Meritocracy, New Haven Firefighters and the Supreme Court

Why should I care about the New Haven firefighters, their written advancement exam and the Supreme Court case involving it?

Because, like most people, I hear this case as a case in point. It's not about firemen; it's about the idea of meritocracy; it's about the nature of the Supreme Court; it's about AMERICA.

So, the first thing that occurred to me is: Why would a firefighter be tested with a written exam? What part of being a fire fighter can be tested better by a written exam than by a practical, physical exam? Why a written exam for a firefighter?

Only things I can think of is:  1/ Firefighting, despite it's physical nature has a lot of mental stuff you have to know, just as wrestlers have to know the science of balance, weight, leverage. But you would never judge a wrestler by a written exam. You could be a "smart" wrestler but none of that matters on the mat, unless you can use it. 2/ For promotions, everyone wants people advanced not because of color or personal connections but because you are "qualified."

This comes back of course, to how do you decide who is qualified? How is one person more "qualified," than another? Before I heard about this exam,  I would have presumed the main qualification for a firefighter is longevity, or maybe who you or your father knows in the department. But that would mean, it's an old boys' club and any Black or Hispanic would be forever blocked from becoming whatever the next level up in firefighter status is, unless there were some more "objective" test of "qualifications."  So they devise an "exam." 

The question is, in a world where mental agility gets translated into physical action, what sort of written exam would you devlse? It reminds me of the scene in Men In Black, where they try to give a written exam to the candidates, who are all, "The Best of the Best," but they already have chosen their candidate based on prior performance in more practical settings.

This whole desire for written exams to distinguish among candidates to discern who is most "qualified," when the fact is almost the whole crew is equally qualified, or if there are any differences, the differences are not great or important, rings true for me.  Doctors take written exams frequently, and they are pretty ridiculous, for the most part. They are devised to separate out people into a bell shaped curve, when in fact the performance of doctors is more of a cresting wave, with most doctors performing at about 80% and very few down around 20% but the test is going to make the cut at 50%, so it becomes very arbitrary and the questions reflect this by being absurd.

Does the fact no Hispanics or Blacks made the cut on the exam mean Hispanic and Blacks simply are less "qualified?" Nobody but a New Haven firefighter could know. Certainly no one on the Supreme Court knows, but that doesn't faze the justices.

Or does the fact the minorities scored lower mean they are simply stupid, or do not possess the type of intelligence it takes to be a leader among firefighters?  Again, I'm not a firefighter, but that doesn't stop me or half of the American citizens from having an opinion.

My best guess is a lot of white fire fighters feel pretty annoyed because it wasn't easy for them to score high on that exam; they had to sweat bullets to get their own high scores, so it's understandable they would be pretty frothy when they manage to score high and then the test is thrown out.

On the other hand, could I devise a test for which those white fire fighters study really hard and fail, while the Blacks and Histpanics score higher?  I suspect I could, but I don't know that for sure.

A lot of this is tied up in the idea of a mertiocracy. What is a meritocracy?  When you are talking about a college, you say well if admission is based on the idea of a meritocracy, you admit kids with the best grades and the best test scores, regardless of whether or not their parents went to the school, whether or not the parents gave millions to the school, whether or not the parents are rich or famous, whether or not the applicant is a movie star or a wonderful athlete all that counts are "smarts."

But what are "smarts?" How do you identify "smarts?"  Are there not multiple forms of intelligence? Is the boy who can scan over a pattern of bodies arrayed in a certain grouping called a "defense" and quickly identify that defense, then call out a verbal code to his own teamates to exploit that defense, is that boy not showing a certain type of intelligence? Do we not value that type of intelligence?

What type of intelligence does the SAT exam test? Why is that type of intelligence, if it is a narrow band of intelligence as has been claimed,why is that intelligence determinant of worthiness? Why are college board exams timed? Does that have to do with the quality of the intelligence of the students or with the convenience of the testers and proctors?

A meritocracy implies we have good tests of quality.

Are grades not a good test of quality? After all, grades are given by teachers who know the students over time, not just over a three hour testing period. But colleges relied more on college board exams because everyone who ever went through high school knows about teachers, grades, differing qualities of schools and so those measures of qualities we call "grades," are so well known noboby places much faith in them.

The problem with mertiocracy as a practical reality is it's an illusion, a delusion. There is no such thing, except in limited spheres. The winner of a wrestling tournament has progressed through an elimination in a meritocracy, espeically if the structure is what is called, "Double elimination," to be sure you didn't get beaten by the champion in your first match. You might be the second best wrestler in the tournament with the bad luck to meet the best guy your first match, so the double elimination gives you the opportunity not to be arbitraily eliminated on the basis of bad luck. There are no comparable written tests like this in the  academic world, or in the professional world.

So the idea of choosing people by the content of their character or the quality of their competence rather than by the color of their skin turns out be a pretty slippery proposition.

As for the Supreme Court. I could and did predict the vote before the case ever got heard. It's like this:  Here you have a case of white guys saying, we took the test and then it was reverse because the Black guys didn't do as well. So you've got the losers trying to take down the winners. How do you think the court is going to divide?  Roberts, Alito, Scalia, Thomas--have they ever voted for the underdog?  So it's only Kennedy who is the question mark.

Which brings me back to the basic point. If you know the way the Court will vote just hearing the case described, how much law could be involved in these decisions and how much pre judging the case by your own predispositions? If you know the personality, the prejudices of the justices and their decisions never surprise you, how impartial, how guided by "THE LAW" is our Supreme Court?

Limited Choices for Health Care USA

Presient Obama is not the supreme leader, so he can only choose from among the options presented him for health care change, and of those bad choices, he's picked the best.

Set up a government insurance policy and you solve the problem of the uninsured (if the policy is inexpensive) and you get healthcare off the backs of employers (who no longer have to offer it, because there's a cheap government option out there) and you make those insurance companies now have to actually compete with something which has as it's basic goal improving the health of the people it serves.

Health insurance companies, of course, pretend they are only interested in the health of their customers, and they run advertisements which say. "We'll pay to keep you helathy," or some such nonsense. That's what they say. What they do is to refuse to pay for the colonoscopy in the 47 year old, when it might detect a cancer because they know by the time the patient actually becomes clinically apparent as a cancer victim at age 50, he will likely be with another insurance company by then and be someone else's problem.

Big bureaucracies, government or private, tend to live and die by "statistics" measurements which do not have to be meaningful, but once they are accepted, these numbers are all that counts.

Big insurance companies care about as much as the Wire's police commander Rawls cares about murders. All he wants is to be able to show the numbers of murders placed in the "Solved" column keeps getting smaller. He does not care whether the person charged with the murder is actually guilty; Rawls just cares about making that "Solved" number better.

With insurance companies the only numbers which count are the dollars of  profit, not that they'll ever admit it. They cannot admit their perfectly reasonable raison d'etre which is to make as much money as possible for their stockholders becasue there is another set of values out there that all of us should care most about prolonging life and healing the sick. In reality, those are only secondary aims of the insurance companies, and when the two desires come into conflict the commercial insurance companies choose to maximize profit becasue they will be judged by their stockholders.

Anyway, that's the way it looks from the trenches, in the doctors' offices.

If a government plan brings to every American the same coverage as the Congressman gets, then there will be no need for commercial health insurance, except for things people with champagne tastes and budgets want, like cosmetic surgery or exotic but unproven therapies.

This may eventually mean the 15 million American citizens employed by health insurance companies will be looking for new jobs,which will create other headaches for the President. But by that time, there may be a new President and the problem will belong to someone else.

               --The Phantom

Supreme Court Nominations

As soon as a President announces a nominee for the Supreme Court members of the opposition party raise objections which are meant to establish:

1/ The Congressman objecting is a reasonable and sober fellow who objects to the nominee only on the basis of high principles and certainly not because he has anything personally against the nominee.

2/ The Congressman is not objecting because he thinks the nominee will disagree with him about abortion.

3/ The Congressman wants only what is best for the country, the Constitution and the mothers of America.

4/ The Congressman wants to be sure the judge will not attempt to legislate from the bench and will decide each case "based on its merits" and without reference to his or her own set of values but will allow the law to trump his own personal set of values.

What does this mean, in practice?

I am not a lawyer, so my own legal training is limited to middle school Civics, but I did once serve on a jury, despite my best efforts to avoid it. It was a case of a man accused of selling marajuana, and at one point the judge asked if there was any reason any of the jurors felt he could not hear this case. I raised my hand and was escorted up to the bench and the judge asked my problem and I said I did not think pot ought to be illegal and I could not see jailing people who sell it. Then he asked, "If the state could prove to your satisfaction this man did in fact sell marajuana and if you knew this act violated the state law could you find this defendant guilty of having violated the law?" I had to say yes and I was on the jury.

This is an example of someone following the facts of the case rather than allowing his own ideas about what ought to be the law guiding his verdict.

But what do we have in the typical supreme court case which is not a corporate or technical case but one in which social values are in play? Cases like bong hits for Jesus, or the Dred Scott case which was about whether or not a man could be considered property, or the Brown vs Board of Education in which the issue was whether or not there is such a thing as "Separate but equal," or the Roe vs Wade in which the line between infanticide and abortion had to be defined?

Now as I said, I've no legal training, but I do read the newspapers and I'd say 90% of the time I can read a brief description of the case in question and predict which justices will vote which way.

Thomas, Scalia, Roberts, Alito will generally see the case the same way. In bong hits, you had a saucey school kid sticking his finger in the eye of authority. Who do you think those four are going to side with, after they've carefully considered the facts of the case?

Those four horsemen will scrupulously seek out the original intent of the founding fathers, and after they've consulted the scripture written by those eighteenth century gents who were writing before the human voice could be amplified or before there was televison, mass communications (beyond the printing press), automatic weapons, or concepts of environmental rape. And yet, these four know all the answers are in that good book, the Constitution. It's all there, if you only know how to read it.

In any case where the plantiff of meager means tries to bring down some Goliath of authority, money and position,on whose side do you think these four will wind up?

So my question is this: How political or apolitical are the actions and deliberations of the Supreme Court?

The fact is, listening to the questions from the justices which are sparingly doled out on radio, one can hear the justices playing with ideas but always returning to the place they began: They have already decided the case based on their own biases toward or against authority and moneyed interest; they are only looking for some legal justification to wend their way to where they wanted to go before all the facts were laid out before them. They have in fact, consciously or not, pre judged the case.

So how much law is actually involved?

I would like to make a modest proposal: The next supreme court nominee be not a lawyer at all. Choose a scientist or an engineer or a physician or a medical researcher.

For years, judges at every level refused to allow DNA evidence admitted into evidence because they simply did not understand DNA. The usual number of innocent people were convicted erroneously of murder or rape or other serious crimes, sent off to prison or executed. Then, finally, the force of DNA evidence pushed past the resistance to new knowlege and lo and behold, it turned out our judicial system had been making mistakes quite regularly, convicting people who irrefutable evidence now made clear were innocent. Science to the rescue, except law did not understand science, so hear no evil, see no evil, and law changed too late for some.

So, let's have a scientist or two on the Supreme Court.

Listening to one of those radio broadcasts of Supreme Court questionning, Justice Ginsberg expressed stupefaction at the idea that a simple intramuscular injection into an arm could get infected and cost a patient an arm. Obviously, the Justice implied, something must be very wrong with whatever was injected or the procedure of injection for such a thing to happen. Someone must have done something wrong.

No Justice who was a doctor would have reacted that way. Physicians know the risks and they know the horror stories. But that's why physicians are systematically excluded from trials with medical content. They know too much. The legal system requires jurors to be a blank slate, lest their knowledge blind them to the law.

Burqas, Sarkozy and French tolerance

President Nicolas Sarkozy describes women in burkas as symbols of the oppression of women.

Oppression by whom?

The implication is women wearing burkas in France are doing so unwillingly, or at least because they have been intimidated into this behaviour by men who have power over them, much as teen age girls in America are told by their parents, "You are not leaving this house wearing that."

At issue here are perceptions, symbolism and unknown "facts."

What is happening in the mind under each of those black burkas is something we cannot know, especially here in America where we simply do not have enough personal experience with the women wearing black from head to fingertip to toe.

How many women who wear these outfits have you spoken with? And if you have spoken with them, were there men or chaperones present? And in what language did you converse? If you spoke in English, there was a selection bias ipso facto, race isp loquitor etc because any woman in a burka who speaks English has been educated in a way which makes her exceptional.

I have had the opportunity to interview women in burkas with women not wearing burkas as translators in my office outside Washington, DC when I practiced medicine there, and while we stuck mostly to symptoms and the medical business at hand, I did occasionally get a glimpse of the woman beneath the veil, so to speak, my view carefully  supervised, of course, but without getting into the details of the circumstances, I have to say I did not get the feeling the burka had been forced upon the women I was facing. It was more a case of these women having been socialized into the burka, just as our children are socialized to absorb on some unconscious level that public nudity, public revelation of genital areas, buttocks, bare breasts (in women) is embarrassing.

I loved that movie, The Gods Must Be Angry, because it alllowed you to see people through another set of eyes:  The Bantu saw blonde hair on women as looking like cobwebs and he felt sorry for the blonde woman he encountered because she looked so unattractive.  In the instance of burkas, we may be looking at the veiled women with our own cultural lenses.


President Sarkozy is likely expressing his own reaction to women in burkas: They look pretty unattractive and they must be sad inside.

It reminds me of that cartoon everyone in my generation remembers where the tiny people or elves or whatever they were rode butterflies to drop milk on the tiny people in black who sang, "We're happy when we're sad."  And once the black clad people were hit with the exploding bottles with the white liquid, they turned white themselves and they became happy.

Personally, I don't see burkas as symbols of oppression, but as expressions of choice, values and yes even religion. 

That lady in black hasn't hurt me. If we really believe in a society which tolerates differences, we ought to let people wear what they want to wear.

I remember a Finnish doctor who was leaving his job at Yale, and none of us could understand why he would want to give up that plum. We were at a backyard cookout and he pointed to a dozen children, frolicking in the backyard, running around, laughing. He said, "Look at that group of kids. Can you tell which are mine?"
None of us could.  He said, "That's why I'm going home. My kids have forgotten they're Finnish. You can't even pick them out from all their American friends. But we are Finnish and I don't want them to forget what that means."

The State and Marriage

Since the whole flap about gay marriage began, opponents have claimed if gays were given marriage licenses by the state, if the state consecrated or legitimized their unions as "marriages" this would somehow mean the end of the legitmacy of marriage.

I could not understand this line of reasoning.  What difference would it make to the married heterosexual couple if their neighbors, a gay couple, were recognized as "married" by the state? What's it matter to the heterosexual couple if the gay couple gets health insurance, visitation rights? Does that make the heterosexual couple's health insurance less valuable?   How does the gay couple's benefits impinge on the heterosexual couple's benefits?

For that matter, I did not quite understand why gay couples wanted to be called "married." If all the legal benefits of marriage were granted a couple through something called a civil union, what difference would it make to the gay couple? What's in a word?  You got all the privileges, what difference does it make what you call it?

The argument came forward if the state recognized the gay couple as "Married," this would be a formal legitimization of the uninon. This would be consensual validation. After all, what is marriage all about if not going public with your commitment to one another? What is marriage if not the community saying, "We understand you are a couple and we respect you for that. We respect your relationship."

So the anti gays wanted to say, we don't approve of you. And the gays want people who do not approve of them to be forced to approve of them? How much sense does that make?  What do the gays care what anyone thinks of them? Do conservative Bible thumpers who think gays will burn in Hell care what gays think of them. Why should gays care what the Bible thumpers think?

To me, none of this made sense.

When two people start dating, sleeping together, it's between those two people. I never understood those advertisements where the man starts shouting to all the people in a city square, "I love this woman!" Who cares? It all smacked of exhibitionism. It called into question the real psychological motivation for why this man wants a relationship with this woman. Is it because he sees value in her or in what she can do for him in the eyes of the community?

Personally, when I was young and unattached, I loved the part of dating when nobody but me and the woman knew we were an item. There might be speculation, but we were alone together and very discrete, and careful about how we were seen in public and she might confide to her friends and the secrecy was part of the fun.

When I did go to weddings I was jarred by that part where the priest or judge says, "And now by the power invested in me by the state of New York, I pronounce you man and wife."  And I thought, what power does the state have to connect two people?

Is this not the most personal choice these two people will ever make? What business is it of the state?

Now, I can understand, if you buy a house together it becomes someone else's business and certainly if you have kids, it's everyone's busienss. But why should you need a license until you have kids? A license? Like a driver's license to prove what? That you are fit to be married?

Made no sense to me.

Why people would want to have a wedding and a party for all their friends, why women would look forward to their wedding day as some magical wonderful transformative moment, I could never figure.

In fact, as soon as a woman started talking about wanting to get married, I sensed immediately she didn't like me for my good looks or my engaging mind--she wanted some sort of social status from a connection to me. And I never had much in the way of social standing, but somehow if you could say, "Wife" that is "Mrs." somehow you were worth more.

Maybe in Jane Austen's day, but women are no longer worth only what they can marry. In many cases they make more money than what they can marry.

I can understand the New York Times marriage advertisements. I think they are called "announcements" but they are advertisements. Those people are saying, "Look at us. Look how successful we are and look how we have arrived at the upper stratum of society. I went to Harvard undergrad and Stanford law and my husband is Princeton and Columbia College of Physicians and Surgeons."  Okay, I get it. You guys are a power couple and you will have power children who will have to go to Sidwell Friends school. Got it. You two deserve to be "married."

I mean no relationship between two people means anything until time has passed, bridges have been crossed together, hard times labored through. What is the idea of a big send off, a celebration of a promise which, statistically is more likely to be broken than kept?

Part of this has to do with my not having been brought up in a church.  Religions tend to say marriages were made in Heaven. Religious people know God intended for these two people to be together. What God has brought together let no man set asunder.  But of course, that is the ultimate audacity, to say you know the mind of God. 

Maybe, in retrospect, you might believe God had a plan for you and your mate, but you have no idea on the wedding day if you made the right choice.

In fact, it would make more sense to me if rather than needing a marriage license, you got a progressive license: maybe one for when you move in together and one for when you have kids.

If there was ever a threat to heterosexual marriage it seems to me the Lee Marvin palimony case was it. When the court ruled the live in partner who never had a judge pronounce her Lee Marvin's wife, was entitled to half his possessions, in essence entitled to the same things as she would have been had they been legally married and then divorced, the state was admitting, marriage can be something that has occurred in retrospect.

In Europe, we are told, especially in Scandinavia, people have simply stopped bothering with marriage; it just doesn't seem necessary.

So maybe this whole gay marriage thing is a threat to marriage. Maybe the defense of marriage act is not such an absurdity, because what the push for gay marriage has done is start a discussion of why we need marriage at all.

I would submit, we do not. And if we do, it should not involve the state. No one should have the power invested in pronouncing anyone man and wife. That power rightfully rests only in two people, the two most intimately involved. It's nobody else's business.

In fact, pronouncements are a fairly strange practice. You can "pronounce" someone dead, which does seem to be rather beside the point. After all, the person most concerned, really does not care what you pronounce him to be.  You "Pronounce" a man and wife, and who are you fooling? Only those two will make it mean anything or nothing. Your pronouncement is all solemnity and no substance. 

If people want to get married in a church and have a priest or rabbi or judge bless the procedings and say God is happy about this union and maybe even planned it all, well that's fine, if it makes the couple happy. Religion is religion. But the state ought to stay out of the church on that fine day. By the power invested in me by the church of, you name it, as God's deputy, I pronounce...all fine. Just don't let the priest be the guy invested with the power of the state of New York or wherever.

This need for the support of others to keep two people together strikes me as defeatism and fear.If you need a crowd to keep you committed to a relationship, maybe you ought to think again about how much you really like that mate you're all ga ga over.

Why is it Hollywood was the first to see the irrelevance of marriage? Maybe because in Hollywood you had women who made enough money to not need men. So they could have sex, have kids and hire their own help to watch over the children. And the Hollywood star did not need a husband to by a house or a car or to go out to a party. She was free and marriage become an encumbrance. Maybe when she got older, marriage appealed to the lady.

Gloria Steinhem, when asked why she had not married, famously replied, "Oh, I can't breed in captivity."  But then she got older, less physically attractive, and she got married. Go figure.

Of course, when you have legislatures involved in passing laws, you get politics and you get people who are only too happy to make speeches about motherhood, marriage and apple pie because it's so much easier to know what to say about marriage than about something complicated, like healthcare or the war in Afganistan or closing a prison in Cuba on an American military base which has no business being in Cuba--but that's another story and another blog posting.

All you have to say is, "I'm for marriage" and that's an applause line.

And here we have this sweet couple whose been married for fifty three years! Hooray. Huzzah. Huzzah.

Who cares? That's their business.

Peter Orszag, Atul Gwande: Where Angels Fear

"I could never practice medicine. It would be like saying to your patient: Your money or your life."

--Alexander Yersin


Atul Gwande is a very pleasant fellow, charming even, the sort you can imagine inviting over for dinner. President Obama's reaction to his recent New Yorker article, he remarked in his guileless way, was a dream come true. You write articles like this hoping to have an effect, to be part of the thinking which guides great events.

The fact is, Gwande was preaching to the choir. President Obama had his staff read the article because Gwande was singing his song, to the tune composed by one of his two most which important economists, Peter Orszag, who decided long ago the road to cost control of the nation's health care is through behavioral modification, through those "incentives" economists of a capitalist system hold so dear.

Orszag has the orthodox training (Exeter, Princeton, London School of Economics) which may have marinated his brain in the theory of incentive, reward, as a way of engineering economies. A month before Gwande's article, a profile in the same magazine quoted Orszag: "I spent several months in very intense study."

Exactly what he learned isn't too hard to discern: He discovered American health care costs are higher than costs in other developed countries because American doctors are unaware or unwilling to practice medicine to take advantage of "comparative effectiveness." Orszag believes if only American doctors would educate themselves, steep their practicees in all the research about using only the options for diagnosis and therapy which result in good outcomes and high quality care, then the whole cost thing would evaporate.

Orszag's solution is direct and simple, see--all you have to do is set up a system where, "You get paid more if the treatment has been shown to be effective and a little less if not."

Gads, why didn't the doctors think of that?

Of course, what the doctors know is, there is no such research for 80% of the patients and problems they face every day. Even after years of training, they wing it a lot, trying to figure out what is wrong with patients and what to do about it.

Enter Gwande, who finds two towns in Texas, one, McAllen, where the doctors are pretty venal, caring not at all about their patients but only about increasing income and fattening hospital balance sheets. Dr. Gwande believes the statistics about quality of care generated by Medicare (and he must be one of the few American doctors actually practicing medicine who does not laugh at those "measures") and what the statistics tell him is there are these two towns, which are identical in all demographics, and in one town Medicare has to spend three times the national average per patient and in the other, El Paso, the cost per patient is just at the average. But the quality measures show the outcomes for patients is about the same, it just costs three times as much to get the "same" care in McAllen.

Bravely, Gwande flies out to talk to the doctors and hospital administrators in McAllen to find out why they are such crooks.

Not unsurprisingly, the doctors there are a little stunned to learn they have been ripping off the system. Actually, and this is the key part of the article, Gwande manages to get some of the McAllen doctors out to dinner, backstage, guard down, and there he produces a Perry Mason like confession scene, where one of the doctors says he thinks the cost difference results from the McAllen doctor's willful attempts to maximize profits by doing more tests and procedures.

By now, of Mr. Orszag is jumping up and down in his White House office saying, "I told you so."


Of course, when you get right down to it, it's never that simple. Gwande points to doctors in high cost cities insisting patients see them monthly to quarterly whereas low cost doctors bring those hypertensives in twice a year. Who is doing better medicine? Who knows? Low cost doctors handle patients' questions over the phone. High cost doctors insist on office visits. Are the low cost doctors better or simply less willing to face the patient and painstakingly take a question or complaint seriously?

I was taught when you are on call and a patient calls with a complaint like abdominal pain, you go to the emergency room and evaluate the patient yourself. When I did, I almost always discovered whatever the patient or the ER doc had told me over the phone was at least partially, often significantly, wrong.

But the patients occasionally thought I was an ambulance chaser, coming in myself and billing for the two hours I spent. Was I a cost raiser or a conscientious doctor? Eventually, I stopped going in. I felt guilty about that at first, but I had to follow the incentives the way Orszag might have predicted: Go to the ER and you might make the right diagnosis but you were exposing yourself to a high risk fo a malpractice suit with an unfamilar patient in that setting and while some patients were profoundly grateful, others could not understand what you offered the ER doc didn't offer.

I recall many a patient advertised as a diabetic ketoacidosis who had something else, hypercalcemia or even inebriation, and I only discovered this when I actually laid hands on the patient and his lab.

Which is not to say Gwande is all wrong. We all know docs who make more money from stuff which has nothing to do with the real practice of medicine: They have an in office lab, a "consultant" position at some unit in the hospital to which they funnel patients, or they sell skin and hair products or even drugs in their office. "So here along the banks of the Rio Grande, in the Square Dance Capital of the World, a medical community came to treat patients the way subprime mortgage lenders treater home buyers: as profit centers."

But think about that. Does the gastroenterologist who does nine colonoscopies a day think of his patients as human beings? No, they are his source of income. He wants to do those procedures on people he barely knows, and be on his boat by four p.m. But if he finds a pre malignant polyp in one and a colon cancer in another, which he snips out, is he a subprime villain?

And come to think of it, does any banker not think of the person he is going to lend money to as a profit center?

The most competitive residencies are the Road to happiness: Radiology, dermatology and opthalmology. In each of these specialities the average practictioner either never sees the patient at all (radiology) or sees them briefly, knows little about them and moves on as quickly as possible. Patients are profit centers. But do they receive bad care?

The system as we have set it up in this country rewards the assembly line doctor who is "Productive," i.e. he sees lots of patients, reads lots of X rays. If I were the benign dictator, I'd have technicians doing all the colonscopies and endoscopies, and biopsying the skin lesions and doing the LASEK eye surgeries and not allow billing above a level a technician might expect. Doctors have been going to medical school, passing strenous board exams just to get to the position where they can bill exhorbitantly for something a person with a high school education can do after six months training, wield a colonoscope, cut out a skin lesion, guide a computer blade.

So what is the solution?

Gwande is enthralled with the Mayo Clinic, where he learns, "The patient comes first." Well, didn't we all learn that in medical school, right before we applied to the dermatology or radiology program?

In fact, the salaried docs at the Mayo Clinic and certainly at the Geisenger Clinic are fed by a huge marketing operation.

Gwande tells the story of a Mayo Clinic doctor who called in a cardiologist right when the patient was sitting there. "The cardiologist adjusted a medication and said that no further testing was needed. He cleared the patient for surgery and the operating room gave her a slot the next day.
The whole interaction was astonishing to me. Just having the cardiologist pop down to see the patient with the surgeon would be unimaginable at my hospital."

Well, that says something about the Brigham.

In my office building in Bethesda, Maryland, about seventy five percent of the offices were occupied by doctors. While the doctor was not the one to move, it was the patient who simply took the elevator up or down a flight and often saw two or three doctors being bounced from one to the other. And that wasn't even an academic institution, not to say a Harvard hospital. But we accomplished the same instant consult as Gwande saw at the Mayo Clinic.

Of course, every doc billed the patient, just as that Mayo cardiologist did. I guarantee even though the cardiologist was on salary, he had to put that patient's name on some billing slip.


The plan President Obama is talking about is probably the best thing he can get out of Congress. Offer a low cost government alternative insurance, an extended Medicare insurance progralm available to everyone and the nation will beat path to your door. Then you'll see some real competition the Republicans and health industry are always talking about; except neither of those groups wants to see real competition.

In England, the citizens have for decades had the choice to bounce between the national health system and a private system which functions side by side for those with champagne tastes. The difference is the English doctor is a government employee when he is in the national health system and Obama would not make American doctors government employees.

Obama's plan would not solve the problem of producing a corps of physicians on salary whose only motivation is supposedly delivering good patient care, not generating income from unnecessary tests.

The problem with those salaried employees, they have little incentive to see lots of patients. They just want to get paid and go home. Mr. Orszag will have to think how to motivate doctors on salary to want to see enough patients to keep the lines from wrapping around the block.

Salaried doctors in almost every setting outside the National Institutes of Health have all sorts of incentives to see more patients and to be more "Productive" at Geisenger and Mayo and any healthcare organization which salaries doctors.

None of these places have ever figured out how to separate the practice of medicine from financial rewards.

All The Healthcare That's Fit to Mint

The American healthcare "system" is, of course, not a system at all, but an overfertilized private plot of land, filled with weeds, on which only members of the club are allowed to tread.

Atul Gwande, excellent writer, caught the eye of President Obama with his New Yorker article about McAllen, Texas, which he decries as the locus of iniquity when it comes to medical care, where medical tests are over ordered for the purpose of generating doctors' income with no improvement in medical care. The problem with Dr. Gwande's analysis is he accepts uncritically, the Medicare indices of "quality" as actually being meaningful. He suggests we know what all the good and cost effective practices are and we know what "overuse" means. If we put more pacemakers in, are we over using medical technology.

Of course, this plays to the suspicion that the business aspects of medicine inevitably drive over treatment (read unnecessary treatment with no benefit) and of course, costs.

Arnold Relman, former editor of the New England Journal of Medicine liked Dr. Gwande's article very much because it fit his own concept that when making money becomes a motivator for doctors and for systems, that is inevitably a path down the road to perdition. As Alexandre Yersin (the man who identified plague bacillus) once said: "I could never practice medicine, because it would be like saying to a patient, 'Your money or your life.'"

In this country we argue about whether healthcare is a right or a privilege. Do you have the right to call a doctor at midnight and roust him out of bed, or do you have to pay for that?

If he is a government employee, you have a right.

Of course, 88% of all dcotors in the USA are now employees. But not government employees. They've fled in some way, the business model of medicine and voted with their feet.

Dr. Crile of the Cleveland Clinic, thirty years ago said all doctors ought to be on salary. To which the wags replied, "Would be very happy, Dr. Crile to be on your salary."

Dr. Relman asserts, quite rightly, the insurance companies add nothing of value to American healthcare. If every health insurance company employee disappeared tomorrow, patients could and would still be cared for without so much as a hiccup in the halls of hospitals and clinics.

But there are 15 million health insurance employees pulling in the neighborhood of 300 billion dollars a year. What would President Obama do if he suddenly had 15 million unemployed health insurance people to deal with?

Dr. Gwande found some pretty venal examples of the pursuit of money by doctors who demanded kickbacks for admitting their patients to a particular hospital. But he does not seem to appreciate the difference between that clearly reprehensible act and the doctor who tells his secretary to insist patients with questions about care make appointments to talk about them in the office. For Dr. Gwande's perspective, those doctors are just raping the system, insisting on an office visit because they get paid for a visit but not for a phone call. Is it not possible that telephone medicine is actually poor quality medicine? Is the motivation always so clear?

Years ago Dr. Gwande had another experience with quality of care. He visited a clinic for cystic fibrosis which had been "rated" as one of the best clinics in the country. He did rounds with the head of the clinic who upbraided a patient, put her into tears, because she had acquired a boyfriend, started living life and was not inclined to do her pulmonary toilet on nights she spent with her boyfriend. This doctor put it to the patient: "What are you doing to keep this clinic number one?"
So the "quality of care" was achieved by driving away patients who do not perform. Improves your statistics. All Gwande could see was the rank of the clinic.

Gwande, Relman and others who have never really practiced "In the trenches," love the Mayo Clinic, where physicians actually get together physically to talk about a patient right when the patient is in the clinic. What he misses is the scene at the airport where the Mayo Clinic shuttle picks up loads of patients as if they are hauling Las Vegas tourists, bringing them in to the maw of the institution. Money drives Mayo, too. It's just better disguised.