Bill Keller: Pay For Performance/ Doctors and the Bandwagon

Bill Keller

There is something to be said for a liberal arts education. Bill Keller, a former editor of the New York Times, now a freelance writer examines in today's Times the whole notion of "pay for performance"  (P4P) as it applies to doctors. This is a response to a recent New York City effort to institute changes which are designed to reward doctors for delivering good care rather than for the number of procedures they do. 

Mr. Keller is not a physician, has never worked in a hospital, and in fact the only way he can know about what drives costs in our medical system would be from reading, talking to people and thinking, the sorts of things a liberal education is suppose to facilitate. Mr. Keller is the son of an oil company executive and Mr. Keller is a graduate of Pomona college. Other than that, he's been in the newspaper business.

Which is not to say being a doctor automatically qualifies you to comment on what drives health care costs and what could reign them in: Atul Gawande is a practicing surgeon, who also has the ear of the New Yorker editors and he has made lots of suggestions over the years in his articles which fit the characterization Mr. Keller applies to the P4P bandwagon:  great in theory, bad in practice. When it comes to analyzing medical care systems, the surgeon Gawande is a naif. A naif with the ear of The President of the United States and others, but wrong most of the time because, while he may be a good surgeon, he is clueless about systems. He is trying to do fresh thinking, but he often winds up simply thinking simplistically. 

Pay for performance has a nice meritocratic ring to it:  Let's pay for value. But all efforts to figure out what good is, what you value,  and then assign a code number to that and then put that number in a column on a spreadsheet,  have been frustrated by the complexity of human behavior.  

The main problem is trying to go to a bottom line and it's the problem with judging teachers by the performance of their students on standardized tests: The teachers have less control over the outcome than the parents,  the socioeconomic status of the students, their friends, the aspirations and resources of the kids taking the tests.

In the case of the doctors, proposals to reward ER doctors for the time it takes to clear a patient out of the ER run up against all the people who stand in the way once the doctor has done his work. The doctor cannot control the transport staff ("the escort service") or the nurses on the floors, or the people cleaning out the ward rooms or a myriad of others.

Citing a variety of studies, Keller notes there really is no good data to suggest American doctors order more tests, do more procedures or spend more of the system's resources on their patients than doctors in Europe. 

The major difference is what American doctors and hospitals get for their efforts: The $5 aspirin pill, the $100 fee for cleaning a hospital room, the $2500 MRI.  As readers of the Phantom will recall, the Phantom has murmured all along there are many procedures which are vastly overpaid--colonoscopy and MRI being the two most egregious examples. Doctors don't like to make enemies of their colleagues by saying this, but you have to come to a Chris Rock moment, eventually, where you say, "There it is! I said it!"  Okay, we all know it's true but we are not willing to speak its name in public.

Is there really any reason a young woman 5 years out of medical school, who has no on call, works no nights, no weekends, works 4 days a week, pays small malpractice premiums, should make $500,000 as a dermatologist for cutting out lesions which a technician with 6 months training could do?  Should the "aesthetic" dermatologist who sells potions from her office store, does laser removal of lacey varicose veins, who never has to face a patient with a potentially lethal disease,  make $500,000 a year?

Should a man who spent 4 years in college, 4 years in medical school, 3 years in fellowship, but who learned colonoscopy and endoscopy in about 9 months be able to charge enough for a colonoscopy to be able to work 4 mornings a week and make $350,000 a year, doing a procedure a technician could learn in a year? 

Why does a MRI cost $75 in Europe and $2500 in the USA? The MRI can be done in Silver Spring, Maryland, read by the radiologist in Mumbai and the hospital in Maryland gets $2500, but the hospital where the doctor in Mumbai does his day job gets $45 for the same test.

The list goes on. 

The problem with P4P is it depends on developing some meaningful metrics. And as Howard Colvin said about statistics, it just ruined the job of being a police. It did more than ruin police work for the police; it ruined police work for the citizen. Before being judged by the number of arrests, the number of tickets written, the number of drug busts made, the cop on the beat, strolled down the sidewalk, and stopped to talk with the woman on the stoop, got to know her, and she got to know him. And when something "went down" in the neighborhood, a rape, a shooting, the police could go to that woman, who knew his name and she knew his name and he could find out what happened. When statistics replaced policing, the policeman became part of an occupying force and nobody would tell him anything. 

No snitching.

The trouble with a system run by organization men is they often have no feel for the real work of the police, or the doctor or the mailman.

There was a mailman in my building who delivered mail to 175 offices in my building alone. One day he delivered a letter from one of my patients, correctly, to me but the the letter had the wrong name on it. She meant it for me, but was talking to someone at her office as she addressed it, and she absent mindedly wrote the name of her co worker rather than mine. She got the rest of the address correct, the name of the building, (but no office number), the street address, town, state, zip code. 

So how did the mailman know the letter was meant for me?  

"That letter from Donnelly Construction," the mailman said. "You got that same letter from that same lady, in the same Donnelly envelop every Friday for two years. I knew her handwriting, and I knew her name and I knew she just got the name wrong, but that was her weekly letter."  

He was right of course. But he begged me not to say anything about it. I wanted to write him a letter of commendation. "Oh, no! Don't do that. That'd cause me a world of trouble. I should have returned that letter to sender. Addressee unknown."

The bosses want every worker to be interchangeable. His memory, his attention to detail, his ability to pick out one letter from the roughly 3500 pieces of mail he delivered in our building every day--and he had five other buildings of similar size on his route--would be considered a negative value. He had not followed the rules. His large brain was something they had not accommodated  their system for.

The Phantom is not saying there is no way to assess quality of care in medicine. He is just saying, the metrics suggested will not do it. The assessment would require people who actually know what good is to be making judgments and you could not just plug anyone with a certain degree on their wall into the judgment panels. And you could not look to U.S. News and World Reports for an indication of excellence.

You'd have to do a lot of thinking and listening to get worthwhile, meaningful, considered and educated judgments. 

And, so far, there isn't a puff of smoke on the horizon to suggest anyone has actually got serious about that.

Inchoate Thoughts About Meritocracy

Fisher Island, Florida

Where the Ragged People Go

Laying low, seeking out the poorer quarters 
Where the ragged people go 
Looking for the places only they would know 

--Paul Simon, "The Boxer"

The Phantom apologizes for throwing down thoughts without organizing them, but three reports have been bouncing around inside his head: The first, a report about Fisher Island, outside Miami, which is the ultimate in a gated community, reported on NPR on Friday. The second, an article the same day by David Brooks about "The Great Migration" in which he ruminated about the futility of the idea--which he says is the motivating basis for President Obama's progressive agenda--the idea that you can redistribute wealth and those stuck in the lower classes can be brought up and society can be remade into a sort of egalitarian Utopia, or a workingman's paradise to borrow from the imagery of Marx and Engels. The third, an episode of This Old House, where workmen measure, measure and then cut using high tech computer driven tools to produce dazzling craftsmanship, transforming a house into a work of art.

Citing statistics about educational levels and where people live, David Brooks points out there are places like Flint, Michigan and Yuma, Arizona, where only 15% of people have college degrees but places like Washington, DC and Raleigh-Durham, where over 50% do. In San Joaquin, California only 2.9% have bachelor's degrees and 80% have not even graduated high school. He says educated, talented people flock to be with each other and the detritus drifts down to the bottom dwelling areas.  

Then, there is Fisher Island, the ultimate in flocking, where the vast majority of home owners have their 4th or 5th home, where you cannot even set foot on the island without permission of one of the owners, because you are not allowed on the ferry, where people travel not in gas driven automobiles, but in golf carts, where the yachts are enormous and a slip to park yours will cost $1 million.

It is not a new observation there are rich parts of town, rich parts of the country and poor parts. What David Brooks is saying, is once you leave your under educated turf in Nebraska, you never go back because you want to live among the people you met at the elite institutions which drew you away from Nebraska in the first place, and you can never go home again to the dull, ignorant, poor and boring people you grew up among.

When he lived in New York City, the Phantom dated several women who had moved to New York from Kansas and other remote states. "The best thing about being from Kansas," one told me, "Is being from Kansas." These ladies, who had moved to New York were a self selected population, who found their home states boring, restricting, claustrophobic, smothering. Their magnet was New York. But in New Hampshire, the Phantom meets people all the time who find small town life enriching, and who like the idea of roots and who play baseball or go hiking in the White Mountains with people they have known since childhood. They find value in that. They are not here because they have to be. They are here because they want to be here. Not that they never travel, but this is where they want to live.

Brooks says the magnet draws the talented among us first to elite colleges, mostly in the Northeast, and from there, the talent is drawn to New York City, Washington, San Francisco, Boston.  This is because the elite, now reprogrammed, begin looking for places and mates where they find stimulation and excitement. There is some evidence about this phenomenon, found in the pages of the New York Sunday Times wedding announcements and in observations from my children about friends who went to Princeton who would never consider marrying anyone who had not gone to Princeton, unless passion overwhelmed them over someone from Harvard, or maybe even Stanford.

What a loathsome idea. The idea that elite educational institutions have figured out what "talent" is, that their metrics, their SAT tests, their admission committees somehow have adequate tools to select from among the 16,000 applicants, by the numbers, the "talent." 

At this point in the Phantom's life, all this has got to jive with his own experience. 

The Phantom remembers seeing fraternity brothers at his semi-elite college spending their 4 years among the upper class drinking on their fraternity house porches, and he thought at the time what a joke the whole idea that a college education at an elite institution prepared you for anything more than cocktail hours at the country club, but certainly not for any productive life. And the Phantom saw, at virtually every elite college, from Harvard to Princeton, people who wound up in the bottom half of their pre med classes, going off to state medical schools, no name medical schools. So there was "downward" migration on the elite scale. Of course, even the last member of a medical school class is still called, "Doctor."

But then there were those who could not gain admission to medical school and settled for schools of osteopathy, and they too are called "Doctor." But, consistent with Brooks' thesis, they usually wind up practicing in smaller towns, less glamorous places, places where their DO degrees place them at the top of the socio-economic scale.

The Phantom saw in the definition of "talent" at Yale the idea that whatever talent is, it is here at Yale. In fact, by definition, if you have been selected for Yale, then you are, by definition, talented.  How far is that from the old idea of the "elect."  If you have succeeded on earth, it is because God looks upon you with favor. Your success is the evidence of your worthiness.  

This is the essence of Mr. Romney's view of life, and it is shared by many at Yale and Princeton and widely in the Republican party and even by Rush Limbaugh, who flunked every course at the one place which would admit him, but who proclaims his worthiness in terms of his success.

And the Phantom well remembers his own choice of Washington,DC, which, after looking at practices from Boston to Atlanta, he chose because, in no small part, he remembered the people there were smart, engaging, analytical  and he knew he would be frustrated dealing with people who were slow, who asked no questions, who could not remember their medications and never knew what their medications were for and had no interest in what was wrong with them, but only in what you could do to make them better.

The Phantom moved from the Upper East Side of Manhattan, where he had done his medical training, to southern Rhode Island, a rural area, where education levels were low, and found working with the patients there frustrating because people seemed passive, uninterested in understanding what they needed to know to get better. So, ultimately, he gave up and went back home to the "magnet" Brooks describes of a highly educated population.

Truth is never so simple as Brooks formulates these demographics. Eventually, after years of dealing with highly educated, highly "entitled" often obsessive and neurotic people, the Phantom moved to coastal New Hampshire, where the percentage of people with college degrees is around 30%. But the percentage of high skilled workers in this area is closer to 80%. These are the people who work at the Boat Yard, who do the sort of work you see on This Old House. They never would , never could go to Harvard. If and when their kids go to college, college is Hesser College, Keene State, or for the really ambitious, the University of New Hampshire, the sort of school David Brooks says looks for faculty from the elite institutions and would never even consider hiring a graduate of their own institution. 

There are a mix of people here, not the clean divide Brooks describes, or the gated communities of a Fisher Island. Drive down the road to York, Maine and you see magnificent mansions built on the rocky cliffs overlooking the ocean, but right next to those are trailer parks with the most modest homes.

There are people here whose eyes glaze over whenever the Phantom tries to explain why insulin works, how a diagnosis is made. All they want is a simple instruction: Take this pill and don't worry your head about why. But there are far more who listen carefully, have read on the internet about their problem and come to the office with good questions and who go back to their jobs as computer workers, skills they learned on the job or in no name community colleges, not in elite institutions. They are self taught or taught on the job and they earn solid livings and they are bright in ways people from Princeton and Harvard and Stanford are not bright. 

There are many sorts of intelligence, but for most of them, humility is part of the mix. The willingness to sound stupid to ask a question which allows you to learn is part of that mix. The curiosity, but first the belief that curiosity will be rewarded rather than derided or frustrated, is essential. The belief in yourself which allows you to learn, to want to learn new stuff every day, is part of most intelligence. The capacity to allow yourself to become excited about things is part of intelligence.

My son had a girlfriend who taught him how to be a successful student. He had a tendency to read and to get excited about something and to get distracted by reading more about it. His girlfriend stopped him. No, you read just enough to write the report and get your "A" and then you move on. Don't get bogged down with wanting to know more, with getting all excited , just read it, write it and move on. She was valedictorian at her college, Phi Beta Kappa, an Ivy Leaguer.  When she got hold of him, he was floundering. Once she arranged his thoughts he never got less than an "A."

But something was lost along that road, for him, as he moved from the unsuccessful student to the ruthless grade grubber. Before he met his girlfriend, he had been assigned a book report on the biography of a famous American and trolling in the Sidwell Friends School library, he came across a very slim volume on Benjamin Franklin, written by none other than D.H. Lawrence, in that breezy British style. Lawrence thought Franklin  a Luddite which would not have bothered Lawrence, but what he hated about Franklin was his hypocrisy.  My son had picked up the book for the sole reason that it was very slim and would take no time to read, but he fell in love with the whole idea of critical history, of thinking, judgmental history. He wrote his own report, trying to echo that breezy style. 

He was crushed when his teacher gave him a C-, which at Sidwell was next to failing. She had been incensed at his insouciance, at his lack of respect for a founding father. She could not understand the style he aspired to and took it as a sign of disrespect for the assignment, for her, for Franklin and for the United States of America, so help us God. She was a graduate of the Columbia School of Education and she could plainly see he had not taken his assignment seriously, the most important part of his semester's grade. 

That is meritocracy for you. 

How The Rich Stay Rich And The Stupid Stay Stupid

Buck McKeon, Republican Representative from California's 25th district which is home to a major facility for each of the services, a naval weapons plant, a Marine training center an Air Force base and an Army base might be said to be the Representative of Lockeed Martin, Northrop Grumman,  Boeing and the National Rifle Association, his biggest campaign contributors (sponsors.)

Opening the fifth of a series of hearings by the House Armed Services Committee, he intoned, "There are some in government who want to use the military to pay for the rest, to protect the sacred cow that is entitlement spending."  (By which he meant Social Security and Medicare.) "Not only should that be a non-starter from a national-security and economic perspective, but it should also be a non-started from a moral perspective."  He added that cuts should be made not to the "protector of our prosperity," but to the "diver of our debt." [Jill LePore, The New Yorker]

Notice what he has done here. Military spending is a good thing, because it protects American prosperity.  Now, what does he mean by that?  Well, in a sense, he is correct.  Government spending does do what Paul Krugman suggests the government should do, i.e. pump money into the American economy, putting money into the hands of the citizens of the 25th district so they can go out and spend. 
So, that is the kind of government stimulus package Mr. McKeon admires and defends and finds morally superior.

On the other hand, government money going to hospitals, nurses, nurses' aides, workers who clean the operating rooms, doctors, hospital administrators, that is government money which does not enhance prosperity but only adds to our debt. That is immoral spending, as Mr. McKeon would have it.

In the first instance, taking money out of government coffers and sprinkling out over the 25th district is a moral imperative, but sprinkling it over the Minnesota district that contains,say, the Mayo Clinic, that's bad. That drives our debt, not our prosperity.

This is economics 101 which Mr. McKeon learned when he was on mission or running his Western apparel store which went bankrupt. Mr. McKeon struggled through college, but apparently he mastered economics 101, as taught by Rush Limbaugh.

Someone from the gallery shouted, "The driver of our debt is our military complex machine!"  

Capitol Hill Police arrested that heckler and hustled him out of the hearing room.

Only Mr. Keon and other Congressmen are allowed to speak at these "public hearings." Comments from the hoi polloi are not allowed, especially when they call a spade a spade.

So, the police moved in and squashed the speakers of the truth and ensured only the speech of the Congressman is free.

Now, to be fair, I'm sure Mr. McKeon would argue that our military ensures our prosperity by killing the bad guys, like Al Qaeda, who would fly planes into our world trade center and cripple our airline industry, and play havoc with our financial institutions, at least for a few weeks, and he has a point.  

But what is more true is what the heckler said. Had there been no planes flying into the World Trade Center, we would have found another reason to have a huge military to support  the 25th district: some embassy getting blown up in Tanzania, some terrorist act somewhere, which we must resist by having a huge standing army, navy and air force. We have been inventing reasons to have all this huge apparatus since Vietnam. 

One of the Phantom's strangest memories is on the day of 9/11, when he stepped outside his house, which, as the crow flies was exactly 10 miles from the Capitol Building and the Rayburn Building, where Mr. McKeon later held his hearings. The Phantom was waiting for his wife to get home from her office a few blocks from the White House, and he heard a roar he had never heard before.

 It was the sound of an airplane. Now, the Phantom's house was hard by the Potomac River, which is the river commercial airplanes follow to National Airport, downstream, so the sound of airplanes was so commonplace he hardly heard them any more. But the sound of this airplane was very different.  The Phantom looked up and saw an F-15 fighter swooping low, above the tree line, and other fighters, black silhouettes against a crystal blue sky, higher up. 

The Air Force had scrambled jets.  They continued flying in big circles around Washington, DC for most of the afternoon, and that brought them over the Phantom's neighborhood, which was across the Potomac from Langley, Virginia, and the headquarters of the CIA.

And the Phantom thought, what good could those magnificent war machines do?  Even by that hour, around 6 PM the day of the attack, we all knew it was terrorists who had hijacked the airplanes and directed them into the Twin Towers. How are you going to fight a few men inside a few planes, who took everyone by surprise with fighter jets?  Sure, you could shoot down any other commercial airplanes headed for the Capitol and the White House, but by that time of day there were no other planes in the air but those fighters. It's not like the terrorists had their own fighters or bombers. 

Those airplanes in the sky were the most visible incarnation of the futility of an air force built to fight other fighters. But terrorism is an asymmetric battle. Terrorists would strike again, using surprise, stealth, cunning and low tech weapons, bus bombs, improvised explosive devices. And none of the billion dollar weapons systems we had built, none of those Top Gun pilots would be any use at all in thwarting the will of those terrorists. We were trying to fight the war we wanted to fight, not the war they were bringing to us. 

Those airplanes which Mr. McKeon to this day wants to pump moral federal dollars into were battleships of their time, but the enemy had discovered he could sink those majestic looking behemoths with stealth. The terrorists had found a stealth weapon as effective as the submarine against the great big battleship. The terrorists had found: Surprise. Those airplanes were just impotent relics of a bygone war.

There are, of course, some effective air weapons against terrorists: Inexpensive drones, made with off the shelf stuff so cheap we can lose dozens of them without worrying about even the expense. But those drones are too cheap to interest Mr. McKeon's financiers  and they are not made in his district

And Mr. McKeon is not the only fool on this stage: Mr. Panetta  testified:  "One thing we do not want is Afghanistan becoming a safe haven again for Al Qaeda."

As if we could simply scrub Afghanistan clean and once that is done, no Al Qaeda would ever creep back.  As if we could simply erase Afghanistan and no Al Qaeda would take root in Yemen or Mali or Pakistan or Somalia or anywhere else in the world. 

Do you have to be a Congressman or a Secretary of Defense to be stupid enough to think that your enemy, who has no tanks or fighter planes, will come out and wave a flag at you and invite you to bomb him? 

Do you have to be a common, ignorant citizen, like the Phantom, to suppose, if you were waging war against the United States,  you would find a nice spot in some mountains or some hospitable village somewhere, or some part of a big city where you could hide?  Or maybe, you would find a nice, convenient jungle. Like the Viet Cong. And that way, you survive and day by day, you could keep drawing blood, day after day, until you'd bled the big bad beast dry.

Do we believe we can defoliate a forest with Agent Orange  and then we will see all the little terrorists running around in Al Qaeda uniforms, out in the open, for us to shoot?

But the Congressmen sit around and pontificate. And those in power talk, while making sure those who see clearly and think clearly are muzzled by the Capitol Police. And that's how the powerful remain in power, the rich armament makers stay rich, the Congressmen in their pocket stay in Congress and the stupid stay stupid.

God Bless America.

Brooklyn Tabernacle Choir and The President

Through blood drawn by lash, and blood drawn by sword, we noted that no union founded on the principles of liberty and equality could survive half slave, and half free.

--President Barack Obama, 2nd Inaugural Address

How do you answer the Rush Limbaugh's, the Mitch McConnell's, the Wayne La Pierre's of the world, who speak with hate dripping from their lips?

I know now.

You bring up the 2013 Inauguration of President Barack Hussein Obama on Youtube and you pause it on the Brooklyn Tabernacle Choir, and you take your hat off and get on your feet and then hit the play button and watch and listen, as they sing the same song Abraham Lincoln listened to, often, "The Battle Hymn of the Republic."  Oh, I know, it's got religion. It's got "As Christ died to make men holy, we die to make men free," but that doesn't bother the Phantom, who has only rarely set foot in a church. This is our secular High Holy Day, and it only happens once every 4 years, and the BTC sanctified it correctly.

What was particularly inspiring, beyond the variety of faces from White to Black, Male to Female was the electrifying performance of the soloist, a young woman I did not know, never seen before, just a citizen with a voice coming from deep down from some wellspring of pride and passion and joy and carrying out over that huge crowd, sweeping from the Capitol building, across the reflecting pool, with its statue of Ulysses S. Grant, in his slouch hat on a horse, looking like he's riding through a rainstorm, bringing freedom to millions of enslaved souls, and down the mall, toward the Washington Monument, rising on a line with the Capitol's portico and beyond that, invisible but present all the same, another reflecting pool running up to the man seated behind the white marble columns, listening, as he listened 50 years earlier to a minister from the Ebenezer Baptist Church in Atlanta, Georgia, cry out that he longed for the day when his little children would be judged not by the color of their skin but by the content of their character, and he ended his call for freedom with words from an  old Negro spiritual, "Free at last! Free at Last. Thank God Almighty, we are free at last!"

And back on the portico, our 45th President invoked the words of a slave owner, Thomas Jefferson, but then he used the words of our greatest President, although I'm not sure how many caught the reference.  In his 1865 address that President wondered aloud why the great calamity of the Civil War had been brought forth upon the nation. Why had so many died, so much destruction and suffering been visited upon the nation? 

Whenever you get the why question, you can listen for a reference to forces beyond human control. And Lincoln, (like Jefferson) who had little truck with organized religion, speculated perhaps this great suffering was the price paid for slavery, perhaps every drop of blood drawn by the bondman's lash had to be paid for in blood drawn by the sword.  Oh, he invoked a vengeful God, but I bet there were plenty of heads nodding in that crowd in 1865.  And of all the lines Mr. Obama could have echoed, he chose these.

His first Inaugural Address, four years ago was a disappointment because he was still in his conciliatory mode. But this time, he came out swinging.

We can only hope he has time to lead us forward.
Glory hallelujah!

Lincoln and the Thirteen Indians

History, it has been said, is one long argument. 

And judgment is best reserved once one has "all the facts."

The problem is, when do you know whether or not you have "all the facts."

In science, we think we have all the facts, until new facts are presented in the next paper on the next experiment.

In murder cases, we have all the facts, at least all the facts which the judge will allow us to see, all the facts the prosecutor will allow us to see, until new facts are made known later, as when DNA evidence exonerates the accused.

That alone is enough to abolish the death penalty: Not because certain people do not deserve to die, but because in too many cases, we get it wrong, because we do not have all the facts, and likely never can.

But then there is the case of Lincoln and the 13 Indians.

In 1862, in the middle of the Civil War, an Indian uprising in Minnesota ravaged hundreds of white families and Lincoln sent a more or less disgraced general, Pope, to quell the uprising. This Pope did, using the best 19th century weapons (particularly cannon) on the Indians, who were sounded defeated. Having captured 300 Indians, Pope was then besieged by white Minnesotans, who wanted them all hanged, who threatened lynchings and wholesale slaughter,  even of Indian women and children.

Pope wrote to Lincoln first asking, then demanding, orders to execute the 300 Indians.

But Lincoln, who we are now told, always looked for ways to avoid signing execution orders, demanded more information, demanded the case files of every one of the 300 Indians be sent to Washington for review by 3 Justice Department lawyers. 

Every week, Pope and various delegates from Minnesota demanded the hanging of all 300 Indians, but the more the lawyers examined the "evidence"  the more it was clear the white community could not even keep the Indian names straight and Lincoln emphatically refused to sign the execution orders, until more was known.

Just at this moment, Lincoln was writing his masterful State of the Union address, in which he built, methodically, the case for union.  That he had bigger issues on his mind with respect to the fate of the country than the fate of 300 Indians, which was important in terms of lives, but insignificant in terms of the national storm which was claiming more lives every week in battle and would claim more lives than all the wars the United States would fight put together, was evident in Lincoln's address.

He built the case that geography required the nation to remain intact, saying that any border drawn by surveyors and map makers were just lines on a map; even when a river was the border, slaves seeking freedom would cross as surely as birds can fly across these man made borders. A congressman from New York was pushing an end to the war based on a plan to combine armies, conquer Mexico and make it into 9 new slave states, so there would be plenty of territory for free and slave states alike, but Lincoln rejected all that and he rejected the idea that a continent could be broken up into different countries and live in peace. He had only look to Europe to see the effects of that state of affairs. 

So, in the middle of all this, Lincoln insisted on going slowly on the case of the Minnesota Indians, and eventually gave the crowd the  raw meat it demanded, and executed actually 38  of the 300. How he chose these, the Phantom still has not learned.

The fact is, this case has been a footnote to history--even the number of executed Indians has been variously reported from 13 to the more recent and accurate 38.
And the cause for the Indians' rampage has been recently examined and said to be treaties were broken and the Indians were starving. More "facts" to be examined.

But, for years, knowing about the execution of the 13 or 38 Indians, the Phantom always reminded himself, Lincoln was not as pristine as history has presented him. Lincoln was a product of his time and place, and clearly harbored misgivings about freeing Black men, based in his own experience and ideas about race. And he had seen Indian massacres, in Kentucky in his youth.

Attitudes toward Indians in 19th century white society were pretty hostile. Phil Sheridan an authentic and some would say indispensable hero of the war to free the Black man, later savaged the savages by killing off their buffalo and starving them back to reservations and was quoted or misquoted as saying, "The only good Indian I saw was a dead Indian."

But again, getting more facts about the case of the 13 or 38 Indians, the Phantom now judges Lincoln more positively. The Phantom is chastened, and reminded once again, about the dangers of rushing to judgment, of speaking with too much certainty, or, as the question which headlines this blog, "Why is it the stupid are cocksure and the intelligent full of doubt?" Perhaps, that is part of what it is to be intelligent.

Dark Zero Thirty, Torture & Kathyrn Bigelow

The Phantom has just returned from the theater, where he spent two hours watching Zero Dark Thirty,  a film he expected to detest because it is said to suggest we would never have found and killed Osama Bin Laden without the use of torture. 

The Phantom is always particularly annoyed by film makers who depict a historical event or events depicting what happens in hospitals or newsrooms which would never have happened that way in real life because the screenplay writer has got the essence of what makes those worlds work all wrong. These auteurs defend themselves with the old "Well, it's not supposed to be real. It's just entertainment."  

A disingenuous dodge if ever there was one.  If you are creating a world for the viewer, and you get it wrong for the sake of a cheap thrill or a Hollywood moment, you have failed. Just admit it. You don't know what you are talking about and you have no business writing or filming what you don't know.

So, the Phantom entered the movie theater in a snit. 

But, and here the Phantom must confess, he must have missed something, because, as he watched the film, and he was looking for this, the statement that information obtained from torture was critical to tracking down Osama Bin Laden went right by his notice. In fact, it seemed to the Phantom most if not all the torture scenes led to no useful information, or to information which was later found in other ways and the most important information was sitting in a file, overlooked until some young eager beaver uncovered it. The information in the file was obtained by interrogation, but the clip shown of the man who claimed he had buried the messenger showed no torture at all.

The only quibble with the film from the Phantom is they spent way too long on repetitive torture scenes which led nowhere, and no time at all showing the model of the Osma Bin Laden compound built in the American desert and the practice and training of the SEALS who would attack the actual compound later. That would have been interesting to see.

What was interesting to the Phantom is the extensive competence implied or shown in the film, with the use of GPS to track down the actual messenger, the use of trade craft to follow him and, ultimately the flight of the stealth helicopters through the mountain passes of Afghanistan and Pakistan to Abbotabad and Osama's compound.

There was a helicopter crash, but unlike the helicopters of Jimmy Carter's mission which went down in a dust storm, there were back ups. What sunk Carter was the symbolism of American helicopters burning in the desert, which seemed emblematic of the incompetence of Carter's presidency. He just could not seem to preside over any successful government operation.

But here we have a difficult mission executed effectively, overcoming obstacles and the vicissitudes of combat and logistics and everyone home safely.

So,  the Phantom has no beef with Ms. Bigelow, or with Zero Dark Thirty. There was no Hollywooding it up, no gratuitous sex, no Hollywood moment, just tough, tense drama.  What's wrong with that?

American Medicine: Trailing in the Wake of Great Britain

Julio Frenk, Harvard School of Public Health

                           

When the Phantom was a 4th year medical student, he was lucky enough to wangle a boondoggle rotation in London.  Medical students in that year, 1972, considered the 4th year of medical school a wonderland, an unsupervised, romp. We were still on our parents' dollar, and we had no grades, and we could sign up for 6 week rotations in any specialty we wanted to learn about, or even in specialties we had no particular interest in but had rotations in really attractive places--like London.

So the Phantom chose London, and had to come up with a place, and lucked into a Cardiology rotation at the Royal Brompton Hospital for Chest Diseases in South Kensington.

It was  a child's fantasy, playing doctor, or at least medical student, among all these pretty nurses in their quaint nursing uniforms and flirting with them, in their own native tongue. 

In those days, English nurses wore blue wool capes with red lining, starched blue blouses with white collars and they all looked beautiful to the Phantom.

The English hospitals looked as quaint as the nurses' uniforms:  There were mostly open wards, with screens pulled around a patient when he or she needed to be examined.  The cafeteria in the basement had linen tablecloths and linen napkins.

The British invasive cardiologist who did all the cardiac catheterizations used a quiet little technique he called a Sonne's approach, feeding his catheter through the right arm rather than using the femoral artery in the groin.  He made it work for him.

Once, a visiting professor, brought in to pay some attention to all the medical students cluttering up the wards, mostly Americans, arranged for a visit for us to an outlying hospital in Uxbridge. 

There, we tagged along after the Registrars, the English equivalent of medical residents and we were horrified to see the apparently lackadaisical way they treated patients. In America, the most arduous, exhausting admission in those years was a GI bleeder, vomiting up liters of blood from a bleeding gastric or duodenal ulcer. It would keep you up all night, running up and down stairs to the blood bank for units of packed red blood cells, following the patient's response, his hematocrit and by morning, if he hadn't stopped bleeding, and if he had received 15 units of blood, you called the surgeons to take him to the operating room. But you had to give him a "trial of medical therapy" first and it was considered a "save" if you could avoid the operating room for the patient.

In Uxbridge, they gave the patient a unit of blood, and went to bed. They made rounds in the hospital, the next morning,  to see if the patient was still alive. We were horrified. The Brits reassured us, "Well, they always are alive in the morning. Well, mostly."

Well, I thought, this is National Health Care. This is rationed medicine. This is socialized medicine with central planning and limited resources. 

Doctors in England were not paid well. They lived in genteel penury,  if not poverty, modestly middle class. Of course, they went into medical school right out of high school and they became "general practitioners' when they graduate medical college with a M.B., a bachelor's in Medicine. There were only a fraction of the specialists we had in America. Fellowships in the specialties were severely limited and highly competitive.

There were for profit hospitals in London, outside the National Health Service, where the Harley Street consultants admitted their rich patients, mostly Saudis. The consultants could make real money in these hospitals where they could charge whatever the traffic would bear there, but they could then come back and admit patients to the NHS hospitals.

Not that doctors actually "admitted" patients to hospital the way American doctors did. In America, your doctor who took care of you in the community did the work of admitting you to the hospital when you needed it, and he called in consultants and he did rounds on you every day, collecting the opinions of the specialists and acting on their advice. In England the local doctors were nowhere to be seen in the hospitals. I asked a patient when she expected her doctor to arrive and she looked at me and said, surprised, "What? You mean my G.P.? Dr. Jones? Come to the hospital? Why would he do that?"  English patients expected to be cared for by hospital doctors and returned to their own doctors after discharge, with a full report.

An English professor of medicine listened to me presenting a patient on rounds one day, with a dreamy expression on his face. Later, he sat down at my table in the cafeteria and said, "Oh, what I'd give for a dozen like you, like any of you Americans."

I was astonished. I thought the British medical students were very bright, better at physical examination and observation than most of us Americans. They were just younger, and they disappeared after five o'clock, while the American medical students were still laboring away on the wards. "Well, we don't work so hard," one British student remarked, "But then again, they don't pay us much either." 

Now, forty years later, we Americans have GP's doing primary care in the communities, who have not gone to medical school--called Nurse Practitioners or Physician Assistants, just as the Brits did then. The American physician's assistants and nurse practioners of today practice very much as English GP's did then, triage-ing, treating the non threatening simple things, referring the more complicated, dangerous things on. 
Today in America, we have hospitalists delivering care in the hospitals while the Primary Care Physicians do not visit, just as the English did in 1972--GP's remained home in the community and patients were treated by doctors they did not know at the hospitals.
We do not limit GI bleeders to one unit of blood, but we rarely see GI bleeders since the advent of drugs like Nexium, the proton pump inhibitors.
 And we are doing the Sonne's technique for cardiac catheterization, even if we do not call it that. At our hospital today, the cardiologists are "discovering" the technique the Brits were using back in 1972,

CAT scans and a whole spate of medical innovations have come out of the British National Health system, and 99% of patients are well taken care of and happy with their care. The other 1% pay premium prices at the swank hotel/hospitals connected to Harley street. 

So, after nearly half a century, America is finally catching up with Great  Britain in medical care and public health. 

We have Atul Gawande writing articles in the New Yorker catching the eye of President Obama, suggesting all we need to do to cut costs sufficiently is to root out the over spending over test ordering fringe of high cost doctors. We have a school of Public Health at Harvard which has not managed to bring American medicine up to the level of quality a country a third our size manages to deliver across the ocean.

Are the Brits that much smarter than us? 

We Need To Talk About Kevin: What To Do About Innate Evil?

The Phantom just watched the movie version of We Need to Talk About Kevin. This is not a movie based on an account of a real family, but on a novel about the mother of a mass murderer.

The Phantom has no knowledge about how close to the actual pattern of someone who goes on to  murder his classmates this story gets in its depiction of this hellion, but it certainly plays convincingly. He is a demon seed sort of child, whose only pleasure seems to be inflicting pain. He is manipulative, cunning, perceptive and takes special pleasure in torturing his mother. He is a creepy, malevolent child from the moment he can convey any sort of response.   He is  amoral, lacks empathy, kills a hamster, maims his sister, and ultimately slays in a carefully planned killing spree. 

His father is in deep denial and is completely duped by his son.

The Phantom once knew a child who did some of the things this child did, but none of the violent things, and his mother was as oblivious as Kevin's father.

The problem of whether or not this work of fiction has arrived at a closer truth than a non fiction work could is not to be resolved. The Phantom is not privy to enough case studies of psychopaths, but one can imagine the child depicted moving on in adolescence to mow down his classmates.

Considering this story, if it is an accurate representation, it makes the confidently espoused plans from Janet Reno and Louis Freh after Columbine look even more ridiculous than history has proved them to be. Our society simply has no mechanism, no institution to identify and head off this sort of aberrant homicidal sociopath.

Gun control laws may inhibit these killers, might drive them to more inventiveness, but if it's not a gun, it will be a bow and arrow or a homemade bomb or a chain saw or some other improvised weapon of mass destruction.
If people like this are growing up among us, then there is no gun law which will protect us very well. Take away the gun,  and there is always the bow and arrow, the bomb, the automobile. 

And there simply is nowhere for the parent of such a child to turn.

If we are seeing more mass killings, especially of children, the Phantom cannot imagine this is because of some sort of mass effect: Not too much fluoride in the water, not too many violent video games nor too much sugar in the diet. No, there is something out there which affects just the rare individual, some mutation.

As depicted in the movie, and one has to suspect these details come from accounts from the mothers, this child would never respond as most children do to smiles as an infant, would not even roll a ball back to the mother, was still in diapers at age five, defecating in ways which were clearly calculated to enrage his mother, and there is one chilling scene where he spews forth an accurately aimed venom at his mother when she has taken him to lunch, and he says, "Oh, this is the part where you reach across to put your arm around me." He rejects warmth, expressions of affection. He is at war with his mother.

At Yale, the Phantom once opened the door to a toilet stall and there, right next to the toilet, on the floor was a pile of feces, placed there very carefully by some psychopathic undergraduate--one of the best and the brightest in the carefully screened and selected student body which Yale claimed to have chosen with such exactitude. This film brought that memory to mind.  

It all leaves you depressed, and disarmed.  Nothing will help.  No expert in mental health, no mental health program, nothing can effectively disarm a child as cunning, determined, hateful, secretive, relentless and homicidal as Kevin. 

Kevin offers no solutions, only despair.

Should New Hampshire Legalize Prostitution?

Recently, the Portsmouth (New Hampshire) Daily Herald has been full of stories about local prostitution cases, a brothel across the river in nearby Maine, local seacoast cases. The issue of legalizing prostitution has arisen. 
The case against legalization has been based in no small part on the notion that every woman who has entered into pay for sex has been exploited, forced into a very bad position and is only engaging in this activity because she has run out of all other viable options.

In this country, prostitution is legal only in Nevada, and it makes headlines to titillate the masses in all others. 

Prostitution is legal in Amsterdam, and apparently the Netherlands have not collapsed.

Some years ago, the Phantom took a wrong turn trying to find a hotel in downtown Washington, D.C. and drove down a part of 7th Street and beheld a sidewalk full of women wearing only bras, panties, garters and stockings, pacing up and down the sidewalk, approaching automobiles. Some of these females looked to be no more than fifteen. 

The Phantom has also met a woman who worked in a hospital, who "turned tricks" for a second income. 

When asked whether she turned tricks for the young doctors, she replied, "Oh, no, the young doctor is an investment. You give free samples to get him hooked for the long term investment; any way that's the way the nurses play it. Then they've got a long term return, bank account, retirement plan and a very good severance package, when things go sour."

From these disparate experiences, the Phantom has concluded there is a very broad spectrum of sex for money and that spectrum may run from the streetwalker, to the call girl to the legally married gold digger, to the proper Jane Austen heroine.

To a greater or lesser extent, they are all in it for the money, my hospital worker friend would say.

But for those who would self identify as "sex workers," who go to work every day to get paid for sex, would it not make some sense to, as Beadie Russell said in The Wire, acknowledge the truth, "What those women need is a union" and be done with it?

How would we "legalize" the trade? Would we permit street walkers? Would we insist all prostitutes work in brothels? Would we legalize call girl "escort" services. Would we outlaw pimps? Would we forbid prostitutes to use drugs? How would we enforce that? How would we handle alcoholic prostitutes?  How would prostitutes be paid? For piece work? On salary? Would seniority increase pay? Or would it decrease pay? Would prostitutes get vacation? Would they be allowed to work on vacation? Would they have retirement pension plans? 

If we brought prostitution above ground, there would doubtless be public health benefits--regular exams for HIV, licenses requiring testing and treatment for sexually transmitted diseases, more consistent use of condoms, not to mention the possibility of taxing the trade. What prostitute enslaved by an abusive pimp would not prefer the government playing the role of protector?

This may be one of those areas which "deserves more study." We'd have to know more about what "sex workers" themselves want, think possible and would be willing to accept. We'd have to understand the full spectrum of the practice. 

But first, we'd have to be willing to look some uncomfortable truths in the face and have the courage to confront them.

Soulmates: Texas and Saudi Arabia

If states could marry, and the Phantom were a matchmaker, then he would try to arrange a marriage between the state of Texas and Saudi Arabia.

Now, at first, this might not seem like an obvious choice--after all there is the religious difference, but Christian or Muslim, they are both fundamentalists, so there is really less difference than similarity there.  Granted, they may not choose to honeymoon on the Israeli riviera, but bigger problems are overcome every day in successful marriages.

What really matters in a good marriage is what binds you together, and here we have the common heritage of oil. Texas was once the wealthiest country's oil source; now Saudi Arabia is the wealthiest  oil source for the same country.

And then there is the whole arena of executions: They both love a good execution, and while Texas leads the world in shear numbers, Saudi Arabia has a real flare for this vanishing ritual of psychopathology. 

Just yesterday, Saudi Arabia beheaded a Sri Lankan woman who, at age 17 was hired to care of a 4 month old baby, who died in her care. She claimed the baby choked, and she was offered no legal counsel, but she was beaten to a nice pulp, in a Saudi jail and she ultimately "confessed."  

She was beheaded, despite Saudia Arabia's signature on an international  treaty called the "Convention on the Rights of the Child" which prohibits the death penalty for people who were younger than 18 at the time of the crime.

Texas has a famous, "Doctor Death" who is trotted out for many capital trials. He has apparently never met a murderer who he is unsure about. In every case, he testifies this particular defendant is guilty as sin, on the basis of his scientific examination of the accused's psyche,  and the good doctor assures the jury this killer, will,  with 100% certainty, kill again. Off with his head.  The Saudis would love him.


And,  as in all good marriages, each can learn from the other. In Saudi Arabia,  there are daily lopping off of hands in town squares, to punish thieves, and as a warning to others. Texans might just get into that.

Or stoning. How about stoning for a method of execution?  It's energy efficient--the pinko liberals would have no cause to complain about wasting good fossil fuels on executions.  In Saudi Arabia, this is a technique most often applied to an adulterous woman. Tell me that would not appeal to red blooded American males.

Women are kept in their place in Saudi Arabia, and cannot drive, which Texans might welcome, after all these years of uppity women in their tight jeans and bad behavior at Ladies' Nights at the local bars.

This is the kind of match which can make a matchmaker's reputation, and when you think of the possibilities, it just makes you giddy.