Category: Labor 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.”)

Did Theranos Fail Because It Had a Flat Structure or Because It Had a Hierarchy with Holmes at the Top (Or Simply Because They Failed at Something Very Hard)?

André Spicer and Elizabeth Holmes infer that Theranos failed due to its flat structure. But weren’t there some employees, such as George Shultz’s grandson, whose efforts to identify the problems that led to failure and fraud, were suppressed by Elizabeth Holmes? If so, then can’t you say that the failure was due to Holmes’s power at the top of the firm? Meaning due to a kind of hierarchy rather than due to flatness? (I remain unclear and conflicted on whether and when flatness or hierarchy is better.)

(p. B2) . . . do flat structures work? André Spicer, a professor of organizational behavior at the Bayes Business School in London, said that, while the “cultural zeitgeist when I was growing up was that hierarchies are bad,” there’s been an increasing recognition of both the need for them and the fact that they often reappear in businesses ‌that, at least theoretically, reject them.

. . .

Mr. Spicer is particularly critical of start-ups that have attempted, or claimed to attempt, flat structures, suggesting that failures — and at least one major scandal — have emerged from these workplaces. He pointed to Elizabeth Holmes and Theranos, her health care technology start-up. In a 2015 interview, Ms. Holmes said that Theranos was “a very flat organization and if I have learned anything, we are only as good as the worst people on our team.”

“The claim that companies like Theranos had a flat structure meant the company fitted into a well-recognized type of agile tech firms,” Mr. Spicer said. In addition to attracting investors and employees, the myth “meant that these companies don’t have to do the difficult and tedious process of putting into place all the systems and controls you would normally find.”

He added that he believed those systems “would have likely stopped much of the wrongdoing.” Ms. Holmes and Ramesh Balwani, the former chief operating officer of Theranos, were each recently sentenced to prison time for defrauding investors and patients.

The notion that start-ups in particular are ill suited to a flat structure was supported in a 2021 study by Professor Lee of Wharton. A flat structure “can result in haphazard execution and commercial failure by overwhelming managers with the burden of direction and causing subordinates to drift into power struggles and aimless idea explorations,” he wrote.

For the full story, see:

Charlie Brinkhurst-Cuff. “‘Flat’ Company Structures Sound Appealing. But Do They Work?” The New York Times (Wednesday, July 5, 2023): B2.

(Note: ellipses added.)

(Note: the online version of the story has the same date as the print version, and has the title “In Business, ‘Flat’ Structures Rarely Work. Is There a Solution?” Where there are minor differences in wording between the versions, the passages quoted above follow the online version.)

The academic paper by Lee mentioned in the passage quoted above is:

Lee, Saerom. “The Myth of the Flat Start-Up: Reconsidering the Organizational Structure of Start-Ups.” Strategic Management Journal 43, no. 1 (Jan. 2022): 58-92.

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.”)

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.”)

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.)

Nursing Slots Filled Via Gig Apps Give More Control to Nurses and More Uncertainty to Hospitals

(p. A3) Hospitals are joining the gig economy.

Some of the nation’s largest hospital systems including Providence and Advocate Health are using apps similar to ride-hailing technology to attract scarce nurses. An app from ShiftKey lets workers bid for shifts. Another, CareRev, helps hospitals adjust pay to match supply, lowering rates for popular shifts and raising them to entice nurses to work overnight or holidays.

The embrace of gig work puts hospitals in more direct competition with the temporary-staffing agencies that siphoned away nurses during the pandemic. The apps help extend hospitals’ labor pool beyond their employees to other local nurses who value the highly flexible schedules of gig work.

. . .

Gig apps give nurses even more control than other common temporary-employment options that lock in workers for multiweek contracts, at least. It opens shifts to a broader labor pool, too, but also a more fluid one, hospital executives said.

That means less certainty for employers.

For the full story, see:

Melanie Evans. “Gig Work Helps Hospitals Fill Nursing Shifts.” The Wall Street Journal (Wednesday, April 19, 2023): A3.

(Note: ellipsis added.)

(Note: the online version of the story has the date April 18, 2023, and has the title “Nurse Shortage Pushes Hospitals Into the Gig Economy.”)

European Farmers Want Climate Protected by More Innovation, Not by Less Agriculture

(p. 4) To meet climate goals, some European countries are asking farmers to reduce livestock, relocate or shut down — and an angry backlash has begun reshaping the political landscape before national elections in the fall.

. . .

Those like Helma Breunissen, who runs a dairy farm in the Netherlands with her husband, say that too much of the burden is falling on them, threatening both their livelihoods and their way of life.

For almost 20 years, Ms. Breunissen has provided the Dutch with a staple product, cow’s milk, and she felt that her work was valued by society, she said. The dairy sector in the Netherlands, which also produces cheeses like Gouda and Edam, is celebrated as a cornerstone of national pride.

But the sector also produces almost half the Netherlands’ emissions of nitrogen, a surplus of which is bad for biodiversity. Ms. Breunissen and thousands of other farmers bridle that they are now labeled peak emitters.

“I was confused, sad and angry,” said Ms. Breunissen, who manages a farm of 100 cows in the middle of the country. “We are doing our best. We try to follow the rules. And suddenly, it’s like you are a criminal.”

. . .

In the Netherlands, the government has asked thousands of farmers to scale back, move or close. The authorities set aside about 24 billion euros, about $26 billion, to help farmers put in place more sustainable solutions — or to buy them out.

. . .

For Ms. Breunissen, who is 48 and works as a veterinarian in addition to her duties on the farm, none of the government-proposed options seem feasible. She is too young to quit and too old to uproot her life, she said, and the authorities have not provided enough support and information on how to change what she now does.

“There are so many questions,” she said. “The trust in the government is completely gone.”

. . .

A host of new groups are vying to displace traditional parties. They include the Farmer Citizen Movement, known by its Dutch acronym BBB, which was established four years ago.

. . .

Caroline van der Plas, the party’s co-founder, used to be a journalist in The Hague covering the meat industry, and she has never worked in farming. But she grew up in a small city in a rural area, and she said in an interview that she wanted to be “the voice of the people in rural regions who are not seen or heard” by policymakers.

She and her party have talked down the need for drastic steps to cut emissions, saying the reductions can be achieved through technological innovation. Policies should be based on “common sense,” she said, while offering no concrete solutions.

“It’s not like science says this or that,” Ms. van der Plas said, referring to how theories can change. “Science is always asking questions.”

For the full story, see:

Monika Pronczuk and Claire Moses. “New Climate Standards Have Farmers in Europe Bristling.” The New York Times, First Section (Sunday, Aug. 27, 2023): 4.

(Note: ellipses added.)

(Note: the online version of the story was updated Aug. 28, 2023, and has the title “Labeled Climate Culprits, European Farmers Rebel Over New Standards.”)