ER May Reveal Basic Problems in Hospitals

One brief — and, as it turned out, not too serious — visit to the emergency room in one of New York City’s biggest and best hospitals this summer proved to be very interesting because it revealed some systemic issues.

Perhaps if the problems seen and encountered there could be better understood and addressed, a trickle effect through the rest of the medical system could be magically launched.

Let’s start at the beginning.

Getting in was half hysterical and half amusing. A telephone call in advance of arrival directed the patient to ask for Joseph on arrival and he would immediately assist.

[The hysterical part] Checking in at the ER, the receptionist, a proud graduate of some school awarding degrees in “do not take no s&%t from nobody,” refused to call Joseph until AFTER she had “processed” the admission. As there were five people in line, that could not be quickly accomplished. The presence of an immediate and urgent problem simply eluded her or failed to impress her. She remained immovable until a medical professional observed what was going on and took charge.

[The amusing part] The receptionist was furious over this usurpation of her authority to insist on the domination of her role and her paperwork, and threatened the career of the registered nurse, as well as the patient, for being difficult.

Then began a series of identical examinations, many unrelated to why the patient was there, by three different categories of caring and competent pros. Despite inquiries, it was impossible to determine why three identical exams were necessary. The most rational explanation was that these procedures required repetition to catch errors. That explains, perhaps, two, but surely the third is either padding the bill or a preemptive defense to a malpractice suit. Or worse, that the staff does not trust each other. And if they do not, why should patients?

By the time this repetitive poking and prodding was finished, the issue that prompted the visit, which had followed an outpatient procedure in the same hospital that same day, had abated. Everyone, including the patient, was satisfied that there was no longer a problem. But no one was able or willing to “discharge” [until discharged a person can NOT leave] the patient until a physician associated with the doctor who had performed the procedure earlier that day signed off. After another hour of wrangling with the ER staff, that doctor showed up. She then she insisted on doing the same exam as the previous three!

Finally, after 3 and ½ hours, the patient was released.

What does this experience teach us?

First, big city emergency rooms are crowded, and it is said that about two out of three people who come in do not have a genuine medical problem. Yet the system requires the hospital to assume they do. Many are intoxicated on drugs or alcohol and need shelter and a place to rest. They have myriad and amazing “the dog ate my homework” reasons why they believe they need medical treatment, which consumes a lot of time and money and clogs the system.

Common sense says there must be some better way of filtering incoming people into appropriate categories and places. The staff mentioned triage but there was no visible sign of that process being applied quickly with judgment. Perhaps halfway houses could become a first (and if necessary very temporary) stop for such unfortunate folks, operating under contract with the hospital.

Next are those people who had recent treatment, in the hospital , and couldn’t reach their doctor for emergency help, who are invariably advised online and by phone to go to the ER. It should be a simple matter, in an age of electronic health records, to identify these cases and immediately direct them to the appropriate treatment. If such patients were able to have someone call or check-in before arrival, a “triage” process could be bypassed entirely for that type of case.

Signs of excessive defensive medicine were rampant, most obviously in the form of repeated tests and exams. I don’t have a solution to medical professional’s fear of being sued, but I am confident that the problem is exaggerated for purposes that don’t benefit front-line providers.

Like many large institutions, ERs have acquired an odd sort of lethargy. Despite the life-and-death environment, a shocking number of ER staff were simply standing around, texting, gossiping, and repeatedly getting in the way of those with something to do. Technology might play a role here, too, using data mining to better anticipate supply and demand and schedule employees accordingly. Time is, indeed, money, and the amount wasted in an era of spiraling costs is appalling.

One wonders what kinds of consultants are used. Smart problem solvers from outside of the health care field could bring fresh eyes and ideas to these obvious problems. But lawyers, insurance companies and doctors — as well as bean counters — have to be in the act too, with divergent motives and interests.

That, in fact, may be the very first problem that has to be addressed. The basic culture as well as the legal structure of our healthcare system needs to be reexamined.

Simple common sense, coupled with organized thinking, ought to be able to produce better medical benefits and patient care at substantially lower costs.

Consider this piece a cry for help. These issues must be looked at in a different way — simpler, with the doctor-patient relationship at the center, envisioning what a modern system could look like, and be, if it were being designed from scratch today.

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Severe Flaws in Polls

Political polls have become daily news in recent years. It begins to appear that we have put the cart before the horse.

Leadership and followership are, of course, Siamese twins in many ways, but we have begun to confuse the two. Horses trying to push carts rarely work.

True leadership is based on clear and strong headed judgment of people qualified by experience to think through issues and negotiate balanced solutions.

The basic problem with polls is that public sentiment is quite like our body temperature; it goes up and down, somewhat randomly, and taking action too quickly in response to changes can lead to serious unintended consequences.

That is why experienced doctors only make judgments after observing various factors over an appropriate period of time.

Democratic societies presumably try to pick political leaders, or they should be, based on their perceived ability to know more than average voters and to use their best collective judgments to steer that society through a complex and rapidly changing world.

When the voter–think patient–says to a pollster what his/her view is on a question, that is only one point of information for an elected leader–think doctor — to consider in prescribing a right long term treatment.

What is happening today is a very dangerous thing. The polls are spurring and spawning too many short term and ill-considered decisions.

Polls could — and probably would if they had their way — take the place of some parts of the legislative process. Therefore voters should be demanding new consideration of how polls are conducted and how and when their results are interpreted and used.

It is also increasingly clear that many polls are tainted by respondents lying to pollsters because they believe they cannot trust where their answers might end up, and lead to political retaliation. Who needs that problem?

That can lead to unintended consequences of self-fulfilling promises because misinformed poll results obviously do not tell the real story. That is very dangerous in misdirecting election results and leading to voter sentiment being distorted and thus driving wrong-headed policies opposite to the actual underlying public view.

Perhaps keeping the identity of poll responders BLIND to the pollster could be managed?

What could be done to change and dampen the other bad effects of poll distortions?

A first issue to be addressed is whether there might be some 1st Amendment problems. Pollsters might argue that they have the right to ask and speak. People polled might insist on their right to respond any way they like. And, of course, the press — which pays for a lot of polls because the public likes them — would argue that constraining their use of polls in any way would infringe freedom of the press.

All that may be correct, but one well-understood limitation of 1st Amendment rights is that people cannot cry “FIRE” in a crowded theater. Many published polls today get massive coverage [which surely is the equivalent of crying fire] which frequently over leverages and misrepresents the public’s real views which often leads to distorted consequences.

One idea that seems reasonable, if there could be a consensus to address any of these problems, would be to prohibit purely political polls too close to election dates. We have done something like this already by prohibiting publishing partial results on election days until the actual polls have closed.

Another idea would be to require specific issue polls to put questions into different forms, from different angles which should also be published, to be sure the question is not leading, and over enough of a time span to offer more than a momentary peek at opinion in response to breaking news. This would be hard to manage, but doing it right could lead to a significant improvement in making public policy.

There is probably no need to worry too much about private polls as long as they stay private. Managed polls for any advertising purposes (e.g., the notorious “push polls” intended not to measure but to shape public opinion through questions such as “Would it change your vote if you knew candidate X is a registered sex offender?” when candidate X is no such thing) are very close to koshering fraud and, hard as they are to control, we should try to eliminate them.

A good debate about polls and how they effect and distort what we do in modern society would be a very healthy thing.

The medical analogy of picking doctors for their judgment and experience–as long as one has confidence in them–is an easy analogy to apply to the process of picking elected leaders and making public policy which is based on solid grounds, not thin ice of simply reflecting the ever-changing momentary whims of random groups of patients/voters.

If we cannot manage that challenge, we may face a future much too dominated by a lot of distorted polling instead of wise heads looking at societies’ longer term needs.

Rules of Life

In primitive societies when the organizing principles were pretty simple, there were some basic rules that were strictly followed. For example, the males did the hunting and the females did the gathering and kept the babies, the hut and what passed for food on the table.

As the lives of humans developed the need for more rules followed. For example, the family group expanded to tribes. And tribes expanded into “nations”. Rules were agreed on as those stages developed on how to select leaders and allocate responsibilities. While rule following was far from perfect, the intimate knowledge and involvement of peers kept most folks in line and things rocked along pretty well.

Fast forward to our modern life and today when we cannot count the rules on which our lives depend and many of us live effectively anonymously in dense populations, how can we expect everyone to know the rules and practice them for the benefit of society at large? The answer is we cannot and should not.

That suggests that we have too many rules, or the wrong kind of rules, or a wrong system of managing and policing those rules.

Let’s be more specific. We talk a lot about the “rule of law”. It is one thing to believe in the general proposition of a rule of law. It is another to know in every case how that rule of law should be applied.

For example, several years ago on Pitcairn Island isolated in the Pacific where about 50 descendants of the Bounty mutineers from the late 1700s had decamped and remained today, two men were charged under applicable Australian law with having sex with underage girls. It was obviously a very messy bad business that properly played very badly in the modern press. There was a trial and the law under which they were tried had been passed in Australia but never published on Pitcairn. The defense lawyer asserted that it was not right to hold a defendant accountable for a law that he in fact never knew about nor had any reasonable basis to have known about as there was at that time little communication between Australia and Pitcairn.

It also turned out that the two defendants were essential members of that tiny community virtually isolated from the world, and the fabric of that little world could not do without them. The result was a negotiated arrangement where they were effectively paroled forever if they stayed out of future trouble and did their community duties.

The notion that the rule of law requires an appropriate context is important despite the fact that the general the standards in the modern world as we know them then clearly draw the line about underage sex.

So we in the modern world have been taught and learned that we must be bound by modern conventions, as well as laws, and we are assumed to have picked up most modern conventions as we grow up.

But, even that notion has flaws. Some years ago I knew a young man who liked to flaunt conventions just for good measure. He refused ever to wear a matching pair of socks, a matching pajama bottom and top, to bathe regularly etc. It was his badge of honor and independence until one day an older friend of his asked him, “Isn’t it just as bad to be bound by unconvention as by convention?”

He heard and moved on to other displays of independence. But the fundamental point remained and remains.

How can we hope and expect for all the nooks and crannies of 7 billion humans on earth today to live peacefully according to what a relatively few people believe to be the proper rules of life.

There are several religions around the world that have professed to have the answers to those questions. For a long time those religions did seem to manage pretty well a quite large number of their believers. Now there is a global clash among those various rule making bodies and we see a great deal more tragedy around the world all the time.

Perhaps it is time for a new universal genius to begin to proclaim a new rule making process that everyone could believe, understand and practice in daily life?

A New Organizing Principle

In the 1930s the biggest international policy problem was isolationism.

Because the United States had two vast oceans protecting two of its borders, many people thought we were safe from the aggression of both Germany and Japan. Thank goodness Franklin Roosevelt thought otherwise and carefully played his cards to surmount an overwhelming national sentiment to go it alone.

We know what happened. The Japanese made a big mistake with a sneak attack that mobilized the nation. By 1945 both Germany and Japan had unconditionally surrendered and for a brief time the world was safe again from state predators who sought world domination.

After that began a process with many smaller state players jockeying for increasing influence around the globe. Under the presumed umbrella of the new atomic weaponry a new strategic doctrine emerged, Mutual Assured Destruction [aptly acronymed “MAD”], which basically held that if you tried to harm me, I would obliterate you.

The plus side of MAD was that it pretty much eliminated major state sponsored aggression. The minus side was that it took attention away from what was developing in its place, which were severe, intractable local conflicts based on long histories of sectarian, ethnic and geographic hostilities to wipe out both competition and increase local power.

Since 1950 there have been several serious “local” wars — Korean, Vietnam, Iran v Iraq, Afghanistan, Egypt v Israel etc. as well as many smaller but deadly events.

It turned out that the bipolar world, which then seemed relatively safe, was an illusion and a breeding ground for a proliferation of small or non-state actors to pop up out of nowhere and stir up various kinds of trouble based on religious animosities, jealousies and territorial ambitions. And, to make it worse most of those new “bad” actors had little experience or interest in any forms of traditional governance — witness Hamas today!

State power we have discovered is extremely inefficient and ineffective in addressing such non-state aggressions. And, worse yet, when state powers chose to engage in faraway places, more often than not they become ‘the enemy’ regardless of the purity of their aims and intentions.

Recently it has been observed that “not doing dumb stuff” is not a sufficient organizing principle to help guide state powers in deciding how to engage with the wide world. A few people even yearn for a renaissance of some ambitious Kissinger-like grand theories to help establish wise tests to determine when and how state power can and should be effectively deployed.

There are many people now who feel very strongly about a wide range of very important human rights abuses being the basis for essential state interventions wherever they occur. But, more and more, despite whatever the merits of those human rights concerns, state interventions have so far in the main failed to effect or promote human rights goals.

We are thus in an impossible situation around the world where we are either seen as wimps, fools or bullies and even a selective application of threats and promises has yielded little or no benefit to our national interests.

The situation now seems to have taken us back in some ways to the pre-World War II period when the vast majority of Americans, protected by those vast oceans, felt safe from most state based threats.

Today it is less a sense of safety based on isolation than it is a sense of frustration at our lack of ability effectively to project our state power abroad.

Thus, it is not isolationism in the literal sense — we obviously MUST maintain our vigilance and abilities to deal with state and non-state threats from abroad — and the need for MAD has not gone away and may never.

Our current need can be best be described, as suggested by a very smart and wise friend, as a need for a Worldwide Organized Watch — or WOW — based on economic power. Our almost anachronistic leading global military power rests solidly on our greatest power — our economy. If military intervention can not work, perhaps money [and a lot of it] can have the effect we have been seeking to redress imbalances in resources in hot spots around the globe. And that just might actually save money that otherwise might have been be spent on military budgets.

The core of our national needs and safety today lie in maintaining mutually assured collective action based on our allocating economic resources [sufficient money] early enough to the good actors in hot spots that they could compensate for their lack of resources. The amounts cannot be too much or too little. To start a fund of at least $250 billion should be appropriated, to be allocated by the President in consultation with the Congress. Of course, some of that money would likely be spent in the US by those people abroad to obtain the tools necessary to solve their problems. That would make the overall process less burdensome to us.

The term MAD quite apart from its powerful threatening substance was an effective icon for keeping big problems in check for a long time. Perhaps WOW could serve a similar purpose in today’s world? A beacon of WOWs just might start a process in which actors good and bad alike might see their respective self-interests in a new and useful light. Bad actors, aware that their opponents could get significant financing, just might be deflected to some extent.

We may have to learn to bite our tongues when some “bad” stuff goes on abroad and CNN drums up passion and concern for oppressed people and horrific atrocities committed against them, when we cannot realistically affect events in any material way other than providing serious money, food and medicine.That will not be easy or popular, but should overall have a less serious negative effect on our national and global interests.

Until the world figures out a way for some form of world governance to take over as policeman of world affairs, we just may have to make do with MAD and WOW?

Yes, I know I may be dreaming. But we really do need some new kind of organizing principle and that just might be supplying a lot of money early.

Obama

While the line of critics of Obama’s presidency has been growing, the evidence of his success as president has become clearer and more secure despite the colossal frustrations and disappointments, even to his most ardent supporters, since his reelection.

History is clear. Presidential success is measured by how well that president did in addressing the main challenges and goals that he [so far only men] set out in his first election.

In the case of Obama those matters were [1] the economy and financial system [2] extricating the country from two impossible wars [3] improving the health care system and health at large.

Though obviously there are still large numbers of folks who will dispute this view, any fair and objective judgment has to give him top grades on the first two and a B+ on the third because the initial execution of Obamacare was very poor.

The economy and financial system were in a very shaky state in the fall of ’07 and winter of ’08. Our current unemployment rate and the stock markets are clear and convincing evidence that his steps taken early and continued have saved the country from what could have been a much longer and serious depression.

We are all but out of both Iraq and Afghanistan despite really intractable issues in both places. That has to rate as a difficult but major success.

Health care in some ways was/is the toughest issue. A lot of folks wish he had tried harder and solved the single payer issue, me included. Still it was a major feat and the evidence grows daily that the there is progress toward the goals of more folks being covered and bending the cost curves to constrain overall growth of costs. The seriously botched roll out was worse than an embarrassment and sadly an indication of pervasive weaknesses in his managerial experience and skills.

Since his reelection Washington has been in a stalemate. It does take two to tango so no one should excessively blame Obama for his role in the stasis. Indeed he could have done a far better job of ‘politicking’ the congress and related interest groups. The Republicans have clearly been determined from the beginning to destroy his Presidency whatever it takes, regardless of his accomplishments or lack thereof. Therefore, one can reasonably conclude that his failures of management and political skills were not caused by his second term Republican opposition.

The sooner that the country comes to the realization that whatever the Republicans try to do to Obama in the next two years, his first term successes have already won him a place in history as a very successful president.

And, therefore when and if that fact becomes clearer, the Republican opposition may finally see that the more they try to diminish the President for wrecking the country, the more they may diminish their political attraction. At least that is way it ought to work.

At that point our national government again might be able to work a bit more for the good of the country.