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.

Lister Used Data, Results, and Amiability to Convince Physicians to Sterilize Hands, Scalpels, and Wounds

(p. C6) What was the most dangerous place in the vast territories of the British Empire in the 19th century? Was it the savage savannas of Zululand? Perhaps the frozen wastes of the Northwest Passage, or the treacherous high passes of the Hindu Kush?

To judge from “The Butchering Art,” a fine and long overdue biography of the great physician Joseph Lister by Lindsey Fitzharris, the answer might be a much more domestic corner of empire: the Victorian teaching hospital.

. . .

Infection rates plummeted when Lister used carbolic acid to wash hands and scalpels, to dress wounds, and to sterilize sutures. He even sprayed it into the air of the operating room. But other physicians were skeptical and bitterly resisted the notion that their sloppy and unhygienic practices were the cause of so many deaths.

. . .

Lister won over his opponents, not with bile and rhetoric but with a relentless focus on data and results, coupled with his innate amiability. He paid particular attention to audiences of medical students, perhaps anticipating Max Planck’s observation that bitter disciples of old dogmas are never won over by new theories, they simply die off and are replaced by a new generation.

The modesty and compassion of Lister would have been remarkable in any man, let alone a surgeon. His patients and students adored him. Lister taught his residents that “every patient, even the most degraded, should be treated with the same care and regard as though he were the Prince of Wales himself.” After he drained a young girl’s knee abscess, the girl showed him her doll, which was missing a leg. As Ms. Fitzharris writes, “The girl fumbled around under her pillow and—much to Lister’s amusement—produced the severed limb.” Lister called for needle and thread and “stitched the limb back onto the doll and with quiet delight handed it back to the little girl.”

For the full review, see:

John J. Ross. “BOOKSHELF; The Butchering Art.” The Wall Street Journal (Saturday, Oct. 14, 2017): C6.

(Note: ellipses added.)

(Note: the online version of the review has the date Oct. 13, 2017, and has the title “BOOKSHELF; Review: ‘The Butchering Art’ Resurrects Joseph Lister.”)

The book under review is:

Fitzharris, Lindsey. The Butchering Art: Joseph Lister’s Quest to Transform the Grisly World of Victorian Medicine. New York: Farrar, Straus and Giroux, 2017.

The reviewer repeats the plausible but debunked view of Planck that old scientists do not change their views. The debunking occurs in:

Diamond, Arthur M., Jr. “Age and the Acceptance of Cliometrics.” Journal of Economic History 40, no. 4 (Dec. 1980): 838-41.

Hull, David L. , Peter D. Tessner, and Arthur M. Diamond, Jr. “Planck’s Principle: Do Younger Scientists Accept New Scientific Ideas with Greater Alacrity Than Older Scientists?” Science 202 (Nov. 17, 1978): 717-23.

Stimulant Ephedrine Was Known and Used in Bronze Age

Ephedrine currently has a variety of medical uses, including as a decongestant.

(p. A4) Bronze Age humans have been credited with a number of civilizational advancements: the invention of irrigation, the wheel, writing systems and the ability to forge weapons and tools from the durable metal that lends the era its name.

Now, strands of human hair discovered in an ancient burial cave in Spain suggest another novelty: a proclivity for consuming psychoactive drugs.

. . .

The findings, published Thursday [April 6, 2023] in Scientific Reports of the journal Nature, provide the first direct evidence that ancient Europeans consumed psychoactive drugs much like their pre-Columbian brethren in Mesoamerica, the researchers said.

Elisa Guerra-Doce, the lead author of the study, said researchers were stunned by the results, especially because the cave interiors yielded no detectable signs of the drugs’ presence. A chemical analysis of the hair revealed evidence of three alkaloid substances known to produce altered states of consciousness: ephedrine, atropine and scopolamine.

The compounds themselves are produced by flora native to Minorca. Atropine and scopolamine, powerful hallucinogens, can be found in plants in the nightshade family, among them mandrake, henbane and thorn apple. Ephedrine, a stimulant, can be extracted from joint pine.

“These findings are so singular,” said Ms. Guerra-Doce, an expert in the anthropology of intoxication at the University of Valladolid in Spain. “Sometimes when people think about drugs, they think it’s a modern practice. These results tell a different story.”

. . .

The three compounds have a long history of human use. Ephedrine is a stimulant that provides bursts of energy and mental clarity, and it can stave off sleepiness. Atropine and scopolamine are powerful deliriants that can produce hallucinations and out-of-body experiences.

For the full story, see:

Andrew Jacobs. “Scientists See Bronze Age In New Light: It Was Trippy.” The New York Times (Friday, April 7, 2023): A4.

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

(Note: the online version of the story has the date April 6, 2023, and has the title “Tripping in the Bronze Age.”)

The academic paper mentioned in the passage quoted above is:

Guerra-Doce, E., C. Rihuete-Herrada, R. Micó, R. Risch, V. Lull, and H. M. Niemeyer. “Direct Evidence of the Use of Multiple Drugs in Bronze Age Menorca (Western Mediterranean) from Human Hair Analysis.” Scientific Reports 13, no. 1 (April 6, 2023): article #4782.

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.”)

“Flowers Never Bend, With the Rainfall”

Sometimes when I am in a dark mood I wonder how you keep moving forward when you do not know how much time is left. Some seek an answer in religion. I am more open to a kind of stoicism combined with the other gift of Prometheus: blind hope.

(p. 3) A few months into treatment, I realized that Josh might not make it to the next spring, when we would normally visit my extended family in Greece. I told Dr. Sara that I would like to take my husband to Greece, because he might not get the chance again.

. . .

My diary reminds me that while we were there, I asked Josh what he would do differently in life. “Not get cancer,” he said.

. . .

As for me, I kept hearing the lyrics to a Simon and Garfunkel song in my head: “So, I’ll continue to continue to pretend, my life will never end, and flowers never bend, with the rainfall.” It was my soundtrack.

For the full commentary, see:

Anemona Hartocollis. “My Husband’s Doctor, Onscreen.” The New York Times, SundayStyles Section (Sunday, November 20, 2022): 1-3.

(Note: the online version of the commentary was updated June 20, 2023 [sic], and has the title “Cancer, My Husband’s Doctor, and Catherine Deneuve.”)

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.”)

“Keeper” of Home Where Walt Disney Screened His Films Wants to “Inspire” the “Creative”

(p. M6) Walt Disney’s former Los Angeles home—now for rent asking $40,000 a month—looks like something out of one of his films: Largely covered in vines, the Storybook-style home has a turret, leaded-glass windows and a cobblestone motor court.

Disney built the four-bedroom Los Feliz home in 1932, and lived there with his wife and family for about 20 years before moving to Holmby Hills, according to Disney historian and blogger Todd Regan. The property is now owned by Kazakhstan-born film director Timur Bekmambetov, who bought it in 2011 for $3.7 million, according to public records.

. . .

He is now renting it out, he said, because he wants people to be able to experience staying there.

. . .

There is a screening room in the house where Disney watched his films, Regan said. In the yard sits a cottage-style playhouse, which Disney gave his daughters on Christmas Day in 1937 following the release of “Snow White and the Seven Dwarfs,” he said.

. . .

Bekmambetov, who has directed movies including 2004’s “Night Watch” and “Wanted” in 2008, said he has always been a fan of Disney’s work. When the home hit the market in 2011, he couldn’t believe it was tied to the late filmmaker. “I got a notification that there was a house for sale and it had the Walt Disney name,” he said. “I called my assistant and said to her, ‘Please call. I think it’s a mistake.’” But it wasn’t a mistake, and Bekmambetov decided to buy the home sight unseen.

Bekmambetov said he considers himself the home’s “keeper.” The house inspired a graphic novel and movie script he is working on, he said, about fictional Disney characters who never made it to the big screen. He said he hopes to rent the house to someone who is creative and will be inspired by the home, just as he has been.

For the full story, see:

Libertina Brandt. “Walt Disney’s Onetime L.A. Home for Lease.” The Wall Street Journal (Friday, June 16, 2023): M6.

(Note: ellipses added.)

(Note: the online version of the story has the date June 12, 2023, and has the title “Walt Disney’s Former L.A. Home Is Now Renting for $40,000 a Month.”)

“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.”)

Some High Performers Find Ways to Avoid Accumulating Microstresses

(p. C5) Have you had days that exhaust you extraordinarily without any particular reason why?

. . .

There’s a common but little-understood reason for that exhaustion. We call it “microstress”—brief, frequent moments of everyday tension that accumulate and impede us even though we don’t register them.

. . .

One study published in the journal Biological Psychology in 2015 found that exposure to social stress within two hours of a meal leads your body to metabolize the food in a way that adds 104 calories on average. “If this happens daily, that’s 11 pounds gained per year,” noted Lisa Feldman Barrett, a psychology professor at Northeastern University and author of “Seven and a Half Lessons About the Brain.”

. . .

In our research, we observed that some of the high performers—a small subset that we came to call the “Ten Percenters”—were much better at coping with microstress than the rest of those we studied, and perhaps than the rest of us, too. What do they do differently?

. . .

. . ., they’re better at removing themselves from interactions that generate microstress in their lives, whether or not they realize the dynamic. Ten Percenters are more likely to shape these interactions by dealing with simmering disagreements head-on or by limiting such contacts.

. . .

Our Ten Percenters were also thoughtful about not creating the kinds of conditions that cause microstress for others. Think about what happens—to both of you—when you push your child too hard on their grades and it comes back in the form of a rebellious attitude. Or the stress you may create as a manager by unnecessarily shifting expectations. Stopping this cycle helps to prevent microstress from boomeranging back on us.

For the full essay, see:

Rob Cross and Karen Dillon. “Combating the ‘Microstress’ That Causes Burnout.” The Wall Street Journal (Saturday, April 22, 2023): C5.

(Note: ellipses added.)

(Note: the online version of the essay has the date April 21, 2023, and has the same title as the print version.)

The essay quoted above is adapted from Cross and Dillon’s book:

Cross, Rob, and Karen Dillon. The Microstress Effect: How Little Things Pile Up and Create Big Problems—and What to Do About It. Boston, MA: Harvard Business Review Press, 2023.