The American Scene

An ongoing review of politics and culture


The Regrettable, Fixable State of Preventive Medicine

This week's TIME Magazine has a story about how nurse practitioners—who have substantially less training than doctors, but are authorized to make many of the same treatment decisions—are growing more important due to a growing shortage of internists (that is, doctors who provide "primary" or "preventive" care—things like your annual physical):

Even without reform, experts on the health-care labor force estimate there is currently a 30% shortage in the ranks of primary-care physicians. Fewer than 10% of the 2008 graduating class of medical students opted for a career in primary care, with the rest choosing more lucrative specialities [sic]. That could pose problems if a national health-care bill is enacted. After Massachusetts enacted mandates for universal health insurance in 2006, those with new coverage quickly overwhelmed the state's supply of primary-care doctors, driving up the time patients must wait to get routine appointments. It stands to reason that primary-care doctors could be similarly overwhelmed on a national scale. . .

But there is an existing group of providers that health reformers are hoping can help fill this gap: nurse practitioners. Depending on the state in which they practice, nurse practitioners, with advanced training often including master's degrees in nursing, can often treat and diagnose patients, as well as prescribe medication. And they can do these things at a lower cost than doctors — Medicare, for example, reimburses nurse practitioners 80% of what is paid to doctors for the same services.

Nurse practitioners may be a stopgap solution, but their growing role is unfortunate. It's great that they can take their time with patients. But a doctor who takes her time will bring more training and expertise to the table, and have a better chance of catching problems early. Detection of early stage cancers, for example, often turns on subtle and eminently overlookable anomalies in patients' lab results—and often saves lives, not to mention substantial amounts of money. A doctor who is forced to see six patients an hour, or a nurse who has more time but lacks the expertise to hone in on early warning signs, is simply not as good. The obvious step is to narrow the pay and prestige gap between primary care and other specialties. Sometimes people talk about a ten percent increase in the rates paid to primary care physicians. Given how bad things currently are, however, that won't be enough. We might save money and lives with physicals that last thirty or forty minutes, rather than seven or ten, but it would take a fundamental realignment of a pay structure that currently forces primary care physicians to rush through their analyses of lab results and patient complaints. We should work backwards from the world we want—the one in which primary care does not represent a substantial opportunity cost for new doctors, relative to other specializations—and set fees to give us that world, with unhurried physicals and robust early interventions.

Admiring Bill Wasik's Writing

In today's Wall Street Journal, I review Bill Wasik's new book, And Then There's This. The book, a treatment of the mysterious cultural fads and trends that seem to crop up on the Internet with no explanation, makes lively reading. As a longtime admirer of Wasik's writing, I was not surprised. I first encountered it in Harper's, where he works, in the best article I've ever read about the financial press. Here's a flavor of that piece:

We do, happily, know what genuine business writing might resemble, because in its earliest years Luce's Fortune, for all its imperfections, achieved it. Reading the Depression-era Fortune at seventy years' remove, one is struck not by the magazine's purported progressivism--scarcely an issue would pass without some sarcastic aside about union labor--but instead by its critical distance. Although aimed at the businessman, Fortune never pretended to serve his immediate self-interest. It held industry apart as an object of analysis; and insofar as it flattered the businessman, it never did so with advice on stock picking. Eric Hodgins, a writer and editor at Fortune who himself penned one of the era's most controversial pieces of journalism, a 1934 expose of European munitions makers, put it thus:

The American businessman remained under the genuine delusion that he, unaided, had built America and was entitled to his corresponding rewards. ... [Fortune] took the view that business was indeed entitled to understanding but that the businessman would have to pay a price for it, which was fuller disclosure and franker criticism than he had been accustomed to. And it was this insistence that gained for Fortune during the 1930's the reputation of being "anti-business."

Of course Fortune was not anti-business: to the contrary, it was incredibly enthusiastic about its subject, but not in the narrow sense that dominates today. Fortune found businesses interesting in their own right, not simply as repositories of shareholder value. Luce had famously declared it "easier to turn poets into business journalists than to turn bookkeepers into writers," and his dictum was followed quite literally: by 1933 the writing staff boasted James Agee, Russell Davenport, Schuyler B. Jackson, and Archibald MacLeish. Lyrical writing was the natural extension of Fortune's interpretive, historical perspective on business.

The magazine's second issue, published in March 1930, featured the first offering from the thirty-eight-year-old MacLeish. The lead paragraph of his unsigned piece, which delved with great and exuberant detail into the "Industry of Pie," ran as follows:

On a buttress of white tile stands a battery of nickeled cylinders with neat glass gauges where the coffee bobs. Above, a steel rack spiders down the wall. On the rack are rows of circles like a frieze of coins. Each coin is approximately ten inches across, two inches through, beveled on the under edge, brown as an antiqued painting. Each weighs a rough three pounds. A knife will cut it. Three divisions will reduce it to six approximate triangles. Each triangle will emit a faint warm smell of cinnamon and nutmeg. Subdivided with a four-pronged fork, and tasted, the mouth remembers apples. Cheese consorts with it. Coffee leaves it sweet.

There is no self-interested angle at which the day's reader could have approached MacLeish's piece, except perhaps as an aficionado of pie. There is no discussion of pie stocks, or of apple futures, or of opportunities in pie work. The Industry of Pie was, to MacLeish, an inherently worthy subject, and by the time one finishes reading the piece one is compelled to agree.

They Might've Been Giants

Last night, unexpectedly, I found myself at a They Might Be Giants show in Princeton. TMBG are a band I’ve known and enjoyed since high school, when their album Flood served my circle of friends as a kind of nerd anthem. I saw them twice during those years (the late nineties) and enjoyed it; the crowd I remember from both of those shows was a mix of youngish nerds and more standard rock audience. Those shows were packed, but last night McCarter theater, the local venue, was only half full, with hardly any undergrads.

The demographics were odd—grad students and older, plus a smattering of parents with kids—leaving me to puzzle over them as I listened. The first clue came when John Flansburgh mock-boasted somewhat sheepishly that the band recently took home a grammy for best children’s album (which, indeed, they did). So they are now stars on the music-bought-for-children-by-their-parents circuit. In fact, they’d done a whole earlier midafternoon show for the bedtime-conscious set. This evening set was the big kids’ version, targeted at adults but still conscious of the kid demographic. S-E-X-X-Y was not on the set list.

The second clue came when Birdhouse in Your Soul, the signature song of the group as I first knew them, drew a muted response from the crowd. It was clear many of the people there had never heard it before. (Which is a shame. It’s sung by a night light in someone’s bedroom: “There’s a picture opposite me / of my primitive ancestry / which stood on rocky shores and kept the beaches shipwreck free”).

That’s when I realized: Even though Flood wasn’t new by the time my friends found it (having been released in 1990), it was still riding the long wave of primary popularity. By the time today’s undergrads first began listening, it had faded from view. Rather than draw in new fans by capturing the new entrants to a fixed age bracket as, say, U2 has over the years, or age with its listeners, as the typical rock band does, TMBG has done something rarer: Allow its primary audience to age and tail off, but simultaenously find a new and younger one. It’s a neat trick, and the fact that they’ve made it work is a tribute to their finesse.

Susan Boyle

I just finished watching this video from “Britain’s Got Talent” for what was either the third or fourth time in three days, and it still gives me chills. It had all three of show’s frequently snarky judges raving. Why?

The performance is a beautiful rendition of “I Dreamed a Dream” from Les Mis—at once both subtly emotive and unreservedly belted out into the audience. The singer, Susan Boyle, is a 47 year old unmarried unemployed and self-describedly never kissed villager from a village so blighted that, reportedly, the film crew that was later sent to do a followup biographical segment for the show chose to film in a neighboring village instead of Boyle’s own.

The irony is overwhelming: by singing this song about broken dreams, Boyle—whose life has apparently, up to that moment, been difficult enough to justify the lyrics as autobiography—makes her lifelong dream of success as a professional singer effectively come true. It’s extremely likely now that she’ll end up with a recording contract and a busy performance schedule.

Before she begins to sing, the judges engage in their usual repartee: How old are you? What do you want to do? They, and the audience, react skeptically, though not cruelly, when Boyle says that she wants to be a famous singer like Elaine Page. Scattered applause.

Afterward, Piers Morgan, one of the judges, says, “When you stood there, with that cheeky grin, and said ‘I want to be like Elaine Page’, everyone was laughing at you. No one is laughing now.”

It’s upsetting to see Morgan rain on Boyle’s super-bright parade. She’s just delivered a bravura performance, and he, impressed as everyone else is, responds by reminding her how low our expectations were. But in truth, the meanness, the low expectations, the expectation that Boyle, who had apparently failed in so many other respects, would make a fool of herself, contributes powerfully to the warmth and joy we feel when we are not only pleased but also surprised (shocked, even) by her success.

There’s a larger pattern here—bitterness that makes the sweet sweeter, or pleasure “spiked” with pain as the Chili Peppers put it, can at times be better than the unalloyed original. Personally, I’m taking the lesson to heart in what might seem a strange, but is for me a very rewarding way: I’m listening to whole albums again instead of songs. For albums that other people love, albums that work together as integrated wholes—OK Computer being yesterday’s example—the fact that some of the songs are less likable than others isn’t simply a regrettable price that I can now avoid thanks to effortless re-ordering of digital playlists. Instead, my dislike of some parts of a listened-through album itself somehow contributes to my enjoyment of the whole.

The Real Palin Problem

I wouldn’t (yet) question the shrewdness of the pick — it might well be brilliant politics, as Reihan explains, though we won’t know that right away.

But regardless of whether or not the pick was shrewd, it puts McCain’s and his party’s political interest squarely ahead of the national interest. As an understudy for the Presidency, she doesn’t pass the straight face test. How much occasion has Governor Palin, and before that Mayor Palin, and before that self-described hockey mom Palin, had to become familiar with the facts of, let alone develop a consistent overall approach to, foreign affairs? She may be thoughtful, she may be an accomplished manager and executive, and she may be a quick study. The decision to put her on the ticket would imply that close scrutiny confirms her to be each of these things. But how long has she spent getting ready for this? Readers, do we know how long the vetting process ran? Do we know if Palin prepared herself for this possibility even before being vetted? Given how unlikely the choice was, it seems that Palin would have had scant incentive to study up for the contingency of being made a vice-Presidential candidate.

Comparisons of life-long experience are interesting, but what most worries me is the difference in preparation between Palin and less startling choices. National political figures who have formally sought the Presidency, or even seriously considered so doing, have had to prepare. They have been extensively briefed. They have recruited and gotten to know advisors. They have thought about, and variously developed, and variously expressed, views on the wide range of subjects a President is required to confront. Even if McCain, Obama, and Biden had each literally fallen off the apple cart following the 2004 election, each has spent a substantial fraction of the last few years in serious, full-on preparation for the Presidency. Palin has not. Each of them has been poked and prodded, tested and parsed, stressed and analyzed. Palin has not.

This means that with McCain, Obama, or Biden, we can at least be confident that we have a competent potential President. With Palin, we cannot.

American Nerd: The Story of My People

That’s the title of a great new book by Ben Nugent, a Brooklyn based journalist and critic. If you’re reading this paragraph, and haven’t read the book, you should. It’s one of those rare books that lives up to its cute premise with a consistently interesting, well-executed text.

Nugent includes a well told tour of what goes on among nerds, considered as a cultural group: Science fiction fanclub meetings, video game tournaments, dungeons and dragons, and a decidedly nonstandard attachment to speaking in standard, formal English are among the highlighted traits. But we don’t just learn that these traits are common, we learn the backstory of why and how they each developed and collectively converged to yield the nerd as we know her or, more often, him.

One thread: It turns out the term, which emerged in college humor magazines at places like RPI in the mid-twentieth century, labels an idea deeply tied to the American story of immigration and assimilation: Poverty in the first generation yields a socially tone-deaf striving for material wealth. The stereotype draws on white anxieties about Jews, Asians and other new arrivals.

Another: the borderland between normalcy and autism spectrum disorders is thickly populated by nerds, who are attached to order, formality, explicitness and logic. These traits are, for whatever reason, characteristically male.

To whet your appetite, here’s a favorite paragraph:

But mostly these are not cool boys. Mostly these boys are nerds. This is not to say they have big glasses and high pants. There are some who would have been recognizable as nerds in my high school: XL heavy-metal T-shirt, slump, short, shapeless hair, unconvincing leer. But the outfit of the contemporary video-game nerd is a stab at a hip-hop ensemble. At some point in the legendary gangsta past, the baggy look alluded to the concealment of contraband, but now it’s an attempt to hide the body. It’s the adolescent equivalent of a comb-over, a look that’s designed to cover a structural problem but worsens the whole package because it’s clearly obfuscatory.

Reflections on Grand New Party

Personally, I was most interested in the policy proposals that pepper the book’s second half. But I predict that the single most influential piece of the book, over the long haul, will be the elegant answer it provides to Thomas Frank’s famous puzzlement about the behavior of Kansans.

Read the full article

The Meta-ness of "Bolt"

So one of the in-theater previews that seems to be accompanying G-rated movies at the moment is for “Bolt,” a Disney film coming out around Thanksgiving. The next paragraph is my best effort to explain its dizzying layers, but the easiest way to understand the discussion that follows is to watch the trailer, here.

The central character is Bolt, a heroic talking dog who protects a little girl from evil villains. Except, he’s not really heroic because he’s actually an actor, in a TV show inside the movie. The TV show is about a heroic dog who protects a little girl from evil villains. What Bolt doesn’t recognize is that he is an actor-dog, playing a hero-dog on a TV show, inside a movie. Only his costars (like the actress-character who plays the little girl in the TV show within the movie) know that he’s an actor.

The amount of wising up required, in order to appreciate the Bolt idea, is staggering. As a viewer, you are expected to understand that you’re watching an actor, playing a dog who “really” is an actor-dog playing a hero-dog, not that he knows it. Since the central action of the film revolves around the actor-dog’s false belief in the authenticity of his hero-dog role, you have to suspend your disbelief of the actor-dog’s implausible ignorance. Can anyone capable of that also be capable of genuine childlike wonder? I’m not sure.

If you’ve read The Tipping Point (and you have… c’mon…. admit it), you may recall a related vignette about a certain episode of Sesame Street, in which Big Bird searches for a new name. The plot of the episode was fun for adults—-Big Bird, in a moment of existential ennui, concludes that his name is oddly functional and lacking in character, and spends the rest of the episode looking for a new one. But the story was confusing to young children, who speed up their learning about the world by assuming (usually correctly) that the things they encounter have one consistent name apiece. The layering was overkill. It makes for an interesting vignette because most of us have long since forgotten what it would be like to lack layers, to view the world as a simple place where the distance between things-as-they-are and things-as-described doesn’t hold a lot of inherent interest.

From Big Bird to Bolt, it seems, we’ve come a long way. But I’m not sure I like the progression. I’m tempted to say that if a typical five-year-old is Bolt-ready, we are doing way, way too much wising up of young kids, way, way too early. My favorite book on this subject is Thomas de Zengotita’s Mediated. De Zengotita writes as if he were speaking, and the book diagnoses this layering as a serious problem—-we aren’t able to experience reality because we’re too darn busy experiencing unreality, and judging things as being unreal in particular ways. It’s as though the only conversation we can have is about layering; everything is unreal and we are constantly tied up diagnosing its unreality.

And now a confession. When I’m writing or reading about mediation, I go back and forth between thinking it’s really profound—-maybe the central observation possible about the world we live in—-and thinking that it’s a bunch of self-referential, naval-gazing nonsense. Either way, there’s a simple truth at the bottom: Exposing young kids to the vertigo of a film like Bolt is, on some level, totally nuts.

Wall-E Preview, cirica 1909

Introductory note: Hello, American Scene readers. I’m this David Robinson, not this one or this one. I work at the Center for Information Technology Policy and sometimes blog at Freedom to Tinker. With Reihan’s kind encouragement, I’ll be giving TAS a shot. Comments welcome…

To follow up on Peter’s post, with something a little different: On Friday night, I too went to see the incontrovertibly adorable new film Wall-E. I started out skeptical—the opening scenes suggested we were in for a buddy movie about the adventures of a trash compactor and cockroach—but was, like basically everyone else, won over by the anthropic charm of its computer-generated, profoundly humane robots.

Ultimately, these robots find their way to a starship containing the remainder of the human race. These people—our imagined descendants—are pampered and infantilized by a ship that takes care of them, caters to their every need, and seems to reduce their existence to hovering around in futuristic floating barcaloungers that can barely contain their uniformly morbid obesity. The ship’s inhabitants appear to direct all communication through the videophone, even when (as in an early vignette in the film) the two parties to a conversation happen to be right next to each other.

These scenes are powerfully reminiscent of The Machine Stops, a 1909 science fiction story by E. M. Forster. It describes a world where people live underground and have lost their ability to care for themselves, relying entirely on a Machine whose workings remain opaque to them but which they treat as a deity. They are obese; they communicate by videoconferencing; they have no sense of their physical surroundings; and they are generally helpless and pathetic. I would wager that some familiarity with this story was deliberately cooked into the Wall-E screenplay.

It struck me as food for thought, particularly given the beautiful new movie theater in which I happened to be watching the film: extra wide seats that made the armrest inconveniently far apart, and large in-arm holders for giant soda cups. The helpless whale-like humans on screen—constantly consuming whatever caloric treat the movie’s Wal-Mart like “Buy ‘n Large” conglomerate had to offer—seemed to be an implicit commentary on the increasing scale of actual Americans. But, as Bill pointed out afterward, the criticism was deftly tempered: by the movie’s end, we’re told that long-term acclimation to reduced gravity is the real reason for this generate state. It lets the filmmakers have their cake and eat it to: Sending an obvious signal of disapproval about our expanding national waistline, under the cover of an exploration of the second-order effects of a high tech future in outer space.