James Fallows

James Fallows is a national correspondent for The Atlantic and has written for the magazine since the late 1970s. He has reported extensively from outside the United States and once worked as President Carter's chief speechwriter. His latest book is China Airborne. More

James Fallows is based in Washington as a national correspondent for The Atlantic. He has worked for the magazine for nearly 30 years and in that time has also lived in Seattle, Berkeley, Austin, Tokyo, Kuala Lumpur, Shanghai, and Beijing. He was raised in Redlands, California, received his undergraduate degree in American history and literature from Harvard, and received a graduate degree in economics from Oxford as a Rhodes scholar. In addition to working for The Atlantic, he has spent two years as chief White House speechwriter for Jimmy Carter, two years as the editor of US News & World Report, and six months as a program designer at Microsoft. He is an instrument-rated private pilot. He is also now the chair in U.S. media at the U.S. Studies Centre at the University of Sydney, in Australia.

Fallows has been a finalist for the National Magazine Award five times and has won once; he has also won the American Book Award for nonfiction and a N.Y. Emmy award for the documentary series Doing Business in China. He was the founding chairman of the New America Foundation. His recent books Blind Into Baghdad (2006) and Postcards From Tomorrow Square (2009) are based on his writings for The Atlantic. His latest book is China Airborne. He is married to Deborah Fallows, author of the recent book Dreaming in Chinese. They have two married sons.

Fallows welcomes and frequently quotes from reader mail sent via the "Email" button below. Unless you specify otherwise, we consider any incoming mail available for possible quotation -- but not with the sender's real name unless you explicitly state that it may be used. If you are wondering why Fallows does not use a "Comments" field below his posts, please see previous explanations here and here.
  • Today's 777s-in-Peril Update: Asiana 214, MH 370

    Lawyers offer their contention of why a pilot is not to blame for one accident. A former NTSB investigator directs blame at the pilot in another.

    How a plane looks just before touchdown into a strong crosswind. This is hard. The Asiana landing at SFO should have been easy. ( YouTube )

    1) Asiana 214. If you'd like to see professional pilots landing big airplanes, under difficult circumstances, with hundreds of lives at stake, watch any 20-second portion of this video below, taken at Dusseldorf airport during a very strong crosswind. Even the first 15 seconds will give you the idea. Or the elegant maneuver by an Air Berlin crew from 1:40 to 1:55.

    What you'll see in all cases are pilots executing the familiar "crab-into-kick" procedure for crosswind landings. First the plane "crabs" -- it approaches at an angle, to keep its direction of flight aligned with the runway. Then, just as the plane is about to touch down, the pilot "kicks" the rudder to align the airplane itself with the runway. That allows the plane to land without putting impossible cross-stress loads on the landing gear.

    Some of the landings in this clip are more precise than others, and some of that variation is beyond the pilots' control, depending on last-minute gusts and shifts in wind. But all of them show the proficiency expected of professional flight crews. 

    Watch a little of that, including artful landings of Boeing 777s, and then consider the claim from Asiana airlines' lawyers, as reported yesterday in the NYT, that autopilot software was somehow to blame for the crash of an Asiana 777 at SFO last year.

    Remember that this crash -- which killed three people, injured many more, destroyed the airplane, and shut down the airport for a time -- happened on a clear day, with light winds, in what would be considered the very most benign flying conditions. Remember that according to cockpit recordings, other members of the flight crew were warning the captain that he was mis-flying the approach and letting the plane get too "low and slow." And consider that in the two decades of the 777's operation, with many hundreds of thousands of landings worldwide by the more than 1000-strong airplane fleet, there appear to have been zero reported incidents of autopilots causing the plane to land short of the runway. You can read a 777 accident/incident list here. The one other episode involving auto-throttles and landing problems, in 2008, was traced to ice that obstructed the fuel system and kept the engines from responding properly. This was not a factor for the Asiana at SFO.

    Of course we shouldn't prejudge the legal process. And if you were a lawyer for Asiana, you'd probably try to push this "the autopilot made me do it" argument too. But, c'mon.

    [For the record, I am an admirer of NYT reporter Matthew Wald, but -- as he knows -- I disagree with the implication of the lead of his story. It was this, with emphasis added:

    While the world has been fixated on the disappearance of Malaysia Airlines Flight 370, the Korean carrier involved in the crash of a different Boeing 777, the Asiana flight into San Francisco last July, raised design issues on Monday that put another question mark over the model of jetliner.

    The Asiana and Malaysia episodes have absolutely nothing in common, and from my perspective nothing in the Asiana lawyers' filing "puts another question mark" over one of the world's most widely used and best-safety-record airplanes. To me, this connection is like saying that a car-jacking put "another question mark" over a certain model of car, if that car had also experienced carburetor problems.]

    2) Malaysia 370. No theory of the plane's disappearance makes sense. But I've mentioned several times that I thought the "Chris Goodfellow scenario" required few logical leaps than most. Goodfellow, a Canadian who now lives in Florida, has hypothesized the following sequence: a sudden inflight emergency, followed by a turn back toward airports in Malaysia, followed by a still-unexplained incapacitation of the crew, and a still-unexplained flight out over the ocean.

    If you would like to see an argued-out (rather than merely speculative) version of a contrary hypothesis, check out this on Leeham News and Comment. The item is based on an interview with Greg Feith, a former NTSB investigator, who argues (a) that the wreckage might well never be found, and (b) that the most likely scenarios, in his view, involve one of the pilots deliberately bringing the plane down. Sample:

    Feith believes there will be several plausible theories that all will point to a deliberate act by someone with intimate knowledge of flying the Boeing 777, most likely one of the pilots.

    Too many deliberate actions maneuvering the airplane and turning off communications systems occurred to have any plausible mechanical failure explanation. He completely discounts theories that a fire, either in the electronics bay or involving lithium-ion batteries being transported in a cargo bay, disabled the airplane.

    He also discounts a theory that there was a depressurization that incapacitated the pilots and allowed the 777 to meander over the skies of the Gulf of Thailand, Malaysia and the Strait of Malacca before turning south 3,000 miles over the Indian Ocean before running out of fuel.

    No one knows what happened, and it's possible that we may never, or not for a very long time, get conclusive evidence one way or another. But this article is worth considering as a strong counter to the inflight-emergency view.

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  • Why the Anti-Corruption Drive in China Is So Important, and So Potentially Destabilizing

    Is the country moving from "efficient corruption" to something worse?

    Protests on Tuesday in Maoming, in Guangdong province in southern China, against a proposed new chemical plant. ( Reuters )

    Here is a crude but effective classification scheme that I have used in distinguishing different economic systems. It is between "efficient" levels of corruption in government and business, and "inefficient" corruption. 

    Through its era of fastest post-war growth, Japan was highly corrupt. Twenty years ago, authorities raided the home of the party boss Shin Kanemaru—and found gold bars and other loot worth something like $50 million. Yet in Japan, and South Korea and Taiwan and even Malaysia, the corruption was efficient. Bridges cost too much and enriched local barons, but they got built. Factories jacked up prices thanks to cartel rules, but they ran and kept people at work. Anybody who has studied the economic/political history of Chicago or Los Angeles will recognize versions of this bargain.

    On the other side were countries like Indonesia under Suharto, or the Philippines under Marcos, or North Korea under the Kims, or a lot of others you can think of, with inefficient corruption. The people who could, looted so much that there was not enough left over to keep the system running.

    Either sort of corruption has a self-reinforcing nature. When an efficient system is running smoothly, officials have a stake in its long-term survival, which allows them to keep taking their cut. Thus they steal but don't loot. But when an inefficient one is deteriorating, all involved have an incentive to grab everything in sight while the grabbing is good. 

    Through its 30-plus years of economic modernization, China has seemed to stick to efficient levels of corruption. Connected families got very rich, but most families did better than they had before.

    An increasingly important question for Xi Jinping's time in office, which bears on the even more urgent question of whether China can make progress against its environmental catastrophe, involves the levels and forms of Chinese corruption. Has it begun passing from tolerable to intolerable levels? If so, does Xi Jinping have the time, tools, or incentive to do anything about it? Will exposing high-level malfeasancelike the astonishing recent case of Zhou Yongkang, who appears to have taken more than $14 billion while he held powerful petroleum and internal-security rolesencourage the public? Or instead sour and shock them about how bad the problem really is? Is it even possible to run a government and command a party while simultaneously threatening the system that most current power-holders have relied on for power and wealth?

    These are yet another set of Big Questions for and about China. Recent useful readings on the theme:

    1) Timothy Garton Ash on "China's Gamble of the Century." Thirty-plus years ago, Deng Xiaoping tightened up politically but overall did so toward the end of enacting economic reforms. Xi Jinping is tightening up politically. This piece examines the possible ends.

    2) The views of former President Jiang Zemin on the same topic, as reported by Jamil Anderlini and Simon Rabinovitch in the FT and as shown by the headline below:

    3) A big piece by Jonathan Ansfield on the front page of the NYT on Tuesday, about the drive against high-level corruption inside the People's Liberation Army, which itself is far more impressive as a business empire than as a fighting force. This is a detailed and enlightening story on an effort whose success or failure will be important in a variety of ways. As the story puts it:

    [Xi's] goal, military analysts said, is to transform a service larded with pet projects and patronage networks into a leaner fighting force more adept at projecting power abroad and buttressing party rule at home, while strengthening his own authority over the army.

     4) An op-ed in the WSJ by Desmond Tutu and Jared Genser about the ongoing struggles not simply of Liu Xiaobo, who won the Nobel Peace Prize in 2010 while serving a long prison term for "subversion," but also of his wife Liu Xia (below). Even as her health deteriorates, she too remains effectively imprisoned under a form of house arrest. E.g.:

    Despite living in the middle of one of the busiest and most populous cities in the world, Liu Xia, a poet and a painter, is cut off and alone. Chinese security officials sit outside her front door and at the entrance to her apartment building.

    Liu Xia, with photo of herself and her husband in better times. AP via WSJ

    5) An essay by Perry Link in the NYRB called "China After Tiananmen: Money, Yes; Ideas, No." Sample:

    At a deeper level, though, Chinese people (like any) do not feel secure in a system built on lies. The wealthy send their money abroad—and their children, too, for education. In 2013 several surveys and reports showed sharp increases in the plans of whole families, especially among the wealthy, to emigrate, and there is no reason to think that poorer people would not follow this trend if they had the means.

    6) Reports like this one from Reuters on the ongoing protests in China against environmental hazards and despoliation. Christina Larson also has a (paywalled) article in Science about farmland in China rendered unusable by pollutants, especially heavy metals.

    For now I am not trying to weave these into a larger prospects-for-China assessment. (I did attempt something like that in the second half of China Airborne.) But individually and as a group, items like these suggest the scale, complexity, and importance of the changes the Chinese leadership must undertake.

    Exposing corruption without delegitimizing the very system that still runs the country; changing the military without alienating it; controlling disastrous pollution without too noticeably slowing the economy; allowing the growth of civil society quickly enough to satisfy the public but gradually enough not to frighten the party—the obligation to do all these things at once, and more, and fast—makes the challenges for European or U.S. leaders look like easy tasks. 

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  • A High School That Teaches Students to Fly, and Other Innovations in 'Career Technical' Education

    "A lot of problem-solving skills grow out of the experience of doing things rather than thinking about things."

    Head coach and players from the Davis Aerospace Technical High School in Detroit. They lost this game by 36 points, but "the Aviators always play with heart." ( Facebook photo )
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    Background: this story on Camden County High School, in Georgia, and its "career technical" academies, followed by this from readers; plus Deb Fallows on an elementary school for engineers, in South Carolina; and John Tierney on the Maine Marine Academy and related aspects of "vocational" education. Now more from readers:

    1) "Vocational ed is 'discriminatory.'"  From a reader in New York City:

    My late husband was for 36 years a teacher of physics at [a public high school in NYC]. According to him, vocational ed has been considered by the "educational establishment" to mean minority education, and thus is objected to by these high-minded folks. In other words, vocational ed is "discriminatory."

    Thus in NYS it has been phased out, and, in its place, all students are required to take, e.g., four years of science in order to graduate. Since most of them cannot handle physics or chemistry, the standards have been dumbed down in order to get a passing rate.

    From a society that has traditionally prided itself on "equality," we have become worse than Europeans about class differences....

    So, yes, vocational ed is a good idea, and I notice in NYC that some high schools are offering "career" alternatives, thus avoiding the stigma of the phrase "vocational ed."

    2) Learning comes from doing things, as much as thinking about things. From a reader in Pennsylvania:

    Thank you for your follow-up post about Camden County High School. It was more impressive than this article in Slate, which combines support for alternatives to college with the elitist assumption that the trades are mostly for below average students:

    My grandfather, who trained workers during World War II for the war effort (including, I think, teaching some women to be machinists), complained about the prejudices of his fellow educators, who thought all bright students should go to college. He said the trades needed smart people. CCHS sounds like a model he would have approved of.

    I certainly approve. I think education in hands-on work should begin in middle school with skills for daily living, including cooking, parenting and child development, sewing, wood shop, nutrition, sewing, gardening, personal finance, small gas engine maintenance and repair, house and apartment maintenance, art and music courses, basic auto maintenance, and health. Students should come out of middle school ready to tackle algebra and more advanced science classes and be pursuing a combination of academic preparation and hands-on study, but they should have learned enough life skills to feel they could cope.

    A lot of problem-solving skills grow out of the experience of doing things rather than thinking about things. I'm convinced some of the students [the Slate author] is so dismissive about could find strengths if exposed to a wide range of skill-building classes in middle school, when students have a lot of energy, want to become more independent, and are wondering about their futures. The students who need remediation might not need quite as much assistance in life if they have life skills to help them cope with particular academic subjects that frustrate them.

    Sure, we don't all live in Lake Wobegon. But below average shouldn't mean a student gets an inadequate education and critical trades shouldn't be filled with below average students who became plumbers or carpenters. CCHS sounds like a good educational model for the school districts where the children aren't all above average.

    3) Fewer people with military experience means fewer people with practical skills. From a reader in the Southeast:

    For many persons, vocational or technical training occurs in the military. Perhaps this accounts, partially, for the smaller number of persons with these skills, since proportionately, the number of persons with military technical training has gone down over the years.

    Best, XXXX,

    (Electronics Technician, US Navy, 1978-1984)

    4) "I wish more parents would consider their sons' and daughters' gifts and interests." From an administrator in a well-known East Coast public school system:

    Having worked in the trades for many years prior to and during attending graduate school, I know how important it is to have opportunities for people who are not “college material.” 

    I wish more parents would consider their sons’ and daughters’ gifts and interests when they help them to plan their transition from high school.  I also think that schools tend to be highly disrespectful of the intelligence, interests, and abilities of those students who are more geared toward tangible, practical work than to working with abstractions.  When I worked in the trades I met some of the brightest people I’ve known.  I also have friends who work in the trades and make much more money than I do, with a Ph.D. 

    I wish our education system would realize how very, very expensive it is for our society to continue to turn out students who are not equipped for the next step in their careers, whether that is college or work in the trades.  Young people without a viable life plan, without a source of competency and pride, are very vulnerable to all sorts of potential downward spirals.  Also, stagnant 20-somethings who end up settling into their parents’ basements don’t contribute much to the tax base, and don’t always maintain the best pro-social lifestyles. 

    Sorry for the excess verbiage here, I know I’m “preaching to the converted”.  I just don’t seem to hear a whole lot about this here in the very much status-conscious [BOS-WASH East Coast] area. It really bothers me to see so much talent and potential wasted.  I’ve seen a lot of really great kids who really didn’t get much of a shot at their dreams because of this bias.

    5) My new favorite high school. From Dexter O'Connell in Detroit:

    I work at Davis Aerospace Technical High School in Detroit. It is a Detroit public school. The most impressive aspect of the school is that there is a full, four year, aviation program that is a fully integrated part of our comprehensive curriculum. 

    Students can graduate with a pilot's license, paid for by the Detroit Public Schools. Our Flight Instructor takes students with good grades and a demonstrated interest in flight, and trains them to be pilots. This year, we will graduate three licensed pilots from our class of 40 graduating seniors. Several others will have substantial flight hours to put towards a license at a later point. 

    Additionally, we have a full Airframe and Powerplant maintenance program. Students begin in a general maintenance course in ninth grade, and then choose Airframe or Powerplant in 10th and 11th grade, to study in depth. In senior year, they can continue studying and then take the certification test. I don't know yet how many certified mechanics we'll be graduating this year, but hopefully it will be many. Students can also take an optional aviation welding class.

    This is all at a comprehensive high school, where aviation technical education is integrated into the curriculum. We also offer arts, Spanish (I'm the Spanish teacher, actually, and I've just begun work at Davis this school year) and a full slate of academic classes....

    At the end of this year, our flight instructor is retiring, and some of our maintenance staff may as well, but hopefully our school will be able to find another instructor and take off again next year. This program is a critical one which provides high-quality education to students who can use it to get well-paying jobs that can't be outsourced. 

    Here is a Detroit Public Schools video showing the school's flight instructor and  several of his students. Seriously, devote three minutes to watching this, and see if it doesn't affect your view of the innovation and commitment underway in places or systems usually written off as struggling or troubled. I found every bit of this, from students and teacher in their respective ways, touching and encouraging. 

    Davis Aerospace from Detroit Public Schools on Vimeo.

    O'Connell adds:

    Most of our students don't come to our school to learn to fly or work on airplanes. There is still a sizable minority of students who come for that (I would imagine that we are one of the few DPS schools that draws kids from the suburbs for our program) including some who commute hours in each direction. However, the majority of our students now attend because we are a DPS school with small class sizes (my largest section is 24, our largest academic class right now is only 32, many classes are in the 15-20 student range)  and a fairly good academic and disciplinary/behavioral reputation. There is little violence and there are no gangs or gang influence. 

    There is certainly more that can be done to strengthen the technical program going forward, and ensure that it's appropriately funded, equipped, and staffed. We could probably do more to attract students. A big billboard over the 94 or the 75 freeways that said "Learn To Fly A Plane For Free In High School" would probably go a long way towards making our student body more sustainable and aviation-focused.

    I do think, though, that what we do now is incredibly worthwhile for our kids, in both the aviation and the comprehensive parts of our school, and I think the blending of our dual curriculum is an important example of a possible way forward for other schools in other places.

    Finally, about the picture at the top of this item:

    Boys basketball is our only sport, and we had a school-record four wins this year! Our small student body means we usually don't stand much chance against 1000-kid comprehensive schools, but the Aviators always play with heart. 

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  • Where to Get Your Next Fix of MH370 News

    Chris Goodfellow, who has offered the so-far least-unlikely explanation of what happened, does a 90-minute Q&A.

    Evolving search areas for Malaysia Air 370. ( via VOA )

    Executive summary of what you'll find below: If you're looking for more discussion of MH370, please swap the first 90-minutes of this "Google Plus Week" (embed below) for the next 90 minutes you would spend with cable news. It features the person who came up with the at-the-moment-least-implausible explanation of what happened, and its BS/insanity quotient is practically nil, in stark contrast to the normal cable level.

    Now the details.

    Yesterday I was on CNN's Reliable Sourceswith Brian Stelter (and Poynter's Andrew Beaujon), talking about the way CNN, in particular, has decided to go wall-to-wall in covering the missing airplane. Stelter pointed out that when CNN dealt with MH370, its ratings went up; when it didn't, the ratings went down. Therefore the network had quite rationally decided to make itself into the Missing Plane Channel for the foreseeable future, much as it became the Gulf War Channel in the early 1990s, in the period that first established its worldwide role.

    I replied: I understand this business logic, which fits the reality of the modern highly diversified news ecology. If you want to find out, right now, what's up with sports, or weather, or the stock market, or political trends, you know where to go. If you want to find out about the MH370 search, you know you can go to CNN.

    But my main complaint was that CNN had been so undiscriminating in filling these hours with nutso speculation -- black holes, "radar shadow," attack on Israel -- right alongside people who kept their discussion within the realm of the plausible. It's one thing to say that almost nothing is known about what happened with the plane. It's something else to have people gas on about things with no evidence to support them and with strong common-sense obstacles to being true.

    Political analogy: no one knows who will be elected president in 2016. But if we treated electoral handicapping the way cable news has often treated MH370, we'd have panelists speculating how Megyn Kelly might do against Stephen Colbert in the crucial swing states. ("Kelly will help the Republicans with the youth vote, and women, without in any way depressing interest from their traditional base of older white men. But Colbert, who is from South Carolina, could open new possibilities...") After all, you can't prove they won't be the nominees.

    Which brings us to Chris Goodfellow. Nearly three weeks ago, when most discussion concerned hijacking or pilot criminality, he offered on Google+ a different MH370 hypothesis. In essence it was: that some mid-flight emergency (probably a fire) had broken out on the plane; that the pilots had immediately turned back toward the nearest big airport, which was on an island off Malaysia; that for some still-unknown reason they had become incapacitated or disabled; that also for unknown reasons, possibly fire that disabled their radios, they had not been able to communicate; and that the plane, on autopilot, had flown on until it either ran out of fuel or crashed for another reason.

    Soon thereafter, I wrote that this was the first hypothesis that made face-value sense to me. Maybe things didn't play out this way --  but this scenario started out with the Occam's Razor advantage of requiring fewer assumptions or suspensions of probability than others.

    An item in Slate immediately and with great certainty declared that Goodfellow's scenario could not be true. Its author, Jeff Wise, became a regular on CNN making that same point -- and meanwhile promoting the hypothesis that the plane had landed in Central Asia. Eg, "the 777 is capable of landing on small airstrips and on relatively unimproved surfaces, such as packed dirt and dry lake beds. In such a scenario, the odds are good that, unless they were murdered, the passengers remain alive." (Also here. For the record, in his original anti-Goodfellow item Wise included me among people who he thought had been taken in by Goodfellow. He knows that I disagree with him.)

    This weekend Chris Goodfellow did a Q-and-A session on the "Google Plus Week" channel on YouTube. The next time you're looking for 90 minutes' worth of discussion of what could have happened, what we know and don't, and why the plane's reported cargo of lithium ion batteries deserves attention, I'd recommend this over any comparable time with cable news.

    It could turn out that Goodfellow's view is entirely wrong, but his pattern of thinking about the puzzle is systematic and worth hearing.

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  • Electronic Medical Records: A Way to Jack up Billings, Put Patients in Control, or Both?

    "Digital records are also being aggressively used to maximize patient billings," and other imperfections on the route to a more sensible health care system.

    What we are leaving behind. ( Money and Medicine )

    Previously on this topic: my Atlantic Q&A with Dr. David Blumenthal, who supervised the Obama administration effort to move medical records into electronic form; and installments one, two, and three. Here is another round of reader responses.

    1) A new way to maximize billings. From Ronald Russell of Kenmore, Washington:

    As a member of Group Heath Cooperative in Puget Sound for over 20 years, I've seen first hand many positive aspects of computerizing patient records. Whomever you see, your records are instantly accessible- that's comforting when you land in the ER in the middle of the night.  Web access means you have access to some of those records yourself, and can communicate with your providers easily. 

    Unfortunately, I've also seen a negative aspect in how EMR's are being used that got only the slightest passing mention in this discussion, one that gets the incentives exactly backwards.  This is the reason I'm now a former GHC member. 

    Digital records are also being aggressively used to maximize patient billings. At GHC, it used to be the case that a standard office visit was a flat charge- most recently $80. Now, when your physician asks a question, responds to one of yours, and makes a note in your record, this becomes another billing code. The result is that a 15 minute office visit can easily run to several hundred dollars, perhaps just because you mention a concern or the physician asks another question.

    Every patient note entered in the digital record rings the cash register again in billing- and not in a way that anyone seems able to explain, or that physicians are aware of. The cynic in me wonders how long until they are compensated on commission, or get bonuses for entering more billing codes per visit. 

    The dollar amounts charged are often absurdly high, there is no accessible "price list" for consumers. My auto mechanic is legally required to explain his charges in advance, my health care provider never has to.

    Of course, for consumers with full coverage or copay-only plans, this would pass unnoticed, as just an accounting detial.  But for those of us with high deductibles that mean we essentially pay out of pocket for everything, this is a powerful disincentive  to discuss concerns with your doctor or interact beyond the minimum business at hand.  I don't believe this is good for patient care.  

    Fortunately, due to the ACA, I've been able to move to another insurance plan that mandates a flat charge for standard office visits, even before you meet the deductible. So perhaps that one small part of the market is working. Unfortunately, this brought up another problem with these records- ours are now locked up inside the Group Health system, and no longer accessible to me- at least, apparently, without paying for them. 

    These issues are not so much inherent problems with EMR's as they are symptoms of a broken health care system, in particular where the provider and the insurer are one and the same.  I put them out there to add to the discussion. 

    2) A way to get the doctor to look at you. In response to a previous complaint about doctors stare at their computers rather than their patients:

    [A previous reader says:] "No, at Kaiser, Northern California, they do not.  The computer is on a roll-around stand, and the doctor or nurse is facing me while using it."

    I'm in IT, and have worked at several hospitals where these stands are used, and the usual nomenclature is COW (computer on wheels, of course). I'm often reminded to be careful there are no women around when discussing the COWs in the room...

    3) Once again the VA is doing it right:

    I'm a 68 yr. old Vietnam vet (USMC) who is rated 90% 'Service Connected' disabled: hearing aids (I was in an artillery battery in Nam for 19 months); Type II Diabetes and Ischemic Heart Disease (Agent Orange exposure) and assorted other things.

    I can't praise the VA enough. Through HealtheVet I can re-order meds and have them mailed to me, same with hearing aid batteries. I can set up or cancel appointments or ask my Primary Care doc, or any of the physicians who treat me, questions and get an answer within 24 hours. I can go to ANY VA facility in the world (yes, there are VA clinics and hospitals outside the US) and they will have total access to my medical records.

    From the hell holes that VA hospitals were in the '70's, as depicted in the movie Born On The Fourth of July, they now are as good as it gets in the US. I give Bill Clinton props for the revamping he and his VA Secretary undertook that got the VA to where it is today. It may be struggling a little with the overwhelming influx from the Bush/Cheney/Rumsfeld fiascos but I have no complaints here in NYC. Semper Fi

    4) Promise from the patients' point of view:

    The use of EMR is obviously in early days, and flaws are easy to identify. My experience, however, shows the great promise of EMR to improve medical care and help patients make medical decisions.

    I have a mild case of MS, and go to [a major medical center] every year for a check-up. These include MRIs of my head every two years or so. I travel 200 miles to visit the clinic, so I want to get everything done on the same day. On MRI years, I’ll have the scan in the late morning at the imaging center that is allied with the clinic. When I see the nurse practitioner or physician’s assistant a few hours later, pictures of my brain are available in my electronic chart, and my medical professional looks at the scan with me, and explains what he or she sees. The reports of my last two scans are available to me right now on the MyChart website that [the center] makes available to its patients. And yes, my case is so boringly stable that there is no current need for me to see “the big man”.

    That’s cool, but the real power was revealed to me in 2011, when the radiologist who reviewed my scan discovered that I have a small benign brain tumor, a meningioma. I was referred to a neurosurgeon, also allied with Strong, where it was recommended that I should have my head screwed painfully into a frame so that a surgeon could aim what is essentially a killer death-ray at my brain.

    Except… when the medical professional and I looked together at the series of scans in my EMR dating back to 2002, there that pesky meningioma was, seemingly the same size as in the 2011 scan. This empowered me to turn down the surgery. I’d had that tumor for a decade or more with no ill effects. Prove to me that it’s growing, and I might consent to the surgery. A repeat scan a year later confirmed that the tumor is not growing.

    There’s one key element here, of course: all of the professionals involved are allied with the same large medical center, so communication between them is smooth and nearly instantaneous. My GP 200 miles away is not part of their system. Still, I’m very happy that I had access to a decent EMR system in this case, which helped me to make an informed decision.

    5) As long as the systems stay in touch:

    I have several chronic illnesses, and because of the specialized nature of them, I have a lot of doctors. I live in the San Francisco Bay area, and have specialists at Stanford, in San Francisco, and then my local team near home. Here’s the thing - all of these facilities have have state of the art EMR systems, but the systems don’t talk to each other.

    This means I spend a lot of my time bringing copies of records between various specialists, and communicating what one doctor said to another. As in telling my primary care  doctor “My rheumatologist is concerned that the medicine you want me to take will have an impact on my spine issue”.  Sometimes I get letters from one doctor that I have to carry to another. I keep my own records of my latest test results, culled from the various sources (included the online tools provided by some medical facilities), and bring them with me to appointments, so I can answer questions about when I last had a test, and what the results are.

    I also have a list of every medicine and treatments I have tried, and the outcomes, as new doctor often has a standard approach to the first thing they want to try. And they haven’t had time to go through all the records that were sent to them. Since the systems are designed around billing, they don’t have easy ways to extract care info, such “Show me the medicines to which this patient has had an adverse reaction”.

    Until there is a well integrated way for your doctors and their systems to communicate, coordination of care is going to be an issue. My career was in computer tech, and I know how hard it is to create interoperability standards.

    To me, yet another argument for single payer system, is that we could standardize on some basic data collection and exchange.

    6) From a Yank in Canada:

    I moved to British Columbia eight years ago from California.

    The first thing I had to get used to when I went to the doctor here was just... walking... out.  No stopping at the receptionist to deal with payment and/or insurance.  Just... walk... out.

    My clinic in California had started doing electronic records before I left, but I recall it as being kind of clunky.  Here, however it doesn't seem as clunky; it seems more integrated into the appointment.  Perhaps it is because I see young doctors (my clinic is a teaching clinic), but I think it's because the appointments are structured differently.  

    Here, the appointment starts with me sitting, fully clothed, in a chair, to the side of a desk.  The doctor sits at the desk with both me and the screen visible.  He or she asks me if anything has changed, and talk about why I came in.  Frequently, the doc will look something up on the web that is out of his/her area of expertise, and they are not shy about doing so.  (Usually not Wikipedia, something more like PubMed.)  If he/she needs to examine me, *then* I get given a gown.  

    By contrast, my recollection of appointments in the US is that they started with height/weight/blood pressure measurements by a nurse.  (This was true even when I was in my 20s and now seems like overkill.  Why did they need to take these measurements every time, when my measurements didn't budge for years at a time?)  Then the nurse would give me a gown, and I'd get undressed and sit on the exam table.  That meant that I would *start* the consultation sitting uncomfortably on the exam table.  (There often weren't even two chairs in the room; maybe there was a chair and a lower stool.)  In that configuration, it is not easy to position the computer so that the doc can see both the screen and the patient.

    Another thing that is different: I almost never fill out a form before my appointment at my regular clinic.  If I am going to a new practice (like an after-hours clinic), yes.  If I am getting some new and different procedure, yes. But they don't ask me to tell them who I am and where I live and what my insurance is and who my next of kin blah blah over and over again.  Occasionally they ask me verbally if anything has changed, and that's it.

    7) Allowing doctors to do more than just fill in the forms. From a librarian:

    One comment based on my experience, I appreciate the doctor who said the system would not let him record what he wanted to say. I think these systems should allow writing free-form notes, sketches, scanned items, etc. 

    I am a retired librarian and early in my career I worked on several of the early computer systems for recording the arrival of issues of magazines in libraries. I'm sure this is much less complex than medical records, but it is more complex than one might think. These early computer systems couldn't accommodate the creativity/inaccuracy of journal publishers and printers when there was an issue number 12 1/2, or, more often, the printer did not change the volume number in the new year until he discovered the mistake midway, so you have volume 14 for a year and a half but number 1-6 in one year were not the same as 1-6 in the next.

    In medicine, the doctor's free-form notes can express his knowledge of how complex things really are, in his best estimation at the time, or the questions he has (another issue, do you want this in a record that will be shared with the insurance company, and thus perhaps used out of context in litigation -- but if the electronic record is the only one you have, where else do you put the information?) 

    I'm all for having evidence-based guidance in medicine, but I want the doctor to be able to take all of this information and then see if I fit the profile the computer predicted. How is this going to happen if the information isn't even recorded?

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  • 'Career Technical' Education: More Middle in the Middle Class?

    Training students for jobs that are less likely to be outsourced, de-skilled, or stuck at minimum wage.

    Part of the Engineering, Architecture, and Industrial Academy at Camden County High School (James Fallows)

    Two days ago I mentioned what my wife and I had seen this month at Camden County High School, in southernmost Georgia. There all students, in addition to regular academic subjects and 20-plus AP offerings, are enrolled after freshman year in one of five "academies" emphasizing specific occupational skills. This approach used to be called "vocational ed," is now known as career technical education, and is designed to equip students, whether or not they are headed for college, with skills that will give them options and leverage for higher-paid jobs.

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    I am no one's idea of an education specialist, but from my book More Like Us onward I've tried to follow the ways American institutions equip people, or hamper them, for the endless process of reinvention and adaptation that is American economic and social life. College education is obviously valuable in its own right and, usually, as a path toward better career options. But not everyone will start or stay in college. The importance of skilled technical jobs, from machinists to construction engineers, is they're generally interesting in themselves, they're less likely to be outsourced or "de-skilled" than even some white-collar work, and they are better paid than retail or low-end service work. Everyone recognizes this when we look at, say, the successful apprenticeship programs in Germany. The news, for my wife and me, was the rise of such efforts in American schools.

    Readers weigh in on this and related points

    1) Another thing that Boomers must answer for. A reader writes:

    I think many baby boomer and younger parents in this country don't take vocational training seriously because that's not what we were steered into and the college path has now become the norm.  Too many feel that a vocational career isn't important/rewarding/prestigious.  The large majority of my high school graduating class had parents who were only high school graduates.  Earning a living was paramount and college wasn't available to them.  They pushed us into college "to be something". 

    Now we are seeing how difficult it is to find a great electrician or plumber or auto mechanic.  Luckily my husband and I finally found great ones, but only after much searching and asking neighbors for recommendations.  

    My dad was a tool and die maker.  He made parts for the space shuttle and the Verrazano Narrows Bridge, among other things, working predominantly in platinum and gold.  I regularly see want ads for people in this trade, and just recently found our local community college has expanded its curriculum to fill these positions.

    Probably the best thing about having a dad who worked with his hands was how much I learned from him.  I know my way around tools and am able to fix most things without calling for help. 

    I am not saying vocational training shouldn't include college. Higher education needs to be formulated around the requirements of society.  We need educated auto mechanics, electricians and plumbers.  

    2) The era of collars is over. A reader originally from southern Georgia writes:

    As an educator myself now--I completely agree with the [Camden County] approach.  College isn't the option for everyone--learning trades could change early gives more people a chance to thrive.

    The era of the "collars" is over.

    I wish I didn't go to school where vocational and "college prep" were segregated.

    3) Finding someone to teach what I know. James Walker, a metalsmith in southern California, writes:

    Yesterday [on Marketplace] you mentioned trade schools and I wanted to say that I believe they need to be emphasized a lot more in the school system. 

    Although I spent several years in college, I've made my living as a metalsmith, which derived from an apprenticeship I served while going to college. The area I chose in the metalsmith's world (repair, restoration, preservation of non-ferrous metals) is specialized enough that I draw work from around the country, with no advertising -- just a web site with examples of what I do. 

    I wish young people could realize that the trades and crafts are alive and well and offer many opportunities. For years I've tried to find someone to teach what I know, but I guess we live in a different world now.

    Different kinds of roofing, in the Engineering, Architecture, and Industrial Academy

    I wrote back to James Walker to get permission to name him and his company. He added, about a specific project:

    I would also like to mention a pet project of mine, Operation Rediscover, which seeks to foster a grass-roots involvement of people locating, caring for and sharing  information about bronze plaques and memorials. 

    Over the years I have often been asked to restore them, since their surface inevitably disintegrates from the weather, sunshine, pollution, etc., making them hard to read. It is a shame to see that happen, so to help deal with the problem I developed a simple process to preserve them and published it as an eBook, which people can download for free from my blog "Operation Rediscover."

     I feature stories about bronze plaques and memorials and another free eBook action plan that has specific step-by-step things people can do. A few days ago I also posted an essay/review of The Monuments Men, which has similar (though way more advanced) goals to mine.

    4) Scholarships for technical training. I got this note from Marty Stockdale of Florida, who has set up a foundation to provide scholarships for high school graduates who want to pursue further technical training.   

    I am the Founder & President of The Stockdale Foundation. Our motto is: A Bachelor's Degree may not be for everyone - Success is. 

    Each year we provide scholarships to current-year high school graduates who plan to continue their education at a vocational/technical/trade school, as well as fire academy attendees. 

    It is our sole focus and since 2009 we have awarded 14 scholarships totaling $31,200.00. 

    I called Marty Stockdale to ask if I could share his information, and about the background of his scholarship. He said that he set it up in honor of his daughter, who was ready to pursue non-college career training after she finished high school but was then killed in an accident. "There are so many young people who could do so much, with some help," he told me. He would of course be happy to hear from others interested in this cause. You can find more about his program at his site

    Map of AP scores in Georgia schools. Camden
    County (lower right) shows up better than others
    in the southern part of the state.

    5) How unusual is Camden County? Did my wife and I just happen to find the school in Georgia that had gone furthest with the "career academy" approach? I asked around yesterday, and the answer is Yes and No. 

    No, CCHS is not unique in Georgia, where many other schools have developed internal "academies" of their own. But Yes, it is unusual, in that most schools have a "Pull-Out" model, where they take students away from the main high school at certain times of day for courses at a technical center. CCHS is unusual in its "Wall-to-Wall" approach, of having everything about one large, integrated campus be built around its component academies.

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  • As the Search Goes On for the Plane That Disappeared, How Can So Many Flights Take Off and Land Safely Each Day?

    More on the details of designing for 1-in-a-billion accident rates.

    Representation of flights underway at any given moment. ( Flixxy.com )

    Earlier today, I quoted the longtime aviation writer J. Mac McClellan on the one-in-a-billion risk factor to which modern aircraft design is held. Someone familiar with such standards writes in:

    I'm a system safety engineer for a small-ish system supplier, so I'm pretty familiar with the 10^-9 standard. There are a number of issues with probabilistic risk assessment, but I think the history of the 1 in a billion standard is pretty interesting. This is an excerpt from the proposed rule change to FAA regulations regarding system design, referred to as the ARSENAL draft of 25.1309. [Excerpt begins:]

    The British Civil Airworthiness Requirements (BCAR) were the first to establish acceptable quantitative probability values for transport airplane systems.  The primary objective in establishing these guidelines was to ensure that the proliferation of critical systems would not increase the probability of a serious accident.  Historical evidence at the time indicated that the probability of a serious accident due to operational and airframe-related causes was approximately one (accident) per one million hours of flight.  Further, about 10 percent of the total accidents were attributed to failure conditions caused by the airplane’s systems. Consequently, it was determined that the probability of a serious accident from all such failure conditions should not be greater than one per 10 million flight hours, or “1 x 10 -7  per flight hour,” for a newly designed airplane.  Commensurately greater acceptable probabilities were established for less severe outcomes. 

    The difficulty with the 1 x 10 -7  per flight hour probability of a serious accident, as stipulated by the BCAR guideline, was that all the systems on the airplane must be collectively analyzed numerically before it was possible to determine whether the target had been met.   For this reason, the  (somewhat arbitrary) assumption that there would be no more than 100 failure conditions contributing to a catastrophe within any given transport category airplane type design was made. It apparently was also assumed that, by by regulating the frequency of less severe outcomes: 

     * only 'catastrophic failure conditions' would significantly contribute to the probability of catastrophe, and  

     * all contributing failure conditions could be foreseen. 

    Therefore, the targeted allowable average probability per flight hour of 1 x 10 -7  was apportioned equally among 100 catastrophic failure conditions, resulting in an allocation of not greater than 1 x 10 -9   to each.  The upper limit for the average probability per flight hour for catastrophic failure conditions became the familiar “1 x 10 -9 .”  Failure conditions having less severe effects could be relatively more likely to occur." [Excerpt ends.]   

    They basically worked backwards from the existing accident rate, made a few assumptions about contributions from complex systems and got us this number. There are a few questionable assumptions such as the number of catastrophic failure conditions. Thankfully, more goes into safety now than estimating probabilities such as human factors and common cause assessments. But it does point out that the standard was arbitrary to begin with, so changes in public perception may eventually change the standard.

    One minor correction on Mr McClellan's note. The 10^-9 standard is referred to as "extremely improbable" rather than just "improbable" and it is in terms of average probability per flight hour, not per average flight. See section 7c(1) of the arsenal draft of 25.1309 under "Probability Ranges."

    (1) Probability Ranges. 

          (i) Probable Failure Conditions are those having an Average Probability Per Flight Hour greater than of the order of 1 x 10-5 .  

          (ii) Remote Failure Conditions are those having an Average Probability Per Flight Hour of the order of 1x 10-5 or less, but greater than of the order of 1 x 10-7 . 

          (iii) Extremely Remote Failure Conditions are those having an Average Probability Per Flight Hour of the order of 1x 10-7 or less, but greater than of the order of 1 x 10-9. 

          (iv) Extremely Improbable Failure Conditions are those having an Average Probability Per Flight Hour of the order of 1x 10-9 or less. 

    I sent this to Mac McClellan, and he replies as shown below. (We added the photo, which is of a different engine failure from the one he mentions):

    Yes, the standard evolved over time and has some interesting twists. For example, passengers can be seated in a turbine engine rotor burst zone and would presumably be killed by a burst. A rotor burst energy is now treated as infinite and debris will pass through anything or anybody in the zone. However, no required crew can be located in the burst zone. The 10-9 standard doesn't necessarily apply to a passenger or passengers staying alive, but to the airplane and it's ability to reach a runway.

    Destroyed turbine engine from a Delta MD-88 with P&W engine, in 1996. (Wikipedia photo)

    Also, much of the historic data floating around is historic. Rules change constantly, and there was a big change after the DC-10 in Iowa where the center engine exploded. Douglas had installed triple hydraulic lines to the tail control surfaces but the lines were routed close together. The engine burst took out all three systems. Up to that time triplex was enough. After that triplex was only good enough when you could demonstrate that no single foreseeable event would take out all three.

    The 777 was certified under pretty current rules, as was its FBW which does meet the 10-9 through triple redundancy and several levels of computer participation. The final level is direct law where the cockpit controls command direct movement of a surface with no enhancement or protection for speed or CG [Center of Gravity] or other considerations.

    This is way more technical detail than most people will want to follow. But so much of this story, which continues to command interests, turns on precise technical details; and for those who are interested in the safety and redundant-design criteria of modern aircraft, this will be instructive.

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  • When a 1-in-a-Billion Chance of Accident May Not Seem 'Safe Enough'

    The very safety of modern air travel makes accidents both intellectually more difficult and emotionally more disturbing.

    Navy pilots fly a P-8A Poseidon during a mission to assist in search and rescue operations for MH370. (US Navy)
    As the mystery about the fate and location of MH370 continues, and as theories come and go about what might have happened, here is a note from J. Mac McClellan, long-time editor of Flying magazine, about a phenomenon I've mentioned frequently. First-world commercial air travel has become so extremely safe that when something does go wrong, figuring it out can be a huge challenge -- which heightens the mystery and, for many people, the terror of these episodes, by making them seem so random. You're sitting there grumbling about the discomforts of modern flight -- and then, for no apparent reason, your plane is the one headed into the sea. McClellan writes: 

    As you probably know the FAA standard, and pretty much the global standard, for certifying critical components and systems is one in a billion probability of failure, or 10 to the minus 9th. The FAA calls this standard "improbable."

    That means in a transport category airplane [JF note: this includes airliners] the certification standard for a failure, or combination of failures, that would prevent the airplane from successfully landing on a runway must be one in a billion flights. Not hours, flights.

    I remember that when the 777 was introduced it was such a sales success and was expected to live such a long service life that some people speculated the fleet could actually make a billion flights. Of course, you don't need to make a billion flights to draw the magic short one-in-a-billion straw. But it is something to think about. Transport flying is now so safe that the long time standard of 10 to the minus 9th may not satisfy the public.

    I'm sure you are also tired of hearing about all of the things a transponder does that it really can't. Every comment on a transponder says it reports course and speed, but we know a transponder, even a Mode S as you have and the 777 has, reports only an identification code and Mode C pressure altitude. Course and speed all must be calculated by observation by radar. I guess the media and experts have mixed up what ADS-B does with what a transponder does. [For more on transponders, here; on for ADS-B, here.]

    Also odd that the 777 FBW [fly-by-wire, or electronic system for directing the airplane's control surfaces] system has escaped almost all speculation. It was the first for Boeing. And it was failure of the pitot input that put the FBW system into "direct law." [That is, it disabled the normal automated limits on "control inputs" the pilots could give to the airplane. In "normal law," which prevails within normal flight circumstances, the autopilot impedes or buffers any control input thought to be unsafe, for instance too sharp a turn or too steep a climb at too low an airspeed.] This handed the Air France crew an airplane that the computer could no longer control while expecting the humans to quickly diagnose a problem the computers couldn't. I'm not saying FBW has anything to do with 370 but it must be on the list of considerations.

    This is not speculation, simply some basic info that I haven't seen touched on during the endless TV interviews and such.

    The sobering point here is again that the very safety of modern air travel makes these episodes both intellectually and emotionally even more difficult.

    One other aspect of the drama is the national reactions and tensions it has highlighted -- of course in Malaysia and China, also in Australia, even in Israel. Thanks to many people writing in with on-scene reports of reactions in China and Malaysia. Will sort them out and report as I can.

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  • High School in Southern Georgia: What 'Career Technical' Education Looks Like

    A school that is famous for football is notable in an entirely different way.

    Walkways over the marshland, and beneath Spanish-moss-draped trees, to Camden County High School (James Fallows)

    Earlier this month my wife and I spent about a week, in two visits, in the little town of St. Marys, Georgia, on the southernmost coast of Georgia just north of Florida and just east of the Okefenokee Swamp. It's a beautiful and historic town, which is best known either as the jumping-off point for visits to adjoining Cumberland Island National Seashore or for the enormous Kings Bay naval base, which is the East Coast home of U.S. Navy's nuclear-missile submarine fleet and which is the largest employer in the area.

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    St. Marys is known to our family for its complicated and often-troubled corporate history, which I described long ago in a book called The Water Lords and which we'll return to in upcoming posts. But it also highlights an aspect of American education which we've encountered repeatedly in our travels around the country and is well illustrated by the school shown above, Camden County High School, or CCHS from this point on.

    CCHS is the only high school in the county, drawing a total of some 2800 students from the cities of Kingsland (where it is located), St. Marys, and Woodbine plus unincorporated areas. Each year's graduating class is around 600 students. Its size gives it one advantage well-recognized in the area: it is a perennial athletic powerhouse and has won the state football championship three times in the past 10 years. It also has another advantage that I recognized from my own time as a student in a single-high-school community: it creates an enforced region-wide communal experience, across class and race, rather than the separation-by-suburb of many public schools. This part of Georgia has relatively few private or religious schools. 

    As a matter of statistics, the CCHS student body is more or less like the surrounding area: about one-quarter black, most of the rest white, and small numbers of other ethnic groups (including from Navy-related families). About 40% of the students qualify for reduced-price lunch, the main school proxy for income level, and about 60% go to post-high school training of any sort.  Each year, a small number go away to out-of-state schools, including selective ones. In 2001, only 50.5% of the school's students graduated from high school. Now that is up to 85%, a change that Rachel Baldwin, the CCHS Career Instructional specialist who showed us around, attributed mainly to the school's application of programs from the Southern Regional Education Board. CCHS has the best AP record of high schools in its part of the state.  

    That's the background. Now what struck us, which was the very practical-minded and well-supported embrace of what used to be called "vocational education," and now is called the "career technical" approach.

    Hallway sign showing stats for the six different "academies" at CCHS.

    In practice what this means is dividing a large, sprawling campus and student body into six "academies," with different emphases. One of them is the Freshman Academy, to get the new students acclimated. ("I don't know if you've seen ninth graders recently," one person there told us. "But some of them look big and old enough to be parents of some others. It's a big range, and it helps to have a special place for them.")

    The other five academies each have a "career technical" emphasis. After freshman year, all students enroll in one of the five. While they still take the normal academic-core range of subjects, they also get extensive and seemingly very-well-equipped training in the realities of jobs they might hold.

    A few examples:

    Rich Gamble, head of the CSI course at CCHS

    - In the "law and justice" curriculum, which is part of the Government and Public Service Academy, a former Navy-Kings Bay NCIS official named Rich Gamble (right) trains students in conducting mock crime investigations, and preparation for testimony in court.

    On the day we were there, he had staged a mock robbery, in which the perp grabbed a cashbox from an office, ran through the hallways, and dumped the box as he was escaping. (The students acting out the scenario wore their white CSI lab coats, so other teachers would know what they were up to.) Then Rich Gamble divided his students into three teams to investigate the crime -- making plaster casts of footprints (below), taking evidence, filing reports, preparing a case. "We emphasize a lot of writing," he said. "I give them issues where they have to defend themselves, in very few words, because courts don't like you to waste words. Some of these papers are as good as any written by NCIS."

    Plaster casts of three footprints, by three of Rich Gamble's CSI student-teams.

     In the Engineering and Industrial Technology Academy, students design and build doghouses and other structures, which they sell in the community; do welding (and compete in state and national welding competitions); run an auto-repair shop that handles county vehicles; do extensive electrical work, and other activities I'll suggest by the photos below. Wood-frame construction:

    Student-built houses.

    Inside the wood-and-electric shop:



    Auto shop:

    This same academy also includes computer-aided design and robotics programs, under the direction of Fred Mercier. The houses in the first photo are ones his students had designed and built, sitting on top of a 3D printer they use. The contraption in the second is part of the school's entry in a national robotics competition. 

    3D printer above, catapult-throwing arm for robot (with Fred Mercier) below.

    (These photos show young men, but that is happenstance of where it was feasible to take pictures. The academies are diversified by gender and race.)

    In the Health and Environmental Sciences Academy, students were preparing for certification tests by administering care to dummies -- in this case, representing nursing-home patients. 

    There is more to show, including from the other two academies: Business and Marketing, and Fine Arts. CCHS has an industrial-scale kitchen and catering facility, overseen by a former Navy chef. It has a very large auditorium, where students not only perform plays, dances, and concerts but also learn to build scenery and make costumes. I'm running out of time, and you've got the point by now.

    Here is why we found this interesting and surprising. Among the non-expert U.S. public, the conventional wisdom about today's education system is more or less this:

      - At the highest levels, it's very good, though always endangered by budget cuts and other problems;

      - At the lower ends, it's in chronic crisis, for budgetary and other reasons;

     - And overall it's not doing as much as it should to prepare students for practical jobs skills, especially for the significant group who are not going to get four-year college degrees. Sure, the Germans are great at this, with their apprenticeship programs and all. But Americans never take "voc ed" seriously.

    Career poster from CCHS hallway

    I'm not trying now to address all levels of this perception, and one high school doesn't prove a national trend. But what struck us at Camden County High was its resonance with developments we have seen elsewhere,: schooling explicitly intended to deal with the third issue, serious training for higher-value "technical" jobs. This is theme that John Tierney has previously discussed regarding schools in Maine and Vermont, and Deb Fallows about South Carolina. "Non-college" often serves as a catchall, covering everything from minimum-wage-or-worse food-service jobs, to highly skilled hands-on technical and engineering jobs that may be the next era's counterpart to the lost paradise of assembly-line jobs that paid a family-living wage in the Fifties and Sixties.

    "In the past, we've encouraged all kids to go to college, because of the idea that it made the big difference in income levels," Rachel Baldwin told me on the phone this morning. She then mentioned a recent public radio series on the origins of success, and said: "The recent evidence suggests really goes back to something like 'grit.' I think you are more likely to learn grit in one of these technical classes. The plumber who has grit may turn out to be more entrepreneurial and successful than someone with an advanced degree. Our goal has been getting students a skill and a credential that puts them above just the entry-level job, including if they're using that to pay for college."

    And oh, yes: What the weight room looks like for a state-champion football team.

    Thanks to all at Camden County High. And Rachel Baldwin has written in with a closing thought on the career-technical/traditional-academic balance:

    As a naval community, Camden County appreciates the phrase “a rising tide raises all ships.” Our AP students at CCHS thrive in Career Technical options (we have more than 20 AP course offerings), along with students who would be considered traditionally  “vocational” in the past. Our administration and faculty, believing in "all ships rise," recognize and provide strong support for both achievement at higher academic levels and meeting the new technical demands of the workplace.

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  • The Freedom and Risk of Wingsuit Flying: Sean Leary

    When a man is tired of wingsuit videos ... 

    The "exit" of a flight ( Great Book of Base )

    I mentioned last week that I was admiringly fascinated by wingsuit videos but could never imagine leaping off those cliffs myself.

    In the video below, Sean "Stanley" Leary, a very well-known figure in the field, describes the exhilaration and freedom he has found in this pursuit. "The best part -- well, there's a lot of best parts, but the first best part..." he says late in this clip.

    Sean's Freedom from Chad Copeland on Vimeo.

    What he is describing sounds dangerous, and is. Earlier this month Sean Leary was killed, at age 38, during a wingsuit flight at Zion National Park in Utah. You can read more about his story here and here.

    The video above is of course all the more poignant in light of how his deliberate embrace of risk ended. But it is also very eloquent, just on its own. For instance, compare Leary's description, during the first minute of this clip, of the "exit" or moment of leaping off and beginning flight, with what you see starting at time 1:40 in the well-known clip below.

    Or with what you see starting at time 0:15 of this terrifying one, from Italy.

    This is posted to close the loop after previous wingsuit mentions, and to note the outlook with which Leary and his colleagues approach these risks, and with great sympathies for his wife, who is now pregnant with their first child.

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  • 'Where Do You Go to Church?' The Video and Mapping Versions

    More ways of taking the measure of this vast country.

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    Last month Deb Fallows did several popular posts -- here, here, and here -- about regional variations in the question you ask someone when you've first been introduced. "Where do you work?" "Who are your people?" "How long have you lived here?" and so on.

    I mention it now for two reasons. One is to tout the wonderful video that Katherine Wells, of the Atlantic's video team, has made about answers to just this question. She phoned people from around the country and recorded their responses, building on leads from Deb's items. I find it haunting and will be surprised if you don't think it worth a look. The direct link is here, and it is embedded below.

    This video also ends with a lovely presentation on the opening question that I have used when meeting people for as long as I can remember.

    Reason two is to highlight another Esri map that John Tierney has made to illustrate a linguistic/sociological point. Earlier, Deb reported that a standard opening question in St. Louis was "Where did you go to high school?" John's map showed why the question had such resonance there. 

    In Greenville and surrounding upstate South Carolina, a standard opening question is "Where do you go to church?" This new map by John Tierney gives an idea why:  

    You can use the Plus and Minus keys to zoom in and out of the map; you can click on the Legend button to see how the color-coding matches the denomination, and you can click on any specific church to get more information about it. The background colors refer to the socio-economic "Tapestry" segmentation, so if you click on any neighborhood you'll get a popup about its social makeup. Of course there's at best a loose connection between neighborhood character and type/density of churches, since people don't necessarily attend services where they live. But the patterns are surprisingly interesting.  (This is a Greenville-specific church map, as the school one was St. Louis-specific, because of the hand-coding involved on John Tierney's part.)

    Now, a bonus third reason, which connects this to some previous posts. In my article on Greenville I mention that the surrounding county was the last one in the state, which itself was the last one in the union, to observe Martin Luther King's birthday as a holiday. Over the weekend I posted a note from Knox White, long-serving mayor of Greenville, saying that the city itself had voted for MLK long before the more-conservative county did. It turns out that there is an entire academic study of just this point. It is "Religious Interests in Community Conflict: The Case of Martin Luther King Jr Holiday in Greenville, South Carolina," by four scholars from Furman University in Greenville. It is interesting, especially about the complexities of class-based and race-based politics, and you can read it here. Thanks to John Tierney for recommending it. 

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  • Bloomberg in China: It's Not About the Terminals, It's About the Data

    Either way, there's a tension with the company's journalistic operations.

    Bloomberg Terminal ( Museum of American Finance )

    In an item yesterday about the latest Bloomberg-in-China flap, I quoted a note I'd received late last year from someone inside the company:

    Outsiders think the worst explanation for this controversy is that it's concerned about selling terminals within China. It's bigger than that. Really it's about continuing sales all around the world, if Bloomberg can't promise having the fastest inside info from China.

    Just now this note arrived, in the same vein:

    I don't work for Bloomberg.  But I do work for a competitor.

    The primary reason for the suppressing China investigating reporting is not about terminals.  It is about DATA.

    Bloomberg terminals are clunky and old, but what makes the terminals valuable is the timeliness of information and data that the terminal delivers.

    The data part is the most important asset for financial professionals that use Bloomberg terminals.

    Bloomberg is afraid of being shut out of access to economic indicators and statistics for China.  Granted this information/data as of today is unreliable and sketchy, but as China is forced to become more transparent (i.e. globalization of the yuan as a currency) it is going to have to provide more transparency on economic/financial indicators and statistics.  

    Bloomberg pulling back is not primarily because of terminal sales, although this is important,  but access to financial information.

    For the record: I've asked for on-the-record responses from Bloomberg spokespeople or officials; the one person I have heard back from said that the company declined to comment. Also, check out this ChinaFile conversation on the topic. 

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  • Jimmy Carter on Colbert

    Our 39th president, at his relaxed best

    The X-Presidents ( Comic Collector Live )

    No doubt I'm biased, but I thought our 39th president did a great job on the show last night—as did Colbert, in being mock-disrespectfully jokey right up to the limit of what is seemly with an 89-year-old former president, but not beyond.

    What I really liked about this segment, apart from seeing Carter so relaxed and quick, was the glimpse it gave of the person with enough political instinct to have become president in the first place. For example, check out Carter's little deadpan retort in the time between 1:05 and 1:15 in this first part of the interview. Or approximately 1:45 through 2:15, in which Carter explains the circumstances in which he might stop being a Baptist and join the Catholic Church. (Pre-roll ads involved.)

    [UPDATE: The embedded videos seem not to be loading. As far as we can tell, this is a problem on Comedy Central's end rather than ours. For the moment, here's the link to Part 1 of the Carter-Colbert interview.]

    While you're at it, why not watch that whole clip, and this second installment of the interview too? It includes great riffs on Carter's home-building activity for Habitat for Humanity and whether the other X-Presidents consider him the odd man out. [Update: Here is the link to interview Part 2.]

    Politicians still bearing the obligations of office, especially presidents, can be only so informal, before the "but let's be serious" part kicks in. Politicians on the rise are often trying a little too hard to show that they are hip. This is a rare instance of someone far enough past those days (though not past the sting of losing, as Carter mentions several times) to be at his relaxed best, and still in good enough mental shape to pull it off. This was an unexpectedly nice moment, by Carter also Team Colbert. 

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  • Let's Talk Electronic Medical Records (Cont.)

    "I can certainly see how, as small business owners, physicians might resist this change. But as a patient, I see the benefits to my family far outweighing the risks of that loss of independence."

    Our new issue has an interview with Dr. David Blumenthal, who was in charge of the Obama administration's effort to promote the use of electronic medical records (EMRs). We've had two previous rounds of responses from doctors, technologists, patients, and others, one and two.

    Now another round. 

    1) It's generational. Previously I quoted Dr. Creed Wait, formerly of Texas and now of Nebraska. He enumerated the practical problems the EMR requirement created for him. A reply:

    I read [those] gripes and wanted to weigh in as well.

    I am a physician and have had the privilege of training and practicing in different places across the country.  I specialize in sports medicine.  My experience with EMR is greatly different from my fellow physician.  

    Some of his complaints are valid, but it seems as though many of his issues are related to his own inadequacies utilizing or adapting to technology.  My observation has been that practitioners above the age of 40 in general have problems adapting their practice habits to new technology.  People under 40 (myself included) are already familiar with computers and can adapt more readily.  Another point to consider is that older physicians (as I assume my colleague is) will eventually retire, and current medical students and residents who will take their places already find the "paper and pen" method quaint, if not antiquated.

    2) Is money the problem, or isn't it? Another rebuttal to Dr. Wait's report:

    I wonder why he doesn't notice the self-contradiction in his complaint about the medical records mandate.

     On the one hand, he complains that small practices like his don't have the big budgets that the VA and others use to make electronic medical records work well.  

    Then he complains about the $19B that the government has paid out to physicians for adopting electronic medical records, saying that if the systems worked well (like the cotton gin) no financial "carrots" would be necessary.  But if lack of money to implement the systems is the problem, why isn't government funding to those using the systems precisely the right policy?

    3) It's all about the software companies. From a doctor on the Gulf Coast of Florida:

    I would parrot the statements of most of the physicians that you have quoted:

    - EMR degrades the quality of information transfer in medical notes.

    - EMR increases time of documentation.

    - EMR costs more than our prior system.

    I would also point out that transcriptionists are part of the disappearing middle class.

    Who wins?  EMR software companies…who I would point out market to CFOs, not physicians.

    4) The driverless vehicle, a century before Google? From a non-physician:

    Some comments:

    - In 1985 I was teaching a group of state-level bureaucrats about our brand-new IBM System/36.  One of the men sitting at the rear was a man with 30 years or so in the agency (USDA-ASCS), very assertive. Midway through the lesson (entering name and address data) he beckoned me over and said: "I don't type."  

    All of the complaints of the first doctor could be echoed in an assessment of our initial automation efforts.  We basically automated what we were doing on paper, without rethinking what we did to use the hardware better.  Took us years before we (the Washington bureaucrats and systems designers) learned better so our applications actually helped the county offices.

    - I recommend this book to the doctor: Lakwete, Angela. Inventing the Cotton Gin: Machine and Myth in Antebellum America. The truth about the cotton gin is that it took a long time (i.e. 20 years or so) to work improve Whitney's gin and change the processing of the lint cotton downstream from the ginning to the point where it represented a great advance.

     -Finally, I'm old enough to remember the transition from horses to tractor on our farm.  Though the tractor then was a reliable machine, changing over was not a simple process--dad underestimated the time and cost.

    So my point is the transition always takes longer than predicted, and usually is complex than the advocates of change  concede.  And there's always a trade-off.  My mother could remember returning from Binghamton, NY after selling their farm produce, and letting the team find their way home--the driverless-car 100 years before Google. 

    5) "I'll choose a universal (electronic) record every time." From a reader in the Midwest.

    I have some experience with EMRs—I’m a technology and healthcare writer and have written about them for many years for provider groups and insurers, and at one point, for an independent EMR lab that allowed small practices to experiment with various solutions before buying. I’m also a patient, of course, and my family here in [a major university city] sees clinicians within the University of [xx] Health System, which uses a very sophisticated EMR.

    Your coverage of this issue has been fascinating. The criticisms of physicians from smaller independent practices do have an air of intransigence (we might call it whining), but many of the concerns are valid. The benefits of an EMR for a small, independent clinical practice are likely outweighed by the costs and complexity, certainly in the near term. But for larger practices and health systems, they’re indispensible. I can’t tell you how reassuring it is as a parent to know that any doctor or specialist we see has access to my daughter’s entire clinical history. If we have to run to the ER at 2am on a Saturday, god forbid, it is immensely comforting to know that the resident examining our child has exactly the same information as her primary care physician, and has a complete picture of her medical history since the day she was born. There is no scenario I can imagine in which the alternative leads to safer or more effective care.

    But the physician who writes that “technological fixes only work in the context of appropriate institutional structures” is correct. The value we see in our local system as patients and parents is not really observed during a regular checkup or sick visit to the doctor’s office. It’s in having clinical information shared across every provider we come into contact with through the course of our lives. The minute we see a doctor outside the university system (if we go to an independent urgent care clinic, for example), those benefits begin to erode, and the larger story is a much harder sell.

    But the market and regulatory regime do seem to be addressing this. The move toward accountable care organizations (ACOs) is very much an institutional framework under which EMRs make sense and begin to add tremendous value. ACOs are geared toward Medicare beneficiaries, but the consolidation happening in the larger industry is following the same path.

    In many parts of the country, smaller practices can have their EMRs partially or entirely subsidized by the larger hospital systems with which they work. This makes sense on many levels. Hospital systems benefit by having a more consistent, universal medical record of the patients they see, while smaller practices and physician groups gain much lower barriers to adoption, as well as ongoing support and training superior to what they could sustain on their own. The downside is the loss of independence of the small practice. I can certainly see how, as small business owners, physicians might resist this change. But as a patient, I see the benefits to my family far outweighing the risks of that loss of independence.

    Consolidation introduces its own challenges, and it’s not yet clear whether the financial incentive structures (especially in consolidation outside of ACOs) will counterbalance the higher prices that can result from fewer competitors in the marketplace. But in terms of quality and safety of the care provided, I’ll choose the larger provider group that’s embraced a universal medical record for my family every time.  

    6) A solution for staring at the computer. A reader in northern California writes:

    Re: information systems in medicine, I am a Kaiser patient, and am intrigued by one small comment made by several people, that doctors must turn their backs on the patient to enter data into the computer.    

    No, at Kaiser, Northern California, they do not.  The computer is on a roll-around stand, and the doctor or nurse is facing me while using it.  Simple solution.   Perhaps there are other simple solutions for some of the complaints. 

    7) Similarly positive experience in Seattle:

    My primary care physician works out of a small non-profit clinic here. An EMR system has been in use there since soon after I my first visit about 5 years ago and my experience has been entirely positive. Examination rooms are arranged so the doctor doesn’t have to turn away from the patient while viewing the screen. Patient history is available at all three locations, to the doctor, nurse, assistant, and front desk. Other information, for example background for interpreting test results, is available promptly. There is a patient portal where doctor and patient can exchange messages such as test results. What’s not to like? 

    I have no knowledge of the system in use nor of the staff’s opinion. My doctor, nurses, and assistants have keyboarded info during a visit and it doesn’t seem to me to be too distracting. The experience described by previous correspondents on this issue is amazingly poor and I can imagine their dislike of those systems. I can’t imagine this small non-profit clinic spending a great deal on an EMR several years ago unless they expected immediate benefit. From my point of view they got it.  

    8) Finally for now, reliance on medical records as category error:

    As an IT practitioner I have been following the slow-motion and entirely predictable train wreck of EMRs for some time now, starting with Microsoft HealthVault and the ill-fated Google Health in 2007

    A timeline, with some observations: 

    - March 2008: ars technica has a decent overview of the situation. The takeaway: "many of the reasons for poor US health outcomes have much deeper structural roots related to a lack of preventative care versus emergency care, issues that are tied in to the lack of a universal healthcare system and the nature of insurance companies, that are outside the scope of medical records databases".

    - March 2010: The announcement of $20 billion in the stimulus bill for electronic health records (EHR) has started a gold rush. There's excellent coverage of the IT issues by Andy Oram on the O'Reilly Radar weblog. It elides the political question unfortunately - with single-payer many of the complexities of the IT implementations simply disappear. The problem of interoperability of competing systems vanishes, for one.

    An IEEE Spectrum article covers some of the security implications. In particular my paranoia is confirmed by Dr. Deborah Peel, who writes

    "Today our [the patient's] lab test results are disclosed to insurance companies before we even know the results. Prescriptions are data-mined by pharmacies, pharmaceutical technology vendors, hospitals and are sold to insurers, drug companies, employers and others willing to pay for the information."

    EHR will only expedite this process. I'd like to see a blunt rule in the HIT regulations that gives ownership of the medical record to the patient and his heirs and assigns. Currently the ownership is vested somewhere in the aether.

    - July 2010: the HIT has released its "meaningful use" criteria for the adoption of EHR by doctors, etc. This offers a few thousand dollars (from the stimulus package) for implementation of an EHR. As Andy Oram observes,

    "The catch is that they can't just install the electronic system, but have to demonstrate that they're using it in ways that will improve patient care, reduce costs, allow different providers to securely share data, and provide data to government researchers in order to find better ways to care for patients. That's what "meaningful use" means."

    A few thousand isn't going to do it. The costs of EHR fall upon the doctor, the benefits accrue to society and the patient. The costs are much higher than a couple of thousand, especially considering the current wholly dysfunctional state of EHR. Many EHRs have no API at all, others have incompatible ones, and so depressingly on. Single-payer with a single EHR solves all these problems at once, but because it's politically impossible, we're left with hideous technical problems.

    Trying to solve US healthcare problems with EMR/EHRs is a category mistake, like trying to take the integral of a head of cabbage.. as your midwest doctor observed, " technological fixes only work in the context of appropriate institutional structures. "

    Thanks for these; more in the queue. 

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  • Bloomberg and China, TL;DR Version

    What would Bloomberg's best reporters make of an institution that tried to stonewall its way past a controversy?

    A little while ago I put up an extended Q-and-A with Ben Richardson, the latest member of the Bloomberg news team who has resigned in protest of the company's approach to stories that might offend the leadership in China.

    I hope you read it; its main payoff are Richardson's answers to the questions, and a timeline of how this story has evolved through the past four months.

    But here is the central point: fundamental questions about Bloomberg's integrity as a news organization have been raised by its own employees over these past few months. Its responsible leaders have -- so far -- refused to say anything in detail (apart from "it's not true"), or to entertain on-the-record questions about these allegations. And one of the rare on-the-record comments, by its chairman, has seemed to confirm assumptions that Bloomberg has decided to place its journalistic operation second to its financial-terminal business.

    On All Things Considered today, David Folkenflik said that ex-mayor Michael Bloomberg had told his staff that they should think of themselves as journalists first. Great! If so, how about saying that in public, and taking questions on it?

    I think I know what Bloomberg's best reporters would make of an institution that refused to answer questions about its decisions and relied on the stonewall policy.

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