I'm grateful to Derek Catsam for drawing attention to this particularly unpleasant piece of conservative writing.
http://www.talkingpointsmemo.com/news/2009/09/full_text_of_newsmax_column_suggesting_military_co.php?ref=fpblg
You know I think everything is now going to be okay!
Thursday, October 1, 2009
Wednesday, September 16, 2009
Jackass = A Person Who Lacks Good Judgment
Okay, I said I wasn't going to comment on this but as the president is now being criticized for an off the cuff remark, here's my take:
Kanye West is a jackass!
Anyone who saw the clip knows that this is a perfectly fair assessment and the pretense of outrage at Obama's comment is ludicrous.
Monday, September 14, 2009
Wilson versus Williams
When South Carolina Congressman Joe Wilson shouted, “You Lie!” during President Obama’s healthcare speech, the whole of the American viewing public must have thought, “Wow, what a magnificently eloquent rebuttal of the president’s proposals!” The people of South Carolina can rest easily in their beds with a political representative of that caliber. Although Wilson later apologized for his outburst, it was clear from his later remarks that he was not in the least repentant
If that wasn’t bad enough, the talented tennis player, Serena Williams, about to lose a match, launched a vitriolic and foul-mouthed diatribe toward a line-judge over a foot-fault call. In the following press conference, Williams, in a rambling and incoherent statement, blamed the outburst on her competitive spirit.
Both outbursts significantly demean the two individuals involved. Personally, I had never heard of Joe Wilson, so this might just be his 15 minutes of fame. I was very disappointed in Serena Williams’s behavior, she is an experienced professional sportswoman but she let herself down very badly.
More interesting and more importantly, the reaction of the president to the unfortunate congressman was poised and dignified – in short, everything that Wilson was not. The tennis officials that had to deal with Williams’s tirade also reacted with poise and dignity that again was in sharp contrast to the athlete who should have known better.
Sadly both the speech and the tennis tournament will now probably be remembered for the wrong reasons. I'm not even going to mention Kanye West, Taylor Swift or Beyoncé - who really places that amount of importance on music video competitions?
If that wasn’t bad enough, the talented tennis player, Serena Williams, about to lose a match, launched a vitriolic and foul-mouthed diatribe toward a line-judge over a foot-fault call. In the following press conference, Williams, in a rambling and incoherent statement, blamed the outburst on her competitive spirit.
Both outbursts significantly demean the two individuals involved. Personally, I had never heard of Joe Wilson, so this might just be his 15 minutes of fame. I was very disappointed in Serena Williams’s behavior, she is an experienced professional sportswoman but she let herself down very badly.
More interesting and more importantly, the reaction of the president to the unfortunate congressman was poised and dignified – in short, everything that Wilson was not. The tennis officials that had to deal with Williams’s tirade also reacted with poise and dignity that again was in sharp contrast to the athlete who should have known better.
Sadly both the speech and the tennis tournament will now probably be remembered for the wrong reasons. I'm not even going to mention Kanye West, Taylor Swift or Beyoncé - who really places that amount of importance on music video competitions?
Sunday, September 6, 2009
Information Asymmetry and its Impact on the Physician-Patient Relationship
Kenneth Arrow, a Nobel Laureate in Economics, commented in 1963, “The marketplace for medicine is characterized by uncertainty, and its functioning essentially represents exchanges of information.” Where professional skills are complex, and only attained after many years of intensive study, the relationship between that professional and their client is unbalanced. In other words, the client cannot hope to have the depth and extent of specialized knowledge that the expert will have. It follows therefore, that the client must trust the professional to give appropriate and honest advice, which is in the best interests of that client. This imbalance is “information asymmetry”. In respect of the relationships between physicians and patients, the vast majority of patients have little alternative other than to trust that his or her physician’s advice is solely motivated by the physical and mental well-being of the patient and tailored to the needs of the individual. This paper will look at the influences and pressures placed upon physicians in the United States, and will show that patients have strong reasons to be gravely concerned about the motives and rationale behind much of the medical treatment (or lack thereof) from the medical profession.
It would be idle, and very wrong, to say that all treatment decisions offered by all physicians are based on a desire to increase their own income or some other self-interested motive. Having said that, it would be equally irresponsible to maintain that all physicians always resist temptation to acquire additional revenue from easily performed (but maybe unnecessary) procedures and treatments, or that additional financial, or other, incentives from pharmaceutical companies never have an influence on prescriptions written.
If taking a section of tissue during a colonoscopy is but the work of a few more seconds, and means another $100.00 for the physician’s bank account, will the physician weigh the costs and benefits in his or the patients favor? What will the decision be when, prescribing a drug for high blood pressure, the physician chooses between a tried and trusted generic product and a new more expensive treatment that will earn a little financial or other incentive? Further, how many physicians subconsciously carry out unnecessary procedures or treatments with an institutionally ingrained pocket-lining motive, when a more conservative program could be equally efficacious and more cost-effective for the patient? Conversely, where there is a motive to limit or downgrade available and necessary treatments, how many practitioners withhold treatment for financial gain? Many physicians employed by health maintenance organizations have a financial incentive to limit and reduce treatment. Put another way, they make more money if they do not treat their patients, than if they do.
There is a natural tendency to take a cynical stance in looking at the consequences of information asymmetry. Many would contend that human nature is such, that any opportunity to get additional payment for services with a little “bending of the truth” or some judicial “withholding of information” is perfectly acceptable. It is after all the “American Way” - caveat emptor represents almost the whole gamut of consumer protection available in the United States. An exaggeration of course, but with malpractice lawsuits against physicians severely curtailed in some states, not entirely without justification.
Many professional people, including those involved in health care, do their jobs in an entirely honest and appropriate manner. They can show sensitivity to the means and situations of their clients or patients and will make sensible and balanced judgments out of respect for those parameters. However, there will always be those that cynically pillage their clients without mercy and without conscience. Almost certainly, there will be a statistical distribution; sadly, it is probably not going to be a “normal”, bell-curve distribution.
The Journal of the Royal Society of Medicine, a United Kingdom publication, looked at the subject of information asymmetry in 2003. The UK does not a have an open market-place system of health care, but some of these issues are still very pertinent.
“When there is uncertainty, information or knowledge becomes a commodity. Like other commodities, it has a cost of production and a cost of transmission, and so it is naturally not spread out over the entire population but concentrated among those who can profit most from it...”[1]
Succinctly and eloquently put! From the same article and more directly about health care,
“The market for healthcare is characterized by uncertainty and exchange of information… Sources of uncertainty include the classification of the patient in terms of disease condition or initial health status, the effects of treatment for a given condition and the preferences of patients.”
The article emphasizes that in an ideal doctor-patient relationship, the physician should be the perfect agent. In other words, the physician would have no objective other than ensuring the physical and mental well-being of the patient. The article then goes on to explain what can and does go wrong in this relationship, “Doctors have interests of their own—income, leisure, professional satisfaction, which are partially congruent and partly in conflict with that of the patient…consultations between doctor and patient often do not follow the classic agency pattern.” That is, the doctor makes most of, if not all, the decisions and patient, almost invariably, just goes along with it based on trust.
As an example, group practices or local physicians will occasionally pool resources to buy an item of specialized medical equipment and the capital expenditure necessary for such items can be high. Therefore, it will be necessary for the utilization of such equipment to be sufficient to allow the physicians to pay for the equipment over the period decided to amortize the value. Put another way, the doctors will have to use the machine on enough patients to generate enough income to make the payments. The temptations are obvious and the potential earnings, once the machine is paid for, can be enormous.
David Blumenthal M.D., MPP, is the Director of the Institute for Health Policy and a Physician at the Massachusetts General Hospital. He also lectures at Harvard Medical School. In a 2002 article in the Milbank Quarterly[2], Blumenthal describes information asymmetry as “an asymmetric competence between doctor and patient.” Blumenthal and others in the profession are concerned at the amount of information that is becoming available on the internet and how that might affect their “ownership” of specialized knowledge.
Blumenthal emphasizes that physicians have two main areas of responsibility. Citing another work[3], he includes these observations in the article,
“In the case of physicians, these skills enable them to diagnose, treat, comfort, and (on occasion) cure. The second attribute is moral. Professionals commit themselves to using their cognitive abilities for the benefit of those they serve. In the case of physicians, this means putting the interests of their patients ahead of their own. The moral basis of professionalism creates trust in the profession, which is crucial to the physicians' status in society and to the success.”
All very high-minded, but Blumenthal goes on to identify a third area of responsibility, which is collegial,
“A collective commitment to ensure the competence of the profession's members by means of self-monitoring and self-discipline…The collegial element of professionalism is essential because laypersons lack the competence to judge professionals' performance. In medicine, this attribute takes the form of peer review, which is recognized in statutes excluding from torts the proceedings of peer review from discovery.”
In effect, Blumenthal first acknowledges the professional obligations of physicians, but then endorses self-regulation, which among other things, ensures that any documented, self-regulation information cannot be made available for attorney discovery in lawsuits.
Repeatedly, in such industries as banking, air transportation and energy, “self-regulation” develops into “no regulation”, In other words professional entities are extremely unlikely to stop themselves doing things they like doing or that improve their overall income. There is no reason to suppose that the medical profession is any different in this respect. Almost all of the professions, including legal, the judiciary, financial, educators and medical have a tendency to believe themselves to be “above accountability” and this is understandable to a degree. However, all these professions protest vehemently at the very idea of their practices being open to outside appraisal or evaluation. They all, without exception, claim that outside agencies or lay people could not possibly understand the intricacies of their work and are therefore incompetent to make sound judgments about their profession. The suspicious unanimity of their protests, suggests that there is very good reason to open these occupations to the public gaze by both lay and peer-review. Cartels invariably act against the interests of the consumer – that is, after all, the intended consequence of a cartel.
Many commentators are critical of what they see as a commercially incestuous relationship between the main players of the medical industry – physicians, insurers and pharmaceutical companies. Physicians and insurers openly indulge in price fixing -seemingly immune to anti-trust legislation. Physicians routinely over-estimate the cost of procedures to compensate for the fact that medical insurance companies will expect a significant discount on these costs. Naturally, these costs are charged in full to uninsured patients who have no power to negotiate the fees (other than by declaring bankruptcy). Clearly, there is a need for a governing body to represent the interests of patients and physicians.
The American Medical Association (AMA) claims as its mission: “To promote the arts and science of medicine and the betterment of public health”. Unfortunately, the AMA represents only the interest of physicians in general. The AMA has stood, foursquare, in the way of any initiative that had the slightest possibility of reducing physician income. The AMA has systematically fought against the establishment of any form of national healthcare, early insurance schemes and Medicare. The AMA has used lobbyists and political donation to kill legislation with which it disagreed. The AMA has surcharged its members for a war chest against national health insurance and the AMA has threatened to expel members who do not follow their directives. This organization, although purporting to represent doctors and patients, has consistently favored physician income over the establishment of better health care for all. In effect, the AMA is a cartel of medical professionals. Perhaps the AMA would do better to look at the, sometimes murky, involvement of physicians in drug promotion.
In a refreshingly, honestly titled article, “Dr Drug Rep”, Dr. Daniel Carlat speaks frankly about his retention by Wyeth Pharmaceuticals as a promoter of the antidepressant drug “Effexor XR”. Dr. Carlat is an assistant clinical professor of psychiatry at Tufts University School of Medicine and the publisher of The Carlat Psychiatry Report. His article shows quite candidly, what can happen to a physician’s ethics when he or she is flattered and well compensated.[4]
Dr Carlat and his wife were entertained at a luxury, New York hotel by Wyeth Pharmaceuticals who also provided meals, lavish receptions, a Broadway show and a cash payment of $750. During the stay, Dr Carlat attended presentations by recognized experts in the field of psychiatry and psychopharmacology where the qualities and attributes of Effexor were promoted. Following his recruitment by Wyeth, Carlat spent several years presenting the drug to medical practices within his designated area. Carlat freely acknowledges misgivings from the start. He eventually became very uncomfortable with what he saw as poorly conducted research. Carlat indentified selective conclusions that both exaggerated the benefits and understated the side effects of Effexor. Dr Carlat confesses thus,
“Was I swallowing the message whole? Certainly not. I knew that this was hardly impartial medical education, and that we were being fed a marketing line. But when you are treated like the anointed, wined and dined in Manhattan and placed among the leaders of the field, you inevitably put some of your critical faculties on hold. I was truly impressed with Effexor’s remission numbers, and like any physician, I was hopeful that something new and different had been introduced to my quiver of therapeutic options.”
Note the use of the word “remission” rather than “response”. In medical jargon, “remission” signifies a degree of “cure”, Medications of this nature are usually said to have a “response”.
Specifically, Carlat came to realize that the benefits reported by Wyeth were based on atypical research subjects and that the side effects of hypertension and the potentially dangerous withdrawal symptoms were statistically significant. When Carlat attempted to highlight these characteristics of the drug, as a caveat in his presentations, Wyeth Pharmaceuticals immediately dropped him as a presenter. It is worth noting here that Federal Drug Administration (FDA) places no requirement upon physicians to report adverse side effects of drugs they prescribe. The FDA considers such a requirement to be an unacceptable reporting burden upon doctors.
Carlat admits to earning around $30,000 a year from Wyeth and confesses that the additional income encouraged him to gloss over discrepancies, which he justified as “not being lies”. He also suggests that one in four physicians in the United States become involved in commercially promoting pharmaceutical products – naturally all primary care physicians are exposed to focused sales presentations from all major pharmaceutical companies. He also notes that these pharmaceutical companies are armed with comprehensive data that illustrates physicians’ prescribing habits. Carlat remarks, “Naïve as I was, I found myself astonished at the level of detail that drug companies were able to acquire about doctors’ prescribing habits…”
In case there is any doubt, in the New England Journal of Medicine of June 29, 2006, Robert Steinbrook M.D. wrote in an article headed, “For Sale: Physicians’ prescribing data”, [5]
“Pharmaceutical companies monitor the return on investment of detailing[6]—and all promotional efforts—by prescription tracking. Information distribution companies, also called health information organizations (including IMS Health, Dendrite, Verispan, and Wolters Kluwer), purchase prescription records from pharmacies. The majority of pharmacies sell these records; IMS Health, the largest information distribution company, procures records on about 70% of prescriptions filled in community pharmacies.”
Using this information, drug companies’ target, particularly high-prescribing, physicians for concerted efforts at persuasive presentations to try to ensure their company is getting its share of the spoils. Some of these companies (including Wyeth) grade doctors according to the number of prescriptions they write. Carlat also notes that, “The American Medical Association is also a key player in prescription data-mining… The A.M.A. makes millions in information-leasing money.” These practices also make a good argument that the adverse effects of information asymmetry are present within the industry, between peers, as well as in the doctor-patient relationship.
In a May 2000 article entitled, “Is Academic Medicine for Sale?” [7] Marcia Angell M.D. broadened the issue to medical research and encapsulated the problem thus,
“What is at issue is not whether researchers can be "bought," in the sense of a quid pro quo. It is that close and remunerative collaboration with a company naturally creates goodwill on the part of researchers and the hope that the largesse will continue. This attitude can subtly influence scientific judgment in ways that may be difficult to discern. Can we really believe that clinical researchers are more immune to self-interest than other people?”
Decisions and opinions about the prevalence of unnecessary treatments or procedures or treatments withheld, are difficult to make and to quantify, if for no other reason than the people with definitive answers are those that may well stand accused. Reduced or induced treatments may be applied for reasons as diverse as uncertain diagnoses, group practice targets, a fear of litigation, the desire for a new car, paying kids’ college fees or simply professional avarice. In the areas where a degree of quantification is possible, all the evidence suggests that the medical profession is at least as likely to take advantage of information asymmetry as any other industry.
Patients have proven reasons to be suspicious of a health care system that perpetuates an environment where physicians are freely able to use their specialized knowledge to systematically modify their treatment programs for patients who place their trust them. Clearly, there is a price on the head of Hippocrates!
[1] Maynard, Alan DSc, Karen Bloor PhD. "Trust and performance in the medical marketplace." Journal of the Royal Society of medicine. November 2003.
[2] Blumenthal, David. "Milbank Memorial Fund." The Milbank Quarterly. Vol. 80, No. 3 (2002).
[3] Mechanic, D. 1996. Changing Medical Organization and the Erosion of Trust. Milbank Quarterly Vol. 74: 171-89.
[4] Carlat, Daniel. "Share and Discover the best of NYTimes.com." New York Times Magazine. November 29, 2007. http://www.nytimes.com/2007/11/25/magazine
[5] Steinbrook, Robert. "For Sale: Physician Prescribing Data." New England Journal of Medicine. June 29, 2006
[6] Detailing is the euphemistic name given to these training sessions at medical practices
[7] Angell, Marcia. "Is Academic Medicine for Sale." New England Journal of Medicine. May 18, 2000.
It would be idle, and very wrong, to say that all treatment decisions offered by all physicians are based on a desire to increase their own income or some other self-interested motive. Having said that, it would be equally irresponsible to maintain that all physicians always resist temptation to acquire additional revenue from easily performed (but maybe unnecessary) procedures and treatments, or that additional financial, or other, incentives from pharmaceutical companies never have an influence on prescriptions written.
If taking a section of tissue during a colonoscopy is but the work of a few more seconds, and means another $100.00 for the physician’s bank account, will the physician weigh the costs and benefits in his or the patients favor? What will the decision be when, prescribing a drug for high blood pressure, the physician chooses between a tried and trusted generic product and a new more expensive treatment that will earn a little financial or other incentive? Further, how many physicians subconsciously carry out unnecessary procedures or treatments with an institutionally ingrained pocket-lining motive, when a more conservative program could be equally efficacious and more cost-effective for the patient? Conversely, where there is a motive to limit or downgrade available and necessary treatments, how many practitioners withhold treatment for financial gain? Many physicians employed by health maintenance organizations have a financial incentive to limit and reduce treatment. Put another way, they make more money if they do not treat their patients, than if they do.
There is a natural tendency to take a cynical stance in looking at the consequences of information asymmetry. Many would contend that human nature is such, that any opportunity to get additional payment for services with a little “bending of the truth” or some judicial “withholding of information” is perfectly acceptable. It is after all the “American Way” - caveat emptor represents almost the whole gamut of consumer protection available in the United States. An exaggeration of course, but with malpractice lawsuits against physicians severely curtailed in some states, not entirely without justification.
Many professional people, including those involved in health care, do their jobs in an entirely honest and appropriate manner. They can show sensitivity to the means and situations of their clients or patients and will make sensible and balanced judgments out of respect for those parameters. However, there will always be those that cynically pillage their clients without mercy and without conscience. Almost certainly, there will be a statistical distribution; sadly, it is probably not going to be a “normal”, bell-curve distribution.
The Journal of the Royal Society of Medicine, a United Kingdom publication, looked at the subject of information asymmetry in 2003. The UK does not a have an open market-place system of health care, but some of these issues are still very pertinent.
“When there is uncertainty, information or knowledge becomes a commodity. Like other commodities, it has a cost of production and a cost of transmission, and so it is naturally not spread out over the entire population but concentrated among those who can profit most from it...”[1]
Succinctly and eloquently put! From the same article and more directly about health care,
“The market for healthcare is characterized by uncertainty and exchange of information… Sources of uncertainty include the classification of the patient in terms of disease condition or initial health status, the effects of treatment for a given condition and the preferences of patients.”
The article emphasizes that in an ideal doctor-patient relationship, the physician should be the perfect agent. In other words, the physician would have no objective other than ensuring the physical and mental well-being of the patient. The article then goes on to explain what can and does go wrong in this relationship, “Doctors have interests of their own—income, leisure, professional satisfaction, which are partially congruent and partly in conflict with that of the patient…consultations between doctor and patient often do not follow the classic agency pattern.” That is, the doctor makes most of, if not all, the decisions and patient, almost invariably, just goes along with it based on trust.
As an example, group practices or local physicians will occasionally pool resources to buy an item of specialized medical equipment and the capital expenditure necessary for such items can be high. Therefore, it will be necessary for the utilization of such equipment to be sufficient to allow the physicians to pay for the equipment over the period decided to amortize the value. Put another way, the doctors will have to use the machine on enough patients to generate enough income to make the payments. The temptations are obvious and the potential earnings, once the machine is paid for, can be enormous.
David Blumenthal M.D., MPP, is the Director of the Institute for Health Policy and a Physician at the Massachusetts General Hospital. He also lectures at Harvard Medical School. In a 2002 article in the Milbank Quarterly[2], Blumenthal describes information asymmetry as “an asymmetric competence between doctor and patient.” Blumenthal and others in the profession are concerned at the amount of information that is becoming available on the internet and how that might affect their “ownership” of specialized knowledge.
Blumenthal emphasizes that physicians have two main areas of responsibility. Citing another work[3], he includes these observations in the article,
“In the case of physicians, these skills enable them to diagnose, treat, comfort, and (on occasion) cure. The second attribute is moral. Professionals commit themselves to using their cognitive abilities for the benefit of those they serve. In the case of physicians, this means putting the interests of their patients ahead of their own. The moral basis of professionalism creates trust in the profession, which is crucial to the physicians' status in society and to the success.”
All very high-minded, but Blumenthal goes on to identify a third area of responsibility, which is collegial,
“A collective commitment to ensure the competence of the profession's members by means of self-monitoring and self-discipline…The collegial element of professionalism is essential because laypersons lack the competence to judge professionals' performance. In medicine, this attribute takes the form of peer review, which is recognized in statutes excluding from torts the proceedings of peer review from discovery.”
In effect, Blumenthal first acknowledges the professional obligations of physicians, but then endorses self-regulation, which among other things, ensures that any documented, self-regulation information cannot be made available for attorney discovery in lawsuits.
Repeatedly, in such industries as banking, air transportation and energy, “self-regulation” develops into “no regulation”, In other words professional entities are extremely unlikely to stop themselves doing things they like doing or that improve their overall income. There is no reason to suppose that the medical profession is any different in this respect. Almost all of the professions, including legal, the judiciary, financial, educators and medical have a tendency to believe themselves to be “above accountability” and this is understandable to a degree. However, all these professions protest vehemently at the very idea of their practices being open to outside appraisal or evaluation. They all, without exception, claim that outside agencies or lay people could not possibly understand the intricacies of their work and are therefore incompetent to make sound judgments about their profession. The suspicious unanimity of their protests, suggests that there is very good reason to open these occupations to the public gaze by both lay and peer-review. Cartels invariably act against the interests of the consumer – that is, after all, the intended consequence of a cartel.
Many commentators are critical of what they see as a commercially incestuous relationship between the main players of the medical industry – physicians, insurers and pharmaceutical companies. Physicians and insurers openly indulge in price fixing -seemingly immune to anti-trust legislation. Physicians routinely over-estimate the cost of procedures to compensate for the fact that medical insurance companies will expect a significant discount on these costs. Naturally, these costs are charged in full to uninsured patients who have no power to negotiate the fees (other than by declaring bankruptcy). Clearly, there is a need for a governing body to represent the interests of patients and physicians.
The American Medical Association (AMA) claims as its mission: “To promote the arts and science of medicine and the betterment of public health”. Unfortunately, the AMA represents only the interest of physicians in general. The AMA has stood, foursquare, in the way of any initiative that had the slightest possibility of reducing physician income. The AMA has systematically fought against the establishment of any form of national healthcare, early insurance schemes and Medicare. The AMA has used lobbyists and political donation to kill legislation with which it disagreed. The AMA has surcharged its members for a war chest against national health insurance and the AMA has threatened to expel members who do not follow their directives. This organization, although purporting to represent doctors and patients, has consistently favored physician income over the establishment of better health care for all. In effect, the AMA is a cartel of medical professionals. Perhaps the AMA would do better to look at the, sometimes murky, involvement of physicians in drug promotion.
In a refreshingly, honestly titled article, “Dr Drug Rep”, Dr. Daniel Carlat speaks frankly about his retention by Wyeth Pharmaceuticals as a promoter of the antidepressant drug “Effexor XR”. Dr. Carlat is an assistant clinical professor of psychiatry at Tufts University School of Medicine and the publisher of The Carlat Psychiatry Report. His article shows quite candidly, what can happen to a physician’s ethics when he or she is flattered and well compensated.[4]
Dr Carlat and his wife were entertained at a luxury, New York hotel by Wyeth Pharmaceuticals who also provided meals, lavish receptions, a Broadway show and a cash payment of $750. During the stay, Dr Carlat attended presentations by recognized experts in the field of psychiatry and psychopharmacology where the qualities and attributes of Effexor were promoted. Following his recruitment by Wyeth, Carlat spent several years presenting the drug to medical practices within his designated area. Carlat freely acknowledges misgivings from the start. He eventually became very uncomfortable with what he saw as poorly conducted research. Carlat indentified selective conclusions that both exaggerated the benefits and understated the side effects of Effexor. Dr Carlat confesses thus,
“Was I swallowing the message whole? Certainly not. I knew that this was hardly impartial medical education, and that we were being fed a marketing line. But when you are treated like the anointed, wined and dined in Manhattan and placed among the leaders of the field, you inevitably put some of your critical faculties on hold. I was truly impressed with Effexor’s remission numbers, and like any physician, I was hopeful that something new and different had been introduced to my quiver of therapeutic options.”
Note the use of the word “remission” rather than “response”. In medical jargon, “remission” signifies a degree of “cure”, Medications of this nature are usually said to have a “response”.
Specifically, Carlat came to realize that the benefits reported by Wyeth were based on atypical research subjects and that the side effects of hypertension and the potentially dangerous withdrawal symptoms were statistically significant. When Carlat attempted to highlight these characteristics of the drug, as a caveat in his presentations, Wyeth Pharmaceuticals immediately dropped him as a presenter. It is worth noting here that Federal Drug Administration (FDA) places no requirement upon physicians to report adverse side effects of drugs they prescribe. The FDA considers such a requirement to be an unacceptable reporting burden upon doctors.
Carlat admits to earning around $30,000 a year from Wyeth and confesses that the additional income encouraged him to gloss over discrepancies, which he justified as “not being lies”. He also suggests that one in four physicians in the United States become involved in commercially promoting pharmaceutical products – naturally all primary care physicians are exposed to focused sales presentations from all major pharmaceutical companies. He also notes that these pharmaceutical companies are armed with comprehensive data that illustrates physicians’ prescribing habits. Carlat remarks, “Naïve as I was, I found myself astonished at the level of detail that drug companies were able to acquire about doctors’ prescribing habits…”
In case there is any doubt, in the New England Journal of Medicine of June 29, 2006, Robert Steinbrook M.D. wrote in an article headed, “For Sale: Physicians’ prescribing data”, [5]
“Pharmaceutical companies monitor the return on investment of detailing[6]—and all promotional efforts—by prescription tracking. Information distribution companies, also called health information organizations (including IMS Health, Dendrite, Verispan, and Wolters Kluwer), purchase prescription records from pharmacies. The majority of pharmacies sell these records; IMS Health, the largest information distribution company, procures records on about 70% of prescriptions filled in community pharmacies.”
Using this information, drug companies’ target, particularly high-prescribing, physicians for concerted efforts at persuasive presentations to try to ensure their company is getting its share of the spoils. Some of these companies (including Wyeth) grade doctors according to the number of prescriptions they write. Carlat also notes that, “The American Medical Association is also a key player in prescription data-mining… The A.M.A. makes millions in information-leasing money.” These practices also make a good argument that the adverse effects of information asymmetry are present within the industry, between peers, as well as in the doctor-patient relationship.
In a May 2000 article entitled, “Is Academic Medicine for Sale?” [7] Marcia Angell M.D. broadened the issue to medical research and encapsulated the problem thus,
“What is at issue is not whether researchers can be "bought," in the sense of a quid pro quo. It is that close and remunerative collaboration with a company naturally creates goodwill on the part of researchers and the hope that the largesse will continue. This attitude can subtly influence scientific judgment in ways that may be difficult to discern. Can we really believe that clinical researchers are more immune to self-interest than other people?”
Decisions and opinions about the prevalence of unnecessary treatments or procedures or treatments withheld, are difficult to make and to quantify, if for no other reason than the people with definitive answers are those that may well stand accused. Reduced or induced treatments may be applied for reasons as diverse as uncertain diagnoses, group practice targets, a fear of litigation, the desire for a new car, paying kids’ college fees or simply professional avarice. In the areas where a degree of quantification is possible, all the evidence suggests that the medical profession is at least as likely to take advantage of information asymmetry as any other industry.
Patients have proven reasons to be suspicious of a health care system that perpetuates an environment where physicians are freely able to use their specialized knowledge to systematically modify their treatment programs for patients who place their trust them. Clearly, there is a price on the head of Hippocrates!
[1] Maynard, Alan DSc, Karen Bloor PhD. "Trust and performance in the medical marketplace." Journal of the Royal Society of medicine. November 2003.
[2] Blumenthal, David. "Milbank Memorial Fund." The Milbank Quarterly. Vol. 80, No. 3 (2002).
[3] Mechanic, D. 1996. Changing Medical Organization and the Erosion of Trust. Milbank Quarterly Vol. 74: 171-89.
[4] Carlat, Daniel. "Share and Discover the best of NYTimes.com." New York Times Magazine. November 29, 2007. http://www.nytimes.com/2007/11/25/magazine
[5] Steinbrook, Robert. "For Sale: Physician Prescribing Data." New England Journal of Medicine. June 29, 2006
[6] Detailing is the euphemistic name given to these training sessions at medical practices
[7] Angell, Marcia. "Is Academic Medicine for Sale." New England Journal of Medicine. May 18, 2000.
Monday, August 31, 2009
Media, Journalists and Gatekeeping
Here is an interesting (but quite long) transcript of a speech about the future of media and the possibility that we might have to buy our hard news in the future. http://www.bbc.co.uk/blogs/thereporters/robertpeston/2009/08/what_future_for_media_and_jour.html
Note that the context is UK based - but in today's world these are global issues. I agree wholeheartedly with his views on the international banking scene
Note that the context is UK based - but in today's world these are global issues. I agree wholeheartedly with his views on the international banking scene
Friday, August 28, 2009
Teddy Kennedy
In a eulogy delivered at the funeral of his murdered brother Robert, Senator Edward Kennedy made the following observation, “My brother need not be idealized, or enlarged in death beyond what he was in life; to be remembered simply as a good and decent man, who saw wrong and tried to right it, saw suffering and tried to heal it, saw war and tried to stop it."
Maybe the same philosophy should be applied to Teddy Kennedy himself – a man who has swung between the depths of outrageous abuses of position and the pinnacles of generous and far-sighted philanthropy. Some have argued that the Massachusetts senatorial selection process was manipulated to ensure his appointment to the United States Senate. Even if that was the case, he subsequently served as an influential member of that august body for the rest of his life.
It is hard to believe that the incident at Chappaquiddick which resulted in the truly horrific death of Mary Jo Kopechne neither saw Senator Kennedy jailed for a long time nor destroyed his political career. If he had been jailed or his career finished, the ordinary people of this country would undoubtedly be worse off. Having said that it appears to be quite clear that Kennedy left this poor woman to die and equally clear that the Kennedy family influenced due processes of law to prevent the level of prosecution that would been applied to a lesser citizen.
Maybe this was a man that learnt from his experiences. As an Englishman I was angry that his early career comments in respect of a united Ireland gave legitimacy to the fund-raising efforts of Noraid. Funds that most commentators believe reached the IRA, helping to pay for their terrorist activities. In later years, Senator Kennedy contributed much to the peace process of Northern Ireland. Alliance leader David Ford summed up his contribution: "He helped to widen the vision of Irish Americans to the realities of Northern Ireland and will be remembered for the part he played in our peace process.”
On balance I believe he was a fine senator. I also believe that his forte was working behind the forefront of national government. In his later years he was a compassionate and caring individual who championed the causes of those United States citizens who would otherwise have little chance of being heard. I don't know whether he will rest in peace or burn in hell, but the world is a little poorer for his passing.
Maybe the same philosophy should be applied to Teddy Kennedy himself – a man who has swung between the depths of outrageous abuses of position and the pinnacles of generous and far-sighted philanthropy. Some have argued that the Massachusetts senatorial selection process was manipulated to ensure his appointment to the United States Senate. Even if that was the case, he subsequently served as an influential member of that august body for the rest of his life.
It is hard to believe that the incident at Chappaquiddick which resulted in the truly horrific death of Mary Jo Kopechne neither saw Senator Kennedy jailed for a long time nor destroyed his political career. If he had been jailed or his career finished, the ordinary people of this country would undoubtedly be worse off. Having said that it appears to be quite clear that Kennedy left this poor woman to die and equally clear that the Kennedy family influenced due processes of law to prevent the level of prosecution that would been applied to a lesser citizen.
Maybe this was a man that learnt from his experiences. As an Englishman I was angry that his early career comments in respect of a united Ireland gave legitimacy to the fund-raising efforts of Noraid. Funds that most commentators believe reached the IRA, helping to pay for their terrorist activities. In later years, Senator Kennedy contributed much to the peace process of Northern Ireland. Alliance leader David Ford summed up his contribution: "He helped to widen the vision of Irish Americans to the realities of Northern Ireland and will be remembered for the part he played in our peace process.”
On balance I believe he was a fine senator. I also believe that his forte was working behind the forefront of national government. In his later years he was a compassionate and caring individual who championed the causes of those United States citizens who would otherwise have little chance of being heard. I don't know whether he will rest in peace or burn in hell, but the world is a little poorer for his passing.
Wednesday, August 19, 2009
Interesting Take on The healthcare Debate
Here is a very informative article about the priorities and discrepencies in US Healthcare.
http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?currentPage=all
If this is the way that costs of healthcare are taking - 20% of GDP is getting very close!
http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?currentPage=all
If this is the way that costs of healthcare are taking - 20% of GDP is getting very close!
What-Ball?
I come from England where the men play football (soccer) in the winter and cricket (when it’s not raining) in the summer. Soccer is a man’s game played by psychopaths and hooligans. Cricket is a gentleman’s game played by amateurs for the enjoyment of the open air but by professionals (or people from northern England) like a Jihad with attitude.
I only mention this in passing because the other day I had the dubious pleasure of watching my grandsons playing baseball. We didn’t have baseball in England – the closest comparison is a game called “rounders” played by high school girls. This observation is not intended as a comparison, merely to put my viewpoint into context.
My wife and I pulled in the parking lot alongside the playing field and parked our modest Japanese compact car amongst the huge trucks and SUVs that dominated the car park. “Is there a gas guzzler convention here as well?” I inquired of my beloved, “No.” she replied, a little tersely I thought, “They have to bring all the equipment as well as the boys.”
I considered this quietly, on the basis that this might be a safer option. I was already sensing an increased level of unexplained tension as we approached what appeared to be a gladiators’ arena.
As we drew closer I became aware of raucous shouting and piles of very expensive looking “stuff”. Running around in what looked like a large animal pen, were vast numbers of identically armor-plated young boys all of whom had stern countenances. Some of the more aggressive combatants would occasionally spit. They must have been practicing this “voiding of rheum”, because they were frighteningly adept at it. I tried to see the tell-tale shape of a “Copenhagen” can in their pockets but was unable to establish any positive identification.
I had been expecting a gentle game of ball with many rules relaxed and much leeway granted in consideration of these physically undeveloped youngsters. I was in error! These games are played with a determination and a fierceness that would give credit (or discredit) to any clash of the Boston Blue-Bras and the New York Wankees.
Coaches were screaming at their players and at the officials while the young players were checking the boundaries of acceptable expletives. They need not have worried for the many parents and other relatives (or perhaps kin) were too busy screaming encouragement and vindictive vilification at (mostly) the players to notice any subtlety of language elsewhere. The gamesmanship deserves a mention here. I saw a diminutive catcher twice hit encroaching players with the ball, both of whom then completed their runs off the ricochet – one crying tears of pain – what dedication!
I was truly shocked; I hadn’t seen this level of violence since watching parents trying to park close to school to pick up their children; or since last Christmas watching late shoppers fight for the carts at the grocery store.
Fellers, it’s only a game – it’s not worth dying for. You are supposed to enjoy the actual playing of the sport, not indulge in it as a vehicle to humiliate some other boys while crowing about how good you are. Where are your ideas of man’s humanity to man?
I only mention this in passing because the other day I had the dubious pleasure of watching my grandsons playing baseball. We didn’t have baseball in England – the closest comparison is a game called “rounders” played by high school girls. This observation is not intended as a comparison, merely to put my viewpoint into context.
My wife and I pulled in the parking lot alongside the playing field and parked our modest Japanese compact car amongst the huge trucks and SUVs that dominated the car park. “Is there a gas guzzler convention here as well?” I inquired of my beloved, “No.” she replied, a little tersely I thought, “They have to bring all the equipment as well as the boys.”
I considered this quietly, on the basis that this might be a safer option. I was already sensing an increased level of unexplained tension as we approached what appeared to be a gladiators’ arena.
As we drew closer I became aware of raucous shouting and piles of very expensive looking “stuff”. Running around in what looked like a large animal pen, were vast numbers of identically armor-plated young boys all of whom had stern countenances. Some of the more aggressive combatants would occasionally spit. They must have been practicing this “voiding of rheum”, because they were frighteningly adept at it. I tried to see the tell-tale shape of a “Copenhagen” can in their pockets but was unable to establish any positive identification.
I had been expecting a gentle game of ball with many rules relaxed and much leeway granted in consideration of these physically undeveloped youngsters. I was in error! These games are played with a determination and a fierceness that would give credit (or discredit) to any clash of the Boston Blue-Bras and the New York Wankees.
Coaches were screaming at their players and at the officials while the young players were checking the boundaries of acceptable expletives. They need not have worried for the many parents and other relatives (or perhaps kin) were too busy screaming encouragement and vindictive vilification at (mostly) the players to notice any subtlety of language elsewhere. The gamesmanship deserves a mention here. I saw a diminutive catcher twice hit encroaching players with the ball, both of whom then completed their runs off the ricochet – one crying tears of pain – what dedication!
I was truly shocked; I hadn’t seen this level of violence since watching parents trying to park close to school to pick up their children; or since last Christmas watching late shoppers fight for the carts at the grocery store.
Fellers, it’s only a game – it’s not worth dying for. You are supposed to enjoy the actual playing of the sport, not indulge in it as a vehicle to humiliate some other boys while crowing about how good you are. Where are your ideas of man’s humanity to man?
“What’s that, my love? Oh, okay – Way to go Guys!”
Tuesday, August 18, 2009
But me no Butts!
Why do people talk about “my” surgeon, or “my” endocrinologist? Listen to me people, they are not yours – they are anybody’s who can pay or who has insurance! Personally, I do not share your delight to hear that “my gynecologist goes to our church.” and is always, “willing to lend a hand at the BBQ.” Lady, believe me, I would rather not know if your “gyny” has had a hand in the potato salad, in fact, given the choice, I would rather not live in the same town as a proctologist!
Which brings me to the point of this article – colonoscopy. Just what sort of person is it that sat down and suddenly thought that pushing a tube fitted with a camera up all and sundry’s rectum was a good idea? I had the misfortune (against my better judgment) to undergo this procedure recently. I should have realized at the first appointment when approximately 1500 patients were gathered in a small waiting room – all with an appointment at 1:00 p.m., that this was not going to be pleasant. Colonoscopies are all about physician profits. Do the math. I exaggerated the 1500, there were only about 30, but you know there was going to be another 30 at 2:00 p.m. and another 30 on the hour, every hour until 6:00 p.m. So 150 @ $140.00 grosses out (in more ways than one) to $21,000. The subsequent procedure generates another $1500 per patient which (allowing for a 25% chickening out) nets $168,000. Lab fees for sections taken, whether necessary or not, earns $22,000 in butt end bonuses.
Leaving the initial appointment, you will be provided with a fistful of prescriptions “loosely” designed to clean out your system the day before your “procedure”.
You may have heard of a medical condition known as “projectile vomiting”. There is another condition (not talked about in polite circles, but fair game here) called “pressure hose motioning”*. By the time you go to bed the night before (having fasted all day) two 18-wheelers traveling side by side, could drive comfortably through your intestines. To add insult to injury and humiliation, you are required to take not one, but TWO enemas the following morning. The procedure itself is not too bad (Yea Demerol!!!) And afterwards the doctor will spend 12.75 seconds telling your “companion” what he found, and that the report on the healthy tissue he lasered from your colon, will take ten days to come in. The patient is then taken to a recovery room where a great deal of gas is passed in the company of 29 strangers who are also passing copious amounts of gas.
This is truly a miracle of modern medicine and economics.
* Actually the real name is far more graphic!
Which brings me to the point of this article – colonoscopy. Just what sort of person is it that sat down and suddenly thought that pushing a tube fitted with a camera up all and sundry’s rectum was a good idea? I had the misfortune (against my better judgment) to undergo this procedure recently. I should have realized at the first appointment when approximately 1500 patients were gathered in a small waiting room – all with an appointment at 1:00 p.m., that this was not going to be pleasant. Colonoscopies are all about physician profits. Do the math. I exaggerated the 1500, there were only about 30, but you know there was going to be another 30 at 2:00 p.m. and another 30 on the hour, every hour until 6:00 p.m. So 150 @ $140.00 grosses out (in more ways than one) to $21,000. The subsequent procedure generates another $1500 per patient which (allowing for a 25% chickening out) nets $168,000. Lab fees for sections taken, whether necessary or not, earns $22,000 in butt end bonuses.
Leaving the initial appointment, you will be provided with a fistful of prescriptions “loosely” designed to clean out your system the day before your “procedure”.
You may have heard of a medical condition known as “projectile vomiting”. There is another condition (not talked about in polite circles, but fair game here) called “pressure hose motioning”*. By the time you go to bed the night before (having fasted all day) two 18-wheelers traveling side by side, could drive comfortably through your intestines. To add insult to injury and humiliation, you are required to take not one, but TWO enemas the following morning. The procedure itself is not too bad (Yea Demerol!!!) And afterwards the doctor will spend 12.75 seconds telling your “companion” what he found, and that the report on the healthy tissue he lasered from your colon, will take ten days to come in. The patient is then taken to a recovery room where a great deal of gas is passed in the company of 29 strangers who are also passing copious amounts of gas.
This is truly a miracle of modern medicine and economics.
* Actually the real name is far more graphic!
Falling Back Into Spring
Daylight saving time was introduced by caring administrations concerned that the people with real jobs had to travel to work in the dark and also to return home in the dark. Politicians were not really affected by this as they never rise before 11:00 A.M. and, in any event, are driven around by somebody else. Of course this time change only worked in the middle latitudes. During the deep winter, places like Scotland and Canada only get about five or six hours of daylight, so messing about with time just confuses these third world countries that already have more than enough problems just coping with modern life.
In the tropics, it’s light from about six in the morning to around six in the evening. No one gets up before eight and by the time it gets dark they are too inebriated to notice whether it’s dark or light. Besides, it’s far too hot to look for the directions on how to change the time on your digital calypso sundial.
It follows therefore, ipso facto (as we educated people are prone to observe), that only people in national capitals like London, Washington and Tokyo even notice any difference. All people who work in these cities are professional “brown-nosers” who arrive for work an hour early and leave an hour late – so they probably don’t notice either – unless they’re driving politicians.
Some people in Mentone, Texas (possibly both of them) have been known to wonder why their clocks go wrong by an hour in spring and then spontaneously recover in the fall.
“Boy!” shouted the teacher, “you are two hours late - explain yourself.”
“Well,” said the boy, “it’s like this sir, I knew we had to change the clocks yesterday, but we couldn’t remember if they went forward or back. So my dad and I worked on an algebraic equation to help us, and this is what we decided.” With chalk in hand, the boy approaches the blackboard, faces the class and with an endearing smile speaks thus, while writing furiously:
“If x = the clock in the den and y = the daylight hours between when I woke up and when I got up, then “ab” must equal the difference between Central Standard time and Mountain time multiplied by granules in the cat litter. So if “ab” smells bad (which it does) then we couldn’t count them all. An estimated 347 to the power of the cat equals the square root of the crop from the back 40. We didn’t get any crops from the back 40 because of root-rot, so that made zero. If y = 2 and there is just one clock in the den, this is what we get:”
“y – x (ab * ba) + √ 2(gross cat-litter) – (- rotten turnip) = +1”
“So,” said the boy, “we put the clock forward by one hour.”
“The clocks were supposed to go forward an hour,” said the now fuming teacher, “so why are you two hours late?”
“Oh, I overslept!”
In the tropics, it’s light from about six in the morning to around six in the evening. No one gets up before eight and by the time it gets dark they are too inebriated to notice whether it’s dark or light. Besides, it’s far too hot to look for the directions on how to change the time on your digital calypso sundial.
It follows therefore, ipso facto (as we educated people are prone to observe), that only people in national capitals like London, Washington and Tokyo even notice any difference. All people who work in these cities are professional “brown-nosers” who arrive for work an hour early and leave an hour late – so they probably don’t notice either – unless they’re driving politicians.
Some people in Mentone, Texas (possibly both of them) have been known to wonder why their clocks go wrong by an hour in spring and then spontaneously recover in the fall.
“Boy!” shouted the teacher, “you are two hours late - explain yourself.”
“Well,” said the boy, “it’s like this sir, I knew we had to change the clocks yesterday, but we couldn’t remember if they went forward or back. So my dad and I worked on an algebraic equation to help us, and this is what we decided.” With chalk in hand, the boy approaches the blackboard, faces the class and with an endearing smile speaks thus, while writing furiously:
“If x = the clock in the den and y = the daylight hours between when I woke up and when I got up, then “ab” must equal the difference between Central Standard time and Mountain time multiplied by granules in the cat litter. So if “ab” smells bad (which it does) then we couldn’t count them all. An estimated 347 to the power of the cat equals the square root of the crop from the back 40. We didn’t get any crops from the back 40 because of root-rot, so that made zero. If y = 2 and there is just one clock in the den, this is what we get:”
“y – x (ab * ba) + √ 2(gross cat-litter) – (- rotten turnip) = +1”
“So,” said the boy, “we put the clock forward by one hour.”
“The clocks were supposed to go forward an hour,” said the now fuming teacher, “so why are you two hours late?”
“Oh, I overslept!”
Fruit Cake
In the aftermath of the 2008 election and her resignation as governor of Alaska, it is interesting to look again at vice-presidential candidate, Sarah Palin’s concerns over her treatment at the hands of the media. Someone (I forget who) much cleverer than I, once remarked, “Intelligence is relative, it depends on the company you keep.”
It is certainly unfair and probably untrue to label Governor Palin as unintelligent or uneducated. People do not get to hold and retain public office without some degree of ability and the GOP would surely not have endorsed a candidate who was considered unintelligent or uneducated. So what was the problem?
Most dictionaries define unintelligent as “without intelligence” and uneducated as “without education” – well duh! Educated simply means “having received education” so, as a general understanding, educated means schooled or perhaps trained. Intelligence however, according to the Oxford English Dictionary, is defined as, “Understanding as a quality of admitting of degree; quickness of mental apprehension, sagacity.” Quite clearly, Governor Palin is neither uneducated nor unintelligent but, equally clearly there was a very serious deficiency in her ability to respond effectively to journalists’ questions.
Here is a somewhat gauche and clumsy word for consideration - unknowledgeable. Microsoft’s spell-check does not appear to reject this word, but my OED does not list it. Accepting that this possible non-word is the antonym of knowledgeable, the definition of unknowledgeable would be: “not possessing, or showing knowledge or mental capacity and not well-informed.”
The difference in meaning between unintelligent and unknowledgeable might be considered subtle, but the difference is nevertheless significant and crucial. For example, a graduate with a cum laude degree in journalism is highly unlikely to be unintelligent, yet may very well be unknowledgeable. Knowledge in this context is concerned with worldly matters. It is an accumulation of knowledge from a rich and varied array of sources over an extended period of time. It is also a never-ending mission and desire to know about “stuff” and to be able to use an inherent intelligence that allows an appropriate and contextual appraisal of that “stuff”.
This is, in my opinion, where Palin had difficulties – she doesn’t have knowledge of the subjects necessary to be an effective statesperson and showed little inclination to become absorbed and involved in those subjects. I get the distinct impression that, like many ideologically confined individuals, Palin’s views and beliefs have been formed and are now set in stone. She sees no need to absorb or assimilate new information or additional knowledge, especially if that information is at odds with her particular doctrine.
Prefabricated opinions and cute one-liners are no substitute for a deep and worldly knowledge.
It is certainly unfair and probably untrue to label Governor Palin as unintelligent or uneducated. People do not get to hold and retain public office without some degree of ability and the GOP would surely not have endorsed a candidate who was considered unintelligent or uneducated. So what was the problem?
Most dictionaries define unintelligent as “without intelligence” and uneducated as “without education” – well duh! Educated simply means “having received education” so, as a general understanding, educated means schooled or perhaps trained. Intelligence however, according to the Oxford English Dictionary, is defined as, “Understanding as a quality of admitting of degree; quickness of mental apprehension, sagacity.” Quite clearly, Governor Palin is neither uneducated nor unintelligent but, equally clearly there was a very serious deficiency in her ability to respond effectively to journalists’ questions.
Here is a somewhat gauche and clumsy word for consideration - unknowledgeable. Microsoft’s spell-check does not appear to reject this word, but my OED does not list it. Accepting that this possible non-word is the antonym of knowledgeable, the definition of unknowledgeable would be: “not possessing, or showing knowledge or mental capacity and not well-informed.”
The difference in meaning between unintelligent and unknowledgeable might be considered subtle, but the difference is nevertheless significant and crucial. For example, a graduate with a cum laude degree in journalism is highly unlikely to be unintelligent, yet may very well be unknowledgeable. Knowledge in this context is concerned with worldly matters. It is an accumulation of knowledge from a rich and varied array of sources over an extended period of time. It is also a never-ending mission and desire to know about “stuff” and to be able to use an inherent intelligence that allows an appropriate and contextual appraisal of that “stuff”.
This is, in my opinion, where Palin had difficulties – she doesn’t have knowledge of the subjects necessary to be an effective statesperson and showed little inclination to become absorbed and involved in those subjects. I get the distinct impression that, like many ideologically confined individuals, Palin’s views and beliefs have been formed and are now set in stone. She sees no need to absorb or assimilate new information or additional knowledge, especially if that information is at odds with her particular doctrine.
Prefabricated opinions and cute one-liners are no substitute for a deep and worldly knowledge.
Corporate Greed
When John Thain, former CEO of ill-fated Merrill Lynch, commissioned a $1.2 million refit of his offices in Lower Manhattan, it was just another illustration of the callous insensitivity that abounds in high-profile corporate life. Ranking CEOs in the troubled financial, insurance and automobile industries have an unfortunate tendency to see themselves as exempt from the financial exigencies that should have been applied to their organizations. When General Motors executives flew with the begging bowls to Washington in their corporate jets, one wonders how they could not have anticipated the fuss that such crass insensitivity would generate. Even more incredible was the stupidity of making a second trip using GM vehicles – a vacuous publicity exercise that fooled nobody and probably made their arrival somewhat uncertain. Scheduled flights (in coach) would have been so much more sensible and efficient!
Mr. Thain has offered to repay the exorbitant refurbishment costs out of the $10 million bonus he hopes to get, after depleting the value of the company by a reported 73 percent – well isn’t he special! There is, however, a much broader and more important issue present here that goes right to the very core of carrying out business in an honorable way.
These days, chief executive officers seldom own the businesses they direct and manage. Fundamentally, they are employees. Worse than that, they are temporary employees on a short to medium term contract. Even worse than that, all their senior company officials are employed under the same criteria. Worst of all though, this entire situation creates a self-perpetuating cartel of senior managers who have no vested interest in the long-term financial health of the organizations they run.
It is a fact that nobody looks after your things better than you do. The more control that someone has of what was once yours; the worse will be the condition when you eventually get it back. The owners these days are normally the shareholders; CEOs are the borrowers - transient workers putting in a couple of years’ labor between wives.
So, what is wrong in appointing high-caliber, high-performing professionals to manage blue-chip companies? In theory, absolutely nothing! The problems arise when these individuals are retained on contracts that will last only two or three years. Inevitably, because of the short-term nature of these contracts, huge value performance bonuses and/or golden parachutes are negotiated as part of the contract. Vulgar human avarice will then supersede any pretense of honorable business practice. Long term sustainable growth will be suffocated under a blanket of spectacular volume growth, powered by the fossil fools of creative accounting. By the time the laundry hits the fan that cools the can of worms, Mr. or Ms. CEO has moved on elsewhere.
As a subprime example, look at the high risk mortgages that were the first positive indicators of the coming melt-down. All the primary instigators of this savagely unethical practice would have known that these loans were not viable in the long-term, but, yet again, when things started to go wrong, they had all moved on to pastures new, leaving the mess for others to deal with.
Self-regulation and deregulation (and the SEC) mean just one thing – no regulation! Sir Edward Heath, a former Conservative prime minister of the UK, often talked about the unacceptable face of capitalism and this is the face that is staring at us now. The most bizarre aspect of this whole sorry affair is that those people responsible for this disaster are just going to walk freely away from that responsibility. They know, but do not care, about the heartache and despair they have caused – just so much grist to their particular mill. What say you Mr. Madoff?
As always, I’m just sayin’.
Mr. Thain has offered to repay the exorbitant refurbishment costs out of the $10 million bonus he hopes to get, after depleting the value of the company by a reported 73 percent – well isn’t he special! There is, however, a much broader and more important issue present here that goes right to the very core of carrying out business in an honorable way.
These days, chief executive officers seldom own the businesses they direct and manage. Fundamentally, they are employees. Worse than that, they are temporary employees on a short to medium term contract. Even worse than that, all their senior company officials are employed under the same criteria. Worst of all though, this entire situation creates a self-perpetuating cartel of senior managers who have no vested interest in the long-term financial health of the organizations they run.
It is a fact that nobody looks after your things better than you do. The more control that someone has of what was once yours; the worse will be the condition when you eventually get it back. The owners these days are normally the shareholders; CEOs are the borrowers - transient workers putting in a couple of years’ labor between wives.
So, what is wrong in appointing high-caliber, high-performing professionals to manage blue-chip companies? In theory, absolutely nothing! The problems arise when these individuals are retained on contracts that will last only two or three years. Inevitably, because of the short-term nature of these contracts, huge value performance bonuses and/or golden parachutes are negotiated as part of the contract. Vulgar human avarice will then supersede any pretense of honorable business practice. Long term sustainable growth will be suffocated under a blanket of spectacular volume growth, powered by the fossil fools of creative accounting. By the time the laundry hits the fan that cools the can of worms, Mr. or Ms. CEO has moved on elsewhere.
As a subprime example, look at the high risk mortgages that were the first positive indicators of the coming melt-down. All the primary instigators of this savagely unethical practice would have known that these loans were not viable in the long-term, but, yet again, when things started to go wrong, they had all moved on to pastures new, leaving the mess for others to deal with.
Self-regulation and deregulation (and the SEC) mean just one thing – no regulation! Sir Edward Heath, a former Conservative prime minister of the UK, often talked about the unacceptable face of capitalism and this is the face that is staring at us now. The most bizarre aspect of this whole sorry affair is that those people responsible for this disaster are just going to walk freely away from that responsibility. They know, but do not care, about the heartache and despair they have caused – just so much grist to their particular mill. What say you Mr. Madoff?
As always, I’m just sayin’.
Do They Play Cricket?
Any criticism of cricket is justifiable grounds for regime change and nation building. As agreed in a recent college class on terrorism, cricket when played properly (i.e. to lose) is the drinking man's baseball. For the sake of clarity, no Englishman can discuss terrorism and cricket at the same time, because global terrorism is quite simply “just not cricket”.
Cricket can be contrasted to modern foreign policy because, played properly, the very idea of a "we win, you lose" premise is not an issue. Cricket, particularly global-village cricket, has to be played with either a lose-lose or lose-win philosophy. The exceptions to this are Australia and South Africa who both practice beforehand (which is unsporting) and cannot tell the difference between cricket and foreign policy anyway. Countries that do not play cricket are seldom, if ever, successful in the foreign relations aspects of government.
Lose-Lose cricket is played when a team travels a long way, only for the long and very dull game to be declared a draw. It is also associated with poor quality meals, no sense of humor, little or no alcohol and little in the way of entertainment. Some individuals (not this author) maintain that Pakistan has suffered criticism in this respect. It is to be hoped that Pakistan’s recent defeat by the Republic of Ireland will encourage the consumption of Guinness in Islamabad and increase the longevity amongst cricket coaches.
The Win-Lose policy is only maintained by sides that actually think the result is important. In this situation the losing side, usually the home side, out of consideration for their guests, will merely watch with amused detachment while the other team, who have obviously been practicing, run themselves ragged in a maniacal desire to win. Naturally after the game is over the home side is full of praise for the victors, safe in the knowledge that when they have gone home, not much will have changed and they can go on as before. Any resemblance to US policy in the Middle East is purely fortuitous.
As everyone knows the British have perfected the Lose-Win philosophy to a fine art. Apart from 1966 when England won the world cup and again in 2003 when they won the rugby world championship in Australia (just to piss-off Australian prime minister, John Howard) the British have skillfully lost just about everything. The thing is they have done it so politely and with such sensitivity that nobody except the English realizes it.
Some individuals have perceptively compared England’s loss of cricket games to countries like Ireland and Sri Lanka as similar to the loss of an empire and previously the loss of the new-world colonies. The contention was that the captain of the global-village cricket team, called George #3 and generally recognized as “one stump short of a wicket”, lost the new world colonies in a game of hazard while waiting for the rain to stop. It didn’t help that the French do not play cricket. Come to think of it, what do the French play? Oh yes! Football, rugby, losing wars, breathing garlic fumes, ignoring EU directives, getting married, disagreeing with everybody and unacceptable interference in foreign affairs.
I digress.
England (I purposefully exclude the hostile colonies of Scotland and Wales) lost its empire that had been built up by a sensitive and caring policy of assimilation, physical abuse, commercial rape and democracy. Actually that was very unfair about Scotland and Wales and I unreservedly and insincerely apologize. Both these countries now have a degree of self-determination, totally financed by the English taxpayers and now have double representation without taxation (they are all unemployed). The Welsh coalmining industry was decimated by a Canadian and a well-balanced Yorkshire Tyke (he had equally sized chips on both shoulders). So with little to occupy the minds of the Welsh people, the local sheep became very preoccupied and anxious.
Once the offshore reserves of fossil fuels were gone, Scotland was also given its own assembly. The Scots are now freely able to smoke heavily, fight in pubs, eat saturated fats and support England’s opponents in any sporting event. You will note that both these countries do play a little cricket, but neither plays it well enough to gain a meaningful contribution to the international community - although both teams could beat Canada. If it seems I have a “down” on Canada you are perfectly correct. As a communications major I learned to despise all the communication experts that country has birthed. Sorry Mr. McLuhan and Mr. Innis but my message is not in the method and I don’t care two hoots for Minerva’s Owl. Also, although Canada does have a cricket team, it is entirely made up of immigrants from the Caribbean and the Sub-Continent and Canada is too far way from anywhere else to engage in foreign affairs. They do think winning is important but cannot remember why.
If Afghanistan weren’t so hilly the English would have succeeded in their 19th century invasion and they would have taught the tribes to play cricket, thus allowing them to vent their aggression on the field of play instead of killing each other. Afghanistan would have then become independent but would still have liked England because they would win their cricket games against them. It is important to realize that the Soviet Union never played cricket. If they had the West would have lost the cold war, but would never have realized it because it would have been done so politely and sensitively.
England taught the hotter parts of the empire to play cricket and taught Canada how to brew ale. Unfortunately the Canadians then passed legislation that made it next to impossible to buy it. This legislation was relaxed during the United States period of prohibition to allow the alcoholic equivalent of sixteen Niagara Falls to flow into the United States every 8.73 minutes. Had the Canadian weather been better and they had been taught to play cricket earlier, the French would have left much sooner (taking Quebec with them) to pursue foreign policy in Syria and Lebanon. If that had happened the area would be much more peaceful now and that nice Mr. Rumsfeld would have been repelled by a wave of garlic fumes that would make WMDs redundant.
I trigress!
Once the English taught these countries of the benevolent empire to play cricket or brew ale, then it was clear they would practice these skills and eventually the Brits would be forced out. Properly coached in the art of wrist-spin bowling, Gandhi could have played cricket up to UN standards – he might even have been good at it. Of course that white frock he always wore would have to go, unless they moved the UN HQ to San Francisco, Sydney or Mykonos.
It will now be clear to readers that have tolerated me so far that I am inclined to wander from the subject. I hesitate to use the word “deviate” on the same page as Mykonos. I will no longer apologize for this, for your erudition, it is caused by an undisciplined brain and some extremely ordinary chardonnay. Actually I now have no idea what subject I have strayed from but this has never stopped me from writing before.
Cricket and foreign policy are the two inextricably linked phenomena invented by the English that have irrevocably changed the world for the better. If we could only get the latter to take place in the middle of a green field and the former to be played in government buildings worldwide, how much more peaceful would this planet be? If Dick Cheney were to be “standing in the gulley with his legs apart waiting for a tickle”, would anyone take his invasion plans for most of the Middle East seriously? Mind you the sheep in Wales might be worried if American Football became popular, the very idea of a tight end and a wide receiver! Then again…?
The consequential question that now springs to mind is how did the United States of America gain independence without knowing how to play cricket, how to brew ale or how to practice foreign affairs? All sorts of sophisticated theories have been put forward, but in fact the answers are all down to series of pragmatic expediencies. Forget taxation without representation, put out of your mind payment for Indian-French wars and obliterate pompous Declarations of Independence for ever.
Some individuals (not this author) blame the Germans for the United State’s inability to brew ale, on the basis that cold efficient people make cold flavorless beer – end of story.
Foreign affairs are irrelevant in the independence process. Anyway Madison spent all of his time in France consorting with prostitutes and government officials – Encoulez moi* seemed to work equally well with both.
The real reason the United States gained independence from England was because early colonists did, in fact, play cricket. However, so many of the male settlers died early in life that it was difficult to get sufficient numbers together to make two teams. This left the colonists with some hard choices to make. They could get the ladies to play, but the girls were busy fighting Indians, farming, practicing witchcraft and didn’t like beer anyway. The logical solutions were to reduce the size of the teams and to disallow scoring behind the wicket. As there were no straight flat pieces of wood in the colonies, they could make neither bat nor stumps, so they did away with stumps and substituted a fat old Native American (later he was replaced with a catcher and an umpire who subsequently went on to be president). The bat was replaced with a round tree branch and instead of running up and down to score, the players ran in circles. There were two reasons for this, the first being that it was difficult to find another fat old Native American to stand at the other end. The second was that running in circles made a tougher target for the Native Americans who were not old and fat and that liked to shoot sharp arrows at the players. Incidentally the first “new world” team was given their name because the blood from their wounds ran down their legs onto their socks, turning them crimson red. Yes, you’ve guessed it – The Yankees.
It was also clear to these early sportsmen that the contemporary life expectancy would not allow for games to run for two or three days so they reduced the time allowed, enabling a match to be completed between church on Sunday and the afternoon farina. This is where America’s love for instant gratification originated. Incidentally, the name baseball came not from running between “bases”, but from a comment made by an unlettered governor of Massachusetts, who upon seeing this sporting blasphemy, remarked, “Encoulez moi, what a base way to play ball.” He was an apparent acquaintance of Madison.
The point of all this is an affirmation that the United States was only able to become an independent nation because they played a type of cricket which in turn gave them skills in foreign affairs. The fact that their politicians have to do these things quickly in case they are no longer there and with whoever is available is immaterial. It is the very fact of the game’s existence (however much besmirched) that matters.
Is the spirit of the game in evidence in the United States? Remember, cricket is a drinking man’s game and that “it is not the winning, it is the taking part that is important”. England invented many of the sports played in the world, but was never any good at playing them. To lessen this mortifying embarrassment they came up with expressions like “it’s the game that matters – not the result”. Eventually this philosophy developed into the way cricket and imperialism should be played.
Remember that cricket played properly is a ceremony, a ritual in which it is important to let the other team take something home with them. Kicking the other team’s butt, stealing their cars, screwing their wives/assorted livestock, killing their sons and selling their daughters is just not cricket.
*Colloquial expression loosely translated as “please have your way with me”
Any criticism of cricket is justifiable grounds for regime change and nation building. As agreed in a recent college class on terrorism, cricket when played properly (i.e. to lose) is the drinking man's baseball. For the sake of clarity, no Englishman can discuss terrorism and cricket at the same time, because global terrorism is quite simply “just not cricket”.
Cricket can be contrasted to modern foreign policy because, played properly, the very idea of a "we win, you lose" premise is not an issue. Cricket, particularly global-village cricket, has to be played with either a lose-lose or lose-win philosophy. The exceptions to this are Australia and South Africa who both practice beforehand (which is unsporting) and cannot tell the difference between cricket and foreign policy anyway. Countries that do not play cricket are seldom, if ever, successful in the foreign relations aspects of government.
Lose-Lose cricket is played when a team travels a long way, only for the long and very dull game to be declared a draw. It is also associated with poor quality meals, no sense of humor, little or no alcohol and little in the way of entertainment. Some individuals (not this author) maintain that Pakistan has suffered criticism in this respect. It is to be hoped that Pakistan’s recent defeat by the Republic of Ireland will encourage the consumption of Guinness in Islamabad and increase the longevity amongst cricket coaches.
The Win-Lose policy is only maintained by sides that actually think the result is important. In this situation the losing side, usually the home side, out of consideration for their guests, will merely watch with amused detachment while the other team, who have obviously been practicing, run themselves ragged in a maniacal desire to win. Naturally after the game is over the home side is full of praise for the victors, safe in the knowledge that when they have gone home, not much will have changed and they can go on as before. Any resemblance to US policy in the Middle East is purely fortuitous.
As everyone knows the British have perfected the Lose-Win philosophy to a fine art. Apart from 1966 when England won the world cup and again in 2003 when they won the rugby world championship in Australia (just to piss-off Australian prime minister, John Howard) the British have skillfully lost just about everything. The thing is they have done it so politely and with such sensitivity that nobody except the English realizes it.
Some individuals have perceptively compared England’s loss of cricket games to countries like Ireland and Sri Lanka as similar to the loss of an empire and previously the loss of the new-world colonies. The contention was that the captain of the global-village cricket team, called George #3 and generally recognized as “one stump short of a wicket”, lost the new world colonies in a game of hazard while waiting for the rain to stop. It didn’t help that the French do not play cricket. Come to think of it, what do the French play? Oh yes! Football, rugby, losing wars, breathing garlic fumes, ignoring EU directives, getting married, disagreeing with everybody and unacceptable interference in foreign affairs.
I digress.
England (I purposefully exclude the hostile colonies of Scotland and Wales) lost its empire that had been built up by a sensitive and caring policy of assimilation, physical abuse, commercial rape and democracy. Actually that was very unfair about Scotland and Wales and I unreservedly and insincerely apologize. Both these countries now have a degree of self-determination, totally financed by the English taxpayers and now have double representation without taxation (they are all unemployed). The Welsh coalmining industry was decimated by a Canadian and a well-balanced Yorkshire Tyke (he had equally sized chips on both shoulders). So with little to occupy the minds of the Welsh people, the local sheep became very preoccupied and anxious.
Once the offshore reserves of fossil fuels were gone, Scotland was also given its own assembly. The Scots are now freely able to smoke heavily, fight in pubs, eat saturated fats and support England’s opponents in any sporting event. You will note that both these countries do play a little cricket, but neither plays it well enough to gain a meaningful contribution to the international community - although both teams could beat Canada. If it seems I have a “down” on Canada you are perfectly correct. As a communications major I learned to despise all the communication experts that country has birthed. Sorry Mr. McLuhan and Mr. Innis but my message is not in the method and I don’t care two hoots for Minerva’s Owl. Also, although Canada does have a cricket team, it is entirely made up of immigrants from the Caribbean and the Sub-Continent and Canada is too far way from anywhere else to engage in foreign affairs. They do think winning is important but cannot remember why.
If Afghanistan weren’t so hilly the English would have succeeded in their 19th century invasion and they would have taught the tribes to play cricket, thus allowing them to vent their aggression on the field of play instead of killing each other. Afghanistan would have then become independent but would still have liked England because they would win their cricket games against them. It is important to realize that the Soviet Union never played cricket. If they had the West would have lost the cold war, but would never have realized it because it would have been done so politely and sensitively.
England taught the hotter parts of the empire to play cricket and taught Canada how to brew ale. Unfortunately the Canadians then passed legislation that made it next to impossible to buy it. This legislation was relaxed during the United States period of prohibition to allow the alcoholic equivalent of sixteen Niagara Falls to flow into the United States every 8.73 minutes. Had the Canadian weather been better and they had been taught to play cricket earlier, the French would have left much sooner (taking Quebec with them) to pursue foreign policy in Syria and Lebanon. If that had happened the area would be much more peaceful now and that nice Mr. Rumsfeld would have been repelled by a wave of garlic fumes that would make WMDs redundant.
I trigress!
Once the English taught these countries of the benevolent empire to play cricket or brew ale, then it was clear they would practice these skills and eventually the Brits would be forced out. Properly coached in the art of wrist-spin bowling, Gandhi could have played cricket up to UN standards – he might even have been good at it. Of course that white frock he always wore would have to go, unless they moved the UN HQ to San Francisco, Sydney or Mykonos.
It will now be clear to readers that have tolerated me so far that I am inclined to wander from the subject. I hesitate to use the word “deviate” on the same page as Mykonos. I will no longer apologize for this, for your erudition, it is caused by an undisciplined brain and some extremely ordinary chardonnay. Actually I now have no idea what subject I have strayed from but this has never stopped me from writing before.
Cricket and foreign policy are the two inextricably linked phenomena invented by the English that have irrevocably changed the world for the better. If we could only get the latter to take place in the middle of a green field and the former to be played in government buildings worldwide, how much more peaceful would this planet be? If Dick Cheney were to be “standing in the gulley with his legs apart waiting for a tickle”, would anyone take his invasion plans for most of the Middle East seriously? Mind you the sheep in Wales might be worried if American Football became popular, the very idea of a tight end and a wide receiver! Then again…?
The consequential question that now springs to mind is how did the United States of America gain independence without knowing how to play cricket, how to brew ale or how to practice foreign affairs? All sorts of sophisticated theories have been put forward, but in fact the answers are all down to series of pragmatic expediencies. Forget taxation without representation, put out of your mind payment for Indian-French wars and obliterate pompous Declarations of Independence for ever.
Some individuals (not this author) blame the Germans for the United State’s inability to brew ale, on the basis that cold efficient people make cold flavorless beer – end of story.
Foreign affairs are irrelevant in the independence process. Anyway Madison spent all of his time in France consorting with prostitutes and government officials – Encoulez moi* seemed to work equally well with both.
The real reason the United States gained independence from England was because early colonists did, in fact, play cricket. However, so many of the male settlers died early in life that it was difficult to get sufficient numbers together to make two teams. This left the colonists with some hard choices to make. They could get the ladies to play, but the girls were busy fighting Indians, farming, practicing witchcraft and didn’t like beer anyway. The logical solutions were to reduce the size of the teams and to disallow scoring behind the wicket. As there were no straight flat pieces of wood in the colonies, they could make neither bat nor stumps, so they did away with stumps and substituted a fat old Native American (later he was replaced with a catcher and an umpire who subsequently went on to be president). The bat was replaced with a round tree branch and instead of running up and down to score, the players ran in circles. There were two reasons for this, the first being that it was difficult to find another fat old Native American to stand at the other end. The second was that running in circles made a tougher target for the Native Americans who were not old and fat and that liked to shoot sharp arrows at the players. Incidentally the first “new world” team was given their name because the blood from their wounds ran down their legs onto their socks, turning them crimson red. Yes, you’ve guessed it – The Yankees.
It was also clear to these early sportsmen that the contemporary life expectancy would not allow for games to run for two or three days so they reduced the time allowed, enabling a match to be completed between church on Sunday and the afternoon farina. This is where America’s love for instant gratification originated. Incidentally, the name baseball came not from running between “bases”, but from a comment made by an unlettered governor of Massachusetts, who upon seeing this sporting blasphemy, remarked, “Encoulez moi, what a base way to play ball.” He was an apparent acquaintance of Madison.
The point of all this is an affirmation that the United States was only able to become an independent nation because they played a type of cricket which in turn gave them skills in foreign affairs. The fact that their politicians have to do these things quickly in case they are no longer there and with whoever is available is immaterial. It is the very fact of the game’s existence (however much besmirched) that matters.
Is the spirit of the game in evidence in the United States? Remember, cricket is a drinking man’s game and that “it is not the winning, it is the taking part that is important”. England invented many of the sports played in the world, but was never any good at playing them. To lessen this mortifying embarrassment they came up with expressions like “it’s the game that matters – not the result”. Eventually this philosophy developed into the way cricket and imperialism should be played.
Remember that cricket played properly is a ceremony, a ritual in which it is important to let the other team take something home with them. Kicking the other team’s butt, stealing their cars, screwing their wives/assorted livestock, killing their sons and selling their daughters is just not cricket.
*Colloquial expression loosely translated as “please have your way with me”
Do They Speak French?
Shortly after starting a new job, my beautifully modulated English accent attracted this question, “My Grandmother has promised me a trip to England if I graduate this year, do they speak French there?” More than a little confused I reconciled this by thinking, “Hey, this was an aberrant brain fry, no danger of a widespread misapprehension.” Sadly, just one day later a gentleman in his mid twenties remarked on my accent, “Man”, he said with a wistful look, “I’d love to go to England, but don’t they speak French there?” “Pardonez moi, je veux fixin’ to get out of here,” I muttered as I fled home to my Maison (Chez Limey) in Midland, Texas, nowhere near the rest of the world.
Let’s get one thing very clear: I love Americans and America; after all I married one and I have no regrets at all about moving to Texas after my wife and I lived and worked in England for the first six years of our marriage.
There is however no mistaking, once I start talking, that I am not from “these parts”. For two years I have been telling everybody that I am from Jackson, Mississippi, but after this caused a choking seizure to a Big Spring resident on a Southwest flight from Dallas I have been more selective in my victims. Just recently I have been telling people that I am in the United States doing TV commercials for Geiko, “Let’s not delve into the private life, love”.
There is a more serious side to this piece and that reflects a desire to want to see Americans and America become more familiar with what really goes on in the rest of the world. Sorry guys but many of you appear to have no idea what goes on outside of the United States and those that do have ideas – well many of your ideas are kind of, well –wrong!
Here are some prime examples but first let me tell you that many of these remarks came from both educated and professional people – all were sincere questions or observations.
“What do you mean you don’t have Republican and Democratic parties in England?”
“68 Euros, What’s that in real money?”
From a United States guest who stayed with us in England. “Do the people that live here have refrigerators and washing machines?”
From an El Paso CPA, “I noticed that Mexicans have a different culture to Americans, are you guys pretty much the same as us?”
Observed in a small town in England when a United States tourist wanted to buy a newspaper using a twenty dollar bill, “Don’t you people respect the United States dollar?” – imagine offering a British pound at the 7-11 in Small Town, Texas.
A visitor from Chicago overheard at the historic Windsor castle which is close by Heathrow Airport, “Why did they build the castle so close the airport, it’s so noisy?”
“Who’s your President, is it still Winston Churchill?”
Heard on the Dave Ramsey Show: “America has the best electoral system in the world; no other country in the world has elections so fair”.
From a local newspaper editorial “…No country in the world accepts the change of leadership as well as Americans because it’s the people that make those changes.”
Take it from me that there are many other countries in the world whose people are rightfully proud of their country. There are dozens of other countries that are highly sophisticated, with a thoroughly educated population and technologically advanced infrastructures. Few of these countries have elections decided by politically motivated judges in Florida – Whoops, just kidding!
Why is it that the most economically advanced country in the world has a population that is largely unfamiliar with the rest of the world? First and foremost it is education, American schoolchildren are just not taught about other countries, not their beliefs and aspirations, not their cultures, not their religion and not their economies. When America played Ghana in the 2006 Soccer World Cup, I was shocked to find how many people had no idea where Ghana was located. No, it is not in the Caribbean. Most well-educated Europeans, Scandinavians, Australians and Asians can discourse knowledgeably about other nations and cultures.
A close, second reason is media. International news is largely ignored in provincial newspapers unless it directly involves the United States or has some anecdotal or humorous element. Worse still, almost all foreign news is “ethnically rewritten” by the news agencies so that American readers will be able to relate to it. As an exercise in supercilious condescension this “dumbing-down” is surely an insult to the intelligence of this nation. The policy infers that the people of the United States are genetically incapable of understanding anything unless it’s related to Uncle Sam and apple pie. All types of media indulge in this practice. Just as an unimportant example I saw a report about a controversial incident in the world of cricket a few months back. I can’t recall the network but very little of the controversy was discussed. In fact most of the effort was directed at poking fun at cricket in general and comparing it unfavorably to baseball. The point here is that the controversy (which was the story) was glossed over and the piece ethnically rewritten to reinforce the baseball culture of the United States. Anyone who wanted to hear more details of the issue in question would have been disappointed.
By the way, how come it’s called the World Series when only teams from America participate?
Does any of this really matter? Well the cricket and the baseball issue does not matter in the slightest but in a society that is irretrievably part of the “Global Village” the serious issues matter very much.
Unless the people and government of the United States gain more knowledge of the rest of the world and generate some sensitivity and understanding about other nations, peoples and religions, the tension so much in evidence today can only get worse. Is the Land of the Free any freer than the land of the Swedes or the French or the British? Are the electoral processes in Australasia, Canada and Europe less honest than that of the United States? If America is the best country in the world, does that mean that all other countries are inferior? If you can answer yes to all these questions – “there’s your sign”.
What is my point? I have absolutely no idea other than I feel that the education system and many media institutions are guilty of a genuine disservice to the American people. The World does not consist of The United States and those poor people that live in other places. The World is a rich tapestry of sophisticated cultures, aspiring peoples and unmitigated screwballs – sound familiar? The vast majority of this planet’s populations do not wake up in the morning worried about what the people of the USA are thinking or doing and neither do they routinely think that America or Americans are superior to them.
As a final thought, a fellow returning student said to me last year, “I know America is the best country in the world for the same reasons I know the Baptist Church is the best way to worship.” I guess I can’t argue with logic like that. And by the way they built Windsor Castle near to the airport so that the nice American tourists wouldn’t have too far to travel.
Let’s get one thing very clear: I love Americans and America; after all I married one and I have no regrets at all about moving to Texas after my wife and I lived and worked in England for the first six years of our marriage.
There is however no mistaking, once I start talking, that I am not from “these parts”. For two years I have been telling everybody that I am from Jackson, Mississippi, but after this caused a choking seizure to a Big Spring resident on a Southwest flight from Dallas I have been more selective in my victims. Just recently I have been telling people that I am in the United States doing TV commercials for Geiko, “Let’s not delve into the private life, love”.
There is a more serious side to this piece and that reflects a desire to want to see Americans and America become more familiar with what really goes on in the rest of the world. Sorry guys but many of you appear to have no idea what goes on outside of the United States and those that do have ideas – well many of your ideas are kind of, well –wrong!
Here are some prime examples but first let me tell you that many of these remarks came from both educated and professional people – all were sincere questions or observations.
“What do you mean you don’t have Republican and Democratic parties in England?”
“68 Euros, What’s that in real money?”
From a United States guest who stayed with us in England. “Do the people that live here have refrigerators and washing machines?”
From an El Paso CPA, “I noticed that Mexicans have a different culture to Americans, are you guys pretty much the same as us?”
Observed in a small town in England when a United States tourist wanted to buy a newspaper using a twenty dollar bill, “Don’t you people respect the United States dollar?” – imagine offering a British pound at the 7-11 in Small Town, Texas.
A visitor from Chicago overheard at the historic Windsor castle which is close by Heathrow Airport, “Why did they build the castle so close the airport, it’s so noisy?”
“Who’s your President, is it still Winston Churchill?”
Heard on the Dave Ramsey Show: “America has the best electoral system in the world; no other country in the world has elections so fair”.
From a local newspaper editorial “…No country in the world accepts the change of leadership as well as Americans because it’s the people that make those changes.”
Take it from me that there are many other countries in the world whose people are rightfully proud of their country. There are dozens of other countries that are highly sophisticated, with a thoroughly educated population and technologically advanced infrastructures. Few of these countries have elections decided by politically motivated judges in Florida – Whoops, just kidding!
Why is it that the most economically advanced country in the world has a population that is largely unfamiliar with the rest of the world? First and foremost it is education, American schoolchildren are just not taught about other countries, not their beliefs and aspirations, not their cultures, not their religion and not their economies. When America played Ghana in the 2006 Soccer World Cup, I was shocked to find how many people had no idea where Ghana was located. No, it is not in the Caribbean. Most well-educated Europeans, Scandinavians, Australians and Asians can discourse knowledgeably about other nations and cultures.
A close, second reason is media. International news is largely ignored in provincial newspapers unless it directly involves the United States or has some anecdotal or humorous element. Worse still, almost all foreign news is “ethnically rewritten” by the news agencies so that American readers will be able to relate to it. As an exercise in supercilious condescension this “dumbing-down” is surely an insult to the intelligence of this nation. The policy infers that the people of the United States are genetically incapable of understanding anything unless it’s related to Uncle Sam and apple pie. All types of media indulge in this practice. Just as an unimportant example I saw a report about a controversial incident in the world of cricket a few months back. I can’t recall the network but very little of the controversy was discussed. In fact most of the effort was directed at poking fun at cricket in general and comparing it unfavorably to baseball. The point here is that the controversy (which was the story) was glossed over and the piece ethnically rewritten to reinforce the baseball culture of the United States. Anyone who wanted to hear more details of the issue in question would have been disappointed.
By the way, how come it’s called the World Series when only teams from America participate?
Does any of this really matter? Well the cricket and the baseball issue does not matter in the slightest but in a society that is irretrievably part of the “Global Village” the serious issues matter very much.
Unless the people and government of the United States gain more knowledge of the rest of the world and generate some sensitivity and understanding about other nations, peoples and religions, the tension so much in evidence today can only get worse. Is the Land of the Free any freer than the land of the Swedes or the French or the British? Are the electoral processes in Australasia, Canada and Europe less honest than that of the United States? If America is the best country in the world, does that mean that all other countries are inferior? If you can answer yes to all these questions – “there’s your sign”.
What is my point? I have absolutely no idea other than I feel that the education system and many media institutions are guilty of a genuine disservice to the American people. The World does not consist of The United States and those poor people that live in other places. The World is a rich tapestry of sophisticated cultures, aspiring peoples and unmitigated screwballs – sound familiar? The vast majority of this planet’s populations do not wake up in the morning worried about what the people of the USA are thinking or doing and neither do they routinely think that America or Americans are superior to them.
As a final thought, a fellow returning student said to me last year, “I know America is the best country in the world for the same reasons I know the Baptist Church is the best way to worship.” I guess I can’t argue with logic like that. And by the way they built Windsor Castle near to the airport so that the nice American tourists wouldn’t have too far to travel.
Saturday, August 15, 2009
Sick of Health
Forgive the pun, but I’m sick of watching and listening to the ideological bigotry being used by both sides in the current debate over healthcare reform. Even the fallacy that the debate could possibly be encapsulated by “two sides” makes me angry. The very idea that being able to shout louder than someone else or that a few words written on a placard contributes anything to a debate on such an important issue is asinine in the extreme. Such behavior, including mindless chanting of simplistic slogans, effectively halts all objective discussion and obscures the real issues.
So, stop mouthing off, stop quoting extreme anecdotal examples and stop using prefabricated, emotive labels designed to perpetuate already polarized thinking.
This maybe a revolutionary idea, but why don’t we start looking at factual evidence backed up by legitimate research. Yes I know this a new concept, but just bear with me for a while, you never know, we might then draw some reasoned and sensible conclusions.
Here is an initial, outrageous idea to open up your thinking:
Starting in 2010, schooling for our children will no longer be funded or provided by either state or federal government. All parents and children will be expected to pay in full for their academic education which will be provided by private institutions. Emergency treatment for difficult math problems and long words will be available at certain schools but waiting times might be quite long.
This policy will be introduced on the overall premise that nobody ever died as a direct result of not being educated. However, people do die as a direct result of health issues. In view of this, all funding currently provided by every level of government to education will be reallocated to healthcare.
Silly idea because that’s not the way we do things – and imagine the increased incidence of illiteracy…Oh, wait a second…
Now that you are smiling broadly and are instantly ready take on new and radical ideas, here are some facts:
So, stop mouthing off, stop quoting extreme anecdotal examples and stop using prefabricated, emotive labels designed to perpetuate already polarized thinking.
This maybe a revolutionary idea, but why don’t we start looking at factual evidence backed up by legitimate research. Yes I know this a new concept, but just bear with me for a while, you never know, we might then draw some reasoned and sensible conclusions.
Here is an initial, outrageous idea to open up your thinking:
Starting in 2010, schooling for our children will no longer be funded or provided by either state or federal government. All parents and children will be expected to pay in full for their academic education which will be provided by private institutions. Emergency treatment for difficult math problems and long words will be available at certain schools but waiting times might be quite long.
This policy will be introduced on the overall premise that nobody ever died as a direct result of not being educated. However, people do die as a direct result of health issues. In view of this, all funding currently provided by every level of government to education will be reallocated to healthcare.
Silly idea because that’s not the way we do things – and imagine the increased incidence of illiteracy…Oh, wait a second…
Now that you are smiling broadly and are instantly ready take on new and radical ideas, here are some facts:
- The United States of America does not have the best health system in the world
- The United States of America does not have the worst health system in the world
- The United States of America has some of most advanced healthcare expertise in the world
- The United States of America’s delivery of overall healthcare and its health outcomes do not compare well to most other industrialized countries
- The United States of America has the capability to offer expert treatment to patients of all ages
- The United States of America has an illogically high incidence of infant mortality and avoidable death rates
Okay, that smile has lessened somewhat, so here are some factual statements and observations:
- I don’t know which country does have the best health system in the world - but neither does anyone else reading this
- The United States of America spends more (per capita) on administering the bureaucracy of its healthcare than any other country in the world. Sometimes by a factor of three or four over countries with effective universal systems
- There is no particular reason why employers should continue to be responsible for providing healthcare. It is an invidious practice that can be extremely detrimental to both employee and employer interests. The practice has its origins in the pay freezes of World War II, yet now seems entrenched in the American working life. Why should your employer decide what health cover you get? Your family physician doesn’t tell you where you should work!
- There is no reason why a national, universal health plan should increase individual or government healthcare costs. Individual tax costs will increase but, if a scheme is implemented effectively, there will be no health insurance premiums to pay. Employers should no longer have to pay their portion to the insurers and there should be no co-pay. In case you missed that – NO CO-PAY! Your employer may even pass his or her savings on to you as a wage increase.
- Effective preventative healthcare makes an enormous contribution to the quality of life and the longevity of that life. In the current situation prevailing in the United States of America, there is little incentive for health insurers to finance preventative care. The premise is that, as people change jobs and healthcare insurers, the financial benefits of preventative medicine might be enjoyed by organizations other than those that originally funded it
- Viewed from afar, the citizens of the United States of America are hypochondriacs obsessed by illness. This hypochondria is fueled by a constant barrage of television commercials for prescription drugs containing information that should only really be evaluated by competent medical professionals. Trendy acronyms only exacerbate the obsession – why not become obsessed by health and wellness instead?
- Market forces and human nature are generally inappropriate in healthcare. Physicians are encouraged to treat where treatment is perhaps unnecessary. Pharmaceutical companies need a steady stream of new illnesses, gullible or mercenary physicians and new drugs to keep them in business. Health insurers need to be able to promise nurturing care from cradle to grave and yet be able to deny treatment on all possible occasions
Now that the smile has been replace by a scowl and you’re thinking about shouting or painting a placard, here are some comparisons that will restore your faith in man’s inhumanity to man:
- Universal schemes can only provide the greatest good for the greatest number and will spend any and all amounts of money provided
- Private schemes will drop you if it looks as though you might get a long-term illness
- Universal schemes will always treat acute cases first and will generally do these well. less urgent cases may well wait some time for treatment
- Private schemes will treat your acute or less urgent conditions entirely in respect of financial considerations, but will have you back in your car about the same time the anesthesia wears off, often causing you to come back again (with another co-pay) in a couple of days
- Universal schemes often provide unintentional long-term accommodation for the homeless
- Private schemes always use the latest and most expensive treatments irrespective of whether they are superior to proven treatments.
- Universal schemes are often unwilling to adopt new procedures until cost and/or patient benefits have been established
Here is a dirty word:
“Single-Payer”
Actually it’s two words, but you get the drift. Most universal or national health schemes operate this policy. Supporters of the status quo in United States health policies consider it blasphemy. It is a prime example of the emotive labeling so apparent in current healthcare discussions.
Single-payer simply means that payment for medicines and treatment comes from a single source. That single source is the organization that operates the health service - almost invariably the government. Pharmaceutical companies and medical practitioners abhor this policy because they are unable to play numerous payers (with differing priorities) off against each other. Instead they have to deal with a single body that has the single objective of balancing cost and patient benefit – more simply known as value for money. The VA health system bureaucracy “sorta-kinda” operates in a similar way to single-payer.
This does mean that many medical practitioners will get less for the work that they do. Pharmaceutical companies will undoubtedly claim that they will be unable to research new treatments. Personally, I can live with this because the physicians that earn substantially less will only be those who have been financially focused in their practices. Pharmaceutical companies will continue to research and develop because that is what they have to do to exist. Maybe these new pressures will force them to be more focused on effective remedies? Am I the only person who wonders whether drug companies develop new products and then look for an illness to treat with it? The objective of a healthcare system is to look after the receivers of that healthcare – not to make a few professionals obscenely wealthy.
The bottom line is that the current healthcare systems (in terms of delivery and outcomes) in the United States of America are ineffectual and probably irreparable in their current form. Federal and state politicians are scared to death of the pharmaceutical lobby and failure to be re-elected (but then I repeat myself). The AMA represents the interests solely of the medical profession and has stood four-square in the way of any proposed initiatives that benefit patients at the expense of their members. I don’t think insurance companies care one way or the other because they think they will still get a large slice of the cake whatever happens. When it dawns on them that single-payer may become a reality, they will get the rest of the politicians that the pharmaceutical companies missed.
It should not (and cannot) be beyond the wit of the US Government to take the time to investigate the healthcare schemes that are the most successfully operated in other industrialized countries. Surely, somewhere in this nation, we have officials with the ability to judge and evaluate the best of those and surely we have the expertise to implement such a scheme here.
According to the Organization for Economic Co-operation and Development (OEDC), in 2003/2004, per capita health expenditure in the United States of America was $6,120 (15.3% of GDP), life expectancy was 77.5 years and infant deaths, per thousand, were 6.9. During the same period in Japan, per capita health expenditure was $2,249 (8% of GDP), life expectancy was 81.8 years and infant deaths, per thousand, were 2.8.
Here are some final kickers. How can the country that considers itself the most advanced economy in the world, allow its citizens to be denied preventative healthcare because of corporate avarice? How can it allow honest citizens to bankrupt themselves seeking healthcare? How can it let people die for lack of healthcare?
For those that say government cannot afford universal healthcare, consider this: in 2003 (according to the World Health Organization) the United States government spent more, per capita, on healthcare that the governments of the United Kingdom and Sweden. Two countries that each have universal healthcare, the citizens of these countries did not have co-pays and both countries achieve generally better health results than the United States of America can boast.
Personal net expenditure on healthcare would drop significantly under a properly implemented universal scheme and a single payer scheme would have the potential to cut billions of wasted dollars out of administrative costs.
Finally, President Obama’s scheme will not work because it does not address the fundamental underlying problems. The supporters of the status quo will gladly watch the percentage of GDP spent on healthcare rise to 20% in the unreasoned belief that the marketplace will deliver effective healthcare and that we already have (of course) the best healthcare in the world. Basically we’re screwed!
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