In the June 1st issue of The New Yorker, Atul Gawande writes about the practice of medicine in McAllen Texas. Why McAllen? It is one of the most expensive health care markets in the country; only Miami is costlier. McAllen is a much poorer community. His measure, and it is a standard one, is medicare dollars per enrollee. In this post I will repeat several of Gawande’s points, but I urge my readers to read the whole article.
One reason the people of McAllen suggest for this anomaly is that theirs is an unhealthy community. Despite its high obesity rate, its high rate of heavy drinking, and its poverty, it has lower than average cardiovascular disease rates, and low incidents of asthma, H.I.V., infant mortality, cancer, and injury. In short if one judges by the statistics McAllen is a realitively heathy place.
Gawande develops his argument carefully through a series of interviews, references to statistics and and his own experience as a doctor. In a short post I need to skip to his conclusions. He finds that in McAllen and other high cost areas order more tests, operate more frequently, refer to other specialist more often. He also finds that doctors there are entrepreneurs; they own imaging centers, ultrasound machines, or serve as medical directors at nursing homes.
Gawande contrasts these practices to low cost areas. One of them Rochester Minnesota is dominated by the Mayo clinic which pays it’s doctors a good salary, but does not allow them to participate in the ownership of the auxillary services. As a result fewer tests and scans are ordered and the patients needs predominate. Several other cities are discussed with similar conclusions.
Respect for the common health means that we must pay doctors well, but prevent them from developing multiple streams of medical income. In fairness, we will also have to do something about the cost of medical education. A new doctor may begin practice so far in debt that he cannot afford not to be an entrepreneur. As Bernard Shaw says, ” 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 to give a surgeon a pecuniary interest in cutting off your leg, is enough to make one despair of political humanity.”
Tagged as:
Atul Gawande,
Common Health,
Health,
Medicine
In my earlier post Doctor’s Dilemma, I offered up the idea of the common health, a parallel, I suppose, to the common wealth. We have a measures of common wealth, but no corresponding number for the common health. It is my idea to offer a series of posts on the health care debate. In this first one I want to set some premises and home truths.
It is my belief if we consider only health care and funding insurance, we will fail. A public program must seek to create public health and private health. We must understand that we have a vested interest in our neighbors’ health as well as our own. The recent swine flu scare brought this idea home to many of us.
Some facts we need to acknowledge:
- Life is 100% fatal. Health means we can live a happier, more active life.
- The rich have always had better access to doctors than the rest of us. It’s not until the 20th century that this becomes a major advantage. Diet, cleanliness, and not doing dangerous work account for most of the upper classes health advantages throughout history. Nothing we do will change this.
- Our public health system is currently strained and any serious threat might break it. If swine flu returns as a pandemic this fall and hits the uninsured, our emergency rooms and public clinics will be overwhelmed.
- Medical science is not as advanced as we like to think.
- Private persons are responsible for their own health. No system we put in place can alter that. A concern for your health means a concern for the health of others.
- Medicine is most expensive at the margins of life.
- Whatever our feelings about statistics, health care must use them. If we know that for a set of symptoms a particular test is useless 97% of the time, no insurance should pay for it. If we are in the 3% whose cancer would have been detected early, we want to sue. No system can give millionaire’s coverage to everybody.
There are probably many more facts I could list here, but I’ll start with these. We will need to be willing to examine both market and non-market solutions. In no other area of our lives is the “role of government” more contentious than this one. We need to think deeply and originally about these problems.
Tagged as:
Emergency department,
Health,
Health care,
Insurance,
Medicine,
Public school,
Swine influenza,
Uninsured in the United States
As I watch my Twitter Stream, I see the idea of a personal brand popping up everywhere. Many blogs promise to help me develop my personal brand, tell me of the importance of my personal brand, or like good romance columnists tell me ten mistakes to avoid in creating my personal brand. When I look at people’s twitter profiles and see how many success trainers, motivational speakers, direct marketers, and other who are trying leverage their personality and knowledge into a living, I fully see the motivation for these entries. But part of me wonders if it is wise to participate in the commodification of one’s self.
By “self,” I mean that internal being whom we think of as who we really, truly are. Various philosophers would argue that this “internal being” is a mental construct made up of our beliefs, our desires, and our choices. Phenomenology would argue that we can know who we are only through the world’s response to us. The only way to see the self is through the mirror of other people’s reactions to us.
If one thinks this way about branding, one notes that the words used to describe an effective brand can also desribe the self–integrity, authenticity, accessibility, etc. Obviously the person creating the brand thinks of it as a persona, a mask, which carries his image out into the world and which remains unchanging in the marketplace. We all know that the brand isn’t the person. But happens to the person who has branded herself? Is she trapped in by this mask? In striving to survive in the market, the face may become much more like the mask. Consider the of the meaning of branding cattle. Are our psyches as mutilated as the cattle by this act?
Through personal branding the distance between commercial life and private life shrinks. We will become like the character Crow in Sam Shepard’s play, The Tooth of Crime, who sings:
`I believe in my mask–the man I made up is me
I believe in my dance and my destiny
The validation of our selves becomes the recognition and spreading of the brand–our mask and our dance.
Tagged as:
Brand,
Marketing,
Philosophy,
Sam Shepard,
Tooth of Crime,
Twitter
Every once in a while the universe rubs your nose in something that has been previously below your radar. Yesterday my twitter stream sent me to an point counter point article on decriminalizing sexting, this morning a piece on illegitimacy in The Washington Post mentioned sexting, and tonight I watched an episode of Law and Order SVU which centered on sexting. In all of these the issue of prosecuting teens as child pornographers was mentioned. This struck me as absurd on the face of it and over kill in terms of penalaties. A fouteen year old girl should not be put on a sex offenders list, if she foolishly sends her boy friend a topless picture of herself.
In different ways these three experiences reminded me how ambivalent American culture is about sex in general and teen sex in particular. Our diet and maybe some environmental factors seem to have lowered the average age of puberty in girls. Our work place has made the age of marriage later and later. We cannot expect sexually mature persons to abstain for long. Yet we have no sense of the limits, education, or the help teens need to manage their sexuality.
Only a small knowledge of 14 year olds allows one to imagine how they might exchange nude pictures via their cell phones. An even smaller knowledge of life allows us to see the disaster created if those pictures go viral through the school via cell phones, Facebook, or other media. What then are the proper constraints we should put on teenagers, the media, etc. The original intent of the teens may be sexual, but in the sense that the pictures are nots not intended to arouse anyone else, they are not pornographic. After an angry break up, revenge may cause one of the two to publish the pictures. What is the crime? Is it a civil matter?
I haven’t a good answer to these questions. But they are ones parents, young adults, and society at large need to answer. People have been and will be hurt by sexting. If embarrassment were the only hurt, I might be willing to argue that the behavior is self-correcting. I help run a therapeutic boarding school and deal with students whose early involvement with sex has injured them psychically. Some of these are sex abuse in the obvious sense that an adult has taken advantage of a child. Others involve promiscuity, physical abuse, and other behavior among teenagers. Of course, I can discuss none of these cases on the web. But the intersection of teenage sexuality and social media is one that requires reasoned examination and an admission that real harm can occur when these two forces collide.
Tagged as:
Mobile phone,
social media,
Teen Life
I combined business and a short vacation two weeks ago and spent some time in Salt Lake City. My last post reflected my visit to the ballet there; in this one I’d like to offer some reflections on my visit to the city and to Utah. For someone from the East, one is struck by the newness of many of the buildings, the width of the streets and the whiteness of the population. There appears to be a small hispanic community and a small Asian community and excellent restaurants sponsored by both. However, people from other parts of America will note the relative absence of African Americans.
The week end I was there coincided with the annual meeting of the LDS church, and since a new apostle had to be selected, it was a very important meeting. There was coverage in the newspaper and on the local TV channels, but given the reputation of Utah and the church. I found the coverage newsworthy and moderate. The meeting was important to many in Utah and was covered positively, but well. My hotel was only a few blocks from temple square and next to the Salt Palace, but had I not read the news, I might not have been aware of the meeting.
When I visit a city, I often try to imagine what my life would be like if I lived there. Salt Lake City offers me a good life, excellent performing arts and museums, a wide variety of good restaurants, and good books stores. The recession seems not to have hit Utah too hard and the church is rebuilding a lot of down town. But I am not a Mormon and as the young ladies who showed me around the Beehive House quickly discerned not likely to convert. (The house is so historically interesting that one should risk the religion to see it.) I suspect that if I lived a long time in Utah, I would feel like an outsider. The picture here is not the best one of my trip, but the one that symbolizes the church-state axis.
Salt Lake City seems to me to represent one view of American life. Set in a beautiful spot, the city represents a homogeneity of values and of population. If one belongs here, one has a real sense of community. The city represents values I share–common culture, service, and civic order and pride. Utah clearly believes in building maintenance in a way New York does not. Now the natives were all hospitable, I saw no overt racism, and I saw little criticism of alternative lifestyles. On the surface Salt Lake seems pluralistic, but I missed the grit that eastern cities have. They cacophony of very different lives interacting, and the excitement that interaction creates.
The challenge Salt Lake City lays down to us is this–Can we create as livable and peaceful a city and maintain the grit diversity brings? I don’t know the answer, but I think we need to strive to say yes.
Tagged as:
Church of Jesus Christ of Latter-day Saints,
civic values,
race,
Salt Lake City Utah,
Temple Square
This past week I attended the Ballet West’s recreation of three dances premiered at the Ballet Russe; the earliest of the pieces was first performed in 1909; the latest in 1929. Before the performance the managing director came out and gave a little speech about the importance of the Ballet Russe. In closing he asked the audience to image that it was 1909 and all we knew of the Ballet was Swan Lake. Of course, we failed.
For those not versed in performance history, the Ballet Russe was a Russian troop performing in Paris under the direction of Sergei Diaghelev who was a genius at finding and combining talent. Georges Rouault, Picasso, and many other of Paris’s artistic elite designed and painted sets for him, he commissioned many of the standards of modern ballet especially the works of his fellow countrymen–Stravinsky and Prokofiev. The premier of Stravinsky’s Le Sacre du Printemps in 1913 started a riot. Oh to have an audience that cared so much.
Now the performances I saw were very well done. I refer any interested readers to Alastair’s Macaulay’s review in The New York Times (April 7, 2009). But we as audience could not bring new eyes and ears to the theatre. What were musical, dance,and artistic innovations are to us old and to a certain extent classics. We can never see tham as radically as their first proponents did.
This does not mean we cannot be moved by the performance–I was. Nor does it mean that we should not perform the pieces. But we must adm’it that performance cannot escape interpretation and any performancec thaat seeks to recreate the 1909 experience is an interpretation of both the ballet and 1909.
The first recording of ballet music I owned and listened to with care was Stravinsky, not Swan Lake. The Ballet Russe is not the avant-garade but the benchmark in my experience. Educated in the Avant Garde we constantly seek the new, the exciting, the revolutionary. But what now have we to rebell against?
Commercial activity and art have always overlapped in the West, but we have no dominate tradition and therefore no place to attack. Revivals like these point this out. It seems to me that mass media has replaced art as society’s thinking point and we are poorer because of it.
Tagged as:
Art,
Ballet,
Ballet Russe,
Ballet West,
Georges Rouault,
Igor Stravinsky,
Paris,
Rite of Spring
A graduate school friend once excused her reading of romance novels as “mind candy.” The phrase has stuck with me to describe that reading we do solely for pleasure with no intention of improvement or learning. For many people this is the sole reason they read; others prefer television.
My confection of choice is the historical mystery novel–a genre practiced by both the Americans and the Brits. I tend to prefer the Brits and the Irish over the Americans. Of course, I prefer Scotch or Irish whiskey to bourbon as well. These tend to come in several varieties–classical Roman, medieval both English and French, and 19th century. There is Bruce Alexander’s wonderful series about John Fielding, Henry Fielding brother, but the 18th century does not attract the mystery writers like the other eras do.
I read all three and although I admire the work of Stephen Saylor, Lindey Davis, and Anne Perry, my preference has always been for the medieval. My aunt, the same one who first gave scotch, started me on this vice by introducing me to Ellis Peters and the Brother Cadfael mysteries. I quickly devoured the series and began to look for similar writers.
Like all historical writing these mysteries reflect the concerns of the time they are written. Many of the readers and many of the writers of these mysteries are women. So it is not surprising that in eras in which womens’ roles were restricted, male detectives acquire strong and intelligent partners. In the 19th century novels many of the women are suffragettes or have become nurses and midwives so they can move more freely in society.
Peter Tremayne Sister Fidelma series seems to fit this bill. However, Tremayne is the writing name of Celtic historian Peter Bransford Ellis. While Sister Fidelma seems to have more freedom that any woman in the 7th century, he is portraying Irish history and Celtic Christianity very accurately. His clear, but mostly unspoken premise is that the West would be place had Celtic Catholicism triumphed over the Roman branch. It would certainly be a different one.
My other favorite bonbons are Bernard Knight’s Crowner John novels. These novels center on John de Wolfe the first man who held the title of coroner in Devon. The author has worked as a forensic scientist most of his life. Clearly he is tracing the history of position he, in fact, has held.
People who like history less than I do may find my taste in mind candy a little too heavy. But I read these for fun and for escape. I read only a little science fiction, but both take us from our world to another where the expression of passions we know are expressed in ways we may not have imagined.
I wondered about my love for Medieval mysteries. Fending off my eight year old nephew’s laser sword attack, I remembered that my friends and I took sticks and trash can lids and fought battles of great chivalry–we all read and loved King Arthur, Robin Hood and whatever else we could find.
What’s your Mind Candy? We all have some and an occasional piece is a real pleasure.
Tagged as:
Anne Perry,
Bernard Knight,
Celtic Christianity,
Henry Fielding,
Historical Novel,
Mystery,
Sister Fidelma
This is only peripherally a religious post, so those looking for the Apostle’s Creed or the Latin Mass can leave now. Depending on how you, the reader, respond to this post, it may have some personal spiritual significance.
When I taught playwriting I used a text by Louis E. Catron. It’s a beginner’s book for those who don’t have a good grasp of dramatic form. It provides lots of advice for the beginning writer. “Write about what you care about, not what know,” is my favorite. Catron has his pupils write a Credo, a list of personal beliefs. He leaves to the student if its style should be epigrammatic or discursive, but asks the student to be thorough and to include many aspects of life not just the moral and religious. My students universally complained when I gave them this assignment; those who did it seriously came to value it. The first year I assigned a Credo, I wrote one myself. Every year I reviewed it and often added to it or crossed ideas out. It remains a way for me to remind me what I think is important.
So I challenge you to write your own Credo in which you deal with what is important to you with “deadly honesty.” It can be as long or as short as you want. Catron reluctantly suggests “eight pages” for the first attempt. He lists a number of benefits for this exercise. Those that apply to writers and non-writers alike are as follows:
- Forces deeper thinking about one’s values
- Introduces the self to the self
- Shows where contradictions may exist
Try this exercise. I think you’ll find it valuable.
Tagged as:
Arts,
Journaling,
Playwright,
Student,
Writers Resources
![Reblog this post [with Zemanta]](http://img.zemanta.com/reblog_e.png?x-id=196efe39-3b90-485c-80c6-a869984dbe61)
![Reblog this post [with Zemanta]](http://img.zemanta.com/reblog_e.png?x-id=9e1f2bab-12ed-4dd2-9a30-a1562cf0004b)
![Reblog this post [with Zemanta]](http://img.zemanta.com/reblog_e.png?x-id=283266c2-b13a-4b62-a412-bbf45d961cd2)
![Reblog this post [with Zemanta]](http://img.zemanta.com/reblog_e.png?x-id=1a4c82bc-32f5-48af-91f9-d326090fee92)
![Reblog this post [with Zemanta]](http://img.zemanta.com/reblog_e.png?x-id=54d6fa06-62f3-4485-b33d-d4313121d79b)
![Reblog this post [with Zemanta]](http://img.zemanta.com/reblog_e.png?x-id=ca81e74f-c06e-48c2-b3aa-2f267662776d)
![Reblog this post [with Zemanta]](http://img.zemanta.com/reblog_e.png?x-id=12649ced-334d-4dab-b03e-16f92f5ae89c)
![Reblog this post [with Zemanta]](http://img.zemanta.com/reblog_e.png?x-id=395c48a2-e6fd-43bc-ad55-7d3a12dbc93c)
![Reblog this post [with Zemanta]](http://img.zemanta.com/reblog_e.png?x-id=673b6ecb-ad48-461c-91a9-bff8770436b4)
![Reblog this post [with Zemanta]](http://img.zemanta.com/reblog_e.png?x-id=fcf76153-d852-4a6e-ab7e-63f465589d80)
