Thursday, December 1, 2016

The Price is Right (wing, that is)


"A Bad Dude?"

President-elect Donald Trump has named Representative Tom Price, MD (R-GA, former orthopedist) to be the next head of HHS. Given that the GOP now controls the Senate (as well as the House), his quick confirmation is assumed (in the absence of some smoking gun dirt emerging, which seems unlikely). Price derisively calls the PPACA ("ObamaCare") "Government-Run Healthcare," notwithstanding that it's really just a huge insurance reform law with a few haphazard QI "pay for performance" pilots thrown in. Private market providers and private 3rd party payment intermediaries (mostly pre-2009 incumbents) remain in firmly place.

Nonetheless, Representative Price is the leader of the "Repeal and Replace" Tea Party faction, and his crosshairs go well beyond just ObamaCare.

e.g., from NBC News:
A Medicare war is coming. What will Trump do?
An interesting thing happened in the 2016 presidential race: There was no big fight over the politics of Medicare, seniors, and entitlements -- like there was in 2010, 2012, and 2014. (The reason why was due to Donald Trump's promise not to touch entitlements, as well as the Clinton campaign's effort to go after Trump on temperament, not policy.) But with Republicans in charge of the White House and Congress come Jan. 20, and with House Speaker Paul Ryan's long-awaited effort to privatize/voucherize/restructure Medicare, entitlement politics are coming back. "Between this nomination of an avowed Medicare opponent [Trump HHS pick Tom Price] and the Republicans here threatening to privatize Medicare, it's clear that Washington Republicans are plotting a war on seniors next year," incoming Senate Democratic leader Chuck Schumer recently said, per Politico. The biggest unknown, however, is whether President-elect Trump goes along with Ryan's plans.
Trump's "I'm not going to cut Medicare" vs. "Modernize Medicare"

On the one hand, Trump declared that he wouldn't touch Social Security or Medicare. "I'm not going to cut Social Security like every other Republican, and I'm not going to cut Medicare or Medicaid," he said in a May 2015 interview, which is still featured on his campaign website. On the other hand, Trump's transition website includes this sentence on health-care policy: "Modernize Medicare, so that it will be ready for the challenges with the coming retirement of the Baby Boom generation - and beyond." Trump joining Ryan's Medicare efforts could achieve a long-standing conservative goal, but open up the GOP to some mighty political attacks from Democrats in 2018 (including that Trump broke his promise on Medicare and entitlements). Or Trump blocking Ryan could uphold his promise on entitlements, especially with the kinds of voters who won him the election, but it would produce a significant fissure inside the GOP and conservative movement (which Democrats could still exploit). This will be one of the most important storylines to watch next year...
Price is the author of H.R. 2300 (pdf), his long-in-the-oven and ready to serve up "Repeal ObamaCare" bill, the "Empowering Patients First Act of 2015").

From The Atlantic:
Although Price’s selection is the clearest signal yet of the direction Trump intends for his replacement of Obamacare—defunding Obamacare subsidies, cuts to Medicaid, expanded high-risk pools, health savings accounts tax breaks, and continuous coverage requirements for pre-existing conditions waivers—now that he’ll be outside of Congress, Price won’t have the authority to simply end Obamacare on his own. Enacting his apparent preferences for diminishing public insurance for children and denying care for elderly people who can’t afford co-pays requires legislative authority. Until a bill comes along that changes the structure of the Affordable Care Act or dismantles it, Price cannot act unilaterally on his stated desires to end it.

But Price can exercise some of the broad powers of the secretary’s office right away to make the ongoing effort to implement Obamacare more difficult, even if some of those provisions survive what is expected to be a rapid move in Congress to repeal it. For one, the text of the ACA was noted—and derided—for its thousands of references to the secretary of HHS in sections known as the “secretary shall” clauses, which placed quite a bit of the burden on the department itself to determine the final shape of several reforms...
"The Secretary shall..."
[T]he text of the ACA was noted—and derided—for its thousands of references to the secretary of HHS in sections known as the “secretary shall” clauses...
Y'know, kinda like these:
...the Secretary shall establish a program for making payments to providers of qualified health insurance (as defined in section 36B(e)) on behalf of taxpayers eligible for the credit under section 36B...

(f) ADMINISTRATION.—The Secretary shall provide for the administration of this section and may establish such terms and conditions, including the requirement of an application, as may be appropriate to carry out this section...

‘(d) CERTIFICATION PROCESS AND PROOF OF COVERAGE.—The Secretary shall establish a process under which individuals are certified as eligible for payment under this section...
Those are three of the 14 "Secretary shall" clauses in Price's brief bill (243 pages, double-spaced, line-numbered, with 2-inch margins).

The word "Secretary" appears 86 times in H.R. 2300 in a number of referential contexts. One expects many, many more "Secretary shall" directives will be in any final passed and enacted ACA repeal bill (in particular in light of the fact that Rep. Price will be the "Secretary") . While this Atlantic writer seems to think such was an anomaly of the PPACA, it's actually a staple of legislation.

In fairness, it's worth noting that the 974 page enacted PPACA (single-spaced, 2-inch margins, no line numbers) contains 866 "Secretary shall" phrases. But, only 21 of those extend to the CFR regulatory purpose "Secretary shall, by regulation..." e.g.,
‘‘(1) IN GENERAL.—The Secretary shall, by regulation, provide for the development of standards for the definitions of terms used in health insurance coverage, including the insurance-related terms described in paragraph (2) and the medical terms described in paragraph (3).
Pick any law at random. Search and tally "Secretary shall." 13 matches in "The Patriot Act." 14 matches in Federal Election Campaign Law.

And so forth.

Was discretionary regulatory delegation as set forth in the PPACA excessive? An outlier? It's not at all clear to me. Moreover, such legislative language is an Article I function.

In the final days of the 2016 Presidential race, Donald Trump claimed that he would "eliminate 3/4 to 80% of federal regulations." He went shortly thereafter on to also assert that “for every one new regulation, two old regulations must be eliminated.”

To which I responded in a comment at THCB:
Which simply reflects his utter ignorance of and indifference to the way statutory federal regulation works.

From the Congressional Research Service, June 17th, 2013:

“Federal regulation, like taxing and spending, is one of the basic tools of government used to implement public policy. Although not as frequently examined as congressional or presidential policy making, the process of developing and framing rules is viewed by some as central to the definition and implementation of public policy in the United States.

Regulations generally start with an act of Congress, and are the means by which statutes are implemented and specific requirements are established…”

“…are the means by which statutes are implemented…”

Statutes tell us the “what” and the “why.” The ensuing regulations tell us the “who,” “how,” and “when.” The business analogies are the “Policies and Procedures” we all equally hate (and frequently ignore).

Moreover, I count no fewer than 17 federal laws that govern the CFR process itself.

But, I know they don’t teach Article I at the Trump® University Skool of Law.
I made the same point on a recent prior KHIT post:
...Trump has no clue regarding "regulations." He claims he will just get rid of 75 to 80% of all federal regulations. First of all (beyond the fact that doing so is the purview of Congress, not the President), an apt analogy to law and regulation is the corporate "policies and procedures" we also all hate.

Laws tell us "what" and "why," and subsequent regulations tell us "who," "how," and "when" (the operational details). Regulations at the federal level are published in draft as Federal Register proposals, which undergo a prolonged period of public review and comment before they are finalized. Moreover, they cannot exceed the scope of the parent law. To the extent they do they are very quickly challenged in court and either overturned or scaled back. The various stakeholder groups are vigilant with respect to proposed regulations. We may not like the volume and complexity of them, but that's simply a function of the way legislation works in a nation of 330 million people.

I have worked in highly regulated environments for 30 years. EPA, NRC, OSHA, OCC, FDIC, and HHS. In my last job, I was the team lead on our staff for writing policies and procedures that were compliant with HIPAA medical privacy and security regulations covering our statewide Nevada Health Information Exchange. I know a thing or two about how this stuff works.

It's maddeningly tedious and complicated and imperfect. But, human affairs get regulated one way or another.

You want polluted water and air, toxic drugs, unsafe vehicles, poisoned foods, airplane crashes routinely?

Fine, do away with regulations.
As noted by the Congressional Research Service, some regulations can be eliminated via the stroke of the Presidential pen (e.g., those enacted via prior "Executive Orders"), but, the bulk of federal regulation is -- as I have described above -- statutory in nature. Requiring statutory revision or elimination.

Finally, apropos of this section, every state in the union promulgates statutory-based regulations in equivalent fashion. "Eliminating regulations" might have a nice unreflective rhetorical ring to it, but the phrase is simplistically unreflective nonetheless.
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A physican contributor over at THCB is positively gushing over the selection of Tom Price (and beat me out of the box with the title play on words).
The Price Is Basically Right
 By NIRAN AL-AGBA, MD


Recently, President-Elect Trump selected Rep. Tom Price, MD to lead the Department of Health and Human Services.  Suffice it to say, this signals Mr. Trumps’ resolve and commitment to definitively repealing and replacing.  Dr. Price has already sunk his teeth into health care reform, having proposed alternative healthcare solutions in every Congressional session since 2009.  As a physician myself, I am delighted at the prospect of having another doctor at the helm of HHS. The last physician to lead HHS was Louis Sullivan, MD as part of the administration of George H.W. Bush.  Having a physician, who can understand the needs of physicians and patients, representing both in health policy decision making at the federal level gives everyone the best chance for meaningful and successful health care reform...

with him wholeheartedly.  His socially conservative stances have angered many; he is pro-life, votes against insurance coverage for women’s health issues, additional funding of CHIP (Children’s Health Insurance Plan), and LGBT issues.  However, the more I struggle to stay afloat in independent practice, the less these differences of opinion actually matter.  Sylvia Burwell and I probably agree on Womens, LGBT, and childrens’ health issues, but my bleeding heart, ironically, has worsened my chance for survival in a career I love.  Reality is what brought this very liberal physician to advocate a different approach to healthcare reform...
Pretty accurate, concise summary of the principal prospective aspects of H.R. 2300 as currently proffered. Suffice it to say that I disagree with the exuberant conclusions.

OK, WHAT ABOUT MEDICARE?

Re-posting a section of my prior post "Treat the numbers instead of the patient?"

INTERESTING HARPER'S ARTICLE ON MEDICARE

A long read by Trudy Lieberman (paywalled, but may be viewable once by non-subscribers):

“Don’t Touch My Medicare!”
Is the beloved program on its last legs?


...The Medicare Modernization Act poked yet another hole in Lyndon Johnson’s fraying compact. It called for wealthier beneficiaries—people with incomes above $85,000 if single or $170,000 if married—to pay higher premiums for Part B benefits. The provision moved through Congress with “unexpected support from some Democrats,” the New York Times reported. As the law neared final approval, though, the Times noted that AARP, the UAW, and liberal Democrats, including Senator Edward Kennedy, viewed some of its proposals as a “dangerous first step in turning Medicare from a universal social insurance program into a welfare program.”

In a sense, the conservative assault on Medicare is two-pronged. On the one hand, there is a drive to privatize. On the other, critics hope to rebrand Medicare as a variety of welfare. The former Hill staffer says that the Republicans have “been on a very consistent march for decades now. They basically want to get rid of the entitlement and want everything means-tested.” Means-testing—that is, basing eligibility for benefits on whether a person has the means to do without that help—saves billions for the government. But it would also make Medicare into the equivalent of food stamps or Medicaid. And that, of course, is the objective.

So far, privatization remains the more politically correct solution for Medicare’s financial shortfalls. These are real, at least potentially. In large part, they have been caused by the lack of serious cost controls, and exacerbated by the influx of millions of baby boomers needing medical services. Even the government’s attempts at cost control introduced during the Reagan era failed to permanently curb medical inflation. Indeed, containing the prices charged by the doctors, hospitals, drug makers, nursing homes, and home-care agencies that rely on the Washington gravy train has been an almost impossible task. The 2003 prescription-drug law, for example, prohibits Medicare from negotiating the prices it pays for drugs. “There are obstacles statutorily and politically,” says former Medicare administrator Don Berwick. “We can’t negotiate for purchasing, in one of the largest insurance systems in the world. The moneyed interests are calling the shots.”

Many of those moneyed interests sell health-care technology, which has long been a major cause of exploding costs. Richard Foster, who was Medicare’s chief actuary from 1994 to 2013, describes the situation: “As long as there’s an automatic market for new technology, even if it’s not any more effective, cost growth will keep going up.” In fact, Medicare has historically not considered cost effectiveness when deciding whether to cover new drugs and technologies...
Read all of it. Of particular interest to me these days, given that my wife and I are now Medicare benes. More broadly, this kind of policy stuff is every bit as important as clinical science, process QI, biotech, and health infotech. The finest clinical capability on earth is of nil utility if it's increasingly out of reach financially.
Policy stuff is every bit as important as clinical science, process QI, biotech, and health infotech. The finest clinical capability on earth is of nil utility if it's increasingly out of reach financially.
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As currently drafted, there's not much of radical substance in Rep. Price's H.R. 2300 pertaining to Medicare specifically. See SEC. 117. PROVISIONS RELATING TO MEDICARE, pretty much a half page. There's also the somewhat more substantive SEC. 901. GUARANTEEING FREEDOM OF CHOICE AND CONTRACTING FOR PATIENTS UNDER MEDICARE.

Dr. Al Agba states that "People on Medicaid, Medicare, and Tricare, could opt to buy private insurance."

Why anyone -- particularly Medicare benes -- would want to do that escapes me. Unless the forthcoming legislative provisions will be so onerous as to eviscerate Medicare to the point where it's really just one more penurious, care-obstructive "welfare" program. House Speaker Paul Ryan has long made no secret of his wish to turn the big federal civilian entitlement programs (Medicare and Social Security) into means-tested spend-down-to-penury welfare programs (which may still be a bridge too far politically, in light of the 3rd-rail mega-wattage of the huge 65+ cohort).
 "Keep yo' Gubmint hands off my Medicare!"
An interesting, if anxious year awaits. Maybe we should all just sing my ObamaCare song.

UPDATE

More from THCB. Margalit having a bit of Buyer's Remorse?
Something Not So Terrific
By MARGALIT GUR-ARIE

The brand new President Barack Obama, whether wittingly or not, invested his entire political capital in reforming health care in America. He gambled and he lost, not because he had nefarious intentions, but because he left the gory details to a corrupt Congress and a shady cadre of lying and conniving technocrats, ending up with something vastly different from what he campaigned on. From everything I’m reading now, Mr. Trump is about to walk in Mr. Obama’s footsteps, and if he does, the results will be unsurprisingly identical...
This week, President-elect Trump picked Rep. Tom Price, a former orthopedic surgeon, to be the next Secretary of Health and Human Services, and Dr. Price is a man with a plan. The plan is to replace Obamacare with age adjusted, tax credits and HSAs, while making the same model available to employers, Medicare and Medicaid too. People would use the tax credits to buy a catastrophic health plans across state lines, and deposit the difference in their HSAs to cover routine health care. Sounds good until you realize that the tax credits proposed by Dr. Price are ridiculously low and would cover less than half the cost of a catastrophic insurance plan. Now, it is possible, that once all Obamacare protections are removed, trashy little health plans, priced exactly the same as the tax credits, will return to the marketplace, but I seriously doubt that anything will be left over for HSA deposits. I’m willing to bet that the majority of employers will jump at the chance to extend the same parsimonious offer to their employees.

Once the Medicare modernization features of Dr. Price’s plan are also implemented and Medicaid gets cut and tossed into the lap of perpetually bankrupt states, America will finally achieve universal catastrophic health care. Let me dispel the bleakness for a brief moment though. Dr. Price’s plan has all sorts of great features for doctors. Malpractice insurance reform, freedom to provide cash services to Medicare beneficiaries, freedom to balance bill, some relief from regulatory burdens and a seat at the table for medical associations, are all included in the plan. It is also quite possible that physicians in non-catastrophic specialties will get to enjoy some well-deserved leisure time. I can’t imagine too many non-catastrophic customers, flush with non-existent HSA cash, banging on their doors...
But, wait! There's more!

From STATnews:
Liberal MDs are furious after top doctors group backed Trump’s pick for health secretary
By REBECCA ROBBINS @rebeccadrobbins

When Donald Trump this week tapped a surgeon-turned-congressman to run the Department of Health and Human Services, the nation’s largest physicians group swiftly endorsed the choice.

The blowback started almost at once.

Liberal doctors peppered the American Medical Association with furious tweets decrying the group’s endorsement of Representative Tom Price as a betrayal of patients and physicians. And by Wednesday night, 500 doctors had signed an online open letter titled “The AMA Does Not Speak For Us” started by the Clinician Action Network, a left-leaning advocacy group...
In that vein, posted at Medium.com:
The AMA Does Not Speak for Us

Yesterday, the American Medical Association (AMA) announced its support for the nomination of Dr. Tom Price for Secretary of Health and Human Services.
The statement highlights Dr. Price’s experience as a physician and legislator, citing his leadership in the development of health policies to “advance patient choice and market-based solutions.”

The AMA represents approximately a quarter of physicians in the US — a loud, but minority voice. It certainly does not speak for us.


We are practicing physicians who deliver healthcare in hospitals and clinics, in cities and rural towns; we are specialists and generalists, and we care for the poor and the rich, the young and the elderly. We see firsthand the difficulties that Americans face daily in accessing affordable, quality healthcare. We believe that in issuing this statement of support for Dr. Price, the AMA has reneged on a fundamental pledge that we as physicians have taken — to protect and advance care for our patients.


We support patient choice. But Dr. Price’s proposed policies threaten to harm our most vulnerable patients and limit their access to healthcare. We cannot support the dismantling of Medicaid, which has helped 15 million Americans gain health coverage since 2014. We oppose Dr. Price’s proposals to reduce funding for the Children’s Health Insurance Program, a critical mechanism by which poor children access preventative care. We wish to protect essential health benefits like treatment for opioid use disorder, prenatal care, and access to contraception...
UPDATE: And the hits just keep on comin'. More STATnews:
Birth control emerges as rallying cry against Trump’s pick for health secretary
By REBECCA ROBBINS @rebeccadrobbins

Reproductive rights activists opposed to Donald Trump’s nominee for health secretary have hit upon a potent rallying cry: the cost of birth control.

The campaign stems from a remark made back in 2012 by Georgia Congressman Tom Price, who this week was nominated to run Trump’s Department of Heath and Human Services. Back then, Price had joined other Republicans in a fierce fight to block an Obamacare mandate that insurers give women free access to contraception.

Price said the rule was unfair to religious employers who considered it immoral for birth control to be covered under the health plans offered to their workers —and also, wholly unnecessary, because no woman he knew of had ever had trouble getting contraception when she needed it...
There are many on the political right for whom the very concept of contraception is anathema. I'd like to know precisely where Tom Price stands on that aspect of the issue. Noting again what I posted on the topic of reproductive rights in a recent prior post:
With respect to human reproduction (in particular the "life begins at conception" canard), the contribution of the male begins and ends with the sperm's successful delivery of the polymer molecules comprising ONE copy of the male's DNA that constitute his 23 chromosomes. Everything that takes place thereafter, starting with the ensuing division process begun by the single cell sperm-fertilized ovum, is a function of the female's gestational biology. all of the subsequent biological reproductive effort, and all of the medical risk.

The assertion that [1] a fertilized ovum is instantly a "person," and, [2] men should be able to declare for themselves "equal reproductive rights" tantamount to a veto over what a woman does with her body once pregnant are the most ignorant and arrogant things I've ever heard. It has nothing to do with "reverence for the sanctity of life," it has everything to do with reverence for dominant male power. Period.

Moreover, take men out of the picture, just to advance the argument a step further. The notion that some women should be able to use the force of law to deny other women the right to control their biology is equally specious. For starters, it violates the Equal Protection clause of the 14th Amendment.
Tom Price on January 24th, 2011:
"Today, citizens from all across the country came to Washington to honor the precious gift of life. The March for Life movement has for nearly four decades given a voice to those who have no voice. It is a privilege to stand together with thousands of Americans in solidarity and faithful commitment to our solemn duty to protect and defend the lives of the most innocent among us."
Again, it's not yet clear to me where he stands on contraception per se. Will have to dig further.


UPDATE: TOM PRICE ON BIRTH CONTROL

As reported by Christina Cauterucci at Slate:
...The vocal Obamacare opponent, a Republican who’s represented a Georgia district since 2005, has established himself as a hardline anti-abortion, anti-contraception extremist during his time in Congress. During his first term, Price co-sponsored a piece of legislation called the “Right to Life Act,” which would have banned abortion in nearly every circumstance, potentially prohibited most types of contraception and in vitro fertilization, and stymied stem cell research.

The bill proposed vesting every zygote (“preborn human person,” the bill says) with all the rights of the Constitution from the moment of fertilization. This kind of “personhood” bill would mark the first step toward a draconian society that punishes women who terminate their pregnancies as if they were murderers, like the one an anti-abortion activist group is trying to establish in Florida. These bills provide no exceptions for rape, incest, or threat to a pregnant woman’s life, and would put control over women’s bodies—including, perhaps, what she ate, drank, or did while pregnant—in the hands of the state... 
Again, read my 2008 thoughts on this topic, on another of my blogs.

Turns out that Rep. Price is a "Personhood at Conception" guy. From his 2005 bill H.R. 618 (pdf):


"The moment of fertilization."

Never mind the clinical impossibility of determining that precise "moment" via which to link the criminal sanctioning of women. An utterly fatuous proposition.
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More to come...

Thursday, November 24, 2016

What might Artificial Intelligence bring to humanity?

You really owe it to yourself to listen carefully to this entire 76 minute podcast.
"In this episode of the Waking Up podcast, Sam Harris speaks with computer scientist Stuart Russell about the challenge of building artificial intelligence that is compatible with human well-being."

I've posted here on "AI vs IA" topics before. At about 61 minutes in this podcast interview they discuss issues reminding me of the postcapitalism "Four Futures" speculative alternative scenarios articulated by Peter Frase. BTW: this excellent essay has finally been released in expanded book format.

"Peter Frase argues that increasing automation and a growing scarcity of resources, thanks to climate change, will bring it all tumbling down. In Four Futures, Frase imagines how this post-capitalist world might look, deploying the tools of both social science and speculative fiction to explore what communism, rentism, socialism and exterminism might actually entail.

Could the current rise of real-life robocops usher in a world that resembles Ender’s Game? And sure, communism will bring an end to material scarcities and inequalities of wealth—but there’s no guarantee that social hierarchies, governed by an economy of “likes,” wouldn’t rise to take their place. A whirlwind tour through science fiction, social theory and the new technologies already shaping our lives, Four Futures is a balance sheet of the socialisms we may reach if a resurgent Left is successful, and the barbarisms we may be consigned to if those movements fail."
Again, listen to Sam's podcast carefully, and at least read the online Peter Frase essay. In the Health IT world these days we're all infatuated with stuff like Watson "curing cancer" and other AI/IA "personalized medicine" proffers. But, the very real and very serious sociological issues pertaining to AI extend far beyond. The Harris-Russell podcast interview above certainly touched on every concern that has crossed my mind as I've thought about AI/IA, and then some.

Below, Sam Harris doing a TED Talk on AI.


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UPDATE: I finished the "Four Futures" book. It is excellent. A fairly quick read. Peter Frase's concluding thoughts:
The transition to a world of abundance and equality, then, is likely to be a tumultuous and conflict-ridden one. If the rich won’t relinquish their privileges voluntarily, they would have to be expropriated by force, and such struggles can have dire consequences for both sides. For as Friedrich Nietzsche said in a famous aphorism, “Beware that, when fighting monsters, you yourself do not become a monster … for when you gaze long into the abyss, the abyss gazes also into you.” Or as the Communist poet Bertolt Brecht wrote in “To Posterity,” a revolution against a brutal system could itself brutalize those who participated in it.
Even anger against injustice
Makes the voice grow harsh. Alas, we

Who wished to lay the foundations of kindness
Could not ourselves be kind.
Or as Mao put it in his characteristic blunt style, “a revolution is not a dinner party."

In other words, even the most successful and justified revolution has losers and victims. In a 1962 letter to the economist Paul Baran, the critical theorist Herbert Marcuse remarks that “nobody ever gave a damn about the victims of history.” The remark was directed at the hypocrisy of liberals who were eager to moralize about the victims of Soviet Communism but were silent about the massive human cost of capitalism. It’s a harsh, perhaps a cruel judgment, and Marcuse himself suggests the need to move beyond it. But it provides an important perspective on the exercise I’ve undertaken here, by allowing us to see that society’s four futures don’t fit into neat moral boxes.

That is one danger, that we underestimate the difficulty of the path we must traverse, or that we allow the beauty of our endpoint to license unlimited brutality along the way. But another possibility is that, at journey’s end, we forget how arduous the journey was and who we left behind. Walter Benjamin, in his essay “On the Concept of History,” talks about the way that historical accounts necessarily tend to empathize with the victors, who are generally the ones who get to write the history. “Those who currently rule are however the heirs of all those who have ever been victorious. Empathy with the victors thus comes to benefit the current rulers every time.” But we can also say that even in a society without clear rulers, history will tend to empathize with the survivors; they are, after all, literally the only ones around to write it. Let’s revisit, on that note, the residents of our first, communist future. Perhaps they’re not at the end of the capitalist road to communism after all, but of a much longer and darker journey through the horrors of exterminism.


Remember exterminism’s central problematic: abundance and freedom from work are possible for a minority, but material limits make it impossible to extend that same way of life to everyone. At the same time, automation has rendered masses of workers superfluous. The result is a society of surveillance, repression, and incarceration, always threatening to tip over into one of outright genocide.


But suppose we stare into that abyss? What’s left when the “excess” bodies have been disposed of and the rich are finally left alone with their robots and their walled compounds? The combat drones and robot executioners could be decommissioned, the apparatus of surveillance gradually dismantled, and the remaining population could evolve past its brutal and dehumanizing war morality and settle into a life of equality and abundance— in other words, into communism.
As a descendant of Europeans in the United States, I have an idea of what that might be like. After all, I’m the beneficiary of a genocide.

My society was founded on the systematic extermination of the North American continent’s original inhabitants. Today, the surviving descendants of those earliest Americans are sufficiently impoverished, small in number, and geographically isolated that most Americans can easily ignore them as they go about their lives. Occasionally the survivors force themselves onto our attention. But mostly, while we may lament the brutality of our ancestors, we don’t contemplate giving up our prosperous lives or our land. Just as Marcuse said, nobody ever gave a damn about the victims of history.

Zooming out a bit farther, then, the point is that we don’t necessarily pick one of the four futures: we could get them all, and there are paths that lead from each one to all of the others. 


We have seen how exterminism becomes communism. Communism, in turn, is always subject to counterrevolution, if someone can find a way to reintroduce artificial scarcity and create a new rentist elite. Socialism is subject to this pressure even more severely, since the greater level of shared material hardship increases the impetus for some group to set itself up as the privileged elite and turn the system into an exterminist one. 

But short of a civilizational collapse so complete that it cuts us off from our accumulated knowledge and plunges us into a new dark ages, it’s hard to see a road that leads back to industrial capitalism as we have known it. That is the other important point of this book. We can’t go back to the past, and we can’t even hold on to what we have now. Something new is coming— and indeed, in some way, all four futures are already here, “unevenly distributed,” in William Gibson’s phrase. It’s up to us to build the collective power to fight for the futures we want.

Frase, Peter (2016-10-11). Four Futures: Life After Capitalism (Jacobin) (Kindle Locations 1886-1930). Verso Books. Kindle Edition. 
 Again, you can begin with his antecedent Jacobin online essay, but the book puts some very nice additional meat on the bones. Some good discourse on the implications of AI/Robotics included.

My quickie Photoshop matrix rendering.


With the November 2016 election of the belligerent, vainglorious Donald Trump to the U.S. Presidency, I have to be concerned that we might be soon teetering more toward a Quadrant IV. I don't think there can be much doubt that the U.S. socioeconomic culture is principally in a Quadrant II mode these days. Whether we slip toward a fully predatory tooth and claw Quadrant IV remains to be seen.

NOTE: also highly recommended apropos of this vein of thought, Paul Mason's bracing book Postcapitalism.


Cited it here, back in April.

UPDATE

apropos of employment projections, just in in my inbox, from The New Yorker:
...Otto, a Bay Area startup that was recently acquired by Uber, wants to automate trucking—and recently wrapped up a hundred-and-twenty-mile driverless delivery of fifty thousand cans of beer between Fort Collins and Colorado Springs. From a technological standpoint it was a jaw-dropping achievement, accompanied by predictions of improved highway safety. From the point of view of a truck driver with a mortgage and a kid in college, it was a devastating “oh, shit” moment. That one technical breakthrough puts nearly two million long-haul trucking jobs at risk. Truck driving is one of the few decent-paying jobs that doesn’t require a college diploma. Eliminating the need for truck drivers doesn’t just affect those millions of drivers; it has a ripple effect on ancillary services like gas stations, motels, and retail outlets; an entire economic ecosystem could break down.

Whether self-driving cars and trucks, drones, privatization of civic services like transportation, or dynamic pricing, all these developments embrace automation and efficiency, and abhor friction and waste. As Erik Brynjolfsson, a professor at the M.I.T. Sloan School of Management told MIT Technology Review, “Productivity is at record levels, innovation has never been faster, and yet at the same time, we have a falling median income and we have fewer jobs. People are falling behind because technology is advancing so fast and our skills and organizations aren’t keeping up.” It is, he said, “the great paradox of our era.”...
SILICON VALLEY HAS AN EMPATHY VACUUM, By Om Malik

Interesting.

ROBOT CODA


The utterly dystopian 1990 sci-fi flick "Hardware." One of my all-time favorites.
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More to come...

Monday, November 21, 2016

Clinical workflow, clinical cognition, and The Distracted Mind

Finished the Gazzaley-Rosen book. It is excellent. Put a link in my permanent right-hand links column. You should get The Distracted Mind and read it.


I find The Distracted Mind directly analogous to Dan Lieberman's also excellent book The Story of the Human Body, which I cited earlier in the year.


"Evolutionary mismatch" ailments, both physical and neurological/cognitive.

Below, another book I've begun that may have some relevant "Distracted Mind" implications.

The neuroscience of attention, despite having greatly advanced over the past few decades, remains too primitive to explain comprehensively the large-scale harvesting of attention. At most it can shed light on aspects of individual attention. But there is one thing scientists have grasped that is absolutely essential to understand about the human brain before we go any further: our incredible, magnificent power to ignore...

Wu, Tim (2016-10-18). The Attention Merchants: The Epic Scramble to Get Inside Our Heads (p. 19). Knopf Doubleday Publishing Group. Kindle Edition.
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Among other things with respect to The Distracted Mind, I've been looking for any useful implications for clinical workflow. apropos of that topic, the latest from Dr. Jerome Carter of EHRscience.com.
Workarounds, Disruptions, and Electronic Health Records

HITECH EHR incentives have been successful in driving EHR adoption. However, as more hospitals and practices have embraced HIT, the number of complaints of poor usability, workflow disruptions, and decreased productivity have grown. As a result, EHR systems have been one of the most important factors in bringing discussions of clinical workflow to the forefront. Of course, this does not mean that inefficient workflows did not exist prior to EHR systems, only that EHR systems provided sufficient contrast with known processes so that the differences became obvious.

Every clinical organization has policies and procedures that guide work activities. Strict adherence is rarely enforced, which gives those charged with carrying out said polices/procedures significant leeway in determining how they are done. If the form is filled out correctly, no one sweats the details. Electronic systems change this dynamic as they are supposed to “help.” As it turns out, the degree to which they help or hurt varies considerably. Some processes are more efficient, some less. Published studies on workarounds provide valuable information on how processes are affected by the presence of electronic systems…

While the research on workarounds reported in these papers is in reaction to EHR systems, its value goes beyond understanding EHR-related changes. Ultimately, the attention paid to common processes may prove to be more valuable. Why? EHR systems are designed to be patient information repositories, not clinical care assistants. As a result, supporting clinical work is seen as a data availability problem, not a process support problem. The underlying assumption is that providing data is the same thing as supporting processes. Workaround research demonstrates just how wrong this assumption is. Workarounds are workflow issues. Every workaround is an alternate path to the same goal.

Workflows consist of a series of steps and each step consumes or produces information, uses resources, and is performed by someone or something. If both groups of authors had rendered their findings in a formal process language (e.g., YAWL, BPMN, Colored Petri Nets) using acknowledged workflow patterns, their findings would have been easier to compare and possibly apply (say for software design).

As with workarounds, usability research has also exploded with EHR adoption. The most obvious usability issue with EHRs—they are designed to provide data, not support processes — remains underappreciated. Thankfully, this is slowly changing...
That's from the sample chapter of Dr. Carter's forthcoming book.


What of "workflow"? I've cited Dr. Carter's work numerous times here. See, e.g., "Announcing the launch of Dr. Jerome Carter's Clinical Workflow Center." See also "Clinical workflow: "YAWL," y'all?"

Uber-geek Chuck Webster is never at a loss for answers. From a comment he left at EHR Science last month:
Chuck Webster, MD, MSIE, MSIS @wareflo October 10, 2016 at 10:07 AM
I like my definitions of workflow and workflow technology:

“I’ve looked at literally hundreds of definitions of workflow, all the way from a “series of tasks” to definitions that’d sprawl across several presentation slides. The one I’ve settled on is this:

“Workflow is a series of tasks, consuming resources, achieving goals.”

Short enough to tweet, which is why I like it, but long enough to address two important concepts: resources (costs) and goals (benefits).

So what is workflow technology? Workflow technology uses models of work to automate processes and support human workflows. These models can be understood, edited, improved, and even created, by humans who are not, themselves, programmers. These models can be executed, monitored, and even systematically improved by computer programs, variously called workflow management systems, business process management suites, and, for ad hoc workflows, case management systems.

Workflow tech, like health IT itself, is a vast and varied continent. As an industry, worldwide, it’s probably less than a tenth size of health IT, but it’s also growing at two or three times the rate. And, as both industries grow, they increasingly overlap. Health IT increasingly represents workflows and executes them with workflow engines. Workflow tech vendors increasingly aim at healthcare to sell a wide variety of workflow solutions, from embeddable workflow engines to sprawling business process management suites. Workflow vendors strenuously compete and debate on finer points of philosophy about how best automate and support work. Many of these finer points are directly relevant to workflow problems plaguing healthcare and health IT.

Why is workflow tech important to health IT? Because it can do what is missing, but sorely needed, in traditional health IT, including electronic health records (EHRs). Most EHRs and health IT systems essentially hard-code workflow. By “hard code” I mean that any series of tasks is implicitly represented by Java and C# and MUMPS if-then and case statements. Changes to workflow require changes to underlying code. This requires programmers who understand Java and C# and MUMPS. Changes cause errors...

Process-aware tech, in comparison to hardcoded workflows, is an architectural paradigm shift for health IT. It has far reaching implications for interoperability, usability, safety, and population health.

BPM systems are ideal candidates to tie together disparate systems and technologies. Users experience more usable workflows because workflows are represented so humans can understand and change then. Process-aware information systems are safer for many reasons, but particularly because they can represent and compensate for the interruptions that cause so many medical errors. Finally, BPM platforms are the right platforms to tie together accountable care organization IT systems and to drive specific, appropriate, timely action to provider and patient point-of-care.”
“Workflow is a series of tasks, consuming resources, achieving goals.”

Ummm... "blinding glimpse of the obvious?"

One of my old summary WKFL takes here, from my MU days with HealthInsight: "Workflow Demystified" (pdf).

 BTW, I have to take a bit of issue with this Chuck Webster assertion from above:
Most EHRs and health IT systems essentially hard-code workflow. By “hard code” I mean that any series of tasks is implicitly represented by Java and C# and MUMPS if-then and case statements. Changes to workflow require changes to underlying code.
That may be true for some really old "legacy" EHRs, but it's a bit of overstatement in general. Yes, technically, if you want to change the layout order of appearance (or other aesthetic attributes) of various data cells on any given EHR tab or template, you might have to go "under the hood" and re-write the source code (such was in case in my ancien lab apps coding days in Oak Ridge in the 80's).


Ugh. Wrote about that here (pdf), published in the EPA Conference Proceedings the and journal Radioactivity and Radiochemistry.

You"might have to" (alter source code). Newer software systems of all types now typically have built-in click/drag-and-drop/cut & paste functionality wherein the user authoring/editing interface serves as a "source code generator" (like, well, this very blogger.com authoring app I use for this and other blog postings. And, yeah. sometimes I have to go in and edit the html code here when something doesn't present as intended, given the bugs in the platform. But, rarely).

Beyond that, the actual workflows, in terms of getting a user to the intended data entry/review/update targets, are independent of the exact screen placement of individual data cells on a given screen.
To this point, once the end-user is adequately trained up past the "learning curve" on a given system, the precise screen location of individual data cells becomes a fairly trivial facet of workflow relative to the resources consumption of getting there and then entering data and moving on.
When I was working in Meaningful Use at my REC, every ONC-certified EHR system (of the 15 or so in my personal MU client caseload, anyway) had multiple keystroke/mouse-click paths via which to direct the user to each MU documentation compliance criterion. The workflow modification task, then, was that of minimizing path travel, greasing the workflow skids.
And, I used to grouse that all repetitive MU data destination paths (there aren't that many) could/should be "one-stroke" -- i.e., via a set of "macros" (common to virtually all major modern commercial software). In fact, I'd have made one-stroke/click MU target functionality a condition of EHR MU Certification.

Anyone recall the old Windows "recorder.exe" utility? Microsoft killed it; nowadays you have to buy (relatively inexpensive) 3rd party macro utility apps. Still, given the workflow enhancement functionality, they're worth it in any "productivity treadmill" environment, particularly those of the irreducibly high cognitive burden medical clinic and hospital.
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BACK TO THE DISTRACTED MIND


The Gazzaley-Rosen book is comprised of three thematic sections spanning its eleven chapters: [1] what neuroscience has learned about the evolution and functionality of the brain, including the central adaptive elements of cognition [2] the increasingly adverse impacts of our 24/7 (mostly now digital) information overload ("information foraging") first-world culture, and [3] what, if anything, can be done to mitigate or otherwise counter those adverse impacts.
The Distracted Mind is not a pseudo-science book that offers colorful brain scans and questionable neuroscience as a way of making a topic appear more credible. In this book, we apply our complementary scientific lenses to present timely and practical insights. Dr. Adam Gazzaley is a cognitive neuroscientist and a trailblazer in the study of how the brain manages distractions and interruptions. Dr. Larry Rosen is a psychologist who has studied the “psychology of technology” as a pioneer in this field for more than thirty years. Our complementary perspectives focus on demonstrating why we fail to successfully navigate our modern technological ecosystem and how that has detrimentally affected our safety, cognition, education, workplace, and our relationships with family and friends. We enrich this discussion with our own research and scientific hypotheses, as well as views of other scholars in the field, to explain why our brains struggle to keep up with demands of communication and information. 

We present our perspectives in three parts. In Part I, we will take you on a tour through new insights into why our “interference dilemma” exists in the first place and why it has become so relevant to us now. We describe how the very essence of what has evolved furthest in our brains to make us human—our ability to set high-level goals for ourselves—collides headfirst with our brain’s fundamental limitations in cognitive control: attention, working memory, and goal management. This collision results in our extreme sensitivity to goal interference from both distractions by irrelevant information and interruptions by attempted multitasking. This noise degrades our perceptions, influences our language, hinders effective decision making, and derails our ability to capture and recall detailed memories of life events. The negative impact is even greater for those of us with undeveloped or impaired cognitive control, such as children, teens, and older adults as well as many clinical populations. We further discuss why we engage in high-interference-inducing behaviors from an evolutionary perspective, such that we are merely acting in an optimal manner to satisfy our innate drive as information-seeking creatures.

In Part II, we will share a careful assessment of our real-world behaviors and demonstrate how the collision described in Part I has been intensified by our constant immersion with the rich landscape of modern information technology. People do not sit and enjoy a meal with friends and family without checking their phones constantly. We no longer stand idle in waiting lines, immersed in thought or interacting with those next to us. Instead, we stare face down into virtual worlds beckoning us through our smartphones. We find ourselves dividing our limited attention across complex demands that often deserve sustained, singular focus and deeper thought. We will share our views of why we behave in such a manner, even if we are aware of its detrimental effects. Building a new model inspired by optimal foraging theory we explain how our high-tech world perpetuates this behavior by offering us greater accessibility to feed our instinctive drive for information as well as influencing powerful internal factors, such as boredom and anxiety. We are most certainly ancient brains in a high-tech world. 

Finally, in Part III we offer our perspectives on how we can change our brains to make them more resilient, as well as how we can change our behavior via strategies to allow us to thrive in all areas of our lives. We first explore the full landscape of potential approaches available to us—from the low-tech to the high-tech—that harness our brain’s plasticity to strengthen our Distracted Mind. This in-depth examination includes traditional education, cognitive training, video games, pharmaceuticals, physical exercise, meditation, nature exposure, neurofeedback, and brain stimulation, illustrating how in these fascinating times the same technologies that aggravate the Distracted Mind can be flipped around to offer remediation. We then share advice on what we can do from a strategic perspective to modify our behavior, without abandoning modern technology, such that we minimize the negative consequences of having a Distracted Mind. Using the optimal foraging model introduced earlier in the book as a framework to approach behavioral change, all of the strategies we offer are practical and backed by solid science.
The Distracted Mind will enlighten you as to how and why our brains struggle to manage a constantly surging river of information in a world of unending interruptions and enticements to switch our focus. We extend this perspective to explore the consequences of this overload on our ability to function successfully in our personal lives, on the road, in classrooms, and in the workplace, and address why it is that we behave in this way. Critically, we provide solid, down-to-earth advice on what we need to do in order to survive and thrive in the information age.

Gazzaley, Adam; Rosen, Larry D. (2016-09-16). The Distracted Mind: Ancient Brains in a High-Tech World, locations 117-151 (MIT Press). The MIT Press. Kindle Edition.
They seriously deliver. Actual neuroscience, in lieu of "neurobabble neurotainment."

Distracted Mind stuff that goes specifically to the workplace and "workflow" -
WORKPLACE INTERFERENCE 
For those of us who work with technology and are surrounded by other employees working with their technologies, interference has become the norm. We are constantly interrupted by others dropping by our desk to chat or attempting to connect with us through a variety of technological communication modalities, including the most popular workplace tool—email. A study by Judy Wajcman, a sociology professor at the London School of Economics, highlighted this phenomenon by shadowing eighteen employees of an Australian telecommunications company during their entire workday. Wajcman selected this company because it was designed to facilitate interactions between workers with open-plan offices and other external distractors, including many large television screens mounted around the office. The employees in this study spent only half their workday on actual “work episodes,” which included any and all work-related activities. Strikingly, most of these work episodes lasted ten minutes or less, with an average of just three minutes per work episode. And even more interesting, nearly two-thirds of the work episode interruptions were self-generated, and most of those involved some form of mediated communication using a technological device. In fact, of the approximately eighty-six daily changes in an employee’s work activity, the workers themselves generated sixty-five of them internally, with the vast majority involving “checking in” with no obvious external alert or notification. Even without the “You’ve Got Mail” notification, these workers checked their email anyway and continued to check other sources of electronic communication and information without being externally directed to do so. 

Whether directed externally via an alert or notification or internally by an unseen process, it appears that in the work environment email and other communication modalities bear a major responsibility for interruptions. One field study that followed workers for two weeks discovered that they were interrupted 4.28 times per hour by email and an additional 3.21 times by instant message communications. And these communications appeared to have a strong draw for the employees, since 41 percent of them responded to the email immediately and 71 percent responded to an instant message immediately. On average, the workers spent ten minutes dealing with the alerts and then took an additional ten to fifteen minutes to return to their appointed task, often visiting several other applications in the interim. Another study by the research group ClearContext indicated that more than half of the 250 workers they queried spent over two hours a day reading and responding to email. A study out of Loughborough University in England found that after dealing with an email, which itself took an average of just under two minutes, it took the studied workers an average of 68 seconds—more than half of the time required to read and respond to that email—to return to their work and remember what they were doing. This study also found that people are responding like Pavlov’s dogs to incoming email communication, waiting only an average of one minute and forty-four seconds to open that message. Strikingly, 70 percent of those alerts were attended to within six seconds, which is about the time it takes a phone to ring three times. And yet another study found that even without an alert, while one in three people claimed to check their email every fifteen minutes, they actually checked it about every five minutes. We are self-interrupting and not even aware of how often we are diverting our attention from our main task—in this case, our job—to another task that may be completely unrelated to work... [ibid, pp. 113-115]
We all mostly have a naive conceit that we are adroit "multitaskers." Reading this book should change our minds. The science says otherwise.


All very interesting, all of it. I would make this book required reading for Health IT "UCD/UX" designers (the "User Centered Design" / "User Experience" peeps).  I would also add clinical management to the "required readers" list, given that the implications go squarely to policy, not InfoTech UX design. A progressive, workflow-friendly EHR that comes out of the development oven only to get deployed in a high interruption/distraction work environment way well have its slick UX negated anyway.

Another aspect to bear in mind. It has become widely fashionable these days to swax rhapsodic over our putatively increasingly "post-EHR" world, a world dominated by "mHealth" (mobile health apps), with patients busily burying their docs with user-generated metrics (of wildly variant SOAP utility and data QA pedigrees) and random patient queries.

More interruptions and distractions (beyond the intractable "interoperability" issues). Just what clinicians need and want.

From the closing chapter of The Distracted Mind:
11 MODIFYING BEHAVIOR 
IT SHOULD NOW be abundantly clear that we live amidst a level of high-tech interference that in the past decade or so has dramatically changed the world, and along with it our thoughts, feelings, and behaviors. In Part II we explored the many ways in which modern technology has aggravated our Distracted Mind; from awakening in the morning until trying to fall asleep at night, we are tempted by technological distractions and interruptions. As we have shown, three main game changers—the Internet, smartphones, and social media—have forever altered our mental landscape. We have painted a detailed picture based on solid research from a variety of fields showing that we are spending our days switching from task to task and affording each only our divided attention. 

Recall the cognitive control limitations that we presented in chapter 5 in the domains of attention (selectivity, distribution, sustainability, processing speed), working memory (capacity, fidelity), and goal management (multitasking, task switching). As described, high-tech influences stress these limitations in just about every possible way: they challenge our attention abilities via frequent distractions, fragment our working memory and diminish its fidelity through interruptions, and drive us to excessive multitasking and task switching, all of which introduce performance costs. In terms of the MVT model, introduced in Part I and elucidated in chapter 9, modern technology has caused this by diminishing the time in which we remain engaged with an information source, causing us to shift to another patch before we have exhausted the information in our current source. We are like a squirrel with an attention disorder, constantly jumping from tree to tree, sampling a few tasty morsels and leaving many more behind as he jumps to the next tree, and the next and the next. It sounds exhausting, and, as we have shown, it is negatively affecting our safety, relationships, school and job performance, and mental health... [ibid, pp. 213-214]
CODA

From the final passages of "The Attention Merchants."
The past half century has been an age of unprecedented individualism, allowing us to live in all sorts of ways that were not possible before. The power we have been given to construct our attentional lives is an underappreciated example. Even while waiting for the dentist, we have the world at our finger tips: we can check mail, browse our favorite sites, play games, and watch movies, where once we had to content ourselves with a stack of old magazines. But with the new horizon of possibilities has also come the erosion of private life’s perimeter. And so it is a bit of a paradox that in having so thoroughly individualized our attentional lives we should wind up being less ourselves and more in thrall to our various media and devices. Without express consent, most of us have passively opened ourselves up to the commercial exploitation of our attention just about anywhere and anytime. If there is to be some scheme of zoning to stem this sprawl, it will need to be mostly an act of will on the part of the individual. 

What is called for might be termed a human reclamation project... [Wu, Tim op cit, location 6471]
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More to come...

Monday, November 14, 2016

Informatics coding update: DSM 300.4.DJT (F34.1.Trump)


 Saw this over at The Daily Beast:
This Election Had Medical Consequences—And I Gave Them a Name
I’m a sleep disorder specialist, and many of my patients couldn’t sleep because of the election—and the anxieties that underlay it.

Qanta Ahmed

For months now, I have left the exam room after a patient visit feeling unsettled- not by my patient’s clinical challenges but by the suffering of my fellow American. Dozens of my patients report fear, sleeplessness, dread, worry and dejection over “America,” “the future,” “what’s coming next?” or, in these past days, what happens “after Election Day.” Some are felled by the shock of the Trump presidency that will soon be a reality, and many have spent long moments sobbing, heartbroken in my office.

Countless are torn at the state of the country and having no choice. Noticing this so often these past months, I came up with a name for these symptoms: Election Dysthymia...
Interesting. She cites this book:

Anthropologist Hugh Gusterson and Catherine Besteman edited a fascinating volume of essays, The Insecure American: How We Got Here and What We Should Do About It. The book, with an eloquent forward by Barbara Ehrenreich, describes how Americans once believed themselves intrepid. But defeat in Vietnam, the energy crisis, our undeniable economic decline and wage stagnation changed all that.

Reading the book rings frighteningly true to me- my patients embody many of these essays. Every day I meet patients working sixteen-hour days or longer, married couples holding down four sometimes five poorly paid jobs between them struggling to make ends meet. And, after almost twenty five years treating Americans I am struck by their escalating poverty- both financial and in quality of life, despite their extraordinary work ethic, an ethic which all too often costs them their health...
"The book, with an eloquent forward by Barbara Ehrenreich..."

to wit,
Fifty or sixty years ago, the word insecurity most commonly referred to a psychological condition. Some people suffered from “insecurities”; otherwise, though, Americans were self-confident to the point of cockiness. Public intellectuals worried over the “problem” of affluence, which was believed to be making us too soft and contented. They held forums to consider the growing challenge of leisure, never imagining that their own children and grandchildren would become accustomed to ten-hour workdays. Yes, there remained a few “social problems” for sociologists to study—poverty, which was “discovered” by the nonpoor in the early sixties, and racial inequality—but it was believed that these would yield easily to enlightened policies. We were so self-confident that Earth itself no longer seemed to offer sufficient outlets for our energy and ambition. We embarked on the exploration of space.

It was at some point in the late 1960s or early 1970s that Americans began their decline from intrepid to insecure. The year 1969 brought the revelation of the massacre at My Lai and the certainty that the Vietnam War would end in disgrace as well as defeat. At the same time, the war was draining federal funds from Lyndon Johnson’s Great Society programs, vitiating health services and hundreds of community development projects. Then 1970 saw the first national observance of Earth Day and the dawning awareness that our environmental problems went beyond scattered cases of “pollution.” For the first time since Malthus, the possibility was raised that we might someday exhaust the resources required to maintain America’s profligate consumer culture.

American business, beginning with the auto industry, woke up, in the 1970s, to the threat of international competition and initiated its long campaign to reduce both wages and the number of American workers. By the 1980s, big business had started the dismantling of American manufacturing—sending the factories overseas and destroying millions of unionized blue-collar jobs. The white-collar workforce discovered that even they were no longer safe from the corporate winnowing process. In the old version of the American dream, a college graduate was more or less guaranteed a middle-class lifestyle.

In the emerging version, there were no guarantees at all. People were encouraged to abandon the idea of job security and take on the project of “reinventing” themselves over and over, as the fickle job market required—to see themselves as perpetual salespeople, marketing “the brand called you.”

Meanwhile, under both Ronald Reagan and Bill Clinton, the old confidence that we could mobilize collectively to solve social problems like poverty and racial exclusion was replaced by a growing mean-spiritedness toward the unlucky, the underpaid, and the unwanted. The war on poverty gave way to a war on crime, and when there were not enough crimes to justify this massive punitive enterprise, the authorities invented new ones—like the “crime” of drug possession and use. America achieved the embarrassing distinction of having the highest proportion of its citizenry incarcerated, surpassing both Russia and South Africa under apartheid.

Even into the new millennium, which brought the threat of terrorism and the certainty of global warming, we held our insecurities at bay with a combination of scapegoating, distraction, and delusion. Gays and illegal immigrants became our designated scapegoats, regularly excoriated by evangelists and cable news anchormen. War was at least a temporary distraction, even though it was the greatest non sequitur in military history: attacked by a group consisting largely of Saudi Arabians, the United States invaded Iraq. And then, at the personal level, there was the illusion of affluence offered by easy credit. If our jobs no longer paid enough to finance anything resembling the American dream of home ownership and college for the children, we could always borrow—take on a dodgy mortgage, refinance the house, sign up for more credit cards.

But distraction and delusion are not long-term cures for underlying anxiety. This book comes out at a time when more and more Americans are tumbling from insecurity into insolvency—bankrupted by medical debts, made homeless by foreclosure, ousted from their jobs by layoffs. The credit crisis that began in 2007, combined with stunning increases in the cost of fuel and ever-growing economic inequality, has created challenges not seen since the eve of the Great Depression. As I write this, the overwhelming majority of Americans believe that the country is “headed in the wrong direction” and fear that they will be the first generation to see their children live in more straitened circumstances than they have known.

The Insecure American would have been essential reading at any time in the last few years, but today it is indispensable. For the most part, we confront problems and issues only as they arise in the news cycle, taking them from sources usually short on facts and devoid of analysis. In contrast, the contributors to this book have been researching and thinking about their subjects—from militarism to health care, from foreign policy to poverty—for years. Many are academics who teach as well as write, and here they offer a powerful overarching lesson in clear and down-to-earth prose: that we can understand the forces that have robbed us of security, and—through understanding, combined with a renewed commitment to collective action—overcome them.

Barbara Ehrenreich
I extracted that from the Amazon "Look Inside" preview, which I also captured in full as a PDF. A fairly generous sample. One well worth your time. Notwithstanding that the book has a 2010 copyright date, it rings true to this election year and month. The takeaway is that "it's not like we couldn't see this coming."

And now we have this guy. Ugh.
 

"...more and more Americans are tumbling from insecurity into insolvency—bankrupted by medical debts, made homeless by foreclosure, ousted from their jobs by layoffs. The credit crisis that began in 2007, combined with stunning increases in the cost of fuel and ever-growing economic inequality, has created challenges not seen since the eve of the Great Depression..."

Yeah. I had a nano-role in the run-up to the FIRE sector crash of 2008, owing to my 2000-2005 tenure working in subprime risk analytics. Wrote about those experiences on another of my blogs. See "Tranche Warfare" and "The Dukes of Moral Hazard."

More Qanta Ahmed:
I am a sleep disorders specialist. People come to see me when they have trouble sleeping. Many of my patients have mental health issues that improve greatly when I treat their sleep disorders. While all my patients see me because they have sleep disorders, the intensity, the depravity and the relentlessness of the 2016 election cycle have resulted in an additionally corrosive assault on my patients...
I am getting close to finishing this book, which also delves into sleep dysfunction (mostly in the context of the adverse impact of 24/7 digital InfoTech obsessions).

Most of us will freely admit that we are obsessed with our devices. We pride ourselves on our ability to multitask -- read work email, reply to a text, check Facebook, watch a video clip. Talk on the phone, send a text, drive a car. Enjoy family dinner with a glowing smartphone next to our plates. We can do it all, 24/7! Never mind the errors in the email, the near-miss on the road, and the unheard conversation at the table. In The Distracted Mind, Adam Gazzaley and Larry Rosen -- a neuroscientist and a psychologist -- explain why our brains aren't built for multitasking, and suggest better ways to live in a high-tech world without giving up our modern technology. The authors explain that our brains are limited in their ability to pay attention. We don't really multitask but rather switch rapidly between tasks. Distractions and interruptions, often technology-related -- referred to by the authors as "interference" -- collide with our goal-setting abilities. We want to finish this paper/spreadsheet/sentence, but our phone signals an incoming message and we drop everything. Even without an alert, we decide that we "must" check in on social media immediately... - from the Amazon blurb
Will be reviewing it soon. For now a little snippet on sleep:
Research has also demonstrated that getting too little sleep can disturb memory in important ways. Of course, memory is a complex process that involves multiple areas of the brain, but one key component to memory is a solid cognitive control system without which the information would never get transmitted effectively or completely to memory centers such as the hippocampus. One study found that adults who routinely slept less than five hours a night were more likely to incorporate misinformation in their morning report of either photos or videos that they had observed before bedtime; some even reported that they had seen video footage of an event that never happened.

Gazzaley, Adam; Rosen, Larry D. (2016-09-16). The Distracted Mind: Ancient Brains in a High-Tech World (MIT Press) (p. 140). The MIT Press. Kindle Edition.
 "...reported that they had seen video footage of an event that never happened."

Anyone come to mind here? Say, a President-elect who prides himself on his manly 4 hours of nightly sleep?

BTW: There are implications for Health IT UX in The Distracted Mind. Stay tuned.

UPDATE

Excellent new post up on THCB:
The Age of Trumpian Uncertainty

The new Chief Executive Officer of the United States of America Inc. will take office January 20th and likely make good on his promise to repeal the Patient Protection and Affordable Care Act. It only requires a majority in both houses of Congress to pass and that’s assured based on the election results last week...
 Should healthcare in the United States be approached as a fundamental right or a privilege? In the constitution, life, liberty and the pursuit of happiness are guaranteed. Is access to a healthcare system a fundamental right for all in this country or is it reserved for those who can afford its services? In our system of government, we’ve concluded that education is a fundamental right for all. Is healthcare akin or different? And what’s included in that assurance: basic services for all, or exactly what?...
JUST IN, FROM THE NEW YORKER

From AFTERMATH: SIXTEEN WRITERS ON TRUMP’S AMERICA

HEALTH OF THE NATION
By Atul Gawande


How dependent are our fundamental values—values such as decency, reason, and compassion—on the fellow we’ve elected President? Maybe less than we imagine. To be sure, the country voted for a leader who lives by the opposite code—it will be a long and dark winter—but the signs are that voters were not rejecting these values. They were rejecting √©lites, out of fear and fury that, when it came to them, these values had been abandoned.

Nearly seventy per cent of working-age Americans lack a bachelor’s degree. Many of them saw an establishment of politicians, professors, and corporations that has failed to offer, or even to seem very interested in, a vision of the modern world that provides them with a meaningful place of respect and worth...


As the new Administration turns to governing, the mismatch between its proffered solutions and our aspirations and ideals must be made apparent. Take health care. Eliminating Obamacare isn’t going to stop the unnerving rise in families’ health-care costs; it will worsen it. There are only two ways to assure people that if they get cancer or diabetes (or pregnant) they can afford the care they need: a single-payer system or a heavily regulated private one, with the kind of mandates, exchanges, and subsidies that Obama signed into law. The governor of Kentucky, Matt Bevin, was elected last year on a promise to dismantle Obamacare—only to stall when he found out that doing so would harm many of those who elected him. Republicans have talked of creating high-risk insurance pools and loosening state regulations, but neither tactic would do much to help the people who have been left out, like Jim Young’s family. If the G.O.P. sticks to its “repeal and replace” pledge, it will probably end Obama’s exchanges and subsidies, and embrace large Medicaid grants to the states—laying the groundwork, ironically, for single-payer government coverage...
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ERRATA

Some remarks I recently posted on Facebook.
Those of us who opposed and voted against Donald Trump are now members of the "loyal opposition." But, it is critical to continue to focus on that to which we are properly to be "loyal." The Constitution, yes. But more importantly, the ideals of equal justice for which it ostensibly stands.

Loyalty to the Constitution presupposes loyalty to the office of President it sets forth in Article II. But, that is a separate consideration from unreflective, unquestioning deference to the person who holds that office at any given time irrespective of how he (and, still a "he") behaves once in power.

To the extent that the new President Trump comports himself within the established confines of the Constitution, fine. We will continue to have the First Amendment right to peacefully disagree vocally with specific policy proposals and actions (which always happens, and is to be expected in a free society), but Mr. Trump should never be permitted to forget that loyalty is a two-way street.

It may become necessary for someone to read the Declaration of lndependence to him, given the voluminous record of autocratic, belligerent statements he has left us with thus far. That perhaps he doesn't actually believe all that crass, incendiary campaign shit is no less of a cause for concern.

Going to be an interesting year, my friends.
Also, Trump has made opaque pander-to-the-Fundies allusions regarding having Roe vs Wade overturned.
With respect to human reproduction (in particular the "life begins at conception" canard), the contribution of the male begins and ends with the sperm's successful delivery of the polymer molecules comprising ONE copy of the male's DNA that constitute his 23 chromosomes. Everything that takes place thereafter, starting with the ensuing division process begun by the single cell sperm-fertilized ovum, is a function of the female's gestational biology. all of the subsequent biological reproductive effort, and all of the medical risk.

The assertion that [1] a fertilized ovum is instantly a "person," and, [2] men should be able to declare for themselves "equal reproductive rights" tantamount to a veto over what a woman does with her body once pregnant are the most ignorant and arrogant things I've ever heard. It has nothing to do with "reverence for the sanctity of life," it has everything to do with reverence for dominant male power. Period.

Moreover, take men out of the picture, just to advance the argument a step further. The notion that some women should be able to use the force of law to deny other women the right to control their biology is equally specious. For starters, it violates the Equal Protection clause of the 14th Amendment.
Don't like abortion? Don't have one.
Then there's the issue of "dismantling regulations."
Consistent with his broad ignorance, Trump has no clue regarding "regulations." He claims he will just get rid of 75 to 80% of all federal regulations. First of all (beyond the fact that doing so is the purview of Congress, not the President), an apt analogy to law and regulation is the corporate "policies and procedures" we also all hate.

Laws tell us "what" and "why," and subsequent regulations tell us "who," "how," and "when" (the operational details). Regulations at the federal level are published in draft as Federal Register proposals, which undergo a prolonged period of public review and comment before they are finalized. Moreover, they cannot exceed the scope of the parent law. To the extent they do they are very quickly challenged in court and either overturned or scaled back. The various stakeholder groups are vigilant with respect to proposed regulations. We may not like the volume and complexity of them, but that's simply a function of the way legislation works in a nation of 330 million people.

I have worked in highly regulated environment for 30 years. EPA, NRC, OSHA, OCC, FDIC, and HHS. In my last job, I was the team lead on our staff for writing policies and procedures that were compliant with HIPAA medical privacy and security regulations covering our statewide Nevada Health Information Exchange. I know a thing or two about how this stuff works.

It's maddeningly tedious and complicated and imperfect. But, human affairs get regulated one way or another.

You want polluted water and air, toxic drugs, unsafe vehicles, poisoned foods, airplane crashes routinely?

Fine, do away with regulations.
POST-ELECTION PHOTOJOURNALISM UPDATE


The first new job created by the incoming Trump® Administration.

CODA
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More to come...