The Educational/Industrial Complex

Here are three separate stories which are connected by a common theme: The damage done by our American idea of higher education and meritocracy is largely unaddressed.

Story #1: Assigned to write a biographical sketch of a historical figure, my son wandered through the library at Sidwell Friends School and discovered a brief biography of Benjamin Franklin by D.H. Lawrence--yes, that D.H. Lawrence--which he plucked up because it was a very thin book but he quickly became captivated by its breezy British wit, its withering criticism of a beloved American hero and he wrote a paper echoing this whole approach. His teacher, who held a degree from the Columbia University school of education was outraged and gave him a C minus. He was devastated. Now, years later, a graduate of Columbia himself (College of Physicians and Surgeons) he says that taught him a valuable lesson--no matter how inspired or captivated you may be by what you are working on as a student, you must not be distracted from the real goal, which is to jump through hoops and focus on doing and say what you need to in order to get the grade from the person grading you. He says all successful students he has known have internalized this concept.

Story # 2. When I ran an inner city clinic in Washington, DC, many of my patients were African Americans from Georgia and the Carolinas. They were just about mute, impenetrable and when I finally did get answers out of them, they struck me as being not very bright. On the other hand, the patients from Liberia, Nigeria, Kenya, who comprised about a third of the clinic,  were very bright, very articulate, responsive, engaging. I tried to imagine why African Americans seemed so much dumber than actual Africans. I realized, I might be misreading the African Americans, who were, after all, facing a white doctor in a white coat, and likely had learned playing dumb is the best strategy for dealing with authorities, especially white authorities.  But that explanation didn't really feel accurate. I finally decided the difference was the Africans, who were educated by other Africans, in a system set up by colonial powers, had simply never been taught they were stupid, and they had learned to ask questions, to be optimistic about their own capacity for learning.

3. Talking with a local friend, here in New Hampshire, about her grandfather, who was mentioned in a book I had been reading about the rescue of the Squalmus, a submarine which sank off the coast of New Hampshire, I told her about the part her grandfather had played as a tugboat captain, and how he had reacted in an emergency with a daring, ingenious and ultimately successful way to prevent the submarine he was towing from sinking in the Piscataqua River and being lost forever. The intelligence, the understanding of currents, vectors, pressures, speed, the calculations he made were very impressive. "Well," my friend said, "He never went to college, of course. Today, he couldn't be a captain because of that. You have to go to college now."
"And who at any college could have taught him anything which would have helped him that day?" I asked.
"No one," she shrugged. "That's just the way it is now."

So my friend has accepted what my son has accepted--our industry, our education system has been corrupted and this corruption has been accepted and institutionalized. Part of this has occurred for money reasons. There is a huge industry in certification. A new technology appears, say reading a bone density, which is actually read by a computer and signed by a doctor: Instantly there is a company or organization offering a "certification" in that technology and the insurance industry accepts this and refuses to pay anyone "reading" a bone density who does not have that certification. The certifying process has little or nothing to do with verifying the holder of the certificate is actually competent and everything to do with money.

Which is not to say all certification is corrupt. There are certifications for welders of airplane engines which are quite rigorous and pristine; certifications of airplane pilots on new airplanes are well done. But in the industry with which I'm most familiar, medicine, everything from licensure exams to board certification exams to procedure certificates are thoroughly corrupt in the sense they claim to separate competence from incompetence and they do nothing of the kind.

Even the welders, who must pass certifications on their welds (which include X ray examination of their work )are beset by the college requirement, if they wish to advance to management. You can work at a GE airplane engine plant for 20 years, master all the technology, organize your team effectively, but at some point, you get hauled aside and told you cannot advance to managerial level because you do not have a college degree, any college degree will do.

Conservatives rail at the stupidity of government for instituting policies which enforce idiocy--their experience in the Army engendered this attitude in some cases. But the government cannot hold a candle to American industry and commerce for this sort of behavior.

In New Hampshire, where many factories are small, three hundred people or less, this sort of imbecility is often absent. The tool and dye maker advances through his company because the people who run it know him and they know what he can do--they would never rely on some ill conceived requirement or test, because their survival depends on the competence of their own workers.

Maybe there's a lesson in all this. But I don't have the college degree to be able to draw any conclusions.

Craig Ferguson has discovered the corruption of expert testimony.
He is horrified by faculty from a variety of universities who earn obscene fees for saying just what their corporate sponsors want them to say, or for testifying in defense of Wall Street high rollers, when those billionaire vulture capitalists wind up on trial for a variety of misdeeds--the professor from Columbia School of Business or the Harvard faculty in economics shows up to wow the jury and pleads the case for the vulture.
To any doctor who has ever had the edifying experience of being paid to testify at a malpractice trial, the corruption of the idea of truthful, unbought, expert opinion is no news.
We have a society which is thoroughly corrupt, when it comes to "truth seekers" in academia and the professions.
Reading The Terrible Hours about Charles Momsen,  the man who developed the first devices which could rescue submariners, trapped three hundred feet below the surface in a dead boat, you realize how uncorrupted that sort of engineer is. And you realize how, whatever it's shortcomings, the military, in those days at least, had the power to set aside the corrupting influence of money when mens' lives were on the line.
So it is possible for institutions to be clean and efficient. It's really just a matter of will and character.

If America fails, I'd have to bet it will not be because we have grown more stupid or more lazy, but we have simply failed to understand how corrosive corruption can be.

I just sat through commencement at Columbia University.  
The president of the university, Lee Bollinger, said Columbia was now the best university in the world.
The deans of each school within the university, whether it was engineering or architecture or business, law or medicine, each proclaimed its students to be extraordinary, peerless, scary smart. 

Among the audience was a richly diverse mix of parents, from white, Brooks Brothers elegant sixty something folks (who likely went to some Ivy League school themselves, ) who paid the full $60-70,000 yearly cost of sending their kid to Columbia out of their bank accounts, stock portfolio happily, to the Hispanic, or Black or newly immigrant Asian parents, whose children may have attended the same school at a cost to the parents closer to a third that, but incurring debt for the rest. 

The question which occurred to me was:  who is the greater fool--the parent who paid full fare or the parent from the underclass who hoped the debt turns out to be worth it?

Maybe neither are fools: Maybe the investment will pay off handsomely for most of those graduates. 

More likely, in financial terms, it will not.
But the experience of those four years, in retrospect, may have been worth it for the students--learning to work hard, having tried  hard to persist through adversity. The students might have had the same experience at their state universities, but they may have grown weary and given up at the state universities, where they had faith to persist at Columbia because they had been sold the fantasy that suffering at Columbia would be worth it.

Time will tell. But for now, these elite institutions can continue to sell their product, with a marketing push which would make Mad Men blush.

Who's Rescuing Whom? Random Acts of Kindness

There is a bumper sticker about rescue dogs: Who's Rescuing Who?
This, of course, refers to the idea that the human being who takes a dog out of the pound and gives it a home is benefited as much as the dog. 
There is a television commercial showing a sequence of strangers on the street who, one at a time, performs some random act of kindness and then in the next scene is benefited by another act of kindness. The woman who helps a little old man pick up things he's spilled onto the sidewalk, then walks down the street and is about to step out in front of an oncoming bus, only to be pulled out of harm's way by a stranger, who himself, in the next scene is saved from a piano crashing on his head by another stranger and so on.

The messages of this ad may be variously interpreted--I cannot even remember the product being advertised--but the message I took home was there is a sort of order to the universe, call it God, or call it universal justice or whatever you like, but somehow the good you do, although it may not seem to benefit you directly, or perceptibly, comes back to benefit you. In this way of thinking, there is some magical connection between seemingly unconnected events, something which is guided by a force for justice, for reward.

Then, there is the less magical view, that virtue is it's own reward, or, as the Beatles said in some song, "In the end, the love you take is equal to the love you make."

Or something.

All of this redounds to an idea which has bothered me since I landed on various tele evangelists, whose message to the throngs seems to be, "Love God, or else," or "Love God, and you will be handsomely rewarded."
These Christian evangelists embrace the essence of capitalism:  You do this for me, and the trade is, you get something you want.
Jesus Christ himself, spoke of rewards:  Heaven.
Heaven, the reward.
It may be unseen down here on earth, but it awaits up there, above the clouds.
Heaven represents the ultimate long term investment. It's the one thing you want in your portfolio, the thing you never want to sell off, even in a down market.
For me, all this is a little disturbing. It's very Ayn Rand.
As I understand Ayn Rand, never having been able to finish one of her books, but as I understand the argument is there is no such thing as an unselfish act. If you do something you know is kind or beneficial to someone else, even if that person doesn't know you did it, you know and you feel better about yourself, so you get the reward, or, if you believe in Heaven, well, you will get your reward by assuring yourself a place in Heaven.
It raises the big question about the question: Do you love God? Do you love Jesus? But, as far as I can see, loving God, for most Christians,  is simply self love, or love which is similar to the love the chorus girl has for the sugar daddy--she can see all his virtues, see past his shortness, his baldness, his obesity, because, he is rewarding her big time.
So is that really love?
I would submit there are some forms of love which are pretty selfless, and any parent likely has experienced this sort of love. I firt experienced it when my first son, age 18 months stepped out of the bathtub and slipped on the wet tile floor and fell right on his chest. He was unhurt, but seeing the terror in his eyes as he fell and hearing the whacking sound as he hit, I was thunderstruck. I would have taken that fall a thousand times rather having him experience it. It was probably the first time I had ever experienced that sort of thing.
Mother wildebeasts will attack a pack of lions, or hyenas to protect their babies. You can argue about evolutionary adaptation and all that, but whatever the force is, wherever it comes from, as far as I'm concerned, it's mystical and pure and much superior to any Christian promise of eternal bliss, or any promise of seven virgins after you blow up yourself.
And it makes no sense, in a capitalist sense. You get nothing back for your impulse.
In fact, if you look at the world God has created, or at least the world over which God presides, lions eat lambs. You would take no lesson from what you see around you to offer a hand if you are imperiling yourself, or even if you do not imperil yourself.
 If there's nothing in it for you:  Both the lords of capitalism and the study of nature would say, don't be a fool.

Oh, yes, talk about ants and bees and cooperative insects and the current discussion of the role of selflessness in evolutionary terms.

But for my money, you should excuse the expression, one of the most wonderous things on this planet is that person who notices a cluster of metal nails and removes it  from behind the tire of a car, because he sees if the driver backs out over it, it will destroy the tire, likely as the driver is speeding down the highway, oblivious, minutes later. The good samaritan gets no reward. Only he knows what he has done. 
For my money, if he feels better about himself, that does not diminish the grace and purity of what he has done.
If character is what you do when you know nobody is watching, then goodness is the good you do when you know nobody but you will ever know about it, expecting no reward but being happy you could help.
I used to see little acts of kindness, occasionally, in the hospital, committed often by people without status, a man who scrubs the room after a patient leaves, a clerk, an escort service person, a nurse, even a doctor, just some simple gesture, done wordlessly, in passing.  It was one of the things which made me feel privileged to work in the hospital, to be among people like that.

Doc Martin and the Real World

Years ago, I was vacationing in Maine, on Kezar Lake, and got invited by some locals to play in a softball game. It quickly became apparent all the other players had been born in raised in this small town by the lake, the plumber, the electrician, a general store owner. They had grown up together playing softball and ice hockey and they knew each other in that way only people who have know each other their whole lives can.

For me, this was a visit to another part of the solar system. Where I grew up, in a suburb of Washington, DC, children knew from age eight they were destined to leave, and likely never to return.  We would grow up knowing the kids in our neighborhood, our schools until we were 18 and then we were expected to leave town and go off to college, and likely we'd go to grad school or professional school and get jobs in parts of the country. It was the Bethesda diaspora. You grew up and part of that was you moved on.

For my wife, an Army brat, this sort of periodic dislocation was also an accepted part of life, but the difference there was as a military family, you kept running across people you'd known earlier at different posts, someone from elementary school who winds up in your high school after a five year absence.  And once you got accustomed to the idea, you sort of liked it--you got to reinvent yourself every three years, when your father got a new posting in Germany or Hawaii or somewhere.

But now I'm looking at the last tuition payment, and thinking, what will the trajectory of this son's life be like?

Which brings me to Doc Martin.  The main character in this wonderful series goes off to London, where he becomes a vascular surgeon, functioning atop the very stratified British medical profession, where, as his edgy old flame, an academic gynecologist says, "the big boys play."  Martin Ellingham, MD then gives up his post and moves back to become a general practitioner in the small Cornwall town by the sea where he had sought refuge as a child with a beloved aunt, on her farm, and now he will be the town doctor. In the British system this is roughly the equivalent of an American doctor who leaves Mass General to become a nurse practitioner in a small town.

"ER" was a good fiction for college students, pre meds, medical students in their first years of medical school, but Doc Martin is literature for doctors who have been in practice for a few decades, done some primary care, been at the university Meccas, and then got out into the real world.  It has characters who keep surprising you and plotlines which never quite work out as you expect. It serves one of the highest functions of literature: it allows you to see your own life from a different perspective and it forces you to ask questions about your own choices in life, the places where you get your own satisfactions.  It is a very intelligent work of art.

It is not The Wire, but in some senses, it is even darker, because the sadness derives not from dysfunctional systems or malignant institutions, for which there is always some implied remedy. The darkness here comes from the depths of the characters we watch. Doc Martin is a deeply injured, often unlikeable fellow. He is inexplicably cruel to his wonderful secretary, writing her a letter of reference saying only that she was "competent" when in fact she has been keeping his practice running, filling in all the gaps of kindness and caring he has omitted.  He cannot allow a moment of tenderness to occur, telling Louisa, who leans in for a kiss, she has bad breath and when she later pulls him off the path to embrace him he says she smells of pherhormones which are derived from urine.

His major attraction, for Louisa, is his astonishing competence. He saves people right in front of her, with daring procedures, despite a nearly incapacitating disability.

I'm reading Dickens now, and it is striking how consistently Dickens writes about the depredations visited upon children. Oliver Twist, Great Expectation, David Copperfield, all about corrupt adult institutions and families damaging young, vulnerable children. That's what happened to Doctor Martin Ellingham as a child, the son of a self absorbed, vile mother and an uninterested father, who was too busy chasing younger women to care much about his foundering son.

But there is something fascinating about a man who is socially awkward, personally brutal and obnoxious, who, nevertheless is driven by a sense of doing something which is important, for whom work gives life meaning the way nothing else, not relationships with people, not money, ever could.

Frederick Banting, shown above, with his young colleague, was such a real life man. He discovered insulin and save the lives of millions, an achievement beyond which, unfortunately, modern medicine has not moved much.

Sometimes, the world needs people like Doc Martin, or Frederick Banting.  No other type will do.

First Class Care, Steerage Care

From the New York Times:

“The concierges act like butlers,” said John Frehse, 37, who was visiting his ailing father, Robert M. Frehse, 86, the retired chief executive of the Hearst Foundations. He and his mother, Dale Frehse, paused in their praise of the care to recall the fate of a family friend stuck for three days in the NewYork-Presbyterian emergency room for lack of a hospital bed last winter. At the time, they recalled, the Saudi king had been granted the whole 14th floor for his entourage.

The younger Mr. Frehse contrasted the unit’s mouth-watering menu with the “inedible food” his father faced when he was treated on the non-elite second floor. “Here he has mushroom risotto with heirloom tomatoes,” he said.

The hospital said in a statement: “NewYork-Presbyterian is dedicated to providing a single standard of high quality care to all of our patients.”

Recent reports of the way the one percenters are treated at American hospitals make me think about Mitt Romney's protests about "class warfare."  Whenever the Democrats start talking about taxing people like him differently, to be sure the percentage of their income paid in taxes matches that of their secretaries, Mitt speaks to his base and to Joe Sixpack and starts screaming "class warfare."

Then you look at the way the average Joe is treated American hospitals and compare that to the way the very rich are treated and you see real class warfare, or at least real class distinctions. It is warfare, you must admit, when it means the average Joe gets kept in the emergency room for three days because there are no beds available upstairs, when in fact those beds are being slept in by members of a large Saudi family accompanying their rich relative who is a patient occupying one bed on an entire ward, while the rest of his family occupies all the others. 

As we have structured our health care system, hospitals are in business to make money, whether they call themselves non profit or for profit, they have to turn a profit enough to pay salaries and buy equipment and they are all for profit in a way no English hospital is for profit. And so, if more money can be made by keeping the hoi polloi shifting on their gurneys in the Emergency Room and renting out beds to rich Saudi oil barons upstairs, well, at this hotel money talks.

The hospital in this report is now called The New York Presbyterian Hospital of the Cornell Weill Medical Center, real mouthful. The name is so ponderous because of money. Part of the name was sold to Sanford Weill, an unappetizing scoundrel of a financier who was looking for respectability by given $150 million to Cornell University Medical College, which was willing to sell its good name for that sum. As benefactors to universities go, that was a pretty paltry sum.  But when you get to whoring, whether it's a big sum or a small sum, as the story goes, we have already established what you are; we are just now haggling about the price.  As for the "Presbyterian" part of the name, well that comes from Columbia Presbyterian hospital, the erstwhile cross town rival of Cornell. The two institutions amalgamated in order to achieve more clout in negotiations with insurance companies, somehow avoiding laws which forbid efforts to monopolize, but that's what they paid expensive lawyers for. 

When I roamed its halls, it was called simply, The New York Hospital, with an arrogance suggesting it was The only hospital in New York, or, at the very least, the only really important hospital in New York City.  

There was an arrogance in those halls in those days, born of a sense of superiority of rigor, effort and intellect.  The chiefs of the various divisions within the department of internal medicine had written the classic textbooks in gastroenterology, infectious disease, cardiology and rheumatology. They were all eventually lured away to be chiefs of departments of medicine at other medical schools. Frank Glenn, a towering figure in surgery was head of surgery and following him, in succeeding generations were other surgeons. Fred Plum and Jerome Posner, authors of a classic textbook in neurology, and chiefs of neurology at The New York Hospital and Memorial Sloan Kettering, also part of the same center, were just as famous in the medical world.

Out of the interns and residents in medicine came Tony Fauci, who became head of the National Institutes of Allergy and Infectious Disease and the head of the AIDS task force. There was  Henry Masur who wrote the original article in the New England Journal of Medicine describing the disease AIDS. He was able to do his work because, he had available to him in the same institution Suzanne Cunningham-Rundles, a PhD in immunology, who took the samples of blood Masur brought her from these mysterious patients dying of this bizarre disease and she ran the blood through her assays and called him back and said, "Whatever this is, it has caused the immune system more than just damage--it's a meltdown." And a few floors upstairs, was  Kathleen Foley, a star in the world of pain management who also came from this farm system, which linked medical school to internship to residency to faculty status.

And the thing about each of these luminaries was they made rounds with the lowliest medical students and with interns and residents every day and they went to the bedside of the patient, who might be a bowery bum or a captain of industry, but the patients were all "Mr" or "Mrs" or "Miss" and they were all treated with elaborate respect. The patients seemed to sense they were important because they were all playing a role in the training of the next generation of students, and they frequently got into their roles. Many was the time I heard a patient say, "Well, being ill has been a blow, but at least I'm helping someone by being here, learn something, to help the next guy." If you could be sick and frightened and proud at the same time, they were.

But all that is gone now, buried under the weight of money, and the ethics of profit and none of these values mean anything to the suits with MBA's who hire and fire doctors at these institutions. 

Okay, I'm a grumpy old man, living in an imagined past of neverwas--so I'll just go back and watch another episode of Doc Martin, set in an English Cornwall town, depicting a system of medical care which is not driven by money or profit, but by pride and the desire to serve.  That's probably an illusion, too.

But no, it's not an illusion. I traveled to the real England forty years ago, spent two months as an American medical student, a stranger in a strange land, where the natives spoke a language I could understand, but they were not just Americans who sounded funny. They were very different from us. I asked the English patients, admitted to hospital when their own doctor was going to come in to see them, and they replied, astonished, "You mean my GP? Whatever would he come here for?" The English didn't expect their GP to see them in hospital. That's what the hospitalists were for. The hospital doctors would care for them and when they returned home, the GP would have a full report. I was appalled. Now, forty years later, it is the system American medicine has discovered and installed.  The English were way ahead of us then and they still are, with midwives delivering most babies and a system of home health care, visiting nurses, which is much less expensive than what we do and which is no financial burden to the individual and which provides  a sort of care the patients really appreciate, at home. 

But here in America, politicians keep saying things like, "Well, here in America, we have the best health care system in the world. Let's not ruin that." We would not want to ruin it, if it were truly the best. The problem is, it is not. It's just the most expensive.

If  you are ever wondering about who we are as Americans, you have to look no further than the difference between the American "system" of medical care and that of the English. There the clothes are stripped off and you see the naked truth about values and the character of a people.