Wednesday, December 24, 2014

Doctoring (the Evidence)

If there's any advantage to having been intermittently under the (unbelievably dreary!) weather lately, it's the fact that I had the chance to read two really interesting books.

Brendan Reilly's One Doctor: Close Calls, Cold Cases and the Mysteries of Medicine (2013) is an engaging and eye-opening memoir.  At the time when it was written, Reilly was Executive Vice Chair for Clinical Affairs at New York Presbyterian-Hospital/Weill Cornell Medical Center.  His narrative opens on a Saturday morning in the ER--as Reilly quickly points out, he's one of the few doctors who still works on weekends--and follows Reilly and the cases he encounters of the span of several weeks. Midway through the narrative, Reilly reflects back on his years as Chief Medical Resident at Dartmouth College.

 In an era of increasingly specialized medical practice, Reilly represents a dying breed of primary care physician--the generalist.  In One Doctor, he examines the significance of the many changes he has witnessed in the health care industry over his 40-year career.

The fact that health care in the US is, ultimately, an industry driven by profit is perhaps one of the strongest notes that Reilly's memoir sounds.  As he considers his own experiences, he incorporates some startling statistics.

For example, in 1975, "health-care spending in the US amounted to 6 to 7 percent of the nation's $1.6 trillion gross national product.  Thirty-five years later, in 2010, US population had grown 50 percent... and health care spending had grown more than 2000 percent (to 17% of the nation's $14.6 trillion gross domestic product)" (164).

As Reilly points out, we have some of the most expensive health care in the world.  The question is, who benefits?  Definitely not the patient, Reilly argues. He points out that, in 2000, 98,000 people died in the hospital, as a result of medical mistakes.  That's more than the number of people who died of breast cancer (42,000) and in car accidents (43,000), combined (29).  It's slightly little less than the number of people who died of HIV (16,000), breast cancer and auto fatalities combined.

In short, Reilly's memoir will make you angry and, if you've even been a patient or compelled to advocate for a patient (particularly an elderly patient), you'll find much of what he says all-too-familiar.  His book is a long-overdue wake-up call, but it's one that the health care industry probably doesn't want anyone to hear.

In a similar vein (excuse the pun), I also really enjoyed Deborah Blum's The Poisoner's Handbook: Murder and the Birth of Forensic Medicine in Jazz Age New York (2010).

In chapters organized around specific poisons (arsenic, wood alcohol, radium, thallium, carbon monoxide, chloroform, cyanide, mercury, and ethyl alcohol), Blum examines the work of Charles Norris, New York City's first Chief Medical Examiner and forensic chemist and toxicologist Alexander Gettler (pictured below, circa 1922).


Blum's narrative looks at how and why the rise of forensic medicine accompanied the "social experiment" known as Prohibition (and its ultimate demise).  Her style is an interesting and informative blend of scientific fact--did you know that radium is similar in chemical structure to calcium, and that this is why, when absorbed, it quickly travels into the bone marrow?--and historical event (Blum looks at various prominent cases of poisoning and murder that made headlines in the first half of the 20th century, along with issues of worker-safety that evolved during the Depression).

It's a fascinating angle from which to considerJazz Age America, and Blum offers a compelling account of the unsung heroes who helped to raise awareness about the dangers of toxic compounds that were, unfortunately, all-too-readily available in the decades before government regulation.

If you're looking for interesting and informative reading, I highly recommend both Blum and Reilly's respective texts.

Saturday, December 20, 2014

Kindly

To say that the last week hasn't gone as planned would be an understatement.

I woke up last Saturday with some kind of chest-based, cold-type ailment (a by-product of Christmas shopping the week before, no doubt), so I decided to hunker down and read and by jiminy, by Monday I was 100% better.

Or so I thought.

Monday and Tuesday went swimmingly.  Got tons done, poised for the remainder of the week, smooth sailing, got the holiday-stuff under control, best laid plans and all that... well, you see where this is going.

Wednesday and Thursday became suddenly, startlingly stressful, and by the time I got it all back under control, I emerged from the fog to realize that the 48-hour headache was a sign that... the illness was back. 

So yesterday, it was back to the drawing board: hunker down and read.  And drink lots of juice and eat well and go to bed early. 

And again, it seems to have worked.  I don't usually get terribly sick (although, when I do, I apparently really mean it because I ended up in the ER twice this year, and at an emergency care clinic once), so I can usually shake things off.  Knock wood.  (I know, I'm an idiot for even writing such a thing: it's like I want the damn lightning bolt to blast me out of the chair here or something.)

While I was in the throes of recovering from all kinds of stress and unhappiness induced by, well, other people (Sartre really was onto something with that whole "hell is other people" idea), I stumbled across an article in Psychology Today by Douglas T. Kenrick.

Thinking about the wisdom he would like to pass on to his children, Kendrick asked readers of his column to weigh in and offer their own pearls.  In the meantime, he consulted with "several prominent positive psychologists, a few authors of well-known books on human behavior, a couple of especially insightful clinicians, a handful of pioneering researchers who have pondered human behavior in light of evolutionary biology, and several non-academic friends whose personalities and sense of humor have had an inspiring and positive effect on those around them."

The most frequently-offered bit of wisdom boiled down to something quite simple: "Be kind."

This hit home for me, because my own stress this week had been caused by someone who was, quite frankly, not kind.  And who showed no signs of becoming kind any time in the near future.  And it resulted in a situation in which I had to deal with all kinds of unnecessary stress and distress.

So when Kenrick pointed out that "being kind" sounds a lot easier than it actually is, my response was, "Yeah, I feel you on that one."

How can you be kind to unkind people?  To people that you are 100% certain don't give a (to put it bluntly) rat's ass whether or not they are needlessly upsetting you and complicating your life.  Who can't even conduct a polite and professional conversation with a relative stranger without trying to bully and gloat?

Oy.  It's a world.

And as Kenrick points out, there are basically 5 obstacles to kindness: 1) others aren't nice to you; 2) others will attempt to exploit your kindness; 3) we tend to overvalue ourselves and undervalue others; 4) there's a price to be paid for being kind and 5) some people just don't have a clue.

I experienced all of the above in a 20-minute phone conversation on Wednesday afternoon.  It took me two days to recover, and I really think the experience was physically so draining that it gave that little cold-bug a renewed foothold in my body.

I say again, Oy.

The aftermath of such experiences is, we kick ourselves for being kind.  "NEVER again, asshole!" is my mantra in the wake of such moments.  "Everyone can just go kiss my ass!" is another frequent refrain during such episodes.

But you have to get out of that mindset, quickly, I think, because it really is soul-sucking.  What's wrong with being kind, after all?  Nothing.  Not. One. Thing.  More people should try it.

That said, I think Kenrick offers useful advice for those of us who are averse to being treated like doormats for other people's shitty shoes (sorry, I'm clearly still working through some residual anger here).  It's a strategy proposed by game theorists: when people are nice, be nice back.

But when people are not nice, you respond in kind (relatively speaking).  Snark can be met with snark.  But then, you immediately go back to being nice.

The goal is that, over time, the person realizes that if they try to exploit or be unkind to you, they won't get away with it.  But if they treat you kindly, well, then, they can expect the same from you in return.

Kenrick has less concrete advice (in my opinion) for the handling the other obstacles to kindness, but in essence they boil down to remembering, in the words of my mom, "It takes all kinds to make a world."

Yes, people will overvalue themselves and undervalue you.  Try to see the humor in it.  Really, it's all you can do.  I think of the line from "Dirty Harry": "You're a legend in your own mind."  In the moments when you find yourself dealing with a self-declared legendary personality, try to step back and savor the sheer fictionality of it all. 

In terms of the advice he offers for people who have trouble being nice (although, I must say, if you're aware that you aren't nice, you're really about 90% cured already--the ones I encounter haven't a clue), he points out some real basics.

Stop whining.

Keep your promises.

Help others without expecting anything in return.

Be likeable.

Show an interest in other people's lives.

All of these things are ways to move through the world kindly.  And, if you practice them enough, they become habits (of a sort).  So that when you do have the occasional, inevitable Wednesday-from-Hell, you'll find that you have something to fall back on.

Friday, December 12, 2014

Blink

I've once again been MIA for over a week and, once again, the days have passed in the blink of an eye.

Which is somehow fitting, because I've been reading Malcolm Gladwell's Blink: The Power of Thinking Without Thinking (2007).  Although Gladwell has come under fire for his work--in particular, for the fact that his information and narrative style are often organized around anecdotes rather than concrete data--I did enjoy Blink and I think it offers some interesting points about the way human thinking often works (or doesn't work).

Blink became enormously popular because, for many, Gladwell seemed to be giving us all kinds of permission to stop over-thinking everything and simply "go with our gut" to make decisions that intuitively "feel right."

And, yes, on some level, Blink explores the potential benefits of doing just this.

Except that Blink is also about the very real dangers of doing just this.  Written seven years ago, Gladwell's book is particularly timely right now, because it also reflects on what happens and how things can go terribly, terribly wrong when people make snap decisions based on unexamined impressions.

As the Bronx police officers did in the shooting death of the unarmed Amadou Diallo in February 1999, an incident that Blink examines in some depth. 

Gladwell probes the information offered by ongoing studies in stereotyping, one of the most insidious forms of "blink" thinking.  When we stereotype, we allow the unexamined, illogical gut reactions that have been insidiously (or not-so-insidiously) instilled in us by our surrounding environments and social contexts to determine our behavior.  And we do this even though these gut reactions in fact contradict what we consciously want to (or even believe that we) believe about others.

We act on impulses or ideas we didn't realize we had and that we might never consciously choose to act on, if we knew we had them.

Gladwell points out that, contrary popular belief, extreme stress only enhances quick thinking and decision-making abilities if a person's heart rate falls within a very specified range--between 114 and 145 beats per minute.

In this range, individuals seemed prone to experience the sensation that "everything was moving in slow motion" and they were able to process events and react with feelings of keen acuity.  This is the stuff on which action-adventure films capitalize (think of the many scenes in "The Matrix," "Crouching Tiger, Hidden Dragon," "Kill Bill," etc. etc.)

Beyond 145 beats per minute, however, all bets are off, as complex motor skills begin to be impaired and vision becomes restricted.  Aggressive behavior mounts to a point at which people can become inappropriately aggressive.  In these cases, their reaction is not keen or intuitive, it's simply an insane reaction to an insane amount of stress.

At a heart rate of 175 beats per minute, stressed-out individuals will often void their bowels.  In such situations, the body is under such duress that it physiologically overrides the more reasoned "you-need-to-wait-until-you-can-find-a-bathroom" impulse ingrained in us through potty-training.

I don't think you'll get Uma Thurman or Angelina Jolie to do their own stunts in that kind of action-adventure scene.   

If a person's heart rate is greater than 175, s/he is little more than a stressed-out loose cannon.  His/her perceptions of reality are no longer reliable.  All cognitive processing has stopped and the primitive emotional centers of the brain have taken over.

As Dave Grossman, former army lieutenant colonel and author of On Killing (2009) has argued, the person has become the human equivalent of an angry dog--they can't be reasoned with.

Under these conditions, a person may in fact do things that s/he wouldn't otherwise do and s/he may also be unable to do things that, to us, seem quite simple--this is why, in emergencies, many people dial 411  instead of 911.

This may also explain why, in cases of police brutality, incidents of racist behavior and stereotyping are both painfully obvious and preternaturally extreme.  Stereotypes are rigid systems of thought that are ingrained in us in ways that operate below the level of consciousness. (Ironically, our brains seem to subconsciously store stereotypes in the same basic category as the impulse to spontaneously void our bowels.)

When it starts hitting the fan, stereotypes all-too-easily become the (subconscious) default settings that guide  actions and perceptions.  This becomes particularly likely if events steadily escalate to such an extreme (think: "life or death") that the people involved are no longer processing reality correctly.

If you're thinking, "Well, luckily, this can't happen to me because I don't have any engrained stereotypes or implicit, intuitive thoughts of this nature," you need to check out Project Implicit.

Project Implicit is a study designed to measure our implicit (think: split-second) social attitudes--those elements of our reactions that we can't control and that we may not even realize we have.  It measures the way in which our intuitive responses have been shaped--without our realizing it--by the social contexts in which we live and by which we've been systematically conditioned.

I can almost promise that you won't like what you find out about yourself, if you take one of Project Implicit's 5-minute tests.  (They actually have a disclaimer warning people that they may not be happy with their test results: you have to explicitly agree to be willing to read opinions that may disagree with your own deeply-held beliefs about who you are and how you think, feel, and react to people of different races, sexualities, genders, and abilities.)

As Gladwell points out, studies have shown that the way to counteract incidents of police brutality is not simply through community outreach programs or sensitivity training, but through the better enforcement of proper police training techniques, on the ground and in real-time.

The only way to avoid the bad, split-second decisions that result from the distorted and inaccurate perceptions brought on by stress-reactions is to try to slow down the unfolding of the event itself.

Police procedures are designed to do exactly this, but if officers are less than diligent in adhering to those  procedures when approaching what might be an unfolding crime-scene, before a suspect is encountered, they may be missing opportunities that would give them the additional time and space needed to react appropriately and rationally.

Police officers have to respond quickly: their ability to do their job relies on immediate, accurate, and appropriate responses to highly stressful situations.  No one questions the inherent difficulty of doing this.

At the same time, however, police officers must walk a fine line.  If they respond too quickly and/or succumb to the inherent stresses of the situation itself, they will simply not be able to do their job appropriately.

It's easy to sit on the sidelines and judge or speculate about what we ourselves "would do" when faced with such situations, but the fact of matter is, in situations of severe stress, when individuals believe that their very lives are in jeopardy, they aren't themselves.

In such moments, people make snap decisions that lead them to do things that they--and others around them--have a hard time believing that they are capable of.

In the wake of the recent grand jury acquittals, my guess--and this is only a guess--is that, when called upon to testify about incidents of police brutality, the police officers involved may offer testimony that is very emotionally compelling and oddly... persuasive... to those who are sitting in the jury box, listening to it.  It's highly probable that the officers involved really do believe that they saw what they saw, and that they really did think that they had to do what they did--because they weren't "thinking" in the way that you and I think of "thinking."

I suspect that grand juries and police brutality cases are, on a very basic level, recipes for legal disaster.  Calm, quiet people in an unstressed situation are being asked to weigh evidence and sit in judgment on the rights and wrongs of highly emotional circumstances that involve stereotyping, high-stress reactivity and scenes of significant social disparity--elements that in turn culminate in violence and death. 

I think that, rather than try to solve the problems that are clearly occurring when grand juries are asked to decide police brutality cases, a better way to protect everyone involved--both the police and the public--might be to use what we already know to be true to better train police and inform the public. 

For example, psychologists and police officials already know that high-speed chases--or chases of any sort, actually--get out of control very quickly.  The heart rate of everyone involved becomes extremely elevated, perceptions become skewed, and the ability to accurately process who is doing what and when (to say nothing of why) is severely compromised. 

The key seems to be to do everything possible to avoid forcing--or allowing--split-second decisions to be made under such circumstances.  Because, more often than not, those decisions will be seriously flawed and based on misperceptions.

A lifetime of consequences can result from a bad decision made in the blink of an eye.  Individual actions and reactions can--and do--have large-scale social ramifications, as we have all witnessed in the events of recent months.

Another option is to better train people in ways that can help inoculate them against the debilitating effects of stress.  If you systematically accustom a person to physiological stress, you can lower their resulting heart rate and potentially keep them within that narrow window of opportunity in which split-second decisions aren't inherently misguided and disastrous.  (The key word being "potentially.")

Ultimately, I think we are best served by remembering one of the key points that Gladwell makes: split-second decisions are precisely that.  Split-second.  

Standing on the outside and reviewing events that have already occurred, we tend to think of them as unfolding across a much longer expanse of time.  It always "feels" as if all of the parties involved had enough time to make better decisions, and we tend to assume that they naturally had the presence of mind--that they were still enough of "themselves," in short--to do what was obviously sensible and appropriate.

We know what they "should" have done, we think of this as unfolding in an indeterminate expanse of time, and we can't imagine why they did otherwise.

And sometimes, yes, events do seem to unfold in just this way.  For instance, Gladwell cites the story of a police officer who confronted a 14-year-old gang member in flight who, in fact, did have a gun and who was reaching for it at the moment when the officer confronted him.

The police officer claims that he didn't shoot because, throughout the incident, he remained instinctively aware of two things: the suspect's age ("He was fourteen, looked like he was nine"), and the fact that, as the arresting officer, he had time--as he put it, "something in his mind" told him that he "didn't have to shoot yet."

The police officer instinctively "felt" that he had time to give the boy (and note: he never lost sight of the fact that the person confronting him was, in fact, a child) the benefit of the doubt, and that was all it took to change the outcome.

As Gladwell points out, the attempted assassination of Ronald Reagan in 1981 was an incident that lasted, in its entirety, a total of 1.8 seconds.  The attempted assassination of the president of South Korea (an event that resulted in the deaths of the president's wife and an 8-year-old boy) lasted all of 3.5 seconds.

The incident involving the police officer described above was similarly brief, and yet it resulted in a very different outcome.    

Gladwell's Blink also looks at the potential benefits of intuitive decision making, of course, and I find his ideas and arguments on this front equally interesting and compelling.

Anyone who works in academia knows that, at times, the influx of research and ideas and acronyms and "information" and statistics and who knows what-all can get positively overwhelming.

Research any paper or idea long enough and, by the time you're through, you won't know what it is that you want to argue.  There's always more reading to be done, but at some point, more reading isn't going to clarify anyone's thinking.

You're simply going to be buried in information that will ultimately impede rather than enhance your decision-making abilities.  In those instances, it's a case of becoming fundamentally unable to see the forest through the trees.

Gladwell describes a particularly compelling instance of this when he chronicles the experiences of General Paul Van Riper in the Pentagon's Millennium Challenge war games in 2000.  Riper led the "Red Team"--the putative enemy of the United States' Blue Team.

The Blue Team had all of the advantages of technology and research on their side.  They devised strategy upon strategy, they created acronyms, they "knew" all about their enemy and his vulnerabilities.  As Gladwell observes, "With the Millennium Challenge ... the Blue Team was given greater intellectual resources than perhaps any army in history."

Van Riper's Red Team, on the other hand, was to be led by a "virulently anti-American" "rogue military commander" who "had broken away from his government somewhere in the Persian Gulf." He was "harboring and sponsoring four different terrorist organizations" and he exhibited "a considerable power base from strong religious and ethnic loyalties" that "threaten[ed] to engulf the entire region in war."

Needless to say, the Blue Team felt it had the clear advantage.  Until the Red Team sank 16 of their ships in a surprise attack.

Van Riper's explanation was simple: rather than running elaborate scenarios or conducting extensive research, he simply noted that the Blue Team would "adopt a strategy of preemption."

So he struck first.  And in the blink of an eye, it was over.

This is the essence of Blink.  Thought is good.  Information is good.  Training is necessary.  And insight is  indispensable.

Monday, December 1, 2014

"The Show"

The month of November represented an all-time low in my blogging history, with only 3 measly posts.  I'm not really sure what happened, except that I was busy with all kinds of things that even I knew wouldn't be particularly interesting to anyone but myself.  And I was away for a weekend.  And then there was Thanksgiving.

So I'll do the month in review, quickly.  Hitting the "highlights," so to speak.

I switched from reading about things like Gulags and the South African Truth and Reconciliation Trials when, one day after writing up a letter of recommendation for a colleague, I caught myself thinking that I would leave a printed and signed copy on my printer, "in case I disappeared in the night or something."

I wish I could say I was mentally "kidding," but I may not have been.  So I switched to reading about happiness studies for a bit.

Turns out, people who expect the worst (like, say, "disappearing in the night") are often happier than people who don't.  Apparently, we set the bar rather low and are therefore quite pleased when things go reasonably well on any given day.

This probably also explains why I was thrilled by my customer service experience the other day.  I've blogged about my past experiences this year-- suffice to say, they haven't been good.

The woman I spoke to the other day, though, assured me that I qualified for a $150. credit, and that since they had made a mistake on my bill, I'd get a $30. credit for that, and then she hacked $10 off of another charge and told me that she decided to "make it $20" for no real reason that I could discern.  And then she announced that my monthly bill will now be about $40. less per month than I had been led to believe it would be.

Nor was this the only such episode.  I went to get the oil changed in my car, and I told the guy I needed to be out by 3:30 p.m., so if it wasn't possible, just let me know and I'd come back another day.  It was 2:00 p.m. when I told him this, and the shop was quite (quite) busy.  Frickin' full, in fact.

Turns out, it's totally possible if the guy you're speaking to happens to be the service manager and vested with the power of bumping you ahead of 5 other people who got there before you, just because.

I think maybe it was the new sweater I was wearing.  (I finished the two of them that I started a couple of months ago, which means I'm actually making some headway on my stash.  This, too, was November.)

In that spirit, I was working on a sock in the oil-change waiting area, and I had an encounter.

Full disclosure: I had previously seen this woman in conversation with the customer service reps.  She was  crowding them in a major way.  

The service rep finally asked her to please move back behind the counter.   It was that bad.

The woman did, but just barely.  I thought maybe she was just a close-talker.  (Either that or she was what my mom used to refer to as "a plain old pain in the ass."  Sometimes it's a toss-up which way it will go.)

Anyway, this woman eventually launched herself into the waiting area where I happened to be sitting in an armchair, glancing at the covers of the magazines on the table next to me while I took out my knitting.

Mind you, this table was round, and about 3 feet in diameter.  Not a small table, in short.  As I was glancing at the magazines, this woman suddenly leaned down so that she was peering into my face and said, "Okay, I'm going to put my coffee cup down here, so I'm going to have to move these magazines, okay?"

Okay.  She had all kinds of room to put her befrigged cup down, and I don't know about you, but I don't like when people kind of stick their face in yours to get your attention.  Boundaries, close-talker, BOUNDARIES.

But I just smiled and said, "Sure."  So she set her cup down, but it didn't end there.  (Of course it didn't.)

Because then she suddenly said, "Okay, I'm just going to take all of these magazines and put them back on the shelf.  All right?"

I was still looking at the covers of said magazines when she said this.  (Of course I was.)

And so I found myself faced with an existential dilemma.  I wasn't really all that interested in any of the magazines, I was just looking at the headlines for a bit.  I planned on knitting, not reading, but now the question was, did I want to let her get away with what we so clearly had going on here?

It was a power-struggle for control of the waiting room coffee table.  As God is my witness, that's what it was.

I believe that, in the grand scheme of things, it's best to pick one's battles, so I said, "Sure.  Fine."

I did so, however, with a slightly bewildered look designed to suggest a feeling of, "Why on earth would anyone care so much about a table and a few magazines?"

Anything I could do to deflate her sense of control and conquest, I decided, was worth doing.  Because if history has taught us anything, it's that you can't let some people take the proverbial Sudetenland just because they happen to think that they should have it.

So that said, I made another executive decision.  I sat there, staring at my knitting and thought, "I'm having a nice day.  Do I really want to voluntarily sit next to someone who I already know for a fact is inclined to crowd and hassle everyone she comes into contact with?"  Because at this point, this was the 4th odd incident involving her that I'd witnessed or been a part of.

This is the difference between being 46 and being 26.  Twenty years ago, I would have thought, "Oh, I don't want to move my seat.  She might realize I'm moving it because of her and she'll think I'm rude and maybe  feel bad."

As a Seasoned Forty-Something (who may or may not be rather jaded about humanity at large), I'm here to say that I not only moved my seat, I looked directly at her for a full minute before I did so, just to make sure that she stood some chance of realizing that I was in fact moving my seat because I didn't want to sit next to her.

Because really, she needs to get a little awareness.  It's a waiting room coffee-table and a few magazines.  I'm not optimistic that awareness is what was achieved in the wake of all of this, but I can safely say that I did my part.

I wonder what she did to the manager when she realized he bumped my car ahead of hers.  She arrived well before I did, he told her, "hour and a half!" and then I left in... 45 minutes.

Sometimes, you have to enjoy the show.