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Sunday, January 17, 2016

How Measurement Fails Doctors and Teachers

Re-posted from National Public VoiceSunday, January 17, 2016

Robert M. Wachter: How Measurement Fails Doctors and Teachers

By ROBERT M. WACHTER, New York Times, JAN. 16, 2016

TWO of our most vital industries, health care and education, have become increasingly subjected to metrics and measurements. Of course, we need to hold professionals accountable. But the focus on numbers has gone too far. We’re hitting the targets, but missing the point.

Through the 20th century, we adopted a hands-off approach, assuming that the pros knew best. Most experts believed that the ideal “products” — healthy patients and well-educated kids — were too strongly influenced by uncontrollable variables (the sickness of the patient, the intellectual capacity of the student) and were too complex to be judged by the measures we use for other industries.

By the early 2000s, as evidence mounted that both fields were producing mediocre outcomes at unsustainable costs, the pressure for measurement became irresistible. In health care, we saw hundreds of thousands of deaths from medical errors, poor coordination of care and backbreaking costs. In education, it became clear that our schools were lagging behind those in other countries.
So in came the consultants and out came the yardsticks. In health care, we applied metrics to outcomes and processes. Did the doctor document that she gave the patient a flu shot? That she counseled the patient about smoking? In education, of course, the preoccupation became student test scores.

All of this began innocently enough. But the measurement fad has spun out of control. There are so many different hospital ratings that more than 1,600 medical centers can now lay claim to being included on a “top 100,” “honor roll,” grade “A” or “best” hospitals list. Burnout rates for doctors top 50 percent, far higher than other professions. A 2013 study found that the electronic health record was a dominant culprit. Another 2013 study found that emergency room doctors clicked a mouse 4,000 times during a 10-hour shift. The computer systems have become the dark force behind quality measures.

Education is experiencing its own version of measurement fatigue. Educators complain that the focus on student test performance comes at the expense of learning. Art, music and physical education have withered, because, really, why bother if they’re not on the test?

At first, the pushback from doctors and teachers was dismissed as whining from entitled and entrenched guilds spoiled by generations of unfettered autonomy. It was natural, went the thinking, that these professionals would resist the scrutiny and discipline of performance assessment. Of course, this interpretation was partly right.

But the objections became harder to dismiss as evidence mounted that even superb and motivated professionals had come to believe that the boatloads of measures, and the incentives to “look good,” had led them to turn away from the essence of their work. In medicine, doctors no longer made eye contact with patients as they clicked away. In education, even parents who favored more testing around Common Core standards worried about the damaging influence of all the exams.

Even some of the measurement behemoths are now voicing second thoughts. Last fall, the Joint Commission, the major accreditor of American hospitals, announced that it was suspending its annual rating of hospitals. At the same time, alarmed by the amount of time that testing robbed from instruction, the Obama administration called for new limits on student testing. Last week, Andy Slavitt, Medicare’s acting administrator, announced the end of a program that tied Medicare payments to a long list of measures related to the use of electronic health records. “We have to get the hearts and minds of physicians back,” said Mr. Slavitt. “I think we’ve lost them.”

Thoughtful and limited assessment can be effective in motivating improvements and innovations, and in weeding out the rare but disproportionately destructive bad apples.

But in creating a measurement and accountability system, we need to tone down the fervor and think harder about the unanticipated consequences.

Measurement cannot go away, but it needs to be scaled back and allowed to mature. We need more targeted measures, ones that have been vetted to ensure that they really matter. In medicine, for example, measuring the rates of certain hospital-acquired infections has led to a greater emphasis on prevention and has most likely saved lives. On the other hand, measuring whether doctors documented that they provided discharge instructions to heart failure or asthma patients at the end of their hospital stay sounds good, but turns out to be an exercise in futile box-checking, and should be jettisoned.

We also need more research on quality measurement and comparing different patient populations. The only way to understand whether a high mortality rate, or dropout rate, represents poor performance is to adequately appreciate all of the factors that contribute to these outcomes — physical and mental, social and environmental — and adjust for them. It’s like adjusting for the degree of difficulty when judging an Olympic diver. We’re getting better at this, but we’re not good enough.

Most important, we need to fully appreciate the burden that measurement places on professionals, and minimize it. In health care, some of this will come through advances in natural language processing, which may ultimately allow us to assess the quality of care by having computers “read” the doctor’s note, obviating the need for all the box-checking. In both fields, simulation, video review and peer coaching hold promise.
Whatever we do, we have to ask our clinicians and teachers whether measurement is working, and truly listen when they tell us that it isn’t. Today, that is precisely what they’re saying.

Avedis Donabedian, a professor at the University of Michigan’s School of Public Health, was a towering figure in the field of quality measurement. He developed what is known as Donabedian’s triad, which states that quality can be measured by looking at outcomes (how the subjects fared), processes (what was done) and structures (how the work was organized). In 2000, shortly before he died, he was asked about his view of quality. What this hard-nosed scientist answered is shocking at first, then somehow seems obvious.
“The secret of quality is love,” he said.

Our businesslike efforts to measure and improve quality are now blocking the altruism, indeed the love, that motivates people to enter the helping professions. While we’re figuring out how to get better, we need to tread more lightly in assessing the work of the professionals who practice in our most human and sacred fields.

Robert M. Wachter is a professor and the interim chairman of the department of medicine at the University of California, San Francisco, and the author of “The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age.”

The NYC Department of Education is Ignoring Pleas For a Safe Learning Environment

As I posted in my previous post (See "Ed Boland Writes About His Experience As A Teacher in The Battle For Room 314", Jan. 17, 2016) kids in many of NYC schools do not have a safe environment that supports their culture and out-of-school experience. We have to change this.

In the story, also today in the NYPOST about bigotry at elite high School Brooklyn Technical ("Brooklyn Tech"), students throughout New York City are crying out for recognition of heritage, culture, equality, respect, and finding appropriate strategies to survive. Devora Kaye, the DOE spokesperson, again states her meaningless answer, "We have zero tolerance for any discrimination. We’ll work to provide open forums for the school community to discuss these important issues and will provide any 
support that is needed.”

She means, I think, "Stop bothering me."

Lets all get to work on this.

Betsy Combier

At-risk students improve when they take a race and ethnicity class – study

Eli Rosenberg, Jan. 14, 2016, The Guardian

Stanford researchers concluded that ‘culturally relevant’ teaching is an important part of the 
education of students who could flunk or might drop out

High school students saw large improvements in their grades and attendance records when they enrolled in a class dedicated to exploring race and ethnicity, researchers in California found.
The Stanford University study analyzed a pilot program of ethnic studies classes at three San Francisco high schools and found that, on average, at-risk ninth-graders encouraged to enroll in the course performed significantly better than their peers who didn’t.
Student attendance increased by 21%, while grade-point averages surged nearly a grade and a half for those enrolled in the class – striking results, according to the researchers.
 “I was surprised that this particular course could have such dramatic effects on the academic outcomes of at-risk kids,” said Thomas S Dee, a professor at Stanford who co-authored the study with postdoctoral researcher Emily Penner. “If I was reading a newspaper with results like this, I would read it with incredulity, [but] the results were very robust.”
The study looked at 1,400 ninth-graders taking part in a pilot program. Students with GPAs of 2.0 or lower in eighth grade were automatically enrolled in ethnic studies during their first year of high school. Their results were compared against students who had similar GPAs who were not automatically enrolled in the ethnic studies class because their GPAs were slightly over 2.0.
The study lends some support to advocates who have worked to make ethnic studies classes a larger part of school curriculums.
Researchers concluded that the results of the study show that “culturally relevant” teaching is an important part of the education of students at risk of flunking or dropping out.
“Slight little nudges that help people reframe their experiences can have a big effect,” Dee said.
Other cities that have instituted ethnic studies offerings in school districts include Oakland and Los Angeles.
In Portland, Oregon, students recently lobbied for the class to be offered on a wide basis in public high schools.
But the non-traditional curriculums have been challenged by some conservatives in places like Arizona, where state legislators passed legislation banning ethnic studies from schools in 2010.
California’s governor, Jerry Brown, a Democrat, vetoed a bill to develop a statewide ethnic studies curriculum in October. In Berkeley, where students have discussed ethnic stereotypes, analyzed history in racial terms, and talked about their own experiences and backgrounds in ethnic studies classes for more than 20 years, black student union leaders recently argued that black history should instead be better integrated into history curricula and that relegating the subject to a portion of a semester-long class was “insulting.”
Dee said that he hoped the study would help move the discussion in a more constructive direction.
“One of my hopes is that this research helps shift the debate away from those heated political outcomes towards student outcomes, about which everyone cares,” he said. “They may have dramatic effects.”
Brooklyn Tech

Students protesting ‘blatant bigotry’ at Brooklyn Tech HS


Racism is rampant at elite Brooklyn Tech HS, black students say.

On a new Facebook page gaining in popularity, Black in Brooklyn Tech, students describe offensive and insensitive treatment by faculty as well as classmates.
A movement to end the “blatant bigotry” erupted after several students, since suspended, allegedly made racist jokes in a private Facebook chat.
The school’s Black Student Union created the hashtag #blackinbrooklyntech to “share the stories of racial discrimination and harassment we face” as a minority in the top-rated school, and to open a dialogue, it said in a statement released to The Post.
The social-media campaign is an embarrassment to the city Department of Education and the 5,400-student Brooklyn Tech, the largest of eight elite high schools which base admissions solely on a special test.
The student body is 81 percent Asian, 20 percent white, 8 percent Hispanic and 8 percent black. Mayor de Blasio’s son, Dante, is a recent graduate.
Among the alleged incidents posted:
·         “Getting sent anonymous lynching & KKK jokes.”
·         A class clown at the front of the classroom did “what he seemed to think was a funny impression of a stereotypical black woman” named “Lakeisha.”
·         Black girls wearing crop tops and shorts in the summer “get sent to the dean’s office while girls of other races who are wearing the same things do not.”
·         A guidance counselor told a student expressing a goal to earn higher grades: “The day you get above a 90 average I’ll grow an Afro.”
·         An English teacher instructed a student who skipped the “N” word while reading the novel “Heart of Darkness” aloud in class to “go back and read that word.”
In response to the uproar, one teacher reportedly told students, “Race relations aren’t that bad in this school. You could have it a lot worse.”
On Friday, members of the Black Student Union met with principal Randy Asher and high school superintendent Karen Watts to discuss solutions. Asher has already begun to “enforce mandatory sensitivity training” for faculty members, they said.
DOE spokeswoman Devora Kaye said: “We have zero tolerance for any discrimination. We’ll work to provide open forums for the school community to discuss these important issues and will provide any support that is needed.”

Ed Boland Writes About His Experience As A Teacher in The Battle For Room 314

Anyone who works in NYC schools can see that we - parents, friends, social workers, teachers, administrators and advocates - are not doing enough to prepare kids to learn by setting up an environment which coincides with the cultures that exist both inside and outside the school.

Kids from families (rich and poor) who live day-to-day with hostile people inside their homes and outside, on the streets, learn to survive in many different ways. The current education system judges and discriminates against children for learning how to survive in the manner they have learned from their parents, or the people they interact with everyday.

There are not enough people or programs to re-direct negative behavior into positive outcomes.

The book "The Battle For Room 314 by Ed Boland seems to address the issue, and I commend him for putting this issue again in the public eye.

Betsy Combier

My year of terror and abuse teaching at a NYC high school

In 2008, Ed Boland, a well-off New Yorker who had spent 20 years as an executive at a nonprofit, had a midlife epiphany: He should leave his white-glove world, the galas at the Waldorf and drinks at the Yale Club, and go work with the city’s neediest children.
The Battle for Room 314: My Year of Hope and Despair in a New York City High School” (Grand Central Publishing) is Boland’s memoir of his brief, harrowing tenure as a public-schoolteacher, and it’s riveting.
Ed Boland
There’s nothing dry or academic here. It’s tragedy and farce, an economic and societal indictment of a system that seems broken beyond repair.
The book is certain to be controversial. There’s something dilettante-ish, if not cynical, about a well-off, middle-aged white man stepping ever so briefly into this maelstrom of poverty, abuse, homelessness and violence and emerging with a book deal.
What Boland has to share, however, makes his motives irrelevant.
Names and identifying details have been changed, but the school Boland calls Union Street is, according to clues and public records, the Henry Street School of International Studies on the Lower East Side.
Boland opens the book with a typical morning in freshman history class.
A teenage girl named Chantay sits on top of her desk, thong peeking out of her pants, leading a ringside gossip session. Work sheets have been distributed and ignored.
“Chantay, sit in your seat and get to work — now!” Boland says.
A calculator goes flying across the room, smashing into the blackboard. Two boys begin physically fighting over a computer. Two girls share an iPod, singing along. Another girl is immersed in a book called “Thug Life 2.”
Chantay is the one that aggravates Boland the most. If he can get control of her, he thinks, he can get control of the class.
“Chantay,” he says, louder, “sit down immediately, or there will be serious consequences.”
The classroom freezes. Then, as Boland writes, “she laughed and cocked her head up at the ceiling. Then she slid her hand down the outside of her jeans to her upper thigh, formed a long cylinder between her thumb and forefinger, and shook it ... She looked me right in the eye and screamed, ‘SUCK MY F–KIN’ D–K, MISTER.’
It was Boland’s first week.
At the time, Boland’s new school was considered a bold experiment — not a charter but an “autonomous” one, given freedom in both management and curriculum. It was endowed in part by the Gates Foundation, and the principal hired only teachers who had once lived abroad.
Boland had taught English in China. This was his favored school — advertised as the last, best hope for kids who had fallen far behind — and he was thrilled to be hired. He went home to his then-boyfriend (now husband) and celebrated over takeout pad Thai and an expensive bottle of red wine.
“I was ready to change lives as a teacher,” he writes.
How wrong he was.
There were 30 kids in his ninth-grade class, some as old as 17. One student, Jamal, was living in a homeless shelter with his mother; most of the other students lived in public housing. There was one white kid in the whole school.
“It was as if Brown v. Board of Education or desegregation had never occurred,” Boland writes.
He had rounded up his students into a semicircle and checked for forbidden items: phones, electronics, sunglasses, clothing in gang colors.
Then someone kicked in the door.
And there, Boland writes, “stood one Kameron Shields in pure renegade glory, a one-man violation of every possible rule. Above the neck alone, he was flaunting four violations: He wore sunglasses and a baseball cap over a red bandanna over iPod headphones. A silver flip phone was clipped to his baggy jeans. Everything he wore was cherry red — the hallmark color of the Bloods.
“He turned his grinning face to the ceiling and howled, ‘WASS ... UP ... N—AS?’
Boland was outmatched. He was petrified. He ran out the clock and asked his fellow teachers who this kid was.
“Oh, yeah, he’s brutal,” one colleague said. Turned out Kameron had thrown a heavy electric sharpener at a teacher’s head the year before, but the principal — whom the teachers sarcastically called their “fearless leader” — refused to expel any student for any reason.
Two weeks in and Boland was crying in the bathroom. Kids were tossing $110 textbooks out the window. They overturned desks and stormed out of classrooms. There were seventh-grade girls with tattoos and T-shirts that read, “I’m Not Easy But We Can Negotiate.” Their self-care toggled in the extreme, from girls who gave themselves pedicures in class to kids who went days without showering.
Kameron was in a league of his own. “I was genuinely afraid of him from the minute I set eyes on him,” Boland writes. After threatening to blow up the school, Kameron was suspended for a few months, and not long after his return, a hammer and a double switchblade fell out of his pockets.
The principal gave up. Kameron was expelled.
“Oh, they getting real tough around here now,” one student said. “Three hundred strikes, you out.”
Here among the kids who couldn’t name continents or oceans, who scrawled, “Mr. Boland is a f—-t” on chalkboards, who listed porn among their hobbies, were a few who had a shot.
There was Nee-cole, who wore thick glasses and pigtails. She was quiet, smart, much more childlike than her peers, and Boland felt for her. He was also intrigued by a tough girl named Yvette, who showed flashes of insight and intelligence yet did all she could to hide it. “PLEASE DON’T TELL ANYONE I WROTE THIS,” she scrawled on one report.
He asked his fellow teachers about the enigma that was Yvette. “One day in class, I intercepted a note,” said a colleague, Tasneen. “It said, ‘Yvette b—s old guys for a dollar under the Manhattan Bridge.’ We punished the girl who wrote it for spreading lies.”
Soon after, the school heard from Child Protective Services. The prostitution rumor was true. Yvette was removed from her home. “She’s not doing it anymore,” Tasneen said, “but she’ll never outrun that story.”
The bookish Nee-cole was also a target, but things were tolerable — until parent-teacher night. Nee-cole’s mother showed up wheeling a suitcase down the hall, listening to Donna Summer on a Discman. She wore off-brand jeans, rainbow leg warmers, a ratty orange vest, dreads festooned with ribbons and shells, and a face tattoo of pin curls where hair should be.
Boland was flummoxed. He closed the classroom door.
She introduced herself as Charlotte and explained Nee-cole’s history: Her daughter had been enrolled in Harlem, but when her mother saw the school was on the city’s list of underperformers, she pulled Nee-cole out and home-schooled her.
“But we didn’t have a home, so I made do and taught her where I could, mostly on the subway, for the year.”
She went on to explain that she had to put Nee-cole in foster care. “I love my child beyond words and am still very involved with her life,” Charlotte said. “Her education is my priority.”
After that meeting, Nee-cole’s life at school was never the same.
“Nee-cole’s mother is a HOBO,” the other kids would say. “Did you get a look at her? Mama look like a homeless clown.”
Boland came to actively loathe most of the student body. He ­resented “their poverty, their ­ignorance, their arrogance. ­Everything I was hoping, at first, to change.”
His colleagues gave him pep talks, reminded him to contextualize this behavior: These kids had no parents, or abusive, neglectful ones. Most lived in extreme poverty. School was all they had, and it was their only hope.
A lifelong liberal, Boland began to feel uncomfortable with his thinking. “We can’t just explain away someone’s horrible behavior because they have had a tough upbringing,” he argued back. “It doesn’t do them — or us — any good.”
Then there was Jesús Alvarez, boyfriend of Chantay and, as Boland writes, “a perfect s--t.” Jesús would stroll by Boland’s classroom and shout, “Bolan’, who you ballin’? It ain’t no chick.”
Boland called in the father, even though he was warned it would do no good. The three sat down, and Boland was surprised.
“Jesús, this is a good school,” the father said. He warned Jesús that it was either school or the street, and Jesús wasn’t tough enough for the street. “You get yourself right, get an education, and show this man some respect.”
It was the one thing that had gone well so far. “I left that meeting brimming with confidence,” Boland writes. “Involving parents was key.”
Next, he turned his attention to Valentina, a transfer student who joined his class in February. She wore tight jeans over what Boland calls “an epic derriere,” and as she walked to her seat, the kids oinked and mooed.
“Step down, all y’all n---as, or I’ll stab you in your neck,” Valentina said. “Don’t get me tight, bitches.”
Boland soon learned Valentina was what the Department of Education calls “a safety transfer” — meaning she was such a threat to her fellow students that she was pulled out of school.
Now here she was, Boland’s newest charge. He was quickly impressed with her observational skills — a bar he had set extremely low, now the victim of some inner-city form of Stockholm syndrome.
Asked to write about an ancient sculpture of two royals, Valentina wrote, “Well, isn’t it obvious that they are a couple? His hand is on her t—y ... The way they sit is ­regal.”
It was the use of the word ­“regal” that blew Boland away. He pulled her aside after class.
“You can’t fool me,” he told her. “I can tell from just that one sheet of paper that you have a very fine mind.”
For that, he received an official complaint of sexual harassment, filed by one Valentina. She claimed Boland said, “You are mighty fine, you turn me on, and I can tell you like fooling around.”
The entire administration knew Boland was gay, yet they still had to follow procedure. He was never to be alone with Valentina again.
By the time he invited a highly decorated Iraq War veteran to speak to class and Valentina greeted him with, “Hey, mister, give me a dollar,” Boland thoroughly despised her.
Nor could he escape the kids outside of school. One winter day, Bolan was mounting his bicycle, on his way home, when he saw a gang fight break out in a parking lot. He saw Jesús in the crowd, and an older man egging the kids on. “That’s it, Nelson, show that punk-ass bitch who’s boss. Whale his ass.”
It was Jesús’ father.
Angry and humiliated, Boland relayed this latest heartbreak to a veteran teacher. “As crazy as sounds,” the teacher said, “that ­father may be trying to teach his son how to survive in a hostile ­environment the only way he knows how.”
Boland didn’t know what to ­believe anymore. At the end of the school year, he quit.
Boland ends his book with familiar suggestions for ­reform: Invest more money, recruit better teachers, retool the unions, end poverty. But there’s no public policy for fixing a broken kid from a broken home, or turning fear into resilience, or saving kids who can’t, or won’t, be saved.
Toward the end of his tenure, Boland asks his sister Nora, a longtime teacher, for help. What is he doing wrong? What could he be doing right? Why can’t he break through to these kids, even the ones who seem to care? How can society absorb such a massive ­human toll?

“I’ve been teaching for a long time now,” Nora tells him. “And my only answer is that there are no easy answers.”