Matthew Savoca - "I would like to marry Matthew, but after reading this lovely work, it suddenly seems like a bad idea"




Matthew Savoca, long love poem with descriptive title, The Scrambler, 2010.


“Matthew Savoca’s poetry is like a slow-spinning ceiling fan. It’s like the feeling of being under the ceiling fan. It’s like the feeling of looking up at the ceiling fan. It’s like the feeling of falling half-asleep beneath it. And this book is the calm, sunny room that you’re in.
I could think of a million other tiny small things to say (probably all of them about things like washing dishes) that make me think of Matthew’s poetry and how it’s one of the best things that I know about that exists. Everything seems a little lighter and easier and sunnier if I think about them after thinking about Matthew’s poetry.
You should probably be in love with Matthew Savoca. He wrote this book for you.” – Colin Bassett

“long love poem with descriptive title has this tender sensibility about domestic life, but it’s still very dour and a little sad. It has this way of displaying the repetitive quality of relationships that is comforting but ultimately depressing as hell. I would like to marry Matthew, but after reading this lovely work, it suddenly seems like a bad idea.” – Kendra Grant Malone

"long love poem with descriptive title is a full-length poetry book consisting of one long poem accompanied by little drawings of plants, animals, and a lamp. an un-named famous musician (has a record review on pitchfork.com) said this to me in an email about this book: “…I especially like your dialogue. You reign all the sadness of the world into short, simple, and sweet phrases that somehow tame all the chaos of corpses leaking into the water pipes…” – Matthew Savoca


"How did this book begin as a manuscript? How did it find its place? How did it end?
- this book began as a manuscript of one line that i couldn’t stop thinking in my head: “large eyes are what make you beautiful”. then i just kept adding to it periodically all summer long as the document sat open on my computer screen on a little desk in a tiny corner of a room four floors up. i think it found its place just by walking calmly wherever it wanted to go, like a dog on a leash so long that it was almost not recognizable as a leash but as part of the scenery.
Are you scared? What are you scared of?
- i am not so scared, but recently i realized that i have no idea at all what friendship is, and that scared me a little.
Do you ever think about what you are going to write about something as the something is happening?
- i do that kind of a lot, but i try not to. the more i do it, the worse it comes out when i write about it later. it always comes out best the stuff i didn’t think “oh, i’m going to write such-and-such about this later on”.
Do you see yourself inside your book, or does it seem like other people? Do you feel you have modes?
- i see a slightly-outdated version of myself inside the book. being involved in the publishing of this book has felt a lot like reading old emails and thinking to myself, “oh, man, i remember this. i remember saying that.” because i wrote this book two years ago and just now people are reading it. and since this book is almost kind of like a conversation that i never had, then people reading it two years later is like all of a sudden finding out that you were on the other end of a conversation that never happened two years ago. i don’t feel that i have modes as in a circle, but maybe stations as in a line. that might just be the way i want to see it. on second thought, i am a circle sometimes.
How does a book correspond with the act of love, as an object?
- if the act of love is choosing to consider someone else before you consider yourself, then this book, as an object, is a bounded stack of paper with particular patterns of ink on it that is being sold for 12 dollars with free shipping in the US.
if the act of love is seeing in another person what you love about yourself, then this book, as an object, is like the search bar in your gmail account that you keep going back to over and over again to find exactly what you need, if it’s there.
What is something you have hid?
- i have hid my face in my arms. my penis, i hide that everyday inside of my clothes. i have hid my family, my upbringing. i have hid what i really think about a lot of people and events. i have hid anger and love and i have hid sickness." - Interview with Blake Butler

That Wheel Was Already Invented: the UN Special Rapporteur's Guidelines for Pharmaceutical Companies

For five years now, we have been writing about concentration and abuse of power in health care, and on specific tactics used predominantly by large health care organizations that threaten the values that physicians and other health care professionals once swore to uphold.

Pharmaceutical companies may not have been the worst offenders when it came to threatening these values, but they have not been laggards.  Specific issues we have discussed included (in a peculiar order that I will explain in a minute): failure of the companies' boards of directors to be accountable for misbehavior by its management, sometimes associated with conflicts of interest affecting these board members (e.g., this recent case); outright crime and corruption (e.g., this case); use of key opinion leaders paid by the company to market products cloaked in the mantle of academia; payments made by the companies to patient advocacy groups (e.g., this one), medical societies, and academic institutions that induce institutional conflicts of interest, and enlist these well-reputed organizations as stealth marketers; ridiculously high prices charged for particular medicines, often to particularly vulnerable patients (e.g., this case); suppression and manipulation of clinical research evaluating the companies' products; and deceptive drug marketing practices.

Many other bloggers have written about these issues.  Some of them have been widely taken up in the mainstream media.  A few have even made it into the medical and health care literature. 

But those of us who bring them up have been attacked as a tiny group of pharmascolds (e.g., here), who get in the way of the needed innovation and scientific advances that the pharmaceutical industry generously brings to the public.  Despite such attacks, it may be that our concerns are somewhat more universal, although those with vested interests in maintaining the status quo might not want that publicized too much.

A new issue of PLoS Medicine included several articles on drug companies' responsibilities for human rights.  One was by a former United Nations Special Rapporteur on the right to the highest attainable standard of health.  I, and I suspect most of even our Health Care Renewal readers were not familiar with that office.  I also confess to being unaware that he had published a report to the UN General Assembly entitled Human Rights Guidelines for Pharmaceutical Companies in Relation to Access to Medicines, which included 47 specific guidelines. 

Amazingly enough, it turns out that some of these guidelines seemed to directly address the issues raised above, to wit:

Board of Directors' Accountability
11. The company should have a governance system that includes direct board level responsibility and accountability for its access to medicines policy.

Anti-Corruption
15. A company should publicly adopt effective anti-corruption policies and measures, and comply with relevant national law implementing the United Nations Convention against Corruption.

Disclosure of Financial Support
18. The company should annually disclose its financial and other support to key opinion leaders, patient associations, political parties and candidates, trade associations, academic departments, research centres and others, through which it seeks to influence public policy and national, regional and international law and practice. The disclosure should extend to amounts, beneficiaries and channels by which the support is provided.

19. When providing any financial or other support, the company should require all recipients to publicly disclose such support on all appropriate occasions.

Drug Pricing
33. When formulating and implementing its access to medicines policy, the company should consider all the arrangements at its disposal with a view to ensuring that its medicines are affordable to as many people as possible. In keeping with Guideline 5, the company should give particular attention to ensuring its medicines are accessible to disadvantaged individuals, communities and populations, including those living in poverty and the very poorest in all markets. The arrangements should include, for example, differential pricing between countries, differential pricing within countries, commercial voluntary licences, not-for-profit voluntary licences, donation programmes, and public private partnerships.

34. The arrangements should take into account a country’s stage of economic development, as well as the differential purchasing power of populations within a country. The same medicine, for example, may be priced and packaged differently for the private and public sectors within the same country.

35. The arrangements should extend to all medicines manufactured by the company, including those for non-communicable conditions, such as heart disease and diabetes.

Suppression and Manipulation of Clinical Research
39. The company should take effective measures to ensure that all information bearing upon the safety, efficacy and possible side effects of a medicine are easily accessible to individuals so they can make informed decisions about its possible use.

Deceptive Drug Marketing
41. The company should publicly disclose its promotional and marketing policies and activities, including costs.

Needless to say, I can see no evidence that any big pharmaceutical companies are trying to adhere to any of these guidelines.  Somehow I suspect that those who are supporting the vested interests of big pharmaceutical corporations may not all have that much respect for the United Nations.  However, I think that the Special Rapporteur's guidelines lend more credibility to the argument that we need better leadership of health care organizations, and specifically that such organizations should follow clear ethical precepts, and their leadership should be held accountable when they do not.

So the next time someone calls you a "pharmascold," you can say, "yeah, yeah, so is the UN Special Rapporteur."

More Tales of Hospital Executive Compensation: Pay for What?

I have collected another series of stories from the wild and wacky world of health care executive compensation.  These are from three different hospitals/ hospital systems, ordered from smallest to largest.

Jefferson Healthcare

This story, from Jefferson County, Washington state, came from the Peninsula Daily News:
When Mike Glenn takes over the Jefferson Healthcare CEO office Oct. 4, he will be receiving $225,000 annually to run the 25-bed publicly funded hospital.

And he will become the highest-paid public official in Jefferson County.

Jefferson Healthcare's budget is $65 million, and it employs 360 full-time workers and about 550 part-timers.

Note that the amount above is apparently salary, not total compensation, which could well be higher.

Lakeland Regional Medical Center

This story, from Lakeland, Florida, came from the Lakeland Ledger.

The latest IRS report available on Lakeland Regional Medical Center shows, for the first time, how much LRMC officials receive in base pay and how much in 'bonus and incentive compensation' based on meeting goals assigned them.

Not-for-profit hospitals are required to release their IRS reports. Previously, those reports combined salary and bonuses, which may or may not be awarded in a given year.

Jack Stephens, president and chief executive, was paid $856,514. Of that, $644,034 was his base pay and $212,480 was bonuses.

Second-highest paid was Paul Powers, vice president and chief financial officer. He earned a total $435,581, of which $352,661 was base pay and $82,920 in bonuses.

Third was Dr. William Sadowski, psychiatrist, earning $430,117, of which $149,226 was base pay and $280,891 bonuses.

Others listed as highest compensated:

Dr. Edward Sammer, chief medical officer, $404,789 ($327,607 base pay, $77,182 bonus).

Dr. Olumide O. Sobowale, who heads trauma services, $306,792 ($227,692 base pay, $79,100 bonus).

Janet Fansler, vice president/cardiac and specialty care, $266,672 ($215,954 base, $50,718 bonus).

Mary Ford, chief information officer, $264,283 ($213,978 base, $50,305 bonus).

Carole Philipson, vice president support services and facilities, $246,530 ($199,474 base, $47,056 bonus).

Hugh Autry, vice president acute/surgical care, $245,216 ($198,408 base, $46,808 bonus).

Jeffery Payne, vice president human resources, $229,304 ($185,696 base, $43,608 bonus).

John Schliesser, vice president planning and external relations, $226,571 ($183,363 base, $43,208 bonus).

Dr. Michael A. Campanelli, neurosurgeon, $197,887, not divided into base/bonus.

Ken Menefee, executive director LRMC Foundation, $181,045 ($151,142 base, $29,953 bonus).

Dr. Joy L. Jackson, physician adviser, $164,923, not divided into base/bonus.

Dr. Rajan K. Raj, trauma surgeon, $141,344, not divided into base/bonus.

Note that LRMC is a bigger institution that Jefferson Healthcare, with operating revenue just under $650 million. However, it is now having financial woes, as reported in a separate story in the Ledger.
Lakeland Regional Medical Center's rates will increase an average 10 percent, for the third year in a row, in the fiscal year starting Friday.

These continual increases reflect the financial pressures affecting hospitals, patients and the health care system nationwide.

Costs are increasing for almost everything LRMC pays for - drugs, bad debts, charity care, write-offs to managed-care and government insurance plans, insurance and utilities among them.

The number of hospitalized patients is expected go up very little, an increase of slightly less than 2 percent, according to Vice President and Chief Financial Officer Paul Powers.

UCLA Medical Center

Our last story, from the Los Angeles Times, is about a large, prestigious academic medical center.
First, the board [of regents] approved $3.1 million in bonuses for medical center executives that are linked to efficiencies and improvements in patient health. That money, which comes from hospital revenues, will be distributed among 37 UC hospital leaders across the state.

As part of that group, Feinberg, UCLA's hospital system chief executive officer, will receive a $210,000 bonus. But in a more divisive matter, UCLA officials also received the regents' approval to give Feinberg an extra raise of about $410,000, boosting his total compensation to more than $1.3 million.

Why was this divisive? It turns out that the University of California system is in deep financial trouble.
The University of California regents took steps Thursday to shore up the university's badly underfunded retirement plans by raising the amounts employees and the university will be expected to contribute to them.

In particular,
Meeting at UC San Francisco, the regents unanimously approved a plan that will raise contributions to the pension and retirement health plans over two years to 5% from the current 2% of employees' paychecks, and to 10% from 4% of payroll for the university. The change will take effect quickly for about half of UC's 115,000 employees, including its faculty, but must be negotiated with its unionized employees.

More tough choices are ahead as UC tries to fill an estimated $21-billion liability gap in its retirement plans. Until this spring, neither the university nor its employees had made any contributions to the plans for 20 years.

In December, the regents are expected to review proposals for even more extensive changes, including one that would create a less generous program for employees hired after 2013 and boost the minimum retirement age to 55 from 50.

So in times of such financial stress, why increase the compensation of the UCLA medical center CEO so much?
UCLA Chancellor Gene Block said Feinberg was doing an excellent job and was being wooed by other employers. 'Keeping this team together is essential,' he said.

Summary

So to summarize, the CEO of a tiny hospital gets $225,000 in salary, presumably more in total compensation. The CEO of a mid-size medical center with stagnant revenues and rising costs got over $850,000 in total compensation, while 11 other executives, mostly non-physicians, all got more than $180,000. The CEO of a large medical center, within a university system with a seriously underfunded pension plan which is increasing deductions from all employees' pay, and contemplating reduced retirement programs for new hires, got a $210,000 bonus and a $410,000 raise for total compensation of more than $1.3 million.

So once again we see that even in tiny, public hospitals, the CEOs are paid well, and in bigger hospitals, even those in the midst of financial problems, the CEOs are paid very well. 

There does seem to be a rough correlation with hospital size.  Executives, and their boosters like to imply that the bigger the institution, the harder the job.  Keep in mind, however, that most hospitals, like most modern corporations, are highly pyramidal.  The CEO hardly manages each and every worker.  Rather, the CEO manages a few top executives, who in turn manage a few middle-managers, etc, etc.  For example, a Bloomberg report noted that only 11 top executive report to the CEO of the huge Bank Of America. 

Another claim by CEOs and their defenders is that it is all about pay for performance.  As noted above, and in other posts about executive compensation, the criteria for performance are rarely stated, and hardly explicit.   Anecdotally, there are many examples, including one above, of financially stressed institutions cutting back in other areas, but paying top executives more.  As in the last case above, nearly every CEO seems to be doing a wonderful job, at least according to the boards of directors or trustees to whom he or she is supposed to be accountable. 

In fact, the real lesson seems to be that top managers almost always do well financially, regardless of performance, regardless of financial pressures on their organizations, and do better and better the longer they hold their jobs.  Top executives are really different from you and me.

I say again, if we do not hold health care leaders accountable, if we do not provide them with incentives that are proportional to their actual performance, why should we expect health care organizations to do any more than satisfy their leaders' self-interest?

Interface Problems, Ill-Informed Leadership, Suppression of Whistle Blowing: A New Look at a Historic Case

Three issues that come up frequently on Health Care Renewal are problems with man-machine interfaces in health care information technology (IT), as in this post by Dr Scot Silverstein; ill-informed and mission-ignorant or hostile leaders, sometimes in a position to overrule health care professionals, as in this post; and whistle-blowers, and their silencing.

A truly amazing story just surfaced that deals with all these issues, albeit not in health care.  If it is true, and if it had been revealed earlier, maybe society would have become more concerned earlier with these issues, and maybe they would have not ended up plaguing health care so.

Let me first just go through the basic structure of the story to underline the parallels with health care issues.  Then I will quote the specifics.

(If you do not instantly recognize the story, I suggest going through this post sequentially, not jumping to the end, to make its impact more clear.)

The Structure of the Story

Introduction
A large corporation had just put on-line, with much publicity, a high-technology system that was advertised as bigger, faster, better than the competition. 

Confusing Interface and Terminology, Wrong Control Input 

A few days after becoming operational, those in charge suddenly noticed a looming and severe problem.  A technician was ordered to make an extreme control input to avoid the problem.  However, there was confusion about the terminology of the input.  While the system he was controlling was new, and had a new interface, it was operating in an area in which the old terminology, from a time in which the interface for the particular control worked in the opposite direction, was still in use.  So his extreme input was in exactly the wrong direction.  By the time the mistake was clear, and the control was reversed, it was too late, and the first stage of the catastrophe ensued. 

Ill-Informed Management Overrules the Professionals

It is possible that the catastrophe could have been ameliorated if a crucial part of the system were then to have been quickly shut down.  The highest ranking professional on duty ordered it shut down.  However, soon after the events above, a top executive in the corporation, who was nearby only because of all the hoopla surrounding the system's roll out, came on the scene.  He countermanded the order for the shutdown, possibly thinking continuing operation would cost less money and result in less bad publicity.  True disaster then ensued.

Whistle Blowing Suppressed

After the disaster, there were several government hearings.  The top executive denied any knowledge of the decision making that lead to the disaster.  A professional who had not been present when the decisions were made, but was told about them by those who were present, avoided mention of the events above, because the top executive had told him that if he were to have told the truth, the company would have been found negligent, its insurance would not have covered the disaster, and it would have gone bankrupt, and everyone would lose their jobs.  So he never told anyone except first-degree relatives.  The other people who were present for the events above did not testify, for reasons to be discussed below.

So this story has all the familiar elements.  But so have many others.  Why was the suppression of this version of the story (assuming its true, which is not proven) so important?

The Real Story

Let us go through the elements again, this time with quotes from the article in the London, UK, Telegraph:

Introduction and Context
All families have their secrets, but usually about things that don’t matter to anybody else. Not in the case of Louise Patten, though – or The Lady Patten to give her her full title, the wife of former Tory Education minister, Lord (John) Patten, though her own career as one of the first women board directors of a FTSE 100 company, and as a successful author of financial thrillers, means that she has plenty of achievements in her own right.

As a teenager in the 1960s, Patten was let in on a secret by her beloved grandmother, which, if revealed, she was warned, would result in two things. The first was awful – it would destroy the good name of her dead grandfather, Charles Lightoller, awarded the DSC with Bar in the First World War, and a hero again for his part in the evacuation of Dunkirk in 1940. But the second would change history, overturning the authorised version of one of the world’s greatest disasters, the sinking of the Titanic with the loss of 1517 lives in April 1912.

The tension between these two outcomes goes some way to explaining why, for 40 years, Patten kept quiet....

'After the collision,’ Patten goes on, 'my grandfather went down with the Captain and [First Officer] Murdoch to Murdoch’s cabin to get the firearms in case there were riots when loading the lifeboats. That is when they told him what had happened.'
Confusing Terminology and Interface

'Instead of steering Titanic safely round to the left of the iceberg, once it had been spotted dead ahead, the steersman, Robert Hitchins, had panicked and turned it the wrong way.’

At first glance it sounds extraordinary that anyone – much less the man put in charge of the wheel on the maiden voyage of what was then the world’s most expensive ocean liner – could have made such a schoolboy error.

'Titanic was launched at a time when the world was moving from sailing ships to steam ships. My grandfather, like the other senior officers on Titanic, had started out on sailing ships. And on sailing ships, they steered by what is known as “Tiller Orders” which means that if you want to go one way, you push the tiller the other way. [So if you want to go left, you push right.] It sounds counter-intuitive now, but that is what Tiller Orders were. Whereas with “Rudder Orders’ which is what steam ships used, it is like driving a car. You steer the way you want to go. It gets more confusing because, even though Titanic was a steam ship, at that time on the North Atlantic they were still using Tiller Orders. Therefore Murdoch gave the command in Tiller Orders but Hitchins, in a panic, reverted to the Rudder Orders he had been trained in. They only had four minutes to change course and by the time Murdoch spotted Hitchins’ mistake and then tried to rectify it, it was too late.

A Manager Countermanding the Professional

If the steersman Hitchins had made a human error, Bruce Ismay, chairman of the White Star Line, owners of the Titanic, and another survivor of the sinking, gave a lethal order.

'Titanic had hit the iceberg at her most vulnerable point,’ explains Patten, 'but she could probably, my grandfather estimated, have gone on floating for a long time. But Ismay went up on the bridge and didn’t want his massive investment to sit in the middle of the Atlantic either sinking slowly, or being tugged in to port. Not great publicity! So he told the Captain to go Slow Ahead. Titanic was meant to be unsinkable.’

However,
'If Titanic had stood still,’ she demonstrates, 'she would have survived at least until the rescue ship came and no one need have died, but when they drove her 'Slow Ahead’, the pressure of the sea coming through her damaged hull forced the water over the bulkheads and flooded sequentially one watertight compartment after another – and that was why she sank so fast.’

Whistle Blower Suppressed, the Cover Up

Why, though, I puzzle, would Patten’s grandfather, who sounds like a thoroughly honest and brave man, have lied and carried on lying? 'Because,’ she explains, 'when he was on the rescue ship, Bruce Ismay pointed out to my grandfather that if he told the truth, the White Star Line would be judged negligent and its limited liability insurance would be invalid. Ismay pretty much said that the whole company would go bust and everyone would lose their jobs. There was a code of honour among men like my grandfather in those days. So he lied to protect others’ jobs.’

But why didn’t her grandmother speak up after her husband’s death in 1952? 'She was worried about showing this heroic figure to be a liar. And my mother, who also knew the secret and was even uncomfortable with Granny having told me, felt even more strongly about it. She hero-worshipped my grandfather.’

So there this secret sat, locked in a family circle from which Patten is now the only survivor.
Conclusion

The story does seem amazing. I am hardly an expert on the sinking of the Titanic, so should not try to comment on its truth. It does have some plausibility, and provides an explanation for one of the most important and influential disasters of the 20th century that is still poorly understood and a cause for controversy.

In my humble opinion, if it were true, and had it come out earlier, this amazing story would have focused society's concerns on issues that have instead become scourges of our current era, and particularly important, if not frequently enough discussed causes of our health care dysfunction.

The Titanic disaster lead to major changes in numerous safety practices, leading to rules about the adequacy of lifeboats and radio communication, and even swimming proficiency requirements in higher education. (I had to pass a swimming test as a Brown University freshman that was a legacy of the sinking of the Titanic, I was told.) Most of these practices increased the survivability of accidents.

What if the focus was also on the causes of accidents? What if there was a groundswell of advocacy, starting in 1912, against pressure from business and financial leaders on professionals sworn to protect the public's health and safety, and against intimidation of whistle-blowers whose revelations could protect public health and safety? Maybe health care, and many other parts of life, would have turned out better?

The Dangers of Critical Thinking in A Politicized, Irrational Culture

My early mentor in biomedicine Victor P. Satinsky MD lived by the credo "critical thinking always, or your patient's dead."

Unfortunately, the motto of today's degraded culture in biomedicine (and other domains) might well be "critical thinking, and your career is dead."

At "Health IT: On Anecdotalism and Totalitarianism" I posted these thoughts:

At the article Blumenthal on EMRs: Debate "raging" over competition vs. standards, ONC czar David Blumenthal is cited as saying several interesting things:

... EMRs make him a better physician, he said, recounting personal anecdotes of discovering patients' allergies through automated EMR alerts and using stored image date to more quickly get a diagnosis for a patient without subjecting them to more radiation and toxic radiation agents ...

It's the EMR "anecdotalists"
(as opposed to the "Markopolists") who say that "anecdotes" of HIT-related injury are meaningless. They deem reports of safety issues and HIT-related misadventures and risk as simply "anecdotal", and that "anecdotes don't make evidence" (or "anecdotes don't make data").

Yet anecdotal reports of EMR "saves" are used by a czar to justify tens of billions of dollars of expenditures?

To the anecdotalists, I say: you can't have it both ways.

I also posted nearly the same complete Healthcare Renewal post to several mailing lists of the American Medical Informatics Association including the Clinical Information Systems working group (CIS-WG). CIS-WG is a mailing list read by something over 1000 healthcare informatics professionals at last time I had access to the statistics a few years ago.

I received some supportive replies from colleagues, including collaborators on the AHIMA (not AMIA) book we co-authored in 2009 entitled "H.I.T. or Miss: Lessons Learned from Health Information Technology Implementations" - itself not exactly a popular exercise among the strictly positivist informatics leadership class.

Now, I thought my posting on the double standard regarding "anecdotes" highly straightforward. From a high ranking academic leader of a major national informatics program, Bill Hersh at OHSU, however, the following reply was posted:

Scot,

For someone who is a faculty in informatics, I am surprised at how unfamiliar you are with the literature. There is solid evidence, much more than anecdotes, on the efficacy of health IT. Even Dr. Blumenthal himself has posted on that. (I think you are taking this quote out of context.

I am then served a platter of literature I must be "unfamiliar with" such as:

Goldzweig, C., Towfigh, A., et al. (2009). Costs and benefits of health information technology: new trends from the literature. Health Affairs, 28: w282-w293.

[Note - I had commented on and linked to this very article at
this Aug. 29, 2010 post - ed.]


Garg, A., Adhikari, N., et al. (2005). Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. Journal of the American Medical Association, 293: 1223-1238.

Amarasingham, R., Plantinga, L., et al. (2009). Clinical information technologies and inpatient outcomes: a multiple hospital study. Archives of Internal Medicine, 169: 108-114.

Longhurst, C., Parast, L., et al. (2010). Decrease in hospital-wide mortality rate after implementation of a commercially sold computerized physician order entry system. Pediatrics, 126: 14-21.

Now, aside from the serious breach of academic etiquette of attacking the competence of your colleagues in a public forum, I seem to be hearing that it's OK to purvey positive anecdotes about health IT, but not anecdotes of HIT malfunctions or of HIT-related adverse outcomes, since there's solid evidence of the efficacy of health IT.

In plain English, an ad hominem fallacy is followed by an appeal to authority of sorts ("the literature") to justify public Pollyanna attitudes towards HIT by high ranking officials. And since the literature is so glowing, negative anecdotes must be of low worth.

[Jan. 2011 addendum - perhaps the literature's not so glowing - ed.]

Actually, the response in its entirety was a non sequitur to my post.

Others in cis-wg took affront. One of my book co-authors responded that:

I didn't read Scot's comment as saying that there is no data in support of EHRs .... despite a body of evidence, Dr. Blumenthal made a statement only about personal experience in what Scot quoted.

At the same time, ONC has asked for EHR users to share their positive experiences, but has not (as far as I have seen) asked for their failures. Quite frankly, the failures would be more instructive and would constitute a very valuable repository. ONC has also not shared the studies on the dangers and failures of EHR implementations with nearly the same passion as the successes. My point is that there is data and there is anecdote for both sides and ONC has not presented a balanced picture so that we can adequately address the real risks.

Another CIS-WG reader shared valuable observations:

Regarding Goldzweig:

Regarding studies conducted by the HIT leaders (e.g. Partners Vandy, Regenstrief, IHC, etc...): "Many of the new studies report modest or even no benefits of the new applications or changed functionalities."

Regarding studies of commercial HIT systems: "These study results were similar to those reported by the health IT leaders—most studies demonstrated modest benefits, some demonstrated no benefits, and a few demonstrated marked benefits."

Regarding Adhikari:

The CDSS improved practitioner performance in 62 (64%) of the 97 studies assessing this outcome,

52 trials assessed 1 or more patient outcomes, of which 7 trials (13%) reported improvements.

And so on.

In other words, the literature's mixed.

Finally, the knock-the-ball-out-of-the-park response came from a Medical Informatics researcher Down Under:

I think such defences are particularly unuseful especially with respect to the dismissal of personal stories and experiences as "anecdotes", hence committing them to the realm of folklore. I offer these notions as a counterpoint.

Discounting Anecdotes:

1. Is a perfidious and specious act.

2. It denies early warning signs of problems.

3. It denies a voice and disempowers the working clinical community who have to operationalise decisions made by others.

4. It denies a route to process improvement within an institution - which is most important for EBM and incremental review of local processes.

5. It defends software manufacturers from fault rectification - cuts off even a need to deliberate on it. Critics of the value of anecdotes are squarely on the side of the faulty and deficient manufacturer.

6. A rule of project management is that projects consist of 3 components, cost, quality and time and if their needs to be a compromise it has to be on quality. Anecdotes are early warning signs of such a compromise.

I, of course, added that ignoring "anecdotes" of HIT problems was even more cavalier if one recognized the context of the stories, that is, that they arise in an environment hostile to diffusion through contractual arrangements, poorly recognized reporting resources, fear, etc. Understood in context, they should be receiving more research attention than otherwise, and certainly not ignored.

However, the comment about my purported lack of knowledge of the literature was sent out to 1000+ people by a nationally-recognized informatics leader, people who may or may not read the followup in detail.

This is unfortunate and perhaps reflects the ethos of our day.

S.

Health Care Leaders in Maine Fail to Learn from Past Experience

From down east Maine comes a telling story about the problems of contemporary health care leadership.  I assembled this case from three articles by Meg Haskell in the Bangor Daily News, links are below. (1-3)

Complaints About the CEO's Clinical Policies

The story begins with complaints about clinical policies instituted by the CEO of Acadia Hospital.

[Acadia CEO David] Proffitt has come under fire in recent weeks from current and former Acadia Hospital employees who say the incidence and severity of staff injuries have risen since he initiated a policy that essentially eliminates the use of mechanical and physical restraints with mentally ill patients who become violent. (2)

The concerns were raised with government agencies:
Since the end of July, the federal Occupational Safety and Health Administration has been conducting an on-site investigation into employee complaints of unsafe working conditions at Acadia. The state Department of Health and Human Services also recently has investigated conditions at Acadia, with a report due later this month. (2)

Furthermore,
The OSHA investigation was triggered earlier this summer by a complaint filed with the agency alleging an increase in patient assaults on staff after Proffitt implemented stricter standards against the use of mechanical and physical restraints, even when patients turn violent.(3)

Loss of Experienced Clinicians

There were also concerns that Mr Proffitt presided over the loss of experienced clinicians who were replaced by those with less experience
Employees also have alleged that Proffitt has fired or pushed out a number of clinical leaders at Acadia, including former Vice President for Medical Affairs Dr. Paul Tisher and former Chief Nursing Officer April Giard. They have criticized his replacements as lacking expertise in psychiatric care.(3)

Lack of Clinical Experience or Training, Questionable Educational Credentials

Given his direct involvement in clinical decision making, it surprising that Mr Proffitt has no clinical training or experience:
Proffitt’s academic qualifications also have been questioned.

Proffitt’s education includes a 1984 bachelor’s degree in therapeutic recreation from the University of Nebraska at Omaha, a 1989 master’s degree in recreational administration from Arizona State University, and a 2007 doctoral degree in health administration from Warren National University, now a defunct, unaccredited on-line program. His academic career has been criticized as being inadequate to prepare him for the top-level positions he has held at both Riverview and Acadia, although neither position requires a doctoral degree.(2)

Repeating the Past

It turns out that similar concerns were raised about Proffitt's performance in his previous position:

Psychiatrists formerly employed at Riverview said this week that both patient care and employee morale eroded under Proffitt’s leadership there.

'Over the course of David Proffitt’s tenure at Riverview, a significant number of long-standing and experienced staff left and were replaced with less experienced or temporary people,' said Dr. Bryan Woods, who was employed at Riverview from 2003 to 2006 and now practices in Portland. “\'In my opinion, this resulted in a decrease in the quality of patient care.'

Woods said Proffitt’s management style was often in conflict with the collaborative 'treatment team' approach commonly used in acute-care psychiatric settings.

'Ultimately, I left, because I simply could not work with him,' Woods said.

Woods’ colleague Dr. Dan Filene, who also worked at Riverview under Proffitt, said direct-care staff at the state hospital were placed at increased risk by a stringent policy that all but eliminated the use of any kind of restraints.

'The staff at Riverview are heroic,' he said. 'It’s not just dangerous; it is emotionally challenging, fatiguing, low-paying work. When they are actively being injured, it can’t help but affect patient care.' Filene stressed that most people with mental illness are not dangerous or violent.

Sen. Stanley Gerzofsky, D-Brunswick, is chairman of the Legislature’s Criminal Justice Committee. The committee oversees the locked forensic unit at Riverview, where criminals with severe mental illness are housed and treated. Proffitt’s policy of doing away with restraints for even the most dangerous patients prompted a number of complaints, he said.

'We heard concerns that staff members were being injured [by patients],' Gerzofsky said in an interview this week. 'Staff were complaining that [Proffitt] didn’t have the right credentials and that he didn’t take the violence very seriously. We had him in front of our committee several times.'

Gerzofsky’s colleague on the committee, Sen. John Nutting, D-Leeds, said he heard from several Riverview patient families and staff members.

'Legislators were called to see if he could be replaced,' he said. 'There was really just one single reason — he was telling doctors how to treat their patients. He was trying to get between the patients and their doctors.

Nutting said parents of patients were especially concerned.

'They wanted their loved ones to get the care their doctors wanted them to receive, not the CEO of the hospital,' he said.(2)

Proffitt's credentials were also questioned before:
Proffitt’s degrees in recreational therapy and his online doctorate, Nutting observed, did little to reassure worried families.(2)

Proffitt's Defenders

The allegations made against Proffitt, which appear to be from clinical professionals and patients' relatives, were countered by support from, perhaps not surprisingly, managers and executives:
Michelle Hood, CEO of the hospital’s corporate parent Eastern Maine Healthcare Systems, says that under Proffitt, Acadia is 'moving in the right direction.' She lauded the progress he has made toward de-stigmatizing mental illness and ramping up Acadia’s outpatient and community services.

Note that Michelle Hood, although she has considerable health care management experience, appears not to have any clinical experience of expertise, from her official biography:
Before arriving at EMHS, Michelle was president and CEO of the Sisters of Charity of Leavenworth Health System, Montana Region, as well as president and CEO of its flagship hospital, St. Vincent Healthcare. She received her Bachelor of Science in 1978 at Purdue University and her Master of Health Care Administration at Georgia State University in 1981. Her early career included roles of associate hospital director at Emory University Hospital in Atlanta Georgia, executive vice president and chief operating officer of St. Vincent’s Hospital (of now Ascension Health) in Birmingham, Alabama and chief administrative officer of Norton Hospital in Louisville, Kentucky.

Somehow, the process that hired Mr Proffitt, presided over by Ms Hood, did not seem to consider his previous work at Riverview:
At EMHS, Michelle Hood said Proffitt’s troubles at Riverview 'did not come up' during his interviews for the position of CEO at Acadia.

One of 16 applicants in a nationwide search to replace outgoing CEO Dorothy Hill, he had appropriate letters of reference from former employers, she said.(2)

By the way, the process involved checking whether his educational credentials were accurate, but apparently was unconcerned with the meaning of an on-line degree from an unaccredited institution (subsequently closed down by state authorities, see here.)
His educational credentials checked out.... (2)

Hood dismissed concerns about losses of experienced staff:
Asked about the loss of key clinical administrators at Acadia, including Vice President for Medical Affairs Dr. Paul Tisher and Chief Nursing Officer April Giard, Hood said 'turnover is normal' with a new administration and that Proffitt has successfully recruited new talent and promoted qualified staff from within the organization.

The board of trustees of Acadia Hospital also supported their CEO
At the end of last week, John Bragg, chairman of the hospital’s board of directors, said the board supports embattled CEO David Proffitt, despite a deluge of concerns raised by current and former employees and unflattering revelations about Proffitt’s educational credentials and his leadership at his previous post.

At its regular meeting last Wednesday, the board went into executive session to discuss the situation, Bragg said Friday.

'We came out supporting Dr. Proffitt and the changes that are in place and the team he has put together,' he said.

As best as I can tell, Mr Bragg is the President of a local industrial firm, N H Bragg.

By the way, here is what George Eaton, chairman of the board of Eastern Maine Healthcare Systems, the parent not-for-profit corporation for Acadia Hospital, said about the executives that are accountable to him:
By making critical decisions, engaging in aggressive fundraising and other activities, 'exceptional senior executives can and should add many multiples of what they cost to the value of the institution,' he said. Eaton said CEO compensation packages within EMHS are determined using information from comparable institutions nationwide.(1)

Also,
The job of the CEO is 'incredibly complex,' working in 'the most regulated environment in any industry,' Eaton said.

'The prudent thing to do is to get the best people you can,' he said, 'and pay them what you need to in order to retain them — so long as they are achieving the performance goals set by their board.'
Note that Mr Eaton appears to be an attorney, according to the EMHS site, "George F. Eaton II, Esq.; Bangor; attorney, Rudman & Winchell."
Summary

This case illustrates much of what has gone wrong with leadership and governance of health care organizations.

We see health care organizations lead by people who have no experience or training in actually giving health care. Yet people who are not doctors, nurses, or therapists make clinical policies and control clinical care, even against the advice of experienced clinicians. In fact, some such leaders seem to regard clinicians as interchangeable widget-makers making interchangeable widgets. The ill-informed leaders of health care organizations often seem sensitive about their lack of knowledge and experience, and hence may be quick to punish any health care professional who protests their ill-informed decisions.  Moreover, the ill-informed leaders of health care seem to band together to support each other, even in the face of criticism from people with real expertise in health care, or from patients and relatives directly affected by health care and how it is delivered.  Higher level executives who are supposed to supervise lower level executives, and boards of directors which are supposed to exercise stewardship and support institutional values may seem more concerned with protecting the prerogatives of all executives rather than than the patient care mission.

As we have said again, again, again, health care desperately needs leadership that understand the context, and believes in the values.  It needs leaders that puts patients first, ahead of the pay and prerogatives of the executive and managerial class, our would-be new aristocracy.

References


1.  Haskell M. Maine's hospitals: big jobs, big pay. Bangor Daily News, March 6, 2009.  Link.


2.  Haskell M. Acadia CEO criticized at previous post.  Bangor Daily News, September 10, 2010.  Link.


3.  Haskell M. Acadia board supports CEO despite claims.  Bangor Daily News, September 20, 2010.  Link. 

Katrina Palmer - Teenage Hooker Became a Žižek Machine

Katrina Palmer, The Dark Object, Book Works 2010.

“Wallace Stevens thought that Heidegger was Swiss, mistaking Fribourg for Frieburg, didn’t read anything by him and knew him as a myth rather than as a person. He thought philosophy was mythical, by which he meant something uncomplimentary when he said it, though he was a poet like Holderlin who thought ‘Poetically man dwells on this earth,’ and who in his ‘Final Soliloquy of the Interior Paramour’ wrote that, ‘… out of the central mind,/ We make a dwelling in the evening air,/ In which being there together is enough.’
I like the idea of an imagined doppleganger-Heidegger so references to Heidegger are to this Swiss version rather than the German Nazi-appointed rector of Frieburg University. Stevens is the great poet of the poetic dwelling time on earth, poised at a pitch between birth and death, as good a poet as Holderlin, and asking the same question as the German: what are times for in times of poverty? As he approached dying he wrote about Pascal as someone who cleaved to imagination as the delusion that might bring ‘ beauty, justice and happiness.’ Getting to the plain real needed analogy and imagination, ‘ his poverty becomes his heart’s strong core’ and what he considered a will to holiness.
Randall Jarrell thought Stevens wrote poems ‘… from the other side of existence, the poems of someone who sees things in steady accustomedness, as we do not, and sees their accustomedness, and them, as about to perish.’ The poet finds the thing seen becoming a thing unseen, and in so doing becomes, in Stevens’ own words, ‘… an intermediary between people and the world in which they live… but not between people and some other world.’ Stevens’ Ulysses is a small town boy returning to ‘… the substance of his region’ where there is a first great river of Conneticut ‘before one comes to the first black cataracts’ of the final one.
I thought of Stevens when reading Palmer’s book because The Dark Object is a kind of speaking the truth that our Swiss/Hartford Heidegger/Stevens unity might write out as ‘… the saying of the unconcealedness of what is,’ where ‘truth’ is chased down to ‘aletheia’ which is ‘unconcealedness.’ Palmer’s book is ‘double plotted’ as the Soviet semiologist Jurij M. Lotman would say. There is the plot that is without anomolies and ‘immanently inherent in the world,’ and there is the ‘primordially opposed’ plot that originates in anecdote, incident, news and excess. The first we might label the mythic and the second the scandalous. Palmer wraps the occult and the obvious together in a curiously episodic text that both tells of the heroine’s story and also the story of that story too. In this respect then it could be prefaced by Henry James who wrote exactly that about his own novel, The Ambassadors.
This links to Stevens who was concerned to dwell in the mysterious occultness of the ordinary, the everyday, the unconcealed, signaling that there was this doubleness, this remarkable atemporal element alongside the temporal, a secret inside a secret hidden in the plainest of plain sights. The Dark Object reminded me of an intense poem that wanted to bring certain things to light, to reveal them so to speak, and as such it reminded me of other several things, but most of all the Kafka parable in The Trial and its troubling, dark intimation to the concealedness inherent in everything. This is the world of ‘dark speeches’, for parable means ‘dark speeches’ in Hebrew, a word riddlingly close to my own name, ‘mashal’, riddlingly close because in terms of scandal and time there is nothing but a coincidence, in terms of myth and magic there lies something of the affrontery of a hidden purpose, a kind of dark, defiling joke. A parable therefore is the opposite of open proclamation; its purpose is to conceal, to retain the secret, to keep people out and in this the Gospel according to Mark is a key text, the one Gospel narrative that has Jesus say that he uses parables to keep the uncircumcised ear from understanding. It is a dark object.
The parable in Kafka is the one about the doorkeeper who won’t let a man in to see the Law. The man waits outside the door for years waiting to be admitted. He tries all kinds of ways of getting past the doorkeeper but fails. He gets close to dying and sees a great light beaming out from the door. As he dies he asks the doorkeeper why no one else tried to see this particular door to get to the Law. And the doorkeeper replies, ‘ this door was intended only for you. Now I am going to shut it.’
The Christian Bible’s Gospel of Mark is a dark speech itself. It is an exact precursor of the Kafkaesque and contains Jesus saying to his twelve disciples after he has told the parable of the sower that the elect know the mystery of the Kingdom but those outside such knowledge need parables ‘… so that they may see and not perceive, and hearing they may hear but not understand, lest at any time they should turn, and their sins be forgiven them.’ (Mark 4: 11-12) Parables are told to conceal not reveal.
Jesus’s ‘so that’ is translated into the Greek as ‘hina’ and is considered a tough, intolerable thing to say. Matthew thought so and he substitutes ‘hoti’, meaning ‘because’ for ‘hina’, which gives a much more gentle meaning to the episode. Matthew often divines a softer Jesus than Mark although having said that it is Matthew who writes that ‘.. to him who has will more be given … but from him who has not, even what he has will be taken away.’ Matthew’s approach renders us a sense of dismay at Mark’s message.
The glosses on the parables, the interpretations that follow in both Kafka and Mark, seem inept, melancholic, depressing. In Kafka the priest, who tells the story to K in the novel, responds to K’s thought that accepting the doorkeeper as telling the truth involved accepting contradictions by saying : ‘ it is not necessary to accept everything as true, one must only accept it as necessary.’ ‘A melancholy conclusion,’ says K. ‘It turns lying into a universal principle.’
All this reminds us of the double plot idea, the occult and the scandalous, that like serpents within serpents swallow whole the very idea of unconcealedness and make it, at the very least, a job to be done. That’s why we have poets. So Palmer’s The Dark Object really works like a parable, and so it has the same feeling of deep mysteriousness and weirdness of Mark and Kafka, a strange atmosphere that signals that there are occult forces tangled up in the episodic narrative of the trapped Addison Cole.
What is the story? Palmer makes sure we know that there are occult forces by having multiple stories performed within the story, each bafflingly self referential at times but in ways that are closed, difficult to grasp. Like Addison Cole herself, the reader is placed in a Russian Doll sort of text, a story in a story in a story, where the ideal of narrative closure, of interpretive closure, is provocatively questioned. In fact, the inclusion of Hegel and Žižek as names in the stories, both key figures in theories of hermeneutical activity makes clear that nothing is to be clear. The dark object is the novel itself, its own dark speech, endlessly offering itself up for a further story about itself.
Hegel is a name of the historical interpreter, who would ask us to return to the historical origin of texts, and resist any canonical mediation. Hegel’s is the nostalgia for the primitive ground of origins, the pre-text, the voices and people before the text. It links us with the opening words of Adam Bede where a drop of ink ‘… reveal to any chance comer far-reaching views of the past… with this drop of ink at the end of my pen… [she]… will show you the roomy workshop of Mr Jonathan Burge, carpenter and builder, in the village of Hayslope, as it appeared on the eighteenth of June, in the year of our Lord 1799.’ It is an occult desire to reveal the dead, to bring back to life the original voices that existed before the recollection, before the writing it down, to bring back from the dead a Lazarus vernacular .
Žižek is a sign of the canonical interpreter, the Lacanian therapist who seeks out the coherence and self-sufficiency of the text itself. History is fine but only as a prehistory to the text itself, the unified, organic complexity that exists as a world in itself, able to both tell its stories and the story of its own story as well, a ‘collection with parameters’ as Brevard S Childs describes a canon, and as Joyce’s Ulysses is the secular modernist exemplar par excellence. His therapy offers a ‘reading’ to recover a hidden or lost meaning that can do so by attending to the text or person as something closed, but requiring, as all canons do, a shadow of commentary. Kermode writes that ‘…in the Jewish tradition the Torah is always accompanied by its shadow, the commentary that will presumably go on forever; and yet they are thought of together as the Torah, a syzygy of that which is fixed and that which changes with time.’
Palmer’s is a book within a series, edited by an author of another book of the series Stewart Home, and by Gavin Everall, general editor of Bookworks. Palmer’s book is inside the Semina series, with all that that entails, historically linking it with the first Semina series and also with the other books of the present one. Yet it also links itself with contexts that are, at first blush, a long way from bookish matters, in particular issues of feminism and wimmin. A reading requires considerations of both scandalous and occult plots, and too quickly sometimes critics may shift to the occult at the expense of scandalous details. And similarly when accruing contexts as anchors, the obvious scandal is sometimes overlooked for the obviously obscure one, sometimes to the detriment of the reading and sometimes for dishonorable reasons.
So in reading this I was brought to attend some small range of a huge genre of scandalous wimmin stories, culled from the nearly current news like: ‘Studies from Australia, Canada, Israel, South Africa and the United States show that between 40% and 70% of female murders were carried out by intimate partners … In South-East Asia, burns are the third leading cause of death [for adolescent girls and women of reproductive age]. While many are the result of cooking accidents, some are homicides or suicides, often associated with violence by an intimate partner … Despite the size of the problem, many women do not report their experiences of violence and do not seek help. As a result, violence against women remains a hidden problem with great human and health-care costs.”
“Because they are less likely to be part of the formal labor market, women lack access to job security and the benefits of social protection, including access to health care. Within the formal workforce, women often face challenges related to their lower status, suffer discrimination and sexual harassment, and have to balance the demands of paid work and work at home, giving rise to work-related fatigue, infections, mental ill-health and other problems.”
The men’s world cup football took place in South Africa and Adriana Stuijt reminds us that, ‘A woman is six times more likely to be killed by an intimate partner in South Africa than anywhere else in the world, a conference on Sexual Violence near Johannesburg was told on Wednesday. And most of their murderers were drunk and HIV-positive.
“Twenty-five percent of women in the general population (out of a total of 47-million people) and in 40% to 50% in the targeted studies have been victims of physical intimate partner violence,” Professor Rachel Jewkes of the Sexual Violence Research Initiative said in Benoni, Johannesburg on Wednesday. The conference was aimed at addressing and preventing sexual assault and violence.’
‘Up to 300 people are sacrificed every year in South Africa so that their body parts to be used in traditional “Muti” medicine. Most of these are young children, tortured to death. And more girls than boys are ’sacrificed’: because of the belief propagated by traditional healers that raping virginal girls cures them of AIDS.
“It’s done while she’s still alive because the more she screams, the more powerful the Muti’s going to be,” explains crime expert Kobus Jonker, gesturing at the picture of a mutilated six year old girl.’
In the light of this scandalous testimony – and this is sadly just the tip of the iceberg – the question about what are the facts, what is real, what is unconcealed, becomes urgent, and the job of the poet the job. The authority and permission to tell these stories is decidedly undecided. Juxtapose the story of football matches and the story of Muti and we have our own version of the Comices scene from Madame Bovary where, while M. Lieuvain and M. Derozeray make eloquent with ideals of freedom, order and duty Emma and Rodolphe have sex whilst the crowd punctuate the sex and the oration with shouts about pigs, manure and sheep.
Authority and repression march and jabber and write hand in hand, and wimmin, like that other troublesome, troubled group, children, are often forced into spaces that refuse them. And even in occult reading a blindspot occurs, reinforcing the refusal, complicit with the whole, so that the interpretation becomes collusion. This is where the scandalous and the occult plots correspond, a determination of ‘ green’s green apogee’, as Stevens puts it in ‘Credences of Summer.’ Such determinations are readings without remainders, finished, complete in themselves, but is something only the Divine divines, and secular readers might avoid in order to avoid the pedagogical and psychological enthusiasms that Carl Gustav Jung suspected of ‘dishonourable intentions’.
This is an issue that Bernhard Schlink’s middlebrow read The Reader of 1998 is impressively perceptive about when discussing children.
The dad is talking to the protagonist Michael about how philosophy forgets children:
Don’t you remember how furious you would get as a little boy when Mama knew best what was good for you? Even how far one can act like this with children is a real problem. It is a philosophical problem, but philosophy does not concern itself with children. It leaves them to pedagogy, where they are not in very good hands. Philosophy has forgotten about children.’ He smiled at me. ‘Forgotten them forever, not just sometimes, the way I forget about you.’
‘But. . .’
‘But with adults I unfortunately see no justification for setting other people‟s views of what is good for them above their own ideas of what is good for themselves.’
‘Not even if they themselves would be happy about it later?’
He shook his head. ‘We’re not talking about happiness, we’re talking about dignity and freedom. Even as a little boy, you knew the difference. It was no comfort to you that your mother was always right.’ (pp. 140-1)
Philosophy forgets about wimmin too. This can be a result of a flight from history, from hermeneutical and therapist approaches that makes too much of a total world out of a text without remainder, over oversimplifying the complexity of knowing how to know the truth about a world. Midrash is the Jewish process of commentary, a lasting process reaching to the end of time, a continuation of the process of finishing a text, one that is more like acknowledgement than any statement of the final end, the finishing line. The Dark Object of Palmer is here being read as the dark speech of Mark, the parable or riddle asking for acknowledgment rather than the truth, a request inevitably betrayed by the dishonorable intentions of those wishing to impose a final interpretation but also inevitably aided by such interpretations, to the exact degree of ineptitude and ignorance they show. This the way of showing Hermes, the God of interpretation, the door, but it’s a revolving door that gets you in and out in one fell swoop. Katrina Palmer winds serpents of narrative within serpents of narrative, mysteriously dark, sinewy, sensual and venom-brainy, not as maps of a territory nor reflection of life lived nor mirrors (of a world) nor perspectives (on life) but just as something indicating an approach to linearity that suggests, hints, gives a glimpse of lines that propose nothing but a wound that ‘.. continues to spread its monstrosity.’ But every storyline is an alternative that may or may not follow from what just happened. Madness, jump starts and stops, weird collusions and collisions breeding hedges, nudges, winks, hooded stories that reveal nothing more than that there may, after all, something behind the mask, but like the legendary Fantomas of Marcel Allain and Pierre Souvestre, not necessarily the same thing each time. Everything reshapes, re-emerges and then disappears again, like Melville’s Confidence Man moving in a fantastical, hysterical, melodramatic zigzag of this and that, defeating the detectives, staying out of the clutches of any law, uninterpreted or multi-interpreted, a demonic narrative of the Gospel of Mark’s Legion swarming in Gerasene down a cliff screaming death and sex, transforming itself into a little apocalypse, like the deliriously insane foetal abattoir line scene from Mam Ki-Woong’s Teenage Hooker Became A Killing Machine movie, a cinematic offering that offers similar poetic delights as Palmer’s ‘fictional construction.’
Alongside therapy is the re-authoring theorisings of post modernity, with its duality search routines, where everything is structured through bipolarities and the weaker element is identified, where the hierarchy is reinterpreted to weaken the pattern of dominance, where the rebel voice denies the dominant voice for the weaker, where the other side of the story is told so the continuous change and disintegration being concealed by any dominant fixed reading is glimpsed, and from where then we role on to deny the plot, turning everything round so that romance becomes tragedy and farce ironical and so on – like the way the first Bruce Willis Die Hard movie rewrites It’s a Wonderful Life as a different version of Christmas in Amerika, and on further to find the exception that takes the story to the extreme, revealing its absurdity, and further on yet to trace what lies between the lines, all those weird gaps in stories, creating subterranean intertexts, like Buñuel’s Belle De Jour, all of Chris Marker, and especially like that intense poetical short film Kanchul, by Teenage Hooker man Mam Ki-Woong, and on again, on again inexhaustively to the story re-authored so that ‘… a new balance of views is attained’, which becomes a story without centres in order to ‘script for new actions’ which leaves everything pulped and smashed, ‘ a repulsive pulpy mass of soft tissue, and still in the process of growing’ as Palmer writes it in the strange inspiration of its final climax, like in nearly every scene of the exceptional Nazi/Zombie film Dead Snow of Tommy Wirkola.
Katrina Palmer is a groove sensation because she gets to the serpent inside all this too, the ‘dishonourable intentions’ that despite everything lead the Po Mo crowd to act like Inspector Juve or Lestrade or any other master who seeks to pull the mask from the face and reveal the final angel of truth. Which is why the disintegrating bones and voice of Hegel is a nasty ghastliness in this cabinet of wonders, a peculiar reminder that even honorable intentions are not always what they seem to be.
So Palmer is writing out of horrors that slither out of a similar type of bad intention, found both in the cults of therapy and of deconstructionism, viz, an intention that seeks a kind of completion, a reading without remainder, a claim to know that is a claim of ownership, the song of the master to the slave, the pimp to the whore. The point of writing is to make things happen. A book is a gun the whore deep-throats the pimp to death with, like in the Ki-Woong movie. It’s the loaded gun from between the girl’s nasty thighs that murders the murderer, blasts away her masters.
Narratives and novels have had a tendency to be treated as ways of knowing, the discrete charm of the bourgoisie is its master narrative, (which is also its blood rite, as Stewart Home clarified in his Semina offering) and Palmer is fragmenting her narrative lines, twisting them, breaking them up and looping them into bloody, buckled, torn, shredded episodes and dissociative blocks of writing suggesting a wise resistance to this, blamming out a reading that pushes us to a sense of acknowledging rather than knowing, in a way that poems, a certain kind of cinema and double plotted novels try for.
The idea of the omniscient narrator grew with the development of the novel but Holderlin observed that ‘we are a poem that cannot be read,’ resisting the notion of language as a tool, celebrating instead what the philosopher Paul Standish sees as ‘the opacity of language, its thickness… its recalcitrance.’ Derrida’s idea of the endless deferral of meaning, the unforeseeability and irretrievability of any reading without remainder is the heart of all this and is what the ‘dishonorable intention’ of certain therapy denies – the Z of Žižek standing in for this.
A reading that requires the gentler, more communing, more democratic acknowledgment is one that recognizes that there are no readings without remainder, that there will always be inaccessibles. Deleuze in Difference and Repetition writes this out as a proper recognition of a metaphysics of selfhood, saying that, ‘A Cogito for a dissolved Self: the Self of ‘I think’ includes in its essence a receptivity of intuition in relation to which I is already an other. It matters little that synthetic identity—and, following that, the morality of practical reason—restore the integrity of the self, of the world and of God, thereby preparing the way for post-Kantian syntheses: for a brief moment we enter into that schizophrenia in principle which characterizes the highest power of thought and opens Being directly onto difference, despite all the mediations, all the reconciliations, of the concept.’
Put like that, it sounds a bit masterful, a bit too much like a final word on the matter itself. Stevens is better: a better philosopher than Holderlin and a better poet than Heidegger: ‘The poem is the cry of its occasion,/ Part of the res itself and not about it./ The poet speaks the poem as it is,/ Not as it was: part of the reverberation/ Of a windy night as it is, when the marble statues/ Are like newspapers blown by the wind.’ (from ‘An Ordinary Evening in Newhaven.’)
Deleuze writes about cuts, bands or grooves between meanings in terms of ‘interstice’. He is the philosopher who says ‘ … the question is no longer that of the association or attraction of images. What counts is on the contrary the interstice between images, between two images… Given one image, another image has to be chosen which will induce an interstice between the two. This is not an operation of association, but of differentiation, as mathematicians say, or of disappearance, as physics say; given one potential, another one has to be chosen, not any whatever, but in such a way that a difference of potential is established between the two, which will be productive of a third or something new …’ But in a movie like the aforementioned Dead Snow the interstices are intestinal, and what they produce are zombies, which represent the dead brutal lifelessness of interpretation without remainder, for zombies are without spirit, are Eliot’s Hollow Men, merely facsimiles of the living.
Katrina Palmer faces two images of Žižek: intellectual Elvis and intellectual Nazi Zombie. And a theory that ensures that the distance between the two images is preserved forever, according to Žižek’s own Lacanian thought. The cut repulses and attracts the images, solders them into a psychological reality that seems irresistable. The good Žižek is the magical singer of songs, singing a world of words to the end of it. The other is the one without any song, wanting just to march the stories that are told, the master of the story and of all who listen. In Kafka there is another parable about leopards that break into the temple to drink from the ceremonial bowls. They do so so frequently they become part of the ceremony. This is the Zizek of melancholic zombie horror, the thief and intruder who knows nothing of his significance in relation to the ceremony, being, like the leopards, ignorant of everything except their thirst and an easy source of its quenching. It is a rapacious stupid hooliganism that replaces the singer of songs, which is pretty much how the Bible thinks of David too.
In the novel is a story which starting at its second line begins:
'Carole E sits on a chair that can unfurl to form a bed. She thinks about the chair silently withholding its contingent bed-ness, like a secret. She stands, flips the chair open, exposing the bed and she gets into the position Z demands of her. It’s a good chair, she thinks, but once opened up, it’s not such a great bed. She wants to ask Z something, but her mouth is dry and her lips are beginning to crack. Just able to reach her tin of Vaseline, she twists it open, applies the balm and then asks a question into the back of the chair. She wants to know if Z’s looking at her.'
This passage is about the gap, the crevice, the interstice, the cut, the groove, the hole, Anne Stevenson’s ditch, the black screen used in the cinema of the Dziga Vertov Group; ‘… black frames were shots we didn’t know how to shoot: shots of bourgeoisie ideology and imperialism and they weren’t even black, they were coloured, like in any James Bond movie….Our problem is to show colours different from those in bourgeois and imperialist films….’ To recut against the groove of the masculine gaze, its double entendre multiplied by Žižek’s own face that becomes the all seeing, all knowing hairy bearded eye planted between her legs drooling over the spooled out intestines of his interpreted wimmin, this is the purpose here.
‘Yes,’ Z says, ‘I am definitely looking at you.’’
And this passage is a response to the opening line of one story in the story, the narrative that unwinds like a mystery of labyrinthine complexity into the completed montage collage text, rooting back according to the startling Pavle Levi’s essay ‘ The crevice and the stitch’ through Laszlo Moholy-Nagy’s ‘typophotos’ Dynamics of the Metropolis of 1924-5, El Lissitsky’s Supremacist tales ‘About Two Squares’ of 1922, Max Ernst’s collage books Une semaine de bonte of 1934, Isidore Isou’s Amos of 1952 to Michael Snow’s slide show ‘Sink’ of 1969 and so on.
Take your knickers off…’ is the opening line of the story.
This is the strange music of Palmer’s text, the riddling hook that connects the obscenity of Muti to anti-wimmin language and the Žižek as stoopid Zombie trope that runs through the whole novel. In Issue 1 of Maria Fusco’s The Happy Hypocrite, the ‘Linguistic Hardcore’ issue of 2008, an interview with the legendary Cosey Fanni Tutti ends with a shuddering collision with the ‘dishonourable intentions’ of such language. Tutti is discussing the language of skin flick magazines. She says, ‘ The language in some of those magazines was sometimes quite shocking. There was a phrase in a magazine I did some work in ‘The Piccadilly’. So the whole 80 odd pages were framed up in three frames, a real eye-opener, at the end of one of the magazines and it said ‘Does she stink?’ and then there was like an open crutch shot… to see it, ‘Does she stink?’ it was just absolutely horrible…’
This carries with it the weight of a dense and intense occult history alongside the scandalous, and the disturbing horror of this plain talk is what Palmer subtly reveals as a drying up of the beautiful excess required as mishrash, a barreness and deafness that is defied by the stubbornness of the world’s secrets but which, nevertheless results in the horrors of Muti and the deadness of a question and an instruction both: ‘Does she stink?/Take your knickers off’.
‘Does she stink?’ This is the Dark Object that Katrina Palmer writes towards. Tutti’s ‘Does she stink?’ is the objective correlative of the line in her novel, ‘Take your knickers off’ spoken by a fictional Z in a fiction inside the fiction, a circular delirium neither possible nor preposterous but more a side effect of Jaromir Hladik’s dream in an apartment in the Zeltnergasse of Prague on the night of 14 March 1943 reported as ‘The Secret Miracle’ by Jorge Luis Borges and prefaced by a Koranic text, ‘ And God had him die for a hundred years and then revived him and said: ‘How long have you been here?’ ‘A day or a part of a day,’ he answered.’ Which is about having a right to your own opinions and perspectives, even if God contradicts you.
A point colludes with space yet must not contain any space. The Dark Object of Tuti and Palmer recognizes the inevitability of collusion. The spider is trapped in his own web. The finite extension is trapped by the possibility of further analysis. Zizek is used to raise the issue: How do we collude with the dreams of the rapist father to kill him? In the novel Z is Zizek. Zizek fantasises Dennis Hopper as psycho Frank in David Lynch’s film Blue Velvet as Isabella Rossellini’s Dorothy’s fantasy father rapist dream. According to Žižek the woman wants the rape. Z is the bad pervert of The Pervert’s Guide to Cinema. Z is an ectoplasmic perve blob in this Semina episode by Katrina Palmer, released from a piece of furniture in the last story in a transformed state.
Žižek thinks that wimmen want what Frank wants them to want. Žižek is a loud-mouthed intellectual on the circuit. He gets called Elvis and is adored. He is a Lacanian psychologist rubbed up with the label Marxism. Yet he thinks that ‘suture’ explains how, in cinema, images run on beyond their closure, that there are things happening in the gaps between images. It is a theory that tries to relate time to image in order to explain how meaning is created out of the flickering montage of light. Jacques-Alain Miller made this approach hip in 1966, taking the Lacanian theory as a kind of weak magic. Yet throughout this there is the bad smell from his mouth, a ‘Does she stink/take your knickers off’ stench.
In the library of Babel Borges believed it likely that there was a total book of the Universe lying on one of its shelves. Its completeness requires the full story of the Dark Object. Perhaps Tuti and Palmer might work on this book and say that this book actually contained only two separate sentences separated by many blank pages: ‘Does she stink?’ and ‘Take your knickers off.’ Borges of course thought that what existed was limited by what was possible. The writers of Star Trek have Captain Kirk at one point asking for all possibilities to be investigated and after that the impossible too, which makes Kirk more sophisticated than Sherlock Holmes and Borges. Blindspots are regarded as impossible. So at risk of disagreeing with Borges, Palmer’s book becomes a curious disclosure of the impossible.
Facts about wimmin are like laws about vacuums. They seem impossible because there is nothing to be a law about. Randomness is absence of law. So a law of randomness is equally paradoxical. Laws of chance and wimmin come under Pascal’s stupefying name ‘The mathematics of chance.’ We stack the dice to see past the blindspot when we look at the numbers. Dice playing and the probabilities of numbers began this. Pausanias mentions a picture painted by Polygnotos in the fifth century which shows dice playing. Palamedo invented dice playing for bored Greek soldiers hanging around in the battle of Troy. Cardano’s treatise on dice De Ludo Aleae was published in 1663 a century after he wrote it. And from this roll all sorts of mysteries.
Laws of chance, probability and so on require solutions that insist that the perception of the problem is taken into account rather than merely the brute problem. And there seems no reason to ban infinities from such calculations. Even the smallest of incremental gains justifies any finite price in an infinite series.
Closure is never total so there’s always more than whatever meets the eye. Z is Palmer’s Žižek. Katrina Palmer is returning his favours by returning his pervert’s stare. It’s an unwavering eye. The prison is the desire for an uninterrupted drift of meaning, one that can accommodate Žižek as he leaps from crack to crack between images, exploding closure into his bossy delectation. All his delectation is the fictional point, the infinite Kabalistic book on the shelf of Borges’s Babel library that uses just two sentences to write the whole damned universe: ‘does she stink?’ and ‘Take your knickers off,’ a book that is larger than itself.
Palmer’s book reminded me of Episode 23 of Season 4 of The Avengers from March 1966, ‘The House That Jack Built’, scripted by the legendary Brian Clemens and directed by droogy Don Leaver. Emma Peel, played by Diana Rigg, is trapped in a house that is a box of psychedelic tricks designed to drive her mad and enter the suicide box. The house design was a black and white druggy labyrinthine design mounted on ingenious mechanicals blended with a computer brain and a stuffed corpse in a glass display. A repetitive thrumming white noise overlaid the repetitive sequences, a rhythm that suggested the occult undertow alongside the obvious sensational trappings of the scandalous plot .
The result was both cranky and quirky. The repetitive violence, confusion, immersion in a wild man’s fantasy is the core to the revolving, endless, murderous revenge of a corpse man. There is an everlasting, infinite, degenerative corruption of imagination at the heart of this version of Tlon, Uqbar, Orbis Tertius, a world where objects are whatever a person wants them to be. The constant and remorseless repetitiveness undermined to some level the scandal plot. For too long the same thing happens again and again and this creates the murky idea that something is happening beneath the surface. It was an occasion when the occult plot took the upper hand in a popular tv action serial. There are episodes of Kojak where the same thing happens, but that’s for a different occasion.
There was a relentless, remorseless menace in the Avengers story and Katrina Palmer’s novel brilliantly keeps to that same atmosphere throughout, despite the cut-ins and ways, despite all those stories interposed between the Gothic escapades. The book stays slow, intriguing but also self-addicted more obviously than the scandalous plot should have allowed, like a very late Beckett. Addison Cole, like the erstwhile Mrs Peel, is also trapped, this time in a ‘School of Sculpture Without Objects,’ a version of ‘The House That Jack Built’, and is forbidden to create an object or escape. Throughout an atmosphere of unbearable menace follows a dark pool of anxiety that floods up, chokes her, threatens her with drowning and never ebbs.
Sinister grotesques appear and disappear, the book is fleshy and brainy, so sex and wounds occur throughout alongside the creepy expansion of a mind that seems to be part of some unhinged Kafkaesque parable. There’s a great scene where a dead Hegel disintegrates throughout a deadly discussion about the ideas of Slovoj Žižek, rattling his corpse bones like a scene from Jan Svankmajer. It’s also funny in a zany daft way, like episodes from the other cult 60’s tv show about nut-job labyrinths and ingenious escape, The Prisoner are. And as with The Prisoner and The Avengers there is always that thought of something chilling going on too, that the fun and games are eye-candy for deeper stirrings, serpents within serpents, subterranean magic.
By bringing Z into the narrative Palmer is re-appropriating his menacing cultural gigantism that threatens to deliver, in disguise, a complete master narrative and deny the beautiful excesses of Kabbalistic commentary. When it comes to wimmin you hear his creepy stupidity when he says, ‘you do something to a woman but you never know what the reaction will be’ in A Perverts Guide to Cinema.
Žižek’s fantasy spaces reach out like psychotic sex nutters; Palmer is fantasizing back, becoming a disruptive element in the symbolic order of aesthetic writing that Semina itself instantiates. She locks him is a desk drawer and then her pocket and turns him into an ectoplasmic blob. Originally just loose leafed pamphlets, the Semina writings have a gob on them rather than a voice, they talk back into itinerant, displaced, open-necked spaces, outside of galleries, more in the tradition of Mail Art where distances, times, places, objects and people sprawl out like spirit-weirds, so fantasies become unpoliced and their ambiguities and vaguenessness begin to collapse everything. Fantasy space reaches out like spectres, and any idea of there being a safe distance is lost in Duchamp’s urinal.
One thought is that labyrinths trap intellects like webs spiders. Although occasionally flies die in the webs the permanent occupant of the web is its spinner, ceaselessly trapped in its own trap. The thought of freedom is its trap. For the therapist the thought of the freedom of others is their trap. It is the corpse in the glass casement who is trapped in his own trap in ‘The House That Jack Built.’ In Teenage Hooker the murderous raping teacher is caught in his own careerism, and in Dead Snow the chief nazi zombie in his own box of gold coins. In The Dark Object it is Z, caught in his own pervert eye.
Emma Peel in ‘The House That Jack Built’ escapes by penetrating the computer with a radioactive key. As she leaves the audience are given a glimpse of the machines that made the house a trap, revealing the obvious mechanisms of oppression but concealing others. In Teenage Hooker the dead girl is rebuilt and returns to shoot the teacher who raped her in strange hallucinatory images that reminded me of the rape of Dinah by Shechem in Genesis 34:3. The issue there was how to translate the Hebrew word ‘nefesh’ into English so as not to suggest fidelity and honour. The unfulfilled lust of Shechem for Dinah remains even after the rape, and finding an English word that caught all this and all the additional mysteriousness of ‘nefesh’ was exactly the problem for English translators. For the film director of Teenage Hooker, his problem was to ensure that the scandalous plot didn’t obliterate the occult plot, and vice versa. The poetic brilliance of Nam Ki-Woong’s images and sound enables the violence and revenge to translate the nuances of lust in the film to an extent that extended the depth of awareness of the girl’s anger and tragedy.
Both in ‘The House that Jack Built’ and in Teenage Hooker the wimmin release themselves from the grip of an overwhelming master narrative by turning back the male gaze in an explicit phallic symbolism: in one Emma Peel jams a large key into the computer’s hole, in the other the teenage hooker rams her literally phallicised gun into the open mouth of the murderous teacher. In The Dark Object, however, Addison Cole receives a gift, some soft fruit, in her hand which then goes deep inside. This then is a different resolution, one where Cole returns the feminine into herself rather than resorting to the carnivalesque reversal of gender that characterises the other two plots.
She takes within herself soft fruit, clothed by a mutual touching hand, the very other side of the crude question and bullying instruction that Z has been made, on this reading, to partly instantiate. The gift reaches deep inside her that frees her into warmth and away from him. It is a mysterious, occult transaction. ‘Without knowing how it’s happened, I’ve got it deep inside, he’s gone and I’m out.’ It is a miracle of translation, that ‘intensest rendezvous’ that Stevens writes about : ‘ Within a single thing, a single shawl/Wrapped tightly round us, since we are poor, a warmth,/A light, a power, the miraculous influence.’ It is an answer to the intense question our (Swiss) Heideggar and Holderlin and Stevens – ‘what are times for in times of poverty?’ Cole rendezvous with Z, their hands enclose and then she is wrapped in a warmth that frees her like ‘a necessary angel of earth’, one who has made ‘a dwelling in the evening air.’
Palmer’s heroine stares back at the assumptions riddling Z’s Lacanian college and detonates each of its insidious ideas with a counter story that substantiates her resistance. Yet The Dark Object remains a parable, a dark speech, retains its mysterious relationship with concealing as well as unconcealing. It winds its many tongues, its many stories, with the other Semina texts, their other stories, forming a Canon within a Canon ‘out of this same mind, out of the central mind’ that knows ‘poetry is the subject of a poem’ and that the dimensions of scandalous and the occult are, as ever, Pascal’s, Kafka’s necessary lies.” – Richard Marshall


Excerpt:

“‘Dear Professor Žižek

It is very cunning of you to get around the problem of replying to my emails by including messages to me in your books. I now understand that The School of Sculpture Without Objects is just a symbolic construct...’

Set within a notional art school in which the Rector’s paranoid conceptual ideology has prohibited the making of objects, one student remains. Increasingly isolated in The School of Sculpture Without Objects and battling with institutional directives and solitary confinement, Addison Cole exercises the prohibition on making things by writing stories, in which the protagonists only meet through the creation of fantasy scenarios. These narrate a series of explicit encounters with texts, objects and artists. Authorial figures are reduced to their pornographic effect: Slavoj Žižek becomes a impotent sexual metaphor, Hegel a skeletal spectre, the anonymous ‘Jay’, Žižek’s lactating Oedipal fantasy, the Rector a scrofulous, paranoid lech.

Made up of inter-related but self-contained short stories, The Dark Object explores the tension between the restraint of narrative form, and the explosion of ontic instability. It aims not to subsume fantasy into the everyday, but rather demonstrate that everything is real, and the everyday is fantastical.

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