Red State, Blue State, which state are you?

It's been a few weeks since I finished Red State, Blue State, Rich State, Poor State. As a denizen of a rich, blue state (possibly the bluest, if not the richest) and a former denizen of a poor, red state (possibly the reddest, though certainly not the poorest) I found the book very interesting. I guess that's mostly as a fan of quantitative social and political science.

To recap for non-readers: the fundamental paradox Gelman's team set out to understand was why wealthy individuals voted Republican but wealthy states voted Democrat. The resolution of the paradox was that individual wealth impacted voter preference much more in poor states (where it made one much, much more likely to be a Republican) than in rich states (where it made one only marginally more likely to be a Republican).

I don't feel that Gelman ever really answered the question of what causes this paradox, at least not to my satisfaction. He analyzes a few other societal features (like race, income inequality and religious ideology), but doesn't come up with a convincing explanation to my mind. Does anyone have a speculative theory on why rich states tend to vary only slightly in partisan id with income, but poor states vary more dramatically?

I thought his insight about the red state-blue state phenomenon occurring primarily at the upper end of the income scale was insightful if not surprising. Poor people seem to be (according to Gelman's numbers) fairly ideologically homogeneous, while it's the rich who are bitterly divided. I think it also speaks to the wealth of the political elites (both in office and in the media) that they seem to be so focused on the partisan divide when it really only impacts a small portion of the overall citizenry (albeit an overwhelmingly influential subpopulation). So why is there such power in the red state-blue state meme? Is it because we want it to be true, in some sense? Because it speaks to a fundamental tension within each of us as citizens and within the structure of the nation as a whole?

A divide that Gelman touches on, but didn't seem to dive into really, is the urban-suburban-rural divide. I read an article during the 2008 election at Salon.com that I thought was somewhat insightful on this topic. As a rural idealist (in the form of Tolkien) I tend to denigrate the urban value system (or lack thereof). Having lived for some time now near a major city I've yet to be persuaded that urbanity has anything positive to offer from a moral perspective. When I've asked proponents of urban values to justify them, they almost universally point to multi-culturalism and tolerance as values you get in a city that you can't in the country. But to my perspective, those who tout the value of such multi-culturalism have only a thin veneer of tolerance, particularly across socio-economic lines. I think I learned significantly more tolerance of "the other" living in rural Utah than I have in multi-cultural Massachusetts. Reminds me of a story a friend of mine told me about flying out to Harvard for graduate school...

Another thing I found interesting in Gelman's development was breaking out social vs. economic value systems. While I don't know that those are necessarily the "right" axes to separate our political ideology, they certainly are evocative. In the comparison of economic values to income, being richer makes you uniformly more economically conservative, and by almost identical amounts regardless of ones stances on social issues. The social values aren't as uniform, but the strong trend is for more money to make you more socially liberal. So the real mass of people seem to be economically liberal (tax and spend, redistributionist Socialists) and socially conservative (values voting, gay-bashing religious Nutjobs). And that's where I tend to find myself, in direct counterposition to the socially liberal, economically conservative libertarians (of which David Frum is a light-hued version; for more pure examples, go to www.reason.com). And yet, as a Republican it's hard to ignore the youth appeal and renewed vigor of the libertarian movement with its Ron Paulistas and Tea Parties. So I feel conflicted; I'd like my party to look more like me (the compassionate conservativism that got lost post-9/11) but I also want my party to be strong and win elections, which right now seems to imply letting it look less like me.

Anway, I liked the book. I hope a few other people had the patience to check it out, and to wait all these weeks until I managed to get a post off about it.

P.S.- One final point I wanted to make (sorry if this reedit is generating lots of extra emails). When contemplating why I'm socially conservative but economically liberal I would point to my religion. But many of my co-religionists are much more economically conservative, and some are much more socially liberal, so I don't know that that captures the true reason. Thinking deeper, my "social image" (for lack of a better term) is that poor people have greater moral authority than rich people. And I think that's what leads me primarily to that upper-left quadrant in Gelman's 2-D political belief matrix. So a question I wanted to put to the crowd is whether you feel rich people or poor people have greater moral standing (or neither)?

Next Book of the Month, and an aside

I'm going with "The Quants" for the Book of the Month.  The question now is, which month?  I have a somewhat long vacation coming up over Easter, and will be reading it then.  And it seems like everyone's been pretty busy anyway, so should we just bump things back and make this the Book of the Month for April?

As an aside, I found this article to be the most sensible political piece I've read from a Republican in a while (granted, I haven't been reading too many political articles lately): http://www.cnn.com/2010/OPINION/03/22/frum.healthcare.gop.strategy/index.html?eref=rss_topstories&utm_source=feedburner&utm_medium=feed&utm_campaign=Feed:+rss/cnn_topstories+(RSS:+Top+Stories)&utm_content=Google+Reader.

I'm especially in favor of dumping government incentives for employer-subsidized health care, for both the reasons he mentions (hiding the cost of health care to the end consumer), and for the reason that, ultimately, I suspect that government incentives for employer-subsidized health care result in an unfair distribution of government subsidies to those who 1) are employed; and 2) are employed by employers who can afford to offer health care.  (However, I'm not familiar enough with the tax code to be able to say with certainty that tax breaks on health care plans selected by individuals aren't commensurate with tax breaks offered to employers).

Anyone want to discuss?

(The only point I disagree with is his point #1.  Surely the $500,000 is or would eventually be keyed to inflation, rendering his primary argument that it would cover increasingly more Americans moot.)

Justice

I've been reading my runner up selection for book o' the month last month (The Idea of Justice by Amartya Sen) and thoroughly enjoying it, although I'm still convinced it would have made a lousy book club selection.

I've also been watching a series of lectures by Harvard professor Michael Sandel called, simply, Justice. The production quality is pretty good; Harvard teamed with WGBH to put it together. The lectures are fairly engaging, even if I feel too much time is given to Harvard underclassmen and not enough to in-depth topical development.

I'm wondering if there would be critical mass here at PVS for a discussion of some of the material. Is anyone interested in watching, say, one lecture a week (25 min.) and then having a collective discussion? Anyway, just a thought.

As for Red State, Blue State, I finished it some time back. I'll try and collect my thoughts and post something about it tonight or tomorrow.

March BOM Candidates

I'm sad that I can't convince myself to find the time to re-read one of my favorite authors of all time (Douglas Adams).  But if you've read Dirk Gently and Hitchhikers, and are now so obsessed with Adams that you need more insight into the man, may I recommend the post-humous collection of his ramblings entitled "The Salmon of Doubt."  I once heard him say that he considered himself more of a philosopher than a comic, but I had dismissed the claim as disingenuous until reading "So Long and Thanks for all the Fish."  I now think he honestly considered himself a philosopher, but was trapped by the realization that he was much better at being a comic--i.e., that he was much better at finding absurdities than reconciling them.

As for the March(ish) book of the month, in traditional PVS fashion, I have narrowed the list to three candidates, in order of the number of characters in their respective titles:

1) Life of Pi

2) The Brief Wondrous Life of Oscar Wao

3) The Quants: How a New Breed of Math Whizzes Conquered Wall Street and Nearly Destroyed It

If anyone has any preferences or thoughts on the list, let me know.  Otherwise, I will choose one early next week.

Other candidates receiving votes: The Return of Depression Economics and the Crisis of 2008 (doesn't seem like a good choice for a book on tape); I Am America (And So Can You!) (the "surprise me" pages off of Amazon were pretty funny, but Colbert's style can get old pretty quickly); The Empathic Civilization: The Race to Global Consciousness in a World in Crisis (heard the author on a radio program once and was impressed, but a quick thumb-through made me think I should read it before recommending it); Star Trek: The Next Generation Technical Manual (seriously, though, raise your hands if you've pulled something like this out of a box of childhood belongings in your parents' attic, and actually reread a few pages just for the memories.  wait.  I can't be the only one).

Accountability

I just want to take a second and say I enjoyed Dirk Gently and I have read a good portion of
Red State, Blue State. I never really got to a meaningful post on Dirk, so this is just me checking in and saying I'm still participating. --DL

Dirk the Great

• The theme of belief vs. doubt: Funny your alternate selections, Glenn, also had connections to Salt Lake City—Conan Doyle's Study in Scarlet is my least favorite Sherlock Holmes (though not because of the Mormon misinformation), and Louis Lamour often shows the Mormon's more favorably. The Walking Drum novel (the first LL I'd read in twenty years), was like a reading a western with swords in the dark ages. Dirk was by far the best choice, and I enjoyed it even more than the Hitchhikers Guide series, which gets progressively sillier.

• "I only believe in SCIENCE": I really feel like I know comparatively less every day. If you consider that there are lots of people learning more and more about the universe every day, even including me, then the ratio of my knowledge compared to the sum of all knowledge gets progressively smaller. Especially when you think that there are worlds without number and endless creations. (I'm hoping one of you will correct my math here). So we really know less and less every day. My prejudice is that the Brits seem to sneer at anything that's not published in three scientific journals.

• It seems that another theme was random coincidence, of which I think Adams was expert. Unlikely things don't just happen. My aha moment occurred when I Dirk said he was more concerned about McDuff breaking into the apartment than about Gordon Way's death.

• Do kids believe in the Easter Bunny? I wonder. I don't think any of my children really believe in Santa or in the Easter Bunny. They sometimes act like they do because it's fun to pretend, but they don't really.

• Audio books vs. paper books. Some books are better read (Peter's choice for this month, for example). I like most fiction in audio format, but I wonder about Douglas Adams—sometimes he's a little tangential.

• I only know one Dirk in real life. He prefers to be called Dirk the Great; maybe I'll try Svlad.
  

Thanks for all the Ghosts

I thoroughly enjoyed Dirk Gently's Holistic Detective Agency. I read it through in about a week. Unfortunately that was almost a month ago now, and so it might not be terrifically fresh in my memory.

Picking out some interesting (to me) instances of the belief/doubt theme:
- I thought Dirk's rejection of his own clairvoyance and any supernatural explanation of his coming up with all the exam questions was interesting. When someone knows for certain that something (e.g. seeing the future) does not exist, no amount of evidence to the contrary can convince them.

- The revelation of how the vase trick was perpetrated, particularly the reliance on a child's naivete, illustrates how Adams simultaneously wants us to think we're too constrained by the rigid ideologies of "acceptable" reality and that we shouldn't go off believing absurd things, like (in his opinion, I suppose) religion. Time travel, if it explains the evidence, is great; I doubt he would exhibit such sangfroid over a religious explanation.

- Gordon Way's surprise at discovering himself to be dead and yet still in existence was interesting. I think Way is set up as a fairly normal, non-introspective member of society. He assimilates the new knowledge rather quickly, all things considered, and dramatically alters his world view to accept the new evidence. Compare that to Robin William's character in What Dreams May Come where he takes some time to accept the fact that 1) he's dead but 2) he still exists. I think that, in general, Adams' writings lead me to believe he approves of rapidly evolving world views in light of new evidence, but again this seems at odds with his antithesis not only to religion but to religionists.

- The music of the spheres that Richard and the others find so enamoring indicates to me Adams' deep-felt desire to believe in an overarching, harmonizing force from which all that is good derives. This is echoed in the whole Anthem (?) development, and Richard's evidence-less conviction that the arc of a bird's wing in flight would produce beautiful music.

- The hypnotism and possession sequences, in which characters behave in ways they believe are rational and reasonable and arrived at by their own agency, but are in fact decided by an agent completely external to the individual.

So, I guess I've belabored the point a bit, but I think it's interesting in its contradictions. We should free ourselves to believe whatever best reconciles the evidence, except when it disagrees with my prejudice which is infallible despite its evidence-free basis, and oh, By the Way, you can't be sure that your logic is really your own because what if you're possessed. From a technical standpoint, my own research touches on some of these topics tangentially, and the more I know about how we know what we know the more I believe ideological devotion to deductive logic in its purest form is utterly insane. There's such a host of evidence-less assumptions that must be made before the first deductive step that anyone who claims such a process is bias-free ought to blush.

I hadn't intended to rant on the failings of deductive logic. Really, I just thought the book was a fun exploration of some of these ideas with a pretty good story that had me guessing for about 200 out of 300 pages and entertained for the full 300. Cami, who says she enjoyed it almost as much as I did, claims to have known exactly what was happening from the very first chapter. I guess some people are just like that.

Those silly Brits

I get a kick out of British humour. Off the wall, subtle, clever. It's not clear to me why, but I enjoyed the book more last time (or my memory tells me that I enjoyed the book more 5 years ago) when I listened to an audiobook version of it. No Alvin, it was not the dramatic version complete with sound effects.

In an effort to get this post on the board and allow the discussion to proceed, I won't spend too much time thinking things through before I type them. It will be like speed chess, but without the chequed board.

• The electric monk is such a creative labor-saving device: "Electric Monks believed things for you, thus saving you what was becoming an increasingly onerous task, that of believing all the things the world expected you to believe." Douglas Adams had a knack for inventing ideas that were funny in an odd way, like the babelfish. What "life-changing" device(s) would you have Mr. Adams create for you if he were still alive? I think I would like to see a device that goes around and scoops up dog poop. Like a Roomba for the backyard.
  
• Douglas Adams' initials happen to be DNA. He was born in Cambridge, England in 1952. Watson and Crick proposed the double helix structure of DNA in 1953 in Cambridge, England. Coincidence? Hmmm.
• DNA's writing style reminds me of the product lead-ins on woot.com
• One of my favourite parts of the book was the description of the software program Reason. Rather than giving it facts so that it could help make a decision, the user gave the program the decision it wanted and the relevant facts, and the program would create "a series of logical-sounding steps to connect the premises with the conclusion." It's creator used Reason to get a Porsche despite the fact that he was broke. He later sells it to the US gov't (which must be what the current administration is using to fix the economy).
• I found the mention of fractals interesting. I remember seeing something on PBS about fractals and their occurrence in nature, and how using fractals in engineering could improve the performance of antennas.
• The two big themes in the book that I saw were belief vs doubt, and regret.
• Theme #2 was covered quite nicely by Alvin
  
• Theme #1: Ironically, DNA's father was a student of theology at Cambridge, and DNA became a "radical atheist." His handling of the idea of evolution, and his implication of blind faith in Salt Lake City, fit with his professed non-beliefs. Another famous atheist, Richard Dawkin, really enjoyed this book, though not necessarily because of its religious undertones.
  I thought it was funny, and somewhat true to life, that "the more vague and ambiguous [Dirk Gently's] 'predictions,' the more other people's wishful thinking would close the credibility gap." While this is not quite the same thing as Dirk's classmates' jumping to illogical conclusions, I think I have been guilty of my brain completing a task that my body hadn't done. Example: "Are you sure I didn't take out the garbage? I could have sworn I did." The mind is an amazing powerful thing, it can almost create a virtual reality. I think DNA was suggesting that anything that is not based on concrete evidence is created by the mind. How did this book affect your thoughts about belief?
• Perhaps my favourite quote from the book: "Only a child sees things with perfect clarity?, because it hasn't developed all those filters which prevent us from seeing things that we don't expect to see." In other words, children see things as they truly are. Do you think that is so? To some degree yes, but if that is completely true, then why in the world do all those millions of kids believe in the Easter Bunny?
• Did you find yourself frequently flipping back in the book in order to try to catch details that you missed the first time through? Did you have an "aha" moment as you approached the last few chapters, or did you see it coming early on?
• I think this book may have prepared me well for this final season of Lost. As the last few episodes come and I realize what the show was all about, I will probably have a urge to watch it all over and see it with new eyes, similar to my experience when I first read this book. I wonder if people in the Spirit Prison might have a similar feeling when they are taught what this life was really all about?

And with that, my time here is finished. Thank you, and good night.

February's Book of the Month

I wish I had a creative response to Alvin's imaginative parody. Unfortunately, all my creativity has been sucked into a thesis vortex where it will remain for the next 12-18 months. The parody was evidently very amusing, as evidenced by the fact that Misty commented on my family blog that she laughed several times while reading it (hmm...maybe her comment was an oblique suggestion that she'd like to become a PVS contributor).

Anyway, as for February's book, I just decided on it last night:
Red State, Blue State, Rich State, Poor State: Why Americans Vote the Way They Do

Hopefully it's fairly available, although it's got enough graphs that I doubt an audio version is particularly coherent. I was trying to decide between this and Amartya Sen's The Idea of Justice, but I decided that Sen's book was too heavy for PVS. But if anyone would rather the Sen tome, just let me know in the comments.

Glenn Jackson's Holistic Book Club: A Play in One Act

I know that its poor form to post on a book before the chooser of the book, but the short play I wrote in honor of Douglas Adams' unique genius has been burning a whole in my virtual pocket. Besides, I don't think it will take away from Glenn's ability to start the typical discussion. Also, I wanted to encourage Peter to choose February's book. (It's a short month.) I apologize in advance to any of you that are misrepresented or underrepresented in the following play. My memory is far less than perfect. No offense was intended towards anyone.

Glenn Jackson’s Holistic Book Club: A Play in One Act

[ Not one to have a boring normal book club, Glenn uses the information in Douglas Adams’ book to build a time machine and travels back to BYU at the beginning Winter semester of 1996 to discuss the book with Merrill Hall residents. Most of the 1100 floor is gathered in Jesse’s room for a late night symposium where he is instructing them in the art of making muscle T’s when Glenn walks into the room…]

Everyone together: GLENN!!!!!!

Christopher B: Greetings and Salutations, my friend.

Paul [sitting closest to the door]: Hug! [Paul stands up and stretches his arms out wide for an embrace, but when Glenn hugs him, he doesn’t close his arms around Glenn, making Glenn and everyone watching feel a bit awkward.]

Robert M: Good to see you, Glenn, but as Elders Quorum President, I feel it is my duty to ask, ‘Aren’t you supposed to be on in the MTC right now with Rob Chirstiansen?’

Glenn: I am in the MTC.

Ron: Dude, you’re right here.

Glenn: My 19-year old self is on a mission, but I am the older and wiser version of myself. I’ve built a time machine and come back in time to discuss a book with you.

Ron: You traveled in time just to discuss a book?

Eliott: Sweet. That’s an achievement that deserves recognition. Glenn gets to wear the Pimp Shirt!

Karl: Did I ever tell you guys how much I love TV shows that involve time travel?

Peter J: Yeah, Quantum Leap was a GREAT show, did you see that episode where… [and the room begins to break up in to 10 different conversations]

Doug: Wait a second, guys! Let’s find out why Glenn came to discuss a book and what book it is.

Glenn: Thanks, Doug. You see, in the future, we are going to start a book club over the internet.

Alvin [mumbles mostly to himself]: I’ve never even used the internet.

Dave T: I knew the internet was going to be big.

Glenn: Oh you have no idea. For example, [looking around the room], Aaron, how much money do you spend every month calling that girlfriend of yours in Hawaii?

Aaron: Let’s see…$100 + $50 +$72…

Glenn: Well, in another 10 years you will be able to call her for free over your computer AND you’ll be able see her talking via video…for free.

Aaron: I’ve gotta go call my girl and tell her. [climbs over bodies and out the door]

Peter J: Well, since you know the future, can you tell me if my relationship with Misty is going to last, you know, forever.

Alvin: You mean it hasn’t already?

Glenn: Sadly, some of these freshman romances won’t last, Peter, but there are some that will be very successful [he looks around the room trying to catch the eyes of Doug, Jesse and Ryan].

Dan [who was sitting between Doug and Ryan]: I KNEW IT! I’m going to call Jenn to tell her we’re destined for each other. [He quickly exits the room]

Doug: Was he looking at me? Does he know we’re not even dating?

Ryan: Me neither, at least not yet…I mean we’ve been on some walks but…

Christopher B.: Gentlemen, Gentlemen, Gentlemen, before this fine symposium devolved into talk of childish romances, our honored guest Glenn, from the future, was going to tell us ask us to discuss a book. Proceed.

Glenn: Thanks, Christopher. The book is…Dirk Gently’s Holistic Detective Agency.

Scott P: What a coincidence! I stayed up all night last night reading it in the bathtub.

Paul: I read it, too. After I read it for my Civil Engineering class, I got on a Douglas Adams kick and read every book he’s ever written. Did you know there is a sequel and a half?

James: It’s weird. I was just noticing how many different majors on campus had to read this book this semester. Maybe it’s part of some master plan by BYU.

Glenn: You’re right, James, none of this is a coincidence. You have to think like Dirk Gently and see the whole picture.

Doug: Wait, did you travel back in time and put this book on the syllabus of all of our classes?

Glenn: You’re quick…and not just when you’re running. What kind of assignments have your teachers given you?

Ryan: In my music class we had to perform the pieces by Bach that have the music of life from the spaceship woven into it. I liked how at the beginning of the book Bach didn’t exist and the best composer of his time was Buxtehude.

Christopher B.: Ah, yes, what would we do without Bach? Well if I were writing the book, I would have said that the scraps of the perfect song, the song reflecting the music of life, were found in Mozart or Vivaldi or Gustav Holst or….

Tim: Or Mahler!

Mark A: My cat can eat a whole watermelon.

Jesse: Maybe they had scraps, but Bob Dylan’s music has it all!

Peter J: In McDuff’s theory, all songs were fractals, or mathematically symmetric pictures that are undefined by Euclidean geometry, and can be reduced to mathematical language that our subconscious understands, though we do not. When I listen to a classic song from Neil Young, I get these fragmented images of the circuits for my EE homework. It’s inspiring

Alvin: I think if complexities of the Bengals’ music could be reduced it would look like the Egyptian pyramids.

[awkward pause]

Karl: Did you know they found fractal patterns in Jackson Pollack’s art? I was a piece of Jackson Pollack art for Halloween.

Jared: I remember Halloween because my nose still hurts from when I punched myself to get blood for my vampire costume.

Robert M: Speaking of things we regret, another interesting theme in the book is the things we are going to regret after we die. I try to live my life with no regrets.

Mark A: My only regret is not eating another bowl of lucky charms for dinner tonight.

Alvin [to himself]: I regret every card I play wrong in a game of UNO, but I think the people on the punisher board are more likely to be haunted by me than I am to be haunted a very few misplayed UNO cards.

Ryan: So Glenn, is there anything we’re going to regret doing, or not doing, in the next 10 years?

Glenn: Hmmm, I know that a few of you may regret some of the votes that you cast. Now that you’re all over 18, maybe you should have a symposium or two on politics. It’s not just about abortion, you know.

Alvin [looking at Karl]: Really?

[Karl shrugs]

Glenn: Sorry, there was a long time in there where we didn’t all do a very good job of keeping in touch, so I don’t know a lot about what’s going to happen to each of you. I will say that you may end up in a career other than what you’re planning on now.

Christopher B.: That’s why I’m getting a double major in music and pre-med. Better to be safe than sorry.

Ron: Hey future boy, is Jesse alive in 10 years?

Glenn: Yes.

Ron: Then it won’t kill him if we all pile on top of him.

Jesse: Wha-

Tim [shouts]: You better protect your posterity!

[The whole room piles on top of Jesse.]

Jake [only half dressed]: Hey some of us are trying to get some sleep. Can you dogs keep it down?

Glenn [climbing off of the pile]: Sorry, Jake. I was just leaving. One last piece of advice: This is a unique, special time in your lives. Enjoy it while you can!

almost random books to choose from

My list of books, vote now or forever (or at least for a month) hold your peace:

Dirk Gently's Holistic Detective Agency (Douglas Adams is GREAT, and though this story is a little odd, it is fun and it comes together surprisingly well at the end)

A Study in Scarlet (the first Sherlock Holmes story, and though not my favorite, it features Brigham Young)

The Walking Drum (my wife read this and can not stop raving about it)

New Year, New PVS List

I meant to do this a week or two ago during my Christmas break. Of course I also meant to do work on my thesis over the break as well. Anyway, the results of randomizing the order for book selection:

1 (Jan) Glenn
2 (Feb) Peter
3 (Mar) Karl
4 (Apr) Rob
5 (May) Paul
6 (Jun) Alvin
7 (Jul) Jesse
8 (Aug) Doug

I don't really expect those months to remain fixed; we'll probably slip a slush month in here and there.

Anyway, Happy 2010 everybody.

P.S.- I don't suppose anyone ever invited a spouse to post to the site? If any of your wives would like to participate in the PVS book club just let me know. I love the current PVS dynamic, but a little feminine perspective (probably) wouldn't hurt.

All Complications Great and Small

It was a good book, but I think it fell short of my expectations after seeing on the cover that it was a National Book of the Year Finalist. The beginning was great, the end really had me turning the pages to see if the case was a zebra or a horse, but the middle seemed to simply contain filler material: Friday the 13th?, rare and idiopathic cases? I guess to me they didn't really fit the title of the book.

The topics you have brought up for discussion have been interesting to consider from the viewpoint of a veterinarian, especially the idea of death panels and "doctorly manipulation".
The first several months that I was in practice I kept a tally of all of the animals that I euthanized, kind of like a fighter pilot might keep a running tally of the enemy planes he shot down. I know that might sound bizarre or morbid, but I guess that was my crazy way of dealing with a very emotionally difficult part of the profession. I have a friend who wanted to be a veterinarian, but she couldn't handle the idea of "putting an animal to sleep." She is now a human anesthesiologist. Ah, the irony.
Related to dealing with euthanasia is the art of "doctorly manipulation." It is amazing how attached people can become to their pets, and yet how removed they can be of the reality of animal suffering. I believe it is often a case of denial. Deep down they know that their cat that is in terminal renal failure is wasting away and is suffering because of it, but they dread letting go of what is more a companion than a pet. And so it is the veterinarian's responsibility to open the eyes of the client. It is a very difficult dance of tactful discussion. Just as difficult are the conversations where there is a treatment available for a patient, but the client is not able to afford the treatment.

On the topic of misdiagnosis and inexperienced physician, I feel that has my name written all over it. There are internships and residencies available to veterinarians, and it is becoming more common for graduating a graduating veterinarian to pursue some area of specialization, but there are still many who go right out on their own after getting their diploma. Such was my route. I remember my first day on the job, I had passed my board exams, but my license had not yet arrived in the mail. I showed up to work a little early in order to make a good impression and make a few preparations for the day. None of the other veterinarians were there yet, so when one of the employees brought in her cat that had been attacked by a dog just before leaving for work, it was to me that she handed the animal. It is hard to put into words the feeling of inadequacy as she looked to me as THE veterinarian that would save her cat. Fortunately it wasn't too bad. I placed an IV catheter help stabilize the animal, and we cleaned up some of its wounds as we waited for the other doctors to show up for the day.
There were other moments where I didn't feel completely up to the task, but I did my best. With difficult cases, referral to a specialist in a neighboring city, wasn't much of an option because of financial restrictions or because of the distance to the specialist. I would sometimes purposefully leave my pen at my desk, so that when I was in the exam room and had little clue as to what I was dealing with, I would go to make a note in the patient's record and then tell the client, "Just a moment, I need to go get my pen," allowing me a couple of minutes to quickly look through one of the medical texts in the office. Another "trick" that I picked up in vet school: one of my professors was faced with a sick cow that required an operation that he had been taught, but had never performed. Just before he began the client asked, "Have you done this kinda thing before?" To which the vet replied, "Oh, I've done a number of them." After relating that story to us during a lecture, the professor grinned and said, "Zero is a number."
I surprised me how forgiving clients could be about my lack of experience. I believe that they understood the challenge in diagnosing a case where the patient can't talk and the resources are limited. I don't feel too much shame in admitting, "I don't know," because most clients don't expect the vet to know everything about every species of animal. Sometimes we have to figure it out as we go. There's a reason we call it "practicing medicine."

Wow, I can't believe how much I have rambled on here. Just one quote from the book before I end this post.
"Conscious learning becomes unconscious knowledge, and you cannot say precisely how." pg 21

2 follow-on comments on Complications

Thanks for all the great discussion on "Complications." Two follow-on points:

Peter - regarding checklists: I am absolutely a proponent of using checklists in medicine. I'm a doctor now, but I was an engineer first. When using humans to perform a task, you improve performance by putting in systems to minimize variation. Intel was great at this; whenever someone made a mistake, our first question was "is this something that could have been prevented by a systems improvement?" This did add sometimes cumbersome layers to a task, but results at Intel are phenomenal.

Back to medicine, this applies directly to Radiology. It can be crucial to have a pre-determined way to approach any given examination. We frequently fall victim to the "satisfaction of search," where a prominent positive finding prevents us from noticing the more subtle abnormalities in a study. Time after time in our M&M conferences, a missed diagnosis comes down to "I guess I just failed to look for _____." I believe that in reviewing a given type of radiology study, the radiologist should take precisely the same steps. I read recently about a hospital (Michigan) who improved radiology reporting by having pre-determined templates for all reports -- basically a checklist of "I checked this, and is was normal, I checked this, and it was abnormal." Many radiologists prefer to dictate their own personalized report, but the standardized report ensures that everything is looked at and reported.

Alvin - Regarding "Death Panels": Actually Becky is the one who came up with this recommendation. A good place to start would be requiring individuals to generate their living will and health care power of attorney documents in order to enroll in Medicare. This would have no effect on many patients, but does take the burden of decision off of the families who find themselves extending care because they don't know what's best for mom or dad, and don't want the burden of having "pulled the plug." And we do see living wills that say "any and all care" on them. Those are fine, too.

Less Complicated and More Anecdotal

In some ways, I think structural engineering and medicine are similar, If we make a mistake, people can die. I like to think that because of that, I have to do a good job. I know, doctors get all the glory, the fame, the TV shows, etc., but the hospitals they work in are designed with importance factors and stuff that makes their work environment safe--so that when other buildings collapse and people get hurt, the ER will be open and ready to help them.

Misdiagnosis
Because the likelihood for misdiagnosis seems to be more likely if the physician has less experience, this means, like many professions, that I want to choose the most experienced physician for what I'm dealing with. Personally, I've been frustrated by the young Physicians Assistants that we have seen that we've had to guide along to the correct diagnosis. I do find comfort in older doctors because it seems like they've seen it all. Surgeons—even more so. I want the guy who does 1000 operations a year as opposed to someone who occasionally does them. I think surgeons are generally aware of their capabilities and I'm glad for that. As an engineer, if I'm not capable of doing something, I recommend that the client uses someone else that can do the job properly. I know when my dad (an eye surgeon) saw a case he wasn't sure about, he'd send them to someone who would be.

Doctorly Manipulation:
“There are times when a doctor has to steer patients to do what's right for themselves.” and “Patients don't want the freedom we've given them.” I agree. I think it's often quite silly to give patients freedom. Again, as an engineer, if I say structure needs to be there, it needs to be there. If it isn't, when the office has a party and people dance where the structure isn't, they'll fall to their deaths (Hyatt Regency catwalk collapse). When I meet with a client who doesn't want the structure, I tell them they need it. I expect a doctor, usually more expert than me in medicine, to tell me when I need something. For example, we had a breech baby last time, and the doctor said, “we're going to do an ECV [turning the baby] and then induce”. My wife said, “well, we were thinking about doing the ECV and then letting the baby come naturally.” The doctor said, “ok” and would have let it end at that. But after asking him some more questions, we chose to do exactly what he initially recommended, and it was a good thing too.

I enjoyed the book very much. Thanks Doug.

The road, the man, and life

Some belated thoughts on the road:

I listened to this while on the road from Vegas to SLC. It was a dreary day, and the landscape through Nevada is very post-apocalyptic. Then the whole family got sick. I had a temporarily deep voice, and found myself talking like the narrator's voice for the man.

It made me think how even in the face of death (you ARE dying), we strive to live. Why? I don't think it's the fear of death—I'm not really scared of death, but I do want to live. Mostly because I enjoy life. I don't know if I would have this same desire if life weren't enjoyable. Because I really believe the next life is a continuation of this, often I find myself thinking, "oh, it would be okay if I died." I'm sure I would feel differently if I were the only source of protection for my children. It seemed the man had a stronger desire to live. It sure wasn't for himself, it was definitely to take care of the boy.

But the movie looks too scary for me.

Why'd You Have To Go And Make Things So Complicated?

Church was cancelled today due to icy conditions at 7 AM that were fine by the time church starts at 11, but it gives me some time to write. I really enjoyed the book Complications and Doug's thoughts. I will just add my comments on the topics Doug put out there.

1. The uncertainty in medicine - I enjoyed how the book portrays doctors as human, whereas we often give them superhuman powers in our minds. As Peter points out, we also do this with General Authorities, and to a lesser degree, I also catch myself doing this with car mechanics, reality TV stars, and politicians.

Before the US went to war in Iraq, I supported the action under the assumption that President Bush knew something that I didn't, something top secret that he just couldn't share with me. Similarly, I often assume that General Authorities know more than I do or have seen something that I haven't and thus they have more power to be spiritual. I thought plumbers knew more than I do, too, that I could never change a sink, until it was pointed out to me that they don't have advanced degrees. They just have more experience and the right tools. It's empowering to realize that I have just as much power and ability to do all of these things, IF I apply myself to learn the relevant skills and use the right tools (or if I invite Glenn over to help me change the sink).

2. Autonomy, consent, and the role of the patient - I have very conflicting feelings on this point. I believe that, as described by Gawande and Doug, patients often make very poor decisions, and particularly at the end of life, a lot of resources are wasted. Survival at all costs is not necessarily best for the community or the patient. Unfortunately, the only solution to this seems to be the dreaded 'Death Panels'.

As I read this book, I often thought about how the roles of doctors and patients compare to the roles of parents and children. Children often don't realize how human their parents are and how much uncertainty there is in what we do. And children may often make poor decisions, but after a certain age all parents can do is offer advice. Right now, my children are so young that my word is the law, but eventually, I'll have to grant them their agency and allow them to make poor choices, even if it's a waste of resources.

3. Top performers and practicing - That really is a great quote. I think Malcolm Gladwell (who was quoted on the book jacket of my copy of Complications) says something similar in his more recent book, Outliers. I think both Gladwell and Gawande are lucid, interesting writers.

4. Learning on the job - There is a lot of learning on the job and uncertainty in my profession, too, but the big difference is that I don't have a direct impact on the life or death of another person. (I may have an indirect impact in the approval or disapproval of a medical device, but I don't have to face them directly.) There may be mistakes in the learning process, but I don't see how the medical profession could do it any other way.

Speaking of my profession, though, I was happy to see that Gawande's attempt to use Decision Analysis didn't work because I think it's a bunch of bunk. It makes the process of arbitrarily assigning probabilities to different events seem scientific, when it's not. My boss is trying to get the FDA to use Decision Analysis on a wide scale, and I'm avoiding the meetings and hoping the movement dies quickly. I do believe that statistics has and will continue to help improve medical decision making, just not though Decision Analysis.

5. Medical errors and liability suits - I keep reading in multiple books how poor the litigation system is in preventing doctors from making mistakes. The worst doctors don't have the most lawsuits, and the best doctors still make mistakes. In the book, "Nudge", the authors suggest that people should be able to waive their right to sue in order to get lower insurance premiums, but the courts and lawmakers for some reason don't think that people should be allowed to waive their rights to sue.

This is the issue that drives me the most crazy about the whole health care debate. If Democrats are truly serious about reducing the cost of health care, then putting a cap on the amount people can sue for seems like an easy way to start (the studies on this issue seem pretty unambiguous), but this issue hasn't even been part of the debate. It just makes me think that Democrats aren't really trying to help fix health care, that it's just politics as usual. (Note: On a broader note, I'm open to universal health care, though I'm skeptical of the government's ability to efficiently distribute health benefits.)

6. The man who couldn't stop eating - Doug says, "If a person is so desparate to change, can they not dig deeply and find the motivation to change themselves?" I guess I'm more sympathetic than Doug to those that are not self-disciplined. I have a compulsion to play games/waste time when I should be working on my unfinished PhD research. Having tried and failed to change myself multiple times, you begin to stop trusting yourself when you say things are going to be different this time. If there were a surgical option such that I could get myself to always do what I thought was right, I would seriously consider it. (Of course, that may be Satanic of me to want to force myself to do good.)

And like the blushing example he gave, sometimes what outsiders perceive as a need to be more mentally disciplined is something rooted in a physical problem. Maybe we weren't born messed up, but perhaps the learned behaviors in childhood become hard-wired. I agree that as a society we are fat and lazy, as Doug said, and admittedly, whenever I see a morbidly obese person (there's one at work) I shudder and think, "Get a grip, Man!" Still, on paper, I'm hesitant to judge anyone too harshly.

Again, thanks Doug for the good read. I look forward to hearing everyone's comments.

Making a list, checking it twice...

I really enjoyed Gawande's book. I may read his follow-up Better: A Surgeon's Notes on Performance.

I agree with Doug that the central theme of the book is the essential human-ness of medicine, even surgical medicine. I have a couple thoughts on that front:

First, although Gawande talks about the dramatic improvement in mortality numbers among anesthesiologists, he doesn't to my recollection mention safety checklists (which is a bit odd, since Gawande has been a vocal advocate of such checklists; maybe he came to it after writing the book).

I was wondering what you think of checklists, Doug? My impression (and its nothing more than that) is that most surgeons view them as a hassle, something that is nice in theory but lousy in practice, not worth the effort, etc. And understandably so; I know the highly formalized type of check-list activities I do for work are an annoyance.

But I think the bigger issue is that perhaps doctors feel it is juvenilizing to have to run the checklist, that pride or ego maybe gets in the way. And not just for individual doctors, but sociologically within the subculture, making it difficult even for doctors who wouldn't mind running a checklist before surgery to do so in the face of colleague disapproval. I don't know; maybe all this is off-base, constructed more from fictionalized views of medicine than reality, but if it is reality I think it's a very understandable one, and one that fits with Gawande's larger narrative.

Second, I was talking with a ward member the other day about the book. Her husband is starting a two-year internship in pediatric radiology at Children's hospital in Boston. I wondered whether Americans have a tendancy to mythologize Doctors more than other cultures do, and thus have less tolerance for the human element of medicine. She said that she certainly feels that to be the case. She said she feels exactly the same sort of mistaken expectations when she tells people that her husband is a surgeon as when she tells people that her father-in-law is a General Authority.

I think we do mythologize doctors, and I think Gawande would like to temper that to some degree, and I think it is healthy to do so. I also think, however, that doctors (and society in general) also receive some benefits from that mythologizing inclination. Specifically, I think people are more likely to trust and have faith in doctors than they otherwise might. This goes to the patient autonomy question, I suppose. As Doug says, in some ways patients are terrible decision makers when it comes to their treatment options. Given the trend toward patient autonomy, eroding the myth of The Doctor could lead to even worse decisions on the part of the patient as they come to see doctors more and more as imperfect, fallible human beings. Perhaps this is why Gawande calls for a move back to the old model of doctors largely deciding what is in the patient's best interest.

One thing that Gawande didn't talk about that I think is particularly timely is the intersection of medicine and public policy. I was recently chatting with a friend who is an Air Force doctor. He went on at some length about the ways in which specialization is increasing, how it is driving policy more and more, and how general practioners are getting squeezed out as a result. His statement, if I remember correctly, is that because the Medicare advisory board is dominated by specialists, they are able to set rates that they feel are appropriate, which means the finite pot of money is increasingly split up with a bias toward recompensing specialists. This has echoes in the health care debate today as they talk about different payment models, like paying per positive patient outcome rather than per procedure. Anyway, not really on topic but something I find fascinating.

Thanks for the great read, Doug.

We've now reached the end of the second book club round. I think we should all take December off and start up again with a January selection. Anyone not on the following list who would like to make a selection, let me know either in the comments or via email: Peter, Alvin, Paul, Glenn, Rob, Doug, Jesse, Karl (Jesse and Karl, I know you've been quite busy with other things and haven't followed along with the book club this round. But if you have time I'd love to keep you in as making one selection, even if that's the only month in which you're able to participate. If you don't feel like you can do that, just let me know and we'll skip you this time around).

I'll give it until next week sometime for anyone who wants to to amend the list, then I'll use my patented, handy-dandy randomegizer to choose an order for the participants.

Glenn's thoughts on Millet's book

I really enjoyed the posts from you guys. I considered your comments and had drafted some responses to them, but that draft disappeared. If I find it someday I may post it. For now I will share with you things that I took note of during the first part of the book. Before I do so, let me just say that I was surprised when I started into the book, how general and broadly applicable the ideas were. I was expected Bro. Millet to say, "Now, when you get asked this by your non-member co-worker, this is what you should say." It's true that the book does contain some of that in later chapters, some of which I found interesting, some of which I have already forgotten. The most useful thing in the book, in my opinion, is that he suggests how to answer a question rather than trying to give us a script to use when answering a question. Teach them correct principles ...

Here are some quotes about faith and testimony that resonate with me, and are of value to me, especially since burying myself in research:

"A testimony is not something you either have or do not have. Rather, it is an impression of the Spirit about the truthfulness of eternal things, an inner awareness that ranges along a spiritual continuum from a simple peaceful feeling to a perfect knowledge" - pg 30

"I believe because of the epiphanies, small and large, that have intersected my path -- small discrete moments of grace when I have sensed a kind of superinteding presence outside of myself. I believe because these moments ... are too precious to discard, and I choose not to trivialize them by reducing them to rational explanation. I believe because, for me, the alternative to belief is far too daunting." - pg 34


I finished Complications this morning. I will read through Doug's post and try to get something equally worthwhile up here soon.

Complications

November's book: Complications, A Surgeon's Notes on an Imperfect Science

The first time I read this book I was pretty early in my medical training. It was fun to read it again after a few years, this time with a much different perspective. I have been there for many of the scenarios that Gawande describes, being as he was a resident. Anyway, I have my own medical opinion of what he has produced. I am interested to know how the rest of you felt about the points he made. Here are some topics of discussion, with my thoughts:

1)"The core predicament of medicine -- the thing that makes being a patient so wrenching, being a doctor so difficult, and being a part of a society that pays the bills they run up so vexing -- is uncertainty." (pg 229)

---This seems to be the theme of the entire book. Other than the "mystery" chapters where he details some rare and bizarre conditions, Gawande mostly seems to be explaining just how human modern medicine really is. In spite of all the advances of science, medicine comes down to a fallible doctor in a room with a patient -- and several unknowns.

Personally, I tend to agree. I of course have been working rather diligently (happy birthday, Alvin) for the past several years to learn things most people don't know. I think it's safe to say that I'm better than the rest of you at being a doctor. But in the end, I'm not really perfect at this -- nor will I ever be. I'm basicaly the guy with a competetive advantage for this field.

I remember prior to my mission, I thought there were people who spoke French and people who didn't. It was incredibly naive, but there it is. I remember listening to my MTC instructors use the language so freely, and I did my best to copy them. Even after I got to the country, I thought the more experienced elders were using perfect French. Only with time and experience (and actually a lot of dedicated study) could I recognize that probably 2/3 of the missionaries were finishing their mission with sub-standard French, and markedly American accents.

I think much of America has the naive thinking I used to have about language ability: "A board-certified physician is qualified to be my doctor." In reality, there are widely disparate levels of ability, care, and dedication - to say nothing of the unknowns we encounter no matter our ability. Back when I got into medical school, there were several people who advised me to work hard but not too hard -- "What do they call the guy who gets last place in his medical school class? . . . Doctor." That may be true, but the title only means so much. This goes to the malpractice comment later, but people expect doctors and medicine to behave like a robot and a factory. It's not that easy. "We look for medicine to be an orderly field of knowledge and procedure. But it is not." (page 7)

2) Autonomy, consent, and the role of the patient.

"The decision was Lazaroff's." (pg 210)
"Could it have been a mistake, then, even to have told him about the surgical option?" (pg 216)
"patients frequently don't want the freedom that we've given them." (pg 219)

---I'm curious how you feel about today's world of patient autonomy and informed consent. This idea, that the patient should approve all medical decisions, is strictly taught in our medical schools. It's one of the basic tenets of ethical medical practice -- as much as beneficence and nonmalfeasance. I personally met with about 30 patients yesterday to have them sign "informed consent" paperwork for interventional radiology procedures. The basic principle is that the patient must be of sound mind and aware of the risks, benefits, and alternatives of a procedure before allowing the doctors to proceed.

This all sounds great on paper, or in a courtroom. But personally I don't really like it. I essentially walk into room after room and say (not really here, folks; I'm using hyperbole to make a point...) "Mrs So-and-so, your doctor has asked us to place a stent in your liver. I'm going to ask you to sign a sheet that says we might kill you, but that you want us to proceed anyway. Of course we never try to kill people in our department, but there's always that one you didn't see coming..." That way, when the patient does die, we can point to our document as protection.

But only in extremely rare cases does the patient grasp what may or may not happen on our table today. And almost nobody can objectively detach themselves from the numbers. I can tell patients the odds that we'll cause internal bleeding, infection, and even death. Still, it almost never means they understand the best course of action. In the end, I get two types of people. 1- the patients who look at me with a carefree smile and say "where do I sign?" and 2- the patients who are shocked by all the complications I am forced to mention and sign with "if you really think this is the best thing for me." Interestingly, I have never personally encountered a patient who refused consent for a medical procedure that was recommended by their physician.

OK so there are some patients who are crazy and who refuse consent, but I mean normal people.

So I'm not saying that we should hide facts and decisions from patients. I do believe our current "autonomy" and "informed consent" framework is built around lawsuit protection rather than patient care. I think a more reasonable approach is to discuss the procedure with the patient, in as much detail as they desire, leaving the words "cardiac arrest," "brain injury," "loss of life," and others out of the discussion.

One other (very real today) problem with the "Patient Autonomy" movement is cost. We let patients dictate how much care they do or do not receive.

Wait... pause... My personal code of ethics and even religion are going to come out in this paragraph. Just bear that in mind; I would not and cannot force my feelings on someone else.

Where was I? We are all going to die. All of us. And experienced doctors can tell when you are on your way out. Almost universally, though, we don't recommend stopping care. We sugar coat things and give patients (or families) the sense that there is a better chance of recovery than there really is. So we talk to patients or their families about these expensive and likely futile options, again having the informed consent discussion. We basically leave it up to them if we continue "agressive" care or not. My experience is that almost no one can choose to give up. Either the patient doesn't want to give up(naturally), or the family doesn't want to live with the burden of "not having done everything we could." So the medical costs in the last year of life skyrocket.

Enough about that...

3) "Top performers dislike practicing just as much as others do. But more than others, they have the will to keep at it anyway."

---just like that quote.

4) "We find it hard, in medicine, to talk about this with patients." (page 23)
"No matter how accomplished, surgeons trying something new got worse before they got better." (page 30)

---Basically, I just like how he describes the learning process within medicine. Would you accept a "trainee" performing your procedure? Are you brave enough to ask your doctor how many of the procedures he or she has done, and would the answer change your willingness to let them proceed?

So for me personally, I take it as my professional responsibility not to touch a patient unless I know what I'm doing. So if I tell you I'm going to cut you open, you can rest assured I know how to do it right. It is true, though, that I don't have the experience that others may have. And when a rare complication occurs, my first move will be to find someone more experienced. This is also not fundamentally a problem of students/residents vs. certified physicians. I listened this morning to a discussion between a junior and senior faculty member in my department. A patient was scheduled with the younger doctor for a procedure he has not done often. The discussion dealt with whether to tell the patient of the doctor's inexperience or recommend the senior faculty member perform the procedure, among other options.

5) "To the public - and certainly to lawyers and the media - medical error is fundamentally a problem of bad doctors." (page 47)
"And a patient's liklihood of winning a suit depended primarily on how poor his or her outcome was, regardless of whether that outcome was caused by disease or unavoidable risks of care." (page 57)
"We are all, whatever we do, in the hands of flawed human beings. That fact is hard to stare in the face." (page 105)

---My wife is already wondering when I'm going to emerge from this entry, and you probably are too. Let me be brief:

When our oldest was born, my wife was given 10 times the correct dose of a medication. Her heart was overloaded, she went into "flash pulmonary edema," and spent the next day and a half on a ventilator. It was a blatant, clear-cut, medical error. My aunt, a hospital administrator, summed up several people's comments when she said that we should get our hospitalization for free, and could get a whole lot more.

We did nothing. Not because we were not harmed, but because I believed that everyone makes mistakes. The doctor, who was indeed responsible, was legitimately contrite. That was enough for me. In the moment, we were concerned about the long term implications -- not just for my wife but also for our family size due to the emergency C-section that was required. But even with all those emotions, I was more prepared to forgive than to litigate.

But, as the book does point out, people love to sue when the outcome is poor. And (some, not all) lawyers love to help them along.

6) The Man Who Couldn't Stop Eating

OK; we could do a whole discussion on obesity and appetite, but let me just say this much. I agree that some people have a pathologic compulsion to eat. That being said, I am not a fan of gastric bypass surgery. The bottom line is that you make it so painful to eat that the patient retrains themselve. Or rather, some patients. Far too many gastric bypass patients learn to accomodate the change and end up worse than before. In the meantime, you are taking some of the worse possible candidates to the OR and undergoing a surgery with a very real risk of death or disability.

If a person is so desparate to change, can they not dig deeply and find the motivation to change themselves? Gawande gives anecdotal reports of patients who could not possibly have improved without the surgery. I would counter his anecdotes with many others who (in the absence of a successful obesity pill) believe that surgery is easier than fixing their broken lifestyle.

We were not nearly as fat as a country 20 years ago, and again less so 40 years ago. I do not believe that appetite is new to our generation. We have just become too indolent to take care of it ourselves.

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Anyway, I enjoyed this book. Share what you thought; feel free to use my discussion points or not.