The Desire to Instruct

I've been thinking lately about why people like Michele Bachmann and Glenn Beck and Rush Limbaugh gravitate to blackboards and presentations and pontification.

One thing they share is a lack of any sort of rigorous education. It's as if, never having had the blessing or curse of a rigorous academic experience, they crave that mantle of authority more than those who have.  


They want to pull on the cap and gown, as if magically, they can acquire by the accourments, the authentic power of knowledge.


Of course, there is a big difference between being formally educated and being intelligent.


And you need only come to New Hampshire to meet a lot of people with no more than a high school education, who are highly intelligent, highly competent but not very educated in the sense of academic ladders.


Lincoln, of course, had little formal education, but he was one of the finest writers and thinkers of his time. And his time included Thoreau, Emmerson and so we're talking about a pretty fast track. But, somehow, he used what he learned more effectively than anyone else, even those who had been educated at Harvard.


He had the power to see through and past convention to truth. When he was upbraided for not being religious he replied, "I feel bad when I do wrong. I feel good when I do right. That is my religion." Considering that religion was the basis for most formal education in the 19th century, and the learned were schooled in the languages in which the Bible was written so they could read it in the original--Greek and Latin, that was a pretty big statement.


When asked if he thought God was on the side of the Union Army and the forces of Union, he replied, "I simply hope the Union Army is on God's side."


In a sense, I have the feeling had he been sent through Phillips Exeter Academy (where he sent his son) and Harvard, Lincoln would have been better educated, but less brilliant.


There is a story about Anthony Fauci, who is the chief of the National Institute of Allergy and Infectious Disease and the head of the federal government  task force on AIDS. Having finished his year as a Chief Resident in the Department of Medicine at Cornell University Medical Center, New York Hospital, he was ushered into the sumptuous office of the Chief of Medicine, where various luminaries of the hospital staff had gathered around some bottles of good congnac and, as was the tradition, the Chief of Medicine shook his hand and intoned that Dr. Fauci would receive his appointment to the staff of Medicine at the New York Hospital and an appointment to the faculty of medicine of the medical college. This was something akin to being given the keys to heaven. A Park Avenue practice, keys to the Doctor's Coat Room, the doctor's lounge, the good life.


Fauci refused the prize.


The news raced through the hospital. Every intern on every ward, every nurse, evry medical student, every "Made Man" on the medical staff was talking about it.


Finally, when one of his friends could contain his curiosity no longer, he asked Tony how he could turn down this glittering opportunity.


"I told them, " Fauci is reputed to have said, "Someday, I will be either very rich or very famous. If I stay here at Cornell, I will be neither."


Fauci has never publicly confirmed this story, but everyone loves it.


So, for those who came up through elite academic institutions, the glow of academic respectability may not be as bright as it is for the Glenn Becks, and Michele Bachmann's and Rush Limbaugh's, who can only dream of what that experience would have meant for them.


But one thing most people get out of such training is a strong sense of what rigor in thinking means. How do you prove something?  How do you ask questions? What else? What are the possible deficiencies of this argument? 


All of which makes me wonder why people want to believe what they believe.


One of my co workers told me, quite appalled, that Barack Obama was not born in the United States, that he refused to say the Pledge of Alliegance and he refused to wear an American flag lapel pin. 


She listened to Rush Limbaugh and learned Obama was trying to detroy America.


I asked her why she wanted to believe these things.

She replied she did not want to believe these things. They were simply true. She had to face the truth.

And how do you know they are true?


Because she had heard them on the radio.


And do you think everything you hear on the radio is true?


That stumped her.

When the report on the causes of the financial crisis came out, there were over 400 pages of data, interviews, pretty straightforward accounting and about 100 pages of analysis.

The committee of four Democrats and three Republicans agreed on the "facts" in the 400 pages but the 100 pages of analysis split them along party lines.


Basically, you could understand where the analysis differences came from: They came from dearly held prior beliefs. The Democrats believe business and the free market pursue only one thing, profit, and ignore every moral, social and patriotic imperative which may impede the maximizing of profit.  The Repulicans believe the source of most, if not all, civic evil is the over reaching arm of the government.


So the Republicans  said the crisis was caused by government--Fannie Mae and Freddie Mac which made responsible, professional bankers give mortgage loans to undeserving, untrustworthy, dead beat low lifes who were probably Democrats. That caused the housing markets to crash and that caused the meltdown.


The Democrats said the bankers, CEO's and Wall Street tycoons dreamed up the idea of packaging mortgage loans and once they saw they could make money by selling these packages, they didn't care what was in them and so they sold damaged goods, bundles of mortgages which were loans made to people no self respecting banker should ever have approved. The whole idea of due diligence went out the window when the vision of huge profits flitted in front of these money movers.


Pundits of all stripes jumped in immediately, not having done the tedious, difficult work of reading the 400 pages of data and declaimed for one side or the other, because they wanted to believe their own dearly held darlings, the beliefs they had espoused for years, were supported by what is in those 400 pages. But few or none of them actually want to do the heavy lifting of reading through it all. 


I sure have not read through it all.


Don't know I ever will. 


I'll just believe, for now, the fault lay with the rapacious money guys, the Goldman Sacks crowd, and the government may not have done much to catch them or to prevent them from raping the system, but Fannie Mae and Freddie Mac are just whipping boys.


So I can understand why people cling to certain beliefs--mental laziness, fear of being shown to have been wrong in basic beliefs.


But why does that woman want to believe those things about Obama?


Why do people want to believe fluoridated water is a government plot?  Why do they want to believe the deficit is more important than spending money to create jobs and to improve infrastructure?  Why do they want to believe the new Healthcare law mandates death panels? Why do they want to believe Glenn Beck when he says the government is out to get your pancreas?


How does that work?


In What's the Matter With Kansas? The author spent hundreds of pages exploring the sources of resentment which caused people to believe crazy things which made them vote against their own economic self interest. 


There were class resentments, the resentment of the farmer whose son could not go to Harvard but that son could a rebuild a tractor engine and re wire a house, things few Harvard seniors could do--so why do the powers that be confer on the Harvard kid the respect and prizes and denigrate the farm kid from Kansas? 


There is the guy who never went to college, but worked at General Electric for thirty years as a welder, progressing up the ranks to the point he was doing the welds on airplane engines, which is so far beyond basic welding as to be the difference between shop class and astrophysics and ceramic chemistry, but when he came up for promotion to a managerial position, GE told him he didn't qualify because he didn't have a college degree.  And he said, "My brother went to college with a bunch of frat boys who were drunk in their fraternity for four years. Why are they more qualified than I am to manage the welding of airplane engines?"


So he wants to believe all regulations are ridiculous and the government makes regulations by the truckload.


But I still don't understand the woman who wants to beleve all those things about Obama.


Where does that come from?

Quintessential American: Supermarket

Many institutions have been said to be prototypical American—the drive in fast food joint, the baseball park, the shopping mall, the amusement park, but for me the quintessential American institution, the thing that has set the mold for what it is to grow up and live in America is the food supermarket.

When my mother-in-law returned to America after a dozen years abroad, what amazed her more than anything was the supermarket where we shopped  for groceries.

Now this is a woman who was born in Missouri, graduated from Berkeley, as white bread and heartland a growing up as you can get. But she had married an engineer who worked for Mobil Oil, so she had spent years living all around the world, wherever they drill for oil: Saudi Arabia, England (North Sea), New Foundland, and Norway.

Coming home, she was unfazed by the traffic, and she adjusted quickly to everything else, but the supermarket we took her to in Bethesda, Maryland stunned her.

The store Giant Food, was not too different from supermarkets you find in any American suburb. It was a typical supermarket, but a little more so. It occupied about a city block, and it had a bakery, butcher, produce, pharmaceuticals, hardware, lawn furniture, a gourmet section, a delicatessen, aisle after aisle of prepared food, barbecued chicken. You could go in and buy food for a month, as some people did, or you could buy a pre cooked dinner, ready to be taken home.

When it was first built around 1959, the locals were just as astonished by it as my mother-in-law was in 1990. It was called Super Giant then, but as other stores were built around the Washington metropolitan area, it became simply, “Giant.”

It was started and for decades own and run by a man named Israel Cohen, who visited each store, and wandered through talking to employees.

One of them told me about his first day on the job, in the produce section, and Israel Cohen ambles up and asks him how the peaches were that day. The stock boy said he didn’t know and Cohen said, “Well, I own this store and I want my employees to know all about the stuff they sell, so every day you come in, take a bite out of a peach, and take a bite out of the other stuff, so if someone asks, you can tell her whether the peaches are ripe or whatever.”

“Gee, Mr. Cohen,”  the stock boy said, “I thought if I were caught eating the food, they’d fire me.”

Cohen laughed and said, no, this was considered part of the job.  Cohen took a liking to the stock boy and eventually offered to pay his way through the University of Maryland, if the boy would promise to work a year at Giant  for every year he went to college.

The check out people, all the employees of the store,  knew Mr. Cohen and I never heard any of them say a bad word about him, and they smiled every time his name was mentioned.  He hired people with Down’s syndrome to help load the cars out front, when people came by for their grocery bags.

Ultimately, after Mr. Cohen died, Giant Food was sold to some international company, headquartered in The Netherlands, and the place became less friendly, less family, but it continued to offer a vast spectrum of food, and other products. 

I always thought of it as one of those big American enterprises which was essentially benign, a positive force in the world, one of those things that made you feel fortunate to be an American.

Later, traveling to Italy, I discovered grocery stores of a similar scale, and considerably higher tech—where you purchased your food simply by placing it in your shopping cart (and it was automatically charged to your credit card) so there was no check out line. And your cart was conveyed automatically down to the basement garage by a sort of cart escalator, so you didn’t have to drive around to have your bags loaded. But nothing anywhere I went ever quite matched the majesty, the efficiency and the sheer diversity of Giant.

And yet, having read Michael Pollin’s Omnivore’s Dilemma  and now being aware how little of what is offered in the American supermarket is actually unprocessed, unadulterated, and how the supermarket is just the final common pathway to the consumer, the final connection from a long line of industrial animal production, the whole institution seems less benign.

It’s the old story of the dazzling product, which seems so wonderful, but it has been gotten to you by a trail of tears, or at least by a pretty dubious process.

Those steaks, wrapped so appealingly in their plastic packages were once a cow imprisoned in a metal gated pen, standing knee deep in its own excrement, pumped full of industrial doses of antibiotics to ward off the bacteria festering in its wounds, and you have no idea when you buy it.

The stuff in the magnificently decorated  cardboard boxes with cereal in side—Gorgeous colorful Fruit Loop boxes—proclaiming their high fiber content as a health benefit of eating what is essentially close to pure sugar, it’s just so many lies, and a road to obesity, early coronary artery disease and dental decay.

Industry does not intend to harm us—it simply is not interested in the question of who may be harmed by its functions. It’s only concern is profit.

And that is, now at least, America.

Money rules.

For a while, in the 60’s, it was fashionable to speak out against commerce and profit and American industry, and the willingness to despoil the environment and to damage the public health, as long as profits increased.

But now that is all out of fashion.  We are back to being hard headed about the bottom line,

We are, after all, Americans.

The Phantom on Medical Education

From the day I got back my first college biology exam and realized I just might be able to be a medical doctor some day, I have had to think about that imperfect, dysfunctional, ridiculous, arduous and discouraging process called medical education, as it exists in this United States of America.

It's a story of sheer stupidity, cupidity, commercialism in the worse sense, but it has produced some pretty good doctors along the way. 

Recently, some New York medical schools and hospitals have expressed misgivings about foreign medical school graduates as they insinuate themselves into training programs at various city hospitals. This provoked a number of letters to the New York Times, mostly from paid spokesmen for various interest groups, but one from an American physician who had moved to Canada and found his American medical training was judged inadequate by the Canadians. He concluded for all our bragging, the American system of medical education was inferior to the Canadian system.


He may have had his own axe to grind, but I am prepared to believe we may not have the best system of medical education in the world.


We likely have among the most exclusive and competitive medical schools, by which I mean we make it difficult for applicants to gain acceptance, but it remains an open question whether we are excluding the right applicants and admitting the "best" ones.


And that just speaks to the process of undergraduate premedical education, by which we cull the applicants. What happens when students actually become medical students is another matter.


Beyond medical school, there is the real show, internship and residency, what is called "Post graduate training" by which newly minted MD's are turned into real, useful doctors. 


The problems with this phase of training have been widely presented, discussed and dissected, mostly by people who do not know what they are talking about, or by people who've been through it and want to tell you how tough it was and how it was the only way to forge physicians and surgeons of sufficient toughness, steel tempered by the hot flames of intensive training.


From the perspective of years and watching all the changes in the system, I'm more humble than I was when I was freshly minted.


For one thing, the landscape into which all these new doctors are dumped has changed.


When I entered private, solo practice years ago, most of the doctors who had trained me and most of the doctors I saw around me were self employed. Now fewer than 12% are. Eighty-eight percent of practicing physicians, I am told, are using W-2 forms, not 1099's. How many of these are actually self employed, but employed by a small doctors' group of 10 or less calling themselves a "practice," is unclear.

But now there are all sorts of "practitioners" out there. In a highly competitive market like Washington, DC, New York, Philadelphia, Boston, most of the doctors are MD's but beyond these concentrations of doctor rich cities, there are significant percentages of "DO's," doctorsof osteopathy, who deliver a lot of medical care in smaller cities and towns. 


Beyond the DO's are nurse practitioners who practice in offices without doctors, doing many of the things only doctors were allowed to do in the past--writing prescriptions, ordering expensive tests like MRI's, nuclear medicine studies, CAT scans.  And there are Advanced Practice Nurse Practioners, Physicians assistants, Nurse practictioners, specialized nurse practictioners in dermatology, urology, as well as general practioners nurse practictioners in family practice and internal medicine.

There are podiatrists doing complicated reconstructions of feet in the operating rooms.  


And in smaller towns you have homeopaths, chiropractors, optometrists, naturopaths, writing presciptions, advising patients.


There are any number of certified practitioners, all the way from certified nurse midwives (who have two to four years of college, two years of nursing school and two years of nurse midwifery training) to certified diabetes educators (who may be nurses or dietitians) and pharmacists, pharmacy techs, 


There are nurse anesthetists, putting patients to sleep in the operating rooms. There are surgical physicians assistants doing procedures we used to sweat bullets over when I was an intern trying to learn these things--thoracentesis, subclavian sticks, cut downs on peripheral veins, harvesting veins for bypass grafting 


Just about any procedure you can name has been "Certified" with some sort of exam and somebody who may have graduated high school can be trained to do it. 


Of course, this does not apply to colonoscopy or any procedure which is still a cash cow for some group of doctors--there the MD's only are allowed to do a procedure which takes six months to a year to master.


And the MD's have changed.  There are now as many or more women medical doctors emerging from medical schools as males, and these women are not at all reluctatn to say their children come first, before the needs of their patients. 


There are women doctors who have changed the whole dynamic the whole psychology of medical practice. One "Laser dermatologist" told me she did not want to cut out a pigmented lesion she noticed on a patient because if it came back as a melanoma, she'd feel uncomfortable having to give the patient the bad news. She wanted to do only cosmetic dermatology in her beautiful office, which she had spent six figures on creating with the help of architects and interior decorators, and where she sold her own line of dermatologic lotions and make up.  She took month long vacations in Europe because she had a European boyfriend. She could do this because she made more than $400,000 a year doing laser dermatology.


And she saw nothing about this to apologize about.


She was trained at  Duke and Harvard.  She was the best of the best, as far as she was  and she practiced in a glamor city among the rich and famous. 

In the same city, I knew a man who graduated from the American Medical School of the Caribbean and he trained at a non university hospital for his residency before gaining his fellowship at Georgetown. He has worked his way up, in status terms from a "fourth rate" medical school to a "third rate" residency to a university fellowship. 

And I never have had the privilege of practicing with a better physician in thirty years. He was up to date in the medical literature, an astute clinician, a wonderful observer, but mostly he always put the needs of his patients first, no matter how late it made him, how much it cost him personally or financially, and he never failed to take the time to remove the dressing to look at the wound, while all the graduates of the first tier medical schools and programs raced past their patients. 


Now, basing broad conclusions on exceptional cases, is an invitation to bad policy, I know, but it's tough to know how to do the best job when you can see the exceptional cases out shining the Ivy Leaguers. 


If I were the benign dictator of medical education, I could (as could many of my friends) do a much better job than is currently done. 


But we do not have a benign dictator.


We've got what the union army had during the civil war, a lot of generals with political connections, who fell along a spectrum of being simply inadquate to being truly disasterous. 

But we're only talking about medical training medical care here. 

It's not like having the wrong people at the head of General Motors and Chrysler. If you have the wrong people in those positions those industries crumble from pressure from foreign competitiors. 


With medicine in this country, you can keep telling everyone they've got the best system money can by and nobody will ever know the difference.