There’s also still a lot of golfing.

“Half of these guys just want to party, and the business facilitates partying” said Mika Mattingly, executive vice president of Colliers International South Florida.

Some women push themselves to head to the golf course or boozy networking events even when it’s uncomfortable. CBRE’s Carol Ellis-Cutler, first vice president of advisory and tenant services in Miami, attended a conference earlier this year where she was one of a handful of women out of a crowd of 800. She later attended the golfing event, where she was the only woman — alongside 32 men.

However, Ellis-Cutler and Arden Karson, senior managing director of CBRE South Florida, both said they also use their gender to their advantage. “Being the only woman at the table, they love that,” Karson said, referencing her male colleagues. She squeezed her way into a dinner during a CRE Finance Council event because she wanted to do business with the group.

“I was the only woman out of 20 people, and they all wanted to sit with me,” Karson said, noting that the extra attention she received was not inappropriate. The men, she said, just wanted to speak to a woman because it was “a refreshing change.”

Men can be more inclined to share information with women, some female brokers said. But that too can have its downside. There’s a fine line between being “approachable and nice” and being “firm,” France said. “You have to deliver this coolness while still keeping that meter stick in front of them,” she said. “Nine out of 10 times, ‘super cool’ can become ‘I can make comments about your new push-up bra.’”

Mentoring the next generation

When considering ways to resolve some of these murky issues, many women said that mentoring a new generation of female brokers is the most important work that needs to be done. And South Florida’s a good place for that: A number of women in leadership roles in commercial real estate own their own companies or work for women who do.

Brooks, of CREC, got her start working in the corporate real estate lending department at Southeast Bank and moved on to the Continental Companies, where she was director of the commercial office leasing department. In the late ‘80s, she considered working at other brokerages and said, “Screw that, I’ll start my own company.”

At that company, a boutique commercial firm she co-founded with Warren Weiser, 51 percent of its 120 employees are female. Two of its six partners are women, and half of its department heads are women. More than 60 percent of CREC’s property managers are women, and 26 percent of the company’s brokers are women. “There are just such high barriers to entry otherwise, so we’ve created our own system,” Brooks said.

Her approach to nurturing female talent development has paid off in the eyes of Sabrina Stimming. Brooks mentored Stimming, who started as an executive assistant and was promoted to marketing assistant, then marketing director. An opening appeared in retail leasing, and now Stimming is director of retail leasing and a partner at CREC. She believes that had she started her career at a traditional brokerage like a CBRE, “it’s probably not likely I would be a head of a department there.”

“If you look around at other firms in our industry, the only women you see in any sort of leadership positions are women who form their own companies,” Stimming added.

Without a mentor, Collier’s Mattingly developed her own strategy for success that many women in the industry adopt: Be the best at the job. She’d pick a neighborhood or area and become an expert on it. “I picked Sunset Harbour, which I liked at the time, and I farmed the fuck out of it,” she said. 

From Metro 1, where Mattingly started in 2006 as a commercial associate, she went to Sterling Equity Commercial, where she’d “transact all day off-market, but no one would trust me with big listings.” She eventually represented Moishe Mana in nearly all of his acquisitions in downtown Miami’s Flagler District, which to date has totaled $267 million on 1 million square feet of building space and eight acres of land.

In 2016, Mattingly joined Colliers and is building her team out of an office in downtown Miami. Although it’s not her own company, it’s clear that she’s running her own operation out of the ground-floor retail space on Flagler Street. She said she’s teaching her team to become neighborhood experts, as she did, by learning every property and zoning before they start selling.

Tere Blanca, founder, chairman and CEO of Blanca Commercial Real Estate, also wants to nurture female talent. She left Cushman & Wakefield to start her own firm in 2008 and is responsible for mentoring everyone in the 22-person office, including a few female agents. In her view, the lack of women in the field may stem from them just not knowing about it. “I don’t think a lot of young women understand the opportunities that exist in the industry,” she said.

Ellis-Cutler and some of her colleagues at CREW-Miami introduced themselves to a group of high school girls by telling them, “We don’t sell single-family homes. We can sell the entire multifamily building.”

CBRE created its Women’s Network in 2000; it now has 3,500 members nationwide and hosts quarterly events. The gender gap at CBRE and other major commercial brokerage persists, but Karson acknowledged that the firm’s numbers are going up.

Forging ahead

While women in commercial real estate today see some struggles and disparities, JLL’s Black said the industry has grown to include more women since she got her start in the early ‘80s. “The one thing I’ve noticed is that women feel more empowered to say to their peers or their managers, ‘Hey, that was an off-color joke’ or ‘I didn’t really like the way you said that about me.’ Women are using their voice now to explain that it’s not right,” she said.

However, Black sees two areas where female representation is lacking: tenant advisory and capital markets, both of which are especially profitable sectors of the business. “That’s predominantly still occupied by men, but in time that will change,” she said.

Jain is also optimistic about closing the gender gap in development.

“We’re starting to see more women take on those roles within their families and more women who want to be developers,” Jain said.

from The Real Deal Miami https://therealdeal.com/miami/issues_articles/bridging-the-gender-divide-in-commercial-real-estate/#new_tab via IFTTT

[juditmiltz]

Bridging the gender divide in commercial real estate

Barbara Liberatore Black’s rise to managing director of JLL’s South Florida office was not an easy one. Currently the only female executive in her office, Black was also one of the first women in commercial real estate in Miami.

She got her start doing tenant representation for Julien J. Studley Inc., the precursor to Savills Studley, in 1981. “I was the only female tenant adviser for years,” Black said. Before securing that gig, she’d tried to get her foot in the door elsewhere, to no avail. 

“If you were a man today, I would hire you,” an interviewer told her, reasoning that as a woman who was going to get married, she wouldn’t have the time for the job. Instead, he offered Black a secretarial position. She turned it down.

Times have clearly changed, but in the wake of the allegations of sexual harassment and assault by Harvey Weinstein — and the many similar charges against high-profile men that followed, including starchitect Richard Meier — several, if not all, industries are facing profound questions about company culture and fairness.

However, many women in South Florida’s commercial real estate industry are not seeing a major push to close the gender gap. They say the #MeToo movement hasn’t kicked off the kinds of productive conversations it was intended to inspire. Rather, many male colleagues are “now afraid to say hello” to women, Carol Brooks, co-founder of the brokerage Continental Real Estate Companies (CREC), said. “It’s coming more from a place of their own self-preservation. It’s interesting to see how men are reacting; it’s more fear than compassion or anything,” she said.

The Real Deal examined the male and female representation of agents working for South Florida’s top five commercial brokerages (determined by the dollar volume of sales and leases as reported by the South Florida Business Journal) by analyzing broker license data filed with the state as of Feb. 23. Marcus & Millichap had the lowest percentage of female agents in the tri-county region of Miami-Dade, Broward and Palm Beach counties, with 18 percent.

Lori Schneider, senior managing director of investments at Marcus & Millichap, said she thinks the firm has fewer women than the others because the company focuses only on investment sales, which takes time and money “until you establish yourself.” Women typically have less of both than men, she said. Leasing, on the other hand, often provides agents with a crucial base salary.

CBRE had the highest percentage of women agents, with 39.8 percent, and JLL closely followed with the second highest representation of women, 38.6 percent, according to TRD’s analysis.

Both CBRE and JLL recently won industry awards for their gender inclusion. CBRE, where three of the firm’s board members are women, received the Diversity & Inclusion Award from the Mortgage Bankers Association in February. In March, JLL was named one of the National Association for Female Executives’ “Top Companies for Executive Women.”

CBRE and JLL’s numbers of female brokers in South Florida are better than national averages. The Commercial Real Estate Women (CREW) Network Benchmark study conducted in 2015 — the most recent data set of its kind that’s available — showed that only 23 percent of leasing and sales brokers in the U.S. were women in 2015. But that number was up from 20 percent five years earlier. Between 2010 and 2015, women went from representing 32 percent of the total commercial real estate workforce to 36 percent nationwide. The subsector with the highest concentration of women was property management, with 51 percent of the asset, property and facilities management workforce female, up from 47 percent in 2010.

And while the CREW research found that women made 23.3 percent less than men in the field in 2015, all of the women contacted for this story had a different experience. Female brokers said that because most positions are commission-based, the wage gap isn’t much of an issue. “The good news about that is a woman who is driven can be equal or better [than a man], and she will get paid,” Black said. “I think this is one of the few careers where women get equal pay.”

The achievement gap

Although there’s been progress in overall male-to-female ratios, the gender gap is still quite vast when it comes to women in leadership positions. CREW’s 2015 study found that only 9 percent of the women who were surveyed held executive roles, compared to 17 percent of the men who participated in the study.

The industry is also facing an aspirational gap between men and women. Forty percent of men surveyed by CREW said they wanted C-suite positions compared to only 28 percent of women. And once men had between six and 10 years of experience, they rose through the ranks at a faster pace than women, the report found.

“Men are much more vocal than women. When you don’t speak up and you don’t ask for the job, you don’t get it,” said Sara Hernandez, president of CREW-Miami.

  Women developers are also lacking in the industry because the field requires a track record and capital, said Avra Jain, a commercial developer in Miami’s MiMo, Little Haiti, Miami River and Overtown neighborhoods.

“When I first came down to Miami [17 years ago] and I walked into a meeting to buy a piece of property, the broker kept talking to the man next to me,” Jain said.

The perils of after-hour events

“‘Welcome to the company. I Googled you hoping to find some bikini shots online,’” Pauldine France, vice president of strategic investments at FIP Commercial, recalled a man saying on her first day at a new job. “I once had a COO I ran into at a party who was trying to get me drunk to take me home. His wife was at the same party,” she added.

Most women in the industry who were contacted for this story agreed that there’s been some progress in hiring more women, but the presence of some bad actors remains a big issue.

France got her start in 2003 as a brand ambassador for Tony Cho when he launched Metro 1 Properties. She was later a financial adviser at Morgan Stanley, then worked for Shawmut Design and Construction in New York, Thor Equities in Miami and, more recently, spent a year working for RKF, also in Miami.

France is, as she describes herself, a “six-foot-tall black chick with green eyes.” She’s faced more than her share of unwanted attention, she told TRD. “I’m used to people looking at me. In commercial real estate, I am a unicorn of a unicorn,” she said. “I’ve had inappropriate, ‘let me take you home’ comments.”

The necessity of after-hours networking doesn’t help things. Going to nightclubs, strip clubs and bars is still a way to get deals done in Miami, sources said. There’s also still a lot of golfing.

“Half of these guys just want to party, and the business facilitates partying” said Mika Mattingly, executive vice president of Colliers International South Florida.

Some women push themselves to head to the golf course or boozy networking events even when it’s uncomfortable. CBRE’s Carol Ellis-Cutler, first vice president of advisory and tenant services in Miami, attended a conference earlier this year where she was one of a handful of women out of a crowd of 800. She later attended the golfing event, where she was the only woman — alongside 32 men.

However, Ellis-Cutler and Arden Karson, senior managing director of CBRE South Florida, both said they also use their gender to their advantage. “Being the only woman at the table, they love that,” Karson said, referencing her male colleagues. She squeezed her way into a dinner during a CRE Finance Council event because she wanted to do business with the group.

“I was the only woman out of 20 people, and they all wanted to sit with me,” Karson said, noting that the extra attention she received was not inappropriate. The men, she said, just wanted to speak to a woman because it was “a refreshing change.”

Men can be more inclined to share information with women, some female brokers said. But that too can have its downside. There’s a fine line between being “approachable and nice” and being “firm,” France said. “You have to deliver this coolness while still keeping that meter stick in front of them,” she said. “Nine out of 10 times, ‘super cool’ can become ‘I can make comments about your new push-up bra.’”

Mentoring the next generation

When considering ways to resolve some of these murky issues, many women said that mentoring a new generation of female brokers is the most important work that needs to be done. And South Florida’s a good place for that: A number of women in leadership roles in commercial real estate own their own companies or work for women who do.

Brooks, of CREC, got her start working in the corporate real estate lending department at Southeast Bank and moved on to the Continental Companies, where she was director of the commercial office leasing department. In the late ‘80s, she considered working at other brokerages and said, “Screw that, I’ll start my own company.”

At that company, a boutique commercial firm she co-founded with Warren Weiser, 51 percent of its 120 employees are female. Two of its six partners are women, and half of its department heads are women. More than 60 percent of CREC’s property managers are women, and 26 percent of the company’s brokers are women. “There are just such high barriers to entry otherwise, so we’ve created our own system,” Brooks said.

Her approach to nurturing female talent development has paid off in the eyes of Sabrina Stimming. Brooks mentored Stimming, who started as an executive assistant and was promoted to marketing assistant, then marketing director. An opening appeared in retail leasing, and now Stimming is director of retail leasing and a partner at CREC. She believes that had she started her career at a traditional brokerage like a CBRE, “it’s probably not likely I would be a head of a department there.”

“If you look around at other firms in our industry, the only women you see in any sort of leadership positions are women who form their own companies,” Stimming added.

Without a mentor, Collier’s Mattingly developed her own strategy for success that many women in the industry adopt: Be the best at the job. She’d pick a neighborhood or area and become an expert on it. “I picked Sunset Harbour, which I liked at the time, and I farmed the fuck out of it,” she said. 

From Metro 1, where Mattingly started in 2006 as a commercial associate, she went to Sterling Equity Commercial, where she’d “transact all day off-market, but no one would trust me with big listings.” She eventually represented Moishe Mana in nearly all of his acquisitions in downtown Miami’s Flagler District, which to date has totaled $267 million on 1 million square feet of building space and eight acres of land.

In 2016, Mattingly joined Colliers and is building her team out of an office in downtown Miami. Although it’s not her own company, it’s clear that she’s running her own operation out of the ground-floor retail space on Flagler Street. She said she’s teaching her team to become neighborhood experts, as she did, by learning every property and zoning before they start selling.

Tere Blanca, founder, chairman and CEO of Blanca Commercial Real Estate, also wants to nurture female talent. She left Cushman & Wakefield to start her own firm in 2008 and is responsible for mentoring everyone in the 22-person office, including a few female agents. In her view, the lack of women in the field may stem from them just not knowing about it. “I don’t think a lot of young women understand the opportunities that exist in the industry,” she said.

Ellis-Cutler and some of her colleagues at CREW-Miami introduced themselves to a group of high school girls by telling them, “We don’t sell single-family homes. We can sell the entire multifamily building.”

CBRE created its Women’s Network in 2000; it now has 3,500 members nationwide and hosts quarterly events. The gender gap at CBRE and other major commercial brokerage persists, but Karson acknowledged that the firm’s numbers are going up.

Forging ahead

While women in commercial real estate today see some struggles and disparities, JLL’s Black said the industry has grown to include more women since she got her start in the early ‘80s. “The one thing I’ve noticed is that women feel more empowered to say to their peers or their managers, ‘Hey, that was an off-color joke’ or ‘I didn’t really like the way you said that about me.’ Women are using their voice now to explain that it’s not right,” she said.

However, Black sees two areas where female representation is lacking: tenant advisory and capital markets, both of which are especially profitable sectors of the business. “That’s predominantly still occupied by men, but in time that will change,” she said.

Jain is also optimistic about closing the gender gap in development.

“We’re starting to see more women take on those roles within their families and more women who want to be developers,” Jain said.

from The Real Deal Miami https://therealdeal.com/miami/issues_articles/bridging-the-gender-divide-in-commercial-real-estate/#new_tab via IFTTT

[kristinsimmons]

The Evidence Crisis: Causal Inference – Don’t be a chicken (Part 3)

By ANISH KOKA

Part 1

Part 2

Physicians have been making up numbers longer than people have been guessing weights at carnivals.  How much does this statin lower the chances of a heart attack? How long do I have to live if I don’t get the aortic valve surgery?

In clinics across the land confident answers emerge from doctors in white coats.  Most of the answers are guesses based on whatever evidence about the matter exists applied to the patient sitting in the room.  The trouble is that the evidence base used to be the provenance of experts and anecdotes that have in the past concluded leeches were good for pneumonia.

And so came the randomized control trial to separate doctors from homeopaths.  Random assignment seeks to achieve balance between two groups for everything but the treating variable to isolate the effect of the treatment.  But does randomization really guarantee a balance between groups?  At least the known confounders may be measured in the two groups, but what about unknown confounders?

Consider some examples:

Blood stream infections are currently treated by antibiotics targeted towards the specific organism found in the blood.  The distribution of organisms within the blood stream is as follows:

Vancomycin is active against S.aureus, Coag Negative Staph (CoNS), and other gram (+) organisms.  Cefepime is active against Gram negatives.  Now imagine a world where there was no understanding of the different organisms that caused blood stream infections, and an earnest researcher seeking to do right by patients with blood stream infections ran a trial which randomized all blood stream infections to either Vancomycin or Cefepime.  In the beautiful table that would accompany the published article to demonstrate balance via randomness of age, sex, gender and perhaps some type of frailty index, the most important factor – the type of organism – would be missing.  What we don’t know in this case drives the outcome.  A trial with a high population of homeless patients could have a very different distribution of organisms than a trial performed in suburban patients in the rich Mainline of Philadelphia.  The inability to generalize a trial of mainline moms to other populations means a trial fails to have external validity.  There are other problems as well.  Perform a large trial that combines the homeless with suburban soccer moms and the average treatment effect loses meaning unless you are a clinician that may randomly take care of a mainline mom or a homeless person on any given day.

But if we knew of this difference in organism prevalence between populations prior to trial initiation, and an analysis of these groups was prespecified, at least there is hope.  Our statistical friends could then very easily account for the difference at the end of the study.  But what if we were unaware of this difference?  We would then have to hope that randomization ensured that unknown confounders spread themselves similarly between the two groups.   Statisticians, interestingly, are unconcerned about the spread of unknown confounders between two groups.

A game of dice

Stephen Senn, the grand emperor of statisticians famously explains this using a game where 2 fair six sided dice are thrown, and the observer is asked to guess the probability the sum of the die will be 10 under three conditions.  In the first condition we are asked to guess the probability of this as the two dice are thrown.  Since there are only three out of thirty six combinations that will work (4/6, 5/5, 6/4), the probability is 3/36, or 1/12th.

In the second condition, the first dice is cast and the number revealed prior to guessing.  In this case if the first die roll is 1, 2 or 3, the probability of getting a 10 is zero.  But if the first die cast is a 4,5 or 6 the probability of a 10 is 3/18 or 1/6.   In the last condition (Variant 3), the first die is cast but the observer is not told what the number is.  Since we don’t know what the first die roll is, the probability here is the same as the first condition.

The moral of the story, Senn tells us, is that we should not throw knowledge away once attained (we can’t and shouldn’t pretend to unsee the roll of the first die), but not knowing doesn’t create a fatal problem because the probability distribution of an outcome is the same whether there is an unknown confounder or not.  So covariates/confounders that could have an effect don’t really have to be balanced between the two groups as long as the distribution of the outcome in the two groups is the same.

This sounds good, but to return to the blood stream infection example, this is like saying that it doesn’t matter what the distribution of vancomycin susceptible organisms were between two groups as long as we don’t know the distribution of organisms.  Statisticians get frustrated with this line of reasoning from ‘algebra challenged’ physicians.  I sympathize.  I’m frustrated with statisticians that are ‘medically challenged’.

Regardless, we have to operate and deal with what we don’t know in the real world, and the point that I gather from Senn is that it is always better to know, but if you don’t know, randomization is your best bet to getting at the truth.  It would also seem that randomization is the best chance for an even distribution of unknown confounders between groups.

Unfortunately, even with all of this a perfectly balanced RCT is no protection to falling prey to false inferences.

Purposeful blindness

Consider the real life case of strokes and patent foramen ovales (PFOs).  PFOs are small congenital connections between the right and left atrial chambers of the heart that persist in ~25% of adults.  In the fetus, this connection is a vital conduit that allows the immature, nonfunctioning lungs to be bypassed.  In adults, this connection closes, and the lungs become not just the oxygenator of the body, but also serve as a filter for little clots and debris that frequent the venous circulation.

As our ability to see this connection developed with the advent of ultrasound, clinicians began to report cases of blood clots transiting through this connection from the right heart to the left heart.  This is a problem because the left heart pumps 1/5th of its blood volume to the brain, and so a cerebral embolism (or stroke) is the feared complication of clots that find their way into the left heart.  When a much higher proportion of patients than expected (40%) with uncertain causes of stroke were found to have a PFO, clinicians suspected these conduits as the cause of the stroke.

In response, cardiologists began closing these connections via catheters that delivered ingenious little double umbrellas to the heart.  Unfortunately, as the experience with these devices closures grew, it turned out that there were possibly other causes of stroke in this population.  Closing a PFO in someone who had a stroke because of a certain type of arrhythmia of the heart made the device company that sold the closure device happy, but did precious little else.  Three randomized control trials comparing PFO closure with medical therapy were carried out to test the prevailing strategy of PFO closures – CLOSURE 1, PC, and RESPECT.

All three were negative trials.  The prevailing wisdom suddenly became that there was no evidence that PFO closures worked in preventing recurrent strokes.  The American Academy of Neurology even put out a position paper arguing against PFO closures. Yet, I read the same trials and arrived at very different conclusions.  There were major issues with the trials that explained the negative results to me.  The CLOSURE 1, and PC trials included patients with Transient Ischemic attacks (TIAs).  For those who don’t know, TIAs are brief neurologic episodes that don’t last long enough to be considered a stroke.  Numbness and tingling on one side of the face could be a TIA, or it could be nothing.  Subjectivity reigns even among neurologists about this diagnosis, and it seems imminently plausible that many of the patients enrolled in these two trials had PFO closures for events that may not have been neurologic.  These first two trials also included patients with lacunar strokes – small strokes that could be a result of hypertension, high cholesterol or advanced age rather than embolism of a clot.  The last trial of this initial set of three studies -the RESPECT trial – sought to rectify the errors of its predecessors by excluding TIAs, and lacunar strokes.  They also sought to analyze the risk of stroke as it related to the size of the PFO.  Not all PFOs are equal – some are very small defects that only allow a minimal passage of blood, while others are much larger conduits.  The reasonable presumption was that most of the benefit to closing PFOs came from closing the large PFOs – the subset analysis would allow an analysis of this potential heterogenous treatment effect.  Strictly speaking, the RESPECT trial was a negative trial – another disappointment.  No statistically significant difference in was found between the PFO closure group and medical therapy group.

There were half as many strokes in the closure groups – 9 strokes in the PFO closure group, vs. 16 strokes in the medical therapy group.  But the trial was reported as negative because when comparing those assigned to the closure device vs. medical therapy, the hazard ratio crossed 1, and the p value was a little over the magical and somewhat arbitrary 0.05 threshold.  The analysis also took the form of the conventional ‘Intention To Treat (ITT)’ where patients are analyzed based on their initial assignment rather than the treatment that was ultimately received.  While this is statistically pure, it does not account for the fact that 4 patients who suffered a stroke after being randomized to a PFO closure device had a stroke while waiting to receive the device.

Effectively, the four strokes were ‘blamed’ on the PFO device.

RESPECT Trial Outcomes

One common explanation for analyzing by ITT is that ITT may best simulate the real world effect size when clinicians assign patients to a certain treatment.  While that is possible, it could also be that clinicians respond to this data by placing closure devices more expeditiously.   Not counting the four strokes that happened before the closure device was placed, (also called as treated, or the per protocol analysis) the numbers (5 vs. 16) did reach statistical significance.  Also not reflected in the yes/no world of clinical trial reporting in journals was the fact that of the 5 patients with a device that had a stroke, only one was considered moderate, or massive, compared to 9 in the medical therapy arm. Finally, the  subgroup analysis of the size of shunt, confirmed that the larger the shunt size, the higher the risk of recurrent stroke, and the greater the benefit of closure.

The other important point was that while closing the PFO may be an effective strategy to prevent recurrent strokes, blood thinners like coumadin to prevent blood clots from forming in the first place were another option supported by prior observational data.  The three initial RCTs had allowed participating investigators free reign with regards to choice of medical therapy in the medical arm – some chose antiplatelet drugs and others chose anticoagulation.  It seemed very unlikely  that closure devices could outperform systemic anticoagulation – yet another possible reason for the lack of effect of closure devices seen.

To me, the RCTs were helpful in confirming who likely had a small or no benefit to closure- patients with TIAs/lacunar strokes and small PFOs.  I wrote about the saga – and concluded that PFO closures were a good option in patients with large PFOs who had suffered a stroke and were loathe to be on blood thinners.

Much of the neurology community and many EBM experts ignored the subtext and focused on the lack of statistical significance.  Luckily, the clues readily apparent to me were also apparent to folks far more significant than me.  The longer term results of the RESPECT trial was enough to convince an FDA panel that despite the lack of statistical significance, there was a clear signal for clinical significance to merit approval of PFO closures for preventing cryptogenic stroke after a careful evaluation to rule out other causes of stroke.

But since we live in a world where no story is settled until an RCT is positive,  unbeknownst to me there were additional trials taking place to prove to the god of epistemology (currently a part-time oncologist in Oregon) that PFO closure devices were indeed beneficial.  In the Sep 14, 2017 issue of the New England Journal of Medicine – three RCTs were published.  One of the trials was a long term follow up of RESPECT that now showed a statistically significant benefit of PFO closures.  The two other trials were the GORE-REDUCE, and the GORE-CLOSE trial.  These latter trials enrolled mostly patients with large PFOs and strokes.  The GORE-CLOSE trial randomized patients to antiplatelet therapy only, PFO closure, as well as oral anticoagulation, while the GORE-REDUCE trial compared PFO closures to antiplatelet therapy.  Clearly the investigators had learned from the prior missteps, by focusing on larger PFOs, sidestepping the subjective nature of TIAs,  and mandating a treatment arm that consisted of antiplatelet therapy only.  Apparently there was clinical equipoise to do this.

Nonsense.

The RESPECT trial should have confirmed to those paying attention that patients presenting with a stroke and a large PFO should NOT be treated with antiplatelets only.  The only folks with equipoise here were those that were logically challenged or those that allowed EBM to suppress what should have been intuitive.  There was a price to pay for suspending logic.  In the GORE-CLOSE trial, which at least allowed for an anticoagulation arm,  14 patients in the antiplatelet group had a stroke, compared to zero in the PFO closure arm, and two in the oral anticoagulation arm.  In the GORE-REDUCE trial 12 patients had a stroke in the antiplatelet only arm, compared to six in the closure group.

So the positive signals gleaned from the original ‘negative’ RCTs had been on the mark.  The perfect balance of the known covariates in the trials had provided no protection against an erroneous inference.  As the subsequent positive trials demonstrated, the initial analysis that got it wrong wasn’t derailed because of unknown confounders, known confounders, poor randomization, or inaccurate average treatment effects.  It was a failure to ask why.

Bertrand’s Chicken

As physicians, it has become our practice to bring experience and personal observations together to allow us to doctor patients.  The fallibility of eminence and personal observations lead us to the realm of hypothesis testing and RCTs.  The idea was that adding this interlocutor would bring us closer to the truth, or at least result in fewer dead ends.   In reality we only ever had the illusion of a more certain truth.  It turns out that regurgitating the weekly New England Journal of Medicine conclusions fortified with p values may have been far less valuable than I thought as Ioannidis and others document.

Bertrand Russell, British philosopher, logician and mathematician wrote about these very same difficulties as it relates to the simple chicken.  The chicken bases what he expects on his experience.  Every day the farmer shows up and food appears.  To the chicken what happens tomorrow is based on the sum total experience of all the days before.  The chicken fully expects the farmer to come tomorrow with food because that has happened every prior day of existence.  Except tomorrow is the day the farmer arrives and wrings its neck.  The chicken got it all wrong.  Before scoffing too much at the chicken’s primitive way of thinking, consider that Russell started his chapter on the problems inherent with inductive inference by asking us to consider why the sun should rise tomorrow.  If your answer is because it has risen every day prior, you are guilty of chicken-headed thinking.

Unfortunately RCTs and null hypothesis testing would serve to advance neither the chicken’s search for the truth or ours, unless we ask questions that lead us to cause.  For this it is important to know why.  Understanding cause has little to do with what happens.  We reduce ourselves to chicken-headed thinking if our efforts are directed at what happened.  Chickens know what happened, what beasts of nature fail to understand is why things happen.  The analogy in medicine is to observe the initial PFO closure trials, note no statistically significant difference, and go no further.  This is chicken-headed.  Dive deeper, understand why the inclusion of patients with TIAs may have resulted in patients without cerebral embolic events being included.  Don’t dogmatically attribute strokes to PFO closure devices if they happen prior to the device being implanted.  And please don’t smugly discount the observations of thrombi transiting through PFOs into the left side of the heart, and the subsequent stroke that happened as true, true and unrelated.

Yes, biological models (leeches for bad humors) have been wrong, but don’t discount all future proposed models out of hand because of it.  By all means allow data in its many forms (case series, anecdotes, parallel control RCTs, adaptive design RCTs, etc. ) to modify, sharpen, or even discard a model.  But don’t give up on models, don’t give up on seeking out why, and please don’t listen to this guy –

Change medical school. Teach EBM first, pathophysiology later. Make students care about whether something does or doesn’t work before they care about why.

— Kenny Lin, MD, MPH (@kennylinafp) April 19, 2018

The common refrain from some quarters is that statistics has come a long way from Fisher’s t-test and the basic parallel controlled randomized control trial.  Different trial designs as well as methods to analyze randomize control trials post-hoc to account for some of the weakness discussed abound.  Bayesian statistics seeks to incorporate various priors – optimistic, neutral, skeptical – to arrive at a range of posterior probabilities.  I am sympathetic to the number crunching whiz kids earnestly trying to help us arrive at scientific truth by better parsing what the data tells us.  But it is a mistake to think that the heavy lifting needed to understand the recent randomized control trial comparing ablation for atrial fibrillation to placebo that had 30% of patients crossover to the treatment arm will come via instrumental variables or something that sounds even sexier.  The closest we can hope to get to the truth at any point in time will lie somewhere within the community of physicians managing patients with atrial fibrillation because they are best able to provide the context any one study needs.  And while this certainly introduces bias and subjectivity into the interpretation of results, it is neither possible or wise to eliminate this.

The move to strip biases, to fight instincts, to discard knowledge at times painstakingly acquired outside of the hallowed RCT construct is ultimately misguided.  The current crisis of evidence will not be soothed by analyzing data better, or by stripping the biases of clinicians.  The words of Bartlett as he explained his reasoning for proceeding with the ECMO RCT should be chilling: ” we felt compelled… we knew that 90% of patients assigned to the control group would die..”  It should have been enough for Bartlett to convince his peers in the intensive care unit of the value of what he was doing.  Statisticians, hospital administrators, and insurance carriers have no business demanding ‘higher’ levels of evidence here, in part because they are woefully unqualified to evaluate any evidence that’s even compelled to be produced.   The creation of clinical equipoise by statisticians who can never be certain of anything is a self defeating proposition.  Causal inference comes from searching for the why of it. If 200/10000 patients exposed to a certain meteorite are stricken with cancer, and only 10/10000 patients not exposed get the same cancer, the question that should consume the clinician and researcher is why this happened.  Why didn’t all 10000 patients in the affected neighborhood get cancer.  What could the underlying mechanism be?  Is there an activator of some kind common to the 200 unfortunate patients?  Do they share some genetic code that predisposes them to being stricken?  Not asking these questions, or proceeding with blinders on to test random treatments in a hundred RCTs lowers us to the level of chickens.  The less we think as chickens, the better.

  Anish Koka (@anish_koka) is a cardiologist in private practice in Philadelphia.  Many thanks to those who provided comments including David Norris (@davidcnorrismd), Saurabh Jha (@roguerad), and John Tucker (@JohnTuckerPhD).  Insights/examples gleaned from the wonderful works of Stephen Senn (@stephensenn ), William Briggs/Uncertainty. Errors in translation of concepts are solely the fault of @anish_koka.

The Evidence Crisis: Causal Inference – Don’t be a chicken (Part 3) published first on https://wittooth.tumblr.com/