Month: July 2009

by Patrick Appel

Responding to Conor's healthcare musings, a reader writes:

I am a beginning doctor who finished my general cardiology fellowship last month and am leaving the nest of academic training for the wide world of private practice.  Not surprisingly, the hospitals and clinics to which I have applied for practice privileges require a list of the medical tasks I have performed in my training. The cardiology certification boards and societies also require a minimum number to these procedures before I am allowed to practice. These tasks are typical, standard cardiology diagnostic and therapeutic techniques, including catheterizations, stress tests, electrocardiograms and ultrasounds, among others, and the list I have completed in my training is likely quite representative of a normal cardiology fellowship graduate. They are not exotic or unusual procedures, just the bread and butter of cardiology, and account for much of the nation's medical bill for heart care. My list includes several thousand of these procedures that I have completed over nearly three years.

Why do you think that it would be cheaper to train nonphysicians to do those thousands of training procedures and then perform them in my stead as accredited practitioners?

I was paid a fellow's salary, in the range of $40,000 to $50,000 per year, which is less than typical wages for an experienced pharmacist or nurse or nurse practitioner, so how would you induce one of them to take the place of a physician, and a pay cut, for three years? Promise them higher income when they complete training? Hmmmm…. seems like that will just lead you back to the same situation in the end, don't you think? With purportedly the same skills to sell, why would they take a discriminatory pay cut severe enough to provide a significant dent in the US health care budget?  You might think to flood the market with lots of cardiologists to drive down prices, but there's a sizable literature suggesting that rising numbers of practitioners may actually INCREASE costs. And wages are not an especially large part of the medical budget, so even if there was a large pool of unemployed cardiologists every year, it's not clear to me that the resulting potential marginal wage reduction wouldn't be mostly offset by the costs of training all the new, redundant providers required to knock the salaries down.

You might think that we can 'unbundle' cardiology practice into discrete, low-cost components– I guess you were thinking of something similar with regards to "professional bone setters" and emergency or orthopedic practice– but even if you teach a high-school graduate how to perform, say, hands-on cardiac catheterizations, the patient still requires SOMEONE to make an informed judgment about the feasibility, risks and benefits, technical reliability and accuracy, importance and clinical meaning of a test result. Who should that be? A general doctor, perhaps? Let's imagine how that would turn out: 'Well, sir, I think the catheterization results show that your (son/daughter/father/mother/etc.) does not need heart surgery or a stent for their symptoms, although, yes, I did not actually DO the catheterization myself, and in fact have never actually performed a catheterization or learned how to read the cath lab images, but that's what the cath guy said and so I'm sure he's right!' Do you expect a system built on this type of arrangement to out-compete what we have currently, at least from a patient's perspective? For another example, again typical, when a patient is rushed to the ER with chest pain, which of these two would be chosen more often? The 'I-know-how-to-do-caths' guy or the experienced cardiologist who knows how to do the cath, how to look at the ECG to make sure a cath is actually necessary, who can put in a balloon pump if the patient's blood pressure drops precipitously during the procedure, who can start the patient on appropriate medications for shock or fibrillation which may occur during catheterization, etc.?

Even so-called 'standard' procedures require a great deal of knowledge, experience and direct expertise, along with good judgment. I don't see your idea as either technically feasible or able to provide quality care at a reduced cost. Why do you think it would work?

by Patrick Appel

Marc Lynch advises Arab leaders:

by Chris Bodenner

A reader writes:

As a follow-up to your post on director Abbas Kiarostami:

This is a scene from Mania Akbari's film "20 Fingers".  (Akbari is the female driver in "10.") The film consists of 7 vignettes featuring Akbari and Bijan Daneshmand. In this scene the couple argue over her desire for an abortion while they navigate Tehran's busy streets on a motorcycle.

Akbari's son, who was featured in both of these films, was arrested in the current upheaval.

IndieWIRE posted an email she wrote on June 23 detailing his arrest:

I had no idea where they had taken my son to, therefore I stared looking in every  ambulance, every police station and every hospital in town I came face to face with other parents looking for their children as well. Mothers screaming and calling the  names of their sons and daughters. Fathers weeping silently. Terrified kids in police stations awaiting their faith…it was a total nightmare.

It was early Wednesday morning when I finally found my son at the Pasdaran’s police station. The reasons for his arrest were that he was wearing a green band to show his support for Mr. Moussavi and also that he had been identified as an active participant during the presidential campaign. Finally on Wednesday he was released with the intervention of some friends, artists and some related police authorities.”

Amin had been subjected to serious beatings and emotional disturbance. I felt ashamed of seeing him in his condition. I had created a false illusion for him regarding the country he had been born in, about prevailing humanism and democratic atmosphere. I had always encouraged him to consider going to top universities in Iran, instead of opting for studying abroad.

by Patrick Appel

The house released its healthcare reform bill (pdf) yesterday afternoon. Here is the CBO analysis. Ezra Klein has a snap analysis. So does Cohn. Here is Ezra on the costs:

I'll keep an eye out for good commentary throughout the day. Let me know if you see any sane conservative critiques.

By Conor Clarke

Over the weekend I did an interview with Nobel Prize-winning economist Thomas Schelling, who has done a lot of pioneering work on game theory and collective bargaining, especially as it pertains to global conflict and nuclear arms control. I wanted to talk to Schelling because of another collective bargaining problem that's been on my mind: global climate change. As I wrote below, weighing the costs and benefits of climate change is both morally fraught and empirically uncertain. Or at least it confuses the heck out of me.

Will Wilkinson is not convinced that Schelling — or any game theorist — is in a position to help with my confusion. And maybe that's completely fair. Climate change questions aren't just math puzzles! So let me take a page from Conor F's playbook and list some of the reasons why I don't know how to make sense of global climate change. Here are seven (!):

1. Any solution to climate change must have a theory for what the present generation owes future generations. That's hard. How do we weigh the interests of people that don't yet exist?

2. Any global solution to climate change must take account the fact that the costs of warming will be borne unevenly around the world. Parts of the northwestern United States will actually benefit from a warmer climate. Bangladesh will not. But why should the U.S. care what happens in South Asia?

3. Any solution should account for the fact that the responsibility for global warming is also borne unevenly. The developing world will bear most of the costs, but the developed world bears most of the responsibility. (My understanding is that this will change at some point in the next 50 years.)

4. Related to #2, the world's ability to adapt to a changing climate is distributed unevenly. It would surprise no one to learn that wealthy nations will have an easier time adapting than poorer ones. So should we allow poorer nations to pursue the most rapid growth possible, before the consequences become dire? Or should we pursue a solution that achieves the maximum possible reduction in global emissions?

5. There is a great deal of uncertainty about what will happen. To be sure: There is no (repeat, no) scientific uncertainty as to whether or not the climate is warming. It is. But the question is, By how much? And when? Will the temperature increase by two degrees Celsius over the next 100 years? Three degrees? Seven degrees? The differences matter.

6. Climate change has an incredibly long time horizon. Any small cost or small chance of a catastrophic outcome must to weighed across hundreds or thousands of years. There is also one-way ratchet here: It isn't clear everything we change about the climate can be reversed.

7. Global warming asks us to weigh economic factors — growth, GDP — against non-economic ones, like the diversity of species and the amount of arable land on the planet. I have absolutely no clue how to do that.

And this is all quite apart from how you would ever enforce any solution we arrived at. Or maybe that's just an eighth reason why I'm confused.

by Patrick Appel

A reader writes:

I agree. Contemporary racism is easier seen by looking at outcomes. That certain Chinese and Thai citizens feel no hatred towards people of color doesn't excuse discriminatory behavior. Though there is nothing necessarily wrong with wanting to learn a particular English accent, using race as job applicant sorting mechanism is highly racist and perpetuates a stereotype, apparently widespread in China, that accents are linked more to race than country of origin. I read the previous e-mails as explanations rather than excuses for Chinese behavior. Another reader makes a similar point:

A reader wrote "a desire for whites is less about racism than it is appearance." Am I missing something or isn't this still racism?  Just because the English schools the reader writes about aren't personally racist, it doesn't mean that acceding to the racist dictates of their customers isn't racism.  The belief that all the best American English speakers are blond hair haired, blue-eyed white people is still a racist belief whether the school administrators or the population that sends their kids to that school holds that belief or not.  There were plenty of business owners in the South during Jim Crow that didn't personally hold racist beliefs but still wouldn't hire blacks because their customers would object, therefore losing business.  That was still a part of the Jim Crow system and they were just as morally culpable as the racist business owners who wouldn't hire blacks out of their own personal racist beliefs.  The same holds true today in China and apparently in Thailand (as the reader suggests) as well.

 
A young Pakistani child internally displaced from Swat, looks out from a bus before departing from the Yar Hussain UNHCR camp in Chota Lahore on July 14, 2009 in Swabi district, Pakistan. Approximately 3 million internally displaced persons (IDPs) have been created as a result of an on-going military operation against the Taliban. Thousands of families have been urged by the government to return to their homes in Lower Swat, Malakand and Buner. By Daniel Berehulak/Getty.

by Conor Friedersdorf

If I understand conservatism correctly, its useful insights include the following:

1) The natural inclination of politicians is to accrue power in ways that threaten liberty if left unchecked.

2) Massive federally run efforts to remake society are bound to fail, and often result in grave unintended consequences.

3) Local decisionmaking is to be preferred when possible.

4) It is unwise to make decisions about how to transform society based solely on first principles, disconnected from questions of tradition, culture, etc.

What I'd like to see in 2012 is a Republican nominee willing to apply these insights — all of which he or she will surely profess to believe — to matters of foreign policy.

Is that too much to ask?

by Patrick Appel

A reader channels my own feelings about the 2012 GOP field:

Your assessment of Romney's "plastic focus-group conservatism" is dead-on, and it gave perennial independents like myself the heebie-jeebies.  But that assertion has been so consistently registered that one would hope it's found its way to Romney, and there is reason (isn't there?) to think he can learn from that.  I think he got caught in a primary campaign still being fought under the Rove rules of the 2000's, a personality contest and wedge-fest that the GOP had better abandon, because the few viable candidates they have don't possess a personality and they're increasingly on the losing side of past tried and true wedge issues.  And regardless of how the next three years go, you can't take a personality contest into the general election against Obama.

 

What Romney can do that others can't is highlight his resume and brand himself as the competent and practical chief exec he actually kinda sorta is. 

In this regard he can actually be a game-changer; as the presumptive front-runner going into 2012, he has the opportunity to establish the rules of the playing field to some degree.  If he can make the central focus ability and competence instead of cuddly and slick, nobody in the GOP can touch him.  As important, it makes indies like me sit up and take notice.  Does it make primary season tough?  You betcha — he'll have to either get on board or around the wackjob wing of the party.  I'd recommend around; don't pander to the Huckabee crowd that likely would have reservations about voting for a Morman anyway, make the case to the sane right and independents that flooding the primaries will put the Palin/Huckabee idealogues to bed and give the GOP a legitimate electoral shot at Obama.

 

Is Romney savvy or patient enough to do all of this?  Well, probably not.  But it's there.