Daniel Larison summarizes the poll evidence that suggests Obama’s problem is that he isn’t liberal enough.
Matt Yglesias posts a list of books that have influenced him. I shall do the same, nonexhaustively, in no particular order.
- Wendell Berry, What Are People For? — I could really list any of Wendell Berry’s books of essays, but I’ll list this one because it’s the first book of his that I read. Berry’s assessment of the dangers posed by our modern way of living to many of the things that I find profoundly valuable is persuasive convincing. I think that everyone, ultimately, has to have a political philosophy, and Berry comes closest to anyone I’ve read to describing mine.
- Gavin DeBecker, The Gift of Fear — I’ve been lucky enough to have lived a fairly safe and mundane life, that for the most part has been free of fear. So, luckily, much of how I like to handle threats and danger, I learned from this book. Plus, Gavin DeBecker tells you exactly why local TV news really sucks.
- J.R.R. Tolkien, The Lord of the Rings — Despite what China Mieville says, this is a great story and it will outlast all of us. I’ve read it about ten times, but I’ve been rereading it throughout most of my life, so it’s possible that I’ve lost count. When the day comes to assemble an army of minions at my compound, I’m naming that compound Rivendell. Even Mieville might understand.
- Various, The Hardy Boys Mystery Stories — Back in the 1970s, when Carter was in the White House, I was reading a lot of Hardy Boys books. Sometimes four in one day. Specifically, I’ve read all of the first 58 books plus The Hardy Boys Detective Handbook (the “Hardy Boys canon”) in their 1959-1973 revisions. Maybe I love to read because of the Hardy Boys? It’s possible. Baffling, but possible.
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Ferdinand the Bull
Munro Leaf, The Story of Ferdinand — Why am I such a sucker for creatures? I don’t know. Why am I not a neoconservative? Because neoconservatives are catastrophically stupid, of course, but how do I know that? There are a lot of books from my childhood that may claim responsibility for some of these traits of mine, but this one is surely one of the most influential.
- Hannah Arendt, The Human Condition — I read this during my senior year of high school on the recommendation of my favorite teacher, and I’ve now read it almost as many times as I’ve read The Lord of the Rings. If any single thing is responsible for my decision to study political philosophy in college, it’s this book. My choice of college major, in turn, has been hugely consequential. I doubt I would have gone to law school otherwise. Hell, medical school might have seemed a lot less attractive to me had I not been insulated, on account of writing a thesis on Hannah Arendt, from the icky, obsessive, preprofessional premed culture in college. Even if that’s all it ever did for me, I’d still be grateful for having read this book.
John Dugan (Reuters/Kevin Lamarque)
John Dugan is at it again.
The head of the Office of the Comptroller of the Currency is still looking and sounding like a banking industry lobbyist, arguing that the already-weakened Consumer Financial Protection Bureau proposal in Chris Dodd’s reform bill is still too strong. From the Financial Times (via the NYT):
“In every case consumer protection has the edge and will trump safety and soundness and I think that is backwards,” said John Dugan, the comptroller of the currency, at an American Bankers Association conference.
Mr Dugan, whose office regulates national banks, said a Consumer Financial Protection Bureau proposed in Mr Dodd’s financial regulation bill, which was published on Monday and is to be revised next week, was too strong.
The comments were unusually forthright from an influential regulator and came amid a surge of lobbying from regulators and banks before next week’s mark-up of the bill in the banking committee.
Dugan is also arguing for greater federal preemption of state consumer protection laws affecting banks — which is coincidentally the same argument the US Chamber of Commerce is making.
How this guy John Dugan has any credibility left as a regulator is a mystery. As I’ve said before, I think Obama should replace him now.
Today is Match Day in the U.S. — congratulations to everyone who matched in emergency medicine this year.
Via the NYT, from a longer article describing the FCCs plan to modernize the American broadband internet infrastructure:
In a move that could affect policy decisions years from now, the F.C.C. will begin assessing the speeds and costs of consumer broadband service. Until then, consumers can take matters into their own hands with a new suite of online and mobile phone applications released by the F.C.C. that will allow them to test the speed of their home Internet and see if they’re paying for data speeds as advertised.
It’s a shame that things like this seem so rare. Little things that hold corporations accountable… I wonder what nice little things a truly independent consumer financial protection commission could do, vis-a-vis the banks?
Fox News chief Roger Ailes
Howell Raines, the former NYT executive editor, asserts that the reason why so many journalists not only don’t excoriate Fox News, but actually alter their own stories to conform to the Fox News model, is that they fear offending a potential employer:
Under the pretense of correcting a Democratic bias in news reporting, Fox has accomplished something that seemed impossible before Ailes imported to the news studio the tricks he learned in Richard Nixon’s campaign think tank: He and his video ferrets have intimidated center-right and center-left journalists into suppressing conclusions — whether on health-care reform or other issues — they once would have stated as demonstrably proven by their reporting. I try not to believe that this kid-gloves handling amounts to self-censorship, but it’s hard to ignore the evidence. News Corp., with 64,000 employees worldwide, receives the tender treatment accorded a future employer.
I’m not a journalist, and I don’t know whether Raines is right or not about what motivates journalists. But knowing what I know about people generally, I’d say this argument is plausible. Normal people usually aren’t willing to sacrifice their entire careers to defend a principle, especially when that principle looks like it’s not capable of being defended successfully.
However bad Fox News is; however much that organization has departed from traditional journalistic standards, the fact is that Fox is attracting an audience at the expense of other outlets that offer more genuine news. People just like us are choosing to watch Fox News. Maybe we’re in it for the entertainment and not for the news, but the consequence of our continued patronage of Fox may be that real journalists try to make whatever they do look like Fox News. In other words, that they stop doing journalism.
I’ve gone back and forth on the health care bill, but at this late hour, I think we should pass it.
At this point, these are our only two options — kill the bill, or pass it. Yes, our elected representatives should be held to account for failing to give us a better bill. But the need to punish spineless Democrats and obstructionist Republicans is a completely separate issue from the need to decide the fate of this bill.
I am one of those people who think that if we are going to require people to buy health insurance, we should also enable them to choose a government-run program to buy their insurance from. So I understand why many people on the traditional left would oppose any bill requiring them to give their money to a private health insurer. But I don’t think the fact that this bill is excessively gentle to private insurers is enough of a reason to kill it.
The choice now is: status quo, or this bill that is much shittier than it could have been but which is still much better than nothing. We know the status quo sucks, especially for people unlucky enough to be in the individual insurance market with no money or with preexisting conditions. This bill — shitty as it is — would pretty obviously be an improvement on the status quo for these people, without doing much to change the status quo for people lucky enough to have insurance through their employer.
So we should pass the bill.
And then we should get to work on getting rid of Lynne Woolsey, Blanche Lincoln, et. al.
Wednesday, March 10, 2010
Vineet Arora, an internist at the University of Chicago, has an interesting post up at Kevin MD (reposted from her own blog) about the controversy between those who want to reduce resident work hours and those who worry about an increased number of handoffs between residents. Both sides say patient safety is the goal.
Arora does an admirable job of describing the controversy without advocating for her favored solution, or even revealing whether or not she has one. She points out that there isn’t a whole lot of evidence backing either side of the debate. So for now, what we’re mostly left with is anecdotal evidence, common sense, and politico-economic pressures for partisans on both sides to wield against one another.
Subject to correction by actual evidence, my anecdotal, common-sense take on the controversy is this:
- we can and should reduce resident work hours from what they are now (or at least, from what they were before the ACGME work-hour restrictions were implemented), but this means that we must be more careful about how we conduct patient handoffs.
- all else being equal, physicians in training with less experience will become fatigued at different rates than experienced and fully trained attending physicians. Not enough attention has been paid to this issue, I suspect. It makes sense that an experienced internist would be less fatigued by 30-straight hours of assessing patients and making decisions about their care than would a second-year resident, for whom all the patient presentations and therapeutic decisions take up so much more conscious brainpower. An experienced attending might be able to admit a patient with pneumonia “in their sleep” because she’s done it so many times before, but the same admission probably requires a much more well-rested resident.
- each specialty has different working environments that contribute differently to fatigue. An hour of duty in the ER is probably more fatiguing than an hour of duty on an internal medicine floor or in a pediatrics clinic. So, each specialty ought to be subjected to different work-hours requirements.
- handoffs have the potential to contribute to patient safety if done right. In the ER where handoffs are regular and frequent, patient care plans often get better after the handoff process where the outgoing physician has to think about how he’s going to present his patients, and the oncoming doc has to clarify each patient in her own mind by asking questions. In an ideal handoff, the patient gets the benefit of two doctors simultaneously thinking intently about their condition.
One thing that I’m very glad to see is that it isn’t enough, anymore, simply to say “I used to work three days straight without sleep, so you need to do it too.” The old-guard attendings that relied on that strategem have been, not to use a too-inflammatory term, defeated. These days, you’ve got to actually make an argument for long work hours, instead of just harrumphing and frowning and talking about how young physicians just don’t have the same kind of commitment to patients that their elders do.
I hold out hope that as we do more studies and subject this issue to more objective analysis, we’ll find that the old harrumphers are discredited even more thoroughly. If we do handoffs right, for example, no internal medicine resident ought to have to work for thirty straight hours in the ICU. I eagerly anticipate real data proving me right.
The Great Communicator in action
The inability of our current Congressional representatives to do anything at all about health care — access or costs — is highlighted by contrasting today’s bumbling Congress with some legendary Congresses of yesteryear.
“Yesteryear” meaning, in this case, 1983.
Michael Millenson has a post at the Health Care Blog describing the wonderful things that happened when those legendary statesmen of yore (i.e., first Reagan administration) wielded the power of government for the sake of helping the nation. Back when the Dukes of Hazzard was must-see TV, Congress managed to cut skyrocketing Medicare costs by passing the DRG-based prospective payment system that shifted financial risk to hospitals and led them to provide quality care for less money.
Millenson’s point: nothing like this is likely to happen today because of ideological zealotry and slavish devotion to special interests.
The Reagan administration understood that being for “small government” as a regulator did not mean abandoning efforts to make sure taxpayers got their money’s worth from government-as-purchaser. Prospective payment was the strategy of a prudent purchaser committed to encouraging efficiency. Hospitals were put at financial risk: those who could efficiently deliver care for less than the average price made money; inefficient hospitals lost money. Within that context, DRGs represented deregulation.
That confidence in appropriate use of government power helped the administration withstand a firestorm of criticism when DRGs actually went into effect. Although the term “death panels” was not used, the same idea quickly surfaced. The president of the American Medical Association, for example, declared that doctors were “not going to be allowed to practice medicine…based on their own judgment” and that “rationing of health care” had begun. Other critics spoke of patients discharged “quicker and sicker” to a “no-care zone.”
Sometimes I long for the good ol’ days, back before we became a nation of pygmies.
Yeeee-haaaaaah!
