When I make a mistake, I admit it. Turns out the photo I featured recently was photoshopped. Above is the orginal.
Tuesday, May 31, 2011
Here is a very meaty speech, given to the graduating class of Harvard Medical School by Atul Gawande who, like me, is a brilliant surgeon also known for his ability to write.... (yeah, yeah, yeah, I know. I know. Academic surgeons aren't all that brilliant in the OR.)
...Medical performance tends to follow a bell curve, with a wide gap between the best and the worst results for a given condition, depending on where people go for care. The costs follow a bell curve, as well, varying for similar patients by thirty to fifty per cent. But the interesting thing is: the curves do not match. The places that get the best results are not the most expensive places. Indeed, many are among the least expensive. This means there is hope—for if the best results required the highest costs, then rationing care would be the only choice. Instead, however, we can look to the top performers—the positive deviants—to understand how to provide what society most needs: better care at lower cost. And the pattern seems to be that the places that function most like a system are most successful.
Unstained by cynicism such as mine, he tells a story:
Not long ago, I had an experience at our local school that brought home the stakes. I’d gone for a meeting with my children’s teachers, and I ran into the superintendent of schools. I told him how worried I was to see my kids’ art classes cut and their class sizes rise to almost thirty children in some cases. What was he working on to improve matters? I asked.
“You know what I spend my time working on?” he said. “Health-care costs.” Teachers’ health-benefit expenses were up nine per cent, city tax revenues were flat, and school enrollment was up. A small percentage of teachers with serious illnesses accounted for the majority of the costs, and the only option he’d found was to cut their benefits.
... That’s when it struck me. I was part of the reason my children didn’t have enough teachers. We all are in medicine. Reports show that every dollar added to school budgets over the past decade for smaller class sizes and better teacher pay was diverted to covering rising health-care costs.
This is not inevitable. I do not believe society should be forced to choose between whether our children get a great education or their teachers get great medical care. But only we can create the local medical systems that make both possible. You who graduate today will join these systems as they are born, propel them, work on the policies that accelerate them, and create the innovations they need. Making systems work in health care—shifting from corralling cowboys to producing pit crews—is the great task of your and my generation of clinicians and scientists.
I'm glad there are guys like Gawande around, with the insights and the energy to pursue the near-impossible. Without such people, changing the system is unimaginable; during my time in practice, my personal solution was just to work as hard as I could to deliver the best care I could to the most people I could for as long as I could. I dropped off committees, resigned from boards, kept my head down and plodded through the oncoming tide until, certain there was no way to get anyone to listen, I couldn't do it any more.
So take my dim view as probably less important than that of Gawande, who's still in it, and seems to be influential. But unless the Republican party returns to its days of thoughtfulness and seriousness, which pretty much ended with the arrival on the scene of Ronald Reagan; until they put aside indulging their basest instincts and stoking ours, leaving Sarah Palin and Michelle Bachmann and Mitch McConnell and Glenn Beck and Fox "news" and the RWS™ and the rest of their shallow, hate-as-policy, recyclers of failed ideas in the ditch where they belong, he's just whistling in the dark.
Monday, May 30, 2011
I watched 60 Minutes last night, a show honoring our troops. Featuring the young man who recently was awarded the Congressional Medal of Honor, it showed him to be humble, amazingly thoughtful and well-spoken (he joined the military at age 17). To me, his heroism is only slightly about what he did. The show can be watched here.
Sunday, May 29, 2011
Saturday, May 28, 2011
A writer -- one who carries more weight than I do -- writes:
What's the matter with an em dash or two, you ask?—or so I like to imagine. What's not to like about a sentence that explores in full all the punctuational options—sometimes a dash, sometimes an ellipsis, sometimes a nice semicolon at just the right moment—in order to seem more complex and syntactically interesting, to reach its full potential? Doesn't a dash—if done right—let the writer maintain an elegant, sinewy flow to her sentences?
Nope—or that's my take, anyway. Now, I'm the first to admit—before you Google and shame me with a thousand examples in the comments—that I'm no saint when it comes to the em dash. ...
The problem with the dash—as you may have noticed!—is that it discourages truly efficient writing. It also—and this might be its worst sin—disrupts the flow of a sentence. Don't you find it annoying—and you can tell me if you do, I won't be hurt—when a writer inserts a thought into the midst of another one that's not yet complete? ...
To some blog posts I devote a fair amount -- by which I mean I delay posting, re-read, edit -- of time and effort. Others -- this being one -- are sort of tossed out there like the pine cones I pick off my lawn and backhand over the bluff. This may not be an excuse -- although I'd hope it was -- but it's an explanation. Or is it the other way around? The main thing is -- and I've thought about it before -- is that me and em are a little too cozy sometimes -- and I admit it.
Friday, May 27, 2011
(Click image for larger view.)
This opinion piece in the NYT makes a compelling case for the role of medical effectiveness research. To me, the need is obvious. Maybe, in fact, it's obvious to everyone on some level. But that's not the question.
After discussing the factors at play (other examples of procedures were given, too) the author, a professor of cardiology, concludes:
Medicare spends a fortune each year on procedures that have no proven benefit and should not be covered. Examples abound:
• Medicare pays for routine screening colonoscopies in patients over 75 even though the United States Preventive Services Task Force, an independent panel of experts financed by the Department of Health and Human Services, advises against them ....
• Two recent randomized trials found that patients receiving two popular procedures for vertebral fractures, kyphoplasty and vertebroplasty, experienced no more relief than those receiving a sham procedure. .... Nevertheless, Medicare pays for 100,000 of these procedures a year, at a cost of around $1 billion.
• A recent study found that one-fifth of all implantable cardiac defibrillators were placed in patients who, according to clinical guidelines, will not benefit from them. But Medicare pays for them anyway, at a cost of $50,000 to $100,000 per device implantation. (note from your blogger: I wrote about this some time ago.)
The full extent of Medicare payments for procedures with no known benefit needs to be quantified. But the estimates are substantial. ... $75 billion to $150 billion could be cut without reducing needed services...
Changing the system would be relatively easy administratively, but would require a firm commitment to determining whether tests and procedures truly benefit patients before performing them. Unfortunately, in a political environment in which doctors providing end-of-life counseling are called death panels, and in which powerful constituencies seek to preserve an ever-increasing array of procedures and device sales, this solution remains hidden in plain view. (My emphasis.)
Of course, doctors, with the consent of their patients, should be free to provide whatever care they agree is appropriate. But when the procedure arising from that judgment, however well intentioned, is not supported by evidence, the nation’s taxpayers should have no obligation to pay for it.
(Some time ago I proposed that if people insist on having procedures that have virtually no chance of helping, they should agree in advance to bear the full costs if it doesn't, as predicted, work. The payor (Medicare) would pick up the tab if odds were defied and there was benefit. I was being only partly facetious. Anyhow, I can't find the post at the moment. But it's my solution to the "no obligation to pay for it" issue.)
Thursday, May 26, 2011
This morning I wrote: it was Republican ideas, Republican policies that got us where we are. As is the case with even my most partisan rants, I'm not just pulling ideas out of my... head. There are data.
The Center on Budget and Policy Priorities has updated and refined a widely cited chart, laying out the origins of the country's current fiscal trajectory. And as before, the lion's share of the problem comes from ongoing George W. Bush-era policies -- particularly deficit-financed tax cuts, which eliminated Clinton-era surpluses and left the Treasury poised for a huge hit when the financial crisis and economic downturn further eroded federal revenues.
The conventionally wise say the special election in New York, wherein a Democrat has just won in a strongly Republican congressional district, was a referendum on the Ryan budget, on to which every Congressional R originally signed (and from which many are backing away like a kid who just witnessed a parental primal scene). I don't know enough about the district in question to argue one way or the other, but since it's been in Republican hands for a long long time, it seems reasonable that it's true.
Wednesday, May 25, 2011
Some readers have -- admirably, I must add -- said they're tired of reading about Sarah Palin here, or anywhere. But this is too informative to pass up.
From a review of Blind Allegiance, a confessional memoir by former Sarah Palin aide Frank Bailey:
Bailey also helped smear a neighbor who complained about excessive tourist traffic around the governor’s mansion. After hearing of the gripe, Palin sent her daughter Piper out to sell lemonade and then derided her neighbor for protesting children at play. Soon, the neighbor was portrayed on conservative blogs as “sick,” “unhinged” and “drug-addicted.” “By the time we finished with our politics of destruction, he surely regretted ever mentioning the governor’s name,” Bailey writes. “He learned firsthand why so few people were willing to speak out against Sarah Palin.”
One of my more teflon-to-truth commenters says she still thinks the lady is wonderful.
I've read a few reactions to the fizzle of the rapture prediction (already revised). There are some who say mocking those who believed is cruel, and maybe it is; but it's not that simple. The point isn't merely that people were deceived out of their life savings, committed suicide, or attempted to murder their kids. The point, which those calling for charity (and many of those snickering) will neither accept nor, more importantly, admit to themselves, is that it's the perfect metaphor for what they themselves believe. Not metaphor, actually: revelation. To borrow a word.
Tuesday, May 24, 2011
Open mouth, drop in word. Suck. Wiggle tongue. Remove.
Saturday, May 21, 2011
Tonight's the night. I'll be heading to my neighbor's garage and taking his Escalade.
Friday, May 20, 2011
To me, President Obama's speech on the Middle East was remarkable for how unremarkable it was. Nice ideas, nothing much new. Particularly his words on Israel/Palestine. But you'd not see it the same way, were you to listen to the edited version carried breathlessly, even by some of the falsely-labelled "liberal" media; and if you check out the usual RWS™ blogs (I don't recommend it if you want to retain any of your [like mine] waning view of humanity as respectable) you'd think he spoke wearing headgear and smoking a hookah. I'd be willing to bet nearly all the commenters at this place (really, I mean it: don't go there. Not a fact within a million pixels) took the word of the writer and never saw the speech. The writer who, among other things, said Obama killed the economy. And if they did see it, well, subtlety ain't exactly in their ouevre.
The shamelessness and opportunism of conservatives in government and media would astound, if movement conservatism hadn't extinguished any sparks of credibility years ago. They say that they are defending Israel while trying to perpetuate a status quo that isolates Israel internationally, dooms it through demographics to a small handful of equally noxious choices, and undermines the moral legitimacy of both the state and the righteous purpose of providing a safe home for Jews in the world. (How many movement conservatives, if they were honest and actually consistent in the application of their religious beliefs, would be forced to say that all Israeli Jews are condemned to hell?)
As Congressional Rs, feeling flush with power and convinced there's nothing they could say or do that would turn teabaggers against them, reveal their real agenda without even pretending it's otherwise, I simply can't figure out how anyone other than crats from Pluto still supports them. Latest in the parade of outrages is Eric Cantor's address in Chicago:
Yesterday morning, House Majority Leader Rep. Eric Cantor (R-VA) visited the Chicago headquarters of the CME Group, “the world’s largest owner and operator” of private exchanges for derivatives products. CME Group specializes in a number of markets, including trading futures contracts for various blends of crude oil and food commodities. Cantor met with executives, and at one point, gave brief remarks before CME Group employees and various commodity speculators.
Cantor told the audience of speculators that his Republican caucus would “do our part” to block the implementation of financial reforms passed last year as part of the sweeping Dodd-Frank law. He even called out the Commodity Futures Trading Commission, the regulators in charge of overseeing derivatives and energy speculation, and promised to stop regulations from going online.
Which is not to disregard their filibuster of a bill to end the tax exemptions for oil companies. You know: voting against even allowing a vote on it.
I'd be less mystified if the NRA came out against assault rifles, or if PETA began carrying ads for KFC. For anyone but a Wall Streeter or a corporate poobah to support these guys simply makes no sense.
Thursday, May 19, 2011
Tuesday, May 17, 2011
[I'm semi-computer-less for a bit. I wrote this one a while back (updated it slightly) and never got around to posting it. Not obsessively peering at a computer screen, reading all the bad stuff out there, makes for less blog-fodder, if also a certain sense of calm. Ignoring reality, it turns out, isn't all bad. Which explains several phenomena about which I've been prone to writing here.]
Read this post by conservative Andrew Sullivan, regarding Republicans going all in on the Ryan budget, of which the following is a part:
Sunday, May 15, 2011
Friday, May 13, 2011
I've heard separately it from two of my conservative friends. One sent me a link in embarrassment at the stupidity of some that share his end of the spectrum. The other implied he thought it might be true.
The latest fake outrage manufactured by Fox "news," repeated and retweeted by the former half-term governor and the rest of the RWS™ is so stupid -- even for them! -- that I've mostly ignored it. Since the deed was done last night, and no cops were killed, I guess I'll waste the pixels to the extent of referring readers to this post, and the excellent video within, especially the ones by Jon Stewart.
Wednesday, May 11, 2011
It’s been a long, grueling and enormously expensive time for this country, a time of endless war and massive fortification, of borrowed money and of missed opportunities.
There’s the human toll. More than twice as many Americans -- over 6,000 -- have now died in the two wars that followed 9/11 than did in the original attacks, along withmore than 100,000 Iraqis and Afghans. Over three million Iraqis and 400,000 Afghans remain displaced. Several hundred thousand U.S. soldiers suffer from long-term war-related injuries and health problems, with more than 200,000 diagnosed with traumatic brain injury alone.
And there’s the extraordinary financial toll. Indeed, even as Washington officials panic about the growing deficit, much of the problem can be traced back to 9/11 -- not to the attack itself, but to the response, and particularly to the decision to go to war in Iraq.
Harvard scholar Linda Bilmes and Nobel-Prize winning Columbia University economist Joseph Stiglitz now estimate that the two post-9/11 wars will end up costing taxpayers somewhere between $4 trillion and $6 trillion. ...
"One of the main reasons that our national debt has increased so much over this past decade is because of the spending on the wars and the military buildup,” Bilmes told The Huffington Post. “All of that money has been borrowed.”
The post-9/11 era is defined by a series of choices, the biggest and most expensive of which was President George W. Bush's decision to invade Iraq. When it comes to the $4-6 trillion estimate, “I think between two thirds and three quarters of it is Iraq," Bilmes said.
"I ask myself, would the economy be so weak, would we still be bogged down in Afghanistan, would oil prices be where they are, would we have lost so much blood and treasure, would the national debt be as high as it is, if we had not made the decision to go into Iraq? “ Bilmes said. “I think the answer is 'no' to all those questions.”
Yet a 2002 Congressional Research Service report did anticipate the effects of post-9/11 spending with great accuracy: "Large amounts of resources are and will be committed to making production, distribution, finance, and communication more secure in the United States," the report said. "Resources that could have been used to enhance the productive capacity of the country will now be used for security. Since it will take more labor and capital to produce a largely unchanged amount of goods and services, this will result in a slower rate of growth in national productivity, a price that will be borne by every American in the form of a slower rate of growth of per capita real income."...
[Some may have seen this post, if briefly, before blogger crashed. It sucked into the ethers the rest of the post, and a couple of others I'd written but not posted. I wish I knew how to find "cached" pages. I'd written a couple more paragraphs here, but I'm not sure I can recreate them very closely. If anyone got it on an RSS feed and could copy and paste it to me, I'll add it in. Otherwise, I'll just end with the gist of what I'd written:]
I'm not saying -- no one is -- that we should have just cleaned up ground zero after 9/11 and moved on. At the time, I was quite okay with the Afghanistan operation, and I was impressed at how quickly the Taliban folded their tents. It resonated around that part of the Muslim world that had rejoiced in the attacks of 9/11, and who'd thought the US was shown to be powerless. Would that we'd not gone off the rails and invaded Iraq, giving Osama more than he could have imagined in his wildest and virgin-filled fantasies. The message might have lasted, and perhaps we'd not have been brought to the verge of economic and moral collapse.
The end of the guy who started it all, while not the end of the need for vigilance, seems an appropriate time to look back at the path we took and to wonder, had we spent but a fraction of the costs of our overreaction on those things that really truly make us great, and safe, what we have become. And what might have been.
Monday, May 9, 2011
Not the first time it's been said, I suppose; but that doesn't make it any less depressing:
Failing Grades on Civics Exam Called a ‘Crisis’
Fewer than half of American eighth graders knew the purpose of the Bill of Rights on the most recent national civics examination, and only one in 10 demonstrated acceptable knowledge of the checks and balances among the legislative, executive and judicial branches, according to test results released on Wednesday.
At the same time, three-quarters of high school seniors who took the test, the National Assessment of Educational Progress, were unable to demonstrate skills like identifying the effect of United States foreign policy on other nations or naming a power granted to Congress by the Constitution.
“Today’s NAEP results confirm that we have a crisis on our hands when it comes to civics education,” said Sandra Day O’Connor, the former Supreme Court justice, who last year founded icivics.org, a nonprofit group that teaches students civics through Web-based games and other tools.
This is exactly the desired result of the long game enacted originally by such hatriots as Karl Rove and Tom Delay: you win by turning minds to mush. And you do that with a multi-faceted and entirely cynical approach, one that makes Machiavelli seem like the Mahatma: degrade or destroy public education, corner the market on credulity by roping in the religious, and discredit legitimate media while single-mindedly replacing it with an Orwellian propaganda empire (so there's no mistake about the Orwellian part, and as a little knee-slapper for those in on it, label it "Fair and Balanced.")
Things in the night that go bump in the polls.
In a positive feedback loop that makes one question the impossibility of perpetual motion, these pieces reinforce one another exponentially; there's now a perfect substrate of ill-informed people, anxious for their perceived aggrievement to be redressed, entirely lacking in the tools of critical thinking that might cause them to question what they're being told, and to where they're being led.
Gary North explains why getting students out of public schools is key to the Christian dominionist camp. “So let us be blunt about it: we must use the doctrine of religious liberty to gain independence for Christian schools until we train up a generation of people who know that there is no religious neutrality, no neutral law, no neutral education, and no neutral civil government. Then they will get busy in constructing a Bible-based social, political, and religious order which finally denies the religious liberty of the enemies of God.”
And the Christian Right has been busy enacting this vision. One of the first goals of the Christian Coalition was to take control of 500 local public school boards, and it's a strategy the Religious Right has continued. ...
... In addition to getting Trojan horses on school boards, the Religious Right has played a significant role in disseminating anti-public school propaganda and forming alliances to support vouchers for private schools.
A nation of the deceived. By design. And working like a charm.
Sunday, May 8, 2011
Saturday, May 7, 2011
The issue of Sarah Palin's truthfulness, or lack thereof, regarding mothership of the baby Trig has never concerned me much. That's why I'm posting this on a Saturday, mostly a time for throwaways.
Friday, May 6, 2011
Two different commenters have implied they're buying the desperate attempts of our home-grown war criminals and their RWS™ apologists to claim that torture played a key role in the killing of Osama bin Laden. I'll repeat a couple of things I've said in commentoid response, and add this, from John McCain, who knows personally the real value of torture; namely, to force false confessions, like the one he made from the Hanoi Hilton. (I would have, too, I'm pretty sure; I know you would have):
'I stand on the side of the United States and by the Geneva conventions,' John McCain said.
Sen. John McCain denounced “advanced interrogation” methods like waterboarding Wednesday amid a growing debate over its effectiveness reopened by the killing of Osama bin Laden.
McCain told reporters leaving an intelligence briefing for senators by CIA director Leon Panetta that he has seen no information so far to indicate that techniques like waterboarding factored significantly in the information gathering that led to bin Laden’s death.
Thursday, May 5, 2011
Let the dark matter flow freely, the conspiracies congeal like the blood of a dead terrorist:
Obama Says He Won’t Release Photos of Bin Laden’s Corpse
WASHINGTON — President Obama has decided not to release photographs of Osama bin Laden’s body, CBS News reported on Wednesday. Mr. Obama said he concluded that images of Bin Laden, bloodied by gunshots, would do nothing to persuade skeptics, but could inflame tensions in the Muslim world and pose problems for America’s national security...
... According to a transcript read aloud at a White House press briefing, Mr. Obama said that there was no doubt Bin Laden was dead and that “we don’t trot this stuff out as trophies — that’s not who we are.”
I say, good for him; although this guy I know, and his friends who send him stuff, will see proof of something dank.
Like Don Corleone during the baptism of his grandchild, this was a hit, one mobster to another. A message: I'm not taking orders anymore -- I'm giving them. Fuck with me and you die.*
Big stories evolve: who knows what explains it all? Early confusion? Miscommunication? Second thoughts?
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