Category: Economics

Experienced Nurses Can Be Disciplined If They Use Hunches from Clinical Observations to Override AI Protocols

(p. A1) Melissa Beebe, an oncology nurse, relies on her observation skills to make life-or-death decisions. A sleepy patient with dilated pupils could have had a hemorrhagic stroke. An elderly patient with foul-smelling breath could have an abdominal obstruction.

So when an alert said her patient in the oncology unit of UC Davis Medical Center had sepsis, she was sure it was wrong. “I’ve been working with cancer patients for 15 years so I know a septic patient when I see one,” she said. “I knew this patient wasn’t septic.”

The alert correlates elevated white blood cell count with septic infection. It wouldn’t take into account that this particular patient had leukemia, which can cause similar blood counts. The algorithm, which was based on artificial intelligence, triggers the alert when it detects patterns that match previous patients with sepsis. The algorithm didn’t explain (p. A9) its decision.

Hospital rules require nurses to follow protocols when a patient is flagged for sepsis. While Beebe can override the AI model if she gets doctor approval, she said she faces disciplinary action if she’s wrong. So she followed orders and drew blood from the patient, even though that could expose him to infection and run up his bill. “When an algorithm says, ‘Your patient looks septic,’ I can’t know why. I just have to do it,” said Beebe, who is a representative of the California Nurses Association union at the hospital.

As she suspected, the algorithm was wrong. “I’m not demonizing technology,” she said. “But I feel moral distress when I know the right thing to do and I can’t do it.”

. . .

In a survey of 1,042 registered nurses published this month by National Nurses United, a union, 24% of respondents said they had been prompted by a clinical algorithm to make choices they believed “were not in the best interest of patients based on their clinical judgment and scope of practice” about issues such as patient care and staffing.” Of those, 17% said they were permitted to override the decision, while 31% weren’t allowed and 34% said they needed doctor or supervisor’s permission.

. . .

Jeff Breslin, a registered nurse at Sparrow Hospital in Lansing, Mich., has been working at the Level 1 trauma center since 1995. He helps train new nurses and students on what signs to look for to assess and treat a critically ill or severely injured patient quickly.

“You get to a point in the profession where you can walk into a patient’s room, look at them and know this patient is in trouble,” he said. While their vital signs might be normal, “there are thousands of things we need to take into account,” he said. “Does he exhibit signs of confusion, difficulty breathing, a feeling of impending doom, or that something isn’t right?”

. . .

Nurses often describe their ability to sense a patient’s deterioration in emotional terms. “Nurses call it a ‘hunch,’ ” said Cato, the University of Pennsylvania professor who is also a data scientist and former nurse. “It’s something that causes them to increase surveillance of the patient.”

. . .

At UC Davis earlier this spring, Beebe, the oncology nurse, was treating a patient suffering from a bone cancer called myeloid leukemia. The condition fills the bones with cancer cells, “they’re almost swelling with cancer,” she said, causing excruciating pain. Seeing the patient wince, Beebe called his doctor to lobby for a stronger, longer-lasting pain killer. He agreed and prescribed one, which was scheduled to begin five hours later.

To bridge the gap, Beebe wanted to give the patient oxycodone. “I tell them, ‘Anytime you’re in pain, don’t keep quiet. I want to know.’ There’s a trust that builds,” she said.

When she started in oncology, nurses could give patients pain medication at their discretion, based on patient symptoms, within a doctor’s parameters. They gave up authority when the hospital changed its policies and adopted a tool that automated medication administration with bar-code scanners a few years ago.

In its statement, UC Davis said the medication tool exists as a second-check to help prevent human error. “Any nurse who doesn’t believe they are acting in the patient’s best interests…has an ethical and professional obligation to escalate those concerns immediately,” the hospital said.

Before giving the oxycodone, Beebe scanned the bar code. The system denied permission, adhering to the doctor’s earlier instructions to begin the longer-acting pain meds five hours later. “The computer doesn’t know the patient is in out-of-control pain,” she said.

Still, she didn’t act. “I know if I give the medication, I’m technically giving medication without an order and I can be disciplined,” she said. She watched her patient grimace in pain while she held the pain pill in her hand.

For the full story, see:

Lisa Bannon. “Nurses Clash With AI Over Patient Care.” The Wall Street Journal (Friday, June 16, 2023): A1 & A9.

(Note: ellipses added.)

(Note: the online version of the story has the date June 15, 2023, and has the title “When AI Overrules the Nurses Caring for You.”)

Blacks Are Migrating Away from Northern Cities, Due Partly to Rising Costs and Violence

(p. B3) The waves of migration that brought Black Americans to many northern cities are reversing.

Departing residents are heading everywhere from nearby suburbs to high-growth areas in the southern U.S., such as metro Atlanta, according to demographers, real-estate agents and public officials.

The latest U.S. Census Bureau estimates, released Thursday, indicate Black residents are continuing to leave many urban centers in the North and elsewhere, adding to decades of decline. These losses have hit many major cities with historically large Black populations, including Chicago, Detroit, Cleveland and Oakland, Calif.

. . .

Some are motivated by rising housing costs and worries about safety.

“I wanted some peace and quiet. I was tired of the gunshots, the sirens,” said Mary Hall-Rayford, a retired teacher who moved from Detroit to neighboring Eastpointe, Mich., in 2012. “Eastpointe was a nice little city.”

She serves on the school board and is running for mayor.

For the full story, see:

Jimmy Vielkind, Jon Kamp, Paul Overberg and Jack Gillum. “Black People Are Departing Cities in North.” The Wall Street Journal (Friday, June 23, 2023): B1 & B4.

(Note: ellipsis added.)

(Note: the online version of the story has the date June 22, 2023, and has the title “Black Americans Are Leaving Cities in the North and West.”)

Exponential Growth Is Not Inevitable and Has Seldom Occurred Outside of Computer Chips

(p. C5) Nothing has affected, and warped, modern thinking about the pace of technological invention more than the rapid exponential advances of solid-state electronics. The conviction that we have left the age of gradual growth behind began with our ability to crowd ever more components onto a silicon wafer, a process captured by Gordon Moore’s now-famous law that initially ordained a doubling every 18 months, later adjusted to about two years.

. . .

Bestselling tech prophets like Ray Kurzweil and Yuval Noah Harari argue that exponential growth will allow us to disrupt our way into a future devoid of disease and misery and abounding in material riches.

. . .

The problem is that the post-1970 ascent of electronic architecture and performance has no counterpart in other aspects of our lives. Exponential growth has not taken place in the fundamental economic activities on which modern civilization depends for its survival—agriculture, energy production, transportation and large engineering projects. Nor do we see rapid improvements in areas that directly affect health and quality of life, such as new drug discoveries and gains in longevity.

. . .

The conclusion that progress is not accelerating in the most fundamental human activities is supported by a paper published in 2020 by the National Bureau of Economic Research. The authors, four American economists led by Bryan Kelly of the Yale School of Management, studied innovation across American industries from 1840 to 2010, using textual analysis of patent documents to construct indexes of long-term change. They found that the wave of breakthrough patents in furniture, textiles, apparel, transportation, metal, wood, paper, printing and construction all peaked before 1900. Mining, coal, petroleum, electrical equipment, rubber and plastics had their innovative peaks before 1950. The only industrial sectors with post-1970 peaks have been agriculture (dominated by genetically modified organisms), medical equipment and, of course, computers and electronics.

For the full essay, see:

Vaclav Smil. “Tech Progress Is Slowing Down.” The Wall Street Journal (Saturday, Feb. 18, 2023): C5.

(Note: ellipses added.)

(Note: the online version of the essay has the date February 16, 2023, and has the same title as the print version.)

The essay quoted above is adapted from Smil’s book:

Smil, Vaclav. Invention and Innovation: A Brief History of Hype and Failure. Cambridge, MA: The MIT Press, 2023.

For Musk “Hard Core” Means “Long Hours at High Intensity”

(p. A24) Have you ever gotten an email at midnight from the boss with ​an ominous subject line like “a fork in the road”? Granted, email etiquette today says we’re not supposed to get midnight emails from bosses at all. But Elon Musk is no ordinary boss, and it’s safe to assume he didn’t get the memo on empathetic leadership. So, true to form, as chief executive of Twitter, after laying off nearly half of his staff, bringing a sink to work and proclaiming he would be sleeping at the office “until the org is fixed,” Mr. Musk recently issued this late-night ultimatum to his remaining employees: From this point forward, Twitter was going to be “extremely hard core.” Were they ready to be hard core? They could select “yes” — or opt for three months of severance pay.

To Mr. Musk, “hard core” meant “long hours at high intensity,” a workplace where only the most “exceptional performance” would be accepted and a culture in which midnight emails would be just fine. I’d wager that more than a few workaholics, bosses or otherwise, weren’t entirely turned off by the philosophy behind that statement, and yet it immediately conjured images of sweaty Wall Street bankers collapsing at their desks, Silicon Valley wunderkinds sleeping under theirs and the high-intensity, bro-boss cultures of companies like Uber and WeWork, with their accompanying slogans about doing what you love and sleeping when you’re dead.

For the full commentary, see:

Jessica Bennett. “Elon, the Mosh Pit Called. It Wants ‘Hard Core’ Back.” The New York Times (Friday, November 25, 2022): A24.

(Note: the online version of the commentary has the date Nov. 23, 2022, and has the title “The Worst Midnight Email From the Boss, Ever.”)

“In Tokyo Good Things Have Been Created Through Private Initiative”

(p. A22) Yuta Yamasaki and his wife moved from southern Japan to Tokyo a decade ago because job prospects were better in the big city. They now have three sons — ages 10, 8 and 6 — and they are looking for a larger place to live. But Mr. Yamasaki, who runs a gelato shop, and his wife, a child-care worker, aren’t planning to move far. They are confident they can find an affordable three-bedroom apartment in their own neighborhood.

As housing prices have soared in major cities across the United States and throughout much of the developed world, it has become normal for people to move away from the places with the strongest economies and best jobs because those places are unaffordable. Prosperous cities increasingly operate like private clubs, auctioning off a limited number of homes to the highest bidders.

Tokyo is different.

. . .

Small apartment buildings can be built almost anywhere, and larger structures are allowed on a vast majority of urban land. Even in areas designated for offices, homes are permitted. After Tokyo’s office market crashed in the 1990s, developers started building apartments on land they had purchased for office buildings.

“In progressive cities we are maybe too critical of private initiative,” said Christian Dimmer, an urban studies professor at Waseda University and a longtime Tokyo resident. “I don’t want to advocate a neoliberal perspective, but in Tokyo good things have been created through private initiative.”

Tokyo makes little effort to preserve old homes. Historic districts subject to preservation laws exist in other Japanese cities, but the nation’s largest city has none. New construction is prized. People treat homes like cars: They want the latest models.

For the full commentary, see:

Binyamin Appelbaum and Andrew Faulk. “Tokyo, the Big City Where Housing Isn’t Crazy Expensive.” The New York Times (Saturday, September 16, 2023): A22.

(Note: ellipsis added.)

(Note: the online version of the commentary has the date September 11, 2023, and has the title “The Big City Where Housing Is Still Affordable.”)

Public Sector Unions Make Government Unaccountable to the Will of the People

(p. A17) In 2008, six years after securing control over New York City’s public schools, Mayor Michael Bloomberg and schools chancellor Joel Klein put forward a program to tie teacher tenure to student performance. The goal was to reward the best-performing teachers with job security, encourage better student outcomes, and hold teachers accountable for demonstrated results. To most New York residents, it surely sounded like a good idea.

To New York’s teachers’ unions, however, the program was utterly unacceptable. Union leaders lobbied Albany, threatened state lawmakers (who could pass legislation binding the mayor) with the loss of political support, and walked away with a two-year statewide prohibition on the use of student test performance in tenure evaluations. In short, the union thwarted the mayor’s authority over the city’s schools and commandeered the state’s legislative power.

In this case and many others, a public-sector union served its own interests at the expense of the public’s. In “Not Accountable,” Philip Howard shows in vivid detail how such practices have made government at all levels unmanageable, inefficient and opposed to the common good. He argues that, in fact, public unions—that is, unions whose members work for the government—are forbidden by the Constitution. The argument, he notes, would have been familiar to President Franklin Roosevelt and George Meany, the longtime president of the AFL-CIO, both of whom championed private-sector labor but believed that public workers—teachers, fire fighters, policemen, civil-service employees—had no right to bargain collectively with the government.

. . .

Mr. Howard makes a persuasive case, but the chances of seeing it affect American political life are, at the moment, remote.

. . .

Still, the goal is admirable and worth pursuing. In place of public-sector collective bargaining, Mr. Howard calls for a merit-based system for hiring and evaluating government employees. Instead of stultifying work rules that thwart creativity, he envisions a public-sector structure in which employees can use their talents and judgment to improve the functioning of government. Fundamentally, Mr. Howard views the Constitution, and the law generally, as a mechanism for both action and accountability, one that entrusts powers to inevitably fallible human beings while subjecting them to the checks of others in authority and, ultimately, to the will of the people.

For the full review, see:

John Ketcham. “BOOKSHELF; Unelected Legislators.” The Wall Street Journal (Tuesday, March 14, 2023): A17.

(Note: ellipses added.)

(Note: the online version of the review was updated March 13, 2023, and has the title “BOOKSHELF; ‘Not Accountable’ Review: Unelected Legislators.”)

The book under review is:

Howard, Philip K. Not Accountable: Rethinking the Constitutionality of Public Employee Unions. Garden City, NY: Rodin Books, 2023.

Cars Give Commuters Flexible Choices Absent from Public Transit

(p. A14) Across the United States, transit systems that have relied for decades on office workers are scrambling to avoid financial collapse as commuters stay home. Many systems are asking their local governments for bailouts as federal pandemic relief runs dry, . . .

. . .

“If anyone says that they know the way out of this difficult situation, they’re fooling themselves,” said Brian D. Taylor, the director of the Institute of Transportation Studies at the University of California, Los Angeles. “This is a really challenging time.”

. . .

“You can put the New York City subway in the middle of Oklahoma and you wouldn’t have any ridership — that’s kind of the harsh reality for American transit,” Mr. Elkind said. “There’s only so much they can do with service and fares to lure riders back.”

In many cities, riders may need to go to the office only on Wednesdays. Or they want to pick up their children from school in the middle of the day or make a run to the grocery store.

For the full story, see:

Soumya Karlamangla. “With Commuters Scarce, Transit Agencies Try New Enticements.” The New York Times (Tuesday, June 20, 2023): A14.

(Note: ellipses added.)

(Note: the online version of the story has the date June 19, 2023, and has the title “With Commuters Staying Home, Transit Agencies Try to Reinvent Themselves.”)

Musk Says Productivity Rises When Firms Fire Employees Who “Slam the Brakes”

(p. B3) Elon Musk said more companies should consider running lean like Twitter.

. . .

“There’s a potential for significant cuts, I think, out of companies without affecting their productivity,” Musk said, adding that staffing cuts could increase productivity by speeding up operations. “At any given company, there are people who help move things forward and people who sort of try to slam the brakes on.”

For the full story, see:

Chip Cutter. “Musk Urges Others to Cut Jobs as Twitter Did.” The Wall Street Journal (Thursday, May 25, 2023): B3.

(Note: ellipsis added.)

(Note: the online version of the story has the date May 24, 2023, and has the title “Musk Urges More Companies to Shrink Like Twitter.”)

Builders of Untested Fragile R101 Airship Feared Revealing Danger to Head of British Air Ministry

The airships called “dirigibles” were sometimes also called “zeppelins” after their German inventor.

(p. 43) . . . zeppelins had fatal flaws. A single ignition source could turn one into a fireball, as British fighter pilots discovered once they started arming their planes with incendiary bullets. Explosive properties aside, dirigibles were all but uncontrollable in high winds and struggled to stay aloft when rain saturated their cloth skins, adding tons of extra weight.

. . .

That Britain persisted with its airship program owes much to the book’s main character, Lord Christopher Thomson, a retired brigadier and Labour Party politician who in 1923 was appointed to run the British Air Ministry. Witty, cultured and handsome, the India-born Thomson had a romantic vision of a “peaceful, air-linked world” that was closely tied to romance of a different sort. Thomson had for years been carrying on a long-distance affair with Marthe Bibesco, a ravishing (and married) Romanian princess and celebrated author. By 1930, during his second stint as air secretary, there was a chance he would be tapped as the next viceroy of India, a job that would take him even farther from his beloved. In Gwynne’s persuasive telling, Thomson believed that airships could save both the empire and his love life.

Thomson comes across as decent but hopelessly naïve, his faith in R101 based partly on bad information from the underlings responsible for building it. They knew the airship was too heavy, and that its gas bags — made from cow intestines — were prone to leakage. But with few exceptions they kept that knowledge to themselves, for fear of displeasing the boss.

It didn’t help that Thomson was on a tight schedule. Having claimed a berth on R101’s inaugural, round-trip voyage to India, he was determined to be back in London in time for a conference of colonial premiers, perhaps imagining a dramatic, Phileas Fogg-style entrance that would underscore the brilliance of his scheme. To accommodate him, flight tests were cut short, and the airship took off despite reports of bad weather along the route over France. There is reason to believe that the airship’s senior officer may have been drunk at the time.

For the full review, see:

John Lancaster. “Hot Air.” The New York Times Book Review (Sunday, June 4, 2023): 43.

(Note: ellipses added.)

(Note: the online version of the review has the date May 1, 2023, and has the title “When Ego Meets Hot Air, the Results Can Be Deadly.”)

The book under review is:

Gwynne, S. C. His Majesty’s Airship: The Life and Tragic Death of the World’s Largest Flying Machine. New York: Scribner, 2023.

The story of the competition between the privately-built R100 and the government-built R101 was earlier well-told in:

Squires, Arthur M. The Tender Ship: Government Management of Technological Change. Boston, Massachusetts: Birkhauser, 1986.

The Role Disney “Fans Play in Creating the Disney Magic”

(p. 10) On Nov. 20, [2022],I was relieved to hear the news that Disney’s chief executive, Bob Chapek, had been fired and replaced with the former chief executive Robert Iger. The news was also met with near-unanimous celebration among my community of super fans.

While his ouster shocked investors and Hollywood, many in our community had been actively campaigning for Mr. Chapek’s firing for the past two years. A Change.org petition to fire Mr. Chapek that started in 2020 garnered over 117,000 signatures. (It now reads “Victory.”) Online forums teemed with complaints about Mr. Chapek’s management style and strategy.

. . .

We also pushed to have Mr. Chapek fired because he didn’t believe in Disney magic. Disney is so much more than just another big business. Understanding that is crucial to its success.

When Walt Disney opened Disneyland, he referred to his theme park customers as “guests,” an understanding that is explicitly reinforced in Disney employee training to this day, and by which Disney’s theme park community refers to itself.

. . .

What Mr. Chapek doesn’t understand is the role we fans play in creating the Disney magic. It is our Instagram accounts, our blogs and our websites that those out-of-towners refer to in order to prepare for that revenue-generating Disneyland trip. I get paid to do it, but many others do this work just because they love it. Mr. Chapek disregarded us.

Worse was the way Mr. Chapek treated “cast members,” as Disney’s park employees are known. The people who greet you at the park entrance, serve you food and get you safely on and off the rides have an enormous influence on the quality of your visit. I’ve talked to many cast members, from young people to older adults, about why they’re willing to wear polyester costumes in Florida’s summer heat for relatively low wages. To a person, they say something like, “I want to make people happy, and Disney is the best place to do that.”

So it was disheartening when, in September 2020, Mr. Chapek announced that the company was laying off 28,000 workers, most of them cast members. While many other businesses were laying off workers during that time, Mr. Chapek was also committing Disney to spending billions to ramp up content production for its Disney+ streaming service. As we saw it, Mr. Chapek viewed the incomes and health care of thousands of people — the people who make the magic — as less important than another season of “The Mandalorian.” Many cast members decided not to return to Disney’s parks when they reopened.

For the full commentary, see:

Len Testa. “Bob Chapek Didn’t Believe in Disney Magic.” The New York Times, SundayOpinion Section (Sunday, December 4, 2022): 10.

(Note: ellipses, and bracketed year, added.)

(Note: the online version of the commentary has the date Nov. 29, 2022, and has the same title as the print version. Where there is a slight difference in wording between versions, the passages quoted above follow the online version.)

Much of Pandemic Funding to Improve Ventilation in Schools “Is Sitting Untouched in Most States”

(p. 1) As the next presidential election gathers steam, extended school closures and remote learning have become a centerpiece of the Republican argument that the pandemic was mishandled, the subject of repeated hearings in the House of Representatives and a barrage of academic papers on learning loss and mental health disorders among children.

But scientists who study viral transmission see another lesson in the pandemic school closures: Had the indoor air been cleaner (p. 16) and safer, they may have been avoidable. The coronavirus is an airborne threat, and the incidence of Covid was about 40 percent lower in schools that improved air quality, one study found.

The average American school building is about 50 years old. According to a 2020 analysis by the Government Accountability Office, about 41 percent of school districts needed to update or replace the heating, ventilation and air-conditioning systems in at least half of their schools, about 36,000 buildings in all.

There have never been more resources available for the task: nearly $200 billion, from an array of pandemic-related measures, including the American Rescue Plan Act. Another $350 billion was allotted to state and local governments, some of which could be used to improve ventilation in schools.

“It’s a once-in-a-generation opportunity to fix decades of neglect of our school building infrastructure,” said Joseph Allen, director of the Healthy Buildings program at the Harvard T.H. Chan School of Public Health.

Schoolchildren are heading back to classrooms by the tens of millions now, yet much of the funding for such improvements is sitting untouched in most states.

Among the reasons: a lack of clear federal guidance on cleaning indoor air, no senior administration official designated to oversee such a campaign, few experts to help the schools spend the funds wisely, supply chain delays for new equipment, and insufficient staff to maintain improvements that are made.

Some school officials simply may not know that the funds are available. “I cannot believe the amount of money that is still unspent,” Dr. Allen said. “It’s really frustrating.”

For the full story, see:

Apoorva Mandavilli. “Bad Ventilation Remains Threat To U.S. Students.” The New York Times, First Section (Sunday, Aug. 27, 2023): 1 & 16.

(Note: the online version of the story was updated Aug. 28, 2023, and has the title “Covid Closed the Nation’s Schools. Cleaner Air Can Keep Them Open.”)