Tuesday, August 18, 2009

Conversation with a Doctor

My brother Al is a doctor who thinks that a single-payer health care system is the only answer and is not too impressed with Obama's so-called plan.

He gave me several examples where evidence-based medicine (referred to as "rationing" by the opponents of reform) could save alot of money. Pointless MRI's for one. But there is no consistent mechanism to restrain doctors from ordering them.

Doctors should be salaried, and the huge expense of training distributed in a way that better encourages frontline practices rather than drawing doctors into lucrative specialties, or to elite institutions which can afford to pay the debt for them.

In the St. Louis area training of support personel in medical services is made difficult by lack of teamwork experience in Secondary Schools. We didn't discuss specifics but its probably "Bossism" that wrecks the ship. Authoritarian rather than democratic work norms and processes. Like in American industry- the lower the level the decision can be made the more effective the outcome. An experienced hand who has worked his way up from the shop floor is better than an MBA any day.

A person who has only learned to take orders "from the top", is wary of taking initiatives and laterally uncommunicative is a drag.

The network of individuals who have been trained in socially cohesive work paradigms, however, extends far beyond a specific work place into the industry and community as a whole. This, in and of itself, has positive epidemiological consequences for health.

My brother has supported Medecins Sans Frontieres for thirty years.


  1. We didn't really need to go into detail since the idea is expressed very well in our father's book "Team Teaching" (Harper and Row, 1964)

    Another source for these thoughts is William Mares' ( a local author) book "Working Together" (1983). Curiously, Bill was born in St.Louis.

    A recent book "The Puritan Gift; Triumph. Collapse and Revival of the Ameican Dream" by Kenneth and William Hopper (I.B. Tauris, 2007) also focuses on this theme. The influx of MBA's, trained primarily in the general principles of financial management- which is supposed to "be good" regardless of the specific products or production processes of a particular industry, and operate in a hierarchial fashion- was a very large factor in the recent meltdown and will greatly inhibit our climb out of recession.

    Just as an example; figure out how Bernie Madoff was able to get away with his Ponzi scheme. In the normal course of affairs the returns he was getting on his "investments" were an absolute impossibility but few in his organization, other businesses with whom he had contact or regulators raised any red flags.

  2. In "Black Swan" Nassim Taleb also shows how, instead of carefully investigating the real 'nuts and bolts' of companies, Wall Street investors often act in a herd-like fashion, following the lead of the "top" guys and firms in orgies of untoward speculation.

  3. It is precisely the breakdown in the long-established system of peer-review in favor of research dominated by marketing and Public Relations that is helping to drive up the costs of medicine and hospital care. In "Our Daily Meds" Melody Peterson gives several examples of the unenviable fate of low-level "whistle-blowers" in the hands of top management at the Drug Companies.

    It should also be noted that for the most part continuing education for teachers mostly consists of taking courses at a local university rather than in-service training based on the specific circumstances of the schools in which they are practicing.

    In this regard, my father's article "Practice in Teaching" in the Harvard Educational Review (1963?) is also helpful in conceptualizing the problem.

  4. Finally, though perhaps not exhaustively, there is the political ethos or zeitgeist of the age as wonderfully outlined in Francine Prose's article "Voting Democracy Off The Island":

    a " flinty individualism, the vision of a zero-sum society in which no one can win unless someone else loses, the conviction that signs of altruism and compassion are signs of folly and weakness, the exaltation of solitary striving above the illusory benefits of cooperative mutual aid, the belief that certain circumstances justify secrecy and deception, the invocation of a reviled common enemy to solidify group loyalty- the exact same themes that underlie the rhetoric we have been hearing and continue to hear from the republican Congress."

    Epidemiologists have identified the ramifications of this ideology as having severe consequences for the health of the American people. Vast numbers of people living in an extremely passive relationship to the hierarchial powers structures that dominate society are highly vulnerable to common "life-style" diseases- diabetes, heart disease and perhaps even cancer.

    Phillippe Bourgois documents some of this in "Righteous Dopefiend".