The Ash Twins Blog

From the New York Times Magazine piece on innovation in health care:

ONE DAY, WHILE I was standing in Intermountain’s cardiology intensive-care unit, which, unlike those in many other hospitals, is next to the cardiac-surgery wing, it occurred to me that Intermountain really was not so unusual. It is unusual for a health care organization. But its story is fairly typical in the rest of the economy.

The executives at a company realize that their industry has built up all kinds of bad practices over the years. Those practices damage the quality of their product and waste money. The executives do a rigorous analysis of their operations, relying on solid information rather than conventional wisdom. And then they persuade their colleagues to make changes. . .

But there is a fundamental difference between Toyota and Intermountain. As Toyota built better cars than its competition for less money, it won new customers. Some rivals matched its successes (as Honda did); some lost market share (as Detroit did). No such dynamic exists in health care. . .

Why? In part, it is the faith that patients have in their doctors. When people are buying a car, they often consult Consumer Reports or Road & Track. When they are choosing a place to have surgery, they ask their doctor to recommend a surgeon and go to the hospital where that surgeon works. Hospitals that provide less than top-quality care are rarely punished in the way that General Motors and Ford have been.

Even more important than how we choose our health care, though, is how we pay for it. One of Deming’s principles is that improving quality also tends to reduce costs. That is not always the case in health care; expensive treatments — implantable cardiac defibrillators, for instance — can bring enormous benefits. But Deming’s principle holds more often than you might think. When in doubt about the best procedure, doctors tend to do more — more tests, more procedures, more surgery. So if a hospital does a rigorous analysis of what actually works, it is likely to discover a fair amount of waste.

But in our current health care system, there is no virtuous cycle of innovation, success and expansion. When Intermountain standardized lung care for premature babies, it not only cut the number who went on a ventilator by more than 75 percent; it also reduced costs by hundreds of thousands of dollars a year. Perversely, Intermountain’s revenues were reduced by even more. Altogether, Intermountain lost $329,000. Thanks to the fee-for-service system, the hospital had been making money off substandard care. And by improving care — by reducing the number of babies on ventilators — it lost money. As James tartly said, “We got screwed pretty badly on that.” The story is not all that unusual at Intermountain, either. That is why a hospital cannot do as Toyota did and squeeze its rivals by offering better, less-expensive care.

Science writer Beryl Benderly reviews sociologist Joseph Hermanowicz’s penetrating study of academic science. It’s uncomfortable stuff for people whose life trajectories are headed straight in that direction (like me).

Here’s the article.

Here’s a quote:

ut there’s no mystery about why so many aspirants to research careers lack an accurate idea of where they’re headed. In fact, Hermanowicz writes, accepting an unrealistically rosy image of one’s future is a basic step on the road to becoming an academic scientist.

That image traditionally includes a pantheon of the greats of one’s discipline, faith in the high intrinsic value of research, and belief that recognition by the scientific community is a valid measure of worth. This image also implies that, with talent and dedication, any young scientist has a chance of making a distinguished contribution.

This set of foundational beliefs is an example of what Emile Durkheim, the Newton of Hermanowicz’s own discipline of sociology, termed a social group’s “moral order.” A moral order, Hermanowicz writes, “conveys how a life (or career) within a group should be lived.”

But as the great majority of faculty members learn–quickly or slowly depending on where they end up–the opportunity to do important science and gain major recognition only ever exists for a relative few–overwhelmingly those educated and employed at the most prestigious universities. The real issue in the distribution of recognition and prestige, Hermanowicz’s meticulous research shows, is not the ability or drive of individual scientists but, to paraphrase the book’s subtitle, “how institutions shape careers.”

For all but a handful of the scientists he studies, the prestige of their institution pretty much determines their professional–and even their personal–destiny. Of the more than 4000 institutions of higher learning in the United States where a scientist can get a faculty post–ranging from world-renowned research universities to local community colleges–only a very limited number possess the resources, reputation, and connections needed for research careers at the highest levels of recognition. (Listing all those schools is impossible because universities’ standing can vary among fields and change over time. But in many disciplines, the relative status of departments is carefully tracked and widely known.) Of the small minority of young scientists who succeed in landing any faculty job, therefore, only a much smaller percentage get a real shot at the big time that so many dream of. This is the reality about which so many young would-be professor/PIs are–and remain–”misinformed.”

…

The professors with the greatest influence on trainees aspiring to faculty posts belong to the stratum of top-ranked universities that Hermanowicz terms “elite,” which “place the highest premium on research” and are either “private research universities [or] some prestigious public universities. The overriding organizational goal is to garner additional prestige through the research and scholarly achievements of the faculty,” he writes. These brand-name schools have renowned departments in many fields and compete nationally and internationally for the top students and the best-known professors. Examples, Hermanowicz writes, “include Caltech, Harvard, Princeton, the University of Michigan and the University of California-Berkeley.”

Below them are institutions he terms “pluralist” because they have multiple goals and place “a premium on both research and teaching.” At these mostly public research universities, the goal of amassing institutional prestige through research coexists with that of “mass teaching and service to community and states.” Because these schools generally lack the resources to bid successfully against the generally much richer elites, professorial “stars” constitute a “decided minority” of their faculties, and their students come from a “mixed regional-national pool of candidates.” Examples, Hermanowicz says, “include the University of Maryland, the University of Kansas, and Purdue University.”

…

“Ability is not distributed along institutional lines,” Hermanowicz says, and many “very smart people” don’t work at top-ranked institutions, including many “who are arguably better than those who do.” Yet, his interviews with faculty members in each of the three categories reveal that opportunity and recognition for research pretty much correlate with institutional prestige.

This insight is hardly new. A 1990 study by sociologists Paul D. Allison and J. Scott Long found research productivity more related to scientists’ departments than to their personal qualities. The same person became more productive at a more prestigious university and less productive at a less prestigious one.

What Hermanowicz’s book adds is insight into the human lives behind these well-known processes. Scientists at elite schools, he found, retain to the end of their careers their original dedication to research, the goal of pursuing eminence, and a belief in the essential fairness of the scientific reward system. In contrast, at pluralist and communitarian schools, most faculty members must accept that their early faith was misplaced and their dreams will never be realized. Some pluralists do succeed in attaining prominence, but most cannot. This early loss of faith has an advantage, Hermanowicz says: The painful task of coming to terms gives many of these individuals an impressive depth of humanity.

Elite faculty, on the other hand, generally perceive only at the end their careers–and to their intense disappointment–that decades of single-minded striving have not won a perch in the “pantheon.” Only then begins their process of re-evaluation. Only after lives of great privilege and good fortune–the extent of which many never appreciate–do most begin to question the basic fairness of science’s system of rewards.

Ironically, Hermanowicz writes, as elite faculty complete careers that less favored colleagues would consider highly successful, some suffer from “a breakdown of order, a collapse of meaning about themselves, the world, and their perceived place in it because of a sharp divide between the realities of their lives” and their long-held beliefs. Durkheim famously called this painful state “anomie.”

Communitarians and pluralists, on the other hand, reconcile themselves much earlier and end their careers with far greater equanimity. Some continue to relish doing research while recognizing that their chances of attaining prominence are small. Many others find consolation, satisfaction, enjoyment, and recognition by redirecting their energies toward goals such as teaching, mentoring, administration, institutional or community service, or personal and family life.

Relative to those of other organisms, human behavioral modules are flexible in their applicability to new problem domains. Compared to the universally optimizing decision strategies available to homo economicus, though, our behavioral modules are narrowly constrained. One strategy that has been available for decades is to model bounded rationality as the costs of search, a fruitful theoretical strategy. But as neurobiology, human behavioral ecology, and evolutionary psychology become more sophisticated, the adaptive problems that the human brain’s mental modules evolved to solve will become better defined. Once those problems are defined sufficiently, we might be able to make more precise – even content-specific – predictions about their effects on aggregate decision-making. The basic emotions, because they are adaptively old and relatively easy to define in function and physiology, are a fruitful starting point for attempting to account for brain modules in decision theory.

In the May edition of New York Magazine, Jennifer Senior wrote that

Kathleen Vohs, a consumer psychologist at the University of Minnesota’s Carlson School of Management, is preeminent among them, and for the sake of better understanding both the past and the future of our city, it’s useful to start by looking at what she’s found. Just thinking about money made her subjects less likely to help strangers struggling with their belongings. Just handling money made her subjects less sensitive to physical pain. My favorite experiment of hers, though, was one in which she divided her subjects into groups, one of which stared at a screensaver of floating dollar bills and another at a screensaver of exotic fish. Subjects were then asked whether they’d like to work on a task alone or with a partner. Eighty percent of those who’d been staring at the dollar bills chose to work alone. Eighty percent of those who’d been staring at the fish wanted to collaborate. . .

Recently, Vohs has been looking at what happens when her subjects spend time reflecting on money they’ve lost. She believes it’s a fairly good proxy for a recession mentality. What she’s found so far, she says, is that they’re more sensitive to physical pain—and social rejection. . .

Enrollments at divinity schools are up: The number of Ph.D. applicants to the Jewish Theological Seminary has doubled; almost twice as many students are set to matriculate at Union Theological Seminary. . .

“The stronger a man’s attachment to breadwinning,” says Stephanie Coontz, author of Marriage, a History, “the more likely he is to salvage his male pride by refusing to do ‘women’s work.’ ” As a rule, able-bodied, unemployed men spend an average of just three and a half extra minutes per day actively caring for their kids, according to Jay Stewart, an economist at the Bureau of Labor Statistics. Most spend their extra time on sleep and “leisure activities” (including almost two extra hours of TV). . .

Most recent studies on the subject suggest that the psychological effect of unemployment is even greater than the loss of income that accompanies it. Andrew Oswald, an economist at the University of Warwick, has collected happiness data from hundreds of thousands of people both here and in the United Kingdom, and what he’s consistently seen is that people recover more quickly from becoming disabled, even widowed, than from the long-term loss of a job. . . Sustained unemployment is one of life’s few upsets that seems to permanently depress it. Even if this recession is shorter than pessimists predict, those who are laid off in this period will still pay a concrete, long-term price. “It’s what economists call ‘scarring,’ ” explains Oswald. “If I lose my job today, the evidence is that my wages will be 10 percent lower, even a decade from now. Your bad luck follows you.” . . .

Those who graduate from college during a recession make less money than those who do not, and these disparities don’t seem to completely erode with time. After looking at hundreds of white men who graduated from college between 1979 and 1989, Lisa Kahn, an assistant professor at the Yale School of Management, came up with an elegant and depressing formula: Each point on the unemployment rate at the time of graduation translates into a 6 percent decrease in starting salary. Specifically: Kids who graduated in 1988, when the unemployment rate was 5.5 percent, made 24 percent more their first year out of school than those who graduated in 1982 (even adjusted for inflation) because the unemployment rate was four points higher, at 9.5 percent. Fifteen years later, there was still a 10 percent differential between them. . .

John Sexton, the president of NYU, is fond of pointing out that the finance, insurance, and real-estate sectors in New York City—collectively known by the acronym FIRE—were shedding jobs before the new millennium, just as they are now, while the city’s intellectual capital only continues to grow: New York has more college students per capita than any other American city; it has the highest concentration of postdocs in both arts and science. So the transformation he hopes for—and this is his nifty coinage—is an economy where FIRE counts for a bit less, and ICE (intellectual, cultural, and educational capital) counts for a bit more.

“How do you magnetize talent in a world where propinquity matters less?” asks Sexton. “Universities. World-class universities.” He acknowledges that our city and state budgets aren’t exactly skewed toward helping them; Fordham is not getting tax breaks like Bear Stearns. But one of the few new line items in this year’s state budget is the Higher Education Loan Program. “We should at least begin to use this as a social moment,” says Sexton, “to reunderstand what we once knew: that education is the ultimate public good.”