Power outages foil criminal behavior

As we head into the weekend following a week of snow and power outages, it is diverting to consider the latest "stupid crook" story, this one from Silver Spring, MD. The essence:

As the burglar was rifling through the rooms in that house, the homeowner's son arrived and startled him. The burglar jumped out a window and fled. The son called police, who searched the house. They were stunned at what was found: a cellphone, charging in an electric socket, that didn't belong to the homeowner. The phone led police to Cody Wilkins, who is now charged in 10 burglaries. Police say that Wilkins's home lost power in the storm and that he needed a place - anyplace, it seems - to charge his phone. In his haste to flee, he left it charging.

Blurred boundaries between news and opinion

Is this happening with your home town newspaper? It used to be that there was a separation of news and opinion columns. I am not saying that editorial and personal biases were ever missing from news stories; but I am saying that columns containing opinions were clearly labeled as "opinion." That seems to be gone now. We are presented with news stories that subtly present the reporter's opinion as part of the news.

Here is an example from today's New York Times and Boston Globe (the same story by Anthony Shadid):

The Egyptian government broadened its crackdown of a 10-day uprising that has shaken its rule yesterday, arresting journalists and human rights advocates across an edgy city, while offering more concessions in a bid to win support from a population growing more frustrated with a devastated economy and scenes of chaos in the streets. (This part is news.)

The campaign was a startling blend of the oldest tactics of an authoritarian government — stoking fears of foreigners — with the air of sincerity of a repentant order. (This part is opinion.)

And another from the Globe:

US Representative Barney Frank announced yesterday that he plans to seek another term, increasing the possibility of a battle — the first in 30 years — between two sitting Massachusetts congressmen over a single congressional district. (News.)

Frank, 70, an irascible (opinion), liberal (news) Newton Democrat....

I am not saying either opinion is wrong. (I don't know Mubarak, but the characterization of Barney is dramatically understated.) What I am saying is that you would expect the newspapers of record to be better about separating reporting from opinion on their front pages. In my view, the story should tell the story, leaving readers to form their own opinions. Opinions should be clearly set forth in stories labeled as opinion or analysis, whether on the front page, the editorial page, or the op-ed page.

How to get into Chuck E. Cheese when you are middle aged

For those of you not familiar with Groupon, it is an internet-based discount coupon service, targeted for individual cities throughout the country. An offer is sent out, and if enough people sign up for it, the discount is awarded. Groupon is known for its humorous descriptions of the service or commodity being offered.

Today's Boston offer has the most clever description I have seen. Will 20 people snow-struck people who have spent weeks trapped in their homes looking in the mirror sign up? Health care experts advise me that this most assuredly is not covered under the Blue Cross Blue Shield global payment plan! Here goes:

Med-Spa Treatment from Boston Plastic Surgery Associates in Concord. Three Options Available.

Maintaining a youthful visage helps get you into hip nightclubs, such as Chuck E. Cheese's, where sentient mice dance wildly in rooms entirely filled with balls. Live it up at the club with today's Groupon to Boston Plastic Surgery Associates in Concord. Choose from the following options:

• $175 for 50 units of Dysport (a $300 value)
• $129 for three laser hair-removal treatments (up to an $800 value)
• $129 for a photofacial skin-rejuvenation intense-pulsed-light treatment (a $450 value)

Dr. Brooke Seckel of Boston Plastic Surgery Associates is a medical Ponce de Leon, immersed in a perpetual quest for age-defying noninvasive and nonsurgical therapies to keep his patients budding and boisterous. The photofacial rejuvenation treatment gives hardened mugs a science-fiction makeover via beams of intense pulsed light, thought to gently remove pigment, brown spots, blood vessels, and shrink enlarged pores. Worry lines are whisked away with Dysport injections, which are similar to Botox injections, smoothing out the area between the brows for clean lightning-bolt-scar application. Patients can also punish their naughty shampoo-stealing pelts with three laser hair-removal treatments on either the lips, chin, sideburns, front of neck, back of neck, underarms, feet, hands, or ears (a $500–$800 value per area for three treatments). All prospective baby faces need to call ahead for an appointment.

Shaw got it right

George Bernard Shaw wrote The Doctor's Dilemma, Preface on Doctors in 1909. It is fun to read some excerpts:

It is not the fault of our doctors that the medical service of the community, as at present provided for, is a murderous absurdity. That any sane nation, having observed that you could provide for the supply of bread by giving bakers a pecuniary interest in baking for you, should go on to give a surgeon a pecuniary interest in cutting off your leg, is enough to make one despair of political humanity. But that is precisely what we have done. And the more appalling the mutilation, the more the mutilator is paid. He who corrects the ingrowing toe-nail receives a few shillings: he who cuts your inside out receives hundreds of guineas, except when he does it to a poor person for practice.

Scandalized voices murmur that these operations are necessary. They may be. It may also be necessary to hang a man or pull down a house. But we take good care not to make the hangman and the housebreaker the judges of that. If we did, no man's neck would be safe and no man's house stable. But we do make the doctor the judge... I cannot knock my shins severely without forcing on some surgeon the difficult question, "Could I not make a better use of a pocketful of guineas than this man is making of his leg? Could he not write as well—or even better—on one leg than on two?"

Why doctors do not differ

The truth is, there would never be any public agreement among doctors if they did not agree to agree on the main point of the doctor being always in the right. Yet the two guinea man never thinks that the five shilling man is right: if he did, he would be understood as confessing to an overcharge of one pound seventeen shillings; and on the same ground the five shilling man cannot encourage the notion that the owner of the sixpenny surgery round the corner is quite up to his mark. Thus even the layman has to be taught that infallibility is not quite infallible, because there are two qualities of it to be had at two prices.

But there is no agreement even in the same rank at the same price. During the first great epidemic of influenza towards the end of the nineteenth century a London evening paper sent round a journalist-patient to all the great consultants of that day, and published their advice and prescriptions; a proceeding passionately denounced by the medical papers as a breach of confidence of these eminent physicians. The case was the same; but the prescriptions were different, and so was the advice.

Now a doctor cannot think his own treatment right and at the same time think his colleague right in prescribing a different treatment when the patient is the same. Anyone who has ever known doctors well enough to hear medical shop talked without reserve knows that they are full of stories about each other's blunders and errors, and that the theory of their omniscience and omnipotence no more holds good among themselves than it did with Moliere and Napoleon.

But for this very reason no doctor dare accuse another of malpractice. He is not sure enough of his own opinion to ruin another man by it. He knows that if such conduct were tolerated in his profession no doctor's livelihood or reputation would be worth a year's purchase. I do not blame him: I would do the same myself.

But the effect of this state of things is to make the medical profession a conspiracy to hide its own shortcomings. No doubt the same may be said of all professions. They are all conspiracies against the laity; and I do not suggest that the medical conspiracy is either better or worse than the military conspiracy, the legal conspiracy, the sacerdotal conspiracy, the pedagogic conspiracy, the royal and aristocratic conspiracy, the literary and artistic conspiracy, and the innumerable industrial, commercial, and financial conspiracies, from the trade unions to the great exchanges, which make up the huge conflict which we call society. But it is less suspected.

Statistical Illusions

Public ignorance of the laws of evidence and of statistics can hardly be exaggerated. There may be a doctor here and there who in dealing with the statistics of disease has taken at least the first step towards sanity by grasping the fact that as an attack of even the commonest disease is an exceptional event, apparently over-whelming statistical evidence in favor of any prophylactic can be produced by persuading the public that everybody caught the disease formerly.

Thus if a disease is one which normally attacks fifteen per cent of the population, and if the effect of a prophylactic is actually to increase the proportion to twenty per cent, the publication of this figure of twenty per cent will convince the public that the prophylactic has reduced the percentage by eighty per cent instead of increasing it by five, because the public, left to itself and to the old gentlemen who are always ready to remember, on every possible subject, that things used to be much worse than they are now ... will assume that the former percentage was about 100.

Flame throwers would work nicely

Now, why didn't I think of this, instead of suggesting that we throw the snow in the Harbor?

Sixty three years ago Boston received so much snow that then Mayor James Curley took a look at it and began pleading with then MIT President Dr. Karl Compton for help. “I am very desirous that [MIT] have a competent group of engineers make an immediate study as to ways and means of removing the huge accumulation,” he wrote, “…be it by the use of flame throwers or chemicals or otherwise.”

Courtesy of the MIT Alumni Association.

Our patients are sicker

What more do we need to know? The British Medical Journal published a study showing that Peter Pronovost's program to reduce central line infections in Michigan saved lives.

A new study finds that a safety checklist program developed by a Johns Hopkins doctor has reduced patient deaths in Michigan hospitals by 10 percent, in addition to nearly eliminating bloodstream infections in health care facilities that embraced the prevention effort.

The research, published in the British Medical Journal, is the first to show a drop in patient mortality in hospitals using the Hopkins program. Previous studies have found major reductions in bloodstream infections from using the checklist when inserting catheters or central lines to give patients medication, fluids or nourishment.

Well, duh. But I guess it is important to have scientific verification. But I can almost hear the comments from some places: "That wouldn't work here. Our patients are sicker."

So, how long will it take for this approach to be used across the country? This study is based on work from nine years ago. If this is like other innovations in medical care, it will take a decade and a half more to spread.

Here's my proposal to jump-start it. Publish the monthly rate of central line infections for all hospitals on a public website. CMS, IHI, the Dartmouth Atlas group or some other organization could do this in a nano-second, creating a voluntary website, giving each hospital a password through which it could enter its own data. There is no need to audit the figures. We can trust people to be honest.

And, at the bottom of the website, the host could list the hospitals that have chosen NOT to publish.

Then, you would see the power of transparency.

Lessons from Cairo

I think most of us would be hard-pressed not to be inspired by the moral power of the crowds in people in Egypt as they throw off a form of government that they find repressive. But, it is about the US reaction to all this to which I turn today. It is the subject of New York Times columns by David Brooks and Nicholas D. Kristof.

Both authors noted the ham-handed manner in which the United States deals with authoritarian regimes and with popular movements for freedom.

Brooks notes,

The . . . thing we’ve learned is that the United States usually gets everything wrong.

Policy makers always underestimate the power of the bottom-up quest for dignity, so they are slow to understand what is happening.

Then their instinct is to comfort the fellow members of the club of those in power.

Then, desperately recalibrating in an effort to keep up with events, they inevitably make a series of subtle distinctions no one else heeds.

Kristof says,

Yet one thing nags at me. These pro-democracy protesters say overwhelmingly that America is on the side of President Mubarak and not with them. They feel that way partly because American policy statements seem so nervous, so carefully calculated.

The upshot is that this pro-democracy movement, full of courage and idealism and speaking the language of 1776, wasn’t inspired by us. No, the Egyptians said they feel inspired by Tunisia — and a bit stymied by America.

Everywhere I go, Egyptians insist to me that Americans shouldn’t perceive their movement as a threat. And I find it sad that Egyptians are lecturing Americans on the virtues of democracy.

Brooks provided a broader context for all of this:

I wonder if sometime around 50 years ago a great mental tide began to sweep across the world. Before the tide, people saw themselves in certain fixed places in the social order. They accepted opinions from trusted authorities.

As the tide swept through, they began to see themselves differently. They felt they should express their own views, and these views deserved respect. They mentally bumped themselves up to first class and had a different set of expectations of how they should be treated. Treatment that had once seemed normal now felt like an insult. They began to march for responsive government and democracy.

You will excuse me if I draw the connection to health care. I hope you don't think it inapposite.

I do not think that it has been a fifty year trend in health care, but a more recent one. Patients and families have decided that they should be equal partners in the process of diagnosis and treatment. They believe that they have a right to the information that can represent life or death, health or suffering. As Brooks would put it, "treatment that once seemed normal now feels like a insult." Opinions from trusted authorities no longer carry the weight they used to. Questions are being asked. Answers are being demanded.

A few weeks ago, author Charles Kenney asked the question, Isn't there a compelling -- perhaps even overriding -- moral component to transparency?

I responded,

The answer, of course, is yes. Doctors and others pledge to do no harm. How can you be sure you are living by that oath if you are unwilling to acknowledge how well you are actually doing the job? As scientists, how can you test to see if you are making improvements in evidence-based care if you cannot validate the "prior" against which you are testing a new hypothesis? At the most personal, ethical level, how can you be sure you are doing the best for people who have entrusted their lives to you if you are not willing to be open on these matters?

But transparency threatens the status quo. In the medical world, status quo confers power, influence, prestige, and money on those who have had a reputational advantage. A close friend and colleague put it this way:

Transparency in self-interested institutions who are making fortunes by deluding themselves and the public that they and only they know what the community wants and needs is a very dangerous concept.

The agents of change in this battle will be the same people who are turning things over in Egypt. Normal people who have experienced pain and suffering, or even just disrespect, in the health care system are starting to find their voice. Like the US in the international arena, the powers that be in the government and their agents, having been captured by the powerful forces of the medical and hospital profession, are slow to react and are protective of the status quo.

Policy makers always underestimate the power of the bottom-up quest for dignity, so they are slow to understand what is happening.

Then their instinct is to comfort the fellow members of the club of those in power.

Then, desperately recalibrating in an effort to keep up with events, they inevitably make a series of subtle distinctions no one else heeds.