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Saturday, 19 August 2017

House: A Retrospective

We used to watch House week in week out. I'm not sure when we started because I was 9 in 2004, but certainly we were watching it "live" in NZ when Chase, Cameron and Foreman all left (2007) to be replaced with the game show recruitment strategy. And we were still watching when House went belly up in 2012. And then we rewatched it a couple of years ago. I'm not 100% why, it might have been because a friend of mine had just got into it... but it had been so long since I'd seen the Tritter episodes, I couldn't really offer an opinion. Sometimes I miss House: its sort of many-episode slick productions aren't made any more or are too hard to find.

The thing is, I still think about House. Just the other week I got off the train at Britomart and found myself thinking about "House Classic". Basically, Foreman resigns just before Cameron does (and hence also Chase's sacking) because he's worried that he's becoming too much like House. But he comes back into the fold pretty quickly. Why? Because he resigned too late. He was already House-lite so only someone who'd hire House-Classic would possibly hire him again. But that's not why I'm writing this (strictly speaking the reason is that I have an essay I should be writing). I am writing this because I watched an episode today, having stumbled across the subject of Euthanasia in a different form of procrastination. You see, today I watched Known Unknowns... the medically worst episode of House (according to this dude's review of Polite Dissent's reviews). Which was where I found this comment:

House was a terrible, terrible doctor. End of story and good riddance. From his dysfunctional, litigation-inducing bedside manner to (yes) his so-called brilliant approach to clinical cases. From the few episodes that I (and other doctors) could stand to watch, I saw a character who consistently put himself and his hospital on the path to malpractice suits and led American healthcare generally to its doom. His approach to clinical medicine is merely an example of how not to practice the trade. This was a man who ordered a gagillion-dollar SPECT scan before a $60 urinalysis and shot from the hip with ridiculously obscure diseases. Functionally he was an overanxious medical student with hospital privileges, and he only happened to be right because the writers made sure he was right. In real life, this guy would’ve been out of a job toute de suite and selling medical equipment out of his car trunk. Perhaps not a bad idea for a follow-up series.

Now, I don't know if House really was a genius. Frankly, I know very little about medicine. I can tell you some exercises if you've got tight hamstrings because I was told to do some of those. I can remark that a bruised tailbone might lead to a prescription for voltaren, because that happened to me. I can say that if you've got a broken arm and you're going to fly overseas, this will mean having a cast with crack in it, so your arm can expand. Why? Because that happened to me too. I can also chuck in a couple of other muscular-skeletal observations based on, you guessed it,  treatments I have received through the years. But I can't tell you why. But this comment has kind of missed the point of House.

As a television show, House was never a medical drama. House was a police procedural set in a hospital where instead of murderers and rapists the main cast chased down diseases and other ailments. The emphasis was always on producing something like Cracker, but for Americans. Hence, House had a drug problem (instead of gambling addiction), had a flirtatious relationship with an age appropriate boss (rather than a substantially younger, um, colleague-subordinate), was thin (not fat) and didn't have a family (versus a near adult son, a much younger daughter and a wife halfway out the door). Don't get me wrong, Cracker is much much better than House (or, indeed, Game of Thrones, The Walking Dead (hah!), House of Cards and pretty much anything from the so called Golden Age of Television) but it is what House was in the style of. And Hugh Laurie probably recognised this... after all, I know he and Robbie Coltrane know each other (from an episode of Blackadder)... which is probably one of the reasons it worked.

But I think the comment also misses a crucial point of how House was depicted within the show. Look at the Foreman example: the only reason House had a job was because Cuddy was in charge. And then he had a job because Foreman was in charge. And his job was to head up a department I'm pretty sure doesn't exist: Diagnostic Medicine.

In medical shows that I have seen (House and Scrubs) one of the phrases you come across is "if you hear hoof beats, think horse, not zebra". This is an alternative expression of something statistics courses like (a lot): Occam's Razor. The basic idea is that of all the possible explanations for a phenomenon (such as a disease) the simplest one is preferable. Obviously, in House, this isn't true. In House the cases have to be cool. For two reasons. One, for the show's on success. Two, because House is built around the ultimate hater of boredom: Sherlock Holmes (Wikipedia says so). But how do you justify it? Answer? A department of Diagnostic Medicine. Or, in plain English, House only meets patients who are zebras.

Now, we might wonder how large a hospital would have to be to get cases like House's regularly. Even if we exclude the ones that Mr Anti-Boredom made interesting through not following standard procedure (if I remember Polite Dissent correctly, what you do is list everything and rule them out systematically rather than thinking up, say, ten things tops), it is a lot. Even if you're only getting interesting cases, you're still having a lot of them if you've got 52 in a year (House treats one patient a week). If that's 5% of all patients are zebras that's 1040 a year, if it's 1% it's 5200 and if it's .01% it's 520,000 a year. That last figure would mean nearly 1500 patients a day. However, Wikipedia says rare diseases are (sometimes) treated as those that fewer than 1 in 2000 to fewer than 1 in 1000 people have. This would translate to having between 52,000 and 104,000 patients a year, if we're getting 52 "zebras" a year, and rare diseases are  a good proxy for "zebras". That's actually reasonable: Waikato Hospital's emergency department averages 210 patients a day, which is 76650 a year. We can note that this is a rather crude methodology, but I think it sufficient to say that it is plausible that a department of Diagnostic Medicine that caters exclusively to zebras could manage one patient a week, if such a department were to exist.

(As to malpractice... I guess it's easier to get a free ride when you're treating only the desperate who then become the only too grateful. Possibly, because it is a fictional world, you have to be more outrageous than in the reality of America.)

House was fun, but it is probably fun in the way that delayed sports matches are fun: if you know the score, you're missing out. That's rotten luck for medical professionals, especially those familiar with diagnosing patients, but it doesn't mean that House was bad for us lay folk. Sure, it had its problems and took wrong turns, but we stuck with it until the end. Which is why you can believe me when I say that House is the sort of dude who you can believe has kids he doesn't know about. I mention this because there's this one episode where a rape victim wants to talk only to House. It's weird in the sense that House isn't the "right" person for that sort of conversation. Since the rewatch, I've thought that maybe the character's mother knew who House was but never got involved (House being House), and in the extreme situation the character sought out House. Or, maybe, House was just a random doctor, and someone like House was just what that particular character needed. Who knows? But that's the fun of fictional characters: absent evidence to the contrary, they can be who you want them to be (although, this doesn't mean all explanations really do explain things just as well).

Thursday, 10 August 2017

Metiria Turei: Gizza Job?

One of the things that amazed me when I was 18 is that some from my school could've lived to 18 without knowing what WINZ was.

Now, sure, my reasons for knowing about WINZ were a bit more personally connected. I remember waiting in the car while my mother had appointments with WINZ. I remember using WINZ for uniforms, glasses and similar. I remember not always being able to pay bills. But still. I'm sure my fellow knew about the dole.

The thing is, when you look at it, WINZ is not a terribly effective version of not just a great idea but an absolutely fundamental one. The welfare state is arguably the defining character of modernity and regardless of one's views on post-modernity, it doesn't matter at all if you don't have a word to describe starving to death: you're still dying. But WINZ is, well, WINZ.

I am reminded of Boys from the Black-stuff. That's a programme from Britain's Thatcher years about unemployed Northerners... who stayed in England (c.f. Auf Wiedersehen, Pet). People like to talk about a "Golden Age of Television" but even ignoring said commentators general ignorance of anything older than The Wire, we might wonder if it's all got just a bit removed from real struggles. The GFC was a pretty big deal, right? Where was the biting commentary? Where were the scenes of whatever Thatcherite Britain's equivalent of WINZ sending agents out to find the "welfare frauds"? Closest I can think of is that poor bastard in The Big Short (a movie) who loses his home because his landlord didn't keep up his end. Or Frank Underwood's ex-chef. But these are throw-away. Television is no longer viscerally depicting real life economic struggle in concept. Or, if it does, society has been so unbuilt no-one cares.

In theory, means-testing sounds like a great idea, right? After all, WINZ has a limited budget so it should try and be efficient. Thing is, means-testing is a function, which means it is a job, which means it incurs costs. That is, means-testing means that you have to worry about administration costs. Or, in other words, you spend money doing stuff that doesn't actually help you achieve the main thing, i.e. providing a system that isn't just there to catch you, but one that puts you back on your feet and keeps everything (and I do mean everything) chugging along. WINZ is, as a concept, about helping people. WINZ is Mr Incredible, and government? Well, it's his dickhead boss. Except, this time the dickhead boss can mind control Mr Incredible.

This is, broadly, where you get people talking about Universal Basic Income. If everyone gets a universal sum, no questions asked, you don't have to pay anyone to ask questions. Logically, this is how you really do make something like WINZ into a lean, mean problem-solving machine. After all, now you can deal with intractable issues with a soft-touch.

(Charities can do this too, by the way. For instance, Andrew Carnegie's deciding to minimise the unhelpful admin costs by having the philanthropy happen with an endpoint in mind strikes me as basically the same idea.)

One of the last times my mother was getting some kind of benefit/assistance from WINZ, she was basically being made to jump through hoops to find a job. Sounds reasonable, I think: people who can work, and who need money, ought to work. Except, the reason we want people to work is so that they're better off. The money will keep flowing up and around whether it comes from WINZ or Job ACME: that bit doesn't matter. What does matter is the personal and social implications (finances aside... obviously any kind of cost is economic). Which is why WINZ was in the wrong here. But even if you ignore that, my mother was a "productive member of society" at the time... she was volunteering with regular hours. Which is to say, even with means testing, the regime in which WINZ is forced to operate creates absurdities counter to both its real point, and the role ascribed to it by people we might term Thatcherites.

(Obviously this is a middle-ground view. It doesn't have the more specific/efficient set of tasks for WINZ that UBI brings, but letting beneficiaries use volunteer hours, with WINZ essentially serving as their employer, does create a soft touch that actually helps. This "compromise" is Mr Incredible not telling that little old lady the ins and outs of the perverse system administered by the aforementioned dickhead boss.)

At this point I should note some really critical things about my personal situation. My mother is a land-owner. Aside from a brief few months prior to my fifth birthday when we were renting, we've been owner-occupiers. Intermittently on the benefit, yes, but owner-occupiers nonetheless. How? My mother's father is a reasonably well off dude, and this helps a lot. And when my mother was sick, I was able to live with some of my second cousins, no worries. Not everyone has family members of means and not everyone is able to leverage familial connections in this way. And if you are renting, your life has another element of uncertainty introduced to it. Even better, my mother worked from home for a long time while I went to schools within walking distance: minimal travel costs! And we had a car. Things, in short, could have been a lot worse. And for many people? Well, they are.

(Yes, this background is one of the reasons I am disgusted when people compare keeping up with the Joneses to the stress of pay cheque to pay cheque existence or even more tenuous personal existence. And, yes, this happens. I read an NZ Herald article doing this a long time ago now. Similarly I am angered by a lot of the "poverty stricken student" discourse because it frequently (a) ignored all those students who qualify for student allowances despite living in the "comforts" of "home" and (b) frames issues that are bigger than just students purely within discourses of the student.)

The question that all this begs is: what do people do?

Look, if you can "defraud" WINZ to create a situation where we can't distinguish its behaviour from how it really ought to be behaving given its real purposes, you're a God-damned hero. WINZ is not, at the moment, fit for purpose (either its real purposes or the misleading efficiency paradigm's) so the kind of fraud that makes it look like it is? Well, how is that bad? Actual welfare fraud is when you're doing stuff that white collar criminals with fancy lawyers (heck, just knowing lawyers is fancy... let alone employing some) do. And while you shouldn't break the law, living in a democracy means laws aren't sacrosanct so I'm never going to apologise for believing in both (a) welfare "fraud" and (b) fraud involving WINZ. Nor should anyone put in such a situation.

Let's put it this way... no-one's going to blame a bull for wrecking the china shop when the truck rear ends the shop window and lets him out. So how can we blame beneficiaries when it's us who set up the situation where all they can do is walk into the china shop? You have to make a move: not eating is literally dying.