Friday, May 23, 2014

The Undeserving Poor

You are no crawfish. I know a lobster when I see one. You are trying to pass for crawfish!

This morning, on Marketplace (NPR) they told the story of the British decision to spend money on a sewer system for the city of London in the reign of Queen Victoria. The advent of the flush toilet meant that the Thames River filled with human excrement, filling London with malodorous fumes and precipitating outbreaks of deadly cholera infections. 

Yet, the British parliament refused to appropriate funds for a sewer system which would alleviate the problem. The Tories argued that the poor, whose water was tainted, were poor as a result of moral turpitude, endemic immorality and defects of character and they held spending public funds, derived from taxes of the affluent, was simply supporting the depravity of the lower classes, who, in effect, deserved their suffering and discomfort.

Ultimately, Parliament, which is hard by the Thames, was so overwhelmed by the stench, they voted through the funds. Only once the nostrils of the rich were enough offended, did the infrastructure get funded. 

Does any of this sound familiar?


Wednesday, May 14, 2014

Benghazi: Kimberly Meuse Has the Last Word

Kimberly Meuse: Artist, Analyst, Citizen

Read it into the Congressional Record.  Read it on the floor of the U.S. Senate. Recite it whole whenever Rush Limbaugh or Bill O'Reilly or Mitch McConnell or the Koch brothers surrogates utter the word, "Benghazi."  Kimberly Meuse has so thoroughly demolished the whole absurd Right Wing blow hard narrative about the Benghazi debacle it is amazing nobody has done what she has done sooner.

An artist in Portsmouth, N.H. has somehow done what all the yammering would be pundits have failed to do: She simply places the deaths of an ambassador and other Americans in historical context and along the way she shames (if it were possible for Republicans to fee shame) Kelly Ayotte for her pandering the the worst excesses of the Republican conspiracy.

Read the Portsmouth Herald's letters to the editor for May 14, 2014, and there it is, all laid out.

Starting with the bombing of the U.S. embassy in Beruit which killed 16, and moving on to the bombing, just 6 months later,  of the U.S. marine compound in Beruit early in the Reagan administration, with the deaths of 241 Americans, Ms. Meuse recalls how very differently a Democratic Speaker of the House responded, with a single, thoughtful, bipartisan effort to analyze what went wrong and to prevent another disaster. After the first attack, the Congressional investigators laid down plans to protect foreign missions from similar attacks, but the Reagan administration failed to implement them in time to prevent the second attack on the marines or a third attack in which the CIA station chief in Beruit was kidnapped and yet another attack killed more Americans. When President Reagan was asked how he could have allowed the subsequent attacks to occur without implementing any of the safeguards and walls of protection the Congressional committee had recommended, he famously shrugged and replied, "Anyone who's ever had their kitchen done over knows that it never gets done as soon as you wish it would." 

Ms. Meuse remarks, "Imagine the Republican response today if President Obama made this quote. Would Sen. Kelly Ayotte, R-N.H., have declared  Reagan's words 'didn't pass the laugh test?'"

Along the way, Meuse builds the case that in the Democratic response to the deaths of Americans in Lebanon was the clear intention to avoid scoring political points but to honor the deaths of those who served by trying to ensure no more of their colleagues would suffer the same fate, while in the Republican response, years later, all that counts is politics and point scoring.  Buried in Senator Ayotte's indignation is the plain fact that the Republicans in Congress have gutted protection for our foreign service officers overseas by cutting funds through sequestration. For Republicans, money is more important than the lives of American foreign service officers. 

But, then again, in the eyes of the Tea Party Republican Congress, foreign service officers are just part of the problem, because they are part of government. 
And you know, as Reagan chanted so often:  Government is not the solution. Government is the problem."

When government is run by Republicans, the Mad Dog must agree this is true.
Joseph Welch: "Senator, At long last,  have you left no sense of decency?"

Al Franken: Best Hope for the Ninety Nine Percent

Mad Dog never thought Al Franken was all that funny. He could make you laugh, and some of his Saturday Night Characters were droll enough--the correspondent who carried his own satellite dish on his back into the field, but was always groaning in pain under its weight, the self esteem guru whose refrain, spoken into a mirror, "You're good enough, and dog gone it, people like you"--were funny one time, but they often got beaten into the ground. 

His radio talk show, launched to counter Rush Limbaugh fell flat. He simply could not contain his rage and he was reduced to calling Limbaugh and Bill O'Reilly big fat idiots, which, while true, was not funny.

But, as a Senator, he has restrained his rage and consciously striven to be not comic, and hearing him on NPR this morning, talking about the efforts of Comcast, Verizon and other big corporations to carve out a "fast lane" of internet traffic, leaving the hoi polloi to wallow in a slow lane, Mad Dog felt a certain hope rising.

This is a man who has grown. With Barney Frank gone, Franken might actually fill that gap. And that is a big gap to fill.

When Democrats are inviting speakers to spot light, Franken should be the go to guy, and he would hold his own with Chris Christie, Mitch McConnell and John Boehner and all the rest of that sorry lot. 

Mad Dog continues to yearn for an answer to right wing talk radio, beyond Jon Stewart and Colbert (RIP).  He still thinks a puppet lampoon a la "Spitting Image" would be ideal for the internet and he thinks a radio show should be carefully crafted to galvanize progressive opinion.

But, for now, in the absence of an embrace from the Democratic party for his schemes to shape public opinion, without funding or support from Mr. Soros, or the MacArthur foundation, Mad Dog will simply hope Mr. Franken can provide some relief.

Sunday, May 11, 2014

News Flash: The Supreme Court--Just Politicos in Fine Black Robes

How many years has it been that Mad Dog has claimed the Supreme Court of the United States is simply a political organism dressed up to look impartial and cleaving to the arcane body of work called "The Law?"

But, of course, Mad Dog has had to admit he is simply a humble citizen, untrained in law, unversed in history, and voicing an opinion based only on what he can find on the internet, which includes the opinions of the court for every year, on every case. 

Now, however, we have experts, professors of law, professors who "study the court" quoted in today's New York Times, saying, in those tempered academic tones, essentially just that.

Mad Dog's argument has been simple: If it is possible for someone untrained in the law  to read a single paragraph summary of any case before the court and to predict with greater than 90% accuracy how the court will divide on the case  then one must conclude the court is not being guided by different interpretations of the law,  but by the very measuring stick used to predict the outcome with such unfailing accuracy. If you can say, well, this case basically pits the interests of the rich or the powerful or the authority against the claims or interests of the underclass, the poor or the weak and Justices Alito, Scalia, Thomas and Roberts will vote for the ruling class in every case, then one must accept that  is what guides the four horsemen of this conservative apocalypse.  Let us always vote establishment.  

So, if it's a schoolboy holding up a derisive poster, thumbing his nose at the principal of his school when she tries to force students to support the "Olympic movement," or if it's the case of a rich corporation trying to claim the right of free speech as an individual, even though there may be stockholders of that corporation who disagree with that speech made in their name, or if it's a law passed by a predominantly black city (Washington, DC) to oppose the authority of the  powerful National Rifle Association and claim that the 2nd Amendment does not guarantee an individual the right to a gun but only guarantees guns to members of a well organize militia--if in any and all these cases you have only to identify who is in power and who is not, to know who this court will embrace, then law has nothing to do with it.

We really should allow each President to appoint one new justice each year of his presidency; and we should allow only the mostly recently appointed  nine to vote.  Then we'd have recognized what the court really is--just another political animal in Washington, which should be at least indirectly controlled by the electorate, to reflect the will of the people.

Saturday, May 3, 2014

The Electronic Medical Record and Quality Control: Coming to a Doctor Near You

We all want high quality medical care. Does anyone out there desire low quality care?
It's one of those things a Senator can say, like "freedom" or "prosperity" and be assured of smiles all around.

And we all agree if a man bills for a service, whether he is a doctor or a mechanic, he ought to be able to show the person or organization which pays him that he actually did provide the service.

So far, everyone is happy.  Freedom. High quality. No fraudulent billing.

The advent of the electronic medical record has meant when you are sitting in front of your doctor in the exam room he is no longer looking you in the eye, or staring at the ceiling or out the window, or at the clock on the wall behind your head: He is now typing furiously on his computer throughout your interview.

But what is he or she doing in that computer he or she is so absorbed with?

The doctor  might be entering data, so he can refer back to it next time you visit or call, to track symptoms, laboratory results, to  track progress or lack of it.

Actually, what he is likely really doing is entering in "quality measurements."

What this means is he has asked whether or not you have had a flu shot and checked off the box that he has asked,  and he checks off a box to document he has told you to get one, never mind if you said "No."  There is another box for whether or not he has told you to stop smoking and another for "lose weight." Check those boxes. Doesn't matter whether or not he mumbled "Good" when you said you were still smoking. The important thing is did he ask and did he check the box. If he said, "ohthenyoushouldstop," when you said yes, then  can check that box, too. More credit.

And there is another box for "family history."   

Why would the powers that be care about whether or not the doctor asked about your father's health?  Actually, there can be valuable information about you in your father's history. 

Until we have a map of everyone's genome in your medical record, the low tech family history is the next best thing. Suppose, for example, you have a high cholesterol. You may be on the launching pad to start a statin drug to bring it down. 


Unless, it turns out your father also had a cholesterol of 300 and so did all his brothers and sisters and so did his father and every single one of them lived to be ninety-nine. Then we do not treat your cholesterol, and you are off the hook. We recognize there is something we don't know how to measure which is protecting your family against that high blood cholesterol, which, in your family,  does not stick to and penetrate the walls of your blood vessels but simply slips by the endothelium like a greased pig sliding down a water slide. 

Now, if your doctor should type in all that information in the "free form" box of your electronic medical record, he gets no credit at all;  but if he does ask and  fails to check the box in the fifth screen of "family history" then he is practicing bad quality medicine. If he scrolls through the screen and finds "father" in family history and clicks the box next to "father" then he has practiced stellar quality medicine and Medicare pays his employer. 

Of course, the doctor may not have asked about your father's cholesterol at all. No matter. All that matters is that he has found the box next to any "first degree relative" and checked it, which is to say, in the eyes of the bean counters, he has done a "reimbursable family history."  High quality medicine right there. 

Multiple that by two dozen other check off boxes on several score of screens and you've got yourself a medical office visit that is easy to score for "quality."
Van Gogh Field with Crows

Remember when you took a test in school and they gave you a multiple choice test about Walt Whitman or the Civil War or geometry or the art of Vincent Van Gogh?  These are not subjects which lend themselves to multiple choice questions, unless you get to some pretty superficial questions, but that multiple choice sheet can now be run through a machine and graded in an instant--even in the 1960's the teacher could lay down a perforated score card over your test answer sheet and grade it in less than a minute.

All of this scoring is about a system which can be graded and "quality controlled" mindlessly by someone who has not the least idea what actual good quality is. 

Can you imagine what playing such games does to the mind of the person in the white coat sitting in front of you? Is he now concerned about your cholesterol,  or morphing into  a mindset  closer to that of a teenager playing a video game?

What we are seeing now is that some minimally trained "health care providers" look better than physicians who have gone through some pretty rigorous training at some very intensive programs, stayed up long nights and undergone ruthless grilling by their professors.  Is the physician's assistant who scores higher on the computer searching his electronic medical record really just more high functioning than the doctor who scores low because the doctor did not check off that box but instead got into the details of your father's actual history?

There are likely ways to judge some physicians by computerized records, but that ain't what we got now. The minds of the "quality control" specialists feeding those bits into their computers are as empty as last year's bird's nest.

Back in the day, we used to say, "The better the surgeon, the worse the note."  There did seem to be that connection--the really wonderful surgeons, the guys you wanted doing surgery on you or your family were fantastic in the operating room, but desultory writing up what they did. Some of this changed when surgeons could dictate their chart notes, but even then it was often a difference between guys who played a good game and those who simply talked a good game.

And your doctor, now an employee, has to check off those boxes or face his employer in a disciplinary meeting which could end in his dismissal. How do you think that affects what he does when he is in the exam room with you?

"Quality control."  In medicine, a work in progress. Done about as well as the healthcare roll out. Well meaning people, not up to the task. And this is not Obama's fault. This has been in the works dating back to George W. It's embedded in government workers and in insurance company workers and in academics who have carved out their niche and drawn their salaries becoming "experts" in quality assurance.  If you cannot do, teach?  If you cannot practice high quality medicine, get a job dreaming up metrics.

Billy Bean of "Moneyball, " where are you now when we need you?