As I recall, our position was likewise greeted by the AMA House of Delegates with great relief, and word quickly circulated in the corridors that Pennsylvania had a position everyone could endorse for the good of the organization. (917)
(1032)
Rodney Sharp fixed up his old home town, and it's an architectural jewel worth visiting. Christmas is the best time. (593)
Elite boarding schools may not perceive their proper role, which is a useful one. (854)
In a few years, the baby boomers will retire and two things will happen. They will have to retire later in life, and the country will have to borrow money to pay for the rest. (1159)
"Well," said Bockus, "Every famous surgeon I know, has a house on an island, somewhere. Where's your island?" (885)
The author's mother decided she wanted to form her own opinion of the Teamster's Boss, a couple of weeks before he was disappeared. (968)
A new book by John A. Kastor compares the doctor-run Cleveland Clinic with the University-run Hospitals of Case Western Reserve under the managed care insurance system. Both hospital systems had plenty of problems, many of them self-inflicted, but it looks like doctor-run is winning the race. (837)
Finding a publisher is often hard, but sometimes easy. (785)
The chief thug in town turns out to be quite a wit. (1054)
A flash of inspiration gets a medical article published. (784)
Your author is probably the only person still alive who personally attended the Senate investigation of Howard Hughes. There is probably a lot to this story yet to emerge. (688)
The of how the author complained to his head master about preparation for college and how it led to the concept of Advanced Placement courses in high schools. (474)
The Delaware Hospital in Wilmington once had a real shoot-out. (874)
A real-life story of bootleggers in a hospital. (1035)
When an entrenched institution, like health insuance, contains basic design flaws, it finds it has always had strange allies quietly defending its flaws. The mark of a really good reform is that it falls so neatly into place in a lot of unexpected ways. (791)
In late 2003, Congress passed and the President signed, legislation enabling tax exemptions for contributions to Medical Savings Accounts. This monumental reform was included in a law which created a number of Medicare prescription drugs benefits which received more attention in the press. Such accounts were renamed Health Savings Accounts, which was the original terminology in 1980 when John McClaughry of Vermont and George Ross Fisher of Pennsylvania, shortly joined by Michael Smith of Louisiana, first introduced the concept. (860)
Every proposal for eliminating illicit drugs has failed except the one Philadelphia used after World War II. (1171)Reminiscences
Watching the constantly passing scene, occasionally opportunities arise to change its flow.
A New Food and Drug Category
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| Nervous System |
An editorial in the April 7, 2006 Wall Street Journal rouses a proposal germinating in my mind for twenty years, a new compassionate status of pharmaceutical regulation for dangerous but effective new therapeutic agents, not presently provided for in law.
The editorial concerned a new drug treatment for multiple sclerosis, a crippling and usually ultimately fatal condition which destroys the nervous system. In hearing of the tests of this new drug, we hear numbers like 85% total remission. Unfortunately, we also hear of four patients who died, quite possibly from the treatment. From that point on, you could write the reports from memory. Patients come forward, declaring their willingness to run any risk to get the drug; politicians are sympathetic. The Food and Drug Administration feels forced to withhold the drug from the market until the situation is clarified; other politicians are sympathetic. We are reminded of thalidomide, which was luckily withheld from the American market until the German experience showed that pregnant women who took thalidomide could have babies without arms or legs. This lucky illustration of the value of bureaucratic procrastination gave Senator Kefauver the strength to push through an amendment bearing his name, demanding proof of efficacy, something quite irrelevant to the safety of thalidomide. Seldom mentioned is the fact that thalidomide has since proved to be quite useful for the bone cancer called Multiple Myeloma; this value took a very long time to surface, under the circumstances. The efficacy rule accomplished the purpose, however, by delaying all drug approvals, unfortunately also shortening the time left for patent coverage, and vastly increasing the cost of drugs by shortening the time on patent to recover development costs. After thirty years of hearing the same arias re-echoing about one drug introduction after another, it begins to look unlikely that Congress will ever be able to stand the political heat which would be generated by a serious attempt to fix this problem. But surely that can't be allowed to continue forever.
Taking the multiple sclerosis treatment as an example, the patients want the drug, and their doctors want to use the drug but they don't want to be sued or prosecuted. It's almost certain that most of these patients would sign anything, accept any risk, even agree to a shortened life expectancy in return for an 85% chance of stopping the disease in its tracks. All the doctors want is to be held harmless by the courts for exercising reasonable care under the circumstances. The same is probably true in a political sense, for the FDA and Congress, who surely would be satisfied to have the doctors take the blame for any problems encountered. The drug companies want to preserve their patent protection, surely that can be accommodated. Perhaps they should be asked to contribute to a fund for the victims of unforeseen accidents; they would probably agree. What would satisfy the trial bar is less certain; they should be asked to stipulate something. As a matter of fact, anyone at all who has qualms about such a system of special defined exemptions, should be asked to come forward with serious suggestions. There would then ensue a lengthy and ultimately tedious debate about details.
This would all take some time; at the end of it someone would have to make some arbitrary decisions. But at least we could expect more progress than we have seen in the last thirty years of indecision.
A Fair Plan for Fire Insurance (and Health Insurance, too?)
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| Philadelphia Fire |
The Fair Plan (sixth and Chestnut, Philadelphia) is a fire insurance company with unusual features. Some day, it is to be hoped some scholar will write a book about the highly mixed motives of the people who created it, compared with the unexpected ways it did or did not fulfill original expectations, of both its creators and its enemies. The Fair Plan only issues fire insurance on houses, when other insurance companies have turned that house down as a bad risk. Such risky houses would normally draw higher premiums for fire insurance, but the Fair Plan insures these risky houses at normal rates. Therefore, it loses money, which is made up by the other regular fire insurance companies in the state in proportion to the business they do, obviously thus raising the price of fire insurance for everybody. But in this way, Pennsylvania guarantees that everybody can get fire insurance. Is this a good idea? Might this be a way to give health insurance to all those people who can't get health insurance? Let's talk about the Fair Plan.
We'll set aside discussion of whether the Fair Plan was a product of cynical politicians pandering for votes, or whether it was a noble gesture for fairness and equality for our poorer citizens. It very likely had elements of both things in it, but that doesn't matter any more. It's a form of hidden taxation, of course, and it has the result of making Fire Insurance seem more expensive in Pennsylvania than in other places that do their social work with real taxes. Go too far with that, and you will end up buying your insurance in Bermuda instead of boarded-up former fire insurance companies of Pennsylvania.
As the story is now told, the other insurance companies had a choice of taking the "substandard" applicants in turn (Assigned Risk) or creating a new company (Joint Underwriting Association). They decided they preferred the JUA. So a company was formed which specializes in nothing but bad risks, including a few arsonists and other unmentionables, but mostly poor people in bad neighborhoods. If we are ever thinking about following the Fair Plan model in health insurance, it does run the risk of being accused of creating a two-class healthcare system. But no one seems to bring up that rhetoric about fire insurance, primarily because there is very little intrusion of politics in the matter, This system is given orders to spread the extra cost of universal fire insurance out to the policy holders of all fire insurance, and it does it very efficiently, without extending its mandate into setting firefighter wages, running fire departments or repainting scorched woodwork. The fundamental decision was whether to spend Society's money this way. Once that decision is taken, the task is to do it efficiently.
After the Fair Plan had been running for ten or so years, a funny thing emerged. There were years when the Fair Plan made a profit! The fire insurance industry had absorbed the Fair Plan into their scheme of things, and felt free to increase the number of applicants they rejected, during years when money was tight or business was bad. In this way, a better class of applicant came to the Fair Plan, which made the plan more profitable. When economic conditions changed, this reversed, and the Fair Plan again lost money. For this reason, the insurance industry is very anxious not to let the Fair Plan become political, or get tangled up in extraneous worthy ventures. And that's probably a good model, too, if we are considering adopting the system for the health insurance world.
Since this simple, tested idea never seems to get into the discussion phase of present agonizing over health insurance for the uninsured, it's one clear sign that such discussions at present are not terribly serious.
Abortion
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| Roe vs. Wade |
The official position of the Pennsylvania Medical Society on the topic of abortion is, we have no position on abortion. I ought to know, because I was the author of this position, proposed at a moment when the PA Medical House of Delegates was obviously going nowhere. After two hours of angry debate we had to stop before we split into two warring medical societies. The Pennsylvania delegation to the AMA was then obliged to hold the same no-position on a national level. As I recall, our position was likewise greeted by the AMA House of Delegates with great relief, and word quickly circulated in the corridors that Pennsylvania had a position everyone could endorse for the good of the organization. For several years, this no-position position was widely referred to whenever the topic threatened to arise. It almost invariably stopped discussion in its tracks, as it was intended to do. In going back over the minutes, it would appear the AMA never actually voted to adopt a no-position motion, a discovery that surprised but did not change the basic determination to let the rest of the nation settle this. We were going to stay out of it.
Because, one hundred forty years earlier, we started it. If you actually read Justice Blackmun's opinion for the majority in Roe v. Wade, as very few agitated proponents seem to have done, the original medical origin is clearly laid out. Blackmun had been a lawyer for the Mayo Clinic before his appointment to the Supreme Court, acquiring unusual medical resources and experiences for a lawyer. Now prepare for a logical leap, to the The Gross Clinic, Thomas Eakins masterpiece painting of Philadelphia's pre-eminent surgeon in black frock coat, holding a dripping crimson scalpel in his bare hand, encapsulates the original situation. Note carefully that anesthesia is being given to the patient, but the surgeon is not wearing a cap, mask, gown, or rubber gloves.
In 1850 medical science had progressed into a forty-year time window when anesthesia made abortions painless, but Pasteur had still not identified bacteria, and Lister had not devised a way to cope with them. Abortions, common in ancient Greece but forbidden by Hippocrates, suddenly were widely demanded by 19th Century women in a situation when their judgment was vulnerable. Abortions were easy to do, all right, but women died like flies from the resulting infections, and the American Medical Association was distraught about it. The Oath of Hippocrates was brought forward to emphasize its prohibition of abortion, and the performance was made unethical for a member of the Association, sufficient cause to warrant expulsion. When that proved inadequate, the delegates agreed to go to their local state legislatures and seek legislation prohibiting the performance of abortion by anyone, member or non-member of the Association. These laws were quickly passed, and it was the Texas version which was overturned by Roe v. Wade as an unconstitutional denial of privacy. Roe was a pseudonym for the patient, and Wade was then Attorney General of Texas, the officer charged with enforcing Texas law. By 1900 abortions became both easy and safe for the mother, and by 1911 the AMA had reversed its position. The scientific surgical situation is well illustrated by a later famous painting about Philadelphia surgery by Thomas Eakins, the Agnew Clinic, in which the surgical team is portrayed in its modern costume of sterile gowns and rubber gloves. But it didn't matter, since by that time various churches had hardened their doctrines. Religious leaders and their constituent politicians simply no longer cared what the medical profession thought about it. For at least the following century, ideological combatants were plainly only interested in whether physician opinion might advance one side or the other of their argument with useful official statements. Our real position, if anyone cares, is that we started out seeking protection for the safety of the mother, but the issue got twisted by others into disputes about the welfare of the unborn fetus.
Since this is the case, there plainly may be reason for state legislatures to reconsider the state laws they passed in the 19th Century, during that forty-year window of time when the scientific facts were in transition. But when a leap is made by the appointed referees of the federal government to overturn state laws, even about a basically medical issue, there has to be some legal reason to intervene; a medical reason somehow doesn't count. Justice Blackmun's discovery of an unnoticed right to "privacy" in the Constitution, where the word does not appear, is just too hard for us non-lawyers to deal with. Suppose we leave the fine points of the Bill of Rights to those constitutional lawyers. What's at stake here, among other things of course, is whether the Federal Courts are justified in overturning well-intentioned state laws which had served well for at least fifty years -- simply out of impatience with the sluggishness and political timidness of state legislatures to revise obsolete laws. That's unbalancing the Constitution for comparatively minor cause. Even major cause is something we have agreed to adjust in other ways, by amendment, not judicial opinion. And that's my opinion, having comparatively little to do with abortion.
It Ain't Necessarily So
The Protestant Reformation provoked a wide variety of reasonings, and the Quaker position is at one extreme of them. One way of looking at it is to see the Reformation as largely a reaction to the invention of the printing press. At first, there was the impact of Latin versions of the Bible, or vulgate, which could be read by priests like Martin Luther, and possibly interpreted by them to vary from established Church doctrine. Translation of the Bible into common languages subsequently permitted educated parishioners to read the Bible for themselves and draw their own conclusions. Fundamentalist branches of the church tend to place almost total reliance on what they can read for themselves, and consequently authenticity is highly important to them. The Quakers go a step further, encouraging each member to come to his own spiritual viewpoint ("There is that of God in every man."), using the Bible as merely one important resource. Although others sometimes regard them as spiritually adrift, the Quaker idea is that if something is really true, everybody who thinks hard about it will eventually come around to much the same conclusion. (Related to this attitude is a strong belief in the ultimate triumph of democracy, and the essential rightness of market-set prices.) Some people try harder than others, of course, and they come to be regarded as "weighty" Friends, likely to have reached the correct conclusion somewhat sooner than others.
One very weighty Friend was Henry Cadbury, an American relative of English candy makers. Henry decided he wanted to spend his life teaching the bible, and went to Harvard Divinity School. He became in time the leading authority in the world on the Book of Acts, editing that section of the Interpreter's Bible, and rising to be Professor of Divinity at Harvard. Henry knew his stuff, so to speak.
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| henry Cadbury |
One fine summer day, Henry was seated in the front row of the Haddonfield Meeting. Birds twittered outside the open doors and windows, but otherwise the gathered meeting was entirely silent. It was even beginning to look as though this meeting would be one of those occasional instances when nothing is said for an entire hour -- a "silent meeting". But, no, a visitor came through the open back door of the meetinghouse, in response to the sign found outside almost every meetinghouse, "All Are Welcome". The man was evidently a fundamentalist, and seeing a large audience all sitting silently waiting for something, he advanced boldly to the front of the meeting and began to speak.
The Bible was the Word of God. Every word in The Bible was true -- literally, and incontestably true. The theme was repeated several times, without apparent response from the audience.
Finally, Henry Cadbury stirred himself. "Well, it has always struck me...". Oh, oh. Look out, here it comes.
"It has always seemed to me, that the most quotable parts of the Bible, are mainly based on faulty translation."
Kenneth Gordon, MD, Hero of Valley Forge
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| Valley Forge |
There's no statue of Ken Gordon at Valley Forge National Park, although it would be appropriate. No building is named after him; it's probable he isn't even eligible to be buried there. But there would be no park to visit at Valley Forge without his strenuous exertions.
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| Governor Milton Shapp |
One day, Ken's seventh grade daughter came home from school with the news that the father of one of her classmates said that Valley Forge Park was going to be turned into a high-rise development. That's known as hearsay, and lots of things you hear in seventh grade are best ignored. But this happened to be substantially true. At that time, the Park was owned by the Commonwealth of Pennsylvania, and Governor Shappwas finding the upkeep on the Park was an expense he needed to reduce. The historic area had two components, the headquarters area, and the encampment area. One part would become high-rise development and the other would become a Veteran's Administration cemetery. Although any form of rezoning has the familiar sound of politics to it, Dr. Gordon (a child psychiatrist) had the impression that Shapp was mostly interested in reducing state expenses, and had no particular objection to some better use of the historic area. At any rate, when Gordon went to see him, he said that he would agree to a historic park if Gordon could raise the money somehow.
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| Dick Schulze |
Well, the sympathetic civil servants at the Natioanal Park Service told him how it was. You get the consent of the local Congressman (Dick Shulze) and it will happen. If you don't get his consent, it won't happen. It seemed a simple thing to visit the Congressman, persuade him of the value of the idea, and it was all done; who could refuse? After the manner of politicians,Schulze never did refuse, but he somehow never got around to agreeing, either. It takes a little time to learn the political game, but after a reasonable time the National Park employees told Gordon he was licked. Too bad, give up.
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| Ronald Regan |
He didn't give up, he went to see his Senators, at that time Scott and Clark. They thought it was a splendid idea, and instead of going pleasantly limp, they sent Citizen Gordon over to see Senator Johnson of Louisiana, the chairman of a relevant committee. Johnson really thought it was a great idea, and called out, "Get me a bill writer!" A bill writer is usually a government lawyer, with the task of listening to some citizen's idea and translating it into that strange language of laws -- section 8(34), sub-chapter X is hereby changed to, etcetera. Bill writers have to be pretty good at it, or otherwise they will misunderstand the intent of the original idea, the personal spin of the committee chairman, the comments of the authorizing committee, and the bargains struck in the House-Senate conference committee. Having negotiated all those hurdles, the bill has to be written in such a prescribed manner that it won't be found to have multiple loopholes when it later reaches the courts in a dispute. A good deal of the time of our courts is taken up with making sense of some careless wording by bill writers. That's what is known as the "Intent of Congress", an ingredient that may or may not survive the whole process.
Ken Gordon had to go through this process, including testimony at hearings, for three separate congressional committees. To get everybody's attention, he organized several hundred supporters to write letters and get petitions signed by several thousand voters. These supporters in turn influenced the media, and started a lot of what is known as buzz. All of this is an awful lot of work, but there is one thing about this case that can make us all proud. Not once did a politician suggest a campaign contribution was essential in this matter.
In time, ownership of the Park did in fact migrate from the Commonwealth to the U.S. Departmentof the Interior, hence to the National Parks Service. Everyone agrees that it has been well managed, and increasing droves of visitors come there every year. It is now clearly a national treasure. Unfortunately, the encampment area got away, and has been commercially developed, although not nearly as high-rise as originally contemplated. Along the way, many discouraging words were spoken about the futility of fighting against such odds. The outcome, however, is the embodiment of two slogans, the first by Ronald Reagan. "It's amazing what can be accomplished, if you don't care who gets the credit for it." And the other slogan is older, and Quaker. All you need, to accomplish anything, is leadership. And leadership -- is one person.
One day Ken Gordon, the very busy doctor, was asked how much of his time was taken by this effort. His answer was, ten hours a week, every week for five years.
Lewis Harlow van Dusen, Jr. (1910-2004)
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| Croix de Guerre |
Lew van Dusen was one of the great story-tellers of a story-telling city. In one continuous lunch conversation he could string together personal anecdotes about Lloyd George, Lawrence of Arabia, William Bingham, the making of the hydrogen bomb, the Croix de Guerre (which he had been awarded), Nicholas Murray Butler, several Supreme Court Justices, Harvard Law School (where he led the class), and on and on until the waitress would just go ahead and clear the table. He even told of his own great suffering as a boy sitting at proper Philadelphia dinners, where it was a firm rule that acceptable topics of conversation were limited to the Wimbleton lawn tennis matches, and the sinking of the Titanic.
When the landmark U.S. Supreme Court case of State Oil v. Kahn came up for arguments, he and I rode together on the Metroliner down to Washington, stayed at a club there, and after the hearing took the train back to Philadelphia. During the entire time, Lew never stopped talking, and his voice was very loud. There was the time in Macao when a retired British diplomat came up to him and said he knew the history of every gravestone in the cemetery for foreigners, except five, and two of those names were on the letterhead of Lew's firm (Drinker, Biddle and Reath). Drinker, it turns out, was American consul and discovered that all of his guests were poisoned by the cook. He traveled all night, getting stomachs pumped out, but not his own, and died the next morning from the poison. Biddle, on the other hand, was also a physician interested in Yellow Fever, and died of it when he contracted the disease from one of the subjects.
There was the time when he was the young guest of Nicholas Murray Butler at a luncheon with British Prime Minister Lloyd George. "Tell Mr. Roosevelt," said George, "That Social Security is nothing but a dole."
And the time when King George gave everybody the day off on his 25th Anniversary as King, so they played cricket. His team mate was Lawrence of Arabia, and after the game, Lawrence hopped on his motorcycle and rode off down the road to be killed. Lew was the last person to see Lawrence alive.
Well, when you get to the Supreme Court, the public stands in line on the steps, out in the rain. But the lawyers go around to the back door, where there is a lounge and a lunchroom. Inside two minutes, Lew was surrounded by lawyers as he told more stories. One of them tugged my sleeve and asked, "Is that who I think it is?" I said I supposed so, although who he had in mind is still a mystery to me.
State Oil turns out to have been as important to antitrust law as we supposed it would be; the fine points of vertical integration were afterwords explained to me. And finally, I was told how, when he was chairman of the Ethics committee of the American Bar Association, Lew's committee caused the ABA to reverse its long-standing opposition to cameras and audio equipment in courtrooms. The effect of this has been slow, but gradually courts are permitting the televising of trials, and eventually they probably all will permit it. But not yet the U.S. Supreme Court. Non-lawyers still stand in the rain outside, and if there are no seats left inside, too bad.
Lin
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| Lindley B. Reagan, M.D |
Lindley B. Reagan, M.D.
July 16, 1918 -- September 10, 1995
The first and oldest hospital in America, the Pennsylvania Hospital at 8th and Spruce Streets, always had a strong Quaker flavor but a unique medical tradition as well. Since it was the only American hospital for decades, later becoming the home hospital of the first medical school in the country, it impressed its ideals and traditions on the whole of American medicine. However, it imposed so many difficult demands on its trainees that a century or more of an evolving profession simply moved away from copying it. It was, in 1960, the last hospital in the country to begin paying its resident physicians anything at all, one of the last privately controlled American hospital to adopt a billing and accounting department, and one of the last if not the last to regard a handful of private beds as merely a convenience for the patients of the staff physicians. In 1970 its method of maintaining inventory was to notice that the supplies on the shelf were running low, and ordering some more. It was founded in Benjamin Franklin's words, for the "sick poor, and if there is room, for those who can pay," and could only survive into the late 20th Century through private donations and the freely contributed services of the doctors, student nurses and administration. No amount of money could induce people to work as hard as they worked. You might say this was the only aspect of Medieval monasteries which Philadelphia Quakers thought worthy of imitating.
Somewhere in this set of ideals was the treasured concept of a rotating internship, preferably two years long, prior to entering specialty training through a residency. In 19th Century Vienna, it was a matter of rule that an intern was just that, physically confined within the walls for the term of service, and a resident was just that, someone who lived on the campus. The Pennsylvania Hospital had no such rule, but since it paid the doctors nothing for five or six years of eighty-hour weeks, their poverty forced them to satisfy the Viennese rules by default. Entertainment was bridge or poker in the intern quarters, conversational chit-chat was a description of bizarre cases or peculiar patients, a weekend "off-call" was a good time to catch up on correspondence. There were student nurses around, of course, but the matron was a pretty no-nonsense chaperon. Every class of interns contained one or two millionaires by inheritance, but peer pressure made them nearly indistinguishable in the daily routines. Aristocrats' main value to the resident physician community was their access to the ruling families in the city, and hence to the governance of the hospital, in case governance should occasionally abuse the vulnerability of the trainees.
I find in retirement that most of my colleagues are now willing to tell stories of the "old days" which they were unwilling to tell at the time. Over several glasses of the finest single-malt in a walnut-paneled club, one such story recently surfaced. It concerned Lin.
Lin was a member of an old Quaker family, surprising everybody during the Second World War by volunteering as a junior physician in the Navy. He was assigned to a marine regiment in the Pacific Theater, and went through some of the most murderous fighting on Iwo Jima and Guadalcanal. Our grapevine reported that the enlisted marines in his outfit absolutely worshipped him, and I easily believe there was a lot of quiet heroism behind that gossip. He told me he had decided to become an internist while in the Pacific, but somehow only a surgical residency was available when the War was over, so he took it. He was probably the best internist on the staff, and it showed in his conduct of surgery, where it sometimes matters more what you decide to cut than what you cut. He always looked exhausted, but never hesitated to drive himself another hour when the situation demanded it. One day, he had to excuse himself from an operation, an almost unheard-of event, and testing his own urine, found it loaded with sugar. So, the soft-spoken Quaker internist who was primarily doing surgery, had to add the burden of insulin injections to his load. If he ever complained about that or any other thing, no one could remember hearing it.
At about the third glass of single malt, the story came out. My old friend, like the rest of us, had to spend a year as a surgical intern during the two-year rotating internship; he hated surgery and didn't mind telling the world. At the moment in question, he was the assistant at some neck surgery, with Lin performing the actual surgery. He was told to take a long pair of scissors and cut off the excess strands of sutures after Lin tied the knots; that was known as trimming the ligatures. They were working deep in the crevices of the patient's neck. Lin held up the loose ends of the knot and ordered, "Cut". My friend inserted the long scissors into the hole and snipped -- accidentally cutting right through the jugular vein.
As would be expected, a fountain of blood came up out of the hole, and Lin stopped it by putting his thumb on the cut ends of the vein. "Well," said Lin, "I guess we'll have to fix that." And did.
With tears in his eyes, my octogenarian friend cried out to the startled clubroom. "God bless you. God bless you, Lin."
* * *
Perhaps the point isn't clear to those who didn't go through the process, so let's be more explicit. Both my friend and I worshipped Lin, as a person, a teacher, and a surgeon. He was the perfect agent for his patients, without the tiniest trace of conflict of interest, income maximizing or whatnot. He was as technically skillful as it is useful to be, but he was the thinking man's surgeon as well as the utterly faithful servant of the best interests of the humblest patient. He was, in the opinion of his closest professional associates, the best surgeon in the world. In need of surgery ourselves, all of us would have flown the Atlantic to have him operate on us. For reasons of his own, he was to spend the forty years of his professional life in a small country town with a small hospital, scarcely a famous surgeon but a beloved one to his community. Over the past sixty years I have had a number of opportunities to know many surgeons who would be in contention for the title of best surgeon in the world. Some have written books, some have struggled successfully upward through vicious competition, some of them would be called "Rainmakers" if the research world followed the pattern of lawyers and architects. One or two have won Nobel Prizes for surgical innovations, but that's different from being the best surgeon around. The best surgeon in the world was Lin, faithfully plying his trade in a little town that could not possibly know how lucky they were.
Odessa, Delaware
Delaware is a pretty small state to be divided into two civilizations, and in fact it seems safe to predict that division will soon be meaningless. New Castle County and Wilmington are in duPont country, with more Ph.D's than anywhere else in America, chatteaux in the suburbs, plenty of Porsche's and other elements of the finer life. The other two counties, "South of the Canal," are rural, marshy, or beach front. Wal-Mart country. Aside from a distinct difference in the weather patterns, all of this is destined to change, and soon. A limited-access toll road, probably mostly intended to carry people to the slot machines of Dover Downs, makes it breezily simple to go from one end of the state to the other in an hour. A ferry from Cape May to Cape Henlopen makes it a shorter simpler way to go from the urban areas of New York to and from Washington, Norfolk and points South. And changes in the tax laws make Delaware a great place to avoid sales taxes, estate taxes, business taxes, usury laws and lots of other things. That brings in businesses, and they in turn will bring in a swarm of home builders.
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The Corbit-Sharp House Built in 1774 Located in Odessa, Delaware. |
Little Odessa (population 280) sits right at the pivotal point in this transformation. This is the very narrowest point of the penninsula between the Delaware and the Chesapeake. In the Seventeenth Century, there was only a five-mile portage from the head of one creek to the head of the other; the town there was called Cantwell's Bridge. Just why the two Delaware-Chesapeake canals were built a few miles further North is an engineering question, but they tended to shelter Cantwell's Bridge from Northern influences. The neck was so narrow, however, that the road couldn't avoid the town, and for a century it was a pleasure to find a little Colonial town, a little Williamsburg so to speak, popping up among the fields of clover bordering a drive to Dover. A few miles to the West, a very fine boy's boarding school adds to the tone of the place, and it's only a short 9-mile commute to the University of Delaware. The finest 18th Century country house, the Corbit-Sharp House sets the tone for the area, and the Christmas season in Odessa is quite memorable. Rodney Sharp was the son of the local school teacher who acquired financial substance, private jet airplanes and all that, on the other side of the canal, restored the Corbit house to the Corbit Mansion, and brought the whole town up to an elegant level. A visit to Odessa at Christmas, touring the open houses and visiting the festivities, is well worth the trip.
You have to hold your breath to see what is going to happen to real estate in the area. The toll road sweeps around the edge of Odessa, and now the people going to the slot machines and the beaches can hardly see it as they race past. But that's mostly weekend traffic, and during the week all of those cornfields are quickly turning into easy commuter villages, full of McMansions. They are going to fill up the schools, demand better ones, demand traffic signals to protect the kiddies, demand retail outlets for all those upscale stores with catalogers. Eventually, all those three-car families will choke up the toll-road, and it will become a great big congested parking lot at rush hour. Sad.
One final comment about the origin of Odessa. It's named after the city in Russia because both of them were wheat exporting cities at one time. However, the one in Delaware is actually the older of the two. Cantwell's Bridge, Delaware was founded in 1731. For reasons unclear its name was changed to Odessa in 1845, perhaps in the mistaken idea that the Russian city was where Odysseus once landed. That's what many Russians claim, but the place they have in mind was really in Bulgaria. The place the Russians call Odessa was founded by Catherine the Great in 1794, some sixty years after Cantwell was collecting toll at his bridge in Delaware. When the Bulgarian mistake was pointed out to Catherine the Great, she wouldn't change the name; she sort of liked it that way.
Pink Slips for Green Doctors
This little story of discarded pink slips, even after fifty years have elapsed, is on the short list of things I am proud of. I probably remember it so well because it was the forerunner of several other seemingly unrelated matters.
In 1956, I was the Chief Resident Physician of the Pennsylvania Hospital. That position doesn't exist any more, but most hospitals at the time had a Chief Resident, who was in charge of the house officers, the interns and residents. The Chief Resident was usually a doctor who had just finished his formal specialty training, and was thinking about starting a private practice. He was the father figure to the doctors still in their post-graduate training years, all of them overworked and tense, concentrating on avoiding dangerous mistakes while learning to assume new and difficult responsibilities. He was old enough to carry the weight of authority, but young enough so the residents could talk to him frankly, and still call him by his first name. The Chief Resident had his office and secretary near the accident or receiving ward, next to the resident's lounge, which contained mailboxes and coat hangers. The lounge was pretty shabby, as bachelor lounges tend to be, but it was all doctors, all the time, coming and going. If you wanted to know what was going on, this was the place to learn it.
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| Pink Slip |
Tom Paton, the credit manager, had his office further down the hall. In spite of his occupation, he was a jovial, convivial fellow, a former rugby player and soccer referee who fit right in with the lounge crowd. One day, I noticed he was throwing away a large stack of pink slips. He seemed surprisingly eager to tell me all about it. These slips represent the life blood of the hospital, sez he, without the flow of cash we would have to close the doors of the institution. Well yes, Tom, but taking care of the sick folk is sort of important, too. After a little explaining, I had to agree that he was talking about an interesting subject.
One of the everlasting problems in any hospital is to have the bill ready at the time the patient goes home. Nowadays, hospitals all have databases and many gigabytes of computing power, but the patient's bill is never ready when the patient is discharged, and may take weeks to be sent to them. Hospitals put on a good face, don't you worry about the bill, madam, we trust you and we'll send it to you when you are feeling better. And all that, but the truth is they haven't a clue what your bill is.
All of that drove Tom Paton nearly crazy. The time to collect a bill is when the tears are still hot. Every day you delay the bill costs you a provable fraction of it, and so on. So, the system was devised that the tabulating machines of the hospital would routinely work all night to produce a bill for everybody, every day. If they went home today, they were handed a bill. If they didn't go home, the bills were thrown away. For accounting purposes, a carbon copy of each bill was kept on pink paper. It was an amazingly simple idea, far less expensive than the random-access real-time whatchmacallits that nowadays do a far less effective job, and are out of commission much of the time. Let the record show that in 1956, every single patient at Nation's First Hospital got his bill as he was leaving, any time night or day. IBM charged us eleven hundred dollars a month to rent the machines, which also did the payroll and inventory systems.
An idea occurred to me. If you are only going to throw them away, could I please have the pink-slip copies of the bills of the patients who did not go home? Those patients are still in the hospital, and these slips show how much cost each patient is in process of running up. So a system was established that my secretary got these pink slips every day, and put them in the mailbox of the doctor taking care of the patients. It was a simple thing to do, and the reaction it got was explosive.
At first, the interns thought I was warning them, or criticizing them, but they soon got over that. We were all appalled at the costs which were being generated, and particularly appalled when a patient stayed a little longer than necessary. In those days before Medicare, any unpaid costs had to be made up by contributions and private endowment. The house officers and the student nurses who did most of the work, received no salary. The sense of guilt that arose from looking at those bills was very strong, and it was obvious that every one of them went back to the wards to try to speed things up. Since they all left their training to practice in various communities for fifty years, I like to believe that the multiplier effect was significant.
In those days, we had a two-year rotating internship. Every month, each intern would summarize the remaining patients on his ward for the benefit of his successor. In doing so, they were able to reflect in retrospect how each case could have been speeded up a little, and wouldn't still be here to require a summary. There is an invisible counter-pressure at work. From a doctor's point of view, most of the heavy work of each admission to the hospital is concentrated in the first couple of days. You get things in motion, and then sort of watch it roll out. But if your ward is full, you can't have any new admissions, so your day suddenly gets a lot easier. Just let one of them go home, and bingo you have a new one. This little human frailty affects every one of them to some degree, and each one thinks he may have discovered it. It was my job as Chief Resident to keep the system from sludging up. As much as for any other reason, an increased turnover meant more cases per intern, and therefore more training and experience. That's what most of them thought I was up to, when I started handing out the pink bills. It really wasn't purposeful at all, it was just sort of an accidental discovery of something useful.
From that, I developed an interest in efficient use of hospitals, a subject we called utilization review. Through the County Medical Society I formed a club of other doctors at other hospitals who had the same interest. When Senator Bennett of Utah got a law enacted, this organization turned into the Philadelphia Professional Standards Review Organization, which became part of the Pennsylvania PSRO, and eventually a national one whose name has changed several times. We had some interesting battles at the AMA House of Delegates, which dissolved into insignificance when the national business organizations took matters into their own hands and used their control of employer health insurance to push HMOs, Health Maintenance Organizations, onto the helpless public. The public outrage about HMOs put egg permanently on the face of national business, but the matter is now worse, not better.
What I got out of all this was an enduring interest in computers, which has served me well for half a century. And a sense of outrage bordering on apoplexy whenever some well-meaning activist declares that the doctors are responsible for pushing up hospital prices.
Please Don't Lose Any Sleep Over This
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| Dr. Charles Czeisler |
The Institute for Experimental Psychiatry Research Foundation meets alternatively in Boston and Philadelphia, in recognition of its rather complicated historical relationship with Harvard and Penn. The Spring 2005 trustees meeting was held in Boston, with Dr. Charles Czeisler of the Brigham and Women's Hospital making a presentation of his work with sleepy resident physicians. Sleep is now a central focus of the work of the Institute, particularly the effect of lack of sleep on performance. Resident physicians are a group with lots of experience with sleep loss, so much that such experiences as residents are a central imprinting in the lifelong brotherhood of the profession. The public tends to regard the torment of protracted craving for sleep as some kind of dangerous hazing inflicted on professional newcomers by sophomoric seniors. Every once in a while, someone gets hurt by these games. That seems to be general public reaction. For the most part, by contrast, members of the profession who have themselves undergone the experience turn away silently from such unfeeling remarks. As the old contraceptive joke about the Pope has it, if you don't play the game, don't make the rules.
In the first place, it is wrong to suggest that resident physicians are somehow helpless victims of authority, abused slaves of somebody's profit motive, or warped masochists enduring the process in order to inflict it on someone else. Perhaps the example of my classmate Seibert is useful. As a freshman medical student, Seibert was so overwhelmed by the volume of facts he was expected to learn, that he decided to give up sleep entirely. Seibert, by the way, was no moron; he was an honors graduate of a very selective Ivy League university. And he actually did stop sleeping for more than two weeks until he collapsed and had to be stopped. This was his own choice, gamely adopted in spite of general ridicule. And to show that over achieving is not limited to physicians, there was my oriental patient, the daughter of the President of her country. She related that as a graduate student she did not go to bed for three years; during all that time, she sat at her desk, slapping her face to keep awake. What we are talking about here is a self-selected group of committed and dedicated people, perhaps overly shamed by the specter of failure.
The work of our Institute has helped document and understand the injurious effect of sleep loss on performance; no one can go very long without sleep before responses and vigilance begin to deteriorate. A great many vehicle accidents are caused by drowsy drivers; it is a concern that pilots of airplanes on long distance flights are to some provable degree less competent to land the plane. Therefore, it is not completely surprising to find that interns on protracted duty do make 20% more errors in medication orders, and nearly 50% more diagnostic errors. It is jarring to discover a measurable increase in the number of intern auto accidents, particularly when driving home from work. Maybe we ought to pass a law about it.
Commiseration is one thing; proposals to interfere are quite another. For one thing, the time-honored protection against the harm of this problem is redundancy. The complex, fast-paced and dangerous environment of a hospital, like that of an airline cockpit , has very little tolerance for lack of vigilance. Our solution has been to do everything three times, with overlapping responsibilities and repeated opportunity for catching errors before they get through to the patient. Although the malpractice lawyer seeks to pin the whole blame on some person, particularly one who is covered by insurance, the reaction of doctors to adverse events is to presume that at least three people must have cooperated in letting it slip through. At night and on weekends, the reduced staff tends to weaken the defensive network . But by every assessment, the greatest threat to our protective screen of redundancy is cost control. Any manager of managed care can find duplication and overlap in ten minutes of searching for it in a hospital; redundancy is a big factor in the high cost of running a hospital. The law of decreasing returns will dictate that it becomes very expensive to eliminate the last one percent of errors. To state it in reverse: it is very tempting to save a bundle of money in a competitive world, by accepting only a small increase in the errors. Since it is a matter of opinion, physicians are grimly determined that it shall be physicians who strike that balance. Those who press for more punitive treatment of physicians in the matter of errors should reflect that it surely will convince physicians to flee the risk of responsibility for the decision of where to strike the balance.
If you bend metal repeatedly it will crack; if you stretch a rope too hard it will snap. These unfortunate events are not called errors, and it is improper to search for blame in them. The medical profession is aghast that the public does not seem to appreciate that average life expectancy has increased by thirty years in the past century. That's not ancient history; life expectancy has increased by thee years in the past ten. A system that produces a result like that is entitled to a certain amount of tolerance for its errors, if we must call them errors. In other environments, that's known as pushing the envelope. Anyone who thinks it's fun to stand on your feet for thirty-six consecutive hours -- hasn't tried it.
Surgeons are perhaps somewhat more conscious of the need to train young professionals to drive themselves beyond ordinary endurance. After all, if an operation is unexpectedly prolonged, the surgeon can't just quit, he must finish. Neurosurgeons, with their fourteen hour procedures, are particularly vehement on the topic. But it is true of every physician, too. When the telephone rings in the middle of the night, will this young fellow haul himself out of bed, or will he tell the patient to take an aspirin and call again in the morning? Increasingly, we hear complaints from patients that other doctors didn't even take the trouble to examine them; the implication that we are somehow not like that is very flattering. Part of the training is forbearance, too. At three in the morning, it is very easy to feel sorry for yourself, and to reflect that an administrator with four times your income is home in his nice warm bed. The fact is, that if the person who is up and on his feet doesn't do the job, no one will.
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| Cadwalader |
Some incomprehension from bystanders must simply be endured with patience. Beyond that, it could be futile to seek complete understanding. Quite recently, I was explaining to a young lady in a tailored suit who Thomas Cadwalader was. His portrait, beneath which we were standing, hangs in the great hall of the Pennsylvania Hospital. Although he died in 1789, Dr. Cadwalader is still famous for his remarkable, unfailing courtesy. A sailor in a tavern on Eighth Street once waved a gun and announced to the crowd he was going out the swinging doors to shoot the first man he met. The first man happened to be Dr. Cadwalader, who tipped his hat and said, "Good morning, sir." So, the sailor shot the second man he met.
The young lady in the tailored suit brightened up. "The moral of that story, " she said, "Is always wear a hat."
Preppies of the Future?
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| civlization |
Modern western civilization had its origin, or revival if you prefer, in the Italian town of Florence six or seven hundred years ago. The rise and fall of Florence is a case example for the two preeminent scholars of civilizations, Peter Hall and Arnold Toynbee. Both of them, for obvious reasons, are British. Toynbee intones the theme that civilizations destroy themselves by overextending their best features. Peter Hall puts that in a larger context. Civilizations flourish in the first place because of competitive tension between two conflicting aspirations; eventual victory by either one starts success on a path of unrestrained decline.
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| florence |
Florentine civilization grew out of the interaction, conflict, and intermarriage, of pugnacious aristocrats with sly calculating merchants. For a time, an optimum balance was achieved, and Florence dominated the Western world. Centuries later, much the same thing happened to England as feudalism grappled, first with Elizabethan maritime buccaneering and subsequently with the Industrial Revolution. That's where Eton comes in.
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| Eton college |
For American purposes, it is enough to focus on two Etonian mottos. Lumping both reckless aristocrats and scheming merchant princes, Eton exists "to exert a civilizing influence upon those who are destined to rule." Eton expresses no pretense about diversity or talent; Eton is not a trade school, a place to make useful contacts, or an elevator for upward social mobility. Labour governments of course do not share such attitudes, enduringly defended by Wellington's proclamation, that "The battle of Waterloo was won on the playing fields of Eton." That school aspires to teach more than Latin or trigonometry; it teaches duty and courage. And, as needed, it works. The graduate of a similar school, Winston Churchill minding the nation that never have so many owed so much to so few, was delivering a subliminal illustration that leadership grows from education in many different ways.
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| derek bok |
So things had not changed much in several hundred years, from Florence to Eton. It became accepted that a nation needs leaders who are smart (no charges of Light Brigades, please), it also needs unflinching bravery, in various combinations at different moments. And then, a research institute very near Lawrenceville, New Jersey, and two Harvard presidents, Conant and Bok, added a new requirement just before the Second World War. By devising multiple choice tests whose results seemed to parallel later academic success in college,
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| conant |
it became possible to identify myriads of ordinary American children who seemed to have equal or greater potential than the children of wealth and success. If the leadership pool needs to be enlarged, that's where they should come from. Besides, examples have always abounded of the children of famous people who, even with an outstanding education, bitterly disappointed their expectations. Perhaps, by the application of scientific testing combined with judicious financial aid, it might be possible to accelerate the unmentionable social Darwinism long visible in competitive concentrations of hormonally active youth. Without being too obvious about it, perhaps we could create a race of supermen by placing genetically superior candidates together, train them well, and let propinquity do the rest.
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| Eric Hoffer |
The American pragmatic way, and the scientific method, both attempt to make decisions by seeing what works. Eric Hoffer, the San Francisco writer, once visited Lawrenceville and pointed out one thing that definitely works. Rich men, he said, marry beautiful women. And so, their children tend to be unusually handsome. It's a circular system that is undeniably at work. Without any conscious scheming by sociologists, an unnerving pragmatism is already at work getting more of whatever it is we need, into leadership positions. Unfortunately, this fiendishly clever system for influencing the genetic choices of promising candidates cannot unequivocally claim to produce long-term success. Like the British royal family, it seems to some the proportion of failed marriages is too high in our system, the incidence of recreational drugs and alcohol is too great, and the number of graceful drifters too numerous among the alumni. Perhaps that is only invidious opinion, based on contrasting unusual opportunities with the ultimate consequences for a fundamentally normal collection of people. Perhaps, if we were truly objective, we might discern a second-generation production of Nobel Prize winners, Senators, Presidents, Olympic champions that might well justify the opportunities bestowed on the bloodlines. What Lawrenceville may need, to defend itself, is a systematic longitudinal study of outcomes that would demonstrate, let us say to Princeton, that more of our graduates are entitled to admission there. Or, maybe, that's the wrong goal entirely. Perhaps graduates of Lawrenceville, Andover and Exeter don't need Yale, Harvard and Princeton . Perhaps they need a different sort of college. Maybe they should skip college entirely, and go on to graduate schools. Instead of being preparatory schools, perhaps they should be finishing schools.
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| SAT's test |
Or, perhaps a longitudinal study would show something even more important, best perceived by ones who passed through the system before there was a SAT. Perhaps the basic premises of the SAT score needs to be confronted, along with the ideals of Presidents Bok and Conant. Perhaps, beyond a certain point, higher SAT scores lead to more schizophrenia and depression, or some other counter-productive trait. Perhaps another President, named Bush, is right in his unspoken assertion that J. P. Morgan had a better system for identifying leaders. That old walrus-nose swept all such schoolishness away. "Brains don't make you rich," he said. "Character does."
Remember This Date: May 18
 Delaware Bay is teeming with successive migrations of seafood. May 18 is a pivotal day, give or take a few days. 
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| Dr. Fisher |
A group of Texas and California friends were recently led on a two-day tour around lower Delaware Bay, down the New Jersey side to Cape May, ferry ride to Lewes on the Delaware side of the bay, and then home. The timing of this adventure had more to do with azalea and dogwood season than wildlife, but the date chosen was very fortunate: May 18.
It just happens that May 18 is the last day of the shad season. That's dictated by Mother Nature of course, but it also has a lot to do with Dill's Seafood in Bridgeton. For almost a century, this wholesale seafood store has dominated the shad business in the region. At one time, they shipped six thousand pounds of shad daily in season, although in recent years business has dropped to five hundred pounds a day. Even today that's a lot of fish, supplying boned shad and roe to every restaurant with shad pretensions for a hundred miles around. They do have a restaurant attached, with pitchers of cold beer on the table, and enthusiasts in great numbers.
The source of this monopoly is a very large family of Italian sisters, who have developed the skill of de-boning shad in about thirty seconds. Shad are just about inedible with the bones intact, and most amateurs make a mess of the matter if they try to de-bone the fish themselves. As the supply has dwindled, few people develop the skill needed to compete with these ladies, and the seafood industry has just surrendered the field to them. Although shad have been successfully transplanted to Oregon, the fish is native to the Atlantic Coast, and my Western visitors had never heard of them. What's really special is to fry or bake the half-pound roe sacs, with bacon of course. Shad roe with bacon and beer, now there's really something to talk about. Shad start to "come in" in January, and the last day of the season, the very last day, is May 18.
We then took a forty-minute ferry ride from Cape May to Lewes Delaware, thirty minutes out of sight of land. The reports in the taprooms of Lewes were that no one had yet seen any horseshoe crabs, it was apparently too early for them. But we had passed the point of no return, so we went on to Slaughter Beach. The origin of the name of this beach is obscure as far as local residents are concerned, although it is fun to remember that these were pirate coves in the Sixteenth Century. Captain Kidd, no less. It is also the place where salt water generally turns fresh, depending on the season and the rainfall, a matter of great importance to migrating fish who tend to hang up here in great abundance.
Well, May 19 turned out to be the first day of the season for horseshoe crabs, so our luck was doubly fulfilled. These terribly ugly brown rascals are about the size of a dinner plate, with a long pointed tail, and they come tumbling in on the surf upside down and sideways. Thousands of them are coming, but on the first day there were a pair of them every six feet or so. This is the famous limulus, which is really more closely related to scorpions than crabs. The tail doesn't seem to have a poison, but it is razor-sharp as my younger son discovered when he picked one up by the tail to throw him (?her?) back into the ocean. He got a deep bloody gash for his reward.
The limulus isn't edible, but it has its uses. It has four eyes, each attached to a single large nerve fiber, making it very useful for ophthalmology and neurology experiments. Its blood is blue, since it uses copper instead of iron in its hemoglobin. That hasn't been put to any use, but the blood has a peculiar ability to clot when it comes in contact with bacterial toxins, and has proved very useful for identifying toxic bacteria.
As far as amateurs are concerned, the horseshoe crabs attract a mob of sea gulls, but we are assured that these are very special birds who take off from South America months earlier. They are said to arrive almost precisely when the crabs do, and love to eat the eggs. One female crab produces twenty to fifty thousand eggs. As you approach the line of feasting birds, the near ones take off but the others remain, so the edge of the flock recedes as fast as you approach it. The vacated beach is peppered with the backs of the half-buried crabs, quite touchingly paired off, two by two. Inevitably, the question is raised how a male tells which one is a female. And inevitably the reply is, "That's his problem."
School Vouchers (7)
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| Milton Friedman |
S chool vouchers might seem unrelated to the struggle to enact Medical Savings Account legislation, but Milton Friedman's June 9, 2005 article in the Wall Street Journal suggests that resistance to both ideas comes from the same source. That's appealing, so let's quote the Nobel Prize winner at length. He's speaking of the 23-year interval since the publication of Paul Copperman's book A Nation at Risk:
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| Supreme Court |
"Throughout this long period, we have been repeatedly frustrated by the gulf between the clear and present need, the burning desire of parents to have more control over the schooling of their children, on the one hand, and the adamant and effective opposition of trade union leaders and educational administrators to any change that would in any way reduce their control of the educational system.
"We have been involved in two initiatives in California to enact a statewide voucher system (in 1993 and 2000). In both cases, the initiatives were carefully drawn up, and the voucher sums moderate. In both cases, nine months or so before the election, public opinion polls recorded a sizable majority in favor of the iniitiative. In addition, of course, there was a sizable group of fervent supporters, whose hopes ran high of finally getting control of their children's schooling. In each case, about six months before the election, the voucher opponents launched a well-financed and thoroughly unscrupulous campaign against the initiative. Television ads blared that vouchers would break the budget, whereas in fact they would reduce spending since the proposed voucher was to be only a fraction of what government was spending per student. Teachers were induced to send home with their students misleading propaganda against the initiative. Dirty tricks of every variety were financed from a very deep purse. The result was to convert the initial majority into a landslide defeat. This has also occurred in Washington state, Colorado and Michigan. Opposition like this explains why progress has been so slow in such a good cause.
"The good news is that, despite these setbacks, public interest in and support for vouchers and tax credits continues to grow. Legislative proposals to channel government funds directly to students rather than to schools are under consideration in something like 20 states. Sooner or later there will be a breakthrough; we shall get a universal voucher plan in one or more states. When we do, a competitive private educational market serving parents who are free to choose the school they believe best for each child will demonstrate how it can revolutionize schooling."
Milton Friedman thus advocates three things: Medical Savings Accounts, School Vouchers, and channeling public funds directly to citizens rather than to the institutions which serve them. As an economist he seems primarily interested in breaking up the financial integration of government and institutions, with school vouchers as a demonstration. As a physician, I was mainly interested in the advantages of Medical Savings Accounts themselves. The theoretical advantage of keeping governments and institutions at financial arms-length was for me only a helpful navigational guideline.
Antitrust agencies have been uneasy for a century about this matter, which lawyers call "vertical integration". The U.S. Supreme Court has repeatedly pondered vertical integration between corporations and suppliers, but so far has drawn back from prohibiting it. The State Oil case suggests the Court perceives such economic concentration is so commonly harmful to the participants that most will learn to avoid it without legal interference. The possibility after all does exist that in some circumstances integration might be of some value to the public. Along those lines, an argument could be advanced that paying hospitals directly reduces administrative costs, as compared with sending bills to preoccupied patients. Or management of hospitals might be more flexible if revenue comes in periodic government payments without economic and seasonal volatility. These and other arguments against the MSA might be examined on their merits, but such arguments have almost never been discussed.
Medical Savings Accounts and school vouchers have encountered the same sort of bewildering guerrilla warfare. Warcries abound, but rarely plausible arguments, and never direct negotiation. Since both proposals are just paperwork reforms, their well-intentioned advocates more astonished at the virulence of the opposition than disposed to imitate it. Somebody is protesting too much. That's all we could see. The common issue between the two reform proposal is whether government funds should flow directly to institutions, or whether it may also flow to individuals, who would then choose between competing institutions. Furthermore, the opponents of reform, which we would have to suppose are the institutions themselves, seem bitterly opposed to any experiments or demonstration projects, as if they recognize that the economic facts will undermine their resistance.
Seventeenth Amendment
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| Seventeenth Amendment |
The Seventeenth Amendment of the "Constitution provides for the direct election of U.S. Senators; prior to that, the states could decide for themselves how to select their Senators. The Amendment was proposed in 1912 and ratified in 1913. Today, so little is written about this matter that most people do not have an opinion whether the Amendment was good or bad, necessary or unnecessary, Indeed, few contestants on TV quiz shows would be able to tell you what the Amendment was about. It would be hard to find a person who would, without further study, be opposed to a reaffirmation of "The Senate of the United States" shall be composed of two Senators from each State, elected by the people thereof, for six years; and such Senators shall have one vote. The electors in each State shall have the qualifications requisite for electors of the most numerous branch of the State legislatures."
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| Constitutional Convention |
If you search for reasons -- why in the world would there be a fuss about this topic, 125 years after the "Constitutional Convention -- several plausible reasons are stated, all of them amounting to legislature incompetence. Such as deadlocks resulting in vacancies remaining unfilled, influence by corrupt political organizations and special interests through purchase of legislature seats, and neglect of duties by legislators because of politics. Even though news of these matters has failed to persist in the national recollection, they seem plausible enough; it sounds like local politics, all right. But the plausibility was there in 1787, too, and the founding fathers must have expected something like that when they let the States select their Senators as they pleased. Mostly, of course, by the State Legislators selecting one of their own members to go to Washington.
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| John Marshall |
We have here a tilting of our governance from a Republic toward a Democracy, following the philosophy of "John Marshall, of all people, that the behavior of all State legislatures everywhere will inevitably lead to mischief. Just a minute, please, let's give this a little thought. Surely the vast amounts of campaign money required to run for a Senate seat compare with the amount a special interest would have to spend to buy a majority in the Legislature of a State. As a practical matter, most special interests have lost interest in State politics and spend their money in Washington -- except for those few special interests that are exclusively State regulated. This comes down to the insurance and real estate industries, with insurance only there because of the McCarran Ferguson Act. This isn't only because of the Seventeenth Amendment, it also has to do with Franklin Roosevelt's Supreme Court attempt, which will be discussed elsewhere.
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| Greek philosopher Plato |
The idea of a Republic, originally set down by the Greek philosopher Plato, was that a small group of elite philosophers (you will have to forgive his professional biases) who meet together occasionally, would be better able to pick a member of their group for higher responsibilities, than would the populace. The inner circle would know who was an alcoholic, a phony, a pervert, a coward or a loafer, whereas these qualities can be concealed from mass audiences long enough to get elected. Such an in-group in a legislature may pick a bad person, or deliberately reject a good one, but they do it on purpose, not because they are fooled. The issue of direct election of Senators comes down to whether you think it is more likely that a legislature will be corrupt, or the voting population will be ignorant. Hard choice.
Meanwhile, election to the State legislature has been reduced to an inconsequential backwater, almost guaranteed to have an adverse effect on the members. There was a time when people who wanted to be U.S. Senator knew they must first run for the Legislature, where their skills could be tested, and perfected. National affairs became State affairs, with legislators well aware that they could unseat a Senator whose national behavior displeased them. There are many States, Pennsylvania among them, who collectively pay far more federal taxes than they receive in federal benefits. Call it pork barrel if you like, the present degree of interstate wealth redistribution could not possibly continue if we repealed the XVII Amendment.
Society Hill Stonehenge
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| hopkinson |
Well, here's the secret. When William Penn laid out the streets of Philadelphia, he did his best to get the numbered streets to be "polar", due North and South. The streets named for trees were perpendicular to that, supposedly due East and due West. However, surveying instruments were fairly crude in those days, long prior to David Rittenhouse and his vernier-adjusted surveyor's transit. So, the East-West streets are just a little off. Large flat buildings like Society Hill Towers have surfaces parallel to the street which are not exactly compass-accurate, as well. If things had been exactly as originally intended, you would be able to go uptown, stand in the middle of any street facing East, and see the sun shining down each street without any shadows. But only twice a year, of course, at the time of the equinox (September 22, and March 20). Because the Society Hill Towers cast wide shadows, it happens there is just a narrow strip -- going right through 255 South 7th Street -- where the sun is exactly framed as it rises and sets, just like the Mayan Temple in the Yucatan, or more famously at Stonehenge. Up till now, that's been a Linck family secret. But there must be dozens of similar solar phenomena in Philadelphia, if you know where to look for them, and when.
The Coming Baby Boomer Retirement Problem
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In a few years, the baby boomers will retire and two things will happen. They will have to retire later in life, and the country will have to borrow money to pay for the rest.
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In 2004, the Nobel Prize in economics was shared by Edward C. Prescott and Finn E. Kydland, for advancing the concept that business cycles are caused as much by what people expect to happen as by what actually does happen. By this reasoning, myriads of individual decisions are constantly made in the direction suggested by simple undeniable truths. What truths face us? Demographic facts related to how many people have already been born, and how fast they are dying, force everyone to acknowledge that both Social Security and Medicare are seriously underfunded. Consequently, it seems inescapable that the boomers must work longer and retire later. To whatever degree they don't, the country must go deeper into debt.
Prescott, writing in the December, 2006 Wall Street Journal, stated this truism slightly differently to reach the next step: the national debt must increase. Increasing the national debt raises interest rates, which is good for savers. At the moment, the main savers are American retirees and foreign governments. However, the bond market is and always has been, a zero-sum game. What's good for American retirees is bad for American business. And mortgage-holders. And everyone else who is in debt. Higher interest rates, which are seemingly inevitable, encourage saving and discourage borrowing. Prescott seemingly welcomes those features, because he is remarkably cheerful about the inevitable coming demographic crunch.
There are at least two things about it which should be bothersome. The first is that the boomers will not be borrowing money from their own generation, but from their children. Getting the chance to live longer than their parents, they seemingly want to retire at the same age or earlier, asking their children to pay for the unearned twenty-year vacation. Boomers simply must be shamed into later retirements. The American Gross Domestic Product has a long term growth rate of about 3% per year; 2% of that total comes from increased productivity, about 1% from population growth. Extending domestic working years has the same economic effect as, say, illegal immigration; it's good for the whole country to make this nativist substitution.
The other disturbing consequence of borrowing our way out of debt is the effect on banks. That's harder to explain, but the interest rates we have been describing are long-term rates, established by the world marketplace. Short-term rates are independently set by the Federal Reserve to control (or "target") inflation, and currently they are higher than market-set long term rates. Any sensible saver will therefore use moneymarket funds rather than buy bonds. That's mostly bad for banks, because their profit largely derives from "borrowing short and lending long". The so-called inverted yield curve, then, is good for old folks and bad for banks. If the Treasury fails to issue enough long term bond debt, or the Federal Reserve fails to issue enough short-term debt, banks are in danger of going broke. To summarize the whole puzzle, the government clearly will become more deeply indebted, but it must preserve a proper balance between short-term and long-term borrowing. Otherwise, either a bank crisis or inflation will sink us.
As a guess, I would say that banks are the likeliest to fail. They are in precarious condition anyway because of wrenching changes in technology. And they are in the process of discrediting themselves by failing to pass along the currently soaring short-term rate bonanza to the public. Just compare your own money-market interest rate with the 5.25% which the Federal Reserve has dumped on the banking system, and see if your blood doesn't boil a little. If this pick-pocketing continues much longer, banks will be in a bad public relations position when they must come to the public with hat in hand.
So, there's only one defensible response to this demographic retirement problem. The baby boomers, having been handed several years of unexpected longevity, must spend a portion of it working longer.
Advanced Placement Gains Attackers and Defenders
An abridged extract of what
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| Naomi Riley |
Naomi Schaefer Riley writes in the October 6, 2006 Wall Street Journal, follows:
"... The rat race complaint is that AP courses put a strain on students-too many facts to memorize, too much reading. And teachers complain, too. They say that AP courses force them to teach to test.. .
"Conceived in the early 1950's by educators from three prep schools (Andover, Exeter, Lawrenceville) and three universities (Harvard, Princeton, Yale),
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| SAT's |
the AP curricula demands that students acquire real knowledge. Unlike the SAT's which measure mental aptitude, the AP tests ask students hard questions on the history exam require students to place quotations and documents in their correct context and to identify events, dates, historical figures and ideas....
"Why? Because college increasingly offers a crazed social experience at the expense of rigorous study. But high school does better: It is often the last time that students are forced to learn something...."
Ms. Riley goes on to imply that colleges have deteriorated into little more than binge drinking hide-outs. Since I am 62 years away from personal observation of the college scene, I can't comment, or even know for certain whether things have changed much in this respect.
But on the topic of resistance to Advanced Placement, Ms. Riley explains enough to justify a comment. The SAT revolution, which took place at the same time and much the same place, effectively converts the old college entrance based on genetic probabilities into the new college entrance based on mental aptitude. Since raw mental aptitude seems to be in oversupply, the final decisions are winnowed by extra-curricular success. It would appear to me that the extra-curricular success industry is threatened by proofs of academic achievement. And more importantly, since grade inflation has destroyed the value of high school transcripts, the AP courses serve as a surrogate for effective nerdiness and bookishness. In other words, the AP tests are a threat to the entitlements created by the SAT, one of which is grade inflation.
If grade inflation is under attack, that puts more pressure on high school teachers to teach, school districts to raise their salaries, and taxpayers to pay. Before that happens, there will be pressure to cut the cost of sports and other extracurricular expenses.
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| Bill Gates |
And, come to think of it, if more nerds are admitted to prestige colleges, perhaps their social inadequacies will reduce college socializing that now appears to alarm Ms. Riley. For proof of that trade-off, I enclose a photograph of some overachievers of 1978, two of whom dropped out of Harvard because it was unchallenging. Mr. Gates is lower left, Mr. Allen lower right.
Beginning Social Security Benefits
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Some should start benefits before age 65, others should delay it for ten years or more
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| Dr. Fisher |
By mail or visit to the local Social Security office in your neighborhood, it is possible for anyone to determine how much you can expect to be paid in benefits, and at what age. In fact, it is a wise precaution to ask for this information every few years, just to be sure your payments are being credited properly, since hundreds of millions of payments are flowing into many millions of accounts, and you want to get things straight before years of problems accumulate. In the early years of the program, one of their biggest problems was that a great many people used the sample numbers on the illustration card instead of their actual "Social".
Assuming payments from your employers have been flowing properly, you currently have the option to retire at the age of 62 and start getting reduced benefits. You will get three extra years of payout, but you may need to pay income tax on some of it, and the payout will be less. My Pennsylvania Dutch uncle used to say it was bad arithmetic to take the money early. But my Scotch-Irish accountant advised everybody to take the money as soon as possible, because money in your pocket is real money, while future payments depend on your living long enough to get them. Who knows, you might get hit by a truck tomorrow. So, ultimately any decision about this matter is based on opinions which differ.
However, the arithmetic is available, once you know a few facts. The longer you wait, the larger the monthly payments will become. However, you can count on about 3% inflation during the interval, so the money might have less purchasing power. Some of the monthly payment will be free of income tax, some of it will be taxable at whatever your tax rate might be. If you spend the money, it's gone; but if you save it, it will grow at an after-tax rate which may or may not be greater than if you leave it with Social Security until you need it. The arithmetic isn't very hard, but if you look around on the Internet, somebody surely provides a fill-in-the-blanks tool which will calculate it for you.
If the arithmetic or your personal situation is such that you aren't going to spend your Social Security check as soon as you get it, here's what you do. Arrange for direct deposit into a world index fund, total market. Historically, that will grow at 8% compounded annually, and will pay about 1.8% taxable dividend. Now, do the math again, and see if y