July 7, 2009

To meet the expenses of my growing family, I recently started moonlighting at a private medical practice in Queens. On Saturday mornings, I drive past Chinese takeout places and storefronts advertising cheap divorces to a white-shingled office building in a middle-class neighborhood.

I often reflect on how different this job is from my regular one, at an academic medical center on Long Island. For it forces me, again and again, to think about how much money my practice is generating.

A patient comes in with chest pains. It is hard not to order a heart-stress test when the nuclear camera is in the next room. Palpitations? Get a Holter monitor — and throw in an echocardiogram for good measure. It is not easy to ignore reimbursement when prescribing tests, especially in a practice where nearly half the revenue goes to paying overhead.

Few people believed the recent pledge by leaders of the hospital, insurance and drug and device industries to cut billions of dollars in wasteful spending. We’ve heard it before. Without fundamental changes in health financing, this promise, like the ones before it, will be impossible to fulfill. What one person calls waste, another calls income.

It is doubtful that doctors and other medical professionals would voluntarily cut their own income (even if some of it is generated by profligate spending). Most doctors I know say they are not paid enough. Their practices are like cars on a hill with the parking brake on. Looking on, you don’t realize how much force is being applied just to maintain stasis.

I recently spoke with a friend who dropped out of medical school 20 years ago to pursue investment banking. Whenever we meet, he finds a way to congratulate me on what he considers my professional calling. He often wonders whether he should have stuck with medicine. Like many expatriates, he has idealistic notions of the world he left.

At our most recent meeting, we talked about the tumult on Wall Street. Like many bankers, he was worried about the future. “It is a good time to be a doctor,” he said yet again, as I recall. “I’d love a job where I didn’t have to constantly think about money.”

I didn’t bother to disillusion him, but the reality is that most doctors today, whether in academic or private practice, constantly have to think about money. Last January, Dr. Pamela Hartzband and Dr. Jerome Groopman, physicians at Beth Israel Deaconess Medical Center in Boston, wrote in The New England Journal of Medicine that “price tags are being applied to every aspect of a doctor’s day, creating an acute awareness of costs and reimbursement.” And they added, “Today’s medical students are being inducted into a culture in which their profession is seen increasingly in financial terms.”

The rising commercialism, driven in part by increasing expenses and decreasing reimbursement, has obvious consequences for the public: ballooning costs, fraying of the traditional doctor-patient relationship. What is not so obvious is the harmful effects on doctors themselves. We were trained to think like caregivers, not businesspeople. The constant intrusion of the marketplace is creating serious and deepening anxiety in the profession.

Not long ago, a cardiology fellow who had been interviewing for jobs came to my office, clearly disillusioned. “I was naïve,” he said. “I never thought of medicine as a business. I thought we were in it to take care of patients. But I guess it is.”

I asked him how he felt about going into private practice. “I’ll be too busy vomiting for the first six months — I won’t have much time to think about it,” he replied.

Of course, there has always been a profit motive in medicine. Doctors who own their own imaging machines order more imaging tests; to take an example from my moonlighting work, a doctor who owns a scanner is seven times as likely as other doctors to refer a patient for a scan. In regions where there are more doctors, there is more per capita use of doctors’ services and testing. Supply often dictates demand.

But financial considerations have never been as prominent as they are today, probably because so many hospitals and doctors, especially in large metropolitan areas, are in financial trouble. More and more doctors are trying to sell their practices, or are negotiating with hospitals for jobs, equipment or financial aid.

At hospitals, uncompensated care is increasing as patients suffering from the economic downturn lose health insurance. Admissions and elective procedures — big moneymakers — are declining. Hospitals are cutting administrative costs, staff and services.

“More and more you’ll see people in medicine get M.B.A.’s,” a doctor told me at a seminar, in a prediction borne out in my experience. “We are in a total crisis, and I don’t know the answer.”

I must admit that part of me wants to see doctors master the business side of our profession. When I hear about executives at health companies getting tens of millions of dollars in bonuses, I am nauseated by the blatant profiteering. As a loyal member of my guild, I want to see doctors exert more control over our financial house.

And yet the consequences of this commercial consciousness are troubling. Among my colleagues I sense an emotional emptiness created by the relentless consideration of money. Most doctors went into medicine for intellectual stimulation or the desire to develop relationships with patients, not to maximize income. There is a palpable sense of grieving. We strove for so long, made so many sacrifices, and for what? In the end, for many, the job has become only that — a job.

Until I went into practice, I never had an interest in the business side of medicine. I sometimes yearn to be a resident or fellow again, discussing the intricacies of a case rather than worrying about the bottom line. “You need to learn a little of the private-practice mind-set,” a doctor friend recently advised me. “You can’t survive with your head in the clouds.”

But something fundamental is lost when doctors start thinking of medicine as a business. In their essay, Dr. Hartzband and Dr. Groopman talk about the erosion of collegiality, cooperation and teamwork when a marketplace environment takes hold in the hospital. “The balance has tipped toward market exchanges at the expense of medicine’s communal or social dimension,” they write.

How this battle plays out will determine to a great extent what medicine will look like in 20 years. This is about much more than dollars and cents. It is a battle for the soul of medicine.

Sandeep Jauhar is a cardiologist on Long Island and the author of the recent memoir “Intern: A Doctor’s Initiation.”


nucifera: 原来公主等待白马王子的降临,还真是场白日梦——科研如是说。


July 7, 2009

Scientists have long observed that women tend to be pickier than men when choosing a mate. The usual explanation is evolutionary: because women have a bigger investment in reproduction — they are the ones who have to endure pregnancy, childbirth and breast-feeding — they need to hedge their bets against selecting a dud to be the father.

In recent years, the emergence of speed dating has given psychologists, economists and political scientists new ways to test this and other hypotheses about mating. Because participants can be randomly assigned to groups and have no prior information about other participants, three-minute speed-dating sessions are about as close to a controlled experiment as researchers are likely to get.

Now, two scientists at Northwestern University have published an experiment that challenges the evolutionary hypothesis. The study by Eli J. Finkel and Paul W. Eastwick was published last month in the journal Psychological Science.The experiment looked at speed-dating sessions to determine whether men or women were choosier. The answer, it turned out, was neither. Regardless of gender, people who were instructed to approach other daters were less selective — that is, they were more likely to ask to meet later for a date.

Dr. Finkel and Mr. Eastwick write that this does not mean men were just as selective as women. But the scientists suggest that the explanation for the gap lies in social conditioning rather than evolution.

By making the first move, a person gains confidence and then finds more people attractive, the theory goes. Culturally, men are expected to approach women more often, which may boost their confidence and make them less selective. Citing what social psychologists call the scarcity principle, Mr. Eastwick and Dr. Finkel write that “individuals tend to place less value on objects or opportunities that are plentiful than those that are rare.” By contrast, they say, women are accustomed to being approached, which may make them feel more desirable and thus more selective.

Scientists have also used speed-dating experiments to examine the tendency for people to mate with people like themselves. A 2006 paper by economists at the University of Essex in England analyzed data from 3,600 male and female speed daters to see if people selected mates with similar traits, like height and education, because that is what they prefer or because they are most likely to encounter them in the dating market.

The economists, Michèle Belot and Marco Francesconi, found that men’s preferences for occupation, height and smoking had little effect on whom they asked out. Those factors also did not matter to women, but age did.

In homogeneous environments, Dr. Belot and Dr. Francesconi wrote, people are more likely to marry others like themselves, while more diverse communities are likely to produce more varied pairings.

“Mating requires meeting,” they wrote. “The pool of potential partners shapes the type of people to whom subjects propose and ultimately with whom they form long-term relationships.”

People narrow their market opportunities, the economists suggested, by selecting for height, weight and age, which tend to be proxies for socioeconomic status.

So how does a person increase the odds of crossing paths with someone who matches his or her preferences? Maybe by tapping into social networks. In “Connected: The Surprising Power of Our Social Networks and How They Shape Our Lives,” a book to be published in September, Dr. Nicholas A. Christakis of Harvard Medical School and James H. Fowler, a political scientist at the University of California, San Diego, argue that dating is not a random process.

They cite a landmark 1992 Chicago sex survey of 3,432 adults ages 18 to 59, which found that 68 percent of married people in the survey reported meeting their spouse through a friend, family member or other mutual acquaintance.

“If you are single and you know 20 people reasonably well, and if each of them knows 20 other people, and each of them knows 20 other people,” Dr. Christakis and Dr. Fowler write, “then you are connected to 8,000 people who are three degrees away. And one of them is likely to be your future spouse.”

From The New York Times
July 3, 2009

O.K., Thursday’s jobs report settles it. We’re going to need a bigger stimulus. But does the president know that?

Let’s do the math.

Since the recession began, the U.S. economy has lost 6 ½ million jobs — and as that grim employment report confirmed, it’s continuing to lose jobs at a rapid pace. Once you take into account the 100,000-plus new jobs that we need each month just to keep up with a growing population, we’re about 8 ½ million jobs in the hole.

And the deeper the hole gets, the harder it will be to dig ourselves out. The job figures weren’t the only bad news in Thursday’s report, which also showed wages stalling and possibly on the verge of outright decline. That’s a recipe for a descent into Japanese-style deflation, which is very difficult to reverse. Lost decade, anyone?

Wait — there’s more bad news: the fiscal crisis of the states. Unlike the federal government, states are required to run balanced budgets. And faced with a sharp drop in revenue, most states are preparing savage budget cuts, many of them at the expense of the most vulnerable. Aside from directly creating a great deal of misery, these cuts will depress the economy even further.

So what do we have to counter this scary prospect? We have the Obama stimulus plan, which aims to create 3 ½ million jobs by late next year. That’s much better than nothing, but it’s not remotely enough. And there doesn’t seem to be much else going on. Do you remember the administration’s plan to sharply reduce the rate of foreclosures, or its plan to get the banks lending again by taking toxic assets off their balance sheets? Neither do I.

All of this is depressingly familiar to anyone who has studied economic policy in the 1930s. Once again a Democratic president has pushed through job-creation policies that will mitigate the slump but aren’t aggressive enough to produce a full recovery. Once again much of the stimulus at the federal level is being undone by budget retrenchment at the state and local level.

So have we failed to learn from history, and are we, therefore, doomed to repeat it? Not necessarily — but it’s up to the president and his economic team to ensure that things are different this time. President Obama and his officials need to ramp up their efforts, starting with a plan to make the stimulus bigger.

Just to be clear, I’m well aware of how difficult it will be to get such a plan enacted.

There won’t be any cooperation from Republican leaders, who have settled on a strategy of total opposition, unconstrained by facts or logic. Indeed, these leaders responded to the latest job numbers by proclaiming the failure of the Obama economic plan. That’s ludicrous, of course. The administration warned from the beginning that it would be several quarters before the plan had any major positive effects. But that didn’t stop the chairman of the Republican Study Committee from issuing a statement demanding: “Where are the jobs?”

It’s also not clear whether the administration will get much help from Senate “centrists,” who partially eviscerated the original stimulus plan by demanding cuts in aid to state and local governments — aid that, as we’re now seeing, was desperately needed. I’d like to think that some of these centrists are feeling remorse, but if they are, I haven’t seen any evidence to that effect.

And as an economist, I’d add that many members of my profession are playing a distinctly unhelpful role.

It has been a rude shock to see so many economists with good reputations recycling old fallacies — like the claim that any rise in government spending automatically displaces an equal amount of private spending, even when there is mass unemployment — and lending their names to grossly exaggerated claims about the evils of short-run budget deficits. (Right now the risks associated with additional debt are much less than the risks associated with failing to give the economy adequate support.)

Also, as in the 1930s, the opponents of action are peddling scare stories about inflation even as deflation looms.

So getting another round of stimulus will be difficult. But it’s essential.

Obama administration economists understand the stakes. Indeed, just a few weeks ago, Christina Romer, the chairwoman of the Council of Economic Advisers, published an article on the “lessons of 1937” — the year that F.D.R. gave in to the deficit and inflation hawks, with disastrous consequences both for the economy and for his political agenda.

What I don’t know is whether the administration has faced up to the inadequacy of what it has done so far.

So here’s my message to the president: You need to get both your economic team and your political people working on additional stimulus, now. Because if you don’t, you’ll soon be facing your own personal 1937.

July 3, 2009

Tragically, Iran’s government appears to have driven back the most significant challenge to its repressive rule since the 1979 revolution.

First, the hard-line mullahs brazenly stole the election for the hard-line president, Mahmoud Ahmadinejad. When hundreds of thousands of Iranians protested, they sent their thugs to beat and shoot them. At least 20 people are dead, and hundreds of journalists, political activists and former government officials have been detained.

Even before the elections, Iranians — likely the majority — were fed up with Mr. Ahmadinejad. They were sick of the corruption and incompetence. They wanted more say in how they are governed and more engagement with the world, including the United States. The regime’s refusal to listen has now exposed deep fault lines in Iranian society. Even some members of the clerical elite seemed to question the thuggery.

Predictably, Mr. Ahmadinejad and his backers were eager to blame others, especially the United States. President Obama rightly has worked hard not to play into that. There is no sign that the government in Tehran is close to toppling. The opposition has not asked for outside help. They know any direct American involvement would discredit them and strengthen the regime.

The difficult challenge now for the United States and other major powers is to come up with policies that give hope to the opposition and reinforce the doubts of Iran’s political elites — without provoking a backlash. The European Union is debating whether to withdraw all of its 27 ambassadors from Tehran to protest the detention of two Iranian employees of the British Embassy. We don’t believe in permanent isolation, but that kind of unified action would send an important message.

When they meet in Italy next week, leaders of the Group of 8 leading industrial nations should issue their own clear statement that Iran has violated international norms with its bogus election and repression.

There are other approaches worth exploring. The Europeans and Americans can quietly withhold visas to selected Iranian officials — or grant them, depending on what is deemed more effective at the time. Europe and the United States should look for ways to expand contacts with Iranian academics, artists and other members of civil society and with more moderate Iranian mullahs.

The fact that Mr. Obama has offered a new relationship with Iran’s rulers could make it harder for the government to discredit such contacts. After a decent interval, the White House should take a serious look at the idea of opening an “interests section” in Tehran to allow direct contact with the Iranian people. If the government rejects the offer, it would only highlight its own insecurity.

There is no question that the events of the last few weeks have complicated Mr. Obama’s offer to negotiate with Iran. Mr. Obama’s critics are already charging that talks will legitimize Tehran’s rulers and reward them for their abuses. But the United States and its allies deal with unelected and unsavory leaders all the time.

And there are too many important issues to talk about. Tehran’s nuclear program is advancing relentlessly. The United States also has a strong interest in trying to enlist Tehran’s help in stabilizing Afghanistan — there was a time when the Iranians saw the Taliban as their enemy — and restraining Iran’s meddling and worse in Iraq.

Mr. Obama has offered improved relations based on respect. But he also warned there will be heavy costs for Iran if it doesn’t abandon its nuclear ambitions. Our concern has always been that Europe, Russia and China would not follow through with tougher sanctions if Iran made the wrong choice. The events of the last few weeks are a reminder of why that line must be held.