The Ladykillers

We are on the two-a-month rental plan from Netflix, which helps keep our video viewing under control. But it also presents a challenge to me as the one who usually gets the job of choosing the films we watch—where to go next, so as to make good use of such a limited resource?

Fortunately or not, I know a lot about movies made before 1990 or so. With a few notable exceptions, the films I think are suitable for family viewing (our family, anyway) were made before 1965. And that still leaves a vast array of choices, whether you choose by genre or studio or actor or director. From which I have to cherrypick, in order to avoid boredom. In days gone by we might have had, say, a Fred Astaire binge, because even if we watched the fifteen or so best movies he made the binge would be over in a few weeks. Now such a binge would dominate a year’s viewing.

Just in the past few months I’ve made some notably successful choices, each very different from the others. There was The Seven Samurai, a three hour film (with subtitles!) set in medieval Japan. And Good Neighbors, the mid-70s British sitcom about a couple who goes self-sufficient in a posh suburb of London. And Jean de Florette/Manon of the Springs, a simple story of tragic proportions set in a peasant village in early 20th century France (again, with subtitles).

For some reason a few weeks ago I remembered the incredible string of black (well, gray) comedies made by Ealing Studios, many of which starred Alec Guinness. They are legendary, but in fact I’d only seen a couple, and those a long time ago. After looking through reviews, I chose The Ladykillers. My description of the film—a gang of crooks involve a clueless old woman in their clever plan to rob a payroll, then decide to kill her because she knows too much—wasn’t received too warmly by the rest of the family, but they went along with the choice.

The movie is extremely funny, but in a very different way than most other comedies, especially contemporary ones. There is some slapstick, but not played broadly—in fact, it is quite gritty and realistic. The robbery is clever and intricate, but unfolds matter-of-factly with no frantic music or activity. Each of the characters is a caricacture of a type, but none of the actors hams it up. The the drama builds along with the comedy, quietly and steadily, and the result is much funnier than if it had been played over the top. (Not that there’s anything wrong with over the top. I love it. But this film was better for having resisted the temptation.)

The weirdnesses of The Ladykillers are quite deliberate, and it’s worth paying attention to them and pondering them. The sets are a cross between ultra-realistic and absurd, e.g Mrs. Wilberforce’s strange out of square (“subsidence after the bombing, you know”) Victorian home set smack between two ominous-looking tenement buildings and right over a tunnel under which trains leave and enter the station day and night. Many of the scenes are practically staged as paintings, as in the frame shown above. The music is some weird modern-sounding score, or what passed for modern in 1956. Some of the incidents, such as the crooks having to rescue Mrs. Wilberforce’s escaped parrot, or having to sit down to tea with her aged friends, do nothing to advance the plot but everything to increase the weirdness of the setting.

Alec Guinness does a remarkable job as the Professor. Although I’m sure that makeup helped, he manages to bring a realistic ugliness to his character that makeup alone can’t provide. It’s all tied up with his walk, his speech, the set of his face. Brilliant stuff.

We’re moving on next to Kind Hearts and Coronets, the first of the Ealing comedies, in which “a distant poor relative of the Duke of D’Ascoyne plots to inherit the title by murdering the eight other heirs who stand ahead of him in the line of succession.” All eight heirs are played by Guinness.

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The upwardly spiraling cost of medicine

Sometimes the answer to a puzzle is simple enough, but rejected because it isn’t what the questioner wants to hear. Why are health care costs spiraling out of control? Looking at McAllen, Texas, where the average annual Medicare expense for each person enrolled is twice the national average, the answer is simple, but who wants to hear it?

Between 2001 and 2005, critically ill Medicare patients received almost fifty per cent more specialist visits in McAllen than in El Paso, and were two-thirds more likely to see ten or more specialists in a six-month period. In 2005 and 2006, patients in McAllen received twenty per cent more abdominal ultrasounds, thirty per cent more bone-density studies, sixty per cent more stress tests with echocardiography, two hundred per cent more nerve-conduction studies to diagnose carpal-tunnel syndrome, and five hundred and fifty per cent more urine-flow studies to diagnose prostate troubles. They received one-fifth to two-thirds more gallbladder operations, knee replacements, breast biopsies, and bladder scopes. They also received two to three times as many pacemakers, implantable defibrillators, cardiac-bypass operations, carotid endarterectomies, and coronary-artery stents. And Medicare paid for five times as many home-nurse visits.

The primary cause of McAllen’s extreme costs was, very simply, the across-the-board overuse of medicine.

Fifteen years ago, the cost per Medicare patient was exactly the national average. What changed?

“Come on,” the general surgeon finally said. “We all know these arguments are [nonsense]. There is overutilization here, pure and simple.” Doctors, he said, were racking up charges with extra tests, services, and procedures.

The surgeon came to McAllen in the mid-nineties, and since then, he said, “the way to practice medicine has changed completely. Before, it was about how to do a good job. Now it is about ‘How much will you benefit?’ ”

Everyone agreed that something fundamental had changed since the days when health-care costs in McAllen were the same as those in El Paso and elsewhere. Yes, they had more technology. “But young doctors don’t think anymore,” the family physician said.

What the surgeon means by “young doctors don’t think anymore” is that they do not make direct diagnoses anymore, relying instead on the results of extensive testing. I’ve heard exactly the same thing from Roger Murrell, our pastor who is also an emergency room nurse.

Depending on test results allows a doctor to distance himself from responsibility for prescribing a particular treatment; the course of treatment is dictated by the test results, not the doctor’s personal judgment. It also is a lucrative path for a doctor to follow.

The surgeon gave me an example. General surgeons are often asked to see patients with pain from gallstones. If there aren’t any complications—and there usually aren’t—the pain goes away on its own or with pain medication. With instruction on eating a lower-fat diet, most patients experience no further difficulties. But some have recurrent episodes, and need surgery to remove their gallbladder.

Seeing a patient who has had uncomplicated, first-time gallstone pain requires some judgment. A surgeon has to provide reassurance (people are often scared and want to go straight to surgery), some education about gallstone disease and diet, perhaps a prescription for pain; in a few weeks, the surgeon might follow up. But increasingly, I was told, McAllen surgeons simply operate. The patient wasn’t going to moderate her diet, they tell themselves. The pain was just going to come back. And by operating they happen to make an extra seven hundred dollars.

This approach has become standard operating procedure in McAllen, known thoroughly by all doctors in the vicinity whether or not they follow it themselves. It isn’t difficult for a group of doctors to predict exactly what expensive, unneeded procedures will occur in response to a common situation.

I gave the doctors around the table a scenario. A forty-year-old woman comes in with chest pain after a fight with her husband. An EKG is normal. The chest pain goes away. She has no family history of heart disease. What did McAllen doctors do fifteen years ago?

Send her home, they said. Maybe get a stress test to confirm that there’s no issue, but even that might be overkill.

And today? Today, the cardiologist said, she would get a stress test, an echocardiogram, a mobile Holter monitor, and maybe even a cardiac catheterization.

“Oh, she’s definitely getting a cath,” the internist said, laughing grimly.

The journalist repeatedly returns to the question: why do some cities have high medical costs, while others are much lower? There seems to be a divide in how inclined a physician is to order expensive procedures in certain situations.

The researchers asked the physicians specifically how they would handle a variety of patient cases. It turned out that differences in decision-making emerged in only some kinds of cases. In situations in which the right thing to do was well established—for example, whether to recommend a mammogram for a fifty-year-old woman (the answer is yes)—physicians in high- and low-cost cities made the same decisions. But, in cases in which the science was unclear, some physicians pursued the maximum possible amount of testing and procedures; some pursued the minimum. And which kind of doctor they were depended on where they came from.

The journalist also asks the same question in a different way: why are costs in El Paso, a city very much like McAllen, so much lower?

There was no sign, however, that McAllen’s doctors as a group were trained any differently from El Paso’s. One morning, I met with a hospital administrator who had extensive experience managing for-profit hospitals along the border. He offered a different possible explanation: the culture of money.

“In El Paso, if you took a random doctor and looked at his tax returns eighty-five per cent of his income would come from the usual practice of medicine,” he said. But in McAllen, the administrator thought, that percentage would be a lot less.

He knew of doctors who owned strip malls, orange groves, apartment complexes—or imaging centers, surgery centers, or another part of the hospital they directed patients to. They had “entrepreneurial spirit,” he said. They were innovative and aggressive in finding ways to increase revenues from patient care. “There’s no lack of work ethic,” he said. But he had often seen financial considerations drive the decisions doctors made for patients—the tests they ordered, the doctors and hospitals they recommended—and it bothered him. Several doctors who were unhappy about the direction medicine had taken in McAllen told me the same thing. “It’s a machine, my friend,” one surgeon explained.

This, I think, is the key to understanding the situation. Doctoring used to be something else, and some doctors behave as if things were as they used to be. But doctoring has now become business, big business, and there is little or nothing in how we view medicine today that can incline a doctor to stand apart from business pressures and continue to doctor in the old way.

From the modern point of view, the old-fashioned doctor is a fool. More important, the modern system makes it increasingly difficult for the old-fashioned doctor to provide his service in an old-fashioned way. The expectations of patients, the threat of lawsuits, the expense of getting licensed, the business-minded outlook of the hospitals and testing laboratories and specialists he must de
al with, all these exert a tremendous pressure on an old-fashioned doctor to get in step with the new way of doing things.

Is there any possibility of modifying the existing system to re-introduce the old-fashioned attitude towards doctoring while still retaining the benefits of modernity? I doubt it. The journalist thinks otherwise, and presents the Mayo Clinic model as a hopeful possibility.

The real puzzle of American health care, I realized on the airplane home, is not why McAllen is different from El Paso. It’s why El Paso isn’t like McAllen. Every incentive in the system is an invitation to go the way McAllen has gone. Yet, across the country, large numbers of communities have managed to control their health costs rather than ratchet them up.

I talked to Denis Cortese, the C.E.O. of the Mayo Clinic, which is among the highest-quality, lowest-cost health-care systems in the country. A couple of years ago, I spent several days there as a visiting surgeon. Among the things that stand out from that visit was how much time the doctors spent with patients. There was no churn—no shuttling patients in and out of rooms while the doctor bounces from one to the other. I accompanied a colleague while he saw patients. Most of the patients, like those in my clinic, required about twenty minutes. But one patient had colon cancer and a number of other complex issues, including heart disease. The physician spent an hour with her, sorting things out. He phoned a cardiologist with a question.

The story of the Mayo Clinic model is an encouraging one, and it’s worth reading what the writer says and weighing the possibility that it might spread. I am skeptical, but that is just an opinion, based on the idea that McAllen seems to more closely exemplify the peculiar brands of wickedness that flourish in this modern world.

One afternoon in McAllen, I rode down McColl Road with Lester Dyke, the cardiac surgeon, and we passed a series of office plazas that seemed to be nothing but home-health agencies, imaging centers, and medical-equipment stores.

“Medicine has become a pig trough here,” he muttered.

Dyke is among the few vocal critics of what’s happened in McAllen. “We took a wrong turn when doctors stopped being doctors and became businessmen,” he said.

Five years ago, when the living was easy and the cotton was high, who would have objected to the idea of doctors becoming businessmen? I think that they would have been admired for their cleverness and upwardly spiraling incomes.

In fact, the exact same businesslike approach that got us into this quagmire is often championed as a possible way out.

The third class of health-cost proposals, I explained, would push people to use medical savings accounts and hold high-deductible insurance policies: “They’d have more of their own money on the line, and that’d drive them to bargain with you and other surgeons, right?”

He gave me a quizzical look. We tried to imagine the scenario. A cardiologist tells an elderly woman that she needs bypass surgery and has Dr. Dyke see her. They discuss the blockages in her heart, the operation, the risks. And now they’re supposed to haggle over the price as if he were selling a rug in a souk? “I’ll do three vessels for thirty thousand, but if you take four I’ll throw in an extra night in the I.C.U.”—that sort of thing?

Dyke shook his head. “Who comes up with this stuff?” he asked. “Any plan that relies on the sheep to negotiate with the wolves is doomed to failure.”

Sheep and wolves. Exactly. Medicine used to work, sort of, because doctors were not wolf-like. Not that they were a nobler strain of human; in fact, I think that because until the 20th century their range of operation was so limited that they were able to imagine their important but marginal role in the community as a noble, selfless pursuit. That imagined nobility had some momentum, and acted as a counter-pressure as medicine became increasingly powerful and invasive. But I think the nobility has largely evaporated at this point, and the rest will be gone shortly.

Wonderful browser-based music toy

I waste a lot of time on the internet, but it’s usually wasted on reading, not on playing with the myriad of interactive gizmos that are available. This one, though, is most excellent: the ToneMatrix. To use it, just click on squares in the matrix to turn them on or off, and see what happens. You can also draw a pattern of squares by holding down the mouse button and dragging the cursor around.

The idea is based on another gizmo, the Tenori-On from Yamaha, which is a synthesizer with an ingenious interface.

Here is a video showing how the ToneMatrix is used as part of a more complex computer program called AudioTool, used to create synthesized music.

The Ron Short Band

We’ve known and played music with Ron Short for more than six years now. In 2005, when the Ridgewood Boys made their first sustained attempt at becoming paid performers, he got us most of our significant bookings. Since then he has often asked us to back him up in contexts where he needed a full band, and we are always thrilled for the opportunity to work with him.

The most extended project we’ve worked together on is the Music of Coal Band, which was formed to support the release of a 2-CD set of coal mining songs recorded over the years by various singers. The original occasion was a CD release party at the Carter Family Fold; Ron asked us to learn a few songs from the CD so we could play them at the Fold with him. Since then we’ve worked together on a couple of sets worth of songs from the CD, and have performed them at maybe fifteen different events so far, with more to come.

A few months ago Ron emailed us a list of songs that had nothing to do with coal, saying that he wanted us to have some non-coal material under our belts as well. Then after the Music of Coal performance in Jonesborough in March he told us that he planned to build a working band around the material. He had decided that he wanted to spend the last third of his life performing music that was fun for him to play, and fun for folks to hear.

As good as that sounded to us, the real honor was that he wanted us to be part of that band. Even better, in this configuration Chris’s primary instrument would be the fiddle. Chris has been working hard on his fiddling for awhile now, but he never gets a chance to perform with it as a Ridgewood Boy, and other such opportunities don’t come along often. Now he would be in a band where he was the main fiddler, with Ron alternating between second fiddle and accordion. Believe me, for a fiddler as experienced as Ron, this shows a lot of confidence in a certain young man’s abilities.

Between March and now we found time to join Ron and rhythm guitarist Roy Tackett for three day-long rehearsals. Then yesterday the Ron Short Band made its debut at the Gathering in the Gap festival in Big Stone Gap, where Ron makes his home. It went well, was a lot of fun, and the audience responded.

gathering

(Apologies to Roy Tackett, who is standing to my left in the above picture.)

First set: Stay All Night, Richmond Blues, Coal Town Saturday Night, My Blue Heaven, Mind Your Own Business, There’s a Higher Power

Second set: Roly Poly, Brand New Day, C’est La Vie, Going Back to Texas, Jambalaya, I Can’t Help It If I’m Still In Love With You, One Love

Note to self: check the math

A reader kindly emailed to let me know that I had messed up a calculation in this post about California personal income tax revenue; when revenue dropped from $13 billion to $7.3 billion, it dropped 45%, not 55% as I stated. Which would mean that some smaller percentage than 31% of state revenue has evaporated, but I won’t risk further embarrassment by trying to recalculate.

Instead, I suggest you look at this very informative analysis just published by California State Controller John Chiang. It is a PDF file, and if you don’t want to take the time to download it here are the pertinent numbers:

Compared to April 2008, General Fund revenue in April 2009 was down $6.3 billion (-39%). The total for the three largest taxes was below 2008 levels by $6.3 billion (-40.3%). Sales taxes were $452 million lower (-50.9%) than last April, and personal income taxes were down $5.7 billion (-43.6%). Corporate taxes were $142 million below (-8.6%) April of 2008.

Sales tax collections year to date are short $327 million (-1.8%) from the 2009-10 Budget Act. Income taxes were $653 million lower (-1.7%) than expected, and corporate taxes were $788 million lower than expected (-9.5%).

The State’s other revenue streams were $299 million below (-6.7%) the estimates. Because the 2009-10 Budget Act contained actual revenue through February 2009, these disparities only occurred in the months of March and April.

Be careful reading these numbers, since the comparisons are not uniform; some are comparisons to April 2008, while others are comparisions to estimates made earlier this year during the state budget crisis.

Getting noticed

I really appreciate Tom Jackson’s writings about the nuts and bolts of music performance and the music business. Even though we are pretty far removed from the kind of bands he works with, I’ve learned a number of important things from him. And I’ve often nodded in recognition at some of his more blunt observations.

This time he writes about the common practice of investing everything in the production of a CD, then passing it around in the hopes that someone important will notice.

I just came back from half a dozen speaking engagements with about 150 CDs from various artists. Some of them are gorgeous! The amount of time, energy, and money spent on them is staggering. And though the intention is right, the way we’re doing it does not help the artist.

Can I tell you how the conversation usually goes? An artist hands me a CD and they say, “I’d love for you to listen to this and tell me what you think.” To be honest, I used to listen to every CD I was given. I even took some notes, so I would be prepared when the artist would call to find out what I thought. (I told them the only stipulation was that they had to contact me, and I would give them my card and number.) I was amazed that over 90% of the artists NEVER followed up with a phone call!

The fact that artists failed to follow up—even after an explicit invitation to do so!—astonishes me, but it doesn’t surprise me. We’re all trained to think that our gifts are innate and fully developed, or mostly so, and that success is merely a matter of being recognized for the wonderful people that we are. The 90% who never contacted Jackson were not looking for critical feedback in the first place—admiration and a hand up, maybe, but certainly not a helpful assessment of their strengths and weaknesses.

I learned this lesson just after we had finished our first CD in August 2005. I had sent a copy to our mentor Pete Wernick, in expectation of … well, I didn’t really know what to expect, I was excited about it and thought he might be as well, in some vague way. I didn’t hear back from him, and didn’t see him again until two months later at IBMA. I located him in the exhibit hall, waited patiently as he talked to other folks who were also hovering, then took my turn.

After catching up, I asked him if he had listened to the CD, and if he had any comments. He very kindly told me two things that, while not exactly deflating me, sobered me up and taught me something about the process. First, he said that he was actually in the business of evaluating CDs—that for $75 an hour he would do careful critiques for a band based on what he heard. Second, he pointed out that once the CD is a finished product (as ours was), there was really no point in critiquing it as a CD, since nothing could be done to improve it.

Actually, he told me a third thing, which was that he kept a tall stack of CDs next to his player, CDs that had been given to him by various artists, and periodically he would shrink the stack by playing them—with his finger hovering over the next track button. For him to spend more than ten seconds listening to a track was unusual, not because the track was bad but because it was nothing unusual, fine for the people who wanted to hear it but nothing he needed to take note of. And he said that when he had gotten our CD he had actually started to listen to it critically, making mental notes of all the problems—and then stopped himself, reminded himself that this was something his friends had done, and then listened through it (quickly) with that in mind.

I actually liked that last part, since it helped me do some level-setting, reminding me that there truly was not much unusual about our CD—it was fine for a first effort, like lots of other first efforts that have come and gone—but also that he wanted to spend a little time listening to how his friends were doing.

Back to Tom Jackson, who says he actually did what those artists unreasonably hoped that he would do, i.e. pass on the more intriguing efforts to someone in the industry—but even that is now impossible:

After doing that for a while, I figured if it wasn’t important enough for the artists to call me, then it wasn’t worth my time to listen. So for a while, I would listen to some of the CDs that intrigued me a bit more and pass them on to someone in the record industry.

Now I say, “I’d love to listen to it, but I don’t know what to do with it!” The reply is usually, “if you like it, pass it on to someone you know in the industry.” But all I can say is, “what industry?!” The industry has changed so much. Plus, why and how I listen to music has changed so much, there’s no physical way I can listen to all these songs (if I want to sleep at night, anyway).

And he goes on to point out that even if it were possible, this isn’t what an artist should be doing anyway. An artist should be soliciting intelligent critiques of his work and responding to them accordingly. The rest will take care of itself.

In the rare circumstance that you are an artist that should be signed to a label in this ever-shrinking music industry, what would help the most? How do you get heard? What would move them to even sign you?

Listen to what Josh Bailey, head of A & R at Word/Warner/Curb, says: “The best and most likely way to get labels’ attention is to build up your career and fan base with your live show SO well that promoters, radio folks, managers, other artists,…start noticing!” Josh says that kind of buzz will eventually get back to labels – and that’s usually the way it happens in the recording industry.

We heard the same cruel but accurate truth at one of the IBMA conventions we attended. When you’re hanging out on the lower rungs as we are, you hear a lot of griping about how if only it were possible to get the attention of the higher-ups, things would really start to happen. People quite literally are looking for someone to share the secret handshake with them. And during a workshop put on by some well-known promoters and publicists, one bold person asked the eternal question: “How do we get you guys to notice us?”

You could hear egos deflating around the room as one of the panelists answered, “Well, just keep working on your stuff. If you’re any good, we’ll hear about you eventually.”

The foolishness of depending on experts

There’s nothing remarkable about the particular questions that are raised and left unanswered in this video, a clip from some congressional hearing about the current financial crisis. What’s remarkable is that we as a society somehow persuaded ourselves that we could barrel carelessly along this dangerous, historically unprecedented path if only we charged a few experts with the impossible task of knowing everything that was happening, all the bad things that could happen as a result, and all the ways of controlling or compensating for any particular bad thing that cropped up.

Perhaps it would have worked, if such a level of understanding were possible. Or if we hadn’t been so eager to believe the lies of those who claimed to have that understanding.