The next day at work, Patricia comes to a grim realization. The bosses of the hospital consulted with the patients and their families because the medical staff didn't agree with the logistics of implementing the protocol. Mostly on how it should be triggered, and what steps to take. Some people wanted nothing to do with it because they feel it's not a matter of mental health. Others didn't agree on who should be exempt, even if they mostly agreed on the criteria, namely that screening for educational issues shouldn't take place until the patients recovered sufficient mental health. The deadline for test providers to submit bids is fast approaching and we need one last member on the selection committee. Quick! I'll circulate a memo about who should be on it! Patricia muses, while reviewing the criteria.

The primary criterion is, of course, that the final committee member should have a working knowledge of psychometric testing and continuing education. On which she admits her knowledge is a little shallow.

Because the main criteria of the request for proposal was that the test would test for functional literacy and numeracy, use computerized adaptive technology, have a high level of reliability, can be partially administered and be billed on a per-administration basis. Beyond that, she wanted the process to be done in good faith, but couldn't tell which test would be more appropriate for the pursuit of continuing education.

At lunch, one of the inpatient rehab counselors running the financial literacy training workshop approaches her:

"Hi Patricia. My name is Deepak, and, although I personally believe this protocol of yours to be deeply flawed..."

"What makes it flawed to you?" Patricia asks Deepak, a little defensively.

"It's as if you were clueless about how people worked. If you knew people better, you would know how to pick out the sort of weaknesses you're looking for without having to administer that kind of screening tests" Deepak retorts to her.

"I get it, Deepak; however, not everyone in the medical staff can do so at the same extent as you do. And I found that too subjective as well. For instance, all I can make out of the trauma aspect is that understanding the personal circumstances of the patient is key to resolve it. Beyond that, I am of no use" Patricia retorts, knowing that she would not be a good counselor or therapist.

What Patricia referred to as "too subjective" is called, in the world of psychometrics, low inter-rater reliability. IRR is about how much the results of a test will be consistent when administered by different people. As for computerized adaptive testing, it promises high IRR while, at the same time, allow for higher sensitivity and specificity. It also makes the difficulty of the next set of test questions go up or down based on the results of the previous set.

"I help run the financial literacy workshop believing it would help my career somehow. In the past, these kinds of issues flew under the radar and then some families filed complaints. But what makes you think that..." Deepak pauses and he catches his breath. "Directing patients to specific continuing education resources would be in the patients' best interests?"

"The initial protocol called for exemption from screening based on some educational attainment benchmarks. Then the patients and their families forced our hands, and so the final version calls for medical personnel to notify the patient and family first, and later ask the patient's approval prior to testing" Patricia rambles on the changes made. "What's in their best interest is ensuring they have adequate education: we have all seen what challenges patients face once rehab ends. So I'll ask this once: is there anyone else you know who would know better about continuing education?"

To this, Deepak draws a blank. He seems a little skeptical not of continuing education per se, or even of whether it can help recovering addicts, but of something else surrounding the aims of continuing education. Ainslee? She's too close to Patricia, because she's also part of the Congressional debate club. Preferably staff who deals with the later stages of rehab; they historically played had more of a hand in addicts' continuing education. Who's left that has a working knowledge of such? Deepak reflects on who he could ask to serve on this committee in his stead.

"For us, continuing education carries two meanings" Deepak explains to Patricia. "You're kind of implying the version for people who dropped out of high school and want to resume their education"

"Especially when even the initial version of the protocol specifically exempted people who successfully passed at least one credit hour of college-level coursework in quantitative or writing-intensive subjects for numeracy and literacy respectively, among other things" a Patricia on the defensive about what continuing education means to an addiction counselor. She definitely wasn't in the mood to talk about the exemptions any further.

"In that case, I guess we don't have a choice" Deepak sighs. "I'll serve on this stupid committee so that I never have to deal with you again!"

There's always career readiness to consider, but in my mind, poorly educated people would not be able to take advantage of vocational training, at least not to the extent we would like, Patricia muses while she gives Deepak the time and place of the committee meeting. In addition, she asks the committee chair to give him access to a spreadsheet of the bids. Said spreadsheet contains information on the manufacturer, the prices, their reliability levels and the range of content covered by section.

Also, test reliability, in psychometrics, has two components: specificity and sensitivity. Specificity means, in this context, the test's ability to correctly identify those who don't have academic weaknesses, and sensitivity means the test's ability to correctly identify those who have academic weaknesses. Of course, the dreaded test anxiety makes it so that no educational screening test will be perfectly sensitive.

-----------------------

That night, she gets strident voices in her dreams, under the forms of three of the most famous ChGK players in history. She was seated in the hunting lodge at the Neskuchny Garden in Moscow (a.k.a. the studio where the Russian TV show is taped) alongside 5 oneiric players.

"We declare the Decisive Round!" the oneiric captain shouted in a strident voice. "We designate Patricia to answer the question"

Declaring the Decisive Round is a risky move, but at the same time, resets the score and the question is worth all 6 points. I am not sold on Patricia as a znatok (expert); she works with narkomany on the Kansas prairie, another oneiric player thought, secretly questioning the captain's Decisive Round Declaration.

These 3 ghosts from ChGK history were standing some distance away from the round table as the roulette was spun. And there happened to be 3 questions remaining on the roulette: the 13th sector, the superblitz and an ordinary sector question. So it's an opportunity to transform a 6-5 game into a 6-0 one... no matter who I picked to answer the question, declaring the Decisive Round makes me nervous, the oneiric captain mused while the roulette landed on the superblitz. Even if the regular blitz was available, any blitz automatically becomes a superblitz in Decisive Round.

The first of these ghosts, Alexander Druz, read the first question in the superblitz in a strident voice: "It isn't related to walking, but alkogoliki (alcoholics) are often directed to one of these, and even then it may not be enough to recover from their zavisimost (addiction) after. What is it?"

"Pospeshnyy otvet! (Early answer!)" Patricia then shouted, in a Russian laden with a heavy Kansas accent, hoping that it would give her an extra 20 seconds on a future question in the superblitz. "Programma iz dvenadtsati shagov! (Twelve-step program!)"

"Pravil'nyy (Correct)" the second ghost, Maxim Potashev, ruled. He later asked the second question in an equally strident voice compared to Alexander's. "This rock caused two epidemics over fifteen years apart. What is this rock made of?"

A rock causing epidemics would contain toxic substances. But we can rule out industrial use since the epidemics happened 15 years apart. That said, drugs can become fads in different areas. That's it! Drugs! Crack is sold in small rocks, cocaine is sold in powdered lines, Patricia reflected on the possibilities when the 20 seconds are up. "Krek-narkotik (crack-drug)" Patricia then answered, facing the camera, again in a Kansas accent.

One last ghost. One last superblitz question. Everyone in this oneiric TV set was shaking, either in their seats or standing around the table around the 6 players. What viewers would have, in this dream, watched this game, harbored hopes that Patricia would answer this final superblitz question correctly.

Anatoly Wasserman, the final ghost, would then be reading the third and final superblitz question for Patricia to answer, in a strident voice reminiscent of the other two: "This medical condition occurs in patients in early stages of zavisimost recovery. One of the names used for the condition in English is a part of an animal. What's the condition?"

Why is it that, even in dreams, somehow, drugs and addictions come up in a dream about TV-ChGK? This does not look like questions on the TV show at all. Medical questions are rarely asked in ChGK, TV or competitive. As stand-alone questions in competitive play, this is nothing like the kinds of questions we would be expecting at even Nats, except for blitzes. But a condition occurring in early stages of recovery and is named after a part of an animal? Patricia's mind started racing with all speed, but her oneiric self began sweating.

Also, her brain's activity increased as she entered a trance-like state, sorting through her knowledge of medical conditions occurring in early stages of addiction recovery. Fifteen seconds later, with the heartbeat of her oneiric self getting louder as her brain guzzled her energy, the siren rang.

"Postabstinentnyy sindrom! (Post-acute withdrawal syndrome!)" Patricia's oneiric self shouted, after snapping out of this brief trance. The ghosts then tell her about how uncommon it is for znatoki (experts) to win a superblitz, before Patricia's physical self awakens in the middle of the night.

-----------------------

The following day, the selection committee meets in a conference room with the clinical operations vice president as its chair.

"Good day everyone. it appears there aren't a whole lot of bids being fielded, and so it should be quick" the clinical operations VP then greets the other two, shaking hands with each one individually.

"Personally, I'd say that, to achieve financial literacy, algebra, data analysis and statistics are what matter most. I can forgive the test we pick today not being so good at testing geometry" Patricia then begins her discussion of what she really wants out of the winning bid.

"But why did you insist on having the option of paying on a per-administration basis?" Deepak questions Patricia, believing that savings could be achieved if another option is used, allowing for a flat fee covering a certain number of administrations, and paying extra for any extra administration thereafter. He then shows a slide with cost forecasts. "Here are forecasts on how many such tests we administer, based on the patient volume we serve"

"It's easier for us to manage billing; under a package with a fixed component, it becomes harder to bill patients accurately" Patricia then adds to his forecasts. "So you expect half the patients to be screened?"

"Against my better judgment, I'd say that more than half will not be covered by exemptions. But not everyone will be screened since a few patients will object. That, even though I know that people with lower educational levels will check in here more" Deepak adds to this analysis.

"But let's go back to the content of the test. Ideally what do you want out of the test?" the clinical operations VP then asks the other two committee members. "The bids we got didn't cover the same material, so we need to sort that out first"

The real kicker that made the bidding process more manageable is the requirement of the administrator being able to choose between partial and total administration, Patricia muses, while trying to formulate an answer for the literacy part of the test. Frankly, adding in the option of partial or total administration doesn't add up to nearly as much as quality assurance in the development costs, Patricia gets much more puzzled while she reflects on another aspect of the whole process than she would have liked.

"Reading and writing at a sufficient level to be able to function in a career and in everyday life" Deepak formulates his answer while Patricia tries to come up with hers.

"On that count I'd say that, for the literacy portion it will look very much like the SAT of the early 2020s if it has all the features Deepak talked about. I already said what I had to say on the numeracy part" Patricia then tells them.

So while Patricia might not agree with me on whether a formal protocol is required to screen for these shortcomings, she mostly agrees with me on what we want out of continuing education. She says she doesn't know a whole lot about it, but what she's truly clueless about is actually far more specific. It's about how mental health conditions make learning more challenging to reach the objectives set forth in the patient's individualized education program, or IEP, and whether providers can comply with it, Deepak muses, based on what Patricia had to say on the topic.

"Personally, I'd say that the best test offers the best balance between reliability and cost, provided it tests content as you both want" the clinical ops VP tells them. "As soon as we decide on a test, your involvement is over. However, the final version of the educational weakness screening protocol comes into effect after the medical personnel has been trained. It shouldn't be that long precisely because of a requirement Patricia set forth"

They also realize that marginal patients (i.e., patients who come close to the thresholds set forth for literacy and numeracy in either direction) fall under a gray area. But the rest of the meeting is actually pretty rapid, and they could agree on a test provider. Deepak wastes no time voicing his dissatisfaction towards Patricia at the end of it:

"Patricia, I start to feel like you are using me for your own career benefit!" Deepak shouts at Patricia, with his face turning red.

"Of course not. It's in the patients' best interests that we know who actually needs IEPs, and for what. The protocol has only introduced a screening stage prior to the IEPs but hasn't really changed how IEPs are drafted and adopted. That must consider the personal circumstances of the patient, much like the treatment of mental health conditions. But that's all I know about IEPs, and I am not involved in those, not even for outpatients" Patricia retorts, trying to deflect the topic to something else altogether.

"Outpatients often have educational or job obligations to attend to. But by no means everyone. Yet just because you don't intervene in the treatment proper, doesn't mean you're not using me for your own career benefit!"

"Must I remind you that your career benefits if you take an active role working on bigger issues that directly concern your work, or your patients? You were involved in this process since the initial version was presented to the addiction medical personnel!" Patricia seems to lose her cool. "We both benefit, but not in the same ways"

"Fine, I'll return to my patients" Deepak then storms off back to the inpatient addiction ward.

Let's see: we gave a month to have the survey circulated among patients and their families, then revised it based on patient and families' feedback, plus another month to field the bids for these tests we picked out today. The finance folks will approve it without a hitch now that all the regulated steps are made, Patricia reflects on the timeline of this entire plan. Now I know I cannot expect rapid changes in the healthcare sector as would be the case in the manufacturing sector. My role in this is essentially over for now. So finance and IT is responsible for the following steps, in that order. Deepak must resent me by now. In the rest of my day-to-day work, I don't interact with inpatient staff much. But the issue was just too big to pass up, and too big to just be about outpatients!

She also realizes it will take weeks to install the required software in the computer lab and then train the medical personnel that have a hand in preparing IEPs, like Deepak. So it won't be until late November that the first patients will be tested. In other words, it will be a few more weeks until this protocol is implemented in full, and a few more months to yield results.

-----------------------

A few hours later, when dinner time comes with Ainslee before the Congressional debate session of the day:

"Patricia, my patient made cookies for us. I assume you have no objections to eat cookies first" Ainslee then tells her.

"Your patient who dropped out of culinary school, I guess?" Patricia asks her colleague. "You never told me her name, but I might have had her in my chamber once or twice without knowing she's your patient"

"Actually, you never had that patient in your chamber because she always was in mine. Her name is Catria" Ainslee then tells her.

"Last night, I dreamed of being on ChGK (the TV show) and I brought victory in a ChGK game by answering a superblitz of three questions about drugs and addictions. But really, ChGK is a team riddle contest at its core" Patricia the continues while grabbing a cookie.

Catria... ah yes, that addict who started drinking by gorging on cooking wine! She has grown as a Congressional debater, but for each Catria, I have at least two or three delusional patients who seem to get too much into being Congressmen, but by now we went beyond health issues in our bills. One bill is about a federal issue and the second is about a state issue, but the third bill, introduced if time allows, is about a health issue at either level, Ainslee reflects on what the club is now doing. Civic illiteracy runs rampant even among the drug-free population, and certainly the mentally ill, so here's our chance to kill multiple birds with the Congressional debate stone.