Charles Kenney, _The Best Practice_

Posted with infant on lap, so expect interruptions.

Kenney is writing the kind of non-fiction I usually like. I liked this a little better than Halpern's _Can't Remember What I Forgot_, but not by much. The challenge, again, was why.

First, the topic. I'm always fascinated by medical policy with a muckraking element and a book about the New Quality Movement in Medicine should have satisfied that. Yet it did not.

Second, the research and presentation stance: following the experts around and asking them questions. Like Halpern, Kenney is a little too wide-eyed and accepting of what he is being told.

Third, the attitude towards the topic. I like a little snarking, but with compassion. I like an author who wants to believe, but discovers problems. Kenney doesn't see any real problems -- it's all blue skies ahead.

I already posted about how he presented as "good work" a new decision not to charge patients for being goat fucked. Yes, it is better to not charge people who have been goat-fucked. The hospitality industry has understood this for a Long, Long Time. I'm a little shocked health care is just now getting that good old time religion. But I think what bugs me the most about this book is the screwed up priorities of the people the author is describing. And he had an opportunity to know better, because he knew about Wennberg's variations work, and the followup being down out of Dartmouth.

Think of it this way. Let's say you've got 20 people about to have a medical procedure, about half of whom will die on the table, and then about half of the rest will die because the procedure couldn't successfully fix whatever was wrong, leaving you with 5 people alive at the end.

You might think, let's fix the medical error; that will save half the people. Probably not, but it would then leave that other half for us to discover whether the procedure would have saved them at different rates than the ones who didn't die of medical error (probably not, but you never know).

But what if it turned out that the procedure really shouldn't have been done on 19 of those people anyway? It was sort of a recreational, we thought it might help, theory said it might work episiotomy kind of thing. Or like an unholy amount of cardiac surgery. Then, medical errors disappear into insignificance. Maybe if you hadn't touched any of them, you'd have 9-10 people alive. Maybe if you could figure out the one person who would benefit, you could operate on those two people. If you didn't eliminate medical error, at that point, you'd probably just be swapping deaths; if you could eliminate medical error, then maybe you'd have 11 people alive. But absolutely, not doing surgery on people it won't help anyway is a Really Great Thing. [ETA: I feel suspicious of my math here. Feel free to correct.]

And this book barely touched it.

Parallel examples can be created for a lot of medication, particularly in folk in skilled nursing facilities where polypharmacy runs rampant. Sure, eliminating conflicting prescriptions is good. But not prescribing stuff that won't help on its own is even better.

Besides, people who think that hospitals should be put in charge of the health of populations are just flat out crazy. And if Berwick thinks it's a good idea to put individual doctors in charge of Learning to Improve, I don't see how he hasn't just returned to the Bad Old Days of Make Up Your Own Practice Rules.

All that aside, there's some interesting information in here about some movers and shakers in health care over the last decade-ish, pushing hard for things like Bundles (detailed procedures for things like managing central lines, surgical sites, vents, etc.), electronic medical records, rapid response teams that can be scrambled within hospitals whenever a patient starts to decline, etc. The work being done by these people is important. It should be publicized. It needs to continue.

But for all the rah rah rah'ing, I came away from this one really profoundly depressed.

ETA: I think my problem was best captured with the whole attack on the status quo (I support attacks on the status quo) based on "Don't Just Stand There". See, I agree, action must be taken to stop the madness. But a lot of the madness is action. The correct stance is, don't just do something, stand there! Look and learn. First do no harm doesn't mean, don't change from the way you were taught because the way you were taught is perfect and the new way might be bad. That's, "Change Is Bad", basic toddlerese. First do no harm is, don't do questionable procedures. Don't prescribe crap. Don't do invasive testing on asymptomatic people. Don't do so much stuff.

After the first read

Books have two lives: the first life, the first reader reading it the first time. After this life, most books die. Their deaths are many and varied, but dead is dead -- that particular copy of that particular book will never be read in its entirety ever again (if, indeed, it even got read through the first time). Book publishers have a lot of weird, semi-arcane and often hidden from the consumer ways to make sure they get paid at least once -- if it takes going remaindered, so be it. If they can't get paid at least once, they want it back so they can pulp it, because they'll be damned if they'll let someone own a book they didn't sold.

What publishers have no good way of knowing about directly is what happens to their book after it is sold. They can get a little information out of public libraries. They can maybe get some sense of what's going on in the used market, especially now that so much of it is online. They certainly have zero sense of how many times that original buyer re-reads that book, not much sense of how many of her friends she loans it out to, what happens at yard sales and so forth.

Some publishers have an inkling of what's happening to that book after it is sold once. Romance novels have more lives than proverbial cats. They're read by the original buyers, sometimes many, many times. They're passed to friends in bags, like outgrown baby clothes and collections of Playboy. Then they go to paperback exchanges ("normal" used book stores refuse to carry them), swap sites, Goodwill, etc. Romance novels are cheap the first time, and they get a crazy number of users and uses for each paperback copy. Needless to say, Harlequin is "platform agnostic" when it comes to e-books. They GET that e-books have a huge barrier to transfer. Stop that chain right in its tracks, er, so to speak. Sorry about that mixed metaphor but let me tell you a typical romance novel contains much worse prose. I know. I read a lot of them. They're very happy to sell that first, flush (as in, has enough money to buy several romance novels a month new) user e-books for less than she was paying for them _because then she won't give them to her less-flush friends, who will have to buy them elsewhere_.

Some other genres experience multiple rereads by the same person, altho few get passed around quite the way romances do. It is unsurprising to discover that, for example, Baen is willing to offer up a chunk of its backlist for free. After all, if you can hook someone on the previous entries in the series, they'll probably catch up and start buying the new ones. And they were just going to buy the earlier versions used anyway, which supports the buying habits of people who buy new, but otherwise does not benefit publishers in any particular way. By making it Really, Really Easy to catch up on a new series (or replace a copy that went missing, that you have to reread RIGHT NOW so you can figure out what you forgot that turns out to be incredibly important in understanding new developments in the series), they maximize sales of new entries -- which is basically where it's at anyway. The tendency of speculative fiction fans to hoard early entries in popular series is really a problem for publishers in this genre. Their audience for backlist is limited and distribution to the right places is hard and depends a lot on what the local reader has available in terms of used choices via market or friends or the library. But if you don't provide a way for people to catch up on the series, you can suffocate it to an early death. A very long-running series presents enormous logistical and financial problems for a publisher -- especially if the author figures out a way to jump publishers partway through (altho that is rare), potentially stranding early entries indefinitely in the no-man's-land of out-of-print but not in public domain.

I think it's very hard for anyone to figure the price of the second through nth reader of a given book. Amazon probably has about as good an idea as anyone, between selling used books and having an ungodly amount of information about the personal book buying habits of individual consumers. Amazon's interests align partly with the publisher, in that Amazon wants to collect every time a reader wants to read a new-to-them book. Amazon isn't trying to collect for each re-read by an individual (apparently SOMEONE learned from Div-X); they're greedy, but they aren't crazy. In a way, they're collecting money on sales that publishers had to give up on, when libraries established a right to lend books, when used book sales were established as legal. Depending on one's perspective, that could be a big bonus to a publisher -- people who once bought paper might buy an e-book priced between paper and hardcover, same with used buyers, and all the way downstream to the person who once bought used paperbacks, now buying e-books priced below new paper because it's been out for a while. But it is currently being seen by publishers as a huge minus: people who once bought new hardcover (even discounted hardcover), now paying $9.99. In hordes. And bragging about it to all their friends. That looks like Amazon is trying to siphon off enough from the publisher to sell their $359 gadget.

And sure. They are. I still think there's enough downstream for everyone to do okay, if not as well or even better. But I don't know. If anyone knows, it's Amazon, or maybe Harlequin. Because remember, when Harlequin authors hit it big and go to a different publisher and get their name above the title or even a hardcover, don't forget what Harlequin does: republishes their early work as a Mira paperback. With very little evidence to the unwary that it isn't just-written by the hot author of the day. Harlequin knows a lot about the reading habits of the people out there who read the most books a year, and how to intercept their dollars for things they've already sold. And sold. And loaned. And given away. And worn out. And Harlequin doesn't give a shit what your platform is. All they know is, they want to sell you their stuff on it.

down the road a piece

Recently, the remaining Republican Senator from the state I live in decided that he couldn't be commerce secretary after all. While he did not pull out the more time with family story, he did produce the head-scratching we-just-couldn't-agree-on-the-important-stuff line. Duh? I mean, Gregg's _real_ conservative. Obama's _really_ not. He's centrist, and conservatives like to say this is a small-c country, but they're wrong.

The Gregg nomination was fascinating. I was worried about the expense and difficulty taking that Senate seat away from him would involve in 2010. I had no particular doubts it would happen, and that Hodes would replace Gregg. Gregg's time has gone away, and Hodes Always Votes Correctly. But it was going to cost. With Gregg in Commerce and his replacement saying she wouldn't run in 2010 (even tho she was Republican, she's at least more like the Moderate Republican Caucus domiciled in Maine than like the idiots from NH who primarily got mercury emissions from coal burning plants right and very little else), I was happy.

With Gregg _not_ in Commerce and saying he's not even gonna run in 2010, we may actually see Hodes and Shea-Porter duke it out in the primary. Nice.

Of course, I'll be south of the border, where my vote won't count, as I'll be overwhelmingly surrounded, once again, by people voting largely the way I do.

Maybe reflect a bit on that.

While the folk from the state of Illinois are Very Worried about what happens in 2010 or 2012 if the economy doesn't turn around by then (small sample size: inferred Obama, and Nate Silver based on what he writes over at 538), I think this is a bunch of foolishness. What, we're going to try a couple years of half-assed regulation and weak stimulus, watch it not work, and then go back to optional wars, tax cutting for the rich, benefits cuts for the needy, Intelligent Design taught in schools with a side of torture? Really? I think the Sock Puppet Party is more appealing than _that_ as an alternative.

But wait! There's a third choice. Okay, not the libertarians; those are just closeted Republicans anyway. No, and I don't actually mean the Greens, either. The Progressive Caucus is the largest caucus in the legislature (or so I've heard on the TV machine). At some point, when efforts at bipartisanship have exhausted everyone's patience, I could sort of see the Progressives and the Blue Dogs duking it out for control of the party. And at that point, there will be an interesting fork in the road.

We might see the return of Reagan in some form, with the Blue Dogs uniting with the neo-John-Birchers to rejuvenate the Republican party. It has happened before -- conservative dems tilting us back to the right. But there's a chance -- at least a small one -- that instead, the Progressive Caucus could break out on its own as the Progressive Party, leaving an anemic Democratic Party in the hands of the Blue Dogs. The Democrats get stuck holding the bag for the weak-ass efforts to fix things. The Progressives get to carry the torch down the road a piece, and the Republicans fade into that dark night that holds the Whigs, the Federalists, the Know-Nothings and a whole lot of other parties.

In that world, my vote in Massachusetts would count. For a lot.

I might be wrong about Obama and bipartisanship, too. The progressives and other Democrats in the house have been a bit pissy about the president, on account of him giving so much Time and Attention to their bratty siblings in the other party, and also the Blue Dogs. After that press release describing Gregg stepping down from Commerce, the progressives might want to rethink that. When Obama spends a lot of time courting folk, those folk often wind up losing out on the deal. Perhaps only a schizophrenic would think that pattern exists, or means something. Now, anyway.

Down the road a piece, however, that pattern might start looking obvious to a lot of people.

paying your debts, without having to actually hand over the green stuff

There are a lot of Democrats From the Past who have been waiting for their party to Rise Again. The party owes them a lot, goes the theory, and the new guy should pay up. Interestingly enough, he has been offering to do so, yet his checks are not being cashed. There was the guy who ran in the 1980s on how he drove his ancient car himself to work every day at the capitol, went down with a no taxes paid on the car and driver supplied by I forget who or what. There was that governor who almost hired Monica as a favor to Bill, lost early on in the last campaign, went down over pay to play allegations. I don't think anyone will suggest the new guy owes any spot to the guy with the hair (no, not Blago, the $400 haircut guy), after the Enquirer's scoop turned out to have some basis in fact.

In some ways, it looks like the only Past Player who has collected wasn't so much a Player from the Past as someone who arose in the interim.

I think it's kind of interesting that people are all hung up on the can't-you-guys-vet question, without necessarily noticing how the Big Guy gets to nominate the people he "owes" -- without having to actually _have_ them in his cabinet. Or, for that matter, ever have to hear anyone nag at him about them ever again. If he _hadn't_ nominated them, he would never have heard the end of it. Just like if he hadn't tried the sweeten-the-deal-for-the-Republicans, he'd never have heard the end of that.

On an unrelated note, I like the girl-boy-girl-boy rotation he's doing in the Town Halls. I would have liked it even better if he _only_ took questions from women, but I'll take what I can get.