Unprofessional Behavior: What it Means To Be A Professional

One college course Mad Dog remembers  was taught in the department of Sociology called, "The Professions" and the professor, a very humble man from the Midwest, spent considerable time trying to define what constitutes a "profession." This imbued Mad Dog with, not a definition, but a sense of the difficulty of defining the idea of a profession.
Part of the problem for Mad Dog, and for the professor,  was neither had ever really had any significant experience as a professional. 

One aspect of being a professional is having been exposed to all the things which are relevant to the execution of the things professionals in a given area do. So the professional football player has seen it all--he recognizes all the patterns and the plays he may see, and he has been coached and taught, so nothing is really a surprise. He may not be able to process everything quickly enough, but he is not surprised. Of course, this is not really true--you see coaches diagram things on the sidelines, teaching players what just happened, things with which they were unfamiliar.  All professions involve ongoing learning. 

Real professionals notice things non professionals do not. They see details and integrate them into meaningful action as non professionals do not. So a doctor notices the subtle jerking at the wrist of the alcoholic, asterixis, when nobody else in the room picks up on that.  The cornerback notices a tell in a wide receiver who always puts two fingers on the ground when he is going on a deep route, but three fingers when he is falling back to block. But, of course, sometimes the professional misses that sign or simply never learned it.

Most professions have a language, which is used not just to exclude others or to make the professionals seem elite, but because it's functional, a shorthand. Of course, in medicine there is no functional reason "pruritus" is better than "itching" but most doctors use that Latinized word out of pride or habit.

Pride is a big part of professional behavior. Mad Dog has long held that 90% of what he learned in medical school in terms of "facts" and "content" and "core knowledge" turned out to be wrong, but what persisted as true were the values by which doctors operate:  You put the patient first, even at your own inconvenience, even at risk to yourself, and you see your duty through as if every patient were your own sister or brother.  

That value has gone out the window with the new generation of doctors, who work "shifts." The new doctor severs his relationship to the patient at the stroke of midnight, when he signs off work and hands over his patients to his replacement on the night shift. Of course, this does not always happen, but with the new rules about limitations on hours interns can work, that is the unintended consequence of the idea of limiting overwork and on team work. If the team takes care of the patient, then no one doctor has to, or can,  feel really responsible to get that patient through the night. 

Now we have MBA's ordering doctors about, determining their work hours, the doctors' salaries, the amount of time they can spend with each patient, what sort of services the doctor can provide for the patient, or how the doctor should use his time with the patient.

Good example:  A patient is referred to an endocrinologist for possible thyroid nodules. The patient's primary care doctor examined the thyroid and thought it might be a bit lumpy. Off goes the patient to the endocrinologist who might do a sonogram of the patient's thyroid and answer the question right then and there.  But no, in order to bill for a full new patient consultation, the endocrinologist has to ask the patient about whether or not he has abdominal pain and diarrhea to fulfill requirements for a full "review of systems" so the doctor can charge the patient the highest consultation fee. The doctor has to ask about drug allergies, which likely will be irrelevant, and about whether or not the patient drinks or smokes. 

 All of this questioning eats up the clock, adds nothing to solving the question at hand, but is required by some legal regulation which determines the "level" of the consultation, and thus the level of payment and the MBA insists all this be done so the maximum charge can be wrung out of each patient. 

The sonogram of the thyroid however, cannot be done at that first visit,  because it is compensated at a low value for the doctor, and the organization for which both the MBA and the doctor work make more money if that study is done in radiology.

So, the patient walks out of the office without her question answered: Do I have thyroid nodules? She has to make another appointment with radiology,  and await word on the endocrinologist's review of the sonogram he could have done in his own office, but for the law laid down by the MBA,  who rules the practice. 

Revenue for the practice has been maximized, but the doctor has been denied the opportunity to answer the patient's question as quickly and easily as possible and the patient has been left dangling. 

Has that doctor been professional? 

And consider the MBA, is he a professional? He has maximized profit for the organization which employs him and the doctor, but has he enhanced or diminished the quality of patient care in doing so? One might say, the MBA's job is not to enhance the quality of care,  but to maximize the quantity of profit in the practice.

If capitalism and the profit motive are the greatest, most rigorous drivers of "efficiency" one might ask, what sort of efficiency are we talking about? Certainly not efficiency of diagnosis in this case, which would have led directly to the endocrinologist taking the patient into the sonogram room. 

No, it is the efficiency of the billing mechanism which has prevailed, dollar driven not patient driven.

 

Falling Out of Love with President Obama

"I had such hopes for us."
               --Jimmy McNulty to Stringer Bell.

"They always disappoint you."
               --Mayor Royce's administrative assistant to Norman, Carecitt's campaign manager


Mad Dog is just about ready to take down his Obama poster, from the far end of his hallway, near the guest bedroom. Reading Peter Maass's article in the New York Time Magazine about the abuse and intimidation of Laura Poitras, a documentary film maker who has covered Iraq and who released some of the Edward Snowden leaks about the National Security Agency spying on Americans, Mad Dog is now Hang Dog.

While it is true the abuse began during the Bush administration, Poitras remained on the list of nice names which got her pulled aside at every airport in America, in  Europe and in  the Middle East, for special attention which read like one of those scenes about Gestapo interrogations, with two interrogators in front and one behind her. No charges. No explanations, her pen grabbed from her so she could not take notes about the names of those who interrogated her.

Real thugs, in the employ of the U.S. government. 

If President Obama came out tomorrow and said, on public TV, he was sorry about what happened to Ms. Poitras, and he would bring the thugs to justice and he welcomed her back into the United States, Mad Dog would consider putting back up his poster. 

There is much we do not know. What exactly did Ms. Poitras do to get on the list? Who else is on the list? How do you qualify for the list? If she has actually committed some malfeasance, why is she not in jail? Doesn't the fact she is free to fly, but simply intimidated every time she does, does this not  not clearly say the government knows she has broken no laws, but they are using this sort of intimidation to punish those they know they have no legal right to abuse?

We have not heard the government's response to Mr. Maass's article. It just appeared this morning, but if President Obama is not on TV tonight, Mad Dog will consider him guilty as charged. This is the printed equivalent of those horrible Abu Gharib photographs. It is an obscenity.

And while Mr. Obama is apologizing for the misbehavior of the thugs at the airports who harass Ms. Poitras, he should add some lines about the thugs who walked up to the farmer who was turning on his irrigation system on his own property near the Mexican border and demanded to know what he was doing. He replied, "Hey, dude, I'm irrigating my land." The official replied, "Don't dude me. I'm a federal officer."  To which the farmer did not reply, "Yeah, and you are trespassing on my land," because, apparently, the law allows federal officers to trespass on a farmer's land without warrant. 

Of course, underlying all this is Mad Dog's dismay that Mr. Obama has continued Mr. Bush's wars,  and he had continued the policy that America must continue perpetual wars. He has said we'll have American troops out by the end of 2014 without explaining why they cannot be out yesterday. Mr. Biden says we cannot remove Americans until there are Afghans to take their places. This has the ring of untruth. 

And it is manifestly stupid. If you have a powerful army, throughout history, you have had two choices:1.  Move in, defeat and destroy then occupy territory, and create an empire, or 2. Sweep across as the Mongol hordes did, vanquish and then disappear back to from where you came. Those you ravaged know you're out there, and can reappear at any time, so they may behave. But they also know, you don't want to move in and live near them.

There is also the Obama doctrine that we can do things like murder outside the USA, especially if we do murder to people who are not US citizens. The distinction is lost on Mad Dog. If it is immoral to act as prosecutor, judge, jury and executioner without trial, if it is not fine to kill a citizen person in this manner, then why is not immoral to do the same to a non citizen? It's not the legal status of the human being you propose to kill which matters, it is the process by which you make the decision, a process meant to insure guilt, fairness and explanation, which makes the taking of life potentially okay.

Mad Dog understands it is not the 18th century. We have people who can do violence to us from any part of the globe. But Mad Dog does not understand why the terrorist you think is guilty cannot be publicly informed of the charges against him and offered a trial. If he does not choose to return, full steam ahead. Drone him. But  to simply meet in a dark room in the West Wing and draw up a list of names and then send out the drones--that is not the President I want on my wall as an icon of Hope.

There is the argument we will send terrorists to ground if we notify them we are after them. But they are already at ground. They do not use cell phones, computers, the internet. They know they are hunted. At least real terrorists do. But some people on those lists may have done nothing more than embarrass some government official.  They may be no more guilty than Laura Poitras.

We need to know more about Ms. Poitras, but evidently, there has never been a real enough transgression on her part to land her in jail or formally charged. 

That, by itself, speaks worlds.

 

Of Raisins and Gaming: The Free Market and Other Fantasies

We are often told by the Rush Limbaughs, the Eric Cantors and the Rand Pauls of the world that we have a free market economy and the only entity which seeks to poison the pure stream of the free market is the big, bad federal government. 
This morning on NPR was a wonderful piece about the raisin board in Calfornia, which periodically tells raisin growers they have to throw out half their crops in order to avoid an increase in supply. This is frank collusion by producers to limit supply, which if airplane companies or tire manufacturers did it would result in CEO's going to jail. In fact, even doctors are forbidden to form groups to negotiate with insurance companies because that would be collusion and a violation of free trade and monoply laws.  But when raisin growers do this, it is protected by a Depression era law enacted to keep raisin prices high and to protect farmers who raise raisins.

Similarly, there is legal manipulation of what one man's vote means. Yesterday a civil rights leader, who marched with Martin Luther King was recorded saying, "We have marched too long, bleed too profusely, died too young to allow these people to take away our vote."  He was referring to legislation in states controlled by Republican legislatures which have reintroduced the 21st century redux of the poll tax and the qualifying exam at voting places which in the 20th century effectively denied the vote to Southern Blacks.  But the fact is, Gerrymandering in these states and others have rendered the individual votes meaningless: If you assign Black votes to voting districts overwhelmed by white votes then you dilute all those Black votes and wash them away in a tidal wave of white votes; or you can game the system by combining all the Black voters into one district and giving them one Representative and then you make six other districts which, in total, contain fewer voters than are voting in the one Black district, and you have 6 white Representatives going to Congress for the one Black Representative.  

So, the ideal of a free market and a democracy can be subverted by clever manipulation and gaming of the numbers. 

It reminds Mad Dog of that wonderful, final scene in Animal Farm where you look around the table from pig to man and from man to pig and you cannot tell who is pig and who is man.

Judge Shira Scheindlin: Stop and Frisk

Which Kids Will Be Stopped and Frisked?

Judge Scheindlin

As expected (see Mad Dog's May 28th post),Judge Shira Scheindlin ruled against the City of New York, its police department, its mayor in the stop and frisk cases.

Why should anyone in New Hampshire care about this? Because we are the Live Free or Die state and we care about intrusive government exerting its will without restraint. As that trusty Yankee from Massachusetts (Thoreau) once said, the only place for a just man in an unjust society, is jail.

Judge Scheindlin wrote a 200 page opinion, which Mad Dog may or may not have the patience to plow through, but already on the New Yorker blog is a post analyzing the statistical basis on which she based at least part of her opinion. She was trying to gather numbers to support the idea that stop and frisk is used not to find weapons carried by malefactors who harbor criminal intent, but to intimidate minorities into passivity.  

The police argue they stop more blacks and Hispanics because it is among this group you find the most weapons and 80% of the crimes are committed by this group. So you go where the money is.

Of course, this is profiling. It means if you see a Black man in a Black neighborhood, you stop him because he is walking while Black, and statistically he is more likely to have a gun than the white guy in this neighborhood. For the same reason, you see a Black man in a white neighborhood, you stop him, because, ipso facto, he's suspicious.

After wending her way through a bunch of absurd academic "studies" and many statistics, the Judge finally arrives at the conclusion we all knew to begin with--in this country you are not supposed to be stopped and accused of something unless you do something to justify the suspicion; in this country you are not supposed to be considered suspicious because you are Black or Hispanic.

It doesn't take academic studies (especially poorly designed, derivative studies in which summaries of pieces of paper are examined) to allow Mad Dog or any mentating citizen to conclude police who are encouraged to throw men up against a wall will happily do this as a way of intimidating, dominating and establishing who is the alpha dog in the neighborhood. 

Mad Dog recalls walking down First Avenue in Manhattan, in 1971, carrying a long umbrella on what turned out to be a sunny day. A police cruiser pulled over. A policeman jumped out and demanded the umbrella, which Mad Dog handed over, dumbfounded, curious, but not intimidated because he was white in a white neighborhood and had never been mistreated by the white police from the 20th precinct.  The policeman pulled and twisted the curved wooden handle and finally handed it back.  "Just checking to see if there was a sword inside." 

That would have been an entirely different experience had Mad Dog been Black or had Mad Dog been walking in Bedford Stuyvestant. As a white guy in a white neighborhood, it was just an amusing kerfuffle.  As a Black guy, in any neighborhood, it would have been an insult and a nasty experience. You would have felt judged. You are Black; therefore, you are dangerous and you should be treated as a potential felon.
 
You have only to watch "The Wire"to understand what this is all about. It's the West Baltimore way of policing and it's done by the most thuggish of the police, with a certain glee--they have a license to bully, and they like to throw their weight around, especially when they have the billy club and the back up and the citizen they are humping is defenseless. 

Mayor Blumenthal says Judge Scheindlin does not understand the Constitution and he says she does not understand police work. 

She may not--Mad Dog has not read her opinion.  But Mad Dog thinks the rest of us understand the Constitution and the Fourth Amendment which forbids unreasonable search and seizure because even in the 18th century Americans knew they did not want to give police too much license, too much power.  

And Mad Dog thinks he understands the policeman who stops and frisks. He is the top dog humping. 

Judge Scheindlin knows what she sees. 
Don't we all?

James Surowiecki, Unions, Jobs, Minimal Wages

James Surowiecki

Mad Dog knew there must be more information out there and that information would help everyone understand the problem with the protests against Walmart and McDonald's paying poverty wages.

This information is provided by James Surowiecki, writing in this week's New Yorker.

It turns out Walmart was founded on the premise of paying low wages--the idea was these stores would employ underemployed married women who would be supplementing a family income. The profit margin of Walmart is 3-4 cents on the dollar; the profit margin for McDonald's is 6 cents on the dollar.

The profit margin at General Motors and Ford, in their heyday, is unspecified by Surowiecki, but presumably it was several orders of magnitude higher. 

The reason people are flocking to Walmart and McDonalds for jobs is there are no other jobs out there, so now instead of teenagers working for pocket money and housewives working for movie money, we've got breadwinners working one 8 hour shift at McDonalds and a second as security guards and still struggling to meet the rent, pay the doctor and day care.

In Germany and the Netherlands, these low paying jobs may suffice because so much else is paid for by the government--there is a stronger safety net in those countries.

What we really need is for "the economy as a whole to grown faster, because that would both increase the supply of good jobs and improve the bargaining power of low-wage earners," Surowiecki notes.  He cites Jared Bernstein (an economist at the Center for Budget and Policy Priorities) "The best friend that low-wage workers have is a strong economy and a tight job market." As Surowiecki notes, "It isn't enough to make bad jobs better. We need to create better jobs."

So, aiming the outrage at McDonalds or Walmart for providing only low wage jobs is misguided. If the government put lots of people back to work on infrastructure building jobs, Walmart and McDonalds would have to raise wages and nobody would feel at all sorry for them when they go begging for employees. Nobody should then be talking about cutting these companies any tax breaks.  We can quote free market theory right back at them then.

The profits from the combined profits of all the major retailers, restaurant chains and super markets in the Fortune 500 are smaller than the profits of Apple alone, Surowiecki notes. But Apple employees just 76,000 people while those combined low margin enterprises employ 5.6 million people. Nobody is walking around with picket signs in front of Apple saying, "Hire a million more employees."  

"The grim truth of those numbers is that low wages are a big part of why these companies are able to stay profitable while offering low prices."

Consumers want low prices for commodities--they don't shop in the small, Ma and Pop stores with the big mark ups on sweaters any more--they don't want to pay more for a smile and sales clerk who knows their names. They want an object for a price. The consumer is every bit as ruthless as the bosses at Walmart--they want low prices and don't talk to them about loyalty or worrying about whether the woman who rings you up at the register has health insurance. All I want to know about is: how much does the shirt cost?

The problem you run into when you start trying to inject loyalty and social consciousness into the transaction at the register is the same problem we had when we were talking about buying shirts with Made in the USA labels--nobody cares where the shirt was made. If the shirt from China looks good, and it costs $5 less than the shirt made in Peoria, forget Peoria.

Mad Dog's grandfather, who labored away in sweat shops making less than minimum wage before there even was a minimum wage, joined a union and his life was improved. But with the global marketplace, that union saw "Made in the USA" sweat shops close down, and ship out to China. 

There has been a sea change in the American economy.  We used to make things here and people were paid more to make them: Bethlehem Steel, Ford, GM made things here and could pay high wages. Now those things can be made by low wage earners in China and Mexico. What is America to do? Should we insist entrepreneurs open shirt factories in the USA and pay their workers well and try to sell their shirts at $30 when the same shirt is selling for $15 at Walmart?

What would Mad Dog do? 

Mad Dog likes public works: Until the private sector can figure out how to create companies like Apple which can employ 5 million people making whatever, then the government can employ those 5 million restoring bridges, building cell phone towers, laying down cable, delivering water, building bicycle trails, high speed railroads, building windmills and solar panels. 

Will that increase the deficit and the national debt? Maybe. Maybe not: with all those people paying taxes, maybe it will not . 

But if the debt goes up, so be it.  Call Paul Krugman; he can figure out what to do with it.

 

Alexandria Goddard, Ariel Levy, Stuebenville Ohio

Alexandria "Brockovich" Goddard

This week's New Yorker has an article about the real America, the heartland, where 17 year old high school football players are knights and the adults are still mired in their own memories of high school, because as Alexandria Goddard, a local blogger who rode to fame on the back of an alledged rape has said, "Grown men. Twenty years out of high school and they're still reliving it. They can't get over that their lives suck."

Ms. Goddard has more piquant observations, but her main interest appears less social commentary than trying to dredge up a career as the Erin Brockovich of Steubenville, which is a phrase her new "agent" used to hype her new book about the rape which she hopes to monetize. She says "We do have a rape culture and violence against women."  Well, that sells. 

Ariel Levy, who writes about the Ms. Goddard, allowing Ms. Goddard to do all the damage which needs to be done to Ms. Goddard does buy the rape culture bit. "Worldwide , women between fifteen and four-four are more likely to be injured or die from male violence than from traffice accidents, cancer, malaria and the effects of war combined. This sustained brutality would be impossible without a culture which enables it; a value system in which women are currency and sex is something that men get--or take--from them."

Well, Mad Dog was with her, for a while, until the malaria got thrown in there. First of all, even without the malaria, Mad Dog's law of large numbers holds that once you get to really big numbers, like millions, you are almost always quoting studies which are wrong and you no longer know what you are talking about. You are saying this is a really big problem because I want it to be because I'm talking about it. 

The thing about malaria: It kills more peopel world wide than any other disease. That's a big number and likely has some meaning, even though death certificate data is almost completely unreliable and where malaria is killing people they don't even do death certificates.

But Mad Dog digresses. 

What interests Mad Dog is the whole problem of young women who get drunk and the young men who see their drunkeness as an opportunity.

Before everyone carried a smart phone, the young men tended to simply sneak off to a quiet room with the drunk girl/woman, but the smart phone has introduced a new dimension to this age old event: Now the young men are not content, in some cases, to avail themselves of a willing, if incompetent, partner, they film the event and brag about it. 

Oh, America! 

When George W. Bush confronted those nasty pictures from Abu Ghraib prison and he said, "This is not who we are," he, apparently, could not have been more wrong. This was exactly who we were and still are.

In the case of the prisoners, of course, there was no complicity. 
In the cases of the girl from West Virginia who may or may not have been raped in Steubenville, there was a problem of complicity--in that she reportedly was determined to get drunk and to  "go with" her accused attacker. 

Then there is also the crowd, the modern day Greek chorus, showing up in masks with signs outside courtrooms, posting photos of the accused males on line with a listing of their class schedules so others can show up outside classroom and chant "rapist." Thirteen hundred people "from across the country" showed up for a rally at the Jefferson County Courthouse, holding signs "Rape Is Not A Sport." Do these people not have jobs? What are they doing in Steubenville, Ohio? 

But then there is Goddard, who got to appear on "Dr. Phil"  and now describes herself as a "catalyst for change. I cause change." She describes the prosecutor in the case as "gravy legs" because "gravy spreads easily." That sort of came out of nowhere, except to say people often accuse others of what they see in themselves.  Ms. Goddard has moved to the Mojave Desert where she has a new boyfriend, a Marine Corps drill sergeant. She likes soldiers, cops and football players. "I got a little boyfriend and he's dark and delicious and twenty-six."

So, where was Mad Dog? He keeps getting distracted. Drunk girls. Football players who video and post themselves having sex, adults who never get past high school, psychologically, and Alexandria Goddard, who rockets to fame and gets herself an agent by blogging about it all.

Is this a fantastic country, or what?

At least it's not New Hampshire.



 

Kill Obamacare! Republicans with Pitchforks and Torches

Paul Krugman, writing in the New York Times yesterday, observed, with some amusement, the frantic efforts of the Republicans in the House to scuttle, amend, kill by a thousand cuts, Obamacare.

In the end, he concluded what is going on is more than simple pique, but a sort of panic.  Panic, that Obamacare may just yet work. It may, eventually, be as popular as the same program is in Massachusetts, as popular as Medicare and Social Security, the two other Democratic programs which people love and which the Republicans hate and have been trying to kill under the guise of saving them year after year.

Watching, "Prime Minister's Questions," the British version of CNN where the Prime Minister must answer questions from the opposition and from his own party in open, unrehearsed session, Mad Dog has long been struck by how many of the questions pertain to the operation of the National Health Care system. It is clear that once health care becomes a government program, a great deal of what government officials do gets devoted to health care.

Obamacare is not a single payor system, not government health care and Congressmen need not fear that they will be answering constitutents questions the way their British counterparts have to do.  But that might be part of the the reason for the hysteria on the part of Repbulicans:  Suppose, some day, we actually have to do something for the people who elected us! There would be no time for hob nobbing with the rich people, the Koch brothers, if we have to investigate why the clinic promised for our districts has been delayed or is looking threadbare.

President Obama got all he could out the the Congress he had when it came to Obamacare. But what he did is nothing close to what Medicare became. It simply corrected some of the most egregious violations of humankind by our current system:  It forbids excluding people because they are or might someday need medical care.  It may well reduce health insurance premiums.  But American medicine will remain a business, not a program.

The best we can hope for is, if the Republicans come to power in 2014 winning the Senate, and they repeal Obamacare, what will rise, eventually, to replace it, will be Medicare from cradle to grave.