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.
https://www.sfchronicle.com/opinion/editorials/article/Editorial-BART-housing-bill-exposes-lots-of-12955524.php
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

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 19^th 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.

Wowsers!

Budd Shenkin

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 May 2018

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.

Exhibit

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.

Exhibit

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

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 9^th 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

EHR - Smart Regulate, Don't Deregulate

https://www.wsj.com/articles/why-your-doctors-computer-is-so-clunky-1521585062

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.

http://buddshenkin.blogspot.com/2017/11/weaponizing-ehr.html

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:

http://buddshenkin.blogspot.com/2017/06/policy-for-emerging-organizational.html

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:

http://buddshenkin.blogspot.com/2015/11/emr-interoperability-and-organization.html

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

Budd Shenkin

What Is The Place Of Doctors In Medical Care?

There's a lot of loose talk in medicine, a lot of loose talk by people who don't know what they are talking about, by people who are casually referred to as “thought leaders.” They say that the days of doctor dominance are over, that teams are the important thing, that doctors need to recognize how replaceable they are by algorithms and technicians, such as Advanced Practice Nurses, who are pushing legislatures all over the country to be able to practice independently. After all, they are professionals, too, and how much anatomy and pathophysiology and clinical training and wide knowledge and candidate selectivity do you really need? How much do you use in the day to day? And how smart do you really have to be?

They say, look at the quality statistics, and who does better, a doctor or an APN, a private practice or a Retail Based Clinic? They look at “consumer acceptance,” and they say, doctors aren't nearly as necessary as they think they are, because “public opinion” seems to indicate as such. Doctors, they say, are simply protecting their turf to the detriment of the public, and to the detriment of those alternative “providers.”

As my college roommate from Caribou, Maine, used to say: “bull-diggy.” Just, bull-diggy. You can always build a cheaper mousetrap, it's true, but it's just as true that you can always sacrifice quality for price, that there is always someone who will work cheaper and provide worse, and therein lies the rub. Sit atop the policy pyramid and all you can do is rely on statistics, no matter how misleading they may be. You watch the quality indicators and you think you are seeing something real, because if you are not a careful observer with a clinical background, you won't detect that “did you run a strep test before you treated with antibiotics?” doesn't mean that the strep test was positive, it just means did you run the test. It doesn't indicate if you did run the strep test (or, rather, that you charged for running one) and then decided to ignore a negative result and tell the patient, “Well, the strep test doesn't pick up some real strep infections that don't test positive, so we're giving you an antibiotic.” Such bull-diggy.

If the policy “thought leaders” ventured forth and looked at reality, they might get another picture. I wonder if they have doctors of their own, personally, or if they consult APNs and algorithms and the internet and their local RBC staffed by an APN with no backup. It reminds me of the 1960's in Washington, DC, when all the liberals (my friends, including George Silver and Phil Lee) were pushing “pre-paid health care,” and large group practices, before they were labelled as “HMOs” by Paul Ellwood and the Nixon Administration and thus became adopted by the corporate community. At that time there was an internist in Washington named Michael Halberstam, the brother of the soon to be famous journalist David Halberstam. These liberal DC docs, the cognoscenti pushing prepaid group practice, used Halberstam as their PCP (another term yet to be invented.) He was a wonderful guy and a wonderful doctor and he wrote a wonderful article in the New England Journal that really pissed me off, because I had had those same thoughts and he beat me to it, although I could never have reached his level of argument and eloquence.ⁱ But the point I'm making is this: Halberstam asked these elite patients, if you guys are pushing this prepaid group idea, and we have such a group right here in Washington, how come you are all visiting me, a solo practitioner?

Exactly. They knew what the best really was. Not that they were hypocrites, because they weren't. It's perfectly possible that for the average patient, given the burden of a large population, and given the average abilities of doctors, and given the disorganized nature of medical care, on average, for the average person, putting your health care in the hands of a prepaid group might have made the most sense, on average. Everybody can't be special. But, if you are an insider, and you really can evaluate good health care because you yourself are a professional in the field, then seeing the best of the best might trump the best of the average. So, it's a complicated proposition, this choice of to whom you entrust your health care.

An Example

Let me show you an example of what someone entrusted with your health care faces. This is not in some fancy place, the Peter Bent Brigham Hospital and Partners Healthcare, for instance, whence cometh many a prescription for health care improvement, and ever increasing size of the group. This comes from averageville, where the institutions are what they are on average in America. But in this case, not with an average PCP, but one who is Halberstamesque, the redoubtable Suzanne K. Berman of Plateau Pediatrics in Crossville, Tennessee, a distinguished member of SOAPM, the most distinguished unit of the American Academy of Pediatrics that concerns itself with actual practice, and a gifted writer. Here is what she contended with the other day:

A 24 day old baby has a fever and is feeding poorly, so the mother takes her to the ER. A fever in a neonate is very concerning, and in this case especially so, because the mother had a Group B Strep positive culture pre-delivery, and was not treated for it in the hospital, which constitutes a strong risk factor for serious infection in the baby. Any competent ER doc should know this is a life-threatening emergency, do the cultures and a spinal tap and admit the child for iv antibiotics. But this doctor and this ER just does some blood work and sends the patient home. This is pure and simple malpractice, but truth to tell, it happens. In fact, Suzanne says that it happened just this same way for another patient at the same ER a few weeks before. The next morning the mother visits her PCP, who is Suzanne:

“Baby comes back to our office for f/u. We do the spinal tap on the baby in our office, do a catheterized urine culture, give antibiotics and ship baby to children’s hospital.  Baby arrives safely, stable.

1.5 hours later, after cerebral spinal fluid has been hand-delivered by our medical assistant to the lab, and after arrival and tucking in of baby at children’s hospital, CSF results still not reported.

Why, do you ask? Because:

1. The lab can’t run the specimen until there’s an order in the computer in the patient’s name to process the specimen, and

2. There’s no order in the computer to run the specimen, because

3. Registration “can’t” put the baby in, because we say that baby’s name is “Maria Ochoa” and their records show that the baby’s name is “Maria Fernandez.”

4. And, WAIT FOR IT:  lab can’t enter results on Maria Fernandez when the CSF tubes are labeled Maria Ochoa.

5. Supervisors leave at 3:30 pm on Friday 'evenings.'”

Holy, holy cow! Make no mistake, this is a question of life or death. If the baby hadn't come to see Suzanne, it could have been curtains, easily, very easily. And here is the lab dicking around with a crucial test that would determine whether or not it was a case of meningitis, and if the proper antibiotics were being used.

OK, all you fancy pants health care policy analysts. Do you still object to the picture of the pediatrician in charge, or would you want a comprehensive team with APN's in charge, or trust in the bureaucracy of the lab which seems caught in its own downward spiral, or the ER that persists in pediatric malpractice?

I remember my own experience when I was Chief of Pediatrics at Summit Medical Center in Oakland, and we were confronted with poor pediatric practice – not to this extent, but clearly poor – in the ER. I informed the Chief of the ER of the poor practice, and instead of his receiving our help to improve their performance, he successfully moved to ban our ability to review pediatric charts in his department. Amazing, but true, so I don't disbelieve Suzanne's account of her ER for a single moment, not one.

Observations

There are a number of observations that flow from this scenario applicable to current health policy issues. Let's let them fly.

One, as they say in the seminal text of Ghostbusters, “Who You Gonna Call?” Are you going to your local prepaid medical care group, or are you going to Michael Halberstam? Are you going to trust in the standard operating procedures of a bureaucratic operation, or do you want your Lone Ranger? And is your Lone Ranger going to be a doctor, or a nurse, or a technician of some sort, or maybe some algorithm and computer? Call me an elitist – go on, do it! – and I'll agree with you. I am. I have always aspired to be outstanding, and I want to trust my care to someone who has done the same. I want to have someone who knows what he or she is doing, in depth, and someone who will move a bureaucracy even when it's his or her time for lunch or time off, because he or she cares as a professional should care. I want someone, male or female, with balls. I want someone who has progressed through a rigorous training program not just for the knowledge garnered thereby, but who knows what it means to insist upon high performance from oneself and from others. Which, if you think about it, is a major function of education at any level.

Corporatists may disagree. They might say that with care, bureaucracies can be perfected, that organizations can learn, that not everyone can be outstanding, that care for the average person is best entrusted to a system, and that system engineering is really the key to high performance. To which I reply, this is not either/or. The best clinicians function best within high performing systems, and it is crucial for them to have such systems, because otherwise their functioning is compromised and in fighting the endless fight they will burn out. But for a system to be genuinely high-performing, the clinicians themselves need to have had a strong voice and a strong hand in creating it. A counter case in point would be Electronic Medical Records, those systems designed to decrease clinician productivity by transforming health care provision into data entry activity. The health care system accepts what Boeing would never tolerate, or rather what the pilots and airline companies would never tolerate from Boeing.

Are corporations and high performing individuals incompatible? Sometimes. Within corporations, something there is that doesn't love an individualist, and for their part high-performing individuals need to give unto routine procedures and other “providers” that which is routine, and to reserve for unique treatment that which demands uniqueness. A corporation has difficulty with the individual who knows what is right for the individual patient. Within a corporation, if you know what the individual needs, you often have to “fight for it.” “Fight for it?” Fight for the lab test result here and now, despite the lab techs being rigid and the supervisor taking off early? You have to “fight for it?” What kind of SOP is that? And yet, I bet you can't find me a practicing doctor who hasn't had to fight to get a lab test, or an imaging study, or a specialist report, or to find the crucial element of an ER visit in 200 pages of boiler plate in an EMR report. Is the Lone Ranger doctor dead? Well, if you want excellence, he or she better not be, because you show me any system, and I'll show you elements that need to be fought. The bigger you get, the less control you have.

And yet, large size is what is happening. Large size is not only accepted, but lauded “because coordination is easier in larger vertically integrated companies.” Merge CVS and Aetna and expect improved services say the corporate apologists. http://www.nejm.org/doi/full/10.1056/NEJMp1717137. Right, vertical integration for improved services. "We can coordinate better when we're all under one roof." Not! Vertical integration is pursued in the great majority of cases to further market dominance rather than improve service or reduce price. Larger units provide larger lacunae. See the brilliant relevant essay: http://buddshenkin.blogspot.com/2017/06/policy-for-emerging-organizational.html.

Size is an impediment to productivity and responsiveness. In general, the farther away anyone is from the actual patient, the more the work is impersonal, and the less actual caring goes into actions. This is "off my plate" syndrome. Labs don't see patients. Administrators don't see patients. Neither techs nor administrators have to look a patient in the eye and say, I'm doing everything possible for your welfare, not my own personal agenda. Neither needs to lie outright when they favor their own interests or indulge their own laziness over the welfare of patients. “This is the way we do things” reigns in large organizations. Large organizations spawn more and more personnel not personally responsible to the patient.

And yet, it is not right, obviously, to lionize doctors excessively. After all, for all the Suzanne's who put the patient first and know what they are doing, there are all the others who persistently do the wrong thing in the ER, who are mal-trained and underperforming and self-indulgent and who resist improvement. It is the clinician's responsibility to make a diagnosis, and the Institute of Medicine estimates that more than 10% of the time, clinicians have have made an incorrect diagnosis on a patient, and what could be more important than a correct diagnosis? (And for those of you with faith in how we evaluate quality, please note that there is no attention paid in quality measurement to correct vs. incorrect diagnosis. What could be a more serious indictment of the present state of quality assessment than that?).

But, even given that serious caveat of the fallibility of doctors, it is still important to contrast the eons-old ethical burden of the physician with the ethical burden assumed by less qualified personnel (techs) and by administrators. Given the state of business ethics he observed, Arnold Relman, late editor of the New England Journal, concluded that all medical organizations should be run by doctors, and that all such organizations should be non-profit. Although he cast this as a serious proposal, I view his prescription as more a cri du coeur than something practical. But it is hard not to believe that as organizations get larger and dominated by non-practicing personnel, the ethical responsibility gets very diluted. Who is going to be more upset by lab intransigence, the hospital administrator or Suzanne?

Size and leadership inevitably play a part. If Suzanne were running the show at the lab, if it answered to highly motivated doctors, would the do-si-do of this patients specimen happen? When I had a Kaiser option with my health insurance years ago I thought I would scout the opposition and get a checkup there. The receptionist was nice and the doctor was nice. The scowling medical assistant, however, wore a badge that didn't say “Kaiser Permanente” but rather “SEIU,” and when my appointment ended during her lunch time, it was my doctor who had to go out to the station and do the MA's job herself. Is this really where we want to go, big and bureaucratic organizations, with less and less control on average for the patient and the PCP who takes care of that patient?

We can discuss quality of care all we want, but the individual doctor taking care of the individual patient is where the rubber hits the road. I severely doubt the capacity of ordinary measurements to comprehend the reality of these encounters in any organization. Anecdotal they may be, but the stories we hear from docs and patients are probably as close as we will be able to get to understanding what is going on. As of now, it seems to me that the most important variable in a patient's care would be, how good is your doctor, and secondarily, how well does the system support him or her? And if that is the case, what we should emphatically not be doing is figuring out how to supplant the doctor with less-trained personnel,ⁱⁱ and we should not be building ever larger units where poor quality and patient unresponsiveness can hide out.

Cowboy on a white horse? Maybe not a good idea. Team leader? Maybe a better idea. Large units with lesser-trained personnel or independent lesser-trained personnel? Doesn't sound like progress to me.

The independent opinion, advocacy, and concern of a highly-trained physician backed by a system that enhances his or her capacity to act intelligently should be the goal. Defining medical deviancy downward to save costs and preserve large organization preponderance isn't something doctors signed up for, and America shouldn't either.

Budd Shenkin

iHalberstam MJ, Liberal thought, radical theory, and medical practice.  N Engl J Med 1971; 284:1180-1185.

iihttps://www.mercatus.org/publications/us-health-provider-workforce

What's The Matter With Parents Today?

Discussing the Florida gun outrage, from my pediatrician friend Glenn Schlundt in Pasadena, in a post to the SOAPM listserve:

In my area, the children, and the parents, are so different now than they were even 10 years ago. So many parents are adult children themselves. Many of them - even those in their 30's - have the coping skills I associate with teen parents. In some cases, it is due to exhaustion from working full time and then coming home to a child that has been left to fend for itself in a daycare setting, and who understandably has more needs than its predecessor twenty years ago. Some of it is from an apparent inability to see what their child needs, and - fundamentally - to set limits in a calm, warm, consistent manner. So many young parents in my practice react with frustration when their child seeks limits, and then are mystified when their child gets anxious.

In our area, the cost of living has exploded. I can't even use the word "soared," as it would be inaccurate. Growing up, homes in my neighborhood went for ~$25,000. This would have been about 1970. Those homes now have bidding wars and sell over the $1.2 million. The public school system is legendarily awful, so those who can send their kids to private school. The average tuition for kindergarten (yup, you read that right) is $25,000.00. High schools are in the $50,000 per year range. Those who can't get their kids in (there are not enough spaces), end up moving to a more expensive neighboring city.

Working parents are drowning. The kids get less time with their parents now than they ever did. Some of them are simply orphans with a bedroom.

The amount of time and energy I spend counseling parents and teaching basic Skinnerian behavior modification, discussing tenets of Bowlby, referring to Jack Shonkoff's website, and helping parents with concepts like their child's magical thinking and regression in the service of the ego has also skyrocketed. The part that is often most difficult is that many of these parents cannot listen until they have been given a chance to talk, and there are not that many hours in the day. When they come back, everyone is often sad to find that their carrier now does not cover any F codes, so they get stuck with their bill, so there is more frustration. Every psychiatrist in our area is $650 per hour. None that I know of worth seeing takes insurance, and they all have wait lists.

What does this have to do with gun violence? I think it has a lot to do with it, and with road rage, and a lot of other things to which those of us in L.A. have long since become inured.

What to do about it?  Rearranging priorities and making time to listen to people, establishing and enforcing rules,  realizing that too much permissiveness, either individually or societally, can makes people of all ages feel as unsafe as easy access to weapons does. 

That would be a wonderful start.

Glenn Schlundt, MD

Rose City Pediatrics

Pasadena, CA

Pediatricians have an advantageous viewpoint; we see the soil from which outrages stem. Tension and anxiety, arising from economic stress, have always been linked to suicide rates. Given a militaristic culture – note how all the ballgames feature military themes with flags along with the national anthem, which is itself military, no “O Canada!” or “Sveriges nationalsång” (Sweden) for us – and gun access, aggression on others replaces aggression upon self. Poor educational institutions arise from poor funding and poor educational training institutions and dead end bureaucracy, and not enough attention to emotional needs. In our area in Alameda county in the lower grades there is a student/teacher ratio of 31:1, and no aides. Unconscionable and just stupid, really. So, this is what pediatricians like Glenn see in the offices.

Social policy and individual psychopathology are linked, and it's not just gun control, although that's involved, surely. Yes, the Right is right, personal psychopathology is important and should be attended to. I have yet to see, however, any Right proposals to do just that, which means money and mouth aren't meeting.

Myself, I see it as an infrastructure problem. “Infrastructure” isn't just asphalt, bricks and bridges; human infrastructure, human capital is the more important infrastructure in the modern world. Paying more for education and social support, more social capital investment, more true long term investment instead of eating the seed corn, less investment in luxury and military. Ojala!

Oh, yes, and more money for patients to visit people like Glenn down in the trenches. Pediatrics is more important than people know.

Budd Shenkin