Category: Jane Jacobs

Assorted Links

Seth Roberts3 Comments

Thanks to Bryan Castañeda.

Assorted Links

Seth Roberts4 Comments

Thanks to Alex Chernavsky.

Another Unintentionally Revealing Response From the American Medical Association

Seth Roberts5 Comments

A few weeks ago I blogged about the lame response of the American Medical Association to HealthTap, a website that solicits doctors’ answers to medical questions. Their criticism was so weak it amounted to praise.

More recently, the AMA was asked about its position on doctor rating websites. Here’s what happened:

Robert Mills, a spokesman, sent me a statement that he said was from the A.M.A.’s president, Dr. Peter W. Carmel, that read, in part, “Anonymous online opinions of physicians should be taken with grain of salt and should not be a patient’s sole source of information when looking for a new physician.” This, however, is almost exactly the same statement it provided to its own publication, American Medical News, in 2008, when it was attributed to Dr. Nancy H. Nielsen, the president-elect of the A.M.A. at the time.

Such plagiarism is more consistent with what Jane Jacobs in Systems of Survival called guardian values (where honesty is unimportant) than commercial values (where honesty is very important). When you grasp that doctors follow guardian values rather than commercial ones their behavior becomes far more predictable — and plainly in need of control by outsiders. That doctors are allowed to charge for their services resembles allowing policemen to write as many parking tickets as they like and pocket the fines.

Thanks to Bryan Castañeda.

An Example of Predatory Medicine

Seth Roberts7 Comments

I recently posted about how doctors act like predators, in the sense of having what Jane Jacobs called “guardian values” (e.g., loyalty to other doctors is more important than honesty to patients). Here is an example of medical behavior that coming from an ordinary business would be shocking:

On February 21 [2012], I had my evaluation for a kidney transplant at a university-affiliated medical center about 100 miles from where I live. The way this institution operates, it takes about 8 months to get from initial referral to evaluation and there are all kinds of diagnostic tests in between (see previous blogs for more details). Once you are an approved transplant candidate and an organ becomes available, you go to the hospital and have surgery. The average stay for a kidney transplant is about 3 days and then you are discharged to a local hotel for 5-7 days. During that time, you return to the hospital every day for blood work, monitoring of the immunosuppressive medications and patient education. Also, you must have a full-time caregiver. That can be a friend, family member, stranger off the street corner, but they must be with you at all times to ensure that you are eating, taking meds, bathing, etc. Also, driving is prohibited until about six weeks post-transplant so the caregiver is also a chauffeur and attends the educational activities as a back-up in case the patient becomes incapacitated or symptoms of rejection appear.

In short, your caregiver must be able to put their own life on hold for about two weeks with as little as two hours notice. When you think about it, that’s a pretty tall order to fill. I have a caregiver, he happens to be a member of this forum. He is a dear, dear friend and always will be if only for the fact that he is willing to undertake this role with only the merest of acquaintance. He is more than willing to put himself and his home at my disposal if necessary. I won’t call him out by name, he obviously knows of whom I speak, but I truly feel as though Karma has smiled on me since our paths have crossed.

So the evaluation finally rolls around. Caregivers must be present during the evaluation. We check in at the medical center and are shown to an exam room. We are seen by a barrage of clinicians; dietician, nephrology resident, nephrology attending (the doctor in overall charge of my medical care while at the transplant unit), and the transplant surgeon. There are physical exams (kind of interesting since my caregiver knows me pretty well, but not THAT well), an EKG and a side trip to the lab. At the lab, the phlebotomist doesn’t pay any attention to my advice about using a butterfly catheter and proceeds to draw 20 (count ‘em, 20) vials of blood for type, cross match, antigen levels, etc, etc through a Vaccutainer. About halfway through, my vein collapses and she has to switch to the other arm, this time with a butterfly. After that, a chest x-ray. Back up to the 9th floor for our final meeting of the day; the social worker.

Up until this time, everything had been encouraging. I can’t say enough good things about the clinical staff, they were all wonderful, professional, warm, willing to answer questions, etc. My transplant surgeon looks like he should be on a TV medical drama, he can unzip me any time! The good vibes ended the minute we sat down with the social worker. She informed me that I would be required to have a second caregiver, a backup so to speak. WTH? People that can call a halt to their lives don’t grow on trees. Talk about hitting a brick wall. Here’s a sample of the conversation:

Social worker: What will you do if you are discharged to home and you can’t take care of yourself?
LadyDoc: Well, if I can’t take care of myself then I guess I shouldn’t be discharged, should I?
Social worker: Well, you could always go into a nursing home.
LadyDoc: Over my dead body.

And there you have it, the standoff. I have looked through every single printed word and email that I have ever gotten from this institution (and I keep very good records) and there is NOT A SINGLE WORD about having a second caregiver. The only family I have in the area is my daughter and she has two little boys under the age of five at home, so I can hardly ask her. My circle of friends is painfully small, many are disabled and not up to the challenge and the others have lives of their own.

The social worker called me a few days later to see if I had changed my mind and it suddenly began to sound like a sales pitch. She was touting all the advantages of this particular institution but I just don’t see it. I am now turning my attention to medical centers where the inpatient stay is closer to 5-7 days and then the patient is discharge directly to home, none of this stay-in-a-hotel stuff. I can’t think of too many places where germs and nastiness run more rampant than a hotel. I am so frustrated, I feel as though the last 7 months of my life have been an utter waste of time. Furthermore, the evaluation day was wasted; if we had met with her first we could have simply gotten up and walked out and said “Thank you for playing, please try again”.

In case you needed any convincing that customers for health care differ from customers for other services. (The difference: they are more desperate.) Think of this example if you are sure that government-run health care must be worse than the current system. You can learn what happened next at the link.

Assorted Links

Seth Roberts6 Comments
  • In praise of Rush Limbaugh.
  • Shangri-La Diet experience (“Bottom line: I lost three pounds in a week and a half”) of an artist named Elizabeth Periale.
  • Long interview with Tucker Max. “His fridge . . . is in one way very different: where you’d expect the six-pack of cold ones waiting for the game, instead you’ll find rows and rows of kombucha, the fermented health beverage.”
  • End of college campuses. Megan McArdle imagines a world in which college is replaced by distance learning. “95% of tenure-track jobs will be eliminated.” Jane Jacobs, in Systems of Survival, divided jobs into taking and trading. Teaching is trading if the student really wants to learn the subject. Teaching is taking if the student is forced to take (and pay for) the class. Scary thought: Every college student is asked about every class: would you take this class if you didn’t need to (and didn’t need to take other classes)?

“Thou Shalt Not Testify Against Another Doctor”

Seth Roberts2 Comments

First do no harm . . . As Robin Hanson has said, what does that mean? In contrast, the rule illustrated by this story, from Bryan Castañeda, who works for a Los Angeles law firm, is quite clear:

At the old firm I used to work at, I was talking to one of the senior attorneys and the topic of medical malpractice cases came up. He said he avoids them. Why, I asked. He said — I’m paraphrasing here — “Because you won’t find a doctor who will testify against another doctor in open court. They may advise you in private, ‘Oh yeah, so-and-so definitely screwed up,’ but you won’t get them to say that on the stand. They all protect each other.”

Judging by this story, if your doctor makes a mistake, the only person who will suffer consequences is you. Thank heavens the rest of us have more power than ever before. A recent survey of doctors found that “more than a 10th (11.3%) admitted to telling patients something that was not true.” The survey did not ask about lies of omission (when silence is misleading); unwillingness to testify that someone else made a mistake is that sort of lie. The survey also showed that doctors (at least, those who took the survey) have a self-serving interpretation of the term not true. Although only about 10% said they had said something “that was not true” — meaning something that they knew wasn’t true — “more than half had described a patient’s prognosis more optimistically than warranted.” Apparently they consider such descriptions not instances of “not true”.

In Systems of Survival, Jane Jacobs described two moral systems (lists of rules/values): The guardian syndrome and the commercial syndrome. In certain areas of life (e.g., military), the guardian syndrome prevailed; in other areas (e.g., small business), the commercial syndrome prevailed. Loyalty (e.g., “never testify against a fellow doctor”) is a guardian value — indeed, the main guardian value. In contrast, honesty is the main commercial value. Jacobs said that the two syndromes corresponded to two ways of making a living: taking and trading. Doctors do not represent themselves as predatory (= taking). But, according to Jacobs, this sort of rule (“never testify against a fellow doctor”) puts them squarely in that camp.

I asked Jim Jacobs, one of Jane Jacobs’s sons, for comment. He replied:

Exactly right. Jane experienced this herself, unfortunately. It’s really a major problem. I see the very same behavior among medical researchers too.

The Beauty and Tragedy of Tokyo

Seth Roberts17 Comments

I told a Chinese friend I would stop in Tokyo on my way home. “Tokyo is a beautiful city,” she said. “Sort of,” I said. After a day in Tokyo, I realized she was right. Tokyo is beautiful, not sort of beautiful. Tokyo business signs and outdoor advertising aren’t beautiful but they are swamped by many things that are:

  1. Small irregular streets. On foot, the weird address system works fine.
  2. Plenty of parks and greenery.
  3. Many small neat attractive shops selling a huge variety of goods. A miso store, for example. Many parts of Tokyo are like Greenwich Village, in other words.
  4. Clean convenient free public restrooms. Unlike other cities, as I’ve said.
  5. Excellent service in shops. Unlike Paris and Amsterdam.
  6. Excellent map and direction signage. In subways, for example, way-finding signs tell the distance, not just the direction, of the destination. This is so basic (distance and direction are orthogonal) yet other places, such as New York, don’t do it. Such creative attention to detail, such improvement on something so old (wayfinding signs) isn’t just helpful, it’s inspiring. I came across a construction site sign that appeared to say how loud the work would be. Again, serious improvement on tradition.
  7. Everyone I asked for directions was helpful, although many were surprisingly ignorant (e.g., didn’t know which direction to Roppongi).
  8. So very walkable. Partly because the streets are curvy, partly there are so many little interesting things everywhere I went but also because when I got tired of random wandering, I could simply go to the nearest subway station and get to my ultimate destination.
  9. The proportions of buildings. Slightly thin, slightly tall.
  10. The repeated exterior details of apartment buildings. They are not smooth slabs. They have visible balconies, stairs, etc.
  11. The food shops in the basements of department stores. There are dozens of small booths. One sells miso, another sells pickles, a third sells salads, a fourth sells eel, and so on. Not only is the food itself often beautiful — Japanese food packaging is supremely lovely — but it is beautifully arranged. You could learn a lot about aesthetics (the hidden laws of beauty) by comparing these displays with similar (less attractive) displays in other countries.
  12. Clean air, clean streets. In spite of heavy use.
  13. Well-maintained neat small houses.
  14. Temples scattered throughout the city.
  15. Healthy-looking people, especially old people. I think it’s all the fermented food they eat (e.g., miso, pickles), not the health-care system.

I did not find Tokyo expensive, even with the dollar way down against the yen. I never took a cab (and never wanted to — in Beijing I always want to). Equated for quality, I think Tokyo is cheaper than New York.

The tragedy of Tokyo is the lack of human diversity: few foreigners. Such a great city should draw people from all over the world, but it doesn’t. It has a a lot to teach the rest of us about how to live in cities (for example, where does Japanese perfectionism come from?) but somehow this sharing hasn’t happened. Like a cure for cancer in a journal no one reads.

SOPA Strike

Seth Roberts6 Comments

SOPA is an example of what Thorstein Veblen called “the vested interests” trying to prevent change. In an essay called “ The Vested Interests and the Common Man” he pointed out “the existence of powerful vested interests which stand to gain from the persistence of the existing, but outdated system of law and custom.” Jane Jacobs said much the same thing. The most important conflict in any society, she wrote at the end of The Economy of Cities, isn’t between the rich and poor or management and labor; it is between those who benefit from the status quo and those who benefit from change. If those who benefit from the status quo usually win, problems stack up unsolved.

Assorted Links

Seth Roberts1 Comment

Thanks to Hal Pashler, Dave Lull and Mike Bowerman.

Duct Tape, the Eurozone, Status-Quo Bias, and Neglect of Innovation

Seth Roberts11 Comments

In 1995, I visited my Swedish relatives. We argued about the Euro. They thought it was a good idea, I thought it had a serious weakness.

ME It ties together economies that are different.

MY AUNT It reduces the chance of war in Europe.

You could say we were both right. There have been no wars between Eurozone countries (supporting my aunt) and the Eurozone is now on the verge of breaking apart for exactly the reason I and many others pointed out (supporting me).

Last week a friend said to me that Europe was in worse shape than America. I was unconvinced. I said that I opposed Geithner’s “duct-tape solution”. It would have been better to let things fall apart and then put them back together in a safer way.

MY FRIEND Duct-tape works.

ME What Geithner did helped those who benefit from the status quo and hurt those who benefit from change. Just like duct tape.

This struck me as utterly banal until I read a one-sided editorial in The Economist:

The consequences of the euro’s destruction are so catastrophic that no sensible policymaker could stand by and let it happen. . . . the threat of a disaster . . . can anything be done to avert disaster?

and similar remarks in The New Yorker (James Surowiecki):

The financial crisis in Europe . . . has now entered a potentially disastrous phase.. . . with dire consequences not just for Europe but also for the rest of us. . . . This is that rarest of problems—one that you really can solve just by throwing money at it [= duct tape]

Wait a sec. What if the Eurozone is a bad idea? Like I (and many others) said in 1995? Why perpetuate a bad idea? Why drive further in the wrong direction? Sure, the dissolution will bring temporary trouble (“disaster”, “dire consequences”), but that will be a small price to pay for getting rid of a bad idea. Of course the Euro had/has pluses and minuses. Anyone who claimed to know that the pluses outweighed the minuses (or vice-verse) was a fool or an expert. Now we know more. Given that what the nay-sayers said has come to pass, it is reasonable to think that they (or we) were right: The minuses outweigh the pluses.

You have seen the phrase Japan’s lost decade a thousand times. You have never seen the phrase Greece’s lost decade. But Greeks lost an enormous amount from being able to borrow money for stupid conventional projects at too low a rate. Had loans been less available, they would have been more original (the less debt involved, the easier it is to take risks) and started at a smaller scale. Which I believe would have been a better use of their time and led to more innovation. Both The Economist‘s editorial writer and Surowiecki have a status-quo “duct-tape” bias without realizing it.

What’s important here is not what two writers, however influential their magazines, think or fail to think. It is that they are so sure of themselves. They fail to take seriously an alternative (breakup of the Eurozone would in the long run be a good thing) that has at least as much to recommend it as what they are sure of (the breakup would be a “disaster”). I believe they are so sure of themselves because they have absorbed (and now imitate) the hemineglect of modern economics. The whole field, they haven’t noticed, has an enormous status-quo bias in its failure to study innovation. Innovation — how new goods and services are invented and prosper — should be half the field. Let me repeat: A few years ago I picked up an 800-page introductory economics textbook. It had one page (one worthless page) on innovation. In this staggering neglect, it reflected the entire field. The hemineglect of economics professors is just as bad as the hemineglect of epidemiologists (who ignore immune function, study of what makes us better or worse at fighting off microbes) and statisticians (who pay almost no attention to idea generation).

MORE Even Joe Nocera, whom I like, has trouble grasping that the Euro might be a bad idea. “The only thing that should matter is what works,” he writes. Not managing to see that the Euro isn’t working.