Month: April 2023

Side-by-Side on the LL

NOTE: I submitted this piece to the Brooklyn Nonfiction Prize and it was selected as a finalist. Yesterday was the reading and though I did not win, I am proud to have participated. It always feels a bit risky to put yourself out there, but if you don’t you can’t grow. My family has been very supportive and encouraging and I thank them for that!

  Rockaway Parkway was my subway station, where I got on the LL (today the L)  to go to The City. In Brooklyn we referred to Manhattan as The City. End to end the LL traveled from Canarsie as a mostly elevated line through Brooklyn and ended up at 8th Avenue and 14th Street, the upper reaches of Greenwich Village. I rode that line countless times growing up in the late 1960s and 70s.

            After the train left Canarsie it headed into East New York, followed by Brownsville, went underground in Bushwick, continued on to Greenpoint and Williamsburg. It traveled under the East River and emerged in Manhattan. In the 1970s it amounted to a grand tour of the most dangerous neighborhoods in Brooklyn.

            The LL sat at the open-air Rockaway Parkway station waiting for passengers, the trains arriving and leaving the station according to some mysterious, unpredictable schedule. The cars were covered inside and out with graffiti. It looked and felt like chaos.

            Aside from the physical appearance, the trains were unreliable. Countless times it would lurch into a station along the route, followed by a garbled announcement that it was going out of service. I heard the collective groan of my fellow travelers. Everyone would exit and crowd onto the platform to wait for the next one. Standing in the bitter cold or sweltering heat -it never seemed to be a moderate temperature – I tried to place myself strategically so that the doors would open in front of me. This was not a time to be timid. When the doors opened, I readied my elbows, and walked with purpose to claim my spot. This is how a New Yorker is made.

            I rode that subway line acutely aware of the danger. In the ‘70s, when it was on the brink of bankruptcy, New York City was the murder capital of the world. Muggings were common. On the subways, chain snatching, where a person would grab hold of a necklace and yank it off, fleeing as the doors slid shut, became a fad. We put our jewelry in our purses and held them close to our chests; when we arrived at our destination, we put our rings and necklaces back on.

            Since the LL traveled above ground, I could see pigeons perched on the fire escapes of the tired tenements that abutted the tracks. I watched the subway doors open and looked at the people who got on the train from those stations, almost all were brown and black, joining the white folks who had boarded in Canarsie. My neighborhood was 80% white, in fact the block where I lived was 100% white. I wondered about the lives of those who got on the train at New Lots Avenue, how was it for them to live in a neighborhood with such a bad reputation. Here we were, side-by-side, but living in different worlds. 

            I was 12 years old the first time my friend Deborah and I took the LL, just the two of us, into Greenwich Village. We emerged from the station to see a protest – people carrying signs, chanting, marching in a circle. We didn’t know what they were protesting but we thought it was the coolest thing in the world. It scared us at the same time. We looked around and quickly headed away from the hubbub, looking for bookstores, of which there were many.

            When I was 16, I got on the LL by myself to go to downtown Brooklyn to apply for my learner’s permit. There was only one Department of Motor Vehicles (DMV) office to service all of Brooklyn and the DMV was spectacularly inefficient so you had to plan to spend hours there. After I got on the train, I realized I had forgotten my birth certificate. I was too afraid to get off at any of the stops until Broadway Junction.  I wouldn’t turn around at 105th St., New Lots, Livonia, Sutter or Atlantic Avenues – five extra stops. Each time the doors opened, I looked at the platform and thought, “Should I risk it?” Each time I decided I wouldn’t. Even though it added so much time to my trip, I wouldn’t take the chance.

            In my travels from Canarsie, I frequently changed trains at Broadway Junction where the A and C lines met the LL. I descended the stairs from the elevated platform, took a deep breath and held it as I walked as quickly as possible through the underground passageway, which was damp and reeked of urine. I gulped the fresh(er) air when I got to the other side.

            One late afternoon I was riding the LL when there was an announcement over the PA. Those announcements were usually so static-y as to be indecipherable, but this one came through quite clearly. “Move away from the windows! There are reports of gunfire. Move away from the windows!” There weren’t very many of us on the train at the time. Most of the people looked incredulous, a few moved tothe windows to see. Some ignored the message entirely. I shifted down on the bench so the wall of the subway car was behind my head. Fortunately, nothing happened.

            Riding the L today reveals almost a whole new Brooklyn. Several neighborhoods have gentrified, especially Williamsburg and Greenpoint. Parts of Bushwick have become desirable real estate, as well. Brownsville and East New York are still impoverished. Compared to the 1970s, the crime rate has fallen all over Brooklyn, but the problems in those communities persist.  The neighborhood of my youth, Canarsie, has also changed. Though it is still middle and working class, the racial composition has flipped. Today it is 90% black.

            The more things change, though, the more they remain the same. People living side-by-side, riding the L, the haves and the have-nots, perhaps still leading segregated lives.

The Power of Words

I often begin blog posts by referring to an interview or podcast I listened to. This one is no exception. George Packer, a journalist and novelist perhaps best known for his writings on American foreign policy, was a guest on Preet Bharara’s Stay Tuned. Most of their discussion was about the status of the United States as a world leader (lots to worry about there, but not the subject of this essay). Toward the end of the interview, they turned to a subject of particular interest to me – the use of language and whether we are increasingly limiting ourselves by removing words that have negative connotations. It is a variation of the idea that it is problematic to be ‘woke.’  As I wrote previously, I strive to be woke and see it as a good thing. However, I thought Mr. Packer had a point. He wasn’t taking aim at ‘wokeness,’ per se, he was voicing his concern that, taken to an extreme, the idea that we can’t hurt anyone’s feelings could prevent us from identifying and solving serious problems. The example he gave related to words used to describe poverty – for instance, poor, impoverished, disadvantaged, at-risk. Apparently, all of these words/phrases have been identified as loaded and therefore to be avoided.

First question: who is doing the identifying? Packer explained that many nonprofit organizations, he cited the Sierra Club as a prominent one, have come out with ‘equity guides.’ These guides provide lists of words that should not be used, and he said they provide clunky, bland alternatives (for example, instead of ‘paralyzed with fear,’ they substitute refused to take action). He characterized the people behind these guides as a small group of educated elites. He thought that though they were well-intentioned, they were doing more harm than good. Packer’s main point was that we need to be less worried about the words and more concerned about the underlying problem that the word describes. I was intrigued by his argument.

I wondered if I would draw the same conclusion as Packer if I looked at the guide, so I googled a few. I also read his article in the Atlantic in which he fleshes out his argument (https://www.theatlantic.com/magazine/archive/2023/04/equity-language-guides-sierra-club-banned-words/673085/).

The Sierra Club equity guide is a 30 page pamphlet which provides much food for thought (here is the link if you want to check it out yourself https://www.sierraclub.org/sites/default/files/sce-authors/u12332/Equity%20Language%20Guide%20Sierra%20Club%202021.pdf). Included in it are references to many other style guides (I counted 9 of them!) as source material.

First, some context. Most news organizations and magazines have style guides – the Associated Press (AP) style guide is one that is frequently cited. If you write for those entities, they have established standards you are expected to follow. Organizations which put out frequent press releases or social media posts or are routinely called upon by the media to express positions are also likely to have one – that is why the Sierra Club has one, as does the American Cancer Society. The equity guide is an offshoot (part of) of the style guide.

Another aspect of the context relates to the Sierra Club specifically. They, like many organizations, have a complicated history in terms of their relationship to historically marginalized communities. In the past the club has mostly been thought of as the purview of white, male environmentalists. As the country has changed, and as the damage done by climate change has hit more broadly, they have needed to reach a more diverse constituency. If they are going to do that successfully, they need to understand those communities and use accessible language. They have taken positions in the past that hurt those communities.  In addition, the original founder, John Muir, was known to use racist language. Thus, the organization felt it had some work to do to repair the damage. That said, equity guides are prevalent beyond this particular nonprofit and Packer believes that as it seeps into the mainstream, it will erode our ability to tell the truth.

So, is there a problem with the equity guide, as Packer argues? My conclusion: Yes and no.

The main impetus of the guide is to remind its users to put people first. I became acquainted with this notion years ago when I was cautioned not to refer to a person with diabetes as a diabetic. A person is more than any single aspect of their identity, whether it be their illness, disability, religion, occupation, etc. It may not seem like a big thing, but I believe it is meaningful and worth reminding folks.

Another main point of the pamphlet is to ask people how they would like to be identified. It reminds us not to make assumptions based on appearance, and to use the terms the individual themselves would like to use. This applies especially to race and gender. To me this is common sense advice and simple enough to follow.

They also ask writers to evaluate whether the descriptor is germane to the subject. Do we need to know the person’s age or race or gender? We are conditioned to include some of those characteristics, but it is worth asking ourselves the question. Is it relevant or does it just contribute to stereotyping? If we are trying to paint a picture of a person or a situation, maybe more specific adjectives would do a better job.

So far so good.

Where things get problematic, and where Packer has a point, is in the avoidance of words that make us uncomfortable. If we are talking about poverty, neighborhoods that are poor, we can’t use euphemisms. It is what it is. The folks who live in those communities know they are poor and/or working class. It won’t come as a surprise to them. The problem isn’t the words. The problem is, in my estimation, the assumptions that get made because of that condition. Just as we should not define an individual by a single characteristic (diabetic), we must not define a whole community by one issue (i.e., its crime rate or the percent who live below the poverty line). We often write-off those communities or try to ignore them. But, we must not ignore all the people who are trying to raise families, make a living, lead healthy, productive lives in those communities. We need to remember that in those communities lots of good things are happening – there is culture, art, humor, good food, etc., etc. No matter what words we ultimately use to describe poverty, it is the associated assumptions that are dangerous, not the words themselves.

Words have power. We need to be mindful of how we use them. Sometimes we need to vividly describe a problem to move people to action. At the same time, we shouldn’t be careless about hurting folks. On balance, I think the equity guides are a good thing. Some of its advice borders on silly (I sincerely doubt that a person in a wheelchair would be offended by using the phrase ‘paralyzed with fear,’ or that a blind person would object to the phrase ‘blind rage’ – though it would be interesting to ask a group), but users of the guide can make their own judgments. In fact, the pamphlets make a point of telling readers to do that, especially in view of regional and local standards. The guides could be problematic if a given organization implements it as if it is law, without leaving room for nuance or the wisdom of the people on the ground. But, if it is a tool to raise awareness and offer alternatives, then it isn’t the bogeyman Packer sets it up to be. As with many things, the question of whether it is a good or bad thing depends on how it is used.

It Shouldn’t Be This Hard

NOTE: Another view from the frontlines written by my husband, Gary Bakst.

I saw a patient for a physical exam and there was a lump found on that exam.  It was not one of those lumps that make you immediately think the worst.  But it also wasn’t a lump that felt obviously innocent.  It would require investigation.  I was concerned but in my gut I thought this is probably going to turn out to be benign.  I also knew that what I needed to do was fairly straightforward.  The work up should be easy.  However, what should be easy is hardly ever easy these days.

I knew he needed a CT of the pelvis with and without contrast to better understand what we were looking at.  However, when I searched our electronic medical record system, there was no option for a CT pelvis with and without contrast.  There was CT abdomen with and without.  There was CT abdomen and pelvis with and without.  There was CT pelvis without any specification as to whether or not it included contrast and there was CT pelvis with contrast.  I have no idea why they made the choices so weird.  Ultimately I decided they must have intended that the CT pelvis (without specifying) was without contrast.  So I ordered CT pelvis with contrast and CT pelvis. 

This electronic medical record system was imposed upon our office.  We did not ask for it and we surely did not want it.  We had an electronic medical record system that was working very well but the larger organization that we are now part of felt it was important to get everyone in the organization on the same platform.  They switched us over a bit more than a year ago knowing they were going to again switch systems for the entire organization in early 2024.  We explained to them that our office is particularly busy and they did not have enough support staff to make this cumbersome system work in the setting of such a busy practice.  They weren’t impressed with that argument. 

When the switchover came, they sent in people to help us with the transition and they were great but the underlying issues were too much to overcome.  Our office became less productive, we were less able to accommodate our patients and new referrals.  The larger organization lost money when they thought they would save money.  Some of our doctors and PA’s became frustrated.  Two have left and one went from full time clinical to half time clinical practice.  We have been able to hire a PA and a nurse practitioner and we hopefully have another physician joining us soon.  Still our productivity is well below where we were before the change.  Belatedly the higher ups came to understand that the transition was a failure and allowed us more staff to deal with it.  Unfortunately, that happened just as the economy got weird and you couldn’t hire anyone.  However, as time went by, we have been able to increase our staffing and it has gotten better. 

We submitted the plan for the CT pelvis to the patient’s insurance company and they rejected it.  We appealed and they again rejected it and said I needed to speak to one of their reviewers.  Ultimately, they finally approved the CT.  Thankfully, it showed nothing terrible.  I had also ordered some lab work for this patient.  Previously, we drew the blood in the office and we also had a very efficient office lab that processed the blood work.  It was accurate and very fast.  The overwhelming majority of lab work was available to me on the day that the blood was drawn.  I would go home from the office and be able to review all of that lab work, call the people who had a problem and create letters to those who had good results so they could know they were fine.  Each evening, that day’s blood work was essentially all dealt with. 

However, the larger organization closed our lab.  We still draw the blood but the plan was to send it to their lab to save money.  We explained that it would lead to delays and be less efficient and not allow us to do as well in dealing with issues that come up with lab work.  However, they felt very strongly that it would be a major savings in lab costs.  To be fair, the higher ups listened to our objections and we were able to speak with them at length about it.  But the decision was made and was not going to be undone.

On the same day that they changed our electronic medical record system, they also closed our lab.  Specimens were to be sent to the hospital but at the same time, the pandemic related supply chain issues got us. There was a shortage of vacutainer tubes needed for blood draws so we had to send all of our labs to Lab Corp except for those patients who have Blue Shield which does not accept Lab Corp.  Lab Corp did pretty well getting us timely results.  They took one day longer than our lab but they were not too bad.  We lost much of our ability to have the lab add on tests as needed or re-run results that were questionable.  Still, it was a moderate, not severe, drop in our function.  For the Blue Shield patients, they had to go to either St. Peter’s labs or Quest labs, both of which were quite slow.  Sometimes we just never got any results and we had to call for them.  Sometimes patients would tell me their results off their portals for those labs and that is how I found out how they were doing.  

Finally, in November, the shortage of vacutainer tubes was over and our hospital lab said they were ready to accept our labs rather than sending them to Lab Corp.  But they were not ready.  We saw labs taking 4 or 5 days to come back.  In quite a few cases, by the time they got to our specimens, they had timed out and it was too late to run them.  For reasons I cannot fathom, they denoted this as “lab accident” and that showed up on patient’s portals.  Patients were naturally concerned about the lab accidents involving their results.  I started sending them to Lab Corp again until the hospital was able to get enough staffing to actually process the labs properly.  They are finally doing better but not great.  

In my patient’s case, there were lab abnormalities that required follow up.  I asked them to add the follow up labs from the blood that we had already collected but they could not do so.  Previously that would have been easily accomplished.  The patient came in for repeat blood work and they did much of what I asked for but somehow left out the most important follow up test.  I am capable of making mistakes but I had correctly ordered it-they just didn’t do the test.  Fortunately, in this case, they were able to run it and it also turned out to be good news. 

I have spent a fair amount of time criticizing the larger organization that owns our practice but I want to make the important point that they are actually pretty good as larger organizations go.  The problem with them is that they are a larger organization.  Speak to doctors anywhere in the country and you will hear similar stories.  Mostly you will hear worse stories.  These guys are really only guilty of being a bit too smart to realize that sometimes when something works, you should let it keep working rather than fix it.  Other organizations do far worse and have more concerning priorities.  The main point is that we now live in a landscape of practices owned by large organizations in which the decision makers are removed from the people taking care of the patients.  They have their own data and jargon and don’t answer to us.  Another part of this is the insurance companies which are increasingly difficult to deal with.  Then there are the ridiculous costs of pharmaceuticals and the shortages of all kinds of common products from blood pressure medications to amoxicillin liquid. 

Ultimately, this patient is well and that is the most important piece of news.  And in the end, we were able to get done what we needed to get done.  But, comparing what it took to make it happen to what that would have involved just a few years ago, the difference is quite stark.  People talk about the problems in health care these days.  You are not imagining them.  This was a fairly straightforward case.  Nobody was hospitalized; nobody had surgery.   It was just a CT and a couple of labs.  But it shouldn’t be this hard.