Friday, May 20, 2016

Innovation and the Hospital Industry

Innovation is so dependent on the structure of an industry!  For instance, this morning I had breakfast with my friend Stu Lovett, a very talented high risk obstetrician and excellent innovative thinker.  Stu has devised a great software program (and invested a lot of his own money in developing it) that would increase the safety of deliveries by enabling clear decision making criteria for handling deliveries.  Hospitals are reluctant to adopt this innovation.  Why?

One, others haven't adopted it yet, so it would be an administrative risk for the first hospital to try it out.  Two, hospitals don't want to take the risk because there isn't that much for them to gain.  After all, they are already insured for bad deliveries, and if they made babies safer, would their business expand?  No, so why do it.  Three, most hospitals are "blame organizations" rather than "achievement organizations."  The incentive for each executive is not to get into trouble, which could cost them their job, rather than to achieve a quality breakthrough, which would not gain them much individually.

It's really a shame.  If there were real competition among hospitals, and if one hospital could eat another's lunch by showing it was safer, then someone would make the try.  But hospitals mostly just cover their territory and if they want to grow, they merge.

Another example of failure of innovation based on industry structure is in the age old health care question, how do we get Emergency Departments to be used only for emergencies, and move the non-emergency cases out of the ED?  I was asked to review an unexciting article for the Yearbook of Pediatrics, excellently edited by Michael Cabana, that showed that indeed, mirabile dictu, EDs are more expensive than other venues.  I used the article to talk about industry structure and innovation.  Here it is, and I hope you enjoy it:


Commentary on Urgent Care and Emergency Department Visits in the Pediatric Population
Montalbano et al., Pediatrics, April 2016

Reviewed for Yearbook of Pediatrics by Budd N. Shenkin, MD, MAPA

“Invent a better mousetrap and the world will beat a path to your door.” Oh, if only it were as true in healthcare as it is in consumer goods!

This article demonstrates that, to no one's surprise, Urgent Care Clinics (UC's) provide less expensive care to patients with mild and non-urgent illnesses than Emergency Departments (ED's), with no apparent loss of quality. One wonders, then, if it should be surprising is that ED's are still handling the bulk of urgent care in the United States. Is this what economists call a “market failure?” where equivalent quality and lower price fail to drive out the more expensive competitor? If so, why has this market failed?

One answer is that it is not in the economic interest of those who would set up and run UC's to do so. Who would the agents of change be? Not hospitals; they would be cutting their own throats. It is easy to set up a UC side by side with an ED, staff it with midlevels supervised by physicians, and divert urgent but non-severe cases from ED to UC at ED triage. The result is less expensive care, true, who experiences the savings? Not the hospital; the hospital experiences primarily decreased revenues, and less profit per patient to subsidize the expensive ED equipment and staffing. Instead, the savings are experienced by insurance companies and patients. Why, then, would a hospital do it?

Although the article does not explore alternative arrangements, private practices and clinics could establish UC's on their own, either by simply extending their hours to evenings and weekends, or cooperating among themselves to set up and staff a UC for out of hours care. This comes at a cost to themselves of convenience, because it means working at less attractive hours or hiring others to do so. There are CPT codes that would be applicable for extra compensation for out of hours care, but the payment is modest, and moreover, many payers choose not to honor those codes. As a result, once again, out of hours care savings redound to the benefit of government, insurance companies and patients, but not sufficiently to practices for them to answer the bell for potential profits.

Perhaps more tellingly, the article calculates that roughly $50 million a year could be saved by Medicaid were UC's to replace ED's for level 1 pediatric cases. While $50 million sounds like a lot of money, how significant would that really be? Total Medicaid spending for the United States in 2014 was about $476 billion. The projected savings to government would thus be .01%. The savings, then (like pediatric care overall in the nation's health care budget) would be “budget dust.” Saving $875 million by seeing all level 1 and level 2 cases would be a more significant .18%, still close to budget dust. By contrast, Medicaid is said to lose $29 billion to fraud, which would be 6%. No wonder government appears not to care much about the apparent ED waste.i

Moreover, one unit's “waste” is another unit's profit. By reducing the acute care income from an ED, the hospital ED would become less profitable. In effect, this extra remuneration for the ER subsidizes the cost of having ready a unit to service the true emergencies that appear there, which in themselves would not be financially worthwhile to serve. It might be true that, were UC's to proliferate, hospitals would be impelled to centralize their true emergency services to one hospital per city, but would that be optimal care? It is not clear that it would be.

Thus, the case for UC's replacing ED's for common acute care appears to be shaky. On the other hand, extending out of hours care at Pediatric Patient Centered Medical Homes appears to be a better choice. True, the savings for Medicaid would still appear to be small. The savings for private insurance might be larger, since private payments are usually higher than Medicaid payments. But even if the economic advantage were small, the improved quality of care and simplified communications conferred by better continuity might impel change. Convenience for the patient could also be enhanced, since waiting times are so much higher in ED's than in an office or many clinics. In addition, since ACOs are ever in search of even small financial advantages, they might encourage pediatric practices to become PPCMHs and to provide the out of hours care that are part of the PPCMH charter. An ACO would also be in a position to make out of hours care financially attractive for a PPCMH, rather than a sacrifice.

If there were to be more research on the economics of replacing routine acute care now performed in the ED, considering the PPCMH might be a better alternative to consider than a UC. The PPCMH is, after all, the American Academy of Pediatrics' preferred solution for transforming the organization of pediatric health care. In sum, despite the small economic advantage of diverting patients from the ED, there is still reason for hope.

iMedicaid Program Integrity:
Improved Guidance Needed to Better Support Efforts to Screen Managed Care Providers
GAO-16-402: Published: Apr 22, 2016. Publicly Released: May 6, 2016.
Accessed at http://www.gao.gov/products/GAO-16-402 on May 9, 2016.

 Budd Shenkin

Tuesday, May 17, 2016

Progress in the World



His contention, which I have seen before in a current economics book, is that recent technological innovations have had less effect on society than did innovations of a century and a century and a half ago. While this argument has some initial appeal, I believe that it is essentially fallacious. He mentions advances such as indoor plumbing, railroads, cars and highways, elements of society that we can't imagine doing without. Yes, these are now essential to us, and there is a huge difference between having enough (toilets), and having more than enough (fancy showers,) but I think the trap Irwin falls into is that of thinking too narrowly.

But first, a little bit on how he is right. Advances in a field often meet the Law of Diminishing Marginal Returns. As an analogy, if you buy a stock at 3, arriving at 6 is a 100% advance, but then a similar gain of 3 points up from 6 is only a 50% advance, and so on. The further you go the less the impact of an equivalent gain. When the United States was a developing economy, we went from horse to train to car, moving from a 3 or 5 mile life experience perimeter to 200 miles – huge – to maybe 1,000 miles to 2,000 – huge, but less so – to intercontinental – still huge, but even less life-altering. From less than enough, to enough, to more than enough. True.

Here is my rebuttal. One, there are other fields of advance to look to in society, so while it might be true for households and transportation, it isn't true for society as a whole. And two, the Law itself is not always true. Readers will not be surprised as I cite, once again, my profession of medicine.

First, society as a whole. Our society is composed of many different sectors. Each one will advance with different start dates and different end dates. It is analogous to the business cycle of leading and lagging sectors of the economy. Transportation and manufacturing started when Irwin says they did. The 19th and 20th centuries had huge advances. Their impact is now slowing down. OK. But medicine started later and is now proceeding faster than ever before. Where the leading sectors faltered in their effects, the lagging sectors have taken over.

Look how impactful medicine has been and will be. In 2011 I had a pituitary adenoma operated on without cutting open my head. Instead, my surgeon used fiber-optics to go in through my nose and sinuses and cut out a tumor the size of a small tomato and I was out of the hospital completely cured in two days. My hormones are easily supplemented by a pill and application of a gel every day. Unlike transportation or home improvements, everyone doesn't see and experience this every day, but to me and thousands like me, it's a pretty big difference in what would have happened just a few decades ago.

Likewise for my friend Bob, who without modern cardiology would be dead as a nail. And what about the millions with hypertension who now go through life normally instead of dying from cerebral hemorrhages the way FDR did, or from heart attacks the way two of our neighbors did when I was a young teenager. And what would Mickey Mantle's knees have looked like with today's orthopedics? Light years differences here, everybody.

Moreover, and here's the second point, it is not at all clear that we are reaching medical nirvana asymptotically. It is not clear that we are going from enough to more than enough. Medicine and other technologies seem not to experience linear advances, but geometric advances, building cumulatively as knowledge expands. In fact, we are on track now to see Star Trek medicine sooner rather than later.

At some point, of course, we will reach an asymptote. Maybe when we conquer aging we will be faced with the dilemma of not enough room for everyone, even more than we are finding that now in the world. Maybe medicine will outrace reaching for satellite civilizations on the Moon and on Mars. Maybe the contradictions will appear at that point. Or, maybe they are appearing already, as medical advances lead to overpopulation right now, as in places like Syria where modern survival statistics and traditional large families combine with drought to produce wars and exodus. Maybe the killer will be the introduction of genetically altered mosquitoes that abolish malaria as the scourge it is, leading to overpopulation and untold hardship and suffering. That will be a horrible asymptote. Who knows where the asymptote will be?

But as of now, I think Irwin is premature in his assessment that progress has found its asymptote. He's right about households and transportation, but wrong about medicine and other technologies. He's probably also wrong about education, which could do a lot better than it has done. He's certainly wrong about the science of the mind. Eventually he will be right, just not now. And then if we last that long, eventually he will be wrong again with the next wave of advancement.

He needs to read some science fiction, probably.

Budd Shenkin

Thursday, May 12, 2016

The Moral Imperative Of Optimism


These days, everything is about the Warriors. At the dentist's I talk Jesse at the front desk, wondering at Monday night's game for the ages, observing that, looking forward, the Spurs are vulnerable and we might face OKC. At the front desk of my gym, the pretty attendant says, “Go dubs!” (“dub” stands for the “W” in Warriors -- phonetically, say "W" and it starts with the sound "dub"). Her colleague Charles asks me what I think about the game last night. It's just all over town, thinking about the Warriors, looking forward to the close out.

I see my old swimming friend Dean in the hot tub after working out. Now retired, Dean was a teacher of at risk kids. His wife is a therapist. She ran a workshop last weekend and wondered to the group what inspired them. There were various things, but they all agree on one: the Warriors. Dean says that he looked back over his list of at-risk students and realized that eight were now dead. Nonetheless, he plowed on with his work and now plows on with his life. When he meditates, he thinks: the Warriors never give up, and I won't either.

We all know it's temporary, like all of life. Appreciate it while you have it. Someone said that the Warriors are at their apogee right now, and that's probably right. Bodies age and decay, contracts expire and greener fields beckon. Coaches get recruited elsewhere. Be Here Now.

At the same time, while working out I listened to the Fareed Zakaria podcast with the former Finance Minister of Greece, Yanis Varoufakis. He tells Fareed how Europe is falling apart. He says, what if Greece were Nevada, and no one were around to bail them out, and the contagion spread to Missouri, and then Oklahoma, and then California. That's what is happening in Europe, that's what must be prevented.

“Are you optimistic or pessimistic?” asked Fareed.

Varoufakis replied: “There is a moral imperative to be optimistic. To be optimistic is to express a faith. There are no facts, just belief.”

In other words, when you launch the shot, you have to think every time that it is going in, and when it doesn't, just launch again and believe again. That's the only way to win. That's what shooters believe, that's what Curry thought when he passed it to Harrison Barnes for the tying shot, “I showed him confidence in him.” Confidence matters.

Which is imitating which, life or sports?

Budd Shenkin

Monday, May 9, 2016

Basketball and the Sense of Place


Part I

Question: “What is more important, basketball or life?”

Answer: “Basketball is life.”

Sometimes this answer makes a lot of sense. But even if it's an exaggeration, it's a great sport, and a young one, where innovation still occurs regularly. And also, as a young sport, some of us can remember the old days pretty well, well enough to compare. I even remember when it was mostly white guys, that's how old I am. I remember the elation of the Texas Western triumph, speaking of race.

Basketball talk can include lots of things, one of which would be the greatest innovator of all time. It could be Hank Luisetti and the jump shot, or Dr. J and the dunk, or as I have argued, Steph Curry for breaking the equivalent of the four minute mile and proving that one could rely on the three-pointer and also for developing the high-off-the-backboard layup over a giant defender.

Another discussion would be the greatest team of all time: this year's Warriors vs. the 1995-96 Chicago Bulls, for instance, vs. Showtime Lakers, vs. 1968 76ers, or even one of the Celtics teams.

Yet another discussion would be the top five one could put together: I have historically chosen Wilt at center, Oscar and West at guards, Bird at forward, and Jordan at small forward (changing his position.) I'm moving away from this five gradually, slanted toward the past as it is.

And yet another is the best backcourt of all time, from West and Goodrich up to Steph and Klay.

But with this too long lead in, the most recent discussion has been, what city has produced the best five of all time? Bruce Jenkins, our excellent and sometimes quite enjoyably discursive SF Chronicle sportswriter who is fond of casting the wide eye, last Saturday submitted his all-time list of Oakland basketball greats.

He puts Russell at center, Paul Silas at power forward, and three guards: Jason Kidd, Gary Payton, and Damian Lillard. His reserves are Joe Ellis, Isaiah Rider, Brian Shaw, Nate Williams, Antonio Davis, Leon Powe and Cliff Robinson. This is a hell of a team, a hell of a team. Russell a candidate for best center of all time, two of the guards Hall of Fame, and if Lillard continues, he'll be the third.

So I challenged our basketball discussion group to erect the Philly all-time great team, although we were conscious of a certain unfairness of comparison, Philly being so much larger.

Correspondent Bob Liss observed: “The Oakland team has zero offensive firepower up front. But that is a very interesting team anyway. They can certainly get rebounds. Maybe they can make room for Vada Pinson or Bob Beamon.”

The definitive Philly list came from Bob Levin, which I then sent on to Jenkins in this email:

“Your column today mentioned your all-Oakland team, which is near and dear to my heart and many of my friends' as well, since many of us have lived here for many years.

“But, it happens that some of us come from Philadelphia. So, here is our all-Philadelphia team as postulated by Bob Levin :

'My All-Philadelphia team would run Wilt, Rasheed Wallace, Kobe, Guy Rodgers, and Earl. My bench would be Gola, Arizin, Wali, Chink Scott, Walt Hazzard, Kyle Lowry or Fred Carter.

If you want to reduce it to one area, West Philly, you have Wilt, Earl, Wali, Walt, Chink, Jellybean Joe, Wayne Hightower, Jim Washington and then a choice of Malik Rose, Lewis Lloyd, Doug Overton, and Hal Lear.

If you want to reduce it to one high school (Overbrook) you have Wilt, Wayne, Wali, Walt, those last four guys above, and Mike Gale.'

Much as I love and respect Oakland, I think Philly (OK, much bigger place) takes the honors. In fact, Overbrook might take honors. Although I have to admit, Oakland's guards are terrific - love Gary, Jason, and now Damian.”

Then Bruce J. responded:

“Budd: Great stuff. Love the all-Philly team. I'd take Oakland because of Russell. I'd take any city if he was on it. But thanks so much for writing -- Bruce J.”

Part II

Basketball aside, this made me think about our affiliations. Why do we root for our hometown teams? That's an old question. There is Jerry Seinfeld's observation, which could have been about the Oakland A's, about the peripatetic nature of the staffing of sports teams. What are we cheering for, asked Jerry, when these guys have been ripped off from here and from there and the teams change all the time? Are we cheering for the uniforms? Are we cheering for a laundry?

Well, when I grew up in Philadelphia – granted teams were much more stable, and there was even the territorial draft – the Eagles, Phillies, A's, and Warriors were all part of who we were. If it had been the Middle East, they would have accused us of tribalism. Leaving Philadelphia for college at Harvard, I found it difficult, indeed impossible to root for Harvard teams. Who were these guys, anyway? I didn't know them personally – at high school I rooted for my friends, and played some myself. Who was I going to root for at Harvard, those preppies, New Englanders, Ohioans? What was the point of that? That changed when I roomed with the basketball team and played JV myself, but otherwise, I rooted for Philly.

Cambridge itself was difficult to absorb. I liked the roast beef sandwiches at Elsies – hey, the chief sandwich maker, Smitty, was from Philadelphia! – but a sub shop instead of a hoagie shop, and putting all that pickle relish on a non-Amoroso bun? Narraganset beer - “Have a 'Ganset!” – or Carling's Black Label? Give me a break. Let alone rooting for the hated Celtics against the Warriors, or the Red Sox against the A's. To me, it was identity.

I thought about it. Not rationally, I just investigated my own feelings. I thought, I'm loyal to Philadelphia; my parents were from there and never left, and I was from there. I'm loyal to the United States. But Boston? Come on, I'm still going to root for Penn. In fact, I couldn't lay down roots there in Boston, hard as I tried, although others could, especially in med school.

So here I am in the East Bay for more than 40 years. I went to grad school at Cal, so I can feel some loyalty there. I have rooted hard for the transplanted Warriors (former season ticket holder) and A's (former season ticket holder), and the Giants (current season ticket holder), and the Niners and Raiders, and I'm here long enough, and I worked in Oakland long enough, to take pride in Oakland, especially now in Lillard for some reason I can't put my finger on. And for Marshawn Lynch. And Jason Kidd. I think I'm double-rooted.

They are all symbols, clearly. We care for them, and they “give back to the community.” We yell and scream at the games and talk about them all the time, and they give speeches about the fan's deserving their victories. It's not frivolous. It's commercial, true, but then so is everything now – our descendants will look back on this commercialism the same way we look back at Roman customs, and marvel at the triumph of capitalism. But you can make money and still care. I'm a doctor, so I know.

I still think of sports as a search for artistic triumph. Honing of skills over a long period of time, intrinsic ability, working together toward a common goal, production of beauty – “beautiful play” is not just a casual term, it's the essence of sport. But there is also identity. And that's why it's important to stick to the rules, not to be dirty, not to cheat, not to cut corners. Because what we are doing is succeeding together in the eyes of God – non-denominational, open to atheists, and benign rather than awful – but something beyond just us.

Is art compatible with competition, or with identity? Sure it is! That's why sports are so great – it's not simple, it's everything combined. Let's not forget that Greek plays, one of the crowning successes of mankind in art, were produced in competitions. I don't know for sure that there were neighbors and friends rooting for Sophocles and Aeschylus, but I bet there were. And around the year 400 BC, and 350 BC, I bet there were arguments about the best of all time. And arguments about how could you compare the Olympics to the theater.

Somehow I think I could have fitted in there. Better than in Boston, where they had the hated Celtics.

Budd Shenkin


Saturday, April 30, 2016

The Devil's Chessboard


The Devil's Chessboard: Allen Dulles, The CIA, and the Rise of America's Secret Government, by David Talbot, HarperCollins, 2015.  http://www.amazon.com/Devils-Chessboard-Dulles-Americas-Government/dp/0062276166/ref=sr_1_1?ie=UTF8&qid=1462036454&sr=8-1&keywords=the+devil%27s+chessboard

I'm having trouble with this book – I'm just over halfway through it. I suggested this as reading for my great, great book club, Norm's Bookies, and then earlier this week I sent them a mea culpa note, regretting that I had done so. Here's what I said:

Gentlemen, I am embarrassed.  I've read almost half the Talbot book by now, I guess.  While there is a lot of interesting stuff, very interesting, it's far too long, not well edited, not terribly well written, and worst of all, the persistent lefty cant is really irritating.  I fear that as the part about the Kennedy assassination comes up, it will be even more irritating.  My favorite rendition of the assassination remains Steven King's.

But now I'm not so sure about my warning and apology. It's true that the style and organization of the book aren't great. It's overwritten at times, with attempts at grand phraseology that fall short. It certainly is filled with moral outrage of a type that I start to resent, because it feels like he is trying to make me feel outrage, and I'd rather come to that conclusion on my own. I've just had it up to here with people who demand that I think and feel the way they do. (And my good friend Bob didn't like Talbot's older book Brothers, which I did like, about how JFK challenged the military/secret government establishment and how there could have been an assassination plot, in fact, there probably was one. I liked it, but I respect Bob's opinion.)

But that doesn't make them wrong. I think that I have trouble with this because of me. I grew up in the fifties and I remember them as far from halcyon days. My parents had been Lefties and lived in fear of suffering for it, as many had. I even knew someone who occupies a couple of pages in the book, a man named Nathan Silvermaster, who I remembered was called Greg. Charged as a spy by Elizabeth Bentley, he was never convicted, and I knew him when he was a homebuilder on Long Beach Island, along with his business partner Lud Ullman, who lived with him and his (Silvermaster's) wife Helen, and built new ranch style homes on an island populated by Cape Cods. I remember his name in Time magazine. I told my 6th grade class at Friends' Central, who knows what the discussion was but I never held back much then or now, so I said that we know people who are accused of being spies and “they're the nicest people.” My parents heard of this somehow – how had they heard of it, from friends who were the parents of a fellow student who were also Lefties, and who said, “Buddy Shenkin said...?” My parents were kindly, and even smiled, and told me that I had better be a little more careful about what I said. I'm wondering now how they found their way to Ullman and Silvermaster. It does appear that they were spies. https://en.wikipedia.org/wiki/Nathan_Gregory_Silvermaster I liked the house they built us.

Anyway, in the fifties my Dad wondered what magazines we ought to get regularly. They settled on The Nation and Scientific American. They would come in the mail and be put up on the hutch and I would come in from high school and look at them, the Nation with big Lefty headlines. Later on in the 60's in med school I would see my classmate Mona Bleiberg, from New Jersey, with her I. F. Stone Newsletter. My friend Fred Gardner at Harvard and his friend Todd Gitlin always knew the truth, and I went with Fred to audit the class given by Robert Paul Wolff on Marxian theory. I would read about The Power Elite by C. Wright Mills, J. Fred Cook about Cuba and what was Castro really and how was he being played by the Establishment (which isn't the term they used then,) and we read Vance Packard's The Hidden Persuaders in English class at school, and somewhere in there Thorstein Veblen's thesis on conspicuous consumption. But at the same time I wanted to be a baseball player when I grew up, and a doctor because that's what my father was, and we got new cars with triple toned paint jobs and fins and I learned to drive and hankered after girls, a lot, and loved high school at Lower Merion (way before Kobe got there.) And at Harvard Frank Bardacke urged us to read Dissent and to go sit in at Woolworth's in 1960, and my father said, be careful, you want to be a doctor, or something like that. I was cautioned.

So, what I'm saying is, when I read this book, all that comes crashing down on me. I wanted to be upright and I wanted to fit in and I wanted to listen to my parents and I wanted to succeed and I wanted to be an educated individual and one of those days I wanted to get laid. Then later, after I was a doctor and worked in the Public Health Service I went to the Graduate School of Public Policy at Berkeley and was exposed to smart and more conservative academics and I exposed my Lefty-ism and they helped me reason through it and by then I was old enough and experienced enough to accept some of their reasoning. I'm still working on it.

When we read we bring ourselves to the book. Everything is interactional. If you believe in history, and I believe in history, and culture, then you believe that the past matters to the present. I think of budgeting – what's the first step in making a budget? Look at spending the year before, then adjust. Isn't that all of life? So, the fifties matter a lot.

It really is unconscionable what Dulles and the CIA did, and it lives today. Here's a Huffington Post review of the book that makes my recommendation more palatable: http://www.huffingtonpost.com/joseph-a-palermo/the-devils-chessboard-all_b_8959302.html.

I wonder if Talbot is truthful, I guess that's part of my problem. How has he learned all this, and how sure is the history? I guess I would feel a lot better about the book if I had a better sense of what he is sure of, and what opposition to his story says. Do they accept the facts, but cast them in a different light? Or do they rebut the facts?  But then I think, yes, what he says has the ring of truth.  It's just uncomfortable.

The past lives in our lives as a country, as well as my past lives in all the books I read.

Hey, book club guys – I now think the book is worth reading. From this mess came the revolt of the 60's, which spawned Reagan and the shadow of conservatism that we have lived our lives under, even as it appears the Republican party is set to lose an election, and we'll see what difference that makes. It does appear that Cuba is out from the cold. I guess.

Budd Shenkin

Friday, April 29, 2016

Race and the Presidency


This is a mini-post. I have had so many ideas running around in my head, and some writing I've been doing for other projects that I'm now reduced to a mini-post, with possibly others to follow. Who knows? I've never been one for planning, sometimes to my detriment. My redeeming quality has been persistence and the capacity for hard work. I keep coming back.

Anyway, mini-post. Toni Morrison in 1998 reflected on the impeachment of Bill Clinton. (Amazing how that has receded, isn't it?) She said, “White skin notwithstanding, this is our first black President. Blacker than any actual black person who could ever be elected in our children’s lifetime. After all, Clinton displays almost every trope of blackness: single-parent household, born poor, working-class, saxophone-playing, McDonald’s-and-junk-food-loving boy from Arkansas.”

She said the message of the Establishment to Clinton, as to any African-American, was this: “'No matter how smart you are, how hard you work, how much coin you earn for us, we will put you in your place or put you out of the place you have somehow, albeit with our permission, achieved. You will be fired from your job, sent away in disgrace, and—who knows?—maybe sentenced and jailed to boot.'”

She continued: “This is Slaughtergate. A sustained, bloody, arrogant coup d’├ętat. The Presidency is being stolen from us. And the people know it.”


Today, a phrase in Paul Krugman's trenchant column on how the Republican Establishment has conned its way through the decades caught my eye: “after seven years of an African-American president (who the establishment has done its best to demonize)....”

This is not new, but when I heard it this time, I thought: you know, racism is so pervasive that there is no magic bullet, it really has to be taken on in stages. Clinton was stage one, a white man with some familiar African-American characteristics, according to Morrison. And Obama is stage two. Only stage two because being African-American isn't just about skin color, it's about culture and experience. Obama's skin color is dark, but he was raised by a white mother and white grandparents from Kansas living in Hawaii. True, not the total white experience – Indonesia and Hawaii are not Kansas.

The ambiguity was sufficient for many African-Americans to say he wasn't black enough to qualify as a Black President. But certainly prejudiced whites viewed him as plenty Black. And that was the label he embraced. If he was viewed by white society as Black, then let's be Black, he said. He chose a spouse who was fully African-American. And then he populated his government with many true African-Americans. One step further than Bill Clinton, I'd say, maybe a step and a half. Black he was but he still was raised by a non-prejudiced white family – his grandparents were really remarkable, both of them, the way they raised that boy. I'm all admiration.

Then as President he got the full illegitimate treatment from Mitch McConnell and other Southern friends – we'll break this Black boy, essentially. We'll challenge his birth, we'll block anything he wants to do. We'll put him in his place.

Well, it didn't work out that way, Mitch. The Confederacy may still live, but it's still shrinking.

Anyway, like I said, a mini-post. Just an observation. My own view is optimistic. Obama has clearly been a superior President in so many ways, and his no-drama temperament has been perhaps the strongest weapon of all. What a gift it is. Basically, I think Obama is step two or two and a half in a three step process. Next time, no more illegitimacy; next time, it will be just on the merits.

Hopefully.

Budd Shenkin

Thursday, April 14, 2016

Primary Pediatrics Laboratory #2


Readers have responded to my proposal for a Primary Pediatrics Laboratory.
#1 Some have pointed out that the proposal needs to meet the objection that it ignores the needs of the general population and might be seen as promoting a double (or even more levels) standard of care.
#2 Others have wondered if we should be looking for ways to test better methods and increasing use of midlevel practitioners as a way of stretching scarce resources of money and personnel.
Answer to objection #1: Building the ideal in a model practice is just that, building an ideal. It's not a prescription for a whole system. You put all your money and effort into building the Warriors, and then the rest of the basketball world can look on with wonder, and emulate as possible. The Warriors inspire, and they instruct. Laws then support a fair distribution of resources. Building the Warriors doesn't hurt, rather it helps the school teams and summer leagues around the nation.
Answer to objection #2: the PPL is kind of a mind bender, or paradigm shifter.  We are so used to operating under budget constraints and being good citizens in primary care.  Think like a procedural specialist where the money just rolls in -- think fine art and walnut paneling of our cardiology colleagues instead.  They are used to thinking in exactly the opposite way we think.
Imagine if cost were no object -- no object.  Where the task was to go higher and higher in every way.  Think different.  Does anyone think about cost when designing a new, better aortic valve?  Etc.  Think about primary care being the Cadillac,  What would you do?
In fact, in an academic center where money could be abundant, could you achieve the highest quality care possible?  No one really tries.  Primary care tries tries this and that, but not the whole ball of wax.  But it is possible to do so.  The barrier is simply our way of thinking.
Benefactors generally think of the traditional -- more top heart surgery, more that sort of stuff, more really deluxe hospitals.  Benefactors want to see kids in their beds getting better because of something their money bought.  But benefactors also think of fixing education in primary care terms, so it is possible that they could look at things differently.  What they need is a proselytizer.  I haven't seen that pediatric primary care proselytizer; the world is looking for that leader.
Think of the Peter Bent Brigham Hospital and the recent scandal of treating a Middle Eastern prince differently as they rent out several rooms on the top floor.  What if, instead of attracting royalty for specialty services, someplace like the Brigham hoped to construct the same quality service for primary care, no costs too high, no patient/clinician ratio too low?  What could one do?  I can think of lots of things.
Someone will want to be that leader. I wonder where it will be.

Budd Shenkin