Monday, October 17, 2016

technology leads ethics, and patient centered care

I was asked an interesting question in class today. We were talking about the movement towards patient centered care - the idea that health care providers should put the patient first and respect the desires of the patient - and away from the old system where the doctor knew best and generally that implied the use of the most aggressive treatments.

I was talking about Atul Gawande's book, "Being Mortal", and how he describes this movement. My father, a retired physician, had come in last Friday to talk to the students about some of his experiences as the chair of the ethics committee at his hospital, and respect for patient decision making was a theme. My father and I had previously discuss Gawande's book, and his experience in his training in the 70's was that he was expected to try to convince patients to take the most aggressive treatment options.

We talked a bit about why we are now moving away from that default approach and instead trying to help the patient make an informed decision about the treatment options available to him/her.

One of the students asked me, where has this movement come from? Why now?

We discussed the rising cost of health care since the 60s. Of course cost is a part of it, even seems on the surface to be an ethical decision. Even though individuals typically only pay a fraction of the cost of their care, society ultimately bears the full cost.

While we were talking about this, I theorized that what has really happened is technology ran too far ahead of our social constructs for decision making. Most people alive today don't remember a time before anti-biotics, but the first antibiotic was developed in 1909 (to treat syphilis), and first general purpose antibiotics (sulf drugs) were only developed in the 1930s. "Modern medicine" is a very modern invention. We were still practicing blood letting as a therapeutic treatment will into the 19th century. That was the best our science could do for us. So suddenly in the 20th century, medicine began to actually work. That was a huge change. Prior to the 20th century, very few of our tools actually worked. Suddenly we could actually cure infections that would have required amputation (if the infections were in limbs) or would have simply killed the victim. Having medicine actually work is a huge change to society. Women no longer routinely die in childbirth. Most children survive to adulthood. Those two facts alone are marvels. A lot of that change has nothing to do with medicine, but a significant part of it does.

Technology and culture are intertwined. Culture evolves to absorb technological advances. Slow technological change, as we had for most of human existence up till the 18th century could easily be accommodated by gradual social change. But in the last 200 years we have had an ever accelerating rate of technological progress. Cultural beliefs - beliefs about marriage, family, religion, morality, and the good life - are all tied up to a certain technological state. Rapid improvements in technology and economic productivity have made many of these beliefs obsolete. But its hard to say which ones and what parts. Birth control can make pre-marital sex suddenly relatively safe, so prohibitions on pre-marital sex seem outdated. But at the same time, we struggle now with sex and relationships in a way or ancestors didn't have to. They had settled answers. In the 21st century, there are relatively few settled answers on how one should live.

So coming back to my discussion in class, what I suggested to my students was that medical ethics are just now catching up with medical technology. Just because we could treat someone with a powerful intervention does not mean that we should. But with a medical education system that is heavily influenced by the sciences, its hard not to use the tools we have in hand. When my father first came to the hospital where he spent most of his career, there was no ethics committee. He helped put the committee into place. Now ethics committees are a standard to help providers deal with difficult questions about treatment. New technologies disrupt our beliefs and traditions. The traditions were put into place to provide us with a short hand to deal with hard questions. But new technology presents new, hard questions. And when you have a tsunami of new technology, it's almost impossible to keep up with the hard questions. A broad acceptance of a relatively simple statement - the patient should be at the center of healthcare - can sound quite trite (and it is definitely a marketing buzz word in a lot of places) - but it's a core statement of what I hope is the future of medical practice.

Why now? My answer was that our ethics are just now catching up with our technology. Technology is going to keep rocketing ahead, but the idea of patient centeredness is a good guide.

so much crappy stuff, better to paddle

October Paddle

Coming out of class this afternoon, I totally intended to get home and get some grading done. But it was Oct 17 and it was 70 degrees. So I decided to go get some exercise instead. There's so much crap in the media right now, I just don't want to hear anymore. What I wanted was to see some foliage, get some fresh air, and work my body.

October Paddle

And not only did I do that, but I found this secret hobbit trail. I'm not sure where it leads, but it's clearly a hobbit trail. No doubt about it.

October Paddle

And I also found this great place to sit and watch the rest of the ridiculous world go by.

Go on by, loud mouth politicians with empty promises and vitriol. Just go on by.

Wednesday, October 5, 2016

screwing around

nothing better to do

I was standing around the kitchen while the dinner was cooking tonight and I noticed we has some thin cardboard lying on the table, so I decided to cut it up and take pictures of it. Because, why not?

I was hoping to get some shadow work on the floor, but holding the screw shape up with one hand and focusing and framing the camera with the other made that process a bit tricky. But I still got some nice light on the screw shape itself.

I feel like I don't do enough of this. It took all of five minutes - five minutes when I was kind of stuck doing nothing anyway. We all have one life, and time runs out so fast.

Saturday, October 1, 2016

walking in the woods

College Woods

I haven't been able to get out into College Woods as much as I would like lately. But I got out the other day for a brain break. Marley loves College Woods, and when we get away from the road, I let her run. She runs back and forth as I mosey along the trail.

old hive

I always see something surprising when I go for a walk in the woods, which is why I always bring my camera, even if it is just my phone cam (these are all phone shots). I walk the same trail every time, but the woods are always changing. With the leaves starting to fall, I was startled to see this abandoned paper wasp nest just a few feet off the trail. Glad it was abandoned, but it was a pretty happening place at one time - the nest was probably 10 inches high.

College Woods

I've photographed this stand of trees before. They change earlier than the trees around them.

The woods are alive, cycling, but also changing. It's good to be outside.

good bread


I've been experimenting with making my bread a little wetter. I was rushing a bit to make this loaf, so I added about 1.5 tablespoons of sugar to urge the yeast along (and it never hurts the flavor - but it's definitely cheating).

I just dumped this on a cookie sheet to do its second rise and to cook. Given the dough was relatively wet, it spread out quite a bit making this a relatively flat bread. Since it was relatively flat, I was able to cook it in about 25 minutes at 400.

Really nice, crusty bread with a moist center.


3.5 C flour
1.25 C warm water
1.5 tbsp sugar
2.5 tsp bread yeast

mix all the ingredients in a large bowl, cover with a towel, and let rise 45 minutes

punch down and knead 5 minutes, add flower if necessary to allow you to knead, but only just enough to allow you to do what you need to do.

spray a cookie sheet, place the dough on the cookie sheet and let rise again 45 minutes

I like to slice the top of the loaf with a sharp knife to give the loaf some character.

heat oven to 400 degrees, (take towel off) and put in the oven for 20-25 minutes.

Thursday, September 22, 2016

come with me

Oyster River Paddle

I'd like to invite you all to come with me and share in the stunning beauty of the river. Six mile paddle yesterday down the Oyster River to Great Bay and around Goat Island and back. I wish I had been on the water just a little longer to catch the full sunset. Paddling is addictive and here's why:

Oyster River Paddle

It's both physically intense - I did the six miles in a little over an hour yesterday - and deeply peaceful. Someday you should all come down to the river.

Wednesday, September 21, 2016

giving it all away

closing this chapter

Yesterday I decided to convert the licensing on my nearly 6,000 Flickr images to a "Creative Commons - Attribution" license.

This is how it is described by the Creative Commons Corporation:

Attribution CC BYThis license lets others distribute, remix, tweak, and build upon your work, even commercially, as long as they credit you for the original creation. This is the most accommodating of licenses offered. Recommended for maximum dissemination and use of licensed materials.
This means that now anyone can do anything they want with my images, including using them to make money, so long as they give me photo credit.

I came to this decision after I was contacted by one of the editors of Task and Purpose to ask if they could use one of images (the one above). The contact came about because I happened to go to high school with the editor's wife, and he recognized my name. I like Task and Purpose and so I was happy to let them use my image. I e-mailed with the editor and asked how he normally found the images that he used for his publication, and his answer was that he searched Flickr, looking for images with CC-A licenses. I mulled this over. I've been a participant in the Getty Stock Images program for a while, where businesses can pay to use your images. I've made exactly one sale, for something like $0.50. By deciding to go with a CC-A license, I basically allow anyone to use my images without paying. So I would be losing all those potential $0.50 payments. All one of them in the two years I have been in the program. So I decided I would just give away the images. I'd rather people used them than not, even if it means they will make money on them and not share it with me.

At some point I'd like to try to monetize my photography hobby. But selling images today, even for pros, has become very difficult. Professionals used to be able to generate a decent income stream from stock photography (photos they took, and then gave to organizations like Getty who then let businesses look through their catalogs for appropriate images for newspaper articles or magazine ads). Today, with so many free images on the web, that incomes stream has largely gone to zero. Why should I, as a committed amateur, think that I would be able to make money when pros can't?

Some time ago I read a book called "Free: The Future of a Radical Price" - and I blogged about it here:  . The book was free for a while; the audio book version remains free. I have the link to the book's site on my blog post.

The basic argument of the book was anything that had zero marginal cost to produce - i.e., something that could be copied for virtually nothing - like an MP3 or a PDF  - will eventually fall to zero in the new internet economy. That would include JPEGs (image files).

To make money in the Free economy, you have to produce something with positive marginal costs. Or else you have to take donations.

I've done the donation thing for my photography. I ran a Kickstarter project that was largely funded by friends so that I could do a photo essay about the Albuquerque Balloon Festival - results here: . 

But I think the sustainable choice is selling actual services. I was doing some wedding photography with a friend and he used to try to prevent people from downloading and printing his images. He realized that was pointless, and now he just gives couples who hire him all of the images so that they can print them themselves. He also offers to help have them printed, for a per-unit fee. His profit now comes primarily from the fee he charges for his time. The images themselves are "free".

For me, I think going CC-A is going to be a bit like that. I'd rather my photos get out there, however they may, and get seen. Then, hopefully, eventually, I'll be able to sell my services. If people see my work, maybe they will be willing to pay more - whenever that time comes.

This is the model that the music industry is headed toward. Artists now make the bulk of their income from live performances. Selling recordings is a thing of the past, and headed toward the dust bin. It's just not possible to stop people from copying. But you can't copy a live performance - you have to buy a ticket to it. I know - I just paid $150 to see Bruce Springsteen.

Free is good - it's excellent for marketing. Some people who were used to making money in a time when free wasn't possible (record companies, for example) are going to lose. But the rest of us - including, I think, the makers and creators, will benefit.

I make images because I like to. And it makes me happy when those images delight other people. And at the end of the day, that's what I really care about.