The .Plan

Ever wonder how HEW determines compliance with national standards? Say, for example, how to get out of a closed refrigerator?

Behavior of young children in a situation simulating entrapment in refrigerators was studied in order to develop standards for inside releasing devices, in accordance with Public Law 930 of the 84th Congress.

Using a specially designed enclosure, 201 children 2 to 5 years of age took part in tests in which six devices were used, including two developed in the course of this experiment as the result of observation of behavior.

Success in escaping was dependent on the device, a child’s age and size and his behavior. It was also influenced by the educational level of the parents, a higher rate of success being associated with fewer years of education attained by mother and father combined. Three major types of behavior were observed: (1) inaction, with no effort or only slight effort to get out (24%); (2) purposeful effort to escape (39%); (3) violent action both directed toward escape and undirected (37%).

Some of the children made no outcry (6% of the 2-year-olds and 50% of the 5-year-olds). Not all children pushed. When tested with devices where pushing was appropriate, 61% used this technique. Some children had curious twisting and twining movements of the fingers or clenching of the hands. When presented with a gadget that could be grasped, some (18%) pulled, a few (9%) pushed, but 40% tried to turn it like a doorknob.
–Katherine Bain et al, “Behavior of young children under conditions simulating entrapment in refrigerators”, Pediatrics, October 1958

Last week, Time magazine reported on an alleged “pregnancy pact”, prompted by an epidemic of 17 pregnant girls at one 1,200-student high school, a spike in the pregnancy rate at 4 times the usual. Subsequent investigation failed to uncover evidence of a “pact”, and the article was more or less retracted. Whether there was or was not a pact seems to be missing the point. Chris Rock, along the lines of his stellar performance in Bigger and Blacker, might wonder out loud why — in light of national data that places pregnancy rates among teenage blacks and Latinas at 70-80 per 1,000 — a thinly sourced story about 17 girls at a largely white high school made the national news at all.

This is the kind of conversation I wish Barack Obama would have with the legions of dreamy-eyed evangelical Christians who think they have found in him a champion of the voiceless (babies) and vulnerable (teenagers), but somehow I doubt that will happen anytime soon. I don’t need for him to suddenly become pro-life overnight; I just want him to admit that abortion is tragic. Is that too much to ask for? Clinton had the balls to do this 3 years ago, but unfortunately she was way ahead of her time. Obama has probably learned from her mistake.

Oh. My. God. Becky, look at his log file.
It’s so… big.
He looks like one of those biostats grad students.
Who understands biostats?
They only hired him because he looks like a total geek.
Okay? I mean, his log file is, like, 200 pages.
I can’t believe he even calculated… what’s a Schoenfield residual?
Gross. Look. He’s just so… smart…

I like good stats and I cannot lie.
You other brothers can’t deny.
When you get some data and you put it in STATA and it spits out a beta of ten,
You get sprung.
And you’re thinking hoorway,
Gonna send that to JAMA today…

Oh data, I wanna get wit’cha
regress and fit’cha…

A few months ago, Lori Gottlieb published an essay in the Atlantic Monthly (”Marry Him! The case for settling for Mr. Good Enough“) urging single women in their 30s to “settle” [*] rather than holding out for Mr. Right. She starts from the observation (which may or may not be true) that

every woman I know — no matter how successful and ambitious, how financially and emotionally secure — feels panic, occasionally coupled with desperation, if she hits 30 and finds herself unmarried.

and then proceeds with the exhortation:

Settle! That’s right. Don’t worry about passion or intense connection. Don’t nix a guy based on his annoying habit of yelling “Bravo!” in movie theaters. Overlook his halitosis or abysmal sense of aesthetics. Because if you want to have the infrastructure in place to have a family, settling is the way to go. Based on my observations, in fact, settling will probably make you happier in the long run, since many of those who marry with great expectations become more disillusioned with each passing year. (It’s hard to maintain that level of zing when the conversation morphs into discussions about who’s changing the diapers or balancing the checkbook.)

At the time, her essay generated a very negative visceral response from me. I dislike Gottlieb’s essay not because of her controversial exhortation — because, as I will explain further, I find some degree of truth to it — but because I think her starting point is a disordered set of fundamentals. Her idea of “settling” has to do with lots of incredibly trivial things. She shows appropriate restraint in that she recognizes that these are in fact fairly trivial matters, but she is at the same time demonstrating a self-centeredness that bodes ill for her future marital bliss (should she ever decide to ’settle’). The marriage she desires (whether the romantic ideal or the realistic consolation) and describes is all about her, her child, her stability, and ultimately, her happiness. The Aquinian, however quaint, notion of love being “to will the good of the other, for the sake of the other” is largely absent.

In some ways, Gottlieb is nibbling around the edges of the truism that our preferences are naturally disordered and that marriage is not just about romance. Stanley Hauerwas is fond of teaching “you always marry the wrong person“. If you are able to get past the deliberate, obstreperous, Hauerwasian provocation in this statement, then you can see that there is a lot of truth to it. After all, how does an unattached person, reared in a culture that accepts and promotes the efficiency of short-term commitments, develop any kind of concept of what it means to form a covenental bond that gives you the practice of monogamous fidelity over a lifetime? Rod Dreher — a fellow Louisiana School alum — commenting on the Gottlieb article at his Crunchy Con blog, elaborates on this theme, accurately [emphasis mine]:

Julie and I, married 10 years now, talked about this last night. We didn’t reach any hard and fast conclusions, but we agreed that married-with-children life is way more difficult than single people realize, and that the things that make for an exciting boyfriend or girlfriend don’t always make for a good partner in a lifelong marriage with children — but that’s something that’s very, very hard for single people to understand. You couldn’t possibly have explained it to me as a single man before I lived it (nor could you have explained the intense joys of childraising).

This is consistent with what my married friends tell me. The daily process of observing the Markan call to die to your self sounds like it is fairly difficult, and somehow I don’t see Gottlieb advocating this.

If I accept Gottlieb’s foundations, I can see how it would make sense to sign up for Internet dating sites such as match.com and eHarmony.com to assist with my search for a spouse. All I have to do is pick a set of characteristics that I believe will maximize my happiness, fill in the checkboxes, see who fits my profile of Prince Charming or Princess Lucinda, and then it’s off to the races. Even if I don’t know myself well enough to complete such a task — or if I am afraid of the miserable choices I seem to make — then I can go to eHarmony.com, fill out an exhaustive battery of questions, and see who fits my personality profile.

Leaving aside for the moment the question of whether one should participate in these ventures (for more on this point, please see Brother Warren’s takedown), there is plenty of research to suggest that they don’t even really work.

But what bothers me most about these approaches is that they assume a very self-centered, pre-specified, and fixed personality or set of preferences, and they ignore the importance of attachment and commitment.

An analogy from my own life might be instructive here. When I was thinking about applying to medical school, I had no idea what being a physician would be like. Working in hospice provided me with the opportunity to obtain a very brief glimpse at only two or three aspects of doctoring. Yet I made a decision to apply. When choosing among medical schools, my only sources of data were a series of one-day interviews and incredibly over-hyped data from the U.S. News and World Report. A priori I think it would have been a stretch to characterize any one of my potential medical school choices as the best one for me. In truth, because I was sufficiently lacking in direction, and because I’m fairly open to new experiences, I’m quite certain that any one on my shortlist would have been a reasonably good match for me and could have provided me with a nurturing environment, intellectually, spiritually, and socially. In the end, I decided to pick one, but I had no accurate idea about whether the medical school I chose would make me a “better” doctor than any of the other schools on my shortlist.

In retrospect, I now see that I incorporated a great deal of faulty data into my decisionmaking process. Nonetheless, things turned out okay — better than okay, in fact, and now I can say without a doubt that I picked the right medical school. But I don’t know that the school I chose was necessarily a priori the best choice. Whatever preferences I had as a college junior have been completely remade in the years since then, and most of my misconceptions have been corrected — so much so that I probably couldn’t even accurately describe what my preferences were in the first place. Key to this outcome, aside from living under the shadow of God, was the process of growing into the commitment I made to become a physician. Because I created and participated in a particular history, because of the ways in which I grew into my decision — the experiences I had were such that I cannot imagine what my life would now be like had I gone somewhere else. Given this particular history, I’m left to conclude that the school I chose was “The One”.

The analogy can be carried too far, but my fundamental point stands: that love is a creature of history and commitment. In his book The Four Loves, C.S. Lewis elaborates his taxonomy of basic human loves. Affection — in contrast to friendship, erotic love, and love of God (and clearly the borders between the four are hazy and not impermeable) — he describes as “warm comfortableness”, “responsible for nine-tenths of whatever solid and durable happiness there is in our natural lives”, a love that “can unite those who most emphatically , even comically, are not [made for each other]“. He continues:

In my experience it is Affection that creates this taste, teaching us first to notice, then to endure, then to smile at, then to enjoy, and finally to appreciate, the people who “happen to be there”. Made for us? Thank God, no. They are themselves, odder than you could have believed and worth far more than we guessed.

We don’t evaluate love in a vacuum. Though sometimes we contemplate it dizzily while fluttering home one evening — even when we are not so deeply entangled in it, we contemplate love in the context of history. It bothers me that we are being fashioned by the world into a people that defaults to thinking under consumeristic models of relationships. Doing so leads us to divorce characteristics of persons from the unfolding narrative of our lives together, and it — falsely, I think — makes sense to say things like, “I like her because she likes cats”, “I like him because he can lead me in the tango”, and so forth. My participation in an Internet dating site like match.com would only feed this deranged propensity by allowing me to specify all of the characteristics I want as well as those I am not willing to accept. But it seems to me that such characteristics cannot be contemplated abstractly, disembodied from the object of one’s love. Properly viewed from within the context of the intertwined lives we live in the Body of Christ, they simply cannot be bought and sold and traded off for one another.

I am not arguing that we should be rolling the dice, consulting magic 8-balls, and just picking spouses more or less at random and relying on commitment and fidelity to get us through the next 50 years. Marriage sounds difficult enough that we probably need every advantage we can get. For this reason, I do believe we should think carefully about what our dealbreakers are vs. what are our soft preferences that can be accommodated (perhaps with training) over time and eventually overcome. This sort of question extends naturally to guys who are widowers and women who have been widowed; alcoholism, drugs, and pornography; emotional baggage from prior relationships and/or sexual partners; infertility; and so forth. Thus, the “settling” I have in mind has very little to do with whether he appreciates Jane Austen or whether she likes beagles; it has to do with whether she and I can together have the love and commitment to sustain a marriage despite all of this stuff — or whether I am compelled to go chasing after the next shiny new make & model of car who has yet to accumulate such baggage (i.e., whose baggage accumulation process has simply been deferred to the future). But I don’t really think of this as “settling”.

In the end, I think Gottlieb is groping towards an adult concept of love, but she hasn’t quite made it all the way. She writes of “settling” as if it were an entirely negative concept, that we shouldn’t drop people we date from spousal consideration just because of minor differences that can likely be worked out in the long run. Realism does require this kind of understanding. We make the commitment to love despite trivial differences in compatibility because our feelings for the Other are deep and abiding. But Gottlieb isn’t writing about being realistic. She abandons the concept of love entirely and simply replaces it with a hard-nosed tolerance. Hers is a rather thin view of marriage. I’m a realistic idealist, and I’m not yet ready to give up on marriage and love. It should be about accepting the flaws in someone I have come to love — not simply dispensing with love for someone whom I grudgingly accept.

—

[*] There is a technical rewording of Gottlieb’s recommendation, derived from my better cousins the mathematicians. This problem is known as the “Secretary Problem“, or the “Fussy Suitor Problem”: suppose I want to find the best match out of a group of N  women. Assuming that applicants who were previously interviewed cannot be recalled, then the decision rule that maximizes the probability that I locate the best match is: after the first N  / e women (where e  is approximately equal to 2.71), I should just pick the next woman in line who is better than the first N  / e women I dated previously. For example: suppose there are 100 women in my dating pool. I can’t date them all, and if I did then that would eliminate them as spousal possibilities. I should then just date 100 / 2.71 = 37 of them, and then stick with the next woman I date who is better than all of the previous 37. In the limit, i.e., if the eligible dating pool is N  =1,000,000, say, then the probability that this decision rule yields the best match converges to 1/e  = 36.8%.

There are a few noteworthy observations to be made here. First, the secretary problem assumes away opportunity costs, when in reality the composition of the dating pool is not static — and the implications of this are asymmetric, gender-wise, as illustrated in the XKCD comic above. Second, the secretary problem assumes that every secretary applying for a job would accept the job if offered one. Third, because the composition of the dating pool is changing and because not every secretary would accept a job if offered one, by extension the pool of secretaries who would accept a position if offered one is also changing.

Acuity on the inpatient ward has been high as of late.

In the span of two weeks, I

• surpassed my previous record of volume of serotonin- and dopamine-hammering agents prescribed to a single patient,
  
• received an invitation by an extremely attractive drug rep to do some consulting work for her employer (curiously, immediately after delivering a withering grand rounds talk that properly eviscerated said employer for questionable research ethics),
  
• admitted three acutely psychotic 18 and 19 year-old Chinese college students (all studying at the same local university, but without any social ties to one another),
  
• was invited to dinner by one of their fathers after a family meeting that included one of his apparently marriageable (and non-psychotic, and attractive) 27 year-old daughters,
  
• revealed my own religious background, for the first time, to two patients and one mother, and
  
• had two bouncebacks of patients with florid borderline personality disorder just when I thought I had gotten them out of my hair.

Each of these list items probably deserves its own entry. But the most draining activity by far has been being challenged to sit with a person whose “either-or” thinking leads her to cut or overdose when confronted with the slightest perturbation from her shaky equilibrium. Teaching rudimentary concepts of cognitive- and dialectical-behavioral therapy on the inpatient ward is a deeply frustrating task. But what you dislike most in other people are the characteristics that are most ingrained in your self, right? Lately I have been trying to take some of my own advice to heart. Instead of “either-or” language, I have been training — begging — myself to use the language of “both-and” in an attempt to appreciate the tensions inherent in everyday life.

For example:

Today, I both felt a little isolated while eating dinner by myself and was relieved to have the freedom to experiment with a new technique of stir-frying my string beans.

I felt both frustrated with the nonvolitional late nights of these past few weeks and appreciative of the opportunity to engage in deep self-reflection.

And so on.

Stumbling on hope…

Few of us can accurately gauge how we will feel tomorrow or next week. That’s why when you go to the supermarket on an empty stomach, you’ll buy too much, and if you shop after a big meal, you’ll buy too little.

Another factor that makes it difficult to forecast our future happiness is that most of us are rationalizers. We expect to feel devastated if our spouse leaves us or if we get passed over for a big promotion at work.

But when things like that do happen, it’s soon, “She never was right for me,” or “I actually need more free time for my family.” People have remarkable talent for finding ways to soften the impact of negative events. Thus they mistakenly expect such blows to be much more devastating than they turn out to be.
–Claudia Dreifus, “The smiling professor”, New York Times, April 22, 2008

Stumped? Just cross your arms.

In this set of psychology experiments, one set of subjects was instructed to solve a puzzle with their hands on their thighs, while the other set was told to sit with their arms folded. The former group only lasted for about 30 seconds, while the arms-crossed students persevered for 55 seconds. In the second experiment, the arms-crossed students came up with more solutions.

Experiment 1 established that arm crossing in an achievement context led to greater persistence on an unsolvable anagram, demonstrating that proprioceptive cues can influence achievement behavior. Experiment 2 replicated this finding, and also revealed that the increased persistence elicited by arm crossing facilitated performance. A mediation analysis confirmed that this performance difference was due to greater persistence in the arms crossed condition… Future research may also seek to identify the precise mental constructs activated by arm crossing. Although the present work demonstrated a specific behavioral tendency elicited by arm crossing within achievement settings, the cognitive nature of this response has yet to be fully explored.
–Ron Friedman and Andrew Elliot, “The effect of arm crossing on persistence and performance”, European Journal of Social Psychology, April 2008

Mercy will you follow me
Mercy will you follow me
Till my final breath at last I take
Mercy will you follow me
Mercy will you follow me
Till the chains of this old world I finally break
–Counting Crows

From Walker Percy’s “Love in the Ruins”, as quoted in a recent New York Times article on federally-funded physics research that may create a black hole where earth used to be.

Lord, grant that my work increase knowledge and help other men.
Failing that, Lord, grant that it will not lead to man’s destruction.
Failing that, Lord, grant that my article in Brain be published before the destruction takes place.”

Ms. Smith [*] was dumped by her board & care at the ED tonight. After being asked by the ED attending to assess her suitability for psychiatric hospitalization, I made a difficult decision to not bring her into the hospital. It was a difficult decision because I think she would receive better care in the hospital than she is receiving at her board & care home, and the hospital social worker could find her a better place; but she clearly did not warrant psychiatric admission, and it would not have been a good use of the hospital social worker’s time and effort.

Then I woke up the board & care operator and spent 20 minutes yelling at her on the phone for dumping off their client in my ED.

Afterwards, I went to speak with Ms. Smith. She was sitting in the corner of her room, shoulder slumped over, looking at the ground, periodically wiping drool off of her lower lip with a napkin.

“I don’t want to go back,” she said. “They don’t want me.”

I crouched down, touched her knee, and said, “But you have to go back. Tonight, at least.”

It all came spilling out — the ways in which the stuttered course of her chronic mental illness had savaged her personal life. Dumped by a philandering husband many moons ago, dumped by a second husband because she could only cook Puerto Rican food, abandoned by her son, dumped at the board & care home by her daughter. And now dumped by her board & care.

“My son’s having a baby,” she said, “and I’m going to be a grandma.” “But he won’t let me see my grandson.” A trickle of tears ran down her cheek, mixing with a rivulet of drool that had accumulated at the corner of her mouth. It quivered under its own weight, then dripped down. She reached up with a napkin to wipe it away.

My pager went off.

She began rummaging around in her purse.

“I know it’s here–”

More rummaging. A few rubber bands. Several wadded up pieces of tissue. A folded receipt for chicken Caesar salad at the Smith [*] Cafe on Smith [*] Blvd. A cheap pleather pocketbook.

“–I think I left it at home. My rosary. This is for you.”

She pressed a crumpled piece of paper into the palm of my hand: a cheap pamphlet, yellowed with age, describing the medal of Mary in the glory of her Immaculate Conception. I glanced at the text: Her feet crush the serpent, to proclaim that Satan and all his followers are helpless before her. It shows her as intercessor, the ray of light from her hands symbolizing the gifts coming through her intercession to all who ask for them…

“I hope I see you again.”

“But not in the hospital, Ms. Smith.”

“Come to Ocean Beach sometime. I like it there. Much better than the zoo.”

–
[*] All names, dates, and other HIPAA non-compliant details have been confabulated.