This Is Not a Board Exam Question

Bill,

There's no manual for teaching young doctors. Although we do give them lectures there are no classes per se and certainly no homework. Despite our best efforts, grading is highly subjective. Mostly training is done the way it has always been done, one-on-one. The trainee presents the case to the attending (me), the attending asks a question or 2 about the details, and then says, "OK, what do you want to do." Depending upon stage of  training, overall competence, and level of courage, the trainee's opinion of what should happen next will vary from spot-on to near malpractice. As is always the case,  teaching the bright ones is  easy. Teaching the dullards bears some similarity to the carry-and-drag event in the World's Strongest Man Contest.

There are many different ways to categories to categorize patients, by disease type or severity, by age or demographics, by prevalence or prognosis. But the way I often chose is to ask; "If you asked 10 doctors how to treat this problem, would they all give you the same answer" That is what I like to call a Board Exam question. There is enough consensus about a particular diagnosis or treatment that all are in agreement what the answer should be. That doesn't mean, alas, that what we currently believe is true will always remain so; cardiology has more than its share of once-accepted  treatments now discredited. Yet there is a broad body knowledge that endures, the mastery of which is considered essential.

Often, however, the answer to my question will be not be so simple. There may in fact be no sure answer at all, just a best guess as to how to proceed. A good doctor in these situations is comfortable with uncertainty. He/she accepts the burden of making decision with incomplete information, and under sometimes rapidly changing circumstances. He/she understands that things may look quite different in a day, or even an hour, and, acknowledges that sometimes one needs to change course. Being willing to change one's mind is sign of wisdom, not weakness.

If only someone could get that message across to our leading Presidential candidates.

Eli

Identity Politics

Bill,

The number of New York Times columnists I read continues to shrink. First off my list was Nick Kristoff, after his resurrection of  a 17 year old accusation of child abuse against Woody Allen (for which he was exonerated after an exhaustive investigation), recirculated as a favor to his personal friend Dylan Farrow. Next was Maureen Dowd, whose pathological hatred of all things Hillary (although there's plenty to dislike) grew too tiresome to tolerate. Now Charles Blow is approaching the danger zone with his myopic, strangulated vision of how the country might achieve equal justice for all its citizens.  In fact that's the problem; there is no vision, no concrete proposals or even philosophical notion of how to get to where we need to be. There's just enraged whining.

This from Mr Blow last Thursday, seeking to excuse the incendiary rhetoric  adopted by some acolytes of the Black Lives Matter Movement:

I actually believe that you have to peel back the vitriol to expose the fundamental, but unarticulated truth at the core of the opposition to this movement: It centers blackness in a country that “others” blackness. It elevates blackness in a country that devalues it. It prioritizes blackness in a country that marginalizes it.

....Discomfort with Black Lives Matter, is, on some level and to some degree, a discomfort with blackness itself. It’s not only about the merits of individual cases, it is also about the collective, ingrained sins of the system committed disproportionately, and by design, against people of color. The movement convicts this country of its crimes.

America has been engaged since its inception in a most gruesome enterprise: Like the mythological Cronus, it has been eating its children, the darker ones, and this movement demands — at least in one area, at least in one moment — that it atone for that abomination.

Here's a response from the Comments that's answers this accusation far better than I ever could.

Okay. Standard White liberal here. Voted for Obama twice. Support affirmative action. Think black people have gotten unfair deal in American and its our responsibility (all of us) to address racism past and present with aggressive prosecution of racists and their removal from public life. Have plenty of black co-workers, friends and family members. All that being said, it's hard for me not to see the BLM "movement" as being, in part, a movement blind to the complicated reality of race in America --- it's just not simple. It's a "movement" led by professional activists in urban centers who have no reason whatsoever to find common ground, productive solutions and peace between races; instead, the goal will be to exacerbate the situation to "prove" America's racism, again and again and again. The rhetoric --- like the talk in this article about hating blackness etc. --- pretends we're all in Mississippi in 1965, if only we were --- the answers would be easy and enemies obvious, but we're not. Urban 21st century whites by and large take it for granted that blackness is great and racism is evil. It's not up for debate. BLM is a 21st century "professionalized dissent fantasy structure" in which we pretend that no one has black family members, friends and co-workers and we all live surrounded by corrupt racist all-white police forces. Basically people who missed the sixties want to replay them now. 

Meanwhile the slaughter of young Black men by their counterparts continues to spike. Again from the Times, here's an account of one recent murder in Milwaukee, an epicenter of such violence.

In Milwaukee, most of the victims and the suspects in their killings are black men under 30, police data shows, who come from neighborhoods where foreclosures, joblessness and poverty are also high. Most involve guns and people — both victims and suspects — who have been arrested before. The most common motive in the slayings was not robbery or gang rivalry but an argument, according to the data.

On July 3, as an annual fireworks display along Lake Michigan ended, Tariq Akbar, 14, was shot in the back of the head while he was leaving the crowded celebration to meet his mother, who was parked not far away.

“The police were right there — not even 50 feet away,” his mother, Arifah Akbar, said. “This is when you know how bad Milwaukee has gotten.”

The police said the shooting had stemmed from a dispute on social media. A 15-year-old has been charged.

About such events we hear nothing from Mr Blow, or Mr Coats, or Mr. West. We hear the keening of grief from the loved ones of these dead children.

Demand equal justice, relentlessly. Accept nothing less. Demand effective, coherent, compassionate policing. A tremendous amount of mayhem is driven by handful of knuckleheads. Find them. Lock them up Condemn violence, everywhere, by anyone.

Eli




  

I'm not patronizing you I'm just mindlessly agreeing with everything that you say.

Eli,

I saw this headline and couldn't believe it was true, but alas, it is:

"Walker would consider building wall on Canadian border,"

My fifteen year-old daughter commented, "It sounds like something a kindergartener would say." Alas, that is also true.

I started complaining about Republicans and immigration. My 15-year old was agreeing with everything I said. I asked her if she was patronizing me. Her response:

"I'm not patronizing you I'm just mindlessly agreeing with everything that you say."

I was so proud.

Bill

The Worst of the Repblican Party.

Eli,

Donald Trump, and his views on immigration, is bringing out the worst of the Republican Party. Unfortunately, it's a strain of hatred and bigotry that goes back to the Know-Nothing Party and its hatred of Catholics, particularly the Irish. Trump, as you know, among other things, wants to deport all illegal aliens, build a giant wall along the Mexican border (and get them to pay for it!) and end birthright citizenship. What is shocking to me is others running for the Republican nomination  actually support some or all of this plan.

My views on immigration are far from either the Left or the Right in that I'm in favor of something as close to open borders as possible. In my view, if someone wants to come to America, come on in. I see very little downside and mostly upside to this trade. People coming to America, desirous of work, desirous of making a better life for themselves and their children? Please come and be my neighbor. I reject the call of the Right and the Left to limit immigration to high-skilled workers or only allow in those under a guest-worker program. Let them all in: the tired, poor, hungry yearning to be free. Let them in.

Strangely enough, Americans have had a love/hate relationship with immigrants since our founding. The Irish, the Italians, Germans, Jews, Poles, Chinese, Japanese, Koreans, Central Americans and Mexicans were all dirty, poor, uneducated, parasites coming here only to spread their diseases, Popish religion, obedience to monarchy. They were unwilling to become "true" Americans; they stayed in their own communities; they spoke their own language; they practiced their own religion; they weren't one us. They were the other, the outsider. This hatred that Trump espouses is nothing new; neither is its vileness.

And in my mind, at least in in the sense that this is an immigrant nation, this hatred of immigrants is unhinged. I understand why this influx of strangers with different customs is upsetting to people and I know I am far removed from the discomfort can cause to established neighborhoods. But still. My paternal great grandparents come to America during the Irish potato famine. And my maternal ancestors came from French Canada. My wife's ancestors also came from Ireland and were Native Americans.  I know your ancestors were not indigenous to America. Of the 330 million Americans I would guess less than 1% are native.

What bothers me most about the Trump hatred is the attempt to blame Mexico for many of the troubles in America. Jobs are tough to find? Blame the Mexicans. Factories are moving out of your community? Blame the Mexicans. It's the other. The outsider. The one who isn't like you that is responsible for your woes. All demagogues use the other as a way to avoid responsibility. Hitler was the example par excellence, but Stalin, Castro, Pol Pot, Idi Amin and every other tyrant uses the other as an excuse to gain and consolidate power. And I am quite aware I just compared Trump to mass murderers.

I read this morning in Ben Domenech's "The Transom,"

Many Republicans support an end to birthright citizenship. Mitch McConnell held hearings on it in 2010, and Steve King and David Vitter have introduced the current versions of the legislation aimed at doing so. In the presidential field, Rand Paul, Lindsey Graham, Chris Christie, Rick Santorum and others have backed ending birthright citizenship. In the wake of Donald Trump’s immigration proposal, two more have added their support for the idea: Scott Walker and Bobby Jindal, the latter of which is a birthright citizen himself. In scattered polling on the issue, a minority of Americans but a majority of Republicans support the idea.

Have they lost their minds? For God's sake Bobby Jindal was born in America of non-American citizens. Even setting aside the Constitution and the 14th Amendment, it's just common sense: If you were born in America, you are an American. Hard Stop!

While the Democrats haven't been as anti-immigration as Republicans, they too blame the other. It's just that the other for the Democrats are the Koch Brothers and Insurance Companies and Wall Street. Frankly, just as ignorant as Trump and the modern Know Nothing Party.

This is becoming a choice between dumb and dumber.

I'm so depressed.

Bill

The Problem We All Live With

Bill,

My daughter has gently dragged me a little further into into the 21st century, introducing me to podcasts. I finished listening to her first recommendation,. "The Problem We Live With, from This American Life, the long running (left leaning to be sure) series produced by its acclaimed creator, Ira Glass. Without giving too much away, the podcast examines, in its signature narrative fashion, the story of a failing minority school district, the solution that was successfully employed to improve that district, and the (inevitable?) abandonment of that solution. I'll bet you can guess what the solution was.

The cast left me disturbed and more than a little ashamed. I find the idea that black or brown children are somehow innately deficient deeply pernicious. And yet, for years I asserted that switching the student bodies of the prosperous, integrated town where my children were raised with the desperately poor, overwhelming minority school district next door would make no difference; the (mostly) white, middle class kids would perform just as well in the crummy inner city schools, and the black and brown kids would continue to fail in the fancy schools. Where did I come up with that?

The podcast's praise of integration not withstanding, consistent data on its effects are not easy to find. It does not appear to affect white student's performance; assessments of its overall effects on minority students performance appear to be more uneven. What is clear is that we are largely back where we were 60 years ago.

Eli

The Iran Deal

Bill

My letter to my congresswomen is posted below. This has been a tough call.

Eli


Dear Rep Esty,

Thanks for your invite to tomorrow's Town Hall. I can't make the event, but I write to urge you to support the deal. I'd be deceiving myself, and you, if I denied my misgivings; there's no question the deal has flaws, and that it carries risk, as the President has acknowledged. Could we have done better? Perhaps. There's no logic or reason to believe that the alternative, its rejection, will move us no closer to our goal of a non-nuclear Iran. Rejection, as argued by many observers, has a high likelihood of producing an escalation of Iran's effort to build a bomb, and the inevitable (and likely unsuccessful) military response to that effort that will follow.
We don't have to like Iranian regime, or even trust it, to reach this agreement. We have follow our own best self interest. For now, this is the best we are going to do.

Sincerely,

 

Ghettoside

Eli,

I’m almost in total agreement with you on your latest, “These Black Lives Also Matter.”

It seems to me we are like the blind men and the elephant each diagnosing one small aspect of a very large issue. I agree, teen pregnancy and violence are important; I tend to focus on the war on drugs and monopolization of  education by the state as key issues; others focus on family structure; others on lack of economic opportunity. All of these are important and it’s probably impossible to say which is THE key. We (as a society) shout past each other because we all know our pet answer is the answer.

I think this is another issue where the attitude that “the science is settled” is harming more than helping. If you think maybe doing nothing is better than something you are a racist (or denier).

But think about the model(s). The dependent variable is improving poverty. In your model the independent variables are teen pregnancy and violence. Reduce both and poverty is reduced. How is your model performing? A link to an HHS study on teen pregnancy from your link to the NY Times story on Colorado’s birth control program states, “The teen birth rate has declined almost continuously over the past 20 years. In 1991, the U.S. teen birth rate was 61.8 births for every 1,000 adolescent females, compared with 26.5 births for every 1,000 adolescent females in 2013.” According to your model there should have been a reduction in poverty. Was there? Your model says effective control of violence is a key element also. Yet you admit violence has declined, but what about poverty? Are you sure your model is valid? And calling me a racist if I don’t agree with your model doesn’t change the model’s results. (Just like calling me a denier doesn’t change the results of a tragically failed model on global warming).

I wonder if the issue might be exacerbated instead of mitigated by our solutions. For instance, those in poverty receive benefits from local, state and national governments. Families get more support. Families with a single parent even more support. That sounds fair and compassionate to everyone, including me. But is it? From an economic perspective it creates an incentive for single parent households. (And taking umbrage at pointing out the obvious doesn’t help). Another “solution” is raising the minimum wage. We’ll just legislate the way out of poverty. However, increasing the minimum wage can result in losing the benefits of the welfare state. A great exploration of this is Andrea Louise Campbell’s, “Trapped in America’s Safety Net: One Family’s Struggle.” But look at this, and this and this (trust me, I didn't need to look too hard to find these) as well. It supports my first point and begs the question if our first solution was flawed, what is flawed about our second solution?

I know comparing the experience of blacks in America to the experience of the Irish, Italians, Jews and Chinese is dangerous, and in many ways not apt. But in others ways it seems quite relevant. If government aid is good and lack of it bad how do we explain the rise of the Irish and Italians and those other groups out of poverty when government actively discriminated against them? I don’t think blacks are any different than the other ethnic groups in terms of ability. What is the difference then? I look at one big difference and that is the active role of government in crafting a solution and certainly it warrants asking if maybe the solution is the problem.

Bill