Tuesday, June 19, 2018

Crimes of Monster Trump: The Horror of Taking Children from Parents

Trump is literally a monster.  He conforms to this definition: "a person of unnatural or extreme ugliness, deformity, wickedness, or cruelty."  This fits him like a sock.  It also fits those around him: Stephen Miller, John Kelly, Kirstjen Nielsen, and others TNTC, as we in medicine say when looking at leukocytes in infected urine (too numerous to count.)

To my mind, the transgressions are so severe that we might need an American Nuremberg Trial, get those people in the docket, get their enablers there, too -- Tucker Carlson, how'd you like that? -- all the monster followers.  ICE agents need to be treated like the Brown Shirts; they can resign or they can follow their immoral orders.

Yes, this is "not normal."  Some abnormality can be tolerated, can be good, but a monster's abnormality needs to be excised.  There must be some accounting.  The midterm elections and how the Democrats choose to approach nationalizing this election, the skill they can bring to getting the Bill Kristol's and Jennifer Rubin's and Max Boot's - Republicans with a conscience - into their camp for this election, that will tell the tale.  If there is not a wholesale rebuke of Trump, there will be blood on the streets.

There is nothing so heinous as torturing a child.  Torturing children is now official state policy, as declared by another prospective docket resident, the elfin racist Jeff Sessions.  Here is a letter from a doctor who has seen some of these children torn away from their parents.

"Dr Kivela,
I live in Denver, CO. I'm approximately 2340km from the Mexican Border, but I grew up in Texas, and I speak Spanish fluently. Despite my distance, I have recently taken care of 3 toddlers, between ages 1-2, who were seized from their parents at the Border. All of the information I have on them, I obtained from their foster parents. While I have no way to independently verify what I was told, I also have no reasson to doubt the information that I was given.
All of the children I took care of were brought to the emergency department by their foster parents (foster mothers in all of these cases). As we discussed today, I suspect that you will find many of these such cases because foster parents are legally required to seek medical care for those in their charge prior to administering any kind of treatment. They are also required to get documentation of these visits, and in many cases, the children are brought to the ED for evaluation because of lack of a pediatrician.
The children I saw had similar stories. Two were from Guatemala. One was from Honduras, Two were boys; one was a girl. All had mild childhood illnesses: gastroenteritis and dehydration, upper respiratory infections, rashes, etc. Their foster parents, none of whom spoke Spanish, knew nothing about their medical histories, their allergies, or their immunization statuses. They knew only two things: 1) the children's parents (both mother and father in 2 cases; father in 1 case) were being detained by ICE and 2) they had no idea how long the child would be staying with them or if they would be in contact with the parents. These are children, who by the definition of our government, are in the safest, most stable possible situations. They are living with experienced, caring foster families, their illnesses were relatively minor, and they were receiving medical care.
While their bodies appeared relatively healthy, their behavior was so far from that of a "normal" toddler so as to be striking to both myself, as a pediatric emergency medicine physician, and to their foster parents. Children this age are rambunctious. They climb on everything, they put things in their mouth that they're not supposed to, they begin to explore the world away from their parents, they begin to seek and to find the limits of their world. These children, in all cases, clung so tightly, and so completely, to their foster mothers, both in the ED and at home, that they were literally unable to be put down. They didn't explore the world, they were terrified that their world would be broken for a second time. Their trauma, and the direct effect it was having on their development, was obvious. One foster mother told me that she couldn't figure out how to bathe the little girl properly. Since she would scream every time she tried to leave her or put her down, she couldn't safely get her into the bathtub. She knew the child would be calmer if she could get into the tub with her, but as a foster parent, she wasn't allowed to do so. Another told me, tearfully, "I'm just trying not to ruin his life. He screams every day for his pappa, and I don't even know where his pappa is."
In all cases, these were experienced foster families. They understood and had dealt with traumatized children in the past. This was not new territory for them. What they hadn't dealt with was the complete lack of a timeline or plan for reconciliation. They had no information on hearing dates/times for the parents; they had no contact information for the parents; they had no idea if/when visitation or contact would be allowed, and they didn't have access to a case worker who could obtain this information. These children, those lucky ones who "made it" into caring foster homes, were floating, unanchored to their past or their future. As a PEM physician, I was utterly useless, a bandaid for a gaping wound.
Tara Neubrand, MD
Pediatric Emergency Medicine"

When is "too much" too much for the American people?  If this isn't too much, what the hell is?

Budd Shenkin

Monday, June 18, 2018

How Democracies Die, Racism, and How The NBA Gives Us Hope

Even with all that's going on, I'm still startled that on our pediatrics SOAPM listserve, immigrants and children of immigrants are fearful, even though they are here legally, but they are still afraid that they will be rounded up. I understand the nervousness of immigrants, but I'd say, if you're legal, you're safe, no if's and's or buts.  It's not Nazi Germany and it won't be.  It's certainly a more than nasty episode, but still, their nervousness is an index of how serious our Trump insurgency problem is.

I read an excellent book, How Democracies Die: https://www.amazon.com/How-Democracies-Die-Steven-Levitsky-ebook/dp/B071L5C5HG/ref=sr_1_1?s=books&ie=UTF8&qid=1529322820&sr=1-1&keywords=how+democracies+die.  The authors detail the death of democracies in some other countries, like Peru, and the steps taken by the dictators in achieving non-democratic power, which are exactly the steps that Trump is trying to take.  They point out how norms are so important, because not everything can be detailed in law, and how important it is that contenders in the political fray respect the legitimacy of opponents, rather than viewing them as enemies of the state. They summarize their guidelines in the words “forbearance” – don't do something just because it is not legally forbidden, but rather respect tradition and reasonableness of the way things have been done – and “respect.” Political opponents are not the enemies of the state. These are very good and important observations.

But what particularly caught my attention was a just a sentence or two. What they said in a very short space was this: as a rule, no ethnic group voluntarily gives up power. Just a small sentence or two, just a small observation in a longer book, but to me, glowing and pulsating like a thumb jammed in a car door.

Of course, I thought, of course. Of course. I have been wrestling with this myself. I have realized the severe lifelong deficiency of my understanding of the pervasiveness and devastation of racism. While in fact there it was staring me in the face: what has led America to continue to be glued together, to respect the norms of democracy and to respect others as opponents and not enemies? To a certain extent, as America was predominantly white, what both parties could agree on was that Blacks should remain oppressed. Even in Roosevelt's America, when the President had the the task of delivering a decent life to the working class, he had to give obeisance to southern senators, as in exempting agricultural workers – Blacks in the South – from labor laws. In very stark terms, part of the basic deal that kept American democracy together was an agreement to let racism thrive.

And of course, as an American, I've been part of that. Case in point: when I was 19 years old I wrote a paper for my freshman English class that I thought was wonderful (and still do.) The title was Mr. Basketball, or Why I Hate Bob Cousy. It was a seminal paper in that, amazingly, now, over 50 years later, my friends and I are still discussing and arguing over its premise, which is that Bob Cousy was severely overrated. This is important for basketball fans! There is an amazing amount of assumptions and detail and statistics and history for us to chew on, and spit out on occasion.

Maybe I was right; I actually think I was, but it's debatable. But some years ago I reflected on my exploration of why Cousy was so overestimated. I thought then that Cousy, a rather short guard for the National Basketball Association's Boston Celtics, was glorified precisely because he was short, and fans could identify with him, David against Goliath. I think he himself made that very point. I thought that the fans' identification with him clouded their appreciation of the real excellence of bigger and better and more effective and less showboaty players. But here's what I realized as I reflected: at the time, in 1960, it never crossed my mind to think the important thought that Cousy was white, and that the league was just then becoming increasingly Black. Talk about opportunities for identification. Whiteness might trump shortness.

In other words, while I was a nice Jewish liberal boy who would go on to become a doctor, in 1960, I was oblivious to racism except in its most obvious forms. Since then, even though I have done good things and thought good things and certainly done my bit for racial justice personally, I have had my eyes opened gradually and progressively to the depth and severity and lethality of racism in America. It was only recently that I realized that even my Black physician friends have experienced being pulled over by police, and followed around stores by security, for the obvious reason. I had no idea.

I could have been more racially conscious at the time I wrote my great paper, since it was written in the midst of the civil rights movement's beginning, and predated civil rights legislation by just a couple of years. But it predated by eight years Nixon's adoption of the Southern Strategy, by 12 years Nixon's use of Donald Segretti's dirty electoral tricks, and it predated by 28 years the Willie Horton ads that propelled George Bush to the 41st Presidency. Political and social movements take time, and so does social understanding.

And now we are engaged in another civil political war that will test whether this nation, or any nation so conceived and so dedicated to democracy, can long endure. Ethnic groups do not easily give up dominance. When faced with a choice between ethnic dominance and democracy, what does one choose? From this point of view it is not surprising that a dominant group would turn to voter suppression (time honored in the South), to electoral tricks such as gerrymandering, to the infusion of large amounts of money to capture cleverly local and state governments just below the radar. It is not surprising that the Other will be demonized, that possession of weapons will be lionized, that mutual respect and norms and expectations and decency will be jettisoned by agents of the historically dominant faction. It just makes sense. Hypocrisies will be revealed. The contradictions of the ideology of democracy and the actuality of its enactment will become evident.

So, scales have been lifted. But I have to say, as outrageous as the Trump Administration the ICE brown shirts and the would-be thug friends of the President are, as scary as this can be to those most vulnerable, as best as I can see, we are not present at the destruction; rather, we are present at the inflection. Democracy will not die here. At heart, we are indeed a decent nation. Many have lost their way. Christians are having their faith tested – do their sympathies lie with the murdered church people of Charleston who forgive their racist murderer, or the bigotry of Franklin Graham? In the end, I'll put my money on decency.

Could it happen here? I guess it could. But it won't. There's too much to live for, there's too much good in the people, there's too much good history and there's too much good memory in being proud of who we are. There's too much music and sports and literature and food and drink and fun and love and racial mixture, and acceptance. It's all here. There's too much basketball, and football and the South and the prejudiced and those out of the mainstream will just have to catch up. We are not dying as a nation, we just have a fever.

In the end, we will go the way of the NBA, which learned to accept not only African Americans, but to glory in them, to bring in foreigners Black, white, and Asian, from all corners, women as coaches, and to glory in them, too. It is a glorious history, and I'm sure it will not stop here. It just can't.

As goes the NBA, so goes the nation.

Budd Shenkin

Thursday, May 31, 2018

More on the "housing crisis"

The SF Chronicle today came out against Berkeley for wanting to protect itself against excessive housing congestion, calling Berkeley hypocritical and dominated by NIMBYism.  As usual, the Chron sucks.
I thought it deserved a reply, although the Chron is notorious for the worst Letters to the Editor section perhaps in the country.  The Maui News has better written letters.  Nonetheless, here's what I wrote -- read it here because you can be assured you won't be able to see it in the Chron, because for one thing, it is grammatically correct....

re Editorial: Bill reveals lots of hypocrisy

NIMBYism my backside! Do Weiner, Chiu, and your editorial board want to Manhattan-ize our communities and destroy their character because “people want to live there?” Why castigate current residents of functional communities who want to preserve what is good in the world? Let's remember the mistakes of well-meaning urban redevelopers of the last century who inadvertently destroyed communities they called “slums.”

Yes, people need to live somewhere, but we should widen our view and think of the crisis not as one of housing, but rather of transportation. Shrinking commuting times by expanding and expediting trains, busses and BART connections would allow peripheral communities to flourish, and would avoid the contagion of ever more congestion. Yes, this would require expanded public investment and preferential treatment of public transportation, and some imagination by transportation planners, but other countries have gone this way. Why not us?

Budd Shenkin

Tuesday, May 22, 2018

The Body's Double-Duty Systems Approach, and Guy de Maupassant

Sometimes I think I'm so smart. I take such pleasure in my ideas. Doesn't matter what the subject is, except physics – I understand relativity, get excited about it, and then I can't remember exactly how it goes. But other things? I'm a bear for my own ideas.

So, when I had my prostate laser vaporization surgery on February 9 and had to recover from that, it led me to thinking about the urogenital system, and the double-duty that the name implies. Some smartasses had suggested that God made an error in designing the body, putting the excrementary system too close to the recreational system. Take the penis: if it's erect, it's in recreational mode, and the pee system shuts off automatically – try to pee when you're erect and you will find it pretty much impossible. It's an on-off instrument, one unit employed for dual usage.

But if you think about it, what's the alternative? What would you do with two penises, one for recreation and one for peeing? The engineer would be rightly condemned. So I was thinking that the critics, the smartasses, who maybe had the female anatomy in mind instead of the male anatomy for their criticism – what would they suggest instead? And this doesn't include the amazing system of ontogeny, how the male and female system develop in a very similar way, with just some adjustments made under hormonal influence, to produce the two systems that then fit together so neatly.

So, as I said, I relish ideas, and reflected on the system as I recovered from the vaporization, necessary because of what I have declared a condition of “too much man,” I thought about how neat it was to have designed a dual use system. But I stopped there.

And then I turned to the book on my bedside table and took up my French reading, which is part of my project to learn French beyond the level I achieved to pass my undergraduate foreign language requirement. I'm reading Guy de Maupassant, the 19th century short story writer who is well represented in the dual language books, among them “My Uncle Jules and other stories.” Among the stories is “L'inutil Beuté, ” or “Wasted Beauty.” And amazingly, just as I was thinking about double-duty engineering, here is what I found. It's a long paragraph, an intellectual discussion between two cutouts to give Maupassant a platform to discuss some of his ideas. Here is the paragraph in full:

Yes, but I say that Nature is our enemy, that we must always fight against Nature, because it always reduces us to animality. All that's clean, lovely, elegant, and ideal in the world was not put there by God, but by man, by the human brain. It's we who have introduced into creation – by singing of it, by interpreting it, by admiring it as poets, but idealizing it as artists, by explaining it as scientists who make mistakes but find ingenious reasons for its phenomena – a little grace, beauty, unknown charm, and mystery. God created only coarse beings, full of the germs of disease, who, after a few years of flourishing like beasts, grow old and infirm, with all the ugliness and impotence of human decrepitude. It seems that he made them only to reproduce themselves filthily and then die just like mayflies on a summer evening. I said, 'to reproduce themselves filthily,' and I emphasize it. In fact, what is more vile, more repugnant than that excremental, ridiculous act of reproduction, which revolts every delicate soul and always will? Since every organ invented by that thrifty, malevolent creator has a double use, why didn't he choose others that weren't unclean and besmirched, to which to entrust that sacred mission, the noblest and most exalting of human functions? The mouth, which nourishes the body with physical food, also disseminates words and thoughts. The flesh is renewed by it and, at the same time, ideas are communicated by it. Our inhalation, which brings the air of life to the lungs, also gives the brain every scent in the world: the fragrance of flowers, forests, trees, the sea. The ear, which lets us communicate with our fellows, has also allowed us to invent music, to create dreams, happiness, infinity, and even physical pleasure with tones! But you'd say that the Creator, sly and cynical, wanted to forbid man ever to ennoble, beautify, and idealize his encounter with woman. And yet, man has discovered love, and that's not bad as a retort to that mocking God, and he has adorned it so finely with literary poetry that woman often forges what physical contacts she is forced to make. Those among us who are powerless to deceive themselves by their own enthusiasm, have invented vice and refined upon debauchery, which is yet another way of hoodwinking God and paying homage, a shameless homage, to beauty.”

OK, so I like my own ideas. But I stand in awe of a really superior intelligence, even though (and maybe especially) I'm not sure I understand all of it.


Budd Shenkin

Thursday, May 10, 2018

City congestion: housing & transportation part II

In my last post I tried to indicate that high speed rail would be a salubrious influence to the problem of city congestion.  Knowing almost nothing about the field, I assumed that others had considered this, but I took advantage of the lack of editorial supervision on my blog.  Oh, the freedom of ignorance!

But the very next day, what should come across my internet desk but an article from McKinsey on the externalities of city congestion.  And solutions to the same.

Amazingly, congestion is simply accepted and the solutions are surprisingly unsurprising.  I present to you the email summary of the McKinsey insights.  I just want to shout -- "Hey, you guys, ever think about high speed rail and ameliorating the congestion in the first place, rather than dealing with its consequences?  At least, for part of the answer?"

But I will content myself with shouting it here, and reproducing what they write.

Article McKinsey Quarterly

Booming cities, unintended consequences

Roadways clogged by commercial vehicles and intense competition for affordable housing are imposing costs on prosperous cities and their most vulnerable residents.
Cities are the hubs of the emerging digital economy, attracting knowledge workers with higher pay and alluring lifestyles. One consequence of this concentrated prosperity is rising rents and a scramble for housing that places disadvantaged citizens in peril—as seen in the increasing rates of homelessness in cities such as Seattle. More people living in urban cores also means more commercial vehicles are needed to serve them, which is fueled by a surge in online deliveries. The resulting congestion is burdening cities with surprisingly high costs. The social stresses of the new growth should be on your radar.

Rising incomes, rising rents, and greater homelessness

By Maggie Stringfellow, Dilip Wagle, and Chris Wearn
The experience of one high-tech hub suggests homelessness can be an unintended consequence of rapid economic growth.
The number of homeless has fallen in most US communities. But it is climbing in affluent coastal cities such as Seattle, in King County, Washington. The exhibit suggests why: the cost of housing. In King County, homelessness has risen in line with the fair-market rent (FMR), which has in turn increased in line with the county’s strong economic growth, propelled by the swelling ranks of high-income digital workers. On a single winter night in 2017, volunteers counted 11,643 homeless people, an annual average rise of 9.2 percent since 2014. Over the same period, the FMR has risen an average of 12.3 percent a year.
Rent increases in Seattle’s King County show a strong correlation with homelessness.
An essential component of the solution in Seattle and other prosperous urban areas is more affordable housing. In King County, as rents climbed, the stock of affordable units1 fell by 13 percent a year between 2014 and 2016, such that in 2017, some 22,000 households sought help from the county’s homeless services, but only about 8,000 affordable units were available. The homeless population had to compete with higher-income individuals for these units.
In King County, we estimate it would cost between $360 million and $410 million a year to tackle current levels of homelessness—that’s twice today’s spending. Action would be needed on three fronts: preventing more people from becoming homeless in the first place, assisting the homeless to find accommodation, and most important, providing more affordable housing. Investments in affordable housing account for about 85 percent of the extra funding required. Housing subsidies—payable to landlords to make unaffordable accommodation affordable—may be the most effective investment, as they quickly boost the supply of cheap housing.
Some corporations keen to alleviate homelessness in their local communities already fund emergency shelters. These are crucial. But they are not a long-term solution. Affordable housing is. Partnerships with local governments to support more of it could therefore be one of the best ways for companies to do more.
About the authors
Maggie Stringfellow is an associate partner in McKinsey’s Seattle office, where Dilip Wagle is a senior partner and Chris Wearn is a consultant.
The authors wish to thank Katy Dybwad and Lukas Gemar for their contributions to this article.

The congestion penalty from urban success

By Shannon Bouton, Eric Hannon, and Stefan Knupfer
Commercial vehicles and online deliveries make city traffic worse and carry significant economic costs that demand creative solutions.
Attracting energetic residents and thriving businesses are signs of urban success. But they also make traffic worse, as does the growing congestion caused by e-commerce deliveries. Commercial vehicles (CVs), such as trucks, vans, and buses, can be particular trouble. Trucks accounted for 7 percent of urban travel in the United States in 2015, for example, but 18 percent of congestion. Cities can’t do without CVs, of course; trucks deliver much of the material and services that residents need to live, from food to power repair. The rise of e-commerce has added to the flow. E-commerce sales in the largest 20 markets could hit $1.6 trillion in 2020, an 85 percent increase over 2015. Congestion costs can be surprisingly high. These “externalities”—in economic parlance—represent as much as 2 to 4 percent of city GDP.
Logistics staging areas outside city centers (urban consolidation centers), load pooling, and parcel lockers have proved successful in reducing miles driven by CVs and the number of deliveries, as well as costs. Allowing night deliveries reduces congestion during peak hours and lowers vehicle-related emissions. These practices, plus the use of electric vehicles and autonomous ground vehicles, show the greatest potential, in both environmental and economic terms. In the longer term, droids, drones, and individualized delivery could also make a difference.
Rising e-commerce sales may flood city streets with delivery trucks.
About the authors
Shannon Bouton is the global executive director of the sustainable-communities program at McKinsey.org and is based in McKinsey’s Detroit office; Eric Hannon is a partner in the Frankfurt office; and Stefan Knupfer is a senior partner in the Stamford office.

Budd Shenkin

Tuesday, May 8, 2018

Transportation Policy Is Housing Policy

I think I have been guilty of NIMBYism; in fact, I know I have. I am not a New Yorker who grew up talking about “my building.” I grew up in single family houses with little back yards, and from 9th grade on in Lower Merion outside Philadelphia, I walked to school past trees and bushes to my beloved suburban high school. Since 1979 I have lived in the same single family house on a one block long street in Berkeley with trees and a back yard and we know our neighbors. It's a nice neighborhood. I like it.

So why should our area, and areas like it, change? People say that other people need places to live. They say that working people – teachers, police, others – are being priced out of living where they work in the Bay Area by tech wealth. They say that what we need is more vertical housing, higher density housing with some affordable units, so that people can live near their work. Scott Weiner proposed a bill to the state senate whereby local authorities would be divested of their power to forbid high density housing around transit hubs, like BART stations, and five story buildings would be automatically approved.

While I understand what people have been saying, I've rejected it. Why destroy what we have? Are trees and nature and a human-scaled life going to disappear into apartment buildings, where single family homes and in-law units will become home to 8 or 10 families on the same footprint? Will renters replace owners? Will the nearby hotel cum health club add hundreds of condo units to provide luxury housing and benefit of the husband of Dianne Feinstein, who refuses to retire, and add to the congestion? Is high density inevitable? I hate the prospect.

I haven't had much to offer as an alternative, though. I've said, well, let alternative development occur on the periphery, why does everyone need to be in San Francisco or Sunnyvale? Give it time, I've said. But that's been a pretty weak argument.

Then I got a call from out of state from a young man named Dr. Eric Feigl-Ding. He has been a scientist at the Harvard School of Public Health and is now moving back to his original home near Harrisburg, PA, where he is running for Congress, hoping to take advantage of Pennsylvania redistricting and an anticipated Blue Wave. Why did he call me? I am a repetitive small donor to Democrats running for congress. I started with scientist Jerry McNerney from Pleasanton who beat worst congressman in the House, Richard Pombo, who distinguished himself by opposing the Endangered Species Act. Since then my name has been shared and I have gotten personal calls from California candidates to whom I have contributed from $100 to $500 at a shot, depending on how much I have liked their schpiel.

Eric's schpiel was that he is scientist, and only Jerry McNerney and one other in Congress are scientists. Fair enough. But when I pressed him about electability and local issues, the conversation took an interesting turn. He said that jobs were hard to come by outside of Harrisburg – which lies in the middle of the state and although it is the state capitol and there are governmental jobs available, it's mostly just central Pennsylvania rust belt depressed area. “So what are you going to do?” I asked.

He said that the area was a nice place to live and people wanted to live there. The jobs, however, were mostly in Philadelphia and Baltimore, which were too far away to commute to. And here is wheremy ears perked up – he said that his solution is high speed rail. With high speed rail the commute would be rather easy; you could work where the jobs are and live where the costs were lower and where the living was nice, and the commute wouldn't be a killer.

I thought – BINGO! My wife Ann and I have been down on Jerry Brown's high-speed rail project as somehow irrelevant and perhaps boondoggle-ish. What's the big deal about connecting LA and SF in a couple of hours? Who will be taking that route, and why? So far, we've thought, the project will mostly connect Bakersfield with Fresno, guffaw. BUT, Harrisburg to Philly in less than an hour, maybe 45 minutes? Hey, that makes a lot of sense! Live in lush hills with neighbors you have known forever, telecommute a day a week maybe, and take the high-speed train four days a week and work on the train and voila! No high-density housing with no trees and no back yards and renters going in and out all the time, NIMBY.

So I thought, the real payoff of Jerry Brown's high-speed rail solution would be in its contribution to the housing crisis. Don't think LA to SF, think regional networks tying together house and work. Now it all made sense to me. Put the money into transportation, not into housing; let the housing take care of itself in the far periphery of what are now commute timed out areas. It's housing, dummy, not transportation.

Getting from here to there is, of course, always very hazardous. When you are talking about trains and transportation, you are talking about public investment. When you are talking about zoning, you are talking about private investment. Both paths to the future need constituencies. Weiner's bill failed, for now. NIMBYism? Environmentalism? I don't know what was decisive. Jerry's high-speed train path has been partially funded. Will Brown's leaving the governorship weaken that movement sufficiently to kill it? I don't know. But to my mind, advocates of that path would do well to emphasize how this regional strategy is an alternative to high-density housing. Make it a housing issue! And while you're at it, try to nurture a high speed rail industry here at home, making things, industry. Now I'm really dreaming, I know.

As for our smart friend Eric running for the house from Pennsylvania, how will he do? Good ideas, certainly a high-minded fellow, smart – but a rookie. When he talked to me, he kept referring back to how many papers he had written and how scientifically qualified he was. Maybe that's because he got my name as a Jerry McNerney supporter. Maybe. But it's also possible that he was violating the first law of salesmanship. Which is: let the product sell itself, don't try to impress the buyer with how great the product is. Instead, try to impress the buyer on how the product could help him or her, how it would fit into their life, how useful it would be to him or her. He was trying to tell me how qualified he was. Unfortunately, tellingly, that's pretty much what people objected to about Hillary. They thought that when she told them about all her qualifications, and about how smart she was, she was telling them that it was her turn, that she was due it. She didn't ask for their votes, she told them she deserved their votes. My fear is that Eric is going down that path. But who knows, maybe that was just his pitch to me.

Well, we'll see. In the meantime, without his trying to do it, Eric turned me into a supporter of Brown's high-speed train. You just never know where conversations will lead you!

Remember, high speed rail is a housing issue, not just a transportation issue. Selling the issue that way could be the key to its success. You have a decent commute on a train where you can read, and you don't have to live in some ant hill.

I think.

Budd Shenkin

Saturday, March 31, 2018

EHR - Smart Regulate, Don't Deregulate

Who's to blame for the Electronic Health Record debacle? And a debacle it certainly is, at least for clinicians. The latest bite of criticism has hit the oped pages of the Wall Street Journal. Drs. Mass (pediatrician) and Fisher (nephrologist) from the Massachusetts General Hospital do a good job of chronicling its ills. MGH uses Epic, the near monopoly of enterprise-level EHRs. I call Epic “by engineers, for engineers,” so unintuitive that the pathways rival those of the old city in a European capital where only the natives or the guides can find their way, who use their special knowledge for fun and profit. With this and other EHRs, doctors become unproductive data entry clerks typing and clicking away to fill up the boxes and navigate the menus, often at home late at night finishing up charting the day's patient notes. The indictment goes on: the software design often causes errors rather than preventing them. The content of the notes is frequently filled with garbage designed to gather more money according to coding rules and to protect the practice legally. For instance, in pediatrics we are used to receiving ER notes that assure us that our three year old patient has attested that he does not smoke, and the pages and pages of verbiage makes finding what actually happened at the visit a needle and haystack adventure. And of course we often receive these notes not by computer but by fax, because the EHR programs are most often not interoperable as they were envisioned to be. The promise of all patient information available everywhere all the time? No way. Everyone looks at the same record within the system, generally hosted by a large medical complex, but you can't see the record if you are outside the system, as smaller independent practices and other units are. So why did we go through all this investment and work for a more troublesome and less productive state of affairs?

It's a familiar catalogue of frustration and vitiated hopes that we all share. What makes the article particularly congenial to the Journal, however, is its attribution of blame and the proposed solution. Blame goes to the government, for funding, encouraging, and requiring that the work of doctors be computerized before the programs were ready for mass consumption. Subsequent blame comes to government also for requiring far too much certification by vendors which, they claim, inhibits innovation. If only this vendor protection were removed, the authors aver, Amazon and Apple and other consumer electronics companies would invade the medical space and bring it up to speed and down in price. In other words, deregulate. WSJ red meat.

But I have to say to these doctors and WSJ, not so fast, my friends. It's not so easy and it's not so simple. For one thing, consider if the medical field and the field of consumer electronics are really so compatible. Medicine is far more complex than the stereotypic tasks of ordering a household item, and the market is far more constricted. The big tech software companies make their money on volume, and there are a lot more ordinary people in the world than there are doctors. How much money would it take to really attract the A team? Is the profit possibility really there?

But that's not the major objection I have; maybe they would come in, maybe not. My major objection is that I think the source of the problem is deeper than it appears. The physician authors might want to think of their medical training. Sometimes a rash is pretty simple and can be cured with a simple cream. But sometimes that rash is the harbinger of a deeper disorder that needs far deeper intervention. I'm afraid that this is one of those more serious situations, where the symptom of the poorly functioning EHR emerges not only from clunky governmental functioning and their less than acute ministrations to the health care system, but also from the organizational structure and political-economic interests of those we call “stakeholders.” Thus, I would not be drinking the Journal deregulation Kool-Aid just yet.

Should the federal health officials and the other pezzonovante who make up the health care establishment have pressed the Obama Administration to include EHR funding in ARRA, taking advantage of a unique time when big time money would be available? Were EHRs shovel-ready? Probably yes, they should have, and no, the EHRs really weren't completely ready. If they hadn't taken the cash opportunity when it presented itself, how could the medical world be computerized? It would have taken a lot longer time, and the money to buy and install and maintain the EHR systems could only have been raised by the institutions that were already predominant. So, the government's getting into the game seems well founded to me.

But did the government, under the Office of the National Coordinator of Health IT (known as ONC) screw the pooch in their administration of the program? To me, unequivocally, yes. They went for micromanagement of what was “meaningful use” (MU) of the EHRs that the practices and institutions bought – making sure that they weren't ripped off, that the government got what it paid for, it seems. He who pays the piper calls the tune, and the ONC didn't want to be accused of a giveaway to industry, understandably. Understandable.

But what the ONC screwed up was in hitting the wrong notes. What they should have concentrated on was interoperability, not every little use modality that took so much effort to document, prone to such error and inconsistency. What they didn't understand was that interoperability is the key. They should have mandated that all EHRs be absolutely interoperable, and then let the smaller details take care of themselves. This was their cardinal sin. Was it a sin of ignorance or one of influence? Were they not sophisticated enough about the usual pathway of progress in free market systems, or were they influenced by the most powerful pezzonovante in the EHR world, and the world of medical institutions?

I can't answer that question because I don't know how the process went. But we do know that interoperability is technically quite feasible, and that lack thereof is a political rather than technical issue. And it's quite clear that the ONC decision to go easy on interoperability only reinforced the controlling forces in our health care system. I detailed in a blog post last November why this is so important, as I described how large organizations have essentially weaponized the EHR.


Seeking business dominance by patient and clinician capture, the large medical centers and enterprise level software manufacturers have essentially weaponized the EHR by keeping it private and unsharable. When patient information is available only within an EHR network, the patient is “nudged” to access only in-network providers and facilities. Likewise, the externally impenetrable EHR pressures clinicians to renounce their independence and join the network not only to defray EHR costs, but also to achieve “featured” status for referrals on the EHR as the networks “nudge” referrals inward, and to utilize data in treating patients that they would have only laborious access to otherwise.

Maintaining strong EHR boundaries for network commercial advantage is regrettable. If large networks are to achieve dominance, they should do so by lowering costs and raising quality, which has been difficult for them, rather than using the EHR as a cudgel. Closed networks and closed EHRs provide diminished incentives to improve efficiency and quality, as services need to be just “good enough” rather than truly excellent to attract captured patients. A closed system even presents an ethical problem, since the primary care provider, who is ethically bound as a medical fiduciary to seek the best and most efficient referral resource for the patient, is nudged by the system to respect instead the financial needs of the network.

The search for root cause leads us inexorably to the organizational structure of health care. Although you wouldn't know it from the density of the propaganda cloud emanating from the large corporate networks, there is a good argument that smaller, decentralized units strung together by modern communication capabilities would deliver better and cheaper care than the large networks. But fighting to remain dominant is typical of economic behavior in any society. That's what is going on now. For a 2,000 word explanation of this argument, see:


So, to return to the start and Mass and Fisher's capitulation to WSJ ideology, what would be the effect of deregulating EHRs? Unfortunately, deregulation would not lead to interoperability. Since interoperability would simply give ammunition to the competitors of the large integrated enterprises, it is likely that they will be content to keep their systems closed.

What is needed is not deregulation, but smarter regulation. A legitimate role of government in our mixed system is to regulate the marketplace so that competition occurs on a level playing field and benefits accrue to the public. Smart regulation would recognize Epic as a dominant platform and regulate it as such, much as the government regulated Microsoft, another dominant platform. If the government made interoperability mandatory, and if they were to require the EHR to display referral opportunities equally, the playing field for clinicians inside and outside the system would be more level. If they also mandated that Epic and other platforms be open to module substitution, EHR competition would be improved. For instance: in pediatrics we have some EHR programs that work fairly well for us because they are specifically designed for us. Other specialties have something similar. If these practices join a big network to help them gain access to referrals, they must give up their more functional module and accept the more generic and inferior Epic module. If plug-in capability were required of the platform, all the EHRs would be subject to competitive pressure and would improve. It is even possible that Amazon, Apple and other A-list companies would enter the field.

That's it in a nutshell. For a more discursive treatment, check this out also, my best effort to describe the organizational structure dilemma facing our system:

But for the smallest nutshell at all, here is the letter I wrote into the WSJ and, mirabile dictu, they published it.

Budd Shenkin