This aphorism has been around since about 1600, originating with Voltaire in French. I have found it to be a useful concept – not an iron-clad rule, but an excellent guiding principle. The perfect is the enemy of the good (sometimes “good enough”).

What this means is that we should not be paralyzed into inaction because we cannot achieve a perfect solution to a specific problem. The idealized perfect solution becomes an obstacle to solutions that are adequate, or at least an improvement on what we have now.

In reality this can be a tricky principle to apply, however. Like the informal logical fallacies, or any informal guideline for clear thinking, there are no rigid rules or definitions. Judgement is required, which means that subjectivity and bias are also involved.

There are two specific ways this principle is either applied to not applied that tends to come up with skeptical topics. The first deals with our own activism – when should we apply this principle?

For example, over the years I and some of my medical colleagues have had a disagreement about how best to approach topics like vaccine exemptions. We all agree that non-medical exemptions decrease vaccine compliance and are a threat to public health. We all agree that in a perfect world states would not allow non-medical exemptions (only exemptions for children who medically are unable to be vaccinated).

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A recent JAMA article is an update on a systematic review of overused interventions in medicine. They list the top ten overused tests and treatments, meant to highlight this problem in medicine. They conclude:

The body of empirical work continues to expand related to medical services that are provided for inappropriate or uncertain indications. Engaging patients in conversations aimed at shared decision making and giving practitioners feedback about their performance relative to peers appear to be useful in reducing overuse.

You can read a summary of the ten overused interventions here.  The one you are likely already familiar with is antibiotic overuse. The others are very specific tests or interventions in specific situations, like Computed Tomography Pulmonary Angiography to help diagnose acute pulmonary embolism.

Reviewing each of these interventions in the top ten list would require a deep dive into the literature and detailed discussion, which is not my intent here. If you want that level of detail, read the original article. What I want to discuss is, in general terms, why this is a problem in the first place.

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After every mass shooting there is a renewed debate and call for better gun control, and pushback from gun owners who say, “Now is not the time to get political,” and “There’s nothing we can do to stop gun violence, it’s the price of freedom.” Then precisely nothing happens until we get distracted by something else and forget about gun violence until the next headline-grabbing shooting.

Clearly whatever we are doing is not working, and it is the oft-cited definition of insanity to do the same thing and expect a different outcome. So what are we doing wrong?

First, we have to acknowledge that there is a problem. There are about 33,000 gun deaths per year in the US. This is more than any other wealthy country – only war-torn banana republics have higher rates of gun deaths. There were 477 mass shootings in the US in 2016.

About two thirds of gun deaths are from suicides. That is a large portion, but that still leaves 11,000 non-suicide gun deaths each year in the US. Gun homicides are a huge problem, not diminished at all because gun suicides are an even bigger problem. About 20% of gun deaths are crime and gang-related homicides, mostly young men killing other young men. Also, about 1,700 women are killed each year from gun-related domestic violence.

I reject the notion that this is the best we can do, that this is the price of freedom. Other Western democracies seem to enjoy freedom without anything close to the same rate of gun violence. So why has this been such a hard problem to solve?

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Remember that time Sarah Palin said:

“[tax] dollars go to projects that have little or nothing to do with the public good — things like fruit fly research in Paris, France. I kid you not.”

OK, she was actually referring to the olive fruit fly, Bactrocera oleae, not the staple of genetics research, Drosophila melanogaster. The comment is still a legitimate target for criticism because it is not clear that Palin understands the difference (or she wouldn’t have said it that way), her statement seems to imply that scientific research into the humble “fruit fly” is a waste, and she is generally anti-science (when it conflicts with her ideology).

At the time of her statement many scientists and reporters delighted in pointing out how central fruit fly research has been to scientific advancements. Well, we can add another example from this year’s Nobel Prize in Physiology or Medicine. The prize goes to three American scientists, Jeffrey C. Hall, Michael Rosbash and Michael W. Young, for their work on the circadian rhythm.  Continue Reading »

Elon Musk is an interesting guy. Also, because of the success of SpaceX, when he makes promises about future technology, it is at least worth a listen. At a recent meeting of the International Astronautical Congress Musk stated that he plans on developing SpaceX’s rocket technology for commercial transportation between cities on Earth. He also made a promotional video.

The idea of using rocket travel for long distances (instead of jets) is not new. It has been featured in various science-fiction views of the future or even alternate realities of the present. The obvious advantage to rocket travel is that it is fast. A suborbital trajectory can get you between almost any two cities on Earth in 30 minutes or less.

This is all part of SpaceX’s new project, the BFR (I could not find anywhere exactly what that stands for – just the implication that it’s “Big Fu**ing Rocket”, which is awesome). Musk wants to stop developing his Falcon series of rockets and focus entirely on one rocket system to do everything they need to do – the BFR. The idea is that this will help reduce overall costs.

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