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....
Tuesday, September 20, 2011
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.
Tuesday, August 23, 2011
Marketing the ER
At many of the nation's hospitals, business is brisk in the emergency department. For large portions of the day (and round the clock in some institutions), all of the treatment rooms are full, patients too sick to stay in the waiting area until there is a room for them are lying on gurneys in the hallways, and there are more in the waiting room.
And yet, as they drive to work, doctors and nurses who care for all of those patients see billboards advertising the services they provide.
You know the one-word question that crosses their minds: "Seriously?"
So why are ED services being marketed? Marketing is all about generating business. If you are advertising your emergency department, there are basically two ways to get more business. The first is to get patients to seek medical care who otherwise wouldn't. If you've read earlier essays in this blog, you know what I think about that. There is a small group of patients for whom that is an appropriate, ethically responsible thing to do: patients with symptoms of something serious, like a stroke, who might not realize their symptoms are cause for concern or that they should seek care promptly rather than waiting around to see if the symptoms will go away. But otherwise, we should not be trying to increase total demand for ED services.
The second way is to take "market share" away from someone else. If that someone else is the ED at a competing hospital, and your place has excess capacity, go right ahead. Tell people you have better doctors, better nurses, shorter waits, a friendlier atmosphere. Tell them whatever you want, as long as it's true, or at least not demonstrably false. But if you're already at or above capacity, don't do it.
If the someone else from whom you are taking "business" away is the patient's primary care doctor, because the patient doesn't need an appointment, and you never close, and you see everybody today whether the problem is urgent or not, that could be OK. "Really?" I hear you asking. Well, yes, IF the local primary care doctors are busier than one-armed paper hangers and your ED has excess capacity, which means seeing more patients doesn't overburden the available resources and helps cover overhead. But that's not the case in most communities, and part of the effect of ED marketing is, indeed, to take patient visits away from the office of the doctor who knows them. This is unwise and not responsible stewardship of health care resources.
Not long ago I saw a bit of marketing fluff (yes, that is advisedly pejorative) from a highly respected tertiary care, academic medical center in my city (not the one where I work) in which one of the emergency physicians was quoted as saying his staff cared for patients with everything from colds to heart attacks. You know what I thought. Colds? Please! You have now officially given permission to people to seek care in the ED for a cold, instead of going to a drugstore.
(Remember those commercials? "Sudafed - Aisle 5." I like Sudafed - the original, that you can still get by asking the druggist, not the new "PE" version that's allowed on the shelf because you can't use it to make crystal meth. And no, I don't own stock in the company that makes it.)
This kind of marketing has many unfortunate effects. One of them - the one that bothers me the most - is that it tends to support the theory that, in health care, supply generates demand. That theory has gotten us into a lot of trouble. It was propounded by Joseph Califano, Secretary of Health, Education & Welfare during the Carter administration. As a result of Califano's influence, funding for medical education was cut in order to restrain growth in the supply of physicians (and thereby restrain growth in demand for their services). Our current shortage of physicians is due in large measure to that mistake.
If we don't want policymakers thinking lots of people use the ED for non-emergencies, which is what they think now, the least we should do is make sure our marketing targets people who have emergencies. I liked one billboard used by a hospital where I worked years ago. It showed a guy falling off a ladder. If he got hurt badly enough to need medical attention, the billboard suggested, our place was his best choice. I believed that, and I wanted him to come to our place even if we were busy.
And yet, as they drive to work, doctors and nurses who care for all of those patients see billboards advertising the services they provide.
You know the one-word question that crosses their minds: "Seriously?"
So why are ED services being marketed? Marketing is all about generating business. If you are advertising your emergency department, there are basically two ways to get more business. The first is to get patients to seek medical care who otherwise wouldn't. If you've read earlier essays in this blog, you know what I think about that. There is a small group of patients for whom that is an appropriate, ethically responsible thing to do: patients with symptoms of something serious, like a stroke, who might not realize their symptoms are cause for concern or that they should seek care promptly rather than waiting around to see if the symptoms will go away. But otherwise, we should not be trying to increase total demand for ED services.
The second way is to take "market share" away from someone else. If that someone else is the ED at a competing hospital, and your place has excess capacity, go right ahead. Tell people you have better doctors, better nurses, shorter waits, a friendlier atmosphere. Tell them whatever you want, as long as it's true, or at least not demonstrably false. But if you're already at or above capacity, don't do it.
If the someone else from whom you are taking "business" away is the patient's primary care doctor, because the patient doesn't need an appointment, and you never close, and you see everybody today whether the problem is urgent or not, that could be OK. "Really?" I hear you asking. Well, yes, IF the local primary care doctors are busier than one-armed paper hangers and your ED has excess capacity, which means seeing more patients doesn't overburden the available resources and helps cover overhead. But that's not the case in most communities, and part of the effect of ED marketing is, indeed, to take patient visits away from the office of the doctor who knows them. This is unwise and not responsible stewardship of health care resources.
Not long ago I saw a bit of marketing fluff (yes, that is advisedly pejorative) from a highly respected tertiary care, academic medical center in my city (not the one where I work) in which one of the emergency physicians was quoted as saying his staff cared for patients with everything from colds to heart attacks. You know what I thought. Colds? Please! You have now officially given permission to people to seek care in the ED for a cold, instead of going to a drugstore.
(Remember those commercials? "Sudafed - Aisle 5." I like Sudafed - the original, that you can still get by asking the druggist, not the new "PE" version that's allowed on the shelf because you can't use it to make crystal meth. And no, I don't own stock in the company that makes it.)
This kind of marketing has many unfortunate effects. One of them - the one that bothers me the most - is that it tends to support the theory that, in health care, supply generates demand. That theory has gotten us into a lot of trouble. It was propounded by Joseph Califano, Secretary of Health, Education & Welfare during the Carter administration. As a result of Califano's influence, funding for medical education was cut in order to restrain growth in the supply of physicians (and thereby restrain growth in demand for their services). Our current shortage of physicians is due in large measure to that mistake.
If we don't want policymakers thinking lots of people use the ED for non-emergencies, which is what they think now, the least we should do is make sure our marketing targets people who have emergencies. I liked one billboard used by a hospital where I worked years ago. It showed a guy falling off a ladder. If he got hurt badly enough to need medical attention, the billboard suggested, our place was his best choice. I believed that, and I wanted him to come to our place even if we were busy.
Friday, August 19, 2011
Thou Art Commanded: Buy Health Insurance
People don't like being told what to do by government. The states don't like being told what to do by the federal government. When this happens, there are always questions raised about whether government is exceeding its constitutional authority.
Over the last couple of centuries the power of Congress has dramatically expanded, and the Supreme Court has very infrequently ruled that Congress was overstepping its bounds. Article I, Section 8 of the Constitution enumerates the powers of Congress, and the last paragraph affords Congress fairly sweeping authority to exercise those powers through the enactment of laws which "shall be necessary and proper" to that exercise. So once the Court can find a basis for Congressional action in some enumerated power, the "necessary and proper" clause, as it was dubbed by Justice Brandeis, provides broad latitude.
But the "necessary and proper" clause doesn't give Congress the power to do whatever it wants. So much of what Congress does falls into the realm of regulating interstate commerce. Pretty much any economic activity that crosses state lines then falls under congressional power. But some are under the misapprehension that the beginning of Section 8, which empowers Congress to provide for the "general Welfare" (they capitalized a lot of common nouns back then), lets Congress do whatever it wants for the good of the country (which is, of course, in the eye of the beholder).
Not so, sayeth the Supreme Court. If you read that first paragraph, it looks that way. But the Supreme Court has said that phrase in the first clause of Article I, Section 8 means only that Congress can use its taxing authority to provide for the general welfare, not that it can do anything at all to accomplish that goal.
(My own view on this is ambivalent. On the one hand, I think limiting congressional authority is generally a good idea. On the other hand, there is a comma in that first clause that must be ignored for the view expounded by Justice Joseph Story to make sense linguistically. Recognizing, however, that commas were sprinkled generously in 18th-century writing, I'll go with Justice Story's interpretation.)
So look at the enumerated powers in Section 8 and try to find one that allows Congress to force a person to buy health insurance. Keep looking. No luck? The 11th Circuit Court of Appeals couldn't find it either. And so it disagreed with the 6th Circuit, which has upheld the "individual mandate" of the Patient Protection and Affordable Care Act (PPACA, also known as Obamacare). Remember what is likely to happen when two appeals courts within the federal judiciary issue contradictory rulings: the issue will wind up in the Supreme Court.
I hesitate to predict how the Supreme Court will settle this question, but I think the 11th Circuit is on firmer ground. Sometimes constitutional law defies practicality. By this interpretation Congress cannot tell me I must buy health insurance, but Congress can confiscate some of my earnings for the purpose of providing me with health insurance.
Why is this so important? Because for the financing of our health care system to work well, everyone must participate in the insurance risk pool. We can do that if we all buy health insurance (or at least all of us who aren't already covered by public health insurance, meaning Medicaid and Medicare). Or we can do that by paying taxes to provide public health insurance for everyone. The 11th Circuit's ruling would seem to push us in the latter direction. Many Americans don't want to go in either direction, even as they acknowledge that having 50 million of us uninsured is a bad thing.
The other major reason is the matter of "pre-existing conditions." Most of us agree that an insurance company should not be allowed to refuse to sell you health insurance because of a pre-existing condition or to exclude that condition from coverage. If we require everyone to purchase health insurance, we can tell the insurance companies they cannot exclude pre-existing conditions. Otherwise, many people will wait until they have something serious wrong with them to buy health insurance. It's like buying car insurance after you get into a crash and expecting it to be covered.
So what is the right answer? The goal is universal coverage, and the surest way to get there is to expand public insurance programs to cover everyone. Many Americans oppose that at the same time they agree we should have universal coverage. It's time to make some hard choices.
(Oh, if you're still wondering about the "states' rights" basis for opposing Obamacare, you'll have to wait for another blog entry. One constitutional issue at a time.)
Over the last couple of centuries the power of Congress has dramatically expanded, and the Supreme Court has very infrequently ruled that Congress was overstepping its bounds. Article I, Section 8 of the Constitution enumerates the powers of Congress, and the last paragraph affords Congress fairly sweeping authority to exercise those powers through the enactment of laws which "shall be necessary and proper" to that exercise. So once the Court can find a basis for Congressional action in some enumerated power, the "necessary and proper" clause, as it was dubbed by Justice Brandeis, provides broad latitude.
But the "necessary and proper" clause doesn't give Congress the power to do whatever it wants. So much of what Congress does falls into the realm of regulating interstate commerce. Pretty much any economic activity that crosses state lines then falls under congressional power. But some are under the misapprehension that the beginning of Section 8, which empowers Congress to provide for the "general Welfare" (they capitalized a lot of common nouns back then), lets Congress do whatever it wants for the good of the country (which is, of course, in the eye of the beholder).
Not so, sayeth the Supreme Court. If you read that first paragraph, it looks that way. But the Supreme Court has said that phrase in the first clause of Article I, Section 8 means only that Congress can use its taxing authority to provide for the general welfare, not that it can do anything at all to accomplish that goal.
(My own view on this is ambivalent. On the one hand, I think limiting congressional authority is generally a good idea. On the other hand, there is a comma in that first clause that must be ignored for the view expounded by Justice Joseph Story to make sense linguistically. Recognizing, however, that commas were sprinkled generously in 18th-century writing, I'll go with Justice Story's interpretation.)
So look at the enumerated powers in Section 8 and try to find one that allows Congress to force a person to buy health insurance. Keep looking. No luck? The 11th Circuit Court of Appeals couldn't find it either. And so it disagreed with the 6th Circuit, which has upheld the "individual mandate" of the Patient Protection and Affordable Care Act (PPACA, also known as Obamacare). Remember what is likely to happen when two appeals courts within the federal judiciary issue contradictory rulings: the issue will wind up in the Supreme Court.
I hesitate to predict how the Supreme Court will settle this question, but I think the 11th Circuit is on firmer ground. Sometimes constitutional law defies practicality. By this interpretation Congress cannot tell me I must buy health insurance, but Congress can confiscate some of my earnings for the purpose of providing me with health insurance.
Why is this so important? Because for the financing of our health care system to work well, everyone must participate in the insurance risk pool. We can do that if we all buy health insurance (or at least all of us who aren't already covered by public health insurance, meaning Medicaid and Medicare). Or we can do that by paying taxes to provide public health insurance for everyone. The 11th Circuit's ruling would seem to push us in the latter direction. Many Americans don't want to go in either direction, even as they acknowledge that having 50 million of us uninsured is a bad thing.
The other major reason is the matter of "pre-existing conditions." Most of us agree that an insurance company should not be allowed to refuse to sell you health insurance because of a pre-existing condition or to exclude that condition from coverage. If we require everyone to purchase health insurance, we can tell the insurance companies they cannot exclude pre-existing conditions. Otherwise, many people will wait until they have something serious wrong with them to buy health insurance. It's like buying car insurance after you get into a crash and expecting it to be covered.
So what is the right answer? The goal is universal coverage, and the surest way to get there is to expand public insurance programs to cover everyone. Many Americans oppose that at the same time they agree we should have universal coverage. It's time to make some hard choices.
(Oh, if you're still wondering about the "states' rights" basis for opposing Obamacare, you'll have to wait for another blog entry. One constitutional issue at a time.)
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