The real trolley problem

If you read intellectualoid blogs enough, eventually you come across the trolley problem. This purports to be some kind of psychophilosophical conundrum about "double effects". You know the one: hurtling trolley about to kill five people. Pull the switch and save them: yay! Uh oh, instead, you have to push an avoirdupois-challenged man in front of the trolley to save the other five: boo! Or, actually, I guess, “yay/boo” (it’s meant to be engage contradictory decision circuits simultaneously).

Aside from the dubious notion that you would actually be able to push an individual big enough to stop a trolley with his sheer bulk if he didn’t want to be pushed, no matter what claims this problem makes for itself, it is actually nothing but a gigantic piece of crypto anti-trolley propaganda.

Because what does it say? Trolleys kill people! They hurtle out of control and smash people into strawberry jam. In some versions of the problem they kill small children. It doesn’t matter how sophisticated your moral reasoning, somebody dies horribly. Was this example funded by GM, Standard Oil, and Firestone?

Trolleys may or may not be a carbon-correct solution to regional transportation problems. But we need to decide this issue on the merits, not based on the sly well poisoning of so-called “philosophers”.

Who makes healthcare expensive?

In the June 1, 2009 issue of The New Yorker, Atul Gawande has one of his usual fine articles about physicians and healthcare, this one about the influence of physicians on healthcare costs.  McAllen, Texas has extremely high costs.  El Paso (in the same state, though some hundreds of miles away) has relatively low costs.  Physicians in McAllen order more tests and order more procedures.

And the higher costs translate, not into better outcomes, but into similar or slightly worse outcomes.  After all, every procedure and every hospital stay increase risk.  I think it's worth some effort to stay out the hospital.  It's Dr. Stork vs. Dr. Log.

The Dartmouth Atlas has been studying this issue for years.  Different areas have wildly different utilizations for various procedures.  With utilization comes higher cost.

Gawande points out that neither single payer or consumer-based models are likely to save us.  I agree that making someone pay a higher percentage of the cost of their emergency cardiac bypass isn't going to affect things at all, though do think a louder consumer cost signal has appeal.

But the real issue here is culture.  Each area has its own physician culture.  Physicians seem arrogant to the rest of us, but between themselves they are intensely conformist.  The seek approval constantly.  After all, think of those premeds at school.  These are people who always want an A, and the way to get the A is the give the right answer.  Like many complex professions, there is an extended time of apprenticeship, where they learn not only the business, but the culture and expectations.  One doctor trains another.

There's also a lot of habit involved.  Referral patterns tend not to vary.  A solution used once will be used again.  Drug company reps have always taken advantage of this.  A drug prescribed once will tend to be prescribed by default for that condition.  The day is just too busy, and the problems too various and complex, for a reevaluation of all the basic facts every time.

Note:  this is not all doctors, and not all of the time.  But we all tend to underestimate the power of our situation in our decision-making.  Culture and habit are incredibly powerful.  Changing a place like McAllen is not just a matter of changing some regulations.  It means changing a culture.  That can be quite a job.

More Civil War street names

Not far from my house is the site of Camp Cameron, where annual musters were held before the Civil War.  It was then an actual camp, for new recruits, until neighbors complained about how rowdy the young troops were, and they were moved elsewhere.  The land, straddling Cambridge and Somerville, was developed in the 1880s.

The short little streets there have names from the Seven Days Battles of the Peninsular Campaign:  Malvern, Glendale, Seven Pines, and Fair Oaks*.  Never mind that Seven Pines and Fair Oaks are two names for the same battle.  I like to think that these were names the soldiers gave to roads between lines of tents, which hung around until houses were built there, but another street is named Yorktown, which is a developer-type name, used for high schools, shopping centers, etc.

History is important to developers.  An attractive conversion of factory buildings to condos on the other side of Cameron Avenue is on a street proudly named Tannery Brook.  In the actual age of tanneries (and there were a lot around here--I live in what was the low-rent, swampy, smelly, Irish and French-Canadian area of town) that would not have been a selling point.

Bloody battles and smelly industrial operations become charming if seen from far enough away.

*I get this wrong all the time:  Seven Pines/Fair Oaks was part of the overall campaign, but not part of the Seven Days Battles.  My apologies to the real buffs.

6 reasons you should donate blood, not money

I don't like getting stuck with needles, but I still give blood.  I did yesterday, in a church basement near work.

I love giving blood because, aside from not costing me any money, it is incredibly efficient.  Money donations are often completely wasted, or used for some purpose other than you intend, or are used in some ineffective way.  Blood is different.

1. Blood isn't fungible.  That is, it can really only be used for putting into someone else's body and not for any other purpose.  So you know where it's going.  I suppose someone could sell it, and thus turn it into fungible money, but I don't hear of that, not in this country.
2. Blood can't be used for fun.  Relatedly, no is tempted to go on a tear with blood.  Most people, actually, don't want the stuff around.
3. Blood can't be used to pay administrative costs.  Most charities spend huge quantities, perhaps most of the money they get, to pay salaries, marketing costs, office rents, etc. etc.
4. Blood is something people really need.  You don't have to worry that your aid is being poured into some useless dam or training course or anything else with an unknown or negative outcome.
5. Blood is something people really need.  And there isn't enough of it.  The people who need it, really need it, in an immediate and clear way.
6. You can always make more.  If you're healthy, you keep cranking out those red blood cells and plasma anyway.  In the end, it really doesn't cost you anything.

When you give money, you often have no idea of what you're giving, and who you're giving it to.  With blood, you're hitting the target.

The Red Cross has improved its processes in the past few years, but I still think they could revamp their marketing and outreach, and get their donation rates up substantially.  But that's for another time.

Clear explanations of complex things

As I've mentioned, in my day job I am a marketing director.  One of the things this means is that I fairly regularly have to learn about and understand a new product, a new service, or a new customer type.  This involves a lot of fairly unsystematic research, because the intersection between customer needs and product is hard to define.

It's always a pleasure to find someone who can explain the customers needs in some clear, easily understood way.  And, as it happens, finding someone like that is fairly rare.

Right now, I am planning to market a physical capital planning product to healthcare clients--hospitals, skilled nursing facilities, continuing care retirement communities, and others with complex buildings and physical systems.  Where their money comes from, where it goes, how they plan, what they worry about most--these are the issues I'm struggling with.

So I was happy to find a useful introductory document from The Access Project at the Harvard School of Public Health:  A Community Leader's Guide to Hospital Finance, Evaluating How a Hospital Gets and Spends Its Money, by Sarah Gunther Lane, Elizabeth Longstreth, and Victoria Nixon.  I certainly could have used this in my days at the Medicaid health plan, where various abstruse issues like Disproportionate Share Hospital or “DSH” payments were a constant conundrum.  Thank you, Lane, Longstreth, and Nixon.

Now, as it happens, this piece did not answer a single one of my questions about how healthcare facilities spend, plan, and budget for fixed equipment and building costs.  Not their fault, that's not what they were after.

So I'm still looking for a similar document about that unsexy and essential feature of hospital facilities:  the actual real estate.  Side point: you can't understand health care finance by looking only at the provision of actual care and reimbursement for it.  That's most important, certainly.  But look at jobs, and look at the value of the real estate, and some seemingly perverse decisions and practices will become, if not clear, at least somewhat less contradictory seeming.

But that's for another time.

Edge Urban -- Why I Live Where I Do

Sometimes I wonder why I live where I do.  It's crowded and expensive.  And there are no sophisticated boutiques or elegant watering holes near me.  My local bar, where I meet my friends to drink, is Joe Sent Me, half sports bar, half college hangout.  It does have a mural of Bogey and Elisha Cook Jr. on the wall (though, for a long time, I wondered if Elisha Cook Jr. was Richard Widmark, though I couldn't imagine what movie that was from).  I live in suburban Cambridge.  I have a driveway and a yard.

But I have a half hour bike ride to work.  I work in a curvy building in the Financial District building in 1873, and the bike messengers get high in the little park in front of my building, beneath an incongruously rustic statue of Robert Burns and his dog--don't ask why that is in Winthrop Square.  When the temperature gets below 10 degrees or there is ice and snow on the ground, I take the subway.

And today I drove 15 minutes to Lincoln, and went cross-country skiing through fresh snow for a couple of hours.  My favorite trail goes past Walden Pond.  That landscape is certainly not wilderness--I was in the Sawtooth Range of Idaho a few months ago, and I know the difference.  It is, instead, a humanized landscape.  You cross roads here and there, sometimes the trail goes across farm fields that have to be kept operational by severe land-use restrictions, and you're never very far from a house, but it is silent and elegant.

Some of Massachusetts, like everywhere, is thoughtless and ugly.  But a lot of it is thoughtful, and lived-in, and gives the distinct impression that there may be more to things than getting and spending.  And I like it fine.