Most people know that hospitals and obstetricians have incentives towards c-sections, but it’s hard to fully appreciate just how many incentives there are unless you see it at work (or, like me, hear regular testimony). The fact that the hospitals get more money is only a part of the equation. The time physicians get back isn’t just for playing golf. When Clancy was in Arapaho, she was regularly faced with one of two options. She could hover over a mother all night, extracting all sorts of costly resources from the hospital along the way. She would be staying there, not seeing her daughter or her husband and not getting much goodsleep. She wouldn’t be generating any other revenue while there because she has to be on stand-by. If she delivered the baby before 6am, she would then finish her paperwork, get maybe an hour of rest, and spend the next day seeing clinic patients. If it is after 6am, then she gets the morning off. Which allows her to get some sleep, but forces patients to reschedule and means less revenue for the hospital/clinic. Alternately, she could reach for the scalpel at 8pm be done with everything before 9, come home, get rest, see all of her patients the next day. And, if she cares, make more money for the hospital and possibly herself (through bonus structures) or at least have better efficiency numbers when it came time for the performance review.
Experts say that even total C-section rates—which include cesareans for all births, not just the low-risk ones we focused on—should rarely be high. “Once cesarean rates get well above the 20s and into the 30s, there’s probably a lot of non-medically indicated cesareans being done,” says Aaron B. Caughey, M.D., chair of the Department of Obstetrics and Gynecology at Oregon Health & Science University School of Medicine in Portland and a lead author of the new ACOG/SMFM recommendations. “That’s not good medicine,” he says.
When asked to explain their high C-section rates, hospitals offered several responses.
Mark Rabson, corporate director of public affairs at Jersey City Medical Center, described how his hospital, which serves “a diverse metropolitan area with many socio-economic issues,” was working to lower C-section rates by, for example, reviewing the care of all providers whose cesarean rates are above 30 percent and offering them assistance in how they manage patients during labor. In addition, he says the hospital is now using midwives, healthcare professionals trained to avoid intervening in childbirth unless medically necessary, and people fluent in multiple languages to educate patients about cesareans.
Patricia Villa, a spokeswoman for Hialeah Hospital, told us “while there are many factors that impact a woman’s decision to have a cesarean section, we are focused on driving improvement in this area.” She also noted that the hospital had been recognized by the March of Dimes for it’s efforts to prevent elective early deliveries before 39 weeks.
My wife is the type of person to hold the line. I’m frankly not sure that I wouldn’t find some sort of way to rationalize interventions.
But while people know about that aspect of it, and probably know that a lot of women pressure their obstetricians for c-sections, that’s really only a part of the equation. The other part involves decisions that the OB makes well prior to the c-section decision. Intervention begets intervention. If a woman gets an appointment for induced labor, a future c-section becomes more likely. If she gets an epidural, a c-section becomes more likely. If labor is sped along through other interventions, c-sections become more likely. Why? Well, as best as I can figure, the more that a hospital intervenes, the less control the body has over the process. So even if two physicians have the exact same philosophy towards c-sections specifically, their philosophy on earlier interventions may lead to different c-section rates. And a woman’s chances of getting a c-section may depend not just on the obstetrician or the hospital, but the specific anesthesiologist on duty and how aggressive their philosophy is.
In the map on Kristin’s article, you notice that a lot of rural states have lower c-section rates. That’s at least part of why. Clancy’s employer in Arapaho didn’t even offer epidurals. The less resources, the less earlier intervention. The less earlier intervention, the less likely a c-section is to become necessary in the first place. My wife’s c-section rate isn’t just low because she views it as the Option of Last Resort, but because she’s not an interventionist generally (in obstetrics and elsewhere).
So it’s not just a question of whether a c-section is medically necessary, but also whether it becomes medically necessary along the way. Both of these things are going to depend on a lot of things like obstetrician philosophy, hospital policy, resources, other personnel, and (as important as anything else) patient philosophy. Whether they want an epidural has a cultural context, and that’s going to vary from place to place. Whether a woman will be the only person she knows that had a c-section, or whether she’s been told that’s the way to go. Whether she lives in a place where people read Mother Jones, or Newsweek.
Right now we live in a culture where, in addition to all sorts of other incentives, c-sections are normal and giving birth on hands and knees or underwater is considered weird and unnatural. Because intervention begets intervention (both psychologically and medically), and our health care system is an interventionist one from top to bottom, I am skeptical that we’re going to see change any time soon.
Last week I posted an Linkage Over There about a superbowl Audi ad:
Well, if you’ve been reading along, I think you’ve figured out what the real message of this Audi advertisement is, but just in case you’ve been napping I will spell it out for you: Money and breeding always beat poor white trash. Those other kids in the race, from the overweight boys to the hick who actually had an American flag helmet to the stripper-glitter girl? They never had a chance. They’re losers and they always will be, just like their loser parents. Audi is the choice of the winners in today’s economy, the smooth talkers who say all the right things in all the right meetings and are promoted up the chain because they are tall (yes, that makes a difference) and handsome without being overly masculine or threatening-looking.
At the end of this race, it’s left to the Morlocks to clean the place up and pack the derby cars into their trashy pickup trucks, while the beautiful people stride off into the California sun, the natural and carefree winners of life’s lottery. Audi is explicitly suggesting that choosing their product will identify you as one of the chosen few. I find it personally offensive. As an owner of one of the first 2009-model-year Audi S5s to set tire on American soil, yet also as an ugly, ill-favored child who endured a scrappy Midwestern upbringing, I find it much easier to identify with the angry-faced fat kids in their home-built specials or the boy with the Captain America helmet.
While some dismissed this characterization, I thought it was rather spot-on. If this were a Chevy or a Nissan ad, I might think that some of the characterizations are happenstance, but this is an Audi ad. That means class is not incidental, but rather core, to the product. So we can likely assume anything involving class in the ad is likely intentional. And in this case, it did so in a rather politically skewed direction.
This ad was clearly conceived when it looked like Hillary Clinton was going to be the first female president. And in the run-up to the ad, Audi did a publicity blitz about its commitment to gender equality (hehe, hehe). It was aimed squarely at a particular segment of its clientele. But before we get too much into that, let’s talk about wine and cheese. For a few months, my Twitter feed contained this ad:
— Maria Santacaterina (@mcsantacaterina) November 13, 2015
There is some really intense social and class signaling going on in that ad. I mean, let’s count the ways: Name-checking the most exclusive university in the country, science!, whiteboard with code, Apple computer, elegant geek girl. It really has it all and it just screams New White Collar through and through. Which, if they’re selling a cultural service like wine, is a pretty good pitch! They know their likely audience. Being close to that audience myself, I actually think it’s pretty well done. Maybe a bit overkill, but I only have one foot in that pond.
Now, the Audi ad goes for a slightly different set. Older and wealthier. More likely for their to be a family involved. As the article says, the protagonist isn’t the girl so much as the dad. The dad with the girl to be proud of. The dad who is on the Right Side of History. The dad who doesn’t need an Audi to be good, but is good and Audi is good and let’s get together. The characterization of The Other is probably a necessary component to that because goodness needs something to be compared to. Something a little grubby and unclean. The ad, as a whole, makes its pitch by equating vanity for virtue. It’s not toxic to conservatives, but to the extent that it appeals to conservative it’s going to be the squishes, the #NeverTrump sort, and those whose sensibilities align with left at least in terms of cultural cues.
Now, lest anybody think I am wanting to pick on one side, it’s not hard to come up with an idea of something similar aimed at conservatives would look like. Even if we’re looking an ad seeking to confuse vanity and virtue – or is it vulgarity and virtue – for the well-to-do right. We don’t even need to leave the auto market. Or the luxury auto market. Or the Superbowl.
A visceral yell. A combination of individualism and group (patriotic so it’s okay) achievement. My accomplishments are mine, your accomplishments are ours. It speaks to some less savory impulses in the same way the Audi ad does. Get this because you’ve earned it. Hard work! While the Audi focuses on a degree of innate you-are-evolved goodness, this one focuses on work and achievement. Which sounds good, if you kind of glide past the part where his achievements are his and others’ achievements are ours. But go America! This struck a positive chord with the people it was meant to, and a negative chord for others.
But just as you know the dad in the Audi ad didn’t vote for Trump, you’re pretty sure this guy did. This guy is, more or less, what I think of when I pass by the house of the guy that had the Trump flag in his yard. Really nice house. Obviously, the person was well off. Given that they put a flag in their yard, along with a Gadsden, suggests that he probably supported Trump throughout. That house has (surprise surprise) a full-size pickup in the driveway. Which is kind of on the opposite end of the spectrum as the electric car this guy is pitching.
Which is actually sort of the point. If the Audi ad is telling a well-to-do liberal that it’s okay to have a car that only rich people can afford because you’re good, this ad was telling future Trumpers that it’s okay to have an electric car because it indicates hard work and you work hard because you’re an American.
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I didn’t know this media personality in Sangamon’s major media market went to my middle school. He did a feature for Good Morning Sangamon about going back to Rotterdam Middle School where he remembers being a sports legend but everybody there remembers something different. I had never heard of the guy, but it was an interesting outside look at my middle school. He did fly down to film the segment (or maybe he was in town anyway). It was obviously meant to be comedic, but I liked seeing my middle school in a TV segment, including pictures of him in the same football uniform I wore!
It was a little weird, though, in that it felt like a fictionalized version of the school. Other than the aforementioned uniform, almost nothing looked familiar. I did recognize one coach, but that was about it. He was talking about “the principal who had been there 20 years” and it was somebody I’d never heard of. There was Principal Warfield, who was there before I was. He was followed by Principal Snidely, who left my seventh great year to be replaced by Ms McDonald whom I don’t remember as particularly impressive but apparently impressed somebody because she was the Superintendent of the entire district by the time I graduated from college and now has a school named after her. Then Warfield came back shortly after I left when Mossman got promoted en route to fame and fortune. Who was this person they were interviewing?!
I had originally thought that they might have taken some liberties or something, then I realized “Holy crap, I’m old.” As in, someone could have been there for 20 years and would still be “after my time.” Indeed, the only teacher/coach I recognized was new my eighth grade year. I remember him as seeming old at the time, but that probably meant he was 25 or something. (Tangential, but another teacher/coach friended my brother on Facebook and it turned out that he was in his twenties despite my remembering him as old.
My friend Clint and I went back and visited the middle school towards the end of our junior year in college. It was… pretty anti-climactic. I thanked the first teacher I ever had that flunked me, which turned out to be a really good thing and turned my academic career around (I got a lot of just-passing grades in elementary school that I am pretty sure were sympathy grades). We had always planned to do an open house at the elementary school one of those years, but they actually discontinued it at some point and so we couldn’t. And since our schools are bunkers now, you can’t just stop by without people assuming you’re some pedo creep or something.
My elementary school isn’t my elementary school anymore. We were re-routed somewhere else. My high school isn’t my high school for the same reason, and also it doesn’t exist because they demolished and rebuilt it. My middle school, though, remains my middle school. Even if they replaced all of the cast.
This creates something of an electronic papal death watch, though, as I wait for certain things to die so that I can replace them. Sometimes I watch with excitement, though usually if it’s that bad it falls into the category of electronics to be replaced. So usually, it’s a pain. But at least when it’s dead, it’s dead. The worst is when a computer or device just lingers. It mostly works, except when it doesn’t, but it fails to work enough that it ceases to be useful in primary duty. So it needs to be demoted, if not replaced. Unless it starts working again.
I’ve had two such instances occur over the last couple of months. The first was my computer, which worked fine most of the time but five or ten seconds every two or three minutes when there would be some issue with hard drive data swapping. Which was not a big deal, except that I couldn’t use it for audio or video. Next to it is another computer that’s fine most of the time, except that it randomly reboots. The third computer at the console is from 2008 and is reaching the end of its lifecycle. This meant that, with the problems of the first machine most recently cropping up, I lost my only primary duty machine downstairs. So it was time to buy a new computer (put randomly reclycling computer on tertiary duty, and retire the oldest).
Kind of a bummer since, but for the aforementioned problem, I was satisfied with what I had.
But I started getting the parts in my online shopping cart. I was starting to get excited about finally having a new computer for the first time in five years. And then… suddenly the stuff started working again. I was doing some diagnostic stuff that I assumed would be fruitless. I don’t even know what fixed it. The diagnostic software couldn’t even find a problem with it. But when it was done, the problem was gone.
Now I feel cheated, almost, out of my new computer.Then the same thing happened with the smartphone. I’ll spare you most of the details, but basically the battery life just collapsed to 2-3 hours. Worse, the battery monitor stopped working, so any time the battery was at less than 40% I had to worry about it going out at any minute. Further, it was chewing through batteries really quickly. I tried switching to my backup phone, but it kept trying to go into international roaming mode. So I went around shopping and finally decided on a brand and model to buy, was getting excited, and then as I was explaining the problem with the backup phone to my friend (who used to work with Verizon) the international roaming mode mysteriously went away. Meanwhile, the phone with the battery problems was fine as a backup (and as a backup was demonstrating much better battery life.
So no new phone. Meanwhile, every time I see an ad for an LG V20 I think to myself “I should have one of those!”
Dead electronics need to stay dead, in my opinion.
In a conversation at the Southern Tech football forum, conversations about high school came up, which reminded me somewhat of of an odd thing that’s not so odd. It turned out, people who didn’t know each other had gone to the same high school. There are roughly 150 public high schools in the greater Colosse area, and a lot of people who went to Southern Tech weren’t from Colosse to begin with, and others went to private school.
Yet, as it happens, when people who are generally from Colosse get together and start chatting, the same high schools keep coming up. Very few from Colosse Consolidated School District. Most from the suburbs. And even then, most from the “right” suburbs. I went to Mayne High School, which is very well regarded and thoroughly upper middle class or lower upper class. Next door to us is Southfield High School, which is about the same size and is a little more economically mixed.
Some of you know of Vikram Bath and others remember him by his previous name. He and I had never met until we ran across one another in blogs. And lo and behold, we went to the same high school (at the same time, it turned out, with a few friends in common). This happens with Mayne High School. Before I asked, I half-expected that we might have gone to the same high school. I almost never run across anyone from Southfield out in the wild. And even high schools that I have very limited contact with, on the other side of the city, I meet people who went there.
I’m sure it comes down to economics and class. The places I am likely to run into people are going to filter through whether or not they went to college or not, and Southfield kids go to college with less frequency. The same applies to the other high schools that come to mind, most of which are upper crest. Most of which located near their own Southfield, where I far less frequently run into someone I know.
But it has the weird effect of seeming like contrived writing. Like Colosse is a fictional city (heh) and the writers only have so many high schools that they’ve bothered to identify, so characters all come from those schools.
Somewhat relatedly, a decade ago they closed one of my middle school’s rival middle schools. Sort of. What they did was built a nice fresh new school a few miles over. They then didn’t invite any of the kids that went to the old school to go to the new school. By sheer coincidence, the new school was places do that it would mostly draw affluent kids from nearby schools, thereby giving the kids who went to old school space at some other old school. My school district really was ruthless when it came to such things.
This is going to be the subject of another post, but they’re in the process of demolishing Mayne High School and rebuilding it. Same spot, same kids going there. The district recently expanded to add two new high schools, and it just wouldn’t do for Mayne – the wealthiest – to have the second oldest facilities.
I noticed a few days ago that the remote to the TV went missing. Also missing, was one of the PC remotes for the TV PC. It’s not uncommon for things to go missing in the somewhat messy living room, but I was surprised when after I cleaned the room up both were still missing. I have another PC remote, so that wasn’t a big deal. The regular TV remote, though, that stung. especially since I was planning to subscribe to Netflix and wanted to use some of the features of the Smart TV. I do have a couple apps on my phone, but they’re kind of a pain for anything involved. Which using the Smart TV is.
Knowing that one can never have too many remotes, I went ahead and ordered one from Samsung. It was set to arrive on MLK Day because Amazon doesn’t give a crap what days the Postal Service considers holidays it just wants them to get it done. Unfortunately, whoever delivers on off-days won’t deliver to our house, meaning that it was stranded at the post office.
I made due with the app on my phone. But I did resolve to get the living room in working order. And so I did. While vacuuming the sofa, I discovered there was a hole in the lining somewhere. And at the bottom I felt a couple lumpy things that felt an awful lot like remote controls. The sofa had really eaten them. I ended up putting the sofa on its side, which Lain thought was the coolest thing ever.
“I’m in a cave!”
“I like it better this way. Is this a cave? I’ve never seen a cave before!”
She also set up the cushions and a couple other things and hopped back and forth across the room (after the sofa was put back upright) and told me how she was “crossing the river.”
Lain, as I think I’ve mentioned, doesn’t walk much.
Her talking about the cave and the river made my day. Moreso than finding the remotes. And five books. And some keys to something.
I mostly got it because their children’s programming is supposed to be pretty good. I haven’t poked around too much, but it… doesn’t seem bad, at least. So maybe we’ll have it for a while and then we won’t. Lain has learned to load up and watch videos on the tablet, which is a mixed blessing. The idea of Netflix occurred to me when we were watching an Amazon Prime video on phonics. YouTube also has a good app for kids.
It’s just amazing how much stuff there is out there.
Despite the above-mentioned bad experience, I am genuinely impressed by Netflix the corporation. One thing in particular jumps out at me, which is that they pivoted really quickly to streaming video and did so before they had to. A lot of the time when a company gets the sort of market position that Netflix does, the tendency is to sit on it until someone innovates around you. In this case, they made the determination pretty early that streaming was the future and basically retired their own business model.
Anyway, with football season over I was able to scale back on our satellite service and still come out way ahead.
Some people did a thing, and some folks are not pleased:
I… sort of like the idea? As an introvert, maybe I should hate it. Or maybe I should love it, since I can decline to wear one if I’m tapped out and people will not bother me? It seems to actually cut across the introvert/extrovert divide, with both sides seeing problems. “Why should someone need a button for me to talk to them?” The extrovert asks.
The perception of the London commuter as an unfriendly curmudgeon has been bolstered by the mixed reaction to a mystery campaign to encourage tube passengers to chat.
Badges emblazoned with the question “Tube chat?” have been distributed on the London Underground network, to the horror of some regular users.
Transport for London (TfL) said it was not behind the badges, which are identical in font and design to the official “Baby on board” pins given to expectant mothers.
Commuters were quick to express their disdain for the idea, for which no individual or group has claimed responsibility.
But those who are not especially socially attuned don’t always pick up on the cues that make the distinction between being friendly and being a bother. This comes up in gender discussions a lot because women often both (a) don’t want to be bothered by strangers unless (b) they are the right strangers. And guys have little or no idea whether they are the right stranger or not. When women complain, men often hear that they’re going to get their heads ripped off if they get it wrong. When men complain, women often hear that men just want license to trap women in conversations that it would be rude to escape. It’s not reasonable to expect women to take all comers, nor is it reasonable to expect men to be mindreaders.
As it applies to that, it also applies to just talking to people. Social dolt that I am, I am not good at picking up on the cues. The only real exception are smoking habitats. You can sort of tell if someone on the smoking deck doesn’t want to talk by their body language and location. If they’re off to the side, or tilted slightly away, you need a reason to talk to them (“Do you have a light?”
For the most part, though, smokers tend to be a really social bunch and if you’re in the communal area, the threshold for starting a conversation can be really low. Which was, really, one of the coolest things about smoking for me. It kind of put me into low-pressure socializations. My social skills improved a lot because of smoking. It provided me an environment where I could understand the rules, and where not wanting to talk to people had to be a conscious decision. One that I would sometimes make, and sometimes not make.
So any sort of opt-in or opt-out mechanism for sociability seems to be in the best interest of everybody. It doesn’t solve the gender problem before (because it’s as likely to be person-specific, not situation-specific), but it’s a start.