Archive | February, 2017

Dear New England Journal of Medicine

24 Feb

In the January 19th edition of the New England Journal of Medicine, a ludicrous article about creating a Yelp for doctors by and for the University of Utah was published on the front page of the journal.  I have severe reservations about the use of customer service metrics on complex professional relationships such as medicine.  While improved communication and compassion can and should be improved in American medicine, I feel this has been over-emphasized and avoids addressing the real structural issues of health care.  This also contributes to the narcotic epidemic as doctors are afraid of displeasing patients who are often pain-seeking.  With life expectancy falling for the first time last year, we need to think harder and smarter about this.  Below is a satire applying patient satisfaction to the practice of law.

Dear Editor:

Suppose we transferred “patient-satisfaction” ratings on to the practice of law.   Affordable access to the legal system is a matter of life, death, or imprisonment.

The Justice Department would devise a rating system for all large group practices and courthouses based on “star ratings.” Lawyers and their practices would pay Press-Ganey to administer randomized surveys to assess “client-satisfaction.”

Even though law is a diverse field with many specialties, many types of clients (who may have pre-existing criminal records), and many kinds of cases with varying evidence-based practice, client satisfaction surveys rate the ability of their lawyer based on bedside manner, promptness, and cleanliness of their office. The general public would then judge the law firms’ courtroom outcomes independent of any case-client-evidence specifics.

Would anyone buy this? Would any lawyer sit still or justify this idea in a premier law journal?  Would we decide judicial elections and presidential nominations by their satisfaction scores?  Or would we evaluate judges by the opinions of their legal colleagues and local bar associations?

I find it incredible that there are those in medicine who would justify patient satisfaction scores and evaluation systems when they have caused so much havoc in public education and the lawyers who wrote these laws would never consent to them being imposed on their own profession. No nation’s health system has improved based using such metrics, and we should not kid ourselves that such feedback systems have anything to do with the real, unseen practices of medicine.  We deserve better or at least as much as attorneys deserve.


A working physician


Issue LIX: The French Election and Mitterand’s Shadow

11 Feb

A hopeful presidential candidate wins office and ends a long period of conservative rule.  He promises a break with the past.  Disappointments rack up, he loses control of the legislature, but he manages to win a historic second term.  By the end of his rule, racist and xenophobic white nationalist organizations have started to grow in disappointed industrial areas.  His party lays broken.  Once staunchly left and unionized areas begin to shift towards the far-right.

Am I describing, dear reader, the end of two terms of Barack Obama?  No, actually this describes the situation after the disappointments of the first Socialist President of the Fifth French Republic, Francois Mitterand.  Instead of the Tea Party and the “alt-right”, we have the National Front and Jean-Marie Le Pen and his daughter Marine Le Pen blaming immigrants and castigating corrupt political insiders for the failings of the nation.  What does this year’s French presidential election tell us about what happens when the left fails in a time of economic crisis?

Dancing in the Street

When Francois Mitterand, after decades in the political wilderness, finally won the presidency the young rejoiced and danced in the streets of Paris in 1981.  He had helped found the French Socialist Party and its critical alliance with the French Communist Party.

He promised to move France beyond capitalism and beyond Swedish social democracy.  The poor, workers, and unemployed awaited the rupture with the past and for complete fulfillment of the French Revolution’s promise of liberté, egalité, and fraternité.  There would be increases in the minimum wage, nationalization of industry, decreases in the work week, and abolition of capital punishment.

By 1983, he performed a U-turn and ended the left’s promise to end capitalism.  Mounting financial difficulties and inflation led him to turn towards austerity and cutbacks in government spending and devaluations of the franc.  After a few years, disappointed voters kicked the Socialists out of the National Assembly leading Mitterand with divided government and power-sharing with the conservatives.  But like Barack Obama, he managed to win his second presidential election.

In his second term, Mitterand gave up on socialism and decided to go for creation of the euro and the European Union. Increased free trade with neighbors (“the Common Market”) and a common currency became his signature priority.  But these treaties came at a strict cost.

Euro rules prevent large deficit spending and would eliminate currency devaluations as a monetary strategy.  Common Market rules promoted capitalism, standardization of rules across the Continent, and effectively banning aid to industry.  In short, they were a straightjacket the prevented any chance of socialism or even robust Keynesianism ever occurring again in France.  He was called the gravedigger of socialism in France and the European Union.

The Rise of the National Front  

The far-right National Front began its rise in the 1980s after the disappointments of the Socialists.  Led by the former paratrooper, Jean-Marie Le Pen, it routinely began winning 10-15% of the vote.  This eye-patched anti-Semite first gained support from Algerian colonists who returned to France after Algerian independence and Vichy France-era Nazi collaborators.  After many unsuccessful years blaming immigrants for the lack of jobs and a lack of “law and order”, Jean-Marie Le Pen’s National Front gained steam while Mitterand developed consensus politics in France.  With no radical alternative on the left, disgruntled voters on the left began to vote for the National Front.

In 1995, Mitterand left office and conservative Gaullist, Jacque Chirac, won the presidency while Le Pen scored 15%.  In 2002, Jean-Marie Le Pen shocked the world by coming in 2nd at 16.86% to President Chirac’s less than 20% in the first round of the presidential election.  In the runoff, all the parties endorsed Chirac who won easily (82%) but Le Pen increased his vote to almost 18%.   After one more presidential run in 2007, he passed off the party to his daughter Marine Le Pen who has taken the party new heights.  But that too required faltering by the left and more unemployment.

The alteration of the presidency from conservative Nicholas Sarkozy (2007) to Socialist Francois Hollande (2012) has again supercharged the far-right.  The Great Recession ultimately did in Sarkozy’s presidency and the continued lack of growth in the Eurozone and terrorism has made Hollande the most unpopular President in the history of France (approval rating of 4%).  The euro, EU treaties, and German austerity policy have ruined any chance of economic stimulation occurring under any French president.  Once again, the failure of a social democratic solution (the old idea of a rupture with capitalism is off the table) has led disgruntled voters searching for jobs into the hands of the National Front.

Marine Le Pen has broken with her father and silenced the anti-Semitic element of her party.  She has pledged to re-enact the death penalty, kick out immigrants, re-issue the franc, and leave the euro.  If she wins, she pledges a vote on leaving the European Union (“Frexit”).  Marine Le Pen now polls around 25% and will likely win the first round of the 2017 presidential election.

Will the rest of the political establishment unite around the second candidate in the runoff the way they did in 2002 against her father?  Likely, but unity will not come as easy this time.  Leading candidates Francois Fillon and Emmanuel Macron pledge nothing but austerity, tax cuts, layoffs,  and more neoliberal economics.  After a year of Brexit and Donald Trump’s election victory, can we really count on Marie Le Pen losing the second round?  Out of touch neoliberal Washington and London elites have been shocked by angry, heartland voters.  Perhaps Paris is next.

Francois Mitterand, destroyer of dreams, thought he ended the chance for a radical transformation of society by creating consensus politics in France and Europe.  This year his straightjacket tears open…. but from the right.


Monocle Radio – “The French Left”
Daniel Singer – “The Resistible Rise of Jean-Marie Le Pen”