Monday, January 15, 2018

Abbas

I can see why decent people might support JVP/BDS out of profound frustration with Israeli policy toward the West Bank — yes, the West Bank, the Occupied Territory, not the Biblical lands of Judea and Samaria. I understand their outrage but think they're being fooled since, if you take care to look into it just a bit, it becomes obvious that Omar Barghouti and other founders/leaders of JVP are not interested merely in addressing Israel's proto-apartheid policy toward the West Bank; no they think of Israel itself as just another, bigger, illegal settlement.
Then I read statements like those made by Mahmoud Abbas, President of the Palestinian Authority in Ramallah this past weekend. In them: 
[he] gave a lengthy history lecture reaching back to the 17th century, saying that Oliver Cromwell had first proposed shipping European Jews to the Holy Land, before tracing the beginning of Zionism to what he called the 19th-century journalist and activist Theodor Herzl's efforts to "wipe out Palestinians from Palestine."
"This is a colonial enterprise that has nothing to do with Jewishness," Mr. Abbas said. "The Jews were used as a tool under the concept of the promised land -- call it whatever you want. Everything has been made up."
If educated, senior (if not yet certifiably senile) leaders of the Palestinian movement think "Jewishness" has nothing to do with the creation of Israel, and that the notion of "the promised land" is alien to Zionism and the creation of Israel, well, that's uniformed, fantastical and more than a little crazy.
It's exactly the sort of nonsense that will buttress the other side, the likes of JVP/BDS.

Saturday, January 13, 2018

Trump Shits

Some have argued, cogently, that Trump has mental problems. Let me suggest he has bowel problems, and further that bowels can trump brains when it comes to being problematic. Yes, both bowels and brains contain neurons, the brain many more of them, of course, but bowel neurons are primed, charged and sunreflective.

Back to Trump, it's his shits not his thoughts that count. His shits fly, and he can barely outrun them to West Wing toilets. He doesn't like his crap wrinkling down his leg into his expensive shoes. He doesn't like screaming "No Shit!" as he discovers that nothing is faster than the speed of shit.

Of course Trump has got the Seventh Fleet if need be, plus Marines, to clean him up, and White House maids by the dozens to provide new linen.

Still, it roils him something wicked to soil himself.

And then he wipes himself and tweets




Saturday, January 6, 2018

Daphne Merkin "Publicly, We Say #MeToo. Privately, We Have Misgivings."

You may know Daphne Merkin as author of "Unlikely Obsession" (New Yorker, 1996), her account of how being spanked was an essential ingredient in her enjoyment of sex. Though BDSM was hardly a secret — think, in brief, of Madonna and The Velvet Underground, old news already, Merkin's piece triggered a fair amount of controversy. Perhaps that was because she was a writer, a littérateur, not a pop star, and should have had better things to do than write about the necessities of being spanked.

You may know Merkin, too, as a widely published author of essays which err, too often, in my view, on the side of being both quite knowledgeable and too decorous, too well-behaved — too defensive and shallow.

Last year she published a very well received memoir: "This close to happy
: a reckoning with depression."

It should also be noted — she has written about it — that she hails from a wealthy New York Jewish family, which after falling prey to Bernie Madoff's pyramid scheme, is now, one gathers, significantly less prone to philanthropic largess than it had been.

I'm mentioning all this now only to call attention away from it, and toward her op-ed in today's NY Times: "Publicly, We Say #MeToo. Privately, We Have Misgivings."

I think it's the most sane, level-headed, both assertive and questioning piece of writing I've come across about the scandal of sexual abuse and how to address it.


Thursday, January 4, 2018

Alpha Zero, Chess God

Chess now has an engine, AlphaZero, that starts off knowing nothing of chess. It does not come equipped with a formidable database of old games, or a list of openings. It was never briefed by the likes of Garry Kasparov or Magnus Carlson, and never needed their assistance.

AlphaZero, "learned to play solely by playing against itself, over and over and over — 44 million games. It kept track of what strategies led to a win, favoring those, and which didn’t, casting those aside. After just four hours of this tabula rasa training, it clobbered the top chess program, an engine called Stockfish, winning 28 games, drawing 72 and losing zero. "

This is the method by which AlphaGo taught itself Go, and in short order became what one competitor called, "the God of Go,"  capable of playing "how I imagine games from far in the future are played."

What's fascinating about AlphaZero's chess play is that it, "adopted an all-out attacking style, making many bold material sacrifices to set up positional advantages." This is contrary to the impeccable but dull style of other chess engines. Without any help from chess history, except for its own four hours of play, AlphaZero revives the original impulse of chess — go for mate.

Oliver Roeder, "Chess’s New Best Player Is A Fearless, Swashbuckling Algorithm"
https://fivethirtyeight.com/features/chesss-new-best-player-is-a-fearless-swashbuckling-algorithm/


Tuesday, January 2, 2018

Cognitive decline, plus shot gun.

You may know Charlie Pierce through his hi-test sports banter with Bill Littlefield on NPR's, "Only A Game." Pierce also happens to be author of five books, among them "Hard to Forget: An Alzheimer’s Story" (2000), which recounts the impact Alzheimer’s had on his father, his uncles and through them his whole family. Pierce brings his personal experience with Alzheimer’s and his research on the subject to bear in his cautionary take on the 12/28/17 interview President Trump gave to the NY Times.

Here are some excerpts from Pierce's commentary:

In my view, the interview is a clinical study of a man in severe cognitive decline, if not the early stages of outright dementia.

Over the past 30 years, I’ve seen my father and all of his siblings slide into the shadows and fog of Alzheimer’s Disease. (The president's father developed Alzheimer's in his 80s.) In 1984, Ronald Reagan debated Walter Mondale in Louisville and plainly had no idea where he was. (If someone on the panel had asked him, he’d have been stumped.) Not long afterwards, I was interviewing a prominent Alzheimer’s researcher for a book I was doing, and he said, “I saw the look on his face that I see every day in my clinic.”

In this interview, the president is only intermittently coherent. He talks in semi-sentences and is always groping for something that sounds familiar, even if it makes no sense whatsoever and even if it blatantly contradicts something he said two minutes earlier. To my ears, anyway, this is more than the president’s well-known allergy to the truth. This is a classic coping mechanism employed when language skills are coming apart. (My father used to give a thumbs up when someone asked him a question. That was one of the strategies he used to make sense of a world that was becoming quite foreign to him.)

In addition, the president exhibits the kind of stubbornness you see in patients when you try to relieve them of their car keys—or, as one social worker in rural North Carolina told me, their shotguns.

For example, a discussion on healthcare goes completely off the rails when the president suddenly recalls that there is a widely held opinion that he knows very little about the issues confronting the nation. So we get this.

But Michael, I know the details of taxes better than anybody. Better than the greatest C.P.A. . . .
This is more than simple grandiosity. This is someone fighting something happening to him that he is losing the capacity to understand.
. . .
. . .
. . .
None of exempts Trump from all sorts of political interpretations. But it would be a mistake to discount what may be the definitive contribution from neuroscience, namely that the president is in the throes of a dangerous and irreversible dementia. Who will take the car keys and the shotgun from him?


Pierce's commentary is here:

For more see: http://www.esquire.com/news-politics/politics/a14516912/donald-trump-new-york-times-michael-schmidt/


Monday, January 1, 2018

Bonus Points for Hospital Directors

Sometimes you think you're dreaming, sometimes you think it just can't be, not even in Trump's America. But you'd be wrong.

As per the NY Times, "An 81-year-old veteran hobbled into the emergency room [at the veterans hospital in Roseburg, Ore] . . . in December, malnourished and dehydrated, his skin flecked with ulcers and his ribs broken from a fall at home."

After Walter Savage waited for nine hours — nine hours — in the emergency room he was denied admission. Doctors said of course he should have been admitted, as did nurses. But director Doug Paxton overruled them. It wasn't that Savage was too healthy to merit admission; no, it was that he was too unhealthy. The hospital earns no bonus points for trying to treat the likes of Savage, and Paxton gets no bonus check.

This is not a dark episode from the Twilight Zone. It is just an example of Trump care.

Maybe this piece of reporting from the "failing" NY Times will help turn things around at the Roseburg, Ore veterans hospital. It should certainly reinforce the notion that, though this is 2018, Trump merits maximum resistance and derision as before.

  . . . 
 . . . 



NY Times 1/1/18

https://www.nytimes.com/2018/01/01/us/at-veterans-hospital-in-oregon-a-push-for-better-ratings-puts-patients-at-risk-doctors-say.html?hp&action=click&pgtype=Homepage&clickSource=image&module=second-column-region&region=top-news&WT.nav=top-news&_r=0

At Veterans Hospital in Oregon, a Push for Better Ratings Puts Patients at Risk, Doctors Say

ROSEBURG, Ore. — An 81-year-old veteran hobbled into the emergency room at the rural Veterans Affairs hospital here in December, malnourished and dehydrated, his skin flecked with ulcers and his ribs broken from a fall at home.

A doctor examining the veteran — a 20-year Air Force mechanic named Walter Savage who had been living alone — decided he was in no shape to care for himself and should be admitted to the hospital. A second doctor running the inpatient ward agreed.

But the hospital administration said no.

Though there were plenty of empty beds, records show that a nurse in charge of enforcing administration restrictions said Mr. Savage was not sick enough to qualify for admission to the hospital. He waited nine hours in the emergency room until, finally, he was sent home.

“The doctors were mad; the nurses were mad,” said Mr. Savage’s son-in-law, Mark Ridimann. “And my dad, he was mad, too. He kept saying, ‘I’ve laid my life on the line, two years in Vietnam, and this is what I get?’”

The denial appeared to be part of an attempt by members of the Roseburg Veterans Administration Medical Center to limit the number of patients it admitted to the hospital in an effort to lift its quality-of-care ratings.

Fewer patients meant fewer chances of bad outcomes and better scores for a ranking system that grades all veterans hospitals on a scale of one to five stars. In 2016, administrators began cherry-picking cases against the advice of doctors — turning away complicated patients and admitting only the lowest-risk ones in order to improve metrics, according to multiple interviews with doctors and nurses at the hospital and a review of documents.

Those metrics helped determine both the Roseburg hospital’s rating and the leadership’s bonus checks. By denying veterans care, the ratings climbed rapidly from one star to two in 2016 and the director earned a bonus of $8,120.

Current and former staff members say the practice may reach well beyond Roseburg. Recent government reports also challenge the reliability of the department’s metrics, casting doubt on a key tool that it says it relies on for reforming its beleaguered health care system.

The hospital’s director, Doug Paxton, acknowledged that being more selective had improved ratings, but denied that the hospital was turning patients away to improve scores. Tightening admissions, he said, benefited patients, not metrics, because Roseburg’s hospital lacks the resources for acute patients, so many need to be sent to larger hospitals in the community.

“The numbers are indicators of the quality of care for the veterans, so, sure, we’re worried about the numbers,” he said. “But if you improve the care to veterans, in turn your numbers are going to improve. That’s the bottom line.”

But five emergency room doctors strongly disagreed. In a letter in response to questions from The New York Times, they said they had warned about the arrangement at Roseburg, where physicians are repeatedly overruled by administrators. “When we voice concern that a process is dangerous and not good for patient care,” they wrote, “we are met with the response that ‘this is what the director wants.’”

“We cannot express strongly enough how detrimental this process has been for patient care and how unacceptable it would be anywhere else,” the letter noted.

The day after Mr. Savage was turned away, he showed up again asking for help. Again, he was denied. He waited for hours in the emergency room until a doctor finally admitted him against the wishes of the administration, his son-in-law said. The administration, ever mindful of metrics, moved him to a nursing home in less than 24 hours.

The Department of Veterans Affairs began grading hospitals about four years ago based on 110 performance indicators such as wait times, infection rates and nurse turnover at its 1,200 hospitals and clinics.

And on the surface, the scrutiny appears to have paid off. In 2016, according to the department, 82 percent of facilities improved.

Even Roseburg. For years, the hospital in this logging town, which had no intensive care unit and limited surgery facilities, has struggled with the challenges many rural hospitals face. It was hard to attract new doctors. A small staff meant that just one open position could create a pileup of delays. Doctors constantly left for higher-paying jobs outside the system.

But as more patients were sent away in recent years, Roseburg was recognized by the Department of Veterans Affairs as one of the rising stars of its health care system.

“It’s a numbers game,” Dr. Steven Blum, a doctor at the veterans hospital in Roseburg, said of the medical center’s approach. “The leadership has figured out the hospital can actually do better by seeing less patients.”

Credit

Ruth Fremson/The New York Times

However, interviews with staff at the hospital suggest that some improvements were pure manipulation. And in some cases efforts to improve the rating actually made care worse.

“It’s a numbers game. The leadership has figured out the hospital can actually do better by seeing less patients,” said Dr. Steven Blum, a hospitalist there who said he has seen patients regularly turned away or transferred to private hospitals. “These numbers show up on the director’s report card, so it is very important they look good.”

On average, more than half the hospital’s beds now sit empty, he said, while patients are either sent home or transferred to private hospitals at government expense. Costly transfers don’t come out of the Roseburg budget, but they do protect the hospital by moving risk to other facilities’ books.

For the few patients who are admitted to Roseburg, other tactics are used to further improve the ratings. The hospital is penalized when patients are hospitalized with congestive heart failure, because it counts as a sign of poor preventive care. So, doctors said, they are told to list it as hypervolemia, a condition that occurs when there is too much fluid in the blood, a diagnosis that isn’t tracked and hides the problem.

Another penalty is assessed for deaths in the hospital or within 30 days of discharge. To avoid counting these, doctors and nurses say, the administration regularly persuades veterans to be admitted only as hospice patients, signaling they are terminal and don’t want treatment. Often neither is true. Doctors said some veterans were switched to hospice without their knowledge.

“It’s extremely unethical, extremely,” Dr. Blum said. “I was asked to do it and so were the emergency department doctors. And we refused, so the administration just did it.”

The focus on improving scores overshadowed deep-seated problems, staff said, including crippling turnover in primary care doctors.

In 2015, 17 of 23 primary care doctors left, according to Laura Follett, who oversaw scheduling for Roseburg’s primary care clinic.

“Teams would have no doctors, and we’d have to just cancel appointments,” Ms. Follett said. She resigned in 2016.

Photo

Laura Follett, who oversaw scheduling for Roseburg’s primary care clinic, at home in Springfield, Ore., this month. She resigned in 2016.

Dangerous gaps appeared when doctors ordering critical tests were no longer around to review the results and alert patients. Several nurses said they saw positive cancer screening alerts and other critical lab results languish for weeks or even months.

“Alerts go into Neverland,” said Treva Moss, a nurse who works in the medical center’s specialty clinic in Eugene, Ore.

This fall, a number of employees complained to their Congressman, Peter DeFazio, who blasted the hospital management on the floor of the House of Representatives as “dysfunctional.” At his request, the department is conducting an investigation.

Roseburg’s decision to cloak deficiencies by manipulating metrics is part of a persistent problem that reaches beyond one rural hospital, said Dr. Michael Mann, a professor of surgery at the University of San Francisco who led the thoracic surgery program at the San Francisco veteran’s hospital for eight years.

Attempts to track performance in the veterans health care system have repeatedly created perverse outcomes, he said. He pointed out that the 2014 scandal exposing hidden wait times for veterans arose only after the department began tracking whether medical appointments were scheduled within 14 days, and veterans hospitals across the country that could not meet the goal began keeping off-the-books lists to hide actual wait times.

During Dr. Mann’s tenure, the veterans department began ranking hospitals on surgical complications. Remarkably, complications across the nationwide system dropped steadily, decreasing 47 percent between 1997 and 2007.

“Of course quality had not really improved by that much,” Dr. Mann said. “People had just learned to make it appear that it had.”

Many hospitals simply stopped performing surgeries on high-risk patients, or cut high risk procedures all together, Dr. Mann said. “I’m very ashamed. I colluded. I was told not to operate and pulled back, and at least one of my patients died because of it.”

The vast health care system has little choice but to rely on metrics, said David J. Shulkin, the veterans affairs secretary.

“Without it we’re like an airport with no air traffic control,” he said in an interview. “We don’t know where our hospitals are, we don’t know where they are headed. All we can do is respond to the crashes. I’d rather be able to look ahead and prevent them.”

The department regularly audits hospitals, he said. But the Government Accountability Office raised doubts in a report this fall noting in many cases the data seems inaccurate but the central office “has not determined the extent to which these problems exist.”

In 2014, when Mr. Paxton took over Roseburg, he vowed to turnaround a hospital that had long ranked one of the worst in the system. He added staff, tried to cut inefficiencies, and tapped his new chief of mental health, a social worker by training named Paul Beiring, to figure out how to improve metrics.

In an interview, Mr. Beiring said focusing on hospital admissions was strategic because it accounted for a big slice of the rating.

“It is weighted really high, so we knew we had to optimize that measure,” he said.

The medical center created an “exclusion list” of conditions deemed too severe for Roseburg and put in place a “utilization management team” of administrators to approve hospital admissions using a risk analysis score.

Doctors were required to call an off-site nurse to ask permission to admit a patient. Patients who had a high risk of death — usually because of advanced age — were routinely transferred to other hospitals or sent home. Even low-risk patients that Roseburg could easily have cared for, such as people with pneumonia, were denied, doctors said.

In a statement, the Department of Veterans Affairs said Roseburg was not manipulating data, adding: “All admission decisions are based on the hospital’s ability to provide the care patients require and are made by clinicians, including the facility chief of staff and her clinical chiefs of service — nonclinical administrators have nothing to do with these decisions.”

The hospital has no plans to change its admitting practices. In November, Roseburg was demoted to one star, because of what Mr. Beiring called “a death or two” but he said it was a temporary setback and the hospital had already “deployed counter measures” that would soon send its ratings up again.

One of those measures, doctors said, appears to be that admissions have become ever more strict.