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.
Wednesday, September 28, 2011
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.
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