The latest polls in this week before the Republican caucuses in Iowa show surprising levels of support for the presidential candidacy of Ron Paul. (Frankly, at this point in the fascinating prelude to the "silly season," with polling showing a dizzying sequence of "flavors of the month," I'm not sure we should be surprised by anything.) And so I find myself doing some reading about what Congressman Paul has to say (and has said over the years) about issues of importance to me.
Dr. Paul was an obstetrician/gynecologist before he went into politics. Despite the fact that he has now been in politics for many years (a member of the House as far back as the 70s), he has nevertheless been more than willing to tell people what he really thinks about a broad range of issues. This, for those of you who completely ignore the U.S. political scene, is most unusual.
There was an interesting recent thread on a listserv to which I subscribe, one whose members are interested in emergency care. My colleagues on this list go "off topic" (meaning they discuss things of marginal relevance to emergency care) quite often, which is maddening to some and quite entertaining to others. One of the frequent contributors is an ardent proponent of libertarian political philosophy, and he has taken opportunities to enlighten the rest of us about some of Congressman Paul's views.
Those who are disposed to challenge the libertarian perspective - and who don't much care for Ron Paul - have posted messages about controversial statements made by Dr. Paul over the years. And so a recent thread was launched (perhaps I should say spun, as one would surely find a challenge in the physics of launching a thread) about whether Paul believes in evolution.
It seems the good doctor has some uncertainties about this, and this has led many participants to draw conclusions about his critical thinking skills and about whether all of that education in the sciences was somehow lost on him.
So I did a bit of reading on the Web to find out what the congressman has actually said, and I find myself inclined to agree with him. Not about the soundness of the theory of evolution, but about its place in public discourse in the context of a presidential campaign.
The Republican caucuses in Iowa are strongly influenced by Christian conservatives, and these are people who typically have very definite views about evolution. They tend to believe that evolution and intelligent design are competing theories about how life as we know it came to be and that these theories should be taught side by side in public schools.
Professional educators - particularly those who run public schools - are fiercely opposed to this notion and say it is preposterous to expect teachers to present articles of religious faith alongside scientific theory with some sort of implication that they are equally "plausible" - when, in fact, they represent two entirely separate ways of thinking about life.
So it isn't possible to have a public discussion of evolution and creation and how these ideas relate to each other without getting into the morass that is the highly politicized and emotionally charged controversy surrounding public education and its connection to separation of church and state.
I might like to know what Congressman Paul has to say about that - and I consider it much more important than what he thinks about the theory of evolution. The libertarian position he espouses actually makes his answer to this question pretty straightforward: questions about evolution are strictly a matter of one's personal beliefs and inclination to think in scientific versus spiritual terms, not terribly relevant for a politician, unless one gets into the messy argument over public education, which can be largely avoided by getting the federal government entirely out of the business of public education and giving parents tax credits to let them choose whatever schools they want (or none at all, opting for home schooling).
Yet we will still have public schools (there seems no easy way around that), and so we will have state and local school boards making decisions about curricula. If they decide to include intelligent design, there will be challenges in the federal courts on church-state-separation grounds. Thus it becomes more important to ask Ron Paul how he is going to find Supreme Court appointees who agree with his originalist interpretation of the Constitution. That means what the framers had in mind, which was simply that there should be no official Church of the United States as there was a Church of England - not that religion or religious teaching should be excluded from all spheres of life touched by public dollars. And if he can find some, can he get the Senate to confirm them? Good luck with that, Congressman.
Thursday, December 29, 2011
Friday, December 23, 2011
A Lump of Coal from Medicare
If you're 65 or older, or the Social Security Administration has declared you disabled (or if you have chronic kidney failure), you are covered by the federal health insurance program called Medicare. This is a good thing: it has kept many millions of senior citizens from becoming medically indigent.
But there is a growing gap between what Medicare pays to doctors and hospitals for caring for its beneficiaries and what it costs to provide that care. There is also a gap, growing even faster, between what Medicare pays and what commercial health insurance (also known as "real insurance") pays.
This is not because commercial insurers are generous. Rather, it is because the federal government has decided that the way to slow the growth of the Medicare budget is to pay the providers of health care services less (in inflation-adjusted dollars) each year.
A large part of the reason so many hospitals struggle to stay in the black is that many of the services they provide to Medicare beneficiaries are paid for at rates so low as not to cover the cost of providing the care.
It wasn't always this way. In the 1970s Medicare paid hospitals for what they did, with a bit of a margin. This is called a "cost-plus" system of financing. But the feds decided that was much too expensive, and in the 1980s they implemented a new system in which hospitals were paid based on what was wrong with the patient. If they could care for the patient for less than Medicare paid for the patient's diagnosis by being very efficient, they did well. If it cost more than that to get the patient well enough to be discharged, the hospital took a loss. This was supposed to give hospitals an incentive to be more efficient.
But life is full of unintended consequences. If innovations become available that improve the quality of patient care, will hospitals use them? When the system of health care financing pays for the patient's diagnosis, not for the treatment provided, this favors innovations that prove to be cost-efficient, while those that improve quality but increase cost may fall by the wayside.
Fortunately hospitals also get paid for taking care of many patients who have real insurance, so the potentially stifling effect of this system of financing on innovation has been substantially mitigated.
Nevertheless, as our nation's population gets older and sicker, and the proportion of patients covered by Medicare grows inexorably, more and more hospitals will be squeezed harder and harder.
The situation for doctors is just as bad, but the approach has been different. In the Balanced Budget Act of 1997 a new formula was introduced: the Sustainable Growth Rate formula, or SGR. As its name implies, the purpose of the SGR was to keep growth in Medicare expenditures for services provided by doctors within the realm of sustainability.
Each year a complicated calculation tells the folks at the Centers for Medicare and Medicaid Services (CMS) how much growth is permitted in payments to doctors for taking care of Medicare patients. If the allowable growth in expenditures is less than the projected growth in expenditures, CMS must adjust for this by paying doctors less.
While on its face this seems patently unfair, there is a rationale based on a certain school of thought in health care economics. The idea is that physicians have a degree of control over utilization of resources. They have some flexibility in deciding what tests and treatments to order or recommend. So the system is devised to give them an incentive to do less. The less they do for Medicare patients, the slower the growth in Medicare expenditures. The slower the growth, the less likely it is that the projected rate of growth will exceed the sustainable growth rate (SGR). Then, instead of getting paid less every year for what they do, they might even get paid a little more.
There are several obvious problems with this approach. First, it assumes that physicians act as a group, in the interests of the group and all its members. After all, if I am constantly looking for ways to practice more cost-efficient medicine, but my colleagues are not, I will not benefit from a reduction in the rate of growth in expenditures. It is only if we are all singing from the same hymnal (the metaphor seems apt on the eve of Christmas) that we will all reap the benefits of economizing.
Second, it assumes that SGR-driven reductions in payments are a sufficiently powerful incentive to physicians to take a less-is-more approach to patient care, when many other factors are pushing them in the opposite direction. These other factors include a focus on doing what is best for the individual patient, with an emphasis on diagnostic certainty and state-of-the-art testing and treatment; a natural inclination to pursue the best possible health outcomes regardless of cost; and concern about the consequences of missing something by being less than very thorough, including the possibility of ending up a defendant in a medical malpractice lawsuit.
For quite a while now, the projected growth rate has exceeded the SGR more often than not, meaning CMS is supposed to reduce what doctors get paid for what they do for Medicare patients. And, more often than not, Congress has intervened to prevent the cuts. Each time that happens the gap between actual growth and "sustainable" growth gets bigger, and so each year the cuts that would be triggered by the SGR grow larger. On January 1, 2012 it would be 27%, except that Congress is about to enact a two-month reprieve to give itself yet another opportunity to figure out what to do about this absurd system.
Why should you, if you are not in a health profession, care a whit about whether doctors get paid poorly by Medicare? (And believe me, the difference between payments by Medicare and those for services provided to patients with "real insurance" are sometimes eye-popping.)
Think about CMS as an employer. If your employer decided to pay you less every year for doing the same work, while other employers were giving raises at least enough to cover inflation, how long would it take before you started looking around for other opportunities?
Now imagine you are a doctor who takes care of a diverse population of patients. Some have real insurance. Some have Medicare. Some have Medicaid (the publicly financed health insurance for the poor). And some are uninsured. If you want your practice to be a going concern, you have to limit the number of patients who have no insurance and cannot pay. You probably also must limit the number on Medicaid, which generally pays very poorly for services rendered. It is now getting to the point where more and more doctors are realizing they must limit the proportion of their patients who are on Medicare.
They are not sending letters to their Medicare patients telling them to find another doctor. But they (actually their receptionists) are saying no to new Medicare patients. They have no choice. They have practice overhead to cover: mortgage payments on the office, utility bills, staff salaries, purchases and maintenance of equipment. Oh, and they want to maintain their own personal income, too, because they have educational loans to pay off, families to support, children's college tuition to pay or save for, mortgage and car payments - you know, the same stuff the rest of us worry about. They may drive fancier cars or live in bigger houses, but they're a lot like you.
Expecting doctors to practice cost-efficient medicine - to get the biggest bang for the buck when making decisions about tests and treatments for each and every patient they see - is reasonable. Expecting them to take responsibility for "unsustainable" growth in Medicare expenditures, when that growth is rooted in so many factors beyond their control, is not reasonable. And punishing them when growth in expenditures exceed targets that are based on a deeply flawed formula is decidedly unreasonable.
When you or your parents reach the age of 65, it's going to be harder to find a doctor who takes Medicare patients. That's why you should care.
But there is a growing gap between what Medicare pays to doctors and hospitals for caring for its beneficiaries and what it costs to provide that care. There is also a gap, growing even faster, between what Medicare pays and what commercial health insurance (also known as "real insurance") pays.
This is not because commercial insurers are generous. Rather, it is because the federal government has decided that the way to slow the growth of the Medicare budget is to pay the providers of health care services less (in inflation-adjusted dollars) each year.
A large part of the reason so many hospitals struggle to stay in the black is that many of the services they provide to Medicare beneficiaries are paid for at rates so low as not to cover the cost of providing the care.
It wasn't always this way. In the 1970s Medicare paid hospitals for what they did, with a bit of a margin. This is called a "cost-plus" system of financing. But the feds decided that was much too expensive, and in the 1980s they implemented a new system in which hospitals were paid based on what was wrong with the patient. If they could care for the patient for less than Medicare paid for the patient's diagnosis by being very efficient, they did well. If it cost more than that to get the patient well enough to be discharged, the hospital took a loss. This was supposed to give hospitals an incentive to be more efficient.
But life is full of unintended consequences. If innovations become available that improve the quality of patient care, will hospitals use them? When the system of health care financing pays for the patient's diagnosis, not for the treatment provided, this favors innovations that prove to be cost-efficient, while those that improve quality but increase cost may fall by the wayside.
Fortunately hospitals also get paid for taking care of many patients who have real insurance, so the potentially stifling effect of this system of financing on innovation has been substantially mitigated.
Nevertheless, as our nation's population gets older and sicker, and the proportion of patients covered by Medicare grows inexorably, more and more hospitals will be squeezed harder and harder.
The situation for doctors is just as bad, but the approach has been different. In the Balanced Budget Act of 1997 a new formula was introduced: the Sustainable Growth Rate formula, or SGR. As its name implies, the purpose of the SGR was to keep growth in Medicare expenditures for services provided by doctors within the realm of sustainability.
Each year a complicated calculation tells the folks at the Centers for Medicare and Medicaid Services (CMS) how much growth is permitted in payments to doctors for taking care of Medicare patients. If the allowable growth in expenditures is less than the projected growth in expenditures, CMS must adjust for this by paying doctors less.
While on its face this seems patently unfair, there is a rationale based on a certain school of thought in health care economics. The idea is that physicians have a degree of control over utilization of resources. They have some flexibility in deciding what tests and treatments to order or recommend. So the system is devised to give them an incentive to do less. The less they do for Medicare patients, the slower the growth in Medicare expenditures. The slower the growth, the less likely it is that the projected rate of growth will exceed the sustainable growth rate (SGR). Then, instead of getting paid less every year for what they do, they might even get paid a little more.
There are several obvious problems with this approach. First, it assumes that physicians act as a group, in the interests of the group and all its members. After all, if I am constantly looking for ways to practice more cost-efficient medicine, but my colleagues are not, I will not benefit from a reduction in the rate of growth in expenditures. It is only if we are all singing from the same hymnal (the metaphor seems apt on the eve of Christmas) that we will all reap the benefits of economizing.
Second, it assumes that SGR-driven reductions in payments are a sufficiently powerful incentive to physicians to take a less-is-more approach to patient care, when many other factors are pushing them in the opposite direction. These other factors include a focus on doing what is best for the individual patient, with an emphasis on diagnostic certainty and state-of-the-art testing and treatment; a natural inclination to pursue the best possible health outcomes regardless of cost; and concern about the consequences of missing something by being less than very thorough, including the possibility of ending up a defendant in a medical malpractice lawsuit.
For quite a while now, the projected growth rate has exceeded the SGR more often than not, meaning CMS is supposed to reduce what doctors get paid for what they do for Medicare patients. And, more often than not, Congress has intervened to prevent the cuts. Each time that happens the gap between actual growth and "sustainable" growth gets bigger, and so each year the cuts that would be triggered by the SGR grow larger. On January 1, 2012 it would be 27%, except that Congress is about to enact a two-month reprieve to give itself yet another opportunity to figure out what to do about this absurd system.
Why should you, if you are not in a health profession, care a whit about whether doctors get paid poorly by Medicare? (And believe me, the difference between payments by Medicare and those for services provided to patients with "real insurance" are sometimes eye-popping.)
Think about CMS as an employer. If your employer decided to pay you less every year for doing the same work, while other employers were giving raises at least enough to cover inflation, how long would it take before you started looking around for other opportunities?
Now imagine you are a doctor who takes care of a diverse population of patients. Some have real insurance. Some have Medicare. Some have Medicaid (the publicly financed health insurance for the poor). And some are uninsured. If you want your practice to be a going concern, you have to limit the number of patients who have no insurance and cannot pay. You probably also must limit the number on Medicaid, which generally pays very poorly for services rendered. It is now getting to the point where more and more doctors are realizing they must limit the proportion of their patients who are on Medicare.
They are not sending letters to their Medicare patients telling them to find another doctor. But they (actually their receptionists) are saying no to new Medicare patients. They have no choice. They have practice overhead to cover: mortgage payments on the office, utility bills, staff salaries, purchases and maintenance of equipment. Oh, and they want to maintain their own personal income, too, because they have educational loans to pay off, families to support, children's college tuition to pay or save for, mortgage and car payments - you know, the same stuff the rest of us worry about. They may drive fancier cars or live in bigger houses, but they're a lot like you.
Expecting doctors to practice cost-efficient medicine - to get the biggest bang for the buck when making decisions about tests and treatments for each and every patient they see - is reasonable. Expecting them to take responsibility for "unsustainable" growth in Medicare expenditures, when that growth is rooted in so many factors beyond their control, is not reasonable. And punishing them when growth in expenditures exceed targets that are based on a deeply flawed formula is decidedly unreasonable.
When you or your parents reach the age of 65, it's going to be harder to find a doctor who takes Medicare patients. That's why you should care.
Monday, December 12, 2011
We are the 2%!
False beliefs abound. In few areas of public discussion is this more true than health policy.
One of these false beliefs is that emergency care is terribly expensive, and that we could save a lot of money if we could just somehow see to it that everyone who goes to a hospital emergency department with a problem that is not a true emergency could be re-directed somewhere else.
So ... is that true or false?
As with so many other things, it depends on how you look at it. And, with a complex proposition such as this one, it is important to recognize that it has several interdependent parts.
If you've been a patient in a hospital emergency department (ED) for something that you might have seen your primary care doctor about, if you could get a timely appointment, you surely noticed that the bill was higher than it would have been at the doctor's office. There are, as you may know, two fundamental reasons for that.
First is that the ED has a lot more "fixed costs" (or overhead) that must be covered by revenues. Second is that we have to engage in "cost shifting." We have a lot of patients who do not or cannot pay, and many more whose form of payment (Medicaid, Medicare) does not cover the cost of the care provided. And we have far more of these patients than the typical primary care doctor. So the hospital must bill paying customers more to make up for the ones who pay little or nothing.
Imagine going to McDonald's and finding that the price of a Big Mac had doubled because half of Mickey D's customers weren't paying for their meals, and so the paying customers had to pick up the tab. You might think Ronald didn't know how to run a restaurant, that he couldn't make a burger for a reasonable price. But the cost of making the burger didn't change - just the price he has to charge you to stay in business. That doesn't happen at McDonald's, because they don't give everybody chicken nuggets regardless of ability to pay. In the ED, we do exactly that. We do it partly because we believe in certain principles of social justice and partly because there is a federal statute that says we must.
So the cost is higher after accounting for overhead, and the price difference is even bigger. And if you have private insurance, the insurance company has ways of discouraging you from using the ED when you could go to your doctor's office instead. For example, if you were sick, but not sick enough to be hospitalized, your ED co-pay might be $100, whereas in the office it would have been $10. And yet people go to the ED anyway. There are lots of reasons for that: convenience, resources available in the ED, and perceptions of the quality and comprehensiveness of care are perhaps foremost among them. Even if you could always get into your doctor's office on very short notice, you wouldn't necessarily go there for everything your insurance company thinks, in retrospect, you could have. You had a kidney stone? That didn't require hospitalization, so you couldn't have been all that sick. You could have gone to your doctor's office. Try that some time, and see how well it goes.
But let us imagine that you really could get care in your doctor's office for every illness not serious enough to require hospitalization, and you could get it in a reasonable time frame. Let us further imagine that your doctor's office was actually equipped to distinguish indigestion from a heart attack and serious from trivial causes of abdominal pain. Let us even suppose that your doctor could evaluate and treat minor injuries not requiring a surgical specialist - and could tell which ones do and do not require such specialty consultation.
How much money could we save?
Do you have any idea what percentage of the U.S. health care budget is spent on emergency care? If you read the headline, you know the answer. That's right. Just two cents of every dollar spent on health care in the United States are used to pay for emergency care.
So if we could just get everyone without a life-threatening problem out of my ED, we would slash the health-care budget by ... a lot less than 2%, because nearly all of them would get care somewhere else, and it wouldn't be free wherever that might be.
In the halls of Congress we hear all the time this nonsense about the need to get all the patients without true emergencies out of those expensive emergency departments. And nonsense is exactly what it is.
We are the 2%! Occupy Capitol Hill!
One of these false beliefs is that emergency care is terribly expensive, and that we could save a lot of money if we could just somehow see to it that everyone who goes to a hospital emergency department with a problem that is not a true emergency could be re-directed somewhere else.
So ... is that true or false?
As with so many other things, it depends on how you look at it. And, with a complex proposition such as this one, it is important to recognize that it has several interdependent parts.
If you've been a patient in a hospital emergency department (ED) for something that you might have seen your primary care doctor about, if you could get a timely appointment, you surely noticed that the bill was higher than it would have been at the doctor's office. There are, as you may know, two fundamental reasons for that.
First is that the ED has a lot more "fixed costs" (or overhead) that must be covered by revenues. Second is that we have to engage in "cost shifting." We have a lot of patients who do not or cannot pay, and many more whose form of payment (Medicaid, Medicare) does not cover the cost of the care provided. And we have far more of these patients than the typical primary care doctor. So the hospital must bill paying customers more to make up for the ones who pay little or nothing.
Imagine going to McDonald's and finding that the price of a Big Mac had doubled because half of Mickey D's customers weren't paying for their meals, and so the paying customers had to pick up the tab. You might think Ronald didn't know how to run a restaurant, that he couldn't make a burger for a reasonable price. But the cost of making the burger didn't change - just the price he has to charge you to stay in business. That doesn't happen at McDonald's, because they don't give everybody chicken nuggets regardless of ability to pay. In the ED, we do exactly that. We do it partly because we believe in certain principles of social justice and partly because there is a federal statute that says we must.
So the cost is higher after accounting for overhead, and the price difference is even bigger. And if you have private insurance, the insurance company has ways of discouraging you from using the ED when you could go to your doctor's office instead. For example, if you were sick, but not sick enough to be hospitalized, your ED co-pay might be $100, whereas in the office it would have been $10. And yet people go to the ED anyway. There are lots of reasons for that: convenience, resources available in the ED, and perceptions of the quality and comprehensiveness of care are perhaps foremost among them. Even if you could always get into your doctor's office on very short notice, you wouldn't necessarily go there for everything your insurance company thinks, in retrospect, you could have. You had a kidney stone? That didn't require hospitalization, so you couldn't have been all that sick. You could have gone to your doctor's office. Try that some time, and see how well it goes.
But let us imagine that you really could get care in your doctor's office for every illness not serious enough to require hospitalization, and you could get it in a reasonable time frame. Let us further imagine that your doctor's office was actually equipped to distinguish indigestion from a heart attack and serious from trivial causes of abdominal pain. Let us even suppose that your doctor could evaluate and treat minor injuries not requiring a surgical specialist - and could tell which ones do and do not require such specialty consultation.
How much money could we save?
Do you have any idea what percentage of the U.S. health care budget is spent on emergency care? If you read the headline, you know the answer. That's right. Just two cents of every dollar spent on health care in the United States are used to pay for emergency care.
So if we could just get everyone without a life-threatening problem out of my ED, we would slash the health-care budget by ... a lot less than 2%, because nearly all of them would get care somewhere else, and it wouldn't be free wherever that might be.
In the halls of Congress we hear all the time this nonsense about the need to get all the patients without true emergencies out of those expensive emergency departments. And nonsense is exactly what it is.
We are the 2%! Occupy Capitol Hill!
I Think, Therefore I ... Should Turn Off News Reporting on Politics
During a recent debate featuring candidates for the Republican presidential nomination, Newt Gingrich expressed the view that a compassionate, humane approach is called for in dealing with undocumented immigrants who have been in the United States for many years.
Gingrich pointed out that it makes no sense for members of a party so focused on the family to want to deport immigrants who have built lives and families here, thereby breaking up those families.
In observing that doing so is neither humane nor compassionate, Gingrich sounded much more like a centrist or moderate than most people think he is. Of course a review of his statements and actions when he was Speaker of the House during the 1990s reveals that he was definitely capable of taking a centrist approach, as evidenced by the various things that were achieved through the joint efforts of the president and the speaker.
The next day this aspect of the debate was reported by CNN. Call me old fashioned, but I think news reporting is a matter of telling people what happened. Of course a bit of context is helpful, and it is entirely reasonable to include something about reactions to what someone has said.
Suppose one of the other candidates had responded by saying, "Newt! That's amnesty! Don't you remember what happened the last time we did that? The floodgates opened. We cannot do that again."
That would have been something to report, but that didn't happen. And it's too bad, because it would really have been interesting to see how Gingrich, who loves history and champions the importance of studying history to avoid repeating mistakes, would have handled it. No, in fact, none of the other candidates replied in a memorable or effective way.
So, absent anything good in the way of a response to report from the debate itself, CNN turned the matter over to its pundits. And I'd be OK with that, because I am a pundit myself - I have a certificate suitable for framing from the online University of Punditry - and I am usually interested in hearing what other pundits think of the events of the day.
That, however, is not what the pundits did. No, instead, they launched into speculation about how what Gingrich said would be received by voters - particularly conservative Republicans in Iowa. All day - OK, maybe not literally, but it sure seemed so - the pundits droned on about how conservative Republicans in Iowa (they may have mentioned New Hampshire or South Carolina, but Iowa was the focus) would not like what Gingrich had to say.
This statement, the pundits said, was sure to go over poorly with Iowa's conservative Republicans, would likely affect Newt's standing in Iowa polls, and might very well torpedo his chances of a big win in the upcoming Iowa caucuses.
This goes far beyond the proper role of a pundit. The reporter tells us what happened. The pundit provides context and gives us some perspective on the news. It is not the pundit's proper role to tell us what to think about the news.
In other words: Now hear this, all you pundits. You may tell me what you think. Do not tell me what I should think. Do not tell the conservative Republican voters of Iowa what they are expected to think or how they are expected to react.
Surely many of you have noticed that the news networks have gone far beyond reporting and analysis. This is not good journalism. So here is my recommendation. Watch the debates, and then turn the television off. Do your own thinking. If you want to know what to think, don't ask me. I will tell you what I think, but don't adopt my thoughts as your own, if you want to stay out of trouble.
Gingrich pointed out that it makes no sense for members of a party so focused on the family to want to deport immigrants who have built lives and families here, thereby breaking up those families.
In observing that doing so is neither humane nor compassionate, Gingrich sounded much more like a centrist or moderate than most people think he is. Of course a review of his statements and actions when he was Speaker of the House during the 1990s reveals that he was definitely capable of taking a centrist approach, as evidenced by the various things that were achieved through the joint efforts of the president and the speaker.
The next day this aspect of the debate was reported by CNN. Call me old fashioned, but I think news reporting is a matter of telling people what happened. Of course a bit of context is helpful, and it is entirely reasonable to include something about reactions to what someone has said.
Suppose one of the other candidates had responded by saying, "Newt! That's amnesty! Don't you remember what happened the last time we did that? The floodgates opened. We cannot do that again."
That would have been something to report, but that didn't happen. And it's too bad, because it would really have been interesting to see how Gingrich, who loves history and champions the importance of studying history to avoid repeating mistakes, would have handled it. No, in fact, none of the other candidates replied in a memorable or effective way.
So, absent anything good in the way of a response to report from the debate itself, CNN turned the matter over to its pundits. And I'd be OK with that, because I am a pundit myself - I have a certificate suitable for framing from the online University of Punditry - and I am usually interested in hearing what other pundits think of the events of the day.
That, however, is not what the pundits did. No, instead, they launched into speculation about how what Gingrich said would be received by voters - particularly conservative Republicans in Iowa. All day - OK, maybe not literally, but it sure seemed so - the pundits droned on about how conservative Republicans in Iowa (they may have mentioned New Hampshire or South Carolina, but Iowa was the focus) would not like what Gingrich had to say.
This statement, the pundits said, was sure to go over poorly with Iowa's conservative Republicans, would likely affect Newt's standing in Iowa polls, and might very well torpedo his chances of a big win in the upcoming Iowa caucuses.
This goes far beyond the proper role of a pundit. The reporter tells us what happened. The pundit provides context and gives us some perspective on the news. It is not the pundit's proper role to tell us what to think about the news.
In other words: Now hear this, all you pundits. You may tell me what you think. Do not tell me what I should think. Do not tell the conservative Republican voters of Iowa what they are expected to think or how they are expected to react.
Surely many of you have noticed that the news networks have gone far beyond reporting and analysis. This is not good journalism. So here is my recommendation. Watch the debates, and then turn the television off. Do your own thinking. If you want to know what to think, don't ask me. I will tell you what I think, but don't adopt my thoughts as your own, if you want to stay out of trouble.
Wednesday, November 23, 2011
Joe Pa
In 1975 I was a college freshman at Pennsylvania State University. I spent only a year there, but I couldn't help noticing that football was a big deal on that campus. Two years earlier the Nittany Lions had finished their season undefeated and won the Orange Bowl. But I was pre-med, and my curriculum didn't lend itself to football Saturdays. During my year there I never got close enough to Beaver Stadium to be able to recall what it looked like.
Joseph Vincent Paterno was still in his 40s then, but he had been head coach for a decade and had already collected five bowl victories. His career totals of bowl victories (24) and appearances (37) are records unlikely to be broken any time soon. I'll go out on a limb and say his Division I record of 409 career wins will likely stand through at least the rest of this century.
Paterno spent six decades in coaching at Penn State, having signed on as an assistant in 1950. He built a culture of success in which academic performance was regarded as equal in importance to what an athlete did between the sidelines. He consistently emphasized team over individual, as symbolized by Lions uniforms that had numbers but not names.
In a national culture obsessed with youth, it came as no surprise that many fans thought the grandfatherly Paterno might be getting too old to continue coaching successfully when the team hit a five-year slide, losing more than winning during the 2000-2004 seasons. There were many calls for his retirement. He finally said he would step down if things didn't turn around in 2005. That year the team went 11-1, winning the Big Ten title and the Orange Bowl. In 2006 Paterno was inducted into the college football Hall of Fame, turned 80, and kept right on coaching. The five years from 2005 through 2010 brought a record of 58-19, and few fans remained convinced that Joe was too old to continue as head coach. The term "living legend" has fit few men in organized athletics as well as when it has been worn by Joe Pa.
In 2002 Joe Paterno, in his mid-70s, was informed by Mike McQueary, a young graduate assistant, that McQueary had witnessed Jerry Sandusky sexually abusing a ten-year-old boy in a shower in a university athletic facility. Sandusky, the former PSU defensive coordinator, had retired from that position in 1999 but had continued access to university facilities because of his involvement in youth programs. Paterno reported McQueary's information to university officials, including the athletic director and the administrator who oversaw the university police.
Accounts of how and why it took nine years for there to be a thorough investigation and a grand jury report are a bit hard to follow, and I certainly won't try to make sense of them here. No, what I want to do instead is tell you what troubles me about this story.
McQueary told the grand jury he was very specific, in his conversation with Paterno, about what he saw in the shower. Paterno says otherwise. Both have reasons for biased recall. Should we believe that a man in his mid-20s would describe what he saw in graphic detail to a man in his mid-70s? It is entirely possible that he did exactly that. But I am firmly in the camp of the skeptics on this one.
Should Paterno have taken the information he was given and gone directly to outside (not university) law enforcement? Joe now says that, in hindsight, he wishes he had done more. But that's the thing about hindsight: you never have it when you need it. He did what he was supposed to do and sent it to university higher-ups whose job it was to handle such problems.
Should McQueary have gone straight to outside law enforcement (not to Paterno)? He knew that Sandusky had been Paterno's friend and protégé. What would you have done in his place? I know my answer. There is plenty of blame to go around when we consider the tragedy of Sandusky's shocking behavior, extending over a period of years with an uncertain number of young victims.
If you've read my profile associated with this blog, you know I like to find fault with the work of professional journalists. And now I have a whole sector to go after: the sports writers, commentators, and pundits. It is very difficult to find a Paterno defender among them. When the university's Board of Trustees rejected Paterno's decision to retire after this season and instead abruptly fired him in a public relations damage-control move (that was stunningly ineffective), I heard no sports journalists even suggest the decision might have been hasty or an overreaction. Why? Well, no one wants to jeopardize his career by saying something that might label him as soft on child sexual abuse.
Just look at what happened to Franco Harris. The Steelers' superstar running back was born the year Paterno joined the PSU coaching staff and played for Paterno in college. Somewhere along the line Harris learned something about loyalty and courage under fire and suggested the Penn State Board of Trustees displayed a lack of both. For taking that stand, Franco was criticized by Pittsburgh Mayor Luke Ravenstahl, who demanded that Harris step down as chair of the board of the Pittsburgh Promise scholarship program.
Ravenstahl? Really? The same Ravenstahl who wasn't even born yet during the 1970s, when the Steelers, whose fans' affectionate names for the franchise included Franco's Army, were the best team that had ever stepped onto an NFL gridiron. The same Ravenstahl who became the youngest (and arguably least qualified) mayor in Pittsburgh history because the city council had made him Council President in a foolish compromise, and Mayor Bob O'Connor died in office. The same Ravenstahl who, in his five years as mayor, has been the subject of a remarkable number of controversies and criticisms surrounding his apparent lack of any sense of ethics. Biblical sayings in abundance (the ones about judging not and about casting the first stone, among others) apply to this buffoon.
Joseph Vincent Paterno gave six decades of his life to the Pennsylvania State University, helping to make its athletic programs not only successful but famous for character and integrity. The university board of trustees, amid swirling controversy and scandal, fired an 84-year-old legend because he didn't do enough after being informed of a very disturbing incident nearly a decade earlier. They did it because, in their view, letting him finish the season would have further tarnished the university's reputation.
I have often sighed and shaken my head when I've seen a football game end with a result different from what would have happened if the officials had not made a bad call late in the game. The Penn State board of trustees made a bad call. Yes, that is an understatement if ever there was one. Thank you to Franco Harris for telling us the honest truth about that.
And thank you to Joe Pa for giving your best to college football for six decades and inspiring generations of players, fans, and alumni.
Epilogue
And now (January 21, 2012), Joseph Vincent Paterno has been laid to rest. I believe he will be remembered for his many contributions to his university and to collegiate football and that Sandusky will ultimately be nothing more than a footnote. Joe has said he really didn't know how to handle the matter and turned it over to people he believed would take the appropriate steps. For that the PSU Board of Trustees dismissed him nearly a decade later - for PR purposes. May Joe rest in peace. May the Board of Trustees reflect upon their actions and struggle to find the peace they denied him in his final months.
Joseph Vincent Paterno was still in his 40s then, but he had been head coach for a decade and had already collected five bowl victories. His career totals of bowl victories (24) and appearances (37) are records unlikely to be broken any time soon. I'll go out on a limb and say his Division I record of 409 career wins will likely stand through at least the rest of this century.
Paterno spent six decades in coaching at Penn State, having signed on as an assistant in 1950. He built a culture of success in which academic performance was regarded as equal in importance to what an athlete did between the sidelines. He consistently emphasized team over individual, as symbolized by Lions uniforms that had numbers but not names.
In a national culture obsessed with youth, it came as no surprise that many fans thought the grandfatherly Paterno might be getting too old to continue coaching successfully when the team hit a five-year slide, losing more than winning during the 2000-2004 seasons. There were many calls for his retirement. He finally said he would step down if things didn't turn around in 2005. That year the team went 11-1, winning the Big Ten title and the Orange Bowl. In 2006 Paterno was inducted into the college football Hall of Fame, turned 80, and kept right on coaching. The five years from 2005 through 2010 brought a record of 58-19, and few fans remained convinced that Joe was too old to continue as head coach. The term "living legend" has fit few men in organized athletics as well as when it has been worn by Joe Pa.
In 2002 Joe Paterno, in his mid-70s, was informed by Mike McQueary, a young graduate assistant, that McQueary had witnessed Jerry Sandusky sexually abusing a ten-year-old boy in a shower in a university athletic facility. Sandusky, the former PSU defensive coordinator, had retired from that position in 1999 but had continued access to university facilities because of his involvement in youth programs. Paterno reported McQueary's information to university officials, including the athletic director and the administrator who oversaw the university police.
Accounts of how and why it took nine years for there to be a thorough investigation and a grand jury report are a bit hard to follow, and I certainly won't try to make sense of them here. No, what I want to do instead is tell you what troubles me about this story.
McQueary told the grand jury he was very specific, in his conversation with Paterno, about what he saw in the shower. Paterno says otherwise. Both have reasons for biased recall. Should we believe that a man in his mid-20s would describe what he saw in graphic detail to a man in his mid-70s? It is entirely possible that he did exactly that. But I am firmly in the camp of the skeptics on this one.
Should Paterno have taken the information he was given and gone directly to outside (not university) law enforcement? Joe now says that, in hindsight, he wishes he had done more. But that's the thing about hindsight: you never have it when you need it. He did what he was supposed to do and sent it to university higher-ups whose job it was to handle such problems.
Should McQueary have gone straight to outside law enforcement (not to Paterno)? He knew that Sandusky had been Paterno's friend and protégé. What would you have done in his place? I know my answer. There is plenty of blame to go around when we consider the tragedy of Sandusky's shocking behavior, extending over a period of years with an uncertain number of young victims.
If you've read my profile associated with this blog, you know I like to find fault with the work of professional journalists. And now I have a whole sector to go after: the sports writers, commentators, and pundits. It is very difficult to find a Paterno defender among them. When the university's Board of Trustees rejected Paterno's decision to retire after this season and instead abruptly fired him in a public relations damage-control move (that was stunningly ineffective), I heard no sports journalists even suggest the decision might have been hasty or an overreaction. Why? Well, no one wants to jeopardize his career by saying something that might label him as soft on child sexual abuse.
Just look at what happened to Franco Harris. The Steelers' superstar running back was born the year Paterno joined the PSU coaching staff and played for Paterno in college. Somewhere along the line Harris learned something about loyalty and courage under fire and suggested the Penn State Board of Trustees displayed a lack of both. For taking that stand, Franco was criticized by Pittsburgh Mayor Luke Ravenstahl, who demanded that Harris step down as chair of the board of the Pittsburgh Promise scholarship program.
Ravenstahl? Really? The same Ravenstahl who wasn't even born yet during the 1970s, when the Steelers, whose fans' affectionate names for the franchise included Franco's Army, were the best team that had ever stepped onto an NFL gridiron. The same Ravenstahl who became the youngest (and arguably least qualified) mayor in Pittsburgh history because the city council had made him Council President in a foolish compromise, and Mayor Bob O'Connor died in office. The same Ravenstahl who, in his five years as mayor, has been the subject of a remarkable number of controversies and criticisms surrounding his apparent lack of any sense of ethics. Biblical sayings in abundance (the ones about judging not and about casting the first stone, among others) apply to this buffoon.
Joseph Vincent Paterno gave six decades of his life to the Pennsylvania State University, helping to make its athletic programs not only successful but famous for character and integrity. The university board of trustees, amid swirling controversy and scandal, fired an 84-year-old legend because he didn't do enough after being informed of a very disturbing incident nearly a decade earlier. They did it because, in their view, letting him finish the season would have further tarnished the university's reputation.
I have often sighed and shaken my head when I've seen a football game end with a result different from what would have happened if the officials had not made a bad call late in the game. The Penn State board of trustees made a bad call. Yes, that is an understatement if ever there was one. Thank you to Franco Harris for telling us the honest truth about that.
And thank you to Joe Pa for giving your best to college football for six decades and inspiring generations of players, fans, and alumni.
Epilogue
And now (January 21, 2012), Joseph Vincent Paterno has been laid to rest. I believe he will be remembered for his many contributions to his university and to collegiate football and that Sandusky will ultimately be nothing more than a footnote. Joe has said he really didn't know how to handle the matter and turned it over to people he believed would take the appropriate steps. For that the PSU Board of Trustees dismissed him nearly a decade later - for PR purposes. May Joe rest in peace. May the Board of Trustees reflect upon their actions and struggle to find the peace they denied him in his final months.
Friday, November 18, 2011
Truth in Advertising
It isn't often that the European Commission does something that I find simultaneously astonishing and hilarious - especially nowadays, when there is so much cause for serious concern in the European Union about the economy on the continent and the lengthening list of member nations having mounting problems with debt. But today's edition of the Telegraph (a London newspaper) brought just that combination of surprise and mirth. Sorry to keep you in suspense, but if you haven't already seen the story, I'll be coming back to that at the end.
"If we can't beat another dealer's price, we'll just GIVE you the car!"
I'm sure you've all heard one like that, and you realize just how ridiculous it is. If one dealer offers you a selling price of $25,000, and you then go to another, the second dealer is sure to offer you a lower price, unless he is short on inventory or for some other reason is just not trying to move cars that day. So the dealer who runs this advertisement will live up to his ad's claim of a $500 difference and sell you the car for $24,500. He will not give you the car.
Not quite so obvious are the ads for dietary aids and supplements that have small print saying the product is not intended to diagnose, treat, or cure any disease or condition.
Really? And you want me to buy it anyway?
Yeah, I know, there's one born every minute. And suckers don't notice the statement that the claims "have not been evaluated by the FDA" - or realize that this disclaimer should put them on notice that the claims are probably baloney.
Then we have direct-to-consumer advertising of prescription drugs. Here the claims have been evaluated by the FDA, which doesn't allow manufacturers to make statements that are blatantly false. Unfortunately, a statement can be remarkably misleading without crossing the line into the territory of blatantly false, and the FDA seems not to take much notice of ads that are misleading. We do get fine print and rapid-fire, monotonous recitation of a litany of side effects. If you read or listen carefully, you will wonder why anyone would take this drug. It may cause your left foot to become permanently lodged in your right ear? Really?
A drug that may cause me to commit suicide? Great. That will cure my depression.
The ones that disturb me the most are the ones that you might suppose are the most accurate, because the audience is well-educated and naturally skeptical. These are the ads in scientific journals and news magazines published for physicians. I have been an ardent critic of the content of these ads for many years, simply because the chasm between accurate information (such as one might expect to find in the peer-reviewed articles in these publications) and promotional information (the content of the ads) is so wide.
Ads in medical journals are subject to a higher level of FDA scrutiny, but a recent study showed that no more than 20% of journal ads were entirely compliant with FDA standards.
You might think the journals themselves would scrutinize the content of these ads. I can tell you, as a reviewer for two major journals in my specialty, that trying to assure high quality in the scientific information presented in the articles is plenty of work. No one is volunteering to review the ads. If we tried to do that, we would soon find ourselves in an adversarial relationship with the advertisers. We could just decide not to accept advertising, but then the journals' subscribers would have to pay a lot more to cover the costs.
By now you can tell that I think we have a lot of work to do in improving truth in advertising. And then along comes the European Union to show, beyond any doubt, that it is possible to get carried away. Earlier this year the European Foods Standards Authority refused to approve a statement for use in advertising by distributors of bottled water, submitted by a pair of German professors, that claims drinking plenty of water is an effective way to prevent dehydration.
This was no claim of superiority of bottled water to tap water. Just plain old water.
According to the article in the Telegraph, "Prof Brian Ratcliffe, spokesman for the Nutrition Society, said dehydration was usually caused by a clinical condition and that one could remain adequately hydrated without drinking water."
A "clinical condition?" Like going to the gym for a workout? Sure, we could make sure we are well hydrated in advance (or rehydrate afterwards) by drinking Coca-Cola, but that doesn't mean water isn't effective for this purpose, and if Ratcliffe really believes water is not a better choice than Coke, he is just as foolish as he sounds.
These days I am anxiously waiting to see what the EU is going to do about the debt crisis spreading across the continent, at the same time our congressional "super committee" is trying to figure out what to do about our own deeply ingrained national habit of spending more money than we have. So comic relief is welcome.
In the words of Roger Helmer, a British politician of the Conservative Party and Member of the European Parliament, "This is stupidity writ large." I fully agree. I am grateful nonetheless, because sometimes stupidity writ large is wicked funny.
"If we can't beat another dealer's price, we'll just GIVE you the car!"
Not quite so obvious are the ads for dietary aids and supplements that have small print saying the product is not intended to diagnose, treat, or cure any disease or condition.
Really? And you want me to buy it anyway?
Yeah, I know, there's one born every minute. And suckers don't notice the statement that the claims "have not been evaluated by the FDA" - or realize that this disclaimer should put them on notice that the claims are probably baloney.
Then we have direct-to-consumer advertising of prescription drugs. Here the claims have been evaluated by the FDA, which doesn't allow manufacturers to make statements that are blatantly false. Unfortunately, a statement can be remarkably misleading without crossing the line into the territory of blatantly false, and the FDA seems not to take much notice of ads that are misleading. We do get fine print and rapid-fire, monotonous recitation of a litany of side effects. If you read or listen carefully, you will wonder why anyone would take this drug. It may cause your left foot to become permanently lodged in your right ear? Really?
A drug that may cause me to commit suicide? Great. That will cure my depression.
The ones that disturb me the most are the ones that you might suppose are the most accurate, because the audience is well-educated and naturally skeptical. These are the ads in scientific journals and news magazines published for physicians. I have been an ardent critic of the content of these ads for many years, simply because the chasm between accurate information (such as one might expect to find in the peer-reviewed articles in these publications) and promotional information (the content of the ads) is so wide.
Ads in medical journals are subject to a higher level of FDA scrutiny, but a recent study showed that no more than 20% of journal ads were entirely compliant with FDA standards.
You might think the journals themselves would scrutinize the content of these ads. I can tell you, as a reviewer for two major journals in my specialty, that trying to assure high quality in the scientific information presented in the articles is plenty of work. No one is volunteering to review the ads. If we tried to do that, we would soon find ourselves in an adversarial relationship with the advertisers. We could just decide not to accept advertising, but then the journals' subscribers would have to pay a lot more to cover the costs.
By now you can tell that I think we have a lot of work to do in improving truth in advertising. And then along comes the European Union to show, beyond any doubt, that it is possible to get carried away. Earlier this year the European Foods Standards Authority refused to approve a statement for use in advertising by distributors of bottled water, submitted by a pair of German professors, that claims drinking plenty of water is an effective way to prevent dehydration.
This was no claim of superiority of bottled water to tap water. Just plain old water.
According to the article in the Telegraph, "Prof Brian Ratcliffe, spokesman for the Nutrition Society, said dehydration was usually caused by a clinical condition and that one could remain adequately hydrated without drinking water."
A "clinical condition?" Like going to the gym for a workout? Sure, we could make sure we are well hydrated in advance (or rehydrate afterwards) by drinking Coca-Cola, but that doesn't mean water isn't effective for this purpose, and if Ratcliffe really believes water is not a better choice than Coke, he is just as foolish as he sounds.
These days I am anxiously waiting to see what the EU is going to do about the debt crisis spreading across the continent, at the same time our congressional "super committee" is trying to figure out what to do about our own deeply ingrained national habit of spending more money than we have. So comic relief is welcome.
In the words of Roger Helmer, a British politician of the Conservative Party and Member of the European Parliament, "This is stupidity writ large." I fully agree. I am grateful nonetheless, because sometimes stupidity writ large is wicked funny.
Saturday, November 5, 2011
The Essayist's Essayist
Thirty-three years and 1,097 commentaries, the last one just a month ago at the age of 92.
Andy Rooney has left us now. He has left us with many memories and many smiles. I often wonder how many people watched the TV news magazine "60 Minutes" mostly because of him. One indication was what happened in 1990, when he made an ill-considered remark about homosexual unions (for which he subsequently issued a public apology). CBS suspended him from the program and in short order lost 20% of its audience.
"A Few Minutes with Andy Rooney" was launched in 1978 as a summer replacement for the short political debate segment called "Point/Counterpoint." A year later the debate segment was gone. This might be an object lesson about the hazards of allowing yourself to be replaced temporarily.
Rooney's subject matter was sometimes trivial and usually whimsical. His presentation was most commonly charming, delivered with a twinkle in the eye, and almost always successful in bringing a smile to his viewers. His essays were of the best form, working well both in print and on the screen.
They have been published in book form as collections. When I read them to myself, I can see and hear Mr. Rooney reading them to me on camera. No doubt when he wrote them, this is exactly what he had in mind. Far too few writers nowadays pay attention to this essential feature of the written word. What will it sound like to my audience when they read it "aloud" in their minds?
One of the things I liked most about Andy Rooney was that he recognized and admitted personal error. The 1990 episode in which he learned how misguided was his remark about homosexual unions was a well-noted example. More meaningful to me, however, was what he learned about war from his experiences as a correspondent during World War II. He was a journalist for Stars and Stripes, the army newspaper, and later wrote a memoir, My War (1995), about his years as a war correspondent. Rooney had been a pacifist and was opposed to America's entry into the war, although he had not sought to avoid service when he was drafted in 1941. But near the end of World War II he was among the first American journalists to enter Nazi concentration camps, and what he saw there forever changed his views on whether there can be such a thing as a just war.
I also liked the fact that he was willing to be politically incorrect without worrying too much about offending people. I agreed with him fully when he said it was "silly" for Native Americans to complain about team names like the Washington Redskins. I'm not sure exactly why he thought that, but I can tell you why I did. With serious social and medical problems like unemployment, alcoholism, tuberculosis, and sudden infant death syndrome all occurring at rates much higher than in the general population, I've always thought the tribal nations had more important things with which to concern themselves.
In the six months since I began putting my thoughts on my computer screen for the essays in this blog, I have occasionally thought that perhaps some day people will be as interested in what I have to say as they have been in the musings of Mr. Rooney. A lofty goal, and quite possibly far out of reach. But his first "few minutes" on "60 Minutes" came when he was older than I am now, so I can dream.
In Rooney's last "few minutes" a month ago he told viewers, "Not many people in this world are as lucky as I have been. All this time I've been paid to say what is on my mind on television. You don't get any luckier in life than that." This reminded me of the Confucian saying, “Choose a job you love, and you will never have to work a day in your life.” The fact that Andy was still doing that job in his tenth decade says it all.
For those who prefer the television format, I suggest the DVDs released by CBS in 2006 (three of them, available on Amazon and elsewhere), which offer an excellent collection of his later essays. For fans such as I, who like to read his work and who can see him and hear him as we read, I suggest the 2003 collection, Years of Minutes.
Thank you, Mr. Rooney, for thirty-three years of thought-provoking commentary.
Andy Rooney has left us now. He has left us with many memories and many smiles. I often wonder how many people watched the TV news magazine "60 Minutes" mostly because of him. One indication was what happened in 1990, when he made an ill-considered remark about homosexual unions (for which he subsequently issued a public apology). CBS suspended him from the program and in short order lost 20% of its audience.
"A Few Minutes with Andy Rooney" was launched in 1978 as a summer replacement for the short political debate segment called "Point/Counterpoint." A year later the debate segment was gone. This might be an object lesson about the hazards of allowing yourself to be replaced temporarily.
Rooney's subject matter was sometimes trivial and usually whimsical. His presentation was most commonly charming, delivered with a twinkle in the eye, and almost always successful in bringing a smile to his viewers. His essays were of the best form, working well both in print and on the screen.
They have been published in book form as collections. When I read them to myself, I can see and hear Mr. Rooney reading them to me on camera. No doubt when he wrote them, this is exactly what he had in mind. Far too few writers nowadays pay attention to this essential feature of the written word. What will it sound like to my audience when they read it "aloud" in their minds?
One of the things I liked most about Andy Rooney was that he recognized and admitted personal error. The 1990 episode in which he learned how misguided was his remark about homosexual unions was a well-noted example. More meaningful to me, however, was what he learned about war from his experiences as a correspondent during World War II. He was a journalist for Stars and Stripes, the army newspaper, and later wrote a memoir, My War (1995), about his years as a war correspondent. Rooney had been a pacifist and was opposed to America's entry into the war, although he had not sought to avoid service when he was drafted in 1941. But near the end of World War II he was among the first American journalists to enter Nazi concentration camps, and what he saw there forever changed his views on whether there can be such a thing as a just war.
I also liked the fact that he was willing to be politically incorrect without worrying too much about offending people. I agreed with him fully when he said it was "silly" for Native Americans to complain about team names like the Washington Redskins. I'm not sure exactly why he thought that, but I can tell you why I did. With serious social and medical problems like unemployment, alcoholism, tuberculosis, and sudden infant death syndrome all occurring at rates much higher than in the general population, I've always thought the tribal nations had more important things with which to concern themselves.
In the six months since I began putting my thoughts on my computer screen for the essays in this blog, I have occasionally thought that perhaps some day people will be as interested in what I have to say as they have been in the musings of Mr. Rooney. A lofty goal, and quite possibly far out of reach. But his first "few minutes" on "60 Minutes" came when he was older than I am now, so I can dream.
In Rooney's last "few minutes" a month ago he told viewers, "Not many people in this world are as lucky as I have been. All this time I've been paid to say what is on my mind on television. You don't get any luckier in life than that." This reminded me of the Confucian saying, “Choose a job you love, and you will never have to work a day in your life.” The fact that Andy was still doing that job in his tenth decade says it all.
For those who prefer the television format, I suggest the DVDs released by CBS in 2006 (three of them, available on Amazon and elsewhere), which offer an excellent collection of his later essays. For fans such as I, who like to read his work and who can see him and hear him as we read, I suggest the 2003 collection, Years of Minutes.
Thank you, Mr. Rooney, for thirty-three years of thought-provoking commentary.
Tuesday, November 1, 2011
Ethics for Kids
Six weeks ago I mentioned in this blog that the College Board reported reading scores on the SAT at an all-time low. A few weeks later the news was of a scandal: cheating on the SAT. Among other stories was one of a 19-year-old college student who was using fake IDs to take the SAT for high school students at $2,500 a pop. Why?
There are answers, both general and specific. The SAT may be viewed as overemphasized. Students (and their parents) may think the stakes are so high that cheating can be justified. If your SAT score is too low it will sink your chances of getting into the college of your choice, even though everything else on your resume indicates you are qualified and would be successful there. This may seem especially unfair if you consider that the "experts," who once agreed that SAT scores foretold academic success in college better than any other single predictor, now say the scores correlate best with family income - and not so well at all with college performance. As family income rises, they say, resources that enable intensive test preparation are more abundant, overwhelming the test's ability to distinguish among students of varying levels of academic talent.
There are also more general arguments used to justify cheating. As with the SAT, all sorts of other tests may be considered unfair. A student may rationalize cheating by deciding that his inability to perform well on tests in a high school or college course reflects poor teaching rather than any lack of effort or aptitude on his part. Or, perhaps, the teacher is competent in the classroom but insists on writing exams that are so difficult as to invite cheating.
Among the more disturbing justifications is that "everyone is doing it." The idea here is that the inclination to seek unfair advantage (or mitigate a disadvantage perceived as unfair) is so widespread that one is placed at a disadvantage by not doing what one believes all his fellows are doing to get ahead.
A well-known example of this is the use of anabolic steroids in competitive athletics. Many players came to believe that "everyone" was doing it. That meant anyone who chose to rely on the combination of innate ability, good nutrition, and hard work through training and practice was placing himself at a competitive disadvantage. Added to that was the rationalization that the logical principles employed to decide which performance-enhancing substances were permitted and which were banned were elusive at best, as this was often a matter of whether there were tests available to discover their use.
Why, you might ask, am I so interested in the justifications used for cheating?
For nearly all of my career I have had an intense interest in ethics, especially biomedical and professional ethics. So many of the most intriguing challenges we face in the practice of medicine relate to ethical dilemmas. That term deserves a definition. An ethical dilemma arises when the right and wrong in a situation are not entirely clear. The dilemma can then be framed in terms of what we call competing interests. Those interests must be described and evaluated and weighed against each other. We try to decide which interests deserve greater weight or higher priority. We have a set of ethical principles to guide our analysis.
When I began looking into the matter of students cheating, I noticed that, for much of the analysis of the problem, journalists went to ethicists. Clearly the thinking is that widespread cheating represents a failure in our society to communicate the well-developed ethical values of one generation to the next. Or does it?
News outlets in recent years have been full of stories about institutionalized cheating in public schools to boost kids' scores on standardized tests and avoid missing benchmark targets set by federal legislation for schools' performance. This means students are getting the message directly from their teachers that cheating is OK.
What about parents? According to a recent report on National Public Radio, two thirds of parents think cheating by students is "no big deal" and "all students do it." Is it any wonder, with these kinds of attitudes among parents and teachers, that most students now cheat? Yes, that's right, most students. Surveys of college students in the 1940s found that 20% admitted to cheating at some time. Today those numbers range from 75-98%. It may be that the real number in the 1940s was higher than the number who admitted it, because of the stigma attached to cheating, which is clearly now much less. But today's percentages are shocking.
It doesn't have to be this way. At the K-12 school attended by my daughters, penalties for cheating were harsh (but appropriate). High school students had an ethics class. I hope my daughters learned nothing in that class they had not already been taught in the home. Cheating does not pose an ethical dilemma. There are no legitimate competing interests. Right and wrong are clear. We must teach our children this; we must demand that their teachers do the same; and we must all consistently model the behavior we know is right.
Update, 10-22-2012
In 1998 Mark McGwire set a new single-season record for home runs with 70, surpassing the longstanding record held by Roger Maris (61 in '61). Everything about McGwire seemed squeaky clean, but rumors of use of anabolic steroids didn't take long to bubble up. McGwire finally admitted it in 2010. Barry Bonds set a new record for home runs in a single season with 73 in 2001. And he passed Hank Aaron and The Babe with 762 career home runs. He is the only major leaguer to have accumulated more than 500 each of home runs and stolen bases in a career. The records go on and on. But in the minds of baseball purists, every one of them should be marked with an asterisk, because Bonds used performance-enhancing anabolic steroids for much of his career.
Unlike baseball, other sports actually take things away from cheaters. Olympic gold medals, for example. Just ask Canadian sprinter Ben Johnson about his 1988 gold in the 100 meters.
And now, after years of swirling controversy, the Union Cycliste International has stripped Lance Armstrong of all seven of his Tour de France championships. The decision follows this month's finding by the U.S. Anti-Doping Agency that there is "overwhelming" evidence that Armstrong was involved as a professional cyclist in "the most sophisticated, professionalized and successful doping program."
Really, Lance? After many years of being idolized by everyone for astonishing athletic accomplishments after winning your battle with cancer? What about all those yellow bracelets honoring those fighting similar battles and symbolizing the work of your foundation? What about Athletes for Hope?
Now, more than ever, we must redouble our efforts to teach our kids about playing by the rules in all spheres of life. And we should thank the Union Cycliste International for reminding us all that cheating has consequences.
There are answers, both general and specific. The SAT may be viewed as overemphasized. Students (and their parents) may think the stakes are so high that cheating can be justified. If your SAT score is too low it will sink your chances of getting into the college of your choice, even though everything else on your resume indicates you are qualified and would be successful there. This may seem especially unfair if you consider that the "experts," who once agreed that SAT scores foretold academic success in college better than any other single predictor, now say the scores correlate best with family income - and not so well at all with college performance. As family income rises, they say, resources that enable intensive test preparation are more abundant, overwhelming the test's ability to distinguish among students of varying levels of academic talent.
There are also more general arguments used to justify cheating. As with the SAT, all sorts of other tests may be considered unfair. A student may rationalize cheating by deciding that his inability to perform well on tests in a high school or college course reflects poor teaching rather than any lack of effort or aptitude on his part. Or, perhaps, the teacher is competent in the classroom but insists on writing exams that are so difficult as to invite cheating.
Among the more disturbing justifications is that "everyone is doing it." The idea here is that the inclination to seek unfair advantage (or mitigate a disadvantage perceived as unfair) is so widespread that one is placed at a disadvantage by not doing what one believes all his fellows are doing to get ahead.
A well-known example of this is the use of anabolic steroids in competitive athletics. Many players came to believe that "everyone" was doing it. That meant anyone who chose to rely on the combination of innate ability, good nutrition, and hard work through training and practice was placing himself at a competitive disadvantage. Added to that was the rationalization that the logical principles employed to decide which performance-enhancing substances were permitted and which were banned were elusive at best, as this was often a matter of whether there were tests available to discover their use.
Why, you might ask, am I so interested in the justifications used for cheating?
For nearly all of my career I have had an intense interest in ethics, especially biomedical and professional ethics. So many of the most intriguing challenges we face in the practice of medicine relate to ethical dilemmas. That term deserves a definition. An ethical dilemma arises when the right and wrong in a situation are not entirely clear. The dilemma can then be framed in terms of what we call competing interests. Those interests must be described and evaluated and weighed against each other. We try to decide which interests deserve greater weight or higher priority. We have a set of ethical principles to guide our analysis.
When I began looking into the matter of students cheating, I noticed that, for much of the analysis of the problem, journalists went to ethicists. Clearly the thinking is that widespread cheating represents a failure in our society to communicate the well-developed ethical values of one generation to the next. Or does it?
News outlets in recent years have been full of stories about institutionalized cheating in public schools to boost kids' scores on standardized tests and avoid missing benchmark targets set by federal legislation for schools' performance. This means students are getting the message directly from their teachers that cheating is OK.
What about parents? According to a recent report on National Public Radio, two thirds of parents think cheating by students is "no big deal" and "all students do it." Is it any wonder, with these kinds of attitudes among parents and teachers, that most students now cheat? Yes, that's right, most students. Surveys of college students in the 1940s found that 20% admitted to cheating at some time. Today those numbers range from 75-98%. It may be that the real number in the 1940s was higher than the number who admitted it, because of the stigma attached to cheating, which is clearly now much less. But today's percentages are shocking.
It doesn't have to be this way. At the K-12 school attended by my daughters, penalties for cheating were harsh (but appropriate). High school students had an ethics class. I hope my daughters learned nothing in that class they had not already been taught in the home. Cheating does not pose an ethical dilemma. There are no legitimate competing interests. Right and wrong are clear. We must teach our children this; we must demand that their teachers do the same; and we must all consistently model the behavior we know is right.
Update, 10-22-2012
In 1998 Mark McGwire set a new single-season record for home runs with 70, surpassing the longstanding record held by Roger Maris (61 in '61). Everything about McGwire seemed squeaky clean, but rumors of use of anabolic steroids didn't take long to bubble up. McGwire finally admitted it in 2010. Barry Bonds set a new record for home runs in a single season with 73 in 2001. And he passed Hank Aaron and The Babe with 762 career home runs. He is the only major leaguer to have accumulated more than 500 each of home runs and stolen bases in a career. The records go on and on. But in the minds of baseball purists, every one of them should be marked with an asterisk, because Bonds used performance-enhancing anabolic steroids for much of his career.
Unlike baseball, other sports actually take things away from cheaters. Olympic gold medals, for example. Just ask Canadian sprinter Ben Johnson about his 1988 gold in the 100 meters.
And now, after years of swirling controversy, the Union Cycliste International has stripped Lance Armstrong of all seven of his Tour de France championships. The decision follows this month's finding by the U.S. Anti-Doping Agency that there is "overwhelming" evidence that Armstrong was involved as a professional cyclist in "the most sophisticated, professionalized and successful doping program."
Really, Lance? After many years of being idolized by everyone for astonishing athletic accomplishments after winning your battle with cancer? What about all those yellow bracelets honoring those fighting similar battles and symbolizing the work of your foundation? What about Athletes for Hope?
Now, more than ever, we must redouble our efforts to teach our kids about playing by the rules in all spheres of life. And we should thank the Union Cycliste International for reminding us all that cheating has consequences.
Saturday, October 22, 2011
Measuring Quality and Value?
Doctors and hospitals nowadays are being asked to demonstrate the value of the health care provided to patients. Value is defined as the relationship between cost and quality. In very qualitative terms, value is the ratio of quality to cost. In other words, as quality increases relative to cost, value increases. Looked at from the cost perspective, if quality is held constant while costs are reduced, value increases.
This would all be well and good if it were a simple calculation - which would be the case if all of these elements were well understood and easily measured. One might think the easiest to tackle would be cost, as that seems an easy number to capture. Even there, however, it is complicated by the nettlesome issue of cost versus charges: the difference between what it costs to provide a service and the price one tries to collect from the customer for that service.
A familiar example of this can be found in the airline industry. I flew to San Diego this past summer for a wedding. I will be making the same trip for Thanksgiving. The cost of my transportation via airplane will surely be about the same, allowing for changes in the price of fuel. But the ticket prices are wildly different, because the airlines can charge whatever they want, and they gouge passengers who want to travel for holidays.
Hospitals exhibit large differences between costs and charges, not because they take advantage of those who get sick during periods of peak demand, but because they have to make up for the people who cannot pay by charging much more than cost to those who can. This is called cost shifting. Everyone in the health care and health insurance industries knows all about it, and nobody likes it, but until everyone has health insurance that pays enough to cover costs, that's how it will be. And by the way, the government programs that cover the poor and the elderly (Medicaid and Medicare) do not pay enough to cover costs, so the rest of us are paying for the health care of these patients both through our taxes and through cost shifting.
How does this affect the value calculation? If Hospital A has more patients with no insurance or with Medicaid and Medicare than Hospital B (which has more patients with real insurance), Hospital A will have to charge higher prices to the insured (unless it wants to go out of business). That will make Hospital B look like a better value, which is hardly fair.
If you are now dismayed that measuring the element of cost in the value equation is not as simple as it should be, wait until you see what happens when we attempt to measure quality!
The Centers for Medicare and Medicaid Services (CMS - don't ask what happened to the extra "M") has many "quality measures" for doctors and hospitals. These are things they expect us to measure and report to them. As you might guess, measuring all of these things is rather labor-intensive, which adds to costs. To make it appealing, they start out by providing a small monetary incentive (pay for reporting) for doing this, but over the next few years that goes away and is replaced by penalties for not reporting.
In addition to penalties for not reporting, CMS also penalizes hospitals for failing to hit targets for the quality measures. This would seem to be a good thing, as it gives us a financial incentive to improve quality. But that assumes the "quality measures" imposed by CMS actually measure quality.
Most of us in healthcare think the important thing to measure is patients' health outcomes. And some of the quality measures actually get at this. For example, CMS thinks patients should not acquire infections while in the hospital. I agree. While rates of hospital-acquired infections probably cannot be reduced to zero, we can get pretty close, and we have good evidence of best practices that will help us to get there.
But many of the other measures are related to processes rather than outcomes. So we are expected to do certain things for patients being admitted to the hospital for treatment of pneumonia. These are things you might think would result in better outcomes, and so it might seem reasonable to measure how good we are at doing those things consistently and reward (which means not penalize) us for that. But here is the problem. First, the connection between processes and outcomes is often surprisingly loose. Second, CMS uses quality measures based on processes that have never been shown to improve outcomes. Why would they do that? Maybe you weren't even asking that question, because you know it's a government agency, but the answer is simple: like everyone else, they do things that seem to make sense, even when there is no evidence to support intuition. Then, when presented with evidence to the contrary, they change their approach only with great reluctance, and resistance, and lengthy delay.
So we find ourselves doing many things that we know contribute nothing to improved outcomes because of government mandate. This, as I'm sure you will understand, is very frustrating. The folks at CMS claim to want to improve quality and reduce cost, thereby increasing value, but instead they cause us to waste resources doing useless things, thereby reducing value.
Fasten your seatbelt, because it gets worse. There are actually things they want us to do that may reduce quality and cost lives.
My favorite current example is what they are telling us about ordering CAT scans of the head for patients who come to the emergency department (ED) with headaches. They have established a set of criteria they want us to follow. If the patient doesn't meet the criteria, we shouldn't order a CAT scan.
By now, you have surely predicted the problem. Yes, you guessed it, the criteria are not scientifically valid. There are ED patients who do not meet the criteria who should get CAT scans. And some of those patients, because of the CMS "quality measure," will not get CAT scans. And some of them will have serious conditions that will go undiagnosed.
These "quality measures" adopted by CMS are typically endorsed by an outfit called the National Quality Forum (NQF). NQF endorsement is by no means a guarantee that a quality measure is good, but they try. This new "quality measure" related to CAT scans for headache patients was rejected by the NQF. And yet it was adopted by CMS anyway. They are convinced that it will save money and improve quality by sparing patients needless and potentially harmful radiation exposure, and that we will not, by following their criteria, miss any important diagnoses. If that were true, it would be great. Why, you may ask, has CMS not been dissuaded by the lack of scientific evidence to support this "quality measure?"
A dear friend and colleague once (many times, in fact) said that CMS makes up the rules not to improve health care but to fit the amount of money they want to spend. This is a very important truth to keep in mind. And it's not just CMS. Any time you read or hear statements about value in health care, maintain a healthy skepticism. Ask whether the better value being promised is really about the ratio of quality to cost, or whether it's really just about cost, with quality only an afterthought (if it is a thought at all). All too often, as the "value equation" is addressed, cost is the focus, and quality is ignored or sacrificed.
This would all be well and good if it were a simple calculation - which would be the case if all of these elements were well understood and easily measured. One might think the easiest to tackle would be cost, as that seems an easy number to capture. Even there, however, it is complicated by the nettlesome issue of cost versus charges: the difference between what it costs to provide a service and the price one tries to collect from the customer for that service.
A familiar example of this can be found in the airline industry. I flew to San Diego this past summer for a wedding. I will be making the same trip for Thanksgiving. The cost of my transportation via airplane will surely be about the same, allowing for changes in the price of fuel. But the ticket prices are wildly different, because the airlines can charge whatever they want, and they gouge passengers who want to travel for holidays.
Hospitals exhibit large differences between costs and charges, not because they take advantage of those who get sick during periods of peak demand, but because they have to make up for the people who cannot pay by charging much more than cost to those who can. This is called cost shifting. Everyone in the health care and health insurance industries knows all about it, and nobody likes it, but until everyone has health insurance that pays enough to cover costs, that's how it will be. And by the way, the government programs that cover the poor and the elderly (Medicaid and Medicare) do not pay enough to cover costs, so the rest of us are paying for the health care of these patients both through our taxes and through cost shifting.
How does this affect the value calculation? If Hospital A has more patients with no insurance or with Medicaid and Medicare than Hospital B (which has more patients with real insurance), Hospital A will have to charge higher prices to the insured (unless it wants to go out of business). That will make Hospital B look like a better value, which is hardly fair.
If you are now dismayed that measuring the element of cost in the value equation is not as simple as it should be, wait until you see what happens when we attempt to measure quality!
The Centers for Medicare and Medicaid Services (CMS - don't ask what happened to the extra "M") has many "quality measures" for doctors and hospitals. These are things they expect us to measure and report to them. As you might guess, measuring all of these things is rather labor-intensive, which adds to costs. To make it appealing, they start out by providing a small monetary incentive (pay for reporting) for doing this, but over the next few years that goes away and is replaced by penalties for not reporting.
In addition to penalties for not reporting, CMS also penalizes hospitals for failing to hit targets for the quality measures. This would seem to be a good thing, as it gives us a financial incentive to improve quality. But that assumes the "quality measures" imposed by CMS actually measure quality.
Most of us in healthcare think the important thing to measure is patients' health outcomes. And some of the quality measures actually get at this. For example, CMS thinks patients should not acquire infections while in the hospital. I agree. While rates of hospital-acquired infections probably cannot be reduced to zero, we can get pretty close, and we have good evidence of best practices that will help us to get there.
But many of the other measures are related to processes rather than outcomes. So we are expected to do certain things for patients being admitted to the hospital for treatment of pneumonia. These are things you might think would result in better outcomes, and so it might seem reasonable to measure how good we are at doing those things consistently and reward (which means not penalize) us for that. But here is the problem. First, the connection between processes and outcomes is often surprisingly loose. Second, CMS uses quality measures based on processes that have never been shown to improve outcomes. Why would they do that? Maybe you weren't even asking that question, because you know it's a government agency, but the answer is simple: like everyone else, they do things that seem to make sense, even when there is no evidence to support intuition. Then, when presented with evidence to the contrary, they change their approach only with great reluctance, and resistance, and lengthy delay.
So we find ourselves doing many things that we know contribute nothing to improved outcomes because of government mandate. This, as I'm sure you will understand, is very frustrating. The folks at CMS claim to want to improve quality and reduce cost, thereby increasing value, but instead they cause us to waste resources doing useless things, thereby reducing value.
Fasten your seatbelt, because it gets worse. There are actually things they want us to do that may reduce quality and cost lives.
My favorite current example is what they are telling us about ordering CAT scans of the head for patients who come to the emergency department (ED) with headaches. They have established a set of criteria they want us to follow. If the patient doesn't meet the criteria, we shouldn't order a CAT scan.
By now, you have surely predicted the problem. Yes, you guessed it, the criteria are not scientifically valid. There are ED patients who do not meet the criteria who should get CAT scans. And some of those patients, because of the CMS "quality measure," will not get CAT scans. And some of them will have serious conditions that will go undiagnosed.
These "quality measures" adopted by CMS are typically endorsed by an outfit called the National Quality Forum (NQF). NQF endorsement is by no means a guarantee that a quality measure is good, but they try. This new "quality measure" related to CAT scans for headache patients was rejected by the NQF. And yet it was adopted by CMS anyway. They are convinced that it will save money and improve quality by sparing patients needless and potentially harmful radiation exposure, and that we will not, by following their criteria, miss any important diagnoses. If that were true, it would be great. Why, you may ask, has CMS not been dissuaded by the lack of scientific evidence to support this "quality measure?"
A dear friend and colleague once (many times, in fact) said that CMS makes up the rules not to improve health care but to fit the amount of money they want to spend. This is a very important truth to keep in mind. And it's not just CMS. Any time you read or hear statements about value in health care, maintain a healthy skepticism. Ask whether the better value being promised is really about the ratio of quality to cost, or whether it's really just about cost, with quality only an afterthought (if it is a thought at all). All too often, as the "value equation" is addressed, cost is the focus, and quality is ignored or sacrificed.
Sunday, October 16, 2011
Hope for the Future of the Medical Profession
The American College of Emergency Physicians is holding its annual Scientific Assembly in San Francisco. Preceding the educational conference there was a two-day meeting of the organization's national, representative, deliberative body (called the Council). I had the opportunity to visit with the delegation from Texas. One of the topics of conversation was the future of the medical profession - specifically the attraction of the profession to young people.
I have worried about this for many years. I believe it is very important for the medical profession to attract the best and brightest of our nation's youth. I don't know about you, but I realize I'm getting older. I'm not old yet, but I can see it on the horizon. And while I hope to be old and healthy, I know I may not be so lucky. I may be old and sick some day. I may even have the misfortune to be afflicted with the medical equivalent of the ancient Chinese curse.
You know the oft-quoted ancient Chinese curse: "You should live in interesting (or exciting) times." The medical equivalent of this curse is, "You should be an interesting case." I guess for those of us in emergency medicine, "You should be an exciting case" would be an appropriate variation, but I've not heard that version.
If I am ever unlucky enough to be an interesting case, I know who I want to be my doctor. Gregory House, as portrayed on the television show by Hugh Laurie, is the guy. I don't care about bedside manner. I want a brilliant diagnostician. Emphasis on the word brilliant - which brings me back to wanting the best and brightest to choose medicine over the many other professional careers open to them.
Many factors enter into a young person's choice of a career. Medicine appeals to those with superior intellect and strong academic aptitude in the sciences and mathematics. It appeals to those who want to help their fellow man, who want to spend their days curing the sick, saving lives, comforting the afflicted. It attracts those who want to devote their professional lives to something the value of which to society is unquestioned.
Those it attracts must be willing to work hard. Entering the profession requires eight years of post-secondary education (college and medical school) followed by three to eight years (depending on specialty) of post-graduate training, for a total of 11-16 years after high school. And then there will be several decades of hard work. Yes, doctors in some medical specialties work harder than others, but there are few really easy ones, and even those are easy only by comparison with the others. Slackers need not apply.
What is the reward? Most of what's really important, I think, is knowing every day that one's work has helped others and made a difference in their lives. And there is a reward in being a member of a profession that is respected and admired by one's fellow citizens. Finally, the profession does provide a comfortable income, an enviable standard of living, an economic position in the top five percent or so of income earners in the US. That matters in an economic culture that typically rewards hard work with financial success, especially when you consider that most young physicians accumulate substantial educational debt from college and medical school.
If you spend a little time crunching the numbers, you see that physicians' incomes, in inflation-adjusted dollars, have been on a slow but steady decline over the last generation. That doesn't mean we really have anything to complain about, as we are still doing just fine, but the trend is worrisome. And, coupled with that, many physicians perceive a variety of other currents that make the practice of medicine less appealing. There is far more government regulation. There are far more outside entities telling us how to practice medicine and interfering with medical decisions that really should be made within the physician-patient relationship, based on the medical information provided by the doctor coupled with the patient's personal values. And we have an absurdly flawed system for addressing harms that come to patients as the result of medical error. I will write more about that in the future, but the system we have of litigating medical negligence claims does a terrible job of fairly compensating patients who are deserving and is poisonous to the doctor-patient relationship.
Surveys of physicians conducted in recent years reveal that more and more of us, severely frustrated by these trends, actively discourage our children from seriously considering following in our footsteps. So, if we want to make sure the medical profession continues to attract the best and the brightest of our nation's youth, we have our work cut out for us.
My own career in emergency medicine, after medical school and residency training, began in 1985. In those early years I had the privilege of working with a colleague named Ken, a warm and jovial Irishman, who taught me much about emergency medicine - and about life. Ken and I shared many of the same concerns about the future of the medical profession. If you had listened to some of our numerous conversations on the subject, you would have predicted that we would be among those who would steer our own children away from medicine.
Last night I attended a social event for registrants here at ACEP Scientific Assembly. Soon after my wife and I took our seats at one of the tables, the remaining seats were filled by a group of young doctors who are in training in the emergency medicine residency program at Wright State University in Dayton, Ohio. Not long into the conversation, I learned that one of them was Ken's daughter Brooke. You can imagine how delighted I was to meet her, after hearing so much about her from her dad when she was a little girl - and to realize that Ken had, after all, not steered her away from our profession.
My younger daughter is a freshman in college, and she aspires to enter the medical profession. She has the intellect and the drive to accomplish that goal. Equally important, she has the warm and caring personality her patients will need, because she wants to be an oncologist. And she has my full support and encouragement, because I know she is exactly the kind of person our nation needs to be choosing medicine over all the other things she could do with her life.
As a nation, we are struggling to make difficult decisions about reforming our health care system. We should be focused on what is best for patients. We must also keep in mind that the doctors trying to help those patients need health care reform to make their work easier rather than harder. At the same time, it will help if legislators, regulators, and policymakers understand that an inexorable trend of expecting doctors to work harder for less money, year after year, is undermining the cause.
I have worried about this for many years. I believe it is very important for the medical profession to attract the best and brightest of our nation's youth. I don't know about you, but I realize I'm getting older. I'm not old yet, but I can see it on the horizon. And while I hope to be old and healthy, I know I may not be so lucky. I may be old and sick some day. I may even have the misfortune to be afflicted with the medical equivalent of the ancient Chinese curse.
You know the oft-quoted ancient Chinese curse: "You should live in interesting (or exciting) times." The medical equivalent of this curse is, "You should be an interesting case." I guess for those of us in emergency medicine, "You should be an exciting case" would be an appropriate variation, but I've not heard that version.
If I am ever unlucky enough to be an interesting case, I know who I want to be my doctor. Gregory House, as portrayed on the television show by Hugh Laurie, is the guy. I don't care about bedside manner. I want a brilliant diagnostician. Emphasis on the word brilliant - which brings me back to wanting the best and brightest to choose medicine over the many other professional careers open to them.
Many factors enter into a young person's choice of a career. Medicine appeals to those with superior intellect and strong academic aptitude in the sciences and mathematics. It appeals to those who want to help their fellow man, who want to spend their days curing the sick, saving lives, comforting the afflicted. It attracts those who want to devote their professional lives to something the value of which to society is unquestioned.
Those it attracts must be willing to work hard. Entering the profession requires eight years of post-secondary education (college and medical school) followed by three to eight years (depending on specialty) of post-graduate training, for a total of 11-16 years after high school. And then there will be several decades of hard work. Yes, doctors in some medical specialties work harder than others, but there are few really easy ones, and even those are easy only by comparison with the others. Slackers need not apply.
What is the reward? Most of what's really important, I think, is knowing every day that one's work has helped others and made a difference in their lives. And there is a reward in being a member of a profession that is respected and admired by one's fellow citizens. Finally, the profession does provide a comfortable income, an enviable standard of living, an economic position in the top five percent or so of income earners in the US. That matters in an economic culture that typically rewards hard work with financial success, especially when you consider that most young physicians accumulate substantial educational debt from college and medical school.
If you spend a little time crunching the numbers, you see that physicians' incomes, in inflation-adjusted dollars, have been on a slow but steady decline over the last generation. That doesn't mean we really have anything to complain about, as we are still doing just fine, but the trend is worrisome. And, coupled with that, many physicians perceive a variety of other currents that make the practice of medicine less appealing. There is far more government regulation. There are far more outside entities telling us how to practice medicine and interfering with medical decisions that really should be made within the physician-patient relationship, based on the medical information provided by the doctor coupled with the patient's personal values. And we have an absurdly flawed system for addressing harms that come to patients as the result of medical error. I will write more about that in the future, but the system we have of litigating medical negligence claims does a terrible job of fairly compensating patients who are deserving and is poisonous to the doctor-patient relationship.
Surveys of physicians conducted in recent years reveal that more and more of us, severely frustrated by these trends, actively discourage our children from seriously considering following in our footsteps. So, if we want to make sure the medical profession continues to attract the best and the brightest of our nation's youth, we have our work cut out for us.
My own career in emergency medicine, after medical school and residency training, began in 1985. In those early years I had the privilege of working with a colleague named Ken, a warm and jovial Irishman, who taught me much about emergency medicine - and about life. Ken and I shared many of the same concerns about the future of the medical profession. If you had listened to some of our numerous conversations on the subject, you would have predicted that we would be among those who would steer our own children away from medicine.
Last night I attended a social event for registrants here at ACEP Scientific Assembly. Soon after my wife and I took our seats at one of the tables, the remaining seats were filled by a group of young doctors who are in training in the emergency medicine residency program at Wright State University in Dayton, Ohio. Not long into the conversation, I learned that one of them was Ken's daughter Brooke. You can imagine how delighted I was to meet her, after hearing so much about her from her dad when she was a little girl - and to realize that Ken had, after all, not steered her away from our profession.
My younger daughter is a freshman in college, and she aspires to enter the medical profession. She has the intellect and the drive to accomplish that goal. Equally important, she has the warm and caring personality her patients will need, because she wants to be an oncologist. And she has my full support and encouragement, because I know she is exactly the kind of person our nation needs to be choosing medicine over all the other things she could do with her life.
As a nation, we are struggling to make difficult decisions about reforming our health care system. We should be focused on what is best for patients. We must also keep in mind that the doctors trying to help those patients need health care reform to make their work easier rather than harder. At the same time, it will help if legislators, regulators, and policymakers understand that an inexorable trend of expecting doctors to work harder for less money, year after year, is undermining the cause.
Thursday, October 6, 2011
The Apple of My Eye
For many years I regarded Apple as a cult. People who bought the company's machines seemed to be a large group of devoted followers. A colleague at work could often be seen reading a trade publication called MacAddict (later MacLife). It was my sense that Apple had a relatively small share of the personal computing market, but what it lacked in market share was overshadowed by the passion of those who believed in the company and its products.
My experience with personal computing was limited to personal computers - by which I mean the original IBM PC, my first one, acquired in the early 80s, and its descendants. The early PCs were not what I would later call user-friendly. Everything I wanted the computer to do had to be entered as a command from the keyboard.
Meanwhile, a company called Apple was revolutionizing personal computing with something called a graphical user interface, which was remarkably intuitive and easy to learn. Microsoft was trying to stake out its own territory with the earliest versions of Windows, but it seemed Windows was a poor attempt to make the Microsoft operating system look and work like the Macintosh OS, and it fell far short.
Each version of Windows seemed to bring with it new maddening flaws, while each new version of the Mac OS seemed a real advance over the last, and the Mac always functioned beautifully, never inciting its users, with infuriating error messages, to throw it out of the window of an apartment on an upper floor. But I didn't know about any of that. I plodded along using Windows-based computers (after I traded "up" from my original IBM PC), unaware that it wasn't really necessary for my computer to enrage me periodically.
I came late (2005) to the everyone-owns-a-laptop trend. It was a Toshiba PC running Windows XP. It lasted a bit more than four years. Early on it had a hard drive failure, but the data turned out to be salvageable, and a new hard drive kept it going another few years before it started doing things that made me wonder if I could find an exorcist for a computer. By then I had taken note that more and more of my friends were using the MacBook. In June of 2009 my older daughter bought one. Two months later my Toshiba PC died, and Diana enthusiastically endorsed the idea of replacing it with the latest MacBook Pro.
More than two years later I am pleased to report that there may be no such thing as "Error Message Withdrawal Syndrome." I can't really be sure about that, because while I never get error messages on my Mac, I still use Windows-based computers at work, and they fill the void - some days often enough to make me glad I don't have ready access to a sledge hammer, because I'd probably get fired, or at least tranquilized.
Steve Jobs, the driving force, the genius, the wizard at Apple, is gone now. And everyone is talking and writing about him and his extraordinary contributions. He changed the world, they say. He was the most important force in technological advancement since Thomas Edison and Henry Ford. He believed that the machines his company built should be physically beautiful and function flawlessly, with seamless integration of software and hardware. He was not interested in giving his customers what they wanted. Like ice hockey legend Wayne Gretzky, whose famous statement (about skating to where the puck was going to be) Jobs liked to quote, his approach was that Apple should build the things its customers would want if they could envision them, and they would prove him right by buying Apple's new products once they learned about them.
I've always been a bit - sometimes more than a bit - behind the curve. Never an early adopter. When the iPhone was introduced in 2007, I sat back and watched - at least partly because I was a loyal customer of a wireless carrier that didn't offer it. And the most interesting part of watching was how other players strove mightily to bring to market something that could compete with the iPhone. The first device that was a legitimate contender, I think, was the Droid X. From there the proliferation of 4G smartphones that offer serious competition for the iPhone just took off.
Some day I may buy a tablet, either an iPAD or one of its competitors, if I ever become convinced that a device that falls somewhere between my MacBook Pro and my smartphone would fill a void that I currently do not perceive. We shall see. My future smartphones may be iPhones, or they may (like my Droid Bionic) be competitors that measure up. After two-plus years with a Mac, I cannot imagine ever buying another Windows-based computer.
I suspect this is the contribution made by Steve Jobs for which I will always be most grateful: producing machines that show what the state of the art can be and driving the competition to try to emulate his vision of perfection.
Thanks, Steve.
My experience with personal computing was limited to personal computers - by which I mean the original IBM PC, my first one, acquired in the early 80s, and its descendants. The early PCs were not what I would later call user-friendly. Everything I wanted the computer to do had to be entered as a command from the keyboard.
Meanwhile, a company called Apple was revolutionizing personal computing with something called a graphical user interface, which was remarkably intuitive and easy to learn. Microsoft was trying to stake out its own territory with the earliest versions of Windows, but it seemed Windows was a poor attempt to make the Microsoft operating system look and work like the Macintosh OS, and it fell far short.
Each version of Windows seemed to bring with it new maddening flaws, while each new version of the Mac OS seemed a real advance over the last, and the Mac always functioned beautifully, never inciting its users, with infuriating error messages, to throw it out of the window of an apartment on an upper floor. But I didn't know about any of that. I plodded along using Windows-based computers (after I traded "up" from my original IBM PC), unaware that it wasn't really necessary for my computer to enrage me periodically.
I came late (2005) to the everyone-owns-a-laptop trend. It was a Toshiba PC running Windows XP. It lasted a bit more than four years. Early on it had a hard drive failure, but the data turned out to be salvageable, and a new hard drive kept it going another few years before it started doing things that made me wonder if I could find an exorcist for a computer. By then I had taken note that more and more of my friends were using the MacBook. In June of 2009 my older daughter bought one. Two months later my Toshiba PC died, and Diana enthusiastically endorsed the idea of replacing it with the latest MacBook Pro.
More than two years later I am pleased to report that there may be no such thing as "Error Message Withdrawal Syndrome." I can't really be sure about that, because while I never get error messages on my Mac, I still use Windows-based computers at work, and they fill the void - some days often enough to make me glad I don't have ready access to a sledge hammer, because I'd probably get fired, or at least tranquilized.
Steve Jobs, the driving force, the genius, the wizard at Apple, is gone now. And everyone is talking and writing about him and his extraordinary contributions. He changed the world, they say. He was the most important force in technological advancement since Thomas Edison and Henry Ford. He believed that the machines his company built should be physically beautiful and function flawlessly, with seamless integration of software and hardware. He was not interested in giving his customers what they wanted. Like ice hockey legend Wayne Gretzky, whose famous statement (about skating to where the puck was going to be) Jobs liked to quote, his approach was that Apple should build the things its customers would want if they could envision them, and they would prove him right by buying Apple's new products once they learned about them.
I've always been a bit - sometimes more than a bit - behind the curve. Never an early adopter. When the iPhone was introduced in 2007, I sat back and watched - at least partly because I was a loyal customer of a wireless carrier that didn't offer it. And the most interesting part of watching was how other players strove mightily to bring to market something that could compete with the iPhone. The first device that was a legitimate contender, I think, was the Droid X. From there the proliferation of 4G smartphones that offer serious competition for the iPhone just took off.
Some day I may buy a tablet, either an iPAD or one of its competitors, if I ever become convinced that a device that falls somewhere between my MacBook Pro and my smartphone would fill a void that I currently do not perceive. We shall see. My future smartphones may be iPhones, or they may (like my Droid Bionic) be competitors that measure up. After two-plus years with a Mac, I cannot imagine ever buying another Windows-based computer.
I suspect this is the contribution made by Steve Jobs for which I will always be most grateful: producing machines that show what the state of the art can be and driving the competition to try to emulate his vision of perfection.
Thanks, Steve.
Wednesday, September 28, 2011
That's Not an Emergency!
Last week the Washington State Health Care Authority (HCA) issued a press release about a new policy. Starting October 1, the state's Medicaid program will limit recipients of this health care coverage for the poor to three visits per year for problems that turn out not to be emergencies. After they reach that limit, Medicaid won't pay, and the patient may be billed.
Any time a government agency decides to do something new, it may be instructive to ask what problem it is intended to solve. It seems the folks at HCA have decided Medicaid recipients are visiting the ED for problems that are not emergencies so often that the state can save a lot of money by imposing restrictions.
The second question I always ask is whether the agency making the rule is aware of the Law of Unintended Consequences. Let us imagine that a Medicaid recipient is concerned about exceeding the limit and therefore develops a reluctance to seek care in the ED for something that might prove not to be an emergency. The articles in the newspapers say chest pain that turns out not to be a heart attack isn't an emergency. Gee, the person thinks, this is probably just indigestion. Half a day and a full bottle of Maalox later, it turns out it was a heart attack after all, and now there has been enough damage to the heart muscle to weaken its pumping function to the point that the patient will, for the rest of his life, have congestive heart failure. Guess what single diagnosis accounts for the largest number of dollars spent by government health insurance programs? You guessed it: congestive heart failure. Penny wise and pound foolish? You make the call.
Sometimes government agencies make rules without considering the possibility that they are illegal. In years gone by, many of us in emergency medicine worried about patients' reluctance to seek ED care for fear their insurance companies would decide after the fact they didn't have real emergencies and refuse to pay the bills. We successfully lobbied state legislatures, starting with Maryland, for the enactment of something called the Prudent Layperson standard: if a prudent layperson would think symptoms might represent a medical emergency, an insurance company must pay. As it turns out, the federal government has applied the prudent layperson standard to the Medicaid program, which is jointly funded by Uncle Sam and the states. So Washington's list of non-emergency conditions would appear to be in violation of federal law.
There are some unintended consequences that seem quite obvious immediately. The letter sent to Medicaid beneficiaries says that it won't count against your three-per-year limit if you are brought to the ED by ambulance. My friends in EMS are going to be apoplectic over that one. They already get far too many calls for patients who could have gone to the hospital by private vehicle. Now they can expect to be called by patients who want to avoid getting bills for ED visits when it is decided, in hindsight, that they didn't have an emergency. How will that affect the savings anticipated with this new rule?
There is also an exception if you are hospitalized and ultimately diagnosed with a condition on the list. Imagine you are the patient with severe pain from a kidney stone at 5 AM. The emergency physician tells you that's what you have. If she can get your pain and nausea under control, you should be able to go home. If not, you should stay in the hospital. An hour later she's back to ask how you're doing. You feel a lot better, but maybe the pain will come back. Oh, and by the way, if you go home, the bill will be your responsibility, because kidney stone is on the list.
It took a bit of a search on the Web, but I was able to find the list. I was interested to see what kinds of conditions might be there that I think are legitimate reasons for ED visits but commonly do not result in hospitalization. (Oh, and they should also be things that wouldn't necessarily require ambulance transportation. So I'm not counting coma from low blood sugar, because we can often fix that and let the patient go home, but patients in a coma really should come in by ambulance. What were they thinking when they put that on the list?) Chest pain that turns out not to be something serious? On the list. Asthma attack that you can't break with the medicine you have at home? It's on the list, so don't let your husband drive you to the hospital. Call 9-1-1. Nail stuck in your foot? Can't get it out, even with pliers? Yep, it's on the list. (Someone in Olympia thinks your primary care doctor can handle that in the office. An interesting delusion.) Twisted your ankle? It looks bad, but if it turns out you didn't break it, the bill will be all yours. Pregnant? Cramps and bleeding? Think it's a miscarriage? You guessed it - it's on the list.
Dr. Jeff Thompson, chief medical officer for Washington state's Medicaid program, has no use for those who question what's on the list. "I don't have time to engage in silly arguments like that," he said.
Maybe if, instead of complaining about not having time for that, he had taken some time to think about rational solutions to the problem, he wouldn't find himself having to dismiss serious concerns as silly arguments. He says 3% of the state's Medicaid beneficiaries are the ones wasting health care resources in this fashion. How about addressing that 3%? How about patient education and case management for those folks?
You see, if you just say you won't pay the bills any more after three visits for things on the list, the hospitals may or not send bills to the patients, but whether they do or not, they will collect very little (if any) money. And the behavior of the patients who are wasting health care resources will change very little (if at all).
Oh, and if you read the news accounts, you find out just what Dr. Thompson's biases are. He clearly thinks those 3% of patients are mostly visiting EDs to get prescriptions for narcotics. I think someone who is so harshly judgmental about the people his agency is supposed to be helping should find himself another line of work.
Any time a government agency decides to do something new, it may be instructive to ask what problem it is intended to solve. It seems the folks at HCA have decided Medicaid recipients are visiting the ED for problems that are not emergencies so often that the state can save a lot of money by imposing restrictions.
The second question I always ask is whether the agency making the rule is aware of the Law of Unintended Consequences. Let us imagine that a Medicaid recipient is concerned about exceeding the limit and therefore develops a reluctance to seek care in the ED for something that might prove not to be an emergency. The articles in the newspapers say chest pain that turns out not to be a heart attack isn't an emergency. Gee, the person thinks, this is probably just indigestion. Half a day and a full bottle of Maalox later, it turns out it was a heart attack after all, and now there has been enough damage to the heart muscle to weaken its pumping function to the point that the patient will, for the rest of his life, have congestive heart failure. Guess what single diagnosis accounts for the largest number of dollars spent by government health insurance programs? You guessed it: congestive heart failure. Penny wise and pound foolish? You make the call.
Sometimes government agencies make rules without considering the possibility that they are illegal. In years gone by, many of us in emergency medicine worried about patients' reluctance to seek ED care for fear their insurance companies would decide after the fact they didn't have real emergencies and refuse to pay the bills. We successfully lobbied state legislatures, starting with Maryland, for the enactment of something called the Prudent Layperson standard: if a prudent layperson would think symptoms might represent a medical emergency, an insurance company must pay. As it turns out, the federal government has applied the prudent layperson standard to the Medicaid program, which is jointly funded by Uncle Sam and the states. So Washington's list of non-emergency conditions would appear to be in violation of federal law.
There are some unintended consequences that seem quite obvious immediately. The letter sent to Medicaid beneficiaries says that it won't count against your three-per-year limit if you are brought to the ED by ambulance. My friends in EMS are going to be apoplectic over that one. They already get far too many calls for patients who could have gone to the hospital by private vehicle. Now they can expect to be called by patients who want to avoid getting bills for ED visits when it is decided, in hindsight, that they didn't have an emergency. How will that affect the savings anticipated with this new rule?
There is also an exception if you are hospitalized and ultimately diagnosed with a condition on the list. Imagine you are the patient with severe pain from a kidney stone at 5 AM. The emergency physician tells you that's what you have. If she can get your pain and nausea under control, you should be able to go home. If not, you should stay in the hospital. An hour later she's back to ask how you're doing. You feel a lot better, but maybe the pain will come back. Oh, and by the way, if you go home, the bill will be your responsibility, because kidney stone is on the list.
It took a bit of a search on the Web, but I was able to find the list. I was interested to see what kinds of conditions might be there that I think are legitimate reasons for ED visits but commonly do not result in hospitalization. (Oh, and they should also be things that wouldn't necessarily require ambulance transportation. So I'm not counting coma from low blood sugar, because we can often fix that and let the patient go home, but patients in a coma really should come in by ambulance. What were they thinking when they put that on the list?) Chest pain that turns out not to be something serious? On the list. Asthma attack that you can't break with the medicine you have at home? It's on the list, so don't let your husband drive you to the hospital. Call 9-1-1. Nail stuck in your foot? Can't get it out, even with pliers? Yep, it's on the list. (Someone in Olympia thinks your primary care doctor can handle that in the office. An interesting delusion.) Twisted your ankle? It looks bad, but if it turns out you didn't break it, the bill will be all yours. Pregnant? Cramps and bleeding? Think it's a miscarriage? You guessed it - it's on the list.
Dr. Jeff Thompson, chief medical officer for Washington state's Medicaid program, has no use for those who question what's on the list. "I don't have time to engage in silly arguments like that," he said.
Maybe if, instead of complaining about not having time for that, he had taken some time to think about rational solutions to the problem, he wouldn't find himself having to dismiss serious concerns as silly arguments. He says 3% of the state's Medicaid beneficiaries are the ones wasting health care resources in this fashion. How about addressing that 3%? How about patient education and case management for those folks?
You see, if you just say you won't pay the bills any more after three visits for things on the list, the hospitals may or not send bills to the patients, but whether they do or not, they will collect very little (if any) money. And the behavior of the patients who are wasting health care resources will change very little (if at all).
Oh, and if you read the news accounts, you find out just what Dr. Thompson's biases are. He clearly thinks those 3% of patients are mostly visiting EDs to get prescriptions for narcotics. I think someone who is so harshly judgmental about the people his agency is supposed to be helping should find himself another line of work.
Tuesday, September 20, 2011
Who Wrote Handel's Messiah?
This question was posed by Jay Leno in one of those person-on-the-street interview segments he does for his late night show ("Jay-Walking"). The man to whom he posed the question did not know the answer. There were also people unable to name the countries in which are located the Great Wall of China and the Panama Canal - and yes, the questions were framed exactly that way.
Especially disturbing, though, was the way the fellow answered the question about Handel's great masterpiece: "I don't read books." He simultaneously revealed that he did not know who Handel was; was unfamiliar with this magnificent composition; did not know it was a piece of music and not a book; and that he was not a reader. Blinding ignorance, as Ann Coulter (my favorite ultra-right-wing shrew) would say, on so many levels (as my daughters would say).
It seems more and more of us are not readers. The College Board recently reported that the average score on the reading portion of the SAT was 497 (out of a possible 800), an all-time low.
[I am assuming they are comparing it not only with the "reading" scores of recent years but the "verbal" scores that preceded the revision of the SAT from two sections (verbal and math) with top scores of 800 each to three sections (math, reading, and writing) with top scores of 800 each.]
An all-time low! To call this disheartening would truly be to formulate a legitimate contender for this year's British Understatement.
Mark Twain said, "The man who does not read good books has no advantage over the man who cannot read them." I'm guessing the man who never "read" Handel's Messiah has never read anything by Mark Twain, either.
In recent months there have been stories in the news about book sales and about how sales of books in electronic format surpassed sales first of hardcover books and then of paperbacks (according to Amazon). I found myself just a bit sad about this trend, as I strongly prefer hardbound books over paperbacks and actual books over virtual books, and I cannot help wondering, as I look toward the library that constantly beckons to me when I sit here in the family room at my computer, whether homes of the future will have libraries - or whether there will be public libraries or university libraries. I won't live long enough, I think, to see them disappear.
But if people are buying more virtual books than actual books, at least they are reading, aren't they? (I try always to look on the bright side.) And then the College Board tells me no, they aren't. Now, I realize the fact that young people are doing worse than ever on the reading portion of the SAT does not necessarily mean they are not reading. But I'm pretty sure it means exactly that. I have a good idea what one must do to score well on that portion of the SAT, and people who read a lot generally do quite well on it, and the more they read the better they do. Not a perfect correlation, of course, but I bet it's good.
When my daughters were in elementary school their teachers asked the students to report on how many books were in the home. I suppose many students were able to count them. At my house, it turned into an interesting exercise in mathematics, as the girls would count the books on a given shelf that seemed to have books of average size, and then multiply by the number of like shelves. This was repeated for one book case or wall of similar shelves after another, until they had worked their way through each room with book cases or shelves on the walls, and then they were ready to add them all up. They were instructed to report that the number was an estimate and how they had arrived at that estimate.
So I realize my views on reading, its importance, and its place in our culture may be a little atypical. But when I read about how many students our system of public education is graduating from high school functionally illiterate, I suspect the chasm between my views and those of society at large must shrink considerably if we are to produce future generations of high school graduates adequately prepared for college - or for any jobs but those requiring only "unskilled labor." And how many "unskilled labor" jobs are left today? Surely by a generation from now there will be far fewer.
So we must get our kids to read more. And it wouldn't hurt them to listen to Handel while they are reading. Maybe not The Messiah, which is quite demanding of one's attention. Maybe some pleasant concerti grossi, not too loud....
Especially disturbing, though, was the way the fellow answered the question about Handel's great masterpiece: "I don't read books." He simultaneously revealed that he did not know who Handel was; was unfamiliar with this magnificent composition; did not know it was a piece of music and not a book; and that he was not a reader. Blinding ignorance, as Ann Coulter (my favorite ultra-right-wing shrew) would say, on so many levels (as my daughters would say).
It seems more and more of us are not readers. The College Board recently reported that the average score on the reading portion of the SAT was 497 (out of a possible 800), an all-time low.
[I am assuming they are comparing it not only with the "reading" scores of recent years but the "verbal" scores that preceded the revision of the SAT from two sections (verbal and math) with top scores of 800 each to three sections (math, reading, and writing) with top scores of 800 each.]
An all-time low! To call this disheartening would truly be to formulate a legitimate contender for this year's British Understatement.
Mark Twain said, "The man who does not read good books has no advantage over the man who cannot read them." I'm guessing the man who never "read" Handel's Messiah has never read anything by Mark Twain, either.
In recent months there have been stories in the news about book sales and about how sales of books in electronic format surpassed sales first of hardcover books and then of paperbacks (according to Amazon). I found myself just a bit sad about this trend, as I strongly prefer hardbound books over paperbacks and actual books over virtual books, and I cannot help wondering, as I look toward the library that constantly beckons to me when I sit here in the family room at my computer, whether homes of the future will have libraries - or whether there will be public libraries or university libraries. I won't live long enough, I think, to see them disappear.
But if people are buying more virtual books than actual books, at least they are reading, aren't they? (I try always to look on the bright side.) And then the College Board tells me no, they aren't. Now, I realize the fact that young people are doing worse than ever on the reading portion of the SAT does not necessarily mean they are not reading. But I'm pretty sure it means exactly that. I have a good idea what one must do to score well on that portion of the SAT, and people who read a lot generally do quite well on it, and the more they read the better they do. Not a perfect correlation, of course, but I bet it's good.
When my daughters were in elementary school their teachers asked the students to report on how many books were in the home. I suppose many students were able to count them. At my house, it turned into an interesting exercise in mathematics, as the girls would count the books on a given shelf that seemed to have books of average size, and then multiply by the number of like shelves. This was repeated for one book case or wall of similar shelves after another, until they had worked their way through each room with book cases or shelves on the walls, and then they were ready to add them all up. They were instructed to report that the number was an estimate and how they had arrived at that estimate.
So I realize my views on reading, its importance, and its place in our culture may be a little atypical. But when I read about how many students our system of public education is graduating from high school functionally illiterate, I suspect the chasm between my views and those of society at large must shrink considerably if we are to produce future generations of high school graduates adequately prepared for college - or for any jobs but those requiring only "unskilled labor." And how many "unskilled labor" jobs are left today? Surely by a generation from now there will be far fewer.
So we must get our kids to read more. And it wouldn't hurt them to listen to Handel while they are reading. Maybe not The Messiah, which is quite demanding of one's attention. Maybe some pleasant concerti grossi, not too loud....
Sunday, September 11, 2011
Remembrance
I left the business hotel where we always stayed at about quarter 'til eight and walked a block down the hill to the headquarters building of the American College of Emergency Physicians in Irving, Texas, not far from DFW airport. About ten minutes later I entered the board room, five minutes before our meeting was scheduled to begin, and saw people clustered around a television set that someone had brought into the room on a rolling cart stand.
This was an odd sight. I had been in this room many times before and had never seen a TV set there. On the screen I could see the World Trade Center. From one of the towers was coming billowing smoke, and I heard the newscasters talking about a plane having collided with it. The sky was a brilliant, clear blue. How could that have happened? I had an uneasy feeling that someone had intentionally crashed a plane into this building. Then, as we were all standing there watching, at a few minutes after eight (9:03 AM Eastern), another plane crashed into the other tower. This immediately confirmed what we had all been thinking in the interval: a deliberate attack.
The meeting of the ACEP Board of Directors was conducted that day, but it was unlike any I had attended before, or any since then. We were all quite distracted. Not long after the meeting started, it occurred to me that the FAA was sure to ground all air traffic, although that action on the agency's part had not yet been reported. I took out my cell phone and, in a hushed voice from the back of the room, called my wife. She hadn't had the TV on and had no idea what had happened. I gave her a very brief capsule and asked her to try to find me a rental car, because I was sure my flight back to Pittsburgh early that evening was not to be.
We struggled through the meeting, covering the essential business that was on our agenda. At the end of the day I went back to the hotel and requested a taxi. My wife, ever dependable and resourceful, had found me a rental car at a Hertz location - not at the airport, which would surely have been inaccessible. The taxi driver had no idea where it was, but there was an address, and my wife, using MapQuest, gave us directions over the phone.
Three of my colleagues, two from Ohio and one from nearby West Virginia, were aware that I had procured a rental car and wanted to join me, sharing the driving. Twenty hours of driving? I would be delighted to share that, and to have the company.
When I walked into the Hertz place, I was thinking that a Dodge Intrepid would not be especially comfortable for four guys, three of whom were a bit bigger than average, even if all of our bags fit in the trunk, for a trip of that length. At the counter was one other customer, a middle-aged woman, inquiring about the car they had for her. "A Lincoln Town Car? That's pretty big, isn't it?" "Yes, Ma'am," said the desk clerk, "it is." "I'm not really comfortable driving a big car," she said, obviously hoping for an alternative. I thought this was too good to be true, but I immediately stepped forward and said, "Ma'am, I think I can help you with that problem." She left the agency quite pleased with her smaller Dodge Intrepid, and I left knowing that my friends and I would be very comfortable in the Town Car. When I got back to the hotel they looked at me in disbelief. "You da man!" (Or something like that. Some details are not as sharp as others.)
Driving across the country that night, our conversation was full of speculation about why this had happened and how the United States should respond. We had many questions, not so many answers. (Ten years later that is still true for me.) I recall being struck by the fact that every light I saw in the sky as we drove through Texas, Arkansas, Tennessee, and Kentucky was a star, because all civilian planes had been grounded.
I do know we were all determined that the American reaction should be an iron fist. I think that was the way nearly everyone felt at the time. It was a time of ardent nationalism, certainly unlike anything I'd ever seen. My formative years were marked by Viet Nam and the intense questioning of the motives underlying everything the U.S. did on the world stage. The appearance of the American flag absolutely everywhere and the chants of "USA! USA!" filled me with feelings about being American that were, if not different from those I'd had before, certainly more impassioned. And yet there was a sense that it would not last long, that many of the ideals being espoused and the behaviors exhibited would quickly fade. We have such short memories. In the nation's capital partisanship disappeared, but I knew it would be back all too soon. And it was.
I am not writing this because I have unique or profound insights into the cultural clash between Islamic fundamentalist extremists and the Judeo-Christian West. Not because I have something to say about how we are different as a nation or about how the world has changed in the last decade. Not because, ten years later, I have found the answers to any of the questions that gripped me on that night with only stars and no planes in the sky.
No, none of that. I just want to remember.
This was an odd sight. I had been in this room many times before and had never seen a TV set there. On the screen I could see the World Trade Center. From one of the towers was coming billowing smoke, and I heard the newscasters talking about a plane having collided with it. The sky was a brilliant, clear blue. How could that have happened? I had an uneasy feeling that someone had intentionally crashed a plane into this building. Then, as we were all standing there watching, at a few minutes after eight (9:03 AM Eastern), another plane crashed into the other tower. This immediately confirmed what we had all been thinking in the interval: a deliberate attack.
The meeting of the ACEP Board of Directors was conducted that day, but it was unlike any I had attended before, or any since then. We were all quite distracted. Not long after the meeting started, it occurred to me that the FAA was sure to ground all air traffic, although that action on the agency's part had not yet been reported. I took out my cell phone and, in a hushed voice from the back of the room, called my wife. She hadn't had the TV on and had no idea what had happened. I gave her a very brief capsule and asked her to try to find me a rental car, because I was sure my flight back to Pittsburgh early that evening was not to be.
We struggled through the meeting, covering the essential business that was on our agenda. At the end of the day I went back to the hotel and requested a taxi. My wife, ever dependable and resourceful, had found me a rental car at a Hertz location - not at the airport, which would surely have been inaccessible. The taxi driver had no idea where it was, but there was an address, and my wife, using MapQuest, gave us directions over the phone.
Three of my colleagues, two from Ohio and one from nearby West Virginia, were aware that I had procured a rental car and wanted to join me, sharing the driving. Twenty hours of driving? I would be delighted to share that, and to have the company.
When I walked into the Hertz place, I was thinking that a Dodge Intrepid would not be especially comfortable for four guys, three of whom were a bit bigger than average, even if all of our bags fit in the trunk, for a trip of that length. At the counter was one other customer, a middle-aged woman, inquiring about the car they had for her. "A Lincoln Town Car? That's pretty big, isn't it?" "Yes, Ma'am," said the desk clerk, "it is." "I'm not really comfortable driving a big car," she said, obviously hoping for an alternative. I thought this was too good to be true, but I immediately stepped forward and said, "Ma'am, I think I can help you with that problem." She left the agency quite pleased with her smaller Dodge Intrepid, and I left knowing that my friends and I would be very comfortable in the Town Car. When I got back to the hotel they looked at me in disbelief. "You da man!" (Or something like that. Some details are not as sharp as others.)
Driving across the country that night, our conversation was full of speculation about why this had happened and how the United States should respond. We had many questions, not so many answers. (Ten years later that is still true for me.) I recall being struck by the fact that every light I saw in the sky as we drove through Texas, Arkansas, Tennessee, and Kentucky was a star, because all civilian planes had been grounded.
I do know we were all determined that the American reaction should be an iron fist. I think that was the way nearly everyone felt at the time. It was a time of ardent nationalism, certainly unlike anything I'd ever seen. My formative years were marked by Viet Nam and the intense questioning of the motives underlying everything the U.S. did on the world stage. The appearance of the American flag absolutely everywhere and the chants of "USA! USA!" filled me with feelings about being American that were, if not different from those I'd had before, certainly more impassioned. And yet there was a sense that it would not last long, that many of the ideals being espoused and the behaviors exhibited would quickly fade. We have such short memories. In the nation's capital partisanship disappeared, but I knew it would be back all too soon. And it was.
I am not writing this because I have unique or profound insights into the cultural clash between Islamic fundamentalist extremists and the Judeo-Christian West. Not because I have something to say about how we are different as a nation or about how the world has changed in the last decade. Not because, ten years later, I have found the answers to any of the questions that gripped me on that night with only stars and no planes in the sky.
No, none of that. I just want to remember.
Tuesday, September 6, 2011
How Nervous Are We?
Every so often a major survey appears reporting the prevalence of a disease or group of diseases, and sometimes the numbers are eye-popping. Over this past weekend the popular press reported that nearly forty percent of Europeans are mentally ill.
Oh, come now, I thought. That has to be exaggerated. But the report was in a respectable publication, the journal European Neuropsychopharmacology, and it detailed the findings of a review of scientific literature that provided the basis for estimates of the prevalence of a range of mental disorders in European countries for the year 2010.
Among the results: 14% suffer from anxiety and 7% from major depression. Five percent of children are hyperactive and 7% of adults cannot sleep.
I guess when you start to add up all these numbers, the aggregate of 38% shouldn't be terribly surprising. In fact, some of the numbers seemed a bit low to me, but I realize that's because I spend so much of my time around people who are patients in emergency departments in the United States. This European study found only 1% of the population suffering from bipolar disorder, while among my patients that diagnosis seems as common as acne in high school kids.
And only 5% of kids are hyperactive? Europeans are clearly missing something. Here in the US we seem to want to medicate every kid who cannot abide by old-fashioned behavioral standards (sit down/shut up/fold your hands on your desk). When I was like that as a child, my teacher got sufficiently exasperated to make me sit out in the hallway about twice a month. Nowadays the thing to do is send a kid to see the school psychologist.
I cannot help thinking part of the reason the European numbers seem low is that they don't watch endless commercials for prescription medicines.
If you're shy, maybe you have social anxiety disorder and should be taking Paxil. Really? There are times when I'm not feeling especially sociable, but that disappears after one glass of wine. I bet if the folks who make those delightful Malbecs in the Mendoza region of Argentina engaged the right marketing people, they could double their exports to the US overnight.
If you think your outlook on life is affected by more than the occasional blues - in other words, if you're mopey more often than your friends - you should be taking an anti-depressant. And, by the way, if your mood has ups as well as downs, ask your doctor if you are bipolar and if she should add Abilify to the anti-depressant you're already taking.
Don't get me wrong: mental illnesses are very real, and many people benefit from pharmacotherapy for them. But I wonder how many of those people would do just as well if they had a good friend to talk to instead. Look at the woman below. Does she really need Zoloft? Or does she just need someone to say, "You wash, I'll dry. Tell me what's on your mind." I'm guessing a friend with a sympathetic ear would be her best bet - without the risk of serious side effects.
Oh, come now, I thought. That has to be exaggerated. But the report was in a respectable publication, the journal European Neuropsychopharmacology, and it detailed the findings of a review of scientific literature that provided the basis for estimates of the prevalence of a range of mental disorders in European countries for the year 2010.
Among the results: 14% suffer from anxiety and 7% from major depression. Five percent of children are hyperactive and 7% of adults cannot sleep.
I guess when you start to add up all these numbers, the aggregate of 38% shouldn't be terribly surprising. In fact, some of the numbers seemed a bit low to me, but I realize that's because I spend so much of my time around people who are patients in emergency departments in the United States. This European study found only 1% of the population suffering from bipolar disorder, while among my patients that diagnosis seems as common as acne in high school kids.
And only 5% of kids are hyperactive? Europeans are clearly missing something. Here in the US we seem to want to medicate every kid who cannot abide by old-fashioned behavioral standards (sit down/shut up/fold your hands on your desk). When I was like that as a child, my teacher got sufficiently exasperated to make me sit out in the hallway about twice a month. Nowadays the thing to do is send a kid to see the school psychologist.
I cannot help thinking part of the reason the European numbers seem low is that they don't watch endless commercials for prescription medicines.
If you're shy, maybe you have social anxiety disorder and should be taking Paxil. Really? There are times when I'm not feeling especially sociable, but that disappears after one glass of wine. I bet if the folks who make those delightful Malbecs in the Mendoza region of Argentina engaged the right marketing people, they could double their exports to the US overnight.
If you think your outlook on life is affected by more than the occasional blues - in other words, if you're mopey more often than your friends - you should be taking an anti-depressant. And, by the way, if your mood has ups as well as downs, ask your doctor if you are bipolar and if she should add Abilify to the anti-depressant you're already taking.
Don't get me wrong: mental illnesses are very real, and many people benefit from pharmacotherapy for them. But I wonder how many of those people would do just as well if they had a good friend to talk to instead. Look at the woman below. Does she really need Zoloft? Or does she just need someone to say, "You wash, I'll dry. Tell me what's on your mind." I'm guessing a friend with a sympathetic ear would be her best bet - without the risk of serious side effects.
Sunday, September 4, 2011
The Politics of Global Warming
Yesterday I was running shopping errands in 95-degree heat, which according to my rules of weather (that are followed nowhere but in Camelot) should not happen in September. I do not like hot weather. I prefer moderation in many things, weather being but one, and my numerous friends in Dallas have had my sympathies this summer as they have endured absurdly long stretches of 100-degree (and even 110-degree) days.
In the midst of winter, when there is a southward movement of an arctic air mass, there are inevitable jokes about global warming. I didn't hear any of those this summer. But I am always bemused when people confuse weather (a short-term phenomenon) with climate (a long-term phenomenon). If you'll allow a medical analogy, it's similar to the folks who come to the emergency department panic-stricken over high blood pressure readings, apparently unaware that high blood pressure has its harmful effects over years or decades, not days or weeks.
Having been educated as a scientist, I am fascinated by all sciences, not only the life sciences and human medicine. And so the studies in climate science published in recent decades have drawn my attention, even though my background in that area is rather thin. But the most striking thing about climate science is how politically charged it has been. I love to blame things on Al Gore, because I thought it was rude of him to heave deep sighs and roll his eyes while George W. Bush was answering questions in debate, and so I will do it now. In his 1992 book Earth in the Balance Gore advocated the death of the internal combustion engine. Nineteen years later I find myself inclined to agree with him, as you will soon see, but in 1992 this was a much less popular view, and Gore was labeled by those who disagreed as a left-wing, loony, tree-hugging environmental whacko. An unfair characterization, perhaps, but he does not help himself when he intones, in his preachy manner, that "the planet has a fever."
So what do we know? Based on what I've read, I think we know there is a warming trend in global climate. We have some idea how this warming trend compares with others in the planet's history, and here is the first place where I find significant disagreement, between those who say the current warming trend is faster and of greater magnitude than seen in any prior era and those who say we lack robust data to substantiate that thesis.
Once we accept the evidence that there is a warming trend, and allow the possibility (albeit uncertain) that it may be more pronounced than any previous such trends, the next question is what is causing it. Here, I think, is where we venture into opinion that often seems far more political than scientific. Our planet's history includes many previous warming and cooling trends, and we have some rough ideas about what causes them. And there is some reason to believe that human activity, especially since the industrial revolution, may be contributing to warming. It is the magnitude of our contribution that is quite controversial. Debates over this are intense, vociferous, and political. At times they are imbued with religious fervor from all sides. Interestingly, both sides invoke the notion of hubristic arrogance. From the minimizers comes the idea that it is supremely and presumptuously human-centric to think that we could be doing anything that would have a large effect on the planet and its natural trends. From the other side we hear that it is supremely and presumptuously human-centric to think we can do whatever we want without dire consequences.
(This echoes the debate over disappearance of species, in which one side blames the human race and the other side says speciation is a dynamic process in which species appear and disappear all the time, so don't sweat it. I'm pretty sure those who blame humans have a point here.)
Scientists have constructed sophisticated computer models that take the evidence we have and use it to predict future climatic events based on established trends and using various assumptions of human activity. Some of these models tell us we are burning fossil fuels and generating greenhouse gases, thereby contributing very substantially to the global warming trend. They tell us further that if we don't alter this behavior very dramatically and very soon, the warming trend will accelerate and become self-propagating and doom all life on the planet (except cockroaches, which it always seems will survive any doomsday scenario ever created).
I realize computer models for climate are very different from those for predicting the weather, but the accuracy of weather forecasts doesn't give me much confidence. For example, predictions of the effects of Hurricane Irene on New England last weekend were wildly inaccurate.
However, as an avid student of the history of science, I am more interested (as regular readers already know) in how convinced we are of things that later turn out to be completely wrong. I have written about this in medicine, and astronomy provides some even more striking examples. One of the most famous - and one of my favorites - is the mathematical model developed by Ptolemy, who lived nearly two thousand years ago, that supported the view of an earth-centric universe.
When one constructs a theory, it should do two things. First, it should be consistent with all available observations (empiric data). Second, it should predict all future observations. Ptolemy's remarkably complex theory was consistent with all contemporary astronomical observations, and it placed Earth at the center of the universe. As that was what people wanted to believe, his theory was readily embraced. But over a period of several centuries, as astronomical observations accumulated - and became increasingly precise, thanks to ever-improving telescopes - the weight of evidence eventually proved Ptolemy wrong.
A mere few decades ago, scientists (they weren't called climate scientists yet) were convinced of the coming - within a century - of another ice age. An intense cooling trend was anticipated, and there was much discussion of ways of modifying it, including spreading some sort of dark material (such as volcanic ash) over the north polar ice cap to absorb more of the sun's energy and thereby counter the cooling.
Sophisticated computer models didn't exist in the 70s, and we have a good deal more historic climate data now than we did then. But what we "know" now is nevertheless diametrically opposed to what we "knew" 35 years ago. And so I find myself wondering what we will "know" 35 years from now.
Yet I agree with Al Gore about the internal combustion engine. I believe we should stop burning fossil fuels for energy, regardless of what we believe about global warming or its causes. The simple fact is that we are going to run out of fossil fuels. The best data I've seen tell me we are on the downslope of global production of oil (past the peak, that is), at a time when global consumption is still on the rise, and that upslope is getting steeper. Yes, we have coal and natural gas, and we will surely find ways to extract more oil from the earth than we have in proven reserves. But we need petroleum for other things (think plastics and other polymers), and future generations will take a very dim view of our behavior if we burn up most of it for energy instead of finding renewable resources and saving the petroleum for them.
In the midst of winter, when there is a southward movement of an arctic air mass, there are inevitable jokes about global warming. I didn't hear any of those this summer. But I am always bemused when people confuse weather (a short-term phenomenon) with climate (a long-term phenomenon). If you'll allow a medical analogy, it's similar to the folks who come to the emergency department panic-stricken over high blood pressure readings, apparently unaware that high blood pressure has its harmful effects over years or decades, not days or weeks.
Having been educated as a scientist, I am fascinated by all sciences, not only the life sciences and human medicine. And so the studies in climate science published in recent decades have drawn my attention, even though my background in that area is rather thin. But the most striking thing about climate science is how politically charged it has been. I love to blame things on Al Gore, because I thought it was rude of him to heave deep sighs and roll his eyes while George W. Bush was answering questions in debate, and so I will do it now. In his 1992 book Earth in the Balance Gore advocated the death of the internal combustion engine. Nineteen years later I find myself inclined to agree with him, as you will soon see, but in 1992 this was a much less popular view, and Gore was labeled by those who disagreed as a left-wing, loony, tree-hugging environmental whacko. An unfair characterization, perhaps, but he does not help himself when he intones, in his preachy manner, that "the planet has a fever."
So what do we know? Based on what I've read, I think we know there is a warming trend in global climate. We have some idea how this warming trend compares with others in the planet's history, and here is the first place where I find significant disagreement, between those who say the current warming trend is faster and of greater magnitude than seen in any prior era and those who say we lack robust data to substantiate that thesis.
Once we accept the evidence that there is a warming trend, and allow the possibility (albeit uncertain) that it may be more pronounced than any previous such trends, the next question is what is causing it. Here, I think, is where we venture into opinion that often seems far more political than scientific. Our planet's history includes many previous warming and cooling trends, and we have some rough ideas about what causes them. And there is some reason to believe that human activity, especially since the industrial revolution, may be contributing to warming. It is the magnitude of our contribution that is quite controversial. Debates over this are intense, vociferous, and political. At times they are imbued with religious fervor from all sides. Interestingly, both sides invoke the notion of hubristic arrogance. From the minimizers comes the idea that it is supremely and presumptuously human-centric to think that we could be doing anything that would have a large effect on the planet and its natural trends. From the other side we hear that it is supremely and presumptuously human-centric to think we can do whatever we want without dire consequences.
(This echoes the debate over disappearance of species, in which one side blames the human race and the other side says speciation is a dynamic process in which species appear and disappear all the time, so don't sweat it. I'm pretty sure those who blame humans have a point here.)
Scientists have constructed sophisticated computer models that take the evidence we have and use it to predict future climatic events based on established trends and using various assumptions of human activity. Some of these models tell us we are burning fossil fuels and generating greenhouse gases, thereby contributing very substantially to the global warming trend. They tell us further that if we don't alter this behavior very dramatically and very soon, the warming trend will accelerate and become self-propagating and doom all life on the planet (except cockroaches, which it always seems will survive any doomsday scenario ever created).
I realize computer models for climate are very different from those for predicting the weather, but the accuracy of weather forecasts doesn't give me much confidence. For example, predictions of the effects of Hurricane Irene on New England last weekend were wildly inaccurate.
However, as an avid student of the history of science, I am more interested (as regular readers already know) in how convinced we are of things that later turn out to be completely wrong. I have written about this in medicine, and astronomy provides some even more striking examples. One of the most famous - and one of my favorites - is the mathematical model developed by Ptolemy, who lived nearly two thousand years ago, that supported the view of an earth-centric universe.
When one constructs a theory, it should do two things. First, it should be consistent with all available observations (empiric data). Second, it should predict all future observations. Ptolemy's remarkably complex theory was consistent with all contemporary astronomical observations, and it placed Earth at the center of the universe. As that was what people wanted to believe, his theory was readily embraced. But over a period of several centuries, as astronomical observations accumulated - and became increasingly precise, thanks to ever-improving telescopes - the weight of evidence eventually proved Ptolemy wrong.
A mere few decades ago, scientists (they weren't called climate scientists yet) were convinced of the coming - within a century - of another ice age. An intense cooling trend was anticipated, and there was much discussion of ways of modifying it, including spreading some sort of dark material (such as volcanic ash) over the north polar ice cap to absorb more of the sun's energy and thereby counter the cooling.
Sophisticated computer models didn't exist in the 70s, and we have a good deal more historic climate data now than we did then. But what we "know" now is nevertheless diametrically opposed to what we "knew" 35 years ago. And so I find myself wondering what we will "know" 35 years from now.
Yet I agree with Al Gore about the internal combustion engine. I believe we should stop burning fossil fuels for energy, regardless of what we believe about global warming or its causes. The simple fact is that we are going to run out of fossil fuels. The best data I've seen tell me we are on the downslope of global production of oil (past the peak, that is), at a time when global consumption is still on the rise, and that upslope is getting steeper. Yes, we have coal and natural gas, and we will surely find ways to extract more oil from the earth than we have in proven reserves. But we need petroleum for other things (think plastics and other polymers), and future generations will take a very dim view of our behavior if we burn up most of it for energy instead of finding renewable resources and saving the petroleum for them.
Friday, August 26, 2011
Medicaid Expansion: A Catastrophe in Waiting?
As noted in my last essay, a major goal of the Patient Protection and Affordable Care Act (PPACA) is a dramatic reduction in the number of Americans without health insurance. The latest estimates I've seen indicate that the number of newly covered people will be 32 million (leaving another 15-20 million still uncovered), and about half of those (16 million) will be covered through expansion of Medicaid, the joint federal-state health insurance program for the poor.
This expansion of Medicaid to cover more Americans will happen chiefly through raising the income level of eligibility. In other words, one will not need to be quite as poor to qualify. This means that some of the working poor who currently earn too much to be eligible for Medicaid will qualify for this assistance.
This approach to covering more people raises many questions. Here are a few of them.
1. Where will the money come from? Most of it will be funded with federal tax dollars, but Medicaid is paid for jointly by the federal and state governments, and some state budgets will be under tremendous strain. Eligibility is currently variable from state to state. Poorer states (those with lower levels of per capita income) tend to have less money to spend on Medicaid, and so in those states you have to be poorer to qualify. Even though the federal government matches state expenditures more generously for these poorer states, you can't draw down federal matching dollars by spending money you don't have. (States, unlike the federal government, typically must balance their budgets.) Under PPACA, a bigger-than-usual share of the money for expansion will come from federal tax dollars, but the poorer states will still struggle.
How might the states struggling to fund their side of the Medicaid program deal with the challenge? Yes, you guessed it: by lowering payments to providers (especially hospitals and doctors). And that brings us to the next question.
2. Is Medicaid "real insurance?" The short answer is no. When you have health insurance procured through the private, commercial insurance market, what your insurance pays to providers is determined by a complex set of factors in that market. One of these factors is negotiation between insurers and providers. Another is competition among insurers. Every insurer wants as much business as possible, and they make their products attractive by doing their best to achieve a balance between cost (to employers and employees) and choice. So the buyers want a plan that will provide excellent coverage, with reasonable out-of-pocket expenditures for patients and wide choice of participating doctors and hospitals. At the same time, they want affordable premium costs. On the provider side, hospitals and doctors want fair payment for the services they render. They expect that if, through negotiation, they agree to accept somewhat lower payments, the insurer will make it more attractive for patients to choose these "participating providers," thus assuring them a greater volume of business.
When the "insurance" is Medicaid, all of these market factors disappear. Patients have no choices, unless they are offered Medicaid managed care, which introduces a few choices that for most patients are confusing and not terribly attractive. And providers are told what they will be paid for taking care of Medicaid patients. The rates are low (or very low) and non-negotiable. Some providers (notably hospitals) don't have a choice about whether to accept Medicaid patients, although if patients have Medicaid managed care, a patient who goes to the "wrong" hospital emergency department may have to be transferred to another hospital if inpatient care is needed. As for doctors, the choice is typically quite simple: accept Medicaid patients or not. More and more of them choose not.
So for many patients, Medicaid is not "real insurance," simply because in some markets it is really difficult to find a doctor who is accepting Medicaid patients. And that brings us to the third question.
3. Will these newly covered patients be able to find a primary care doctor? Again, the short answer is no. Remember, the number of newly insured patients is expected to be some 32 million. Half of those will have Medicaid. The current shortage of primary care doctors is estimated to be 40,000. Most uninsured patients don't have a primary care doctor. Most of those newly insured under PPACA will try to find one. The first challenge, in a health care system with a serious shortage of primary care doctors, will be finding one who is taking new patients. Now imagine that you are among the half of the newly insured patients with Medicaid. What do you think your chances will be of finding a primary care doctor who will be just as accepting of new Medicaid patients as new patients with "real insurance?"
4. What is the plan for providing primary care for all of these newly insured folks? There is no plan. At least there is no plan that appears likely to remedy the shortage of primary care doctors in the foreseeable future.
5. Where will these patients go? Remember, these are folks who currently have no insurance. Many of them are afraid of huge medical bills they cannot pay, and so they do not seek medical care when they think they probably should, hoping things will somehow get better on their own. When that doesn't happen, they wind up in the emergency department, much worse off than if they had sought care earlier, and have to be hospitalized. Under PPACA, they will have coverage, eliminating their fear of bills they can't pay. But without access to primary care, they will go to the only place they know that will always take care of them, 24/7/365. The upside: they will be less likely to wait until they are critically ill. The downside for those of us in the emergency care system: our capacity is limited, too, and we will be overwhelmed.
Elected officials and policymakers, are you listening? I think we know that answer.
This expansion of Medicaid to cover more Americans will happen chiefly through raising the income level of eligibility. In other words, one will not need to be quite as poor to qualify. This means that some of the working poor who currently earn too much to be eligible for Medicaid will qualify for this assistance.
This approach to covering more people raises many questions. Here are a few of them.
1. Where will the money come from? Most of it will be funded with federal tax dollars, but Medicaid is paid for jointly by the federal and state governments, and some state budgets will be under tremendous strain. Eligibility is currently variable from state to state. Poorer states (those with lower levels of per capita income) tend to have less money to spend on Medicaid, and so in those states you have to be poorer to qualify. Even though the federal government matches state expenditures more generously for these poorer states, you can't draw down federal matching dollars by spending money you don't have. (States, unlike the federal government, typically must balance their budgets.) Under PPACA, a bigger-than-usual share of the money for expansion will come from federal tax dollars, but the poorer states will still struggle.
How might the states struggling to fund their side of the Medicaid program deal with the challenge? Yes, you guessed it: by lowering payments to providers (especially hospitals and doctors). And that brings us to the next question.
2. Is Medicaid "real insurance?" The short answer is no. When you have health insurance procured through the private, commercial insurance market, what your insurance pays to providers is determined by a complex set of factors in that market. One of these factors is negotiation between insurers and providers. Another is competition among insurers. Every insurer wants as much business as possible, and they make their products attractive by doing their best to achieve a balance between cost (to employers and employees) and choice. So the buyers want a plan that will provide excellent coverage, with reasonable out-of-pocket expenditures for patients and wide choice of participating doctors and hospitals. At the same time, they want affordable premium costs. On the provider side, hospitals and doctors want fair payment for the services they render. They expect that if, through negotiation, they agree to accept somewhat lower payments, the insurer will make it more attractive for patients to choose these "participating providers," thus assuring them a greater volume of business.
When the "insurance" is Medicaid, all of these market factors disappear. Patients have no choices, unless they are offered Medicaid managed care, which introduces a few choices that for most patients are confusing and not terribly attractive. And providers are told what they will be paid for taking care of Medicaid patients. The rates are low (or very low) and non-negotiable. Some providers (notably hospitals) don't have a choice about whether to accept Medicaid patients, although if patients have Medicaid managed care, a patient who goes to the "wrong" hospital emergency department may have to be transferred to another hospital if inpatient care is needed. As for doctors, the choice is typically quite simple: accept Medicaid patients or not. More and more of them choose not.
So for many patients, Medicaid is not "real insurance," simply because in some markets it is really difficult to find a doctor who is accepting Medicaid patients. And that brings us to the third question.
3. Will these newly covered patients be able to find a primary care doctor? Again, the short answer is no. Remember, the number of newly insured patients is expected to be some 32 million. Half of those will have Medicaid. The current shortage of primary care doctors is estimated to be 40,000. Most uninsured patients don't have a primary care doctor. Most of those newly insured under PPACA will try to find one. The first challenge, in a health care system with a serious shortage of primary care doctors, will be finding one who is taking new patients. Now imagine that you are among the half of the newly insured patients with Medicaid. What do you think your chances will be of finding a primary care doctor who will be just as accepting of new Medicaid patients as new patients with "real insurance?"
4. What is the plan for providing primary care for all of these newly insured folks? There is no plan. At least there is no plan that appears likely to remedy the shortage of primary care doctors in the foreseeable future.
5. Where will these patients go? Remember, these are folks who currently have no insurance. Many of them are afraid of huge medical bills they cannot pay, and so they do not seek medical care when they think they probably should, hoping things will somehow get better on their own. When that doesn't happen, they wind up in the emergency department, much worse off than if they had sought care earlier, and have to be hospitalized. Under PPACA, they will have coverage, eliminating their fear of bills they can't pay. But without access to primary care, they will go to the only place they know that will always take care of them, 24/7/365. The upside: they will be less likely to wait until they are critically ill. The downside for those of us in the emergency care system: our capacity is limited, too, and we will be overwhelmed.
Elected officials and policymakers, are you listening? I think we know that answer.
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