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Reflections and ideas on justice and being human

Docs and Cops and Burnout

Policing and medicine analogize in many ways.  One similarity is the effect of the work on the people who do it for a living.

Check out this piece from WBUR.  It’s reporting on a study of burnout effects on MDs.  In many places, substitute ‘police officer’ for ‘doctor’ and the story still works.

Boston Medical Center takes a step in the right direction with appointment of a high-level wellness officer and program.  Police and other CJ agencies should be looking at the same thing.

Burnout Among Doctors Is A Public Health Crisis, Report Says

Increasing burnout among physicians is a dire public health crisis, new research out of Harvard says.

The paper cites research that nearly half of American doctors experience symptoms of professional burnout. And a 2018 survey found that 78 percent of over 8,000 physicians polled reported feeling burned out at least sometimes.

“At some point, you can’t go much higher, or you’re going to hit 100,” said Dr. Ashish Jha, dean of global strategy at Harvard T.H. Chan School of Public Health and an author on the new study. “We’ve got to start addressing this.”

But according to Dr. Elisabeth Poorman, a primary care physician in Everett, part of the problem with treating symptoms of burnout is that there’s no exact definition for what burnout is.

Jha and his fellow authors say “professional burnout” is typically manifested by three main symptoms: emotional exhaustion; a sense of depersonalization and disconnection from work; and feeling a lack of efficiency at work.

Poorman, who has written for WBURabout her experience with clinical depression as an intern, agrees. But she also says that the lack of consensus on what constitutes burnout leads to a mischaracterization of the problem.

Specifically, she says it lets the medical education system off the hook as the main culprit in making such issues the norm.

“I feel that it recasts a systemic problem as an individual one,” Poorman said. “Starting in medical school and continuing throughout our lives, we [physicians] are discouraged from seeking mental health care. And I think that it’s what allowed this toxic and dysfunctional culture to proliferate without any real pushback.”

Furthermore, Poorman suggested affected doctors often misdiagnose serious mental health disorders as simply being “burned out.”

“We’re supposed to be invulnerable,” she said.

Jha echoed Poorman’s assertion about the medical community’s culpability in perpetuating stigmas about doctors’ mental well-being. He says a cultural change is needed.

“It’s really important to separate out somebody who’s so dysfunctional and incapable of taking care of patients that they are a danger to patients,” Jha said, “and having a mechanism where people can just come forward and talk about these feelings and issues and symptoms and get them addressed. Right now we conflate these things. And I think it’s made the problem much worse.”

Improvements to mental health treatment are prominent among the Harvard paper’s suggestions for solutions to the growing problem.

For starters, the authors challenge medical institutions and officials to “facilitate appropriate treatment and support without stigma or unnecessary constraints on physicians’ ability to practice.” And they suggest that health care organizations add a chief wellness officer charged with studying and seeking to reduce burnout.

Also, the authors point out a need for improving the electronic health records system. The paper asserts that the computer-based system used by many health providers requires physicians to spend two hours doing computer work for every one hour spent in face-to-face interaction with a patient. That also often means many late-night hours in the office.

Jha and his co-authors highlight that patients are less likely to be satisfied with care from doctors who are experiencing symptoms of burnout. Furthermore, research implicates symptoms of burnout with increases in physician error.

If these burnout factors are not meaningfully addressed, the issue could have drastic long-term ramifications for health care throughout the country, the paper says. The authors say physicians experiencing burnout are more at risk for ending their practices or leaving medicine altogether. 

The U.S. Department of Health and Human Services has predicted a nationwide shortage of up to 90,000 physicians by 2025. In addition to the lack of health care access that would create, recruiting new physicians or replacing departed ones can cost employers anywhere between $500,000 and $1 million.

Jha’s own experience with burnout has left him at times feeling “thwarted” rather than aided by the medical system in his quest to help patients. That toll, he says, is a challenge for any physician to bear.

“You get home and you say, ‘Am I doing good here? Am I actually doing what the patient needs?’ ” Jha said. “It is distressing. It is at times incredibly demoralizing. I think all of us feel those kinds of dysfunctions.”

 

 

 

Looking at Urban History in Stationhouse Architecture

We learned about this piece from Gary Cordner. https://urbanomnibus.net/2018/03/beacon-bunker/

The article is a photo report on the history of architecture of police precinct houses in NYC.  One can can see the evolution of how city authorities viewed the community.  Many 19th century and early 20th century houses look like courthouses and municipal administration buildings.  The design says that the police are an important democratic institution in a stable society.  Things were never so stable as the designs suggest — at the same time we were building armories as fortresses for militias to put down labor struggles–  but one can see the main tendency: Romanesque and renaissance facades communicating dignity.

By the mid-20th century, one sees the emergence of the bunker architecture, the us against them design.  The buildings look like fortresses.  The design is a response to the deeply-felt threats of massive increases in urban crime and violent rioting as well as social unrest, as many formerly excluded peoples asserted themselves.

In my city, Boston, one can compare the late 19th century District 14 building in Brighton with the 1960’s stations in Dudley Square and on New Sudbury Street in Government Center (formerly the West End).  District 1 on New Sudbury is complete with embrasures (loop holes) to facilitate fire at invaders.  Compare these fortified positions with some of the re-purposed 19th and early 20th Boston houses like 28 Seaverns Avenue (old Division 13) in Jamaica Plain, the old Station Nine on Dudley Street near St. Patrick’s Church and the old Division 16 in the Back Bay.

Then look at the buildings opened since the 1990’s.  No more bunkers; we are back to civic institutions placed in prominent settings, like the jazzy new house in Staten Island in this article or the new Boston houses in the South End (District 4) and in Dudley Square (2).

https://urbanomnibus.net/2018/03/beacon-bunker/

Houston police focus on choking in prevention of domestic violence homicides

The HPD has adopted an investigative tactic that progressive departments across the US are using in DV cases.  Research and the experiences of victims and officers long have established the personal and extreme nature of violence in assaults on intimate partners.  Evidence of choking is not always easy to spot.  It takes the extra care HPD is exercising.

By Brian Rogers, Houston Chronicle, March 7, 2018

Houston police commanders who are targeting domestic violence in an effort to prevent homicides implemented a new policy Wednesday, and will now send a supervisor to crime scenes where there are allegations of domestic violence but no arrests have been made.

The change is an effort to increase awareness among law enforcement and prosecutors that victims of domestic violence, specifically those who are strangled and survive, are eight times more likely to be killed by the abuser within a year, according to studies.

 

At a press conference Wednesday where they were flanked by more than a dozen senior police officers and prosecutors, HPD Chief Art Acevedo and Harris County District Attorney Kim Ogg announced the new policy. It requires supervisors to go to domestic violence calls where there is not an arrest to double check whether charges should be filed. HPD officers are also being trained to look for signs of strangulation that may not be readily apparent, such as victims who say they saw stars or exhibited raspiness in their voice.

Preventing

“We know that too often, domestic violence leads to homicides,” Acevedo said. “We want to put perpetrators on notice that the Houston Police Department will be putting you in jail if you commit acts of domestic violence.”

Acevedo said Houston recorded 43 domestic violence homicides last year.

Acevedo also encouraged immigrants in Houston without documentation to report crime, especially domestic violence.

 

“We’re not interested in somebody’s immigration status,” he said. “If a person is a victim of a crime or a witness to a crime, we want them to understand that this department, this DA, our mayor, our community, stands with victims and witnesses of crime.”

 

In April, Acevedo said a police department analysis found the number of Hispanics reporting rape was down 42.8 percent from last year, and those reporting other violent crimes had registered a 13 percent drop. He blamed the drop on fear about deportation among immigrants, and said fewer people reporting crime affects the safety of the entire community.

 

On Wednesday, law enforcement officials said they hope collecting evidence of strangulation early in the process will mean they can file more serious charges and prosecute them more aggressively.

 

The policy adds to an ongoing initiative by the DA’s office, called the strangulation task force, to increase communication between police called to the scene of domestic violence and prosecutors who sign off on charges being filed.

 

“The solutions are not that difficult,” Ogg said. “Train our lawyers, train our officers and make more appeals that are evidence-based to our judges when setting bail.”

The initiative was applauded by domestic violence experts, including officials with the Houston Area Women’s Center, who said they hope it prevents the escalation of violence that leads to fatal confrontations.

 

“Domestic violence is very prevalent in our community.” said Sonia Corrales, the interim president of HAWC. “Domestic violence is a preventable crime. We know what it is, and we know what to do about it. The only way to do it, is by working together.”

brian.rogers@chron.com

twitter.com/brianjrogers

 

Cognitive Bias Loses the Game

This piece from the NY Times, co-written by Dr. Richard Thaler, who won the Nobel Prize last year for research on these questions, demonstrates that a cognitive bias common to all brains — aversion to loss — can distort our decisions.  This piece is reproduced in this blog because criminal justice practitioners can benefit from better management of their brains.  The conclusions seem “counter-intuitive” but are really just counter-cognitive bias.

Force Overtime? Or Go for the Win?

By JESSE WALKER, JANE L. RISEN, THOMAS GILOVICH and RICHARD THALER, NY Times Feb. 4, 2018

“The Packers had fallen prey to a common fallacy: When facing decisions like this, people are often myopic, focusing too much on the possibility of an immediate loss. They avoid the risk of instant defeat, even when taking that risk offers the best path to victory.”

On Jan. 16, 2016, with time expiring in the fourth quarter of a playoff game between the Green Bay Packers and the Arizona Cardinals, the Packers quarterback Aaron Rodgers completed an improbable Hail Mary touchdown pass to bring the Packers within 1 point of the Cardinals.

The Packers then had a choice to make. They could kick an extra point, which would send the game into overtime. Or they could go for a 2-point conversion, which though more difficult would win the game.

Ultimately, the Packers chose to tie the game with an extra point. Then their fans watched in dismay as the Cardinals promptly scored a touchdown in overtime and won the game.

The Packers had fallen prey to a common fallacy: When facing decisions like this, people are often myopic, focusing too much on the possibility of an immediate loss. They avoid the risk of instant defeat, even when taking that risk offers the best path to victory.

Most other National Football League teams behave this way, too. In research to be published in the forthcoming issue of The Journal of Personality and Social Psychology, we examined every instance over a recent 10-year period in which N.F.L. teams faced a choice in the final minutes between kicking an extra point to tie the game or going for a 2-point conversion to win. The teams overwhelmingly chose to avoid the risk of immediate defeat: Of the 47 times teams faced this situation, they opted to kick the extra point 42 times (89 percent).

This bias can be costly. Teams that chose to avoid the 2-point conversion won the game only 40 percent of the time, which is well below the average rate of successful 2-point conversions (about 50 percent). Surely some of those teams should have known they were underdogs if the game went into overtime, and mistakenly avoided a risk they should have taken.

This error is not limited to the N.F.L. We also looked at all instances in the past five years in which teams in the National Basketball Association trailed by 2 points with less than 24 seconds to play. In this situation, a team can attempt a 2-point shot that would send the game to overtime or try a (more difficult) 3-point shot that would win the game immediately.

Again, a clear bias emerged: Of the 772 instances in which teams faced this situation, they avoided the 3-point shot 71.1 percent of the time.

This bias appears to be costly in the N.B.A. as well. The teams that attempted the 3-point shot won the game more often (17.3 percent) than those that attempted the 2-point shot (14.5 percent).

Basketball fans in a laboratory environment make this same mistake. In one study, we asked participants to imagine that they were the coach of an N.B.A. team that was down by 2 points in the final seconds. Just as N.B.A. teams did, our participants avoided the superior strategy, opting for the 2-point shot 81 percent of the time.

Why do people make this error? Part of the explanation lies in our tendency to treat problems in isolation rather than as part of a larger whole. Just as investors often mistakenly evaluate stocks individually rather than as part of a portfolio, coaches and fans often evaluate decisions in terms of their immediate impact and give less consideration to how those decisions fit in the larger context of the game.

In our laboratory study, we found that whether participants opted for the 2-point or 3-point shot was unrelated to their beliefs about how the team would perform in overtime. They made their decision by focusing almost entirely on the prospect of losing immediately, neglecting how the future was likely to play out.

But there is more to the story than myopia. People also seem to be unnecessarily wary of risks that they feel they are choosing to take (as opposed to risks they feel they are forced to take).

In a study that highlights this point, we asked football fans to imagine that a team had scored a touchdown in the final seconds of a game. Then we told half the fans that the team trailed by 1 point and the other half that the team trailed by 2 points. We then told all the fans that the team was going to attempt a 2-point conversion.

Those who were told the team was down by 1 point (and thus had the viable option of kicking the extra point to force overtime) thought the 2-point conversion was more likely to fail than did those whose team had to attempt a 2-point conversion just to force a tie. That is, the same decision was thought to be riskier when it was seen as optional than when it was seen as unavoidable.

“Live to fight another day” is often a good rule of thumb, but it is not always the best strategy to pursue. Good judgment, in sports and elsewhere, sometimes requires the presence of mind to take the risk of an immediate setback to achieve lasting success.

 

Jesse Walker is a graduate student and Thomas Gilovich is a professor in the psychology department at Cornell. Jane L. Risen and Richard Thaler are professors at the University of Chicago Booth School of Business.

 

Cops, Docs and Choices

Policing and medicine analogize pretty closely. Cops and docs could learn a lot about decision-making from one another.  They make consequential choices with fragmented information and within constraints of time, fatigue and biological stress.  One can manage one’s brain to improve one’s decision-making ability.  Here is one doc’s late-career reflection.

“The Conscience of a Brain Surgeon”

“The difficulty of neurosurgery lies not so much in the operating as in the decision-making. Surgeons must balance the risks and benefits of surgery against the risks and benefits of not operating. These are probabilities, not certainties, and they are easy to misjudge.”

By Henry Marsh, MD, Sept. 29, 2017 Wall Street Journal

I fell in love with neurosurgery at first sight, almost 40 years ago, when I first saw an aneurysm operation.

Aneurysms are fragile blowouts only a few millimeters wide, growing off the major cerebral arteries. They can rupture without warning, causing death or a major stroke. The surgeon puts a microscopic clip across the aneurysm to prevent such a rupture. But if the surgeon bursts the aneurysm while trying to clip it—a small but very real risk—the patient can die or suffer a catastrophic stroke, causing the very harm that you are trying to prevent. The operation combined exquisitely difficult, microscopic surgery with all the excitement of bomb-disposal work, without any risk to the surgeon.

A career in neurosurgery appealed to my competitive, alpha-male nature, as well as to my deep intellectual fascination with the brain. What could be more glorious than being a brain surgeon? I signed up for the specialty more or less the next day

Now, facing retirement, I am still in love with neurosurgery, but my view of it has changed profoundly. I soon came to understand that brain surgery is very crude relative to the microscopic intricacy of the brain. Our main tool is a small sucker, two millimeters in diameter, 50 times as large as the average brain cell—a low-tech device in the face of such complexity.

Worse, the brain has only a limited capacity to recover; it doesn’t heal like bone, muscle or other tissues. So brain surgery is particularly dangerous, risking not only death, paralysis or blindness but also changes to our intellect and personality—our very being.

The difficulty of neurosurgery lies not so much in the operating as in the decision-making. Surgeons must balance the risks and benefits of surgery against the risks and benefits of not operating. These are probabilities, not certainties, and they are easy to misjudge.

Overtreatment is a major problem in modern medicine, especially in the U.S. The patient may be perfectly well after an operation that was actually a mistake—one in which a less biased or emotional assessment would have shown that the probable risks of not operating were less than the probable risks of operating. My worst mistakes—the times patients came to harm at my hands—have almost always stemmed from bad decision-making on my part.

Other people are always better at seeing our blunders than we are. Only toward the end of my career did I fully grasp the importance of having good colleagues willing and able to criticize me.

In a safe surgical department, the senior surgeons get on well and don’t feel threatened by each other. This often doesn’t happen. Surgical egos are large. One cannot carry out high-risk surgery if one suffers from low self-esteem. Teamwork doesn’t—and to some extent shouldn’t—come naturally to surgeons.

‘It is dangerously easy to become corrupted by your patients’ gratitude.’

It is also dangerously easy to become corrupted by your patients’ gratitude, which can often verge on adulation (although it is, of course, grounded in fear). You can be rude with patients, but if their operation goes well, they will still think you are wonderful. And if the patient “does badly,” we have many ways of exculpating ourselves. We can blame the pathology, the anesthetist, the equipment or the postoperative care, all of which lets us continue to see ourselves as the infallible, Godlike creature that our poor, frightened patients want us to be.

As the French surgeon René Leriche put it, all surgeons carry within themselves an inner cemetery containing the headstones of the patients who came to harm at our hands. The triumphs are triumphant only because disasters also occur.

Complacency, I have learned, is the worst of all surgical sins. All doctors face the central challenge of balancing professional detachment with painful compassion. You can care too much for your patients and become overwhelmed—because however skillful and diligent you are, some of your patients will suffer and die.

But if you fail to suffer with them to at least some extent, you will have lost not only your humanity but also your drive to do better. I still love the struggle to find this balance—and to justify the respect and confidence that our patients have little choice but to place in us.

___________________

Dr. Marsh is the author, most recently, of “Admissions: Life as a Brain Surgeon,” which was published by St. Martin’s on Oct. 3, 2017.

 

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